Thursday, April 27, 2017

China's CDC Reassures On H7N9's Intrusion Into The North

FAO Apr 26th - Modified With North/South Line
















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During its first four years of circulation, H7N9 has been largely a central and southern Chinese problem.  Reports of human infections, or detections in birds or the environment, above the 38th parallel have been rare.  
As of the start of this 5th wave (October 2016), Beijing had only reported 9 cases since the virus emerged in 2013, while Jilin and Liaoning Province had each only reported 1.  Gansu Province, in the northwest of the country, had never detected the virus at all.
As of the latest HK CHP report (Apr 24th), Beijing had jumped to 22 cases,  Liaoning to 4, Jilin to 3, and Gansu had reported 2 cases. These regions have also reported increased bird and environmental detection.  Most of these `northern' cases have come in the past month.

While these numbers still pale compared to the 138 cases reported this year in Jiangsu, the 87 from Zhejiang, or the 63 reported by Guangdong, the late season encroachment of H7N9 into the capital city and surrounding northern provinces has started to raise concerns.
Apart from the public health implications, the entrenchment of the virus in Beijing  - just months before their 19th National Congress of the Communist Party of China - could cause some serious political ramifications this fall.
This recent surge in northern cases, combined with a drop off in reports from the south (noticeably Guangdong province, which hasn't reported a new case in a month), has led to some speculation in the Chinese media that the virus is starting to spread better in the north, than in the south. 
While understandably disconcerting to the millions of northern Chinese who have - until recently - felt relatively separated from these yearly H7N9 epidemics, the numbers this year don't support that assertion.
But speculation in China has apparently grown to the point that their CDC felt compelled to address the issue, and overnight a number of Chinese media outlets are carrying versions of the following (translated) story.


Northern areas are more susceptible to H7N9 bird flu? CDC denies the existence of this trend

2017-04-26 19:16:05
Beijing News News (Reporter Wu) April 26, for the "northern region of human infection with H7N9 influenza cases increased significantly," the media release and reprint of "bird flu this year, the North is more susceptible than the south" and other phrases, Chinese Center for Disease Control and Prevention virus disease control and prevention deputy director, director of the national influenza Center Shu Yuelong to Beijing News reporter said there was no evidence that the northern regions are more susceptible to H7N9 avian influenza.

Some media reports said, "The recent human infection with H7N9 influenza northern region of cases showed an increasing trend, April 24, according to incomplete statistics, in April, Shandong, Hebei, Liaoning, Beijing and other regions reported a total of 17 cases of human infection with the H7N9 flu."
Beijing News reporter combing found that according to public information, since this month, there are indeed more northern Shandong, Henan, Hebei, Liaoning, Jilin, Beijing and other provinces reporting cases of human infection with H7N9. April, Shandong report four cases; Henan, Hebei new cases were reported two cases and four cases; confirmed in Liaoning April 20 Nisshin one case; and Jilin also on April 22 this year the first case was found.

However, public data also show that since 2017, Guangdong, Guangxi, Jiangxi, Zhejiang, Jiangsu, Hunan, Gansu and Anhui and other areas also appear more cases of human infection with the H7N9 flu. According to the National Health and Family Planning Commission recently informed, in 2017, China's mainland has 22 provinces reported cases, 511 cases of H7N9, which killed 188 people.

In this regard, Shu Yuelong, said Nationwide, this year there is no evidence that the northern people more susceptible to H7N9 influenza. "The recent increase in the northern region, due to the wider spread of the virus, reported cases in northern and southern regions has increased." Shu Yuelong said there was no detection of cases of human infection with H7N9 flu a "South", "North" so obvious the regional differences.

Since we've seen some significant genetic changes in the H7N9 virus (more accurately, viruses) this year - along with some subtle changes in behavior - it is impossible to say what this summer and next fall have in store.
There have been concerns raised that the virus is becoming more `heat tolerant', which may increase its presence during the summer months. And the impact of an HPAI version of the virus, reported last January in Guangdong Province, remains to be seen.
As we've seen with H5N1, H5N8, and H5N6, avian flu viruses in China have a habit of eventually expanding their geographic range. While northern China may be at greater risk of seeing cases than in the past, the bigger concern is what happens if, and when, H7N9 hitches a ride on migratory birds into Russia, North Korea, Japan, India, Vietnam, or Laos.

