HPAI H5Nx Clade 2.3.4.4. Shedding In Cottontail Rabbits

Credit Wikipedia

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Regular readers will recall that over the past several years we've been looking into the carriage of novel (and seasonal) flu by domestic and peridomestic animals, and how they might fit into the ecology and evolution of influenza viruses.

On the domestic front, dogs and cats take center stage, as both are susceptible to at least some novel flu strains.  A few (of many) blogs include:

mBio: Novel Reassortant Influenza A Viruses in Canines in Southern China

EID Journal: Avian H7N2 Virus in Human Exposed to Sick Cats

Study: Dogs As Potential `Mixing Vessels’ For Influenza

Korean CDC Statement On H5N6 In Cats

Influenza A(H6N1) In Dogs, Taiwan

On the peridomestic front, in recent years we've seen growing evidence that small mammals - like rabbits, skunks, mink, and even small rodents - can be infected by, and potentially spread, flu viruses.

While these types of animals may not pose as much as a direct threat of transmitting flu viruses to humans, they do provide a way for viruses in the wild to gain entry into farms, or to jump to dogs and cats.  

And carriage of novel flu viruses by any mammalian host provides the virus with an opportunity to develop host adaptations, potentially making it easier to jump to other mammals. 

A few past blogs include:

H9N2 Adaptation In Minks

Sci Rpts: Characterization of Avian H7N2 in Wild Birds and Pikas in Qinghai-Tibet Plateau Area

Taking HPAI To The Bank (Vole)

EID Journal: Guinea Pigs As Reservoirs For Influenza

One of the leaders in research into flu carriage and shedding by peridomestic animals is  Dr Jeffery Root - a Research Wildlife Biologist at the National Wildlife Research Center -  whose work we've been following for several years.

• Dr. Root was one of the authors of a 2014 PLoS One study called Shedding of a Low Pathogenic Avian Influenza Virus in a Common Synanthropic Mammal – The Cottontail Rabbit, which was the first to show shedding of LPAI by cottontail rabbits.
• In 2015, this work was followed up with Virology: Experimental Infection of Peridomestic Animals With Avian H7N9 where Dr. Root et al. demonstrated H7N9’s ability to infect, and to be shed by, peridomestic animals like skunks, raccoons, and rabbits.  
• And again in 2016, in Report: Skunks and Rabbits Can Catch And Shed Avian Flu, we looked at an AP News report that quoted Dr. Root as saying that small mammals like rabbits and skunks can become infected with avian flu, and they can shed enough of the virus to pass it onto ducks (and presumably other types of birds). 

Which brings us to a new brief report (alas, mostly behind a pay wall) in the Archives of Virology, where Dr. Root et al. show that the HPAI H5 clade 2.3.4.4. virus - which sparked last year's European record setting epizootic - can infect cottontail rabbits, and that they can then shed the virus for one or more days. 

This is of particular interest since most clade 2.3.4.4. viruses - while causing huge losses in the poultry industry and among wild birds over the past four years - have shown a very limited ability to infect mammals. 

The exception (so far) being the HPAI H5N6 virus which has infected at least 17 people in China (see Human Clade 2.3.4.4 A/H5N6 Influenza Virus Lacks Mammalian Adaptation Markers and Does Not Transmit via the Airborne Route between Ferrets).

First the (very) brief abstract, then I'll return with a bit more.

Cottontail rabbits shed clade 2.3.4.4 H5 highly pathogenic avian influenza A viruses

J. Jeffrey Root, Angela M. Bosco-Lauth, Nicole L. Marlenee, Richard A. Bowen

First Online: 13 June 2018

Abstract

During 2014-2015, clade 2.3.4.4 H5Nx highly pathogenic (HP) avian influenza A viruses (IAV) were first detected in North America and subsequently caused one of the largest agricultural emergencies in U.S. history.

Recent evidence has suggested that cottontail rabbits can shed multiple IAV subtypes. We experimentally infected cottontail rabbits with three HP H5Nx IAVs. All rabbits tested shed virus on at least one day by at least one route.

Cottontail rabbits appear to be an exception to the limited capacity for replication that has been previously reported for certain other mammalian species inoculated with clade 2.3.4.4 HP H5Nx avian influenza A viruses.

While clade 2.3.4.4. H5N8, H5N5 and (European Lineage) H5N6 viruses have not been shown to infect humans, we did see early reports out of South Korea in 2014 of dogs having been infected (see MAFRA: H5N8 Antibodies Detected In South Korean Dogs (Again)) and just over a year ago we looked at J. Vet. Sci.: Experimental Canine Infection With Avian H5N8.

