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April 18th, 2014 posted by Paul Rega, MD, FACEP April 18, 2014 @ 5:11 am

April 18,1906 at 5:13 a.m., an estimated 8.0M earthquake strikes San Francisco, California, killing hundreds and toppling numerous buildings.

Soldiers in streets of San Francisco after 1906 earthquake


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April 18th, 2014 posted by Paul Rega, MD, FACEP @ 5:03 am

ABC: The ferry captain left the bridge before the S. Korean vessel sank Wednesday, leaving the steering and command to the ship’s third mate, someone with just over a year’s worth of experience.

Disasters - Maritime

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April 18th, 2014 posted by Paul Rega, MD, FACEP @ 5:00 am

CNN: 12 Sherpa guides are killed and 3 are seriously injured Friday after a high-altitude avalanche on Mt. Everest.



On Top of the World: Everest and Makalu


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April 18th, 2014 posted by Paul Rega, MD, FACEP @ 4:58 am

Ebola virus disease, West Africa (Situation as of 16 April 2014)

Viral Hemorrhagic Fever


As of 18:00 on  16 April, the Ministry of Health (MOH) of Guinea has reported a cumulative total of  197 clinical cases of Ebola Virus Disease (EVD), including  122 deaths. To date, 101 cases have been laboratory confirmed, including 56 deaths,  43 cases ( 33 deaths) meet the probable case definition for EVD and  53 cases (33 deaths) are classified as suspected cases. Twenty- four (24) health care workers have been affected with 13 deaths.  Clinical cases of EVD have been reported from Conakry ( 47 cases, including 16 deaths), Guekedou (117/80), Macenta (22/16), Kissidougou (6/5), Dabola (4/4) and Djingaraye (1/1).

Contact tracing activities continue in all affected areas including new contacts generated by a HCW who passed away 3 days ago. In Conakry, 60 community volunteers are assisting the MOH and response partners in following up the 221 contacts currently under medical observation. Seven contacts who developed symptoms have been placed in isolation as a precautionary measure. A total 249 contacts are being followed in Guekedou, 54 in Macenta 17 in Kissidougou, 63 in Dabola and two (2) in Dingaraye.

A total of 36 patients are currently in isolation; 23 in Conakry, 12 in Guéckédou and 1 in Macenta. Clinical teams from WHO, the Global Outbreak Alert and Response Network (GOARN) and Médecins Sans Frontières (MSF) are supporting national medical and nursing staff at the Donka Hospital to strengthen patient triage, case management and infection prevention and control (IPC). Training on the safe handling of patients with EVD and the deceased was conducted jointly by the IPC and Logistics teams at the Donka hospital for staff working at the morgue, and for drivers and staff transporting patients in stretchers. A training of trainers activity for the directors of all 20 Centres de Santé in Conakry is planned for 17 April.  IPC training is also scheduled at two community health centres tomorrow.

Numbers of cases and contacts remain subject to change due to consolidation of cases, contact and laboratory data, enhanced surveillance and contact tracing activities and the continuing laboratory investigations.


The Ministry of Health (MOH) of Mali has today reported that the clinical samples on the 6 suspected cases have tested negative for ebolavirus.

The samples were tested at the WHO Collaborating Centre for Arbovirus and Viral Haemorrhagic Fever of the Institut Pasteur, Dakar, Senegal. The samples were also tested using real-time PCR at the newly established, mobile high security laboratory at the SEREFO Center for HIV and TB Training and Research, University of Bamako. Malian laboratory experts from the SEREFO Center, the National Institute of Public Health (INRSP), the Centre National d’Appui à la lutte contre la Maladie (CNAM), the National Blood Transfusion Centre (CNTS) and the Faculty of Medicine and Dentistry, University of Science, Technics and Technology, Bamako (FMOS) were trained in ebolavirus diagnosis by staff of the US National Institutes of Health (NIH).

As of 16 April, no new suspected cases have been reported in Mali.

