CDC Acute Flaccid Myelitis (AFM) Update - Oct 22nd

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As promised early last week, the CDC has updated their AFM Surveillance page this afternoon - and while the total number of confirmed cases remains unchanged at 62 - roughly 2 dozen new PUIs (Patients Under Investigation) have been added since last week's update (n=155).

Acute flaccid myelitis (AFM) is a rare illness that affects a person’s nervous system - specifically the spinal cord - and while rare, most cases occur in children. AFM falls under a broader `umbrella' of syndromes called Acute Flaccid paralysis (AFP).

Given the delays in both reporting cases, and confirming diagnoses, it seems likely that the numbers we have today will continue to rise over the next few weeks.  AFM remains exceedingly rare, striking fewer than 1 person in a million each year, but of those who are affected, 90% are under the age of 18.

Although Enterovirus D68 and EV-A71 have both been implicated in past cases (along with a number of other viral suspects), as of now no definitive cause has been determined for the bulk of these cases.  

Last week, in mBio: Contemporary EV-D68 Strains Have Acquired The Ability To Infect Human Neuronal Cells, we looked at a new study that adds plausibility - but not proof - that EV-D68 may be behind many of these cases.

Making diagnosis more difficult, paralysis often only appears days or even  weeks after a mild viral infection, and all too often no trace of the initiating virus remains detectable in the patient.

From the CDC AFM Surveillance page:

At a Glance

• CDC is concerned about AFM, a serious condition that causes weakness in the arms or legs.
• From August 2014 through September 2018, CDC has received information on a total of 386 confirmed cases of AFM across the US; most of the cases have occurred in children.
• Even with an increase in cases since 2014, AFM remains a very rare condition. Less than one in a million people in the United States get AFM each year.
• While we don’t know the cause of most of the AFM cases, it’s always important to practice disease prevention steps, such as staying up-to-date on vaccines, washing your hands, and protecting yourself from mosquito bites.

What This Graph Shows

The graph shows the number of AFM cases confirmed by CDC as of October 19, 2018, with onset of the condition through September 30, 2018.

• So far in 2018, there are 62 confirmed cases of AFM. (Note: The cases occurred in 22 states across the U.S.)
  Note: These 62 confirmed cases are among the total of 155 reports that CDC received of patients under investigation (PUIs). CDC recently received increased reports for PUIs with onset of symptoms in August and September. CDC and state and local health departments are still investigating some of these PUIs. With enhanced efforts working with local and state health departments and hospitals, we were able to gather information on PUIs and confirm a number of these cases faster. CDC is now providing the number of patients still under investigation so people can better anticipate increases in confirmed cases over the coming months.
• In 2017, CDC received information for 33 confirmed cases of AFM. (Note: The cases occurred in 16 states across the U.S.)
• In 2016, 149 people were confirmed to have AFM. (Note: The cases occurred in 39 states across the U.S. and DC)
• In 2015, 22 people were confirmed to have AFM. (Note: The cases occurred in 17 states across the U.S.)
• From August to December 2014, 120 people were confirmed to have AFM. (Note: The cases occurred in 34 states across the U.S.)
• The case counts represent only those cases for which information has been sent to and confirmed by CDC.

It is currently difficult to interpret trends of the AFM data. Collecting information about suspected AFM cases is relatively new, and it is voluntary for most states to send this information to CDC. There may initially be more variability in the AFM data from year to year making it difficult to interpret or compare case counts between years.

We defer to the states to release additional information on cases as they choose.

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If you suspect you or your child is suffering from unexplained muscle weakness or paralysis, it is important to seek medical care immediately. The CDC continues to investigate, but until more is known, the CDC can only offer the following advice.

Prevention

Poliovirus and West Nile virus may sometimes lead to AFM.

• You can protect yourself and your children from poliovirus by getting vaccinated.
• You can protect against bites from mosquitoes, which can carry West Nile virus, by using mosquito repellent, staying indoors at dusk and dawn (when bites are more common), and removing standing or stagnant water near your home (where mosquitoes can breed).

