It is official now that Outbreak of 2019-nCoV constitutes is a Public Health Emergency of International concern

It is official now that Outbreak of 2019-nCoV constitutes is a Public Health Emergency of International concern

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV)

30 January 2020 

Representatives of the Ministry of Health of the People’s Republic of China reported on the current situation and the public health measures being taken. There are now 7711 confirmed and 12167 suspected cases throughout the country. Of the confirmed cases, 1370 are severe and 170 people have died. 124 people have recovered and been discharged from hospital. 

 The WHO Secretariat provided an overview of the situation in other countries. There are now 83 cases in 18 countries. Of these, only 7 had no history of travel in China. There has been human-to-human transmission in 3 countries outside China. One of these cases is severe and there have been no deaths. 

 The Committee believes that it is still possible to interrupt virus spread, provided that countries put in place strong measures to detect disease early, isolate and treat cases, trace contacts, and promote social distancing measures commensurate with the risk.

 The Director-General declared that the outbreak of 2019-nCoV constitutes a PHEIC and accepted the Committee’s advice and issued this advice as Temporary Recommendations under the IHR. 

Role of CMAAO and other countries

It is expected that further international exportation of cases may appear in any country.

All countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of 2019-nCoVinfection, and to share full data with WHO. 

 Countries are reminded that they are legally required to share information with WHO under the IHR. 

 Any detection of 2019-nCoV in an animal (including information about the species, diagnostic tests, and relevant epidemiological information) should be reported to the World Organization for Animal Health (OIE) as an emerging disease.

 Countries should place particular emphasis on reducing human infection, prevention of secondary transmission and international spread, and contributing to the international response though multi-sectoral communication and collaboration and active participation in increasing knowledge on the virus and the disease, as well as advancing research.  

 The Committee does not recommend any travel or trade restriction based on the current information available.  

 Countries must inform WHO about any travel measures taken, as required by the IHR. Countries are cautioned against actions that promote stigma or discrimination, in line with the principles of Article 3 of the IHR. 

 The Committee asked the Director-General to provide further advice on these matters and, if necessary, to make new case-by-case recommendations, in view of this rapidly evolving situation. 

Diagnostic testing of concurrent suspected dengue or Zika in symptomatic patients

Dr KK Aggarwal

The United States Centers for Disease Control and Prevention (CDC) has issued updated guidance for diagnostic evaluation of Zika and dengue virus infection in symptomatic patients. According to the guideline, nucleic acid amplification tests (NAATs) are the preferred method of diagnosis for patients with suspected dengue or Zika virus disease. 

The key recommendations are:

·         For symptomatic nonpregnant persons, dengue and Zika virus NAATs should be done on serum collected ≤7 days after symptom onset. A positive NAAT in symptomatic persons with possible exposure to dengue and Zika virus typically provides evidence of acute infection, and no antibody testing is indicated.

·         If NAAT is negative or serum is collected >7 days after symptom onset, dengue and Zika virus IgM antibody tests should be done.

·         Positive IgM antibody test results with negative NAAT results should be confirmed by neutralizing antibody tests when clinically or epidemiologically indicated, including for all pregnant women.

·         Pregnant women with a clinically compatible illness and recent possible exposure to dengue and Zika virus should have concurrent diagnostic testing for dengue and Zika virus infection performed by NAAT and IgM antibody testing on a serum specimen and NAAT on a urine specimen to diagnose Zika virus infection 

·         If either dengue or Zika virus IgM antibody testing is positive without a positive NAAT or NS1 antigen test, and definitive diagnosis is needed for clinical or epidemiologic purposes, confirmatory Plaque reduction neutralization tests (PRNTs) should be performed against dengue, Zika, and other flaviviruses endemic to the region where exposure occurred.

(Source: MMWR Recomm Rep. 2019 Jun 14; 68(1): 1–10).

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Prior dengue infection protects children against Zika

Children who have previously been exposed to dengue virus appear to be protected from getting sick when infected with Zika virus, according to a study published Jan. 22, 2019 in PLoS Medicine by Aubree Gordon of the University of Michigan and Eva Harris of the University of California, Berkeley.

Prior and recent dengue virus infection was found to be associated with protection from symptomatic Zika virus infection. Children with prior dengue infection had 38% less risk of showing symptoms when infected with Zika than those who were dengue-free. Zika symptoms include fever, rash, conjunctivitis, muscle, joint pain and headache.

These findings support the hypothesis that prior dengue virus immunity might cross-protect against symptomatic Zika. The two already share many similarities: They belong to the same Flavivirusgenus. Both viruses are transmitted by the Aedes aegypti mosquito, which preys on the same populations.

In a patient with previous dengue infection, the second dengue infection may be more severe via antibody-dependent enhancement. But if the second attack occurs within six months of each other it may get nullified. 

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Zika & the oncoming marriage season

Dr KK Aggarwal

A total of 22 positive laboratory confirmed cases of Zika virus infection have been detected so far in Jaipur, Rajasthan. And, this number will only rise. On Sunday, the Health Ministry sounded an alert for Bihar after a student of computer science from Siwan, studying in Jaipur, tested positive for the Zika virus. He was in Siwan between August 28 and September 12 to appear for an exam.

Zika virus is gaining foothold in India and is now here to stay. Public awareness about Zika is low and diagnostic facilities are not available everywhere.

In August 2018, the Centers for Disease Control and Prevention (CDC) released updated guidelines for preconception counseling and prevention of sexual transmission of Zika virus for men with possible Zika virus exposure.

