WHO Update: Guillain-Barre Syndrome (GBS) In Columbia & Venezuela

Credit CDC

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On Monday, in Guillain-Barre syndrome: The Other Zika Concern, we looked at growing  evidence that Zika virus infection might - in rare instances -  provoke an autoimmune disease called Guillain-Barre Syndrome that can present with muscle weakness and even paralysis.

I wrote about the first sign that Zika might be capable of such a thing nearly two years ago in Zika, Dengue & Unusual Rates Of Guillain Barre Syndrome In French Polynesia. In March 2014 the journal Eurosurveillance carried a Rapid Communications describing the first case and reporting a 20-fold increase in GBS during their Zika outbreak.

While a handful of cases of GBS have been linked to Dengue and Chikungunya, neither have been viewed as a strong risk factor. But once again we seem to be seeing an increase in Guillain-Barre Syndrome in countries (Brazil, El Salvador, Columbia, and Venezuela) where the Zika virus is currently circulating. 


While a Zika-GBS link has yet to be fully established, the evidence seems to grow stronger with each passing day.  This update on recent surges in GBS in South America comes from the World Health Organization.

Guillain-Barré syndrome – Colombia and Venezuela

Disease Outbreak News
12 February 2016 

Between 30 January and 2 February 2016, the National IHR Focal Points of Colombia and Venezuela informed PAHO/WHO of increases in the number of Guillain-Barre Syndrome (GBS) cases recorded at the national level.

Colombia

From epidemiological week (EW) 51 of 2015 to EW 3 of 2016, 86 GBS cases were reported. On average, Colombia registers 242 GBS cases per year or approximately 19 cases per month or 5 cases per week. The 86 GBS cases reported in those 5 weeks is three times higher than the averaged expected cases of the 6 previous years.

Initial reports indicated that all the 86 reported GBS cases presented with symptoms compatible with a Zika virus infection. Of the 58 cases for which information is available, 57% were male and 94.8% were 18 years old or older.

Venezuela

From 1 January to 31 January 2016, 252 GBS cases with a spatiotemporal association to Zika virus were reported. While cases were recorded in the majority of the federal territories of the country, 66 were detected in the state of Zulia, mainly in the Maracaibo municipality.

Preliminary analysis of the GBS cases in the state of Zulia indicates that the 66 cases originated from six municipalities. Of the 66 cases, 30% were 45 to 54 years old and 29% were 65 years or older; 61% were male and 39% were female. A clinical history consistent with Zika virus infection was observed in the days prior to onset of neurological symptoms in 76% of the GBS cases in the state of Zulia. Associated comorbidities were present in 65% of the cases. Patients were treated with plasmapheresis and/or immunoglobulin. In some cases, according to medical indication, both treatments were used following the treatment protocol established by the Ministry of Popular Power for Health.

Zika virus infection was confirmed by polymerase chain reaction in three GBS cases, including a fatal case with no comorbidities. A total of three cases presenting with other neurological disorders were also biologically confirmed. 

Between late November to 28 January 2016, 192 cases of Zika virus infection were laboratory confirmed through reverse transcription polymerase chain reaction. Of the 192 cases, 110 (57%) are from the state of Zulia.

WHO risk assessment

Zika virus infection has been laboratory confirmed in only three of the reported GBS cases from Venezuela, while the infection has not been detected in any of the GBS cases from Colombia. Although the cause of the rise in GBS cases has not yet been established, similar increases have been observed in other countries, notably El Salvador and Brazil (see DONs published on 21 January and 8 February 2016, respectively). Further investigations are needed to identify the potential role of previous infections known to be associated, or potentially associated, with GBS.

WHO recommends Member States affected or susceptible to Zika virus outbreaks to:

• monitor the incidence and trends of neurological disorders, especially GBS, to identify variations against their expected baseline values;
• develop and implement sufficient patient management protocols to manage the additional burden on health care facilities generated by a sudden increase in patients with Guillain-Barre Syndrome;
• raise awareness among health care workers and establish and/or strengthen links between public health services and clinicians in the public and private sectors.

(Continue . . .)

