The University of Auckland - New Zealand

Master of Health Leadership 

The Master of Health Leadership is a new qualification for 2016 offered by the School of Population Health.

It is an innovative qualification for health professionals and graduates of health sciences, public health, commerce, law and arts degrees, who seek to improve the experiences of patients, the health of communities and populations and the operations of health services.

Programme highlights

• Choose from three specialization areas: Health Management; Clinical Quality and Safety; or International Health.
• This programme has strong appeal for practitioners, planners, leaders and funders in the health sector.
• Flexible programme enabling health sector employees to combine work and study.
• Clinical Quality and Safety specialisation supported by the Chair of The Health Quality Commission.
• Health Management specialisation supported by the Chair and the CEO of Health Workforce New Zealand.
• Includes a workplace-based project.

Summer Research Scholarships

Summer Research Scholarships are a great way to get some research experience, work with leading researchers at the University of Auckland, enhance your career opportunities and help you think about pursuing postgraduate study.

• Conduct a research project under supervision for 10 weeks over the summer months.
• Receive a tax-free stipend of $5000.
• Open to high-achieving domestic and international students who have the potential to succeed in postgraduate study.

For more information, please contact/visit your nearest JM Office today

                  

                                                                                                                               Article is courtesy of  The University of Auckland

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The International Spread Of H5N1 Clade 2.3.2.1c – Dubai 2014

 

UAE

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After its initial surge in 2006-2007 – at one point showing up in more than 60 countries – the H5N1 virus began a slow retreat and by 2010 was pretty much relegated to a dozen or so countries where it stayed well entrenched.  What it lost in geographic range, it made up for with diversity, as over the years the H5N1 virus has evolved into numerous clades, sub-clades, and variants.

 

(click to load larger image)  (Note: Chart only goes through 2011, and not all clades continue to circulate)

 

So while we often talk about H5N1 as a single entity, in truth it now encompasses a large family of viruses with varying degrees of infectivity and pathogenicity (see Differences In Virulence Between Closely Related H5N1 Strains). These clades are constantly evolving, and reassorting, and so new versions of H5N1 are continually appearing. 

 

Some are destined to fade away, while others being more biologically `fit’  are able to successfully compete, and thrive.

 

Over the past two years, the H5N1 virus and its progeny have seen a striking renaissance, with recently emerged clades and their reassorted subtypes (H5N8, H5N2, H5N3, H5N6) spreading with renewed vigor around the globe.   Nations that have not seen outbreaks in poultry, or wild birds, since the last decade are now reporting sporadic HPAI H5 once again.

 

Even more impressively, last fall HPAI H5 has made it to North America for the first time.  H5 is clearly on the move again, and helping to drive this revived expansion are two relatively new clades;  2.3.2.1c and 2.3.4.4.

 

• Clade 2.3.4.4 includes subtypes  A(H5N1), A(H5N2), A(H5N6)  and A(H5N8), HPAI viruses that have spread rapidly in China over the past couple of years, and some have migrated to Europe and North America.
•  Clade 2.3.2.1c  has been showing up in Vietnam, China,  India, Bulgaria, and Indonesia for several years, and was recently detected in Western Africa  This clade was isolated from a nurse who returned to Alberta, Canada from a trip to China (see Alberta Canada Reports Fatal (Imported) H5N1 Infection) in late 2013, and similar to one that killed a captive tiger in Jiangsu Province in 2013.

 

Just last month we looked at an outbreak of clade 2.3.2.1c last January  at Sanmenxia reservoir in Henan province, where scores of migratory birds suddenly died (see Novel H5N1 Reassortment Detected In Migratory Birds – China).  Another outbreak occurred in the same region last July, but we have no information on the clade.

Worth noting since in 2005, and again in 2009, large outbreaks of emerging clades of H5N1 in the Qinghai Lakes region of China presaged major expansions of the virus (see 2011 EID Journal New Avian Influenza Virus (H5N1) in Wild Birds, Qinghai, China).

 

Today we’ve a report of clade 2.3.2.1c showing up in hunting falcons in Dubai (and their captive prey) during the fall of 2014.  These detections pre-date the recent arrival of clade 2.3.2.1c in Western Africa, and help to plot the westward expansion of this new HPAI clade. 

