OUTLOOKS

National Preparedness Levels

The National Multi-Agency Coordination Group (NMAC) establishes Preparedness Levels throughout the calendar year to help assure that firefighting resources are ready to respond to new incidents. Preparedness Levels are dictated by fuel and weather conditions, fire activity, and resource availability.

The five Preparedness Levels range from 1 to 5, with 5 being the highest level. Each Preparedness Level has specific management directions. As the Preparedness Levels rise, more federal and state employees become available for fire mobilization if needed.

Preparedness Level 1

Geographic Areas accomplish incident management objectives utilizing local resources with little or no national support.
– Conditions are not favorable to support significant wildland fire activity in most geographic areas.
– Resource capability is adequate with little or no mobilization of resources occurring through the National Interagency Coordination Center.
– Potential for emerging significant wildland fires is expected to remain minimal.

Preparedness Level 2

Active Geographic Areas (GA’s) are unable to independently accomplish incident management objectives. Resource capability remains stable enough nationally to sustain incident operations and meet objectives in active GA’s.
– Significant wildland fire activity is increasing in a few geographic areas.
– Resources within most geographic areas are adequate to manage the current situation, with light to moderate mobilization of resources occurring through the National Interagency Coordination Center.
– Potential for emerging significant wildland fires is normal to below normal for the time of year.

Preparedness Level 3

Mobilization of resources nationally is required to sustain incident management operations in the active Geographic Areas (GA’s). National priorities established as a necessary measure to address the heavy and persistent demand for shared resources among active GA’s.
– Significant wildland fire activity is occurring in multiple geographic areas, with Incident Management Teams (IMTs) actively engaged.
– Mobilization of resources through the National Interagency Coordination Center is moderate to heavy.
– Potential for emerging significant wildland fires is normal for the time of year.

Preparedness Level 4

Shared resources are heavily committed. National mobilization trends affect all Geographic Areas (GA’s) and regularly occur over larger and larger distances. National priorities govern resources of all types. Heavy demand on inactive/low activity GA’s with low levels of activity for available resources.
– Significant wildland fire activity is occurring in multiple geographic areas; significant commitment of Incident Management Teams.
– NICC increasingly engages GACCs in an effort to coordinate and fill orders for available resources.
– Potential for significant incidents emerging in multiple GA’s indicates that resource demands will continue or increase.

Preparedness Level 5

National mobilization is heavily committed and measures need to be taken to support GA’s. Active GA’s must take emergency measures to sustain incident operations.
– Full commitment of national resources is ongoing.
– Resource orders filled at NICC by specifically coordinating requests with GACCs as resources become available.
– Potential for emerging significant wildland fires is high and expected to remain high in multiple geographic areas.

SitRep

National Preparedness Level 5

National Fire Activity Initial Attack Activity: Light (122 fires)

New large incidents: 5

Large fires contained: 9

Uncontained large fires:** 56

Area Command teams committed: 0

NIMOs committed: 0

Type 1 IMTs committed: 12

Type 2 IMTs committed: 16

Nationally, there are 51 large fires being managed under a strategy other than full suppression.

**Uncontained large fires include only fires being managed under a full suppression strategy. Link to Geographic Area daily reports.

One hundred thirty-eight fireline management personnel from Australia and New Zealand are assigned to support large fires in the California and Northwest Areas.
Two MAFFS C-130 airtankers and support personnel from the 152nd Airlift Wing (Nevada Air National Guard), one from the 146th Airlift Wing (California Air National Guard) and one from the 302nd Airlift Wing (Colorado Springs, Air Force Reserve) have been deployed to McClellan Airfield, CA in support of wildland fire operations.

One RC-26 aircraft with Distributed Real-Time Infrared (DRTI) capability and support personnel from the 141st Air Refueling Wing (Washington Air National Guard) has been deployed to Spokane, WA in support of wildland fire operations in the West.

WHO

Between 2012 and 30 June 2018, 2229 laboratory confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection were reported to WHO, 83% of whom were reported by the Kingdom of Saudi Arabia (Figure 1). In total, cases have been reported from 27 countries in the Middle East, North Africa, Europe, the United States of America, and Asia (Table 1). Males above the age of 60 with an underlying medical conditions, such as diabetes, hypertension and renal failure, are at a higher risk of severe disease, including death. To date, 791 individuals have died (crude CFR 35.5%).

