NY Times

CIDRAP

Lancet

Multidisciplinary assessment of post-Ebola sequelae in Guinea (Postebogui): an observational cohort study.                                                                                                                                                                                                                 Etard, Jean-François et al.                                                                                                                                                                                                                       The Lancet Infectious Diseases

Findings

Between March 23, 2015, and July 11, 2016, we recruited 802 patients, of whom 360 (45%) were male, 442 (55%) were female; 158 (20%) were younger than 18 years. The median age was 28·4 years (range 1·0–79·9, IQR 19·4–39·8). The median delay after discharge was 350 days (IQR 223–491). The most frequent symptoms were general symptoms (324 [40%] patients), musculoskeletal pain (303 [38%]), headache (278 [35%]), depression (124 [17%] of 713 responses), abdominal pain (178 [22%]), and ocular disorders (142 [18%]). More adults than children had at least one clinical symptom (505 [78%] vs 101 [64%], p<0·0003), ocular complications (124 [19%] vs 18 [11%], p=0·0200), or musculoskeletal symptoms (274 [43%] vs 29 [18%], p<0·0001). A positive RT-PCR in semen was found in ten (5%) of 188 men, at a maximum of 548 days after disease onset. 204 (26%) of 793 patients reported stigmatization. Ocular complications were more frequent at enrolment than at discharge (142 [18%] vs 61 [8%] patients).

Interpretation

Post-EVD symptoms can remain long after recovery and long-term viral persistence in semen is confirmed. The results justify calls for regular check-ups of survivors at least 18 months after recovery.

PLOS

Abad-Franch F, Zamora-Perea E, Luz SLB (2017) Mosquito-Disseminated Insecticide for Citywide Vector Control and Its Potential to Block Arbovirus Epidemics: Entomological Observations and Modeling Results from Amazonian Brazil. PLoS Med 14(1): e1002213. doi:10.1371/journal.pmed.1002213

ZipLine

Miami Herald

“…building a consortium to finance long-term water and sanitation needs in Haiti….”

“….The United Nations announced the long-term project last month as part of a new approach to eliminating the water-borne disease in Haiti. The proposal is part of a $400 million package then-U.N. Secretary General Ban Ki-moon laid out after delivering a long sought after apology to the people of Haiti for the U.N.’s role in introducing the deadly disease in Haiti with the arrival of Nepalese peacekeepers nearly seven years ago. Since then, the disease has killed more than 9,400 Haitians and infected more than 802,000 people….”

PLOS

Piso RJ, Käch R, Pop R, Zillig D, Schibli U, Bassetti S, et al. (2017) A Cross-Sectional Study of Colonization Rates with Methicillin-Resistant Staphylococcus aureus (MRSA) and Extended-Spectrum Beta-Lactamase (ESBL) and Carbapenemase-Producing Enterobacteriaceae in Four Swiss Refugee Centres. PLoS ONE 12(1): e0170251. doi:10.1371/journal.pone.0170251

“….261 refugees at four refugee centers in Switzerland were screened to determine colonization rates for MRSA and extended-spectrum beta-lactamase (ESBL) and carbapenemase-producing Enterobacteriaceae. Pharyngeal, nasal, and inguinal swabs were used for MRSA screening, and rectal swabs and urine were used for ESBL and carbapenemase screening.

The refugees were from five different regions—Middle East, East Africa, Central/West Africa, Northern Africa, and Far East—with the majority coming from Afghanistan, Syria, and Eritrea. Three quarters of the screening participants were male.

The screening results showed that 15.7% of the refugees were colonized with MRSA, a rate roughly 10 times higher than found in the Swiss population…..”

WHO

On 6 January 2017, the Brazil Ministry of Health (MoH) reported 12 suspected cases of yellow fever from six municipalities in the state of Minas Gerais.

On the same day, the Brazil IHR National Focal Point (NFP) informed PAHO/WHO that the 12 cases are male, residing in rural areas, and have an average age of approximately 37 years (range: 7–53 years). The first of these cases had onset of symptoms on 18 December 2016. Samples from the cases were sent to the State Reference Laboratory (the Ezequiel Dias Foundation) for differential diagnosis, including dengue, hantavirus, leptospirosis, malaria, Rocky Mountain spotted fever, and viral hepatitis (A, B, C, D, and E). Results are pending.

