Monday, September 18, 2017

Maria: Getting Stronger And Aimed At Puerto Rico


With Hurricane Maria today becoming the 4th major hurricane of the 2017 Atlantic season, one is tempted to ask if this sort of thing has happened before.  Unfortunately, the answer is yes.  1961 saw no fewer than 7 CAT 3+ storms, as did 2005. 
And before you ask, 1950 and 1933 both saw 6 major storms.  That we know of, as this was before age of weather satellites.
Meaning that as tired as we already are of this unrelenting hurricane season, with 9 weeks left to go, this year's threat is far from over. Currently in the cross hairs are the already hard hit northern Leeward Islands, the British and U.S. Virgin Islands, followed by Puerto Rico.

The eastern Bahamas are also in the path of this strengthening storm, which is expected to become a CAT 4 in the next 12 to 24 hours.
Although current models appear to keep the storm off the eastern seaboard of the United States, it is far too early to completely write off the threat to the mainland.
So, if you haven’t already downloaded the updated Tropical Cyclone Preparedness Guide, and visited NOAA's Weather-Ready Nation Hurricane Preparedness Week 2017 web page, now would be an excellent time to do so.

When it comes to getting the latest information on hurricanes, your first stop should always be the National Hurricane Center in Miami, Florida. These are the real experts, and the only ones you should rely on to track and forecast the storm.
If you are on Twitter, you should also follow @FEMA, @NHC_Atlantic, @NHC_Pacific and @ReadyGov.

This from the 11am Advisory from the National Hurricane Center.

Hurricane Maria Discussion Number   9
NWS National Hurricane Center Miami FL       AL152017
1100 AM AST Mon Sep 18 2017

Reports from an Air Force Reserve Hurricane Hunter aircraft indicate that Maria is undergoing rapid intensification.  The aircraft reported 700-mb flight-level winds of 115 kt in the northeastern eyewall, along with reliable-looking surface wind estimates from the Stepped Frequency Microwave radiometer as high as 104 kt.  In addition, the estimated central pressure inside the 10 n mi wide eye has fallen to 959 mb.  The initial intensity is increased to 100 kt, making Maria a major category 3 hurricane on the Saffir-Simpson Hurricane Wind Scale.  The small eye is also apparent in radar data from Martinique.

The initial motion is 285/9, a little to the left of the previous motion.  Other than that, there is little change in either the forecast philosophy or the forecast track.  A high pressure area to the north of Maria should maintain a general west-northwestward motion for the next three days or so.  After that, the high weakens, which should allow the hurricane to turn gradually northwestward and north-northwestward.  The new forecast track is changed little from the previous one, and it calls for Maria to move through the Leeward Islands in 12-24 h, approach the Virgin Islands in about 36 h, then cross Puerto Rico between 48-72 h.  The new track lies to the left of the center of the guidance envelope in best agreement with the ECMWF.

Atmospheric and oceanic conditions appear favorable for additional rapid strengthening for the next 24 h and possibly longer. This is reflected in the intensity forecast, which now calls for Maria to become a category 4 hurricane in 12 h and reach a possibly conservative peak intensity of 130 kt in about 36 h.
From 72-120 h, land interaction and less favorable upper-level winds are expected to cause some weakening.  On top of these general trends, there is also the possibility that eyewall replacement cycles could occur that would affect the intensity.  However, Maria is likely to maintain category 3 to 4 intensity through the forecast period.


1. Maria will affect portions of the Leeward Islands and the British and U.S. Virgin Islands as an extremely dangerous major hurricane during the next couple of days, and hurricane warnings are in effect for many of these islands.

2. Maria is likely to affect Puerto Rico as an extremely dangerous major hurricane, and a hurricane watch is in effect for that island. A hurricane warning will likely be issued later today.

3. The potential for a life-threatening storm surge, accompanied by large and destructive waves, has increased for the Leeward Islands, the Virgin Islands, and Puerto Rico.

