MERS around the world...

China was the 26th country to host a MERS-CoV infected person, when a 44-year old symptomatic male (onset 21-May-2015) travelled from South Korea, through Hong Kong to Huizhou in Guangdong Province,  China on 26-May-2015.[1] 

Click on it!
It gets bigger!!!

Reference...

1. http://www.who.int/csr/don/30-may-2015-mers-china/en/

Ebola mysteriously returns to Liberia...[UPDATED]

v2-1JULY2015 AEST
In a gut-wrenching, but not wholly unexpected event, a new case of Ebola virus disease (EVD) has popped up in a town called Nedowein (or Nedowian [8]), about 50km south west of Liberia's capital, Monrovia.

Liberia had been declared a country free of EVD on 9-May-2015 - 52 days ago, or 1 month, 21-days, or 1248 hours.  

The 17 year old male (17M) died on Wednesday (about 6 days ago) and has already been buried by all accounts. Samples from his corpse tested positive at least twice.[3]

It's not an unexpected event because both Guinea and Sierra Leone, adjoining countries, continue to struggle with EVD and have been unable to stop the disease from spreading, even though in relatively small numbers compared to what was occurring in 2014. 

What makes this new case in Liberia a little mysterious is that 17M died far from the border with either of these countries; approximately 150km from Sierra Leone's south-eastern border and about 200km from the nearest Guinean border. Sure, these are not insurmountable distances to travel while incubating an Ebola virus infection, but it would have been a simpler call that this was an imported case if it had occurred on or nearer to the border of one of the two countries with ongoing disease. However, it seems the young man did not travel outside Liberia.[8]

Hopefully the contact tracing and investigations that are going on now will find that 17M simply made contact with someone who had traveled from outside of Liberia, perhaps to Nedowein, which is described as the home town of 17M.[2,7] If this is not an imported case then one is left to wonder about various other scenarios including:

1. sexual or other less common transmission of Ebola virus from an as yet undiscovered convalescent EVD case
2. contact with an unknown case who had traveled across the border from a country with EVD
3. a new zoonotic acquisition of a different Ebola virus variant
4. there may still be clusters of EVD within Liberia that have been smouldering on without the knowledge of any authorities

Time and further hard work will no doubt tell.

UPDATE: A second  case, associated with 17M ("Abraham") has been diagnosed.[9] Some discussion is evolving around the consumption of dog meat by 17M,[11] however, the same questions around how a dog would become infected (no record of the detection of active replication in a dog have been recorded to date, although antibodies have suggested the possibility in earlier outbreaks) will apply.

Further reading...

1. http://www.frontpageafricaonline.com/index.php/news/5660-ebola-back-in-liberia-1-month-20-days-after-free-declaration
2. http://www.bbc.com/news/world-africa-33323664
3. http://www.ibtimes.com/ebola-liberia-corpse-tests-positive-deadly-virus-weeks-after-liberia-declared-ebola-1989248
4. http://bigstory.ap.org/article/581e523aeb1144f68aa1a1629b0e9252/liberian-official-says-corpse-tests-positive-ebola
5. http://news.yahoo.com/liberia-announces-return-ebola-one-death-094057018.html
6. http://www.nytimes.com/2015/06/30/world/africa/liberia-new-ebola-death-is-reported.html
7. http://newsworldmap.com/ebola-returns-to-liberia-but-health-minister-tells-public-no-need-to-panic-washington-post/ 
8. http://news.sciencemag.org/africa/2015/06/liberias-puzzle-how-did-new-ebola-patient-become-infected 
9. http://www.nytimes.com/2015/07/01/world/africa/liberia-ebola-epidemic.html?partner=rss&emc=rss&smid=tw-nytimesscience&_r=0  
10. http://frontpageafricaonline.com/index.php/health-sci/5667-ebola-mystery-dog-meat-story-eclipses-border-lapse-theory

Version history..

1. New links added; town name variation added from Science report; hypothesis of contact with another imported case - #2; note on lack of travel outside of Liberia; announcmene tof a 2nd case

Matching MERS case identification numbers from two differing sources...

Update #1 27JUNE2015
Update #2 28JUNE2015

Sometimes people work from different playbooks.

