WHO Guidance On The Management Of Asymptomatic MERS Cases

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One of the big unanswered questions about the MERS coronavirus is what role – if any – do asymptomatically infected individuals play in the spread of the virus?  It’s a topic that  we’ve looked at repeatedly over the past couple of years, but answers have been slow in coming.

Part of the problem has been that Saudi MOH – by their own admission – doesn’t treat RTPCR positive MERS-CoV cases as `real cases’ unless they are symptomatic.   

 

A position long suspected, but confirmed two weeks ago in a twitter conversation with Dr. Ian Mackay and FluTrackers, when Dr. Hail Alabdely of the Saudi MOH stated:

As discussed previously,  there are serious questions over how one defines  `symptomatic’.  Are `sniffles’ considered symptomatic?  Malaise?  Is there a specific fever threshold?   Are non-respiratory symptoms (gastrointestinal) counted?

 

And quite frankly, we don’t know what level of symptomology is required for a carrier to be contagious.  We’ve seen some evidence to suggest that mildly symptomatic - or even asymptomatic cases - may be able to pass on the virus (see Study: Possible Transmission From Asymptomatic MERS-CoV Case).

 

Last week, we saw the WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS, that chastised the Saudi Response to MERS in unusually blunt terms, specifically mentioning their handling of asymptomatic cases:

 

The Committee further noted that its advice has not been completely followed. Asymptomatic cases that have tested positive for the virus are not always being reported as required.

Timely sharing of detailed information of public health importance, including from research studies conducted in the affected countries, and virological surveillance, remains limited and has fallen short of expectations. 

Inadequate progress has been made, for example, in understanding how the virus is transmitted from animals to people, and between people, in a variety of settings. The Committee was disappointed at the lack of information from the animal sector.

 

All of which brings us to a new interim guidance document (dated July 27th, but I just discovered it last week), on the management of PRC positive, asymptomatic MERS cases.

 

Management of asymptomatic persons who are RTPCR positive for Middle East respiratory syndrome coronavirus (MERS-CoV)

Interim Guidance

Authors: WHO

Publication details

Editors: WHO
Publication date: 27 July 2015
Languages: English

• View publication in WHO library database

Overview

The clinical spectrum of Middle East respiratory syndrome coronavirus (MERS-CoV) infection ranges from asymptomatic infection to severe pneumonia with acute respiratory distress syndrome (ARDS) and other lifethreatening complications. This document provides a standardized approach for public health authorities and investigators at all levels to plan for and conduct investigations around confirmed and probable cases of MERS-CoV infection. It should be read in conjunction with other detailed guidance referenced throughout the text, such as current laboratory testing guidelines and study protocols. It will be updated as necessary to reflect increased understanding of MERS-CoV transmission and control.

 

You’ll obviously want to download, and review, the entire document (it is very short), but the following excepts illustrate how seriously the WHO treats the potential threat posed by asymptomatic cases.

 

The potential for transmission from asymptomatic RT-PCR  positive persons is currently unknown. One study found that on day 12 after a first positive test, 30% of asymptomatic or mildly symptomatic persons (n=13) that had been in contact with a case remained positive for viral RNA in the upper respiratory tract4. Another study reported prolonged nasal virus RNA detection (more than 5 weeks) from one  asymptomatic RT-PCR positive health-care worker5.

If feasible and as a cautious approach during outbreaks in health care settings, WHO recommends that all close contacts of confirmed cases of MERS-CoV infection6, especially health care workers and other inpatient hospital contacts (e.g. non-health-care workers, patients and visitors), be tested for MERS-CoV regardless of the presence of symptoms.

 

For now, the WHO strongly urges that asymptomatic PCR-positive MERS cases be isolated, and their contacts be monitored as well.

 

Until more is known, asymptomatic RT-PCR positive persons should be isolated, followed up daily for symptoms and tested at least weekly – or earlier, if symptoms develop – for MERS-CoV.

The place of isolation (hospital or home) shall depend on the health-care system’s isolation bed capacity, its capacity to monitor asymptomatic RT-PCR positive persons daily outside a health-care setting, and the conditions of the household and its occupants8.

