Bulgaria: Additional H5N1 Outbreak Reported

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Earlier this week we saw media reports, and then an OIE Notification Of H5N1 In Bulgaria, when a dead pelican near the Poda Protected Area located south of the port city of Bourgas on the Black Sea tested positive for avian flu. This was the first detection of the virus in Bulgaria since 2010.

Today there are media reports of a small outbreak in the nearby village of Konstantinovo.

 

 

Secondary outbreak of bird flu discovered in Bulgaria’s Konstantinovo

31 January 2015 | 16:36 | FOCUS News Agency

 

Burgas. A secondary outbreak of bird flu was discovered in the village of Konstantinovo, coastal Kameno Municipality, Dr Georgi Mitev, head of the district directorate of the Bulgarian Food Safety Agency, told Radio FOCUS – Burgas.

The case concerns hens in the yard of the village and tests have been run to confirm it but will be officially announced on Monday.

The village borders Lake Mandra, where there are many wild and migratory birds.

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CDC Interim Guidance On Antiviral Chemoprophylaxis For Persons With Exposure To Avian Flu

Photo Credit – FAO

 

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Last night the CDC released a pair of interim guidance documents for clinicians and public health officials on how to deal with patients suspected of being exposed to novel (primarily avian) influenza. I blogged about the first guidance document earlier today in CDC Interim Guidance For Testing For Novel Flu.

Although we haven’t had to deal with HPAI much in North America, the standard procedure it to treat – prophylactically with antivirals – anyone with known exposure to infected birds. 

 

Often in Asia or the Middle East, this has included cullers who have been charged with destroying an infected flock of poultry, or family members of someone diagnosed with H5N1 or H7N9.  With the recent arrival of HPAI H5 viruses in migratory and wild birds to North America, it is possible that some North American poultry workers (or hunters) may be exposed to infected birds. 

 

While the HPAI H5 viruses currently circulating in North America have not been directly associated with human infection, viruses evolve over time, and the CDC is wisely considering them a potential human health hazard.  The CDC has therefore released the following interim guidance.

 

Interim Guidance on Influenza Antiviral Chemoprophylaxis of Persons Exposed to Birds with Avian Influenza A Viruses Associated with Severe Human Disease or with the Potential to Cause Severe Human Disease

• Español
• Background
• Exposure to Birds Infected with Avian Influenza
• Monitoring of Exposed Persons
• Post-exposure Chemoprophylaxis of Exposed Persons
• Footnotes

Background

This document provides interim guidance for clinicians and public health professionals in the United States on follow-up and influenza antiviral chemoprophylaxis of persons exposed to birds infected with avian influenza A viruses associated either with severe human disease or thought to have the potential to cause severe human disease. Examples of viruses associated with severe human disease include Asian avian influenza A (H5N1) and A (H7N9) viruses. Examples of viruses with the potential to cause severe human disease include avian influenza A (H5N2) and (H5N8) viruses, and a new reassortant avian influenza A (H5N1) virus¹, all of which were detected in wild and domestic birds in North America in December 2014 and January 2015. There is limited experience with these newly detected viruses to inform public health guidance. However, these viruses are thought to have the potential to infect people and cause severe illness. To date no human avian influenza infections have been documented in the U.S. CDC will update this guidance as additional information becomes available.

Exposure to Birds Infected with Avian Influenza

An exposed person is defined as a person with contact² in the past 10 days³ to infected sick or dead birds, or infected flocks. Infected refers to infection with avian influenza A viruses associated with severe human disease or which have the potential to cause severe human disease.

Top of Page

Monitoring of Exposed Persons

Exposed persons should monitor themselves for new illness for 10 days after the last known exposure. The presence of fever and respiratory symptoms (e.g., cough, sore throat, shortness of breath, difficulty breathing) should be assessed daily during this period.

Any exposed person who has a new fever or respiratory symptoms should be referred for prompt medical evaluation, antiviral treatment, and testing for avian influenza (A) virus infection.

Post-exposure Chemoprophylaxis of Exposed Persons

Chemoprophylaxis with influenza antiviral medications can be considered for all exposed persons. Decisions to initiate antiviral chemoprophylaxis should be based on clinical judgment, with consideration given to the type of exposure and to whether the exposed person is at high risk for complications from influenza.

If antiviral chemoprophylaxis is initiated, treatment dosing for the neuraminidase inhibitors oseltamivir or zanamivir (one dose twice daily) is recommended in these instances instead of the typical antiviral chemoprophylaxis regimen (once daily).⁴ For specific dosage recommendations for treatment by age group, please see Influenza Antiviral Medications: Summary for Clinicians. Physicians should consult the manufacturer’s package insert for dosing, limitations of populations studied, contraindications, and adverse effects.

Chemoprophylaxis is not routinely recommended for personnel involved in culling non-infected or likely non-infected bird populations as a control measure or personnel involved in handling sick birds or decontaminating affected environments (including animal disposal) who used proper personal protective equipment.

See CDC guidance for follow-up and antiviral chemoprophylaxis of contacts of cases of human infection with avian influenza A viruses associated with severe human disease.

Footnotes

¹ The H5N1 virus isolated from a US wild bird is a new mixed-origin virus (a “reassortant”) that is genetically different from the avian H5N1 viruses that have caused human infections with high mortality in several other countries (notably in Asia and Africa). No human infections with this new reassortant H5N1 virus have been reported.

² This direct exposure may include: contact with birds (e.g., handling, slaughtering, defeathering, butchering, preparation for consumption); direct contact with surfaces contaminated with feces or bird parts (carcasses, internal organs, etc.); or prolonged exposure to birds in a confined space.

³ The potential incubation period is unknown for avian influenza A viruses which are not yet known to cause human disease. Available data suggest that the estimated incubation period for human infection with H5N1 and H7N9 viruses is generally 3 to 7 days, but has been reported to be as long as 10 days.

⁴ This recommendation for twice daily antiviral chemoprophylaxis dosing frequency is based on limited data that support higher chemoprophylaxis dosing in animals for avian A(H5N1) virus (Boltz DA, et al JID 2008;197:1315) and the desire to reduce the potential for development of resistance while receiving once daily dosing ( BazM, et al NEJM 2009;361:2296; Cane A et al PIDJ 2010;29:384; MMWR 2009;58:969).