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EID Journal: Zika Virus Detection in Semen

Credit CDC PHIL

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Although there was only one case on record at the time (from 2008 see Probable Non–Vector-borne Transmission of Zika Virus, Colorado, USA), in late January the UK PHE Warned On Potential Sexual Transmission Of Zika strongly recommending that:

Sexual transmission of Zika virus has been recorded in a limited number of cases, and the risk of sexual transmission of Zika virus is thought to be very low. However, if a female partner is at risk of getting pregnant, or is already pregnant, condom use is advised for a male traveller :

• for 28 days after his return from a Zika transmission area if he had no symptoms of unexplained fever and rash
  
• for 6 months following recovery if a clinical illness compatible with Zika virus infection or laboratory confirmed Zika virus infection was reported

Less than a week later, a second case was confirmed (see Dallas, Texas: DCHHS Confirms Locally Acquired Sexually Transmitted Zika Infection), and soon other public health agencies were issuing similar advice.

Today we may know what prompted the UK's initial strong recommendations. 

A letter, published ahead of print today in the CDC's EID journal, describes the detection of ZIKV by rRT-PCR in a 68 year old man's semen by the UK's PHE in 2014, more than 2 months after the onset of his illness.


While live virus was not cultured from the sample, it suggests that sexual transmission may be possible weeks or even months after initial infection.  Not unlike what we've seen (albeit, very rarely) with Ebola.


While the persistence of ZIKV in semen for weeks or months increases the risks of sexual transmission, the mosquito-vector remains the primary way the virus is transmitted to humans.

Volume 22, Number 5—May 2016

Letter

Detection of Zika Virus in Semen

Atkinson B, Hearn P, Afrough B, Lumley S, Carter D, Aarons EJ, et al.

To the Editor: As an increasing number of autochthonous Zika virus (ZIKV) infections are reported from several South America countries (1), we read with interest the report from Musso et al. on the potential sexual transmission of ZIKV (2). We report additional evidence for this potential route of transmission after identification of an imported case of ZIKV infection into the United Kingdom.

After an outbreak alert for ZIKV in French Polynesia, active ZIKV screening was implemented at Public Health England (Porton Down, United Kingdom). In 2014, a 68-year-old man had onset of fever, marked lethargy, and an erythematous rash 1 week after returning from the Cook Islands. Serum samples taken 3 days into the febrile illness tested negative for dengue and chikungunya viruses by real-time reverse transcription PCR (rRT-PCR). Test results for dengue virus IgM and chikungunya virus IgM also were negative; a test result for dengue virus IgG was indeterminate.

An rRT-PCR test result for ZIKV (3) was positive and indicated a crossing threshold value of 35 cycles. This low viral load, commonly observed even in the acute phase of disease (3), meant that attempts to obtain sequence data were unsuccessful. 

Convalescent-phase serum, urine, and semen samples were requested; only semen was positive for ZIKV by rRT-PCR, , at 27 and 62 days after onset of febrile illness. These results demonstrated stronger signals than those obtained in tests of the original serum sample, with crossing threshold values of 29 and 33 cycles, respectively. ZIKV-specific plaque reduction neutralization test results were positive on convalescent-phase serum samples.

Although we did not culture infectious virus from semen, our data may indicate prolonged presence of virus in semen, which in turn could indicate a prolonged potential for sexual transmission of this flavivirus. Moreover, these findings could inform decisions regarding what control methods are implemented and which specimen types are best suited for diagnostic detection.

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WHO: Updated Information For Travelers Visting Zika Affected Countries

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The World Health Organization has updated their travel information, once again emphasizing that WHO is not recommending any travel or trade restrictions related to Zika virus disease.

The remainder of their advice, when compared to that which we've seen issued by many other public health agencies, comes across as noticeably less urgent in tone.

While the CDC strongly urges pregnant women avoid travel to Zika prone areas, the WHO advises pregnant women consult their health care provider first, and `consider delaying travel'. 

Information for travellers visiting Zika affected countries

Updated

12 February 2016 

Travellers should stay informed about Zika virus and other mosquito-borne diseases and consult their local health or travel authorities if they are concerned.

Based on available evidence, WHO is not recommending any travel or trade restrictions related to Zika virus disease. Countries reporting sporadic Zika infections in travellers arriving from affected countries pose little, if any, risk of onward transmission.

As a precautionary measure, some national governments may make public health and travel recommendations to their own populations, based on their assessment of the available evidence and local risk factors.

