DISPATCHESDr. Hall is a research virologist at the USGS National WildlifeHealth Center. His research interests include emerging viraldiseases of wildlife, virus evolution, and zoonotic diseases.Figure. Genealogy of subtype H5N8 HPAIV, its spread from Chinato other countries, and its evolution in wild birds. Stars representprobable spread of virus and/or reassortment in wild birds;question marks indicate unknown mode. GER, Germany; HPAIV,highly pathogenic avian influenza virus; ITA, Italy; LPAIVs, lowpathogenicity avian influenza viruses; Neth, the Netherlands; UK,United Kingdom; US, United States.were fed infected duck carcasses (7). In North America,other raptor species have been found infected with H5N8or H5N2 virus: Cooper’s hawk (Accipiter cooperii), greathorned owl (Bubo virginianus), red-tailed hawk (Buteo jamaicensis),peregrine falcon (Falco peregrinus), and baldeagle (Haliaeetus leucocephalus). It is not known whateffect these viruses will have on small, at-risk wild birdpopulations, such as California condors (Gymnogyps californianus),that may prey on or scavenge infected birds, butthe possible effects should be considered in conservationmanagement decisions.As HPAIVs continue spreading and evolving, thequestions posed here, along with many more questions,will need to be answered to understand the risks to agriculture,zoologic collections, wildlife, and, potentially,human populations. As other researchers have recentlypointed out, robust, targeted surveillance programs amongwild birds (11) and poultry, modeling of the movementsof HPAIV-infected wild birds, and experimental researchstudies will provide the knowledge required for intelligentpolicy and management decisions regarding agriculture,wildlife, and public health.References1. Jeong J, Kang HM, Lee EK, Song BM, Kwon YK, Kim HR.Highly pathogenic avian influenza virus (H5N8) in domesticpoultry and its relationship with migratory birds in South Koreaduring 2014. Vet Microbiol. 2014;173:249–57. http://dx.doi.org/10.1016/j.vetmic.2014.08.0022. Kang HM, Lee EK, Song BM, Jeong J, Choi JG, Jeong J.Novel reassortant influenza A(H5N8) viruses among domestic andwild ducks, South Korea, 2014. Emerg Infect Dis. 2015;21:298–304. http://dx.doi.org/10.3201/eid2102.1412683. Lee YJ, Kang HM, Kee EK, Song BM, Jeong J, Kwon YK, et al.Novel reassortant influenza A (H5N8) viruses, South Korea, 2014.Emerg Infect Dis. 2014;20:1087–9. http://dx.doi.org/10.3201/eid2006.1402334. Webster RG, Bean WJ, Gorman OT, Chambers TM, Kawaoka Y.Evolution and ecology of influenza A viruses. Microbiol Rev. 1992;56:152–79.5. Verhagen JH, Herfst S, Fouchier RAM. How a virus travels theworld. Science. 2015;347:616–7. http://dx.doi.org/10.1126/science.aaa67246. Center for Infectious Disease Research and Policy (CIDRAP).Avian flu rampages in Taiwan, hits China, India [cited 2015 Mar22]. http://www.cidrap.umn.edu/news-perspective/2015/01/avian-flu-rampages-taiwan-hits-china-india7. Ip HS, Torchetti MK, Crespo R, Kohrs P, DeBruyn P,Mansfield KG, Baszler T, et al. Novel Eurasian highly pathogenicinfluenza A H5 viruses in wild birds, Washington, USA, 2014.Emerg Infect Dis. 2015 May [cited 2015 Mar 22]. http://dx.doi.org/10.3201/eid2105.1420208. Torchetti MK, Killian ML, Dusek RJ, Pedersen JC, Hines N,Bodenstein B, et al. Novel H5 clade 2.3.4.4 reassortant virus(H5N1) from a green-winged teal in Washington, USA. GenomeAnnounc. 2015;3:e00195-15. http://dx.doi.org/10.1128/genomeA.00195-159. Dusek RJ, Hallgrimsson GT, Ip HS, Jónsson JE, Sreevatsan S,Nashold SW, et al. North Atlantic migratory bird flyways provideroutes for intercontinental movement of avian influenza viruses.PLoS ONE. 2014;9:e92075. http://dx.doi.org/10.1371/journal.pone.009207510. Hall JS, Ip HS, Franson JC, Meteyer C, Nashold S, TeSlaa JL,et al. Experimental infection of a North American raptor, Americankestrel (Falco sparverius), with highly pathogenic avian influenzavirus (H5N1). PLoS ONE. 2009;4:e7555. http://dx.doi.org/10.1371/journal.pone.000755511. Machalaba CC, Elwood SE, Forcella S, Smith KM, Hamilton K,Jebara KB, et al. Global avian influenza surveillance in wild birds:a strategy to capture viral diversity [online report]. Emerg InfectDis. 2015 Apr [cited 2015 Mar 22]. http://dx.doi.org/10.3201/eid2104.141415Address for correspondence: Jeffrey S. Hall, USGS National WildlifeHealth Center, 6006 Schroeder Rd, Madison, WI 53711, USA;email: jshall@usgs.gov1252 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 7, July 2015
