Tuesday, March 28, 2017

WHO Avian Flu Risk Assessment - March 2017


The World Health Organization has released an updated Influenza at the human-animal interface report - one that reflects H7N9 cases officially notified to WHO by the Chinese government through March 16th of this year, along with two H5N1 cases reported by Egypt in February.
Since this report is dated March 16th, and China doesn't always notify WHO immediately of cases, today's report is running about 40 behind Hong Kong's most recent tally. 

 First the summary, then some excerpts from the report:

Summary and assessment, 14 February to 16 March 2017

  • New infections1: Since the previous update, new human infections with influenza A(H5N1) and A(H7N9) viruses were reported.
  • Risk assessment: The overall public health risk from currently known influenza viruses at the human-animal interface has not changed, and the likelihood of sustained human-to-human transmission of these viruses remains low. Further human infections with viruses of animal origin are expected.
  •  IHR compliance: All human infections caused by a new influenza subtype are required to be reported under the International Health Regulations (IHR, 2005).2 This includes any animal and non-circulating seasonal influenza viruses. Information from these notifications is critical to inform risk assessments for influenza at the human-animal interface.

As the chart at the top of this blow shows, after a record-breaking winter/spring of human cases in 2014-15, case reports dropped dramatically. We still hear of `possible' cases in the Egyptian media (see Egypt: Peering Down The Rabbit Hole), but so far in 2017 Egypt has only confirmed two cases:

The report continues:

Avian influenza A(H5) viruses
Current situation:

Since the last update, two new laboratory-confirmed human cases of influenza A(H5N1) virus infection were reported to WHO. A 4-year-old male resident of Menia Governorate, Egypt, had onset of illness on 2 February 2017, was hospitalized on 10 February and treated with antivirals for pneumonia. A sample collected on admission tested positive for influenza A(H5N1). The patient recovered and was discharged on 20 February. Prior to his illness, the case had contact with domestic birds in his household.

In addition, a 48-year-old man from Fayoum Governorate had onset of illness on 10 February 2017, was hospitalized on 15 February and treated with antivirals for pneumonia. A sample collected on admission tested positive for influenza A(H5N1). The patient developed severe disease and passed away on 24 February. Prior to his illness, the case had contact with sick and dead backyard poultry.

Investigation and follow up of contacts of the two cases took place for 14 days with no further cases reported. Avian influenza A(H5N1) viruses are enzootic in poultry in Egypt.
Since 2003, a total of 858 laboratory-confirmed cases of human infection with avian influenza A(H5N1) virus, including 453 deaths, have been reported to WHO from 16 countries (see Figure 1).
Influenza A(H5) subtype viruses have the potential to cause disease in humans and thus far, no human cases, other than those with influenza A(H5N1) and A(H5N6) viruses, have been reported to WHO. According to reports received by the World Organisation for Animal Health (OIE), various influenza A(H5) subtypes continue to be detected in birds in West Africa, Europe and Asia. There have also been numerous detections of influenza A(H5N8) viruses in wild birds and domestic poultry in several countries in Africa, Asia and Europe since June 2016, and influenza A(H5N5) in wild birds in Europe. For more information on the background and public health risk of these viruses, please see the WHO assessment of risk associated with influenza A(H5N8) virus here.

Avian influenza A(H7N9) viruses

Current situation:

During this reporting period, 84 laboratory-confirmed human cases of influenza A(H7N9) virus infection were reported to WHO from China. Case details are presented in the table in the Annex of this document. For additional details on these cases, public health interventions, and the recently detected influenza A(H7N9) viruses with genetic changes consistent with highly pathogenic avian influenza, see the Disease Outbreak News, and for analysis of recent scientific information on the A(H7N9) influenza virus, please see a recent WHO publication here.

As of 16 March 2017, a total of 1307 laboratory-confirmed cases of human infection with avian influenza A(H7N9) viruses, including at least 489 deaths3, have been reported to WHO (Figure 2).

According to reports received by the Food and Agriculture Organization (FAO) on surveillance activities for avian influenza A(H7N9) viruses in China4, positives among virological samples continue to be detected mainly from live bird markets, vendors and some commercial or breeding farms.

