Saudi MOH: Two Asymptomatic MERS Cases With Camel Contact

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Two days ago the Saudi MOH reported a symptomatic MERS case in Jeddah, a primary case linked to camel contact.   Today they report two asymptomatic cases - also linked to camel exposure - in Alkhumra (which appears to be Al-Khumra, a sub district of Jeddah). 

These two cases were detected due to the enhanced surveillance conducted in the wake of yesterday's announcement that Camels Test Positive For MERS-CoV In Jeddah Market. 

Today they've also added a new graphic (camel contact) to their daily report. 

While asymptomatic MERS cases have been documented for several years - usually discovered during the process of contact tracing - the Saudis haven't been particularly aggressive in testing anyone without severe symptoms, and so many have gone undetected.


Last September, we saw the WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS  chastise the Saudi Response to MERS in unusually blunt terms, specifically mentioning their handling (or lack thereof) 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. 

The role (and incidence) of `mild’ or asymptomatic carriage and transmission of the virus remains unresolved, although the lack of identifiable exposures among many primary cases at least suggests that they may play a part in the spreading of the virus. 

In  WHO Guidance On The Management Of Asymptomatic MERS Cases, the World Health Organization strongly urges that asymptomatic PCR-positive MERS cases be isolated, and their contacts be monitored as well.

Today's announcement may be a sign the Saudi MOH is taking the WHO's advice to heart. 

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Thailand Reports 2nd Imported MERS Case From Oman

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In a report that is strikingly similar to one we saw last summer, overnight (US time) Thailand's Ministry of Health announced the detection of a second imported MERS case, and as before, it comes from an Omani businessman seeking medical care after going undiagnosed after being hospitalized at home.

According to the MOH Statement (which doesn't translate particularly well), the patient is a 71 y.o. who flew to Thailand on January 22nd after a week of being hospitalized in Oman with a fever and cough, but without improvement. 

It appears the hospital in Thailand quickly determined the patient's MERS positive status, and placed him in isolation, and he has been transferred to an infectious disease hospital.  In his travels, and before he could be tested and isolated in Thailand, the patient had contact with a number of people.


The Bangkok Post reports:

The Public Health Ministry is looking for people who had contact with the patient. They included a relative who accompanied the patient, 218 crew and passengers who are still in Thailand, one taxi driver, a hotel employee, and 30 hospital staff.

These people will be kept under close surveillance for 14 days. Of them, 37 are categorised as high-risk. They are the patient's relative, 23 air passengers, the taxi driver, the hotel employee, and 11 hospital staff.

Those with a high risk will also be quarantined.

All of this raises questions (again) over the diligence or ability of hospitals in the Middle East - which arguably should be aggressively looking for MERS cases -  to detect and isolate cases, and makes the low case counts they report to the WHO suspect.

 
Oman reported its most recent MERS case three weeks ago (see Oman: MOH Announces 7th MERS Case), which was the first new case since May of last year (excluding the exported case to Thailand last June).

Also last May, two truck drivers transporting camels from Oman to the UAE were found to be asymptomatically infected (see WHO: Asymptomatic MERS-CoV Case – UAE).

In November of 2013, we looked at a study published in The Lancet Infectious Diseases, that attempted to quantify the likely extent of transmission of the MERS virus in the Middle East. (Middle East respiratory syndrome coronavirus: quantification of the extent of the epidemic, surveillance biases, and transmissibility).

They calculated  that for every case identified, there were likely 5 to 10 that went undetected.

The assumption is that most of these are mildly symptomatic patients, not ill enough to be hospitalized and tested. But when you consider that of the 9 MERS cases known to have originated from Oman - two were hospitalized and released without diagnosis - their `capture rate'  is less than enviable.

This is also a reminder that MERS (and avian flu, Ebola, Lassa fever, etc.) can turn up at any hospital's front door, anywhere in the world, without warning.  

Which is why every health care facility – large and small - needs to plan, train and equip themselves for the possibility that the next patient that comes through the ER entrance could be carrying something considerably more exotic than the flu.

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Media: Camels Test Positive For MERS-CoV In Jeddah Market

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The Saudi MOH website isn't responding this morning, but the MOH did post an update on twitter this morning (see above) indicating that no new MERS cases have been recorded since yesterday's two `camel-contact' cases. 