4. Life-threatening flash floods and mudslides from heavy rainfall are expected across the Leeward Islands, including Puerto Rico and the U.S. and British Virgin Islands.


INIT  18/1500Z 14.7N  60.1W  105 KT 120 MPH
 12H  19/0000Z 15.1N  61.2W  115 KT 130 MPH
 24H  19/1200Z 15.9N  62.6W  125 KT 145 MPH
 36H  20/0000Z 16.8N  64.1W  130 KT 150 MPH
 48H  20/1200Z 17.6N  65.5W  130 KT 150 MPH
 72H  21/1200Z 19.5N  68.5W  125 KT 145 MPH
 96H  22/1200Z 21.5N  71.0W  120 KT 140 MPH
120H  23/1200Z 24.0N  72.5W  110 KT 125 MPH

Forecaster Beven

#NatlPrep: When Its Time To Get Out Of Dodge

Note: This is day 18 of National Preparedness Month . Follow this year’s campaign on Twitter by searching for the #NatlPrep hash tag.
This month, as part of NPM17, I’ll be rerunning some edited and updated older preparedness essays, along with some new ones. 


Although I've had a couple of close calls over the years, last week's brush with Hurricane Irma was the first time I've actually been forced to leave my home in the face of a natural disaster.  I wrote about my decision 10 days ago in #NatlPrep: Disaster Buddies - The Most Important Prep Of All.
It is not a pleasant thought, but sometimes circumstances and common sense dictate that you must leave your home - and the bulk of your belongings  - behind.
Luckily, I had several prearranged places I can go. Friends, who are also disaster buddies (see In An Emergency, Who Has Your Back?), who know my couch is always available to them should they need it.

Being able to leave in a hurry when an evacuation has been ordered means having a plan, a destination, and an emergency `to go’ kit or `BOB’ already equipped, and standing by. 
In the vernacular, a `bug-out bag'  or `BOB’  (or sometimes GOOD bag for `Get Out Of Dodge’) a bag of emergency supplies, ideally kept at the ready, that one can grab on the way out the door during an emergency.
Every hurricane season I go through my personal bug out bag, and replace flashlight and radio batteries from last year, and swap out older emergency rations for newer ones.
A BOB isn't supposed to be a survival kit, but rather, is supposed to provide the essentials one might need during the first 72 hours of a forced, and sometimes unexpected, evacuation. 
It should contain food, water, any essential prescription medicines, copies of important papers (ID's, insurance, important Phone #s), a first aid kit, portable radio, flashlight, extra batteries, and ideally blankets and extra clothes. 
While having to evacuate your home may seem like an unlikely event, every years hundreds of thousands of Americans are forced to do so.  Rivers spill their banks, dams break, brush fires rage out of control, even sudden industrial accidents can force evacuations. 
And unlike with a hurricane, you won’t always have advance warning. has the following advice on how to prepare for an evacuation, after which I'll have some notes on what I would do differently next time.

 Evacuating Yourself and Your Family

There may be conditions under which you will decide to get away or there may be situations when you are ordered to leave. Follow these guidelines for evacuation:
  • Plan places where your family will meet, both within and outside of your immediate neighborhood. Use the Family Emergency Plan to decide these locations before a disaster.
  • If you have a car, keep a full tank of gas in it if an evacuation seems likely. Keep a half tank of gas in it at all times in case of an unexpected need to evacuate. Gas stations may be closed during emergencies and unable to pump gas during power outages. Plan to take one car per family to reduce congestion and delay.
  • Become familiar with alternate routes and other means of transportation out of your area. Choose several destinations in different directions so you have options in an emergency.
  • Leave early enough to avoid being trapped by severe weather.
  • Follow recommended evacuation routes. Do not take shortcuts; they may be blocked.
  • Be alert for road hazards such as washed-out roads or bridges and downed power lines. Do not drive into flooded areas.
  • If you do not have a car, plan how you will leave if you have to. Make arrangements with family, friends or your local government.
  • Take your emergency supply kit unless you have reason to believe it has been contaminated.
  • Listen to a battery-powered radio and follow local evacuation instructions.
  • Take your pets with you, but understand that only service animals may be permitted in public shelters. Plan how you will care for your pets in an emergency.

