Monday, January 16, 2017

H7N9: Muddled Media Reports & A Hong Kong Update












#12,123


After last week's flurry of H7N9 reports (see HK CHP: China Reports An Additional 83 H7N9 Cases For December), official reports have become few and far between, but we continue to see vague, often muddled, media reports suggesting new cases continue to turn up.

The problem is, we have so few details on the earlier cases that it makes it nearly impossible to tell whether `new' cases in the media are really new, or simply a rehashing of old reports.   I suspect it is a combination of both.

Trying to make sense of all of this (and with a patience far beyond what I could muster), is Sharon Sanders of FluTrackers, whose H7N9 case list provides the best conservative listing of cases (with links to reports) publicly available. 


Over the past few days, FT has added 8 cases to their list:

#940 - Female, 72, hospitalized January 8 in Zhongshan, traveled to Macao and hospitalized again January 10, Zhongshan, Guangdong province

#941-944 - This line adds 4 cases. Anhui province announced 14 cases for December and we have 10 of those cases listed above. Anhui province

#945 - Male, 36, [Zhang], onset December 25, died January 11, 2017 in Jiangsu province, traveled though Henan province, duck trader from Zhejiang province

#946 - Male, 35, hospitalized in critical condition, Wuhan City, Hubei province

#947 - Patient, 79, Kaili City, Guizhou province

Given China's habit of making `belated' bird flu announcements, it seems likely (based on the volume of cases reported in December), that this under represents the current level of activity.   While things seem slow right now, at some point the dam will probably bust again, and we'll get a new flurry of case reports to analyze.


Today, Hong Kong's CHP has posted an update which confirms cases #946 and #947 above, and once again warns the public of the risks of live bird exposure and avian flu.

     The Centre for Health Protection (CHP) of the Department of Health is today (January 16) closely monitoring two additional human cases of avian influenza A(H7N9) in Guizhou and Hubei, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.
 
     According to the Health and Family Planning Commission of Guizhou Province, the patient, aged 79 from Qiandongnan Prefecture, has been hospitalised.
 
     The Health and Family Planning Commission of Hubei Province reported that the male patient, aged 38 from Wuhan and in a critical condition, had exposure to a poultry market.
 
     From 2013 to date, at least 906 human H7N9 cases have been reported by the Mainland health authorities, 131 of which have been recorded from November 2016 thus far, including 57 in Jiangsu, 22 in Zhejiang, 15 in Guangdong, 14 in Anhui, seven in Jiangxi, four in Shanghai, three each in Fujian, Guizhou and Hunan, two in Shandong and one in Hubei. Four cases (imported) and two cases were respectively recorded in Hong Kong and Macau.
 
     "We strongly urge the public to avoid touching birds, poultry or their droppings and visiting poultry markets or farms during travel, particularly in the upcoming Lunar New Year holidays. If feeling unwell, such as having a fever or cough, wear a mask and seek medical advice at once. Travellers returning from affected areas should consult doctors promptly if symptoms develop, and actively inform the doctors of their travel history for prompt diagnosis and treatment," a spokesman for the CHP said.
 
     "Adults and parents should also look after children with extra care in personal, hand, food and environmental hygiene against infections during travel," the spokesman said.
 
     "While local surveillance, prevention and control measures are in place, we will remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments," the spokesman said.
 
     As the H7N9 virus continues to be detected in animals and environments in the Mainland, additional human cases are expected in affected and possibly neighbouring areas. In view of the heavy trade and travel between the Mainland and Hong Kong, further sporadic imported human cases in Hong Kong every now and then are expected, especially in the coming few months.
 
     The CHP's Port Health Office conducts health surveillance measures at all boundary control points. Thermal imaging systems are in place for body temperature checks on inbound travellers. Suspected cases will be immediately referred to public hospitals for follow-up.
 
     The display of posters and broadcasting of health messages in departure and arrival halls as health education for travellers is under way. The travel industry and other stakeholders are regularly updated on the latest information.
 
     The public should maintain strict personal, hand, food and environmental hygiene and take heed of the advice below while handling poultry: 

  • Avoid touching poultry, birds, animals or their droppings;
  • When buying live chickens, do not touch them and their droppings. Do not blow at their bottoms. Wash eggs with detergent if soiled with faecal matter and cook and consume them immediately. Always wash hands thoroughly with soap and water after handling chickens and eggs;
  • Eggs should be cooked well until the white and yolk become firm. Do not eat raw eggs or dip cooked food into any sauce with raw eggs. Poultry should be cooked thoroughly. If there is pinkish juice running from the cooked poultry or the middle part of its bone is still red, the poultry should be cooked again until fully done;
  • Wash hands frequently, especially before touching the mouth, nose or eyes, before handling food or eating, and after going to the toilet, touching public installations or equipment such as escalator handrails, elevator control panels or door knobs, or when hands are dirtied by respiratory secretions after coughing or sneezing; and
  • Wear a mask if fever or respiratory symptoms develop, when going to a hospital or clinic, or while taking care of patients with fever or respiratory symptoms.
 
