Thursday, March 23, 2017

Brazil: Yellow Fever Updates From The MOH, The CDC, and University of Wisconsin


As we've discussed so often in the past (see The International Exchange Rate Of Infectious Diseases) - in this highly mobile and interconnected 21st century - we are no longer protected by vast oceans or prolonged travel times against the importation of exotic and potentially deadly infectious diseases.

An infected, but still asymptomatic traveler can board a plane in Beijing, Rio,  Cairo, or Los Angeles and be in any international city in less than 24 hours.

It's a harsh lesson that South Korea learned when a single imported  MERS carrier sparked a brief but intense mini-epidemic (186 patients across 16 hospitals) in the summer of 2015.

This is also assumed to be the mechanism that delivered West Nile to New York City in 1999, Dengue to South Florida in 2009, Chikungunya to the Caribbean in 2013, and most recently Zika to South, Central and North America.

In the past few years we've seen (in North America alone) imported cases of MERS, H5N1, H7N9, Ebola, and Lassa Fever - to name just a few of the more exotic viruses.  Other, more mundane viruses (Dengue, Zika, Measles, mumps, etc.) arrive daily.

All of which means that Brazil's growing Yellow Fever Epidemic, which we've been following since early January (see latest WHO: Yellow Fever Update - Brazil), is more than just of humanitarian and academic interest.

Just last week the ECDC released a Rapid Risk Assessment On Introduction Of Yellow Fever To Europe.

Today, three updates.  First, excerpts from the latest Brazilian MOH Surveillance report, followed by an updated Travel Advisory from the CDC, and then some excerpts from a fascinating report from the University of Wisconsin on the toll Yellow Fever is taking on Brazil's howler monkey population.

Registration Date: 03/20/2017 


Ministry of Health updates reported cases of yellow fever in the country

The cases mainly involve the Southeast and are residents in rural areas or who had contact with wild areas for work or leisure

The Ministry of Health updated the information passed by state health departments on the situation of yellow fever in the country. Until this Friday (17), were confirmed 448 cases of the disease. In all, 1,561 suspected cases were reported, of which 850 remain under investigation and 263 were discarded. Of the 264 reported deaths, 144 were confirmed, 110 are still investigated and 10 were discarded.

Routine vaccination for yellow fever is offered in 19 states (Acre, Amazonas, Amapá, Pará, Rondônia, Roraima, Tocantins, Distrito Federal, Goiás, Mato Grosso do Sul, Mato Grosso, Bahia, Maranhão, Piauí, Minas Gerais, São Paulo, Parana, Rio Grande do Sul and Santa Catarina) with recommendation for immunization. Note that in Bahia, Piauí, São Paulo, Paraná, Rio Grande do Sul and Santa Catarina, vaccination does not occur in all municipalities. In addition to the areas with a recommendation at this time is also being vaccinated in stages the population of Rio de Janeiro and Espirito Santo. All people living in these places should take two doses of the vaccine over a lifetime.
         (Continue . . . )

The CDC has updated their Feb 1st travel advisory (see CDC Level II Travel Notice: Yellow Fever in Brazil), with additional vaccination recommendations:

Yellow Fever in Brazil

Alert - Level 2, Practice Enhanced Precautions

What is the current situation?

The Brazilian Ministry of Health has reported an ongoing outbreak of yellow fever starting in December 2016. The first cases were reported in the State of Minas Gerais, but confirmed cases have since been reported in the neighboring states of Espirito Santo, São Paulo, and Rio de Janeiro (not Rio de Janeiro City). Cases have occurred mainly in rural areas, with most cases being reported from Minas Gerais state. Some cases have resulted in death. Health authorities in the affected states, with assistance from the Brazilian Ministry of Health, are conducting mass vaccination campaigns among unvaccinated residents of affected areas.

In response to this outbreak, health authorities have recently expanded the list of areas in which yellow fever vaccination is recommended for travelers. The expanded list of areas in which yellow fever vaccination is now recommended includes: the entire State of Espirito Santo; the State of Rio de Janeiro, with the exception of the urban areas of Rio de Janeiro City and Niterói; the State of São Paulo, with the exception of the urban areas of São Paulo City and Campinas.