Continuing preparedness and response activities include raising awareness among health care workers and the broader community about EVD and reinforcing personal and community-based risk reduction strategies.  The need for strict adherence with infection prevention and control measures within health care facilities remains a key intervention.

WHO is supporting the national health authorities of Mali, Guinea and Cote d’Ivoire in the planning of a cross-border meeting on Ebola Virus Disease. Response partners supporting the MOH include WHO, the US Centers for Disease Control and Prevention (CDC), MSF, the European Community Humanitarian Office (ECHO), Agence Française de Développement (AFD), the Japan International Cooperation Agency (JICA), the NIH and the UN Children’s Rights and Emergency Relief Organization (UNICEF).


As of 16 April the Ministry of Health and Social Welfare (MOHSW) of Liberia has reported a cumulative total of 27 clinical cases of EVD, including 13 deaths attributed to EVD. One new suspected case reported yesterday from Nimba County has been laboratory confirmed as a case of Lassa fever. Two patients remain hospitalised and 33 contacts remain under medical observation. The MOHSW commissioned a new ebolavirus laboratory today in collaboration with Metabiota.

The MOHSW, in collaboration with WHO and the GOARN team in Liberia, has conducted visits to the John F. Kennedy Medical Center in Monrovia and the Redemption Hospital, New Kru Town in Montserrado County, and conducted the first training in case management, triage and infection prevention and control.

Sierra Leone

On 15 April, the Ministry of Health and Sanitation (MOHS) provided a consolidated report of surveillance activities conducted in that country from 19 March onwards. A total of 12 suspected cases have been identified during that period. Two previously reported suspected EVD deaths occurred in individuals from one family who died in Guinea and their bodies repatriated to Sierra Leone for burial. All of the 15 case contacts have completed 21 days of medical follow-up and have remained well.  The Metabiota laboratory team working at the Kenema Government Hospital Lassa Fever Isolation Unit have received and tested clinical samples from 11 of the suspected cases using 2 different real-time PCR protocols for Ebola Zaire, other viral haemorrhagic fevers and important locally endemic pathogens.  All of the samples have tested negative for ebolavirus and the other pathogens included in the test panel.
Follow up on rumours of EVD cases and active case finding is ongoing in Sierra Leone.  Metabiota in collaboration with the MOHS have conducted training of trainers for 75 clinicians and nurses from the main referral government, private and mission hospitals in the 13 districts on EVD preparedness and response at the Kenema Lassa Fever unit. Multimedia community sensitisation activities are also continuing.

WHO does not recommend that any travel or trade restrictions be applied to Guinea, Liberia, Mali or Sierra Leone based on the current information available for this event.

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April 18th, 2014 posted by Paul Rega, MD, FACEP @ 4:54 am

5 laboratory-confirmed and 5 probable coccidioidomycosis cases linked to a movie set.


Coccidioidomycosis Among Cast and Crew Members at an Outdoor Television Filming Event — California, 2012


April 18, 2014 / 63(15);321-324

Jason A. Wilken, PhD1,2, Patricia Marquez, MPH3, Dawn Terashita, MD3, Jennifer McNary, MPH1, Gayle Windham, PhD1, Barbara Materna, PhD1 (Author affiliations at end of text)

In March 2013, the California Department of Public Health (CDPH) identified two Doctor’s First Reports of Occupational Injury or Illness (DFRs)* regarding Los Angeles County residents who had worked at the same jobsite in January 2012 and had been evaluated for possible work-associated coccidioidomycosis (valley fever). Occupational exposure to Coccidioides, the causative fungi, typically is associated with soil-disrupting activities (1). The physicians noted that both workers were cast or crew members filming a television series episode, and the site of possible exposure was an outdoor set in Ventura County, California. On the basis of their job titles, neither would have been expected to have been engaged in soil-disrupting activities. Los Angeles County Department of Public Health (LACDPH) conducted an outbreak investigation by using CDPH-provided occupational surveillance records, traditional infectious disease surveillance, and social media searches. This report describes the results of that investigation, which identified a total of five laboratory-confirmed and five probable cases linked to this filming event. The employer and site manager were interviewed. The site manager stated that they would no longer allow soil-disruptive work at the site and would incorporate information about the potential risk for Coccidioides exposure onsite into work contracts. Public health professionals, clinicians, and the television and film industry should be aware that employees working outdoors in areas where Coccidioides is endemic (e.g., central and southern California), even those not engaged in soil-disruptive work, might be at risk for coccidioidomycosis.