On 12 January, the Brazil IHR NFP provided an update on the event informing that a total of 110 suspected cases, including 30 deaths, had been reported from 15 municipalities of Minas Gerais: Ladainha (31 cases, 11 deaths), Caratinga (20 cases, 1 death), Imbe de Minas (14 cases, 1 death), Piedade de Caratinga (12 cases, 4 deaths), Poté (6 cases, 3 deaths), Ubaporanga (6 cases, 2 deaths), Itambacuri (5 cases, 3 deaths), Ipanema (4 cases, 1 death), Malacacheta (4 cases, 2 deaths), Entre Folhas (2 cases), Frei Gaspar (1 case), Inhapim (2 cases), São Domingos das Dores (1 case), São Sebastião do Maranhão (1 fatal case), and Setubinha (1 fatal case). Serological tests for 19 suspected cases were positive for yellow fever. Among them, 10 deaths (CFR: 53%) were reported. The report also confirms that there had been epizootics in 13 municipalities of Minas Gerais. Six of these 13 municipalities have not so far reported human cases of yellow fever: Agua Boa, Durande, Ipatinga, Sao Pedro do Sacui, Simonesia, and Teófilo Otoni.

Public health response

Health authorities at the federal, state, and municipal levels are implementing several measures to respond to the outbreak:

• The MoH has deployed technical teams to the state of Minas Gerais to assist the state and municipal secretary of health with surveillance and outbreak investigation, vector control, and coordination of health care services;
• A house-to-house immunization campaign is being conducted in the rural areas of affected municipalities;
• Preparedness activities are being conducted in states bordering Minas Gerais, for a potential introduction of yellow fever;
• The local press is working together with the MoH to keep the public constantly informed on the situation.

WHO risk assessment

Yellow fever outbreak has previously been detected in Minas Gerais. The most recent outbreak occurred in 2002–2003, when 63 confirmed cases, including 23 deaths (CFR: 37%), were detected.

The current yellow fever outbreak is taking place in an area with relatively low vaccination coverage, which could favor the rapid spread of the disease. The concern is that transmission may extend to areas located in proximity of Minas Gerais, such as the state of Espírito Santo and the south of Bahia, which have favorable ecosystems for the transmission of the virus. These areas were previously considered to be at low risk of transmission and, consequently, yellow fever vaccination was not recommended. The introduction of the virus in these areas could potentially trigger large epidemics of yellow fever. There is also a risk that infected humans may travel to affected areas, within or outside of Brazil, where the Aedes mosquitoes are present and initiate local cycles of human-to-human transmission. Response efforts are further complicated by the fact that it is occurring in the context of concomitant outbreaks of Zika virus, chikungunya and dengue.

WHO continues to monitor the epidemiological situation and conduct risk assessment based on the latest available information.

WHO advice

Yellow fever can easily be prevented through immunization provided that vaccination is administered at least 10 days before travel. WHO, therefore, urges Members States especially those where the establishment of a local cycle of transmission is possible (i.e. where the competent vector is present) to strengthen the control of immunisation status of travellers to all potentially endemic areas.

WHO does not recommend any restriction of travel and trade to Brazil based on the current information available.

WHO

Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia

Between 16 and 31 December 2016 the National IHR Focal Point of Saudi Arabia reported fifteen (15) additional cases of Middle East Respiratory Syndrome (MERS) including two (2) fatal cases. Five (5) deaths among previously reported MERS cases were also reported.

