HK CHP Monitoring Another Human H5N6 Case On The Mainland (Hunan Province)

 

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Mainland China's summer surge in human H5N6 infections continues today, with a new case reported in Hunan Province. This is the 19th case reported by China since last December, meaning that over 42% of all known cases (since the virus emerged in 2014) have been reported over the past 10 months.   

Prior to the past year, we'd never seen more than 9 cases reported in any calendar year (2016).

While we've not seen any obvious clustering of cases (other than a husband & wife in Hunan province who likely shared an exposure), this abrupt uptick in H5N6 cases - particularly occurring in late summer - is concerning, as this is normally the slowest time of the year for avian flu transmission. 

H5N6 reports declined dramatically between the summer of 2017 and the summer of 2020, following the nationwide release of a new H5+H7 poultry vaccine in China (see OFID: Avian H5, H7 & H9 Contamination Before & After China's Massive Poultry Vaccination Campaign).

First today's Hong Kong report, then I'll return with a brief postscript. 

CHP closely monitors human case of avian influenza A(H5N6) in Mainland

 
The Centre for Health Protection (CHP) of the Department of Health is today (September 17) closely monitoring a human case of avian influenza A(H5N6) in the Mainland, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

The case involves a 40-year-old woman living in Yongzhou in Hunan Province, who had prior exposure to a live poultry market before the onset of symptoms. She developed symptoms on September 8 and was admitted for treatment on the following day. The patient is in serious condition.

From 2014 to date, 43 human cases of avian influenza A(H5N6) have been reported by Mainland health authorities.

"All novel influenza A infections, including H5N6, are notifiable infectious diseases in Hong Kong," a spokesman for the CHP said.

Travellers to the Mainland or other affected areas must avoid visiting wet markets, live poultry markets or farms. They should be alert to the presence of backyard poultry when visiting relatives and friends. They should also avoid purchasing live or freshly slaughtered poultry, and avoid touching poultry/birds or their droppings. They should strictly observe personal and hand hygiene when visiting any place with live poultry.

Travellers returning from affected areas should consult a doctor promptly if symptoms develop, and inform the doctor of their travel history for prompt diagnosis and treatment of potential diseases. It is essential to tell the doctor if they have seen any live poultry during travel, which may imply possible exposure to contaminated environments. This will enable the doctor to assess the possibility of avian influenza and arrange necessary investigations and appropriate treatment in a timely manner.

While local surveillance, prevention and control measures are in place, the CHP will remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments.

The public should maintain strict personal, hand, food and environmental hygiene and take heed of the advice below when handling poultry:

Avoid touching poultry, birds, animals or their droppings;

• When buying live chickens, do not touch them and their droppings. Do not blow at their bottoms. Wash eggs with detergent if soiled with faecal matter and cook and consume the eggs immediately. Always wash hands thoroughly with soap and water after handling chickens and eggs;
• Eggs should be cooked well until the white and yolk become firm. Do not eat raw eggs or dip cooked food into any sauce with raw eggs. Poultry should be cooked thoroughly. If there is pinkish juice running from the cooked poultry or the middle part of its bone is still red, the poultry should be cooked again until fully done;
• Wash hands frequently, especially before touching the mouth, nose or eyes, before handling food or eating, and after going to the toilet or touching public installations or equipment, such as escalator handrails, elevator control panels or door knobs, or when hands are dirtied by respiratory secretions after coughing or sneezing; and
• Wear a mask if fever or respiratory symptoms develop, when going to a hospital or clinic, or while taking care of patients with fever or respiratory symptoms.

The public may visit the CHP's pages for more information: the avian influenza page, the weekly Avian Influenza Report, global statistics and affected areas of avian influenza, the Facebook Page and the YouTube Channel.

Ends/Friday, September 17, 2021
Issued at HKT 17:42

NNNN

While human H5N6 infections still appear to be rare, iis likely that many - probably most - have gone unrecognized.  Many people get infected with, and even die from, severe influenza in China (and other parts of Asia) and are never hospitalized or tested.

In the early days of 2013's H7N9 outbreak in China, we saw credible estimates (see Lancet: Clinical Severity Of Human H7N9 Infection) suggesting that the true number of cases might have run between 10 and 100 times higher than reported.