Since the last global update published on 21 July 2017, 189 laboratory-confirmed cases of MERS-CoV from four countries were reported to WHO (182 from Saudi Arabia, three from Oman, three from the United Arab Emirates, and one from Malaysia), of whom 60 (31.7%) have died. Among these cases, 75.5% were male and the median age was 54 years old (IQR 40-65.5; range 10-93 years old). The median age is similar to the median age of all cases reported to WHO since 2012 (52 years old, IQR 37-65).
At the time of writing, 19 of 189 (10.0%) patients were reported as asymptomatic or having mild. At least one underlying condition was reported in 137 cases (72%) since the last update, including chronic renal failure, heart disease, diabetes mellitus, and hypertension.
Overall, the epidemiology, transmission patterns, clinical presentation of MERS patients and viral characteristics reported since the last update are consistent with past patterns described in previous WHO risk assessments: MERS-CoV is a zoonotic virus that has repeatedly entered the human population via direct or indirect contact with infected dromedary camels in the Arabian Peninsula. Limited, non-sustained human-to-human transmission mainly in health care settings continues to occur, primarily in Saudi Arabia. The risk of exported cases to areas outside of the Middle East due to travel remains significant.
While there have been significant improvements in surveillance for MERS, especially in the Middle East, and in reacting to suspect clusters, early identification in the community and in health care systems, compliance with the infection prevention and control measures and contact follow up remain major challenges for MERS outbreak prevention and control.

The continued importance of MERS-CoV in health care settings
Since the last global update of 21 July 2017, 17 of the 45 secondary cases reported to WHO were associated with transmission in a health care facility. These cases included health care workers (12 cases), patients sharing rooms/wards with MERS patients, or family visitors.
Though not unexpected, these transmission events continue to be deeply concerning, given that MERS-CoV is still a relatively rare disease about which medical personnel in health care facilities have low awareness. Globally, awareness for MERS is low and, because symptoms of MERS-CoV infection are non-specific, initial cases are sometimes easily missed. With improved compliance in infection prevention and control, namely adherence to the standard precautions at all times, human-to-human transmission in health care facilities can be reduced and possibly eliminated with additional use of transmissionbased precautions.
Since the last update of July 2017, several MERS clusters were reported, including the following:
 In July-August 2017, two clusters of MERS were reported from AL-Jawf Region, Saudi Arabia. These clusters were not epidemiologically linked.
 The first health care associated cluster included 13 cases, 2 who died. Among the 12 secondary cases, 10 were asymptomatic, including 8 health care workers.
 The second cluster included 7 cases, 6 of whom were household contacts. Of the 6 secondary cases, five were asymptomatic. None of the cases identified in this cluster were health care workers and there were no fatalities.
 In January-February 2018, a health care associated cluster was reported in Hafr Al Batin Region, Saudi Arabia. The cluster included 4 cases and 1 death, including 3 asymptomatic health care workers identified through contact tracing.
 In February-March 2018, a health care associated cluster of 6 cases occurred in a hospital in Riyadh, Saudi Arabia. Of the 6 cases, none were health care workers and three were fatal.
 In March 2018, there was a household cluster reported from Jeddah, Saudi Arabia. This cluster included 3 individuals, all of whom survived.

In May-June 2018, a household cluster was reported from the Najran Region, Saudi Arabia. The index case reported regular contact with dromedary camels. Ten family contacts and one health care worker were identified as secondary cases. Out of the 12 cases identified in this cluster, none were fatal.
Since 2015, the increase in the number of asymptomatic contacts identified in health care settings is due to a policy change by the Ministry of Health of the Kingdom of Saudi Arabia, in which all high-risk contacts are tested for MERSCoV regardless of the development of symptoms. This comprehensive contact identification, follow-up, testing and isolation of positive cases continues into 2018.
Drivers of transmission and the exact modes of transmission in health care settings still are unclear and are currently the focus of collaborative scientific research. From observational studies, transmission in health care settings is believed to have occurred before adequate infection prevention and control procedures were applied and cases were isolated. Investigations at the time of the outbreaks indicate that aerosolizing procedures conducted in crowded emergency departments or medical wards with sub-optimal infection prevention and control measures in place resulted in human-to-human transmission and environmental contamination.
Community-acquired cases and reported links to dromedary camels
Since the last update, 56 human cases are believed to have been infected in the community. Of these 56 reported cases, 37 (66.1%) reported direct or indirect contact with dromedaries in Saudi Arabia (33 cases), Oman (2 cases), the United Arab Emirates (one case) and Malaysia (one case; contact with dromedary was in Saudi Arabia).
Improvement in multi-sectoral investigation of community-acquired cases is evident, including testing of dromedary animals/herds in the vicinity of community-acquired laboratory-confirmed cases and follow-up of human contacts of laboratory-confirmed cases. The Ministries of Health in affected countries notify the Ministries of Agriculture when human cases report a link with animals. Investigations in animals are carried out by officials from the Ministries of Agriculture and results, if positive for MERS-CoV, are reported to OIE.
Exported cases identified outside the Middle East Since the last update, one case was reported outside of the Middle East. The case, a 55 year old, had recently returned from Jeddah to Malaysia in December 2017. The patient was treated and recovered, contacts were identified and followed and no further cases were identified by authorities in Malaysia.