Details of the cases

• A 49-year-old male national living in Khurmah city, Taif Region. He developed symptoms on 25 December and was admitted to hospital on 29 December. The patient who has comorbidities tested positive for MERS-CoV on 30 December. He has a history of contact with camels and consumption of their raw milk in the 14 days prior to the onset of symptoms. Currently the patient is in stable condition and admitted to a negative pressure isolation room on a ward. Ministry of Agriculture has been informed and investigation of camels is ongoing.
• A 41-year-old female non-national health care worker living in Abha city, Assir Region. She is asymptomatic and was identified through tracing contacts of the 50-year-old MERS case reported to WHO on 28 December (See case no. 7 below). She tested positive for MERS-CoV on 28 December. She has a history of caring for the MERS cases between 25 to 26 December. Currently she is asymptomatic in stable condition at home isolation.
• A 30-year-old female non-national health care worker living in Abha city, Assir Region. She is asymptomatic and was identified through tracing contacts of the 50-year-old MERS case reported to WHO on 28 December (See case no. 7 below). She tested positive for MERS-CoV on 28 December. She has a history of caring for the MERS cases between 25-26 December. Currently she is asymptomatic in stable condition at home isolation.
• A 66-year-old male national living in Madinah city, Madinah Region. He developed symptoms on 21 December and was admitted to hospital on 26 December. The patient who has comorbidities tested positive for MERS-CoV on 28 December. He has a history of contact with camels and consumption of their raw milk in the 14 days prior to the onset of symptoms. Currently the patient is in stable condition and admitted to a negative pressure isolation room on a ward. Ministry of Agriculture has been informed and investigation of camels is ongoing.
• A 46-year-old female national living in Riyadh city, Riyadh Region. She developed symptoms on 21 December and was admitted to hospital on 26 December. The patient who has comorbidities tested positive for MERS-CoV on 27 December. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing. Currently the patient is in stable condition and admitted to a negative pressure isolation room on a ward.
• An 82-year-old male national living in Najran city, Najran Region. He developed symptoms on 21 December and was admitted to hospital on 24 December. The patient who has comorbidities tested positive for MERS-CoV on 26 December. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing. Currently the patient is in critical condition and admitted to the intensive care unit on mechanical ventilation.
• A 50-year-old male national living in Abha city, Assir Region. He developed symptoms on 21 December and was admitted to hospital on 25 December. The patient who has comorbidities tested positive for MERS-CoV on 26 December. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing. Currently the patient is in critical condition and admitted to the intensive care unit on mechanical ventilation.
• A 44-year-old male national living in Riyadh city, Riyadh Region. He developed symptoms on 20 December and was admitted to hospital on 24 December. The patient who has no comorbidities tested positive for MERS-CoV on 25 December. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing. Currently the patient is in stable condition and admitted to a negative pressure isolation room on a ward.
• A 64-year-old female national living in Najran city, Najran Region. She developed symptoms on 17 December and was admitted to hospital on 21 December. The patient who had comorbidities tested positive for MERS-CoV on 23 December. She was admitted to a negative pressure isolation room on a ward. However, her conditions deteriorated and she passed away on 30 December 2016. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing.
• A 78-year-old male national living in Riyadh city, Riyadh Region. He developed symptoms on 18 December and was admitted to hospital on 19 December. The patient who has comorbidities tested positive for MERS-CoV on 21 December. He has a history of contact with camels in the 14 days prior to the onset of symptoms. Currently the patient is in stable condition and admitted to a negative pressure isolation room on a ward. Ministry of Agriculture has been informed and investigation of camels is ongoing.
• A 24-year-old male national living in Makkah city, Makkah Region. He was asymptomatic and identified through tracing of household contacts of the 47-year-old MERS case reported to WHO on 20 December (See case no. 12 below). The case tested positive for MERS-CoV on 21 December. He has no comorbidities and no history of exposure to the other known risk factors in the 14 days prior to detection. Currently he is asymptomatic in stable condition at home isolation.
• A 47-year-old male national living in Makkah city, Makkah Region. He developed symptoms on 17 December and was admitted to hospital on 18 December. The patient who has comorbidities tested positive on 19 December. He has a history of contact with camels and consumption of their raw milk in the 14 days prior to the onset of symptoms. Currently the patient is in stable condition and admitted to a negative pressure isolation room on a ward.
• A 57-year-old male national living in Riyadh city, Riyadh Region. He developed symptoms on 13 December and was admitted to hospital on 18 December. The patient who has no comorbidities tested positive for MERS-CoV on 19 December. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing. Currently the patient is in stable condition and admitted to a negative pressure isolation room on a ward.
• A 22-year-old female national living in in Taif city, Taif Region. She developed symptoms on 14 December and was admitted to hospital on 16 December. The patient who has comorbidities tested positive for MERS-CoV on 18 December. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing. Currently the patient is in stable condition and admitted to a negative pressure isolation room on a ward.
• A 60-year-old male national living in Mahd Aldhahab city, Madinah Region. He developed symptoms on 1 December and was admitted to hospital on 6 December. The patient who had comorbidities tested negative for MERS-CoV on 11 December. Another nasopharyngeal swab was collected on 14 December and tested positive for MERS-CoV on 15 December. The patient was admitted to a negative pressure isolation room on a ward. However, his conditions deteriorated and he passed away on 24 December 2016. He had a history of contact with camels and consumption of their raw milk in the 14 days prior to the onset of symptoms. Ministry of Agriculture has been informed and investigation of camels is ongoing.

