H5N1

Tomato flu outbreak in India

Via The Lancet Respiratory Medicine, another new threat to children and perhaps adults: Tomato flu outbreak in India. Excerpt:

Just as we are dealing with the probable emergence of fourth wave of COVID-19, a new virus known as tomato flu, or tomato fever, has emerged in India in the state of Kerala in children younger than 5 years. The rare viral infection is in an endemic state and is considered non-life-threatening; however, because of the dreadful experience of the COVID-19 pandemic, vigilant management is desirable to prevent further outbreaks.

Although the tomato flu virus shows symptoms similar to those of COVID-19 (both are associated with fever, fatigue, and bodyaches initially, and some patients with COVID-19 also report rashes on the skin), the virus is not related to SARS-CoV-2. Tomato flu could be an after-effect of chikungunya or dengue fever in children rather than a viral infection. The virus could also be a new variant of the viral hand, foot, and mouth disease, a common infectious disease targeting mostly children aged 1–5 years and immunocompromised adults, and some case studies have even shown hand, foot, and mouth disease in immunocompetent adults. Tomato flu is a self-limiting illness and no specific drug exists to treat it.  

The tomato flu was first identified in the Kollam district of Kerala on May 6, 2022, and as of July 26, 2022, more than 82 children younger than 5 years with the infection have been reported by the local government hospitals. The other affected areas of Kerala are Anchal, Aryankavu, and Neduvathur. This endemic viral illness triggered an alert to the neighbouring states of Tamil Nadu and Karnataka. Additionally, 26 children (aged 1–9 years) have been reported as having the disease in Odisha by the Regional Medical Research Centre in Bhubaneswar. To date, apart from Kerala, Tamilnadu, and Odisha, no other regions in India have been affected by the virus. However, precautionary measures are being taken by the Kerala Health Department to monitor the spread of the viral infection and prevent its spread in other parts of India.

The primary symptoms observed in children with tomato flu are similar to those of chikungunya, which include high fever, rashes, and intense pain in joints. Tomato flu gained its name on the basis of the eruption of red and painful blisters throughout the body that gradually enlarge to the size of a tomato. These blisters resemble those seen with the monkeypox virus in young individuals. Rashes also appear on the skin with tomato flu that lead to skin irritation. As with other viral infections, further symptoms include, fatigue, nausea, vomiting, diarrhoea, fever, dehydration, swelling of joints, body aches, and common influenza-like symptoms, which are similar to those manifested in dengue. 

In children with these symptoms, molecular and serological tests are done for the diagnosis of dengue, chikungunya, zika virus, varicella-zoster virus, and herpes; once these viral infections are ruled out, contraction of tomato virus is confirmed. Because tomato flu is similar to chikungunya and dengue as well as hand, foot, and mouth disease, treatment is also similar—ie, isolation, rest, plenty of fluids, and hot water sponge for the relief of irritation and rashes. Supportive therapy of paracetamol for fever and bodyache and other symptomatic treatments is required.

Increased detection of enterovirus A71 infections, Germany, 2019

Eurosurveillance has published Increased detection of enterovirus A71 infections, Germany, 2019. The introduction:

In Europe, enterovirus A71 (EV-A71) has mainly been detected sporadically in patients with neurological disorders. C2 has been the predominant sub-genogroup during the last decade. A multi-recombinant C1 lineage (C1-like) emerged in 2015 in Germany. Since then, it was detected in sporadic cases with severe neurological disease in several European countries, as well as in an outbreak in Catalonia, Spain in 2016. In south-eastern Asia, EV-A71, sub-genogroup C4 strains have been mainly associated with severe and even fatal courses of hand, foot and mouth disease (HFMD) in children. 

Here we report on an increase of EV-A71 C1-like strains in Germany in 2019 and first detections of EV-A71 C4 strains in patients with neurological disease and HFMD.

Hong Kong: CHP investigates hand, foot and mouth disease outbreaks in three schools

Via the Centre for Health Protection: CHP investigates hand, foot and mouth disease outbreaks in three schools. Excerpt:

The Centre for Health Protection (CHP) of the Department of Health is today (December 17) investigating outbreaks of hand, foot and mouth disease (HFMD) in two secondary schools and one primary school, and again urged the public, schools and institutions to maintain strict hand, personal and environmental hygiene.      

The first outbreak affected four male and 16 female students aged 12 to 17 at a secondary school in Sha Tin. They have developed oral ulcers, rash and vesicles on hands or feet, and fever, since November 2. All of them sought medical attention but none required hospitalisation.        