Figure 1. MERS in South Korea. Most cases now plotted
on graph using their dates of illness onset.
An outbreak in decline. This is up-to-date - 3 new cases
from 21JUN2015 added (column at right hand side -
onset dates unknown)
Click on graph to enlarge

In this instance, the data from the World Health Organization's (WHO) new list of Middle East respiratory syndrome (MERS) cases - with extra detail - uses a case identification key that's out of synchrony with that produced by the South Korean (SK) Health Authority which can be found in each of its posts announcing new MERS cases and deaths. 

Attempting to link the two lists has mostly been an exercise in pedantry, but sometimes it is useful to know which case one is talking about when discussing an outbreak or cluster of disease....'Hey Bill, what didja think of that 70 year old MERS case who drove the ambulance carrying that infected 75 year old MERS case and then those others got MERS as well..?' doesn't really roll off the tongue does it?

Figure 2. What the graph above looked like before
we had dates of illness onset. Many cases
were 'moved' to earlier time points because
report dates always follow onset of illness dates
and they can follow by varying periods of time -
sometimes a day, sometimes a week or more.

Two file formats are in the folder I've linked to below. This is my first attempt - yes, it is a work in progress - to match up the new WHO case list from the 19th June which includes the highly prized date of illness onset (DOOs) for most cases - with that of the South Korean (SK) Health Authority. They do differ. Quite a bit. And in several ways. For example, the numbering scheme is off by one or more, SK69 seems to be missing from the WHO list, there is a question mark hanging over SK152 & SK156 and the WHO data seem to have a number of different ages from the SK data- mostly differing by one year (presumably someone is rounding up or down). 

If I've stuffed anything up or if you can solve my problem cases - please pass that info along and I'll update the files on this page. Hopefully the next WHO version will have addressed all of this anyway (it didn't but perhaps a future one will).

These are publicly available and you can download them for your own interest.

There is a download arrow at the top of the Google Drive page.

1. Google Drive folder with MERS data files
   https://drive.google.com/open?id=0B5sEcTjB5Ailfm1PcU1oNDF6M2hiaDduUDgzQUdxNlZxeHBkU0FHeVBRRFJkbHIxTmdjX3c&authuser=0

Updates...

1. With the help of FluTrackers updated line list to cross check against, the first half of my list has been updated - some bugs fixed. 
2. After about 5 hours - on and off - FluTrackers helped me sort out a few errors and the latest version of my list has been uploaded into the the folder linked above. Some typos corrected.

MERS-CoV jumps a flight to South Korea...but from where?

It could be Qatar, Bahrain, the United Arab Emirates (UAE) or the Kingdom of Saudi Arabia (KSA). Any of these may have been the country of origin for the infected person who returned with a bunch of microscopic passengers, to the 24th country to host a case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection - South Korea. 

The infected man then passed the spiky parasites on to his 63-year old wife and to a 76-year old man with whom he shared his hospital room. Close contact. From what we know of the MERS-CoV - it's a pretty ineffective transmitter among us humans types, preferring instead to give the hump to dromedaries.

Qatar seem less likely as it appears to have only been an airport transit point. If it's Bahrain, then we have 25 countries as Bahrain has not yet reported a MERS-CoV positive person. Both the people and the camels of the UAE and KSA are well known to this virus both in humans and camels. 

We await the clarity of the World Health Organization's analysis in a Disease Outbreak News (DON) article - although this might be a tough one to unravel.

Click on image to enlarge.

Influenza A(H7N9) virus: detection numbers and graphs...

This is a static page that houses my graphs of influenza A(H7N9) virus ("H7N9") numbers produced by the various Ministries of Health for the provinces and municipalities of China, Hong Kong's Centre for Health Protection (CHP) the World Health Organization and FluTrackers.

Please be aware that these numbers are in flux during the winter epidemic. They are a guide only.

There is also an accompanying map page which for now is located here.

Learn About Tableau

Reminders: 

• The graphs above, as with all on VDU, are made for general interest only. They are also freely available for anyone's use, just cite the page and me please. The data can be downloaded by clicking on the "Download" link at the bottom-right of each dashboard. It may be that I have misinterpreted the language in the reports (sometimes a little tricky to wade through) or miscalculated some totals based on the way data have been presented.
• In any outbreak, epidemic or pandemic caused by a know or emerging pathogen, the numbers presented publicly, and used in these graphs, are expected to represent only a fraction of all the cases that have and are occurring. This is just the nature of the imperfect biological'ness of these events.
• I am only able to plot what is publicly available-you could do this too. No secret associations or back-room deals provide me with these data.

