WHO Statement On New Ebola Case

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The brief WHO announcement this morning (see WHO Confirms Ebola Death In Sierra Leone), has been followed up by the statement below:

New Ebola case in Sierra Leone; WHO continues to stress risk of more flare-ups

WHO statement
 
15 January 2016 

A new case of Ebola has been confirmed in Sierra Leone, reflecting the ongoing risk of new flare-ups of the virus in affected countries.

The Sierra Leone government acted rapidly to respond to this new case. Through the country’s new emergency operations centre, a joint team of local authorities, WHO and partners are investigating the origin of the case, identifying contacts and initiating control measures to prevent further transmission.

WHO stressed in a statement yesterday (14 January), that Guinea, Liberia and Sierra Leone remain at high risk of additional small outbreaks of Ebola in the coming months due to the virus persisting in survivors after recovery. 

"We are now at a critical period in the Ebola epidemic as we move from managing cases and patients to managing the residual risk of new infections,” said Dr Bruce Aylward, WHO’s Special Representative for the Ebola Response, yesterday. “We still anticipate more flare-ups and must be prepared for them.”

Sierra Leone is still in a 90-day period of enhanced surveillance following the declaration on 7 November 2015 of the end of Ebola transmission in the country. This period is designed to ensure no hidden chains of transmission have been missed and to detect any new flare-ups of the disease. 

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More Korean Media Backlash On the MERS `Mutation' Story

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Last week, in `The `M' Word' we looked at the media's first reaction to a study (Variations in Spike Glycoprotein Gene of MERS-CoV, South Korea, 2015) that found enough genetic variance among a small subset of the Korean viruses sequenced from last summer's MERS outbreak to place them into a new clade.

Two mutations were located in the receptor binding domain of the virus's spike protein, although scientists still don't know what effect - if any - they would have on the spread, or impact, of the virus. 

Last summer, when the virus was running rampant through Korean hospitals, the WHO (see Yonhap News report WHO chief says no mutation of MERS virus found in S. Korea) - and others - reassured that the Korean MERS Sequences Closely Match Middle Eastern Virus. 

The rub being that `Closely' isn't the same thing as `Exactly'. 

And determining what - if any - impact minor genetic changes might have on a virus's behavior can take months of observation. A fine point that officials - perhaps more interested in dampening concerns than in explaining the nuances - didn't exactly stress. 

Simple, reassuring statements are often preferred by governments and agencies in the midst of a crisis, but they sometimes come back and bite you.

Which explains why - seven months later - the scathing headline in the Korean Times today reads:

WHO suspected of lying about MERS mutation 

By Jung Min-ho

When the Middle East Respiratory Syndrome (MERS) outbreak swept the country last year, The Korea Times raised the possibility of a virus mutation (http://www.koreatimes.co.kr/www/news/nation/2015/06/116_180045.html), citing its unusually high infection and low fatality rates.

Following the report, the World Health Organization (WHO) and the government conducted genome sequencing studies of the virus together and concluded that no genetic mutation had occurred.

Speaking to reporters on June 18 in 2015, WHO Director-General Margaret Chan said, "The virus has been sequenced. So far, no genetic changes have been detected that could make the virus easier to transmit among humans."

However, after their own sequencing program, a group of researchers drew a different conclusion this month: the virus apparently had mutated from the one found in Saudi Arabia, where Korea's first MERS patient was infected.

(SNIP)

It is unclear whether WHO investigators lied about the virus mutation. If not, however, the study suggests that they failed to figure it out at a critical time of crisis.

(Continue . . .)

I've only printed a few excerpts from a much longer story, so follow the link to read the (English Language) report in its entirety.

The problem with all of this is that we still don't know whether the genetic changes detected in the Korean MERS virus affected its transmissibility. The authors of the study that found these changes wrote `we cannot conclude that deleterious effects promoting spread of infection will occur because of these mutations.'

If we don't know now, it is hard to fault the WHO for not knowing seven months ago. Could they have been a little more up front about the limits of their knowledge of role of minor genetic changes?

Absolutely.

After the declaration that `no mutations' were found, it would have been a good idea to add that the impact of small genetic changes are not always immediately apparent. An uncertainty I went into in my blog last June in some detail.