Cluster of Ebola Virus Disease, Bong andMontserrado Counties, LiberiaTolbert G. Nyenswah, Mosaka Fallah,Geoffrey M. Calvert, Stanley Duwor,E. Dutch Hamilton, Vishwesh Mokashi,Sampson Arzoaquoi, Emmanuel Dweh,Ryan Burbach, Diane Dlouhy, John E. Oeltmann,Patrick K. MoonanLack of trust in government-supported services after thedeath of a health care worker with symptoms of Ebola resultedin ongoing Ebola transmission in 2 Liberia counties.Ebola transmission was facilitated by attempts to avoid cremationof the deceased patient and delays in identifying andmonitoring contacts.Reports of what has become the largest and longest epidemicof Ebola virus disease (EVD) began in March2014 in West Africa (1). To interrupt Ebola transmission,health care authorities must promptly isolate and treat personswith EVD and identify and monitor exposed personsbefore symptoms develop (2). Effective contact tracing canlimit the number of new cases; however, a single missedcontact can result in many new cases (3). Gaps in contacttracing have been reported as challenges for infectiousdiseases such as sexually transmitted infections and tuberculosis(4–6). Because contact tracing requires patients toreveal names of persons with whom they have had contactand whom they may have exposed to illness, public healthofficials must quickly establish trust with sick persons andthose at risk for disease (3,7).We describe a cluster of EVD cases involving transmissionacross 2 jurisdictions in Liberia. Data for this reportwere derived from interviews, case reporting forms,treatment records, and laboratory results. This EVD clusterhighlights the challenges associated with public healthmeasures to interrupt transmission of Ebola.Author affiliations: Ministry of Health and Social Welfare,Monrovia, Liberia (T.G. Nyenswah, M. Fallah, S. Duwor); Centersfor Disease Control and Prevention, Atlanta, Georgia, USA(G.M. Calvert, D. Dlouhy, J.E. Oeltmann, P.K. Moonan); UnitedNations International Children’s Emergency Fund, Monrovia(E.D. Hamilton); United States Navy, Silver Spring, Maryland, USA(V. Mokashi); Ministry of Health and Social Welfare–Bong County,Suokoko, Liberia (S. Arzoaquoi, E. Dweh); International MedicalCorps, Los Angeles, California, USA (R. Burbach)DOI: http://dx.doi.org/10.3201/eid2107.150511The InvestigationOn December 8, 2014, a 78-year-old man (patient 1) fromGbarnga (Bong County), Liberia, was admitted to the BongCounty Ebola Treatment Unit (ETU) where test resultswere positive for Ebola by reverse transcription PCR. Hereported recent travel to Monrovia (Montserrado County),where he cared for his 32-year-old son, a health care workerwho died from an acute illness.On December 9, another son of patient 1 (patient 2, 39years of age), who lived in Monrovia, had fever, headache,and malaise and sought care at hospital A in Bong County.He did not report contact with patient 1, nor did he reportthat he provided care for his sick brother in Monrovia. OnDecember 10, hematemesis developed, and the patient wastransferred to the Bong County ETU and treated for laboratory-confirmedEVD. Contact tracing identified 20 contactsliving in Gbarnga. All contacts were initially symptom freeand were quarantined at a local holding center for 21-daymonitoring. No contacts in Monrovia were reported by patients1 or 2.On December 16, Bong County health officials werenotified that a 15-year-old girl (patient 3) with fever, subconjunctivalhemorrhage, and thrush was at hospital A.She had traveled 4 hours by taxi from Monrovia to be nearher ill grandfather and father (patients 1 and 2) and did notreport exposure to EVD patients or contacts in Monrovia.She was admitted to the ETU, and EVD was confirmed.The next day, 4 additional family members who traveledby taxi from Monrovia were stopped at a roadsidemonitoring station in Gbarnga. All had fever and nonhemorrhagicsymptoms and were transferred by ambulance tothe ETU for evaluation; 2 family members (patients 4 and5) had positive test results for EVD. The 2 family memberswhose results were negative for EVD, along with the taxidriver and a nonfamilial passenger, were transferred to alocal holding center for 21-day monitoring. Contact investigationsfor patients 4 and 5 revealed no new contacts inMonrovia, but the patients reported that they resided in thesame house in Monrovia with patients 2 and 3, who werereceiving treatment in Bong County. Because family memberswith EVD had recently arrived from Monrovia andwere being treated in Bong County, yet sources of infectionand additional contacts were uncertain, Bong Countyrequested that Montserrado County health officials conductan investigation to identify patients and contacts at theMonrovia address so that potential EVD patients could beisolated and monitored.Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 7, July 2015 1253
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