Sunday, October 23, 2016

KSA Announces 2 New MERS Cases & 2 Recent Deaths


The Saudi MOH caught up with their MERS reporting after going 48 hours without an update, posting numbers for the 22nd and 23rd of October.

Yesterday's report showed no new cases, but one death - that of the 53 y.o. male from Abha who was listed in critical condition last Thursday. 

Today's report adds 2 new cases.  First, yet another nosocomial case from Hufoof - the 3rd in the past week or so.  This patient is described as a male, age 55, who had already died at the time of this announcement.

The second new case is a primary case from Arar; a 58 y.o. male listed in critical condition.

Posthumous announcements - and cases that are already listed in critical condition when announced - are worthy of notice since they might  indicate delayed detection and/or isolation, thus raising the chances of seeing additional hospital acquired cases.

At this point, however, we don't know the onset of illness date, or date of diagnosis for these cases. 

After going the first two weeks of October without a single case, in the past 8 days Saudi Arabia has now announced 10 cases, with 4 of those listed as secondary cases (2 HCWs & 2 Patients) exposed at two different health care facilities.

India: H5N8 Detected At 3rd Location


According to media reports, avian H5N8 has been detected at a second park in New Delhi, bringing to total number of outbreaks to 3 over the past several days.  The following excerpt comes from the Deccan Herald

Bird flu: Threat of infection to migratory birds
New Delhi, Oct 23, 2016, (PTI)
The Centre had yesterday formed a three-member committee to keep a constant vigil around the park, as well as monitor and contain the H5 Avian Influenza.

A total of 40 birds have died of the Influenza in the national capital since October 14. While 12 deaths were reported at the Delhi zoo, 28 ducks died at the Hauz Haas Deer Park. A death was also reported from the Asola Bhatti Wildlife Sanctuary.

The Department of Animal Husbandry, Dairying and Fisheries at the Centre had on Friday said a new bird flu virus subtype, H5N8, has been confirmed in samples from Gandhi Zoological Park, Gwalior.

The government has also issued an advisory to all wildlife/bird sanctuaries in this regard.
      (Continue  . . . )

Another report - this time from the Business Standard - suggests the bird die continues today at the Hauz Hass Deer Park, which is about 5 miles south and west of the first outbreak reported on Friday at the New Delhi Zoological Park.

Because of bird flu deaths, the Delhi Zoo has also been ordered shut until further notice.

IANS  |  New Delhi 
So far, we've not seen any reports from poultry farms, but the alert has been raised to look for any signs of infection.
Although some migratory birds have already arrived in the region from their northern nesting areas, the bulk of the migration will occur in November and December.
As you'll recall, it was in November of 2014 when H5N8 turned up in Japan, Western Europe, and the Pacific Northwest.  After causing numerous outbreaks through the spring of 2015, the virus failed to return last fall.

While it is impossible to predict where or when H5N8 will turn up next, the detection of the virus in Russia and of H5N2 in Alaska over the summer - and these recent outbreaks reported from India - certainly suggests that HPAI H5 is alive and well, and on the move again this fall in migratory birds. 

Saturday, October 22, 2016

India: Second Zoo Reports H5N8 (Madya Pradesh)


According to media reports, a second Zoo, this time in Gwalior, Madhya Pradesh State - about 100 miles to the south and east of New Delhi - is also reporting a bird die off due to avian H5N8.  

This comes on the heels of the announcement overnight that the recent bird die off at the New Delhi Zoological Park was due to avian H5N8 (see New Delhi Bird Flu Identified As H5N8),

The following report is from the New Indian Express:

Birds in Gwalior zoo died of H5N8 infection: Officials
By PTI  |   Published: 22nd October 2016 06:48 PM  |  
Last Updated: 22nd October 2016 06:48 PM
GWALIOR: Analysis of samples collected from two of the around 15 painted storks that died in the zoological park here, revealed the avians were infected with a new bird flu virus subtype, H5N8, a top official said today. Around 15 painted storks in the zoo died in the last few days, prompting the authorities concerned to send their samples for testing for bird flu virus.


"A close watch is also being kept on the poultry farms and birds around the zoo that have been closed for visitors since yesterday," Goyal said. Gwalior Municipal Corporation Commissioner Anay Dwivedi said the zoo currently houses around 300 avians of different species. "The zoo staffers have been given gloves and as well as tamiflu (an antiviral medication)," he said, adding spraying of disinfectants in the zoo is on. Meanwhile, sources said some groups working for bird and animal protection have written a petition to different ministries in Delhi to block a possible move of bird culling in Gwalior.

As we discussed in my last blog, avian H5N8 is new to the Indian sub-continent - and while it has yet to cause human illness - it poses a very serious threat to the poultry industry.

