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20 Jul 2017

#Cluster of #AFM in Five #Pediatric Patients — Maricopa County, #Arizona, 2016 (@CDCgov, MMWR)

Title: #Cluster of #AFM in Five #Pediatric Patients — Maricopa County, #Arizona, 2016.

Subject: Acute Flaccid Myelitis, cluster of cases in Arizona, USA.

Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK).

Code: [     ]


Notes from the Field: Cluster of Acute Flaccid Myelitis in Five Pediatric Patients — Maricopa County, Arizona, 2016


Weekly / July 21, 2017 / 66(28);758–760

Format: [ PDF [177K] ]

Sally A. Iverson, DVM1,2,3; Scott Ostdiek, MD4; Siru Prasai, MD2; David M. Engelthaler, PhD5; Melissa Kretschmer, MA2; Nicole Fowle2; Harlori K. Tokhie, MD4; Janell Routh, MD6; James Sejvar, MD7; Tracy Ayers, PhD6; Jolene Bowers, PhD5; Shane Brady, MPH3; Shannon Rogers, MS6; W. Allan Nix, PhD6; Ken Komatsu, MPH3; Rebecca Sunenshine, MD2,8; AFM Investigation Team

Authors Affiliations: 1Epidemic Intelligence Service, CDC; 2Maricopa County Department of Public Health, Phoenix, Arizona; 3Arizona Department of Health Services; 4Phoenix Children’s Hospital, Arizona; 5Translational Genomics Research Institute, Flagstaff, Arizona; 6Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC; 7Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 8Career Epidemiology Field Officer Program, CDC; 9Maricopa Integrated Health System, Phoenix, Arizona.

Corresponding author: Sally A. Iverson,, 602-359-0424.

Suggested citation for this article: Iverson SA, Ostdiek S, Prasai S, et al. Notes from the Field: Cluster of Acute Flaccid Myelitis in Five Pediatric Patients — Maricopa County, Arizona, 2016. MMWR Morb Mortal Wkly Rep 2017;66:758–760. DOI:



In 2016, CDC saw an increase in cases of acute flaccid myelitis (AFM); 144 persons in 37 states and the District of Columbia were confirmed to have AFM. After investigations in California (1) and Colorado (2) in 2014, CDC characterized AFM as an acute flaccid paralysis (AFP) distinguishable by magnetic resonance imaging (MRI) abnormalities of the gray matter of the anterior and posterior spinal cord segments, involving one or more spinal segments (3). Although certain viruses (e.g., nonpoliovirus enteroviruses, adenoviruses, and West Nile virus) can cause rare cases of AFP, and findings from the 2014 outbreak investigations indicated that enterovirus D68 (EV-D68) was temporally associated with AFM, no viral etiology for AFM has been definitively established (3). In September 2016, an acute care hospital in Arizona notified the Maricopa County Department of Public Health (MCDPH) of a suspected case of AFM and subsequent cluster of 11 children who were evaluated with similar neurologic deficits; differential diagnoses included transverse myelitis and AFM. The Maricopa County Department of Public Health, in cooperation with the Arizona Department of Health Services, CDC, the Translational Genomics Research Institute (TGen, Flagstaff, Arizona), and the acute care hospital, initiated an investigation to confirm AFM cases and identify an etiology.

The 2015 Council of State and Territorial Epidemiologists and CDC case definition for probable AFM requires acute onset of flaccid limb weakness and cerebrospinal fluid (CSF) pleocytosis (CSF white blood cell [WBC] count >5/mm3 when corrected for red blood cells).

A confirmed case must have an MRI demonstrating lesions restricted primarily to the gray matter of the spinal cord, in addition to acute onset of flaccid limb weakness (4).

Based on medical chart abstraction and review of the MRI images, a CDC neurology subject matter expert verified four confirmed cases of AFM and one probable case.

Among the six patients whose cases did not meet the AFM confirmed or probable case definition, two had focal limb weakness and pleocytosis (CSF WBC = 7/mm3 and 22/mm3, respectively), but MRI results indicated alternative etiologies (acute disseminated encephalomyelitis and neuromyelitis optica, respectively). The case that met the probable case definition had pleocytosis (CSF WBC = 7/mm3), but MRI findings were inconsistent with AFM, and no other plausible diagnosis was identified.

Onset dates for the four confirmed cases occurred during August 19–September 15, 2016. All four patients had preceding respiratory (three patients) or gastrointestinal illness (one patient), with onset dates for those illnesses occurring during August 14–September 13. Their illness began a median of 2 days (range = 2–5 days) before onset of focal limb weakness; three patients experienced tactile or measured fever preceding onset of neurologic symptoms (Table).

Among patients with confirmed cases, focal limb weakness was present in a single limb (one case), three limbs (two cases), and four limbs (one case). Two patients with confirmed cases and one patient with a probable case had a prior medical history of asthma, and a third patient with a confirmed case reported a family history of asthma.

The investigation team conducted hypothesis-generating interviews with all confirmed AFM patients and their proxies. Three of the four patients with confirmed cases were residents of Maricopa County, and no epidemiologic links were detected among the four patients. None of the patients had traveled to an area with ongoing Zika virus transmission in the month prior to symptom onset.

CSF was collected from all four patients with confirmed AFM. Median CSF WBC count was 133/mm3 (range = 50–207), and initial viral testing at the hospital included CSF reverse transcription–polymerase chain reaction (RT-PCR) assays for enterovirus (three patients) and West Nile virus (WNV) (two patients), polymerase chain reaction (PCR) assay for herpes simplex virus (two patients), and enzyme immunoassay to detect immunoglobulin M (IgM) or immunoglobulin G (IgG) for WNV (three patients). All results were negative.

All four CSF specimens were negative on TGen amplicon sequencing assay (5,6) using primers based on the 2014 circulating EV-D68 virus.

Results of microbiome analysis by metagenomic sequencing of RNA and 16S rRNA gene sequencing of DNA extracted from CSF revealed bacterial sequencing dominated by Propionibacterium, which is a normal component of the skin flora and most likely represents a contaminant (7).

Serum collected from one patient at initial evaluation was negative for WNV IgM and IgG on a hospital immunoassay; serum collected from the same patient 47 days after onset of focal limb weakness and from two additional patients (19 and 26 days after onset of focal limb weakness) were negative for WNV IgM and St. Louis encephalitis IgM at the Arizona State Public Health Laboratory.

Three of the four patients had nasopharyngeal (NP) swabs available from initial evaluation that were forwarded to CDC; one specimen was positive for enterovirus/rhinovirus on a panviral respiratory PCR panel at the admitting hospital laboratory and for EV-D68 at CDC. RNA extracted from NP swabs from all three patients was positive by the TGen amplicon sequencing test for EV-D68 (GenBank Bioproject); an NP specimen from a patient who did not meet the AFM confirmed or probable case definitions also was positive for EV-D68 by the same assay.

Stool specimens were collected from two patients at the time of initial evaluation; vital cultures of these specimens were negative on viral. One available specimen and three additional specimens, collected 28, 47, and 63 days after onset of focal limb weakness, were sent to CDC for four enterovirus/parechovirus RT-PCR assays. A stool specimen, collected at day 28 from the patient who did not have an NP swab available, was positive for coxsackievirus A10.

This cluster of AFM at one children’s acute care hospital is the largest cluster identified to date in Arizona and is part of a nationally identified increase in AFM cases. Although no statewide surveillance system specific to AFM is available, this cluster was detected by physician reporting, highlighting the need for physicians to remain vigilant for this emerging disease and to report cases that fit the AFM case definition to their local health department.

Metagenomic analyses identified EV-D68 in NP swabs from the three patients for whom specimens were available, along with a specimen from a patient who did not meet the AFM case definition; therefore, no single etiology or risk factor was associated with only confirmed cases.

Patient and family history of asthma was the most common comorbidity reported among confirmed AFM cases and should be considered in future case investigations. Expanded analysis of infectious, postinfectious, and noninfectious etiologies might provide further insight into the mechanism of AFM.


Kathryn Putman; Jennifer Adair, Bernny Apodaca, Phoenix Children’s Hospital, Neurology Department; Phoenix Children’s Hospital Infection, Department of Infection Prevention and Control; Arizona State Public Health Laboratory, Virology Section.

AFM Investigation Team

Tammy Sylvester, Maricopa County Department of Public Health, Arizona; Veronica Harrison, Translational Genomics Research Institute, Flagstaff, Arizona; Jennifer Heim, MD, Phoenix Children’s Hospital, Arizona; Susan Robinson, MPH, Arizona Department of Health Services; Gholamabbas A. Ostovar, MD, Maricopa Integrated Health System, Arizona; Kathryn Fitzpatrick, Arizona State Public Health Laboratory, Virology Section.

