H5N1

Molecular epidemiology and high mortality of Crimean-Congo hemorrhagic fever in Oman

Via bioRxiv: Molecular epidemiology and high mortality of Crimean-Congo hemorrhagic fever in Oman: a re-emerging infection. The abstract:

Background 

Crimean-Congo hemorrhagic fever (CCHF) is a serious disease with a high fatality rate reported in many countries. The first case of CCHF in Oman was detected in 1995 and serosurveys have suggested widespread infection of humans and livestock throughout the country. 

Methodology 

Cases of CCHF reported to the Ministry of Health (MoH) of Oman between 1995 and 2017 were retrospectively reviewed. Diagnosis was confirmed by serology and/or molecular tests in Oman. Stored RNA from recent cases was studied by sequencing the complete open reading frame (ORF) of the viral S segment at Public Health England, enabling phylogenetic comparisons to be made with other S segments of strains obtained from the region. 

Findings 

Of 88 cases of CCHF, 4 were sporadic in 1995 and 1996, then none occurred until 2011. From 2011-2017, incidence has steadily increased and 19 (23.8%) of 80 cases clustered around Eid Al Adha. The median (range) age was 33 (15-68) years and 79 (90%) were male. The major risk for infection was contact with animals and/or butchering in 73/88 (83%) and only one case was related to tick bites alone. Severe cases were over-represented: 64 (72.7%) had a platelet count < 50 x 109/L and 32 (36.4%) died. There was no intrafamilial spread or healthcare-associated infection. The viral S segments from 11 patients presenting in 2013 and 2014 were all grouped in Asia 1 (IV) lineage. 

Conclusions 

CCHF is well-established throughout Oman, with a single strain of virus present for at least 20 years. Most patients are men involved in animal husbandry and butchery. The high mortality suggests that there is substantial under-diagnosis of milder cases. Preventive measures have been introduced to reduce risks of transmission to animal handlers and butchers and to maintain safety in healthcare settings.

McKenna: What is behind the spread of a mysterious allergy to meat?

Via The Guardian, Maryn McKenna writes a long read: What is behind the spread of a mysterious allergy to meat? Excerpt:

It was early morning in early summer, and I was tracing my way through the woods of central North Carolina, steering cautiously around S-curves and braking hard when what looked like a small rise turned into a narrow bridge. I was on my way to meet Tami McGraw, who lives with her husband and the youngest of their kids in a sprawling development of old trees and wide lawns just south of Chapel Hill. Before I reached her, McGraw emailed. She wanted to feed me when I got there.

“Would you like to try emu?” she asked. “Or perhaps some duck?” 

These are not normal breakfast offerings. But for years, nothing about McGraw’s life has been normal. She cannot eat beef or pork, or drink milk or eat cheese or snack on a gelatine-containing dessert without feeling her throat close and her blood pressure drop. Wearing a wool sweater raises hives on her skin; inhaling the fumes of bacon sizzling on a stove will knock her to the ground. Everywhere she goes, she carries an array of tablets that can beat back an allergy attack, and an auto-injecting EpiPen that can jolt her system out of anaphylactic shock. 

McGraw is allergic to the meat of mammals and everything else that comes from them: dairy products, wool and fibre, gelatine from their hooves, char from their bones. This syndrome affects thousands of people in the US and an uncertain but likely larger number worldwide, and after a decade of research, scientists have begun to understand what causes it. It is created by the bite of a tick, picked up on a hike or brushed against in a garden, or hitchhiking on the fur of a pet that was roaming outside.  

The illness, which generally goes by the name “alpha-gal allergy” after the component of meat that triggers it, is a trial that McGraw and her family are still learning to cope with. In much the same way, medicine is grappling with it, too. Allergies occur when our immune systems perceive something that ought to be familiar as foreign. For scientists, alpha-gal is forcing a remapping of basic tenets of immunology: how allergies occur, how they are triggered, whom they put in danger and when. 

For those affected, alpha-gal is transforming the landscapes they live in, turning the reliable comforts of home – the plants in their gardens, the food on their plates – into an uncertain terrain of risk.

MMWR: Multistate infestation with the exotic disease–vector tick Haemaphysalis longicornis — United States, August 2017–September 2018

Via MMWR: Multistate Infestation with the Exotic Disease–Vector Tick Haemaphysalis longicornis — United States, August 2017–September 2018. The summary: 

What is already known about this topic?  

Haemaphysalis longicornis is a tick indigenous to Asia, where it is an important vector of human and animal disease agents, which can result in human hemorrhagic fever and substantive reduction in dairy production. 