While we don’t know if it is effective in preventing AFM, washing your hands often with soap and water is one of the best ways to avoid getting sick and spreading germs to other people. Learn about when and how to wash your hands.

For more information on what CDC is doing, see our AFM Investigation page.

FAO: South Korea Confirms HPAI H5 In Environmental Samples

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Three weeks ago South Korea announced this fall's arrival of migratory birds, and since then we've seen a number of reports of Avian Influenza (AI) detection in wild bird feces (see here), including one identified as H5N2. 

Until today, all of those detections have been identified as LPAI (low path) viruses, which are not unexpected, and rarely pose a serious threat. 

Today we've the first two HPAI FAO announcements, one from Chungbuk Province in the center of the country, and one from Jeonbuk Province to the south and west. 

The full subtype has not been identified, and we'll be very interested to see which flavor of HPAI H5 has returned this fall.

So far, South Korea hasn't reported any infected poultry this fall and Japan's Ministry of Environment hasn't reported any AI detections since last spring.

Japan MAFF: ASF Virus Detected In Luggage At Hokkaido Airport

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Roughly two months ago South Korea reported several detections of the African Swine Fever Virus among foodstuffs brought back by travelers arriving from China. Important because even dried or cured pork products can contain live ASF virus.

As mentioned in my last blog, the movement of ASF contaminated food, feed, vehicles or animals has been linked to the rapid spread of the virus both in China, and in Eastern Europe.

Last August, in African swine fever (ASF) threatens to spread from China to other Asian countries, the FAO described just how easily ASF can cross borders, and even oceans.

A robust virus with a long life

The ASF virus is very hardy and can survive long periods in very cold and very hot weather, and even in dried or cured pork products. The strain detected in China is similar to one that infected pigs in eastern Russia in 2017 but, so far, and while the investigations continue, the China Animal Health and Epidemiology Center has found no conclusive evidence of this latest outbreak's source or linkages.

"The movement of pig products can spread diseases quickly and, as in this case of African Swine Fever, it's likely that the movement of such products, rather than live pigs, has caused the spread of the virus to other parts of China," explained Juan Lubroth, FAO's Chief Veterinarian.

Today Japan's MAFF has an all too familiar sounding report of ASF infected sausages detected at Hokkaido Airport in the luggage of a traveler returning from China (see Japanese PDF [Notification] for re-thoroughness of feeding and health management standards compliance associated with the detection of African swine fever virus gene from the passenger of mobile products (2018 October 22) (PDF: 1,506KB)).

Between the PDF formatting and the translation software, most readers will probably do better with the English Language report published by Kyodo news, at the link below.

African swine fever virus detected in luggage at Hokkaido airport

While Japan remains ASF free, it lost its coveted Classical Swine Fever (CSF) free status last month after going 26 years without detecting the virus (see Japan: MAFF Confirms Classical Swine Fever Outbreak).

Exactly how CSF arrived to Japan is unknown, but there's a pretty good chance it arrived from China - or some other endemic country - via the (legal or illegal) transport of contaminated products. 

While we generally think of infected travelers or migratory birds carrying infectious diseases across international borders (see ECDC: RRA On Imported Monkeypox Cases From Nigeria), the legal (and illegal) transport of live animals, food, animal feed, and even the contaminated conveyances themselves can deliver a stunning variety of zoonotic and agricultural diseases around the globe.  

Some recent blogs on these topics include:

Russia: Rosselkhoznadzor Tracing ASF Contaminated Meat Products

Hong Kong FEHD Finds Another Shop Selling H5 Contaminated Poultry

Bulgarian NVS: Confirmed Avian Flu In 2 Illegally Transported Birds

Taiwan Seizes 210 Bottles of Illegal Chinese `Poultry Vaccine'

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

African Swine Fever Reaches Southern China (Yunnan Province) & 2nd Outbreak in Zhejiang

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Until now, China's ASF epidemic has been concentrated in the Northeastern part of the country (see USDA map below, dated Oct 17th), with the bulk of the nation's 40+ outbreaks reported in Liaoning & Anhui Provinces.