So we know that mammalian infection with at least some genotypes of H5N8 is at least possible.  Today's report expands that host range a bit.

Over the past two years we've looked at a number of studies that have explored the potential for H5N8 or its spin offs to evolve into a human health threat. A few include:

J Vet Sci: Evolution, Global Spread, And Pathogenicity Of HPAI H5Nx Clade 2.3.4.4 

Study: Virulence Of HPAI H5N8 Enhanced By 2 Amino Acid Substitutions

Sci Rpts: H5N8 - Rapid Acquisition of Virulence Markers After Serial Passage In Mice 

Perhaps most telling of these came last September in J. Virulence : Altered Virulence Of (HPAI) H5N8 Reassortant Viruses In Mammalian Models, which found:

Taken together, our study demonstrates that a single gene substitution from other avian influenza viruses can alter the pathogenicity of recent H5N8 viruses, and therefore emphasizes the need for intensive monitoring of reassortment events among co-circulating avian and mammalian viruses.

Last October's J. Virulence Editorial: HPAI H5N8 - Should We Be Worried? reviewed and summarized the literature, and found enough reasons to be concerned over the future evolutionary path of H5N8, stating that:

The extensive distribution of HPAI H5N8, as well as the gene reassortment with other circulating avian viruses already observed for H5N8 suggests there is a potential risk for human cases of H5N8 infections.

While expanding H5's host range is always a concern, the ability of small mammals like rabbits, raccoons, and rodents to breach farm biosecurity measures, and infect poultry populations is also troubling.

And may require the the rethinking of some farm biosecurity measures in the future to prevent a repeat of 2016/17 epizootic.

  

WHO MERS-CoV Update - Saudi Arabia

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With the Saudi MOH MERS-CoV information portal remaining shut down (33 days and counting - see More On The Silence Of The Saudis), today we've received a very welcome - and unusually long-delayed - update from the World Health Organization on MERS cases reported by Saudi Arabia since their last update in January. 

Of note: The format of this update's case line list differs from what we've seen with recent WHO MERS-CoV reports,  it is presented in static PDF Format (not as a spreadsheet), it only contains the most recent Saudi Cases, and it contains slightly fewer data columns than before.

Since this new format presents clusters separate from the rest of the cases, I must assume anything not listed as a cluster can be taken as not having had exposure to a MERS-CoV case. 

Which means of 54 non-cluster aka `primary' cases, 23 (42%) are reported to have known camel exposure while 31 (58%) are not, making their source of infection undetermined.   

Whether this is a new format that WHO is adopting, or is simply a one-off change due to the way data has been supplied these past few months from the Saudis remains to be seen.
 

Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia
Disease outbreak news
18 June 2018

Between 12 January through 31 May 2018, the National IHR Focal Point of The Kingdom of Saudi Arabia reported 75 laboratory confirmed cases of Middle East respiratory syndrome coronavirus (MERS_CoV), including twenty-three (23) deaths. 

Details of the cases

Among these 75 cases, 21 cases were part of four distinct clusters (2 health care and 2 household clusters). The details of these clusters are described below, followed by a table listing all 75 laboratory confirmed cases reported to WHO during this time period: 

Cluster 1: From 2 through 4 February, a private hospital in Hafer Albatin Region reported a cluster of three (3) health care workers in addition to the suspected index case (four [4] cases in total).

Cluster 2: From 25 February through 7 March, a hospital in Riyadh reported six (6) cases, including the suspected index. No health care workers were infected.

Cluster 3: From 8 through 24 March, a household cluster of 3 cases (index case and 2 secondary cases) was reported in Jeddah. No health care workers were infected. 

Cluster 4: From 23 through 31 May, a household cluster was reported from Najran region with eight cases including the suspected index case. This cluster is still under investigation at the time of writing. As of 31 May, no health care workers have been infected and the source of infection is believed to be camels at the initial patient’s home.

MERSCoVCasesSaudiArabiaJanMay2018.pdf
pdf, 488kb

As of 31 May, the total global number of laboratory-confirmed cases of MERS-CoV reported since 2012 is 2,220, including 1,844 cases that have been reported from the Kingdom of Saudi Arabia. Among these cases, 790 MERS-CoV associated deaths have occurred since September 2012.

The global number reflects the total number of laboratory-confirmed cases reported to WHO under IHR to date. The total number of deaths includes the deaths that WHO is aware of to date through follow-up with affected member states. 