Given the rapidity of spread of this virus we've seen in South Korea, China, and North America, the detection of a second outbreak this soon - 100 miles to the south of New Delhi - has to be viewed as a worrisome sign.

New Delhi Bird Flu Identified As H5N8


Three days ago, in India: New Delhi Zoological Park Closed Due To Suspected H5N1, we looked at the initial reports of a die-off of birds at a 176 acre park which lies in the heart of that nation's capital.
Overnight, the National Institute for High Security Animal Diseases (NIHSAD) in Bhopal reportedly announced that the subtype has now been identified as H5N8, not H5N1.

Local officials and the media are treating this as relatively `good' news - since H5N8 has yet to be found to infect humans - but the arrival of a new (to India) strain of bird flu is not without some  potentially serious consequences.

First, the H5N8 virus is continually mutating, and easily reassorts  with other subtypes, meaning its current inability to infect humans may not last forever.
The H5N8 virus belongs to the same H5 clade as two subtypes (H5N1 & H5N6) which can infect, and sometimes kill, humans.

Secondly, H5N8 has proven to be an exceptionally good traveler, hitchhiking its way on migratory and wild birds, and able to cover vast distances in a short period of time.

Our last H5N8 sighting outside of China (see FAO/EMPRES: H5N8 Clade Detected Over Summer In Russia) was around Ubsu-Nur lake, some 2,800 km north and east of New Delhi.

In the wake of the Russian detection, last August the FAO warned:

Countries and places in Central Asia, the Caucasus, the Middle East, Europe and West Africa – especially those that have experienced outbreaks in 2005/06, 2009/10 and/or 2014/15 (as shown in Maps 2, 3 and 4) – should be on alert over the next 6 to 12 months, as westward and southern spread of the H5N8 virus is likely. If the virus enters Egypt or West Africa, where H5N1 HPAI viruses are already present or even entrenched in poultry populations it would further complicate disease control. 

South Asia may also be at risk of incursion of this H5N8 HPAI clade virus, potentially arriving there with fall migration in 2016.

Almost on cue, the H5N8 virus has now shown up in South Asia, and it has the potential to move further down the Indian subcontinent as migratory birds continue their way south.

Although there are two annual bird migrations (spring and fall) to worry about, a recent report (see Sci Repts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission Of HPAI H5N1) pegs the fall migration as the biggest risk for the spread of HPAI by migratory birds.
While not unexpected, the discovery of H5N8 in India also raises concerns over where else the virus may appear this winter.

As the DEFRA graphic below illustrates, the migratory flyways that brought the virus to India could also deliver the virus to the Middle East, Africa, and Europe.


The arrival of H5N8 to North America, Taiwan, and Korea has wreaked havoc oin their poultry industries, and in the spring of 2015 sparked the largest epizootic in North America's history.

Just as H5N8 appears to be following the expansionist footsteps we saw H5N1 undertake a decade ago, there are at least two other avian viruses circulating widely in China that could someday follow suit; H7N9 and H5N6.

Unlike H5N8, these two recently emerged viruses can infect humans as well as poultry, and if they were to spread, could conceivably cause even more harm. 

For more on the threat of migratory birds spreading avian flu, you may wish to revisit a blog from earlier this month called:

Migratory Birds & The Spread Of Highly Pathogenic Avian Flu


Friday, October 21, 2016

Saudi MOH Announces 3 New MERS Cases (2 Nosocomial, 1 Primary)


After a couple of relatively quiet months we've seen - over the past week - an uptick in MERS cases reported by the Saudi MOH.  The graph below compares this year's MERS activity (Red Line) in KSA to the previous two years.

Today's announcement brings the number of new cases since Oct 15th to 8, with 3 of those listed as secondary cases (2 HCWs & 1 Patient) exposed at two different health care facilities.

While the size and number of hospital associated MERS clusters has dropped considerably in 2016, three new nosocomial infections reported this week suggest the Saudis still have a ways to go on their hospital infection control procedures.

NEJM: Guillain–Barré Syndrome Associated with Zika Infection - Colombia

Credit WHO Zika SitRep 10/20/16


According to the latest WHO Zika SitRep:

19 countries and territories have reported an increased incidence of GBS and/or laboratory confirmation of a Zika virus infection among GBS cases (Table 4). Puerto Rico, which has previously reported GBS cases with confirmed Zika virus infections, has reported an increase in incidence of GBS cases in the last week. 

While this temporal-geographic link between Zika and GBS has been on our radar for  2 1/2 years (see 2014's Eurosurveillance: Zika Virus Infection Complicated By Guillain-Barré Syndrome), proof of GBS's causation by Zika infection is still lacking. 