Wednesday, April 26, 2017

FAO H7N9 Update - Apr 26th

Credit FAO












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Like many other agencies, the FAO is expending a lot of resources to monitor and analyze China's H7N9 epidemic - and while their focus is primarily on how this avian virus affects the world's food and agriculture - they keep a pretty good watch on human cases as well. 
One of the recent trends - easily discernible on the their map (see below) - has been an increase in the number of H7N9 positive human, bird, and environmental samples coming the northern part of china, particularly in and around Beijing and in Gansu Province (see Monday's report Jilin Province Reports 1st H7N9 Case Of 2017).  
I've only included some excerpts from a much larger report. Information added or changed since the last H7N9 situation update (Apr 12th) appears in red.

H7N9 situation update

26 April 2017, 17:00 hours; Rome

The next update will be issued on 3 May 2017

Overview

Situation: Influenza A(H7N9) virus with pandemic potential.


Country: China; three human cases originated in China and were reported in Malaysia (1) and Canada (2).


Number of human cases: 1444 confirmed; 545 deaths (since February 2013).

Number of new findings in birds or the environment since last update (12 April 2017): 66.


Number of new human cases since last update (12 April 2017): 47.

Provinces/municipalities: Beijing, Chongqing, Shanghai and Tianjin Municipalities; Anhui, Fujian, Gansu, Guangdong, Guizhou, Hebei, Henan, Hubei, Hunan, Jiangsu, Jiangxi, Jilin, Liaoning, Qinghai, Shandong, Sichuan, Taiwan, Yunnan and Zhejiang Provinces; Hong Kong SAR; Macao SAR, Guangxi, Ningxia Hui, Tibet and Xinjiang Uyghur Autonomous Regions; Sabah (Malaysia); British Columbia (Canada).

Animal/environmental findings: around 2,500 virological samples from the environment, chickens, pigeons, ducks and a tree sparrow tested positive; positives mainly from live bird markets, vendors and some commercial or breeding farms.

Highly pathogenic virus findings: Out of the 1444 confirmed human cases, H7N9 virus isolates from three cases (two from Guangdong and one from Taiwan Provinces) were found to be highly pathogenic for chickens.
The H7N9 highly pathogenic avian influenza virus was detected in a total of 41 poultry or environmental samples (30 chickens, 1 duck and 10 environmental samples) from 23 live bird markets (LBMs) in: Fujian (Longyan City), Guangdong (Dongguan, Guangzhou, Huizhou, Lufeng, Meijiang, Meizhou, Zhongshan Cities and Haifeng County), Guangxi (Guilin City) and Hunan (Chenzhou City) Provinces; and from 3 farms in: Guangxi (Guilin City) and Hunan (backyard in Chenzhou City and a large farm in Yongzhou City [reference]) Provinces.

FAO actions: liaise with China and partners, monitor situation, monitor virus evolution, conduct market chain analysis, risk assessment, surveillance guidance and communication. 


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KSA: Another Asymptomatic MERS Case From Wadi Al Dawasir


















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The Saudi MOH is reporting another asymptomatic MERS case  - the 4th  case in a week - from Wadi Al Dawasir, which was the site of a household/hospital cluster of cases during the first half of March.

Today's case involves a 26 y.o. male who is described as a `secondary household contact'.  On April 21st, KSA reported 3 additional asymptomatic cases, 1 listed as a `secondary Healthcare Acquired HCW', and the other two as `secondary household contacts'.

http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-04-21-001.aspx

No dates are provided for these cases, and we've not seen a WHO update since April 3rd (covering cases Feb 23rd - March 16th), so it isn't immediately apparent whether all of these are `new' cases, or if some are belated discovery (or reporting) of cases from the March outbreak.
Adding to the mystery, on April 19th we saw the Saudi MOH Announce A Primary MERS Case In Wadi Al Dawasir. No risk exposure was provided.

Of the 10 original cases reported in March from Wadi Al Dawasir, 2 were listed as `Under Review' (possibly household members), 4 were listed as `Secondary Hospital Acquired (patients)', 2 are described as `Secondary Household contacts', and 2 were listed as HCWs.   Of these 10, 3 were listed as `asymptomatic'.
This week's reports bring that total to 8 asymptomatic cases - or roughly 50% of the cases reported from Wadi Al Dawasir since early March.
Prior to 2016, the assumption was (based on very limited contact testing by the Saudis), that only about 10% of MERS cases were asymptomatic (or mildly ill).  Recent testing has suggested that number may be low.
Following unusually candid (and public) criticism of the Saudi's lack of testing and reporting of asymptomatic cases (see Sept 2015 WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS), we've seen a significant jump in the number of asymptomatic cases reported. 
Last summer we saw a large hospital outbreak (see Saudi MOH On KKUH MERS Outbreak & Increased Asymptomatic Detections) in Riyadh, which involved at least 28 cases - 21 (75%) of whom were asymptomatic. 
Since contact tracing and testing is much easier in a hospital environment, it makes sense that nosocomial outbreaks would reveal a higher rate of asymptomatic infection.
Unknown are how many undetected mild and/or asymptomatic cases there are in the community, and how much of a role - if any - they may play in the spread of the virus.