While I keep the requisite `bug out bag' (several duffels, in fact), something I hadn't given enough thought to is what would I take if I had 24 hours warning.  It's one thing to flee a burning house with your BOB and your life, it's another thing to have a full day to triage your preps and your life's belongings. 
Ninety-five percent of what I took were emergency supplies, since even where I was going was forecast to be hard hit. But I had to leave a lot behind, partially because I had no good way to pack and tote the stuff.
High on my list of things to get before the `next time' are more duffel bags.  In fact, I'm headed out this morning to hit the thrift stores to buy up what I can find.  And most of my emergency supplies are going to be kept pre-packed, and stored in these bags. 
I'll tag (or color code) these bags as `Essential', `Nice to Have', or `Optional'.  And load my car accordingly. 
I managed to pack one of my 40 watt solar panels, a spare 12 volt (tractor) battery, and my homebrew USB charging station, but it was bulky, heavy, and a bit overkill. Instead, I'm going order a folding solar panel with a USB battery bank for bug-out purposes.
Despite being well prepared to shelter in place, I found I was less organized than I needed to be to evacuate the bulk of my preps.  And that added both work and stress my evacuation.
Luckily, I now have a second chance to remedy that.

CDC: Flu Vaccination & Possible Safety Signal

Credit CDC


While I was mostly offline last week due to a brush with Hurricane Irma, a study in the Journal Vaccine reported on a possible link between receiving repeated doses of the seasonal flu vaccine and a higher rate of miscarriage.
CIDRAP has covered this report in detail (see Study signals association between flu vaccine, miscarriage), as have a number of news organizations. 
At this point, this study is an outlier, as there are numerous other studies that have not uncovered this signal.  While this study falls far from proving a causal relationship between receipt of the flu vaccine and an increased chance of miscarriage, it does warrant additional investigation.

Since nearly every anti-vax conspiracy theory has the CDC covering up the health risks of the flu vaccine, it is worth nothing this study was funded by the CDC, and last week they posted the following summary on the CDC website.