         (Continue . . . )

While the risk assessments for these two viruses remains unchanged - and the virus has not demonstrated the ability to transmit efficiently from human to human -  it is fair to say that  recent developments with H7N9 have raised concerns world wide.
  1. This year's surge in human cases not only ends a two year decline in the number of  human infections, it appears likely to double the size of biggest previous epidemic (winter 2013-14).  
  2. H7N9 has recently split into two major lineages - Pearl River Delta and Yangtze River Delta - (see MMWR:Increase in Human Infections with Avian Influenza A(H7N9) In China's 5th Wave) This new lineage will require a new vaccine - meanwhile the virus continues to evolve at an impressive rate.
  3. Previously only an LPAI virus, a new virulent (in birds) HPAI version of H7N9 emerged in Guangdong province this winter, and has demonstrated the ability to infect humans. 
  4. And just last week we learned that this HPAI H7N9 virus is mobile, and `fit' enough to have turned up in a different province, several hundred miles away from it first appeared (see China MOA: High Mortality In Poultry Infected With H7N9 In Hunan Province). 

 Download the PDF File to read the entire report.

CDC Update On Candida Auris - March 2017


Last summer the CDC issued a Clinical Alert to U.S. Healthcare facilities about the Global Emergence of Invasive Infections Caused by the Multidrug-Resistant Yeast Candida auris.

C. auris - an emerging fungal pathogen  - was first isolated about 8 years ago in Japan, found in the discharge from the patient's external ear (hence the name `auris') - although retrospective analysis has traced this fungal infection back over 20 years.

A week later we saw a release from the UK's PHE On The Emergence Of Candida auris In The UK, where they detailed a large (and ongoing since April 2015) nosocomial outbreak at an adult critical care unit in England.

While still rare, we've seen an increasing number of cases (and hospital clusters) reported internationally, generally involving bloodstream infections, wound infections or otitis.

Unlike most systemic Candida infections, which usually arise when a previously colonized person is weakened from illness or infirmity, this strain appears to have a propensity for nosocomial transmission.
When you add in that:
  1. C. auris infections have a high fatality rate
  2. The strain appears to be resistant to multiple classes of anti-fungals 
  3. And it can be difficult for labs to differentiate between Candida strains 
It is little wonder that the CDC is placing a high priority on improved testing, surveillance, and reporting. Last August, in MMWR: Investigation of the First Seven Reported Cases of Candida auris In the United States, we looked at - what was then - only a handful of known US cases.

In the eight months since that report the CDC has recorded an additional 46 cases - mostly from New York State - and all in patients with underlying medical problems staying in health care facilities.  
While this jump may indicate increased incidence of the infection, it may also be the product of improved surveillance and reporting. 

The CDC update for March Follows:
What's New?
Candida auris is an emerging fungus that presents a serious global health threat. Healthcare facilities in several countries have reported that C. auris has caused severe illness in hospitalized patients. Some strains of Candida auris are resistant to all three major classes of antifungal drugs. This type of multidrug resistance has not been seen before in other species of Candida.

Also of concern, C. auris can persist on surfaces in healthcare environments and spread between patients in healthcare facilities, unlike most other Candida species. CDC has developed Interim Recommendations to help prevent the spread of C. auris.

C. auris is difficult to identify with standard laboratory methods and can be misidentified in labs without specific technology. CDC encourages all U.S. laboratory staff who identify C. auris strains to notify their state or local public health authorities and CDC at candidaauris@cdc.gov

Find answers to frequently asked questions about C. auris on our questions and answers page and in the Candida auris: Interim Recommendations.

CDC is working with state and local health departments to identify and investigate cases of C. auris. The following map displays where C. auris cases have been identified in the United States as of March 16, 2017. This map will be updated monthly.

For a bit more on this emerging health threat, you may wish to revisit mSphere: Comparative Pathogenicity of UK Isolates of the Emerging Candida auris.

HK CHP Avian Influenza Report Week 12


Hong Kong's CHP has published their latest weekly avian influenza report, which adds 18 H7N9 cases from the Mainland -  all of which were reported last Friday by the NHFPC (see Hong Kong CHP Notified By Mainland Of 18 Additional H7N9 Case). 

