Monday, October 05, 2015

Philippines: 15 Contacts Of Suspected MERS Case Now In Isolation - Media



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Official information on the Philippines’s suspected MERS fatality – reported on Saturday (see Suspected MERS Case Dies – 12 HCWs In Quarantine) – remains in short supply as the Philippine Department of Health has yet to post anything on their website.


The story – at least as it is being reported by local media – indicates a Saudi National fell ill several days after arriving from KSA with `MERS-like’ symptoms, was hospitalized, and died the following day.


The hospital where he was treated inexplicably failed to test him for MERS, and then sent his remains to a funeral parlor before notifying the DOH.  From there the story grows even murkier, although some reports suggest his body was shipped back to KSA for immediate burial.

Whatever the finer points of this incident, it appears that – at least for now – this case is being treated as a `probable’ case of MERS by the Philippine DOH, despite no lab confirmation.  


As of the latest report (see below), 101 contacts of this case have been identified and contacted, with 15 reportedly isolated with `symptoms’ at the San Lazaro Hospital and Research Institute for Tropical Medicine, and the balance on home quarantine.


101 contacts of Saudi man with MERS located

By Sheila Crisostomo (The Philippine Star) | Updated October 6, 2015 - 12:00am

MANILA, Philippines - All 101 people who encountered the Saudi national suspected of dying from Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) are now accounted for, Health Secretary Janette Garin said yesterday.

Garin noted health officials were able to locate all the persons who came in contact with the 63-year-old foreigner at the hotel, hospital and funeral parlor.

However, three more contacts manifesting MERS-CoV symptoms have been placed in quarantine at hospitals. This brought to 15 the total number of people isolated at the San Lazaro Hospital and Research Institute for Tropical Medicine. “The rest are on home quarantine,” according to Garin.

(Continue . . .)


Exactly what `symptoms’ these 15 isolated individuals are displaying, and the results of any testing, have not been released.  Hopefully we’ll get more detailed information from the World Health Organization soon.

WHO Statement On 7th IHR Emergency Committee Meeting On Ebola


@WHO & Partners Ebola Response In Guinea


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Although the number of new Ebola cases in Western Africa has dropped precipitously over the past few months, at least 2 active chains of infection continue in Sierra Leone and Guinea, albeit producing fewer than 10 cases a week.  The brief Recurrence Of Ebola Transmission In Liberia over the summer -  after 3 months without a case -  is a grim reminder of how fragile these victories really are.


Since the outbreak began, the WHO has convened 7 IHR Emergency Committee Meetings to discuss the crisis.  Thirteen months ago, the 1st WHO Emergency Committee Declared Ebola Outbreak a PHEIC (Public Health Emergency of International Concern).


Today the WHO has released the following statement on the IHR Committee’s latest meeting, which retains the PHEIC designation for this Ebola outbreak .



Statement on the 7th meeting of the IHR Emergency Committee regarding the Ebola outbreak in West Africa

WHO statement
5 October 2015

The 7th meeting of the Emergency Committee convened by the WHO Director-General under the International Health Regulations (IHR) (2005) regarding the Ebola virus disease (EVD) outbreak in West Africa took place by teleconference on Thursday, 1 October 2015, and by electronic correspondence from 1-3 October 2015.

As in previous meetings, the Committee’s role was to advise the WHO Director-General as to:

  • whether the event continues to constitute a Public Health Emergency of International Concern (PHEIC) and, if so,
  • whether the current temporary recommendations should be extended or revised, and whether new temporary recommendations should be issued.

Presentations were made by representatives of Guinea, Liberia and Sierra Leone on the current epidemiological situation in those countries, response operations and exit screening.

Since the 6th meeting of the Committee, Liberia has been declared free of EVD transmission for a second time (3 September 2015), the overall case incidence in Guinea and Sierra Leone has been below 10 cases per week, and the Sierra Leonean capital city of Freetown has remained free of EVD transmission for over 42 days. The Committee noted the enhanced Ebola control measures being implemented in each country and reaffirmed the importance of the community outreach, social mobilization, and other best practices.