Tuesday, April 25, 2017

More Reports Of Bird Flu In Russia












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On the heels of last week's report of a bird flu outbreak at a commercial turkey farm (see Russia: Rosselkhoznadzor Reports Bird Flu Outbreak In Rostov Region), the government's Federal Service for Veterinary and Phytosanitary Surveillance is now reporting the discovery of avian flu in a small flock in a suburb of Moscow.

         (translated)
Clarification of avian influenza virus in the Noginsk municipal district, Moscow region April 24, 2017

© Central body

Office of Rosselkhoznadzor for Moscow City, Moscow and Tula regions inform the citizen Zlatovoy detecting bird flu outbreak in the personal subsidiary plots TP (Moscow Region, Noginsky area Yamkinskoe ri, d. Pochinki).

April 21, at the request of a citizen Zlatovoy ETC. nominative of 13 heads of chickens contained in LPH, the corpse of dead birds was selected pathological material and sent to study in the BS MO "Moscow Regional Veterinary Laboratory". April 21, 2017 based on the results of laboratory tests BS MO "Moscow Regional Veterinary Laboratory" has been revealed the genetic material of the pathogen avian influenza.

To confirm the diagnosis of pathological material samples sent to the State Organization "ARRIAH" (Vladimir).

Currently, the State Veterinary Service of the Moscow region the complex of organizational, economic and animal health measures in accordance with the order of the Russian Federation Ministry of Agriculture of 27.03.2006 number 90 "On approval of rules for combating avian influenza."

Held forced disinfection area. The corpses of birds have been incinerated. Disinfection farm buildings and equipment. The nearest settlements are conducted homestead rounds in order to monitor possible contamination.


Although it hasn't received near the attention as has HPAI H5 in Europe, Russia has been waging its own battle against HPAI this winter, with a number of those outbreaks in and around Moscow (see Rosselkhoznadzor: Avian Flu Outbreak In Moscow Region).  

While HPAI H5N8 and H5N1 are currently its biggest concerns, Russian officials are keenly aware of the dual threats posed by H7N9 and H5N6 - both of which loom large on Russia's  eastern and southern borders.
Last summer - although we didn't realize it at the time - a bird die off at Ubsu-Nur Lake in central Russia was our first clue that a new, more virulent version of H5N8 had emerged (see EID Journal: Reassorted HPAI H5N8 Clade 2.3.4.4. - Germany 2016),

Which is why - given all of the bird flu subtypes potentially passing through that part of the world via migratory flyways - we'll be keeping a particularly close eye on bird flu reports out of Russia over the summer.
 

Sweden Reports Fresh Outbreak Of HPAI H5N8

Nyköping



















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With the return of warmer spring temperatures and the departure of many migratory birds, Europe's unprecedented HPAI H5 epizootic has been on the decline for several weeks.  Enough, in fact, that many countries have begun to relax their orders to keep poultry indoors or under cover.
Sweden - which was hit far less severely than many other European nations - last reported poultry outbreaks in late January. Earlier this month, they too lowered some of their biosecurity rules after two months without an outbreak. 
Today, in a reminder that the avian flu threat - while diminished - hasn't completely passed, the Swedish Department of Agriculture is reporting an outbreak of HPAI H5N8 in a commercial laying flock in Nyköping.
(Translated)
Bird flu in poultry laying crew in Nyköping

2017-04-25

Bird flu has been detected in one laying flock in Nyköping. Test results from the National Veterinary Institute show that the herd is infected with the virus type H5N8. Agriculture has imposed restrictions in the area to avoid contamination. This type of virus that has been circulating in birds in autumn and winter has never infected humans.

Avian influenza type H5N8 has been circulating in Europe during the fall and winter, in Sweden, Denmark, Finland and several countries on the continent. A laying crew in southern Sweden was hit in December 2016 by the bird flu. Although a number of backyard flocks, a zoo and a number of wild birds have suffered.
- A couple of weeks ago we reduced the level of protection in Sweden from 2 to 1. This means that poultry and other domestic birds must go fenced outdoor with water and feed under cover. The affected farm is free-range laying hens go indoors, and it is unclear where the infection came from, says Karin Åhl on Agriculture
Protection and surveillance zone around the infected farm

Regarding the infected laying hens crew in Nyköping Agriculture has now decided on the refusal of access, and where there is specific restrictions, which means that no animals or animal products may leave or enter the yard.