(SNIP)

Isolation should continue until two consecutive upper respiratory tract samples (e.g. nasopharyngeal [NP] and/or oropharyngeal [OP] swabs) taken at least 24 hours apart test negative on RT-PCR.

 

The guidance also offers the following advice on the management of Healthcare workers who are asymptomatically infected.

 

Asymptomatic RT-PCR positive health care workers – isolation and follow up

As noted above, the potential for transmission from asymptomatic RT-PCR positive individuals is still unknown. Therefore, asymptomatic health-care workers who are RT-PCR positive for MERS-CoV should be isolated and should not return to work until two consecutive upper respiratory tract samples (i.e. NP and/or OP swabs) taken at least 24 hours apart test negative on RT-PCR. Tests should be conducted at least weekly until a first negative test and then every 24-48 hours, so as to reduce isolation time for health-care workers.

 

Over the past five weeks Saudi Arabia has reported more than 2 dozen HCWs infected with MERS.   At the same time, we’ve seen 100 cases or more described as having visited, or been admitted to a medical facility where MERS cases were being treated. 

 

Rarely is direct contact with a confirmed symptomatic MERS case cited, with the WHO usually reporting: `Investigation of possible epidemiological links with the MERS-CoV cases admitted to their hospital or with shared health care workers is ongoing.’

 

How much of a role asymptomatic carriage of MERS-CoV may have played in those hospital acquired cases is unknown -  but when large nosocomial outbreaks becomes the norm rather than the exception - it’s probably long past the time for a new game plan.

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Saudi MOH Announces 3 Additional MERS Cases

 

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Although the number of new MERS cases in the nation’s capital Riyadh has slowed somewhat, we continue to see sporadic cases reported in other regions, often – as in today’s report – without an indication of a source of exposure.

While camel (or camel product) exposure is believed responsible for repeatedly reseeding the virus into the community, it is probably responsible for only a small number of infections.  Far more cases occur when hospitals amplify – through inadequate infection control practices - single community-acquired cases into larger nosocomial clusters.

 

But for a substantial portion of community acquired cases, no known exposure is ever determined.

 

Testing of contacts of confirmed cases has shown that roughly 20% of those who test positive for the virus are either asymptomatic, or only experience mild symptoms. Whether these mild cases can transmit the virus to others remains uncertain (see Study: Possible Transmission From Asymptomatic MERS-CoV Case).

While mild undetected cases in the community are a plausible – if not proven - source for some of these sporadic community cases, we remain badly hampered by the lack of a well mounted case control study out of Saudi Arabia (see  WHO EMRO: Scientific Meeting Reviews MERS Progress & Knowledge Gaps).

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#NatlPrep - The Gift Of Preparedness

 

CDC Infographic

 

Note: This is day 8 of National Preparedness Month.  Follow this year’s campaign on Twitter by searching for the #NatlPrep hash tag.  This month, as part of NPM15, I’ll be rerunning some updated  preparedness essays, along with some new ones.

 

#10,500

 

Despite years of campaigns by FEMA, Ready.gov, and the Red Cross to try to get Americans prepared for disasters (see America’s Preparathon! : It Started Like Any Other Day), polling shows that half of American families remain ill prepared to deal with even a 3-day disruption in essential services like electrical power, water, or the ability to run to the grocery store.  

 

Those that say they are prepared often overestimate their ability to fend for themselves during a prolonged crisis.

 

Which is why, for many years, I’ve given preparedness gifts to family and friends in lieu of the traditional ugly sweater, necktie, or boxed meat and cheese selection for birthdays, anniversaries, or holidays. I first started blogging this concept back in 2007 (see Hickory Farms Will Hate Me For This), and have updated the list every year since then.

 

Products mentioned below are to provide a general idea of the type of gift, and should not be viewed as an endorsement of one brand over another. I often find these gifts on sale in discount stores, bargain basements, and flea markets, and stock up whenever I come across a good deal.

 

Sometimes I make the gifts myself, as when several years back I put together some first aid kits, and distributed them to a number of friends and relatives. You can either put one together yourself, or purchase one already assembled.  There is no substitute for having a well stocked first aid kit when you need one.