What is added by this report?  

During 2017–2018, H. longicornis has been detected in Arkansas, Connecticut, Maryland, New Jersey, New York, North Carolina, Pennsylvania, Virginia, and West Virginia on various species of domestic animals and wildlife, and from two humans.  

What are the implications for public health practice? 

The presence of H. longicornis in the United States represents a new and emerging disease threat. Characterization of the tick’s biology and ecology are needed, and surveillance efforts should include testing for potential indigenous and exotic pathogens.

Eurosurveillance: Crimean-Congo haemorrhagic fever in a Greek worker returning from Bulgaria, June 2018

Via Eurosurveillance: Crimean-Congo haemorrhagic fever in a Greek worker returning from Bulgaria, June 2018. The discussion:

Crimean-Congo haemorrhagic fever (genus Orthonairovirus, family Nairoviridae) circulates in nature in an enzootic cycle between ticks and non-human vertebrates. It is transmitted to humans by bite of infected Ixodid ticks (mainly Hyalomma spp.) or by contact with blood or tissues of viraemic patients or animals. Nosocomial infections are often reported. Here we report a CCHF case imported into Greece from south-western Bulgaria, where the patient was working on a construction site. He presented with the first symptoms 1 day after the removal of a tick from his abdomen.  

CCHF was first recognised in Bulgaria in 1952; since then, several cases have been reported. Genetic characterisation of the Bulgarian strains showed that they cluster into the clade Europe 1. Our patient was infected in an area that was considered at low risk for CCHF outbreaks up to 2008, when a cluster of cases was observed in the region. 

Although the seroprevalence in the human population in Blagoevgrad province is low (1%), a seroprevalence of 41.9% in livestock was reported recently. Since CCHFV is transmitted mainly by bite of infected Ixodid ticks, persons living in rural areas are at increased risk for acquiring the infection. This was the reason that information about preventive measures was sent to our patient’s Greek co-workers in Bulgaria, and all related public health authorities were informed about the case.  

Regarding Greece, no other imported cases have been reported so far and the only autochthonous CCHF case was observed in 2008. A review of travel-associated CCHF cases published during 1960–2016 reported 21 cases; two imported cases have been reported within Europe: Bulgaria to Germany in 2001 and Bulgaria to the United Kingdom in 2014.  

Due to the high pathogenicity of the CCHFV, the absence of a specific drug treatment or vaccine and the risk of person-to-person transmission, rapid diagnosis is crucial to ensure that appropriate infection control measures (e.g. isolation of patient and barrier precautions) can be implemented in a timely manner. A detailed medical history of the patient, including travel history and possible risk factors, is important for the timely diagnosis of the disease. In our case, information regarding the tick bite was not provided immediately and this, in combination with the non-specific initial symptoms, meant that CCHF was first suspected on day 8 of illness. 

Despite this delay, the patient fully recovered and no secondary cases of CCHF have been reported. Since the northern part of Greece is close to CCHF-endemic countries, HCWs in this region should be made aware of CCHF; including the provision of training to better help them address questions from patients about travel history (identify potential risk of exposure). Physicians should include CCHF in the differential diagnosis for patients with haemorrhagic syndromes, especially if patients report a tick bite, outdoor activities or occupation in rural areas and recent travel to an endemic area.

Tropical disease outbreaks are growing threat in Europe as temperatures rise

Via The Guardian: Tropical disease outbreaks are growing threat in Europe as temperatures rise. Excerpt:

Europe is facing a growing threat of tropical disease outbreaks, as rising temperatures linked to climate change cause illnesses brought by travellers to spread more easily, health experts warned. 

This summer has seen a sharp spike in West Nile virus infections in Europe, following soaring temperatures, compared with the past four years. Until the middle of August, 400 cases of the disease, which is carried by mosquitos, were recorded in Europe, with 22 fatalities, according to the European Centre for Disease Prevention and Control (ECDC). Countries affected include Italy, Greece, Hungary, Serbia and Romania, all of which have recorded cases of the tropical infection in the past. 

The spike was due to an early start to the transmission season, caused by high temperatures followed by wet weather, conditions ideally suited to mosquito breeding, according to the World Health Organization’s regional office for Europe.  

“We are all a bit taken aback about how fast these change are coming down the pipeline,” said Prof Jan Semenza, who leads on scientific assessment for the ECDC. “We are seeing more and more of these extreme weather events.” 

