Sunday, September 21, 2014

NPM14: Giving Preparedness A Shot In The Arm


Photo Credit PHIL


Note: September is National Preparedness Month, and this is one of a series of new or updated preparedness articles I will be running for the occasion.


# 9098


While it is hard to quantify the absolute risks from any of them, in the nearly 9 years that I’ve been doing this blog, I don’t ever recall seeing as many infectious disease threats on the horizon as I do this fall and winter. 


In addition to the standard onslaught of seasonal flu (which can vary greatly in intensity each year) and our usual host of winter respiratory viruses (RSV, Adenoviruses, Rhinoviruses), we’ve got a rogue enterovirus sweeping across the nation called EV-D68, affecting mostly (but not solely) kids (see CDC EV-D68 Update & FAQ).




Another cause of `flu like’ symptoms, but less common than the winter respiratory viruses, are infection via one the vector borne diseases like West Nile Virus, Dengue and Chikungunya. 

What all of these have in common is that they can initially present as do most viral infections  – like a mild cold or the flu; Fever, malaise, body aches . . . sometimes accompanied by a cough or other respiratory symptoms.

All of which not only makes getting a firm diagnosis from your doctor (other than you’ve picked up `a virus’ ) problematic, it increases your chances of picking up `something’. 


Much, much further down the list of things to be worried about (at least in North America) are imported exotics like H7N9, H5N1, and MERS-CoV. 


Still, they cannot be ruled out completely, as 2 of the 3 have already happened this year (see CDC Statement On 1st H5N1 Case In North America & CDC : 2nd Imported MERS Case Confirmed In Florida), and public health officials continue to watch for additional cases.


With heightened scrutiny over these imported threats (not to mention Ebola), traveling while symptomatic (fever, cough, vomiting) may prove exceedingly difficult this fall.  Many international airports are screening passengers for fever, and showing up at the terminal with `flu-like symptoms’  just might get you bumped from your flight . . . or worse.


Making this year – perhaps more than ever before – a good year to go ahead and get that flu shot early.  


No, the shot won’t protect against any of these exotics.. The vaccine only offers protection against 3 or 4 pre-selected stains of seasonal influenza. Sill, flu is a relatively common severe winter respiratory virus – and claims tens of thousands of lives every year – making it well worth avoiding if at all possible.  


As we’ve discussed before, flu vaccines – while considered very safe – most years only offer a moderate level of protection against influenza. Their VE (vaccine effectiveness) can vary widely between flu shot recipients, and is often substantially reduced among those older than 65 or with immune problems.


In 2011, NFID - the National Foundation for Infectious Diseases - convened a group of experts to address the issues of influenza and the elderly. From that panel a 5-page brief has emerged, called: Understanding the Challenges and Opportunities in Protecting Older Adults from Influenza.


While the elderly generally see less protection from the flu vaccine, they state that older individuals may still mount a robust immune response. Even if the vaccine doesn’t always prevent infection in the elderly, studies suggest that the vaccine may blunt the seriousness of the illness in those over 65.


You might not have thought about it, but getting your seasonal flu shot each year should be part of your overall preparedness plan. During a disaster or prolonged emergency you are likely to be tired, stressed, and your immune systems could be weakened.


The last thing you need during a crisis is to be sick with the flu on top of it.


Which is why I’ve already paid a visit to my local CVS pharmacy and got my yearly seasonal flu shot.  The process (and the shot – nice job, Carol) were painless.


According to the CDC, more than 50 million doses of this year’s flu vaccine have already been distributed, so finding a shot should be no trouble.



September might seem a little early to be getting the flu shot, but we are already seeing scattered reports of influenza around the country, and it takes a couple of weeks after getting the shot for immunity to kick in. 


While the vaccine can’t promise 100% protection, it – along with practicing good flu hygiene (washing hands, covering coughs, & staying home if sick) – remains your best strategy for avoiding the flu (and other viruses) this winter. urges all Americans to follow these 3 steps to better preparedness:





Sage advice. But if you want to be truly prepared, I would add an important 4th step.