     The public may visit the CHP's pages for more information: the avian influenza page, the weekly Avian Influenza Report, global statistics and affected areas of avian influenza, the Facebook Page and the YouTube Channel.
Ends/Monday, January 16, 2017



France : MOH Announces 15 More H5N8 Poultry Outbreaks



















#12,022


Today the French MOA added another 15 H5N8 poultry oubreaks, and 3 new wild bird detections, to their list - bringing the number of farm outbreaks to 129 since the first week of December.   These are just the HPAI H5N8 outbreaks, and do not include numerous LPAI outbreaks in the same regions.
While Gers has been the hardest hit department of late, this latest surge comes almost entirely from Landes, which reported 13 outbreaks between January 10th-13th.  

Gers and Landes - along with Haute-Pyrenees - have been targeted for extended prophylactic culling of ducks and geese, to try to curb these outbreaks.  While scattered outbreaks are still being reported across Europe, France and Bulgaria appear to be getting the worst of it the past couple of weeks.

 
Avian Influenza: France in the home monitoring

16/01/2017 avian influenza
© Pascal Xicluna / Min.Agri.Fr

In France

Situation on January 16, 2017: 129 H5N8 outbreaks in farms and 8 cases in wildlife confirmed and communicated.
List of homes in the departments
  • Landes: 34 homes
  • Tarn: 8 homes
  • Gers: 66 homes
  • Lot-et-Garonne: 7 homes
  • Hautes-Pyrénées: 6 homes
  • Pyrénées-Atlantiques: 3 homes
  • Aveyron: 2 homes
  • Deux-Sèvres: 3 homes

List of outbreaks in wildlife

  • Pas-de-Calais: 1 home
  • Haute-Savoie: 2 homes
  • Tarn: 2 homes
  • Channel: 1 home
  • Ain : 1 foyer
  • Lot et Garonne 1 home

Internationally

the data updated 01/08/2017

Since the last point location January 2, 84 new outbreaks of HPAI were reported in Europe, which also includes Switzerland, mainly in Bulgaria (25 breeding households), and France (20 breeding households).

The virus has now been detected:

- Slovenia (Maribor swan 1)
- and the Czech Republic (Moravia, 3 wild cases and aged in household).

The total number of outbreaks of HPAI and reported cases continues to increase and is now 809 (against 724 last week) including 368 in wild birds (58 species affected), 428 livestock and 13 in of captive birds.

The Challenge Of Avian Flu Surveillance In Sub-Saharan Africa

HPAI Reports 2016 - Credit OIE





















#12,021


Over the weekend we've seen media reports (see AP's Uganda confirms Avian flu in wild terns, domestic birds) of a mass die off of wild birds on Lake Victoria (reportedly of white-winged black terns) as well as in a handful domestic ducks and chickens, which have tested positive for an, as yet, unannounced strain of bird flu.

While Nigeria and a handful of other West African nations reported outbreaks of H5N1 during the middle of the last decade, bird flu reports from Sub-Saharan Africa dried up by the middle of 2008. The virus has remained endemic in Egypt, but in late 2014 - after an absence of nearly 7 years - we began to see reports emerge from West Africa again.

In April of 2015, in EID Journal: H5N1 In Nigerian Poultry – 2015, we saw the first reports that it was clade 2.3.2.1c  of H5N1 - previously detected in  China - that had emerged, not the old clades  2.2 and 2.2.1 which had previously circulated in the region.

Since then - see the OIE map above - western Africa has remained a hotbed of H5N1 activity, although no human infections have been reported (note : H5N1 is endemic in Egypt, and so they are no longer reported to the OIE). 

Exactly why hundreds of Egyptians (and some seroprevalence studies suggest that is a major under count) have been infected with H5N1, yet only 2 human infections have been reported in all of Sub-Saharan Africa, is unknown.

One strong possibility: avian flu surveillance in across Africa is often - to put it kindly - suboptimal.  Our assumption is that it is far more widespread than is officially reported.

A good example came last March in Libya's Under Reported Burden Of H5N1 (FAO Workshop), where we saw an FAO report which cited `at least 4 deaths' due to H5N1 in Libya beginning in December of 2014, and more than 100 suspected or confirmed poultry outbreaks.

