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#Avian #Influenza #H7N9 in #China: Preventing the Next #SARS (@WHO, Apr. 2 ‘17)

  Title : #Avian #Influenza #H7N9 in #China: Preventing the Next #SARS. Subject : Avian Influenza, H7N9 subtype (Asian Lineage), poultry e...

22 Jul 2017

#HK, Secretary for Food and #Health on seasonal #influenza (Jul 22 ‘17)


Title: #HK, Secretary for Food and #Health on seasonal #influenza.

Subject: Seasonal influenza epidemic in Hong Kong, current situation.

Source: Government of Hong Kong PRC SAR, full page: (LINK).

Code: [     ]

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SFH on seasonal influenza

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Following is the transcript of remarks made by the Secretary for Food and Health, Professor Sophia Chan, after attending a public function today (July 22):

Reporter: ‘’....... hospital wards with the outbreak of influenza A. What would the Hospital Authority (HA) do to control such outbreak?’’

Secretary for Food and Health: ‘’Actually the Hospital Authority has done a lot of short term measures to deal with this summer surge of flu season.

‘’One of the measures is using some of the private hospital beds of St Teresa Hospital.

‘’Another measure is to increase the number of medical and healthcare staff, using some part-time and special honorarium scheme for people already working in the hospitals.

‘'Another measure is to delay some of the non-urgent procedures in the hospitals to allow more beds to cater for the additional number of admission.

‘’The HA will continue to monitor the situation and the increased service demand.

Reporter: ‘’There has been some reports saying that hospital wards had outbreak of influenza A, for example, the Caritas Medical Centre. How would HA do to control such outbreak within wards? ‘’

Secretary for Food and Health: ‘’Infection control measures are very important in the hospitals or within the wards. Therefore, the HA really focusses on different infection control measures such as hand hygiene or other hygiene measures within the clinical wards so that people admitted to hospitals could be shielded from some of the infections around them.

(Please also refer to the Chinese portion of the transcript.)

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Keywords: HK PRC SAR; Updates; Seasonal Influenza; H3N2.

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#Influenza and other #Respiratory #Viruses #Research #References #Library– July 22 2017 Issue


Title: #Influenza and other #Respiratory #Viruses #Research #References #Library– July 22 2017 Issue.

Subject: Human and Animal Influenza Viruses, other respiratory pathogens research, weekly references library update.

Source: AMEDEO, homepage: (LINK).

Code: [  R  ]

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New References:

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  1. MGBERE O, Ngo K, Khuwaja S, Mouzoon M, et al.
    • Pandemic-related health behavior: repeat episodes of influenza-like illness related to the 2009 H1N1 influenza pandemic.
      • Epidemiol Infect. 2017 Jul 20:1-7. doi: 10.1017/S0950268817001467.
  2. KANDEIL A, Kayed A, Moatasim Y, Webby RJ, et al.
    • Genetic characterization of highly pathogenic avian influenza A H5N8 viruses isolated from wild birds in Egypt.
      • J Gen Virol. 2017 Jul 18. doi: 10.1099/jgv.0.000847.
  3. TULLY CM, Chinnakannan S, Mullarkey CE, Ulaszewska M, et al.
    • Novel Bivalent Viral-Vectored Vaccines Induce Potent Humoral and Cellular Immune Responses Conferring Protection against Stringent Influenza A Virus Challenge.
      • J Immunol. 2017 Jul 19. pii: ji1600939. doi: 10.4049/jimmunol.1600939.
  4. NTURIBI E, Bhagwat AR, Coburn S, Myerburg MM, et al.
    • Intracellular Colocalization of Influenza Viral RNA and Rab11A is Dependent upon Microtubule Filaments.
      • J Virol. 2017 Jul 19. pii: JVI.01179-17. doi: 10.1128/JVI.01179.
  5. BOYOGLU-BARNUM S, Todd SO, Meng J, Barnum TR, et al.
    • Mutating the CX3C motif in the G protein should make a live respiratory syncytial virus vaccine safer and more effective.
      • J Virol. 2017 Mar 8. pii: JVI.02059-16. doi: 10.1128/JVI.02059.
  6. ZHANG L, Li H, Hai Y, Yin W, et al.
    • CpG in Combination with an Inhibitor of Notch Signaling Suppresses Formalin-Inactivated Respiratory Syncytial Virus-Enhanced Airway Hyperresponsiveness and Inflammation by Inhibiting Th17 Memory Responses and Promoting Tissue-Resident Memory Cells in Lungs.
      • J Virol. 2017;91.
  7. WIEGAND MA, Gori-Savellini G, Gandolfo C, Papa G, et al.
    • Respiratory syncytial virus (RSV) vaccine vectored by a stable chimeric and replication-deficient Sendai virus protects mice without inducing enhanced disease.
      • J Virol. 2017 Mar 1. pii: JVI.02298-16. doi: 10.1128/JVI.02298.
  8. MORCL T, Hurst BL, Tarbet EB.
    • Calcium phosphate nanoparticle (CaPNP) for dose-sparing of inactivated whole virus pandemic influenza A (H1N1) 2009 vaccine in mice.
      • Vaccine. 2017 Jul 14. pii: S0264-410X(17)30912.
  9. MAKARKOV AI, Chierzi S, Pillet S, Murai KK, et al.
    • Plant-made virus-like particles bearing influenza hemagglutinin (HA) recapitulate early interactions of native influenza virions with human monocytes/macrophages.
      • Vaccine. 2017 Jul 13. pii: S0264-410X(17)30908.
  10. ALKHERAIF AA, Topliff CL, Reddy J, Massilamany C, et al.
    • Type 2 BVDV Npro suppresses IFN-1 pathway signaling in bovine cells and augments BRSV replication.
      • Virology. 2017;507:123-134.