Highlighting uncertainties and unknowns is viewed by some, however, as complicating the message.  But doing so can help avoid the kind of second guessing we are seeing in the Korean media today.

Public health agencies have a habit of issuing overlyreassuring statements, or in not clarifying the limits of their knowledge.  And time after time, we see that come back to haunt them.


Last September, in FAO: Addressing Avian Influenza A(H7N9) Risk Communications, we looked at some sage advice offered by risk communications expert Dr. Peter Sandman, where he strongly advises:

• Inform early, often and transparently as the situation develops

—— Warn that messages designed early in an unfolding event may change as knowledge evolves.
—— Be open about your level of uncertainty.
—— Share your wish that you could be more certain.
—— When you modify your recommendations, highlight the fact that you are making a change and explain why the
change needs to be made.
—— Avoid both overly optimistic and overly alarming speculation.
—— Share the worst-case and most-likely scenarios that you are considering.
—— Show empathy (rather than contempt) for the excessive fears or undue complacency of your audience.

• Do not over-reassure—— Avoid the temptation to say “The situation is under control.”
—— Instead of saying “the government is taking all possible/necessary measures,” convey the honest extent of your activities and explain them in detail.

This is just a sample, you'll find a great deal more available on that blog.  For more on effective risk communications, you may wish to revisit:

Sandman & Lanard On Ebola & Failures Of Imagination

NPR: Jody Lanard On Addressing Ebola Fears

Sandman & Lanard: Ebola Risk Communications

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WHO Confirms Ebola Death In Sierra Leone

0435 EST Today

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With a brief email to journalists this morning and a tweet (above) the World Health Organization has confirmed the suspected Ebola fatality reported in Sierra Leone last night (see Crofsblog Sierra Leone: Ebola death suspected hours after WHO declares end to epidemic in Liberia) - a disappointing, but not unexpected setback in the fight against Ebola in West Africa. 

Just yesterday the WHO declared the Current Ebola Outbreak Over In Liberia - West Africa At Zero, but everyone involved was well aware how tenuous this hold on `zero' would be.  

The virus is still in the environment, and it is likely that hundreds of recovered Ebola victims still carry - and may still shed - small amounts of the virus. Getting to `zero' transmissions - defined as going 42 days within in a country without a reported case - was a gargantuan task.

Staying there is proving very difficult. 

We've seen similar setbacks in Liberia (twice), and yesterday the WHO warned that new flare ups were not only possible, they were likely.    For now, the focus will be on tracing contacts of this latest victim, and containing any chains of transmission. 

The victim is reportedly a 22 year old woman who died earlier this month after seeking medical assistance in Northern Tonkolili District, but hailing from the Northern Kambia district near the Guinea border.

I imagine we'll get a more detailed official statement later today, once the details of this case are pinned down.

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RESEP SOTO AYAM KOYA KHAS LAMONGAN

Resep Soto Ayam Lamongan Koya - Soto Lamongan asli Jawa Timur merupakan salah satu menu kuliner spesial yang sangat populer di dunia persotoan nusantara. Selain bumbu soto lamongan dengan kuah yang kuning serta berbagai pelengkapnya, penyajian dengan taburan bubuk koya soto merupakan ciri khas utama yang menjadikan soto lamongan semakin sedap dan gurih saat disantap.

Resep soto ayam khas lamongan yang enak dengan cara membuat koya soto yang praktis dan unik dapat dengan mudah kita olah di rumah. Kalau ada ayam kampung tentunya bisa menjadi pilihan untuk menambah gurihnya cota rasa hidangan soto spesial ini.

Persiapan Bahan dan Bumbu Soto Lamongan Koya

• 1 kg daging ayam dan 1 buah jeruk nipis untuk lumuran
• 2200 ml air
• 2 lembar daun jeruk
• 3 lembar daun salam
• 2 batang serai digeprek
• 3 cm lengkuas
• 1 sdm garam
• 1 sdm gula pasir
• 1/2 sdt kaldu bubuk

Bumbu dihaluskan :

• 8 butir bawang merah
• 5 siung bawang putih
• 4 butir kemiri
• 3 cm jahe
• 5 cm kunyit

Bahan koya :

• 5 buah kerupuk udang
• 4 siung bawang putih diiris tipis
• 1/4 sdt garam

Bahan sambal :