It doesn’t matter whether we are talking about seasonal influenza, West Nile Virus, Salmonella, or avian flu, we are almost always dealing with a subset of the actual number of cases. 

Unless, and until, HPAI H5N6 becomes easily transmissible among humans - it will remain a localized  problem - and mostly a concern for those raising poultry. But each human infection provides another opportunity for the virus to better adapt to human physiology, which makes this recent uptick worthy of our attention.

It is also worth noting that while most of those who have been infected had recent, close contact with poultry, we've not been hearing of any poultry outbreaks of HPAI H5N6 from China's MOA.

While it is possible that China is simply not reporting poultry outbreaks, another possibility is the H5N6 virus is spreading asymptomatically in vaccinated poultry (see PLoS Bio: Imperfect Poultry Vaccines, Unintended Results), allowing it to spread without notice. 

Either way, with fall approaching, we'll be monitoring H5N6 (and other) avian influenza viruses with considerable interest.

Wyoming DOH Reports A Rare Case Of Pneumonic Plague

 

Credit CDC

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Plague in the United States is rare, but it isn't unheard of, at least in states west of the Mississippi (see map below). The last major urban outbreak of plague in the United States occurred in 1924-25 in Los Angeles. Since then, only scattered cases have been reported, with about 7-15 cases each year in the U.S..

Most of the world's plague activity today is in Africa, Asia, and South America. Madagascar is currently dealing with what has become an almost yearly resurgence of Bubonic and Pneumonic Plague.  The WHO reports:

On 31 August 2021, the preliminary results of the investigation showed a total of 30 suspected cases of pulmonary plague, including seven deaths (four community deaths and three health facility-based), giving a case fatality ratio of 23%. Twenty laboratory samples (12 blood and eight sputum) were collected and sent to the Pasteur Institute of Madagascar for analysis. Of these 20 samples, 12 (60%) were PCR positive, confirming the outbreak of pneumonic plague in the country.

Two months ago, in Colorado Health Department: Plague Activity Alert, we learned of the death of a 10 y.o. boy in La Plata County, Colorado from Bubonic plague. Plague - which is caused by the bacteria Yersinia pestis - is treatable by antibiotics if caught early enough, so deaths in the United States are rare.

Plague can present in three forms: bubonic, septicemic and pneumonic. If untreated, bubonic plague can evolve to a more transmissible pneumonic plague.

• Bubonic Plague (Yersinia Pestis) - carried by rats, squirrels, and other small rodents, and transmitted by fleas - sets up in the lymphatic system, resulting in the tell-tale buboes, or swollen lymph glands in the the groin, armpits, and neck.

• Less commonly Pneumonic Plague may develop, when the infected individual develops a severe pneumonia, with coughing and hemoptysis (expectoration of blood), which may spread the disease by droplets from human-to-human.

In the United States, 80% of cases are of the less worrisome Bubonic plague, and further transmission is rare.  Today we have a report of an unusual case of Pneumonic Plague from Wyoming. 

Wyoming Detects Rare Human Case of Pneumonic Plague

September 15, 2021

The Wyoming Department of Health (WDH) announced today the detection of a rare but serious case of pneumonic plague in a northern Fremont County resident.

Plague is a bacterial infection that can be deadly to humans and other mammals, including pets, if not treated promptly with antibiotics. This disease can be transmitted to humans from sick animals or by fleas coming from infected animals; in this case, the person had contact with sick pet cats.

Plague can also be transmitted from person to person through close contact with someone who has pneumonic plague. Individuals with a known exposure to plague require post-exposure treatment with antibiotics to help prevent illness. WDH is notifying individuals who may need this kind of treatment.

Plague symptoms depend on how the patient is exposed. The most common form is bubonic plague, where patients develop the sudden onset of fever, headache, chills, and weakness and one or more swollen, painful lymph nodes called buboes. This form usually results from the bite of an infected flea. Individuals with septicemic plague develop fever, chills, extreme weakness, abdominal pain, shock, and possible bleeding into the skin and other organs. Septicemic plague can occur as the first symptom of plague or may develop from untreated bubonic plague and can be caused by the bite of an infected flea or the handling of an infected animal. Individuals with pneumonic plague develop fever, headache, weakness, and a rapidly developing pneumonia with shortness of breath, chest pain, and sometimes watery or bloody mucous.