Also included are the following municipalities in the southern and southeastern parts of the State of Bahia:

Alcobasa; Belmonte; Canavieiras; Caravelas; Ilheus; Itacare; Mucuri; Nova Visosa; Porto Seguro; Prado; Santa Cruz Cabralia; Una; Urusuca; Almadina; Anage; Arataca; Barra do Chosa; Barro Preto; Belo Campo; Buerarema; Caatiba; Camacan; Candido Sales; Coaraci; CondeUba; Cordeiros; Encruzilhada; Eunapolis; Firmino Alves; Floresta Azul; Guaratinga; Ibicarai; Ibicui; Ibirapua; Itabela; Itabuna; Itagimirim; Itaju do Colonia; Itajuipe; Itamaraju; Itambe; Itanhem; Itape; Itapebi; Itapetinga; Itapitanga; Itarantim; Itororo; Jucurusu; Jussari; Lajedao; Macarani; Maiquinique; Mascote; Medeiros Neto; Nova Canaa; Pau Brasil; Piripa; Planalto; Posoes; Potiragua; Ribeirao do Largo; Santa Cruz da Vitoria; Santa Luzia; São Jose da Vitoria; Teixeira de Freitas; Tremedal; Vereda; Vitoria da Conquista.

The Brazilian Ministry of Health maintains a list of all other municipalities in Brazil for which yellow fever vaccination continues to be recommended (not including recently added municipalities). It is located at

Note: because yellow fever vaccination was previously recommended and continues to be recommended in western parts of the states of São Paulo and Bahia, some municipalities in each of these states are included on this older list.

Anyone 9 months or older who travels to these areas should be vaccinated against yellow fever. People who have never been vaccinated against yellow fever should not travel to areas with ongoing outbreaks. CDC no longer recommends booster doses of yellow fever vaccine for most travelers. However, a booster dose may be given to travelers who received their last dose of yellow fever vaccine at least 10 years ago and who will be in a higher-risk setting, including areas with ongoing outbreaks. Because of the ongoing outbreak, travelers to the Brazilian states of Minas Gerais, Espirito Santo, Sao Paulo, Rio de Janeiro, and parts of Bahia may consider getting a booster if their last yellow fever vaccination was more than 10 years ago. Travelers should consult with a yellow fever vaccine provider to determine if they should be vaccinated. For more information on booster shots, see “Clinician Information,” below.

Because of a shortage of yellow fever vaccine, travelers may need to contact a yellow fever vaccine provider well in advance of trave

And our last stop is an article published by the University of Wisconsin-Madison News. Follow the link to read it in its entirety.

Yellow fever killing thousands of monkeys in Brazil
March 21, 2017 By Kelly April Tyrrell
In a vulnerable forest in southeastern Brazil, where the air was once thick with the guttural chatter of brown howler monkeys, there now exists silence.

Yellow fever, a virus carried by mosquitoes and endemic to Africa and South America, has robbed the private, federally-protected reserve of its brown howlers in an unprecedented wave of death that has swept through the region since late 2016, killing thousands of monkeys.

(Continue . . . )

Wednesday, March 22, 2017

Alabama Confirms 4th County With LPAI H7N9 - Additional Tests Pending


Without fanfare Alabama's Department of Agriculture has added a 4th county to their list of confirmed LPAI H7N9 locations, while local news reports indicate tests are pending from additional locations across the state.
Cullman county is located in the north central part of Alabama, albeit a bit south of the first three counties where the virus was detected.  No other details, apart from the listing on the chart, have been released.

Meanwhile, local news TV-12 (WSFA) and the Associated Press are reporting that samples are being testing in Covington County, very near the Florida state line, in extreme southern Alabama (see Samples being tested in Covington County for bird flu). That report states:
The State Veterinarian’s Office says, along with the Covington County sample, samples from other places are also being tested.

Meanwhile, a late afternoon check on the Ag sites for Tennessee (which has reported two HPAI, and 1 LPAI outbreaks), and Kentucky (which reported a single LPAI Outbreak), reveals no new reports. 

These LPAI and HPAI H7N9 avian viruses - while they share a common name with the China's H7N9 virus - are of a different lineage, and are therefore not expected to pose anywhere near the threat to human health as the Asian strain. 

Nature Comms.: NS Mutation Enhances H7N9's Ability To Infect Humans


We are just one week shy of the 4th anniversary of the identification of a new avian influenza virus - H7N9 - in China. You can revisit that initial revelation in my March 31st, 2013 blog China: Two Deaths From H7N9 Avian Flu.