Conflict of Interest

David Engelthaler and Jolene Bowers have a provisional patent application in progress for a real-time polymerase chain reaction assay for the detection of Enterovirus D68 in complex specimens. No other conflicts of interest were reported.


  1. CDC. Notes from the field: acute flaccid myelitis among persons aged ≤21 years—United States, August 1–November 13, 2014. MMWR Morb Mortal Wkly Rep 2015;63:1243–4. PubMed
  2. Pastula DM, Aliabadi N, Haynes AK, et al. Acute neurologic illness of unknown etiology in children—Colorado, August–September 2014. MMWR Morb Mortal Wkly Rep 2014;63:901–2. PubMed
  3. Sejvar JJ, Lopez AS, Cortese MM, et al. Acute flaccid myelitis in the United States, August–December 2014: results of nationwide surveillance. Clin Infect Dis 2016;63:737–45. CrossRef - PubMed
  4. Council of State and Territorial Epidemiologists (CSTE). CSTE position statement: standardized case definition for acute flaccid myelitis. Atlanta, GA: Council of State and Territorial Epidemiologists; 2015.
  5. Colman RE, Anderson J, Lemmer D, et al. Rapid drug susceptibility testing of drug-resistant Mycobacterium tuberculosis isolates directly from clinical samples by use of amplicon sequencing: a proof-of-concept study. J Clin Microbiol 2016;54:2058–67. CrossRef - PubMed
  6. Bowers JR, Lemmer D, Sahl JW, et al. KlebSeq, a diagnostic tool for surveillance, detection, and monitoring of Klebsiella pneumoniae. J Clin Microbiol 2016;54:2582–96. CrossRef - PubMed
  7. Grice EA, Segre JA. The skin microbiome. Nat Rev Microbiol 2011;9:244–53.


TABLE. Characteristics of five pediatric patients with acute flaccid myelitis* — Maricopa County, Arizona, October 2016

[Characteristic - Patient 1 - Patient 2 - Patient 3 - Patient 4 - Patient 5]

  • Case status – Confirmed – Confirmed – Confirmed – Confirmed – Probable
  • Age at onset (yrs) - 3.5 – 10 – 4 – 9 – 12
  • Sex – Boy – Girl – Girl – Girl – Girl
  • Onset of focal limb weakness - August 23, 2016 - August 19, 2016 - September 15, 2016 - September 8, 2016 - August 27, 2016
  • Onset of preceding respiratory or gastrointestinal illness - August 21, 2016 (respiratory) - August 14, 2016 (respiratory) - September 13, 2016 (respiratory) - September 6, 2016 (gastrointestinal) - August 17, 2016 (respiratory)
  • Presence of fever (tactile or measured) – Yes – No – Yes – Yes – No
  • Limbs affected (region) - 1 (LUE) – 4 - 3 (BUE, RLE) – 4 - 1 (LUE)
  • Cranial nerve features and timing – None - Facial droop subsequent to onset of limb weakness - Facial droop subsequent to onset of limb weakness - Facial droop before onset of limb weakness - Diplopia concurrent with limb weakness
  • Patient and family history of asthma - Asthma and family history of asthma – Asthma – None - Family history of asthma - Mild asthma, seasonal allergies, food allergies, eczema
  • Corticosteroid history - Maintenance inhaled fluticasone; oral budesonide for asthma exacerbation August 15–19 - Maintenance inhaled fluticasone; oral prednisolone for asthma exacerbation beginning August 14 – None - Oral prednisolone for treatment of Bell’s palsy beginning September 5 - Maintenance inhaled fluticasone
  • Magnetic resonance imaging (MRI) findings - T2 signal abnormalities in anterior and posterior columns of the central gray cervical cord - T2 signal abnormality with anterior and posterior involvement, contiguous through multiple levels of the cord - T2 signal abnormality in the anterior horn of the central gray cord - Anterior horn signal abnormality extending four cervical levels - Normal MRI result
  • Cerebrospinal fluid/white blood cell/mm3 – 50 – 150 – 207 – 115 – 7
  • Nasopharyngeal swab polymerase chain reaction results from TGen - Positive for EV-D68 - Positive for EV-D68 - Positive for EV-D68 – Unavailable – Unavailable
  • Stool specimen testing results - Negative enterovirus/parechovirus by RT-PCR - Negative viral culture and enterovirus/parechovirus by RT-PCR - Negative viral culture and enterovirus/parechovirus by RT-PCR - Positive for coxsackievirus A10 by Sanger sequencing of the VP1 region – Unavailable

Abbreviations: BUE = bilateral upper extremities; EV = enterovirus; LUE = left upper extremity; RLE = right lower extremity; RT-PCR = reverse transcription–polymerase chain reaction; T2 = T2 weighted image; TGen = Translational Genomics Research Institute (Flagstaff, Arizona); VP1 = viral protein 1.

{*} Four with confirmed cases and one with a probable case.

{†} Felt warm to the touch, according to parent.


Keywords: US CDC; USA; Arizona; Updates; AFM; EV- D68.


#Zika Virus–2017 #CaseCounts in the #US (@CDCgov, Jul 20 ‘17)

Title: #Zika Virus–2017 #CaseCounts in the #US.

Subject: Zika Virus Infections and related complications, current situation in the US.

Source: US Centers for Disease Control and Prevention (CDC), full page: (LINK).

Code: [     ]


2017 Case Counts in the US


Language: [ English (US) | Español | Português ]


See Also

Provisional Data as of July 19, 2017

  • Zika virus disease is a nationally notifiable condition.
  • Cases are reported to CDC by state, territorial, and local health departments using standard case definitions.
  • This webpage contains provisional data reported to ArboNET for January 1, 2017 – July 19, 2017.

US States

  • 175 symptomatic Zika virus disease cases reported*
    • 174 cases in travelers returning from affected areas
    • 0 cases acquired through presumed local mosquito-borne transmission
    • 1 case acquired through sexual transmission

US Territories

  • 532 symptomatic Zika virus disease cases reported*
    • 0 cases in travelers returning from affected areas
    • 532 cases acquired through presumed local mosquito-borne transmission
    • 0 cases acquired through other routes†


{*} Excludes congenital disease cases. Data reported to the US Zika Pregnancy Registry for outcomes of pregnancies with laboratory evidence of possible Zika virus infection in the United States is available on Outcomes of Pregnancies with Laboratory Evidence of Possible Zika Virus Infection in the United States.

{†} Sexually transmitted cases are not reported for US territories because with local transmission of Zika virus it is not possible to determine whether infection occurred due to mosquito-borne or sexual transmission.

See Also

  • Cases in Pregnant Women
    • CDC reports the number of pregnant women with any laboratory evidence of possible Zika virus infection in the United States and territories.
  • Pregnancy Outcomes
    • CDC reports the outcomes of pregnancies with laboratory evidence of possible Zika virus infection in the United States.
  • Information for Blood and Tissue Collection Centers
    • See information on areas of active Zika virus transmission risk for the purposes of blood and tissue safety intervention.

Cases by State and Territory

Map of laboratory-confirmed symptomatic Zika virus disease cases reported to ArboNET by states and territories


Laboratory-confirmed symptomatic Zika virus disease cases and presumptive viremic blood donors reported to ArboNET by states and territories— United States, 2017 (Provisional data as of July 19, 2017)

[States - Symptomatic disease cases* (N=175): No. (%) - Presumptive viremic blood donors† (N=8): No. (%)]