The United States of America is the 6th country to host a 2014 West African Ebola virus variant..

v4 08102014 07:00am AEST

First thing...

CALM DOWN!

This (announced 30-Sept) is the first case of Ebola virus infection to arrive in the United States that was not deliberately flown in. Its not the first viral haemorrhagic fever case though (1 case of Marburg virus disease and at least 4 Lassa virus infections and the Reston ebolavirus outbreak among imported animals[3,5]), and none of the earlier infections resulted in secondary transmission among humans; no-one else got infected from by the case.[4]

Countries that have hosted people infected
with the Ebola virus variant causing the
& 2014 West African Ebola virus
disease epidemic.
Click on image to enlarge.

The male is in critical condition.
When he flew from Liberia to the United States (finally arriving in Dallas,Texas). The man was not showing signs of disease when leaving Liberia or on the plane or immediately after arriving.[6]

This means that the man was not infectious - he could not spread it to fellow travellers or airport workers - because it is well known that disease in another does not develop due to virus being shed before disease is obvious in the infected person.

Briefly[1,2]:

• 19th: Departed Liberia, checked and found to be symptom-free
• 20th: Arrived in Dallas, US (Brussels to Washington on United Airlines 951, then to Dallas Fort Worth on 822 [7])
• 24th: Started to develop symptoms
• 26th: Initially sought care for fever and abdominal pain (not vomiting). Sent home with antibiotics.[8]
• 28th: Admitted to Texas Health Presbyterian hospital in Dallas, Texas. Vomited as leaving home to get into ambulance.
• 30th: Texas public health laboratory found Ebola virus this morning of 30th Sept. CDC received samples, tested and confirmed as Ebola virus disease
• CDC announced case
• 1st Oct: WHO announced case
• Patient is ill and is under intensive care

US family and community contacts (a "handful") are known or being traced and will be under observation/monitoring for 21-days (~21-Oct) for fever. Will any become positive for Ebola virus? Perhaps. I look to Port Harcourt (Nigeria) for some comfort. There were around 60 "high risk" contacts of there and they did not all become ill.

The man identified his country of recent origin, Liberia-the country carrying more cases of Ebola virus disease than any other in history, to a triage nurse on the 26th when he first reported to the Texas Health Presbyterian Hospital. That the information was not passed along sufficiently.[7] While the signs and symptoms were non-specific-all sorts of infectious agents could cause fever and gut issues-the travel history should have been a very important red flag. 

He was sent home with antibiotics. Many acute febrile illnesses are viral  in nature, and antibiotics do not treat viral infections, just bacterial ones but do a great job at helping out antibiotic resistance. Sigh.

So now we have evidence that supports all those talking heads (me included) who noted that it was possible for sporadic cases of EVD to be imported into countries outside of those in West Africa (Guinea, Liberia, Sierra Leone, Nigeria, Senegal). It also, sadly, shows how human infectious disease are - literally by infecting us and using us to cough, vomit and bleed the bug onto to another person, but also figuratively in the roles we play in helping that spread to happen.

Soon, I very much believe, we will also have evidence that in richer countries with functioning healthcare systems, a good knowledge of what is needed to contain virus infections spread by all possible routes, stocks of the necessary personal protective equipment needed to protect healthcare workers from nosocomial infections and the training to use those stocks...that even when unexpected Ebola virus disease cases arrive or incubate and emerge, they will not result in outbreaks.

References...

1. https://www.youtube.com/watch?v=6Bxencye1cg&feature=youtu.be
2. http://www.nytimes.com/2014/10/01/health/airline-passenger-with-ebola-is-under-treatment-in-dallas.html?partner=rss&emc=rss&smid=tw-nytimes
3. http://scienceblogs.com/aetiology/2014/08/02/ebola-is-already-in-the-united-states/.
4. http://blogs.scientificamerican.com/molecules-to-medicine/2014/09/30/ebola-in-usno-need-to-panic/?WT.mc_id=SA_sharetool_Twitter
5. http://www.cdc.gov/media/releases/2014/s930-ebola-confirmed-case.html
6. http://news.sciencemag.org/health/2014/09/one-more-ebola-question-dr-frieden-answers-journalists-would-have-first-u-s-case?rss=1
7. http://www.usatoday.com/story/news/nation/2014/10/01/hospital-ebola-patient/16527143/
8. http://www.usatoday.com/story/news/nation/2014/10/01/texas-ebola-patient/16525649/

*POSSIBLY NOT* Country #22 to have been paid a visit by the MERS-CoV: Bangladesh [UPDATED x2]

Looking like this result could not be confirmed 

by external testing.