A couple of years ago I also bought several 5 gal. buckets (with lids) from a home improvement store, along with mylar bags and oxygen absorbers from Amazon, and put together some long-term food storage buckets for friends.  

Cost per bucket?  About $30.  But enough food to keep two people going for a week or more in an emergency.  

 

Anyone who knows me knows that I have a particular interest in (ok, its more of a compulsion to buy)  LED flashlights and lanterns.  In 2006 I lucked upon a closeout bin of cheap imported `shake flashlights’ for .77 cents each, and bought out the store (40 of them, 38 of which I gave as gifts).

A couple of years later I ran across a deal on LED headlamps, and bought about 20 of them for $2 apiece.  The following year, I found LED Cap lights (they clip to the bill of a baseball style cap) for $3 each, which I confess I like even better.

 

And it seems each year the LED lanterns get lighter, brighter, and cheaper. 

 

This year I ran across a display of LED light sticks, with three modes of light, and a built in whistle.  The button batteries promise 200 hrs of running, but even if they last half that, at $3 each they were a bargain.  I bought 5 to test out.  One for my car, one for my bug out bag, and three for stocking stuffers.

My collection of LED lights continues to grow, and the best part is none of the items pictured below cost me more than $5 each.

Every home should have a battery operated radio, yet many do not. A few years ago I bought my daughter a combination windup-battery-solar AM/FM/SW radio for under $40, and she uses it every day.  I have larger windup Baygen shortwave radio for my own use, plus several small battery operated radios.

I also found a combination AM/FM Weather ALERT radio at a discount store for under $20. Again, every home and business should have an emergency alert radio.

Last year I upgraded my FRS radios from my old Motorola Walkabout T5000s to a pair of Motorola MJ270R 22-Channel Two-Way Radios.  They not only have a built in NOAA Weather Radio, they each have an LED Flashlight as well (nirvana!).

My old T5000s still work, so they will be handed out to neighbors in the event of a local crisis, to help with neighborhood communications.

 

A couple of years ago  I bought several water filtration systems, one to keep and a couple to give to prepping buddies.  LifeStraw ® is now available in the United States and Canada; at just 2 ounces, this personal water filter will reportedly filter 1000 liters down to .2 microns. Not bad for around $20.

Speaking of water, having a way to store enough water for three days (1 gal/person/day) is essential. A family of 4 will need at least 12 gallons for 72 hours.   Personally, I keep enough on hand for a couple of weeks.  While there are plenty of `free options’ – like rinsed and recycled 2-liter plastic soda bottles or other food-safe plastic jugs – you can also buy collapsible 5 gallon containers.

I also picked up a few single burner Propane stove units on sale for $10 each. Add a couple of 1 pound propane cylinders (about $3 each) and you can cook for a week. 

I also buy a  few magnesium fire starters each year (at $4 each) which will end up as stocking stuffers.

 

As I’ve described in  Preparedness: Solar Power On A Budget, it is a relatively easy task to set up a simple solar charging system. No, you won’t keep the A/C or refrigerator running on a budget system, but you can keep your LED lantern batteries, cell phone, iPod or iPad, or notebook computer running.

 

I’m seeing reasonably priced `briefcase’ solar panels – often for between $50 and $80 – that, when unfolded, can charge a 12 volt storage battery with up to 13 watts of power.  Add a $20 inverter (converts 12 volt battery power to 120v AC), and you can do a heck of a lot.

 

If I didn’t already have a couple of more powerful panels left over from my sailboat, I’d seriously consider one of these.

Typical 13 watt Solar System

Speaking of inverters, I have a 400 watt unit for my solar setup, but I’ve also just purchased an 80 watt cigarette lighter inverter for my car.  It can power a small laptop, and has a USB charger port as well.  Under $20. A few of these will end up in the stockings of friends this year. .

And for under $10, you can pick up a cigarette lighter USB charger, that can top off your phone or mobile device.

 

Something as simple, and as utilitarian, as a multifunction `Swiss’ army knife or a `Multi-tool’ makes a great preparedness gift.

Another inexpensive gift idea that is handy every flu season, and could be even more valuable during an epidemic – is for under $10 you can buy a box of exam gloves, and a box of facemasks.