While still elevated, weekly case counts continue to decline (down almost 20% over last week) - a sign perhaps that the closing of live bird markets in areas reporting cases is having its desired effect. 

Since the start of this 5th epidemic season last October, just shy of 550 H7N9 infections have been reported - 541 on the Mainland - plus 8 exported cases (5 in Hong Kong, 2 in Macao & 1 in Taiwan).

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).  

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.


Reporting period: March 19, 2017 – March 25, 2017 (Week 12)

(Published on March 28, 2017)


1. Since the previous issue of Avian Influenza Report (AIR), there were 18 new human cases of avian influenza A(H7N9) reported by Mainland China health authorities in Guangxi (5 cases), Hunan (4 cases), Hubei (2 cases), Zhejiang (2 cases), Anhui (1 case), Fujian (1 case), Henan (1 case), Jiangxi (1 case) and Guizhou (1 case). Since March 2013 (as of March 25, 2017), there were a total of 1347 human cases of avian influenza A(H7N9) reported globally. Since October 2016 (as of March 25, 2017), 541 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 March 25, 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. There were no new human cases of avian influenza A(H5N1) reported by the World Health Organization (WHO) in 2017. From 2011 to 2015, 32 to 145 confirmed human cases of avian influenza A(H5N1) were reported to WHO annually (according to onset date). In 2016, there have been 10 cases in Egypt.*

        (Continue . . .)

The full report (which runs 9 pages) is well worth downloading and reading, as it contains updates not only on avian flu activity in Mainland China, but around the world. 

While it still doesn't reflect it, we are aware of at least 2 H5N1 cases (1 fatal) in Egypt this year.

After two years of declining epidemic numbers, this winter's surge in H7N9 cases - along with its continual evolution (see MMWR:Increase in Human Infections with Avian Influenza A(H7N9) In China's 5th Wave) - keep H7N9 firmly atop the growing list of novel flu viruses with pandemic potential (see IRAT: Revisited).

Monday, March 27, 2017

Georgia Dept Of Agriculture Confirms Avian H7 (Presumptive LPAI) in Chattooga County


While hardly unexpected given the report earlier today (see HK Suspends Poultry Imports From Chattooga County, Georgia), Georgia's Department of Agriculture has confirmed that lab testing of a commercial flock in the far northwestern part of the state has come back positive for avian H7.

Over the past three weeks we've seen more than a half dozen other detections - all a newly reassortant North American H7N9 virus - centered in southern Tennessee and North Alabama.

Georgia Department of Agriculture
Gary W. Black, Commissioner
19 Martin Luther King Jr. Dr. SW
Atlanta, GA 30334

Press Release
Monday, March 27, 2017
Office of Communications
Confirmed H7, Presumptive Low Pathogenic Avian Influenza in a Commercial Flock in Georgia
A flock of chickens at a commercial poultry breeding operation located in Chattooga County has tested positive for H7, presumptive low pathogenic avian influenza (LPAI). This is the first confirmation of avian influenza in domestic poultry in Georgia. Avian influenza does not pose a risk to the food supply, and no affected animals entered the food chain. The risk of human infection with avian influenza during poultry outbreaks is very low.
The virus was identified during routine pre-sale screening for the commercial facility and was confirmed as H7 avian influenza by the USDA National Veterinary Services Laboratory (NVSL) in Ames, Iowa. As a precaution the affected flock has been depopulated. Officials are testing and monitoring other flocks within the surveillance area and no other flocks have tested positive or experienced any clinical signs.

The announcement follows similar confirmations from Alabama, Kentucky and Tennessee in recent weeks. The Georgia case is considered a presumptive low pathogenic avian influenza because the flock did not show any signs of illness. While LPAI is different from HPAI, control measures are under way as a precautionary measure. Wild birds are the source of the virus. Avian influenza virus strains often occur naturally in wild birds, and can infect wild migratory birds without causing illness.

“Poultry is the top sector of our number one industry, agriculture, and we are committed to protecting the livelihoods of the many farm families that are dependent on it,” said Georgia Commissioner of Agriculture Gary W. Black. “In order to successfully do that, it is imperative that we continue our efforts of extensive biosecurity.”

