H5N1

A novel coronavirus emerging in China: Key questions for impact assessment

Via NEJM: A Novel Coronavirus Emerging in China — Key Questions for Impact Assessment. The concluding paragraphs:

The substantial involvement of nosocomial transmission in both SARS-CoV and MERS-CoV outbreaks suggests that such transmission is a serious risk with other newly emerging respiratory coronaviruses. In addition to the vulnerability of health care settings to outbreaks of emerging coronaviruses, hospital populations are at significantly increased risk for complications from infection. Age and coexisting conditions (such as diabetes or heart disease) are independent predictors of adverse outcome in SARS-CoV and MERS-CoV. Thus, emerging viruses that may go undetected because of a lack of severe disease in healthy people can pose significant risk to vulnerable populations with underlying medical conditions.  

A lack of severe disease manifestations affects our ability to contain the spread of the virus. Identification of chains of transmission and subsequent contact tracing are much more complicated if many infected people remain asymptomatic or mildly symptomatic (assuming that these people are able to transmit the virus). More pathogenic viruses that transmit well between humans can generally be contained effectively through syndromic (fever) surveillance and contact tracing, as exemplified by SARS-CoV and, more recently, Ebola virus. Although containment of the ongoing Ebola virus outbreak in the Democratic Republic of Congo is complicated by violent conflict, all previous outbreaks were contained through identification of cases and tracing of contacts, despite the virus’s efficient person-to-person transmission.  

We currently do not know where 2019-nCoV falls on the scale of human-to-human transmissibility. But it is safe to assume that if this virus transmits efficiently, its seemingly lower pathogenicity as compared with SARS, possibly combined with super-spreader events in specific cases, could allow large-scale spread. 

In this manner, a virus that poses a low health threat on the individual level can pose a high risk on the population level, with the potential to cause disruptions of global public health systems and economic losses. 

This possibility warrants the current aggressive response aimed at tracing and diagnosing every infected patient and thereby breaking the transmission chain of 2019-nCoV. 

Epidemiologic information on the pathogenicity and transmissibility of this virus obtained by means of molecular detection and serosurveillance is needed to fill in the details in the surveillance pyramid and guide the response to this outbreak. Moreover, the propensity of novel coronaviruses to spread in health care centers indicates a need for peripheral health care facilities to be on standby to identify potential cases as well. In addition, increased preparedness is needed at animal markets and other animal facilities, while the possible source of this emerging virus is being investigated. 

If we are proactive in these ways, perhaps we will never have to discover the true epidemic or pandemic potential of 2019-nCoV.

China coronavirus: Death toll rises to 41; more than 1,000 cases of infection confirmed in mainland

Years ago I spoke with a European healthcare worker who talked about "the pandemic" (H1N1 in 2009) the way combat veterans talk about "the war." He even had the thousand-yard stare I'd seen in Vietnam veterans. 

 

Today's healthcare workers are likely to talk about "coronavirus" the same way, and with the same faraway stare. Via the South China Morning Post: China coronavirus: Death toll rises to 41; more than 1,000 cases of infection confirmed in mainland. Conditions in Wuhan presage conditions in healthcare systems around the world: 

A medical doctor suspected to have coronavirus died on Saturday in Hubei – marking the first death of a medical professional since the outbreak of the virus – as the number of confirmed cases in mainland China exceeded 1,000. 

Liang Wudong, a surgeon at Xinhua Hospital in Hubei province, died at 7am at the age of 62, Shanghai-based news portal thepaper.cn reported. 

Liang was suspected of being infected last week, before he was transferred to Wuhan’s Jinyintan Hospital for treatment.

Some 29 provinces in China have reported 1,287 cases of the deadly pneumonia-like virus, with 729 in Hubei, the epicentre of the outbreak, according to data released by local governments on Saturday. 

Hubei’s death toll was 39, with the other two fatalities in the provinces of Hebei and Heilongjiang. 