Several years ago Joel over at Preparedness and Response came up with what I consider to be an excellent preparedness idea, giving USB flash drives to family and friends and instructions on how to back up their important papers and documents.

Inexpensive USB Drives start under $10.

 

He explains it in  his essay Helping others prepare (Personal Preparedness), where he gives his rationale for going with the durable mil-spec and encrypted, but fairly pricey IronKey brand.

 

My thanks to Joel for a terrific idea. 

 

These are all useful, indeed, potentially lifesaving items, that most people simply don't think about buying fror themselves until it is too late.

 

Giving them as gifts, instead of more traditional items, not only helps prepare the people you love and care about for an emergency, it opens the door for conversations about pandemic and disaster preparedness.

 

We need to cultivate a culture of preparedness in this country, and around the world.

 

We can start doing that, one gift at a time.

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RESEP BAKWAN TAHU TELUR GORENG SAYURAN

Resep Bakwan Tahu campur telur serta sayur kol dan buncis yang digoreng renyah dan gurih. Jenis gorengan sederhana dari adonan tepung terigu yang dicampur dengan sayuran ini di Indonesia lebih umum dikenal dengan sebutan bakwan. Beberapa jenis sayuran yang biasa digunakan adalah irisan kol, toge dan wortel sedangkan penggunaan bahan lainnya adalah udang, daging, kornet, jagung dan sebagainya termasuk juga bakwan tahu sayuran yang dibagikan kali ini. 

Resep membuat bakwan tahu goreng yang renyah dan gurih dengan pemakaian telur dan campuran sayuran merupakan versi lainnya untuk memperkaya aneka variannya selain bakwan sayur dan bakwan jagung yang telah diposting pada artikel-artikel terdahulu. Tahu kuning atau tahu putih bisa dihaluskan semuanya atau juga hanya sebahagiannya saja hanya sekedar untuk memberikan variasi pada teksturnya.

RESEP BAKWAN TAHU TELUR SAYUR

Bakwan juga disebut bala-bala bagi masyarakat sunda dan karena kemiripan adonannya juga sering disebut perkedel. Bakwan tahu telur enak disantap langsung bersama cabe rawit dan aneka saus sambal termasuk saus kacang atau dihidangakan sebagai pelengkap menu makan yang tentunya dapat menambah selera.

Bahan dan bumbu :

• 200 gram tahu
• 2 butir telur ayam
• 50 gram kol diiris tipis
• 30 gram buncis dipotong kecil-kecil
• 100 gram tepung terigu
• 100 ml air
• 2 buah cabe merah keriting diiris tipis
• 1 batang daun bawang dipotong-potong kecil
• minyak untuk menggoreng secukupnya

Haluskan :

• 4 siung bawang putih
• 1/4 sendok teh merica
• 1 sendok teh ketumbar
• 1 sendok teh garam
• 1/2 sendok teh gula pasir

CARA MEMBUAT BAKWAN TAHU

1. Bagi tahu menjadi 2 bagian, 100 gram dipotong-potong dadu kecil sedangkan sebagian lainnya dihancurkan atau dihaluskan.
2. Siapkan wadah kemudian kocok lepas telur dengan bumbu halus dan aduk hingga rata. Masukkan tahu bubuk, irisan kol, buncis, cabe merah keriting, daun bawang serta tuangkan air.
3. Aduk rata sambil memasukkan tepung terigu kemudian lanjutkan dengan potongan tahu, aduk perlahan supaya tahu tidak hancur.
4. Panaskan minyak yang banyak, ambil adonan tersebut dengan menggunakan 1 sendok makan lalu goreng dalam minyak panas hingga matang dan warnanya kuning kecoklatan. Angkat dan tiriskan dari minyak dan bakwan tahu sudah siap untuk disajikan.

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There Ain’t No Cure For The Summer Bird Flu

Seasonality of H5N1 in poultry 

Source FAO H5N1 HPAI Global Overview

#10,499

 

While North American poultry farmers, the USDA, and public health agencies anxiously await the expected return of HPAI H5 bird flu this fall and winter, for many other parts of the world bird flu hasn’t taken its usual seasonal sabbatical.  From Asia, to Africa, and even from parts of Europe – bird flu reports have continued to stream in to the FAO and OIE over the summer.

