News Scan for Nov 13, 2014

News brief

Five more cases of puzzling polio-like sickness reported

The Centers for Disease Control and Prevention (CDC) has identified five more cases of unexplained polio-like illness in children, raising the total over the past few months to 75.

The CDC has been investigating the cases and their possible causes, which include enterovirus D-68 (EV-D68), the source of a respiratory illness outbreak involving 1,116 cases in recent months, nearly all of them in children.

Today the CDC reported one more death associated with EV-D68, raising the total to 12. But the total case count (1,116 in 47 states and Washington, DC) has not changed since a week ago.

The 75 polio-like cases occurred in 29 states, according to a CDC update today. While the case count is up by five since a week ago, the number of states stayed the same. The illnesses involve acute onset of focal limb weakness in individuals no more than 21 years old, with lesions in the spinal cord's gray matter.

The mysterious neurologic cases began with a cluster in Colorado in August, where 4 of 10 patients tested positive for EV-D68. The CDC has not yet reported any conclusions about the role of EV-D68 in the neurologic illnesses. Today's update does not say how many of the 75 patients were infected with EV-D68.

After updating the EV-D68 case count several times a week for several weeks, the CDC now plans to update it just once a week, CDC spokeswoman Jeanette St. Pierre told CIDRAP News yesterday. She said the agency had finished testing its backlog of specimens from suspected EV-D68 cases.

The CDC is still receiving about 20 to 30 samples a day, some of which are from neurologic illness patients and some of which are for "routine" enterovirus testing, St. Pierre reported.

As for the 12 deaths in patients who had EV-D68 infections, the agency has not released any findings on what role the virus played, saying state health departments are investigating those cases. In early October, New Jersey officials said the virus caused the death of a 4-year-old boy there who died in his sleep.
CDC information on unexplained neurologic illnesses
CDC page on 2014 EV-D68 outbreak
Related Nov 6 CIDRAP News story


Saudi Arabia reports 2 new MERS cases, 1 fatal

Today Saudi Arabia's Ministry of Health (MOH) reported two new MERS-CoV cases, one of which was fatal, in Sakakah in the north. It also reported the death of a previously confirmed patient.

The first Sakakah case involves a 53-year-old Saudi man who has preexisting disease and had recent contact with animals. He had no contact with suspected or confirmed MERS-CoV (Middle East respiratory syndrome coronavirus) patients.

The Sakakah man who died was a 29-year-old expatriate who had no preexisting disease or contact with animals. The MOH, however, is investigating whether he had contact with other MERS patients. Neither man is a healthcare worker, and the MOH didn't say whether the cases are connected. Sakakah is in Al Jawf province.

The agency also confirmed the MERS-related death of a 70-year-old Saudi woman in Al-Kharj, a city not far from Riyadh in central Saudi Arabia. She was not a health worker but had preexisting disease. It appears her case was first reported by the MOH 2 days ago, when she was listed in critical condition.

The cases bring the Saudi MERS-CoV total to 804 cases and 342 deaths.
Nov 13 Saudi MOH update
Nov 11 CIDRAP News scan on Al-Kharj case


Officials note apparent interruption of WPV3 transmission

No isolation of wild poliovirus type 3 (WPV3) has been identified since 2012 even though the number of cases of acute flaccid paralysis (AFP) has grown, indicating that transmission of disease caused by that strain may have been interrupted, says a report today in Morbidity Mortality Weekly Report (MMWR).

Certification of an area as polio-free can be considered when 3 or more years have passed since isolation of WPV, say the authors, from the CDC and The World Health Organization (WHO). Four of the six WHO regions have been certified as such. WPV2 was last seen in 1999.

The last case of WPV3 in Asia was in a 1-year-old child in the Federally Administered Tribal Area (FATA) of Pakistan in April 2012. In Africa the last case was in an 11-month-old in November 2012. The most recent environmental isolates (gathered through testing of sewage samples) of WPV3 in Asia and Africa were identified in 2010 and 2012, respectively.