  1. Alabama – 3 (2) – 0 (0)
  2. Alaska – 1 (1) – 0 (0)
  3. Arizona – 1 (1) – 0 (0)
  4. Arkansas – 0 (0) – 0 (0)
  5. California – 17 (10) – 1 (13)
  6. Colorado – 4 (2) – 0 (0)
  7. Connecticut – 0 (0) – 0 (0)
  8. Delaware – 0 (0) – 0 (0)
  9. District of Columbia – 0 (0) – 0 (0)
  10. Florida – 16 (10) – 3 (38)
  11. Georgia – 1 (1) – 0 (0)
  12. Hawaii – 1 (1) – 0 (0)
  13. Idaho – 0 (0) – 0 (0)
  14. Illinois – 3 (2) – 0 (0)
  15. Indiana – 1 (1) – 0 (0)
  16. Iowa – 1 (1) – 0 (0)
  17. Kansas – 2 (1) – 0 (0)
  18. Kentucky – 1 (1) – 0 (0)
  19. Louisiana – 1 (1) – 0 (0)
  20. Maine – 1 (1) – 0 (0)
  21. Maryland – 6 (3) – 0 (0)
  22. Massachusetts – 7 (4) – 0 (0)
  23. Michigan – 6 (3) – 0 (0)
  24. Minnesota – 4 (2) – 0 (0)
  25. Mississippi – 2 (1) – 0 (0)
  26. Missouri – 1 (1) – 0 (0)
  27. Montana – 0 (0) – 0 (0)
  28. Nebraska – 1 (1) – 0 (0)
  29. Nevada – 1 (1) – 0 (0)
  30. New Hampshire – 0 (0) – 0 (0)
  31. New Jersey – 4 (2) – 0 (0)
  32. New Mexico – 0 (0) – 0 (0)
  33. New York – 36 (21) – 1 (13)
  34. North Carolina – 5 (3) – 0 (0)
  35. North Dakota – 0 (0) – 0 (0)
  36. Ohio – 3 (2) – 0 (0)
  37. Oklahoma – 1 (1) – 0 (0)
  38. Oregon – 3 (2) – 0 (0)
  39. Pennsylvania – 4 (2) – 1 (13)
  40. Rhode Island – 3 (2) – 0 (0)
  41. South Carolina – 2 (1) – 0 (0)
  42. South Dakota – 0 (0) – 0 (0)
  43. Tennessee – 0 (0) – 0 (0)
  44. Texas – 16 (9) – 1 (13)
  45. Utah – 2 (1) – 0 (0)
  46. Vermont – 3 (2) – 0 (0)
  47. Virginia – 3 (2) – 0 (0)
  48. Washington – 3 (2) – 0 (0)
  49. West Virginia – 1 (1) – 1 (13)
  50. Wisconsin – 2 (1) – 0 (0)
  51. Wyoming – 2 (1) – 0 (0)

[Territories - Symptomatic disease cases* (N=532): No. (%) - Presumptive viremic blood donors† (N=3): No. (%)]

  1. American Samoa – 19 (4) – 0 (0)
  2. Puerto Rico – 474 (89) – 3 (100)
  3. U.S. Virgin Islands – 39 (7) – 0 (0)


{*} Includes reported confirmed and probable Zika virus disease cases per the CSTE case definitions.

{†} Presumptive viremic blood donors are people who reported no symptoms at the time of donating blood, but whose blood tested positive when screened for the presence of Zika virus RNA by the blood collection agency. Some presumptive viremic blood donors develop symptoms after their donation or may have had symptoms in the past. These individuals may be reported as both Zika virus disease cases and presumptive viremic blood donors.


Keywords: US CDC; USA; Updates; Zika Virus.


#HIV #drug #resistance #report 2017 (@WHO, Jul 20 ‘17, summary)

Title: #HIV #drug #resistance #report 2017.

Subject: HIV/AIDS, antiviral drugs resistance, current situation.

Source: World Health Organization (WHO), full PDF file: (LINK). Summary.

Code: [     ]


HIV drug resistance report 2017


ISBN 978-92-4-151283-1

© World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.

Suggested citation. HIV drug resistance report 2017. Geneva: World Health Organization; 2017.

Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at

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Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The photographs in this material are used for illustrative purposes only; they do not imply any particular health status, attitudes, behaviors, or actions on the part of any person who appears in the photographs. The mark “CDC” is owned by the US Dept. of Health and Human Services and is used with permission. Use of this logo is not an endorsement by HHS or CDC of any particular product, service, or enterprise. Printed in Switzerland

