2014-05-11 ~ Medical News Blog

Editor's Note #19: Just a pause...

Hi all,

Nothing fills me with more self-loathing than seeing VDU's charts being used when they are out of date...and I only have myself to blame!

Generally speaking of course, I love seeing the charts used - that's what I make 'em for. But for some events, like the MERS-CoV localised epidemic, VDU's posts are out-of-date as quickly as the front page of yesterdays newspaper. So there is a need for a lot of night work.

I've been a little occupied with (drowning in) other paperwork of late - I do have a day-job after all - including a review of the fairly diverse MERS-CoV literature for a manuscript I'm writing.

As a result, I've fallen behind in updating my MERS-CoV (detections consistently roll in overnight but in smaller numbers than during April) and H7N9 (not many to add) charts.

I'll remedy this as soon as I can.

Cheers,
Ian

Welcome to the Netherlands MERS-CoV...

case announcement, IHR, MERS-CoV, PHEIC, The Netherlands, WHO

Click on map to enlarge.

New map format coming. The Netherlands enlarged.
Click on map to enlarge.

The 19th country for the Middle East Respiratory syndrome coronavirus is the Netherlands. The virus was carried in on an (?elderly) male returning from a visit to the Kingdom of Saudi Arabia.[1,2]

And it occurred in amongst the announcement from the Fifth Meeting of the International Health Regulations (IHR)Emergency Committee concerning MERS-CoV, which concluded that conditions have not been met to require the declaration of a Public Health Emergency of International Concern (PHEIC, pronounced "fake").[3]

In the meantime I'm sticking with Public Health Epidemic of International Eyebrow Wrinkling (pronounced "phew").

References...

http://www.rtlnieuws.nl/nieuws/binnenland/eerste-geval-levensgevaarlijke-mers-virus-nederland
http://www.rivm.nl/Documenten_en_publicaties/Algemeen_Actueel/Nieuwsberichten/2014/Eerste_MERS_patient_in_Nederland
http://www.who.int/mediacentre/news/statements/2014/mers-20140514/en/

Keep calm and call the lab...without it, you know less than you think you do [UPDATED x2]

Acute respiratory tract infections, differential diagnosis, MERS, MERS-CoV, respiratory viruses, United States of America

This morning there are 2 symptomatic healthcare workers (HCWs) in the United States (of America; I'm just going to use the "US" from from here on) who came into contact with the recently diagnosed MERS-CoV positive 44M (age and sex confirmed yet?) imported case.

The news has driven something of a twitter storm in the #MERS channel. Not unexpected I guess. The implication is that these 2 have acquired MERS-CoV from contact with the imported MERS-CoV-positive person.

But that link is still far from proven yet. [UPDATE: both HCWs tested negative for MERS-CoV [1]]

This is a slightly revised version of that which I posted 18-March.
Thanks to Dr K Arden for helpful advice.
Click on image to enlarge.
VDU images are free to re-use. I can provide a better quality if needed.
Please just cite Dr Ian M Mackay, and this blog, http://newsmedicalnet.blogspot.com.au/,
if used elsewhere.

...Something to remember, or become aware of...

There are >200 known human viruses that have at one time or another been linked to patients with signs and symptoms that defined an 'influenza-like illness" (ILI). No-one can predict what these HCWs are infected with, but they have been or currently are infected by something. Lab tests are essential to know this.

I've asked Orlando Health's social media team (@orlandohealth) if these 2 HCWs are also being tested for the more "standard" 8 or 9 endemic human respiratory viruses/virus groups in parallel with MERS-CoV testing. I'll update this post with what I learn.

These standard viruses include influenzaviruses (A and B; red above), respiratory syncytial virus (dark pink), adenoviruses (orange), human metapneumovirus (pale pink) and parainfluenzaviruses 1, 2, 3 (purple). I'd also hope the rhinoviruses (in green above) since they are numerous and a frequent cause of ILI that can confound the very broad ILI tag. This panel of viruses comprise a standard testing menu which may be further extended, or shrunk, depending on the lab and they are included in commercial PCR-based kits.

Keep in mind too that a positive PCR (if that's what is used) result does not mean the virus found is the cause of the illness. It may be that another virus, that has since dropped below the limit of assay detection was the cause, or a couple of viruses working in series or parallel, or a virus & bacterium working in synergy or a virus that wasn't tested for, or a virus that is not even known yet...pant.

