Monday, March 27, 2017

ECDC: Rapid Risk Assessment On Multi-Country Cluster Of MDR-TB In Migrants


Whether it is a tourist returning from Carnival in Rio, a businessman traveling from the Arabian Peninsula to Asia, or a migrant making their way from North Africa into Europe - they all have one thing in common.

They all have the ability to be exposed to - and then inadvertently carry - exotic infectious diseases (like Zika, MERS, Dengue, Yellow Fever, Avian Flu, TB, etc.) from one part of the world to another.

Last December the ECDC reported on a cluster of MDR-TB among a group of 16 migrants who had recently entered the EU during the first six months of 2016 (see Multidrug-resistant tuberculosis in migrants, multi-country cluster, first update 19 Dec 2016).

An international whole genome sequencing cluster involving 16 cases of multidrug-resistant tuberculosis (MDR TB) in asylum seekers has been detected. The first seven cases were identified in Switzerland between February and August 2016. Their countries of origin are Somalia (5 cases), Eritrea (1) and Ethiopia (1). Whole genome sequencing (WGS) showed no difference among isolates in four cases and differences of one allele in the three others. Based on the WGS results, the strains belong to a single molecular cluster. The same genetic clone with the same and so far unknown drug resistance profile was detected in nine additional cases from Somalia, six of them diagnosed in Germany, two in Austria, and one in Sweden.
Fast forward a little more than 3 months and the ECDC has published an updated RRA, which has now identified 25 cases.  Follow the link to read the full 4-page report.

Conclusions and options for response 

A multi-country cluster of multidrug-resistant tuberculosis (MDR TB) involving 25 migrants has been delineated by whole genome sequencing (WGS). All cases have a recent history of migration from Somalia (22 cases), Eritrea (2 cases) and Ethiopia (1 case). Cases have been reported by Germany (13 cases), Switzerland (8 cases), Austria (2 cases), Finland and Sweden (1 case each). 

A WGS analysis of the 25 cluster isolates supports the hypothesis that the cases are part of a chain of recent transmission likely to have taken place either in the country of origin or in a place along the migration route to the country of destination. Based on the currently available information, it is not possible as of yet to rule out that transmission occurred in an EU/EFTA country. 

It therefore remains important to rapidly investigate exposure risk factors, including the travel history and itineraries of patients and their contacts, and share this information to determine whether transmission may have taken place in the EU/EFTA, during migration, or in the country of origin. Depending on the results of the investigation, appropriate prevention and control measures should be taken. 

Although the number of cases detected so far suggests that there is only a limited risk of this cluster becoming a widespread event in Europe, more cases may yet be identified in association with this cluster. Early case finding of active TB and drug susceptibility testing, especially in newly arriving migrants from the Horn of Africa, is important in order to identify and treat active cases and to provide preventive treatment or monitoring for those diagnosed with latent tuberculosis infection.

Saudi MOH Announces 1 New MERS-CoV case


After a lull of 7 days without reporting a new MERS case, the Saudi MOH today has announced a primary (Direct Camel Contact) case in Al Kharj, in a 54 y.o. male who is listed in stable condition.

There are a total of 10 active cases receiving treatment in Saudi Hospitals.  We've not heard of any new cases in the Wadi Al Dawasir Cluster - which produced at least 10 cases earlier in the month - in nearly two weeks. 

HK Suspends Poultry Imports From Chattooga County, Georgia


Over the weekend we've been watching media reports of poultry testing for avian flu in Northwestern Chattooga county Georgia (see Test Results on Possible Bird Flu Near Menlo Expected Today), adjacent to the Alabama border. 

While there's no official announcement (yet) from state agricultural officials, Hong Kong's CFS (Centre for Food Safety) has apparently already been notified, as evidenced by the following statement issued this morning.

The Centre for Food Safety (CFS) of the Food and Environmental Hygiene Department announced today (March 27) that in view of a notification from the World Organisation for Animal Health (OIE) about an outbreak of low pathogenic H7N9 avian influenza in Pickens County, Alabama in the United States (US), and a notification from the US authorities about an outbreak of low pathogenic H7 avian influenza in Chattooga County, Georgia, the CFS has banned the import of poultry meat and products (including poultry eggs) from the two areas with immediate effect to protect public health in Hong Kong.

Assuming this is confirmed by the USDA and state agricultural officials later today, Georgia will become the 4th state to report this new LPAI H7N9 virus.  