Executive Summary

  • Antimicrobial resistance (AMR) is a growing global public health threat, which urgently requires collective action to ensure effective prevention and treatment of infections. Minimizing the emergence and transmission of HIV drug resistance (HIVDR) is a critical aspect of the broader global response to AMR. Prevention, monitoring and response to HIVDR is key to building and sustaining gains in HIV treatment scale-up, and achieving the global 90-90-90 targets for treatment. These widely adopted targets reflect the global community’s commitment to expanding access to antiretroviral therapy (ART) including: diagnosing 90% of all people with HIV infection; providing treatment to 90% of those diagnosed; and ensuring 90% of people on treatment achieve virological suppression, by 2020. By the end of 2016, 70% of people living with HIV (PLHIV) were diagnosed,77% of those who knew their HIV status received ART, and 82% of those on treatment were virally suppressed.
  • The human cost of HIVDR cannot be underestimated: people with non-nucleoside reverse-transcriptase inhibitor (NNRTI) resistance are less likely to achieve viral suppression; more likely to experience virological failure or death; more likely to discontinue treatment; and more likely to acquire new HIVDR mutations. Preventing, monitoring and responding to HIVDR is therefore critical to maintaining current achievements, improving treatment outcomes for PLHIV, protecting investments, and guaranteeing the long-term sustainability of care and treatment programmes. Mathematical modelling predicts that if NNRTIs continue to be included in first-line ART regimens, and the level of pretreatment HIV drug resistance (PDR) to NNRTIs reaches above 10% in subSaharan Africa, the global targets to end AIDS as a public health threat by 2030 will not be attained. Achieving and sustaining “the last 90” target will therefore require efforts to contain and respond to HIVDR.
  • Recognizing the importance of addressing HIVDR, within the context of ART scale-up, the World Health Organization (WHO), in collaboration with partners, developed a comprehensive HIVDR surveillance approach in 2004, with guidance updated in 2014 to yield nationally representative estimates of HIVDR.
  • This second HIVDR report has been jointly developed by WHO, the United States Centers for Disease Control and Prevention (US-CDC) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (“The Global Fund”). It provides an update on recent population levels of HIVDR covering the period 2014–2016. The report includes data from 16 nationally representative surveys from 14 countries1 estimating resistance in: adults initiating ART (PDR), children younger than 18 months newly diagnosed with HIV, and adults on ART (acquired HIV drug resistance or ADR). To contextualize results from representative HIVDR surveys, the report is supported by systematic reviews of the published literature on PDR in adults, children and adolescents, and ADR in paediatric and adult populations. Finally, the report includes the prevalence of transmitted HIV drug resistance (TDR) in recently infected people in Malawi and Zimbabwe, estimated as part of recent household Population-based HIV Impact Assessment (PHIA) surveys, supported by the United States President’s Emergency Plan for AIDS Relief (PEPFAR).
  • Twenty-six countries have completed or are currently implementing national HIVDR surveys, based on WHO’s guidance. The swift uptake and implementation of HIVDR surveillance in recent years reflects the commitment of countries, partners and donors to AMR and the monitoring of HIVDR as part of ART scale-up efforts.
  • Of the 26 countries with national HIVDR surveys that are completed or ongoing, 14 have reported data to WHO, and are captured in this report. Brisk uptake of WHO’s revised HIVDR surveillance methods since their publication in 2014 reflects the collective efforts and commitment of countries, and pivotal support provided by US-CDC, the Global Fund, WHO and other partners.
  • Levels of pretreatment resistance to efavirenz or nevirapine, the most affordable and widely used drugs in first-line ART, reached 10% or above in six out of 11 countries that reported PDR survey data.
  • Nationally representative surveys of PDR monitor resistance in people starting ART, including antiretroviral (ARV) drug-naive individuals and people reporting prior exposure to ARV drugs. Levels of NNRTI resistance (defined as resistance to efavirenz or nevirapine) were high (>10%) in six of the 11 countries reporting data (see figure below).
  • Three out of the five countries with NNRTI resistance below 10% monitored PDR only in ARV drug-naive individuals, which may explain the lower prevalence estimates observed in these countries. In the African Region, levels of NNRTI resistance were greater than 10% in three out of four countries, with NNRTI PDR ranging from 8.1% (95% CI 4.3–14.7) in Cameroon to 15.4% (95% CI 10.3–22.5) in Uganda. In Mexico, Central and South America, pretreatment NNRTI resistance exceeded 10% in three of six surveys, ranging from 6.3% (95% CI 3.8-10.2) in Colombia to 19.3% (95% CI 12.2–29.1) in Nicaragua. Finally, in Myanmar, the only country reporting PDR survey data from South-East Asia, NNRTI resistance was low at 3.9% (95% CI 2.1–7.4). Overall, the prevalence of NNRTI resistance reported in PDR surveys is broadly consistent with available data from the PHIA surveys among recently infected people in Malawi and Zimbabwe, where four out of 26 and two out of 30 ARV drug-naive individuals had NNRTI resistance, respectively.
  • Survey findings are also consistent with a systematic review of studies published between 2001 and 2016, which assessed levels of PDR in 56 044 adults across 63 low- and middle-income countries. NNRTI resistance was higher in more recent studies across all regions (Eastern Africa, Southern Africa, Western and Central Africa, Latin America and Asia; P<0.05 for all). Yearly incremental increases in NNRTI resistance were greatest for studies in Eastern Africa (29%, 95% CI 17–42) and smallest for those in Asia (11%, 95% CI 2–20).
  • Pretreatment drug resistance is more than two fold higher among people starting first-line ART with prior ARV drug exposure, compared to ARV drug-naive individuals. With continued ART scale-up, this group is likely to represent an increasing proportion of people initiating treatment who may not be receiving effective treatment.
  • Notably, individuals with prior ARV drug exposure initiating or reinitiating first-line ART had higher prevalence of NNRTI PDR in both PDR surveys and the systematic review. Across the seven PDR surveys that included both individuals with prior ARV exposure – previously on first-line ART or past exposure for prevention of mother-to-child transmission (PMTCT) – and ARV drug-naive individuals, NNRTI resistance was considerably higher among ART initiators with prior ARV drug exposure (21.6%, 95% CI 13.8–32.2), compared to ARV drug-naive treatment initiators (8.3%, 95% CI 6.0–11.4; P<0.0001). The high levels of NNRTI resistance in people reporting prior ARV drug exposure is particularly concerning, as this group is likely to represent an ever-increasing proportion of first-line treatment initiators in some countries. Recognizing that levels of NNRTI resistance are increasing, and that NNRTIs are an essential component of currently recommended first-line ART, WHO has published Guidelines on
    the public health response to pretreatment HIV drug resistance, as a supplement to the 2016 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. These guidelines include new recommendations on the selection of ARV drugs in response to high levels of PDR. They recommend countries consider changing their first-line ART regimen if levels of NNRTI PDR reach 10%. These publications are an important step forward in the global response to HIVDR.
  • Most available PDR data come from adult populations, while data for children and adolescents are limited. Only one nationally representative HIVDR survey among children younger than 18 months was reported between 2014 and 2016; this survey was from South Africa, and documented NNRTI prevalence as high as 63.7% (95% CI 59.0–68.4) in infants diagnosed with HIV through early infant diagnosis. The high levels of NNRTI resistance observed in this survey and in other recent publications strongly support WHO’s 2013 recommendation that all children younger than 3 years of age be started on protease inhibitor (PI)-based regimens, irrespective of PMTCT exposure. Unfortunately, implementation of this policy has been slow, largely due to the unavailability, until recently, of heat stable and palatable paediatric formulations, which do not require a cold chain until the point of dispensing.
  • The global target of 90% virological suppression in people retained on ART was reached in two of the four countries that reported survey data. Among the four countries, it ranged from 68% to 90%, indicating variability in programme quality and service delivery that should be addressed.
  • Achieving optimal viral load suppression and minimizing HIVDR is critical to reaching the 90-90-90 fast track targets by 2020 and eliminating AIDS as a public health threat by 2030. Between 2014 and 2016, four countries (Cameroon, Guatemala, Viet Nam and Zambia) implemented ADR surveys among adults on ART and reported data to WHO. Only Zambia and Viet Nam reached the 90% target for viral load suppression. The heterogeneity in the viral load suppression rates reported among people on ART suggest substantial differences in programme performance across countries.
  • NNRTI resistance among people retained on ART ranged from 4% to 28%, while among people with unsuppressed viral load on first-line NNRTI regimens, it ranged from 47% to 90%. This speaks to the need to scale up viral load testing, promptly switch individuals with confirmed virological failure to second-line treatment, and strengthen adherence support in countries with lower levels of ADR.
  • Overall, the prevalence of NNRTI resistance among individuals on ART for 12–24 months ranged from 4.3% (95% CI 1.9–9.5) in Zambia to 16.7.% (95% CI 13.7–20.2) in Cameroon; among those on treatment for longer durations (36–48+ months), it ranged from 4.2% (95% CI 2.4–7.4) in Viet Nam to 28.3% in Cameroon (95% CI 17.4–42.5). Among people on first-line NNRTI-based regimens with unsuppressed viral load, the prevalence of NNRTI resistance at the 12–24 month time point ranged from 47.3% (95% CI 10.7–87.0) in Zambia to 80.0% (95% CI 51.0–93.9) in Guatemala. At the late time point, among people failing NNRTI-based first-line ART, NNRTI resistance ranged from 84.3 (95% CI 69.4–92.7) in Guatemala to 89.5% (95% CI 71.0–96.7) in Cameroon. High levels of resistance in people with unsuppressed viral load indicate the need for rapid switch to effective second-line regimens. However, ADR surveys show that the use of PI regimens was low across all countries, suggesting inadequate switch to PI-based ART in people failing first-line NNRTI-based ART.
  • Additional data from the PHIA surveys conducted in Malawi, Zambia and Zimbabwe suggest high levels of viral load suppression among people who self-report being on ART for a variable range of time. In this population, the prevalence of viral load suppression ranged from 86% in Zimbabwe to 91% in Malawi among adults aged 15–59 years, suggesting that ART regimens are effective for the majority of individuals who report being on treatment in these countries.
  • Despite the high levels of ADR observed in national surveys and supported by a review of the published literature, the mutations and mutation patterns observed among people failing treatment suggest that currently recommended PI-based second-line ART remains an effective option for most people failing first-line ART. Nonetheless, strategic use of increasingly affordable drugs with higher barriers to development of resistance (e.g. dolutegravir) has the potential to mitigate concerns regarding ongoing treatment efficacy of NNRTI-based therapy, and may possibly reverse the observed trend of increasing NNRTI resistance.
  • As of December 2016, 19.5 million people were receiving ART globally, and over the next decade, ever-larger numbers of people must initiate and be successfully maintained on HIV treatment for life, to achieve global targets for epidemic control. To date, several countries have reported high levels of viral load suppression among people receiving treatment, attesting to the effectiveness of available therapy and the success of ART scale-up. The fact that “the third 90” target is being achieved in several countries is reassuring. However, in other countries viral load suppression in people on ART is well below the global target, and merits attention.
  • This global report demonstrates that levels of PDR are increasing, mostly driven by increasing levels of NNRTI resistance. Although levels of NNRTI PDR have reached above 10% in some of the countries surveyed, viral load and TDR prevalence estimates from the PHIA surveys suggest high levels of viral load suppression among people retained in care who self-report taking ART. Taken together, these data are consistent, and indicate that the majority of PLHIV who are taking ART are likely to control their infection. However, in several countries, significant and increasing proportions of people are infected with a virus resistant to NNRTI, and are therefore significantly less likely to achieve viral suppression when they start ART. In addition, a proportion of people receiving ART may not adhere to it due to individual-, clinic- or programme-level factors, and may therefore develop NNRTI resistance. High levels of NNRTI PDR have the potential to undermine the future success of global ART scale-up; therefore, this report underscores the need to strengthen the quality of HIV programmes to prevent further increases in HIVDR, to monitor when levels of resistance are unknown, and to respond to HIVDR when levels are high.
  • Preventing, monitoring and responding to HIVDR form the basis of the Global Action Plan on HIV drug resistance, a five-year framework for action spearheaded by WHO, which engages global and local stakeholders in a coordinated and resourced response to HIVDR. The Global Action Plan focuses on five strategic objectives: 1) prevention of and response to HIVDR; 2) monitoring of HIVDR through surveillance and routine programmatic data; 3) research and innovation; 4) laboratory capacity; and 5) governance and enabling mechanisms. The Global Action Plan articulates a global consensus and commitment to minimizing AMR and preventing HIVDR from undermining attainment of global HIV targets, including an AIDS-free generation by 2030.
  • The treatment landscape of HIV is rapidly evolving with introduction of new classes of drugs which are becoming available and more affordable in LMIC. As new drugs become available ongoing surveillance in real world settings will be required to preserve their long term efficacy and durability.


{1} Argentina (PDR survey), Brazil (PDR survey), Cameroon (PDR and ADR surveys), Colombia (PDR survey), Guatemala (PDR and ADR surveys), Mexico (PDR survey), Myanmar (PDR survey), Namibia (PDR survey), Nicaragua (PDR survey), South Africa (HIVDR survey in children <18 months), Uganda (PDR survey), Viet Nam (ADR survey), Zambia (ADR survey) and Zimbabwe (PDR survey).


Keywords: WHO; Updates; HIV/AIDS; Antivirals; Drugs Resistance.


Seasonal #influenza #vaccination in #Europe - eight seasons 2007–08 to 2014–15 (@ECDC_EU, summary)

Title: Seasonal #influenza #vaccination in #Europe - eight seasons 2007–08 to 2014–15.