Summary – information available from 2012 to date
Thus far, no sustained human-to-human transmission has occurred anywhere in the world, however limited non-sustained human-to-human transmission in health care facilities remains a prominent feature of this virus. WHO continues to work with health authorities in the affected countries to prevent and minimize health care-associated cases. WHO understands that health authorities in affected countries, especially those in the most affected countries, are aggressively investigating cases and contacts, including testing for MERS-CoV among asymptomatic contacts, and applying mitigation measures to stop human-to-human transmission in health care settings. These efforts are proving successful in mitigating the size of outbreaks.

Of all laboratory-confirmed cases reported to date (n=2228), the median age is 52 (IQR 37-65) and 67.2% are male.
At the time of reporting, 21% of the 2228 cases were reported to have no or mild symptoms, while 46% had severe disease or died. Overall, 18.6% of the cases reported to date are health care workers.

Since 2012, 27 countries have reported cases of MERS-CoV infection. In the Middle East: Bahrain, Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, the United Arab Emirates and Yemen; in Africa: Algeria and Tunisia; in Europe: Austria, France, Germany, Greece, Italy, the Netherlands, Turkey and the United Kingdom; in Asia: China, the Republic of Korea, Malaysia, the Philippines and Thailand; and in the Americas: the United States of America (Table 1).
The majority of cases (approximately 83%) have been reported from Saudi Arabia (Figure 1).
Populations in close contact with dromedaries (e.g. farmers, abattoir workers, shepherds, dromedary owners) and health care workers caring for MERS-CoV patients are believed to be at higher risk of infection. Healthy adults infected with MERS-CoV tend to have mild subclinical or asymptomatic infections. To date, limited human-to-human transmission has occurred between close contacts of confirmed cases in household settings. More efficient human-to-human transmission occurs in health care settings due to inadequate and/or incomplete compliance with the infection prevention and control measures and delay in triage or isolation of suspected MERS patients. Health care-associated transmission has been documented in several countries between 2012-2016, including Saudi Arabia, Jordan, the United Arab Emirates, France, the United Kingdom, and the Republic of Korea with varying outbreak sizes (2-180 reported cases per outbreak). The largest outbreak outside of the Middle East occurred in the Republic of Korea resulting in 186 cases (including one case who travelled to China) and 39 deaths. Overall, the reproduction number (R0) of MERS-CoV is <1 with significant heterogeneity in specific contexts. Specifically, outbreaks in health care settings can have R>1, but they can be brought under control (R<1) with proper application of infection prevention and control measures and early isolation of subsequent cases.

NYT

“…..aid had been slow in reaching victims, especially those in far-flung areas.

“There are some refugees who have not received aid,” he said, “especially in remote or isolated areas.”

But….the government had sent out 200 pickup trucks on Wednesday to deliver rice, cooking oil, drinking water and food staples.

In North Lombok, the region hit hardest by the quake, tent camps have sprung up in open fields near ruined villages. Some in the camps said they had received government deliveries of instant noodles and drinking water, but little else.

Increasingly desperate, many displaced villagers have taken to standing in the middle of the area’s main road, seeking donations from passing motorists.

https://www.youtube.com/watch?v=65d5Lc4S5lU

To slow traffic and attract attention, some locals stand in the middle of the road, holding out cardboard boxes for donations or flags and handwritten signs asking for assistance. Some even bring out plastic chairs and sit in the middle of the road with their donation boxes……”

WHO

As of 17 July 2018, a total of 19 Nipah virus (NiV) cases, including 17 deaths, were reported from Kerala State: 18 of the cases were laboratory-confirmed and the deceased index case was suspected to have NiV but could not be tested. The outbreak was localized to two districts in Kerala State: Kozhikode and Malappuram. No new cases or deaths have been reported since 1 June 2018 and, as of 30 July, human-to-human transmission of NiV has been contained in Kerala State.

As reported in the Disease Outbreak News published on 31 May 2018, three deaths due to NiV infection were reported on 19 May from Kozhikode District, Kerala State. Three of the four reported deaths were confirmed positive for NiV by real-time polymerase chain reaction (RT-PCR) and IgM ELISA for NiV.

Two patients recovered completely and were discharged from the hospital. Acute respiratory distress syndrome and encephalitis were observed among the patients infected. This was the first NiV outbreak reported in Kerala State and the third NiV outbreak known to have occurred in India; the two previous outbreaks occurred in the state of West Bengal in 2001 and 2007.