Get a shot

Saturday, September 20, 2014

It’s Not Just Ebola


Photo Credit- CDC


# 9097


With its exponential growth, high mortality rate, and potential to escape the confines of West Africa, it is admittedly difficult to get anyone to think beyond the expanding Ebola threat right now. Other emerging threats seemingly pale in comparison, but there is nothing that says we are exempt from being forced to fight a viral battle on more than one front.


It wasn’t but five months ago when the outbreak of MERS-CoV on the Arabian Peninsula was capturing headlines, and three months before that, it was H7N9 in China.


While both have receded as threats over the summer, there is little reason to believe that one, or both, won’t threaten again later this fall and winter.  And they aren’t alone.  Over the past several years we’ve heard plenty of `viral chatter’, from a variety of emerging threats. 


Between 2006 and 2008 the biggest pandemic threat was believed to be H5N1 from Asia, but as it turned out, we were blindsided by a North American origin flu pandemic in the spring of 2009. 


Few could have predicted this; not only did it emerge on the `wrong’ continent, it came from the `wrong’ host (pigs), and was of the `wrong’ subtype (H1N1).


H5N1 continues to circulate, and remains a legitimate pandemic threat, but a dozen years after it re-emerged in Vietnam it has yet `to figure us out’.  For now, it remains primarily a threat to poultry and wild birds.

The H7N9 virus, which emerged suddenly in China 20 months ago, has sparked two winter waves of illness, with the second year’s toll roughly twice that of the first year.  Similar to what we’ve seen over these past several months, the virus all but disappeared during the summer months between the first and second wave.


Two Waves of H7N9  - Credit Hong Kong’s CHP


While we can’t know what this fall holds in store for the H7N9 virus, studies released earlier this year (see EID Journal: H7N9 As A Work In Progress), show that the H7N9 avian virus continues to reassort with local H9N2 viruses, introducing new clades of the virus into China’s poultry population.


Last June, in Eurosurveillance: Genetic Tuning Of Avian H7N9 During Interspecies Transmission, researchers working for China’s National and Provincial CDCs, announced that the genetic diversity of the H7N9 virus was even greater than previously described, and that continual reassortment with the H9N2 virus, along with passage through a variety of host species, appears to be influencing its ongoing evolution.


A process the authors call `genetic tuning’.


Remarkably, out of 146 H7N9 viruses with full genome sequences they examined, they detected at least 26 separate genotypes, mostly from the first wave in 2013. Of those 26, twenty were only detected once or twice, suggesting they were transient, and perhaps not as `biologically fit’ as some of the other genotypes.


The authors wrote:


Overall, due to the genetic tuning procedure, the potential pandemic risk posed by the novel avian influenza A(H7N9) viruses is greater than that of any other known avian influenza viruses. A response to this threat requires the combined effort of different sectors related to human health, poultry and wild birds, as well as vigilance and co-operation of the world.


Influenza viruses, because they are spread via droplets, aerosols, and fomites (contaminated inanimate objects like door handles, coffee pot handles, keyboards) – and because carriers can often be infectious prior to showing symptoms – are the type of  pandemic threats that keep most epidemiologists up at night. 


Last year, in  EID Journal: Predicting Hotspots for Influenza Virus Reassortment, we looked at research that ranked eastern China as one of the globe’s top breeding grounds for new flu strains. 


And indeed, over the past two years we’ve seen the emergence of no less than four new subtypes (H7N9, H10N8, H5N8, H5N6) from this region that pose significant risks to poultry or human health. 


Of course, we are perfectly capable breeding home-grown viruses here in the United States, as we’ve seen one pandemic virus (2009’s H1N1), and a number of swine variant viruses (H1N1v, H1N2v, H3N2v) emerge from pig herds and go on to infect humans (see Keeping Our Eyes On The Prize Pig) over the past decade.


But the close call with SARS in 2003 showed that non-influenza viruses can have `legs’, too.