 

Outbreaks of highly pathogenic avian influenza H5N1 clade 2.3.2.1c in hunting falcons and kept wild birds in Dubai implicate intercontinental virus spread

Authors: Mahmoud M Naguib¹,  Jörg Kinne²,  Honglin Chen³,  Kwok-Hung Chan⁴,  Sunitha Joseph⁵,  Po-Chun Wong⁶,  Patrick CY Woo⁷,  Renate Wernery⁸,  Martin Beer⁹,  Ulrich Wernery¹⁰, Timm C Harder¹¹

Published Ahead of Print: 07 September, 2015 Journal of General Virology doi: 10.1099/jgv.0.000274

Published Online: 07/09/2015

Highly pathogenic avian influenza viruses (HPAIV) of subtype H5N1 have continued to perpetuate with divergent genetic variants in poultry within Asia since 2003. Further dissemination of Asian origin-derived H5 HPAI viruses to Europe, Africa and, most recently, to the North American continent, have occurred.

We report an outbreak of HPAI H5N1 virus among falcons kept for hunting and other wild bird species bred as falcon prey from Dubai, United Arab Emirates, during fall 2014. The causative agent was identified as avian influenza virus H5N1 subtype, clade 2.3.2.1c, by genetic and phylogenetic analyses. High mortality in infected birds was in accordance with systemic pathomorphological and histological alterations in affected falcons. Genetics analysis showed the HPAI H5N1 of clade 2.3.2.1c is a reassortant in which the PB2 segment was derived from an Asian origin H9N2 virus lineage.

The Dubai H5N1 viruses were closely related to contemporary H5N1 HPAI viruses from Nigeria, Burkina-Faso, Romania and Bulgaria. Median-joining network analysis of 2.3.2.1c viruses revealed that the Dubai outbreak was an episode of a westward spread of these viruses on a larger scale from unidentified Asian sources. The incursion into Dubai, possibly via infected captive hunting falcons returning from hunting trips to central Asian countries, preceded outbreaks in Nigeria and other Western African countries.

The alarmingly enhanced geographic mobility of clade 2.3.2.1.c and clade 2.3.4.4 viruses may represent another wave of transcontinental dissemination of Asian origin HPAIV H5 viruses, such as the outbreak at Qinghai lake caused by the clade 2.2 ("Qinghai" lineage) in 2005.

 

Thus far H5N1 and its reassortant progeny have failed to adapt well enough to human physiology to pose more than a minor public health threat, although 2015 has already set new records in the number of human infections (mostly in Egypt). Reassuringly, almost all cases have been linked to close contact with infected poultry.

 

But the rapidly increasing diversity and geographic spread of these HPAI viruses is a concern.  One that was voiced quite strongly last spring by the World Health Organization, which warned that H5 is Currently The Most Obvious Avian Flu Threat.

 

Which makes the tracking, and classification, of avian flu strains more than just of academic interest.

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Saudi MOH Reports 2 New MERS Cases

 

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The MERS reporting streak for Saudi Arabia rolls into its 37th consecutive day, with one more HCW reported infected from hard-hit Riyadh, and one new case from Dawadmy (aka Dawadmi), a city of about 50K population about 200 km west of the capital.

 

This appears to be the first case we’ve seen from that area, and the source of infection is not specified. 

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mBio: Origin & Possible Genetic Recombination Of MERS-CoV - China

Coronavirus – Credit CDC PHIL

 

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We’ve a fascinating bit of genetic detective work - published yesterday in the open access journal mBio - where Chinese researchers fully sequenced the genome of their imported MERS Case from Korea last May - and compared those results to 92 other MERS sequences on file,  gathered from Korea and the Middle East.

 

While they found that  the Chinese isolate (ChinaGD01) was 99% identical to other MERS viruses in the database, they also discovered that both the Korean and Chinese samples had picked up a number of specific amino acid changes that they theorize may affect the transmissibility of the virus.

 

Very early into the Korean outbreak, when the number of  hospital acquired cases was rapidly escalating, we saw a good deal of speculation over that very possibility; that the virus had mutated into a `Korean Variant'.  Early analysis, however, suggested that probably wasn’t the case (see Korean MERS Sequences Closely Match Middle Eastern Virus).

Today’s study, appearing in the open access journal mBio, takes a much deeper look at the complete genome sequences, and describes instead what they believe to have been a relatively recent recombination of the MERS coronavirus virus.

 

In very simple terms (which is about all I can manage), recombination is similar in concept to the reassortment we see with influenza viruses, although in practice it differs considerably. 