• 20 buah cabe rawit merah
• 1 siung bawang putih
• 1/4 sdt garam
• 50 ml air matang

Bahan pelengkap penyajian :

• 100 gram soun direndam air
• 100 gram toge dibuang ekor
• 100 gram kol diiris tipis
• 1 batang daun bawang diiris tipis
• telur rebus, potongan jeruk nipis dan bawang goreng sesuai selera

Cara Membuat Soto Ayam Lamongan

1. Potong-potong daging ayam dan cuci hingga bersih, lumuri dengan air jeruk nipis sekitar 15 menit lalu cuci kembali. Rebus ayam dengan 2200 ml air bersama daun salam hingga kuah berkaldu dan daging matang atau sekitar 20 menit. Angkat dan tiriskan daging ayam, sedangkan air rebusan biarkan dalam panci untuk kuah soto.
2. Panaskan sedikit minyak, tumis bumbu halus, daun jeruk, lengkuas dan serai hingga harum. Panaskan kembali kuah kaldu dari rebusan ayam tadi, kemudian masukkan tumisan bumbu, aduk rata dan masak hingga mendidih. Beri garam dan gula pasir, cicipi rasanya bila perlu tambahkan kaldu bubuk lalu aduk rata, lanjutkan memasak hingga mendidih kembali dan kuah matang.
3. Daging ayam yang sudah direbus tadi digoreng dalam minyak panas hingga berwarna kecoklatan, angkat dan tiriskan lalu suwir-suwir.

Cara Membuat Koya Soto Lamongan

1. Kerupuk udang digoreng hingga matang, selanjutnya bawang putih juga digoreng hingga matang kecoklatan.
2. Tumbuk bawang putih dan garam hingga halus, masukkan kerupuk udang lalu tumbuk halus sambil aduk rata hingga menyatu dengan bawang putih.

Cara Membuat Sambal

Rebus cabe rawit dan bawang putih dengan air secukupnya hingga layu, angkat dan tiriskan lalu blender bersama 50 ml air hingga halus. Tuang dalam wadah sambal lalu tambahkan garam dan aduk rata.

Cara Penyajian Soto Ayam Lamongan Koya

Siapkan mangkuk saji, masukkan irisan kol, toge, soun dan suwiran ayam beserta telur rebus, kemudian sirami dengan kuah soto. Taburi irisan daun bawang, bawang goreng dan koya, lalu sajikan soto lamongan bersama sambal dan jeruk nipis.

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Arboviruses: (Already) Coming To America

Regions Where Aedes Mosquitoes Are Endemic

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The news this week that an imported case of Zika arrived in Harris County, Tx is only the latest in a steady stream of arbovirus infected travelers who arrive in the United States pretty much on a daily basis.  Zika is a new threat, but for years we've had imported cases of Dengue, Malaria, and more recently - Chikungunya - to deal with. 

In 2009, Dengue fever returned to Florida after six decades without a locally acquired case (see MMWR: Dengue Fever In Key West), and since that time we've seen sporadic outbreaks in South Florida, Texas, and most recently Hawaii. 

That MMWR report described Florida's vulnerability to Dengue as follows:

The environmental and social conditions for dengue transmission have long been present in south Florida: the potential for introduction of virus from returning travelers and visitors, the abundant presence of a competent mosquito vector, a largely nonimmune population, and sufficient opportunity for mosquitoes to bite humans.

The same mosquito vectors (Aedes) that transmit Dengue also can transmit Chikungunya, (and Zika) and so this assessment is likely valid for all three arboviruses. In late 2013, soon after Chikungunya began to spread rapidly across the Caribbean, the CDC issued a HAN Advisory On Recognizing & Treating Chikungunya Infection for clinicians in the United States. 

True to form, in 2014 Florida reported 459 International Travel-Associated Chikungunya Fever Cases and 11 cases of locally acquired CHKV (cite Fl. DOH).  Nationally, in 2014, the United States reported roughly 2,800 imported cases. 

We got lucky in that CHKV failed to establish a foothold that year, but past failures are no guarantee that our luck will hold forever. Now, CHKV and Dengue are joined by a new threat - Zika - and 2016 could be a very challenging year for mosquito control in Florida, and across the country.


The State of Florida published it's 2015 Arbovirus re-cap last week, and it it we find that more than 200 international travelers with either Dengue (83 cases), Chikungunya (73 cases), or Malaria (53 cases) were reported to the Health Department last year. 