However, 2 active chains of EVD transmission continue, one in Guinea and one in Sierra Leone. The Committee highlighted that the continued identification (including post-mortem) of cases not previously registered as contacts, resistance to response operations in some areas, and the ongoing movement of cases and contacts to Ebola-free areas, all constitute risks to stopping all EVD transmission in the subregion. The Committee noted the small number of Ebola cases in which virus from a convalescent individual could not be ruled out as the origin of infection; while viral persistence is understood to be time-limited, further investigation is needed on the nature, duration and implications of such persistence.

The Committee was concerned that although some improvements have been observed in the rescinding of excessive or inappropriate travel and transport measures, 34 countries continue to enact measures that are disproportionate to the risks posed, and which negatively impact response and recovery efforts. Furthermore, a number of international airlines have yet to resume flights to the affected countries.

The Committee advised that the EVD outbreak continues to constitute a Public Health Emergency of International Concern. In addition, the Committee advised the Director-General to consider the following temporary recommendations, which supersede and replace those issued previously:

States with Ebola transmission

1. The Head of State should continue to address the nation to provide information on the situation, the steps being taken to address the outbreak and the critical role of the community in ensuring its rapid control.

2. There should be no international travel of Ebola contacts or cases, unless the travel is part of an appropriate medical evacuation. To minimize the risk of international spread of EVD:

  • Confirmed cases should immediately be isolated and treated in an Ebola Treatment Centre with no national or international travel until 2 Ebola-specific diagnostic tests conducted at least 48 hours apart are negative;
  • Contacts (which do not include properly protected health workers and laboratory staff who have had no unprotected exposure) should be monitored daily, with restricted national travel and no international travel until 21 days after exposure;
  • Probable and suspect cases should immediately be isolated and their travel should be restricted in accordance with their classification as either a confirmed case or contact.

3. States should conduct exit screening of all persons at international airports, seaports and major land crossings, for unexplained febrile illness consistent with potential Ebola infection. The exit screening should consist of, at a minimum, a questionnaire, a temperature measurement and, if there is a fever, an assessment of the risk that the fever is caused by Ebola virus. States should share exit screening data with WHO on a regular basis. Such exit screening must be maintained for at least 42 days after the last case has twice tested negative for Ebola virus; countries are encouraged to maintain exit screening until EVD transmission has stopped in the entire subregion.

4. The cross-border movement of the human remains of deceased suspect, probable or confirmed EVD cases should be prohibited unless specifically authorized on a case-by-case basis by relevant national authorities of both the exporting and receiving country.

All States

5. There should be no general ban on international travel or trade; there should be no restrictions on the travel of EVD survivors; only those restrictions outlined in these recommendations regarding the travel of EVD cases and contacts should be implemented.

6. Those States which currently implement excessive or inappropriate travel and transport measures that go beyond these Temporary Recommendations should terminate such measures by end-October 2015.

7. States should provide travellers to areas of active Ebola transmission with relevant information on risks, measures to minimize those risks, and advice for managing a potential exposure.

8. States should be prepared to detect, investigate, and manage Ebola cases; this should include assured access to a qualified diagnostic laboratory for EVD and, where appropriate, the capacity to manage travellers originating from areas of active Ebola transmission who arrive at international airports or major land crossing points with unexplained febrile illness.

9. If active Ebola transmission is confirmed to be occurring in the State, the full recommendations for States with Ebola transmission should be implemented, on either a national or subnational level, depending on the epidemiologic and risk context.

Based on this advice and information, the Director-General declared that the 2014-2015 Ebola outbreak in these West African countries continues to constitute a Public Health Emergency of International Concern. The Director-General endorsed the Committee’s advice and issued that advice as Temporary Recommendations under the IHR. These Temporary Recommendations supersede and replace all previous recommendations issued under the IHR in the context of the Ebola Outbreak in West Africa.

The Director-General thanked the Committee members and advisors for their advice and requested their reassessment of this situation within 3 months should circumstances require.