CDC Interim Guidance For Testing For Novel Flu

 

Credit NIAID 

 

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While the risk to the public remains low, the importation this month of two cases of H7N9 into Canada from China, the ongoing outbreak of H5N1 in Egypt, and the recent introduction of HPAI H5 viruses via wild and migratory birds into North America are all reasons why doctors around the country need to be aware of the potential for seeing novel flu cases.

The HPAI H5 viruses currently circulating in North America have not been associated with human infection - but they are related to H5 viruses that have - and so they are deserving of extra scrutiny and vigilance.  

Last night the CDC published extensive interim guidelines on the handling of suspected novel flu patients for clinicians and public health entities, excerpts of which I’ve posted below:  They also published Interim Guidance on Influenza Antiviral Chemoprophylaxis of Persons Exposed to Birds with Avian Flu, which I will cover in my next blog.

 

 

Interim Guidance on Testing, Specimen Collection, and Processing for Patients with Suspected Infection with Novel Influenza A Viruses with the Potential to Cause Severe Disease in Humans

On this Page

• Background and Purpose
• Recommendations for Surveillance, Testing, and Investigation
• When Specimens Should Be Collected
• Infection Control when Collecting Specimens
• Preferred Respiratory Specimens
• Swabs
• Storing Clinical Specimens
• Shipping Clinical Specimens to State Public Health Laboratories
• Diagnostic Testing
• Testing at State Health Departments
• Antiviral Treatment
• Shipping Clinical Specimens to CDC

Background and Purpose

This document provides interim guidance for clinicians and public health professionals in the United States on appropriate testing, specimen collection and processing for patients who may be infected with novel influenza A viruses with the potential to cause severe illness in people. Examples of such viruses include Asian-lineage avian influenza A (H5N2), (H5N8), and (H5N1)¹ viruses, which were detected in wild and domestic birds in North America in December 2014 and January 2015; these viruses may have some or all of their genes from Asian avian influenza viruses, but for simplicity will all be referred to as “newly detected avian influenza A H5” viruses in this guidance document. Other newly detected avian influenza A H5 viruses also may have the potential to cause severe disease in humans. For a list of avian influenza A H5 virus infections identified in birds in the United States, and their locations, please see an update on avian influenza findings maintained by the US Department of Agriculture. CDC will update this guidance as additional information becomes available.

The appearance of newly detected avian influenza A H5 viruses in North America may increase the likelihood of human infection with these viruses in the United States. Because these newly identified avian influenza A H5 viruses are related to avian influenza A viruses associated with severe disease in humans (e.g., highly pathogenic Asian-lineage avian influenza A (H5N1) virus), they should be regarded as having the potential to cause severe disease in humans until shown otherwise. Other CDC guidance provides recommendations for influenza viruses known to be associated with severe disease in humans.

¹ The H5N1 virus isolated in the United States in January 2015 is a new mixed-origin virus (a “reassortant”) that is genetically different from the H5N1 virus found in several other countries (notably in Asia and Africa), which has caused human infections with high mortality. Although it is related to the H5N1 virus that has caused human infections with high mortality, the ability of this new reassortant H5N1 virus to cause severe disease is currently unknown.

Recommendations for Surveillance, Testing, and Investigation

Clinicians and public health personnel should consider the following recommendations for surveillance and testing:

1. Consider the possibility of infection with novel influenza A viruses with the potential to cause severe disease in humans in patients with medically-attended influenza-like illness (ILI) and acute respiratory infection (ARI) who have had recent contact¹ (<10 days prior to illness onset) with sick or dead birds in any of the following categories²:
   1. Domestic poultry (e.g., chickens, turkeys, ducks)
   2. Wild aquatic birds (e.g., ducks, geese, swans)
   3. Captive birds of prey (e.g., falcons) that have had contact with wild aquatic birds
2. If infection with a novel influenza A virus with the potential to cause severe disease in humans is possible, respiratory specimens should be collected with appropriate infection control precautions and sent to the state or local health department for immediate testing (see guidance below).
3. If infection with a novel influenza A virus with the potential to cause severe disease in humans is suspected, state health departments are encouraged to initiate a public health investigation with animal health partners and should notify CDC promptly.

¹ Contact may include: direct contact with birds (e.g., handling, slaughtering, defeathering, butchering, preparation for consumption); or direct contact with surfaces contaminated with feces or bird parts (carcasses, internal organs, etc.); or prolonged exposure to birds in a confined space.

² For questions or concerns about possible human infection in patients with exposures to birds not listed here, please contact CDC. Exposures that occur in geographic regions in the United States where newly detected avian influenza A H5 viruses have been identified are of most concern.

When Specimens Should Be Collected

The duration of shedding of novel influenza A viruses in humans is largely unknown, and there are currently limited data describing prolonged shedding of people infected with these viruses. Therefore, the estimated duration of viral shedding is based upon seasonal influenza virus infection. Specimens should be obtained for novel influenza A virus testing as soon as possible after illness onset, ideally within 7 days of illness onset. However, as some persons who are infected with seasonal influenza viruses are known to shed virus for longer periods (e.g., children and immunocompromised persons), specimens should be tested for novel influenza A virus even if obtained after 7 days from illness onset. Note that prolonged shedding of influenza virus in the lower respiratory tract has been documented for critically ill patients with highly-pathogenic avian influenza A H5N1 virus and avian influenza A H7N9 virus infections.

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HK CHP Notified Of 2 H7N9 Cases In Guangdong Province

Credit Wikipedia

 

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Guangdong Province’s streak of H7N9 reports continues with two more cases reported to Hong Kong’s CHP today.

 

 

CHP notified of two human cases of avian influenza A(H7N9) in Guangdong

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (January 31) closely monitoring two additional human cases of avian influenza A(H7N9) notified by the Health and Family Planning Commission of Guangdong Province (GDHFPC), and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the GDHFPC, a male patient aged 48 (in Jieyang) died while a female patient aged nine (in Shanwei) is in stable condition and was hospitalised for management.