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Keywords: Research; Abstracts; Influenza References Library.

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21 Jul 2017

#HK, First local #blood-borne case of #Japanese #encephalitis confirmed (CHP, Jul 21 ‘17)


Title: #HK, First local #blood-borne case of #Japanese #encephalitis confirmed.

Subject: Japanese encephalitis, autochthonous case in Hong Kong.

Source: Centre for Health Protection, Hong Kong PRC SAR, full page: (LINK).

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First local blood-borne case of Japanese encephalitis confirmed

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The Centre for Health Protection (CHP) of the Department of Health today (July 21) confirmed the first local case of Japanese encephalitis (JE) transmitted by blood transfusion in hospital.

The Controller of the CHP, Dr Wong Ka-hing, said,

"Following investigations into the case reported yesterday (July 20), experts in epidemiology, public health, infection control and microbiology of the CHP and the Hospital Authority have been working closely and held meetings on public health assessment and necessary follow-up to be conducted by parties concerned."

Investigations revealed that the male patient aged 52 had received a number of blood transfusions during hospitalisation.

Residual samples of the blood transfused to the patient in the incubation period were retrieved for laboratory investigations.

Upon the CHP's testing, one blood sample from Queen Mary Hospital (QMH) and one from the Hong Kong Red Cross Blood Transfusion Service tested positive for JE virus, both originating from the same donation which was transfused to the patient on June 22.

Of note, the genetic sequence of the virus from the positive sample from QMH was identical to that of the patient. Samples from three other donations transfused to the patient on different dates tested negative.

The CHP has swiftly conducted source tracing and identified the 46-year-old male blood donor concerned who gave blood on May 29. He has been asymptomatic all along.

Contact tracing has identified two other patients who had received the donor's blood products. One is a discharged patient of QMH who received transfusion on June 2 and QMH is contacting the patient for clinical assessment and blood testing. The other is a patient of Queen Elizabeth Hospital who died of chronic illness on July 4 after surgery, during which the patient received transfusion on June 20. Relatives will be contacted.

Epidemiologically, the donor had no travel history to JE-endemic areas and his home contact has remained asymptomatic. He lives in Kingswood Villas, Tin Shui Wai and recalled no mosquito bites.

"The CHP will proceed standard public health actions as a precautionary measure. The Food and Environmental Hygiene Department (FEHD) and the Agriculture, Fisheries and Conservation Department have been informed for necessary follow-up," Dr Wong said.

Officers of the CHP will conduct site visit and field investigations by questionnaire surveys at the donor's residence for active case finding and arranging blood tests. A health talk will be held at 9.30am tomorrow (July 22) with the FEHD to deliver health advice to residents and the public.

In addition, site visit has been conducted at Grantham Hospital and a health talk was held this afternoon.

The CHP's JE hotline (2125 1122) will operate from 9am to 5.45pm this weekend and next week.