WHO risk assessment

Infection with MERS-CoV can cause severe disease resulting in high mortality. Humans are infected with MERS-CoV from direct or indirect contact with dromedary camels. MERS-CoV has demonstrated the ability to transmit between humans. So far, the observed non-sustained human-to-human transmission has occurred mainly in health care settings.

The notification of additional cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a health care setting). WHO continues to monitor the epidemiological situation and conducts risk assessment based on the latest available information.

WHO advice

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for acute respiratory infections and to carefully review any unusual patterns.

Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. It is not always possible to identify patients with MERS-CoV early because, like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, health care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.

Community and household awareness of MERS and MERS prevention measures in the home may reduce household transmission and prevent community clusters.

Until more is understood about MERS-CoV, people with diabetes, renal failure, chronic lung disease, and immunocompromised persons are considered to be at high risk of severe disease from MERS-CoV infection. Therefore, in addition to avoiding close contact with suspected or confirmed human cases of the disease, people with these conditions should avoid close contact with animals, particularly camels, when visiting farms, markets, or barn areas where the virus is known to be or potentially circulating. General hygiene measures, such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to.

Food hygiene practices should be observed. People should avoid drinking raw camel milk or camel urine, or eating meat that has not been properly cooked.

WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

EID Journal: Geographic Distribution of MERS-CoV among Dromedary Camels, Africa

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Six years ago this week, Dr. Ali Mohamed Zaki - an Egyptian virologist working in Saudi Arabia - collected blood and sputum samples from a 60 year old Saudi male hospitalized with with pneumonia and acute renal failure and began testing to determine the pathogen involved (see Nature Middle East The story of the first MERS patient).

Although he was able to isolate and culture a virus, his laboratory lacked the facilities to sequence its genome. He decided to send a sample to Dr. Ron Fouchier, at the Erasmus Medical Centre in the Netherlands, who had the equipment to do a proper analysis.

Two months later, Dr. Zaki emailed ProMed Mail (see Sometimes They Come Back), announcing the discovery of a new `SARS-like' coronavirus. Dr. Zaki's eventual `reward’ was that he was fired by the Saudis for going public with his discovery, proving once again that no good deed goes unpunished.  

Roughly one year - and 91 confirmed cases MERS Cases later - dromedary camels were pegged as the likely zoonotic conduit of the virus to humans (see Lancet: Camels Found With Antibodies To MERS-CoV-Like Virus).

At first the Saudis were slow to accept the idea that camels - a beloved symbol of their country - could carry a deadly disease (see Saudi Health Minister denies relation between camels, Mers).

In the face of mounting evidence, however, (see EID Journal: MERS Coronaviruses in Dromedary Camels, Egypt & The Lancet: Identification Of MERS Virus In Camels), in May of 2014 the Saudi Ministry Of Agriculture Issued Warnings On Camels, urging breeders and owners to limit their contact with camels, and to use PPEs (masks, gloves, protective clothing) when in close contact with their animals. 

Once camels in KSA were implicated, researchers began testing camels in other regions of the Middle East and Africa. Looking for, and finding, evidence of carriage of the MERS coronavirus going back many years.

EID Journal: MERS Antibodies In Camels – Kenya 1992-2013

Kuwait Tests Camels - Finds 6% Positive For MERS-CoV

EID Journal: Three Decades Of MERS-CoV Antibodies In Camels

Last year, in MERS-CoV In Camels: The Gift That Keeps On Giving, we saw a study that demonstrated that camels can be reinfected by the MERS virus, despite having substantial antibody titers.  A finding that may significantly complicate vaccine creation.

One of the (many) mysteries surrounding MERS-CoV is that while camel infection appears common on the Arabian peninsula, Saudi Arabia accounts for roughly 90% of known human MERS infections in that part of the world.

Even further afield, in early 2017 we saw EID Journal: Serologic Evidence Of MERS-CoV Infection in Pakistani Camels, and in 2015 Eurosurveillance: MERS-CoV In Nigerian Camels, yet South Asia and Africa have never reported a human infection.

Today we can add another study, published in the EID Journal, that further expands the geographic range of MERS-CoV in African camels, and shows its prevalence to be very high.   

I've only posted some excerpts, so you'll want to follow the link to read it in its entirety.  I'll have a bit more when you return. 