But if these 2 HCWs do test positive for the MERS-CoV, it's not all that unexpected. Respiratory viruses on the scale you see above have not co-evolved with us/been introduced to us recently because they are easy to get rid of or stop from spreading between/to us.

MERS-CoV is just one of a long line of (probable) respiratory viruses that keep taking us to school to teach us just how sneaky and effective they can be at spreading and just how much our preconceptions trip us up, letting them finish with the best grade.

To stop the spread of them in an environment full of sick people, like a hospital, or even a school, a daycare centre, a long term care facility, a cruise ship, a plane, bus, or even a living room, is no mean feat. It's worth remembering that no single virus does only one thing. There is no "pneumonia virus", no "bronchitis virus", there's not a "common cold virus", there's no "droplet-only" spread, there's not "only replicates in nasal cells", there are just respiratory viruses and their very complex multicellular hosts. I'm happy to argue any of these points, but come prepared to show me that every avenue has been exhausted to support your argument beforehand. I'll give you the drum right now, they really haven't.

Respiratory viruses can each do lots of things and the outcome on our health is heavily determined by us; our previous exposures, our age, our general health, our maternal antibody levels, our underlying diseases, our genetic makeup, our environment, our climate, our animal and human contacts, our personal hygiene and our habits.

End of monologue.

Reference...

http://www.flutrackers.com/forum/showpost.php?p=534975&postcount=49

MERS-CoV on a plane!

air travel, MERS, MERS-CoV, spread, transmission

"Assessment of the MERS-CoV epidemic situation in the Middle East region."
Reprinted with kind permission of author (Dr Vittoria Colizza, pers comm).Click on image to enlarge.

This is perhaps a timely reminder of where cases of MERS-CoV may pop-up if we look at the author's analysis of destinations from major departure airports in the Kingdom of Saudi Arabia, Jordan, Qatar and the United Arab Emirates.

The figure above also goes to show that the numbers and predictions are great, but biological systems and bad luck prevail. The US gets 2 cases so far, the same as all of Asia. Still, the point is valid; that we live in a highly interconnected world where no 2 points are separated by more time than it takes to silently incubate a respiratory virus and produce signs and symptoms, and virus, after arriving at a new destination.

Reference...

Chiara Poletto, Camille Pelat, Daniel Levy-Bruhl, Yazdan Yazdanpanah, Pierre-Yves Boelle, Vittoria Colizza,
Assessment of the MERS-CoV epidemic situation in the Middle East region. arXiv:1311.1481 [q-bio.PE]

Snapdate: MERS-CoV detection by month...

epidemiology, Kingdom of Saudi Arabia, MERS, MERS-CoV, monthly cases, snapdate

We are living in the 2.17th year, or 113th week, since the first known MERS-CoV-related illness affected a 25-year old Jordanian.

April stands out as the biggest MERS-CoV detection month ever, with 286 cases either becoming ill, being hospitalised or being reported as positive. But don't be confused by the differing values on the axes in the chart below. For all that May looks like a smaller cousin of April, its tally has already outstripped every other month of 2012 or 2013.

72 cases so fall into May. But the rate of cases this month is slower than in April (see previous post).

The tally of detections announced officially through WHO (which remains in a galaxy far, far, far away when it comes to detail on April-May cases) and from various Ministries of Health brings my worldwide tally to 580 MERS-CoV detections listed of which ~166 people have died of MERS. I'm still awaiting detail from WHO or UAE on 4 MERS-CoV cases that I do not list.

38% of May's case have died compared to 13% of April's (where I'm able to assign fatal cases to a month).

Click on image to enlarge.

Middle East respiratory syndrome coronavirus detections on the downward trend under Acting Health Minister Fakeih..[UPDATE]

case announcement, cases per day, epidemiology, fatal, MERS, MERS-CoV

Click on image to enlarge.

Apart from the looming spike in MERS-CoV detection among farmers who have taken to YouTube to kiss their camels in proof of their obviously over-stated role in being a viral source (sigh; that's a post unto itself*), the trend, after accounting for last nights cases is still one of declining case numbers since the change in management at the KSA Ministry of Health.

Some brief thoughts on the very early morning (my time; AEST) case reports from the KSA.[1] There were 8 cases announced which included 2 deaths plus another 3 deaths from previously announced cases. No asymptomatic cases (h/t @HelenBranswell) or healthcare workers and few mentions of comorbid disease were included; all bucking the recent trend. There were 4 possible hospital-acquired infections listed too, including illness onset from 11-May. Clearly infection prevention and control (ICP) messaging/action is still not succeeding, at least in Riyadh and Al-Madinah.