June 20th 

The case, a 53-year old male (53M) returned to Dhaka, Bangladesh on 4-June from New York (the United States of America), via Abu Dhabi (United Arab Emirates). He became symptomatic on 6-June and was hospitalized 9-June.

Director of the Institute of Epidemiology, Disease Control and Research (IEDCR), Prof. Mahmudur Rahman, speculated that 53M was likely to have contacted MERS-CoV in the UAE. It's not clear whether he transited through the Abu Dhabi airport (apparently he was at the airport for 3-hours, h/t @influenza_bio; seems like a very unlucky acquisition then[4]), or stayed there for some time. 

If new Bangladesh #MERS patient truly contracted #MERS in Abu Dhabi airport or on an airplane, this suggests a spreader was also traveling.
— A biologist (@influenza_bio) June 15, 2014

It's also not clear how long he stayed the the USA for. The WHO have been informed, according to reports.

A 2-day incubation period is a bit on the short side for MERS-CoV though. Eagerly awaiting the WHO DON on this case.

[UPDATE] It looks like this sample could not be repeated. If I read any further announcements I'll post them here buit for now it appears that the two samples may have been false positive results. How that could happen I'm really not able to imagine. But we'd need to know more about the testing to answer that.

Sources...

1. FluTrackers thread
   http://www.flutrackers.com/forum/showthread.php?p=537546#post537546
2. Treyfish's H5N1 pandemic information news blog
   http://swineflumagazine.blogspot.com.au/2014/06/more-on-bangladesh.html
3. The Daily Star
   http://www.thedailystar.net/mers-detected-first-time-in-bangladesh-28635
4. Channel NewsAsia
   http://www.channelnewsasia.com/news/health/bangladesh-reports-first/1162024.html

MERS-CoV detected in 21st country....no party ensues

Algeria has reported 2 cases of MERS-CoV infection among two men (66 and 59-years of age) returning from performing Umrah in the Kingdom of Saudi Arabia (KSA).[1,2] 

No indication of any local transmission as yet. Seems the pilgrims arrived with signs and symptoms of disease so, as Crawford Kilian asks[6], just how carefully are authorities at KSA exit points examining departing people for signs of respiratory disease? 

Click on image to enlarge.

While we await confirmation that all the laboratory "I"s have been dotted and "T"s crossed, I wonder if there was any camel/animal contact or if these men visited a hospital while there? If the answer to these questions is no, then we're left to suspect that there may be a lot more community transmission going on than we are getting wind of. 

Daily total MERS-CoV detections have dropped to low levels and healthcare worker involvement no longer noted (i. because there are none or ii. because profession is no longer considered valid demographic detail for public consumption), so if not from animals or hospitals...then from where?

Less speculative is that we're also waiting on scrubbed detail from the WHO on hundreds of KSA cases, a Philippines case and detail about what is happening in Iran too. We've been waiting a while for some of that.

hat-tipping @crof, @Fla-Medic and @FluTrackers 

References...

1. http://www.tsa-algerie.com/2014/05/31/coronavirus-deux-cas-confirmes-en-algerie/
2. http://www.aljazeera.com/news/middleeast/2014/05/algeria-confirms-first-mers-cases-201453118430877511.html
3. http://www.flutrackers.com/forum/showthread.php?p=536454&posted=1#post536454
4. http://afludiary.blogspot.com.au/2014/05/algerian-moh-statement-on-two-mers-cases.html
5. http://www.sante.dz/communique_coronavirus.pdf
6. http://crofsblogs.typepad.com/h5n1/2014/05/algeria-a-very-litte-more-about-the-two-mers-cases.html

Iran reports 2 MERS-CoV cases: 20th country [UPDATED]

Click on map to enlarge.