Agriculture has also decided to establish a protection zone with a radius of three kilometers around the farm and a surveillance zone of 10 km radius. In the protection zone, particularly the following restrictions:
  • Poultry and other captive birds must be kept indoors. 
  • It is forbidden for unauthorized persons to enter the stables in poultry and other birds.
  • It is prohibited to transport poultry, live birds, hatching eggs and poultry products from poultry farms.
Even within the surveillance area, the prohibition of transport. It is possible to apply for exemption of the provincial government for certain shipments in the fields.

To combat the spread of infection, parts or all laying hens crew to be killed, and the plant is blocked and will then be cleaned up. This of course means a strain on the animal's owner. Spread the infection among domestic birds, it can mean huge costs for society and unnecessary suffering of the birds affected, says Karin Åhl.
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HK CHP Avian Flu Report Week 16

Credit HK CHP











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Hong Kong's Centre For Health Protection has published their latest weekly avian influenza report, and as was telegraphed on Friday by the NHFPC (see HK CHP Notified Of 27 New H7N9 Cases From The Mainland), today's report features the largest weekly tally of H7N9 cases since since the end of February.  
After weeks of  decline, recent outbreaks in Beijing, Tibet, Hunan, Hebei, and Sichuan have more than doubled this week's total over last week's (29 vs. 14).
While the fragmented, sometimes conflicting, and often belated reporting coming out of China makes it difficult to discriminate between new cases and those already announced, reports over the weekend suggest this elevated level of activity continues.

At the same time, some provinces which had been reporting heavy H7N9 activity earlier in the year (Guangdong, Fujian, Jiangsu) are reporting fewer cases. Guangdong province, in particular, has been eerily quiet, not having reported a new case in over a month.
The flow of information from individual provinces to their NHFPC - and from there to outside agencies like Hong Kong's CHP - often involves considerable delays. Which means we can never be quite sure how current, or complete, the information we have really is (see The Skies Aren't They Only Thing Hazy In China).
And of course, the standard caveat applies: 
Since only those those ill enough to be hospitalized are generally tested, and H7N9 can produce a wide spectrum of illness - ranging from asymptomatic to severe - the actual number of infections is unknown (see Beneath The H7N9 Pyramid).  
Despite highly publicized concerns (see NPR: A Pessimistic Guan Yi On H7N9's Evolution) over recent, worrisome changes in the virus (see MMWR: Increase in Human Infections with Avian Influenza A(H7N9) In China's 5th Wave), H7N9 continues to show no signs of sustained or efficient transmission among humans, and the lack of recent imported cases into Hong Kong and Macao continue to reassure. 
That said, this virus continues to evolve and it remains at the very top of the CDC's list of viruses with pandemic potential (see Updated CDC Assessment On Avian H7N9).

This week's full PDF report runs 9 pages, follow the link, as I've only included a few excerpts below:
Avian Influenza Report

Avian Influenza Report is a weekly report produced by the Respiratory Disease Office, Centre for Health Protection of the Department of Health. This report highlights global avian influenza activity in humans and birds.


VOLUME 13, NUMBER 16
Reporting period: April 16, 2017 – April 22, 2017 (Week 16)
(Published on April 25, 2017)


Summary


1. Since the previous issue of Avian Influenza Report (AIR), there were 29 new human cases of avian influenza A(H7N9) reported by Mainland China health authorities in Beijing (7 cases), Hunan (5 cases), Hebei (4 cases), Sichuan (3 cases), Shandong (2 cases), Zhejiang (2 cases), Anhui (1 case), Gansu (1 case), Guangxi (1 case), Jiangxi (1 case), Jilin (1 case) and Liaoning (1 case). Since March 2013 (as of April 24, 2017), there were a total of 1422 human cases of avian influenza A(H7N9) reported globally. Since October 2016 (as of April 24, 2017), 616 cases have been recorded in Mainland China.


2. Since the previous issue of AIR, there were no new human cases of avian influenza A(H5N6). Since 2014 (as of April 22, 2017), 16 human cases of avian influenza A(H5N6) were reported globally and all occurred in Mainland China. The latest case was reported on December 1, 2016.


3. Since the previous issue of AIR, there were no new human cases of avian influenza A(H5N1). From 2011 to 2016, 10 to 145 confirmed human cases of avian influenza A(H5N1) were reported to the World Health Organization (WHO) annually (according to onset date). In 2017, there have been so far two cases in Egypt.*