Yet `officially',  Libya has never reported a human H5N1 infection to WHO and their only OIE report in 2015 listed 12 chickens affected by H5N1.

West Africa, in particular, has reported a great many outbreaks in poultry, but outside of Egypt, only two human infections have ever been confirmed by the WHO in Africa; one in Djibouti in 2006, and one the following year in Nigeria.

There were three other suspected Nigerian cases at the time - including the mother of the confirmed case in Lagos – but testing was delayed, and `inconclusive’.

The sad reality is, roughly six thousand people die each and every day in Africa, from all manner of diseases. AIDS, lassa fever, malaria, pneumonia, water borne illnesses, and TB; just to name a few. In many (probably most) cases, these people aren't afforded access to modern medical care, and even if they are, they are almost never tested for `novel' flu strains.

A lack of reported cases in areas where no testing is done, doesn't really tell us much.

These surveillance gaps are no secret. In the summer of 2015 , in FAO: Concerns Rising Over Spread Of Avian Flu In Africa and again in October of that year, in WHO Scales Up Influenza Surveillance In Africa, we looked at growing concerns over the recent spread of highly pathogenic avian flu in Africa and the very limited surveillance and reporting from the region.

Again, last summer, in The FAO Calls For Increased Vigilance On H5N1 In Africa,  we looked at concerns over the lack of surveillance in Sub-Saharan Africa.





If you look at a map of the migratory bird flyways (see above), you see that West Africa sits at the southern intersection of no fewer than three major migratory flyways. Routes that begin in the northern climes of Russia, Mongolia, and China where H5N1, H5N8, H5N6 and H7N9 are  known to circulate in wild birds – and that cross both Europe and the Middle East.

The recent breakout of  both H5N8 in Europe and H5N6 in Asia illustrate how quickly these viruses can expand their geographic range, carried in by migratory birds. 
The unidentified virus behind the bird die off in Uganda is most likely HPAI H5 (and that could include H5N1, H5N8, or a very, very long shot H5N6), but last November we also saw Algeria: Large Bird Die Off Due To HPAI H7N1 - OIE, so other subtypes are certainly possible. 
We take special note of  large die offs because in the past they have occasionally heralded a change in the virus (i.e.  a new clade, or a novel reassortment).  A few notable examples: 

We ought to learn the subtype from the Ugandan outbreak in the next few days. Even if it is H5N1 or H5N8, it could be weeks or months before we learn if they carry any significant genetic changes.

Meanwhile, assuming that HPAI is confirmed in Uganda by the OIE/FAO, this should put the rest of Sub-Saharan Africa on alert that avian flu could turn up pretty much anywhere on the continent.



Japan: Gifu Prefecture Poultry Outbreak Confirmed As H5N6

 













#12,020


Although hardly unexpected, Japan's 8th HPAI poultry outbreak  of this winter 2016-17 season - reported on Saturday (see Japan: HPAI Outbreak At Gifu Poultry Farm) - has tested positive for the HPAI H5N6 virus.
Unlike South Korea, which has reported a couple of H5N8 detections interspersed among their much larger H5N6 epizootic, Japan has only reported the H5N6 virus this year in poultry.
Despite a relatively light hit to their poultry industry (compared to South Korea), Japan continues to detect and report numerous wild bird and environmental detections of HPAI H5 across a large swath of the nation.  The following tally comes from Japan's Ministry of Environment.

January 15, 2017 17:30 current 16 prefectures 171 


Today's announcement from Japan's Ministry of Agriculture (MAFF) follows:

For determination of NA subtypes of highly pathogenic gene analysis of suspected affected animals of avian influenza and highly pathogenic avian influenza virus has been identified in Gifu Prefecture 


1989 May 16, 29 years 

the Ministry of Agriculture, Forestry and Fisheries
For suspected affected animals of highly pathogenic avian influenza has been confirmed in Gifu Prefecture, a result of the genetic analysis animal health research department was carried out, it has been confirmed that the highly pathogenic avian influenza. 

In addition, the virus of the highly pathogenic avian influenza, found NA subtype, has been confirmed to be the subtype H5N6. 