The National IHR Focal Point for the Kingdom of Saudi Arabia also notified WHO of the death of 5 MERS-CoV cases that were reported in previous DONs published on 28 November (case no. 2), 19 December (1) (case no. 6), and 19 December (2) (case no. 1, 2, and 9).

Contact tracing of household and healthcare contacts is ongoing for these cases.

Globally, since September 2012, 1879 laboratory-confirmed cases of infection with MERS-CoV including at least 666 related deaths have been reported to WHO.

WHO risk assessment

MERS-CoV causes severe human infections resulting in high mortality and has demonstrated the ability to transmit between humans. So far, the observed human-to-human transmission has occurred mainly in health care settings.

The notification of additional cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a health care setting). WHO continues to monitor the epidemiological situation and conducts risk assessment based on the latest available information.

WHO advice

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for acute respiratory infections and to carefully review any unusual patterns.

Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, health-care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.

Until more is understood about MERS-CoV, people with diabetes, renal failure, chronic lung disease, and immunocompromised persons are considered to be at high risk of severe disease from MERS-CoV infection. Therefore, these people should avoid close contact with animals, particularly camels, when visiting farms, markets, or barn areas where the virus is known to be potentially circulating. General hygiene measures, such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to.

Food hygiene practices should be observed. People should avoid drinking raw camel milk or camel urine, or eating meat that has not been properly cooked.

WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

WHO

Human infection with avian influenza A(H7N9) virus – China

On 5 January 2017, the Department of Health, Hong Kong Special Administrative Region (SAR) notified WHO of a case of laboratory-confirmed human infection with avian influenza A(H7N9) virus and on 9 January 2017, the National Health and Family Planning Commission of China (NHFPC) notified WHO of 106 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus.

Details of the cases

On 5 January 2017, a human case of infection with avian influenza A(H7N9) was reported from the Department of Health, Hong Kong Special Administrative Region (SAR). The case is a 62-year-old man with underlying illnesses, who travelled to Zengcheng, Guangzhou on 15 December 2016. He developed influenza-like symptoms on 1 January 2017 while he was in Guangzhou. He was admitted to a hospital in Dongguan on 2 January 2017 and returned to Hong Kong SAR on 3 January 2017, where he was admitted to hospital on 4 January 2017 for further treatment. His condition deteriorated and he was transferred to an intensive care unit for further management. He passed away on 6 January 2017. His samples tested positive for A(H7N9) by RT-PCR on 5 January 2017. The patient reported no recent exposure to poultry or live poultry markets. Contact tracing is underway.

On 9 January 2017, 106 human cases of infection with avian influenza A(H7N9) were reported from the NHFPC. The onset dates ranged from 22 November 2016 to 29 December 2016. Of these 106 cases, 36 are female. The median age is 54 years (age range among the cases is 23 to 91 years old). The cases are reported from Jiangsu (52), Zhejiang (21), Anhui (14), Guangdong (14), Shanghai (2), Fujian (2) and Hunan (1). At the time of notification, there were 35 deaths and 57 severe cases. Eighty of the cases are reported to have had exposure to poultry or a live poultry market.

Two clusters were reported.