Head of Communicable Disease Control (CDC) at the Iran Ministry of Health (MOH), Dr. Mohammad Mahdi Reports seem to indicate 2 sisters, one critically ill, have been confirmed as cases and 2 suspected cases, perhaps family members, are being observed/investigated for MERS-CoV.

I'll await the WHO report (which will hopefully appear soon) with more details but what we have so far suggests local spread, so the pink (unknown origin of case acquisition) will change to another colour of some sort, in the future.

The WHO were awaiting official notification from Iran's MOH about 10-hours ago.

@HelenBranswell Aware of reports on this, but have not receive official notification as per International Health Regulations (IHR)
— WHO (@WHO) May 26, 2014

A story from AFP [7] notes that the 2 sisters are being treated in the same hospital in Kerman, where they were believed to have acquired their infection from a pilgrim returning to Iran from Saudi Arabia. No mention of whether that pilgrim was tested and found to me MERS-CoV positive.

h/t to @Malaekeh and @HelenBranswell for alerting us to the CDC report.

Resources...

1. Crawford Kilian's post..
   http://crofsblogs.typepad.com/h5n1/2014/05/iran-reports-first-mers-cases.html
2. MOH announcement..
   http://www.behdasht.gov.ir/?siteid=1&fkeyid=&siteid=1&pageid=127&newsview=108713
3. FluTracker's thread..
   http://www.flutrackers.com/forum/showthread.php?t=223788
4. Treyfish's post
   http://swineflumagazine.blogspot.com.au/2014/05/iran-identification-of-novel-virus-2.html
5. Mike Coston's post..
   http://afludiary.blogspot.com.au/2014/05/irans-moh-reports-2-mers-cases-testing.html
6. PressTV - English detail
   http://www.presstv.ir/detail/2014/05/27/364327/iran-confirms-two-cases-of-mers/
7. AFP Report
   http://www.interaksyon.com/article/87818/iran-reports-first-2-mers-cases

MERS-CoV cluster in Al Qunfudhah...

5 cases in 4 days from a city we haven't seen prior MERS-CoV detection in (as far as I can tell) = a cluster.

The south western coastal city of the Kingdom of Saudi Arabia (KSA) is home to ~200,000 people[1].

While the cases have been asymptomatic when reported, the first, a 65-year old male (65M; was isolated at home [2]), came into contact with another case (see below) while at a government hospital. Which case that was and at what hospital, is unclear.

But there are other worrying issues here:

• This city is in Makkah region, home to the 2 holiest Mosques and not a site in which anyone wants to see active spread of this virus again as we get closer to the Hajj; we don't want to see it spread anywhere at all of course.
• FluTrackers has a thread on this (when don't they!?; my thanks to Sharon Sanders for pointing me to it) from 21-May and at least one of the 5 cases seems to be a teacher at a school in Al Quoz, 25 km south of Al Qunfudhah. No school-children have been reported positive to date though. The 4 cases after 65M were aged 25, 28, 25 and 45 - could some be teachers or are they all family of 65M? Family accompanied 65M to visit a relative in a Jeddah hospital (presumably the contact for 65M?). We no longer get any information from the KSA's Ministry of Health (MOH) about occupation, so one is left to guess...as usual. There seems to be mention of symptoms among some of these cases?
• Could healthcare workers in Al Qunfudhah be among these younger asymptomatic (presumable) contacts of 65M?

This city may be seen written as Al Qunfudah, Qunfudah, Qunfutha, Kunfuda, Gonfodah or Gonfothah. I was helped out on the naming of this city recently - my thanks to @AmboceptorBlog

@MackayIM Arabic only has 3 vowels- usually translated A/I/U (each has short&long forms) This also depends on dialect. Short U -> O in Egypt
— Amboceptor (@AmboceptorBlog) May 22, 2014

Sources...

1. http://en.wikipedia.org/wiki/Al_Qunfudhah
2. http://www.moh.gov.sa/en/CoronaNew/PressReleases/Pages/mediastatement-2014-05-22-001.aspx
3. http://www.moh.gov.sa/en/CoronaNew/PressReleases/Pages/mediastatement-2014-05-24-001.aspx
4. http://www.moh.gov.sa/en/CoronaNew/PressReleases/Pages/mediastatement-2014-05-25-001.aspx
5. http://www.flutrackers.com/forum/showthread.php?p=535788#post535788
6. 
   