Cases have also been reported in Hong Kong, Macau, Taiwan and eight other countries.

Tens of millions of people in Hubei are effectively on lockdown as a travel ban has been imposed on most of the province. 

Flights, trains, buses and ferries connecting Wuhan to other cities in Hubei have been suspended. Wuhan is the hub for several major high-speed rail lines. 

Eighteen Chinese provinces have activated a top-level public health emergency response to the outbreak, meaning public events, businesses and schools can be suspended and the migrant population quarantined in these areas. 

In Wuhan, video footage of people desperately seeking help was widespread on social media. Some nurses and doctors were reported to be suffering emotional breakdowns in hospital consulting rooms while outpatients crowd corridors with some pictured lying on the floor. 

More than 20 hospitals in Wuhan have posted statements pleading for aid from various sectors as there has been a shortage of masks, latex gloves, protective goggles and surgical gowns.

Hubei has also tightened restrictions on private vehicles from Wuhan. A notice posted by a petrol station in Chibi, next to Wuhan, said all fuelling stations in the city were now off-limits to vehicles with Wuhan licence plates, on orders of the Chibi municipal government. 

On Friday, China Development Bank granted a 2 billion yuan (US$288.3 million) emergency loan to Wuhan for virus prevention and treatment. On Thursday, China’s finance ministry announced an allocation of 1 billion yuan to be used by Hubei authorities to halt the contagion’s spread.

Wuhan confirmed 15 medical workers infected! Zhong Nanshan: It is important to wear masks

Zhong Nanshan. Credit: Guangzhou Daily

Via Guangzhou Daily: Wuhan confirmed 15 medical workers infected! Zhong Nanshan: It is important to wear masks. Excerpt from a long article:

In the early morning of the 21st, the Wuhan Municipal Health and Health Committee reported through the Health Wuhan official microblog that a total of 15 medical staff in Wuhan were diagnosed with pneumonia cases of new coronavirus infection, and another suspected case.  

According to the report, of the 16 patients, one was critically ill and the rest were in stable condition, and all had been treated in isolation. 

The report said that medical personnel were the main force in the prevention and control of the epidemic. In order to ensure the health of medical staff, Wuhan has recently strengthened the prevention and control measures of various hospitals, strictly controlled nosocomial infections, strengthened the protection of medical staff, and cared for medical staff to deploy again. It strengthened the daily monitoring of the health of medical staff. The cases were tested and treated in a timely manner.  

Zhong Nanshan: The new type of coronavirus can be passed on from person to person. It is important to wear a mask to prevent it! 

The official Weibo of Guangdong Health Commission announced on the evening of January 20th that 13 new cases of pneumonia confirmed by new coronavirus infection were confirmed in Guangdong today. The distribution of new cases is as follows: 8 cases in Shenzhen, 3 cases in Zhuhai, 1 case in Zhanjiang and Huizhou, all were treated in isolation at local designated medical institutions. Eleven cases had a history of living or traveling in Wuhan, and two had a history of close contact with the case. 

On the evening of January 20, the National Health and Health Commission confirmed the first confirmed case of pneumonia imported from Shanghai with a new coronavirus infection. The patient was a 56-year-old female and registered in Wuhan City, Hubei Province. The patient's temperature is normal and her vital signs are stable. Two close contacts in Shanghai are undergoing medical observation. 

As of 20:00 on the 20th, a total of 218 cases of new coronavirus pneumonia were confirmed in China (198 in Wuhan, 5 in Beijing, 14 in Guangdong, and 1 in Shanghai).

Picard: There is a new coronavirus on the loose, but we don’t have to repeat the mistakes of SARS

Via The Globe and Mail, health reporter André Picard writes: There is a new coronavirus on the loose, but we don’t have to repeat the mistakes of SARS. Excerpt:

The world learned a lot from its missteps during the SARS crisis – no country more so than Canada. 

First and foremost, China is being far more forthcoming with information about the Wuhan-linked outbreak, a stark contrast to its secrecy during the early months of SARS.  