The second outbreak was at a secondary school in Kwai Chung, affecting 16 male and three female students aged 16 to 18, as well as one female staff member. They have developed oral ulcers, rash over hands or feet and fever since December 7. All of them sought medical attention and one required hospitalisation.        

The third outbreak affected 18 male and two female students aged 6 to 10 at a primary school in Wan Chai. They have developed fever, rash over hands or feet and oral ulcers since November 24. All of them sought medical attention but none required hospitalisation.       

All patients of the above outbreaks are now in a stable condition.      

Officers of the CHP have conducted site visits to the schools and advised the management on necessary infection control and preventive measures. The schools have been put under medical surveillance. Investigations are ongoing.

Travel-related infections in mainland China, 2014–16: An active surveillance study

Via The Lancet Public Health: Travel-related infections in mainland China, 2014–16: an active surveillance study. The summary:

Background 

Transmission of infection through international travel is a growing health issue, and the frequency of imported infection is increasing in China. We aimed to quantify the total number of infections imported into mainland China by arriving travellers. 

Methods 

We actively surveyed arriving travellers at all 272 international entry–exit ports in mainland China. Suspected cases were detected through fever screening, medical inspection, self-declaration, and reporting by on-board staff. Participants completed a standardised questionnaire with questions about demographics, their travel itinerary (including detailed information about all countries or regions visited), and clinical manifestations. Nasopharyngeal swabs, sputum samples, faecal samples, vomitus, blood, and serum were collected as appropriate for diagnoses. Diagnosis was made by specific laboratory tests according to the national technical guidelines. 

Infections were classified as respiratory, gastrointestinal, vector-borne, blood-transmitted and sex-transmitted, or mucocutaneous. We divided arriving travellers into two groups: travellers coming from countries other than China, and travellers coming from Hong Kong, Macau, and Taiwan. We integrated surveillance data for 2014–16, calculated incidences of travel-related infections, and compared the frequency of infections among subgroups.  

Findings 

Between Jan 1, 2014, and Dec 31, 2016, 22 797 cases were identified among 805 993 392 arriving travellers—an overall incidence of 28·3 per million. 45 pathogens were detected in participants: 18 respiratory (19 662 cases), ten gastrointestinal (189 cases), seven vector-borne (831 cases), seven blood-transmitted and sex-transmitted (1531 cases), and three mucocutaneous (584 cases). Both the overall number and incidence of infection were more than five times higher in 2016 than in 2014. Case numbers and incidences also varied substantially by province, autonomous region, and municipality. 

Overall, 17 643 (77%) infections were detected by fever screening, but 753 (49%) blood-transmitted and sex-transmitted infections were identified through medical inspection. 14 305 (73%) cases of respiratory infection and 96 (51%) of gastrointestinal infections were in tourists. Tuberculosis, hepatitis A virus, vector-borne, and blood-transmitted and sex-transmitted infections were common among Chinese labourers who worked abroad. Dengue and malaria were most commonly diagnosed in travellers arriving from Africa. 12 126 (93%) of the 12 985 cases arriving from Hong Kong, Macau, or Taiwan were respiratory infections. Hand, foot, and mouth disease accounted for 2·90% of infections in travellers from Hong Kong, Macau, or Taiwan and 0·31% of infections in international travellers. 

Interpretation 

This report is the first to characterise the profile of travel-related infections among arriving travellers in mainland China. Our findings should increase public awareness of the potential risk of imported infections, and help health-care providers to make evidence-based health recommendations to travellers.

Hong Kong: CHP investigates case of severe enterovirus 71 infection

Via the Hong Kong Centre for Health Protection: CHP investigates case of severe enterovirus 71 infection. Excerpt:

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (July 5) investigating a case of severe enterovirus (EV) 71 infection, and again urged the public and institutions to maintain strict hand, personal and environmental hygiene.      

A girl, aged 17 with good past health, has presented with fever, rashes and vesicles over hands and feet, oral ulcer and sore throat since June 28. Subsequently, she developed headache, neck pain, drowsiness and confusion, and was admitted to United Christian Hospital for treatment on July 1. She was transferred to the Paediatric Intensive Care Unit for further management on July 4. The patient is now in a stable condition.      

Her rectal swab specimen tested positive for EV71 upon laboratory testing. The clinical diagnosis was EV71 infection complicated with encephalitis.      

Initial enquiries revealed that the patient had no travel history during the incubation period and her home contacts have remained asymptomatic.        

Separately, the CHP's epidemiological investigations also revealed that there is a hand, foot and mouth disease (HFMD) outbreak in the secondary school, Chinese Foundation Secondary School in Siu Sai Wan, where the patient attended. Apart from the patient, two girls aged 14 and 17 have developed HFMD symptoms since June 28. Both sought medical attention and no hospitalisation was required. They are now in a stable condition.        