While it shares the same subtype name as China's H7N9 virus - this North American Lineage virus is genetically distinct from its Asian counterpart - and is not currently expected to pose a serious human health threat.

H7 viruses, however - even LPAI strains - have caused minor illnesses in humans in the past (see A Brief History Of H7 Avian Flu Infections and  NYC Health Dept Statement On Human H7N2 Infection), and viruses can change their behavior and virulence over time 

Since it appears that LPAI H7N9 continues to spread in the wild bird population, and may spark additional outbreaks in backyard and commercial poultry this spring, those in contact with live birds should heed the CDC's advice on avoiding infection.

Saturday, March 25, 2017

Tsunami Preparedness Week - 2017


The National Tsunami Hazard Mitigation Program (NTHMP) recognizes  Tsunami Preparedness Week during the last week in March to coincide with the date of the 1964 Great Alaska Earthquake and Tsunamis.
Some states and territories recognize other times of the year, and this year that includes:
While truly massive tsunamis don't happen very often, when they do they can produce extremely high mortality, and extensive property and infrastructure damage.

The two biggest ones in recent history are the 2004 Indian Ocean Tsunami, which killed upwards to 250,000 people, and Japan's 2011 Tōhoku Earthquake/Tsunami which killed in excess of 15,000 people.

While less deadly, Alaska's 1964 earthquake produced significant tsunami effects both locally, and thousands of miles away, killing 5 in Oregon and 13 in California. Chile's 1960 Valdivia earthquake sent a train of tsunamis across the Pacific, causing heavy damage and loss of life in Hawaii, Japan, and beyond (see NOAA Report).

While we think of these disasters as primarily localized events, impacting a few thousand square miles, the photo above shows how our oceans can transfer the released energy from an earthquake, meteor strike, volcanic eruption, or undersea landslide across distances of thousands of miles in the form of a tsunami (or more likely, a series of tsunami waves).

The west coast of North America, since it is vulnerable to tsunamis generated by seismic events in Japan, Alaska, the South Pacific - and even the long expected `big one'  off the Pacific Northwest's coast (see Just A Matter Of Time) - is viewed as the most `at risk' region of the  United States and Canada.

But two years ago, in The Caribbean’s Hidden Tsunami Potential (Revisited), we looked at that region’s history – and potential – for generating tsunamis that could affect the Gulf Coast and Atlantic coastlines of the United States, along with Mexico, Central America, and South America.
  • This past week Tsunami preparedness drills were held for the Caribbean (March 21: Exercise - Caribe Wave (3 scenarios: Costa Rica, Cuba, and Northern Lesser Antilles) and for the Atlantic (March 22: Exercise - Lantex (Off Portugal)).
  • This coming week (March 29th), Exercise - Pacifex (Off British Columbia) will take place.  Last summer, FEMA, the Canadian government, and many other agencies took part in the massive Cascadia Rising 2016 drill, to prepare for the (likely overdue) `big one' striking the Pacific Northwest. 

While you may think it unlikely that a tsunami will affect you or your region - they are just one of many potential hazards that may threaten you and your community - and they all require similar preparedness steps.

Knowing your local threats, whether they be tsunamis, forest fires, floods, earthquakes or hurricanes  . . . and then becoming prepared to deal with them, will provide you and your family the best safety insurance available.

As far as what to do before a tsunami threatens, READY.GOV has a Tsunami Awareness Page with helpful hints. NOAA  provides several useful documents, including a Tsunami Zone PDF (see below) and Tsunami Web page.

Since you can't predict what disaster you might someday have to face, it makes sense to maintain a general level of preparedness against `all threats’.

Everyone needs an appropriate family disaster plan, just as everyone should have a good first aid kit, an Emergency NOAA Weather radio, a `bug-out bag’, and sufficient emergency supplies to last a bare minimum of 72 hours.

As the graphic above from NOAA advises, people should consider maintaining a 2-week supply of supplies in their home. A topic I address in When 72 Hours Isn’t Enough.

As we move into the spring severe storm season, and ultimately back into the Atlantic Hurricane season, now is a good time to review and refresh your emergency preparedness plans.