The number of countries reporting WPV3 declined from nine in 2010 to zero in 2013, and WPV3 isolations from stool specimens declined from seven to zero. During that time, the number of tested AFP cases increased from 98,788 to 101,701. The authors note that the decline in WPV3 has resulted from substitution of bivalent oral vaccine for monovalent vaccines and supplemental immunization campaigns using trivalent vaccine.

If eradication of WPV3 is certified, it will be the third time transmission of a human pathogen has been stopped through immunization, following smallpox and WPV2.

"Continued sensitive surveillance is needed before the evidence of WPV3 eradication is conclusive, particularly given evidence of remaining limitations of surveillance in Pakistan, Nigeria, and elsewhere," say the authors.

Circulation of WPV1 remains a concern in several countries, particularly Pakistan.
Nov 14 MMWR article


Study: France identifies 433 tularemia cases in a decade

A total of 433 cases of tularemia—with direct contact with hares and exposure to dust aerosols during outdoor leisure as the major likely causes—were reported in France over the first 10 years of national surveillance, according to a study in today's issue of Eurosurveillance.

Epidemiologic surveillance for human tularemia was implemented in France in October 2002 as part of a bioterrorism preparedness plan. Since then, notification of regional health agencies by means of a standard form has been mandatory for physicians and microbiologists. The authors report results of such surveillance from Oct 1, 2002, through Dec 31, 2012.

A case is defined as a patient with clinically suggestive signs and symptoms. A case is considered confirmed if results of polymerase chain reaction testing are positive, Franciscella tularensis is isolated in a sample, or seroconversion or a four-fold increase in serologic titer on two samples taken a minimum of 2 weeks apart occurs. A probable case is defined as like findings except for only a single serologic titer increase.

The authors counted 433 cases over the study period, 30% confirmed and 70% probable. Median age was 49 years, and the male-female ratio among cases was 1.8.The most common presentations were glandular (46%) and ulceroglandular (26%). Hospitalization was required in 43% of patients.

The vast majority of cases (91%) were sporadic, with the remainder (9%) occurring in one of the 10 clusters (more than 1 case in a household, 2 or more cases in a social circle, or 3 or more cases in a district over a 30-day period) identified. The most common at-risk exposures to tularemia were outdoor leisure exposure to dust (50%), handling of hares (41%), and tick bites (16%).

There was a progressive increase in cases over the 10-year period with the exception of a spike during the 2007-08 winter, when an outbreak of tularemia in hares occurred.

The authors state that mandatory notification of tularemia "has demonstrated its value for the detection of clusters and outbreaks," and they note that the incidence they report is probably an underestimation owing to underdiagnosis and undernotification.
Nov 13 Eurosurveillance report


Eye infections cause almost 1 million US doctor visits each year

Keratitis, or inflammation of the cornea, causes almost 1 million US healthcare visits each year, the CDC noted today in MMWR. The visits cost an estimated $175 million annually in direct medical expenses, and wearing contact lenses is the single largest risk factor, CDC researchers said.

To estimate the incidence and cost of keratitis, the team analyzed national ambulatory-care and emergency department databases. They estimated that keratitis or contact lens disorder leads to 930,000 doctor's office and outpatient clinic visits and 58,000 emergency department visits each year. Of all keratitis visits, 76.5% result in antimicrobial prescriptions, the researchers reported.

Of the $175 million in annual direct medical costs, Medicare patients account for $58 million and Medicaid patients account for $12 million.

"Contact lenses can provide many benefits, but they are not risk-free—especially if contact lens wearers take shortcuts and don't take care of their contact lenses and supplies," said author Jennifer Cope, MD, MPH, a CDC medical epidemiologist, in a CDC press release.

The CDC in the release lists several steps to promote good contact lens care, such as washing hands with soap and water and drying them well before touching lenses.
Nov 14 MMWR report
Nov 13 CDC news release

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