To date, 504 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities, respectively in Zhejiang (146 cases), Guangdong (142 cases), Jiangsu (63 cases), Shanghai (44 cases), Fujian (28 cases), Hunan (24 cases), Anhui (17 cases), Jiangxi (nine cases), Xinjiang (nine cases), Shandong (six cases), Beijing (five cases), Henan (four cases), Guangxi (three cases), Jilin (two cases), Guizhou (one case) and Hebei (one case).

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The number of case reports in Guangdong are about on par with what we saw this time last year, unfortunately we’ve heard relatively little news from the other provinces.  Hopefully we’ll get a better idea of China’s overall situation from their respective monthly provincial epidemiological reports and from China’s notifications to the World Health Organization.

CIDRAP News On The Lancet Oseltamivir (Tamiflu ®) Meta-Analysis

Photo Credit – Wikipedia

 

 

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I had plans this morning to write an overview of meta-analysis of Tamiflu effectiveness published January 29th in The Lancet, but I’m happy to note that last night Robert Roos of CIDRAP News has beaten me to it. Since I’m unlikely to improve upon his reportage, I’ll direct you to his excellent review – which you’ll want to read in its entirety - after which I’ll return with a little bit more.

 

Meta-analysis supports oseltamivir use in adults, notes side effects

Robert Roos | News Editor | CIDRAP News

Jan 30, 2015

A comprehensive new meta-analysis on the controversial topic of oseltamivir's effectiveness found that the drug reduces the duration of influenza symptoms and the risk of hospitalization in adults and adolescents, while increasing the risk of nausea and vomiting.

A US-British team, with Arnold S. Monto, MD, of the University of Michigan as senior author, included in the analysis all randomized controlled trials sponsored by Roche, the drug's manufacturer, as well as other relevant trials. The study, reported yesterday in The Lancet, was funded by Roche, but the researchers worked independently.

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Over the past few years we’ve seen the demonization of influenza antivirals in the media (see Daily Mail: Ministers blew £650MILLION on useless anti-flu drugs), warnings of potential aberrant psychiatric behavior (see 2007 New Worries On Tamiflu), and repeated Cochrane group analyses that have found insufficient evidence that the drug reduces influenza complications.

Add in some serious foot-dragging by manufacturer Roche in releasing all of their testing data, and Tamiflu has become an easy drug for the public, and some doctors, to distrust.

Despite all of this `baggage’  the CDC, ECDC, UK’s PHE, and other public health agencies have steadfastly supported the early use of oseltamivir in the treatment of severe flu (see this week’s CDC Antiviral Letter to Providers and ECDC Influenza Season Risk Assessment).

The reason?

Even without the `gold standard’ Randomized controlled trials (RCTs) that the Cochrane group relies on for their analyses, we’ve seen numerous observational studies that lend support to the use of antivirals in severe influenza.

 

A few I’ve written about in the past include:

 

• In 2010 we saw an observational study that appeared in JAMA (see Study: Antivirals Saved Lives Of Pregnant Women) that strongly suggested that Tamiflu was life saving for some patients with pandemic flu.
• And again in 2010, in BMJ: Efficacy of Oseltamivir In Mild H1N1, we saw a study which suggested that the administration of oseltamivir may have significantly reduced the incidence of pneumonia among otherwise healthy pandemic H1N1 patients.
• In December of 2012, in Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic we looked at a meta-analysis of 90 observational studies that appeared in the  Journal of Infectious Diseases that spanned nearly 35,000 patients, 85% of whom has laboratory confirmed H1N1.

Their main finding was antiviral therapy - principally oseltamivir - initiated within 48 hours of onset, reduced the likelihood of severe outcomes, namely admission to a critical care unit or death, by 49 to 65%.

• Last March in The Lancet: Effectiveness Of NAI Antivirals In Reducing Mortality In Hospitalized H1N1pdm09 Cases we looked at yet another observational study conducted by researchers at The University of Nottingham – that reviewed more than 29,000 hospitalized H1N1pdm cases across 38 countries between 2009 and 2011, and found that the administration of NAI antivirals was associated with a 19% reduction in mortality compared to receiving no NAI treatment at all.
• And last summer, in  CID Journal: Under Utilization Of Antivirals For At Risk Flu Patients, we saw a study showing that antiviral drugs are underused for at-risk patients, while antibiotics (which don’t work against viral infections) are overused.

 

Added to this, we now have this new meta-analysis of the data from all published and unpublished clinical trials from 1997-2001, involving more than 4,300 patients. Patients with influenza (not just an ILI), who received the drug within 36 hours of onset of symptoms saw a reduction in the duration of their illness of 21% and a significant reduction in the risk of developing pneumonia or requiring hospitalization.

 

While nausea (9.9% vs 6.2% in controls) and vomiting (8.0% vs 3.3%)  were common side effects, no serious adverse reactions were reported, with no increase in psychiatric or neurological symptoms.

 

For uncomplicated influenza in a healthy individual (essentially what the Cochrane studies looked at), antivirals probably offer limited benefits.

 

But for severe influenza, or for people at risk of complications . . .

 

The preponderance of evidence shows that taking antivirals early can limit the severity and duration of symptoms – and for patients at risk of complications – that  could help keep them out of the hospital . . .  or worse.

Nevada Reports HPAI H5N8 in Wild Bird

 

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Nevada becomes the sixth western state to report HPAI H5 in wild birds this winter, as we learn from this release from the Nevada Department of Agriculture. 

 

Dept. of Ag Says Highly Pathogenic Avian Flu Found in Nevada

Posted: Jan 30, 2015 7:57 PM EST Updated: Jan 30, 2015 7:57 PM EST

From the Nevada Department of Agriculture:

The Nevada Department of Agriculture (NDA) confirms the first case of Highly Pathogenic Avian Influenza (HPAI) was found in Nevada. HPAI is a virus that is highly contagious among birds, and can be deadly to them. This strain (H5N8) has not been shown to cause any human infection.

The infected bird was a female mallard found in Lincoln County on January 23, 2015. The bird was then taken to the California Animal Health & Food Safety Laboratory, where it tested positive for HPAI.

NDA will be working with the United States Department of Agriculture's (USDA) Animal and Plant Health Inspection Service (APHIS) to monitor the situation. HPAI was confirmed in a commercial turkey flock in California, other cases were reported in Oregon, Washington and Idaho.