Welcome to the Netherlands MERS-CoV...

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...

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

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

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...

1. http://www.moh.gov.sa/en/CoronaNew/PressReleases/Pages/mediastatement-2014-05-12-001.aspx
2. http://www.latimes.com/science/sciencenow/la-sci-sn-mers-florida-20140512-story.html
3. http://www.cdc.gov/media/releases/2014/t0512-US-MERS.html
4. http://www.orlandosentinel.com/health/os-mers-case-central-florida-20140512,0,5928176.story
5. http://crofsblogs.typepad.com/h5n1/2014/05/us-a-little-more-on-the-florida-mers-case.html

Dump the garbage...

Sharon from @FluTrackers and I had an exchange on Skype this morning - always a useful way to message, even with my high rate of typos - and we agreed (or perhaps I bullied) that there was little point to keeping  "TheUAE12" (as I've taken to calling the 12 cases announced in the Kuwaiti News Agency [1]) on the list. 

In the past I've also argued that if samples get dropped, such as when Spanish or other cases could not be confirmed as MERS-CoV-positive, for whatever reasons, that FluTrackers retain their case numbers and "count around them". So the numbers become discontinuous. Those arguments are based on the numbers having already become embedded among flublogians/coronablogians and this way they could continue to be trackable by those who have used them. For example, FluTrackers makes a note saying this case is now a probable case, not included in the tally as it could not be suitably confirmed or somesuch. This is akin to not making wholesale changes to the name of a virus because you no longer like the "look" of the name when it already has decades of published literature behind it and is in the head of every researcher in the field. 

I proposed to Sharon that the MERS-CoV detections over the past few days were not yet embedded enough to be missed. So we've cleaned our lists. The FluTracker's tally [2] now sites at 360 cases using Ministry and WHO data. And I follow that excellent list.

So my Tweets this morning (AEST) were about those numbers having now been deleted and the case list comprising ~6-days and 70 cases has been "moved up" to fill the gap, but the numbers remain continuous. The new list [2] is thus 12 cases down from a few hours ago, but that has little impact on April's surge of new cases. 

We think that some of TheUAE12 are included in recent WHO Disease Outbreak News posts but they are not linked to the announced 12, no-one could/would link them to the announced 12 and so retaining them as empty case numbers was pointless.

On with the show.

Resource...

1. UAE Media Report: 12 New (Asymptomatic?) MERS Cases Detected
   http://afludiary.blogspot.com.au/2014/04/uae-media-report-new-asymptomatic-mers.html
2. FluTrackers MERS-CoV line list | MASTER LIST
   http://www.flutrackers.com/forum/showthread.php?t=205075

2 Middle East respiratory syndrome coronavirus (MERS-CoV) cases emerge in the Philippines and Malaysia [UPDATED]

In a surprising pair of temporally related announcements, there has been an imported and fatal case of MERS occurring in a 54-year old man (54M) originally from Johor, Malaysia [1] and a distinct case in a  recently returned 45-year old [5] Filipino male nurse working in the United Arab Emirates (UAE).[2,3,4]

• 54M had returned from performing an Umrah pilgrimage ("mini-Hajj")  at Mecca (Makkah), Saudi Arabia on 29-March , becoming ill 8-9-Apr, dying of pneumonia secondary to his MERS-CoV infection, 13-Apr.[8]
• Passengers on board the same flights are urged to contact the Health Ministry for testing but he was not symptomatic while in transit [8]
• Diabetic (a comorbidity) [6]
• Had visited a camel farm but source of infection remains unknown [6]
• 45M, currently in quarantine with his family, was a friend of the recent fatal MERS case in a Filipino paramedic
• The nurse was asymptomatic
• Returning from vacation in the Philippines when retrospective testing results were released to Philippines embassy by UAE authorities  [5]
• Testing was conducted in the UAE, referred to as a "blood test" ?serology not PCR-based?
• Source of infection remains unknown

In 2013, Kingdom of Saudi Arabia's (KSA) Health Minister Abdullah Al-Rabeeah, said that 4,800,000 pilgrims visited to perform Umrah and not one left having had MERS-CoV infection. That will not be the case in 2014.

References...

