CDC FluView: An Additional Four Cases Of H1N2v Reported Across 3 States (CA, MI, OH)

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For the second week running the CDC is reporting 4 new novel H1N2v infections, all of which appear to be linked to attendance of county and state fairs.  Three of the four report exposure to swine, while one did not.

Somewhat unusually, it has been the least commonly reported swine variant virus over the past dozen years - H1N2v - which has accounted for 8 of the 9 documented swine variant infections this year.

First the announcement from today's FluView, then I'll return with a bit more.

Novel Influenza A Virus:

An additional four human infections with novel influenza A viruses were reported by three states (California [2], Michigan [1], and Ohio [1]). All four persons were infected with an influenza A(H1N2) variant (A(H1N2)v) virus. Three patients reported exposure to swine at an agricultural fair during the week preceding illness onset, while one patient attended an agricultural fair but no contact with swine was reported.

Three of the patients were children < 18 years of age and one patient was an adult < 25 years of age. No patients were hospitalized and all are recovering or have fully recovered from their illness. No human-to-human transmission has been identified.

A total of nine variant viruses have been reported to CDC during 2018. One of these has been an influenza A(H3N2) variant (A(H3N2)v) virus (Indiana [1]) and eight have been A(H1N2)v viruses (California [4], Michigan [3], and Ohio [1]).

Early identification and investigation of human infections with novel influenza A viruses are critical so that the risk of infection can be more fully understood and appropriate public health measures can be taken. Additional information on influenza in swine, variant influenza infection in humans, and strategies to interact safely with swine can be found at http://www.cdc.gov/flu/swineflu/index.htm.

Additional information regarding human infections with novel influenza A viruses can be found at http://gis.cdc.gov/grasp/fluview/Novel_Influenza.htm

While most of the reported swine variant infections over the past decade have been mild-to-moderate in severity, some people have required hospitalization, and deaths - while rare - have occurred (see J. Virology: Analysis Of A Swine Variant H1N1 Virus Associated With A Fatal Outcome).

Several weeks ago the CDC released a new infographic on preventing the spread of these viruses.

https://www.cdc.gov/flu/pdf/swineflu/transmission-between-pigs-people.pdf

The CDC's recommendations for people at a higher risk of influenza complications is to avoid pigs and swine barns altogether.

If you are at high risk of serious flu complications and are going to a fair where pigs will be present, avoid pigs and swine barns at the fair. This includes children younger than 5 years, people 65 years and older, pregnant women, and people with certain long-term health conditions (like asthma, diabetes, heart disease, weakened immune systems, and neurological or neurodevelopmental conditions).

A week ago, the CDC - in conjunction with the USDA and 4H - released an ambitious 60-page graphic novel on swine variant flu and how disease detectives investigate outbreaks.

Today, the CDC is releasing new educational materials to go along with this graphic novel.

CDC Releases Educational Materials for Teachers for Use with "Junior Disease Detectives: Operation Outbreak" Graphic Novel

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The Junior Disease Detectives graphic novel and associated educational content is available at graphic novel

August 17, 2018 ̶ Today, the Centers for Disease Control and Prevention (CDC) released new educational materials for use in kindergarten through grade 12 (K-12) classrooms across the country in association with the CDC’s new graphic novel, “The Junior Disease Detectives: Operation Outbreak.” The graphic novel is intended to raise youth awareness of variant flu, which is caused by a kind of flu virus that spreads from pigs to people[1.2 MB, 2 pages], and to educate children and teens about careers in public health and outbreak investigations. The release of these new education materials today coincides with the report of four new variant virus infections in three states.

        (SNIP)

Variant virus infections also have the potential to cause flu pandemics, should these viruses gain the ability to spread easily between people. In 2009, a flu virus that had avian, swine and human genes emerged with the ability to spread easily among people, causing the 2009 H1N1 pandemic. Human infections primarily occur from exposure to infected pigs, as opposed to from person to person, but public and animal health officials investigate outbreaks of variant flu to ensure these viruses have not obtained the ability to spread easily between people and cause a pandemic. This year, nine variant virus infections have been reported in the United States, all attended agricultural fairs where swine were present, and most occurred in children.

