summary September to December 2014

Infectious Disease Surveillance and Monitoring System for Animal and
Human Health: Summary of notable events/incidents of public health
significance September to December 2014
Outbreaks and incidents
Ebola virus disease (EVD), West Africa (link to PHE Weekly Ebola Epidemiology
Epidemiological overview:
It has been over one year since the proposed index case of the Ebola virus disease
outbreak occurred in Guinea’s southern province of Guéckédou. Based on the latest
information from WHO, as of 14 December (9 December for Liberia), a total of 18,603
clinically compatible cases (CCC) of Ebola virus disease (EVD), including 6,915 deaths,
have been recorded. Case totals and deaths are an underrepresentation of the true
impact of the outbreak in West Africa. Currently, affected countries can be designated into
three groupings: countries with widespread and intense transmission (Guinea, Liberia and
Sierra Leone), countries awaiting EVD-free declaration (the US and Mali) and previously
affected countries (Senegal, Nigeria and Spain). If no further cases are reported, the US
and Mali should be declared EVD free on 22 December 2014 and 18 January 2015,
Countries with widespread and intense transmission:
The trends in national incidence continue to vary across Guinea, Liberia and Sierra Leone
(PHE map). In Guinea, the trend nationally has fluctuated since September without clear
evidence of either upward or downward trend. In Liberia, case incidence continues to
decline (although there are some data gaps) with Montserrado continuing to report the
majority of cases. In Sierra Leone there is some initial evidence that incidence may no
longer be increasing nationally however, transmission remains intense in the northern and
western districts. Freetown and the Western Rural area remain among the worst affected
Cases outside of Africa:
To date, a total of 23 EVD cases have been cared for outside of Africa; 18 repatriated
cases (hospitalised in the US (6), Germany (3), France (2), Spain (2), UK (1), Norway (1),
Switzerland (1), Italy (1) and the Netherlands(1)), two imported cases (both diagnosed in
the US) and three incidents of local transmission (in Spain (1) and the US (2)).
UK risk assessment:
The risk of EVD being imported into the UK is currently considered to be low. The latest
update to the risk assessment (8 December) determined that there was no evidence to
suggest any change in the risk the current EVD outbreak in West Africa presents to the
UK population. The risk of transmission occurring within the community in the UK is, and
PHE publications gateway number: 2014615
Published: 19 December 2014
is expected to remain, very low due to the range of robust measures that have been put in
place. There remains an expectation that a handful of cases may occur in the UK over the
next three months.
UK response and guidance:
A wide range of public health information about Ebola is available. The collection includes
guidance for a range of healthcare and other settings, and is regularly reviewed and
updated. Information about the UK response in Africa and in the UK is also available.
Wider impacts:
 an array of sequelae is being observed in survivors – Post Ebola syndrome, WHO
 food security crisis in affected countries – FAO report
 future strengthening and resilience of health care systems – WHO and partners
 large numbers of orphans face stigma and continuing hardship
 lack of education for millions of children as schools remain closed. Liberia starts
radio lessons
 Clinical overlap with malaria requires optimised treatment: WHO report, MSF
massive roll out
Further information can be found in PHE’s weekly Ebola virus disease
epidemiological updates
Ebola virus disease (EVD), Democratic Republic of Congo (link to previous update)
At the end of August 2014 an EVD outbreak was reported in the Equateur Province in the
Democratic Republic of Congo (DRC), their seventh since the disease was discovered
here in 1976. The index case was a pregnant woman from Ikanamongo Village who had
butchered a bush animal in early August. WHO declared the outbreak over on 21
November with a total of 66 cases (38 confirmed and 28 suspected) including 49 deaths
(Maganga et al., NEJM). This and the concurrent outbreak in West Africa were distinct
and independent events. WHO attribute the successful containment of this outbreak to
strong leadership, effective coordination of the government’s response in collaboration
with international partners and the early engagement with traditional, religious and
community leaders.