Also announced this morning was a second imported case into the USA.

The Patient (possibly a 44-year old male[2]) was symptomatic - including a cough, (later some diarrhoea), fever and chills (1-May) - during flights from Jeddah to London, from London to to Boston>Atlanta>Orlando, Florida.[2,3]
Symptomatic does not necessarily mean infectious [3]
Patient was a healthcare provider (?worker, HCW)
Patient was admitted to hospital in Orlando 9-May and is isolated.
Over 500 potential contacts from the US-based flights are being contacted and after 1,000 person hours by CDC staff over the weekend, no-one has been found to be reporting illness so far.[3]
Little risk of spread from casual contact.[3]

*I'm being sarcastic

References...

VDU Quote for the night...

epidemiology, Kingdom of Saudi Arabia, lab testing, MERS, MERS-CoV, Quote for the night

From:

Z.A. Memish et al.

Screening for Middle East respiratory syndrome coronavirus infection in hospital patients and their healthcare worker and family contacts: a prospective descriptive study.

Clinical Microbiology and Infection, 2014.

"Surveillance studies also help in defining and monitoring transmission rates, case load, and epidemic risk assessment, and assist in instituting infection control measures with new diagnostic methods and treatments."

MERS-CoV detections and deaths: is the war on MERS making headway?

death, epidemiology, MERS, MERS-CoV, proportion of fatal cases

For a few days now its felt as though we are seeing a more deaths in each Kingdom of Saudi Arabia (KSA) Ministry of Health (MOH) report, than we had been for a while. All very precise language there.

Currently there are about 161 fatalities among the 571 MERS-CoV detection. According to those numbers, 28.2% of people testing positive for MERS-CoV have died.

NOTE: Specific dates for some deaths are missing; date of reporting has been used instead.
The chart use 151 of approximately 161 deaths.
Click on image to enlarge.

Earlier in April, when the case numbers exploded thanks to a healthcare-associated outbreak, I wondered on Twitter if we'd see deaths "catch-up" to announcements as cases struggling for life in hospital, eventually succumbed to the damage started by their MERS-CoV infection. This is a virus with an apparently determined ability to wreak havoc in the lungs and kidneys of those who often already have an associated underlying disease of these tissues, and/or the cardiovascular system.

From the chart above, it looks like that catch-up is happening as the number of fatal outcomes (red dots) among the total of laboratory-confirmed MERS-CoV detections (green mountain) has been rising from mid-April onward.

Most notable to me is that the proportion of fatal cases (PFC) is now also rising as the number of new detections no longer outstrips the number of deaths being reported.

This is the first rise (rise >1% in PFC at least) since the beginning of March and reverses a trend of relatively stable PFC which dated back to late Aug-2013.

This bears watching both at face value but also in light of the recent concerns about extra testing and its impact on straining the KSA healthcare system. It might be more prudent to discuss the significant strain being placed on the KSA healthcare system by filled hospital beds and intensive care units and the supportive management of severely ill people detected as result of that testing.

The testing should be telling the MOH (even if it no longer tells us) in which hospitals the problems lie. At this stage, 21-days after the KSA Health Minster was replaced (21-April-2014), we'd expect to see the case numbers dropping as (hopefully) changes have been implemented that (hopefully) focused a stern gaze toward (hopefully) improving healthcare worker safety and (hopefully) infection prevention and control (IPC).

21-days into the new Health Minister's watch lies well outside the upper limit of the known MERS-CoV incubation period. If changes were sufficiently sweeping and if the war on MERS was entering a phase, detection numbers should be dropping as steeply as H7N9 cases do after a wet market closure. But they are not. Not yet anyway.

The accumulating MERS-CoV detections (green mountain) are looking to be slowing a little, which is good news. But of course with that slowing, I expect we'll see those red and back lines rise in the weeks ahead as deaths keep occurring. Which is not, and will not be reported as, good news. About the only thing to stop that numerical marker from rising would be a new outbreak of cases. Not something we want to see. And of course, it would only be a smoke-screen for the fact that MERS-CoV positive people are still dying from MERS-CoV infection and the complications that ensue.

Last point for this post. Recent KSA MOH reports are more up-to-date than they have been for a while so we can see that MERS-CoV infected people are still being admitted to hospital, even in recent days (e.g. 7-May), and MERS-CoV infected people are dying relatively recently too (e.g. 10-May).