        (Continue . . . )

 
We regularly cover swine and swine variant influenza in this blog, both in North America and around the world.  For some recent blogs - in just the past 90 days - on its pandemic potential, you may wish to revisit:

BMC Vet.: Novel Reassortant H1N2 & H3N2 Swine Influenza A Viruses - Chile

J. Virology: Pathogenesis & Transmission of H3N2v Viruses Isolated in the United States, 2011-2016

JVI: Divergent Human Origin influenza Viruses Detected In Australian Swine Populations

The `Other' Novel Flu Threat We'll Be Watching This Summer

Emerg. Infect. & Microbes: Novel Triple-Reassortant influenza Viruses In Pigs, Guangxi, China

WHO Ebola Update - DRC August 17th

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The World Health Organization has published their weekly DON (Disease Outbreak News) summary of the the ongoing Ebolavirus outbreak in the DRC, with the sobering news that 8 more HCWs have been diagnosed with the  virus.

The only good news is that reports earlier this week of suspected cases outside of the DRC - including in Uganda - have all tested negative for the virus.

That said, the potential for exporting cases to other regions remains a genuine concern. I've only posted some excerpts from a much longer report, so follow the link to read it in its entirety.

Ebola virus disease – Democratic Republic of the Congo

Disease outbreak news
17 August 2018

On 1 August 2018, the Ministry of Health (MoH) of the Democratic Republic of the Congo declared a new outbreak of Ebola virus disease (EVD) in the town of Mangina, Mabalako Health Zone, North Kivu Province. Confirmed cases have since between reported from Beni and Mandima health zones, Ituri Province; however, all confirmed exposures and transmission events to date have been linked back to the outbreak epi-centre, Mangina. North Kivu and Ituri are among the most populated provinces in the country, share borders with Uganda and Rwanda, and experience conflict and insecurity, with over one million internally displaced people and migration of refugees to neighbouring countries.

As of 15 August 2018, 78 EVD cases (51 confirmed and 27 probable), including 44 deaths, have been reported.1 Since the DON published on 9 August, 34 new confirmed cases have been reported: seven from Ituri Province (Mandima Health Zone) and 27 from North Kivu Province (one in Beni and 26 in Mabalako health zones). The 78 confirmed or probable cases reside in five health zones in North Kivu and one health zone in Ituri. The majority of cases (39 confirmed and 21 probable) have been reported from Mangina in Mabalako Health Zone (Figure 1). As of 15 August, 24 suspected cases are currently pending laboratory testing to confirm or exclude EVD.

Eight new confirmed cases among health care workers have been reported, bringing the total number of infected health care workers to 10 (nine confirmed and one probable deceased case).

These health care workers were likely exposed in clinics, not Ebola treatment centres (ETCs), many of which may have been infected before the declaration of the outbreak. WHO and partners are working to increase awareness of Ebola among health care and other frontline workers, and to strengthen infection prevention and control (IPC) measures.

The MoH, WHO and partners continue to systematically monitor and rapidly investigate all alerts in other provinces and in neighbouring countries. Since the last DON was published, alerts in several provinces of the Democratic Republic of Congo as well as in Uganda, Rwanda, and the Central African Republic were investigated; EVD was ruled out for all.

For more information, see:

Ebola situation reports: Democratic Republic of the Congo

(Continue . . . )

Russia Notifies OIE Of A Second HPAI H5N2 Outbreak In Kostroma Oblast

Kostroma Oblast - Credit Wikipedia

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Amid dozens of reports of HPAI H5 (presumably H5N8) in Western Russia over the past two months we have a new report of HPAI H5N2 - the second reported from Russia - once again from Kostroma Oblast.