“So far this is an isolated case,” said Nevada State Veterinarian Michael Greenlee. “If commercial poultry producers or bird owners are concerned about the possible spread to domestic foul, they need to take the proper steps to limit exposure. Prevent contact between their birds and wild birds.”

If you see a sick bird or an unusual bird death, contact officials immediately. If contact occurs, wash hands with soap and water, and change clothing before having any contact with healthy domestic poultry and birds.

HPAI would have significant economic impacts if detected in U.S. domestic poultry. Commercial poultry producers should follow strict biosecurity practices and raise their birds in very controlled environments.

Call USDA's toll-free number at 1-866-536-7593 if there is concern about sick or dying birds. Biosecurity practices for backyard flocks can be found at healthybirds.aphis.usda.gov.

 

 

So far only one commercial poultry producer has been affected in the United States (see APHIS: H5N8 Infects California Commercial Turkey Farm), but a small number of backyard flocks have been affected.  While not updated with this latest Nevada detection, the USDA’s Update on Avian Influenza Findings in the Pacific Flyway (Last Modified: Jan 30, 2015) shows the following cases.

 

Since November we’ve seen H5N8 and/or H5N2 turn up in six western states as well as in British Columbia – all of which lie either beneath, or adjacent to,  the Pacific Flyway  Although primarily north-south migratory routes - migratory flyways overlap – providing opportunities for lateral (east-west) spread of avian viruses as well.

 

The H5N8 virus has never been known to infect and sicken humans, so for now, it is considered primarily a threat to poultry operations.  The HPAI H5 outbreaks in Taiwan this winter have already affected more than 500 farms, and have caused millions of dollars in losses, and so poultry producers in North America are urged to increase their biosecurity measures.

 

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FluView Week 3: Senior Hospitalizations Soar & H1N1v In Minnesota

 

  *** Correction ***  H1N1v was inadvertently listed as H3N2v in original post – Mea culpa.

 

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Since we’ve got a drifted `H3N2’ virus running rampant across much of the northern hemisphere, an unusually vigorous outbreak of H5N1 in Egypt, our regular winter H7N9 mini-epidemic in China, avian HPAI H5 viruses spreading impressively internationally, and even a pair of imported H7N9 cases in Canada this week  . . .it makes perfect sense that the latest MMWR & FluView would include news of an uncharacteristically out-of-season H1N1v infection in Minnesota as well.

H1N1v is  a swine H1N1 virus - that when it jumps to humans - gets the `variant’ tag.

 

Although telegraphed in yesterday’s MMWR, the following announcement appears in today’s FluView Report.

Novel Influenza A Virus:

One human infection with a novel influenza A virus was reported by the state of Minnesota. The person was infected with an influenza A (H1N1) variant (H1N1v) virus, and has fully recovered from their illness. No ongoing human-to-human transmission has been identified and the case patient reported contact with swine in the week prior to illness onset.

Early identification and investigation of human infections with novel influenza A viruses are critical in order to evaluate the extent of the outbreak and possible human-to-human transmission. 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.

Over the past few years we’ve watched as several swine variant influenza viruses (H1N1v, H1N2v or H3N2v) have made tentative jumps into the human population (see Keeping Our Eyes On The Prize Pig) and each summer the CDC has issued advice on preventing infection at county and state fairs (see Measures to Minimize Influenza Transmission at Swine Exhibitions, 2014).

We’ve not seen many reported cases the past couple of years, but during the summer of 2012 more than 300 cases were detected, with Indiana and Ohio accounting for roughly 80% of the cases. 

 

Illnesses were usually mild or moderate (1 fatality was recorded), and infection usually occurred in the summer and fall and was associated with attendance of local and state fairs where pigs were being shown.  Of course, some people have contact with swine all year round, and so while uncommon, it isn’t terribly surprising that someone would contract H3N2v during the winter.

What is surprising is that it  - like we saw with H7N9 in Canada earlier this week – this novel virus was detected against the background noise of a particularly nasty H3N2 influenza season. 

 

While occasional cases are not particularly alarming,  we keep an eye on these swine variant viruses because research has shown there to be only limited community immunity against them (see CIDRAP: Children & Middle-Aged Most Susceptible To H3N2v).

Of more immediate concern is this year’s seasonal flu activity, which remains brisk across much of the country, although in some states are seeing a drop in cases. 

 

Hospitalization rates for the elderly (65+) are the highest ever recorded since the CDC began tracking that data in 2005, and the CDC continues to remind providers of value of early administration of antiviral medications (see Antiviral Letter to Providers).

 

This from today’s FluView Report.

 

2014-2015 Influenza Season Week 3 ending January 24, 2015

All data are preliminary and may change as more reports are received.

Synopsis:

During week 3 (January 18-24, 2015), influenza activity remained elevated in the United States.

• Viral Surveillance: Of 23,339 specimens tested and reported by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories during week 3, 4,651 (19.9%) were positive for influenza.
• Novel Influenza A Virus: One human infection with a novel influenza A virus was reported.
• Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was above the epidemic threshold.
• Influenza-associated Pediatric Deaths: Five influenza-associated pediatric deaths were reported.
• Influenza-associated Hospitalizations: A cumulative rate for the season of 40.5 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported.
• Outpatient Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) was 4.4%, above the national baseline of 2.0%. All 10 regions reported ILI at or above region-specific baseline levels. Puerto Rico and 29 states experienced high ILI activity; New York City and seven states experienced moderate ILI activity; six states experienced low ILI activity; eight states experienced minimal ILI activity; and the District of Columbia had insufficient data.
• Geographic Spread of Influenza: The geographic spread of influenza in Puerto Rico and 44 states was reported as widespread; the U.S. Virgin Islands and five states reported regional activity; and the District of Columbia, Guam, and one state reported local activity.

Pneumonia and Influenza (P&I) Mortality Surveillance:

During week 3, 9.1% of all deaths reported through the 122 Cities Mortality Reporting System were due to P&I. This percentage was above the epidemic threshold of 7.1% for week 3.