Avian influenza A(H5N8), worldwide (NEW)
Since November, highly pathogenic avian influenza A H5N8 outbreaks in poultry farms
have been reported from Germany, Italy, Netherlands and the UK. H5N8 has also been
detected in wild bird samples from Japan, Netherlands and in a wild gyrfalcon that was fed
on hunter-killed birds in Washington, US. Within Europe, the introduction of H5N8 and its
subsequent spread are possibly two separate events with different transmission vectors
however investigations of infected poultry holdings have yet to determine the source of the
virus. The current hypothesis is that H5N8 was introduced into poultry holdings indirectly
via humans, vehicles, equipment, fomites, live animals and/or animal-derived products
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contaminated with virus from infected birds [EFSA]. There have been no reported human
cases associated with H5N8, however as a recently emerged virus with limited information
available, the zoonotic potential of H5N8 cannot be ruled out [PHE risk assessment].
Chikungunya virus, Americas outbreak (link to previous update)
Extensive transmission has continued in the Americas with case counts more than
doubling to over a million since the end of July. As of 12 December 2014, 1,021,347
suspected and 20,209 confirmed autochthonous cases have reported from 40 countries
(most from Dominican Republic). A parallel outbreak has also occurred in the Pacific
region where over 20,000 cases have been reported. In the Caribbean, the Asian lineage
is circulating in a naïve human population with high prevalence of Aedes mosquitos, with
establishment of endemicity and further spread likely. Imported cases (in tourists) and
secondary transmission in non-endemic areas (France and the US) have occurred. PHE
reports that 197 cases have been identified in travellers during 2014, of which 162 cases
were associated with travel to the Caribbean and South and Central America.
Cholera outbreak, Haiti (update)
Although cholera has been present in Latin America since 1991, an epidemic had not
been reported in Haiti for at least 100 years. Since October 2010, more than 717,000
cases of cholera have been reported across all departments in Haiti, with disease
spreading across the border to the Dominican Republic (over 31,000 cases). In recent
months, a national increase in incidence has been reported in Haiti, and issues continue
with providing sufficient medical care to affected populations [MSF]. Recent phylogenetic
analysis (Eppinger et al., mBio) has provided further evidence that the outbreak initially
resulted from a single-source accidental introduction from Nepal into Haiti (by UN relief
workers), followed by rapid dissemination.
Seasonal influenza activity, antigenic drift, Northern Hemisphere (NEW)
Preliminary analysis from the US suggests that this year’s influenza season may be
severe than 2013/14. While influenza A(H3N2) continues as the predominant circulating
strain, as of 7 December 67.5% of H3N2 isolates show evidence of antigenic drift resulting
in reduced titres to antisera produced against the influenza A(H3N2) Northern Hemisphere
2014/15 vaccine strain [CDC]. In the UK, an initial increase in influenza activity has been
observed [PHE]. Since mid-October, PHE have characterised 16 influenza A(H3N2)
viruses. Of these, the majority (13) were similar to the 2015/15 vaccine strain, however,
three isolates showed reduced reactivity and were similar to the antigenically drifted virus
circulating in the US. Further characterization of these isolates by genetic analysis is
Dengue fever, new incidents, France and Japan (link to previous update)
The outbreak associated with Yoyogi Park, Tokyo resulted in a total of 160 cases reported
between August and the end of October 2014. This was the first report of locally acquired
cases in Japan since the 1940s. A number of tourists (from England and Australia) also
contracted dengue whilst visiting the affected area, highlighting the potential risk of further
transmission in countries where competent vectors may be present. In such areas, vector
surveillance, preparedness and planning are essential (Schaffner et al. 2014).
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Elsewhere, significant numbers of cases have been reported from Malaysia (where
dengue serotype 1 cases have increased compared to case numbers in 2013), Taiwan
(more than 14,00 cases) and China (43,053 cases).
Two additional autochthonous cases were reported in France in September and October.
Both cases were from the same area (Bouches du Rhône) and had the same serotype but
were not linked to the cases reported in the Var department (link to last report).
Enterovirus D68, North America and Europe (NEW)
US: Since the summer, a nationwide outbreak of EV-D68 associated with severe
respiratory illness has been reported. By December 11, a total of 1,149 people across the
country were confirmed. Some infections were fatal, and further investigations are in
progress to the role of EV-D68 in these deaths. In addition, a total of 94 cases of acute
flaccid myelitis have been reported in children across 33 states, and some of these tested
positive for EV-D68. Further investigation of the syndrome’s aetiology is under way.