Public health response

Government response

• A multi-disciplinary central team from the National Centre for Disease Control was sent to Kerala to investigate and respond, in close coordination with state government officials.
• More than 2600 contacts were identified and followed up during the outbreak. All symptomatic contacts were investigated and tested for NiV.
• Syndromic surveillance was enhanced in Kerala State. Hospital and community surveillance were also strengthened in Kerala. The Virus Research Diagnostic Laboratory at Manipal Hospital and the National Institute of Virology conducted laboratory testing to confirm and rule out cases.
• The central team provided Kerala officials with the following guidelines and reference materials for Nipah virus, which were made publically available during the outbreak: case definitions; guidelines for hospital infection prevention and control; guidelines for sample collection and transportation; clinical management guidelines for suspected and confirmed cases; guidelines for safe disposal of dead bodies of confirmed Nipah virus cases; and information for the general public and for health care personnel. Risk communication messages were delivered to the community, public, partners and other stakeholders.
• Training and capacity building for health care personnel were done in the following areas: sample collection and transportation; safe disposal of dead bodies; contact tracing; hospital waste management; hospital infection prevention and control; and the use of personal protective equipment.
• The government coordinated amongst all relevant sectors including zoonoses, wildlife, animal husbandry, human health, clinicians, pulmonologists, neurologists and private sector.
• The Strategic Health Operations Centre (SHOC) at the National Centre for Disease Control was activated to monitor the outbreak.
• The Ministry of Health provided the Kerala government with 5000 personal protective equipment kits and 100 body bags.
• Samples from animals (bats, pigs, cows, and goats) tested at National High Security Animal Diseases Laboratory at Bhopal early in the outbreak tested negative for NiV. Later, Pteropus giganteus bats (the reservoir of NiV infection) were collected from areas around the house of the index case in Kozhikode, Kerala to understand the circulation of NiV in bats in the affected area; 19% (10 of 52) of the bats were found positive by RT-PCR for NiV.

WHO response

• As per the International Health Regulations (IHR 2005), the event was notified to WHO on 23 May 2018 and WHO published a Disease Outbreak News on 31 May 2018.
• WHO provided technical materials and guidance on Nipah virus disease to the Ministry of Health and Kerala State health authorities, and provided technical support to the Ministry of Health.
• WHO continues to work closely with the Ministry of Health to strengthen overall indicator- and event-based surveillance for epidemic-prone diseases and strengthen overall IHR (2005) capacities.
• WHO is also working with the Indian Council of Medical Research (ICMR) to advance the research agenda for the Nipah research and development (R&D) blueprint. WHO will continue working closely with the Ministry of Health to ensure that health systems preparedness for emerging zoonoses is strengthened in the country.

WHO risk assessment

NiV infection is an emerging zoonotic disease of public health importance in the WHO South-East Asia Region with a high case fatality rate estimated to range between 40 and 75%; however, this rate can vary by outbreak depending on local capabilities for epidemiological surveillance and clinical management. NiV was first recognized in 1998-1999 during an outbreak among pig farmers in Malaysia and Singapore. No subsequent outbreaks have been reported in Malaysia or Singapore since 1999. NiV was first recognized in India and Bangladesh in 2001; since then, nearly annual outbreaks have occurred in Bangladesh. The disease has been identified periodically in eastern India (2001, 2007).

Limited human-to-human transmission of NiV can occur among unprotected family members and health workers who treat infected patients. Fruit bats of the genus Pteropus are the natural reservoirs of NiV. Possible routes of transmission of NiV include consumption of fruit contaminated by the saliva of infected bats, from direct contact with infected bats or their feces/urine, or human-to-human transmission through unprotected close contact with an infected patient in the community or hospital. Many cases identified in the current outbreak were infected through direct unprotected contact with other infected persons.

This outbreak is the third Nipah virus outbreak in India. The country demonstrated its capacity to rapidly contain the outbreak, including by the identification of cases, verifying cases with laboratory testing and caring for patients.

WHO advice

Currently, there is no evidence of NiV infection in humans in Kerala State; however, surveillance for NiV in humans and fruit bats should be maintained in endemic areas.

WHO advises against the application of any travel or trade restrictions on India based on the information currently available on this event.

Currently, there are no specific treatments available for Nipah virus disease and care is supportive. Intensive supportive care is recommended to treat severe respiratory and neurologic complications.

NiV infection can be prevented by avoiding exposure to bats and sick pigs in endemic areas, and by avoiding consuming fruits partially-eaten by infected bats or drinking raw date palm sap/toddy/juice. The risk of international transmission via fruit contaminated with urine or saliva from infected fruit bats can be prevented by washing them thoroughly and peeling them before consumption. Fruit with signs of bat bites should be discarded.

In health care settings, staff should consistently implement standard infection prevention and control measures when caring for patients to prevent nosocomial infections. Health care workers caring for a patient suspected to have NiV fever should immediately contact local and national experts for guidance and to arrange for laboratory testing.

Research is needed to better understand the ecology of bats and NiV.

DRC 

One more Ebola case was confirmed.

• The overall total is now 44, which included 17 confirmed and 27 probable cases.
• Health officials are investigating an additional 47 cases.
• So far 36 deaths have been reported.