Subject: Human Influenza Viruses, vaccinations; European Region report.

Source: European Centre for Disease Prevention and Control (ECDC), full PDF file: (LINK). Summary.

Code: [     ]



Seasonal influenza vaccination in Europe  - Vaccination recommendations and coverage rates in the EU Member States for eight influenza seasons 2007–2008 to 2014–2015


This report was commissioned by the European Centre for Disease Prevention and Control (ECDC), coordinated by Suzanne Cotter (Health Protection Surveillance Centre, Ireland), Svetla Tsolova and Kari Johansen (both ECDC); and produced by Jolita Mereckiene Author Jolita Mereckiene, Health Protection Surveillance Centre, Ireland This report is based on data obtained from annual or bi-annual surveys on seasonal influenza vaccination in EU/EEA countries for eight influenza seasons (from 2007–2008 to 2014–2015). The surveys were conducted by the Vaccine European New Integrated Collaboration Effort III (VENICE), in collaboration with the European Centre for Disease Prevention and Control (ECDC).


VENICE national gatekeepers and contact points: Austria: Elisabeth Kanitz, Maria Paulke-Korinek, Daniela Schmid; Belgium: Pierre Van Damme, Martine Sabbe, Tine Grammens, Nathalie Bossuyt; Bulgaria: Mira Kojouharova, Radosveta Filipova; Czech Republic: Jan Kyncl, Martina Havlickova, Jana Kostalova; Cyprus: Maria Koliou; Croatia: Vesna Visekruna Vucina, Bernard Kaić; Denmark: Palle Valentiner-Branth, Tyra Grove Krause; Estonia:Natalia Kerbo, Irina Filippova; Finland: Hanna Nohynek, Ulrike Baum; France: Daniel Levy-Bruhl, Isabelle Bonmarin, Emmanuel Belchior, Jean Paul Guthman, Eliane Vanhecke; Germany: Ole Wichmann; Greece: Theano Georgakopoulou, Theodora Stavrou; Hungary: Zsuzsanna Molnàr; Iceland: Thorolfur Gudnason; Ireland: Suzanne Cotter; Italy: Fortunato D’Ancona, Cristina Giambi, Caterina Rizzo, Maria Cristina Rota; Latvia: Larisa Savrasova, Jurijs Perevoscikovs; Lithuania: Asta Kriaučiūnaitė, Daiva Razmuvienė; Liechtenstein: Marina Jamnicki Abegg; Luxembourg: Serge Krippler; Malta: Tanya Melillo, Vicky Farrugia Santangelo; The Netherlands: Joost Timmermans, Marit de Lange; Norway: Marianne A R Bergsaker, Kjersti Rydland; Poland: Iwona Paradowska-Stankiewicz; Portugal: Paula Valente; Romania: Rodica Popescu, Aurora Stanescu; Slovakia: Helena Hudecova, Elena Ticha; Slovenia: Marta Grgic Vitek; Spain: Aurora Limia, Mar Andreu; Sweden: Ingrid Uhnoo, AnnaSara Carnahan, Mia Brytting; United Kingdom- England: Richard Pebody, Camille Tsang; United Kingdom–Northern Ireland: Naomh Gallagher; United Kingdom– Scotland: Jim McMenamin, Alison Potts, Arlene Reynolds, Naoma William; United Kingdom–Wales: Simon Cottrell

Suggested citation: European Centre for Disease Prevention and Control. Seasonal influenza vaccination in Europe. Vaccination recommendations and coverage rates in the EU Member States for eight influenza seasons: 2007–2008 to 2014–2015. Stockholm: ECDC; 2017.

Stockholm, July 2017

ISBN 978-92-9498-076-2 doi: 10.2900/153616 TQ-02-17-810-EN-N

Cover picture: AJC1 via Flickr, image licensed under a Creative Commons attribution 2.0 generic license

© European Centre for Disease Prevention and Control, 2017 Reproduction is authorised, provided the source is acknowledged.  For any use or reproduction of photos or other material that is not under the EU copyright, permission must be sought directly from the copyright holders.


  • In Europe, influenza occurs in regular annual epidemics in the winter season. Annual influenza epidemics are associated with high morbidity and mortality.
  • Severe illness and complications are more common in certain risk groups, which include those with chronic medical conditions (e.g. cardiovascular, respiratory, renal and hepatic diseases; diabetes mellitus; immunosuppression due to disease or treatment; obesity; children and teenagers on long-term aspirin therapy) and individuals 65 years of age and above.
  • The main public health intervention to prevent influenza is vaccination. To protect vulnerable individuals and reduce transmission, vaccination is also recommended for healthcare workers. 
  • The aim of this report was to summarise the information on seasonal influenza immunisation recommendations and vaccination coverage rates in the European Union (EU) and the European Economic Area (EEA) between 2007– 08 and 2014–15, a total of eight influenza seasons.
  • A standardised questionnaire was developed for the first survey and made available online in January 2008. For each subsequent survey the questionnaire was amended reflecting changes in European Commission/WHO recommendations for seasonal influenza.
  • Questionnaires were completed by experts in the EU/EEA Member States.
  • Overall, six surveys were conducted, with eight influenza seasons covered. The participation rate was high for each survey, with only one or two countries not responding to any given survey.
  • The United Kingdom has provided data separately for England, Northern Ireland, Scotland and Wales since 2012 (influenza season 2011–12). 
  • All Member States recommended seasonal influenza vaccination to older age groups, with the age ranging from ≥50 to ≥65 years of age, depending on the country.
  • Over time, a growing number of countries lowered the recommended age for adult influenza vaccination.
  • All in all, 30 countries have lowered the recommended vaccination age at some point in time during the eight seasons covered in this report. 
  • Six countries (Hungary, Germany, Greece, Iceland, the Netherlands and Portugal) recommended that people aged 60 years or older get vaccinated (2014–15), while for the 2007–08 season, only three (Iceland, Greece and Germany) of 27 countries made such a recommendation.
  • Recommendations to vaccinate those 65 years or older were made by 18 countries in 2014–15, and by 19 countries in 2007–08.
  • Two countries (Poland and Malta) recommended adult influenza vaccination for those aged 55 years and above in 2007–08 and 2014–15; Slovakia recommended vaccination for people 59 years of age or above for the 2014–15 and the 2007–08 seasons.
  • In 2014–15, Austria, Belgium and Ireland recommended vaccination for those 50 years or older.
  • In 2007–08, Austria and Ireland also recommended that this age group should be vaccinated. An increase in the number of countries recommending vaccination for children was noted.
  • Nine countries (Austria, Estonia, Finland, Malta, Latvia, Slovenia, Slovakia, Poland and United Kingdom) recommended vaccination of different age groups of children and adolescents under 18 years of age in the 2014–15 influenza season; for the 2007–08 season, only six countries did so. 
  • Similarly, an increase in the number of countries recommending influenza vaccine for healthcare workers (HCWs) was observed.
  • Of 30 responding Member States, 29 recommended influenza vaccinations for HCWs in 2014–15; 24 of these had recommendations in place to vaccinate all HCWs; four recommended vaccination only for certain HCWs.
  • In Northern Ireland and Scotland, vaccine was offered to all HCWs, while England and Wales recommended that only HCWs in direct contact with patients should be vaccinated.
  • Of the 27 responding countries, 22 recommended that HCWs should be vaccinated for the 2007–08 influenza season.
  • All Member States recommended seasonal influenza vaccine for people with immunosuppression due to disease or treatment, metabolic disorders, chronic pulmonary diseases, cardiovascular diseases and renal diseases for six of the eight influenza seasons covered in this report.
  • The number of countries that recommended influenza vaccination for people with morbid obesity increased (nine Member States in 2010–11, 19 in 2014–15).
  • Also on the increase are vaccination recommendations for hepatic diseases (15 Member States in 2007–08, 27 in 2014–15).
  • Twenty-six Member States recommended vaccination for people with neurological diseases in 2014–15 (2010–11: 19 Member States).
  • Ten Member States recommended the vaccination of pregnant women in 2010–11; in 2014– 15, 27 Member States recommended influenza vaccination for pregnant women. 
  • A decrease in the number of Member States recommending influenza vaccination for children under 18 years of age on long-term aspirin treatment was noted: the number dropped from 18 countries in 2007–08 to 15 countries in 2014–15. 
  • Between 2007–08 and 2014–15, 26 Member States reported vaccination coverage rates for older populations for at least one season; coverage rates for this demographic ranged from 1.0% to 76.3% (median 47.6%).
  • Seventeen Member States provided coverage data (reported for at least one influenza season) for HCWs: coverage ranged from 5.7% to 54.4% (median 26.9%).
  • Coverage for those with chronic medical conditions was provided by nine Member States and ranged from 28.7% to 78.7% (median 44.4%).
  • Seven Member States submitted coverage data for pregnant women: coverage ranged between 0.3% an 58.2% (median 22.6%).
  • Four Member States were able  to report vaccination coverage rates for residents of long-term care facilities: coverage was 68.7% in Belgium (2008–09), 72.2% in Ireland (2014–15), 96.6% in Slovakia (2014–15), and 77% in Portugal (2014–15).
  • The predominant payment mechanism for influenza vaccinationsi, as reported by Member States, was through national health services (or equivalent) for those population groups for whom seasonal influenza vaccine was recommended (children, adolescents, adults, those with chronic medical conditions, pregnant women, HCWs and members of closed communities).
  • In conclusion, the results of the VENICE surveys indicate that most of the Member States have clear recommendations as to which population groups should receive seasonal influenza vaccine, i.e. those with chronic medical conditions, pregnant women, older age groups, and HCWs.
  • There has been an increase in the proportion of Member States which now recommend vaccine for high risk groups as identified by WHO and ECDC.
  • However, there was a notable discrepancy between issuing recommendations and the ability to monitor and report vaccination coverage among those with chronic medical conditions and pregnant women: less than a quarter of EU/EEA Member States have the capability to do so. 
  • Just under half of the Member States were able to report on vaccination coverage for HCWs. It is notable that more Members States were able to report on coverage in this and other risk groups.
  • Another noticeable trend is the lowering of the recommended age for the influenza vaccine in older populations; there were no major changes in recommendations for children.
  • Although there has been a widespread consensus for many years that the older age groups should be vaccinated, the EU target of 75% vaccination coverage was reached in only two Member States (the Netherlands and the United Kingdom (only Northern Ireland and Scotland) in some of the influenza seasons covered in this overview.
  • As the ability to monitor vaccination coverage is a key component of any vaccination programme, all Member States may need to reconsider their approach in order to collect more comprehensive and accurate information on vaccination coverage for all targeted population groups.
  • Member States that do not monitor vaccination coverage among older age groups are encouraged to implement monitoring systems that are age-group-specific, in accordance with national recommendations, to enable them to track their progress or identify obstacles that keep them from achieving national and EU targets.   


