Tag Archives: pandemic

Hong Kong’s Flu Express Wk 2: A Rapid Increase In Institutional Outbreaks

pandemic time again – two weeks until Lunar New Year



We’re seeing a highly variable 2018-2019 Northern Hemisphere flu season, with Canada and South Korea kicking off very early, while Russia – which over the past two decades has seen a shift to earlier flu seasons (see Eurosurveillance: Changes In Timing Of Influenza Epidemics – WHO European Region 1996-2016 –  still remains far below their epidemic threshold (see Russia Influenza Surveillance Week 1, 2019).

Last week Hong Kong announced they had passed their epidemic threshold – and like most of the globe – is reporting mostly H1N1, which typically has a greater impact on younger people than does H3N2.

A good illustration of this demographic impact is the chart (above) showing an impressive 30-fold increase in institutional (mostly school) outbreaks in Hong Kong over the previous reporting week.  This is their biggest, and fastest ramp up in recent memory.

Over the past 3 days Hong Kong’s CHP has announced investigations into numerous influenza outbreaks, including:

CHP investigates case of severe paediatric influenza A infection and outbreaks of influenza A at primary school and kindergartens

Update on cluster of Influenza A cases in Kowloon Hospital

CHP investigates cases of severe paediatric influenza A infection and outbreaks of influenza A and influenza-like illness at kindergartens

CHP investigates influenza A outbreaks at kindergarten-cum-child care centre and primary school 

One week into their flu season and already hospitals are getting slammed,  with yesterday’s average hospital occupancy rate reaching 111%.  With the Chinese New Year’s celebration only about 2 weeks away – where millions of families will gather all over Asia – these numbers could continue to rise.


The headlines in the South China Morning Post (SCMP) this morning – just one week into their flu season – highlight the pressures their healthcare system is already under.

Nurses plan protest as Hong Kong’s public hospitals reach flu season breaking point

Medical staff having to work extra shifts and skip meals to care for influx of flu patients

Bed occupancy rate across Hong Kong’s public hospitals reached average of 111 per cent on Wednesday
PUBLISHED : Thursday, 17 January, 2019, 1:26pm

 Some excerpts from today’s much longer CHP Flu Express follow:

VOLUME 16, NUMBER 02 (PUBLISHED ON Jan 17, 2019)


Flu Express is a weekly report produced by the Respiratory Disease Office of the Centre for Health Protection. It monitors and summarizes the latest local and global influenza activities.s.

Local Situation of Influenza Activity (as of Jan 16, 2019)

  • Reporting period: Jan 6 – 12, 2019 (Week 2)The latest surveillance data showed that the local influenza activity increased markedly last week.
  • Currently the predominating virus is influenza A(H1).
  • Children aged under 6 years were particularly affected as reflected by the very high number of outbreaks of influenza-like illness (ILI) in kindergartens and child care centres, as well as
    influenza-associated admission rate in public hospitals among children aged below six years.
  • Among the severe influenza cases in adults, persons 50-64 years constituted a relative higher proportion (36%), as compared with 15% and 20% during the 2017 summer season predominated by influenza A(H3) and the 2017/18 winter season predominated by influenza B respectively.
  • Influenza can cause serious illnesses in high-risk individuals and even healthy persons. Given that seasonal influenza vaccines are safe and effective, all persons aged 6 months or above except those with known contraindications are recommended to receive influenza vaccine to protect themselves against seasonal influenza and its complications, as well as related hospitalisations and deaths.


Global Situation of Influenza Activity In the temperate zone of the northern hemisphere influenza activity continued to increase slowly. In East Asia, influenza season appeared to have started, with predominantly influenza A(H1N1)pdm09 detected. In Europe, influenza activity increased, with both A viruses circulating. In the temperate  zones of the southern hemisphere, influenza activity returned to inter-seasonal levels with exception of some parts in Australia. Worldwide, seasonal influenza A viruses accounted for the majority of detections.

  • In the United States (week ending Jan 5, 2019), influenza activity remained elevated. The proportion of outpatient visits for ILI decreased from 4.0% to 3.5%, but remained above the national baseline of 2.2%. The percent of respiratory specimens testing positive for influenza decreased to 12.72% from 16.58% recorded in the previous week. Influenza A(H1N1)pdm09, influenza A(H3N2), and influenza B viruses continued to co-circulate.

  • In Canada (week ending Jan 5, 2019), influenza activity remained high. The influenza season started in late October which was earlier than in recent years. Laboratory detections for influenza declined from the previous week, suggesting that nationally the influenza season may have reached peak levels in the last week of December. Influenza A was the most common influenza virus, and the majority of these viruses were A(H1N1)pdm09.

  • In the United Kingdom (week ending Jan 6, 2019), there was evidence that influenza was now circulating in the community as activity indicators breached baseline threshold levels at low intensity. The positivity of influenza detection was 16.4%, which was above the baseline threshold of 9.2%.