Pneumonic plague is the most serious form and is the only form that can be spread from person to person. Pneumonic plague can develop from inhaling infectious droplets or may develop from untreated bubonic or septicemic plague.

Dr. Alexia Harrist, state health officer and state epidemiologist with WDH, said while the risk for humans to contract plague is very low in Wyoming, the disease has been documented throughout the state in domestic and wild animals.

“It’s safe to assume that the risk for plague exists all around our state,” Harrist said. “While the disease is rare in humans, it is important for people to take precautions to reduce exposure and to seek prompt medical care if symptoms consistent with plague develop.”

To reduce the risk of plague, WDH recommends:

• Reducing rodent habitats around the home, workplace, and recreational areas by removing brush, rock piles, junk, cluttered firewood, and possible rodent food supplies.
• Wear gloves if handling or skinning potentially infected animals to prevent contact between your skin and the plague bacteria.
• Use repellent if exposure to fleas is possible during activities such as camping, hiking, or working outdoors. Products containing DEET can be applied to the skin as well as clothing.
• Keep fleas off indoor and outdoor pets by applying flea control products. Animals that roam freely outdoors are more likely to come into contact with plague-infected animals or fleas.
• If pets become sick, seek care from a veterinarian as soon as possible.
• Do not allow dogs or cats that roam free to share beds with people.

This human plague case is the seventh thought to be acquired in Wyoming since 1978. Other recorded Wyoming cases include a 1978 out-of-state case acquired in Washakie County, a 1982 Laramie County case, a 1992 Sheridan County case that resulted in death, a 2000 Washakie County case, a 2004 out-of-state case acquired in Goshen County, and a 2008 out-of-state case acquired in Teton County.

(Continue . . . )

Modern medicine, particularly the advent of effective antibiotics, makes plague far less fearsome than it once was, but Madagascar's recent epidemics, and a large 1994 India outbreak that infected more than 5,000 people (see WHO Summary), show that large urban outbreaks are still possible.

In 2019's CDC: The 8 Zoonotic Diseases Of Most Concern In The United States, we looked at a joint CDC, USDA, DOI report on the top (n=56) zoonotic diseases of national concern for the United States. 

While Zoonotic Influenzas (avian, swine, etc.) were at the top of the list, Plague ranked 4th, and novel coronaviruses (MERS, SARS, etc.) ranked 5th.

I confess to having a particular interest in Plague, which stems from my working as a paramedic in Phoenix, Arizona where Bubonic plague cases are still occasionally found, and my reading – around the age of 11 – of James Leasor’s  The Plague and The Fire  which recounts two incredible years in London’s history (1665-1666) - which began with the Great plague, and ended with the Fire of London.

A fascinating read (if you can find a copy) for both history and epidemic aficionados.   

 

Idaho DOH Expands Crisis Standards of Care Statewide Due to Surge in COVID-19 Patients Requiring Hospitalization

 

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Five days ago, in Idaho DOH Activates Crisis Standards Of Care In Northern Districts Due To COVID-19  we looked at a September 7th declaration of a healthcare delivery crisis in the the Panhandle and North Central Health Districts of Idaho and their authorization of `Crisis Standards of Care'. 

As I recounted nearly a month ago, in Through A Scanner Darkly, hospitals and EMS crews where I live (central Florida) are already overwhelmed, with delayed response times for emergency crews, hospitals constantly on and off `Divert' status, and long waits for beds.

Ambulances (and hospital rooms) have to be decontaminated after caring for a confirmed or suspected COVID patient (see Interim Guidance for Emergency Medical Services (EMS)Systems for COVID-19 in the United States), which can make a unit 10-7 (Out of Service) for prolonged periods of time.

Today, almost anywhere in the country - if you are in need of emergency or elective healthcare procedures - the demands of COVID pandemic will likely impact how (and sometimes even `if') it will be delivered.  

And that goes for everyone, not just COVID cases. 

For some, it means some elective procedures may be postponed, or longer waits at the Emergency Room or your doctor's office. For others, the impacts could be more severe, as described in the the Idaho State DOH FAQ on their Crisis Standard of Care:

(Excerpt)

During a disaster, such as an earthquake or a pandemic, healthcare systems may be so overwhelmed by patients, or resources may be so scarce, that it may not be possible to provide all patients the level of care they would receive under normal circumstances. In those situations, crisis standards of care would guide decisions about how to allocate scarce resources, such as hospital beds, medications, or breathing machines. 

(Snip)

How would crisis standards of care affect me and my care? 

When crisis standards of care are in effect, people who need medical care may experience care that is different from what they expect. For example, emergency medical services may need to triage (prioritize) which 9-1-1 calls they respond to. Patients admitted to the hospital may find that hospital beds are not available or are in repurposed rooms (e.g. a conference room) or that laboratory or radiology services are limited or unavailable.

In rare cases, ventilator (breathing machines) or intensive care unit (ICU) beds may need to be used for those who are most likely to survive, while patients who are not likely to survive may not be able to receive one. The goal in all cases is to provide the best medical care possible with the resources that are available and to save the greatest number of lives. 

If crisis standards of care are implemented during the COVID-19 pandemic, will all medical care be affected, or just COVID-19-related care?

 If crisis standards of care are implemented during the COVID-19 pandemic, all types of medical care may be affected. If, for example, a patient needs ICU level care for the treatment of a severe infection or a traumatic accident, and there are not enough ICU beds available to treat all the patients who need one, that patient would enter a triage algorithm just like patients with COVID-19 who need an ICU bed. 

Today - with the pressures of increased COVID hospitalization continuing to grow - the Idaho Department of Health and Welfare has extended that declaration to include the entire state.

Idaho expands Crisis Standards of Care statewide due to surge in COVID-19 patients requiring hospitalization

September 16, 2021

The Idaho Department of Health and Welfare (DHW) has activated Crisis Standards of Care (CSC) in accordance with IDAPA 16.02.09 – Crisis Standards of Care For Healthcare Entities. CSC is activated statewide because the massive increase of COVID-19 patients requiring hospitalization in all areas of the state has exhausted existing resources. CSC was activated on Sept. 6 in North Idaho. This activation, declared today, expands the declaration to the rest of the state.

This action was taken after St. Luke’s Health System requested that CSC be activated. DHW Director Dave Jeppesen convened the CSC Activation Advisory Committee virtually on Sept. 15. The committee recommended that CSC be activated statewide.

“Our hospitals and healthcare systems need our help. The best way to end crisis standards of care is for more people to get vaccinated. It dramatically reduces your chances of having to go to the hospital if you do get sick from COVID-19. In addition, please wear a mask indoors in public and outdoors when it’s crowded to help slow the spread” said DHW Director Jeppesen. “The situation is dire – we don’t have enough resources to adequately treat the patients in our hospitals, whether you are there for COVID-19 or a heart attack or because of a car accident.”

Although DHW has activated CSC, hospitals will implement as needed and according to their own CSC policies. However, not all hospitals will move to that standard of care. If they are managing under their current circumstances, they can continue to do so.

Crisis standards of care are guidelines that help healthcare providers and systems decide how to deliver the best care possible under the extraordinary circumstances of an overwhelming disaster or public health emergency. The guidelines may be used when there are not enough healthcare resources to provide the usual standard of care to people who need it. The goal of crisis standards of care is to extend care to as many patients as possible and save as many lives as possible.

When crisis standards of care are in effect, people who need medical care may get care that is different from what they expect. For example, patients admitted to the hospital may find that hospital beds are not available or are in repurposed rooms (such as a conference room) or that needed equipment is not available. They may have to wait for a bed to open, or be moved to another hospital in or out of state that has the resources they need. Or they might not be prioritized for the limited resources that are available. In other words, someone who is otherwise healthy and would recover more rapidly may get treated or have access to a ventilator before someone who is not likely to recover.

The process to initiate crisis standards of care began when resources were limited to the point of affecting medical care. DHW Director Jeppesen convened the Crisis Standards of Care Activation Advisory Committee on Sept. 15, 2021, to review all the measures that were taken to provide care for the increased number of COVID-19 patients requiring hospitalization. The committee determined that the ability of all Idaho hospitals and healthcare systems to deliver the usual standard of care has been severely affected by the extraordinary influx of patients, and all contingency measures have been exhausted. The committee recommended to the director that crisis standards of care be activated statewide. Director Jeppesen issued his decision on Sept. 16, 2021, under the authority vested in him through the temporary rule.

Efforts will continue with earnest to alleviate the resource constraints in the state caused by the massive increase in the number of COVID-19 patients needing hospitalization. The crisis standards of care will remain in effect until there are sufficient resources to provide the usual standard of care to all patients.

Learn more about crisis standards of care and see an FAQ at https://coronavirus.idaho.gov/idaho-resources/

The Idaho Department of Health and Welfare is dedicated to strengthening the health, safety, and independence of Idahoans. Learn more at healthandwelfare.idaho.gov.

Contact: Niki Forbing-Orr

Public Information Manager

208-334-0668

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 We've looked at the thorny issues of triage, and the allocation of scarce medical resources, previously in HHS ASPR-TRACIE: COVID-19 Crisis Standards of Care Resources and Contemplating A Different `Standard of Care'. 

How bad things will get this winter is unknown, and a lot will depend upon whether we see a `twindemic' of influenza and COVID. But Idaho probably won't be the only state to declare a medical crisis in the months ahead. 

All good reasons, if you still need one, to get your COVID vaccine, to get the seasonal flu vaccine, and avoid any `risky' behavior puts you at risk of infection this fall and winter.   

#NatlPrep: Giving Your Preparedness Plan A Shot In The Arm

 

Note: September is National Preparedness Month.  Follow this year’s campaign on Twitter by searching for the #NatlPrep #BeReady or #PrepMonth hashtags.

This month, as part of #NPM21, I’ll be rerunning some updated preparedness essays, along with some new ones.

#16,191

A short while ago - as I've done every September since the mid-2000's - I rolled up my sleeve to get my annual flu shot.  This year - and for the very first time - I elected to get the Hi-Dose vaccine for those over 65, which should provide a bit more protection given my ageing immune system. 

While you might not have thought about it, getting your seasonal flu shot each year should really be part of your overall preparedness plan. During a disaster or prolonged emergency - like, say a pandemic - you are going to be tired, stressed, and your immune system will likely be weakened. 

The last thing you need to be dealing with during a crisis is to be sick with the flu. Granted, if I were truly committed, I'd also eat healthier, lose weight, and exercise more . . . but at this late date, I'm pretty sure that's not going to happen.

But I do get the flu shot every fall, and have now for 15 years in a row.  Which is why this morning I masked up and visited my local CVS pharmacy, where I got my yearly jab. I made an online appointment, so it was quick, easy, and covered by my insurance.  

While I'm fully aware of the limitations of flu shots, and their lower effectiveness in those over 65, I also know that I haven't had the flu - or any other respiratory illness - for more than a  decade.  

I've participated in the Flu Near You surveillance program - a partnership between HealthMap (healthmap.org), Boston Children’s Hospital, and the Skoll Global Threats Fund - every week since 2011 (see The `Flu Near You’ Survey), and haven't had to report an illness until I contracted COVID in January of this year (note: I've since been double-vaccinated for COVID). 

While I'm sure my obsessive use of hand sanitizer when out in public, my avoidance of crowds during the winter, and no small amount of good luck have probably been big contributors to that remarkable run . . . I've also not missed a flu vaccine since 2005.

This year, the return of seasonal flu, and the how well this year's vaccine will match circulating strains, is more up in the air than usual.  But given my age, comorbidities - and what we know about co-infection with COVID-19 and influenza - I'll take whatever extra insurance I can get. 

Even when the flu shot doesn't prevent infection, there is growing evidence it can reduce the severity of one's illness, and reduce your odds of having a heart attack or stroke.  Some recent studies include:

CDC: Another Study Linking Severe Influenza To Heart Damage

(AAIC®) 2020 Presentation : Flu & Pneumonia Shots Appear To Reduce Dementia Risk In Elderly

NEJM: Acute Myocardial Infarction After Laboratory-Confirmed Influenza Infection

 

Flu Vaccine May Lower Stroke Risk in Elderly ICU Patients

And to that we can add a number of studies showing a correlation between getting the flu shot and a lower risk of COVID infection, or severe illness if you are infected.   While causality hasn't been proven, there are some pretty strong signals here. 

Another Preprint Suggesting Flu Vaccination May Offer Some Protection Against COVID Infection

PLoS One: Potential Benefits of the Influenza Vaccine Against SARS-CoV-2 (Retrospective Cohort Analysis

AJIC: Impact of the Influenza Vaccine on COVID-19 Infection Rates and Severity

While the current flu vaccine is far from perfect, and can’t promise 100% protection, it – along with practicing good flu hygiene (washing hands, covering coughs, & staying home if sick) – remains your best strategy for avoiding the flu and staying healthy this winter.

And with our concurrent COVID pandemic, anything that can help keep you out of the hospital this fall and winter is worth considering.

Alaska Reports 3rd & 4th Case of A Novel Zoonotic Orthopoxvirus (Alaskapox) Near Fairbanks

 

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Although smallpox has been eradicated globally for more than 40 years, and the last natural outbreak of this scourge in the United States occurred in 1949, there remain other poxviruses - often carried by small mammals and arthropods - with at least some zoonotic potential around the world.  

Among them are Cowpox, Camelpox, and currently of greatest concern, Monkeypox (see WHO: Modelling Human-to-Human Transmission of Monkeypox) which is endemic in central and western Africa, and has shown signs of increased transmission over the past decade (see EID Journal:Extended H-2-H Transmission during a Monkeypox Outbreak).

While none of these poxviruses have shown anywhere near the severity, or transmissibility, of smallpox in humans, they are a reminder that poxviruses remain a public health concern. Over the past decade we've seen several novel poxviruses - for which we have limited knowledge - emerge, including:

• Three years ago, in EID Journal: Novel Poxvirus in Proliferative Lesions of Wild Rodents in East-Central Texas, USA we looked at research into a new poxvirus discovered in east-central Texas.
• In 2017, Italian researchers isolated a new pox virus in a cat (see EID Journal Novel Orthopoxvirus and Lethal Disease in Cat, Italy).
• In 2013 two people were found infected with a novel poxvirus in Eastern Europe (and a 3rd from 2010 identified retrospectively) (see NEJM Human Infection with a Zoonotic Orthopoxvirus in the Country of Georgia).

But most pertinent to today's blog, a little less than a year ago in A Novel Zoonotic Orthopoxvirus Resurfaces In Alaska, we looked at the second known case of a human infection with a recently discovered Alaskapox virus.

The first case - identified in 2015 - was in a middle-aged female resident of Fairbanks, Alaska who presented to an urgent care facility with what she thought was a spider bite on her shoulder, along with fever, fatigue and tender lymph nodes (see Clin. Inf. Dis Novel Orthopoxvirus Infection in an Alaska Resident).  

Tests for shingles and chickenpox were negative, and subsequent lab tests revealed she had a never-before-seen novel pox virus.  The lesion resolved after about 6 months. 

While she had contact with a house guest from Azerbaijan, and there were signs of small mammals around her residence, no source of exposure was determined. The virus was determined to be genetically distinct from other known poxviruses, and was likely locally acquired. 

The second case, reported in October of 2020, was described by the Dept of Health:

In August 2020, a different woman who also lived in the Fairbanks area presented with similar symptoms. A small grey lesion appeared on her left upper arm, followed by erythema approximately 4 days later. She reported tender axillary adenopathy, shoulder pain, fatigue, and subjective fever at night. This patient’s lesion was deroofed and submitted to the US Centers for Disease Control and Prevention (CDC) for orthopoxvirus testing. The specimen tested positive on a generic orthopoxvirus PCR assay and sequencing confirmed that it belonged to the lineage identified in 2015.

While there is little reason to suspect that this Alaskapox virus will ever pose a major public health, this week the State of Alaska Department of Health reports two more cases - both occurring over the summer of 2021 - in the following epidemiological report.

Additional Cases of Orthopoxvirus Infection in Fairbanks-area Residents, 2021

(Excerpt)

In July and August 2021, two unrelated persons from the Fairbanks area presented with orthopox-like lesions to an urgent care clinic. The first patient was a young child with a lesion on the inside of her left elbow. About 4 days after the lesion first appeared, she had a mild subjective fever and axillary lymphadenopathy. These systemic symptoms lasted approximately 4 days. The lesion was substantially healed approximately 3 weeks after onset.

The second patient was a middle-aged woman with a lesion on her upper right inner thigh. In addition to her lesion, she reported lymphadenopathy and joint pain beginning about 2 days after lesion onset. Approximately 3 weeks after symptom onset, the patient remained symptomatic but was improving. The lesions from both patients were deroofed and both tested positive on a generic PCR assay for orthopoxviruses. Viral genome sequencing yielded sequences very similar to previous Alaskapox viral sequences. 

Methods 

We interviewed the July patient’s parent and the August patient to identify exposures including travel history, any recent illness or skin lesions in household members, and contact with animals. We focused on the period starting 4 weeks prior to symptom onset; the incubation period for Alaskapox virus infection is unknown, but that of other orthopoxvirus infections is often ≤2 weeks.5 

Results 

Neither patient traveled outside of the Fairbanks area in the 4 weeks prior to symptom onset and neither had household members or other contacts with skin lesions or compatible symptoms. For both patients, the only close contacts identified were family members.

Dogs and at least one cat were present in both households and the cats in both households hunted small mammals. None of the pets were observed to have had pox lesions or other characteristic symptoms. Neither patient had known direct contact with small mammals or small mammal feces.

While no specific source of infection was identified for either patient, both spent time outdoors in the Fairbanks area during the summer. The August patient spent considerable time performing yard work (e.g., cutting weeds) approximately one week before symptom onset. 

Discussion 

As more Alaskapox virus infections in humans are identified, some patterns are beginning to emerge. The identification of these two cases with no travel history and no epidemiologic links to other known cases provides further evidence that human cases occur following occasional spillover from an animal reservoir. The first two patients and one of the 2021 patients lived within about 10 km of Fairbanks, but one of the 2021 patients lived more than 25 km away. 

All four cases occurred in persons living in low-density housing in forested areas; small mammals are widespread in these areas. The 2020 case and both 2021 cases lived with cats. Cats serve as intermediate hosts for another orthopoxvirus, cowpox virus, and can transmit the virus to humans. The potential role of cats or other pets in the epidemiology of Alaskapox virus is unknown.

Small mammal trapping in October 2020 at the residence of the patient identified in August 2020 and other locations in the Fairbanks area yielded evidence of Alaskapox virus infection in small mammals, with the most extensive evidence in voles (data pending publication). The Alaska Section of Epidemiology is continuing to work with the University of Alaska Museum and CDC to investigate the role of small mammals in Alaskapox virus transmission.

Alaskapox virus infection may be more common than initially thought. However, available evidence continues to suggest that the public health impact of Alaskapox virus is limited. No evidence of human-to-human transmission has been documented and all four known infections were detected in the outpatient setting. Increased awareness among clinicians may lead to identification of additional cases and thereby inform a fuller understanding of the geographic distribution, risk factors, and spectrum of illness. 

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Emerging infectious diseases are considered such an important public health threat that the CDC maintains as special division – NCEZID (National Center for Emerging and Zoonotic Infectious Diseases) – to deal with them, and more than 25 years ago the CDC established the EID Journal dedicated to research on emerging infectious diseases.

Over the past 16 years this blog has followed dozens of EIDs, including MERS-CoV, H5N1, H7N9, H5N6,  EA H1N1 G4, Zika, Chikungunya, Ebola, Lyme Disease, SFTS, Nipah and Hendra, Hantavirus,  Monkeypox, The Heartland Virus, the Bourbon Virus, and many others.  

While most of these emerging diseases will never pose a serious pandemic threat, the sudden emergence of the COVID-19 pandemic illustrates how quickly we can be blindsided by an obscure or unknown pathogen. 

Which is why, whenever a novel virus makes the jump to humans, we take note. 

Another Preprint Suggesting Flu Vaccination May Offer Some Protection Against COVID Infection

Credit CDC

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In July, and again in early August (see PLoS One: Potential Benefits of the Influenza Vaccine Against SARS-CoV-2 (Retrospective Cohort Analysis)) we looked at a study that found that those who received a flu vaccine within 6 months of contracting COVID appeared significantly less likely to experience severe disease.

Previously, we'd seen a few studies suggesting that - at least statistically - receipt of the flu vaccine had been linked to lower SARS-CoV-2 infection rates, and/or reduced severity.

 A few of those studies include: 

• In 2020, in the preprint The effect of influenza vaccination on trained immunity: impact on COVID-19, researchers from the Netherlands hypothesized that receipt of the quadrivalent flu vaccine could boost innate immunity after finding SARS-CoV-2 infection `. . .  was less common among Dutch hospital employees who had received influenza vaccination during the 2019/2020 winter season (RR = 0,61 (95% CI, 0.4585 - 0.8195, P = 0.001).'
• Similarly, last January researchers from the University of Missouri School of Medicine published The Flu Vaccination May Have a Protective Effect on the Course of COVID-19 in the Pediatric Population, finding that children vaccinated against flu were less likely to be symptomatically infected with SARS-CoV-2 (p=0.028, adj. OR=0.714, 95% CI [0.529, 0.964]) than those not vaccinated
• And yet another study, Inactivated trivalent influenza vaccination is associated with lower mortality among patients with COVID-19 in Brazil, looking at over 53,000 hospitalized COVID patients during the first half of 2020, found mortality was consistently lower among patients who received a flu vaccine after March 1st, 2020. 
• And last March, in AJIC: Impact of the Influenza Vaccine on COVID-19 Infection Rates and Severity, we saw another study that found that receipt of the flu vaccine appears to be linked to reduced infection, and severe illness, with COVID-19.

While the exact mechanism behind this protective effect is unknown, one plausible explanation is that that receipt of the flu vaccine - in addition to creating flu-specific immune responses - temporarily ramps up the body's innate immune system. 

This is often referred to as the `temporary immunity hypothesis'.

Adding to this growing list we have a new preprint that finds a statistical correlation between hospital employees receiving the quadrivalent flu shot and their having a lowered risk of COVID infection.  

Interestingly, it also demonstrates that receipt of the flu vaccine strongly downregulates nearly 370 inflammatory proteins while boosting anti-inflammatory proteins, which could help explain the reduced severity of COVID in that cohort.

The link, Abstract, and link to the 27-page PDF follow.  I'll have a brief postscript when you return. 

Induction of trained immunity by influenza vaccination - impact on COVID-19

Priya A. Debisarun, Katharina L. Gössling, Ozlem Bulut, Gizem Kilic, Martijn Zoodsma, Zhaoli Liu, Marina Oldenburg, Nadine Rüchel, Bowen Zhang, Cheng-Jian Xu, Patrick Struycken, Valerie A.C.M. Koeken, Jorge Domínguez-Andrés, Simone J.C.F.M. Moorlag, Esther Taks, Philipp N. Ostermann, Lisa Müller,Heiner Schaal, Ortwin Adams, Arndt Borkhardt, Jaap ten Oever, Reinout van Crevel, Yang Li, Mihai G. Netea

doi: https://doi.org/10.1101/2021.09.03.21263028

This article is a preprint and has not been peer-reviewed [what does this mean?]. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.

ABSTRACT

Non-specific protective effects of certain vaccines have been reported, and long-term boosting of innate immunity, termed trained immunity, has been proposed as one of the mechanisms mediating these effects. Several epidemiological studies suggested cross-protection between influenza vaccination and COVID-19. 

In a large academic Dutch hospital, we found that SARS-CoV-2 infection was less common among employees who had received a previous influenza vaccination: relative risk reductions of 37% and 49% were observed following influenza vaccination during the first and second COVID-19 waves, respectively. 

The quadrivalent inactivated influenza vaccine induced a trained immunity program that boosted innate immune responses against various viral stimuli and fine-tuned the anti-SARS-CoV-2 response, which may result in better protection against COVID-19. Influenza vaccination led to transcriptional reprogramming of monocytes and reduced systemic inflammation. 

These epidemiological and immunological data argue for potential benefits of influenza vaccination against COVID-19, and future randomized trials are warranted to test this possibility.

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While certainly no substitute for getting the COVID vaccine, we continue to see studies which appear to show some additional, and unexpected, benefits against severe illness from SARS-CoV-2 infection.  

Despite its often lackluster effectiveness  - particularly in my age group (65+) - I get flu vaccine every year because even a little protection can be lifesaving. The downsides of doing so are miniscule and it not only helps to protect me, it helps to protect others. 

We've also seen evidence over the past few years that influenza - and other respiratory viruses - can trigger heart attacks and strokes (see JAHA: Another Study Linking ILI To Increased Risk Of Heart Attack & Stroke), and that getting the flu shot can substantially reduce those risks as well.  

The evidence that it may help prevent, or attenuate, COVID-19 may not be robust, but there continues to be enough of a pattern in the data to warrant further research. 

In the meantime - the benefits of the flu vaccine are already well established - and if it helps lower the impact of  COVID-19, so much the better.