(i) By ‘vaccination’ we refer to both cost factors: the vaccine itself and the administration of the vaccine.



Keywords: ECDC; Updates; Seasonal Influenza; Vaccines; European Region.


#Avian #Influenza [#H5N1, #H5N6, #H7N9]–Weekly #Update No. 593 - 14 July 2017 (@WHO WPRO, edited)

Title: #Avian #Influenza [#H5N1, #H5N6, #H7N9]–Weekly #Update No. 593 - 14 July 2017.

Subject: Avian Influenza, H5 & H7N9 subtypes, human cases in the Asia-Pacific Region.

Source: World Health Organization (WHO), Office for the Western Pacific Region, full PDF file: (LINK).

Code: [     ]


Avian Influenza - Weekly Update No. 593 - 14 July 2017



Keywords: WHO; Updates; Avian Influenza; H5N1; H5N6; H7N9; Human; Asian Region.


19 Jul 2017

#Bovine spongiform #encephalopathy [#BSE], #USA (#OIE, Jul 19 ‘17)

Title: #Bovine spongiform #encephalopathy [#BSE], #USA.

Subject: BSE, atypical, cattle epizootics in the US.

Source: OIE, full page: (LINK).

Code: [     ]


Bovine spongiform encephalopathy, United States of America


Information received on 18/07/2017 from Dr John Clifford, Official Delegate, Chief Trade Advisor, Animal and Plant Health Inspection Service, United States Department of Agriculture, Washington, United States of America

  • Summary
    • Report type  Immediate notification (Final report)
    • Date of start of the event  05/07/2017
    • Date of confirmation of the event  16/07/2017
    • Report date  18/07/2017
    • Date submitted to OIE  19/07/2017
    • Date event resolved  19/07/2017
    • Reason for notification  Recurrence of a listed disease
    • Date of previous occurrence  30/06/2012
    • Manifestation of disease  Clinical disease
    • Causal agent  Prion (atypical low-type BSE)
    • Nature of diagnosis  Laboratory (advanced)
    • This event pertains to  a defined zone within the country
  • New outbreaks
    • Summary of outbreaks
      • Total outbreaks: 1
        • Outbreak Location  -   ALABAMA ( Perry County, Perry )
      • Total animals affected:  Species -  Susceptible -  Cases -  Deaths -  Killed and disposed of -  Slaughtered
        • Cattle  -  1  -  1  -  1  -  0  -  0
      • Outbreak statistics:  Species -  Apparent morbidity rate -  Apparent mortality rate -  Apparent case fatality rate -  Proportion susceptible animals lost*
        • Cattle -  100.00% -  100.00% -  100.00% -  100.00%
          • * Removed from the susceptible population through death, destruction and/or slaughter;
  • Epidemiology
    • Source of the outbreak(s) or origin of infection
      • Unknown or inconclusive
      • random mutation
  • Epidemiological comments
    • As part of the United States’ targeted surveillance program for bovine spongiform encephalopathy (BSE), a case of Atypical BSE was identified in an 11 year old beef type cow.
    • This Atypical BSE was classified as L-type.
    • Native cases of BSE in the United States have all been atypical BSE cases -- this is only the fourth case of atypical BSE identified in over 20 years of surveillance. The last case was in 2012.
    • The identified animal did not enter any food supply channels and at no time presented a risk to human health.
    • Specified risk material removal and the ruminant-to-ruminant feed bans continue to be effectively applied.
  • Control measures
    • Measures applied
      • Screening
      • Traceability
      • Official disposal of carcasses, by-products and waste
      • Vaccination prohibited
      • No treatment of affected animals
    • Measures to be applied
      • No other measures
  • Diagnostic test results
    • Laboratory name and type -  National Veterinary Services Laboratories (NVSL) ( National laboratory )
      • Tests and results:  Species -  Test -  Test date -  Result
        • Cattle -  enzyme-linked immunosorbent assay (ELISA) -  15/07/2017 -  Positive
        • Cattle -  western blot -  16/07/2017 -  Positive
  • Future Reporting
    • The event is resolved. No more reports will be submitted.




Keywords: OIE; Updates; BSE; Cattle; USA; Alabama.


#HK, #Public should observe strict #hygiene amid very high #influenza activity (CHP, Jul 19 ‘17)

Title: #HK, #Public should observe strict #hygiene amid very high #influenza activity.

Subject: Human Influenza Viruses, seasonal epidemic in Hong Kong.

Source: Centre for Health Protection, Hong Kong PRC SAR, full page: (LINK).

Code: [     ]


Public should observe strict hygiene amid very high influenza activity


The Centre for Health Protection (CHP) of the Department of Health today (July 19) reported that local seasonal influenza activity further increased to a very high level in the past week, coupled with ongoing severe influenza cases, high consultation rates in sentinel clinics/doctors and a large number of institutional outbreaks.

"The latest surveillance data of the summer influenza season showed that the rate of influenza-like illness in Accident and Emergency Departments and the influenza-associated admission rate in public hospitals remain high.

‘’Influenza activities in Guangdong and Macau are also high.

‘’As local influenza is expected to remain very active in the coming weeks, we strongly urge the public, particularly children, the elderly and chronic disease patients, to adopt strict personal, hand and environmental hygiene both locally and during travel in the summer," a spokesman for the CHP said.

The positive percentage of seasonal influenza viruses among respiratory specimens received by the CHP further increased from 35.87 to 40.66 per cent from the week of July 2 to that of July 9. The vast majority (92 per cent) was influenza A(H3).

"Epidemiological experience shows that the predominance of H3 virus has affected elderly persons most, many of whom have underlying illnesses, as observed from more outbreaks reported by elderly homes. They should promptly report to the CHP in case of an increase in respiratory illnesses for immediate epidemiological investigations and outbreak control," the spokesman added.

In the above period, the number of institutional outbreaks of influenza-like illness increased from 42 (affecting 234 persons) to 44 (229 persons).

As of yesterday (July 18), 16 (83 persons) had been recorded this week. In the last four weeks, about half of the outbreaks (53 per cent) were reported by residential care homes for the elderly, followed by about one-fifth (21 per cent) from kindergartens and child care centres.

Regarding severe influenza cases, in adults, 289 cases of influenza-associated admission to the Intensive Care Unit or death (including 199 deaths) were recorded with the Hospital Authority and private hospitals during the enhanced surveillance from May 5 to yesterday. Most (249 cases) were H3.