Review of DFRs for coccidioidomycosis diagnoses initially identified two patients who worked for the same employer and listed work-associated coccidioidomycosis as the claimed illness. Patient 1, an actor, sought evaluation at an emergency department on February 28, 2012, after a 2-week history of fever and cough. Patient 1 had received a letter from his employer dated February 17, 2012, stating that a member of the cast or crew present at an outdoor filming event during January 17–19 in Ventura County had a diagnosis of coccidioidomycosis; patient 1 had also worked at this filming event. A copy of the letter sent to the employee was included with the DFR. Patient 2, a camera operator who had sought evaluation at an emergency department on February 24 after a 2-week history of cough, joint aches, and muscle pain, was identified by review of the health-care provider’s notes as having worked at the same outdoor filming event; patient 2 was not the patient referenced in the original letter.

Subsequent review of information obtained from the California Department of Industrial Relations (DIR) identified six additional workers with the same employer who had sought evaluation for possible work-associated coccidioidomycosis. Because all workers identified were residents of Los Angeles County, CDPH informed LACDPH of the possible outbreak, and LACDPH led the local investigation.

A confirmed outbreak case was defined as a laboratory-confirmed illness (including clinical presentation with an influenza-like illness, pneumonia or pulmonary lesion, erythema nodosum or erythema multiforme rash, or extrapulmonary disease) meeting the 2011 Council of State and Territorial Epidemiologists coccidioidomycosis surveillance case definition (3) that occurred in a person who was present at the filming event (performing site preparation work during January 15–16 or at the filming event during January 17–19). A probable case was a clinically compatible illness in a person present at the filming event. Patients were identified through review of DFRs and information obtained from DIR, review of social media, or interview with another patient. LACDPH contacted the employer and obtained cast and crew rosters, which were cross-referenced with the LACDPH coccidioidomycosis surveillance database. Patients, or family contacts of a decedent, were interviewed by LACDPH, and the employer and filming site manager were interviewed by CDPH and LACDPH.

Eight patients initially were identified through review of DFRs and information obtained from DIR. One was identified by review of social media, wherein the patient had posted details about his hospitalization, and one was identified by another patient as a relative (nonemployee) who had been onsite during the filming event. The patient referenced in the employer letter was among those with laboratory-confirmed illness. Of 10 persons identified, seven were interviewed; three could not be contacted. LACDPH ascertained five confirmed and five probable cases. The employee roster indicated 655 workers were associated with that particular television episode. The attack rate for all identified cases was 1.5%.

Median time to symptom onset was 11 days (range = 3–28 days), as determined by interviews of seven patients and medical record review for two patients (Table 1); an estimate could not be made for one patient. Two patients were hospitalized, one for 2 days and one for 4 weeks. The seven interviewed patients reported symptom duration ranging from 1 week to 6 months (Table 2) and reported recovering fully from their illness. One patient had died of an unrelated illness. Five of the interviewed patients reported dry, dusty conditions during the filming event. Only two of the interviewed patients, a construction coordinator and a prop or set maker, engaged in soil-disrupting activities (digging and moving dirt). However, substantial soil-disruptive work, including grading and digging and filling a mud pit, occurred shortly before the filming event. Furthermore, the site manager reported to LACDPH and CDPH that substantial dust from an adjacent mining company blew onto the site daily. CDPH has not identified any cases among employees of the mine at this time.