As 80% of Dengue and Chikungunya cases are believed asymptomatic (or produce only mild symptoms), one can assume these reported cases are only subset of the total. 

Each one of these infected travelers has the potential to provide a blood meal to an Aedes mosquito, who could then spread the virus (or an Anopheles mosquitos with the malaria parasite) to others. Granted, unless conditions are ideal, it may take many repeated introductions of these diseases over years  before one becomes established in the United States.

But as we saw with West Nile Virus, which only arrived in 1999, it can happen much quicker than we ever imagined.   In 2015 WNV killed at least 119 Americans.

2015 Neuroinvasive WNV

WNV has an advantage in that it has a sylvatic cycle (birds to mosquitoes). Human infection is basically a result of incidental collateral damage (see graphic below).  

Zika, Dengue, and Chikungunya - at least outside of Africa and Asia - have no known non-human animal reservoirs, which means they have a harder time becoming endemic. But when enough people become infected, these viruses are sometimes able to sustain themselves in an Urban Cycle, where transmission is strictly human-to-mosquito-to human.

The conventional wisdom, however, says that (at least in colder climes), the virus must be reintroduced each year as infected mosquitoes die off during the winter.


Possibly throwing a wrench into that idea is a recent study (Feb 2015) suggesting that some mosquitoes may be capable of vertical transmission of some arboviruses (see  Natural transovarial transmission of dengue virus 4 in Aedes aegypti from Cuiabá, State of Mato Grosso, Brazil), allowing new generations of mosquitoes to be born already carrying the disease.  The authors write:

The findings reported in this study demonstrate that natural transovarial infection by DENV-4 is occurring in Ae. Aegypti in Cuiabá with a relatively high MIR index, which favors the birth of mosquitoes already infected with DENV at the beginning of epidemics. This mechanism may be responsible for virus maintenance during interepidemic periods, especially in critical areas with elevated mosquito density and human disease incidence.

There are a lot of factors at work - a lot of unknowns - but the upshot of all of this is that Zika, Chikungunya, and Dengue all have at least some potential to spark (likely regional, and limited) epidemics in the contiguous United States.

Maybe not this year, or next, but the requisite ingredients are all here.

A continual and growing influx of infected travelers and a competent mosquito vector. Just add in the right weather conditions, and a tightly packed urban population - and you have a recipe for an outbreak.

And it isn't just the United States at risk. 

Europe, Australia, and Japan have all reported arbovirus outbreaks in regions that haven't reported mosquito borne diseases for decades. A few months ago, in ECDC Vector Maps: Invasive Ticks, Mosquitoes & Sand Flies we looked at numerous places in Europe where these diseases might become established once again.


While the United States and Europe have waged very successful wars against mosquitoes over the past 70 years, many of our mosquito control tools are starting to lose effectiveness around the world.


The WHO warns:

Insecticide resistance already widespread

Resistance is known to affect all major malaria vector species and all four recommended classes of insecticides. Since 2010, a total of 60 countries have reported resistance to at least one class of insecticide, with a total of 49 of those countries reporting resistance to two or more classes. However, our understanding of the extent of the problem is incomplete, because:

• many countries do not carry out adequate routine monitoring for insecticide resistance in local vectors; and
• monitoring data are often not reported in a timely manner.

A 2014 PLoS One Study Insecticide Resistance Status of United States Populations of Aedes albopictus and Mechanisms Involved noted some pockets of mosquitoes resistant to DDT and malathion in both Florida and New Jersey.  They wrote:

This study showed standard larvicides and pyrethroids used for mosquito control are still effective against USA populations of Ae. albopictus, but it also demonstrates the importance of research on insecticide resistance and the constant need to develop new tools, new insecticides, and innovative strategies to prevent the development of insecticide resistance in these critical vectors of human diseases. 

And in 2010, in From the `Nature Bats Last’ Dept we looked at reports that one of our most effective mosquito repellents - DEET, or N,N-Diethyl-m-toluamide  (a name that, for some reason, never really caught on with the public) - may be losing some effectiveness.  A story I followed up with in 2013 with PLoS One: Mosquitoes Less Deterred By DEET After Previous Exposure. 