At first, all the people who fell ill from the new pathogen – which doesn’t yet have a catchy acronym, though in infectious-disease circles it goes by nCoV2019 – seem to have shopped at the Huanan seafood market, which has since been closed.  

But on Monday, Chinese officials revealed that there were cases with no link to that market. A Chinese news agency also revealed that 14 health workers had been infected – all of whom treated a single patient. That pretty well confirms human-to-human transmission. 

Let’s not forget that those at greatest risk when new pathogens emerge are health workers. Half of all SARS cases in Canada were among health workers, and a physician and two nurses were among the dead.  

One of the main reasons SARS spread in Canada is because hospitals did not take adequate precautions, such as masking, gloving and isolating patients being treated for respiratory illnesses. This is difficult to do during flu season, when hospitals are filled with coughing, feverish patients. Presumably, we won’t be complacent this time around.  

The 2003 SARS crisis prompted a lot of introspection in Canada, including two public inquiries that gave us the 1,200-page opus from the SARS Commission, led by the late Justice Archie Campbell, and the National Advisory Committee on SARS, headed by David Naylor. 

In fact, the essence of all the retrospective studies can be boiled down to a Boy Scout motto: “Be prepared.” 

One of the most important corrective measures taken after SARS was the creation of the Public Health Agency of Canada.  

PHAC has an outbreak-preparedness division, and it appears to be on top of the Wuhan coronavirus story. The agency has already issued a couple of advisories, and they are appropriately cautious. 

What will be essential when the first case of nCoV2019 appears in Canada – which is possible in the coming days or weeks – is that Dr. Theresa Tam, the Chief Public Health Officer of Canada, take the lead and continue to respond “with an abundance of caution,” as she did Monday. (During SARS, some will recall, there were a multitude of provincial and federal officials speaking, often with contradictory messages.)  

The World Health Organization has also been careful with its language – another good sign. It has convened an emergency meeting for Wednesday, at which officials will decide what measures, such as travel advisories, are appropriate. But it needs to exercise some restraint.  

At the height of SARS, there were breathless WHO daily updates on the body count that fuelled fears, as well as a fair bit of hyperbolic media coverage, and those mistakes were repeated during the H1N1 pandemic.  

The number of cases of nCoV2019 is significant enough now that the spread cannot be stopped. But it can be contained with a sound, co-ordinated public health response. 

The challenge, from a communications perspective, is informing the public about the risks of this novel coronavirus while at the same time not overstating the dangers.  

That’s not an easy balance to find in the social-media age. But among the many lessons SARS taught us is that misinformation and fear can cause a lot more carnage – especially the economic kind – than a new pathogen.

Zhong Nanshan: 14 medical staff infected with new coronavirus pneumonia (including video)

Many thanks to Hayes Luk for sending the link to this Sina.News report: Zhong Nanshan: 14 medical staff infected with new coronavirus pneumonia (including video). Dr. Zhong is a major authority in Chinese medicine. The Google translation:

In response to the prevention and control of the "pneumonia epidemic of new coronavirus infection", Academician Zhong Nanshan, leader of the high-level expert group of the National Health Commission and members of the high-level expert group of the National Health Commission, Gao Fu, Li Lanjuan, Yuan Guoyong, Zeng Guang, etc. Questions of public concern are answered by reporters. As for the investigation and judgment of the epidemic situation, Academician Zhong Nanshan said that there are currently three characteristics.  

Zhong Nanshan, academician of the Chinese Academy of Engineering, leader of the high-level expert group of the National Health and Health Commission: More than 95% have a relationship with Wuhan. Having been to Wuhan and coming from Wuhan is a feature. The second characteristic is that human infection has been confirmed. It is confirmed that there is human infection in two regions, one in Guangdong and one in Wuhan. The third feature also confirmed the infection of medical staff. Then these three conditions and the infection of medical staff finally confirmed that the infection around the patients with the new coronavirus was caused by 14 medical staff in all aspects of care. 