Precautionary measures for pregnant women and women considering pregnancy

Based on the latest evidence that Zika virus infection during pregnancy may be linked to microcephaly in newborns, WHO is issuing further precautionary travel advice to women who are pregnant and their sexual partners.

Women who are pregnant should discuss their travel plans with their health care provider and consider delaying travel to any area where locally acquired Zika infection is occurring. 

Zika virus is spread by mosquitoes, and not by person-to-person contact, though a small number of cases of sexual transmission have been documented.

Zika has been found in human semen. Two reports have described cases where Zika has been transmitted from one person to another through sexual contact. 

Until more is known about the risk of sexual transmission, all men and women returning from an area where Zika is circulating - especially pregnant women and their partners - should practice safe sex, including through the correct and consistent use of condoms.

All travellers, including pregnant women, going to an area where locally acquired Zika infection is occurring should adhere closely to steps that can prevent mosquito bites during the trip. These include:

• using insect repellent: repellents may be applied to exposed skin or to clothing, and should contain DEET. Repellents must be used in strict accordance with the label instructions;
• wearing clothes (preferably light-coloured) that cover as much of the body as possible;
• using physical barriers such as screens, closed doors and windows;
• sleeping under mosquito nets, especially during the day, when Aedes mosquitoes are most active; and
• identifying and eliminating potential mosquito breeding sites, by emptying, cleaning or covering containers that can hold even small amounts of water, such as buckets, vases, flower pots and tyres.

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Saudi MOH Reports 2 MERS Cases

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After going 8 days without reporting any MERS cases, the Saudi MOH announces two today, one of which (M,34, Najran) has already died.  The second case (M,41, Al-Kharj) is listed in stable condition.

The likely exposure of the fatal case is still under investigation, but the Al Kharj case is listed as a Household Contact - Indirect Contact with Camel. It is likely this person is connected to the 47 y.o. male with camel contact from Al-Kharj reported on January 27th.
 

In what is hopefully part of an ongoing trend, Saudi Arabia has now gone more than four months without reporting a large hospital-related MERS outbreak. The last one of any size was in Riyadh last summer.  

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WHO: Press Conference On Zika Research With Dr Marie-Paule Kieny (Audio)

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The WHO's Dr Marie-Paule Kieny held a press conference this morning in Geneva on the plans to develop pharmaceuticals and diagnostics for the Zika virus. During this 35 minute presser Dr. Kieny also fielded a wide variety of reporter's questions on the evidence of links between Zika and Microcephaly and GBS, as well as the evolution of the virus.

Dr. Kieny stressed that while a number of firms are researching a vaccine, it will likely be  18 months before widespread trials can begin.  There are hopes that a prophylactic treatment - as exists for malaria - could be developed sooner. 

Vector control is another issue the WHO is looking at, and they find that biological approaches like Wolbachia (see A Mosquito STD To Fight Dengue) or genetically modified mosquitoes (see Brave New Mosquito) to be promising avenues of research. 


As to the time to establish a link between Zika and Microcephaly and GBS, Dr. Kieny spoke in terms of a `few weeks to a few months'. There is a relatively large cohort of pregnant women in Columbia with Zika exposure whose births will be monitored, and we should have better answers in the next month or so.


You'll find Dr. Kieny's prepared remarks below (via email), but you'll glean far more from the 35 minute audio file.

Dr Kieny was speaking at a press conference in Geneva today 12 February 2016


The audio file of her press conference can be found:

Direct link: http://terrance.who.int/mediacentre/presser/WHO-RUSH_Zika_research_presser_KIENYm_UNOG_12FEB2016.mp3

Good morning:

As you know, our relatively poor knowledge of the Zika virus presents a series of challenges for R&D.  However, I am pleased to say that, based on our experience with R&D during the West Africa Ebola epidemic, WHO’s R&D response is proceeding very quickly for Zika.

After Ebola, WHO began to draw up a master plan for R&D to both prepare for health emergencies and to be able to mount a fast R&D response in case of need.  The R&D Blueprint – as the initiative is called – aims to accelerate the availability of medical countermeasures during epidemics and limit damage as much as possible.  We now have established critical paths for coordinated action, and industry interest in providing platform technologies for the development of medical products.

We have already identified a large number of manufacturers and research institutions either involved in the development of medical tools for Zika, or interested in embarking on such research.

Apart from what has already appeared in the press, numerous other groups are looking at the feasibility of initiating animal or human testing, particularly for vaccines and diagnostics.