This first epidemic wave - which would grow to over 130 cases by May of 2013 - was the first real contender to the H5N1 virus, which had been the primary pandemic virus concern for over a decade.

This was more than a little surprising because HPAI H7 viruses - while known to be lethal to poultry - rarely caused more than mild illness in humans (see A Brief History Of H7 Avian Flu Infections). 

And since China's H7N9 was an LPAI (Low pathogenic Avian Influenza) virus - basically benign in birds - it was considered even less likely to produce significant morbidity or mortality in humans.

Only it did. Among those sick enough to be hospitalized, nearly all were in serious or critical condition, and 30% succumbed. 

For the past 4 years we've followed the evolution, and origins, of this avian threat.  We've seen it eclipse H5N1's case counts - despite H5N1's 10 year head start - putting it atop the CDC's list of novel viruses with pandemic potential (see IRAT: Revisited).

Along the way we've seen evidence of its continual evolution - including signs of mammalian adaptations (see Eurosurveillance: Genetic Tuning Of Avian H7N9 During Interspecies Transmission) - and more recently its divergence into two genetically distinct lineages, and the emergence of an HPAI version of the virus (MMWR:Increase in Human Infections with Avian Influenza A(H7N9) In China's 5th Wave).
Yesterday Hong Kong media was filled with reports of recent discoveries by Hong Kong University - published in Nature Communications - that unlock some of the secrets behind H7N9's unlikely success as a human/avian pathogen. 

The culprit in this case appears to be a mutated nucleotide inherited from LPAI H9N2 during an early reassortment. This same mutation shows up in H5N6 and H10N8, also reassortant recipients of gene segments from H9N2, which both emerged in late 2013 and early 2014.

As we've discussed so many times over the years, whenever something `bad’  happens with an avian flu strain – if we look deep enough – we usually find highly promiscuous H9N2's genetic fingerprints at the scene.

In early 2014 The Lancet carried an on-point report entitled Poultry carrying H9N2 act as incubators for novel human avian influenza viruses.
Since 2013, reassortment with LPAI H9N2 viruses have `enabled' at least three new subtypes of avian flu (H7N9, H5N6, and H10N8) to emerge as human health threats. And there is no good reason to suppose that H9N2 couldn't help to spawn additional subtypes in the future.

Two reports on this - admittedly technical - open access study, published yesterday.  First the link and abstract to the actual study, followed by a link and some excerpts from a University of Hong Kong press release.

An NS-segment exonic splicing enhancer regulates influenza A virus replication in mammalian cells
Xiaofeng Huang, Min Zheng, Pui Wang, Bobo Wing-Yee Mok, Siwen Liu, Siu-Ying Lau, Pin Chen, Yen-Chin Liu, Honglian Liu, Yixin Chen, Wenjun Song, Kwok-Yung Yuen & Honglin Chen


Influenza virus utilizes host splicing machinery to process viral mRNAs expressed from both M and NS segments. Through genetic analysis and functional characterization, we here show that the NS segment of H7N9 virus contains a unique G540A substitution, located within a previously undefined exonic splicing enhancer (ESE) motif present in the NEP mRNA of influenza A viruses. G540A supports virus replication in mammalian cells while retaining replication ability in avian cells. Host splicing regulator, SF2, interacts with this ESE to regulate splicing of NEP/NS1 mRNA and G540A substitution affects SF2–ESE interaction. The NS1 protein directly interacts with SF2 in the nucleus and modulates splicing of NS mRNAs during virus replication. We demonstrate that splicing of NEP/NS1 mRNA is regulated through a cis NEP-ESE motif and suggest a unique NEP-ESE may contribute to provide H7N9 virus with the ability to both circulate efficiently in avian hosts and replicate in mammalian cells.
         (Continue . . .)

Many will find parts of this report tough sledding (I know I did), but luckily we've a pretty clear explanation of the their findings in the following report from HK University. 