The Arabic media, however, is filled with numerous reports that the 58 y.o. male from Jeddah (reported yesterday) was a butcher working in a camel market, and that his infection has prompted testing of camels at his facility.   

The translations are murky (one returns `in one of the ten heads of camels out of 20 head examined', while another `eleven straight camels out of 20 straight screened.').  Whatever the actual number of positive tests, it was sufficient to prompt the MOH and MOA to halt the movement of camels to markets in Jeddah. 
 

Representative of the media coverage, this is from http://alhadathonline.org/

"Corona" prohibit the movement of camels in Jeddah 

The Ministry of agriculture has banned movement of camels and camel market in the winery in Jeddah against the background of positive results from the Ministry of health on a butchers in Jeddah "SK".

 

Undersecretary of the Ministry of agriculture livestock Dr. Hamad bin Abdulaziz Al-albetshan, the results of laboratory tests by the Ministry of Agriculture allocated by specialized veterinary teams stood on the camel market in the winery in Jeddah on Friday showed positive results of Middle East respiratory syndrome "SK Mirs" eleven straight camels out of 20 straight screened.

 

Said Dr. albetshan: Veterinary teams specialized applied all necessary actions to complete investigating the source of infection, and all precautionary measures to prevent the transmission of disease in coordination with the relevant government authorities (health, Jeddah, police) which includes the prohibition of movement of camels from the market while making sure they are free of disease and isolate virus detachment until the camel stops virus excretion, and sensitize contacts should take preventive measures to reduce transmission, in addition to clearing all camel pens inside the market in coordination with the administration of the cattle market.

The idea that camels – a beloved national symbol that literally made settlement of that arid region possible – could carry a disease deadly to humans, has been a difficult public health message to `sell' in Saudi Arabia. 

A concept made even harder to accept due to the widespread belief in the healthful effects of camel’s milk and urine in the treatment of disease.

But the camel-MERS connection has been recognized since the summer of 2013 (see Lancet: Camels Found With Antibodies To MERS-CoV-Like Virus), and since then we’ve seen numerous studies that demonstrate not only prior infection, but active shedding of the MERS virus from dromedary camels (see EID Journal: Replication & Shedding Of MERS-CoV In Inoculated Camels).

After months of inaction – and sometimes outright denial - in May of 2014 the Saudi Ministry Of Agriculture Finally Issued Warnings On Camels, urging breeders and owners to limit their contact with camels, and to use PPEs (masks, gloves, protective clothing) when in close contact with their animals.

Compliance with these recommendations has been limited, with considerable backlash from camel owners, who have even threatened legal action (see Saudi Camel Owners Threaten Over MERS `Slander’).


While camels are likely responsible for only a fraction of the human infections in Saudi Arabia (most are human-to-human), they continue to `seed' the virus into the human population, thereby setting off new rounds of human-to-human transmission.

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APHIS Updates HPAI Response Plan

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Primarily of interest to poultry producers, and those called upon to respond to avian flu outbreaks, the USDA's APHIS has released an update to their response plan they released last September (see AP HIS: Fall 2015 HPAI Preparedness & Response Plan).

Although the anticipated return of HPAI H5 hasn't happened yet, an entirely new HPAI virus (H7N8) did appear, resulting in the culling of 400K birds across 10 Indiana poultry farms.

And as `avian flu season' runs into early summer, there are plenty of opportunities for seeing additional outbreaks in the months ahead.

USDA Issues Updates to Highly Pathogenic Avian Influenza Fall Plan

Published: Jan 22, 2016

 

January 22, 2016 – The U.S. Department of Agriculture’s (USDA) Animal and Plant Health Inspection Service (APHIS) today issued updates to its Highly Pathogenic Avian Influenza (HPAI) Fall Plan.  The updates include additional detail around reimbursement for any virus elimination activities and the results from an August 2015 industry survey on preparedness. APHIS has also finalized its vaccination policy, which was previously released as a draft policy.  These updates will help APHIS, states, industry and producers to be even better prepared to address the HPAI virus if it returns this winter or spring.