A couple of my (many) blogs on this subject include:

  • In An Emergency, Who Has Your Back?
  • When Evacuation Is The Better Part Of Valor
  • Friday, March 24, 2017

    OIE Confirms HPAI H7N9 In Hunan Province


    Earlier today, in China MOA: High Mortality In Poultry Infected With H7N9 In Hunan Province, we looked at a report highly suggestive of an HPAI H7N9 outbreak in Hunan Province, China.

    Significant if true, because this would be the first detection of this mutated virus outside of Guangdong province, where it was first reported a little over a month ago.

    This afternoon the OIE has confirmed that assumption with the following notification

    This latest detection of HPAI H7N9 is a little over 300 miles north and west of the first outbreak reported in  Meizhou city, Guangdong province.

    China MOA: High Mortality In Poultry Infected With H7N9 In Hunan Province

    Credit Wikipedia

    UPDATED 1500 hrs: OIE Confirms HPAI H7N9 In Hunan Province


    For nearly four years - since H7N9 first emerged in China in the spring of 2013 - its most unusual feature was its low pathogenicity in birds (LPAI) yet its ability to produce severe, even life threatening illness in humans.

    Unlike the HPAI H5 viruses - which dramatically impact poultry - LPAI has been a `stealth virus' in chickens, geese, and ducks. Often our first sign of trouble comes only after a human in contact with healthy-looking birds falls ill.

    Last month (Feb 18th) China announced the discovery of two patients in Guangdong Province infected with a newly discovered highly pathogenic (HPAI) variant of H7N9 (see Guangdong CDC: Two H7N9 `Variants' Isolated From Human Cases). Additional HPAI samples were isolated in local poultry. 

    The following day, we also saw the Taiwan CDC: January's Imported H7N9 Case Carried HPAI Mutation. All three cases showed signs of antiviral resistance, although it wasn't clear if that developed after they received treatment.

    All HPAI H7N9 reported to date have been in Guangdong province, and so its `fitness' to spread further remains unknown. Although our knowledge of this new mutation is limited, for now we've no evidence that it substantially increases the risk to humans (see ECDC Comment On HPAI Mutation Of H7N9).
    All of which brings us to a report from China's Ministry of Agriculture detailing a recent outbreak of H7N9 in Hunan Province which resulted in observable morbidity and substantial mortality in poultry.

    Both atypical of LPAI H7N9 outbreaks. 

    Today's dispatch opens by stating the importance of following up on the H7N9 influenza virus mutant strains - a pretty good idea of what they are thinking - but it never directly refers to this outbreak as HPAI.  A genetic analysis of the HA gene is required to confirm HPAI - and perhaps they are waiting for that - but this outbreak has all the outward appearances of high path bird flu.

    Hunan province lies adjacent - and to the north and west - of Guangdong province. Hunan province reported 5 human cases last Friday, and 4 human cases today (onsets go back to early March) making it one of the more active regions these past two weeks.

    Any indication that HPAI H7N9 is on the move (possibly via migratory birds) would be an important finding. But whether LPAI or HPAI, the H7N9 virus continues to evolve, and so we must remain ready for surprises. 

    Hopefully we'll get a more definitive report (and genetic analysis) on this outbreak in the days to come (see update).

    Hunan Provincial Department of Agriculture veterinary guidance departments earnestly poultry H7N9 influenza prevention and control
    Date: 2017-03-24 17:58 Author: Source: Ministry of Agriculture Information Office

    For some of the recent detection of H7N9 influenza virus mutant strains, the Ministry of Agriculture attaches great importance to the timely follow-up, on the basis of preliminary work, to guide the local animal husbandry and veterinary departments to further carry out targeted prevention and control work. All in accordance with the requirements of a good grasp of monitoring and emergency treatment, the detection of pathogen positive or the outbreak of the farm households poultry, and resolutely culling and harmless treatment, the timely elimination of risks.

    March 19, Yongzhou City, Hunan Province, Dong'an County Veterinary Department in the monitoring found that some farmers raised breed chickens suspected bird flu symptoms, the incidence of 29,760, only 18,497 died.

    March 20, Hunan Province, animal disease prevention and control center diagnosed as suspected avian influenza epidemic. March 24, by the National Avian Influenza reference laboratory confirmed the outbreak for the H7N9 flu epidemic. After the outbreak of the epidemic, the local start of the plan, in accordance with the technical specifications to prevent the epidemic disposal work, has been culling and harmless treatment of 171179 poultry. At present, the epidemic has been effectively controlled.