Canada: Since the summer, EV-D68 has been causing respiratory illnesses, some
severe, mostly in young children but also young adults. As of November 4, 2014, a total of
214 specimens tested positive.
Other: Sporadic cases of disease, including acute flaccid paralysis, due to EV-D68 have
been reported in other countries including Israel, Finland, France and the UK.
ECDC risk assessment: Although EU/EEA countries have not reported any unusual
increase in numbers of undiagnosed acute respiratory infections, clusters of neurological
disease or an increase in hospital admissions, circulation of this strain seems to be
geographically widespread. It is considered likely that severe cases will occur.
MERS-CoV, worldwide update (link to previous update)
Since April 2012 and as of 17 December 2014, 938 cases (including at least 343 deaths)
of MERS-CoV have been reported to WHO. The incidence of cases in September to
October 2014 was slightly higher than in July to August 2014, a pattern also observed in
2012 and 2013. The majority of MERS-CoV cases are still being reported from the Arabian
Peninsula, specifically from Saudi Arabia, and all cases have epidemiological links to the
outbreak epicentre. Although an imported case was reported in Europe (Austria) during
October, this does not indicate a significant change in the epidemiology of the disease and
the risk of sustained human-to-human transmission in Europe (including the UK) remains
very low.
A recent paper (Al-Gethamy et al) describes long‐term excretion and subclinical infection
with MERS‐CoV in a healthcare worker who had attended a symptomatic patient. The
authors comment that silent infections such as this may lead to the appearance of new
cases without clear chains of transmission or after intervals longer than the incubation
Marburg virus disease, Uganda (NEW)
On 5 October 2014, the Uganda Ministry of Health notified WHO of a confirmed case of
Marburg virus disease in Kampala. The case was a healthcare worker whose disease
onset was on 11 September 2014 while working at Mengo Hospital, Kampala. He
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subsequently presented to hospital in Mpigi district on 23 September with fever,
headache, abdominal pain, vomiting and diarrhoea, and died on 28 September. There was
no history of travel beyond Mpigi, no contact with a person with similar illness, nor contact
with animals or bushmeat. A total of 197 case contacts were followed up for 21 days.
Thirteen of these developed Marburg-like symptoms but all tested negative for the virus.
After 42 days without further cases, the outbreak was declared over on 13 November.
Polio virus, worldwide update (link to previous update)
Polio was declared a public health emergency of international concern (PHEIC) on 5 May
2014. 325 cases have been reported to WHO to date in 2014, compared with 359 for the
same time period in 2013. This year, nine countries have reported cases: Pakistan (276),
Afghanistan (24), Nigeria (6), Equatorial Guinea (5), Somalia (5), Cameroon (5), Iraq (2),
Syria (1), and Ethiopia (1). In November 2014, WHO extended the previously issued set of
Temporary Recommendations that called for the vaccination of all residents in, and longterm visitors to, countries with polio transmission prior to international travel.
Yersinia pestis, Madagascar (NEW)
In Madagascar an outbreak of plague has been taking place since 31 August 2014. As of
12 December 2014, 189 cases and 52 deaths (CFR28%) have been reported. The
majority have been bubonic but there have been occasional pneumonic cases. Plague is
known to be endemic in Madagascar, but the recent occurrence of cases in the capital city
increases the risk of rapid spread of the disease due to the population density in areas
with poor sanitation and a weak healthcare system. ECDC had published a rapid risk
assessment on 5 December 2014 acknowledging the potential risk of spread of
pneumonic plague in a city, but considered that the risk to EU citizens travelling to or
visiting the affected areas was low. WHO has not issued any travel or trade restrictions.
Foodborne organisms outbreaks
Hepatitis A
 in 2013 a large outbreak of hepatitis A was reported across Europe (Denmark, Finland,
France, Germany, Ireland, Norway, the Netherlands, Poland, Sweden, and the UK)
with 313 confirmed cases associated with the consumption of frozen berries. A recent
report [EFSA] of the Europe wide analysis failed to identify a single point source of
contamination for known affected lots of frozen mixed berries but concluded that it
could have occurred at either the primary production stage or during the freezing
process. It is possible that contaminated product related to this outbreak could still be
circulating in the food chain.
 in May 2013 a distinct hepatitis A outbreak was also reported in the US, the first
foodborne hepatitis outbreak for almost ten years. A total of 165 confirmed cases were
reported across ten states with imported frozen pomegranate seeds the implicated
vehicle. Hepatitis A prophylaxis in addition to public notifications and product recall
were used to achieve control (Collier et al., Lancet ID)
Novel agents and rare pathogens
 Batrachochytrium salamandrivorans: Chytridiomycosis has resulted in the serious
decline and extinction of more than 200 species of amphibians worldwide. B.