In the original fall plan, released in September 2015, APHIS outlined its intent to use a flat rate reimbursement for virus elimination activities (cleaning, disinfecting) on infected properties.  However, the details were still being finalized.  The updated plan provides greater detail about how flat rate reimbursement will work.  APHIS will provide a flat rate to the producer, based upon the type of facility and the number of birds in the flock.  The flat rates are based upon averages and lessons learned during the spring outbreak.  They cover the cost of barn preparation, dry cleaning and heat disinfection.  The flat rates are:

• Turkey $3.55 / bird
• Layer $6.45/ bird
• Broiler $1.15 / bird (This is an estimate based on industry averages because no broiler flocks were affected in the previous outbreak)

The producer will be able to use the funds provided to do the work themselves or to hire an outside contractor.  They can also use the flat rate money to help fund alternate effective virus elimination methods after consultation with APHIS representatives.

The survey on industry preparedness was in progress when the original version of the plan was published, so APHIS is including the results in today’s update.  The survey found that the poultry industry has made important efforts in implementing preparedness and response capabilities for future HPAI cases.  However, APHIS is recommending some additional actions, such as increasing the use of premises IDs and having these entered in APHIS’ emergency database, which would greatly facilitate response activities.

The original fall plan included a draft vaccination policy, which has since been updated and finalized over the past several months to clarify a few points. The policy updates include:

• Clarifying that while USDA will cover the cost of purchasing vaccine, it will not incur the costs associated with administering the vaccine.
• Clarifying that should USDA decide to vaccinate, there may be justification for not vaccinating certain commercial subpopulations within an area, such as short-lived birds (broilers, ducks) or primary breeders that are under high biosecurity or compartmentalization
• Clarifying that surveillance testing for layer flocks would be through serological testing of vaccinates and dead bird surveillance using rRT-PCR followed by confirmatory testing at NVSL.

The changes APHIS made to the HPAI fall plan are important and support continued preparation for any future HPAI outbreak that might occur.

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CDC MMWR Early Release: Zika Spread & Possible Association With Microcephaly

Credit MMWR

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Coming off a 2pm embargo, the CDC has published two Early Release MMWR reports on the rapidly emerging Zika virus; one on the potential link between Zika and Microcephalic birth defects and the other on the rapid spread of the virus to new regions around the world.

Due to their combined length, I've only presented the link, a short description, and the summary for each MMWR report.  

Follow the link to read each in its entirety.

Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015

JANUARY 22, 2016

An outbreak of Zika virus infection was first recognized in northeastern Brazil in early 2015. By September, a sharp increase in microcephaly cases was reported from affected areas. The Brazil Ministry of Health developed a case definition for Zika virus–related microcephaly, and established a task force and a registry to investigate Zika virus–related cases of microcephaly and to describe the clinical characteristics of cases.

Summary

What is already known about this topic?

 An outbreak of Zika virus infection, a flavivirus transmitted by Aedes mosquitoes, was first recognized in northeastern Brazil in early 2015. In September, a sharp increase in the number of reported cases of microcephaly was reported in areas affected by the outbreak.

What is added by this report?
The Brazil Ministry of Health developed a case definition for Zika virus–related microcephaly (head circumference ≥2 standard deviations [SD] below the mean for sex and gestational age at birth). A task force and registry were established to investigate Zika virus–related cases of microcephaly and to describe the clinical characteristics of cases. Among the first 35 cases of microcephaly reported to the registry, 74% of mothers reported a rash illness during pregnancy, 71% of infants had severe microcephaly (>3 SD below the mean), approximately half had at least one neurologic abnormality, and among 27 who had neuroimaging studies, all were abnormal. Cerebrospinal fluid from all infants is being tested for Zika virus; results are not currently available.

What are the implications for public health practice?
The increased occurrence of microcephaly associated with cerebral damage characteristically seen in congenital infections in Zika virus-affected areas is suggestive of a possible relationship. Additional studies are warranted to confirm the association and to more fully characterize the phenotype. In addition to removing potential breeding areas for mosquitoes, pregnant women in Zika-affected areas should wear protective clothing, apply a U.S. Environmental Protection Agency (EPA)-approved insect repellent, and sleep in a screened room or under a mosquito net.

Zika Virus Spreads to New Areas — Region of the Americas, May 2015–January 2016
 
JANUARY 22, 2016
 
In May 2015, the World Health Organization reported the first local transmission of Zika virus in the Americas, with autochthonous cases identified in Brazil. In December, the Ministry of Health estimated that 440,000–1,300,000 suspected cases of Zika virus disease had occurred in Brazil in 2015

Summary

What is already known on this topic?