The Guangdong and Macau health authorities have been informed of the case and the CHP will issue letters to doctors and hospitals to alert them to the latest situation.

While JE is principally mosquito-borne, overseas scientific literature show that, based on nature of similar flaviviruses, blood transfusion and organ transplant are considered to be potential modes of transmission of JE virus.

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Keywords: HK PRC SAR; Updates; Japanese Encephalitis; Blood Safety.

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Highly pathogenic #avian #influenza #H5N8, #DRC [three #poultry #outbreaks] (#OIE, Jul 21 ‘17)


Title: Highly pathogenic #avian #influenza #H5N8, #DRC [three #poultry #outbreaks].

Subject: Avian Influenza, H5N8 subtype, poultry epizootics in the Dem. Rep. of the Congo.

Source: OIE, full page: (LINK).

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Highly pathogenic avian influenza H5N8, Congo (Dem. Rep. of the)

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Information received on 19/07/2017 from Mr Honoré Robert N'Lemba Mabela, Directeur et Chef de service, Service de la Production & de la Santé Animale, Ministère de l'Agriculture, Pêche et Elevage , KINSHASA, Congo (Dem. Rep. of the)

  • Summary
    • Report type    Follow-up report No. 3
    • Date of start of the event    25/04/2017
    • Date of confirmation of the event    24/05/2017
    • Report date    19/07/2017
    • Date submitted to OIE    19/07/2017
    • Reason for notification    First occurrence of a listed disease
    • Manifestation of disease    Clinical disease
    • Causal agent    Highly pathogenic avian influenza virus
    • Serotype    H5N8
    • Nature of diagnosis    Laboratory (advanced)
    • This event pertains to    a defined zone within the country
  • Summary of outbreaks   
    • Total outbreaks: 3
      • Total animals affected: Species    - Susceptible    - Cases    - Deaths    - Killed and disposed of – Slaughtered
        • Birds    - 336    - 348    - 348    - 0    - 0
      • Outbreak statistics: Species    - Apparent morbidity rate    - Apparent mortality rate    - Apparent case fatality rate    - Proportion susceptible animals lost*
        • Birds    - **    - **    - 100.00%    - **
          • *Removed from the susceptible population through death, destruction and/or slaughter
          • **Not calculated because of missing information
  • Epidemiology
    • Source of the outbreak(s) or origin of infection   
      • Unknown or inconclusive
  • Epidemiological comments   
    • Highly pathogenic avian influenza virus H5N8 serotype clade 2.3.4.4 was confirmed.

(...)

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Keywords: OIE; Updates; Avian Influenza; H5N8 ; Poultry; DRC.

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Highly pathogenic #avian #influenza #H5N8, #Italy [two #poultry #outbreaks] (#OIE, Jul 21 ‘17)


Title: Highly pathogenic #avian #influenza #H5N8, #Italy [two #poultry #outbreaks].

Subject: Avian Influenza, H5N8 subtype, poultry epizootics in Italy.

Source: OIE, full page: (LINK).

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Highly pathogenic avian influenza H5N8, Italy

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Information received on 21/07/2017 from Prof. Dr. Romano Marabelli, Chief Veterinary Officer, Secretary General, Ministry of Health, Rome, Italy

  • Summary
    • Report type    Follow-up report No. 16
    • Date of start of the event    20/01/2017
    • Date of confirmation of the event    21/01/2017
    • Report date    21/07/2017
    • Date submitted to OIE    21/07/2017
    • Reason for notification    Recurrence of a listed disease
    • Date of previous occurrence    17/01/2015
    • Manifestation of disease    Clinical disease
    • Causal agent    Highly pathogenic avian influenza virus
    • Serotype    H5N8
    • Nature of diagnosis    Clinical, Laboratory (advanced)
    • This event pertains to    a defined zone within the country
  • Summary of outbreaks   
    • Total outbreaks: 2
      • Total animals affected: Species    - Susceptible    - Cases    - Deaths    - Killed and disposed of  - Slaughtered
        • Birds    - 20563    - 18874    - 1692    - 0    - 0
      • Outbreak statistics: Species    - Apparent morbidity rate    - Apparent mortality rate    - Apparent case fatality rate    - Proportion susceptible animals lost*
        • Birds    - 91.79%    - 8.23%    - 8.96%    - **
          • *Removed from the susceptible population through death, destruction and/or slaughter
          • **Not calculated because of missing information
  • Epidemiology
    • Source of the outbreak(s) or origin of infection   
      • Unknown or inconclusive
  • Epidemiological comments   
    • The National Reference Laboratory has sequenced HPAI subtype H5N8.
    • A protection zone of 3 km and a surveillance zone of 10 km have been established.