First cluster:

• A 66-year-old male from Suzhou city, Jiangsu province. He had symptom onset on 25 November 2016, was admitted to hospital on 28 November 2016 and died on 12 December 2016. He was exposed to a live poultry market.
• A 39-year-old female from Suzhou city, Jiangsu province. She had symptom onset on 8 December 2016 and was admitted to hospital on the same day. She is the daughter of the 66-year old male. At the time of report, she was suffering from severe pneumonia.

Human-to-human transmission between the 66-year-old male and the 39-year-old female cannot be ruled out.

Second cluster:

• A 66-year-old male from Hefei city, Anhui province. He had symptom onset on 16 December 2016, and was admitted to hospital on 17 December 2016 and died on 20 December 2016. He was exposed to a live poultry market.
• A 62-year-old male from Hefei city, Anhui province. He had symptom onset on 22 December 2016. He was admitted in the same ward as the 66-year old male. His current condition is severe.

Human-to-human transmission between the 66-year-old male and the 62-year-old male cannot be ruled out.

To date, a total of 916 laboratory-confirmed human infections with avian influenza A(H7N9) virus have been reported through IHR notification since early 2013.

Public health response

Considering the increase of laboratory-confirmed cases of human infection with avian influenza A(H7N9) in December 2016, the Chinese government has enhanced measures:

• NHFPC strengthened epidemic surveillance, conducted timely risk assessment and studies for any changes in epidemiology.
• NHFPC requested local NHFPCs to implement effective control measures on the source of outbreaks and to minimize the number of affected people.
• Strengthened early diagnosis and early treatment, treatment of severe cases, and reduce occurrence of severe cases and deaths.
• Further enhanced medical treatment.
• Joint investigations between NHFPC and Ministries of agriculture, industry and commerce visited Jiangsu, Zhejiang, Anhui and Guangdong provinces where more cases occurred for joint supervision, inspection and guidance on local surveillance, medical treatment, prevention and control and to promote control measures with focus on live poultry market management and cross-regional transportation.
• Relevant prefectures in Jiangsu province have closed live poultry markets in late December 2016 and Zhejiang, Guangdong and Anhui provinces have strengthened live poultry market regulations.
• Conducting public risk communication and sharing information with the public.

The Centre for Health Protection of the Department of Health in Hong Kong SAR has taken the following measures:

• Urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.
• Issued an alert to doctors, hospitals, schools and institutions of the latest situation.

WHO risk assessment

Similar sudden increases in the number of human cases of avian influenza A(H7N9) infection have been observed in previous years during this period of time (December-January). Nevertheless close monitoring of the epidemiological situation and further characterization of the most recent viruses are critical to assess associated risk and to make timely adjustments to risk management measures.

Most human cases are exposed to avian influenza A(H7N9) virus through contact with infected poultry or contaminated environments, including live poultry markets. Since the virus continues to be detected in animals and environments, further human cases can be expected. Although small clusters of human cases with avian influenza A(H7N9) virus have been reported including those involving healthcare workers, current epidemiological and virological evidence suggests that this virus has not acquired the ability of sustained transmission among humans. Based on available information we have, further community level spread is considered unlikely.

Human infections with the avian influenza A(H7N9) virus are unusual and because there is the potential for significant public health impact, it needs to be monitored closely.

WHO advice

WHO advises that travellers to countries with known outbreaks of avian influenza should avoid, if possible, poultry farms, contact with animals in live bird markets, entering areas where poultry may be slaughtered, or contact with any surfaces that appear to be contaminated with faeces from poultry or other animals. Travellers should also wash their hands often with soap and water, and follow good food safety and good food hygiene practices.

WHO does not advise special screening at points of entry with regard to this event, nor does it currently recommend any travel or trade restrictions. As always, a diagnosis of infection with an avian influenza virus should be considered in individuals who develop severe acute respiratory symptoms while travelling in or soon after returning from an area where avian influenza is a concern.

WHO encourages countries to continue strengthening influenza surveillance, including surveillance for severe acute respiratory infections (SARI) and influenza-like illness (ILI) and to carefully review any unusual patterns, ensure reporting of human infections under the IHR (2005), and continue national health preparedness actions.