Part of the problem is that the onset and diagnosis of GBS often occurs 1 to 2 weeks (or longer) after infection with the Zika virus, when many conventional Zika testing methods are no longer able to detect the virus. 

The co-circulation of Dengue and Chikungunya - which can produce similar symptoms - also clouds the issue.  A patient recalling a recent fever-rash-like illness is suggestive of Zika, but far from exclusive to it. 

There is also evidence that other arbovirus infections (WNV, Dengue, CHKV, etc.) may occasionally spark the onset of GBS as well (see Guillain-Barre syndrome: The Other Zika Concern).

And if things were complicated enough, there is evidence to suggest that concurrent or sequential flavivirus (Dengue, Zika, etc.) infection may increase the severity of an  individual's illness through a process called ADE (see PLoS Currents: Another In Vitro Study Suggests Previous Dengue Exposure May Exacerbate Zika Severity).

It is against this `noisy' background that researchers must work to connect recent Zika infection with the rare neurological complication of Guillain-Barré Syndrome.  All of which is why the CDC's Zika-GBS website states:

Current CDC research suggests that GBS is strongly associated with Zika; however, only a small proportion of people with recent Zika virus infection get GBS.

Adding to our understanding of this association today is the following study appearing in the NEJM that used RT-PCR testing of urine samples to help extend the detection time for prior Zika infection, and help bolster the case for a Zika-GBS link.

The full article is available at the link below, as well as an accompanying editorial (HERE).  Follow the links to read:

Original Article
Guillain–Barré Syndrome Associated with Zika Virus Infection in Colombia

Beatriz Parra, Ph.D., Jairo Lizarazo, M.D., Jorge A. Jiménez-Arango, M.D., Andrés F. Zea-Vera, M.D., Ph.D., Guillermo González-Manrique, M.D., José Vargas, M.D., Jorge A. Angarita, M.D., Gonzalo Zuñiga, M.D., Reydmar Lopez-Gonzalez, M.D., Cindy L. Beltran, M.D., Karen H. Rizcala, M.D., Maria T. Morales, M.D., Oscar Pacheco, M.D., Martha L. Ospina, M.D., Anupama Kumar, M.B., B.S., David R. Cornblath, M.D., Laura S. Muñoz, M.D., Lyda Osorio, M.D., Ph.D., Paula Barreras, M.D., and Carlos A. Pardo, M.D.
N Engl J Med 2016; 375:1513-1523October 20, 2016DOI: 10.1056/NEJMoa1605564


Zika virus (ZIKV) infection has been linked to the Guillain–Barré syndrome. From November 2015 through March 2016, clusters of cases of the Guillain–Barré syndrome were observed during the outbreak of ZIKV infection in Colombia. We characterized the clinical features of cases of Guillain–Barré syndrome in the context of this ZIKV infection outbreak and investigated their relationship with ZIKV infection.


A total of 68 patients with the Guillain–Barré syndrome at six Colombian hospitals were evaluated clinically, and virologic studies were completed for 42 of the patients. We performed reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assays for ZIKV in blood, cerebrospinal fluid, and urine, as well as antiflavivirus antibody assays.


A total of 66 patients (97%) had symptoms compatible with ZIKV infection before the onset of the Guillain–Barré syndrome. The median period between the onset of symptoms of ZIKV infection and symptoms of the Guillain–Barré syndrome was 7 days (interquartile range, 3 to 10). Among the 68 patients with the Guillain–Barré syndrome, 50% were found to have bilateral facial paralysis on examination. Among 46 patients in whom nerve-conduction studies and electromyography were performed, the results in 36 patients (78%) were consistent with the acute inflammatory demyelinating polyneuropathy subtype of the Guillain–Barré syndrome. Among the 42 patients who had samples tested for ZIKV by RT-PCR, the results were positive in 17 patients (40%). Most of the positive RT-PCR results were in urine samples (in 16 of the 17 patients with positive RT-PCR results), although 3 samples of cerebrospinal fluid were also positive. In 18 of 42 patients (43%) with the Guillain–Barré syndrome who underwent laboratory testing, the presence of ZIKV infection was supported by clinical and immunologic findings. In 20 of these 42 patients (48%), the Guillain–Barré syndrome had a parainfectious onset. All patients tested were negative for dengue virus infection as assessed by RT-PCR.


The evidence of ZIKV infection documented by RT-PCR among patients with the Guillain–Barré syndrome during the outbreak of ZIKV infection in Colombia lends support to the role of the infection in the development of the Guillain–Barré syndrome. (Funded by the Bart McLean Fund for Neuroimmunology Research and others.)