Flu Vaccination & Possible Safety Signal

Information & Guidance for Health Care Providers


Health care providers of pregnant women play a vital role in advising patients on how to protect themselves and their developing babies against many threats, including influenza (flu). This fact sheet contains information about influenza and influenza vaccination during pregnancy and provides guidance on how to address concerns that patients may have about influenza vaccination.
Flu can be dangerous to pregnant women and their developing babies. A number of studies have shown that flu vaccination can protect pregnant women and their babies from flu. Because pregnant women are at high risk of serious flu complications, they are recommended for influenza vaccination during any trimester of their pregnancy. Millions of flu vaccines have been given for decades, including to pregnant women, with a good safety record. While there is a lot of evidence that flu vaccines can be given safely during pregnancy; these data are limited for the first trimester.
A Potential Safety Signal Associated with Flu Vaccination of Pregnant Women
A CDC-funded study found that women vaccinated early in pregnancy with a flu vaccine containing the pandemic H1N1 (H1N1pdm09) component and who also had been vaccinated the prior season with a  H1N1pdm09-containing flu vaccine had an increased risk of spontaneous abortion (miscarriage) in the 28 days after vaccination. While most miscarriages occurred in the first trimester, several occurred during the second trimester. The median gestational age at the time of miscarriage was 7 weeks. This study does not quantify the risk of miscarriage and does not prove that flu vaccine was the cause of the miscarriage. Earlier studies have not found a link between flu vaccination and miscarriage. There is an ongoing investigation to study this issue further among women who were pregnant and eligible to receive flu vaccine during the 2012-13 through 2014-15 flu seasons. Results are anticipated in late 2018 or 2019.
CDC Recommendation
CDC and its Advisory Committee on Immunization Practices (ACIP) are aware of these data, which were first presented to ACIP at a public meeting in June 2015. At this time, CDC and ACIP have not changed the recommendation for influenza vaccination of pregnant women. It is recommended that pregnant women get a flu vaccine during any trimester of their pregnancy because flu poses a danger to pregnant women and a flu vaccine can prevent influenza in pregnant women.
CDC Guidance
As always, health care decisions should be part of an ongoing discussion between provider and patient. CDC recommends that any pregnant woman who has questions about vaccines talk to her health care provider. Providers should use their clinical judgement based on various factors including their patient’s health status, local influenza activity, and the benefits versus the potential risks from flu vaccination when deciding whether and/or when to immunize their patient against influenza.
Study Details
Article title: Association of Spontaneous Abortion with Receipt of Inactivated Influenza Vaccine Containing H1N1pdm09 in 2010-11 and 2011-12.
  • This was a “case-control” study: women who had a miscarriage were compared with a control group of pregnant women who did not.
  • Researchers compared 485 women aged 18-44 who miscarried (cases) to 485 pregnant women aged 18-44 who did not miscarry (controls) to determine if the women who had miscarriages were more or less likely to have received the 2010-11 or 2011-12 flu vaccine 1 to 28 days before their date of miscarriage.
    • Cases and controls both had pregnancies confirmed by the medical record. Cases had a miscarriage confirmed by medical record review.
    • Cases were compared with controls from the same age group (less than 30 years or 30 or more years), had nearly the same date of last menstrual period, and were enrolled in the same health care plan.
  • This study used vaccine safety data collected through the Vaccine Safety Datalink (VSD).
    • VSD is a collaboration between CDC’s Immunization Safety Office (ISO) and several integrated healthcare organizations across the United States.
    • The VSD uses electronic health information from more than 9 million people, approximately 3% of the US population.
  • The health information includes demographic characteristics, vaccinations, and medical outcomes.
  • The study has some limitations. These include:
    • The study examined data from a small number of women in a subgroup who received H1N1-containing vaccines in consecutive years. The small numbers in the study could have led to imprecise results.
    • It is possible that women who have an increased risk for miscarriage might also be more likely to have received influenza vaccine. These conditions could have made the women more likely to miscarry.
    • Many miscarriages occur early in pregnancy and may not come to medical attention. The impact on the study findings of miscarriages that were not identified is unknown.
      • Flu vaccinations could have been incompletely recorded because some women could have received flu shots in another setting. The possible impact of unidentified vaccinations is unknown. However, this effect cannot account for the observed association if unidentified vaccinations occurred with similar frequency in cases and controls.
    • This study was a case-control study that estimated an odds ratio of vaccination among women who had a miscarriage compared to those who did not. The study did not estimate risk of miscarriage after influenza vaccination. Therefore, the findings cannot be used to estimate the probability of miscarriages for pregnant women who received an H1N1-containing flu vaccinations two years in a row.
    • Finally, it is not known how many women in the study were aware they were pregnant at the time of vaccination.
     (Continue . . . )

While it remains to be seen if there is any substance to this safety signal, we already know that influenza during pregnancy can have serious impacts on both the mother and developing fetus.  A few past blogs on that include:

Pediatrics: Maternal Flu Vaccination Extends Protection To Infants

Clinical Infectious Diseases: Flu Vaccine May Reduce Incidence of Stillbirth
Pregnancy, Flu and The Next Pandemic

Pregnancy, Influenza & Elevated Psychosis Risks In Adult Offspring


    Thursday, September 14, 2017

    Into (Internet) Darkness


    Given the damage to power lines here in Florida from Hurricane Irma, it is a bit remarkable that just 4 days later the power has been restored to my home.  Internet, alas will take a few more days.

    I've been `bugged out' to a friends house in Tampa since Saturday, but tomorrow I'll return to my own abode.  It may be a few days before I'll have Internet access, so I probably won't be updating this blog again until next week.