 

Influenza is a segmented virus, and during reassortment entire gene segments are swapped.  Most non-influenza viruses are not segmented, and so with recombination, only a small section of genetic material is exchanged.

 

I’m the first to admit that interpreting all of this is well above my pay grade, so I’m happy to say we have a plain-language commentary from none other than Dr. Ian Lipkin – world renown virus hunter and the Director of the Center for Infection and Immunity at Columbia University’s Mailman School of Public Health.

 

But first, the link and abstract to the actual study, after which we’ll look at Professor Lipkin’s commentary.  Follow the link to download the entire study.

 

Origin and Possible Genetic Recombination of the Middle East Respiratory Syndrome Coronavirus from the First Imported Case in China: Phylogenetics and Coalescence Analysis

Yanqun Wang^a, Di Liu^b,^c, Weifeng Shi^d, Roujian Lu^a, Wenling Wang^a, Yanjie Zhao^a, Yao Deng^a, Weimin Zhou^a, Hongguang Ren^e, Jun Wu^b, Yu Wang^f, Guizhen Wu^a, George F. Gao^a,^b,^f, Wenjie Tan^a

ABSTRACT

The Middle East respiratory syndrome coronavirus (MERS-CoV) causes a severe acute respiratory tract infection with a high fatality rate in humans. Coronaviruses are capable of infecting multiple species and can evolve rapidly through recombination events. Here, we report the complete genomic sequence analysis of a MERS-CoV strain imported to China from South Korea.

The imported virus, provisionally named ChinaGD01, belongs to group 3 in clade B in the whole-genome phylogenetic tree and also has a similar tree topology structure in the open reading frame 1a and -b (ORF1ab) gene segment but clusters with group 5 of clade B in the tree constructed using the S gene.

Genetic recombination analysis and lineage-specific single-nucleotide polymorphism (SNP) comparison suggest that the imported virus is a recombinant comprising group 3 and group 5 elements. The time-resolved phylogenetic estimation indicates that the recombination event likely occurred in the second half of 2014. Genetic recombination events between group 3 and group 5 of clade B may have implications for the transmissibility of the virus.

IMPORTANCE The recent outbreak of MERS-CoV in South Korea has attracted global media attention due to the speed of spread and onward transmission. Here, we present the complete genome of the first imported MERS-CoV case in China and demonstrate genetic recombination events between group 3 and group 5 of clade B that may have implications for the transmissibility of MERS-CoV.

 

Providing some perspective of all of this is the following commentary from Dr. Lipkin, whose words carry considerable weight in the world of virology.  Simply put, if he thinks this is important, then he has my full attention.

 

Middle East Respiratory Syndrome Coronavirus Recombination and the Evolution of Science and Public Health in China

1. W. Ian Lipkin

COMMENTARY

Since the discovery of Middle East respiratory syndrome coronavirus (MERS-CoV) in late 2012, more than 1,400 people have received a laboratory diagnosis of MERS and over 450 people have died. Most of the cases have been documented on the Arabian Peninsula; however, sporadic cases have also been reported in Europe and Asia in travelers returning from the Middle East. Except in South Korea, the imported MERS-CoV has not established a substantive chain of infection beyond the index traveler case. The spread within South Korea to 186 people, resulting in 36 deaths, has been attributed to a delay in diagnosis and isolation of the index case, lapses in infection control, and care of patients by family members rather than trained medical staff. This interpretation was supported by a preliminary report from a World Health Organization panel wherein no mutations linked to transmissibility or pathogenesis were found in sequences obtained in South Korea and China. However, in a recent mBio article, Wang and colleagues report detailed genomic analysis of the virus implicated in the first known case of MERS in China (1). They describe 11 amino acid substitutions, 8 of them shared with the South Korean strain and MERS-CoV strains recently circulating in Saudi Arabia, and define a recombination event that they speculate may have contributed to enhanced human-to-human transmission of MERS-CoV and the rapid spread of the virus in South Korea.

Recombination is common in coronaviruses and has been implicated in the emergence of pathogenic coronaviruses in poultry, cats, and pigs (2, 3). It would not be surprising, therefore, if recombination were to occur in MERS-CoV and to result in enhanced transmission or virulence. Wang et al. clearly demonstrate through bootstrap scanning and single-nucleotide polymorphism analyses that the viruses found in South Korea and China represent a recombinant virus that contains a clade B group 3 coronavirus sequence in the 5′ portion of the genome and a clade B group 5 coronavirus sequence in the 3′ end of the genome, with a site of recombination between nucleotide positions 17206 and 17311, a region that spans the junction between the ORF1a and S genes. They note that the recombination is evident in recent strains identified in human cases of MERS in Saudi Arabia and estimate that the recombination occurred in Saudi Arabia in the later months of 2014.