(...)

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Keywords: OIE; Updates; Avian Influenza; H5N8 ; Poultry; Italy.

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Highly pathogenic #avian #influenza #H5N8, #Italy [two #poultry #outbreaks] (#IZSVE, Jul 21 ‘17)


Title: Highly pathogenic #avian #influenza #H5N8, #Italy [two #poultry #outbreaks].

Subject: Avian Influenza, H5N8 subtype, poultry enzootic in Italy.

Source: Italy National Reference Laboratory for Avian Influenza, Padua, full page: (LINK).

Code: [     ]

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Highly pathogenic avian influenza H5N8, Italy

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|-- Outbreaks | PDF (last update: 21/07/2017) —|

|-- Map | PDF (last update: 21/07/2017) –|


Summary

  • 21/07/2017 
    • On 20 July, the National Reference Laboratory (NRL) for Avian Influenza and Newcastle Disease confirmed as positive for Avian Influenza virus subtype H5N8 two farms located in Lombardy region: a rural holding and a fattening turkey industrial farm in Mantua province.
    • Epidemiological investigations are ongoing in both outbreaks.
    • An increase in mortality was reported in the previous days in one of the sheds of the industrial farm where about 18.900 fattening female turkeys (106 day-old) were present.
    • Further information on virus characterization and on the cases will be provided as soon as available.
    • In the same date, Regional Authority of Lombardy notified a suspect of avian influenza in a laying hens farm (500.000 heads) in Mantua province.
    • Today, the NRL characterised both the viruses as Highly Pathogenic Avian Influenza.

(…)

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Keywords: Avian Influenza, H5N8, Poultry; Italy, Update.

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#Cholera – #Kenya (@WHO, Jul 21 ‘17)


Title: #Cholera – #Kenya.

Subject: Cholera outbreak in Kenya, current situation.

Source: World Health Organization (WHO), full page: (LINK).

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Cholera – Kenya

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Disease Outbreak News / 21 July 2017

Since the beginning of 2017, Kenya is experiencing an upsurge of cholera cases. The first cholera outbreak reported in 2017 was in Tana River County. The outbreak started on 10 October 2016 and was controlled by April 2017.

A second wave of cholera outbreaks started in Garissa County on 2 April 2017 and was reported later in nine other counties including Nairobi, Murang’a, Vihiga, Mombasa, Turkana, Kericho, Nakuru, Kiambu, and Narok.

The outbreak is being reported in the general population and in refugee camps. In Garissa County, the outbreak is affecting mainly Dadaab refugee camps and cases and deaths are being reported from Hagadera, Dagahaleh, and IFO2 camps. In Turkana county, the disease is also affecting Kakuma and Kalobeyei refugee camps.

In addition to the outbreak reported in the general population, there have been two point source cholera outbreaks in Nairobi County.

One occurred among participants attending a conference in a Nairobi hotel on 22 June 2017. A total of 146 patients associated with this outbreak have been treated in different hospitals in Nairobi. A second outbreak occurred at the China Trade Fair held at the KICC Tsavo Ball between 10 and 12 July 2017. A total of 136 cases were reported and one death.

Currently, the outbreak is active in two counties, namely Garissa and Nairobi. As of 17 July 2017, a total of 1216 suspected cases including 14 deaths (case fatality rate: 1.2%) have been reported since 1 January 2017. In the week ending 16 July 2017, a total of 38 cases with no deaths were reported.

A total of 124 cases tested positive for Vibrio cholerae in the reference laboratory. In the week ending 25 June 2017, 18 samples out of 25 tested positive for Vibrio cholerae Ogawa by culture at the National Public Health Laboratory in Nairobi.

The main causative factors of the current outbreak include the high population density that is conducive to the propagation and spread of the disease, mass gatherings (a wedding party held in Karen and in a hotel during an international conference), low access to safe water and proper sanitation and the massive population movements in country and with neighbouring countries.

Since December 2014, the Republic of Kenya has been experiencing continuous large outbreaks of cholera, with a cumulative total of 17 597 cases reported (10 568 cases reported in 2015 and 6448 in 2016).