  • In Europe (week ending Jan 6, 2019), influenza activity continued to increase. 44.6% of sentinel specimens were tested positive for influenza virus. The majority of influenza virus detections were type A. Both influenza A(H3N2) and A(H1N1)pdm09 viruses were detected.

  • In Mainland China (week ending Jan 6, 2019), influenza activity in southern and northern provinces continued to increase, reaching the peak of the influenza season currently. Influenza viruses detected were mainly influenza A(H1N1), followed by influenza A(H3N2), and there were few influenza B(Victoria) and B(Yamagata) detections.

  • In Taiwan (week ending Jan 12, 2018), influenza activity increased significantly and was above the national baseline. Influenza A(H1N1) (43.1%) and A(H3N2) (29.4%) viruses co-circulated in the community in recent four weeks.

  • In Macau (Jan 16, 2019), influenza activity remained at the peak level. The proportions of ILI cases in emergency departments among both adults and children remained at a high level, and were on an
    increasing trend. The proportion of influenza detections reached 42% in the first two weeks of 2019. Influenza viruses detected were influenza A(H1) (75%) and influenza A(H3) (25%).

  • In Japan (week ending Jan 6, 2019), influenza activity continued to increase and the influenza season started in early December. The average number of reported ILI cases per sentinel site increased to 16.30 in the week ending Jan 6, 2019, which was above the baseline level of 1.00. The predominating virus in the past four weeks was influenza A(H1N1)pdm09

(Continue . . . )

During the run up to last year’s Chinese New Year’s Holiday – during an unusually severe influenza B season – Hong Closed Schools & Called For Stringent NPIs To Combat Flu. According to an EID analysis published last November, the decision was made after the peak of the outbreak, and only had modest effect.

Mitigation of Influenza B Epidemic with School Closures, Hong Kong, 2018


In winter 2018, schools in Hong Kong were closed 1 week before the scheduled Chinese New Year holiday to mitigate an influenza B virus epidemic. The intervention occurred after the epidemic peak and reduced overall incidence by ≈ 4.2%. School-based vaccination programs should be implemented to more effectively reduce influenza illnesses.

Although school closures can be disruptive – particularly to working families –  previous studies have shown a more profound effect can be achieved when the trigger is pulled earlier.

As no two flu seasons are ever alike, a one size-fits-all solution isn’t guaranteed to work.  It will be interesting to see what Hong Kong decides to do this year, based on the conflicting results from past school closures.

Argentina’s Growing Hantavirus Outbreak

Credit Wikipedia
Hantaviruses – which are carried by rodents in many parts of the world – are contracted by humans primarily through the inhalation or ingestion of aerosolized rodent feces, urine, saliva.
Once infected, however, humans are sometimes able to transmit the virus to those they are in close contact with. 
Scientists have identified dozens of viruses within the genus Hantavirus (named after the Hantaan River of Korea), with mortality that varies from 1%-2% for some varieties (i.e. Seoul Virus, Puumala Virus) to more than 30% for the North American Sin Nombre and South American Andes Virus.

In humans, there are two severe (sometimes fatal) diseases caused by Hantavirus: Hemorrhagic Fever with Renal Syndrome (HFRS) and Hantavirus Pulmonary Syndrome (HPS). 

HFRS is found in Europe, Asia, and Africa, while HPS is found in the Americas (North, Central and South).  
While relatively rare, every year the U.S. reports between 10 and 50 Hantavirus Pulmonary Syndrome (HPS) cases, of which, roughly 35% prove fatal. Cases have been reported in 35 states (see map below), with 96% of all cases reported west of the Mississippi River.


For the past few days there have been reports of an unusually large outbreak of Hantavirus in the small village of Epuyén in the Patagonian province of Chubut.  The local provincial government’s website (Gobierno del Chubat) front page prominently displays the following warning:



Argentina’s Ministry of Health website shows their last update on January 11th, where they talk in general terms about their response and identify the virus as the Southern Andes strain.  

They state the National Administration of Laboratories and Health Institutes (ANLIS) has `. . .  also initiated studies of viral genome sequencing entire human genome and to identify whether there are mutations that increase the transmissibility and lethality‘.

Health continues to work with Chubut coordinated by the outbreak of hantavirus in Epuyén
In order to study and contain the outbreak, authorities and technical teams from both jurisdictions held meetings to assess the evolving outbreak affecting the Patagonian locality.

Published on Friday January 11, 2019

Meanwhile, media reports indicate there are now 28 cases and 10 deaths, including reports of a 29 year-old nurse who died in neighboring Santiago, Chile.

This (translated) report from LaRepublica.pe:

Hantavirus travels to Argentina and arrives in Chile: nurse dies in Santiago

The 29-year-old woman died in Santiago de Chile and joins the nine fatalities of the Hantavirus outbreak that originated in Argentina.

The Republic

13 Jan 2019 | 9:21 pm

The Hantavirus caused the death of a person in Chile. A 29-year-old nurse had contact with a person from Epuyén, the town where the outbreak of the viral disease began, and died at a health center in her country. In addition, there are two more cases of contagion.