 

Influenza-Associated Pediatric Mortality:

Five influenza-associated pediatric deaths were reported to CDC during week 3. Four deaths were associated with an influenza A (H3) virus and occurred during weeks 53, 1, 2, and 3 (weeks ending January 3, January 10, January 17, and January 24, 2015, respectively). One death was associated with an influenza A virus for which no subtyping was performed and occurred during week 1.

A total of 61 influenza-associated deaths have been reported during the 2014-2015 season from New York City [1] and 24 states (Arizona [1], Colorado [2], Florida [2], Georgia [1], Indiana [1], Iowa [3], Kansas [2], Kentucky [3], Louisiana [2], Michigan [1], Minnesota [4], Missouri [1], North Carolina [2], Nevada [3], New York [1], Ohio [5], Oklahoma [4], Pennsylvania [1], South Carolina [1], South Dakota [1], Tennessee [4], Texas [7], Virginia [3], and Wisconsin [5]).
Additional data can be found at: http://gis.cdc.gov/GRASP/Fluview/PedFluDeath.html.

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Influenza-Associated Hospitalizations:

Between October 1, 2014 and January 24, 2015, 11,077 laboratory-confirmed influenza-associated hospitalizations were reported. The overall hospitalization rate was 40.5 per 100,000 population. The highest rate of hospitalization was among adults aged ≥65 years (198.4 per 100,000 population), followed by children aged 0-4 years (38.2 per 100,000 population). Among all hospitalizations, 10,690 (96.6%) were associated with influenza A, 290 (2.6%) with influenza B, 29 (0.3%) with influenza A and B co-infection, and 62 (0.5%) had no virus type information. Among those with influenza A subtype information, 3,016 (99.7%) were A(H3N2) virus and nine (0.3%) were A(H1N1)pdm09.

Clinical findings are preliminary and based on 1,729 (15.6%) cases with complete medical chart abstraction. The majority (93.7%) of hospitalized adults had at least one reported underlying medical condition; the most commonly reported were cardiovascular disease, metabolic disorders, and obesity. There were 230 hospitalized children with complete medical chart abstraction, 94 (40.9%) had no identified underlying medical conditions. The most commonly reported underlying medical conditions among pediatric patients were asthma, obesity, neurologic disorders and immune suppression. Among the 173 hospitalized women of childbearing age (15-44 years), 47 were pregnant.

Additional FluSurv-NET data can be found at: http://gis.cdc.gov/GRASP/Fluview/FluHospRates.html and http://gis.cdc.gov/grasp/fluview/FluHospChars.html

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Despite its reduced effectiveness, the CDC continues to recommend that people get the flu shot – partially because it may provide some modicum of protection against this drifted flu strain, and partly because we often see a wave of Influenza B late in the flu season, and the shot can help protect against that virus.

 

Beyond that, practicing good flu hygiene remains your best strategy for staying well; Staying home when sick, washing your hands, covering your coughs, and disposing of your tissues properly .

Saudi Arabia Reports 2 New MERS Cases

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Saudi Arabia’s intermittent outbreak of winter MERS cases continues today after a couple of days with no reports, with two new cases , bringing January’s total to 20.

Yesterday, in anticipation of seeing more cases later in the spring, the CDC’s MMWR posted a  MERS Epidemiological Update & Guidance document for clinicians, public health, and the public.

Guangdong’s H5N6 Patient Recovers

Credit Wikipedia

 

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Normally the recovery of a single avian flu patient wouldn’t rate a separate blog entry, but since this is only the second human H5N6 case diagnosed - and the first one was fatal (see Sichuan China: 1st Known Human Infection With H5N6 Avian Flu) - the recovery of the 58-year old man diagnosed last December from Guangdong Province is not only good news, it is newsworthy.

 

Guangdong The first H5N6 bird flu patient rehabilitation

(O-Vision) at 19:57 on January 30 2015

(Macau Radio News) Guangdong The first H5N6 bird flu patient rehabilitation, quarantine has been lifted. 59-year-old male patient, on March 4 disease, symptoms of fever and cough, followed by isolation and treatment in Guangzhou, was in critical condition. This is the first case in Guangdong, is also the world's first two confirmed cases of H5N6, the first case case patients from Sichuan, was the death last May. (Liang Shuting Huangcai Chan)

 

While H5N1 and H7N9 are probably still the two avian viruses of greatest concern, the avian flu field has been rapidly expanding the past few years. Over the past year four new avian viruses – H10N8, H5N8, H5N3 & H5N6 – have emerged, and we don’t have a good handle on how much of an impact they will ultimately have.

 

H5N8 has certainly shown the ability to travel well, having already shown up in Europe, North America and Asia, but so far it doesn’t appear to infect humans.   H10N8 and H5N6 have only made a few appearances, but have infected and killed a handful of people. 

 

How all of these viruses will interact (and evolve) is something we are going to have to watch closely over the coming months and years.  For now, the good news is none of these avian viruses appears capable of transmitting efficiently from human to human, and they remain primarily a threat to birds and the poultry industry.

Taiwan Bird Flu: Eating Chicken Is Safe – Raw Raw Raw!

Credit China Times

 

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One of last year’s genuinely `bad ideas’ came from Saudi Arabia, where for a time it became a thing to post pictures of people kissing camels in order to prove that `beauty’  did not spread the MERS coronavirus. 

 

While there is no evidence that anyone died from this practice, it nonetheless undermined their public health’s messaging on MERS prevention, which recommends wearing masks and gloves around camels.

 

Today, in the midst of Taiwan’s worst avian flu outbreak (in poultry) in a decade, with more than 500 farms affected and well over 1.5 million birds culled, we have an ill advised PSA emerge from the Taipai City council meeting where several people apparently ate raw chicken in solidarity with the embattled poultry producers  to prove it’s safety.

Given the general prevalence of Campylobacter, E. coli  and Salmonella in raw poultry, exposure to bird flu may be the least of the dangers of consuming chicken tartare. 

But desperate economic times apparently call for desperate measures.  This from the China Times.

 

Taiwan members of the bird flu outbreak Taipei, raw chicken leg chicken farmers (photo)

16:22 on January 30, 2015 source: China News Network to the engagement (0)

 Beijing, January 30, according to Taiwan's China Times reported bird flu outbreaks spread throughout the island, people can smell chickens, chicken raising business plunge, several Taipei City councilors 29th came out to support farmers, Mr Lin Ruitu followed by eating raw chicken meat, called "to be a human Guinea pig, eat to see if any deviations from the".