All signs that  - with a growing array of mosquito-borne threats in the wings - we can't afford to take the mosquito threat lightly anymore.  Not even in places that have been considered `safe' from these types of diseases for decades.

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HK CHP Notified Of 2 H7N9 Cases In Guangdong Province

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Between inconsistent reporting by various provinces, and little identifying information on the cases that are announced, keeping track of H7N9 cases in China gets harder every day. It is a mind numbing task that Sharon Sanders has thankfully taken on, and you can access FluTracker's extensively linked and annotated H7N9 case list here.

Today Hong Kong's CHP received notification of 2 additional recent H7N9 cases in neighboring Guangdong Province.

Other than their locations (Jieyang & Zhongshan), no other information (age, gender, onset dates, exposure, etc.) is provided. Omissions that make keeping track of these cases, and matching them to other (similarly sparse) reports, all the more difficult.


As with H5N1 in Egypt, confidence in the accuracy and timeliness of avian flu reporting by the  Chinese government has declined significantly over the past year.  Guangdong province, likely due to its proximity to, and trade relations with Hong Kong, tends to be more open to reporting human cases than some of the other provinces. 


This report from Hong Kong's CHP.

CHP notified of two additional human cases of avian influenza A(H7N9) in Guangdong     

 
The Centre for Health Protection (CHP) of the Department of Health (DH) was today (January 14) notified of two additional human cases of avian influenza A(H7N9) in Guangdong, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the Health and Family Planning Commission of Guangdong Province, the two patients in Jieyang and Zhongshan were hospitalised for treatment in stable condition.

"H5 and H7N9 avian influenza viruses can cause severe infections in humans. Due to the seasonal pattern, our risk assessment shows that the activity of avian influenza viruses is expected to increase in winter months. Increased numbers of human H5N6 and H7N9 cases have been recorded in the Mainland since this winter. Locally, birds positive for H5N6 were also detected this winter. The public, particularly poultry traders, travellers and those who may visit the Mainland in the coming Lunar New Year, should be highly alert. Do not visit poultry markets and farms. Avoid poultry contact. We will continue to monitor the regional and global disease situation," a spokesman for the CHP said.

From 2013 to date, 680 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities.

The DH's Port Health Office conducts health surveillance measures at all boundary control points. Thermal imaging systems are in place for body temperature checks on inbound travellers. Suspected cases will be immediately referred to public hospitals for follow-up.

The display of posters and broadcast of health messages in departure and arrival halls as health education for travellers is under way. The travel industry and other stakeholders are regularly updated on the latest information.

Travellers, especially those returning from avian influenza-affected areas with fever or respiratory symptoms, should immediately wear masks, seek medical attention and reveal their travel history to doctors. Health-care professionals should pay special attention to patients who might have had contact with poultry, birds or their droppings in affected areas.

(Continue . . .)

The actual (translated) notice published by Guangdong Province lumps several previously reported H5N6 and H7N9 cases into their report.   But as of yesterday, only 1 H7N9 case had been reported in Guangdong province in 2016.

Guangdong H7N9, H5N6 epidemic reporting (January 14)

2016-01-14 16:19:57   Ministry of Health and Family Planning Commission  

2016 The first two weeks (January 7 to January 14 10:00) province reports new H7N9 cases, two cases, current address, respectively Jieyang City and Zhongshan. New H5N6 cases one case, the Shenzhen report. Up to now, the province reported a total of 2016 H7N9 cases, 3 cases, 1 death; H5N6 cases, 2 cases.

Experts judged : the province H7N9, H5N6 sporadic cases, January-February period of as much; the popular features and pathogenic biological characteristics have not changed, does not have human transmission conditions, the public need not panic too much. 

Experts advise : the epidemic season, the people (especially the elderly, children, pregnant women, there is the basis of low population immunity disease patients) should as far as possible not to have the sale of live poultry farmer's market. Reducing unnecessary people in close contact with live poultry may be effective in preventing human infection with H7N9, H5N6 flu.

Prevention and control of H7N9, H5N6 flu, to achieve the "three to three not" want to wash their hands: after contact with poultry, wash hands before meals and after. To cook: poultry and eggs should be cooked before eating. To early treatment: If fever, cough, headache, general malaise and other respiratory symptoms, we should as soon as possible to the nearest medical institution for treatment. If contact with poultry before, to take the initiative to tell the doctor. Do not eat dead poultry. Do not buy from unknown sources poultry products.