Zika virus is a mosquito-borne flavivirus transmitted primarily by Aedes aegypti mosquitoes. Most infections are asymptomatic, and symptomatic disease generally is mild. In May 2015, the first local transmission of Zika virus in the Region of the Americas was reported in Brazil. Following the spread of Zika virus in Brazil, there has been a marked reported increase in the number of infants born with microcephaly; it is not known how many of these cases are associated with Zika virus infection.

What is added by this report?

By mid-January 2016, local Zika virus transmission had been reported to the Pan American Health Organization from 20 countries or territories in the Region of the Americas; spread to other countries in the region is likely. Although local transmission of Zika virus has not been documented in the continental United States, infections have been reported among travelers visiting or returning to the United States, and  these likely will increase. Imported cases might result in local transmission in limited areas of the continental United States.

What are the implications for public health practice?

The best way to prevent Zika virus infection is to avoid mosquito bites by avoiding exposure and eliminating mosquito breeding areas. Until more is known, pregnant women should consider postponing travel to any area with ongoing Zika virus transmission. Health care providers should contact their state or local health department about testing patients with symptoms of Zika virus infection and a compatible travel history.

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CDC Expands Zika Travel Advisory Country List

Credit PAHO - Epi Wk 2

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Seven days ago the CDC issued a Level-II travel advisory for 14 countries and territories over the Zika Virus threat, and warned that list would likely grow. Two days ago, in PAHO: Zika Marches On, we looked at an updated list of affected countries from the Pan American Health Organization, which had increased to 20 nations and territories.

Today the CDC has released a statement adding Barbados, Bolivia, Ecuador, Guadeloupe, Saint Martin, Guyana, Cape Verde, and Samoa to the list. 

Given the speed with which this virus is spreading, it seems likely this list will continue to expand in the weeks ahead.

CDC adds countries to interim travel guidance related to Zika virus

Media Statement

For Immediate Release: Friday, January 22, 2016Contact: Media Relations, (404) 639-3286

CDC is working with other public health officials to monitor for ongoing Zika virus‎ transmission. Today, CDC added the following destinations to the Zika virus travel alerts:  Barbados, Bolivia, Ecuador, Guadeloupe, Saint Martin, Guyana, Cape Verde, and Samoa.  On January 15, CDC issued a travel alert (Level 2-Practice Enhanced Precautions) for people traveling to regions and certain countries where Zika virus transmission is ongoing: the Commonwealth of Puerto Rico, a U.S. territory; Brazil; Colombia; El Salvador; French Guiana; Guatemala; Haiti; Honduras; Martinique; Mexico; Panama; Paraguay; Suriname; and Venezuela. 

Specific areas where Zika virus transmission is ongoing are often difficult to determine and are likely to continue to change over time.

As more information becomes available, CDC travel alerts will be updated. Travelers to areas where cases of Zika virus infection have been recently confirmed are at risk of being infected with the Zika virus. Travelers to these areas may also be at risk of being infected with dengue or chikungunya viruses. Mosquitoes that spread Zika, chikungunya, and dengue are aggressive daytime biters, prefer to bite people, and live indoors and outdoors near people. 
There is no vaccine or medicine available for Zika virus. The best way to avoid Zika virus infection is to prevent mosquito bites.

Some travelers to areas with ongoing Zika virus transmission will become infected while traveling but will not become sick until they return home. Symptoms include fever, rash, joint pain, and red eyes. Other commonly reported symptoms include muscle pain, headache, and pain behind the eyes. The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon and case fatality is low. 

Travelers to these areas should monitor for symptoms or illness upon return. If they become ill, they should tell their healthcare professional where they have traveled and when.

Until more is known, and out of an abundance of caution, CDC continues to recommend that pregnant women and women trying to become pregnant take the following precautions:

• Pregnant women in any trimester should consider postponing travel to the areas where Zika virus transmission is ongoing. Pregnant women who must travel to one of these areas should talk to their doctor or other healthcare professional first and strictly follow steps to avoid mosquito bites during the trip.
• Women trying to become pregnant should consult with their healthcare professional before traveling to these areas and strictly follow steps to prevent mosquito bites during the trip. 

Guillain-Barré syndrome (GBS) has been reported in patients with probable Zika virus infection in French Polynesia and Brazil. Research efforts will also examine the link between Zika and GBS.

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