Public health response

The country has activated the national task force to coordinate the response to the outbreak. Since January 2017, WHO and partners are providing technical support to the country for the control of the outbreak. The country will develop a response plan with focus on the preparedness interventions to avert further spread of the outbreak.

The WHO country office will repurpose their staff members and experts deployed in Nairobi for the management of the post El Niño effects in the Horn of Africa to support the quick control of this outbreak. WHO will also support the five most at risk counties with disease surveillance and response coordination. Partners on the ground are committed to provide support to the ongoing response efforts including support to primary health care and social mobilization by United Nations Children’s Fund (UNICEF).


WHO risk assessment

Cholera is an acute enteric infection caused by the ingestion of bacterium Vibrio cholerae present in faecally contaminated water or food. It is primarily linked to insufficient access to safe water and adequate sanitation. Cholera is always considered a potentially serious infectious disease and can cause high morbidity and mortality. It has the potential to spread rapidly, depending on the exposure frequency, population exposed and the context.

Cholera outbreaks have been reported in the Republic of Kenya every year with large cyclical epidemics every five to seven years.

The risk of the current outbreak is assessed as high at national and regional levels and moderate at global level. The outbreak occurred in the context of a sub-regional drought, conflicts and insecurity in the Horn of Africa. In addition, the outbreak is affecting the densely populated capital city Nairobi, and two large refugee camps (Kakuma and Dadaab) with massive population movements within country and between neighbouring countries.

Previous large outbreaks in the Republic of Kenya have originated from similar settings, and the risk for propagation of cholera within the affected area as well as to other parts of the country is high. The country has identified a limited capacity for response and low access to safe water. There is an opportunity to implement early preparedness and response measures to contain the outbreak and prevent spread.

The current outbreaks linked to mass gathering activities poses additional risk of food safety as well as the need to conduct sanitary inspection in restaurants and hotels.


WHO recommendations

WHO recommends improving the readiness of counties and health facilities to early detect and respond to the cholera outbreak as well as the reinforcement of coordination and multisectoral approaches. In addition, hygiene practices in households, restaurant, hotels, refugee camps and health facilities should be improved and food safety interventions should be strengthened.

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

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Keywords: WHO; Updates; Cholera; Kenya.

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#WestNile fever in #Europe in 2017; updated 21 July (@ECDC_EU, summary)


Title: #WestNile fever in #Europe in 2017; updated 21 July.

Subject: WNV activity in the European Region, current situation.

Source: European Centre for Disease Prevention and Control (ECDC), full page: (LINK).

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West Nile fever in Europe in 2017; updated 21 July

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Summary

  • This week the first confirmed human case of West Nile fever in the EU was reported and detected in southern Greece.
  • In the neighbouring countries, three new cases have been detected in Israel of which one is confirmed.
  • Since the beginning of the 2017 transmission season and as of 20 July 2017, one human case of West Nile fever has been reported in the EU.
  • In the neighbouring countries, one confirmed case and three probable cases have been reported by Israel.

(…)

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Keywords: ECDC; Updates; European Region; WNV; Israel; Greece.

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#HK CHP notified of one #human case of #avian #influenza #H7N9 in #China (Jul 21 ‘17)


Title: #HK CHP notified of one #human case of #avian #influenza #H7N9 in #China.

Subject: Avian Influenza, H7N9 subtype, human cases in China, weekly report.

Source: Centre for Health Protection, Hong Kong PRC SAR, full page: (LINK).

Code: [     ]

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CHP notified of human case of avian influenza A(H7N9) in Jiangsu

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The Centre for Health Protection (CHP) of the Department of Health is today (July 21) monitoring a notification from the National Health and Family Planning Commission that one additional human case of avian influenza A(H7N9) was recorded from July 14 to 20 in Jiangsu, and strongly urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

The 62-year-old female patient in Nanjing was known to have exposure to live poultry market and had onset on July 12.

(…)

The public may visit the CHP's pages for more information:

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Ends/Friday, July 21, 2017 / Issued at HKT 20:35 / NNNN

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Keywords: HK PRC SAR; Updates; H7N9; Avian Influenza; Human; China; Jiangsu.

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20 Jul 2017

#Cluster of #AFM in Five #Pediatric Patients — Maricopa County, #Arizona, 2016 (@CDCgov, MMWR)


Title: #Cluster of #AFM in Five #Pediatric Patients — Maricopa County, #Arizona, 2016.