In children, 23 cases of severe influenza-associated complication or death (four deaths) have been detected so far in 2017, with 16 H3, six H1, and one influenza B cases.

"Hong Kong has entered the summer influenza season since mid-May. The public should wash or clean hands frequently, especially before touching the mouth, nose or eyes, or after touching public installations such as handrails or door knobs. Wear a mask when respiratory symptoms develop, especially when going to crowded places or attending gatherings. High-risk persons may wear masks against infections," the spokesman said.

"Young children aged six months or above yet to receive seasonal influenza vaccination of the current season may get vaccinated as soon as possible for better personal protection," the spokesman added.

In addition, influenza activities in neighbouring areas remained high with H3 virus predominating so far. Macau has entered the summer influenza season. Influenza activities in southern provinces of the Mainland have been on the rise recently. In the southern hemisphere, influenza activity in Australia and New Zealand is rising.

The public should maintain good personal and environmental hygiene for protection against influenza and other respiratory illnesses:

  • Receive seasonal influenza vaccination for personal protection;
  • Wash hands with liquid soap and water properly whenever possibly contaminated;
  • When hands are not visibly soiled, clean them with 70 to 80 per cent alcohol-based handrub as an effective alternative;
  • Cover the nose and mouth when sneezing or coughing, and wash hands thoroughly afterwards;
  • Dispose of soiled tissue paper properly in a lidded rubbish bin;
  • Put on a surgical mask when respiratory symptoms develop;
  • Maintain good indoor ventilation;
  • When influenza is prevalent, avoid going to crowded or poorly ventilated public places; high-risk individuals may consider putting on surgical masks in such places; and
  • Maintain a balanced diet, exercise regularly, take adequate rest, do not smoke and avoid overstress.

The CHP has prepared easy-to-read infographics (see attachment) for the public on necessary health precautions against influenza. The public may visit the CHP's influenza page and weekly Flu Express for more information.


Keywords: HK PRC SAR; Updates; Seasonal Influenza; H3N2.


Highly pathogenic #avian #influenza #H5N2, #Taiwan [six #poultry #outbreaks] (#OIE, Jul 19 ‘17)

Title: Highly pathogenic #avian #influenza #H5N2, #Taiwan [six #poultry #outbreaks].

Subject: Avian Influenza, H5N2 subtype, poultry epizootics in Taiwan.

Source: OIE, full page: (LINK).

Code: [     ]


Highly pathogenic avian influenza H5N2, Chinese Taipei


Information received on 19/07/2017 from Dr Tai-Hwa Shih, Chief Veterinary Officer, Deputy Director General, Bureau of Animal and Plant Health Inspection and Quarantine Council of Agriculture Executive Yuan, Ministry of Agriculture, Taipei, Chinese Taipei

  • Summary
    • Report type    Follow-up report No. 68
    • Date of start of the event    07/01/2015
    • Date of confirmation of the event    11/01/2015
    • Report date    17/07/2017
    • Date submitted to OIE    19/07/2017
    • Reason for notification    Recurrence of a listed disease
    • Date of previous occurrence    23/07/2014
    • Manifestation of disease    Clinical disease
    • Causal agent    Highly pathogenic avian influenza virus
    • Serotype    H5N2
    • Nature of diagnosis    Clinical, Laboratory (advanced)
    • This event pertains to    a defined zone within the country
  • Summary of outbreaks   
    • Total outbreaks: 6
      • Total animals affected: Species    - Susceptible    - Cases    - Deaths    - Killed and disposed of – Slaughtered
        • Birds    - 95778    - 7715    - 7715    - 88063    - 0
      • Outbreak statistics: Species    - Apparent morbidity rate    - Apparent mortality rate    - Apparent case fatality rate    - Proportion susceptible animals lost*
        • Birds    - 8.06%    - 8.06%    - 100.00%    - 100.00%
          • *Removed from the susceptible population through death, destruction and/or slaughter
  • Epidemiology
    • Source of the outbreak(s) or origin of infection   
      • Unknown or inconclusive
  • Epidemiological comments   
    • Samples from 5 poultry farms in Yunlin County were sent to the National Laboratory, Animal Health Research Institute (AHRI) for analysis.
      • Highly pathogenic avian influenza H5N2 subtype was confirmed by the AHRI.
      • The farms have been placed under movement restriction.
      • All animals on the infected farms have been culled.
      • Thorough cleaning and disinfection have been conducted after stamping out operation.
      • Surrounding poultry farms within a 3 km radius of the infected farms are under intensified surveillance for 3 months.
    • Suspected signs were observed in poultry carcasses during post-mortem inspection in 1 abattoir in Kaohsiung City.
      • Samples were sent to the AHRI for diagnosis.
      • H5N2 subtype HPAI was confirmed by the AHRI.
      • The carcasses were destroyed and thorough cleaning and disinfection have been conducted in the abattoir.
      • After tracing back to the farm of origin, any positive results will be included in follow-up reports.




Keywords: OIE; Updates; Avian Influenza; H5N2 ; Poultry; Taiwan.


#Dengue fever – #SriLanka (@WHO, Jul 19 ‘17)

Title: #Dengue fever – #SriLanka.

Subject: Dengue, current epidemiological situation in Sri Lanka.

Source: World Health Organization (WHO), full page: (LINK)

Code: [     ]


Dengue fever – Sri Lanka


Disease Outbreak News / 19 July 2017

From 1 January to 7 July 2017, the Epidemiology Unit of the Ministry of Health (MoH) Sri Lanka reported 80 732 dengue fever cases, including 215 deaths. This is a 4.3 fold higher than the average number of cases for the same period between 2010 and 2016, and the monthly number of cases exceeds the mean plus three standard deviations for each of the past six months. Based on sentinel site surveillance for the past seven years the expected peak months of May to July coincides with the south-western monsoon which commences in late April.

Approximately 43% of the dengue fever cases were reported from the Western Province and the most affected area with the highest number of reported cases is Colombo District (18 186) followed by Gampaha (12 121), Kurunegala (4889), Kalutara (4589), Batticaloa (3946), Ratnapura (3898), and Kandy (3853).

Preliminary laboratory results have identified Dengue virus serotype 2 (DENV-2) as the circulating strain in this outbreak.

Although all four DENV have been co-circulating in Sri Lanka for more than 30 years and DENV-2 has been infrequently detected since 2009.

The current dengue fever outbreak occurs in a context of massive heavy rains and flooding and is currently affecting 15 out of 25 districts in Sri Lanka where almost 600 000 people have been affected.

Heavy monsoon rains, public failure to clear rain-soaked garbage, standing water pools and other potential breeding grounds for mosquito larvae attribute to the higher number of cases reported in urban and suburban areas.

Public health response

World Health Organization (WHO) is supporting the MoH Sri Lanka to ensure an efficient and comprehensive health response and the following response measures include:

  • Support from the military forces has been requested by the MoH to increase the number of beds as the health care facilities are overwhelmed. Three temporary wards in a hospital 38km north of Colombo have now been completed.
  • The MoH launched an emergency response including vector control activities that is also supported by the mobilization of defense forces. The army, police and civil defense forces have been mobilized to conduct house-to-house visits in the high-risk areas with health staff. In addition, they are involved in mobilizing the community for garbage disposal, cleaning of vector breeding sites, and in health education.
  • The Regional Office for South-East Asia (SEARO) has constituted a Task Force to guide the response.
  • WHO/ SEARO deployed an epidemiologist, an entomologist and two dengue management experts from the WHO Collaborating Center for case management of Dengue/Dengue Haemorrhagic Fever (Queen Sirikit National Institute of Child Health, Thailand) and Ministry of Public health (MoPH) Thailand. The triage protocol was updated in June 2017 to assist with better management of the patients in the health facilities.
  • The WHO Sri Lanka country office has purchased 50 fogging machines to support vector control activities.
  • MOH and WHO have worked together to prepare a strategic and operational plan for intensive measures to control dengue outbreak in next few weeks.

WHO risk assessment

Dengue fever is a mosquito-borne viral infection caused by four dengue virus serotypes (DENV-1, DENV-2, DENV-3, and DENV-4). Infection with one serotype provides long-term immunity to the homologous serotype but not to the other serotypes; secondary infections put people at greater risk for severe dengue fever and dengue shock syndrome.

Aedes aegypti and Aedes albopictus are the vectors widely adapted to urban and suburban environments. Dengue fever is endemic in Sri Lanka, and occurs every year, usually soon after rainfall is optimal for mosquito breeding. However DENV-2 has been identified only in low numbers since 2009 and is reportedly over 50% of current specimens which have been serotyped.