Roughly 8 months ago, in OIE: Outbreak In Kostroma, Russia Now Identified As HPAI H5N2, we learned of the first appearance of this HPAI H5N2 virus in Russia, where it forced the culling of 600,000 birds. 

Today the OIE is reporting a second outbreak in Kostroma Oblast, affecting a poultry farm with nearly 500,000 birds.   This report also confirms that this virus is of clade 2.3.4.4. - which suggests this may be a relatively new reassortment - likely from either HPAI H5N8 or HPAI H5N6.

Source of the outbreak(s) or origin of infection    

    Unknown or inconclusive

Epidemiological comments     

The virus isolate was identified as H5N2 subtype by PCR and nucleotide sequencing. The comparative analysis of the obtained nucleotide sequences of the H gene and N gene fragments revealed that the isolate belongs to the Asian genetic lineage of highly pathogenic avian influenza (Clade 2.3.4.4.) which spread in the Russian Federation as well as in Asian, European, Middle Eastern and African countries in 2016-2018. The hemagglutinin cleavage site has a –REKRRKRGLF- structure, characterizing the virus as potentially highly virulent.

Clade 2.3.4.4. H5 viruses have proven themselves to be highly promiscuous, reassorting readily with other flu viruses, and generating a number of viable hybrids. Last year we saw the emergence and spread of HPAI H5N6 (see Tottori University: Shimane HPAI H5N6 A New Reassortment) while the year before a new H5N5 virus was spreading in parts of Europe.  

Going back even farther, in 2014-2015 we saw a reassorted clade 2.3.4.4. HPAI H5N2 virus help spark the largest avian epizootic in North American history (along with HPAI H5N8), affecting at least 15 states and parts of Canada.

This second appearance of HPAI H5N2 in Kostroma Oblast suggest this reassorted virus is likely circulating in wild or migratory birds - and while we don't know much how this particular reassortment behaves  - this will raise fresh concerns over this fall's bird migration into Europe, the Middle East and Africa.

China MOA Confirms 2nd Outbreak Of African Swine Fever - Henan ex Heilongjiang Province

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For the second time in two weeks China's MOA has confirmed an outbreak of African Swine Fever (ASF) among commercial pigs, this time originating in Heilongjiang Province.

Thirteen days ago, in China MOA: 1st Reported Outbreak Of African Swine Fever, we saw the report of the long anticipated, but dreaded first arrival of ASF to China among pigs in Liaoning Province, which borders North Korea.

This discovery prompted the Chinese MOA To Hold An Emergency Meeting On African Swine Fever (ASF) last week, where the Ministry announced a major offensive against this threat.

While not a human health concern, ASF could severely impact pork production in China, which provides much of the animal protein for the dietary needs of 1.4 Billion Chinese.

Within the past few hours China's MOA confirmed a second detection, this time at a Henan Province slaughterhouse, among pigs recently transported from Heilongjiang Province.

Heilongjiang transferred to Zhengzhou, Henan Province, pigs were diagnosed with African swine fever

Date: 2018-08-16 15:42 Author: Source: Ministry of Agriculture and Rural Press Office 

The news office of the Ministry of Agriculture and Rural Affairs was released on August 16th. A pig swine epidemic occurred in a slaughterhouse of a food company in Zhengzhou Economic Development Zone, Henan Province.

On August 14, a pig in a slaughterhouse of a food company in Zhengzhou Economic Development Zone of Henan Province died of unexplained deaths, with 260 heads, 30 diseases and 30 deaths. The quarantine certificate showed that the pigs came from Tangyuan, Jiamusi City, Heilongjiang Province. County Heli Town Trading Market. In the early morning of August 16, it was confirmed by the National Center for Animal Diseases and Diseases of the National Center for Animal Health and Epidemiology of China, and the epidemic was caused by the African swine fever.