Officers of the CHP have conducted a site visit to the school and advised the management on necessary infection control and preventive measures. The school has been put under medical surveillance. As a precautionary measure, the school was advised to suspend the two affected classes.     

The CHP's investigations are ongoing.      

"EV71 is one of the causative agents for HFMD. The infection is transmitted from person to person by direct contact with nose and throat discharges, saliva, fluid from blisters, or the stool of infected persons. Good personal and environmental hygiene are the most important measures to prevent EV71 infection," a spokesman for the CHP said.

Hand, foot and mouth disease kills 6 in China

Via the National Health Commission of the PRC, a Xinhua report: Hand, foot and mouth disease kills 6 in China. Excerpt:

More than 140,000 people have been infected with hand, foot and mouth disease (HFMD) and six died from the disease in China this year, according to China's Center for Disease Control and Prevention (CDC). 

As of April 20, a total of 141,978 cases had been reported, with six deaths and 581 in critical condition. The disease incidence rate was lower than the same period of last year, the CDC said in a statement. 

Zhang Jing, researcher with the CDC, said HFDM was a common infectious disease that usually affects infants and children younger than five years old.  

During the peak season for HFMD, from April to June, the CDC said measures are needed to closely monitor and prevent transmission of the disease, especially at primary schools and kindergartens.

ECDC: Expert panel reviews neuraminidase inhibitors for the prevention and treatment of influenza

An ECDC news release: Expert panel reviews neuraminidase inhibitors for the prevention and treatment of influenza. Excerpt:

An ECDC expert opinion concludes that there is clear evidence supporting the use of neuraminidase inhibitors in the treatment and prevention of influenza. Moreover, the current recommendations in European countries on the use of the neuraminidase inhibitors oseltamivir and zanamivir are appropriate and should be applied by prescribing physicians. 

The debate on antivirals’ effectiveness and safety has led to some uncertainty within the public health community regarding their potential benefits as a treatment option or as prophylaxis for influenza. 

The ECDC expert opinion demonstrates that there is evidence for use of neuraminidase inhibitors for treatment and prophylaxis of influenza, in particular for the most vulnerable and their families. It also highlights the importance of further studies and the urgent need for the development of new antivirals with greater efficacy.  

The expert opinion reviews three large systematic reviews and meta-analyses assessing efficacy, effectiveness and safety of two licensed neuraminidase inhibitors, oral oseltamivir and inhaled zanamivir: the 2014 Cochrane Collaboration report (Jefferson et al.), the 2015 MUGAS study (Dobson et al.), and the 2014 PRIDE study (Muthuri et al.). Additional reviews and studies were also considered.  

The expert opinion was opened for public consultation in spring 2016; the report has now been revised in light of the submissions and a final version published.

China: Infectious diseases in the decade after SARS

Via The Lancet Infectious Diseases: Epidemiological features of and changes in incidence of infectious diseases in China in the first decade after the SARS outbreak: an observational trend study. The summary:

Background 

The model of infectious disease prevention and control changed significantly in China after the outbreak in 2003 of severe acute respiratory syndrome (SARS), but trends and epidemiological features of infectious diseases are rarely studied. In this study, we aimed to assess specific incidence and mortality trends of 45 notifiable infectious diseases from 2004 to 2013 in China and to investigate the overall effectiveness of current prevention and control strategies.  

Methods 

Incidence and mortality data for 45 notifiable infectious diseases were extracted from a Chinese public health science data centre from 2004 to 2013, which covers 31 provinces in mainland China. We estimated the annual percentage change in incidence of each infectious disease using joinpoint regression.  

Findings 

Between January, 2004, and December, 2013, 54 984 661 cases of 45 infectious diseases were reported (average yearly incidence 417·98 per 100 000). The infectious diseases with the highest yearly incidence were hand, foot, and mouth disease (114·48 per 100 000), hepatitis B (81·57 per 100 000), and tuberculosis (80·33 per 100 000). 132 681 deaths were reported among the 54 984 661 cases (average yearly mortality 1·01 deaths per 100 000; average case fatality 2·4 per 1000). 

Overall yearly incidence of infectious disease was higher among males than females and was highest among children younger than 10 years. Overall yearly mortality was higher among males than females older than 20 years and highest among individuals older than 80 years. Average yearly incidence rose from 300·54 per 100 000 in 2004 to 483·63 per 100 000 in 2013 (annual percentage change 5·9%); hydatid disease (echinococcosis), hepatitis C, and syphilis showed the fastest growth. The overall increasing trend changed after 2009, and the annual percentage change in incidence of infectious disease in 2009–13 (2·3%) was significantly lower than in 2004–08 (6·2%).  