The current dengue epidemic is likely to have repercussions on public health in Sri Lanka.

WHO advice

WHO promotes the strategic approach known as Integrated Vector Management (IVM) to control mosquito vectors, including those of dengue.

The proximity of mosquito vector breeding sites to human habitation is a significant risk factor for dengue virus infection.

Prevention and control relies on reducing the breeding of mosquitoes through source reduction (removal and modification of breeding sites) and reducing human–vector contact through adult control measures. Both control measures need to implemented simultaneously for effective control.

This can be achieved by reducing the number of artificial water containers that hold water (cement tanks for water storage, drums, used tyres, empty bottles, coconut shells, etc.) in and around the home and by using barriers such as insect screens, closed doors and windows, long clothing and use of insect repellents, household insecticide aerosol products, mosquito coils etc. and space spraying with insecticide can be deployed as an emergency measure. As protection from the Aedes mosquitoes (the primary vector for transmission), it is recommended to sleep (particularly young children, the sick or elderly) under mosquito bed nets, treated with or without insecticide.

WHO does not recommend that any general travel or trade restrictions be applied on Sri Lanka based on the information available for this event.


Keywords: WHO; Updates; Dengue Fever; Sri Lanka.


#Human #infection with #avian #influenza A(#H7N9) virus – #China (@WHO, Jul 19 ‘17)

Title: #Human #infection with #avian #influenza A(#H7N9) virus – #China.

Subject: Avian Influenza, H7N9 subtype, human cases in China.

Source: World Health Organization (WHO), full page: (LINK).

Code: [     ]


Human infection with avian influenza A(H7N9) virus – China


Disease outbreak news  / 19 July 2017

On 19 June 2017, the National Health and Family Planning Commission of China (NHFPC) notified WHO of five additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus in China. On 24 June 2017, the NHFPC notified WHO of 10 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus in China. On 30 June 2017, the NHFPC notified WHO of six additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus in China.

Details of the case patients

  • On 19 June 2017, the NHFPC reported five laboratory-confirmed human cases of infection with avian influenza A(H7N9) virus in China.
    • Onset dates ranged from 25 April to 6 June 2017.
    • Of these five cases, one was female.
    • The median age was 55 years (range 41 to 68 years).
    • The case patients were reported from Beijing (1), Guangxi (1), Guizhou (1), Hunan (1), and Zhejiang (1).
    • At the time of notification, there was one death.
    • Four cases were diagnosed as having severe pneumonia.
    • Three cases were reported to have had exposure to poultry or live poultry market, and two had no known poultry exposure.
    • No case clustering was reported.
  • On 24 June 2017, the NHFPC reported 10 laboratory-confirmed human cases of infection with avian influenza A(H7N9) virus in China.
    • Onset dates ranged from 5 to 19 June 2017.
    • All cases were male.
    • The median age was 53.5 years (range 31 to 79 years).
    • The cases were reported from Anhui (1), Beijing (2), Guizhou (1), Hebei (1), Inner Mongolia (1), Jiangsu (1), Sichuan (2), and Tianjin (1).
    • This is the first case reported in Inner Mongolia since the virus emerged in 2013 although two cases were recently reported from Shaanxi province but who had likely exposure in Inner Mongolia.
    • At the time of notification, there were two deaths.
    • Eight cases were diagnosed as having either pneumonia (4) or severe pneumonia (4).
    • Nine cases were reported to have had exposure to poultry or live poultry market, and one had no known poultry exposure.
    • One cluster with two cases was reported and both cases are from Panzhihua City, Sichuan Province, and had exposure to the same live poultry market.
    • The cluster includes:
      • A 79-year-old male, who had symptom onset on 12 June 2017 and was admitted to hospital with severe pneumonia on 15 June 2017, then died on the 21 June 2017. He was living on an upper floor of the live poultry market and passed regularly through the market.
      • A 48-year-old male, who had symptom onset on 7 June 2017 and was admitted to hospital with severe pneumonia on 11 June 2017. He is a seller of poultry at the same live poultry market.
  • On 30 June 2017, the NHFPC reported six laboratory-confirmed human cases of infection with avian influenza A(H7N9) virus in China.
    • Onset dates ranged from 11 to 23 June 2017.
    • Three cases were male.
    • The median age was 37.5 years (range 4 to 72 years).
    • The cases were reported from Guizhou (1), Shanxi (1), and Yunnan (4) provinces.
    • At the time of notification no associated deaths were reported.
    • Four cases were diagnosed as having either pneumonia (1) or severe pneumonia (3).
    • Two mild cases, identified through ILI surveillance, were reported: one in a child with exposure to market poultry and one in an adult.
    • Five cases were reported to have had exposure to poultry or live poultry market, and one had no known poultry exposure.
    • These are the first cases reported with exposure to the virus in Yunnan province. Previous cases reported from Yunnan province had likely exposure in a neighbouring province.
    • One cluster with two cases was reported, which include:
      • A 33-year-old female from Wenshan, Yunnan Province had symptom onset on 17 June 2017 and was admitted to hospital with severe pneumonia on the same day. She had no apparent exposure to live poultry.
      • Her sister-in-law, a 42-year-old female also from Wenshan, Yunnan Province, visited her in the hospital, developed mild symptoms on 21 June and was hospitalized on 24 June 2017. Investigation of the case revealed that she ran a shop near a live poultry market and bought live poultry from the market on a daily basis before her symptom onset. The investigation concluded that the likely source of her infection was exposure to the virus from visiting live poultry markets.

To date, a total of 1554 laboratory-confirmed human infections with avian influenza A(H7N9) virus have been reported through IHR notification since early 2013.

Public health response

The Chinese government at national and local level is taking preventive measures which include:

  • Continuing to guide the provinces to strengthen assessment, and prevention and control measures.
  • Continuing to strengthen control measures focusing on hygienic management of live poultry markets and cross-regional transportation.
  • Conducting detailed source investigations to inform effective prevention and control measures.
  • Continuing to detect and treat human infections with avian influenza A(H7N9) early to reduce mortality.
  • Continuing to carry out risk communication and issue information notices to provide the public with guidance on self-protection.
  • Strengthening virology surveillance to better understand levels of virus contamination in the environment as well as mutations, in order to provide further guidance for prevention and control.

WHO risk assessment

The number of human infections with avian influenza A(H7N9) virus and the geographical distribution in the fifth epidemic wave (i.e. onset since 1 October 2016) is greater than earlier waves. This suggests that the virus is spreading, and emphasizes that further intensive surveillance and control measures in both human and animal health sector are crucial.

According to the epidemiological curve, the number of reported cases on a weekly basis seems to have peaked in early February and is slowly decreasing. The peak in cases this year corresponds to the timing of the peak in cases in previous years.

Most human cases are exposed to avian influenza A(H7N9) virus through contact with infected poultry or contaminated environments, including live poultry markets.

Since the virus continues to be detected in animals and environments, and live poultry vending continues, further human cases can be expected.

Additional sporadic human cases of avian influenza A(H7N9) in other provinces in China that have not yet reported human cases are also expected.

Similarly, sporadic human cases of avian influenza A(H7N9) detected in countries bordering China would not be unexpected.

Although small clusters of cases of human infection with avian influenza A(H7N9) virus have been reported including those involving patients in the same ward, current epidemiological and virological evidence suggests that this virus has not acquired the ability of sustained transmission among humans. Therefore the likelihood of further community level spread is considered low.

Close analysis of the epidemiological situation and further characterization of the most recent viruses are critical to assess associated risk and to adjust risk management measures in a timely manner.

WHO advice

WHO advises that travellers to countries with known outbreaks of avian influenza should avoid, if possible, poultry farms, contact with animals in live poultry markets, entering areas where poultry may be slaughtered, or contact with any surfaces that appear to be contaminated with faeces from poultry or other animals. Travellers should also wash their hands often with soap and water, and follow good food safety and good food hygiene practices.

WHO does not advise special screening at points of entry with regard to this event, nor does it currently recommend any travel or trade restrictions. As always, a diagnosis of infection with an avian influenza virus should be considered in individuals who develop severe acute respiratory symptoms while travelling in or soon after returning from an area where avian influenza is a concern.

WHO encourages countries to continue strengthening influenza surveillance, including surveillance for severe acute respiratory infections (SARI) and influenza-like illness (ILI) and to carefully review any unusual patterns, ensure reporting of human infections under the IHR 2005, and continue national health preparedness actions.


Keywords: WHO; Updates; H7N9; Avian Influenza; Human.