The official order prohibiting poultry exhibitions and the assembling of poultry to be sold issued by the state veterinarian’s office on March 16, 2017, remains in effect. The order prohibits all poultry exhibitions, sales at regional and county fairs, festivals, swap meets, live bird markets, flea markets, and auctions. The order also prohibits the concentration, collection or assembly of poultry of all types, including wild waterfowl from one or more premises for purposes of sale. Shipments of eggs or baby chicks from National Poultry Improvement Plan (NPIP), Avian Influenza Clean, approved facilities are not affected by this order.

Owners of poultry flocks are encouraged to closely observe their birds and report a sudden increase in the number of sick birds or bird deaths to the state veterinarian’s office at (855) 491-1432. For more updates and information regarding biosecurity tips visit www.ga-ai.org or www.allinallgone.com.

ECDC: Rapid Risk Assessment On Multi-Country Cluster Of MDR-TB In Migrants



Whether it is a tourist returning from Carnival in Rio, a businessman traveling from the Arabian Peninsula to Asia, or a migrant making their way from North Africa into Europe - they all have one thing in common.

They all have the ability to be exposed to - and then inadvertently carry - exotic infectious diseases (like Zika, MERS, Dengue, Yellow Fever, Avian Flu, TB, etc.) from one part of the world to another.

Last December the ECDC reported on a cluster of MDR-TB among a group of 16 migrants who had recently entered the EU during the first six months of 2016 (see Multidrug-resistant tuberculosis in migrants, multi-country cluster, first update 19 Dec 2016).

An international whole genome sequencing cluster involving 16 cases of multidrug-resistant tuberculosis (MDR TB) in asylum seekers has been detected. The first seven cases were identified in Switzerland between February and August 2016. Their countries of origin are Somalia (5 cases), Eritrea (1) and Ethiopia (1). Whole genome sequencing (WGS) showed no difference among isolates in four cases and differences of one allele in the three others. Based on the WGS results, the strains belong to a single molecular cluster. The same genetic clone with the same and so far unknown drug resistance profile was detected in nine additional cases from Somalia, six of them diagnosed in Germany, two in Austria, and one in Sweden.
Fast forward a little more than 3 months and the ECDC has published an updated RRA, which has now identified 25 cases.  Follow the link to read the full 4-page report.

Conclusions and options for response 

A multi-country cluster of multidrug-resistant tuberculosis (MDR TB) involving 25 migrants has been delineated by whole genome sequencing (WGS). All cases have a recent history of migration from Somalia (22 cases), Eritrea (2 cases) and Ethiopia (1 case). Cases have been reported by Germany (13 cases), Switzerland (8 cases), Austria (2 cases), Finland and Sweden (1 case each). 

A WGS analysis of the 25 cluster isolates supports the hypothesis that the cases are part of a chain of recent transmission likely to have taken place either in the country of origin or in a place along the migration route to the country of destination. Based on the currently available information, it is not possible as of yet to rule out that transmission occurred in an EU/EFTA country. 

It therefore remains important to rapidly investigate exposure risk factors, including the travel history and itineraries of patients and their contacts, and share this information to determine whether transmission may have taken place in the EU/EFTA, during migration, or in the country of origin. Depending on the results of the investigation, appropriate prevention and control measures should be taken. 

Although the number of cases detected so far suggests that there is only a limited risk of this cluster becoming a widespread event in Europe, more cases may yet be identified in association with this cluster. Early case finding of active TB and drug susceptibility testing, especially in newly arriving migrants from the Horn of Africa, is important in order to identify and treat active cases and to provide preventive treatment or monitoring for those diagnosed with latent tuberculosis infection.

Saudi MOH Announces 1 New MERS-CoV case


After a lull of 7 days without reporting a new MERS case, the Saudi MOH today has announced a primary (Direct Camel Contact) case in Al Kharj, in a 54 y.o. male who is listed in stable condition.

There are a total of 10 active cases receiving treatment in Saudi Hospitals.  We've not heard of any new cases in the Wadi Al Dawasir Cluster - which produced at least 10 cases earlier in the month - in nearly two weeks.