Volume 20, Number 8—August 2014
Dispatch
Geographic Distribution of MERS Coronavirus among Dromedary Camels, Africa

Chantal B.E.M. Reusken1 , Lilia Messadi1, Ashenafi Feyisa1, Hussaini Ularamu1, Gert-Jan Godeke, Agom Danmarwa, Fufa Dawo, Mohamed Jemli, Simenew Melaku, David Shamaki, Yusuf Woma, Yiltawe Wungak, Endrias Zewdu Gebremedhin, Ilse Zutt, Berend-Jan Bosch, Bart L. Haagmans, and Marion P.G. Koopmans

Abstract

We found serologic evidence for the circulation of Middle East respiratory syndrome coronavirus among dromedary camels in Nigeria, Tunisia, and Ethiopia. Circulation of the virus among dromedaries across broad areas of Africa may indicate that this disease is currently underdiagnosed in humans outside the Arabian Peninsula.

A novel betacoronavirus, Middle East respiratory syndrome coronavirus (MERS-CoV), was identified as the cause of severe respiratory disease in humans during 2012 (1). In August 2013, dromedary camels (Camelus dromedarius) were implicated for the first time as a possible source for human infection on the basis of the presence of MERS-CoV neutralizing antibodies in dromedaries from Oman and the Canary Islands of Spain (2).

Since then, the presence of MERS-CoV antibodies in dromedaries has been reported in Jordan (3), Egypt (4,5), the United Arab Emirates (6,7), and Saudi Arabia (8,9). In October 2013, analysis of an outbreak associated with 1 barn in Qatar (10) found dromedaries and humans to be infected with nearly identical strains of MERS-CoV.

Further proof of widespread circulation of MERS-CoV among dromedaries was provided by studies from Egypt and Saudi Arabia (5,9). These findings have raised questions about the geographic distribution of MERS-CoV among camel populations elsewhere. Here, we report our assessment of the geographic distribution of MERS-CoV circulation among dromedaries in Africa by serologic investigation of convenience samples from these animals in Nigeria, Tunisia, and Ethiopia.

        (SNIP)

A question raised by these findings is whether human cases occur outside the Arabian Peninsula and if such cases are currently underdiagnosed in Africa. In addition, for the whole region, the possibility exists that MERS-CoV illness occurred before its discovery in 2012 and that such infection has been overlooked in the areas with evidence for virus circulation among animals during the past 10 years. Retrospective studies of cohorts of humans with respiratory illnesses of unknown etiology should address this notion.

Alternative explanations for the lack of cases in Africa could be the following: a different risk profile, for instance, related to demographics and local practices; or subtle genetic differences in the circulating virus strain.

Full-genome sequencing, virus isolation, and phenotypic characterization of viruses circulating outside the Arabian Peninsula will resolve this issue. Meanwhile, awareness of MERS-CoV infections should be raised among clinicians in Africa.

(Continue . . . )

While it may seem unlikely than any significant number of clinical MERS cases could go undetected in Africa, it isn't as far-fetched of an idea as it may sound.

Despite years of reporting outbreaks of H5N1 in Sub-Saharan African poultry, only one human infection with the virus has ever been confirmed there by the WHO (see 2007’s Nigeria Confirms Human Bird Flu Case).

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

According to local media reports at the time (see The Nigerian Paradox), the only reason we have the one confirmed case is because the husband/father of the two related victims paid for a private autopsy and lab testing when his daughter died two weeks after his wife. 

The reality is, in Nigeria (pop. 175 million) - the average life expectancy is about 53 years - and roughly 6,000 people die each and every day.  Many are never  afforded medical care, and testing for exotic diseases like H5N1 or MERS-CoV is rarely - if ever - done.

According to the CDC, the top 10 causes of death in Nigeria are:

Deaths from lower respiratory infections in Nigeria, which can cover a lot of territory – including novel influenza or MERS-CoV – are second only to malaria.

The story is much the same in many other African nations where MERS has been detected in camels, with lower respiratory infections claiming 4% of lives in Egypt, 10% in Ethiopia, 5.4% in Tunisia, and while good data is hard to come by, at least 10% in Sudan.

Even in Saudi Arabia, where decent medical care is available, and the threat of MERS is well recognized, we've seen estimates that many - perhaps even most - MERS cases go undetected.

• In November of 2013, we looked at a study published in The Lancet Infectious Diseases, that estimated for every case identified, there are likely 5 to 10 that go undetected.
• In 2015, when Saudi Arabia had recorded fewer than 1200 MERS cases, a seroprevalence study (see Presence of Middle East respiratory syndrome coronavirus antibodies in Saudi Arabia: a nationwide, cross-sectional, serological study by Drosten & Memish et al.,) suggested nearly 45,000 might have been infected. 
• And a 2016 study (see EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016) suggested that as much as 60% of severe Saudi MERS cases go undiagnosed.