Semenza, who studies how climate change and other global environmental changes, such as the rise in international travel, affect public health, said higher temperatures make it easier for disease-carrying vectors, such as mosquitos, to transmit disease. 

“Mosquitos and ticks are cold-blooded and are affected by higher temperatures. At higher temperatures, mosquitos replicate faster. Pathogens in the mosquito also replicate faster. Everything is speeded up and you get higher turnover, bigger populations of mosquitoes and a growing epidemic potential for viruses.”

Lyme disease is spreading fast. Why isn’t there a vaccine?

Via The New York Times: Lyme Disease Is Spreading Fast. Why Isn’t There a Vaccine? Excerpt:

We’ve all heard the advice about avoiding Lyme disease. If you walk through wooded or grassy areas where it’s prevalent, you should use insect repellent. Cover exposed skin. Check yourself thoroughly once you return home, and take a shower. If you see a tick, pluck it off your skin with tweezers. Look out for a bull’s eye-shaped rash and flulike symptoms in the summer. A

bout 30,000 cases of Lyme disease are reported to the Centers for Disease Control and Prevention each year, making it the most commonly reported vector-borne illness in the United States. That number has tripled over the last 20 years. And experts estimate that the actual number of cases — not just those that happen to be reported to the agency — is more like 300,000 per year. 

If Lyme has become so common, why isn’t there a vaccine for it? Well, here’s something you may not know: There used to be one, but it was taken off the market more than 15 years ago. And there’s only one new vaccine candidate in the pipeline.  

“Clearly, the problem is getting worse,” said Dr. Paul Mead, a top scientist at the C.D.C. “For years, we have been advocating that people use repellents, do tick checks, spray their yards. That remains good to do, but it’s not enough.”

Tickborne diseases: Confronting a growing threat

Via NEJM: Tickborne Diseases — Confronting a Growing Threat. Excerpt:

Every spring, public health officials prepare for an upsurge in vectorborne diseases. As mosquito-borne illnesses have notoriously surged in the Americas, the U.S. incidence of tickborne infections has risen insidiously, triggering heightened attention from clinicians and researchers.

According to the Centers for Disease Control and Prevention (CDC), the number of reported cases of tickborne disease has more than doubled over the past 13 years. Bacteria cause most tickborne diseases in the United States, and Lyme disease accounts for 82% of reported cases, although other bacteria (including Ehrlichia chaffeensis, Anaplasma phagocytophilum, and Rickettsia rickettsii) and parasites (such as Babesia microti) also cause substantial morbidity and mortality. 

In 1982, Willy Burgdorfer, a microbiologist at the Rocky Mountain Laboratories of the National Institute of Allergy and Infectious Diseases, identified the causative organism of Lyme disease, a spirochete eponymously named Borrelia burgdorferi. B. burgdorferi (which causes disease in North America and Europe) and B. afzelii and B. garinii (found in Europe and Asia) are the most common agents of Lyme disease. The recently identified B. mayonii has been described as a cause of Lyme disease in the upper midwestern United States. 

Spirochetes that cause Lyme disease are carried by hard-bodied ticks (see graphic), notably Ixodes scapularis in the northeastern United States, I. pacificus in western states, I. ricinus in Europe, and I. persulcatus in eastern Europe and Asia. B. miyamotoi, a borrelia spirochete found in Europe, North America, and Asia, more closely related to the agents of tickborne relapsing fever, is also transmitted by I. scapularis and should be considered in the differential diagnosis of febrile illness occurring after a tick bite.

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.

Uganda: Press statement on rumoured Ebola outbreak in Mubende district

Via the government of Uganda: a press statement: Press statement on rumoured ebola outbreak in Mubende district. Excerpt:

HON. SARAH OPENDI STATE 

MINISTER OF HEALTH – GENERAL DUTIES 

27th May, 2018 

The Ministry of Health has noted with concern reports of an Ebola outbreak in Mubende district making rounds across the different media platforms. We would like to inform the public that there is no Ebola outbreak in Mubende or any other part of the country.  

What was quoted in the media is rather a case of Crimean-Congo Haemorrhagic Fever (CCHF). It is worth noting that the CCHF outbreak in the districts of Luwero and Nakaseke - which share a boarder with Mubende district - was declared on January 4th this year, and efforts to contain it are still ongoing.  