Interpretation 

Although the overall incidence of infectious diseases was increasing from 2004, the rate levelled off after 2009. Effective prevention and control strategies are needed for diseases with the highest incidence—including hand, foot, and mouth disease, hepatitis B, and tuberculosis—and those with the fastest rates of increase (including hydatid disease, hepatitis C, and syphilis).

Hong Kong: Local hand, foot and mouth disease and acute gastroenteritis activity increasing

Via the Centre for Health Protection: Local hand, foot and mouth disease and acute gastroenteritis activity increasing. Excerpt:

The Centre for Health Protection (CHP) of the Department of Health today (October 5) reported that the local activity of hand, foot and mouth disease (HFMD) and acute gastroenteritis (AGE) are increasing, and again urged the public and management of institutions to maintain strict personal and environmental hygiene.       

"The latest surveillance data show that activity of both diseases is increasing and may further increase in the following weeks. Members of the public should heighten vigilance," a spokesman for the CHP said.   

A. Hand, foot and mouth disease        

The number of institutional HFMD outbreaks increased from three (affecting 18 persons) in the week ending September 3 to 24 (77 persons) last week. As of yesterday (October 4), 14 (42 persons) had been reported this week. In the past four weeks, kindergartens and child care centres reported most outbreaks (69 per cent), followed by primary schools (20 per cent).        

"The usual summer peak of HFMD is from May to July, with a possible smaller peak from October to December. Last year, the summer peak lasted longer than usual. Schools, institutions and play facilities should observe our guidelines and health advice against outbreaks to better protect young children who are more prone to infections," the spokesman added.        

As for enterovirus (EV) 71 infection, as of yesterday, 22 cases (including one with severe complication) had been recorded this year. Last year, 56 cases including six with severe complications were filed. Regarding severe paediatric EV infection other than EV71 and poliovirus, nine cases had been detected so far this year with eight last year.   

B. Acute gastroenteritis

The number of institutional AGE outbreaks rose from one (six persons) in the week ending September 3 to eight (88 persons) last week. As of yesterday, seven (91 persons) had been reported this week. In the last four weeks, most outbreaks occurred in kindergartens and child care centres (70 per cent).        

The laboratory surveillance revealed a similar trend in gastroenteritis virus activity. The percentage that tested positive for norovirus increased from 6.5 per cent in August to 16.0 per cent last month as of September 23 among faecal specimens received by the CHP's Public Health Laboratory Services Branch.

Three more New Jerey schools infected by ‘unprecedented’ hand-foot-and-mouth disease outbreak

Thanks to Angie Baxlie for sending the link to this NJ.com report: Three more schools infected by ‘unprecedented’ hand-foot-and-mouth disease outbreak.

What some athletic officials have described as an "unprecedented" outbreak of hand-foot-and-mouth disease continues spreading across New Jersey. 

Holmdel High, Mendham High and North Warren High are the latest schools to report cases of the virus in their athletes, prompting all three schools to postpone their varsity football games previously schedule for Friday night.  

Holmdel moved its game at Red Bank Regional after several players came down with the disease, according to a report by the Asbury Park Press, while Mendham postponed its game at Roxbury and North Warren pushed its matchup against Boonton.  

It's the second time this season Boonton has been forced to move a game because of HFMD. The Bombers were supposed to play Pequannock High Sept. 9 before several visiting players came down with the disease. 

The virus also has been found in athletes at Don Bosco Prep, Kinnelon High, Hunterdon Central High, Wallkill Valley High and High Point High. All total so far, nine New Jersey high schools in six counties have reported cases of HFMD in their athletes.  

The outbreak at Holmdel and North Warren marked the first time the virus has been reported in Monmouth and Warren counties, respectively.  

HFMD causes painful sores inside the mouth as well as a skin rash on a person’s hands or feet, and it can also lead to high fevers and body aches, according to the Center for Disease Control and Prevention. The virus can be spread through contact or the air from coughing or sneezing, and it’s most commonly diagnosed in younger children.  

Although the virus can cause significant discomfort, it doesn’t pose serious risks if properly treated with rest, fluids and Tylenol, according to doctors. Typically, the illness subsides in one to two weeks.  

Doctors and athletic trainers have called the outbreak “unprecedented.”  

“It’s very unusual,” Jack Kripsak, a sports medicine and family practice physician and also the chair of the state athletic association’s medical advisory board, said earlier this month. “The only thing I can speculate is that there’s a new strain of this virus in the air and people are coming down with it. It has to be something that people haven’t been exposed to before. It has to be a new strain. Otherwise, why would this be happening? No one’s ever seen this before.”