WHO SEARO Statement On Thailand's Imported MERS Case

MERS Exported Cases As of October 2015 - Credit ECDC

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While MERS activity has been on the decline the past few months, last summer in Our Global Game Of Whac-A-MERS we looked at the ongoing threat of seeing MERS infected travelers arriving unannounced anywhere in the world.  

As the ECDC map above illustrates, while MERS cases have all originated from the Arabian peninsula, its prolonged (up to 15 day) incubation period allows those exposed ample time to board a plane and unknowingly transport the virus globally (see Why Airport Screening Can’t Stop MERS, Ebola or Avian Flu).

In Korea, a single introduction last May led to 185 additional infections, and 36 deaths, spread across a dozen or more medical facilities.  By contrast, the following month a single infected traveler arrived in Thailand, and was quickly diagnosed and isolated, preventing further spread.

Once again Thailand is dealing with an imported MERS case (see yesterday's Thailand Reports 2nd Imported MERS Case From Oman), and while it is too soon to know if they have contained the threat, they appear to have acted quickly once again.

First a statement from WHO SEARO (South-East-Asia Regional Office), then I'll be back with a bit more on containing the spread of MERS.

Thailand confirms MERS CoV in traveler, WHO cautions against continued risk of importation

SEAR/PR/1618

New Delhi, 24 January 2016: Thailand today confirmed Middle East respiratory syndrome coronavirus (MERS CoV) disease in a traveler, the second such case in the country in the last seven months, as WHO cautioned other member states in its South-East Asia Region against the continuing risks and the need to remain vigilant.

“The new case of MERS CoV is a reminder of the continued risk of importation of the disease from countries where it still persists. All countries need to further enhance surveillance for severe acute respiratory infections, focus on early diagnosis, and step up infection prevention and control procedures in health-care facilities to rapidly detect any case of importation and effectively prevent its spread,” Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region, said.

A 71-year -old national from Oman, who arrived in Bangkok, Thailand for treatment on 22 January, and was admitted to a private hospital, tested positive for MERS CoV. He has since been transferred to the Bamrasnaradura Infectious Disease Institute. Measures are being taken to trace all those who could have been in his contact during his journey to Thailand, and within Bangkok.

This is the second MERS CoV case in Thailand and in the WHO South-East Asia Region. Earlier, on 18 June 2015 another Omani national who arrived in Bangkok for treatment, was tested positive for MERS CoV.

In the recent past, countries in the WHO South-East Asia Region have been reviewing and strengthening preparedness to respond to MERS CoV.

WHO has been strongly advocating for strengthening health systems and ensuring strict infection control measures are in place in countries to respond to infectious diseases such as MERS CoV.

In the Region, WHO is supporting Ministries of Health to build capacities and strengthen preparedness as required under the International Health Regulations (2005) to effectively detect and respond to outbreaks and other hazards.

MERS CoV is caused by a virus. Typical symptoms include fever, cough and shortness of breath. Pneumonia is common, but not always present. Gastrointestinal symptoms, including diarrhea, have also been reported.

Due to the risks of seeing imported MERS, Ebola, or Avian flu cases, last summer TFAH Issue Brief: Preparing The United States For MERS-CoV & Other Emerging Infections, looked at the steps that governments, healthcare facilities, and public health departments around the world need to take in order to prepare for the arrival of MERS and other Emerging infections.


While most imported MERS cases around the world have been quickly identified and isolated, in Eurosurveillance: Estimating The Odds Of Secondary/Tertiary Cases From An Imported MERS Case, we looked at modeling that put the odds of seeing at least one secondary case derived from an imported MERS case at 22.7%, while the odds of seeing at least one tertiary case is 10.5%.  

Based on their models they calculated the odds of seeing at least 8 cases as the result of a single importation at a non-trivial 10.9%.

 
Reason enough to take calls for better surveillance, diagnosis, and infection control for MERS (and other emerging infectious diseases) seriously.

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PAHO Statement On Zika Transmission & Prevention

Epi Week 3 - Credit PAHO

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On December 1st, 2015 PAHO (the Pan American Health Organization) issued its first epidemiological alert on the Zika virus (see  Neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas – Epidemiological Alert).

At the that time, only 9 nations in the Americas had reported local transmission of the virus; Chile (on Easter Island), Colombia, El Salvador, Guatemala, Mexico, Paraguay, Suriname, and Venezuela.