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salamandrivorans was first recognised as an agent of chytridiomycosis in 2013. Since
then, it has been responsible for the rapid decline of European fire salamanders.
Screening of more than 5000 samples representing about 150 species of amphibians
from four continents determined that B. salamandrivorans is restricted to, but highly
pathogenic for, salamanders and newts (Martel et al., Science). With the vast global
trade of amphibians, B. salamandrivorans has the potential to decimate further the
global biodiversity of these species unless biosecurity measures are strengthened
Halicephalobus gingivalis: In December 2013, two patients in Wales died shortly
after receiving a kidney transplant from the same donor [NHS]. They died as a result of
an exceptionally rare infection caused by the saprophagous nematode species H.
gingivalis, transmitted through the transplanted organs. The organs were received from
an individual who died of encephalitis of an unknown cause. Only five previous cases
of human H. gingivalis infection have been reported in the scientific literature (Papadi
et al., AJTMH) though it is recognised as an infrequent equine pathogen
Mycobacterium lepromatosis: Since 2006 six cases of a distinctive novel
presentation of dermatitis in red squirrels from various locations across Scotland have
been reported. Histological analysis determined the squirrels to be affected by a
diffuse lepromatous leprosy caused by an organism with 99% sequence homology with
M. lepromatosis. While further research is required to characterise this novel disease
in squirrels, this is the first description of leprosy in a squirrel species (Meredith et al.,
Vet Rec)
Mycobacterium marseillense – In 2009 M. marseillense was added as a novel
species to the Mycobacterium avium complex. While previous reports of M.
marseillense infection associated with immunocompromised have been published, a
recent case report from Italy describes a case of pulmonary disease caused by M.
marseillense in an immunocompetent individual. All strains isolated from the patient
were preliminarily identified as Mycobacterium intracellulare; however, a retrospective
molecular analysis corrected the identification to M. marseillense (Grottola et al., EID)
Novel poxvirus: Osadebe et al., CID report two cases of cutaneous infection caused
by a novel poxvirus species in people with equine contact. Both isolates were
genetically similar, suggesting a potential common geographic origin. While zoonotic
transmission was presumed, extensive sampling of in-contact animals and the
environment failed to detect the same virus
O’nyong-nyong virus (ONNV): ONNV is a mosquito-borne RNA virus genetically and
serologically related to chikungunya virus (CHIKV), both which cause a similar clinical
presentation in humans. Unlike CHIKV, ONNV is restricted to the African continent.
Cases outside of East Africa are rarely recorded. In October 2013, an imported case of
ONNV infection was reported in Germany (Tappe et al., EID). This case highlighted
potential difficulties associated with the diagnosis of ONNV, including serological
cross-reactions with other alphaviruses, and the possibility of underdiagnosis of ONNV
in travellers
Psittacine adenovirus HKU1: Investigations into a human psittacosis outbreak in an
animal management centre in Hong Kong revealed the presence of a novel coinfection in sick parrots. These were co-infected with Chlamydophila psittaci and a
novel adenovirus called Psittacine adenovirus HKU1, and the microbial loads of each
were positively correlated. The virus was not detected in any human samples, but the
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authors speculate that it may have caused immunosuppression among infected parrots
resulting in a higher C. psittaci bacterial load in some parrots and thus a greater
chance of zoonotic transmission to humans. (To et al., PLoS NTD)
Raccoon dog and fox amdoparvovirus (RFAV): A novel viral species (Carnivore
amdoparvovirus 3), called RFAV has been isolated from sick racoon dogs and arctic
foxes farmed for their fur in China (Shao et al., EID). The virus showed some antigen
cross-reactivity with Aleutian mink disease virus. This is the first time a natural
amdoparvovirus infection has been reported in racoon dogs and arctic foxes
Red fox fecal rhabdovirus (RFFRV): A novel rhabdovirus, RFFRV, has been
identified by PCR in fecal samples collected from red foxes found dead in Basque
Country, Spain (Bodewes et al., EID). Attempts to culture the virus were unsuccessful.