Today, China's MOA reports ASF for the first time in the southern province of Yunnan - representing a jump of well over 1000 km from the nearest previous  outbreak - along with a re-occurrence in Zhejiang province.

Two (translated) reports:  First two outbreaks in Yunnan Province, followed by a single outbreak in Zhejiang.

African swine fever epidemic in Zhaotong City, Yunnan Province

Date: 2018-10-22 08:41 Author: Source: Ministry of Agriculture and Rural Press Office 

The Information Office of the Ministry of Agriculture and Rural Affairs was released on October 21, and an African pig swine epidemic occurred in Zhenxiong County, Zhaotong City, Yunnan Province.

At 20 o'clock on October 20, the Ministry of Agriculture and Rural Affairs received a report from the China Animal Disease Prevention and Control Center. The Yunnan Provincial Center for Animal Disease Control and Prevention received samples for diagnosis in Africa by the China Center for Animal Health and Epidemiology (National Center for Animal Diseases Research). Swine fever.

The positive samples were from a farm and a breeding professional cooperative in Niuchang Town, Zhenxiong County, Zhaotong City, Yunnan Province. The cattle farms in Niuchang Town had 804 live pigs, 298 cases, and 298 deaths. There were 353 live pigs, 247 onset, and 247 deaths.

Immediately after the outbreak, the Ministry of Agriculture and Rural Affairs sent a steering group to the local area. The local government has started the emergency response mechanism as required, and adopted measures such as blockade, culling, harmless treatment, disinfection, etc., to treat all the sick and culled pigs harmlessly. At the same time, all pigs and their products are prohibited from being transferred out of the blockade, and pigs are prohibited from being transported into the blockade. At present, the above epidemic has been effectively disposed of.

 Report #2:

African swine fever epidemic in Taizhou City, Zhejiang Province

Date: 2018-10-22 12:51 Author: Source: Ministry of Agriculture and Rural Press Office 

The Information Office of the Ministry of Agriculture and Rural Affairs was released on October 22, and the pig swine fever in pigs in Taizhou City, Zhejiang Province.

At 1700 on October 21, the Ministry of Agriculture and Rural Affairs received a report from the China Center for Animal Disease Control and Prevention. The sample submitted by the Zhejiang Provincial Center for Animal Disease Control and Prevention was diagnosed as Africa by the China Center for Animal Health and Epidemiology (National Center for Animal Disease Research). Swine fever.

The positive samples were from a breeding professional cooperative in Sanmen County, Taizhou City, Zhejiang Province. The breeding professional cooperatives had 2,280 live pigs, 56 diseases and 56 deaths.

Immediately after the outbreak, the Ministry of Agriculture and Rural Affairs sent a steering group to the local area. The local government has started the emergency response mechanism as required, and adopted measures such as blockade, culling, harmless treatment, disinfection, etc., to treat all the sick and culled pigs harmlessly. At the same time, all pigs and their products are prohibited from being transferred out of the blockade, and pigs are prohibited from being transported into the blockade. At present, the above epidemic has been effectively disposed of.

Exactly how ASF arrived to China earlier this year - and quickly spread across half the country - remains a mystery.  That said, it is almost certain that ASF's dissemination is being aided and abetted by human activities, such as the movement of contaminated food, feed, vehicles or animals.

While not a human health risk, African Swine Fever represents a serious threat to the pork industry, local economies, and even to food security for some nations.

ASF has never been reported in North America, but the potential exists for its importation - such as we saw with the arrival of PEDV five years ago - which is believed to have arrived from China (see mBio: PEDV - Porcine Epidemic Diarrhea Virus – An Emerging Coronavirus). 