Crimean-Congo Haemorrhagic Fever (CCHF) is a viral zoonosis (Animal to Human) caused by infection with a tick-borne virus. The hosts of the CCHF virus are mostly wild and domestic animals including cattle, sheep and goats. These animals become infected after being bitten by infected ticks and the virus remains in their bloodstream for about two weeks after infection, allowing the tick-animal-tick cycle to continue when another tick bites. 

Human transmission may occur when human beings get into contact with infected ticks (through tick bites) or direct contact with blood or tissues of an infected animal. CCHF can be transmitted from one infected human to another by contact with infectious blood or body fluids. In humans, CCHF can present with several symptoms including sudden onset of high-grade fever, muscle aches, neck pains, neck stiffness, backache, headache, sore eyes, vomiting, diarrhoea, abdominal pain, and sometimes bleeding from body openings.  

In Uganda, the risk of acquiring and spread of CCHF is high among communities within the cattle corridor (occupational exposure). CCHF is known to be ENDEMIC (always present) in Africa among cattle, and OCCASIONALLY shows up in humans. 

There is no known effective vaccine or definitive treatment among humans. General supportive care with treatment of symptoms is the main approach to managing CCHF infected patients. 

Prevention of human to human transmission is through isolation of patients, use of Personal Protective Equipment (PPE), and application of universal precautions for Infection Prevention and Control (IPC) including hand-washing hygiene, safe injection practices, in healthcare setting as well as safe and dignified burial of deceased cases. 

THE CRIMEAN-CONGO HEMORRHAGIC FEVER (CCHF) SITUATION IN MUBENDE DISTRICT  

On the night of 21st May 2018, a 35-year-old male from Nkoko subcounty in Bugangaizi county, Kakumiro district presented at Melt Care Clinic with a high fever and vomiting and was admitted for two days. Since he was not improving, the relatives transferred him to Galde medical clinic in Kakumiro district on 23rd May from where he was referred to Mubende Regional Referral Hospital. 

The clinician on duty at Mubende RRH immediately transferred the patient to the hospital isolation room where he received intravenous fluids. 

Unfortunately, he died during that same night at around 1am. Samples were taken off the body and were sent to the Uganda Virus Research Institute (UVRI). 

The attendants of the diseased who included his expectant wife and 4 others were immediately quarantined and they are closely being monitored.

Tick and mosquito infections spreading rapidly, CDC finds

Via The New York Times: Tick and Mosquito Infections Spreading Rapidly, C.D.C. Finds. Excerpt:

The number of people who get diseases transmitted by mosquito, tick and flea bites has more than tripled in the United States in recent years, federal health officials reported on Tuesday. Since 2004, at least nine such diseases have been newly discovered or introduced into the United States.  

Warmer weather is an important cause of the surge in cases reported to the Centers for Disease Control and Prevention, according to the lead author of a study in the agency’s Morbidity and Mortality Weekly Report. 

But the author, Dr. Lyle R. Petersen, the agency’s director of vector-borne diseases, repeatedly declined to connect the increase to the politically fraught issue of climate change, and the report does not mention either climate change or global warming.  

Many other factors are at work, he emphasized, while noting that “the numbers on some of these diseases have gone to astronomical levels.”  

C.D.C. officials called for more support for state and local health departments. Local agencies “are our first line of defense,” said Dr. Robert Redfield, the C.D.C.’s new director. “We must enhance our investment in their ability to fight these diseases.” 

Although state and local health departments get brief infusions of cash during scares like the 2016 Zika epidemic, they are chronically underfunded. A recent survey of mosquito control agencies found that 84 percent needed help with basics like surveillance and pesticide-resistance testing, Dr. Petersen said.  

The C.D.C. did not suggest that Americans drop plans for playing outdoors or lying in hammocks this summer, but Dr. Redfield emphasized that everyone — especially children — needed to protect themselves against tick and mosquito bites.  

Between 2004 and 2016, about 643,000 cases of 16 insect-borne illnesses were reported to the C.D.C. — 27,000 a year in 2004, rising to 96,000 by 2016. (The year 2004 was chosen as a baseline because the agency began requiring more detailed reporting then.) 

The real case numbers were undoubtedly far larger, Dr. Petersen said. For example, the C.D.C. estimates that about 300,000 Americans get Lyme disease each year, but only about 35,000 diagnoses are reported.  

The study did not delve into the reasons for the increase, but Dr. Petersen said it was probably caused by many factors, including two related to weather: Ticks thriving in regions previously too cold for them, and hot spells triggering outbreaks of mosquito-borne diseases.  

Other factors, he said, include expanded human travel, suburban reforestation and a dearth of new vaccines to stop outbreaks.