The employer responded promptly to the initial identification of one illness among cast and crew by sending the original letter to employees, encouraging anyone with symptoms to seek medical evaluation. After interviewing the employer’s environmental health and safety manager and discussing future prevention practices, CDPH provided a “Preventing Work-Related Coccidioidomycosis (Valley Fever)” fact sheet (4) to the employer for integration into their Injury and Illness Prevention Program (IIPP). The site owner informed LACDPH and CDPH that they had already halted digging and excavation at the site. After consultation with CDPH, he stated they would no longer allow soil-disruptive work at the site and would advise future film crews of the potential risk for Coccidioides exposure onsite. CDPH also advised the site owner to consult the local air pollution control district for assistance in mitigating offsite dust.


The outbreak described in this report was identified by review of DFRs, using a pilot occupational coccidioidomycosis surveillance system recently established by CDPH. Title 17 of California’s Code of Regulations requires health-care providers to report coccidioidomycosis diagnoses and outbreaks to the local health jurisdiction (5). Although coccidioidomycosis diagnoses for four of the five confirmed cases were reported to LACDPH, the outbreak was only detected by use of a nontraditional database for occupational surveillance. CDPH previously had used workers’ compensation claims data to identify these industries as having the highest incidence of coccidioidomycosis: mining, quarrying, and oil and gas extraction; public administration; agriculture, forestry, fishing, and hunting; and construction (1). Coccidioidomycosis outbreaks among archaeologists (6,7), military personnel (8,9), and construction workers (10) have been described previously. This outbreak investigation identified occupations and an industry not previously known to be at risk.

The outbreak described in this report is illustrative of the risk to employees working outdoors in Coccidioides-endemic areas. Although most patients did not engage in soil-disruptive activities, substantial soil disruption immediately preceded the filming event, and the site owner reported ongoing dust intrusion from a neighboring mining company onto the filming site. Because no reliable methods for environmental Coccidioides sampling are available, identifying the source of the spores was not possible. CDPH previously had recommended a comprehensive approach to reducing incidence and severity of work-associated coccidioidomycosis (4). The approach includes limiting workers’ exposure to outdoor dust by controlling dust generation at the source (e.g., continuous soil wetting), providing employee training, and consistently enforcing an IIPP, which includes providing respiratory protection with particulate filters. However, the majority of patients in this outbreak were not involved in excavation or set construction and might not have been considered at increased risk for coccidioidomycosis in the existing IIPP. Nevertheless, working at a site immediately after soil disturbance might expose workers to Coccidioides spores, and a comprehensive IIPP for these employees should include 1) covering spoils piles and wetting disturbed areas, 2) establishing criteria for suspending work on the basis of wind and dust conditions, and 3) prompt disease recognition and referral to occupational medicine clinics for evaluation, treatment, and follow-up (1,4). Clinicians, including occupational health providers, should be aware that work-associated coccidioidomycosis can occur among patients who do not actively engage in soil-disruptive activities and include relevant information (e.g., employer, worksite, industry, occupation, and other information on activities or locations that might be related to exposure) when reporting cases to local health officials.

1California Department of Public Health; 2EIS officer, CDC; 3Los Angeles County Department of Public Health, Los Angeles, California (Corresponding contributor: Jason A. Wilken,, 510-620-3622)