Snapdate: MERS-CoV detected among asymptomatic people

asymptomatic, case accumulation, epidemiology, MERS, MERS-CoV

A quick look at the numbers of people without symptoms who have tested MERS-CoV positive, presumably by reverse-transcription real-time polymerase chain reaction (RT-rtPCR).

MERS-CoV detection cases are up to 571 worldwide, (575 once we get some detail of 4 UAE cases that are still AWOL) of which 117 are asymptomatic (20.4%) based on public data.

While the number of asymptomatic detections spiked along with the recent healthcare-associated outbreak, the proportions of asymptomatic detections in a week are not that different from other periods in 2013.

Click on chart to enlarge.

First Aid Response Training in Mbrarara, Uganda.

Emergency Medicine, First Aid Training, trauma, uganda

Uganda

Arriving in Rwanda

After a 3 yr hiatus, I am getting back on the road (or plane if you will). Last time I was abroad, I was so anxious to one day be able to go back into the world with a little knowledge under my belt. My year abroad taught me so much, but it was frustrating for me to not have the medical experience to be able to give back. I was a little medical student following the Senegalese/ Laotian resident around. I am now returning as an MD. A little baby MD with training wheels still on, but a Doctor nonetheless. I am very excited but also nervous to get back on my travel horse. Although I have traveled a great deal, it is still scary to jump on a plane to a unknown land and culture. Here we go once again!

May 2, 2014

I started of my adventure with a 21 hour journey from Boston to Uganda (Boston -> Amsterdam -> Rwanda- > Uganda), which was followed by another 13 hours on the ground until I reach my final destination of Mbarara, Uganda. I arrived into Kampala, the Ugandan capital, at 10pm. It was a surreal experience to be setting foot in Africa again. My first hour here, from the airport to the hotel, was one giant flashback. It made me truly miss Senegal. I have kept Senegal very close to my heart since I left. It will forever be my first time in Africa and first time I went out into the world completely on my own. Uganda had big shoes to fill. As I walked out of the airport, all I could see and hear were the Senegalese taxi drivers yelling to get your attention in French and Wolof. I remembered those butterflies in my stomach, the sweat in my palms, and the feeling of my heart racing that I felt when I first landed in Dakar 3 years ago. I was so scared back then. All I kept thinking was to keep walking forward and seem as calm as possible, when all I really wanted to do was crawl in to a little ball and be teleported back home with my Momma. This time it was different. I knew what to expect, and my appearance of calm was not a facade but reality. It made me a little sad. You only get to have your first kiss once, and you only get to be a 24yr old girl during her first time in Africa once too. As I looked up and saw the million stars in the sky, I smiled and thought to myself, � Hi

Africa, I�m back!� Uganda is very beautiful. Senegal is in the middle of the Sahara, so it was nothing but desert and Boaboa trees. Uganda is dead center on the equator. It is about 80 degrees year round, so it is very green, a little humid, and filled with valleys. All the nervous feelings I had as I prepared for my trip disappeared on my way to the hotel. It was like riding a bicycle. I immediately adjusted to the stores on the side of the road, the aluminum roofs, and old concrete or brick. The familiar smell of 1970s cars mixed with fresh air and old world was all around me. I was thinking of how wonderful it was to be able to come back to such a beautiful part of the world, when we arrived to the hotel gates with a security guard holding a machine gun the size of a small child. It was reality reminding me of where I was in the world.

May 6, 2014

Mbarara

It has barely been 2 days, and I already feel like I have been here a week. Right away it is very obvious that this trip is unlike any trip I have taken. I have always gone abroad to study or work on a project. Yet, my trips have always been focused on me learning. Even when I have gone abroad to complete a project, no one was depending on my results for anything. The expectation was that I get out as much as I could out of the trip and my experience in order to further my knowledge that specific field or topic. This trip is different because I have very real responsibilities. There are both Ugandans and Americans that are depending on my work and the results I obtain. It feels like the first trip of the rest of my life and career. I feel like my previous trips were done in preparation for this trip and the work I will do from now on. It is both daunting and very exciting.