How the fox acquired the virus and whether it played a role in the animal’s death are
unknown. Further studies are required to elucidate the prevalence, original host, and
pathogenic potential of this novel virus
Spiroplasma turonicum: A recent case report from Spain describes the first systemic
infection caused by Spiroplasma in humans (Aquilion et al., JCM). Spiroplasma is a
helical Mollicute genus normally associated with infections in plants and insects. S.
turonicum, first described in 1998, was isolated from multiple blood cultures from a
patient with hypogammaglobulinaemia. The infection was successfully treated with
doxycycline and levofloxacin. Further research is required to determine whether S.
turonicum is an emerging infection in immunocompromised individuals
Streptococcus dysgalactiae subsp. dysgalactiae (SDSD) – SDSD has until recently
been regarded as an enzootic pathogen, predominantly a causative agent of bovine
mastitis. In recent years SDSD has been acknowledged as an emerging infection in
mammals and aquatic species. Human infections caused by SDSD are rarely reported.
Jordal et al., JCM describe the first known case of SDSD infective endocarditis. The
patient reported no direct contact with animals and a potential source or mode of
transmission was not determined
Toscana virus (TOSV): TOSV is a Phlebovirus transmitted from phlebotomine
sandflies belonging to the subgenus Larroussius. The geographical range of TOSV
encompasses countries bordering the Mediterranean sea where the majority of cases
are reported between July and September. Marlinge et al., EuroSurv report a rare case
of facial paralysis as a result of TOSV infection in France in 2014. Such a presentation
has only been reported twice previously in the scientific literature, however this is the
first incident were the patient remained afebrile for the course of infection. TOSV
should be considered as a possible cause of neurological syndromes in patients living
in or returning from TOSV endemic areas, even in the absence of fever
West Nile virus (WNV): On December 9, Brazil reported the first detection of a human
case of WNV [WHO]. The case became symptomatic in August 2014 and WNV
infection was confirmed in late November. Serological evidence of WNV circulation in
horses and birds in Brazil has been reported previously
Also of interest
 a multicenter outbreak of fatal infections by Saprochaete clavata in France was
associated with a medical device used in platelet concentrate preparation
 brucellosis associated with occupational cattle exposure in Northern Ireland: clinical
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features of 53 cases
ECDC has published their annual epidemiological report on emerging and vectorborne diseases based on 2012 data.
botulism: gene replacement therapy is being investigated as a potential alternative for
botulinum antitoxin
infant botulism due to a Clostridium botulinum producing two toxins, designated type
Af, first report
in November a large Legionellosis outbreak occurred in a suburban area of Lisbon,
Portugal. As of 15 December a total of 375 cases, including 12 deaths, have been
associated with this outbreak linked to a cooling tower in a local factory.
new ECDC guidelines have been published for mosquito surveillance in Europe
quantifying the risk of introduction of West Nile virus into Great Britain by passerine
birds migrating north from France
reservoir host expansion of hantavirus, China. The study demonstrated that Hantaan
virus not only infects its traditional host, the striped mouse, but also infects house
mice and rats; and Seoul virus infects not only rats but also shrews. This suggests
host expansion for both hantaviruses in China, and possible underestimation of the
roles of these animals in zoonotic transmission
results from mosquito surveillance studies in 2013/14 have described the further
geographical distribution of Culex modestus in Kent, and possibly Essex, England.
reviews have been published on the role of mites in the transmission of Hantaan virus
and on the ecological dynamics of emerging bat virus spillover
small number of human cases of avian influenza A(H7N9) have been reported in
China since September. The majority of cases continue to report poultry contact. The
risk of widespread European dissemination following an imported European case is
still considered to be very low.
Streptococcus equi subsp. zooepidemicus: a family cluster of serious infection
associated with pet guinea pigs
the deaths of 15 children following vaccination in northern Syria in September were
most likely caused by the use of an incorrect diluent in preparation of the vaccine
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Published: 19 December 2014
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Summary of notable events/incidents of public health significance