Wednesday, February 21, 2018

Nigeria's Lassa Fever Outbreak - Epi Week 7

Credit CDC


Lassa fever is a Viral Hemorrhagic Fever (VHF) endemic to a handful of West African nations - commonly carried by multimammate rats - a local rodent that often likes to enter human dwellings. 
Exposure is typically through the urine or dried feces of infected rodents, and roughly 80% who are infected only experience mild symptoms.
The incubation period runs from 10 days to 3 weeks, and the overall mortality rate is believed to be in the 1%-2% range, although it runs much higher (15%-20%) among those sick enough to be hospitalized.

Although endemic in West Africa, between 2013 and early 2016 Nigeria had seen a steady decline in the number of Lassa Fever cases  - and deaths - with the last significant outbreak reported in 2012.
But in early 2016 that trend began to change with outbreaks starting in Nigeria (see Nigeria: Lassa Fever Outbreak With 40 Fatalities), and then flaring up in both Benin and Togo (see ECDC: Rapid Risk Assessment On Lassa Fever In Nigeria, Benin, Togo, Germany & USA).
Exported cases turned up in Germany and Sweden (see Germany's RKI Statement On Lassa Fever Cluster In Cologne & WHO Lassa Fever Update - Sweden (Imported)). Although Lassa reports in Nigeria eventually slowed, by December of 2016 they were on the rise again, and were fairly consistent through 2017 (see chart below).

Beginning in early January of 2018 those numbers began to increase markedly again (see chart below).

 Some excerpts from the latest (week 7) Epidemiological report from the Nigerian CDC:
  •  In the reporting Week 07 (February 12-18,2018) sixty eight new confirmediI cases were recorded from seven States Edo (35), Ondo (19), Bauchi (1), Ebonyi (7), Anambra (4), Imo(1) and FCT (1) with four new deaths in confirmed cases from two states Ondo (2), and Bauchi (2)
  • From 1st January to 18th February 2018, a total of 913 suspected cases, and 73 deaths have been reported from 17 activeiv States- (Edo, Ondo, Bauchi, Nasarawa, Ebonyi, Anambra, Benue, Kogi, Imo, Plateau, Lagos, Taraba, Delta, Osun, Rivers, FCT, and Gombe) - Figure 1
  • Since the onset of the 2018, 277 cases have been classified as: 272 confirmed cases, 5 probable cases with 59 deaths (54 in Lab confirmed and 5 in probable) -Table 1
  • Case Fatality Rate in confirmed and probable cases is 21%
  •  Fourteen Health Care workers have been affected in six states –Ebonyi (7), Nasarawa (1), Kogi (1), Benue (1), Ondo (1) and Edo (3) with four deaths in Ebonyi (3) and Kogi (1)
  • Predominant age group affected is age group 30-50 (Median Age = 32) - Figure 4
  • The male to female ratio for confirmed cases is 2:1
  •  74% of all confirmed cases are from Edo (45%) and Ondo (29%) states
  •  National RRT team (NCDC staff and NFELTP residents) batch A replaced with batch B to continue response support in Ebonyi, Ondo and Edo States
  • Irrua Specialist Hospital has 39 cases on admission this weekend. FMC Owo has 29 isolation beds, all occupied.
  • A total of 2351 contacts have been identified from 17 active states and 1747 are currently being followed up
  •  Joint NCDC and WHO team on high level visit to Edo, Ondo and Ebonyi states
  • NCDC is collaborating with ALIMA and MSF in Edo, Ondo and Anambra States to support case management
  •  NCDC deployed teams to four Benin Republic border states (Kebbi, Kwara, Niger and Oyo) for enhanced surveillance activities
  • National Lassa fever multi-partner multi-agency Emergency Operations Centre(EOC) continues to coordinate the response activities at all levels
(Continue . . . )

Like many other hemorrhagic fevers, person-to-person transmission may occur with exposure to the blood, tissue, secretions, or excretions of an individual, although the CDC reassures:
Casual contact (including skin-to-skin contact without exchange of body fluids) does not spread Lassa virus. Person-to-person transmission is common in health care settings (called nosocomial transmission) where proper personal protective equipment (PPE) is not available or not used. Lassa virus may be spread in contaminated medical equipment, such as reused needles.
While likely to remain primarily a localized public health threat, we've seen exported cases before, and in 2016 the ECDC offered the following advice to travelers to the region.
Advice to travellers
Travellers to West Africa should be informed of the risk of exposure to Lassa fever virus, particularly in areas currently experiencing outbreaks. The risk is higher in rural areas where living conditions are basic.

Travellers should avoid consumption of foods and drink contaminated by rodent droppings, exposure to rodents or to patients presenting with haemorrhagic fever.

People travelling to these regions to provide care should be aware of the risk of exposure and should apply appropriate personal protective measures.