Saudi Camel Owners Threaten Over MERS `Slander’

Photo: ©FAO/Ami Vitale

Credit FAO

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The camel-MERS connection was first recognized in the summer of 2013 (see Lancet: Camels Found With Antibodies To MERS-CoV-Like Virus), and since then we’ve seen a steady parade of studies that have demonstrated 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.


This caused an immediate backlash among camel owners, and much of the general public. The idea that camels – a beloved national symbol that literally made settlement of that arid region possible – could carry a disease deadly to humans, was simply unthinkable.  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.


In response, posting selfies of `Camel Kissing’ to prove camel contact wasn’t dangerous briefly became a thing.

Image Credit: A Saudi farmer kisses a young she-camel - Credit: Al Sharq


Studies have shown that nearly all Middle Eastern camels become infected with the virus (usually early in life), but they only shed the virus for a week or two.   Re-infection is possible, but camels appear to be infectious for only brief periods of time during their lifetime.


So, most of the time, it looks like you can get away with kissing your camel without fear of contracting MERS.  


The problem is, you are playing a game of camel-roulette.  You can never be quite sure when your camel is `loaded’ with the active virus. Last April in the Lancet’s Presence of Middle East respiratory syndrome coronavirus antibodies in Saudi Arabia: a nationwide, cross-sectional, serological study by Drosten & Memish et al., researchers found MERS antibodies in 15 of 10009 serum samples analyzed from across Saudi Arabia, and that:


`Seroprevalence of MERS-CoV antibodies was significantly higher in camel-exposed individuals than in the general population.’


While only briefly infectious, camels appear to be the main zoonotic source for the sporadic re-introduction of the MERS virus into the human population.  Direct camel-to-human transmission, however, appears to account for only a minority of MERS cases.  


Most humans contract the virus from other humans, often in large hospital outbreaks.  So one camel-to-human transmission can, theoretically, plant the seed for a hospital or community outbreak that involves hundreds.


Limited mild or asymptomatic transmission in the community are another plausible route, although we lack specific evidence to prove it. Incredibly, more than three years after the virus was first discovered, we still haven’t seen the long-awaited case-control study on MERS, which is hoped will shed some light on how the virus is transmitting in the community.


The exclusion of camels from this year’s Hajj (see Hajj: Camel Sacrifice Prohibited To Help Prevent MERS), along with constant warnings to tourists to avoid riding, or coming in contact with camels, and caveats about the dangers of consuming camel products have all helped to drive the price of camels down dramatically over the past year.


Camel owners threaten to sue ‘rumor mongers’

October 4, 2015

Camel owners are accusing “hidden hands” behind the campaign against camels, which has led to the deterioration of the animal market and deeply impacted their prices, alleging that government agencies are mainly supporting these parties.

Owners say they are prepared to sue all those who have been spreading rumors that camels are mainly causing coronavirus, including the Ministry of Health (MoH) and the Ministry of Agriculture and other government agencies.

Camel owners say they have suffered extreme losses due to the escalation of accusations of a possible role of camels in the spread of coronavirus, insisting instead that there is no relationship between the two.

(Continue . . . )


Granted, a lawsuit against the Saudi MOH and MOA is unlikely to get very far.  More importantly, this tells us that three years into the slow-rolling MERS epidemic, those who are best positioned to stop the virus at its zoonotic source remain unconvinced of the threat. 


Until that changes, the odds of containing MERS in the Middle East remain low.

Sunday, October 04, 2015

The Lancet: WHO Estimates That 50% Of Drugs For Sale Online Are Fake



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It’s a story we’ve covered before (see Study: Substandard & Falsified TB Drugs & Interpol & FDA: Operation Pangea V), but according to experts, it is getting worse:  The rise in fake, or substandard prescription drugs, often sold via online pharmacies.  


Some of these drugs have none of the promised active ingredients, while others may be less potent than advertised, or are laced with potentially dangerous substitutes or fillers. Often more money is spent trying to duplicate the packaging of a legitimate product, than is spent producing the medicine itself.