It was reported that the Tipei City Council on 29th "save chicken farmers" activities, a number of city councillors to attend solidarity speaker Wu Bizhu said in Taipei, she will tell "Government" in the fight against bird flu at the same time, don't forget the chicken farmers livelihoods.

Reports said Mr llyr was eating raw chicken leg, in places someone exclaim, discourage, but Lin Ruitu insisted, before eating says "to dip soy sauce or eat."

(Continue . . .)

 

Forget the soy sauce, what this dish needs is a nice combination oseltamivir-penicillin-imodium dipping sauce.

H7N9 Confirmed In 2nd B.C. Patient

Credit Wikipedia

# 9646

 

On Monday we learned of the first known imported case of H7N9 into North America (see PHAC Statement On Canada’s Imported H7N9 Case) when a woman, recently returned from China with her husband, developed flu-like symptoms and was tested by her doctor in Vancouver.  

 

Her husband briefly developed flu-like symptoms as well, and also suspected as having been infected. Neither were sick enough to be hospitalized, self-isolated at home, and are now recovered.

 

Last night it was announced that the husband’s tests had come back positive for H7N9 infection. He developed symptoms about a day before his wife, suggesting they had a shared exposure, but the exact route of their infection remains unknown.  

 

None of these patient’s close contacts have developed symptoms, and given H7N9’s incubation period, authorities believe it unlikely any additional cases will arise in Canada linked to this event.

 

This from Helen Branswell.

 

H7N9 bird flu case confirmed in 2nd B.C. patient

Couple believed to have contracted virus in recent trip to China

By Helen Branswell, The Canadian Press Posted: Jan 29, 2015 9:24 PM PT Last Updated: Jan 29, 2015 9:28 PM PT

A British Columbia man has been confirmed as Canada's second case of H7N9 bird flu.

The unidentified man and his wife are believed to have contracted the virus during a recent trip to China.

They are the first North Americans known to have been infected with this virus.

B.C.'s deputy provincial health officer says the positive test result was confirmed late Thursday by the National Microbiology Laboratory in Winnipeg.

(Continue . . .)

 

It is remarkable that these cases were diagnosed at all, given their mild symptoms and their occurring during the midst of a very busy regular flu season. 

 

While 30% of known H7N9 cases have died, this is essentially the mortality rate among those sick enough to be hospitalized and tested.  Unknown is how many mild or moderate cases occur each winter in China, that are never picked up by surveillance.

That two travelers should return from China with mild symptoms suggests that mild or moderate cases are more common than we know .Something that the researchers at the University of Hong Kong have been saying for the past 18 months.

 

In Lancet: Clinical Severity Of Human H7N9 Infection) we saw a study that proposed, after roughly 130 cases were confirmed in the spring of 2013, that:

 

Our estimate that between 1500 and 27 000 symptomatic infections with avian influenza A H7N9 virus might have occurred as of May 28, 2013, is much larger than the number of laboratory-confirmed cases.

 

How accurate these estimates are is unknown, but it is highly likely that the official case counts under-represent the real burden of H7N9, perhaps by a sizable margin.

 

Somewhat more reassuring, we’ve seen a relatively low number of family clusters or contacts of known cases test positive for the virus, suggesting a low human-to-human transmission rate.  For now, direct contact with infected birds is believed the primary route of infection.

 

That said, a study published earlier this week (see EID Journal: H7N9 Antibodies In Close Contacts Of Known Cases) looked at 225 close contacts of confirmed H7N9 cases in China, and found 22 (9.8%) with elevated HI H7N9 antibody titers (>1:40). 

All of these seropositive contacts were asymptomatic.

 

All of which means we still have major gaps in our understanding of how fast and how far this virus is spreading in China.  And given the amount of travel to and from Asia, we should not be surprised to see future introductions of H7N9, and other novel flu viruses, to North America.

MMWR: MERS Epidemiological Update & Guidance

Coronavirus – Credit CDC PHIL

 

# 9645

 

While all eyes right now are on our current flu season, and the merry band of novel flu viruses harassing people and poultry operations on four continents (Africa, Asia, Europe, North America) - if last year is any indication - in a few months the MERS coronavirus will be making headlines as well.

 

As the chart below from today’s MMWR illustrates, MERS seems to blossom in the spring, although exactly why is still up for grabs.  The most popular theory involves the winter calving of camels. Young camel are the most susceptible to the virus, and are believed a likely conduit to pass it on to humans.

FIGURE. Number of cases of Middle East respiratory syndrome coronavirus infection reported by the World Health Organization,* by month of illness onset — worldwide, 2012–2015

 

As both a `head’s up’ and an overview, today the MMWR has published a brief epidemiological review of the MERS coronavirus.

Update on the Epidemiology of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection, and Guidance for the Public, Clinicians, and Public Health Authorities — January 2015

Weekly

January 30, 2015 / 64(03);61-62

Brian Rha, MD1, Jessica Rudd, MPH1, Daniel Feikin, MD1, John Watson, MD1, Aaron T. Curns, MPH1, David L. Swerdlow, MD2, Mark A. Pallansch, PhD1, Susan I. Gerber, MD1 (Author affiliations at end of text)

CDC continues to work with the World Health Organization (WHO) and other partners to closely monitor Middle East respiratory syndrome coronavirus (MERS-CoV) infections globally and to better understand the risks to public health. The purpose of this report is to provide a brief update on MERS-CoV epidemiology and to notify health care providers, public health officials, and others to maintain awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula.*

MERS-CoV was first identified and reported to WHO in September 2012 (1). As of January 23, 2015, WHO has confirmed 956 laboratory-confirmed† cases of MERS-CoV infection, which include at least 351 deaths. All reported cases have been directly or indirectly linked through travel or residence to nine countries: Saudi Arabia, the United Arab Emirates, Qatar, Jordan, Oman, Kuwait, Yemen, Lebanon, and Iran. In the United States, two patients tested positive for MERS-CoV in May 2014, each of whom had a history of fever and one or more respiratory symptoms after recent travel from Saudi Arabia (2). No further cases have been reported in the United States despite nationwide surveillance and the testing of 514 patients from 45 states to date.