For vaccines:

• The landscape is evolving very rapidly and numbers change daily.  About 15 companies/groups have been identified so far, most have only just started work.
• Two vaccine candidates seem to be more advanced: a DNA vaccine from the US National Institutes for Health, and an inactivated product from Bharat Biotech, in India.
• The current absence of standardized animal models and reagents is slowing down development.

In spite of this encouraging landscape, vaccines are at least 18 months away from large-scale trials. 

For Diagnostics:

• 10 biotech companies have been identified so far that can provide nucleic acid or serological tests.  Nucleic acid tests are based on a molecular technique used to detect a virus in the blood; serological tests measure the levels of antibodies as a result of exposure to a particular virus
• 10 other companies are at various stages of development.
• It is important to point out, however, that none of these tests have been independently validated and none have regulatory approval.
• The biggest task in the area of diagnostics will probably be to ensure an adequate reference method is used by manufacturers when generating their data, so that the performance of the various Zika diagnostics can be tested through an independent assessment. This will help prevent the distribution of poor quality or fake Zika tests that are sure to come up rapidly – as was the case with Ebola. 

Laboratory based Zika diagnostics (mostly non-commercial) are already playing an important role to better understand this outbreak, however, new validated and broadly available diagnostics are urgently needed to step up research, clinical management and surveillance. Although it is difficult to predict the time for the first commercial and independently validated tests to be available, we are talking weeks and not years.

WHO will continue working on landscape analyses for diagnostics and vaccines, as well as therapeutics, and innovative vector control measures.  These analyses will be published on our web site in the next two weeks.

Immediately after, we will convene independent experts to gauge which of these products seem the most promising as they move to the testing phase.

At the same time, WHO is developing what is called “target product profiles” for these medical tools – for example, what may be the best characteristics for a vaccine to immunize women of child-bearing age?

In terms of diagnostics, we need to understand which type of product – nucleic acid, serologic, rapid test, etc. – will best serve our purposes.  We should have target product profiles ready in the next weeks.

In the area of therapeutics, studies are being carried out on medicines and other therapies that could prevent infection in vulnerable groups, especially pregnant women, as is done for malaria.   This seems for the moment a more viable and faster option than a curative treatment.

For vector control, innovative methods seem promising options – biological approaches for example, such as the controlled release of bacteria to prevent viral replication in mosquitoes; or genetic approaches, such as the release of genetically modified mosquitoes to reduce the mosquito population.

In terms of what happens afterwards, when potential products reach an advanced stage of testing and show promising data: we have in place the WHO Emergency Assessment and Listing procedure for the use of experimental products during an epidemic.  This accelerated assessment process was established during the Ebola epidemic and aims to ensure that products meet acceptable levels of quality, safety and efficacy – even if evaluation is fast-tracked - before they are rolled out in countries.

We will also provide support to countries wishing to register proven products to compress the time it takes to carry out ethical and regulatory reviews, so that these tools become available rapidly.
 
Thank you 

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Kisah Semut dan Belalang

Seekor semut yang pikirannya tersusun dalam rencana teratur, sedang mencari-cari madu ketika seekor capung hinggap menghisap madu dari bunga itu. Capung itu melesat pergi untuk kemudian datang kembali.