In 2016, in EID Journal: MERS-CoV Antibodies in Humans, Africa, 2013–2014, we looked at the results of a seroprevalence study conducted in Kenya, which produced remarkably similar results to what Drosten & Memish et al found in KSA;  

1.52% vs. 1.43% positivity by rELISA and 0.15% vs. 0.18% positivity by PRNT for Kenya vs. Saudi Arabia, respectively.

Whether the MERS virus carried by African dromedaries pose the same human health risks as those on the Arabian peninsula remains an open question - but given the limits of surveillance and testing in the region - we’d be remiss in excluding that possibility simply because we haven't seen any confirmed cases.

Clinical & Epidemiological Characteristics of A(H9N2) Infection In A Young Child - China, 2017

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At first glance, H9N2 - a ubiquitous (at least in Asia and the Middle East, and recently reported in Africa), low pathogenic avian influenza (LPAI) virus that  generally produces mild symptoms in poultry - appears fairly tame. 

We've seen no large outbreaks in humans - only a few dozen widely scattered, usually mild infections over the past 20 years - mostly reported from China, Egypt, and Bangladesh (see FluTrackers Global Cumulative H9N2 Partial Case List 1998-2017).

Despite all of that, H9N2 is regarded as having at least some pandemic potential (see CDC IRAT SCORE), and so several candidate vaccines have been developed over the years.

Avian H9N2 virus occupies a special spot in our bird flu coverage because - while so far only an LPAI virus in poultry - its internal genes routinely make up the backbone of many of the HPAI viruses (including H5N1, H5N6, and H7N9) that pose the greatest risks to both poultry, and human health.

H9N2's reach extends beyond just avian flu subtypes, as we've also seen evidence of it reassorting with other influenza viruses, including A Canine H3N2 Virus With PA Gene From Avian H9N2 - Korea and PNAS: Reassortment Of H1N1 And H9N2 Avian viruses.

In 2014, in PLoS Path: Genetics, Receptor Binding, and Transmissibility Of Avian H9N2 researchers found evidence of Chinese H9N2 viruses binding preferentially to alpha 2,6 receptor cells -  the type commonly found in the human upper respiratory tract - rather than to alpha 2,3 receptor cells which are found in the gastrointestinal tract of birds.

Also in 2014  The Lancet carried a report entitled Poultry carrying H9N2 act as incubators for novel human avian influenza viruses  where  researchers warned that `reassortment between the prevalent poultry H9N2 viruses (providing genetic segments) and the influenza virus from wild birds could make the influenza evolve to adapt to domestic hosts.'

Earlier this year, in H9N2 Adaptation In Minks, we saw even more evidence of mammalian adaptation of H9N2, in a study that found H9N2 influenza virus isolated from minks has enhanced virulence in mice.

While relatively few human infections have been reported, we've seen a decided uptick in the past few years.  Although this is likely due to better surveillance, its (generally) mild presentation probably means most cases go undetected. 

We've a case report of a 2017 infection from China - one which was reported by the WHO in their 27 September 2017 Monthly Risk Assessment - albeit without much in the way of details:

Since the last update, one laboratory-confirmed human cases of A(H9N2) virus infection was reported to WHO from China. The patient is a child who had mild illness onset of 18 September, received outpatient care and had no apparent exposure history to live poultry.

Today we learn more about the case, along with some surprising statistics  about just how spotty surveillance is in China when it comes to detecting mild, novel flu virus infections.   I've only included some excerpts, so you'll want to download the PDF to read the report in its entirety.

Clinical and epidemiological characteristics of a young child infected with avian influenza A (H9N2) virus in China

First Published June 13, 2018 Case Report

Download PDF

ABSTRACT
Three cases of the avian influenza A (H9N2) virus have been documented in Changsha, which is a large city that has nine districts and a population of 7.04 million in central South China. Among these patients, one was a girl and two were boys. The ages of the patients were 9 months, 2 years, and 15 years. Two cases of H9N2 were detected in September, 2015 and one was detected in 2017.

Two patients were children who had not reached the age for kindergarten and one was a student. These three cases were all mild and were detected in a sentinel hospital of the Chinese Influenza Surveillance System. We describe the clinical and epidemiological features of the youngest patient with H9N2 in 2017 and the surveillance results of the H9N2 virus in live poultry markets in Changsha.

From January 2014 to December 2017, 4212 samples were collected in live poultry markets in Changsha, among which 25.81% (1087/4212) were H9N2-positive. Public health concerns should be addressed for emerging H9N2 virus infection, and more strategies should be performed before this virus mutates to be more transmissible and highly pathogenic.