After the outbreak, the Ministry of Agriculture and Rural Affairs immediately dispatched supervisory components to Henan and Heilongjiang. In accordance with the requirements, Henan has launched an emergency response mechanism and adopted measures such as blockade, culling, harmless treatment and disinfection to prohibit all pigs and susceptible animals and products from being transported into or out of the blockade. Heilongjiang Province has carried out investigations and epidemiological investigations. At present, the epidemic has been effectively controlled.

Considering that ASF was confirmed less than 24 hours prior to this announcement, the assurances that  `Heilongjiang Province has carried out investigations and epidemiological investigations. At present, the epidemic has been effectively controlled.' are probably best taken with a sizable grain of salt. 

  Meanwhile, the OIE has published the official notification (see below).

 

Source of the outbreak(s) or origin of infection 

Legal movement of animals 

Epidemiological comments 

Strict blockade, disinfection, and movement control measures were conducted in the slaughterhouse. The local government launched the African swine fever contingency plan and emergency response according to the Standard & Protocol for African swine fever. All live pigs and animal products were prohibited to enter and exit the area. Epidemiological survey and screening have been initiated in the Heilongjiang province.

Technically, this outbreak is in Henan Province, although the infected pigs were recently transported from Heilongjiang province. Last March, the FAO issued a Rapid Risk Assessment on the potential for seeing ASF in China, where they wrote:

The most likely regions for ASf spread are the northeast (Heilongjiang), followed by the central eastern area (Henan, Shanxi, Ammui, and Hubbei) and the southeast (Hunan). Surveillance for swine diseases in this region should be heightened.

While one outbreak might be dismissed as happenstance, a second outbreak in another province within two weeks is a pretty solid sign that ASF has already established a beach head in China.

One which has the potential to become a major economic, and societal problem for China in the months ahead.

Evaluation of a Visual Triage for the Screening of MERS-CoV Patients

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With the Hajj scheduled to begin in 3 days time, and with more than 2 million religious pilgrims from around the globe gathering in the Holy Cities of Saudi Arabia, the way that the Saudi MOH screens for potential MERS-CoV cases is of particular interest.

As we've seen previously, respiratory infections are the most commonly reported illness among religious pilgrims (see  EID Journal: ARI’s In Travelers Returning From The Middle East).

This study also found that  `Pneumonia is the leading cause of hospitalization at Hajj, accounting for approximately 20% of diagnoses on admission.’

Four years ago, in EID Journal: Respiratory Viruses & Bacteria Among Pilgrims During The 2013 Hajj, we looked at another study that examined a small group of French pilgrims (n=129) both before and after attending the Hajj, and compared nasal swabs.  They found: 

. . .  that performing the Hajj pilgrimage is associated with an increased occurrence of respiratory symptoms in most pilgrims; 8 of 10 pilgrims showed nasal or throat acquisition of respiratory pathogens. 

It is against this confusing backdrop that medical authorities must evaluate, and hopefully accurately identify and isolate, potential MERS cases among hundreds of thousands of symptomatic travelers presenting with a variety of respiratory symptoms.

While laboratory tests are available, they generally take between 24-48 hours to get the results,  and it usually requires two negative tests - 24 to 48 hours apart - to rule out MERS, during which time the patient should be isolated. 

Doable when you are dealing with a few dozen suspected cases, but impractical on a much grander scale.  Instead, the Saudi MOH has developed a scoring system - based on visible symptoms, and exposure history - to decide who to isolate and test as a potential MERS case.

The $64 question is:  Does it work?

The answer, as provided by prolific MERS researcher and former KSA Deputy Minister of Health,  Ziad Memish, MD et al.,  in a new analysis published this week in NMNI, is not particularly well.
 

Evaluation of a Visual Triage for the Screening of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Patients

Sarah H. Alfaraj, MBBS, Jaffar A. Al-Tawfiq, MD, Philippe Gautret, MD, Mishal Ghazi Alenazi, MBBS, Ayed Yahya Asiri, MBBS, Ziad A. Memish, MD

Open Access

DOI: https://doi.org/10.1016/j.nmni.2018.08.008
 
Introduction
The emergence of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in September 2012 in Saudi Arabia had attracted the attention of the global health community. Recently in the beginning of 2017, the Saudi Ministry of Health released a visual triage system with scoring to alert healthcare workers in emergency departments and hemodialysis units for the possibility of occurrence of MERS-CoV infection in their patients.

Patients and Methods

This is a retrospective analysis of the visual score of the Saudi Ministry of Health to determine its sensitivity and specificity. The study included all cases from 2014 to 2017 in a MERS-CoV referral center in the city of Riyadh, the capital of Saudi Arabia.

Results

During the study period, there were a total of 2435 suspected MERS cases. Of these cases 1823 (75%) tested negative and the remaining 25% tested positive for MERS-CoV by PCR assay. The application of the visual triage score revealed a similar percentage of MERS-CoV and non-MERS CoV patients with each score from 0 to 11.

The percentage of patients with the cut-off score of > 4 was 75% in patients with MERS Cov infection and 85% in patients without MERS-CoV infection (P =0.0001). The sensitivity and specificity of this cut off score for MERS-CoV infection were 74.1% and 18.6%, respectively.

Conclusion

The sensitivity and specificity of the scoring system was low and further refinement of the score is needed for better prediction of MERS-CoV infection.

The two main measures of the accuracy of any diagnostic test are sensitivity and specificity.

• Sensitivity is defined as the ability of a test to correctly identify individuals who have a given disease or condition.

• Specificity is defined as the ability of a test to exclude someone from having a disease or illness.

This visual scoring system failed to identify more than 25% of MERS cases, and at the same time more than 80% of `tagged' patients were negative for the virus.

The authors provide two strategies to improve screening:

Firstly, revise the case definition after careful review of the data available to the MoH for 5 years and secondly invest in developing a highly sensitive and specific point of care (POC) testing in the EDs and haemodialysis units where the results will be available in 1-2 hours [24–26].

The authors were particularly blunt in their assessment (bolding mine) of the current system.

The  current  study  conducted  on  a  large  number  of  patients  shows  that  clinical  scoring  is not predictive  of  MERS  infection. 

Our  results  are  robust  and  confirm  that  MERS  cannot  be distinguished from other respiratory infections based on  risk factors  and clinical features.  Thus all  patients with  non-specific  symptoms  in  a  MERS  endemic  area  will  have  to  be  isolated  until MERS can be ruled out by rapid PCR testing.

All of which adds weight to the notion that a substantial number of MERS cases may be going undiagnosed in Saudi Arabia, and elsewhere in the world.  We've seen estimates that many - perhaps even most - MERS cases go undetected.

• In November of 2013, we looked at a study published in The Lancet Infectious Diseases, that estimated for every case identified, there are likely 5 to 10 that go undetected.
• In 2015, when Saudi Arabia had recorded fewer than 1200 MERS cases, a seroprevalence study (see Presence of Middle East respiratory syndrome coronavirus antibodies in Saudi Arabia: a nationwide, cross-sectional, serological study by Drosten & Memish et al.,) suggested nearly 45,000 might have been infected. 
• And a 2016 study (see EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016) suggested that as much as 60% of severe Saudi MERS cases go undiagnosed.

While we've been lucky in the past, with no large MERS outbreaks linked to the Hajj, the possibility of seeing one or more infected pilgrims returning to their home countries while silently incubating the virus remains a genuine concern.

All of which will have public health officials around the world particularly on alert for the next 30 days.

California: CDFA Expands Quarantine For Virulent Newcastle Disease (VND)

Updated Quarantine Order

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Five weeks after the California's Department of Food and Agriculture (CDFA) ordered a poultry Quarantine In 2 Counties (San Bernardino & Riverside) due to outbreaks of Virulent Newcastle Disease - amid rising case counts and a surge in Los Angeles County - the agency has issued a second, follow-up quarantine order.

