Wednesday, October 18, 2017

Madagascar MOH: 878 Cases Of Plague Reported (80 Deaths)


Madagascar's MOH has updated their plague statistics page adding 73 cases and 6 deaths since their last updated tally on Monday.

The situation of the plague epidemic currently affects 39 Districts,in 17 regions of Madagascar.

For the time being, 878 cases of plague have been recorded for the whole country. The balance sheet reports 80 deaths.

As of today, 44 new cases (27 Antananarivo-Analamanga, 5 Toamasina- Atsinanana, 4 Vakinankaratra, 1 Bongolava, 4 High Matsiatra, 1 Alaotra Mangoro, 1 Amoron'i Mania and 1 Analanjirofo) and 4 deaths (3 Antananarivo-Analamanga and 1 Toamasina-Atsinanana) were observed.
(Source: Ministry of Public Health - 18 October 2017)
 The following figure shows the distribution of the plague situation (by Region) registered to date.

WHO SitRep #4: Plague In Madagascar


Although the numbers don't exactly align with those posted 2 days ago by Madagascar's MOH (see Confirmed & Suspected Plague Now Exceeds 800 Cases), today's update from the World Health Organization shows an increase of 164 cases between Oct. 13th and Oct. 15th. 
The MOH report on the 16th showed fewer overall cases (n=805), but 6 more fatalities (n=73).  Differences in data collection and cut off dates are likely behind these minor differences.
Perhaps most significant is the jump in the number of health care workers who are reported to have contracted the plague.  On October 12th, the WHO report listed 15 HCWs, while today's report references 39.

 Some excerpts from today's WHO Situation Report #4:

Date of issue: 17 October 2017

Madagascar is experiencing a large outbreak of plague affecting major cities and other non-endemic areas since August 2017. Between 1 August and 15 October 2017, a total of 849 cases (suspected, probable and confirmed) including 67 deaths (case fatality rate 7.9%) have been reported from 37 (32.5%) out of 114 districts in the country. Of these, 568 cases (67%) were clinically classified as pneumonic plague, 155 (18.3%) were bubonic plague, one case was septicaemic plague, and 125 cases were unspecified. At least 39 healthcare workers have contracted plague since the beginning of the outbreak.

Of the 849 reported cases, 78 (9.2%) were confirmed, 304 (35.8%) were classified as probable after testing positive on rapid diagnostic tests (RDT) and 467 (55%) remain suspected. Eleven strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.

Eighteen (81.2%) out of 22 regions in the country, including traditionally non-endemic areas, have been affected. The district of Antananarivo Renivohitra has been the most affected, accounting for 57.1% of the reported cases. As of 16 October 2017, a total of 3745 contacts were identified, 79.2% (2 967) of them were followed up on the day of reporting.

Plague is endemic on the Plateaux of Madagascar, including Ankazobe District where the current outbreak originated. There is a seasonal upsurge, predominantly of the bubonic form, which occurs every year, usually between September and April. The plague season began earlier this year and the current outbreak is predominantly pneumonic and is affecting non-endemic areas including major urban centres such as Antananarivo (the capital city) and Toamasina (the port city).

There are three forms of plague, depending on the route of infection: bubonic, septicaemic and pneumonic (for more information, see the link
         (Continue . . . )

Meanwhile, the Seychelles MOH has announced that all suspected plague cases - including the index case - have tested negative.

Press Release: Update on Plague Alert

Regional overview and update
The Plague outbreak in Madagascar persists and is expanding into new areas. However, there is now a strong WHO and other partners’ support on the field that is doing active contact tracing and providing prophylaxis. About 3000 current contacts are on prophylaxis.
Mauritius has reported a suspected case but the person has since been tested negative and was discharged.
All countries in the region are on heightened surveillance and have issued travel advisory.
Local update
•All samples that were sent to Institut Pasteur Paris have been tested by using the PCR technique (Polymerase Chain Reaction). This was a confirmatory test and they were all NEGATIVE.
•All the patients who were isolated on the ward have now been discharged home, including the index case without any further risk. All admitted persons were on antibiotics, including second line.
•They can carry on with normal life as they do not have the plague.
•As of today all persons who were still on passive surveillance have completed their time and those who were still on antibiotics can stop.
People on active surveillance
•Last night four (4) Seychellois and one American were admitted at the Perseverance military academy. They had arrived through Mauritius from Madagascar. They are well and will remain there until 24th October. The American is leaving Seychelles today.
•Three (3) other Seychellois nationals who returned via Nairobi a week ago were released to go home this morning.
•A French national who left Madagascar on 13th October via Reunion will remain in the facility until tomorrow 19th of October.
•Two (2) Australians have also been discharged today.
•The Public Health Authority (PHA) continues to emphasise the advisory to discourage people from travelling to Madagascar for the time being. Anyone who has information that a Seychellois national is planning to travel to Madagascar should send a report to the Public Health authority or refer to CDCU.
•Hotline 141 is active and people can call for information and advice.