But with ASF also spreading widely in Eastern Europe and Russia, and recently detected as far west as Belgium, China isn't the only avenue for introduction.

For more on the growing threat of ASF to China, its neighbors, Europe, and potentially the world, you may wish to revisit:

FAO: African Swine Fever (ASF) `Here to Stay' In Asia

African swine fever (ASF) threatens to spread from China to other Asian countries

McKenna On African Swine Fever

Flu Resistant Poultry (Revisited)

2005 CSIRO Report

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Between a steadily rising global population, increasingly erratic climatic conditions, and the constant threat of epizootic and other agricultural diseases, there are genuine concerns on how we feed an increasingly hungry planet going forward.

The FAO's report The State of Food Security and Nutrition in the World 2017 shows a sharp rise in food insecurity around the world since 2014 (see chart below), and warns: AFTER A PROLONGED DECLINE, WORLD HUNGER APPEARS TO BE ON THE RISE AGAIN.

 
Avian influenza has long been known to circulate in wild aquatic birds of the orders Anseriformes (ducks, geese, and swans, etc.) and Charadriiformes (shorebirds, gulls, and auks, etc.) - and importantly - these species can often carry these viruses will little or no ill effect. 

Less well adapted to the viruses, and therefore far more susceptible to illness, are the Galliformes; an order of heavy-bodied ground-feeding birds that includes turkey, chicken, quail and pheasant. 

Commercially raised gallinaceous birds are easily infected by both low and high path viruses, and can rapidly succumb to HPAI infection. 

Over the past several decades we've seen massive losses in the poultry sector due to an array of (mostly) H5 and H7 HPAI viruses, causing not only severe economic losses, but also increases in food insecurity around the world (see Iran: Bird Flu, Food Insecurity & Civil Unrest).

For the past 20 years, serious consideration has been given to developing - either through selective breeding or genetic modification - a flu resistant chicken, in the hopes that it would reduce not only the risk to the poultry sector, but might also diminish the chances of seeing an avian flu pandemic. 

Six years ago, in CSIRO: The Quest For Flu Resistant Poultry, we looked at the progress made in this endeavor by Australia's national science agency CSIRO (Commonwealth Scientific and Industrial Research Organisation).

One of those projects involved CSIRO research scientist, Dr Tim Doran, who was using a technique called gene silencing to “switch off” genes that make chickens susceptible to HPAI H5 viruses (see Silencing the bird flu gene: scientists prep live hen trials).

Dr. Doren is back today, along with other researchers from Australia and the Netherlands, with a review of the options for creating flu resistant poultry, the progress to date, and the challenges that still lie ahead in the following review article from the journal Viruses.    

I've only included a couple of small excerpts, so you'll want to follow the link to read it in its entirety.   When you return, I'll have a postscript.

Review

Creating Disease Resistant Chickens: A Viable Solution to Avian Influenza?

Fong Yang Looi ¹, Michelle L. Baker ², Thomas Townson ¹, Mathilde Richard ³, Ben Novak ², Tim J. Doran ² and Kirsty R. Short ^1,4,*

Received: 27 September 2018 / Accepted: 12 October 2018 / Published: 15 October 2018

Abstract:

Influenza A virus (IAV) represents an ongoing threat to human and animal health worldwide. The generation of IAV-resistant chickens through genetic modification and/or selective breeding may help prevent viral spread. The feasibility of creating genetically modified birds has already been demonstrated with the insertion of transgenes that target IAV into the genomes of chickens. This approach has been met with some success in minimising the spread of IAV but has limitations in terms of its ability to prevent the emergence of disease.

An alternate approach is the use of genetic engineering to improve host resistance by targeting the antiviral immune responses of poultry to IAV. Harnessing such resistance mechanisms in a “genetic restoration” approach may hold the greatest promise yet for generating disease resistant chickens. Continuing to identify genes associated with natural resistance in poultry provides the opportunity to identify new targets for genetic modification and/or selective breeding.