22 Mar 2017

Research findings

The latest study published by the research team from State Key Laboratory for Emerging Infectious Diseases and Department of Microbiology, Li Ka Shing Faculty of Medicine, HKU, reveals the reason why H7N9 avian influenza virus possesses distinct fitness in circulating in avian host and causing human infections.  The team performs analysis of the H7N9 virus genome collected from 2013 onwards and reveals that efficient infection of both avian and human cells by H7N9 viruses is supported by a unique nucleotide substitution (NS-G540A) in NS segment, where the mutation is located within a previously undefined exonic splicing enhancer (ESE).  The researchers show that the position of this nucleotide is part of an RNA sequence motif that binds the human host cellular mechanism which supports virus replication and it is a common function in all influenza viruses.  Host splicing regulator, SF2, regulates the virus replication efficiency as it interacts with ESE.  Mutation in ESE identified in the viral genome of H7N9 virus enhances the ability of virus replication in mammalian cells.

The team proves that this mutation in viral genome provides H7N9 virus with the ability to both circulate efficiently in avian hosts and replicate in mammalian cells.

It is notable that human infections with H10N8 and H5N6 subtype avian influenza viruses contain the same mutation in the viral genome.  This mutated nucleotide emerged in early 2000 in H9N2 strains and has since spread in avian influenza viruses, becoming the dominant genotype among avian influenza viruses from 2012 onwards.  The H7N9 virus inherits the mutation from H9N2 virus.  The 2013 H7N9 virus acquires internal genes from H9N2 virus and reassorts with haemagglutinin (HA) and neuraminidase (NA) genes from viruses present in wild birds, becoming the H7N9 virus that currently causes human infection.

Significance of the study

“This study provides a plausible mechanism to explain the molecular properties which allows H7N9 virus to infect humans while retaining the ability to circulate in avian species.  It provides an important biomarker for monitoring the emergence and transmission of avian influenza viruses in humans and preventing human-to-human infection of the viruses.  The mutation can also serve as a novel target of anti-influenza drug development,” says Professor Chen Honglin, Professor of State Key Laboratory for Emerging Infectious Diseases and Department of Microbiology, Li Ka Shing Faculty of Medicine, HKU.
(Continue . . . )

For more on H9N2's role in the evolution of other, more formidable avian flu viruses, you may wish to revisit:

Qatar: MOH Statement On Their 19th MERS-CoV Case


While primarily a Saudi problem, scattered MERS-CoV infections have been reported across the Arabian Peninsula; most prominently in the UAE, Jordan, and Qatar.  While a number of these non-Saudi cases had recent travel history to KSA, many - like the one announced today from Qatar's MOH - appear to be locally acquired.

My thanks to @Crof at Crofsblog who published a media account (see Qatar: Fresh MERS case; HMC takes all precautions) overnight.

Below you'll find the (translated) MOH statement, which while lengthy, provides more reassurance than actual details on the case. We do learn the patient did not travel outside of Qatar in the two weeks prior to falling ill, and that the patient had a chronic health condition.

Beyond that, we'll probably have to wait for a WHO Update.

Ministry of Public Health announces the registration of the case of infection Coruna

date of issue: March 21, 2017 

Ministry of Public Health announced the registration of new cases of laboratory confirmed infection corona virus that causes AIDS Middle East respiratory a resident at the age of 62, suffers from a chronic disease, thus registering the first case that is recorded during the current year, bringing the number of cases that have been registered in the State of Qatar since the beginning of the virus was detected 19 cases resulted in seven deaths.

The symptoms of fever and night sweats, abdominal pain had begun to appear in the patient showed laboratory tests that were made in the reference laboratories of the Hamad Medical Corporation diagnosis Koruna emerging cause of the syndrome Middle East respiratory virus has been isolated to receive proper medical care, it is recalled that the patient did not mix with people with symptoms similar , he did not travel outside the country during the past few weeks.

Upon receipt of the communication of the situation by the Rapid Response Team of the Department of Health Protection and Anti - Communicable Diseases at the Ministry of Public Health to conduct epidemiological investigation and joint , which aims to identify the possible source of infection and follow up on all potential contacts of the patient to check if it was them who matches the standard definition of a case of suspected , according to the Organization of definition World Health work is currently underway to conduct the necessary tests on them, which will continue to keep tabs on for two weeks to make sure that the appearance of any symptoms they provide them with appropriate preventive advice.

And calls on the Ministry of Public Health all members of society, especially those at risk of complications from the disease to consult a doctor when feeling symptoms of fever, coughing and sore throat with adherence to hygiene measures such as avoiding contact with sick animals Continuously wash your hands with soap and water.

The rapid response team at the Ministry of Public Health is working around the clock and have any complaints or concerns related to the transition of diseases hotline 66740948 or 66740951 numbers.