1. FluTrackers thread on fatal MERS-CoV case in 54M, Malaysia
   http://www.flutrackers.com/forum/showthread.php?t=221664
2. FluTrackers on Filipino nurse positive for MERS-CoV
   http://www.flutrackers.com/forum/showthread.php?p=531474#post531474
3. http://www.gmanetwork.com/news/story/357189/news/nation/pinoy-nurse-tests-positive-for-mers-virus-first-case-in-phl
4. OFW who returned home from UAE tests positive for MERS-CoV – DOH chief|Inquirer.net article http://newsinfo.inquirer.net/594740/ofw-who-returned-home-from-uae-tests-positive-for-mers-cov-doh-chief#ixzz2z2x7xUEr
5. OFW with MERS arrives in Manila
   http://www.philstar.com/headlines/2014/04/17/1313580/ofw-mers-arrives-manila
6. Health Ministry Confirms Umrah Pilgrim Died Of MERS-CoV
   http://www.bernama.com/bernama/v7/bu/newsmarkets.php?id=1031217
7. MERS Coronavirus Makes First Appearance In Asia: Malaysia, Philippines Report MERS-CoV Cases
   http://www.theglobaldispatch.com/mers-coronavirus-makes-first-appearance-in-asia-malaysia-philippines-report-mers-cov-cases-43672/
8. First Mers death recorded in Asia
   http://www.thenational.ae/world/first-mers-death-recorded-in-asia
9. Mike Coston on Malaysia imported case
   http://afludiary.blogspot.com.au/2014/04/malaysian-moh-statement-on-imported.html
10. Mike Coston on Philippines imported case
    http://afludiary.blogspot.com.au/2014/04/philippines-quarantines-imported.html

Yemen announces its first case of MERS-CoV...

The MERS-map. This broadly highlights the sites of
all cases to date. It is not yet clear whether the Yemeni
case was locally acquired or imported from the
Kingdom of Saudi Arabia.
Click on image to enlarge.

Mike Coston has just detailed over on his blog, Avian Flu Diary, the culmination of his FluTracker's Sharon Sanders searching and discussion about the social media noise pointing towards there being a possible case of MERS in Yemen.[1] Mike notes that Reuters is now carrying a general story about an ill male aeronautical engineer.[4]

FluTrackers is now carrying a confirmation [3 and also 4 and others] by the Minister of Public Health and Population, Dr. Ahmed Qasim Al-Ansi, that a case has been confirmed in San'a (popn ~2-million), the capital city of Yemen.

This is the 1oth State to host the virus.

It is not yet clear who did the testing, the condition of the patient, if the testing has been confirmed to the WHO's satisfaction or whether the case was acquired within Yemen (any travel or contact with another known case from outside the country) or is an imported case.

We await the WHO disease outbreak news article or a more detailed account from Yemeni Health Officials.

Sources...

1. Mike Coston's post on the first major media report about the Yemini MERS case
   http://afludiary.blogspot.com.au/2014/04/yemen-reports-1st-mers-cov-case.html
2. FluTrackers link to confirmation
   http://www.flutrackers.com/forum/showthread.php?p=531154&posted=1#post531154
3. Discovery of the first infected "Corona" in Yemen and specialty health operations room to continue.
   http://www.althawranews.net/portal/news-78927.htm
   Yemen announces record first case of HIV Corona [Editor: its a translation thing]
4. http://marebpress.net/news_details.php?sid=67463&lng=arabic

MERS in Kuwait...

It's a "MERS-in.." kinda day. 

The World Health Organization todayannounced a fatal case of confirmed MERS-CoV infection diagnosed in Kuwait [1].

Summary of the case details:

1. The infected person was a 60-year old male
2. A Syrian national
3. Hospitalised 13-Feb-2014
4. Died 6-Mar-2014
5. Lab confirmed 9-Mar-2014
6. He had comorbidities

A few things here worth noting I think:

• There was quite a gap (24-days) between being hospitalised (not sure when the case started showing signs of illness) and having a laboratory confirmation (also 3-days after death)
• While this is the 3rd case identified within Kuwait, it seems to be the first case that could be nailed down as having been acquired in Kuwait. I tend to try and list my numbers and maps by where the case was acquired rather than where they were diagnosed. Two previous MERS-CoV cases (FluTrackers #158 and #159; includes 1 case with camel contact noted) diagnosed in Kuwait had travelled outside Kuwait blurring the ability to see where they had picked up the virus

.@setiogi @MackayIM @FluTrackers Not the first Kuwaiti case. and infection acquired in #Kuwait, we believe. #MERS
— Gregory Härtl (@HaertlG) March 20, 2014

References...