However, as with any new technology, economic, societal, and legislative barriers will need to be overcome before we are likely to see commercialisation of genetically modified birds.

(SNIP)

8. Conclusions

The recent outbreaks of H5Nx viruses across the world highlight the continual threat that avian influenza viruses pose to both poultry and human health. Rapid advances in genomics and gene editing suggest that disease resistant, genetically modified chickens could represent a viable solution to the problem of avian influenza.

However, whilst the creation of influenza resistant chickens is technically possible, there still remain many barriers in place blocking their commercial implementation. These include issues such as consumer concerns and a detailed assessment of their commercial and environmental viability.

It is possible some of these issues can be circumvented and/or mitigated with alternative approaches such as selective breeding and/or genetic restoration. However, regardless of the methodology used, novel approaches to address the issue of avian influenza must remain a global health priority.

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Over the years we've looked at the relative susceptibility of different bird species to Highly Pathogenic Avian Influenza, including.

Vet. Micro.: Experimental Infection Of Mandarin Ducks & Pigeons With HPAI H5N8

Avian Path: Susceptibility of Wild Passerine Birds To HPAI H5N1

Emerg. Microbes & Infections: Wild Ducks Shed (2014-15) HPAI H5N8 Asymptomatically

DEFRA: Assessing The Risk Of Pigeon Racing In Spreading Avian Influenza

As a general rule, waterfowl are the most resistant to infection and/or illness - poultry are the most susceptible - and passerine species (perching birds) fall somewhere in between.

However, when the H5N8 virus sparked Europe's largest epizootic over the winter of 2016/17, it exhibited a number of genetic and behavioral changes following a reassortment that took place sometime in the spring of 2016 (see EID Journal: Reassorted HPAI H5N8 Clade 2.3.4.4. - Germany 2016).

Among the changes, this reinvented HPAI H5 virus displayed rapid geographic spread (including to Africa & the Middle East), increased virulence and mortality in wild birds (including waterfowl), and a greatly expanded avian host range.

Finding ways to make farm animals more disease resistant - particularly without feeding them a constant diet of antibiotics and antivirals - is an incredibly important goal, and worthy of pursuit. 

But flu viruses have continually demonstrated an ability to evolve, adapt, and overcome when confronted by barriers like vaccines and antivirals.  And recently, we can add HPAI H5's recent persistence and increased pathogenicity in waterfowl.

Assuming the substantial challenges of creating a `flu-resistant' chicken can be met - either through genetic modification or selective breeding - and that it is broadly accepted by both the public and the poultry industry, the obvious concern will be just how permanent of a solution this actually turns out to be.

And that is something I don't expect we can really know until we try.

CDC Travel Advisories: Monkeypox, Ebola & More

Credit CDC Twitter Feed

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Over the past 6 weeks we've seen 3 exported cases of Monkeypox from Nigeria (2 to the UK, 1 to Israel), resulting in at least 1 secondary infection in a UK Hospital Worker.

Nigeria reported their first Monkeypox outbreak in nearly 4 decades in the fall of last year, but had stated it was winding down last winter, and issued their last outbreak update in epi week 9 of 2018.

Following the first two exported cases, the Nigerian CDC released their first Monkeypox update in more than 6 months (see Nigeria: CDC Monkeypox Update Epi Week 37), indicating only low levels of detection over the spring and summer.

 Nigeria CDC - Epi Week 37
 

Although the Nigerian CDC website hasn't updated their Monkeypox situation in almost a month, late this week the CDC updated their travel advisory page with the following notice:

Monkeypox in Nigeria

Alert - Level 2, Practice Enhanced Precautions

Key Points

• An outbreak of monkeypox has been ongoing since September 2017 in Nigeria.
• Monkeypox is spread through contact with an infected person or animal (alive or dead), or with material contaminated with the virus. It can also be spread through droplets when infected people cough, sneeze, or talk.
• Travelers to Nigeria should protect themselves from monkeypox by washing hands often with soap and water, and avoiding contact with animals or people that may be sick.