 

Like human flu, bird flu is largely seasonal, and spreads better in cooler, less humid environments.  

 

While summer outbreaks are not unheard of – particularly in countries where the virus is heavily entrenched – the past three months has seen an unusual number of outbreaks.   A mapped comparison of HPAI reports to the OIE over the past four summers (June 1st-Sept 1st) illustrates the point nicely.

Reports made in June likely reflect outbreaks in May, but the difference in both volume and geographic range between 2015 and previous years is striking.  Missing from these maps are outbreaks from Egypt and Indonesia, neither of which routinely file OIE reports.

Although we’ve seen sporadic outbreaks in the UK, Germany, and Mexico - Asia (primarily China, Taiwan, Korea, and Vietnam) and Africa (primarily Nigeria, Ghana, Côte d'Ivoire, and Egypt)- have been the hardest hit regions this summer.  

 

There are, of course, areas of the world where surveillance and reporting is either nonexistent or unreliable.

 

After the great H5N1 Diaspora of 2006, avian flu activity began to gradually recede around the world, and by 2010 outbreaks were mostly confined to a handful of countries (China, Egypt, Indonesia, Bangladesh, India, etc.)

 

The emergence of H7N9 in China in the spring of 2013, followed quickly by the arrival of H10N8, H5N6, H5N8, has helped to reverse this trend.   Of these, H7N9 and H5N8 (and its reassorted progeny) have had the biggest impact so far, but other subtypes continue emerge, evolve, and threaten.

 

Last February, in response to this unprecedented emergence of new flu subtypes, the remarkable and rapid spread of HPAI H5 viruses to Europe and North America, and Egypt reporting the worst human H5N1 outbreak in history, the World Health Organization released a blunt assessment called:

 

Warning signals from the volatile world of influenza viruses

February 2015

The current global influenza situation is characterized by a number of trends that must be closely monitored. These include: an increase in the variety of animal influenza viruses co-circulating and exchanging genetic material, giving rise to novel strains; continuing cases of human H7N9 infections in China; and a recent spurt of human H5N1 cases in Egypt. Changes in the H3N2 seasonal influenza viruses, which have affected the protection conferred by the current vaccine, are also of particular concern.

(Continue . . .)

 

As we’ve seen in the past, avian flu is extremely unpredictable.  In 2008, when it appeared as if H5N1 would sweep the world, it began an unexpected retreat.  Instead of the bird flu threat, we were blindsided the next year by a swine origin H1N1 pandemic.   Proving that past performance is no guarantee of future results.

The difference in 2015 is that we have multiple HPAI subtypes making major inroads around the globe. 

 

H7N9 is expected to return for a 4th winter appearance this fall, and while it has only impacted China so far – like with the HPAI H5 viruses – it too could hitch a ride on migratory birds and reach other nations.  H7N9 is also continually evolving and reassorting (see EID Journal: H7N9’s Evolution During China’s Third Wave – Guangdong Province), meaning the virus we see this fall and winter may not behave the same as the H7N9 of the past.

H5N1 has shown new vigor in 2015, showing up in countries that have not reported sightings in years.  A new clade has recently emerged in Egypt (see Eurosurveillance: Emergence Of A Novel Cluster of H5N1 Clade 2.2.1.2), spreading quickly among poultry, and is apparently the driving force behind the biggest human outbreak of H5N1 to date.

 

With its unexpected arrival in Taiwan, Russia, Europe, and North America, in just over a year H5N8 and its reassortant progeny (H5N2, H5N3, H5N1) have become better travelled than H5N1 had managed in more than a decade of trying.

 

Where it turns up this fall and winter – and whether it produces any new reassortants – are the $64 questions.

 

While the summer’s level of bird flu activity doesn’t necessarily portend what is to come this fall and winter, it is only prudent to take note of recent trends . . .  and plan accordingly.