    As always, I recommend you keep tabs on infectious disease news from:




    Ian Mckay's Virology Down Under Blog

    Sci. Repts: Adaptation of H7N9 in Primary Human Airway Epithelial cells



    Since it first emerged as a human health threat in the spring of 2013 H7N9 has undergone constant evolution, spawning dozens of genotypes spread across two major lineages, and even spinning off an HPAI version last winter. 
    Like its HPAI H5 cousins, H7N9 is extremely promiscuous, and reassorts easily with a number of other avian subtypes. 
    While H7N9 has yet to achieve efficient or sustained human to human transmissibility, we've watched it make incremental and worrisome steps towards a more mammalian adapted virus over the past 5 years.  A few recent blogs include:

    PLoS Pathogens: Three Mutations Switch H7N9 To Human-type Receptor Specificity

    EID Journal: 2 Expedited HPAI H7N9 Studies

    Eurosurveillance: Preliminary Epidemiology & Analysis Of Jiangsu's 5th H7N9 Wave
    While reassortment can introduce large, abrupt changes to an influenza virus, host adaptation can help fine tune the virus for easier infection, carriage, and spread from a specific species.  In nature this typically happens through an extended chain of infection, but for research purposes it is often done in the laboratory with animals, or tissue samples.

    There are a number hurdles an avian influenza virus must overcome in order to efficiently infect and spread in humans. While not all are known, two of the biggest are: it needs to bind preferentially to human (a2,6) receptor cells and it needs to replicate efficiently at the lower temperatures found in the mammalian respiratory tract.
    For a more detailed look, you may wish to revisit Nature Comms: Host Adaptation Of Avian Influenza Viruses.
    Which brings us to a new study, published this week in Nature, which looks at the host adaptation of H7N9 after multiple passages through lung tissue.

    While the virus's replication rate did not increase, it did increase its preference for biding to human receptor cells, albeit at a lower rate (53.4%)  than seasonal H1N1 did (76.9%) in a parallel experiment. Additionally, later viruses in the passage study provoked a stronger inflammatory cytokine responses, suggesting increased virulence.

    Adaptation of influenza A (H7N9) virus in primary human airway epithelial cells
    Daniel Tsung-Ning Huang, Chun-Yi Lu, Ya-Hui Chi, Wan-Ling Li, Luan-Yin Chang, Mei-Ju Lai, Jin-Shing Chen, Wen-Ming Hsu & Li-Min Huang

    Scientific Reports 7, Article number: 11300 (2017)

    Received:25 April 2017
    Accepted:14 August 2017
    Published online:12 September 2017


    Influenza A (H7N9) is an emerging zoonotic pathogen with pandemic potential. To understand its adaptation capability, we examined the genetic changes and cellular responses following serial infections of A (H7N9) in primary human airway epithelial cells (hAECs).

    After 35 serial passages, six amino acid mutations were found, i.e. HA (R54G, T160A, Q226L, H3 numbering), NA (K289R, or K292R for N2 numbering), NP (V363V/I) and PB2 (L/R332R). The mutations in HA enabled A(H7N9) virus to bind with higher affinity (from 39.2% to 53.4%) to sialic acid α2,6-galactose (SAα2,6-Gal) linked receptors. A greater production of proinflammatory cytokines in hAECs was elicited at later passages together with earlier peaking at 24 hours post infection of IL-6, MIP-1α, and MCP-1 levels. Viral replication capacity in hAECs maintained at similar levels throughout the 35 passages.

    In conclusion, during the serial infections of hAECs by influenza A(H7N9) virus, enhanced binding of virion to cell receptors with subsequent stronger innate cell response were noted, but no enhancement of viral replication could be observed. This indicates the existence of possible evolutional hurdle for influenza A(H7N9) virus to transmit efficiently from human to human.