SARS was a coronavirus, likely with a bat origin, that swept out of China in 2002 and infected nearly 8,000 people worldwide before it was contained. While SARS hasn’t been seen in a decade, a distant cousin – MERS-CoV – appeared in the Middle East in the spring of 2012 and continues to threaten the region, and the world.  



Increasingly bat viruses – including coronaviruses, Nipah, Hendra, and Lyssaviruses (including Rabies) – are viewed as emerging or re-emerging human health threats. As if that weren’t enough, over the past couple of years we’ve also seen two new subtypes of influenza identified in bats (see A New Flu Comes Up To Bat & PLoS Pathogens: New World Bats Harbor Diverse Flu Strains).


All things considered, the past 20 years have been a Chiropterist’s delight.

And of course, to this rogues gallery of pandemic threats you can also add any number of influenza subtypes in the wild (including old pandemic viruses like H2N2 and H3N8), the growing ranks of antibiotic resistant bacteria which could prove every bit as deadly as a pandemic, and Virus X . . .  the one that isn’t on our radar, yet.


The point here is that once Ebola is contained (I remain cautiously optimistic that it will be, but fully expect it to exact a horrendous cost) the threat posed to global public health by these emerging diseases doesn’t go away. If anything, with our growing population and increasing mobility, the threat grows greater with each passing year.


If fact, we will be lucky if another shoe doesn’t drop this winter while our international efforts are focused primarily on West Africa.


Earlier this year, in Influenza Pandemic As A National Security Threat,  we looked at a threats assessment by the Director Of National Intelligence that included:

Worldwide Threats Assessment – published January 29th, 2014,


Health security threats arise unpredictably from at least five sources: 

  • the emergence and spread of new or reemerging microbes;
  • the globalization of travel and the food supply;
  • the rise of drug-resistant pathogens;
  • the acceleration of biological science capabilities and the risk that these capabilities might cause inadvertent or intentional release of pathogens; and
  • adversaries’ acquisition, development, and use of weaponized agents. 


Similarly, last year the UK’s National Risk Registry of Civil Emergencies listed Influenza at their nation’s #1 threat.

The highest priority risks

2.2 The following are considered by the Government to be the highest priority risks of emergency, taking both likelihood and impact into account:

Pandemic influenza – This remains the most significant civil emergency risk. The outbreak of H1N1 influenza in 2009 (‘swine flu’) did not match the severity of the scenario that we plan for and is not necessarily indicative of future pandemic influenzas; the three influenza pandemics of the 20th century (1918–19, 1957–58 and 1968–69) all had differing levels of severity. The 2009 H1N1 pandemic does not change the risk of another pandemic emerging (such as an H5N1 (‘avian flu’) pandemic) or mean that the severity of any future pandemics will be the same as the 2009 H1N1 outbreak.


Somehow we’ve reached the 21st century without truly accepting that a disease threat in one part of the world can quickly become a disease threat for the entire world.  We’ve convinced ourselves that vast oceans, border guards and airport screening, and our modern medical prowess can protect us from the ravages of a pandemic. 


Nearly halfway into this second decade of the 21st century, we still don’t take global (or even local) public health seriously. 


So we continue to gut the budgets of the very organizations and agencies that are on the frontlines, attack disease problems in piecemeal fashion when we can no longer ignore them, and then wonder how a crisis like Ebola can threaten not only Africa, but have repercussions around the world. 


I don’t pretend to know what comes after Ebola.  I only know that something will. 


And unless we get our collective public health acts together, it won’t be pretty.  For more on pandemics, and pandemic planning, you may wish to revisit:


NPM14: Because Pandemics Happen

UK: Updated Pandemic Response Plan & Exercise Cygnus

Pandemic Planning For Business

NPM13: Pandemic Planning Assumptions

The Pandemic Preparedness Messaging Dilemma

Friday, September 19, 2014

Saudi MOH Announces 3rd Recent MERS Case In Taif






The slow uptick in MERS cases reported out of Saudi Arabia over the past 10 days continues today with the announcement of KSA’s 7th case this month – which is also the third case reported from Taif  in the past 7 days. 