        (SNIP)

       CASE REPORT

The patient, who lives in a six-person family in District A in Changsha, was a 9-month- old boy with no vaccination history of influenza vaccine and no other disease history. The boy had symptoms of fever (no temperature measurement was taken at this time) and was sneezing at 4:00 h on 18 September, 2017. Several hours later, with an auxiliary temperature of 39.5 C, he was sent to the paediatric emergency department of a sentinel hospital of the CISS system. 

A routine blood examination showed that the white blood cell count was 10.31 Â 10 9 /L and neutrophils represented 45.9% of blood cells. A throat swab sample was collected at the emergency department for pathogenic detection. Influenza virus antigen detection showed a positive result for influenza A.

Consequently, he was diagnosed with influenza and treated with oseltamivir and ibuprofen. However, the patient’s symptoms did not improve after treatment. He returned to hospital three times since 16:00 h on 18 September to 15:00 h on 20 September. Besides oseltamivir and ibuprofen, he was then prescribed oral medi-
cine, including Bifidobacterium and a Chinese traditional medicine (Xiao’er Chiqiao Qingre Keli), as well as intravenous medicine, including andrographolide injection, vitamin C, amino acids, potassium chloride, and a paediatric electrolyte supplements injection. No symptoms were observed after 15:00 h on 20 September.

The result of a throat swab sample (collected on 18 September) was H9N2-positive by using polymerase chain reaction, which was performed in the influenza surveillance network laboratory in Changsha Center for Disease Control and Prevention on 22 September. Another throat swab sample that was collected on 23 September was H9N2-negative when tested on 24 September.

        (Continue . . . )



While this child did not have recent poultry exposure, his parents both worked at a retail market where poultry was sold, and his father and sister both reported mild, non-specific symptoms in the days leading up to his illness. Again from the report:

The patient’s elder sister developed a mild fever, which rapidly disappeared between 16 and 17 September. She did not receive any medical treatment during these days. The patient’s father had mild nasal obstruction, which rapidly disappeared on 18 September. The other family members did not have any symptoms of the upper respiratory tract or influenza-like illness before the patient’s illness onset date.

Blood samples were pulled from the father and sister on the 23rd, but came back negative for H9N2.  There is no mention of additional testing for H9N2 among the remainder of the 36 close contacts identified, none of whom were reportedly symptomatic.

From the discussion section of the case report, we get a much better idea of the limits of routine testing of flu samples in China.  

Because of the mild symptoms, children infected with H9N2 and other subtypes of avian influenza virus were commonly detected by sentinel hospitals of the CISS system. However, a large amount of hospitals are not covered by this system. In Changsha, there are more than 50 hospitals, excluding private clinics and health care centres, but only two hospitals are included in the CISS system.

The authors conclude by writing:

Although no environmental surveillance evidence of our case was provided to show a full transmission chain, the positive rates of H9N2 were high in live poultry markets in nine districts of Changsha. Owing to the high prevalence of H9N2 virus in live poultry markets, more H9N2 viral infections might be missed in China. Therefore, public health concerns should be addressed for emerging H9N2 virus infection, and more strategies should be performed before this virus mutates to be more transmissible and highly pathogenic.

Whether H9N2 ever poses a direct pandemic threat or not, it continues to aid and abet in the creation of new, potentially deadly, bird flu viruses. That alone makes it worthy of our attention, although any substantial increase in human infection would be of concern as well.

Unfortunately, the two regions of the world where these human infections tend to occur (China & Egypt) are also among the least likely to publicize their existence.
 

DAERA: H5N6 Confirmed In Wild Bird In Northern Ireland

Credit DAERA

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Although the summer is traditionally the slow season for avian flu reports in the Northern Hemisphere, over the past couple of days we've seen outbreaks from both Russia and Bulgaria, and today DAERA is reporting on the discovery of a dead goose recently recovered in County Armagh that has tested positive for HPAI H5N6.

A reminder that while poultry outbreaks have been greatly reduced this past winter and spring, that the virus continues to circulate in wild birds.

Avian Influenza confirmed in a wild bird in Co Armagh

Date published: 15 June 2018

The Department of Agriculture, Environment and Rural Affairs today confirmed that a wild greylag goose, found in Lurgan Park, Co Armagh, has tested positive for H5N6 Avian Influenza.