And the end result can not only be tragic for the user – but also to society – as using substandard medicines is one of the ways that drug resistant bacteria, viruses, and parasites can be created and spread.


A prime example, In 2012, in FDA Warning On Fake Adderall we learned that some of these drugs don’t even come close to containing what they advertise:


FDA’s preliminary laboratory tests revealed that the counterfeit version of Teva’s Adderall 30 mg tablets contained the wrong active ingredients. Adderall contains four active ingredients – dextroamphetamine saccharate, amphetamine aspartate, dextroamphetamine sulfate, and amphetamine sulfate. Instead of these active ingredients, the counterfeit product contained tramadol and acetaminophen, which are ingredients in medicines used to treat acute pain.


And if you think buying from a `Canadian online pharmacy’ is some kind of guarantee that you won’t get ripped off, know some of those are just web fronts for illegal pharmacies operated around the globe.  

Yesterday The Lancet published a long report on the spectacular growth of fake online prescription drugs in:


Rise in online pharmacies sees counterfeit drugs go global

Fiona Clark 



In high-income countries it might not be at the forefront of every practitioner's mind, but the rise of online pharmacies in Europe and the USA could change that. WHO estimates that 50% of the drugs for sale on the internet are fake and even though the online dispensaries might look legitimate, a survey of 10 000 of them done by America's National Association of Boards of Pharmacy (NABP) found that 9938 did not comply with NABP patient safety and pharmacy practice standards or US state and federal laws. Most said they were based in Canada but were really a front for illegal offshore operations.

. . . .

WHO puts the annual death toll from counterfeit drugs at around 1 million. The largest single group is in Africa where around 200 000 people are said to die each year as a result of fake antimalarial drugs. In the USA, in the late 2000s, 81 people died from using an adulterated heparin imported from China and another 68 lost their lives in other parts of the world.

(Continue . . . )



Unless you are buying your prescription drugs from an unscrupulous online pharmacy, Americans are most likely to encounter these fake or substandard medications while traveling to developing countries.  The CDC’s Traveler’s Health website offers the following advice.

Counterfeit Drugs

Bottle of pills

Counterfeit (or fake) medicines are manufactured using incorrect or harmful ingredients. These medicines are then packaged and labeled to look like real brand-name and generic drugs. Counterfeit medicines are unsafe because they may not be effective or may even harm you.

Counterfeiting occurs throughout the world, but it is most common in countries where there are few or no rules about making drugs. An estimated 10%–30% of medicines sold in developing countries are counterfeit. In the industrialized world (countries such as the United States, Australia, Japan, Canada, New Zealand, and those in the European Union), estimates suggest that less than 1% of medicines sold are counterfeit.

The only way to know if a drug is counterfeit is through chemical analysis done in a laboratory. Counterfeit drugs may look strange or be in poor-quality packaging, but they often seem identical to the real thing. The only way to make sure you have the real thing is to bring all the drugs you will need during your trip with you from the United States, rather than buying them while you are traveling.

Pills being manufactured

If an emergency occurs and you must buy drugs during your trip, you can reduce your chances of buying drugs that are counterfeit:

  • Buy medicines only from licensed pharmacies and get a receipt. Do not buy medicines from open markets.
  • Ask the pharmacist whether the drug has the same active ingredient as the one that you were taking.
  • Make sure that the medicine is in its original packaging.
  • Look closely at the packaging. Sometimes poor-quality printing or otherwise strange-looking packaging will indicate a counterfeit product.
  • If you buy drugs online, visit Buying Prescription Medicines Online: A Consumer Safety Guide to learn how to buy safely.

Media: Shengzhou Reports 1st H7N9 Case Of The Fall


Zhejiang Province – Credit Wikipedia




Although I can find nothing on the Zhejiang Provincial MOH website, we’ve an unusually detailed report in the local state media ( of what is reportedly China’s first H7N9 case of the fall. China’s H7N9 season doesn’t usually get started in earnest until winter, but this is still a rather late date for the first report of the fall.