Italy: IZSV Reports 2 More Outbreaks Of HPAI H5N8


For the fourth time in the past two weeks Italy's IZSV (Istituto Zooprofilattico Sperimentale delle Venezie) has posted an update announcing new outbreaks of HPAI H5N8 in the northern half of that country. 
Today's two outbreaks bring to 10 the number reported in October alone and is Italy's 50th poultry outbreak of 2017. Of those, 35 have been reported in the past 90 days.
Although a handful of other European countries (including the UK, Sweden, Germany, Belgium, Luxembourg, etc.) have reported a smattering of H5N8 cases over the summer (see DEFRA: Outbreak Assessment On H5N8 In Europe - Summer 2017) , Italy has reported the most outbreaks by far.

This persistence over the summer - albeit at low levels across most of Europe - is in sharp contrast to previous years when reports of H5N8 in Europe and North America all but disappeared once spring ended (see PNAS: The Enigma Of Disappearing HPAI H5 In North American Migratory Waterfowl).

First today's report, then I'll return with a bit more:

Highly pathogenic avian influenza (HPAI) in Italy

2016/2017 - H5N5, H5N82016 - H7N72014/2015 - H5N8, H5N12013 - H7N7
2016/2017 – H5N5, H5N8

Outbreaks | PDF (last update: 17/10/2017)
Maps | PDF (last update: 17/10/2017) 

October 2017

17/10/2017 On 13 October, the Istituto Zooprofilattico Sperimentale della Lombardia e dell’Emilia-Romagna identified as positive for Avian Influenza A virus subtype H5 a fattening turkeys farm located in Brescia province (Lombardy region). The farm hosted 16.178 male birds. Following the confirmation of H5N8 in another fattening turkey farm belonging the same owner, samples were collected on 10 October, testing negative for Avian Influenza. Further samples were collected on 13 October, after increased mortality was reported to the local Veterinary Services.

On 14 October, IZSLER confirmed as positive for Avian Influenza A virus subtype H5 a backyard flock in Sondrio province (Lombardy region). Approximately 10 broilers were present in the flock. All the birds were dead at the time of confirmation. Epidemiological investigations revealed an epidemiological connection with the grower farm in Bergamo Province confirmed as HPAI H5N8 case on 11 October.

On 16 October, the National Reference Laboratory (NRL) for Avian Influenza and Newcastle Disease characterised as subtype H5N8 the viruses isolated in the last two outbreaks.

As Italy continues to deal with what are presumably remnants from last winter's epizootic, we are rapidly approaching the heart of this year's fall migration (see 2016's Sci Repts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission Of HPAI H5N1).
Exactly what that will bring to Europe, North America and Asia this fall is unknowable. Some years - for reasons we don't yet understand - avian flu is simply a no-show.
But we've seen growing concerns expressed by both DEFRA and the ECDC not only over the expected return of HPAI H5N8 this winter -  but that HPAI H5N6 - which broke out of China last year and surfaced in South Korea, Japan, Taiwan and the Philippines, could potentially follow H5N8 into Europe (see ECDC/EFSA Joint Report: Avian Influenza Overview Oct 2016–Aug 2017).

That said, our track record for second guessing what these avian flu viruses will do next has been spectacularly bad - so above all - we should be prepared for some surprises along the way.

Tuesday, October 17, 2017

Seychelles MOH Update On Plague - Oct 17th


While the most recent reports from Madagascar (see MOH: Confirmed & Suspected Plague Now Exceeds 800 Cases) continues to show their pneumonic plague epidemic to be out of control, the news from the Seychelles is far more positive with only their imported index case presumed positive for plague.
Although test results on some of his contacts are still awaited, all have received prophylactic antibiotics and remain asymptomatic.
 This was posted on the Seychelles MOH Facebook page about an hour ago.
Press Release: Update on Plague Alert

The Plague outbreak in Madagascar continues and remains uncontrolled. According to the latest report, currently, the epidemic is now circulating in 38 of the 114 districts of Madagascar. Antananarivo is the most affected city/district. By yesterday, (16th Oct 2017), 805 cases have been reported (595 pneumonic and 210 bubonic). There has been 74 deaths (9.2% of notified cases) 

Training in contact tracing was conducted today for 60 health care workers, red cross volunteers and other key partners by two WHO experts in conjunction with DSRU. 

Update of cases admitted on suspicion or for precautionary measure

A total of 12 people remain admitted in isolation in hospital.

  • The index patient (probable case) is still admitted on the hospital ward and has no symptoms and is stable. Today is the 9th day of treatment as per clinical guidelines, the patient is no longer infectious. He remains in isolation to complete his antibiotic course.
  •  The other eleven (11) patients in the hospital are stable on treatment and asymptomatic. This includes the foreign national.
Contact tracing and surveillance
  • The total number of people admitted at the Perseverance military academy for active surveillance remain 6. None of them has developed any symptoms.
  • Three (3) Seychellois nationals returned from Madagascar via Nairobi on Thursday 12th October. They remain well and are receiving prophylaxis and will go home if they remain asymtomatic.
  •  A French national who left Madagascar on 13th October via Reunion will remain in the facility until 19th of October.
  • Two (2) Australians who arrived on Friday 13th October from Mauritius after having spent time in Madagascar will remain in active surveillance for 7 days before being released on 19th October if they do not develop any symptoms.
  •  A total of 577 children and 63 teachers (640) at Anse Boileau Primary School and crèche have reached 7 days after last potential contact with the admitted child. They are also off passive surveillance as of today.
  • Laboratory samples were successfully shipped on Sunday evening and received on Monday afternoon by Pasteur institute France. We are now awaiting results.
  • Should anyone who is on prophylaxis develop fever, cough or other symptoms, they should contact their health centre, the Hotline 141, Dr Jastin Bibi on 2723739 or Dr Naomi Adeline 2711818.
  • Regional Health facilities (Beau Vallon, English River, Les Mamelles, Anse Boileau health centres and Anse Royale and Baie Ste Anne Hospitals) are being used to assess contact and provide prophylaxis.
  • The Public Health Authority (PHA) is reinforcing the advisory to discourage people from travelling to Madagascar for the time being. Anyone who has information that a Seychellois national is planning to travel to Madagascar should send a report to the Public Health authority or refer to CDCU.
  • Hotline 141 is active and people can call for information and advice.

China MOA: Outbreak Of HPAI H5N6 In Anhui Province


Reports out of China have been fairly subdued the past month or so - likely due to reduced late summer bird flu activity - but also likely due in part to an extended holiday (National Day Golden Week) held in the first week of October and to the politically sensitive closed-door sessions of the 19th CCP Congress, which is set to begin on the 18th. 
There is a strong tendency towards not `rocking the boat' during this once-every-five-years session of China's Communist Party's Congress, as many political fortunes could rise or fall over the next week or 10 days.
Today, however, China's MOH is reporting an outbreak of HPAI H5N6 at a poultry farm in Anhui Province.

Ma'anshan City, Anhui Province and County in poultry with H5N6 subtype highly pathogenic bird flu

Issued by: Ministry of Agriculture press office Date: 2017-10-17 16:42 Keywords: bird flu; epidemic; Anhui

  Ministry of Agriculture press office issued October 17, Ma'anshan City, Anhui Province and County in poultry with H5N6 subtype highly pathogenic bird flu.

  October 11, Ma'anshan City, Anhui Province and County, some farmers raise chickens suspected bird flu symptoms appear, the incidence of 28,650, 15,066 died. October 13, animal disease prevention and control center in Anhui diagnosed as suspected bird flu. October 17, by the National Avian Influenza Reference Laboratory confirmed the outbreaks as H5N6 subtype highly pathogenic bird flu.

  After the outbreak, according to the relevant local prevention plans and technical specifications, adhere to the prevention and control law, science and prevention and control, really good job epidemic disposal, have been culling and safe disposal 30 196 poultry. Currently, the outbreaks has been effectively controlled.

The last big outbreak of H5N6 in China was announced 2 months ago (see China MOA Confirms H5N6 Outbreak In Quail - Guizhou Province).

Study: Experimental Infection Of Dogs With HPAI H5N1 & HPAI H5N6


When it comes to the spread and evolution of influenza A viruses -  birds, pigs, and humans top our list of primary hosts - but over the years we've also looked at a growing list of other (presumably less important) players in the flu world.
That Touch Of Mink Flu (H9N2 Edition)
Taking HPAI To The Bank (Vole)
Report: Skunks and Rabbits Can Catch And Shed Avian Flu
SwAM: European Seal Deaths Continue From H10N7 Flu
While the opportunities for a bank vole or a seal to transmit avian influenza to humans are admittedly limited, the same cannot be said for companion animals like dogs and cats.
Since the early 2000's it has become apparent that both canines and felines are susceptible to a variety of influenza A viruses (see HPAI H5: Catch As Cats Can), with 2015's transmission of avian H7N2 to a veterinarian in New York City and the recent arrival of a new canine H3N2 virus to North America from Asia bit of a wake up call. 
While canine H3N2 (a formerly avian virus) has not been shown to infect humans, numerous reports coming out of China and Korea suggest it may be adapting to other hosts, and that it continues to reassort with other avian and human flu viruses. Including:
A Canine H3N2 Virus With PA Gene From Avian H9N2 - Korea

Canine H3N2 Reassortant With pH1N1 Matrix Gene

Virology J: Human-like H3N2 Influenza Viruses In Dogs - Guangxi, China

Interspecies Transmission Of Canine H3N2 In The Laboratory

Two months ago we looked at a study (see J. Virology: Zoonotic Risk, Pathogenesis, and Transmission of Canine H3N2) where researchers created and tested canine H3N2 - pdmH1N1 reassortants, and concluded some `may pose a moderate risk to public health and that the canine host should be monitored for emerging IAVs'.
But dogs (and cats) can also be exposed to novel HPAI viruses like H5N1 and H5N6 in the wild.
In 2014 we saw multiple reports of farm dogs infected with HPAI H5N8 in South Korea (see Korea Finds More Dogs With H5N8 Antibodies) while over the summer we saw a report from the Arch. Of Virology: Novel Reassortant H5N6 Isolated From Cats - Eastern China.

In April of this year, in J. Vet. Sci.: Experimental Canine Infection With Avian H5N8, we saw a study published in the Korean Journal of Veterinary Science, where researchers inoculated dogs with the 2014 Korean strain of HPAI H5N8, in order to document its pathogenicity and ability to be transmitted to other dogs. 
While producing only mild illness in these experimental animals, 2 of 4 that were inoculated shed small quantities of the virus and seroconverted, and at least one contact dog became infected. The authors wrote that these dogs appeared only weakly infected and the virus didn't appear fully adapted to a canine host.
All of which brings us to a new study, published this past week in Transboundary and Emerging Diseases, where researchers experimentally infected dogs with two different clades of HPAI H5N1 (1.1.2  & and clade H5N6.

While the bulk of the study is behind a paywall, we get the highlights from the abstract below:

Experimental infection of clade 1.1.2 (H5N1), clade (H5N1) and clade (H5N6) highly pathogenic avian influenza viruses in dogs.


Since the emergence of highly pathogenic avian influenza (HPAI) H5N1 in Asia, the haemagglutinin (HA) gene of this virus lineage has continued to evolve in avian populations, and H5N1 lineage viruses now circulate concurrently worldwide. 

Dogs may act as an intermediate host, increasing the potential for zoonotic transmission of influenza viruses. Virus transmission and pathologic changes in HPAI clade 1.1.2 (H5N1)-, (H5N1)- and (H5N6)-infected dogs were investigated. 

Mild respiratory signs and antibody response were shown in dogs intranasally infected with the viruses. Lung histopathology showed lesions that were associated with moderate interstitial pneumonia in the infected dogs. In this study, HPAI H5N6 virus replication in dogs was demonstrated for the first time. 

Dogs have been suspected as a "mixing vessel" for reassortments between avian and human influenza viruses to occur. The replication of these three subtypes of the H5 lineage of HPAI viruses in dogs suggests that dogs could serve as intermediate hosts for avian-human influenza virus reassortment if they are also co-infected with human influenza viruses.

The idea that dogs could be a `mixing vessel - producing a hybrid human-avian (or human-swine) reassorted virus - is something we've looked at before (see Study: Dogs As Potential `Mixing Vessels’ For Influenza). 
While perhaps not the most likely host for viral reassortment -  is is certainly plausible. 
With H5N6's breakout performance in Asia last year, and the huge strides H5N8 has made in the past year (see ECDC/EFSA Joint Report: Avian Influenza Overview Oct 2016–Aug 2017) the potential threat that these viruses pose to non-avian species cannot be ignored (see J. Virulence Editorial: HPAI H5N8 - Should We Be Worried?).

It is worth noting that - while currently quantified as a relatively low-risk virus -  over the summer the CDC added Canine H3N2 to their IRAT (Influenza Risk Assessment Tool) listing of novel flu subtypes/strains that circulate in non-human hosts and are believed to possess some degree of pandemic potential. Their evaluation reads:
H3N2: [A/canine/Illinois/12191/2015]
The H3N2 canine influenza virus is an avian flu virus that adapted to infect dogs. This virus is different from human seasonal H3N2 viruses. Canine influenza A H3N2 virus was first detected in dogs in South Korea in 2007 and has since been reported in China and Thailand. It was first detected in dogs in the United States in April 2015. H3N2 canine influenza has reportedly infected some cats as well as dogs. There have been no reports of human cases.
Summary:  The average summary risk score for the virus to achieve sustained human-to-human transmission was low risk (less than 4). The average summary risk score for the virus to significantly impact public health if it were to achieve sustained human-to-human transmission was in the low risk range (less than 4).