Subject: Acute Flaccid Myelitis, cluster of cases in Arizona, USA.

Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK).

Code: [     ]

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Notes from the Field: Cluster of Acute Flaccid Myelitis in Five Pediatric Patients — Maricopa County, Arizona, 2016

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Weekly / July 21, 2017 / 66(28);758–760

Format: [ PDF [177K] ]

Sally A. Iverson, DVM1,2,3; Scott Ostdiek, MD4; Siru Prasai, MD2; David M. Engelthaler, PhD5; Melissa Kretschmer, MA2; Nicole Fowle2; Harlori K. Tokhie, MD4; Janell Routh, MD6; James Sejvar, MD7; Tracy Ayers, PhD6; Jolene Bowers, PhD5; Shane Brady, MPH3; Shannon Rogers, MS6; W. Allan Nix, PhD6; Ken Komatsu, MPH3; Rebecca Sunenshine, MD2,8; AFM Investigation Team

Authors Affiliations: 1Epidemic Intelligence Service, CDC; 2Maricopa County Department of Public Health, Phoenix, Arizona; 3Arizona Department of Health Services; 4Phoenix Children’s Hospital, Arizona; 5Translational Genomics Research Institute, Flagstaff, Arizona; 6Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC; 7Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 8Career Epidemiology Field Officer Program, CDC; 9Maricopa Integrated Health System, Phoenix, Arizona.

Corresponding author: Sally A. Iverson, lyu3@cdc.gov, 602-359-0424.

Suggested citation for this article: Iverson SA, Ostdiek S, Prasai S, et al. Notes from the Field: Cluster of Acute Flaccid Myelitis in Five Pediatric Patients — Maricopa County, Arizona, 2016. MMWR Morb Mortal Wkly Rep 2017;66:758–760. DOI: http://dx.doi.org/10.15585/mmwr.mm6628a4.

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Abstract

In 2016, CDC saw an increase in cases of acute flaccid myelitis (AFM); 144 persons in 37 states and the District of Columbia were confirmed to have AFM. After investigations in California (1) and Colorado (2) in 2014, CDC characterized AFM as an acute flaccid paralysis (AFP) distinguishable by magnetic resonance imaging (MRI) abnormalities of the gray matter of the anterior and posterior spinal cord segments, involving one or more spinal segments (3). Although certain viruses (e.g., nonpoliovirus enteroviruses, adenoviruses, and West Nile virus) can cause rare cases of AFP, and findings from the 2014 outbreak investigations indicated that enterovirus D68 (EV-D68) was temporally associated with AFM, no viral etiology for AFM has been definitively established (3). In September 2016, an acute care hospital in Arizona notified the Maricopa County Department of Public Health (MCDPH) of a suspected case of AFM and subsequent cluster of 11 children who were evaluated with similar neurologic deficits; differential diagnoses included transverse myelitis and AFM. The Maricopa County Department of Public Health, in cooperation with the Arizona Department of Health Services, CDC, the Translational Genomics Research Institute (TGen, Flagstaff, Arizona), and the acute care hospital, initiated an investigation to confirm AFM cases and identify an etiology.

The 2015 Council of State and Territorial Epidemiologists and CDC case definition for probable AFM requires acute onset of flaccid limb weakness and cerebrospinal fluid (CSF) pleocytosis (CSF white blood cell [WBC] count >5/mm3 when corrected for red blood cells).

A confirmed case must have an MRI demonstrating lesions restricted primarily to the gray matter of the spinal cord, in addition to acute onset of flaccid limb weakness (4).

Based on medical chart abstraction and review of the MRI images, a CDC neurology subject matter expert verified four confirmed cases of AFM and one probable case.

Among the six patients whose cases did not meet the AFM confirmed or probable case definition, two had focal limb weakness and pleocytosis (CSF WBC = 7/mm3 and 22/mm3, respectively), but MRI results indicated alternative etiologies (acute disseminated encephalomyelitis and neuromyelitis optica, respectively). The case that met the probable case definition had pleocytosis (CSF WBC = 7/mm3), but MRI findings were inconsistent with AFM, and no other plausible diagnosis was identified.