The majority (504) of the 956 MERS cases were reported to have occurred during March–May 2014 (Figure). However, WHO continues to receive reports of MERS cases, mostly from Saudi Arabia.§ From August 1, 2014, through January 23, 2015, WHO confirmed 102 cases, 97 of which occurred in persons with residence in Saudi Arabia, including three travel-associated cases reported by Austria, Turkey, and Jordan; of the remaining cases, two cases were in persons from Qatar, and three cases were in persons from Oman.

CDC continues to recommend that U.S. travelers to countries in or near the Arabian Peninsula protect themselves from respiratory diseases, including MERS, by washing their hands often and avoiding contact with persons who are ill. If travelers to the region have onset of fever and symptoms of respiratory illness during their trip or within 14 days of returning to the United States, they should seek medical care. They should call ahead to inform their health care provider of their recent travel so that appropriate isolation measures can be taken in health care settings. Health care providers and health departments throughout the United States should continue to consider a diagnosis of MERS-CoV infection in persons who develop fever and respiratory symptoms within 14 days after traveling from countries in or near the Arabian Peninsula, and be prepared to detect and manage cases of MERS.

Recommendations might change and be updated as additional data become available. More detailed travel recommendations related to MERS, including general precautions posted by WHO for anyone visiting farms, markets, barns, or other places where animals are present, are available at http://wwwnc.cdc.gov/travel/notices/alert/coronavirus-arabian-peninsula.

The website also lists more specific WHO recommendations for persons with diabetes, kidney failure, or chronic lung disease, and immunocompromised persons, that include avoiding contact with camels.¶ Guidance on the evaluation of patients for MERS-CoV infection, infection control, home care and isolation, and clinical specimen collection and testing is available on the CDC MERS website at http://www.cdc.gov/coronavirus/mers/index.html.

Treatment is supportive; no specific treatment for MERS-CoV infection is available. WHO has posted guidance for clinical management of MERS patients at

http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf?ua=1.

1Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC; 2Office of the Director, National Center for Immunization and Respiratory Diseases, CDC (Corresponding author: Brian Rha, wif8@cdc.gov, 404-639-3972)

References

1. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med 2012;367:1814–20.
2. Bialek SR, Allen D, Alvarado-Ramy F, et al. First confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States, updated information on the epidemiology of MERS-CoV infection, and guidance for the public, clinicians, and public health authorities—May 2014. MMWR Morb Mortal Wkly Rep 2014;63:431–6.

* Countries considered in the Arabian Peninsula and neighboring include: Bahrain; Iraq; Iran; Israel, the West Bank and Gaza; Jordan; Kuwait; Lebanon; Oman; Qatar; Saudi Arabia; Syria; the United Arab Emirates; and Yemen.

† Confirmatory laboratory testing requires a positive polymerase chain reaction test result on at least two specific genomic targets for MERS-CoV or a single positive target with sequencing on a second.

§ Additional information available at http://www.who.int/csr/don/archive/disease/coronavirus_infections/en.

¶ Additional information available at http://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_RA_20140613.pdf?ua=1.

WHO H5N1 Update – January 26th

 

# 9644

 

Although dated the 26th, I believe this latest Influenza at the Human-Animal Interface report from the World Health Organization only went live on their website overnight.   In it, they list 24 new H5N1 cases in Egypt since their January 6th report, some of which saw the onset of their illness in late 2014.

 

The abundance of yellow in the epidemiological curve chart (below) for Nov-Dec-Jan illustrate how big Egypt’s latest outbreak of H5N1 really is, compared to other outbreaks we’ve followed.  We’ve not seen this kind of concentrated human infection activity since the `bad old days’ of 2005, in Vietnam.

The good news is, that although another family cluster was reported in this latest batch of cases (siblings with onset the same onset dates, suggesting a mutually shared environment exposure), there are no signs of enhanced human-to-human transmission of this virus.  The risk still appears to be from direct contact with infected birds.

 

Some excerpts from today’s report follow:

 

Influenza at the human-animal interface

Summary and assessment as of 26 January 2015

Human infection with avian influenza A(H5) viruses

From 2003 through 23 January 2015, 718 laboratory-confirmed human cases of avian influenza A(H5N1) virus infection have been officially reported to WHO from 16 countries. Of these cases, 413 have died. Since the last WHO Influenza update on 6 January 2015, 24 new laboratory confirmed human cases of avian influenza A(H5N1) virus infection, including 11 fatal cases, were reported to WHO from Egypt. Of the 24 cases, seven had onset of disease in December 2014 and the rest had onset of disease in January 2015. The cases were reported from nine different governorates of Egypt (see table 1).

Of the new cases, there was one cluster which included two confirmed cases in siblings from Assiut governorate.  Both of these cases had disease onset on the same day and both had exposure to backyard poultry. All cases had exposure to poultry or poultry markets, except for three cases in which the sources of infection are still under investigation.

Currently, there are reports of an increased number of outbreaks and detections of influenza A(H5N1) viruses in poultry in Egypt compared to previous months and compared to this month in previous years.

The number of laboratory confirmed human cases of avian influenza A(H5N1) virus infection reported by Egypt in December was the highest reported by any country in a single month. Although all influenza viruses evolve over time, preliminary laboratory investigation has not detected major genetic changes in the viruses isolated from the patients or animals compared to previously circulating isolates. The increase in the number of human cases is likely attributed to a mixture of factors, including increased circulation of influenza A(H5N1) viruses in poultry, lower public health awareness of risks in middle and upper Egypt and seasonal factors such as closer proximity to poultry because of cold weather and possible longer survival of the viruses in the environment. Epidemiological and virological investigation in humans and animals is ongoing.

Various other H5 subtypes, such as influenza A(H5N2), A(H5N3), A(H5N6) and A(H5N8), have recently been detected in poultry in Europe, North America, and Asia, according to reports received by OIE. Although these influenza A(H5) viruses might have the potential to cause disease in humans, so far no human cases of infection have been reported, with exception of the 2 human infections with influenza A(H5N6) virus detected in China in 2014.