CDC now recommends that men with possible Zika virus exposure who are planning to conceive with their partner wait at least 3 months after symptom onset (if symptomatic) or their last possible Zika virus exposure (if asymptomatic) before engaging in unprotected sex to prevent sexual transmission of Zika virus and also to reduce the risk for fetal Zika virus infection.

Relevant exposure is defined as residence in or travel to an area where mosquito-borne transmission of Zika virus infection has been reported, or unprotected sexual contact with a person who meets these criteria.

For couples who are not trying to conceive, CDC recommends that men can consider using condoms or abstaining from sex for at least 3 months after symptom onset (if symptomatic) or their last possible Zika virus exposure (if asymptomatic) to minimize their risk for sexual transmission of Zika virus.

Winter season is on the horizon and so is the marriage season. In India, the marriage season will commence from the end of Chaturmas in November.

All newly-weds should avoid starting a family if one of them has or is recovering from dengue-like illness. Rule out Zika virus infection first.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

 

Eight Zika-positive cases in Jaipur: It seems that Zika is now here to stay

Eight people in Jaipur have tested positive for the Zika virus. Of these, three are pregnant women, reports TOI. The first case was reported in the end of September. The health department has directed compulsory tests on pregnant women with fever in the Shastri Nagar area. There are 318 would-be mothers in the locality. Over 20 samples were sent to National Institute of Virology, Pune, and results of the remaining samples are awaited.

Last year in May, the WHO confirmed the first three cases of laboratory-confirmed Zika virus infection in India from Ahmedabad in Gujarat. The cases then detected were a 34-year-old female patient admitted to hospital with complaints of fever following delivery of a healthy baby, who had no travel history to any Zika affected country. The other two cases include a 22-year-old pregnant woman in her 37th week of pregnancy and a 64-year-old male with 8 days history of fever.

Eight people have reportedly tested positive for Zika virus. It seems that Zika is now here to stay in India.

Dengue and Chikungunya are already endemic in the country. Like Dengue and Chikungunya, Zika is a viral infection and also shares a common vector with them, the Aedes mosquitoes.

Here is an update of Zika virus disease.

·         Zika is caused by the Zika virus transmitted by Aedes mosquitoes. This is the same mosquito that transmits dengue, Chikungunya and yellow fever.

·         Zika virus derives its name from the Zika forest in Uganda, where it was first identified in 1947 in monkeys. It was then identified in humans in 1952. The first recorded outbreak of Zika virus disease was reported from the Island of Yap (Federated States of Micronesia) in 2007. This was followed by a large outbreak of Zika virus infection in French Polynesia in 2013 and other countries and territories in the Pacific.

·         In March 2015, Brazil reported a large outbreak of rash illness, soon identified as Zika virus infection, and in July 2015, found to be associated with Guillain-Barré syndrome.In October 2015, Brazil reported an association between Zika virus infection and microcephaly. Zika virus disease was declared as a Public Health Emergency of International Concern (PHEIC) by the WHO in February 2016, which was declared as ended in November 2016.

·         A pregnant woman can pass Zika virus to her fetus. Infection during pregnancy can cause serious birth defects such as microcephaly and other congenital malformations, known as congenital Zika syndrome. Other complications include preterm birth and miscarriage. Pregnancy loss due to asymptomatic Zika virus infection may be a common but under-recognized adverse outcome related to maternal Zika virus infection (Nat Med. 2018 Aug;24(8):1104-1107.

·         Zika virus infection is also a trigger of Guillain-Barré syndrome, neuropathy and myelitis, particularly in adults and older children.

·         The incubation period is 3 to 14 days.

·         Most people are asymptomatic or have mild symptoms such as fever, rash, conjunctivitis, muscle and joint pain, malaise or headache. Symptoms generally last for 2–7 days.

·         Dengue or Chikungunya-like symptoms of fever with a rash or joint pain, with red eyes, should not be ignored. Such cases could be Zika. Eliciting a travel history in such patients is very important.

·         At present, there is no vaccine or specific drug available to prevent or to treat Zika infection. Patients should be advised to take paracetamol to relieve fever and pain, plenty of rest and plenty of liquids. Avoid aspirin, products containing aspirin, or other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.

·         Use of measures to protect against mosquito bites is very important to prevent Zika infection such as using insect repellent, covering as much of the body as possible with long, light-colored clothing, eliminating places where mosquitoes can breed and putting screens on windows and doors.

·         People traveling to high risk areas should take protections from mosquito bites. Pregnant women should avoid traveling to high risk areas.

These new cases tell us that all this time, the Zika virus has been circulating in the community and suggest low level transmission of Zika virus and the likelihood of more cases occurring in the near future. This should be of great concern to all, especially the public health authorities given India’s huge population, climate that is favourable to vector-borne diseases and India being a hotspot on the tourist map.

It has been suggested that the Zika virus in India “is distinct from the both African as well as pathogenic Asian strains; thus, it does not replicate profusely as the African and Asian prototype strains are known to do, and this is also the reason that there is low susceptibility in mosquitoes and they do not pick up and transmit the infection easily” (Indian J Med Res. 2017;146:572-5). But, if this Zika strain mutates to more efficiently infect mosquitoes, it could become a major public health problem in the future similar to Chikungunya virus, which re-emerged in India after decades of remaining dormant.

While enhanced surveillance, community-based including at international airports and ports, to track cases of acute febrile illness is the need of the hour, creating public awareness about the disease including preventive measures should be the focus. At the same time, the public should be assured that there is no need to panic.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA