ECDC On Increased Mycoplasma Pneumonia Reported In EU/EEA Countries

Credit CDC

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While tabloid, social, and even some mainstream media outlets seem determined to present the recent uptick in respiratory illnesses in China - and around the world - as scary precursors to the next pandemic, so far we've seen no indication of anything `novel' at work, or any direct link between China's outbreaks and those being reported in Europe or the United States. 

Admittedly, global surveillance, testing, and data sharing are limited - and new information could change that assessment - but right now we appear to be dealing with an uptick in known, seasonal respiratory illnesses. 

The `Mystery Pneumonia' which has been identified in China and many other countries is by all accounts Mycoplasma pneumoniae, which sparks minor epidemics every few years.  Exact numbers are hard to come by, since this in not a `reportable' disease in most countries, but the CDC estimates:

Estimated incidence

M. pneumoniae infections are common, but the true number of people affected is unknown. An estimated 2 million cases of M. pneumoniae infections occur each year in the United States.

Trends over time

The number of M. pneumoniae infections varies over time, with peaks of disease every 3 to 7 years. This illness can happen any time during the year but may be more common in summer and early fall.

Outbreaks

Outbreaks occur mostly in crowded environments like college residence halls and nursing homes. Outbreaks can be prolonged due to the long incubation period of M. pneumoniae.

It is always possible for a new strain to emerge, or one that has increased antibiotic resistance, but so far we haven't seen any reports suggesting either in the EU/EEA or the United States.  

Yesterday the ECDC published their weekly Communicable Disease Threats Report, where they reported on upticks in M. pneumoniae in the EU/EEA in recent months.  

Increase in respiratory infections due to Mycoplasma pneumoniae in the EU/EEA during the season 2023/2024

Overview:

Epidemics of M. pneumoniae occur periodically, typically every one to three years [1]. Transmission requires close contact with an infected individual, with slow-onset and often atypical respiratory symptoms once infected. Infections typically present with mild, self-remitting upper respiratory tract symptoms; however, patients presenting with prolonged or atypical, severe lower respiratory tract symptoms require antibiotic treatment. 

Six EU/EEA countries have reported recent increases in M. pneumoniae infections at the national level or in specific hospitals. Increases have been reported in all age groups but are predominantly observed in children and adolescents. Additionally, one country observed an increase in severe cases admitted to the intensive care unit.

There are currently no reports of atypical strains or evidence of resistance to first-line macrolide antibiotics.

ECDC assessment:

M. pneumoniae is not notifiable in most EU/EEA countries, leading to limited available information regarding diagnosed cases, proportion of detections amongst respiratory laboratory samples, or historical detection data. As a result, making country-level comparisons should be done with caution. M. pneumoniae epidemics occur cyclically in Europe every one to three years [1]. 

Various factors contribute to this cyclical pattern, such as the decline of population immunity over time or the introduction of new strains into the population. The reported increases are observed following a three-year period of very limited transmission and detection of M. pneumoniae in the EU/EEA, following widespread implementation of non-pharmaceutical measures during the COVID-19 pandemic,resulting in reduced population immunity, particularly amongst those with little or no pre-existing exposures to M. pneumoniae.

There are currently no reports of atypical M. pneumoniae strains or resistance to first-line macrolide antibiotics from reporting countries. However, it remains important for countries to monitor and report the occurrence of atypical and/or severe forms of disease, evidence of resistance to antibiotics, and strains on the healthcare system related to M. pneumoniae cases as winter progresses and the combined burden of respiratory pathogens increase.

Actions:

ECDC continues to monitor the situation. Countries are encouraged to continue reporting to EpiPulse with additional information: 2023-IRV-00008. In particular, countries with laboratory systems that routinely screen respiratory samples for M. pneumoniae are encouraged to report current and historic trend data for detections, as well as strain characterisation and antibiotic susceptibility data, if available

Not surprisingly, we are also seeing reports of sporadic outbreaks here in the United States (see Warren Ohio Health Dept. Press Release), and additional outbreaks are to be expected. While there doesn't appear to be anything `novel' about these outbreaks, that doesn't make them benign. 

The CDC advises:

People at Risk 

Mycoplasma pneumoniae infections are most common in young adults and school-aged children, but can affect anyone. People living and working in crowded settings are at increased risk. These settings include:

• Schools
• College residence halls
• Military training facilities
• Long-term care facilities
• Hospitals

Other people at increased risk for serious infections include those:

• Recovering from a respiratory illness
• With a weakened immune system

Prevention 

Help protect yourself and others from Mycoplasma pneumoniae infection by practicing good hand hygiene.

People can get infected with Mycoplasma pneumoniae more than once. While there is no vaccine to prevent M. pneumoniae infections, there are things people can do to protect themselves and others.

Good hygiene

Like many respiratory germs, Mycoplasma pneumoniae most commonly spread by coughing and sneezing. Some tips to prevent the spread of M. pneumoniae include:

Cover your mouth and nose with a tissue when you cough or sneeze.

• Put your used tissue in a waste basket.
• If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.
• Wash your hands often with soap and water for at least 20 seconds.
• If soap and water are not available, use an alcohol-based hand rub.

Preventive antibiotics

Doctors generally do not prescribe antibiotics to help prevent someone else from getting sick (for example, a close contact of an infected person).

Treatment

Mycoplasma pnuemoniae infections are generally mild, but some people may need care in a hospital.

Most people will recover from an infection caused by Mycoplasma pneumoniae without antibiotics. Ask your doctor or pharmacist about over-the-counter medicines that can help you feel better while you are recovering.

However, if someone develops pneumonia (lung infection) caused by M. pneumoniae, doctors usually prescribe antibiotics. There are several types of antibiotics available to treat pneumonia caused by M. pneumoniae. Antibiotics can help patients recover from the infection faster if started early on.

Some M. pneumoniae are resistant to some antibiotics used for treatment. Learn more about the potential danger of antibiotic resistance, and how to prevent it at CDC’s Be Antibiotics Aware website.

Complications

While M. pneumoniae usually cause mild infections, severe complications can occur that require care in a hospital. M. pneumoniae infections can cause or worsen the following complications:

• Serious pneumonia
• Asthma attacks or new asthma symptoms
• Encephalitis (swelling of the brain)
• Hemolytic anemia (too few red blood cells, which means fewer cells to deliver oxygen in the body)
• Renal dysfunction (kidney problems)
• Skin disorders like Stevens-Johnson syndrome, erythema multiforme, toxic epidermal necrolysis

 
We are entering what is likely to be a messy winter respiratory season, with a mixture of influenza viruses, COVID, RSV, adenoviruses, rhinoviruses, and bacterial pneumonia. 

Some can be reduced by vaccines, while others are susceptible to non-pharmaceutical measures like hand hygiene and face masks. 

As always . . . 

WHO DON Update On H1N2v Virus Infection in the UK

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On the heels of the UK's release of Guidance for the Public in the event they are identified as having had contact with a possible H1N2v case, we have the WHO DON (Disease Outbreak News) report on the UK's first case.

Thus far we've seen no indication of additional cases, although contract tracing is apparently still ongoing. 

The link and some excerpts from the WHO update follow.  Click the link to read it in its entirety. 

Influenza A(H1N2) variant virus infection - United Kingdom of Great Britain and Northern Ireland
1 December 2023

Situation at a Glance

On 25 November 2023, the International Health Regulations National Focal Point (IHR NFP) of the United Kingdom of Great Britain and Northern Ireland (United Kingdom) notified the World Health Organization (WHO) of a human case of swine-origin influenza A(H1N2) virus infection. This is the first swine influenza A(H1N2)v case reported in the United Kingdom. 

Human infections with swine-origin influenza viruses have been sporadically detected in the past in countries in the Americas, Asia, Australia and Europe. When a human is infected with a swine-origin influenza virus, the virus is referred to as a variant (or “v”) virus. Most human cases result from exposure to swine influenza viruses through direct contact with infected swine or contaminated environments. Current evidence suggests that these swine-origin influenza viruses have limited ability for sustained transmission among humans. 

This case was identified as part of routine surveillance of respiratory illnesses. The source of infection for this case is under investigation and contact tracing is in process. To date, no other confirmed cases associated with this event have been reported. WHO is in communication with national authorities to monitor the situation closely. Ongoing investigations are in place to identify the source of the infection and to characterize the risks of this influenza variant virus. WHO assesses the risk of spread of swine-origin influenza viruses through humans and/or community-level spread among humans as low.

However, because these viruses continue to be detected in swine populations worldwide, further human cases following direct or indirect contact with infected swine can be expected. Current evidence suggests that these viruses have not acquired the ability to sustain transmission among humans. Due to the constantly evolving nature of influenza viruses, WHO continues to stress the importance of global surveillance to detect virological, epidemiological and clinical changes associated with circulating influenza viruses that may affect human (or animal) health and timely virus sharing for risk assessment.

Description of the Situation

On 25 November 2023, under the IHR (2005), the United Kingdom notified the WHO of a human case of influenza A(H1N2)v virus infection. The case reported onset of mild symptoms on 5 November. He visited his general practitioner on 9 November; during this visit, a respiratory sample was collected and further analyzed as part of the national routine influenza surveillance programme. On 13 November, the sample was sent to United Kingdom Health Security Agency (UKHSA) laboratories and tested positive on 23 November for influenza A(H1N2)v virus, using reverse transcription polymerase chain reaction (RT-PCR). The sample was further characterized by whole genome sequencing and results were available on the same date. On 25 November, a follow-up RT-PCR test was performed and tested negative for influenza. The case is now fully recovered.

Further laboratory analyses conducted at the Worldwide Influenza Centre at the Francis Crick Institute (a WHO Collaborating Centre) and the World Organization for Animal Health (WOAH) avian and swine influenza reference laboratory at the Animal and Plant Health Agency, indicated that this influenza A(H1N2)v virus belongs to the swine influenza virus genetic clade 1B.1.1. Similar A(H1N2) viruses from this genetic clade have been previously detected in pigs in the United Kingdom. However, this is the first time a virus from this swine genetic clade has been detected in a human in the United Kingdom.

According to ongoing investigations, pig farms are located within a few miles of where the case resides; however, the case reported no direct exposure to pigs, pets, or farms. The source of infection is currently under investigation and contact tracing is continuing.

          (SNIP)

WHO Risk Assessment

Influenza viruses circulate in swine populations in many regions of the world. Depending on geographic location, the genetic characteristics of these viruses differ. Most human cases result from exposure to swine influenza viruses through contact with infected swine or contaminated environments, although some cases have been reported without an apparent source of exposure to swine in the weeks prior to illness onset. Because these viruses continue to be detected in swine populations worldwide, further human cases following direct or indirect contact with infected swine can be expected.

Current evidence suggests that these viruses have not acquired the ability to sustain transmission among humans. There has been limited, non-sustained human-to-human transmission of variant influenza viruses, although ongoing community transmission has not been identified.

This is the first swine influenza A(H1N2)v case reported in the United Kingdom. There is no clear indication of direct contact with pigs or any ill individuals. Though the source of infection is unknown at this time, the virus is closely aligned to that circulating in the swine population in the United Kingdom. Several previous variant cases have also not had clear exposure histories to swine and there was no evidence of sustained human-to-human transmission in these cases. Limited human-to-human transmission may have played a role, but there is no definitive evidence.

Further virus characterization is ongoing. National routine surveillance indicators do not show any unusual increases in respiratory illness in the local population. The risk of there being additional human cases associated with this event appears to be low – though the possibility of limited person-to-person transmission cannot be excluded at this stage.

The risk assessment will be reviewed should further epidemiological or virological information become available.

         (Continue . . . )

 

UKHSA Issues Guidance For Public On Possible H1N2v Exposure

 

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Five days ago the UKHSA Announced the 1st H1N2v (Swine Variant) Infection In the UK, in an individual who apparently tested positive in early November.  The patient reportedly had mild illness and has recovered.  

H1N2v is a swine variant influenza A virus that has been identified in other countries, including the United States, more than 4 dozen times over the past decade. 

Normally swine variant viruses don't transmit well between humans, but some human-to-human transmission has been reported.  This patient in the UK reportedly did not have direct or indirect contact with pigs, and their exposure had not been identified. 

While no additional cases have been reported, today the UK's HSA has released detailed, and unusually stringent, guidelines for any one who has been notified that they have had contact with a ` . . . person who has or probably has influenza A(H1N2)v'

This guidance is divided into 3 parts, depending upon the category (High, Medium, Low) of exposure.  The main announcement follows, after which I'll have some excerpts from the guidance for High Category Contacts, including self-isolation and home testing.

Guidance
Influenza A(H1N2)v: guidance for affected members of the public

Information for members of the public who have been affected by the detection of influenza A(H1N2)v in humans for the first time in the UK.

From:UK Health Security Agency Published 1 December 2023

Influenza A(H1N2)v: information for high category contacts

Influenza A(H1N2)v: information for medium category contacts

Influenza A(H1N2)v: information for low category contacts

Details

This guidance is for members of the public affected by influenza A(H1N2)v. You will have been told if this guidance applies to you.

It contains information about the disease and the actions that people should take if they have potentially been exposed to influenza A(H1N2)v. It also contains information about the disease and the actions that people should take if they potentially have an influenza A(H1N2)v infection. If this guidance is relevant to you, you will be told which piece of guidance applies to your situation.

Influenza A(H1N2) is a virus which normally infects pigs. Humans can be infected with this virus and the symptoms experienced are similar to human seasonal influenza (also called ‘flu’). The first human case of influenza A(H1N2)v in the UK was detected in November 2023. More information about what this means is provided in a press release issued by the UK Health Security Agency (UKHSA).

The disease is usually mild to moderate and symptoms typically last for 3 to 5 days. More serious complications, such as pneumonia, are possible but rare.

It isn't clear from these documents what constitutes a High, Medium, or Low Category Contact, a determination that is apparently made by the UKHSA during contact tracing.

For High Category Contacts, they've announced some unusually rigorous guidelines (excerpts below), that far exceeds anything I've seen published for swine variant influenza exposure before.  

Follow the links to read all of the documents in their entirety.  Hopefully we'll learn more about their decision to publish these guidelines in the near future.

Guidance

Influenza A(H1N2)v: information for high category contacts

Published 1 December 2023

You have been given this information as you have been identified as someone who has had contact with a person who has or probably has influenza A(H1N2)v.

While you are at low risk of developing an infection, it can take up to 10 days for an infection to develop after you were exposed to influenza A(H1N2)v.

To help limit the spread of influenza A(H1N2)v and to protect others that you come into contact with, you should self-isolate until at least 10 days after you were last in contact with the person who has or probably has influenza A(H1N2)v. Your self-isolation period will end if you receive a negative test result for all of the nose and throat swabs you take during your isolation period, including the last swab which you will take on day 10.

You will have been given a designated contact number to phone. If you do not have this number, contact your local health protection team. Report any symptoms that develop to your designated contact up to 10 days following your last exposure.

(SNIP)

Actions to take

You should take the following actions to protect the health and safety of you, your family and anyone else that you may have contact with. These actions will reduce the spread of virus to others and ensure that if you develop the infection, it can be identified quickly.

As a precautionary measure, you should self-isolate at home for at least 10 days from when you were last exposed. This means you should stay at home and not go to work, school or public areas. You may end your self-isolation period if you receive a negative test result from the swab you will take on day 10 of your self-isolation period, and if all of your other test results have also been negative.

If you live on a farm with pigs, or keep these animals as pets, you should avoid any contact with them during your isolation period if you can.

If it is not possible to avoid contact with  pigs, wear a face covering, and clean your hands with alcohol gel or soap and water before and after contact. Your face covering should cover your nose and mouth and fit well without gaps between the covering and your face.

Try to maintain distance from people living in the same household during your self-isolation period. If possible, stay in separate rooms from other household members.

If you use shared facilities, like the kitchen or bathroom, during your self-isolation period, avoid using them at the same time as other people and use a separate towel. Use them after everyone else, wear a face covering and clean surfaces after use. Your face covering should cover your nose and mouth and fit well without gaps between the covering and your face.

Clean surfaces in your home often. Pay particular attention to surfaces that are touched frequently, such as handles, light switches, work surfaces and electronic devices such as remote controls.

Maintain good ventilation of rooms by opening windows and leaving them open for at least 10 minutes after leaving rooms, particularly in shared rooms.

If you have to be in the same room as others during your self-isolation period, try to maintain good ventilation of the room, keep at least 2 metres away from others, and wear a face covering. Follow the advice given in the guidance on ventilation to reduce the spread of respiratory infections, including COVID-19.

Clean your hands regularly with alcohol gel or soap and water, especially before using shared rooms and after coughing, sneezing or blowing your nose.

Any non-essential medical or dental treatment should be postponed during your isolation period. You should discuss any essential treatment required with your designated contact before attending a healthcare facility.

Do not invite or allow social visitors, such as friends and family, to visit at home during your isolation period.

On days 1, 3, 5, 8 and 10 of your isolation period, use the nose and throat swab provided to you to test if you have developed an infection. If you were given the swabs later than 1 day after you were exposed, then use your first swab as soon as you receive it. Then continue with swabbing on correct days. For example, you may receive your swabs on day 4 and use the first one on day 4. You would then take your day 5, 8, and 10 swab as normal. You may only have received some of these swabs. In this case, you should use the swabs you have on the days instructed.

You may only end your isolation period if you receive a negative test result for all of the swabs you take during isolation period. This means you must wait until you receive the result of your day 10 test before you know whether you can end isolation.

Inform your designated contact point daily of any of the symptoms listed below within 10 days of your last exposure.

During your self-isolation period, you may be offered medication to help prevent an infection or to reduce the severity of your symptoms if you were to become ill.

You may be asked to take blood tests to help understand and control the spread of  influenza A(H1N2)v.

 

Stay tuned.

Taiwan CDC: Preliminary Airport Surveillance Report On Travelers From Mainland China, Hong Kong & Macau

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While the tabloids, social media, and even some mainstream media are having a field day speculating about the uptick of respiratory illnesses in China - using terms like `Mysterious' or `While-Lung Syndrome' - it is worth noting that so far, we've seen no evidence of anything other than an increase in already-known seasonal illnesses. 

Seasonal viruses (and other pathogens) can change over time, making it always possible that a mutation has increased the transmissibility, pathogenicity, or antimicrobial resistance (see past examples here, here, here and here) of one of the `usual suspects'. 

But we've also seen similar upticks of respiratory illnesses in many other countries in the months (and years) following their dismantling of pandemic restrictions, with no indication of significant mutations.

 For it to happen in China, less than a year after abandoning their strict Zero-COVID policies, is hardly unexpected. 

We've also seen evidence suggesting that Severe COVID-19 Can Alter Long-term Immune System Response, and that may be playing a role as well. Ask again in a few years, and we may have some better answers. 

Frankly, we are still trying to figure this newfangled Post-COVID world of ours, and how new, existing, and future pathogens will interact and how they may impact our immune systems.   

While a novel virus (or other pathogen) could certainly emerge at anytime, and from any corner of the earth, so far we've seen no evidence of that currently happening in China.

But as you would expect, some countries outside of China have ramped up their surveillance and testing - particularly of international travelers from Asia - in order to detect anything suspicious as early as possible.  

Today we get the first report from Taiwan's CDC on their surveillance and testing of symptomatic travelers entering the country from China, Hong Kong and Macau. While testing appears to be voluntary, so far they have detected no signs of anything `novel'. 

The translated statement follows, after which I'll have a postscript.

The CDC has conducted "fixed-point monitoring and encouraged testing" for symptomatic travelers arriving from China, Hong Kong and Macao at four international airports.

Currently, the majority of cases detected are influenza. Influenza is also the most prevalent respiratory infection in domestic communities. Parents are advised to pay attention to the health of young children and the public is encouraged to get vaccinated.

Release date: 2023-12-01

The Department of Disease Control and Prevention (hereinafter referred to as the CDC) stated today (1) that in order to strengthen monitoring of the respiratory disease epidemic in China, the Department has launched a total of 10,000 people in Taipei, Taoyuan, Taichung and Kaohsiung starting from November 26, 2023. Four international airports have implemented the "fixed-point monitoring and encouragement of inspection" measures. 

This measure is aimed at symptomatic (influenza-like) travelers arriving from China, Hong Kong and Macao, and encourages testing for 17 types of viruses including influenza virus, new coronavirus, rhinovirus, Mycoplasma pneumoniae, adenovirus, human interstitial pneumonia virus and 4 species of bacteria. 

Currently, a total of 38 people have been tested in the first four days, of which 13 cases were influenza virus, 3 cases were new coronavirus, 3 cases were adenovirus, 2 cases were rhinovirus, 6 cases were negative, and 11 more cases are being tested.

Based on the current surveillance data and test results, the current risk assessment of the respiratory tract infection epidemic in China remains unchanged. Known pathogens are highly prevalent in the community. In the near future, influenza viruses have become the dominant epidemic. Mycoplasma epidemic has declined. China will continue to closely monitor its epidemic development.

Regarding external concerns about the current epidemic situation of Mycoplasma pneumonia in China, Dr. Huang Yucheng, Professor of the Department of Pediatric Infectious Diseases at Chang Geng, Linkou, and Chairman of the Society of Pediatric Infectious Diseases, explained that Mycoplasma pneumoniae is a common pathogenic bacteria of respiratory tract infections and pneumonia, and is more common in young people. People and children over 5 years old have cases all year round in Taiwan, especially at the turn of spring and summer and early autumn. 

Generally speaking, the symptoms caused by Mycoplasma pneumoniae are mild, and most people can recover on their own after infection. Common symptoms include sore throat, fatigue, fever, and cough that can last for weeks or even months. About 10% of people will develop it. pneumonia, but the symptoms are relatively mild, so it is commonly known as "walking pneumonia." Although data from the U.S. Centers for Disease Control and Prevention shows that mycoplasma pneumonia may have a major epidemic every 3 to 7 years, the proportion of domestic surveillance has been low recently, indicating that it is a low-level epidemic. Please do not worry or worry. 

The CDC stated that in response to external concerns about the shortage of related drugs, the Food and Drug Administration has stated that in terms of Mycoplasma pneumonia drugs, the import of original potions for children has increased in October, and domestic generic drugs with the same ingredients will be mass-produced in December; There are currently sufficient stocks of adult medicines and there is no doubt about shortages. Dr. Huang further pointed out that at present, influenza is still the most common respiratory infection, and the peak of influenza epidemic is approaching. Young children are a high-risk group for influenza. Getting vaccinated as soon as possible to gain protection is the most effective prevention method. At the same time, it is also reminded that if danger signs such as dyspnea, shortness of breath, cyanosis (hypoxia) and other danger signs occur, please seek medical treatment as soon as possible and follow the doctor's instructions to take medication to reduce the risk of severe complications.

The CDC emphasized that according to the latest research from Dr. Dayi He's team in the United States, vaccination with XBB vaccine can significantly increase the vaccine's resistance to current COVID-19 epidemic strains (XBB.1.5 and EG.5.1) and emerging mutant strains (such as HV.1, HK. 3. In the immune response of JD.1, JN.1), neutralizing antibodies can increase up to 27 times. It is recommended that the public receive the XBB vaccine to enhance self-protection. People over the age of 65 who receive the COVID-19 vaccine can receive health education supplies and COVID-19 rapid screening reagents worth less than 500 yuan (inclusive) provided by each county and city. In addition, in order to improve the accessibility of vaccination for all, each county and city also provides Come to the vaccination service on demand. For vaccination centers, you can check the vaccination centers on the official website of the CDC in the "Autumn and Winter Vaccine Zone" (https://gov.tw/eU4).

It doesn't take a novel virus to put you or a loved one in the hospital, or for that matter, in the morgue. Seasonal flu, RSV, CAP (Community Acquired Pneumonia), and Norovirus are all quite capable of doing so, as they kill hundreds of thousands of people every year. 

Luckily there are vaccines that can offer some protection against many of these illnesses.

 

Unfortunately, far too few eligible people elect to get them every year, which puts all of us at risk of seeing overcrowded hospitals and excess winter mortality, even from something as mundane as seasonal flu.

For a look at what a severe `non-pandemic' flu season can look like, you may wish to revisit 2018's:

CDC: More Than 900,000 Hospitalizations & 80,000 Deaths In Last Winter's Flu Season

UK NHS: An Early Surge In Norovirus Hospitalizations

The busy 2022-2023 Norovirus Season

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Last winter the UKHSA reported the Worst Norovirus Season In A Decade (see chart above), with the season's cumulative number of laboratory positive results running 31% higher than the 5-season average prior to the pandemic (2014/2015 to 2018/2019). 

Noroviruses, which are often mistakenly called `stomach flu’, are single-stranded RNA viruses that are able to evolve rapidly. Victims usually experience nausea, frequent vomiting & diarrhea, and stomach pain – and may also suffer from headache, fever, and body aches. 

The illness generally runs its course in 1 to 3 (very long) days, and most people recover fully. But among those who are aged or infirmed, the virus can take a heavy toll. According to the CDC, in the United States each year the norovirus produces:

While norovirus infections can occur anytime, they tend to be most common between November and April, and can increase the impact of an already busy winter cold/flu/COVID season.  

The peak of norovirus cases unusually isn't seen in the UK until January or February, but yesterday the NHS warned that hospitalizations are already running well ahead of this time last year.  

I've posted excerpts from an NHS news release below. I'll have a bit more after the break.

Hundreds of patients in hospital with norovirus ahead of winter
30 November 2023

The number of patients in hospital with norovirus last week was almost triple the number during the same period last winter, new NHS figures show today.

An average of 351 people were in hospital with diarrhoea and vomiting symptoms every day last week compared to 126 in the same week last year. There were also 13 children with the virus in hospital each day, compared to an average of just three for the same period in 2022.

New weekly figures published today and for the first time this winter, show the NHS is seeing high levels of demand in hospitals with evidence that winter pressures are already mounting on staff ahead of December.

NHS teams have worked hard to expand hospital capacity with almost 1,500 more beds open now (100,701) compared to the same week last year (99,243), but adult bed occupancy remains high at 95.3% with over 1,200 more patients in adult general and acute beds last week compared to the end of November 2022 (90,144 vs 88,902).

There was an average of 153 flu patients in general and acute hospital beds each day last week with seven a day in critical care, and an additional 131 children in hospital each day with RSV.

The weekly winter update also shows the hard work of staff and innovative measures to prepare for winter are paying off, with the time lost to ambulance handover delays reduced by more than a fifth on the same week last year (from 24,372 hours to 18,987), despite thousands more patients arriving via ambulance (up from 77,054 to 89,506).

There were 419,676 calls to the NHS 111 service last week, similar to 423,969 the same week last year. Yet thanks to measures to boost resilience and grow the number of call handlers, almost twice the proportion of calls answered were answered within a minute (from 36% to 67%).

However, challenges discharging patients who no longer need to be in hospital into settings such as social and community care are still having a considerable impact, with an average of 12,654 beds each day last week occupied by patients who were ready for discharge, taking up one in seven of all occupied adult general and acute beds (90,144).

The new data also shows that an average of 46,201 staff per day were off work sick last week, of which 1,715 absences were due to Covid-19.

Robust NHS plans for winter, set out earlier than ever before, have seen the nationwide rollout of care ‘traffic control’ centres, extra ambulances and beds and the rapid expansion use of the world-leading and innovative virtual ward programme, keeping patients out of hospitals and treating more people at home and in the community where appropriate.

(SNIP)

The weekly situation report publications can be found here: Statistics » Urgent and Emergency Care Daily Situation Reports 2023-24

The `standard’ mode of norovirus transmission is considered to be the fecal-oral route, but limited airborne transmission is suspected as well. In 2015, in CID Study: Airborne Norovirus In Healthcare Facilities, a study looked for - and found - norovirus in ambient air samples taken from 8 hospitals, both inside and outside of an infected patient’s room.

While the act of vomiting (see Vomiting Larry And His Aerosolized Norovirus) could account for this airborne infusion of the virus, the usual receptacle is a toilet, followed by a power flush (see Nature: Another Toilet Plume Study To Consider) which may also help disperse the virus through the air. 

All of which makes the rapid spread of norovirus the bane of crowded cruise ships, hospital wards, schools and households. Making matters worse, alcohol hand sanitizers are largely ineffective against norovirus (see Aye, There’s The Rub).  

While norovirus infection is mostly likely to produce an extremely unpleasant 24-48 hours for a healthy adult, it can be far more serious in young children and the elderly.  Globally, the CDC estimates:

Norovirus is the most common cause of acute gastroenteritis, annually causing an estimated 685 million cases. About 200 million cases are seen among children under 5 years old, leading to an estimated 50,000 child deaths every year, mostly in developing countries.

Regardless of your current age or health, this is virus very much worth avoiding if at all possible.  

Finland: Food Safety Authority Statement On H5N1 In Fur Farms

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According to the Finnish Food Safety Authority (Ruokavirasto), more than half of the fur farms in Finland have now been tested for avian H5N1, with 32 farms testing positive in the month of November. In all, 65 farms have tested positive since July.

This is the first statement we've seen since November 10th, although we've seen the infected farm list updated several times. 

First today's statement, after which I'll has a postscript.

The bird flu survey of foxes and raccoons has progressed rapidly

November 30, 2023

The avian flu survey for domesticated foxes and raccoons has progressed more than halfway. The Food Agency's laboratory has examined samples from 182 fur farms, of which bird flu has been found in 32 farms. The infected fur farms are located in the five provinces where bird flu infections have occurred before.

The bird flu survey of the fox and raccoon kennels really started in week 45, and more bird flu has been found in the survey than in the mink kennels. In the first carried out survey of mink farms, bird flu was found in only three farms out of more than a hundred examined. Possibly foxes are more sensitive than minks to getting infected with bird flu, or the bird protection in fox farms has not been as good as in mink farms.

In the survey, blood samples were taken from foxes and sable dogs in fur farms. The Regional Administrative Agency of Western and Central Finland has been responsible for organizing the sampling and coordinating the mapping for the whole of Finland. The samplers are mainly municipal control veterinarians, who have performed their work effectively. Samples have already been taken from 216 shelters and there are still around 80 shelters left. Sampling has been carried out in the nurseries in good agreement with the producers.

In the Food Agency's laboratory, the blood samples are first tested for antibodies caused by the Influenza A virus using the ELISA method. Antibody-positive samples are confirmed by the HI method ( hemagglutination inhibition ). The method examines the binding of the antibodies in the sample to the HA protein of the influenza A virus, which is the same subtype as the virus isolated from fur farms. The test accurately identifies antibodies to the H5 virus.

A total of 65 fur farms have been diagnosed with bird flu. So far, the Food Agency has ordered the culling of fur animals from 53 shelters. The total number of animals ordered to be killed is about 425,000, of which there are about 121,000 minks, about 287,000 foxes and about 17,000 raccoons. The preparation of termination decisions is in progress for 12 shelters. The basis for termination decisions is the protection of people's health.

While Finland initially concentrated their efforts on testing for H5N1 in mink - which are regarded as particularly susceptible to influenza A viruses - the surprise has been the high seropositivity among foxes and raccoons. 

 Finland's Institute for Health and Welfare (THL)  warned of this possibility last August, writing:

Although mink is considered to be the most problematic animal species in terms of avian influenza virus infections, there are also risks associated with bird flu epidemics in dense, large animal populations of foxes and other fur-bearing animals, that the virus becomes more adaptable to mammals.

With the detection of H5N1 in 65 mixed species fur farms in Finland, it begs the question, how many other fur farms around the world are similarly infected?

Unfortunately, unless unusual mortality events are reported to local authorities, it is highly likely that no one is looking.