H7N9, which spreads silently and asymptomatically in birds, can produce a wide spectrum of illness in humans.  While fewer than 700 human infections have been identified since 2013, this is likely just a subset of the total – the `sickest of the sick’.


Mild or even asymptomatic cases have been detected, and it is assumed that there may have been thousands of such cases that have gone unidentified (see Lancet: Clinical Severity Of Human H7N9 Infection).   Perhaps even tens of thousands.


Worth noting, over the past few weeks Sharon Sanders of FluTrackers, who scours the Chinese and Arabic media every day, has posted a number of media reports of heightened respiratory virus activity in Zhejiang province.  While there is no evidence that any of them have anything to do with H7N9, heavy flu activity may increase the chances that mild H7N9 cases go undetected.


China - 20% growth in pediatric outpatient visits in last 2 weeks at a Hangzhou hospital, Zhejiang province - September 23, 2015

China - Flu, respiratory patients up 3% "more than normal" - Hangzhou, Zhejiang province - September 16, 2015


While we wait for an `official’ confirmation, we have the following media report on the Zhejiang’s first H7N9 case of the fall.


Shaoxing Shengzhou confirmed one case of H7N9 cases has started contingency plans Ningbo, China   2015-10-04 14:32:09 Manuscript Source: Zhejiang News

October 2, Shaoxing Shengzhou confirmed one case of H7N9 cases, this is the first case since the autumn of this year in the city appear.

According to CDC epidemiological investigation, the patient Moumou, female, 62 years old, who lives in the town of Shengzhou three realms. It has purchased two weeks before the onset of breeding, slaughter poultry history. Currently serious condition, is in active treatment.

After the outbreak, Shengzhou people infected with H7N9 government to immediately start working mechanism of joint prevention and control and relevant emergency plans, held a special conference, a clear focus on the prevention and control tasks: First, to strengthen surveillance, diagnosis and treatment of patients with fever specification, unexplained pneumonia patient investigation and Early antiviral treatment work; the second is to do poultry "slaughtering, killing white listing" to regulate the live bird market transaction management; third, to conduct joint special rectification, investigate and punish the illegal trading of live poultry behavior.

Experts advise consumers to ban live poultry trading, the implementation kill white marketed not only the government's requirements, but also to prevent bird flu, pay attention to science healthy lifestyle inevitable choice. We hope that the public changes in consumer attitudes, consumption of chilled poultry products set to kill white listed healthier and more secure scientific ideas.

Meanwhile, the current time when respiratory diseases high season, the public should pay attention to personal hygiene, indoor ground ventilation, fewer trips to places with poor ventilation, do not contact with sick / dead poultry category, careful contact with live poultry, fever, cough, symptoms should go directly to medical institutions fever clinic as soon as possible, and be sure to tell the doctor if there is a history of exposure before the onset of poultry.

(Continue . . . )


A final note:  Official reporting on H7N9 in China degraded significantly last season, with some provinces only reporting aggregate totals in their monthly epidemiological reports.   Recent WHO DON Updates – which are based on information provided by the Chinese MOH – have been disappointingly light on epidemiological data.


While we still continue to see some excellent scientific papers coming out of China on H7N9, our day-to-day feel for what is going on there with the virus is significantly less than what we had during the first two waves.

Saturday, October 03, 2015

9 Killed, 37 Seriously Wounded When MSF Hospital Bombed In Afghanistan


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The pictures and accounts coming out of last night’s bombing of an MSF (Médecins Sans Frontières) hospital in Afghanistan are both tragic and disturbing.   Details on how this happened, or who was responsible, are still emerging. 


CNN reports that the Pentagon is investigating whether a AC-130 gunship operating in the area may have been involved, but the facts of the matter are far from clear.


For now, all we really know is the MSF – which has suffered terrible losses and hardships battling Ebola in West Africa over the past 18 months – has endured yet another tragedy. 

This from their twitter feed.