    Six amino acid mutations were found in A(H7N9) virus during the process of adapting to human cells, including three in HA (R54G, T160A, Q226L, H3 numbering), one in NA (K289R, or K292R for N2 numbering), one in NP (V363V/I), and one in PB2(L/R332R). Our findings showcase the extent of influenza A (H7N9) virus adaptation in human cells and can provide information for the design of vaccine and management of potential outbreak. The adapted virus can bind better to human receptor and has the potential to cause more severe diseases. However, it still cannot replicate efficiently.
    (Continue . . . )
    Of note, this study was submitted last April, and completed before last year's record H7N9 outbreak and the emergence of an HPAI variant.  The study used a relatively early Pearl River Delta version of the virus, imported to Taiwan in 2013 (A/Taiwan/1/2013(H7N9)).

    The CDC's IRAT system now ranks the newly emerged Yangtze River Delta lineage as being slightly more worrying than the original Pearl River Delta Lineage (see Updating the CDC's IRAT (Influenza Risk Assessment Tool) Rankings), although both sit atop their list of viruses with the greatest pandemic potential.

    Wednesday, September 13, 2017

    CDC HAN: Rifampin/Penicillin-Resistant Strain of RB51 Brucella From Consumption Of Raw Milk


    This afternoon the CDC released a HAN Advisory regarding a rare case of Brucella RB51 infection in Texas related to the consumption of raw milk. The United States sees about 100 cases each year, although most are not this resistant strain.
    HAN messages (Alert, Advisory, Update, or Info) are designed to ensure that communities, agencies, health care professionals, and the general public are able to receive timely information on important public health issues.
    An `Advisory’ is a second tier message that provides important information for a specific incident or situation, but may not require immediate action. As others may have been exposed, the CDC is issuing guidance for clinicians who might run across a suspected infection.

    Rifampin/Penicillin-Resistant Strain of RB51 Brucella Contracted from Consumption of Raw Milk
    This is an official CDC Health Advisory

    Distributed via the CDC Health Alert Network

    September 13, 2017, 1230 ET (12:30 PM ET)



    The Texas Department of State Health Services, with assistance from CDC, is investigating Brucella RB51 exposures and illnesses that may be connected to the purchase and consumption of raw (unpasteurized) milk from K-Bar Dairy in Paradise, Texas. Symptoms of brucellosis can include: fever, sweats, malaise, anorexia, headache, fatigue, muscle & joint pain, and potentially more serious complications (e.g., swelling of heart, liver, or spleen, neurologic symptoms).


    A person who drank raw milk from K-Bar Dairy in Paradise, Texas, has been hospitalized with brucellosis. Milk samples from the dairy have tested positive for a Brucella strain called RB51. People who consumed milk or milk products from this dairy from June 1, 2017, to August 7, 2017 are at an increased risk for brucellosis and should receive appropriate post-exposure prophylaxis (PEP). They are advised to consult with their health care providers regarding PEP care and possible diagnostic testing. Please note: the incubation period for brucellosis can range from five days to six months.


    Brucella strain RB51 is resistant to rifampin and penicillin. A combination of doxycycline and trimethoprim/sulfamethoxazole for 21 days is the recommended first-line PEP regimen for RB51 exposure. There is no serological test available to detect RB51 infection. Blood culture is the recommended diagnostic test for exposed symptomatic individuals. When ordering blood cultures to diagnose brucellosis, please advise the laboratory that blood culture may grow Brucella and that appropriate laboratory1 precautions should be observed. If brucellosis occurs despite prophylaxis, treatment regimens2 should be selected based on antimicrobial susceptibility results. Please see the diagram below for information on developing an evaluation and treatment plan for exposed patients. Women who are pregnant or breastfeeding should consult with their health care provider.
    Treatment Decision Tree for Patients Who Were Exposed to (Consumed) Raw Milk/Raw Milk Products

    (Continue . . . )

    It is particularly important that lab personnel are made aware that they might be culturing Brucella, as in recent years most U.S. infections have been lab-acquired (see CIDRAP's 2015 report Exposures in NYC labs prompt alert on brucellosis risk for workers).

    The CDC maintains a Brucellosis web page where you'll find additional information, including more on the risks of consuming raw milk.