NPM14: Your Daily Threats Assessment Briefing


Photo Credit- NOAA Know your Risk


Note: Today is day 19 of National Preparedness Month, and this is one of a series of updated blogs and articles about personal preparedness that I am featuring this month.

# 9095


Every day the President of the United States, along busy CEOs, investors, emergency planners, and public health officials receive specialized Daily Intelligence briefings outlining current or anticipated threats, along with other vital information.


While you may not hold the fate of nations, a billion dollar portfolio, or a fortune 500 company in your hands you do have a need to know your risks if you want you and your family to be prepared for a disaster.


And those risks can, and do, change on a daily basis. Particularly those involving climate and weather.


Fortunately, the Internet makes it easy to create a short list of websites to visit each day (I do so early each morning) that in a few short minutes will give you an early warning of what threats might be expected in the next few days.


Depending where you live, and where your personal interests lie, you will probably want to customize your `daily briefing’.  But to get you started, a quick tour of mine.


Note: I quickly scan these websites for news, alerts, or forecasts of interest for my region.  I certainly don’t attempt to read them in depth each day.


First stop, The National Weather Service’s Daily Briefing - which replaces the recently discontinued NOAAWatch’s Daily Briefing – and provides an excellent overview of the natural threats facing the nation.



My second stop is usually NOAA’s Storm Prediction Center, which looks ahead as far as a week for areas that may expect severe weather.  At a glance I can see when, and where, weather trouble is expected.  This is particularly important during the spring and summer tornado season.


And during hurricane season, I also swing by the National Hurricane Center website each morning (and if there is an active storm, several times each day).


Although the sun remains unusually quiet, I also swing by or NOAA’s SPACE WEATHER PREDICTION CENTER for the latest on solar activity. 


And last, but not least, I visit the FEMA Blog to see what they are keeping an eye on.


During the day and overnight, I rely on NOAA WEATHER RADIO (NWR) and Twitter to follow @FEMA, @NHC_Atlantic, @NOAA and @CraigAtFEMA for real-time emergency alerts.


Like having an emergency kit and a first aid kit - having a weather radio is an important part of being prepared.


Of course, just knowing about the threats isn’t enough. You have to make use of that information.


To learn how to prepare as an individual, family, business owner, or community I would invite you to visit the following sites and use THIS LINK to access some of my recent preparedness blogs.





While some people lie awake at night worrying about disasters, I’ve discovered that being prepared is the key to sleeping well.

Preparing is easy.

It’s worrying that’s hard.

Guinea: Ebola Health Team Members Killed By Villagers



# 9094



Details continue to emerge on the horrific slaying of (reports range from 7 to 9) members of an Ebola health team this week in Wome - a small village near Nzerekore in the southern part of Guinea - with this latest report from the BBC.


19 September 2014 Last updated at 04:58 ET

Ebola outbreak: Guinea health team killed

Nine members of a team trying to raise awareness about Ebola have been killed by villagers using machetes and clubs in Guinea, officials say.

Some of the bodies - of health workers, local officials and journalists - were found in a septic tank in a village school near the city of Nzerekore.

Correspondents say many villagers are suspicious of official attempts to combat the disease.


A government delegation, led by the health minister, had been dispatched to the region but they were unable to reach the village by road because a main bridge had been blocked.

(Continue . . .)


One of the huge problems in combating Ebola has been the belief – perpetuated in some cases even by local media – that Ebola is either not real, or part of some evil plot hatched by the western world (see WaPo article Largest Liberian Newspaper: US Government Manufactured Ebola, AIDS Virus) to kill Africans.


All of which makes working in the hot zone doubly dangerous. 


Adding to the challenges of educating the public, the literacy rates in West Africa are among the lowest on the continent, with Guinea coming in 49th (29.5%) out of 52 African nations.  Sierra Leone fares only slightly better (35.1%) and Liberia is just shy of midway in the pack, with a literacy rate of 57.5% (source The African Economist).