Saudi MOH Reports 2 MERS Cases


The Saudi MOH has updated their MERS surveillance page today announcing 2 new cases, but for some reason the standard graphics (map & chart) are not available in the English language report, and so I've lifted the graphic (above) from the Arabic version.
No report was filed at all for the 18th, while a `zero cases' report was posted for the 19th
So far, we've seen just 8 days reported during the month of February, with at least two cases announced on the Arabic page that were never posted on the English site, and several recoveries that were never announced as having been infected.
Exactly what is behind this recent erratic reporting, and discrepancies, remains a mystery. 

Details on today's two cases  (one from Riyadh & 1 from Taif) follow:

FEMA PREPTalks: John M. Barry On `The Next Pandemic: Lessons from History"


Historian and author John M. Barry - whose seminal work is The Great Influenza: The Epic Story of the Deadliest Plague in History (pub. 2004)has rightfully become the most coveted speaker in the world when it comes to pandemic history, and planning. 
He is a tremendous speaker, whom we've seen often, but most recently as a featured presenter last November in Smithsonian Livestream: “The Next Pandemic: Are We Prepared?"
With 2018 being the 100th anniversary of the 1918 pandemic (and the 50th anniversary of the 1968 H3N2 pandemic), I'm certain he has a very busy year of speaking engagements ahead.

But last week, Barry was at George Washington University, speaking in front of a room full of emergency managers in Washington D.C. on the challenges we will face with the next pandemic, and the lessons we can take from 1918.
The main video presentation runs about 19 minutes, but a second video of audience Q & A from last week's event can be found on another page (see below).

Even if you've read his book, seen him speak, or think you've already heard everything there is to hear about the 1918 pandemic, you owe it to yourself to take 30 minutes out of your day to watch these two videos.

And after that, pass the links on to your friends.

Tuesday, February 20, 2018

WHO EMRO MERS-CoV Report - Jan 2018


Although daily reporting from the Saudi MOH has faltered badly this month (see Saudi MOH Reports 2 MERS Cases), with reports issued for only 6 of the past 22 days (see list  below) - last month, before reporting fell off a cliff - we saw a quadrupling of cases over what had been reported in December.

The World Health Organization's EMRO (Eastern Mediterranean Office) issues a monthly summary - usually about mid-way through the month - on the previous month's MERS activity in KSA, and the Middle East.
While these monthly reports are chock full of data, and graphs, and can help us peer into the murky MERS situation in KSA, sometimes even their numbers are difficult to reconcile. 
First  we'll look at January's report, and then compared it to December's.

Click to Enlarge

MERS situation update, January 2018

  • At the end of January 2018, a total of 2160 laboratory-confirmed cases of Middle East respiratory syndrome (MERS), including 773 associated deaths (case–fatality rate: 35.8%) were reported globally; the majority of these cases were reported from Saudi Arabia (1786 laboratory-confirmed cases, including 699 related deaths with a case–fatality rate of 39.1%).
  • During the month of January, 25 laboratory-confirmed cases of MERS were reported in Saudi Arabia including 8 associated deaths. A nosocomial outbreak of MERS occurred in a private hospital in Hafr Albatin region, the date of onset of the first case was 23 January 2018; while on 4 February 2018, three asymptomatic healthcare workers were reported through contact tracing.
  • The demographic and epidemiological characteristics of the cases reported in January 2018 do not show any significant di erence compared with cases reported during the same period from 2012 to 2017. Owing to improved infection prevention and control practices in the hospitals, the number of hospital-acquired cases of MERS has dropped significantly in 2015, 2016 and 2017 compared to previous years.
  • The age group of those aged 50–59 years continues to be the group at highest risk for acquiring infection as primary cases. For secondary cases, it is the age group of 30–39 years who are mostly at risk. The number of deaths is higher in the age group of 50–59 years for primary cases and 70–79 years for secondary cases.

While the reported numbers for January are 25 new cases and 8 deaths, when you look at the ending numbers for December (see excerpt below) we find a jump of 33 cases, and 16 deaths.
At the end of December 2017, a total of 2127 laboratory-confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV), including 757 associated deaths (case–fatality rate: 35.6%) were reported globally; the majority of these cases were reported from Saudi Arabia (1753 laboratory-confirmed cases, including 683 related deaths with a case–fatality rate of 38.9%).
As to what accounts for these discrepancies? 

The most likely cause is that previously unidentified cases (or deaths) may turn up after  delayed or retrospective lab testing, get added to the total, yet are never detailed. We saw this happen in 2014 (see Saudi MOH: Review Finds 19 `Historical’ MERS Cases Prior to June 2014) and it likely still occurs. 
Additionally - asymptomatic cases - who are tested as contacts of known cases, may not be immediately identified and may account for some back filling of data.
While it would be nice to be able say with some degree of accuracy how many MERS cases have occurred in the Middle East - or around the world - the simple fact is that surveillance probably only picks up a fraction of the cases (see EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016).
Even with the best of outbreak surveillance and reporting, there's always a bit of `fog' to deal with.
The big question, with the recent erratic reporting from the Saudi MOH, is how much visibility we're going to have going forward.