Tuesday, March 21, 2017

Alabama Dept. Of Agriculture Confirms Two Additional (LPAI) H7N9 Infections

Credit Wikipedia


On Thursday of last week Alabama Agriculture Department confirmed LPAI H7N9 in a sample collected from a guinea fowl at the TaCo-Bet Trade Day flea market in Scottsboro (see Alabama Ag. Dept. Update On Avian Flu).

At the time, tests on two other flocks in northern Alabama were pending.   Today, we have the results of those tests as well, with both indicating LPAI H7N9.

 While not unexpected, this comes on the heels of this morning's report: Kentucky Becomes 3rd State To Report (LPAI) H7N9

Tuesday, March 21, 2017 Contact: Daniel Autrey 334-240-7100

Additional Poultry Flocks Test Positive for Low Pathogenic Avian Influenza

Montgomery, Ala. - State Veterinarian, Dr. Tony Frazier, confirms that a flock of chickens at a commercial poultry breeding operation located in Pickens County and a backyard flock located in Madison County have both tested positive for low pathogenic avian influenza (LPAI). 

During routine screening, a commercial company collected samples from their Pickens County flock and submitted them to the Alabama Department of Agriculture and Industries State Diagnostic Laboratory located in Auburn, Alabama. These samples, suspected positive for avian influenza, were forwarded to the USDA National Veterinary Services Laboratory (NVSL) in Ames, Iowa. NVSL confirmed the commercial flock is positive for LPAI. This commercial flock has been placed under quarantine. While this is different from the highly pathogenic avian influenza (HPAI) virus that has been found recently in the United States, control measures are under way as a precautionary measure. 

In addition to the suspected case in Pickens County, a backyard flock located in Madison County has also been confirmed positive for low pathogenic H7N9 avian influenza (LPAI) by NVSL. Surveillance zones have been put in place surrounding the locations in both Pickens and Madison counties. 

This suspected strain of avian influenza does not pose a risk to the food supply and no affected animals entered the food chain. 

On Tuesday, March 14, 2017, Dr. Tony Frazier issued an official Order Prohibiting Poultry Exhibitions and the Assembling of Poultry to Be Sold. The order prohibits: all poultry exhibitions, sales at regional and county fairs, festivals, swap meets, live bird markets, flea markets and auctions. The order also prohibits the concentration, collection, or assembly of poultry of all types, including wild waterfowl from one or more premises for purposes of sale.  
This order remains in effect. Shipments of eggs or baby chicks from National Poultry Improvement Plan (NPIP) approved facilities are not affected by this order. 

“The health of our poultry is critically important at this time,” said Dr. Frazier. “With confirmed cases of low pathogenic avian influenza in Alabama in both commercial and backyard flocks, the order reducing the assembly and commingling of poultry is the most effective way to practice strict biosecurity measures in our state.” 

USDA Animal and Plant Health Inspection Service (APHIS) continues to work closely with the ADAI on a joint incident response. The U.S. has the strongest avian influenza surveillance program in the world and USDA is working with its partners to actively look for the disease in commercial poultry operations, backyard flocks, livebird markets and in migratory wild waterfowl populations. 

“The Alabama Department of Agriculture and Industries’ staff is working diligently to defend the health of poultry in our state,” said Commissioner John McMillan. “We are committed to protecting the livelihoods of Alabama farmers.” 

Dr. Frazier reminds poultry producers and backyard flock owners to observe their birds closely and to be vigilant about practicing strict biosecurity measures. These include: 
•           Isolating poultry from other animals;
•           Wearing clothing designated for use only at the poultry house;
•           Minimizing access to people and unsanitized equipment;
•           Keeping the area around the poultry buildings clean and uninviting to wild birds  and animals;
•           Sanitizing the facility between flocks;
•           Cleaning equipment entering and leaving the farm;
•           Having an all-in, all-out policy regarding the placement and removal of the poultry;
•           Properly disposing of bedding material and mortalities;
•           Avoiding contact with migratory waterfowl.    

Dr. Frazier reminds all poultry owners and producers to strictly adhere to the biosecurity guidelines mentioned above.  During this time, backyard flock owners should refrain from moving birds offsite or introducing new birds. The ADAI Poultry Division is available to answer any questions concerning movement of poultry and should be notified at 334-240-6584 and/or USDA at 1-866-536-7593 if birds show unusual signs of disease (flu-like symptoms) or flocks experience unexplained mortalities. 