  1. Das R, McNary J, Fitzsimmons K, et al. Occupational coccidioidomycosis in California: outbreak investigation, respirator recommendations, and surveillance findings. J Occup Environ Med 2012;54:564–71.
  2. California Code of Regulations, Title 8, §14006. Form 5021, Rev. 4, Doctor’s First Report of Occupational Injury or Illness. Available at Web Site Icon.
  3. Council of State and Territorial Epidemiologists. Position statement 10-ID-04. Coccidioidomycosis (valley fever) (Coccidioides spp.) 2011 case definition. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at
  4. Hazard Evaluation System and Information Service. Preventing work-related coccidioidomycosis (valley fever). Richmond, CA: California Department of Public Health and California Department of Industrial Relations; 2013. Available at Adobe PDF fileExternal Web Site Icon.
  5. California Code of Regulations, Title 17, §2800-2812, Reportable Diseases and Conditions. Available at
  6. Petersen LR, Marshall SL, Barton-Dickson C, et al. Coccidioidomycosis among workers at an archaeological site, northeastern Utah. Emerg Infect Dis 2004;10:637–42.
  7. Werner SB, Pappagianis D. Coccidioidomycosis in northern California: an outbreak among archaeology students near Red Bluff. Calif Med 1973;119:16–20.
  8. Williams PL, Sable DL, Mendez P, Smyth LT. Symptomatic coccidioidomycosis following a severe natural dust storm: an outbreak at the Naval Air Station, Lemoore, Calif. Chest 1979;76:566–70.
  9. Crum N, Lamb C, Utz G, Amundson D, Wallace M. Coccidioidomycosis outbreak among United States Navy SEALs training in a Coccidioides immitis-endemic area—Coalinga, California. J Infect Dis 2002;186:865–8.
  10. Cummings KC, McDowell A, Wheeler C, et al. Point-source outbreak of coccidioidomycosis in construction workers. Epidemiol Infect 2009;138:507–11.

* In California, health-care providers who believe a patient’s injury or illness might be work-related are required to submit a DFR to the employer or their workers’ compensation insurance carrier, who forward it to the California Department of Industrial Relations (2). DFRs are provided to CDPH for occupational injury and disease surveillance purposes.

What is already known on this topic?

Work-associated Coccidioides infections and outbreaks have been linked to soil-disrupting activities, including construction, in areas where Coccidioides is endemic.

What is added by this report?

Occupational surveillance identified an outbreak of coccidioidomycosis in an unexpected industry (i.e., film and television). Employees working outdoors in any industry, even those not actively engaged in soil disruption, might be exposed to Coccidioides where it is endemic.

What are the implications for public health practice?

Occupational injury and illness surveillance can identify outbreaks not otherwise detected by traditional infectious disease surveillance. Education about coccidioidomycosis, including signs and symptoms, and exposure prevention measures should be implemented at outdoor worksites in areas where Coccidioides is endemic, including worksites of industries and occupations not typically associated with soil-disrupting activities. Health-care providers should consider the possibility of work-relatedness among patients with coccidioidomycosis diagnoses and note employer, work location, industry, and occupation when reporting cases.

TABLE 1. Demographic characteristics and outcomes of coccidioidomycosis patients — California, 2012
Characteristic No.
Case status
Confirmed 5
Probable 5
Age (yrs) median (range) 37 (23–58)
Male 7
White 6
Black 3
Asian 1
Visited emergency department 5
Hospitalized (2–28 days) 2
Time to symptom onset (days) median (range) (9 patients) 11 (3–28)
TABLE 2. Occupation and outcomes of coccidioidomycosis patients — California, 2012
Patient no. Confirmed/Probable Interviewed Occupation Time to illness onset (days) Hospitalized Symptom duration Identification source
1 Probable No Actor 28 N/A N/A DFR
2 Probable No* Sound technician 15 N/A N/A DFR
3 Confirmed Yes Prop/Set construction 4 No 4 wks DIR
4 Confirmed Yes Actor 6 No 1 wk DIR
5 Probable Yes Actor 3 No 3 wks DIR
6 Probable No Actor N/A N/A N/A DIR
7 Confirmed Yes Camera operator 22 No 6 mos DIR
8 Probable Yes Construction manager 11 No 3 wks DIR
9 Confirmed Yes Actor 7 4 wks 4 wks Social media
10 Confirmed Yes N/A (visitor) 15 2 days 3 wks Patient interview
Abbreviations: DFR = Doctor’s First Report of Occupational Injury or Illness; DIR = California Department of Industrial Relations; N/A = not available.* Deceased from unrelated illness; family contacts interviewed.