August 14, 2018 - California Area Quarantine Notice #2: Los Angeles and San Bernardino County Areas

 The operative part of the new order reads:

You are hereby notified that the State Veterinarian has imposed a Quarantine pursuant to Food and Agricultural Code, Section 9562 on the following population of animals and animal products:

Description of Population of Animals and Animal Products: Poultry species (including chickens, turkeys, ducks, geese, partridges, pheasants, quail, guinea fowl, peafowl (peacocks), doves, pigeons, grouse, swans, and ratites), poultry products including eggs, manure/fertilizer, and used equipment or other items that could be contaminated due to exposure to poultry or poultry manure.

Present Location: In those areas of Los Angeles and San Bernardino Counties as described above.

Reason for Quarantine: This Quarantine is imposed because the population of animals and animal products described above may be infected with virulent Newcastle disease virus (VND) or may have been exposed to VND and can transmit an illness that could kill or seriously damage other birds, or may be at risk for such exposure.

Required Action: Pursuant to California Food and Agricultural Code Section 9562 and Title 3, California Code of Regulations, Section 1301 et seq., require the following:

• Hold the population of animals and animal products described above on the premises where it is now located.

• Segregate and Isolate the population of animals and animal products described above from other animals or products no later than: 5:00 PM on August 15, 2018.

• The method of isolation shall be confinement to one premises in a pen, cage or other means that prevents poultry from moving off the premises.
• No poultry or hatching eggs shall be moved onto the premises and no poultry, poultry products, used poultry equipment or other items that could spread disease due to contact with poultry or poultry manure shall be moved off the premises until this quarantine is rescinded or revised; or unless the owner has signed a compliance agreement with the California Department of Food and Agriculture (CDFA) and such movement is made using a CDFA or United States Department of Agriculture (USDA) movement permit.
• All owners shall immediately report any clinical signs suggestive of VND (described on CDFA website at https://www.cdfa.ca.gov/go/VND) and any unexpected decreases in egg production or increase in mortality (above expected rate for strain and age) by phone to the sick bird hot line at (866) 922-2473 or California State Veterinarian at (916) 900-5000.

• Euthanize and Dispose of the population of poultry that cannot be isolated as described above. Due to the high risk of exposure to VND in the above designated disease control areas, CDFA or USDA will assist with euthanasia if poultry are free roaming and not isolated as described by 5:00 PM on August 16, 2018.

All outbreaks, so far, have been limited to backyard exhibition poultry. No commercial poultry operations have been affected yet. The last poultry outbreak in the United States was reported in 2003 (described below), although sporadic detections in wild birds have continued around the country.

This from the California Dept. of Food & Agriculture (Note: VND was called END - Exotic Newcastle Disease in 2003). 

The 2002-03 END outbreak, originally confirmed in backyard poultry in Southern California, spread to commercial poultry operations in California and backyard poultry in Arizona, Nevada and Texas.  The Governor of California declared a State of Emergency, the Secretary of the United States Department of Agriculture (USDA) declared an Extraordinary Emergency, and local emergencies were declared in San Diego, Riverside, Los Angeles, and San Bernardino Counties.

A USDA and the California Department of Food and Agriculture (CDFA) Task Force was formed that involved over 7,000 individuals rotating in and out over the course of the outbreak.  Trade restrictions resulting from the disease had negative impacts on California and U.S. poultry and egg producers.  The outbreak, from discovery to eradication, lasted eleven months.  The outbreak response led to the depopulation of 3.16 million birds at a cost of $161 million.

In 1971, an outbreak that began in Southern California led to the culling of 12 million birds and a loss of tens of millions of dollars.

We won't get a new weekly report until sometime tomorrow, but as of last weekend CDFA had reported - since May 18th - 93 cases of VND in backyard birds in California; 73 in San Bernardino County, 8 in Riverside County and 12 in Los Angeles County.

While there is a very slight risk of human infection, illness is generally mild and usually presents as conjunctivitis. The real threat is to the poultry industry, should the virus find its way again into commercial flocks.

Stay tuned.