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WHO: Current Ebola Outbreak Over In Liberia - West Africa At Zero

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While warning that additional flare-ups are likely - setbacks we've already seen twice this year  in Liberia - the World Health Organization has cautiously announced the end of 42 days in Liberia without a new Ebola case. 

This is a milestone used to indicate the end of active chains of Ebola transmission - and with Guinea and Sierra Leone both beyond their 42 day watch periods -  all of West Africa is now considered to be at zero transmission. 

The caveat being that the Ebola virus undoubtedly still exists in the environment and we've ample evidence that some recovered Ebola patients can still carry, and shed, the Ebola virus for months despite being `cured'.

• In ECDC On Ebola Persistence & Rapid Risk Assessment, we looked at the unexpected relapse of Scottish nurse Pauline Cafferkey, nine months after her recovery from the the virus
• In WHO: Study Shows Ebola Virus Fragments May Be Detectable In Semen For > 9 Months, we saw additional evidence of the long-term presence of the Ebolavirus in male semen, and last May (see MMWR & WHO On Risks Of Sexual Transmission Of Ebola) we saw evidence of the sexual transmission of the virus.

All of which makes `staying at zero' a daunting task and far from assured.   This from WHO. 

Latest Ebola outbreak over in Liberia; West Africa is at zero, but new flare-ups are likely to occur

News release
 

14 January 2016 | Liberia - Today, WHO declares the end of the most recent outbreak of Ebola virus disease in Liberia and says all known chains of transmission have been stopped in West Africa. But the Organization says the job is not over, more flare-ups are expected and that strong surveillance and response systems will be critical in the months to come.

Liberia was first declared free of Ebola transmission in May 2015, but the virus was re-introduced twice since then, with the latest flare-up in November. Today’s announcement comes 42 days (two 21-day incubation cycles of the virus) after the last confirmed patient in Liberia tested negative for the disease 2 times.

All 3 countries at zero

“WHO commends Liberia’s government and people on their effective response to this recent re-emergence of Ebola,” says Dr Alex Gasasira, WHO Representative in Liberia. “The rapid cessation of the flare-up is a concrete demonstration of the government’s strengthened capacity to manage disease outbreaks. WHO will continue to support Liberia in its effort to prevent, detect and respond to suspected cases.”

This date marks the first time since the start of the epidemic 2 years ago that all 3 of the hardest-hit countries—Guinea, Liberia and Sierra Leone—have reported 0 cases for at least 42 days. Sierra Leone was declared free of Ebola transmission on 7 November 2015 and Guinea on 29 December.

“Detecting and breaking every chain of transmission has been a monumental achievement,” says Dr Margaret Chan, WHO Director-General. “So much was needed and so much was accomplished by national authorities, heroic health workers, civil society, local and international organizations and generous partners. But our work is not done and vigilance is necessary to prevent new outbreaks.”

Vigilence needs to be maintained

WHO cautions that the 3 countries remain at high risk of additional small outbreaks of Ebola, like the most recent one in Liberia. To date, 10 such flare-ups have been identified that were not part of the original outbreak, and are likely the result of the virus persisting in survivors even after recovery. Evidence shows that the virus disappears relatively quickly from survivors, but can remain in the semen of a small number of male survivors for as long as 1 year, and in rare instances, be transmitted to intimate partners. 

“We are now at a critical period in the Ebola epidemic as we move from managing cases and patients to managing the residual risk of new infections,” says Dr Bruce Aylward, WHO’s Special Representative for the Ebola Response. “The risk of re-introduction of infection is diminishing as the virus gradually clears from the survivor population, but we still anticipate more flare-ups and must be prepared for them. A massive effort is underway to ensure robust prevention, surveillance and response capacity across all three countries by the end of March.” 

WHO and partners are working with the Governments of Guinea, Liberia and Sierra Leone to help ensure that survivors have access to medical and psychosocial care and screening for persistent virus, as well as counselling and education to help them reintegrate into family and community life, reduce stigma and minimize the risk of Ebola virus transmission.

The Ebola epidemic claimed the lives of more than 11 300 people and infected over 28 500. The disease wrought devastation to families, communities and the health and economic systems of all 3 countries.

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