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April 17th, 2014 posted by Paul Rega, MD, FACEP April 17, 2014 @ 6:16 pm

The ferry, the 6,825-ton Sewol tilted to the left for as-yet-unexplained reasons shortly before 9 a.m. Wednesday and began sinking in the waters off South Korea.

Disasters - Maritime

“……As of Thursday evening, the confirmed death toll was at 25, and just 179 passengers had been rescued…..”


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April 17th, 2014 posted by Paul Rega, MD, FACEP @ 3:20 am

NASA: The wildfire blazes through parts of Valparaiso, Chile, on April 13, 2014. It quickly became the largest fire in the history of this port city.

Fire / Wildfire / Fire Safety

Wildfire Burns Valparaiso, Chile

High winds propelled a wildfire through parts of Valparaiso, Chile, on April 13, 2014. It quickly became the largest fire in the history of this port city. The fire started in a forested area on April 12 and eventually reached wooden homes built on steep hills around the city. According to news reports, at least 12 people died, 2,000 homes were destroyed, and about 10,000 people evacuated as the fire moved through a section of the historic city.

The Moderate Resolution Imaging Spectroradiometer (MODIS) on NASA’s Terra satellite acquired this image of the fire at 11:10 am local time (14:10 UTC) on April 13. Fire detections are outlined in red in the forest south of the city, which is pale gray. A long plume of smoke stretches northwest over the Pacific Ocean, a clear indication that winds were strong and blowing the flames toward the city.

Valparaiso is the third largest city in Chile, with a population of more than 280,000 people. It was established in 1536 and developed into an important international seaport in the 19th century. The city is a UNESCO World Heritage site.

  1. References

  2. El Mercurio (2014, April 14) Bomberos: “El más grande de Chile en toda la historia.” Accessed April 14, 2014.
  3. Fox News Latino (2014, April 14) Raging fire in Chile claims at least 12 lives, destroys hundreds of homes. Accessed April 14, 2014.
  4. NPR News (2014, April 14) For second night, Valparaiso fire spreads misery in Chile. Accessed April 14, 2014.
  5. UNESCO World Heritage Center Historic quarter of the seaport city of Valparaiso. Accessed April 14, 2014.

NASA image courtesy LANCE/EOSDIS MODIS Rapid Response Team at NASA GSFC. Caption by Holli Riebeek.

Terra – MODIS

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April 17th, 2014 posted by Paul Rega, MD, FACEP @ 3:10 am

UAE reports a cluster of 10 laboratory-confirmed cases of MERS-CoV infection among health-care workers

Infectious Disease, Outbreak & Pandemic

The following details were provided to WHO:

Currently, all the cases are in stable condition and their family and health care contacts are being followed up.


click map

Earth Science and Remote Sensing Unit, NASA-Johnson Space Center. “The Gateway to Astronaut Photography of Earth.”

<>04/16/2014 20:38:11.

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April 17th, 2014 posted by Paul Rega, MD, FACEP @ 3:03 am

At least one in every 20 adults who seeks medical care in a U.S. ER or community health clinic may walk away with the wrong diagnosis.


Misdiagnosed: Docs’ Mistakes Affect 12 Million a Year

“At least one in every 20 adults who seeks medical care in a U.S. emergency room or community health clinic may walk away with the wrong diagnosis, according to a new analysis that estimates that 12 million Americans a year could be affected by such errors.

Of those misdiagnosis mistakes, about 6 million could potentially cause harm, according to patient safety expert Dr. Hardeep Singh, who is the first to provide robust population-level data on the impact of the problem in outpatient settings.

That means patients with conditions as varied as heart failure, pneumonia, anemia and lung cancer could have serious problems that remain unrecognized by a doctor, according to the study published Wednesday in the journal BMJ Quality and Safety…..”

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April 17th, 2014 posted by Paul Rega, MD, FACEP @ 2:24 am

Nigeria: Scores of female students kidnapped by Islamic militants from a north-eastern Nigerian school are free


8 still missing.

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