Hong Kong's Post-Holiday Flu Surge

Credit HK CHP


After a month of very high (mostly influenza B) flu numbers, and the forced closure of all of Hong Kong's schools a week early for the Lunar New Year Holiday, we were beginning to see some subtle signs that their flu epidemic might have peaked, with Friday's average Hospital Occupancy rate and A&E Attendance numbers (see graphic below) unexpectedly having dropped sharply over a period of just a few days.

A 93% occupancy rate is a bit surprising because only 4 days earlier, I blogged about Hong Kong's Hospital Occupancy Rates Rising, with the average occupancy rate reaching  117%. 

Given the importance of the Lunar New Year Holiday in Asia, I suspect a lot of patients may have checked out of the hospital late last week in order to spend it with their families, while others - who maybe should have gone to the hospital - may have put that off until after the New Year.

On Saturday the occupancy rate rose to 97%, on Sunday to 104%, and by Monday was back up to 111%. 
Today's numbers show the average occupancy rate to have reached 119%, with Pok Oi Hospital in the New Territories West dealing with a whopping 138% occupancy rate.  That's an impressive average jump of 26% since Friday.

Some of this sudden rise could also be due to a spike in influenza transmission, propelled  by the traditional large family gatherings, travel, and celebrations, that are part and parcel to the Chinese New Year's celebration. 
With an incubation period of 2 - 4 days, the timing is about right.
Today's South China Morning Post carries the following headline, with a the dismal expectation that this winter's flu epidemic could last until late May.

Hospitals see rush of patients amid flu surge and end of Lunar New Year break, resulting in waits of over eight hours
There remains a desperate need for flu vaccines across the city, with the winter flu peak season expected to last until the end of May 
PUBLISHED : Tuesday, 20 February, 2018, 3:05pm

Although Hong Kong and China have been reporting primarily influenza B this winter, both H1N1 and H3N2 are in the mix as well.  Today Hong Kong's CHP reports on a severe pediatric H1N1 case, in a child who arrived from the Mainland last week.

     The Centre for Health Protection (CHP) of the Department of Health is today (February 20) investigating a case of severe paediatric influenza A infection.
     A 7-year-old boy, who lives in the Mainland and has had good past health, travelled to Hong Kong on February 15 and presented with fever, cough and muscle pain since February 18. He developed seizures the next day and was admitted to Queen Mary Hospital. His nasopharyngeal aspirate tested positive for influenza A (H1) virus upon laboratory testing. The clinical diagnosis was influenza A infection complicated with encephalopathy. He is now in a stable condition.
     Initial enquiries revealed that the patient had not received seasonal influenza vaccination for the current season. His home contacts and travel collaterals are asymptomatic so far. Investigations are ongoing.
     Meanwhile, in view of the continuous high level of seasonal influenza activity locally and the end of the Lunar New Year holiday for schools soon, the CHP today issued letters to schools to appeal for heightened vigilance and reinforcement of preventive measures to mitigate the impact of seasonal influenza.

(Continue . . . )

Most Kong Kong schools remain closed for the Lunar New Year's holiday, but are expected to resume classes on Monday, 26 February.

We'll get the next Hong Kong Flu Express on Thursday, which should tell us more about the post-holiday impact of this year's flu season.

Monday, February 19, 2018

Saudi MOH Reports 2 MERS Cases


The Saudi MOH continues to only intermittently update their MERS-CoV surveillance and reporting page, with an update overnight dated the 17th, announcing 1 new MERS cases (74,F) from Rafhaa listed with `indirect camel contact'.
While `Direct camel contact' is fairly self-explanatory, indirect camel exposure has been defined as: Having visited settings where animals were kept but without having direct contact; or exposure to household members who themselves had direct animal exposure.
This definition covers a lot of possibilities, including asymptomatic transmission from a household member.

For reasons that remain unclear, the Saudi MOH has become increasingly sporadic in updating their surveillance page.   Previously, and for the past 5 years or so, the MOH has issued updates daily even when no cases, recoveries, or deaths were announced.

On this 19th day of February, the MOH has only posted 5 daily updates announcing 2 cases for the month, on their  English language portal.

But there's more.

The Arabic language list shows three more additional daily updates during February, with two containing cases not mentioned on the English side; one on the 9th, and another on the 16th

This latest case makes the second report for today.  
Unfortunately, being posted in a .jpg format, machine translation software won't work for these entries.  Both appear to be from in or around Riyadh, the most recent one with recent camel contact and the other without. 
While the Saudi MOH is under not obligation to publish these reports, they have been greatly appreciated, and their loss - like the cancellation of their Weekly MERS Monitor back in 2016 - would be sorely missed.