The goose was reported to DAERA as part of its dead wild bird surveillance programme, and was submitted for testing at the Agri-Food and Biosciences Institute (AFBI), where initial testing has indicated avian influenza, sub-type H5N6. This is the same strain as confirmed in a wild buzzard in Co Antrim in March this year.

The Chief Veterinary Officer for Northern Ireland, Dr Robert Huey, said: “This is the second case of H5N6 in a wild bird in Northern Ireland this season and is not unexpected given that avian influenza continues to circulate in wild birds across Europe.

It further emphasises the requirement for all bird keepers to remain vigilant and to critically review their biosecurity measures, for example, feeding and watering birds under cover to help reduce the risk of their poultry coming in contact with wild birds. It is important that flock keepers report early any suspicions of disease.

“While the risk of an avian influenza incursion in wild birds remains, the risk to poultry is low. However, it is essential that we take the necessary steps to protect our poultry industry, international trade and the wider economy.

“I continue to encourage strongly all bird keepers to register their flocks. This will ensure they receive the latest information from the Department and also allow them to be contacted in an avian disease outbreak enabling them to protect their flock at the earliest opportunity. I would also encourage bird keepers to subscribe to the Avian Influenza text service by simply texting: ‘BIRDS’ to 67300”

Advice from the Public Health Agency is that the risk to public health from the virus is very low, however the general public is advised to take appropriate biosecurity precautions before touching or picking up birds that are dead, or appear to be sick or dying. Further advice can be found on the DAERA website.

The Food Standards Agency has confirmed that Avian Influenza does not pose a food safety risk for UK consumers. Thoroughly cooked poultry and poultry products, including eggs, are safe to eat.

Members of the public are encouraged to report dead waterfowl (swans, geese or ducks) or gulls, or five or more dead wild birds of other species in the same location, to the DAERA helpline on 0300 200 7840, Mon-Fri 9am to 5pm).

If you are concerned about the health of your birds you should seek advice from your veterinary surgeon. If you suspect that your birds are showing signs of the disease you should immediately report it to your nearest Department Veterinary Office.

More On the Bulgarian Avian Flu Outbreak In Dobrich

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The Bulgarian Agency For Food Safety has posted another update on their website on the avian flu outbreak reported yesterday (see Bulgarian Food Safety Agency Reports Avian Flu At Poultry Farm In Dobrich), and we are beginning to get more details from the local press. 

At this point the full subtype has not been announced, although we've seen outbreaks of HPAI H5N8 in this region over the past several months. 

First, we have the following (translated) statement on the Food Safety website:

Take measures following the detection of an outbreak of avian influenza in. Donchevo m. Dobrich 

14.06.2018
 
On 06/13/2018 Bulgarian Agency for Food Safety confirmed an outbreak of highly pathogenic avian influenza in the holding of rearing laying hens in. Donchevo m. Dobrich. Immediately after the establishment of the disease NVS ordered to take measures in accordance with Decree № SG-103 of 21 August 2006 on measures for prevention, control and eradication of avian influenza (flu) influenza including:

1. Forced humanely killed and destroyed under official supervision of the corpses laying hens in a manner precluding spread of the disease;
2. Performing multiple mechanical cleaning and disinfection of premises for poultry, equipment, vehicles, and yards and roads in and around the poultry facility.
3. They are defined protection zone, which includes the settlements within a radius of three kilometers and a surveillance zone within a radius of ten kilometers around the outbreak of the disease. The measures in these areas are:

• a ban on trade and movement of poultry, wild, other birds and eggs for breeding;
• ban on organizing and conducting fairs, markets and exhibitions for poultry;
• a ban on releasing of birds renewal of game reserves;
• conducting a census, registration and daily clinical examinations of birds kept in settlements located in the protection and surveillance zones;
• carrying out periodic clinical examinations of birds kept in the villages on the territory of Dobrich;
• sampling for laboratory testing in any doubt about avian influenza;
• doing research and tracking over the past three weeks, which covers movements of poultry and other birds, eggs, products and animal by-products derived therefrom feed for poultry and means of transport associated with the process in the protection and surveillance zones ;
• verification for the implementation of biosecurity measures at poultry sites in Dobrich. The owners of the objects that have not adopted biosecurity measures will be penalized.
• Control the entry of people in and from farms where the birds are kept;
• strict control over the production, processing and marketing of poultry meat products from poultry meat and eggs in Dobrich.

Not mentioned in either of the two official reports we've seen, but being reported by local media, is that the affected farm is supposedly the largest egg producer in the country, where more than 550,000 birds are housed.

So far, only two barns -  involving about 35,000 birds - are reported to be  affected.  This from TVN News.