Academician Zhong Nanshan said that the occurrence of human-to-human transmission and medical staff infection was a very important sign. The reason for the increased number of cases is more complicated.  

Zhong Nanshan, academician of the Chinese Academy of Engineering, leader of the high-level expert group of the National Health and Health Commission: There is a process of understanding the disease. There are many reasons for the rapid detection of new detection technologies, not just one. If it is to be determined, it was previously issued from the national CDC or after a strict national identification, and now the consideration is not the same, because the two tests can be determined, which is also a reason.

DRC Ebola: CMRE update, January 19

CMRE has published Situation épidémiologique du 19 Janvier 2020. Excerpt from the Google translation:

EVOLUTION OF THE EPIDEMIC IN THE PROVINCES OF NORTH KIVU AND ITURI ON 18 JANUARY 2020   

Sunday January 19, 2020  

• Since the start of the epidemic, the cumulative number of cases is 3,412, of which 3,293 are confirmed and 119 probable. In total, there were 2,237 deaths (2,118 confirmed and 119 probable) and 1,136 people healed; 

• 438 suspected cases under investigation; 

• 1 new confirmed case in North Kivu in Beni; 

• No new deaths among the confirmed cases, of which: 

o No community death was recorded; o No death among the confirmed cases of CTE; 

• 2 healed people out of CTE in North Kivu, including 1 in Beni and 1 in Butembo;  

• 1 health worker, alive and vaccinated, is among the new confirmed cases in North Kivu in Beni. The cumulative number of confirmed / probable cases among health workers is 166 (approximately 5% of all confirmed / probable cases), including 41 deaths. 

The data presented in this table are likely to change later, after in-depth investigations and after redistribution of cases and deaths in their respective health zones.

NEWS  

NOTHING TO REPORT 

VACCINATION  

• Massive support from participants in the vaccination in Butembo and Katwa; 

• Low participation in vaccination around confirmed cases from December 26, 2019 to January 15, 2020 in the Aloya and Bingo health areas in Mabalako in North Kivu, where with 6 local teams; 

• 6,317 people were vaccinated, until January 17, 2020, with the 2nd vaccine Ad26.ZEBOV / MVA-BN-Filo (Johnson & Johnson) in the two health areas from Karisimbi to Goma; 

• Since the start of vaccination on August 8, 2018 with the rVSV-ZEBOV vaccine 269,480 people have been vaccinated; 

• Approved on October 22, 2019 by the Ethics Committee of the School of Public Health at the University of Kinshasa and on October 23, 2019 by the National Ethics Committee, the second vaccine, called Ad26.ZEBOV / MVA-BN -Filo, is produced by Janssen Pharmaceuticals for Johnson & Johnson; 

• This new vaccine complements the first, rVSV-ZEBOV, a vaccine used until then (since August 08, 2018) in this epidemic manufactured by the pharmaceutical group Merck, after approval by the Ethics Committee on May 20, 2018. It was recently pre-qualified for certification.

SURVEILLANCE AT ENTRY POINTS

• Since the start of the epidemic, the total number of travelers checked (temperature taken) at health checkpoints has been 140,563,910 ;

• To date, a total of 109 entry points (PoE) and health control points (PoC) have been set up in the provinces of North Kivu and Ituri in order to protect the country's major cities and avoid the spread of the epidemic in neighboring countries.

WHO: DRC Ebola update, January 16

WHO has published Ebola virus disease – Democratic Republic of the Congo. Note one error in the last paragraph of the excerpt, which refers to the start of the outbreak on May 8, 2018. That was the beginning of the 9th outbreak, in Equateur province, and it was briskly wrapped up even as the 10th outbreak began in North Kivu; it was declared on August 1, 2018.