1. WHO Disease Outbreak Notification 20-Mar-2014
   http://www.who.int/csr/don/2014_03_20_mers/en/
2. FluTrackers thread on Kuwait MERS-CoV case #1
   
   http://www.flutrackers.com/forum/showthread.php?p=514258#post514258
3. FluTackers on Kuwait MERS-CoV case #2
   
   http://www.flutrackers.com/forum/showthread.php?p=528694#post528694

MERS in the UAE....[UPDATED]

For the second time this month, there has been a case of Middle East respiratory syndrome coronavirus (MES-CoV) infection confirmed in the United Arab Emirates (UAE; Abu Dhabi to be precise). 

What added to my confusion (as you'll know if you were following me on Twitter this morning) was that both cases, apart from being from Abu Dhabi, were also 68-year old males and both have had camel contact. 

Today's 68M UAE case frequently visited his camel farm in the Kingdom of Saudi Arabia (KSA; had just returned from there 5-days earlier, thus in my mind making this a likely KSA acquisition) while the earlier 68M UAE case owns his farm in the UAE where he contacted animals including camels which he breeds.

This raises another question from me; why do we see proportionately more camel contact outside the KSA than we do inside the KSA (I haven't done the maths so this may just me my unfounded gut feeling)? Is it something simple like better epidemiological investigations conducted by Qatari and UAE investigators or are things, yet again, different somehow inside the KSA than they are outside the KSA? 

Surely there are some clues in there for investigators to use either to either improve how the epidemiology investigations are conducted or to look beyond camels in the KSA at other sources of acquisition?

H7N9 snapdate: nothing new to report

No new human cases of avian influenza A (H7N9) virus yesterday.

None.

Markets.

Precipitous.

First Taiwan, then Hong Kong, now Malaysia becomes a holiday destination for an H7N9 case...[UPDATED x2]

Mike Coston has just made us aware via a Tweet that avian influenza A(H7N9) virus has escaped its usual roosting ground in southern eastern China by hitching a lift in a tourist to Malaysia. 

A more detailed post on his Avian Flu Diary wrangles the issue of language very nicely and tells us that the infected Chinese tourist has been hospitalized and is currently in a stable condition. 

Brief details..

• 66-year old female
• Fever, 01-Feb prior to leaving China
• Travelled from Guangzhou City in Guangdong province to Peninsular Malaysia 04-Feb then to Sabah, Malaysian Borneo 06-Feb then to Kota Kinabalu
• Hospitalised 07-Feb in Kota Kinabalu, Sabah, Malaysia 
• Laboratory confirmed 11-Feb and remained positive 13-Feb and 22-Feb
• No sign of R294K (N9 numbering) mutation associated with oseltamivir resistance despite virus "persistence" wihc may have been related to treatment with steroids
• 191 contacts; 6 were symptomatic but tested negative for H7N9

It is worth highlighting here that this sort of export is not unexpected and not even surprising. We live in a hyper-connected world. It's nigh on impossible to stop respiratory viruses from spreading. This case highlights that even when we're ill, we still feel the pressure to continue on with our jobs, our daily routine or our holiday. After all, we've all been a bit crook before and it has mostly been nothing much to speak of. Why should this time be any different? 

To date, H7N9 does not jump easily between humans as far as we know. The 20 negative contacts stand in testimony to that. But if you see some articles or posts or Tweets in the coming hours and days which suggest that the sky is falling...I think you can rest assured that this is not it falling. 

Not yet anyway!  

Now, go follow Mike via @Fla_Medic if you are not already.

Sources...

1. http://afludiary.blogspot.com.au/2014/02/malaysia-reports-their-1st-imported.html
2. Right-click and use Google translate (in Chrome at least)
   http://www.moh.gov.my/index.php/database_stores/store_view_page/21/479
3. Xinhua story
   http://news.xinhuanet.com/english/health/2014-02/12/c_133110102.htm
4. Avian Influenza (H7N9) Virus Infection in Chinese Tourist in Malaysia, 2014. EID. Jan 2015.http://wwwnc.cdc.gov/eid/article/21/1/14-1092_article