The Alabama Department of Agriculture and Industries will maintain updates of suspected cases of avian influenza on our website:

The Alabama Cooperative Extension System has created a website to assist backyard flock owners with maintaining healthy birds and to provide answers for avian influenza control.  It can be found at

CDC Grand Rounds (Today): Emerging Tickborne Diseases


Each month the CDC holds a Grand Rounds web presentation that focuses on a single health-related issue.  In the past I’ve highlighted their broadcasts on such diverse topics as Multidrug-Resistant Gonorrhea, Childhood Emergency Preparedness, and Discovering New Diseases  . . . to name a few.

The CDC maintains an archive of these informative presentations – going back to 2009 – which you can access at Grand Rounds – ArchivesHighly recommended.

With the arrival of spring also comes an inevitable increase in vector borne diseases.  And while mosquito-borne diseases like Zika, Dengue, and Yellow Fever tend to garner the most headlines - in terms of their impact on the health of Americans - tickborne diseases inflict a far greater toll (see CDC: Estimate Of Yearly Lyme Disease Diagnoses In The United States).
While Lyme disease is best known by the public, the The CDC lists a growing number of diseases carried by ticks in the United States, including: Anaplasmosis, Babesiosis , Ehrlichiosis, Heartland Virus, Powassan Disease, Rickettsia parkeri Rickettsiosis, Rocky Mountain Spotted Fever (RMSF), STARI (Southern Tick-Associated Rash Illness), Tickborne relapsing fever (TBRF), Tularemia, and 364D Rickettsiosis . . . 

Complicating both diagnosis and treatment, many ticks carry more than one disease.

The details of today's presentation follows.  The presentation may be viewed live on their website, or the archived version will be posted in 3 to 4 days here.

Emerging Tickborne Diseases

Tuesday, March 21, at 1:00 p.m. ET Infections from tickborne diseases in the US are steadily increasing — and new tickborne diseases have been discovered in recent years. Ticks are vectors that can carry infectious agents such as bacteria, viruses, or parasites. When an infected tick bites a person or an animal, the tick’s saliva transmits infectious agents that can cause illness. Some ticks can transmit multiple diseases. These “co-infections” pose challenges for diagnosing, treating and preventing tickborne diseases.

he geographic ranges of ticks also are expanding. Ticks differ in their tolerance to heat, cold and aridity, making certain tick species more common than others in any given location in the United States. Different species transmit different diseases and this leads to differences in incidence of tickborne diseases by geographic region in the US.
Join us for this session of Public Health Grand Rounds as experts discuss emerging tickborne diseases, treatment options, prevention strategies, and advances in diagnosing tickborne diseases.

Future Grand Rounds topics include the National Amyotrophic Lateral Sclerosis Registry, promoting hearing health across the lifespan, and new frontiers in workplace health.
CDC’s Public Health Grand Rounds Presents:

“ Emerging Tickborne Diseases ”
Tuesday, March 21, 2017
1:00 p.m. – 2:00 p.m. ET
Global Communications Center (Building 19)
Alexander D. Langmuir Auditorium
Roybal Campus
Presented By:

Rebecca Eisen, PhD
Research Biologist, Bacterial Diseases Branch
Division of Vector-Borne Diseases
National Center for Emerging and Zoonotic Infectious Diseases, CDC
“Expanding Diversity and Distribution of Tickborne Diseases”

Christopher D. Paddock, MD
Medical Officer, Rickettsial Zoonoses Branch
Division of Vector-Borne Diseases
National Center for Emerging and Zoonotic Infectious Diseases, CDC

“ Tickborne Spotted Fevers – Old and New”

Gregory D. Ebel, ScD
Associate Professor, Department of Microbiology Immunology and Pathology
Director, Arthropod-Borne and Infectious Diseases Laboratory
College of Veterinary Medicine and Biomedical Sciences
Colorado State University
“ Emerging Tickborne Viruses “

Bobbi Pritt, MD, MSc, DTM&H
Director, Clinical Parasitology Laboratory
Co-Director, Vector-borne Diseases Laboratory Services
Professor of Pathology and Laboratory Medicine
Division of Clinical Microbiology
Mayo Clinic
“Advances in Diagnosing Tickborne Diseases”