The paper is important in two respects. First, the recombination event may have resulted in the evolution of a new lineage of MERS-CoV with different transmission properties. Additional field work in epidemiology and studies of recombinant viruses in culture and in animal models will be required to determine whether this proves true. However, the paper itself is evidence of an evolutionary advance in scientific expertise and transparency that is at least as important for microbiology and public health. China has come a long way since the emergence of SARS-CoV in 2002/2003.

 

While we aren’t exactly seeing unbridled transmission of the MERS virus, over the past 16 months we have seen an significant uptick in cases, and a number of very large nosocomial outbreaks (Jeddah, Taif, Hofuf, Korea, Riyadh,etc.). Whether these amino acid substitutions have enhanced, or altered, the transmissibility of the MERS virus is something I’ll leave those with far more expertise than I to debate. 

 

But this is a reminder that viruses continually adapt and change.  Evolution may be slow and incremental, but it never stops.

 

Which is why one should never become too complacent whenever we see an emerging virus like MERS or novel Flu attempting -  but not quite succeeding - in making inroads into the human population.   Like getting to Carnegie Hall, sometimes that sort of thing takes years of practice.

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Study Group - Australia & New Zealand

Bursary offer for Malaysian students!

AUD $5,000

Study Group is pleased to announce a fee reduction of AUD $5,000 for Malaysian students who accept their offer for selected Study Group Australia and New Zealand programs on or before Friday 25 Sept. 2015

Terms and Conditions: October 2015 intake only Students must hold a Malaysian passport The Early Bird special will be given as a discount of $2,500 from the deposit and another $2,500 from the 2nd instalment Students must have an offer without conditions attached Valid for: ANU College - Foundation Year Program Auckland Foundation Year Flinders International Study Centre Foundation Program Flinders International Study Centre's Diploma of Commerce & Diploma of Science University of Sydney Foundation Program University of Western Australia Foundation Program UWA ISC Diploma of Commerce & Diploma of Science

For more information, please contact/visit your nearest JM Office today

                  

                                                                                                                               Article is courtesy of  Study Group

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The Jordanian MERS Outbreak Continues To Expand

 

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While Saudi Arabia has pretty much cornered the MERS market the past couple of months, starting about 2 weeks ago we learned of one imported case (not surprisingly, from Saudi Arabia) in Amman Jordan, and over the next few days that number grew to 5 (see Jordan Reports 5th MERS Case In A Week). 

 

A week ago, with the count standing at 6, the WHO released an update where we learned the index case was treated, and released after a week, from a hospital in Amman.  He relapsed, and was admitted to another hospital five days later, where he tested positive for MERS two days post-admission, and died two days later.

 

The subsequent cases in Jordan appear to be the result of nosocomial transmission of the virus at one or more facilities where he was treated.

 

Last Saturday a media report (see Jordan: 3rd MERS Fatality Of 2015) indicated the number of cases had grown to 7, although details on the 7th case weren’t provided.   Yesterday PETRA, the state news agency of Jordan reported a 4th fatality, although the limited details made identifying the patient difficult. 

 

It was possibly the mysterious 7th case previously mentioned.

 

Today we have a very cryptic announcement of a 5th fatality at a private hospital, and an offhand mention that the number of cases now sits at 8.   No details are provided on the fatality, or on the 8th case (who may be one and the same . . .or not).

 

Jordan recorded the fifth death Balchorona

Amman, September 8 (Petra) - The Ministry of Health reported new deaths virus Koruna citizen torrid, was diagnosed with the disease in a private hospital. He Communicable Diseases director Dr Mohamed Abdullat in a statement issued by the Information Center on Tuesday evening that the deceased was admitted to a private hospital in Aasmhaz was suffers from pressure, diabetes and cardiac ischemia.

He added that the number of cases registered in Jordan since the first case of this year amounted to 8 cases died, including five cases. - (Petra) A T /

 

The Jordanian Ministry of Health website remains silent about these cases, although they have posted some generic information assuring the public all steps are being made to end this outbreak (see Committee Epidemiology confirms the safety measures to deal with Koruna).

When it comes to holding MERS information close to the vest, the Saudis obviously have nothing on the Jordanians.

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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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