Onset dates for the four confirmed cases occurred during August 19–September 15, 2016. All four patients had preceding respiratory (three patients) or gastrointestinal illness (one patient), with onset dates for those illnesses occurring during August 14–September 13. Their illness began a median of 2 days (range = 2–5 days) before onset of focal limb weakness; three patients experienced tactile or measured fever preceding onset of neurologic symptoms (Table).

Among patients with confirmed cases, focal limb weakness was present in a single limb (one case), three limbs (two cases), and four limbs (one case). Two patients with confirmed cases and one patient with a probable case had a prior medical history of asthma, and a third patient with a confirmed case reported a family history of asthma.

The investigation team conducted hypothesis-generating interviews with all confirmed AFM patients and their proxies. Three of the four patients with confirmed cases were residents of Maricopa County, and no epidemiologic links were detected among the four patients. None of the patients had traveled to an area with ongoing Zika virus transmission in the month prior to symptom onset.

CSF was collected from all four patients with confirmed AFM. Median CSF WBC count was 133/mm3 (range = 50–207), and initial viral testing at the hospital included CSF reverse transcription–polymerase chain reaction (RT-PCR) assays for enterovirus (three patients) and West Nile virus (WNV) (two patients), polymerase chain reaction (PCR) assay for herpes simplex virus (two patients), and enzyme immunoassay to detect immunoglobulin M (IgM) or immunoglobulin G (IgG) for WNV (three patients). All results were negative.

All four CSF specimens were negative on TGen amplicon sequencing assay (5,6) using primers based on the 2014 circulating EV-D68 virus.

Results of microbiome analysis by metagenomic sequencing of RNA and 16S rRNA gene sequencing of DNA extracted from CSF revealed bacterial sequencing dominated by Propionibacterium, which is a normal component of the skin flora and most likely represents a contaminant (7).

Serum collected from one patient at initial evaluation was negative for WNV IgM and IgG on a hospital immunoassay; serum collected from the same patient 47 days after onset of focal limb weakness and from two additional patients (19 and 26 days after onset of focal limb weakness) were negative for WNV IgM and St. Louis encephalitis IgM at the Arizona State Public Health Laboratory.

Three of the four patients had nasopharyngeal (NP) swabs available from initial evaluation that were forwarded to CDC; one specimen was positive for enterovirus/rhinovirus on a panviral respiratory PCR panel at the admitting hospital laboratory and for EV-D68 at CDC. RNA extracted from NP swabs from all three patients was positive by the TGen amplicon sequencing test for EV-D68 (GenBank Bioproject); an NP specimen from a patient who did not meet the AFM confirmed or probable case definitions also was positive for EV-D68 by the same assay.

Stool specimens were collected from two patients at the time of initial evaluation; vital cultures of these specimens were negative on viral. One available specimen and three additional specimens, collected 28, 47, and 63 days after onset of focal limb weakness, were sent to CDC for four enterovirus/parechovirus RT-PCR assays. A stool specimen, collected at day 28 from the patient who did not have an NP swab available, was positive for coxsackievirus A10.

This cluster of AFM at one children’s acute care hospital is the largest cluster identified to date in Arizona and is part of a nationally identified increase in AFM cases. Although no statewide surveillance system specific to AFM is available, this cluster was detected by physician reporting, highlighting the need for physicians to remain vigilant for this emerging disease and to report cases that fit the AFM case definition to their local health department.

Metagenomic analyses identified EV-D68 in NP swabs from the three patients for whom specimens were available, along with a specimen from a patient who did not meet the AFM case definition; therefore, no single etiology or risk factor was associated with only confirmed cases.

Patient and family history of asthma was the most common comorbidity reported among confirmed AFM cases and should be considered in future case investigations. Expanded analysis of infectious, postinfectious, and noninfectious etiologies might provide further insight into the mechanism of AFM.


Acknowledgments

Kathryn Putman; Jennifer Adair, Bernny Apodaca, Phoenix Children’s Hospital, Neurology Department; Phoenix Children’s Hospital Infection, Department of Infection Prevention and Control; Arizona State Public Health Laboratory, Virology Section.

AFM Investigation Team

Tammy Sylvester, Maricopa County Department of Public Health, Arizona; Veronica Harrison, Translational Genomics Research Institute, Flagstaff, Arizona; Jennifer Heim, MD, Phoenix Children’s Hospital, Arizona; Susan Robinson, MPH, Arizona Department of Health Services; Gholamabbas A. Ostovar, MD, Maricopa Integrated Health System, Arizona; Kathryn Fitzpatrick, Arizona State Public Health Laboratory, Virology Section.