How much of a chill this latest tragedy will put on Ebola outreach efforts in the more remote areas of Guinea remains to be seen, but this incident – and the Health Ministry’s inability to launch a timely rescue mission -  illustrates how little actual control the government has over some regions of their country.

Saudi MOH: Review Finds 19 `Historical’ MERS Cases Prior to June 2014


Saudi Arabia


# 9093


Yesterday there were 732 MERS cases reported by the Saudi MOH, and today that number climbs to 748: all  stemming from of an audit of cases from before June 3rd of this year, and mostly arising from Jeddah.  


While 19 cases were added to the tally - 1 duplicate case, and 2 false positives were removed -  resulting in a net gain of 16 cases.


While the number of identified MERS cases has remained reassuringly stable over the summer, earlier studies have suggested that the bulk of those infected  - being either mildly ill, or asymptomatic – are never identified. Given the apparent seasonality of MERS we would need to get through an entire winter-spring cycle without seeing a spike in cases before attaching too much significance to this pause.


Despite the somewhat self-congratulatory tone of this press release, we continue to see only the bare minimum of information released on recent cases out of Saudi Arabia, and we’ve yet to see results from the long-promised case control study (see KSA Announces Start To Long-Awaited MERS Case Control Study).




​JEDDAH 18 September 2014. The Ministry of Health released information today about 19 historical (old) cases of MERS-CoV, as part of an ongoing review of patient data. Each of these cases had a date of onset prior to 3 June, 2014.

Since launching a comprehensive response to MERS-CoV earlier this year, the number of reported cases in Saudi Arabia has declined dramatically.

Other aspects of MoH response include public health education, new procedures and equipment to quickly identify and treat patients and promotion of best practice to prevent the spread of MERS-CoV between healthcare workers.

The new information was discovered during an ongoing validation process designed to ensure the accuracy of MERS-CoV historical infection data. The review, undertaken by an independent auditor, is part of MoH’s effort to minimize data discrepancies, with the goal of capturing information that enables healthcare workers to better control the disease.

MoH is conducting a retrospective analysis that includes a case-by-case review to better understand how to capture patient data in a more timely and complete way. It has also stepped up efforts to communicate to healthcare workers the requirement for quick and accurate reporting of infectious disease information. The new data has been shared with the World Health Organization.

Many of the additional cases were identified through a review of patient records at hospitals that perform on-site laboratory testing. All but three of the cases were in Jeddah.

Further revisions to the overall MERS-CoV statistics include:

1. The status of 18 cases was changed from active to recovered, while the categorization of three cases was changed from active to deceased
2. One duplicate case was identified and deleted
3. In addition, two cases reported 9 June and 26 August, were subsequently identified as a false positive and have been removed from the statistics.

This effort complements the on-going implementation of the Health Electronic Surveillance Network (HESN), a comprehensive, integrated public health information system that helps public health workers collaborate to manage individual cases, outbreaks, immunizations, and medical inventories. Regular reviews are part of the MoH effort to introduce internationally accepted standards for due diligence, and can result in changes to reporting statistics arising from reclassification, retrospective investigation, consolidation of cases and laboratory data, and enhanced surveillance outcome.

In total, MoH had identified 748 laboratory-confirmed cases of MERS-CoV as of 18 September, 2014. 



Update:   Shortly after posting this blog I found the Dr. Ian Mackay on his VDU blog has written an open letter to the Saudi MOH requesting the release of additional information on MERS cases.    Follow the link to read:


To the Saudi Arabian Ministry of Health: A request for missing data on retrospective MERS-CoV detections

From: Ian M Mackay

To: The Office of the Minister of Health, Kingdom of Saudi Arabia

I write to humbly ask for your help on a matter of infectious disease communication. I ask that you please consider completing the already near-complete public data picture for all retrospectively confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) that have occurred on your soil. I ask that this be publicly released for analysis, and suitably acceptable citation, by all. The Ministry of Health has already made a number of advances in tracking and communicating new cases of MERS-CoV, addressing criticisms along the way. But there remain some small but epidemiolgically important gaps in an otherwise complete set of data that could be easily closed.

(Continue . . . )