1. Overview
(1) For suspected affected animals of highly pathogenic avian influenza has been confirmed in the Gifu Prefecture of the farm, the results of genetic analysis that animal health research department (Note) has been carried out, the sequence is determined to be highly pathogenic has been confirmed.
(2) In response to this, the Ministry of Agriculture, Forestry and Fisheries, on the basis of the "specific livestock epidemic quarantine guidelines for highly pathogenic avian influenza and low pathogenic avian influenza", was judged the poultry with the affected animals.
(3) In addition, the virus of the highly pathogenic avian influenza, animal health research department inspection of the results in, found NA subtype, has been confirmed to be the subtype H5N6.
(Note) The National Research and Development Institute of Agriculture and Food Research Organization of Animal Health Research Institute: Japan's only research institute on animal health (Kenichi Division Sakamoto) 
2. Other
(1) In Japan, this by eating poultry meat and poultry eggs to, cases of avian influenza virus was transmitted to humans has not been reported.
(2) coverage in the field is, that there is a possibility that the cause of the spread of the disease, since it could violate the privacy of those farmers, thank you for your cooperation as abstain strictly.
(3) in the future, so we will endeavor to provide quick and accurate information, so as not to be confused by such production relations and consumers, such as who is unfounded rumor, thank you for your cooperation.


Sunday, January 15, 2017

The Fog Of Bird Flu




#12,019


Although the above map of recent bird flu outbreaks around the world is lit up like a Christmas tree, it undoubtedly under-represents what has truly been a remarkable resurgence of avian flu around the world over the past three months.  
Unlike the dramatic diaspora of H5N1 in 2005-2006 - when a single HPAI virus jumped from 15 Southeast Asian countries to more than 60 nations across Europe and the Middle East - we're watching more than a half dozen subtypes (H5N1, H5N8, H5N6, H7N9, H7Nx, and H5Nx) spreading around the world. 

As they spread, these viruses continue to evolve into new genotypes, and increasingly, are producing new subtypes as well.  Clade 2.3.4.4. H5 viruses (H5N8 in particular), has spun off multiple subtypes (H5N2, H5N1, H5N5, etc.) in Taiwan, North America, France, and Northern Europe (see OIE Notification: HPAI H5N5 In The Netherlands).


In addition to their growing diversity and greatly increased geographic range, some of these subtypes (H5Nx & H7N9) have demonstrated subtle changes in behavior, including greater virulence, increased host range, and/or enhanced transmission from birds to humans (see EID Journal: Morens & Taubenberger On The Evolution Of HPAI H5Nx and MMWR: Assessing The 4th Epidemic Wave Of H7N9 In China).

Tracking bird flu outbreaks has always been a game of incomplete information, and so even under the best of circumstances, we are likely only seeing the tip of the iceberg. 

Some countries have very limited surveillance and testing capabilities, with large regions too remote - or not under full government control - to allow for reliable reporting. Countries like Libya, Nigeria, Myanmar, Cambodia, and North Korea come to mind, along with numerous other countries in Sub-Saharan Africa.


Other countries have a documented history of suppressing or delaying news of avian flu outbreaks (think: China, Indonesia, Egypt, etc.) - and while logistics of surveillance, testing, and reporting are likely partially to blame - are often calculated political decisions.

The day-to-day trickle of cases we get from China's individual provinces, and local media, are often `augmented' weeks (or sometimes months) later by NFHPC reports, or reports to the WHO (see HK CHP: China Reports An Additional 83 H7N9 Cases For December).


Egypt, which two winters ago saw the largest outbreak of human H5N1 infections (160+) ever recorded in a single year, has been absolutely silent this winter. Their Ministry of Health website is only rarely updated, and their MOH Bird Flu FAQ hasn't been updated since the summer of 2014, and still shows 180 cases since 2006 (WHO shows 356 as of Dec 2016).

What, if anything, is going on with H5 avian flu in Egypt this winter is unknown.  Perhaps there is simply nothing to report, but that would represent a remarkable turnaround, given its recent history in that country. 

Indonesia, Vietnam, and Cambodia are also countries that have been heavily impacted by avian flu in the past, but currently are reporting little or no activity in poultry, and no human cases.  India, for all of its outbreaks over the past 10 years, has yet to report a human infection with H5N1.


We know that even small differences in HPAI viruses can change their behavior (see Differences In Virulence Between Closely Related H5N1 Strains), so it is possible that in these areas, the strains of H5N1 circulating either are, or have become, less infectious to humans. Some of the credit may go to public health messaging, aimed at reducing the risks of infection. There could be other factors we simply don't know.

Bird flu moves in mysterious ways, and just when we think we have a handle on it, it changes. 

But despite these unusual blank spots on our bird flu radar, avian flu is clearly on the ascendant around the globe, and so no one should be too surprised if we start seeing reports from some of these `quiet' areas over the next few months.



Saturday, January 14, 2017

Saudi MOH Announced 3 MERS Cases Over 2 Days













#12,118


The Saudi MOH website has been been having problems again the past couple of days, and has finally posted both yesterday's and today's update, adding a total of 3 cases.  Two from Hafuf, and one from Najran. 


 One has recent camel contact, while the other two have no listed risk exposure.