Seven weeks later, that number has climbed to 22 nations, and the virus seems poised to spread to wherever the Aedes mosquito is present. 

While most people experience a mild, self-limiting illness - a concurrent rise in microcephalic birth defects in Brazil and neurological disorders like Guillain-Barre Syndrome in El Salvador and French Polynesia, have scientists frantically looking for a link.

Ten days ago the CDC issued a Level-II travel advisory to affected regions, and last week we saw a detailed CDC MMWR Early Release: Zika Spread & Possible Association With Microcephaly outlining what we know - and don't know - about this viral threat.

 
Below you'll find PAHO's most recent statement on the Zika Virus, and their interim recommendations.

PAHO Statement on Zika Virus Transmission and Prevention

24 January 2016

Zika is a mosquito-borne virus that is new to the Americas. Since Brazil reported the first cases of local transmission of the virus in May 2015, it has spread to 21 countries and territories* of the Americas (as of 23 January 2016).

There are two main reasons for the virus's rapid spread: (1) the population of the Americas had not previously been exposed to Zika and therefore lacks immunity, and (2) Aedes mosquitoes—the main vector for Zika transmission—are present in all the region's countries except Canada and continental Chile.

PAHO anticipates that Zika virus will continue to spread and will likely reach all countries and territories of the region where Aedes mosquitoes are found.

The most effective forms of prevention are (1) reducing mosquito populations by eliminating their potential breeding sites, especially containers and other items (such as discarded tires) that can collect water in and around households; and (2) using personal protection measures to prevent mosquito bites (see also recommendations below).

The role of Aedes mosquitoes in transmitting Zika is documented and well understood, while evidence about other transmission routes is limited. Zika has been isolated in human semen, and one case of possible person-to-person sexual transmission has been described. However, more evidence is needed to confirm whether sexual contact is a means of Zika transmission.

Zika can be transmitted through blood, but this an infrequent mechanism. Standard precautions that are already in place for ensuring safe blood donations and transfusions should be followed.

Evidence on mother-to-child transmission of Zika during pregnancy or childbirth is also limited. Research is currently under way to generate more evidence regarding perinatal transmission and to better understand how the virus affects babies.

There is currently no evidence that Zika can be transmitted to babies through breast milk. Mothers in areas with Zika circulation should follow PAHO/WHO recommendations on breastfeeding (exclusive breastfeeding for the first 6 months, followed by continued breastfeeding with complementary foods up to 2 years or beyond).

Other PAHO recommendations:

To prevent or slow the spread of Zika virus and reduce its impact, PAHO recommends the following:

• Mosquito populations should be reduced and controlled by eliminating breeding sites. Containers that can hold even small amounts of water where mosquitoes can breed, such as buckets, flower pots or tires, should be emptied, cleaned or covered to prevent mosquitoes from breeding in them. This will also help to control dengue and chikungunya, which are also transmitted by Aedes mosquitoes. Other measures include using larvicide to treat standing waters.
• All people living in or visiting areas with Aedes mosquitoes should protect themselves from mosquito bites by using insect repellent; wearing clothes (preferably light-colored) that cover as much of the body as possible; using physical barriers such as screens, closed doors and windows; and sleeping under mosquito nets, especially during the day when Aedes mosquitoes are most active.
• Pregnant women should be especially careful to avoid mosquito bites. Although Zika typically causes only mild symptoms, outbreaks in Brazil have coincided with a marked increase in microcephaly—or unusually small head size—in newborns. Women planning to travel to areas where Zika is circulating should consult a healthcare provider before traveling and upon return. Women who believe they have been exposed to Zika virus should consult with their healthcare provider for close monitoring of their pregnancy. Any decision to defer pregnancy is an individual one between a woman, her partner and her healthcare provider.

PAHO is working with its member countries to strengthen vector-control, communicate the risks of Zika and promote prevention, and establish or improve surveillance of both Zika virus infections and suspected complications, such as microcephaly, Guillain-Barre syndrome, and other autoimmune and neurological disorders.
* Barbados, Bolivia, Brazil, Colombia, the Dominican Republic, Ecuador, El Salvador, French Guiana, Guatemala, Guadeloupe, Guyana, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Puerto Rico, Saint Martin, Suriname and Venezuela.

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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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