Fourteen new confirmed cases were reported from 8 to 14 January in the ongoing Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo. The confirmed cases were reported from Mabalako (64%, n=9), Beni (29%, n=4) and Musienene (7%, n=1) Health Zones in North Kivu Province. All new confirmed cases (100%, 14/14) reported in the past seven days were registered contacts prior to symptom onset and had epidemiological links to the transmission chain which originated from Aloya Health Area in Mabalako Health Zone. 

In the past 21 days (25 December 2019 to 14 January 2020), 40 confirmed cases were reported from 14 health areas within seven active health zones in North Kivu and Ituri Provinces (Figure 1, Figure 2, Table 1): Mabalako (43%, n=17), Butembo (20%, n=8), Beni (13%, n=5), Mambasa (10%, n=4), Kalunguta (8%, n=3), Katwa (5%, n=2), and Musienene (3%, n=1). Mabalako Health Zone remains the current hotspot of the outbreak, having reported 43% of confirmed cases in the past 21 days. The majority of cases (88%, 35/40) reported from this period are linked to known chains of transmission, which is similar to the period from 4 to 24 December 2019 (89%, 47/53). In the past 21 days, 8% (3/36) of the confirmed EVD deaths were people who died in the community, outside of Ebola treatment centres. From these three community deaths, 15 additional cases occurred, which reinforces the need for continued activities to follow contacts, detect symptomatic patients as early as possible, and engage communities in response efforts.  

As of 14 January, a total of 3406 EVD cases were reported, including 3288 confirmed and 118 probable cases, of which 2236 cases died (overall case fatality ratio 66%) (Table 1). Of the total confirmed and probable cases, 56% (n=1910) were female, 28% (n=960) were children aged less than 18 years, and 169 (5% of all reported cases) were health care workers. 

In the coming week, there will be nine health zones in North Kivu and Ituri Provinces that will have contacts in or entering their high-risk period (seven to 13 days after last exposure to the virus). In Kalunguta Health Zone, North Kivu Province, where five individuals were confirmed with EVD from 24 to 28 December 2019, all 153 contacts have cleared their 21-day follow-up, with no new cases reported. In Mambasa Health Zone, Ituri Province, where four new cases were reported from 4 to 5 January 2020, more than 400 followed contacts are nearing the end of their high-risk period. 

It has been 20 months since the outbreak was first declared on 8 May 2018. The number of cases reported per week is lower than the period from March to September 2019 (Figure 1). However, there are several health areas which are difficult to reach due to insecurity, including Mandima Health Zone, where there are rumours of several community deaths in Lwemba Health Area. Continued response efforts in active health zones, including in insecure areas, and preventing reintroduction of the disease into health zones with dense populations which have previously been cleared are crucial to ending ongoing transmission.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published Ebola virus disease – Democratic Republic of the Congo. Excerpt:

Twelve new confirmed cases were reported from 1 to 7 January in the ongoing Ebola virus disease (EVD) outbreak in North Kivu and Ituri Provinces. The confirmed cases in this week were reported from nine health areas in four health zones: Butembo (42%, n=5), Mambasa (33%, n=4), Mangina (17%, n=2), and Beni (8%, n=1). The new case reported in Beni is linked to a transmission chain that originated in Aloya Health Area, Mabalako Health Zone. 

In the past 21 days (18 December 2019 to 7 January 2020), 41 confirmed cases were reported from 13 health areas within six active health zones in North Kivu and Ituri Provinces (Figure 2, Table 1): Mabalako (49%, n=20), Butembo (22%, n=9), Kalunguta (12%, n=5), Mambasa (10%, n=4), Katwa (5%, n=2), and Beni (2%, n=1). Mabalako Health Zone remains the main hotspot of the outbreak having reported 49% of confirmed cases in the past 21 days. 

Although the majority of the cases (76%, n=31) are linked to known chains of transmission, there are concerns around the reintroduction of the disease into health zones with dense populations which have previously been cleared, such as Butembo, Katwa, and Beni Health Zones. The sources of exposure for five new cases reported in Kalunguta Health Zone and four new cases reported in Mambasa Health Zone in the past 21 days are currently under investigation. 