Conflict of Interest

David Engelthaler and Jolene Bowers have a provisional patent application in progress for a real-time polymerase chain reaction assay for the detection of Enterovirus D68 in complex specimens. No other conflicts of interest were reported.


References

  1. CDC. Notes from the field: acute flaccid myelitis among persons aged ≤21 years—United States, August 1–November 13, 2014. MMWR Morb Mortal Wkly Rep 2015;63:1243–4. PubMed
  2. Pastula DM, Aliabadi N, Haynes AK, et al. Acute neurologic illness of unknown etiology in children—Colorado, August–September 2014. MMWR Morb Mortal Wkly Rep 2014;63:901–2. PubMed
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  4. Council of State and Territorial Epidemiologists (CSTE). CSTE position statement: standardized case definition for acute flaccid myelitis. Atlanta, GA: Council of State and Territorial Epidemiologists; 2015. http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2015PS/2015PSFinal/15-ID-01.pdf
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TABLE. Characteristics of five pediatric patients with acute flaccid myelitis* — Maricopa County, Arizona, October 2016

[Characteristic - Patient 1 - Patient 2 - Patient 3 - Patient 4 - Patient 5]

  • Case status – Confirmed – Confirmed – Confirmed – Confirmed – Probable
  • Age at onset (yrs) - 3.5 – 10 – 4 – 9 – 12
  • Sex – Boy – Girl – Girl – Girl – Girl
  • Onset of focal limb weakness - August 23, 2016 - August 19, 2016 - September 15, 2016 - September 8, 2016 - August 27, 2016
  • Onset of preceding respiratory or gastrointestinal illness - August 21, 2016 (respiratory) - August 14, 2016 (respiratory) - September 13, 2016 (respiratory) - September 6, 2016 (gastrointestinal) - August 17, 2016 (respiratory)
  • Presence of fever (tactile or measured) – Yes – No – Yes – Yes – No
  • Limbs affected (region) - 1 (LUE) – 4 - 3 (BUE, RLE) – 4 - 1 (LUE)
  • Cranial nerve features and timing – None - Facial droop subsequent to onset of limb weakness - Facial droop subsequent to onset of limb weakness - Facial droop before onset of limb weakness - Diplopia concurrent with limb weakness
  • Patient and family history of asthma - Asthma and family history of asthma – Asthma – None - Family history of asthma - Mild asthma, seasonal allergies, food allergies, eczema
  • Corticosteroid history - Maintenance inhaled fluticasone; oral budesonide for asthma exacerbation August 15–19 - Maintenance inhaled fluticasone; oral prednisolone for asthma exacerbation beginning August 14 – None - Oral prednisolone for treatment of Bell’s palsy beginning September 5 - Maintenance inhaled fluticasone
  • Magnetic resonance imaging (MRI) findings - T2 signal abnormalities in anterior and posterior columns of the central gray cervical cord - T2 signal abnormality with anterior and posterior involvement, contiguous through multiple levels of the cord - T2 signal abnormality in the anterior horn of the central gray cord - Anterior horn signal abnormality extending four cervical levels - Normal MRI result
  • Cerebrospinal fluid/white blood cell/mm3 – 50 – 150 – 207 – 115 – 7
  • Nasopharyngeal swab polymerase chain reaction results from TGen - Positive for EV-D68 - Positive for EV-D68 - Positive for EV-D68 – Unavailable – Unavailable
  • Stool specimen testing results - Negative enterovirus/parechovirus by RT-PCR - Negative viral culture and enterovirus/parechovirus by RT-PCR - Negative viral culture and enterovirus/parechovirus by RT-PCR - Positive for coxsackievirus A10 by Sanger sequencing of the VP1 region – Unavailable

Abbreviations: BUE = bilateral upper extremities; EV = enterovirus; LUE = left upper extremity; RLE = right lower extremity; RT-PCR = reverse transcription–polymerase chain reaction; T2 = T2 weighted image; TGen = Translational Genomics Research Institute (Flagstaff, Arizona); VP1 = viral protein 1.

{*} Four with confirmed cases and one with a probable case.

{†} Felt warm to the touch, according to parent.

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Keywords: US CDC; USA; Arizona; Updates; AFM; EV- D68.

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