What is the current situation?

As of September 2018, health officials in Nigeria have reported more than 100 confirmed cases of monkeypox, including multiple deaths. As of October 2018, three cases of monkeypox have been reported in travelers to the United Kingdom (2) and Israel (1), including one to GeoSentinel (a global travel surveillance network).

What is monkeypox?

Monkeypox is a rare disease that occurs throughout remote parts of Central and West Africa, often near tropical rainforests. It is spread through contact with the monkeypox virus from an animal or human (alive or dead) or with materials contaminated with the virus. Symptoms begins with fever, headache, muscle aches, swollen lymph nodes and exhaustion, and is followed by a rash. Patients are usually ill for 2-4 weeks. Monkeypox is fatal in as many as 10% of people who get it.

How can travelers protect themselves?

Because monkeypox is spread by contact with animals or humans that have monkeypox, travelers to Nigeria should take steps to prevent illness:

• Wash your hands often with soap and water.
• Don’t touch your eyes, nose, or mouth. If you need to touch your face, make sure your hands are clean.
• Avoid close contact with people who are sick.
• Avoid contact with wild animals or wild animal products and meat that could harbor the virus (including animals that are sick or that have been found dead in areas where monkeypox occurs).
• Avoid contact with any materials, such as bedding, that has been in contact with a sick person or animal.
  

If you feel sick and think you may have monkeypox:

• Seek medical care right away.
• Before you go to a doctor’s office or emergency room, tell the doctor about your recent travel and your symptoms.
• Cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing.

Traveler Information
CDC Monkeypox Homepage
Clinician Information
Monkeypox Information for Health Care Professionals
Monkeypox Information for Veterinarians

The CDC also has an updated Level 2 Travel Alerts for Ebola in the DRC.

Ebola in Democratic Republic of the Congo
 
Alert - Level 2, Practice Enhanced Precautions

Key Points

• There is an outbreak of Ebola in the North Kivu (Kivu Nord) and Ituri provinces in the the northeastern part of the Democratic Republic of the Congo (DRC).
• The outbreak is in a part of the country identified by the U.S. State Department as a “do not travel” zone because of armed group activity and major outbreaks of violence targeting civilians.
• The armed conflict and violence in the outbreak area is hampering response activities including early identification of cases, and monitoring of "contacts" (people who may have been exposed to Ebola).
• Travelers to this area could be infected with Ebola if they come into contact with an infected person’s blood or other body fluids.
• Travelers should seek medical care immediately if they develop fever, headache, body aches, sore throat, diarrhea, weakness, vomiting, stomach pain, rash, or red eyes during or after travel.

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You'll find more than 40 current LEVEL 2 ALERTS on the travel page, covering such health risks as Zika, Polio, Yellow Fever, and Extensively Drug Resistant Typhoid Fever around the globe.

You'll also find two LEVEL 3 warnings:

Warning Level 3, Avoid Nonessential Travel

• Updated  Earthquake and Tsunami in Indonesia October 11, 2018 Because of the recent earthquake and tsunami that struck Indonesia on September 28, travelers to the province of Central Sulawesi may experience serious health and safety risks, and medical care may not be available. CDC recommends that travelers avoid all nonessential travel to the province of Central Sulawesi, Indonesia. Read More >>
• Health Infrastructure Breakdown in Venezuela May 15, 2018 CDC recommends that travelers avoid all nonessential travel to Venezuela. The country is experiencing outbreaks of infectious diseases, and adequate health care is currently not available in most of the country. Read More >>

Along with several dozen Watch Level 1, Practice Usual Precautions reminders.

Before you travel, always visit the CDC Traveler's Health Advice Page for information on current health threats, and any recommended vaccinations.