As of 7 January, a total of 3392 EVD cases were reported, including 3274 confirmed and 118 probable cases, of which 2235 cases died (overall case fatality ratio 66%) (Table 1). Of the total confirmed and probable cases, 56% (n=1903) were female, 28% (n=956) were children aged less than 18 years, and 169 (5% of all reported cases) were healthcare workers.

Meanwhile, the MoH/WHO AFRO dashboard reports 1 new case on January  9, making the total 3,393 since the outbreak began.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published Ebola virus disease – Democratic Republic of the Congo. Excerpt:

Since the last disease outbreak news published on 19 December 2019, 29 new confirmed cases were reported from 18 to 31 December in the ongoing Ebola virus disease (EVD) outbreak in North Kivu province. The confirmed cases in this week were reported from eight health areas in four health zones: Mabalako (62%, n=18), Butembo (14%, n=4), Kalunguta (17%, n=5), and Katwa (7%, n=2). Three of the four cases reported in Butembo in the past fourteen days are linked to a transmission chain of more than 50 people that originated in Aloya Health Area, Mabalako Health Zone. 

One individual classified as a relapse case of EVD, infected several other individuals within the family and through nosocomial transmission (for more information, please see the disease outbreak news published on 19 December 2019). 

In Kalunguta Health Zone, the five cases reported between 24 and 28 December 2019, are a distinct epidemiologically linked chain of transmission, although the source of exposure is currently under investigation. 

In the past 21 days (11 December to 31 December), 40 confirmed cases were reported from 10 health areas within five neighbouring active health zones in North Kivu province (Figure 2, Table 1): Mabalako (68%, n=27), Butembo (13%, n=5), Kalunguta (13%, n=5), Katwa (5%, n=2), and Biena (3%, n=1). The majority of the cases (75%, n=30) are linked to known chains of transmission. 

As of 31 December, a total of 3380 EVD cases were reported, including 3262 confirmed and 118 probable cases, of which 2232 cases died (overall case fatality ratio 66%) (Table 1). Of the total confirmed and probable cases, 56% (n=1900) were female, 28% (n=953) were children aged less than 18 years, and 168 (5% of all reported cases) were healthcare workers.

WHO AFRO: Ebola virus disease outbreak in DRC - Sitrep 73 (2019)

WHO AFRO has published Ebola Virus Disease Outbreak in DRC - Sitrep 73 (2019). Excerpt:

In the week of 16 to 22 December 2019, 14 new confirmed Ebola virus disease (EVD) cases were reported from four health areas within two health zones in North Kivu province in the Democratic Republic of the Congo. The new confirmed cases in the past week are from Mabalako Health Zone (12/14; 86%) and Butembo Health Zone (2/14; 14%). 

 All 14 cases reported in the past seven days are linked to the case in Aloya health Area, in which one individual was a potential source of infection for a transmission chain currently linking 39 people reported between 8 and 22 December 2019. Based on the preliminary sequencing of samples from this individual, this is being classified as a relapse of EVD. A total of 29 reported cases are thought to have direct epidemiological links to this case, and 10 cases are likely the result of further secondary transmission of EVD. 

In the past 21 days (2 to 22 December 2019), 49 confirmed cases were reported from 12 health areas within six neighbouring active health zones in North Kivu and Ituri provinces: Mabalako (76%; n=37 cases), Beni (12%; n=6), Mandima (4%; n=2), Butembo (4%; n=2), Oicha (2%; n=1), and Biena (2%; n=1). 

 As of 22 December 2019, a total of 3362 EVD cases, including 3244 confirmed and 118 probable cases have been reported, of which 2226 cases died (overall case fatality ratio 66%). Of the total confirmed and probable cases, 56% (n=1892) were female, 28% (n=945) were children aged less than 18 years, and 5% (n=169) were healthcare workers.