Bird flu struck the biggest Bulgarian company for production of eggs

Author: June 15, 2018 Video

Only two weeks after the secondary outbreak of bird flu in the village of Stefanovo in Dobrich kindled a new outbreak.

Is smitten largest enterprise for production of eggs in Bulgaria, which is located in the village Donchevo. It raised 550 000 laying hens, so far struck two warehouses in commodity laying hens. A destruction of 35,000 birds, as hopes of owner Ivan Ivanov have this limit contagion.

He informed the Regional Directorate for Food Safety on Tuesday, but yesterday issued an order for the destruction of dead birds flu, it has not really begun.

The owner rejected versions of deliberately infecting with the aim of favoring by insurance or benefits. According to him, they would not be enough to restore production. The farm bred 350 000 200 000 hens and breeding hens produce around 150 million. Eggs per year. Now gives bread to over 200 families.

The main reason for the emerging country outbreaks of avian ban the EC to vaccinate birds and too little spacing of 200 meters between farms categorically Ivanov. The village people today have not yet been notified.

Mayor Donchevo accidentally found out about the situation of the extraordinary session of Dobrich Municipality yesterday, which ironically was convened for the untimely disclosure of the outbreak in the village Stefanov. Official document is not received. Both epizootic commissions - regional and municipal met behind closed doors.

All commercial establishments were sent letters - eggs infected in the last two weeks, to be harvested by commercial halls and be disposed of in the shops themselves.

Determined is a 3-km protection zone, which includes the villages Bogdanovo, Donchevo and Opanets. The marketing and movement of poultry and wild birds and eggs for breeding.

Experts will monitor poultry farms in the 10-kilometer zone. They will be constantly checked by veterinarians.

Regular readers will recall that just over a year ago H5N8 contaminated poultry products shipped from a single infected turkey farm in the Rostov region of Russia sparked a massive months-long operation to remove potentially tainted products from their food chain.

A few blogs on that incident include:

Rosselkhoznador Investigation Into HPAI Contaminated Meat Distribution & Sale

Rosselkhoznador: HPAI Contaminated Poultry Shipped To At Least 9 Regions Of Russia

Russia: Rosselkhoznadzor Finds More HPAI Contaminated Meat In Retail Stores

The concern then was less about human infection with the H5N8 virus - which has never been documented - and more about preventing the inadvertent spread of the virus to farms or to wild birds in other regions of the country.

And those are essentially the same concerns today in Bulgaria, as orders have gone out to destroy all eggs recently shipped from the afflicted farm.  

This (translated) report from Topnovini.bg.

Imposed a prohibition on eggs produced on a farm in. Donchevo


Outlined measures to suppress the outbreak of bird flu in Dobrich farm

Imposed a prohibition on eggs produced on the farm in the village of Dobrich Donchevo where there has been an outbreak of influenza. Letters were sent to all outlets, charge the eggs from the facility in the past two weeks, forbidden to sell products will be disposed of in stores, the press office of the regional government.

At a meeting of the Regional epizootic commission has identified measures to suppress the outbreak of avian influenza in. Donchevo, Dobrich region.

Holdings is located in 10 km zone defined on occasion found fireplace for the second time on a farm in. Stefanovo, said Dr. Kamenov in his report. Holding in. Donchevo is divided into different sectors.

Sunday evening veterinarian farm noticed increased mortality in one sector. On Sunday, there was again a large number of dead birds than usual. This gave rise to the veterinary specialist to a signal for increased mortality in the subject, were immediately taken and sampled.

Their results have confirmed the presence of influenza type H5 while awaiting the results of the second part of the virus, added Dr. Kamenov. Increased mortality was recorded in the production halls, where there is a total of about 320 thousand. Birds. Throughout holding birds are total 551 300 units.

According to the regulations and the regulations are taken immediate action. The object is divided into sectors introduced is increased biosecurity. Today we move on to the humane killing of birds in two of the rooms, as in every one of them has about 16 thousand. Number of birds. In parallel, monitor the condition of hens in other rooms. Imposed a foreclosure and produced eggs. Letters were sent to all outlets stocked eggs otfermata over the past two weeks.

Dr. Anelia Andonova clarify that these eggs are forbidden for sale and will be disposed of in commercial establishments on the ground. The very birds on the farm will be liquidated in the incinerator site, which is expected within today be delivered.

        (Continue . . . )


While likely not a human health concern - given the damage to Europe's poultry industry from their record setting H5N8 2016-17 epizootic - these measures are quite understandable.

Stay tuned.