May 7, 2014

A&E = Emergency Department

Working in the A&E ( accidents and emergencies), which is the Ugandan version of the emergency department is going to be such an incredible learning experience. I have been working hard these last 2 years as a resident to learn as much as I could and gain as much experience as possible as a clinician. It has been a very steep learning curve. Going from an oblivious little intern to now an up-coming PGY-3, the difference in my skills as a doctor are incredible. On my first day of residency, it took me an hour and a half to see and complete the evaluation of my first patient. I still remember his face, the room he was in, and his chief complaint. I was so scared to prescribed Tylenol because I knew that if I put in the order, the nurse would actually give it. It wasn�t like medical school, where everything is practice and things have to be approved by your senior resident or attending. Although I had plenty plenty of support and help if I needed it, my orders for medications and interventions would actually be given. Anyway, so I went from getting butterflies from prescribing Tylenol to being able to confidently treat septic patients,

Procedure Room

strokes, doing intubation, placing central lines, and ordering medications that could rapidly and drastically alter someone�s physiology as well as having the ability of being responsible of as many as 15-20 patients at the same time on my overnight shifts. I still have a lot to learn, but the difference is mind-boggling.

Type and Crossing

Well, I came from that back to step one again. Being here in the Uganda A&E, I don�t know where any of the medications are, how the system works, the extent of the capabilities of the department, or how to simply write a note. My first day, it took me 2 hours to complete the evaluation and admission of 1 patient. Obviously, some of that had to do with how the system works, but the intern had to talk me through how to write a note and work up a patient. I felt like a day 1 intern all over again. I was learning more from the Ugandan doctors and interns than they were learning from me. Me, the American doctor being trained with �advanced� techniques and was here to teach them a few things! Because they do not have the tools and technology we have available to us in the west, they rely mostly on their skills as clinicians and physical exam. It is an art that is quickly fading in the west due to our growing reliance on technology.

Blood Bank

I needed it, my orders for medications and interventions would actually be given. Anyway, so I went from getting

It reminded me that I have to always be paying attention. There is no difference between me and the 13yo boy I say in the A&E the other day, who was hit by a boda boda. He came in with a head injury, cuts, and a very large open wound that involved the entire left side of his abdomen. He was lucky because it didn�t involve the part of the body that keep your organs and intestines inside. He was sutured up and discharged home later in the day.

May 8, 2014

I wake up at 630am-7am every morning and have not been able to go to sleep until about 11pm every night, not much difference than my days back in the US. Well, I little different. I don�t think I will have to take-on strings of days/weeks of getting 5-6hrs of sleep per night.

I have already had two amazing experiences. On Tuesday, I tagged along with a field team who deliveries HIV medications to rural communities. We drove out about 1 hour from Mbrarara into the tiny huts and houses that are in the middle of banana plant fields and miles from anything remotely modern. It was awesome!! I was honored to be the guest into their homes and sit in the one chair or bench of their home. The houses are usually made of clay, using old palm tree leaves as the structure backbone of the clay walls. The roof is usually made tin or dry palm leaves weaved together.

View of Mbarara Regional Referral Hospital

Today, I accompanied one of the internal medicine residents who is also here to a rural clinic that was 4 hours away from Mbarara. In order to get there, you have to drive through Queen Elizabeth National park, which is the main game reserve here in Uganda. There we were, making a very ordinary drive out to the clinic while seeing elephants, water buffalo, water bucks, and exotic birds on the way. No big deal. Just another part of our day! I couldn�t help but laugh and smile about the life I am lucky enough to live.

The clinic experience was eye-opening. These patients are so far away from any major city, that this clinic is all they have for medical assistance. There is no doctor. There is a chief medical officer, who was trained for 3 years after high school and is responsible for every patient, and a team of nurses. The clinic has a catchment area of about 40, 000 people, so it is no small task. He is able to work with limited medications to treat diseases that would require entire medical teams in the west. It was very humbling.

May 11, 2014

This first week was all about getting to know my environment, the people, the culture. I spent months trying to plan out my project, but it is so different to actually arrive and to start doing it. The beginning stages of organizing the first aid course have started. I have a specific plan of action. The program coordinator, Sarah, has been here for about 2 years so she knows the system very well. I had the curriculum and overall concept of the course planned out in my mind, but she is helping me adjust it to the setting in which I am working. Next week will be very busy. We are implementing the course in 8 days. It is not a lot of time to implement a course that I have never executed before in a setting that I am just getting familiar with. Yet, I know that we will get it done. We are going to start off small. We are planning to have only 40 participants this time around. My hope is that this course will grow and develop to become a city-wide event.

Central Market

Chickens for sale at market.

Roadside Rest Stop

Elephant on my way to rural clinic.

Lake Bunyonyi

Ugandan kids

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