Kali ini Si Semut berkata,
“Kau ini hidup tanpa usaha, dan kau tak punya rencana. Karena kau tak punya tujuan nyata ataupun kira-kira, apa pula ciri utama hidupmu dan kapan pula berakhir?”
Kata Si Capung,
“Aku bahagia, dan aku mencari kesenangan, ini jelas ada dan nyata. Tujuanku adalah tanpa tujuan. Kau boleh merencanakan sekehendakmu; kau tak bisa meyakinkanku bahwa ada yang lebih berharga daripada yang kulakukan ini. Kaulaksanakan saja rencanamu, dan aku rencanaku.”
Semut berpikir,
“Yang tampak padaku ternyata tak tampak olehnya. Ia tahu apa yang terjadi pada semut. Aku tahu apa yang terjadi pada capung. Ia laksanakan rencananya, aku laksanakan rencanaku.”
Dan semutpun berlalu, sebab ia telah memberikan teguran sebaik-baiknya dalam masalah itu.
Beberapa waktu sesudah itu, mereka pun bertemu lagi.
Si Semut menemukan kedai tukang daging, dan ia berdiri di bawah meja tumpuan daging dengan bijaksana, menunggu saja apa yang mungkin datang padanya.
Si Capung, yang melihat daging merah dari atas, menukik dan hinggap diatasnya. Pada saat itu pula, parang tukang daging berayun dan membelah capung itu menjadi dua.
Separoh tubuhnya jatuh di lantai dekat kaki semut itu. Sambil menangkap bangkai itu dan mulai menyeretnya ke sarang, semut itu berkata kepada dirinya sendiri.
“Rencananya tamat sudah, dan rencanaku terus berjalan. Ia laksanakan rencananya -sudah berakhir, Aku laksanakan rencanaku -mulai berputar. Kebanggaan tampaknya penting, nyatanya hanya sementara. Hidup memakan, berakhir dengan dimakan. Ketika aku katakan hal ini, yang mungkin dipikirkannya adalah bahwa aku suka merusak kesenangan orang lain.”
Catatan
Kisah yang hampir serupa ditemukan juga dalam karya Attar, Kitab Ketuhanan, meskipun penerapannya agak berbeda. Versi ini dikisahkan oleh seorang darwis Bokhara dekat makam Al-Syah, yakni Bahaudin Naqsibandi, enam puluh tahun yang lalu. Sumbernya adalah buku catatan seorang Sufi yang disimpan dalam Masjid Agung di Jalalabad.

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RESEP ES GABUS BUSA HUNKWE ENAK BERLAPIS

Resep Es Gabus - Sering disebut juga Es Busa merupakan varian jajanan warung atau jajanan sekolah yang populer di masanya bahkan masih diminati hingga sekarang. Olahan dari tepung hunkwe ini rasanya memang sangat enak dan segar, sepintas keras karena es beku tetapi lembut dan empuk atau bertektur seperti gabus atau busa saat digigit. Aneka rasa pada masing-masing warna semakin memikat sehingga untuk dijual pun bisa diandalkan.

Cara membuat es gabus memang cukup mudah dibuat sendiri di rumah, tetapi sensasinya sangat dapat memuaskan penikmatnya. Bentuk dan tekstur serta lapisan warna-warninya seperti kue lapis sebelum dibekukan, tetapi setelah dibekukan empuk dan krenyesnya sering juga disebut sebagai es kue, es lapis, es roti, hingga es pelangi karena tampilan aneka warnanya yang menarik.

Selain variasi warna, es busa gabus juga biasa diolah dengan aneka rasa lainnya, seperti coklat, pandan, variasi buah, mutiara maupun kacang hijau dan lain sebagainya. Jajanan es ini sering dipasangan dengan es mambo, salah satunya bisa dilihat pada Resep Es Mambo Coklat.

Persiapan Bahan Bikin Es Gabus Busa

• 150 gram tepung hunkwe
• 250 gram gula pasir
• 1200 ml santan dari 1 butir kelapa
• 1 sdt garam
• 1 sdm pasta mangga atau sesuai selera

Cara Membuat Es Gabus (Es Busa)

1. Pertama-tama kita bagi terlebih dahulu bahan-bahan es gabus menjadi 2 bagian, atau bisa disesuaikan dengan berapa lapisan yang diinginkan. Untuk masing-masing lapisan, siapkan mangkuk atau wadah lalu campur dan aduk rata tepung hunkwe beserta sedikit saja santan sekedar untuk melarutkan.
2. Sementara itu setelah bahan dibagi, kita awali dengan lapisan pertama. Panaskan santan, gula dan garam untuk warna putih (tambahkan pasta atau pewarna kue untuk warna lainnya) sambil diaduk rata hingga mendidih, baru kemudian masukkan larutan hunkwe tadi. Aduk terus hingga mengental, lalu matikan api dan tuang adonan ke dalam loyang serta ratakan.
3. Lanjutkan membuat lapisan berikutnya dengan cara yang sama, kemudian tuang ke loyang di atas adonan pertama serta ratakan. Diamkan adonan hingga dingin terlebih dahulu, setelah cukup dingin keluarkan dari loyang dan potong-potong.
4. Bungkus dengan palstik dan lipat, simpan dalam freezer semalam atau hingga beku dan mengeras. Es gabus atau es busa telah siap untuk disantap dingin.

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