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Saudi MOH Announces 4 New MERS Cases

 

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The drumbeat of MERS reports continues from the Saudi MOH, which for the 35th day in a row has announced new cases.  Three are from hard-hit Riyadh, with unspecified exposure history, while one is from Madinah.  Three fatalities and two recoveries are also announced.

The Madinah case is listed as a `contact’ of a confirmed or suspected case, although this is the first case we’ve seen reported from Al Madinah in many months.

Hopefully we’ll learn more when the WHO releases an update on these cases.

 

During the first 7 days of September – normally a quiet time of year for MERS cases -  Saudi Arabia has announced 36 new cases.  With the start of the Hajj now only a couple of weeks away, last week the World Health Organization warned:

 

. . . . the current outbreak is occurring close to the start of the Hajj and many pilgrims will return to countries with weak surveillance and health systems. The recent outbreak in the Republic of Korea demonstrated that when the MERS virus appears in a new setting, there is great potential for widespread transmission and severe disruption to the health system and to society.

 

For those intending to make this year’s pilgrimage, the CDC has some important health advice (see  CDC Traveler’s Advice: Umrah, The Hajj and MERS).

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WHO MERS Update – Jordan: Sept 6th

Credit WHO

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On Saturday (see Jordan: 3rd MERS Fatality Of 2015) we saw a media report of a third fatality and a reference to a 7th patient in Jordan’s recent MERS cluster, but without details. The first 4 cases were described last week in WHO Update On Jordanian MERS Cluster, while today we have descriptions of cases #5 and #6.

 

Both of these cases had the ill fortune to be seeking medical care at a facility already treating a MERS case.  While the exact route of exposure is unknown, the update states:

`Investigation of possible epidemiological links with the MERS-CoV cases admitted to their hospital or with shared health care workers is ongoing.’

 

To date, at least 26 countries have dealt with MERS cases, yet only 4 nations (Saudi Arabia, South Korea, UAE, & Jordan) account for 97% of the world’s known cases, and all have reported extended nosocomial outbreaks. The remaining 22 affected countries been able to identify, isolate, and treat MERS cases with either minimal or no secondary transmission to patients or hospital staff. 

 

Whether - or how long -  that luck will hold is an open question.  But the experience so far suggests that a combination of vigilance and good infection protocols can prevent the spread of this virus. 

 

After their spectacular failure to contain MERS earlier this summer, last week Korea Announced Major Changes In Wake Of MERS Outbreak they hope will prevent a reoccurrence.  Unless and until a similar commitment is forthcoming from hospitals and Health Ministries across the Arabian Peninsula, healthcare facilities there are likely to continue to amplify outbreaks of the virus.  

 

 

Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Jordan

Disease outbreak news
6 September 2015

Between 30 and 31 August 2015, the National IHR Focal Point of Jordan notified WHO of 2 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 1 death. Both cases are associated with a MERS-CoV outbreak currently occurring in a hospital in Amman city.

Details of the cases

1. A 73-year-old female from Amman city was admitted to hospital due to her chronic conditions on 21 August and, on 24 August, was discharged. This hospital has been experiencing a MERS-CoV outbreak. On 28 August, the patient developed symptoms and, on the same day, was admitted to the same hospital. She was treated symptomatically and discharged from hospital on 29 August. As her symptoms worsened, the patient visited a different hospital and was admitted on the same day. She tested positive for MERS-CoV on 31 August. Currently, the patient is in stable condition in a negative pressure isolation room on a ward. Investigation of possible epidemiological links with the MERS-CoV cases admitted to her hospital or with shared health care workers is ongoing. The patient has no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms.
2. A 56-year-old male from Amman city was admitted to hospital for a medical procedure on 18 August. This hospital has been experiencing a MERS-CoV outbreak. While hospitalized, on 28 August, the patient developed symptoms and, on 30 August, tested positive for MERS-CoV. The patient, who had comorbidities, passed away on 1 September. Investigation of possible epidemiological links with the MERS-CoV cases admitted to her hospital or with shared health care workers is ongoing. The patient had no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms.

Contact tracing of household and healthcare contacts is ongoing for these cases.

Globally, the WHO has been notified of 1,495 laboratory-confirmed cases of infection with MERS-CoV, including at least 528 related deaths.

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