The woman, identified by Chilean media such as Patricia Martínez, was an officer of the Hospital de Palena, an area where there were conflicts bordering Argentina and Chile. She is the first victim of the Chilean Los Lagos region. He died of a cardiopulmonary picture caused by the Hantavirus in Santiago.

According to the authorities of Los Lagos, his death is related to infections in Epuyen, Argentina. The woman would be the tenth mortal victim of the Hantavirus. The Government of Chile would have imposed the sanitary barrier.

“We were informed of the death of the patient from Palena, as a result of her case of cardiopulmonary syndrome due to hantavirus,” said José Antonio Vergara, the Epidemiology physician at the Los Lagos health center, according to Clarín. It was linked to the outbreak that originated in the town of Epuyen, in the province of Chubut, “he said.

(Continue . . . )

A summary of the outbreak was published yesterday by Navva.org.

The first people affected by the virus were people who attended a birthday party on 24 November in an event hall, reported the mayor of Epuyen, Antonio Reato.

A field spy from the area was the first to be infected after cleaning a shed where he would have been in contact with an infected mouse. Later the man attended the celebration in which he infected his wife and other assistants.

The outbreak is motivated safety precautions in the Patagonian city that has already been proclaimed quarantine. Meetings are forbidden and even to view the deceased.

A court decision ordered the insulation for 30 days to 85 residents who had contact with neighbors tested positive for Hantavirus or suspected of having it. Isolated people are not allowed to leave their homes and receive visitors.

Complicating matters is the potentially long incubation period for the virus.  A 2006 EID Journal Dispatch (below) suggests – that with new cases still being identified  – it could be some time before this outbreak can be resolved.

Volume 12, Number 8—August 2006

Incubation Period of Hantavirus Cardiopulmonary Syndrome

Pablo Vial*email.gif , Francisca Valdivieso*, Gregory Mertz†, Constanza Castillo‡, Edith Belmar*, Iris Delgado*, Mauricio Tapia§, and Marcela Ferrés¶


The potential incubation period from exposure to onset of symptoms was 7–39 days (median 18 days) in 20 patients with a defined period of exposure to Andes virus in a high-risk area. This period was 14–32 days (median 18 days) in 11 patients with exposure for < 48 hours.

Given its unusual size and duration, we’ll be keeping an eye on this outbreak in the days and weeks ahead.

CDC Candida Auris Update – December

Credit CDC


In June of 2016 the CDC issued a Clinical Alert to U.S. Health care facilities about the Global Emergence of Invasive Infections Caused by the Multidrug-Resistant Yeast Candida auris.

C. auris is an emerging fungal pathogen that was first isolated in Japan in 2009. It was initially found in the discharge from a patient’s external ear (hence the name `auris’).  Retrospective analysis has traced this fungal infection back over 20 years.

Since then the CDC and public health entities have been monitoring an increasing number of cases (and hospital clusters) in the United States and abroad, generally involving bloodstream infections, wound infections or otitis.

Adding to the concern:

  1. C. auris infections have a high fatality rate
  2. The strain appears to be resistant to multiple classes of anti-fungals  
  3. This strain is unusually persistent on fomites in healthcare environments.
  4. And it can be difficult for labs to differentiate it from other Candida strains

The CDC has published their November update on their  C. Auris surveillance page, where they show – as of November 30st  – 493 confirmed cases and 30  probable cases, across 12 states.

New York, New Jersey, and Illinois continue to lead the pack, making up 95% (n=472) of the 493 confirmed cases. Additionally, 899 patients have been found to be colonized with C. auris by targeted screening conducted in six states with clinical cases. 

Tracking Candida auris

December 21, 2018: Case Count Updated as of November 30, 2018

Candida auris is an emerging fungus that presents a serious global health threat. C. auris causes severe illness in hospitalized patients in several countries, including the United States. Patients can remain colonized with C. auris for a long time and C. auris can persist on surfaces in healthcare environments. This can result in spread of C. auris between patients in healthcare facilities.

Most C. auris cases in the United States have been detected in the New York City area, New Jersey, and the Chicago area. Strains of C. auris in the United States have been linked to other parts of the world. U.S. C. auris cases are a result of inadvertent introduction into the United States from a patient who recently received healthcare in a country where C. auris has been reported or a result of local spread after such an introduction.

Candida auris was made nationally notifiable at the 2018 Council for State and Territorial Epidemiologists (CSTE) Annual Conference. For the updated case definition and information on the nationally notifiable condition status, which will go into effect in 2019, please see the 2018 CSTE position statement[PDF – 16 pages].



As depicted the the following CDC map, C. auris is very much a global problem, although limited surveillance prevents us from knowing just how widespread this fungal infection really is.


For more information visit the CDC’s Information for Laboratorians and Health Professionals page, including:


Information for Laboratorians and Infection Preventionists

Patient Education