Wednesday, April 26, 2017

FAO H7N9 Update - Apr 26th

Credit FAO


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

H7N9 situation update

26 April 2017, 17:00 hours; Rome

The next update will be issued on 3 May 2017


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

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

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

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

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

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

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

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

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

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KSA: Another Asymptomatic MERS Case From Wadi Al Dawasir


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

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

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

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

Tuesday, April 25, 2017

More Reports Of Bird Flu In Russia


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

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

© Central body

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

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

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

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

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

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

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

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

Sweden Reports Fresh Outbreak Of HPAI H5N8



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


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

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

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

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

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

Credit HK CHP


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

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

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

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

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


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

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

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


Monday, April 24, 2017

WHO MERS Update - A Household Cluster In The UAE


On April 11th the UAE's Health Authority announced the detection of a single MERS case in Abu Dhabi, albeit with almost zero details provided.

Overnight, the Arabic media has carried reports (which I've been unable to verify off the HAAD website), saying the UAE's health authority has recently issued new, stronger guidelines for testing of respiratory samples.

Abu Dhabi Health" issued an updated standard for monitoring influenza

Date: April 24 2017   

The Health Authority in Abu Dhabi has issued a standard up to date to control and monitor the active influenza and diseases like influenza cases, and called on all health facilities and laboratories in the Emirate of Abu Dhabi to the need to follow the ways of dealing with similar symptoms of influenza cases and infection control in accordance with the instructions and standards body and prompt reporting electronically for any case applicable case definition sick infected with influenza, as well as laboratory results.

The Commission stressed that all health care facilities on the epidemiological investigation of the virus Middle respiratory center «Corona» syndrome and demanded to take all precautions with any confirmed or suspected to be infected with the virus case, and compliance with the directives guiding the World Health Organization regarding the verification and examination and taking into account the procedures for the prevention of infection and control of epidemic diseases acute respiratory symptoms, stressing the need to follow the due precautions in cases dealing with any patient suffering from symptoms similar to the flu.
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While I was waiting for some official confirmation or further details on this story, the World Health Organization published details on the April 11th case, which we now learn involved two cases. The index patient, a 31 y.o. male who died, and a `household contact' who tested positive, but remained asymptomatic.
Asymptomatic MERS cases, once thought to be fairly rare, are turning up more often as more rigorous testing of contacts of known cases (see last summer's Saudi MOH On KKUH MERS Outbreak & Increased Asymptomatic Detections) has become policy in the Middle East. 

While suspected, the role of asymptomatic or mildly symptomatic cases in spreading the virus in the community remains unproven.   

Middle East respiratory syndrome coronavirus (MERS-CoV) – United Arab Emirates
Disease outbreak news
24 April 2017

Between 9 and 11 April 2017, the National IHR Focal Point of United Arab Emirates (UAE) reported two additional cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV). 

Details of the cases

The two cases identified in Abu Dhabi, UAE, were roommates. The case reported to WHO on 9 April 2017 (31-year-old) passed away on 16 April 2017 and the second case reported to WHO on 11 April 2017, identified through tracing of household contacts, is asymptomatic and has been admitted to a negative pressure isolation room on a ward in hospital. The source of infection of the 31-year-old MERS case is under investigation. Contact tracing of household and healthcare contacts is ongoing. Detailed information concerning the cases can be found in a separate document (see link below).
  MERS-CoV cases reported between 9 April and 11 April 2017
xlsx, 22kb

To date, United Arab Emirates has reported 81 laboratory confirmed cases of MERS. The last case was reported in June 2016 (see Disease Outbreak News published on 21 June 2016).

Globally, since September 2012, 1938 laboratory-confirmed cases of infection with MERS-CoV including at least 691 related deaths have been reported to WHO.

WHO risk assessment

MERS-CoV causes severe human infections resulting in high mortality and has demonstrated the ability to transmit between humans. So far, the observed 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.

Although reported MERS activity has been fairly low across the Middle East this year, we've seen estimates that a lot more cases probably occur than are diagnosed.  This call by the UAE's Health Ministry for more rigorous testing of suspected MERS cases could go a long way towards firming up those estimates.