Overall public health risk assessment for avian influenza A(H5) viruses: Whenever avian influenza viruses are circulating in poultry, sporadic infections and small clusters of human cases are possible in people exposed to infected poultry or contaminated environments. Human infections remain so far rare and these influenza A(H5) viruses do not currently appear to transmit easily among people. As such, the risk of community-level spread of these viruses remains to be low.

Although H7N9 cases are documented elsewhere on the WHO site, this document also provides a brief summary of China’s recent activity as well.

 

Human infection with avian influenza A(H7N9) viruses

A total of 486 laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus, including 185 deaths, have been reported to WHO: 469 cases by China National Health and Family Planning Commission, four cases by the Taipei Centers for Disease Control (Taipei CDC), 12 cases by the Centre for Health Protection, China, Hong Kong SAR, and one case in a Chinese traveler, reported from Malaysia.

The majority of recently reported human cases are associated with exposure to infected live poultry or contaminated environments, including markets where live poultry are sold. A(H7N9) viruses continue to be detected in poultry and their environments in the areas where human cases are occurring. There have been no major genetic changes in the viruses isolated from recent patients compared to previously isolated viruses from humans. Information to date suggests that these viruses do not transmit easily from human to human.

Overall public health risk assessment for avian influenza A(H7N9) viruses: Overall, the public health risk from avian influenza A(H7N9) viruses has not changed since the assessment published on 2 October 2014.

H7N9: HK’s CHP Notified Of 3 More Cases In Guangdong Province

Credit Wikipedia

 

# 9643

 

Guangdong province continues to find, and report, new H7N9 cases with three more added today. We are also seeing a fair amount  of `noise’ in the Chinese press about the severity of this year’s epidemic, but you couldn’t prove it by the official reports we’ve seen released this month by China’s other provinces.

Of course, an absence of data doesn’t necessarily mean an absence of cases.  Hopefully some of these cases will end up reported in their monthly epidemiological summaries.

Meanwhile, Hong Kong’s CHP has published the following notification, which makes this Guangdong’s 7th day in a row reporting 2 or more cases.

 

CHP notified of three human cases of avian influenza A(H7N9) in Guangdong

 

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (January 29) closely monitoring three additional human cases of avian influenza A(H7N9) notified by the Health and Family Planning Commission of Guangdong Province (GDHFPC), and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the GDHFPC, two male patients aged 21 (in Shenzhen) and 59 (in Meizhou) and a female patient aged 42 (in Foshan) were hospitalised for management. The male patients are in a stable condition while the female patient is in a critical condition.

To date, 502 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities, respectively in Zhejiang (146 cases), Guangdong (140 cases), Jiangsu (63 cases), Shanghai (44 cases), Fujian (28 cases), Hunan (24 cases), Anhui (17 cases), Jiangxi (nine cases), Xinjiang (nine cases), Shandong (six cases), Beijing (five cases), Henan (four cases), Guangxi (three cases), Jilin (two cases), Guizhou (one case) and Hebei (one case).

(Continue . . .)

 

ECDC Influenza Season Risk Assessment

Credit ECDC – Week 3

 

# 9642

 

While North America’s flu season is already well underway (and in some regions has already peaked), seasonal flu is getting a later - but no less strenuous start - in Europe this year.  And as we’ve seen here in the United States, the predominant flu strain in Europe this season is a `drifted’ H3N2 virus, one which has reduced the effectiveness of this year’s vaccine.

This morning ECDC released an updated Rapid Risk Assessment and summary on this year’s flu season, and  Director Dr. Marc Sprenger  tweeted:

 

First a press release summary, with links to the Rapid Risk Assessment, and then I’ll be back with a few words on the CDC & ECDC’s strong recommendations for the use of antiviral medications.

 

More severe influenza season to be expected in Europe

28 Jan 2015

Medium or high rates of influenza intensity are likely to be observed in the vast majority of EU and EEA countries, concludes ECDC annual risk assessment on influenza for the remainder of the season. The number of severe cases of influenza as well as fatal outcomes especially among older people and other risk groups can be expected to rise.

Strenuous start of this influenza season

• Influenza activity in Europe started in week 50/2014 without a particular geographic progression, affecting the Netherlands, Sweden and England first, and then followed by Iceland, Malta and Portugal.
• Children between 0 and four years of age have been the most affected age group according to primary healthcare data in almost all reporting countries, similarly as in other seasons.
• Influenza-like illness and acute respiratory infections have been increasing in adults and older people in almost all countries.
• Most of the first affected countries report greater pressure on primary healthcare services during this season compared to the peak activity in previous season.
• Among the countries reporting hospitalised influenza cases, 34 fatal outcomes were reported, two thirds of these in the elderly.

Drifted A(H3N2) viruses dominant

• Subtype A(H3N2) viruses, known to cause more severe disease, are dominant in almost all reporting European countries.
• Majority of A(H3N2) viruses analysed are antigenically distinct from the A(H3N2) virus included in the vaccine for this season.
• Reduced vaccine effectiveness is expected as a result of this mismatch between the vaccine and the circulating influenza strains.

ECDC Director, Dr Marc Sprenger, said:
“We face an influenza season that could be more severe and exert bigger pressure on health care systems than in the last few years. As each year, ECDC undertakes a risk assessment early in the season, combining a multitude of data sources and aiming to inform and strengthen EU and EEA countries in their response to the influenza epidemics.”

How to protect oneself and others from the flu

• Self-isolation when sick, hand-washing and good respiratory hygiene as well as cough etiquette remain simple yet effective measures to protect from catching or passing on influenza.
• A lower overall vaccine effectiveness due to the circulation of drifted A(H3N2) viruses is expected, however, the vaccine may still reduce complications and severe outcomes associated with this subtype of influenza viruses.
• Influenza vaccine offers good protection against the circulating A(H1N1)pdm09 viruses.

Antivirals particularly important this season

• Treatment and post-exposure prophylaxis with antivirals protects the elderly and people in other risk groups against severe influenza illness.
• The circulating viruses are susceptible to antiviral drugs oseltamivir and zanamivir.

Dr Marc Sprenger emphasizes:

“In a season dominated by a drifted A(H3N2) strain of influenza viruses, more severe illness can be expected especially among older people and those in medical risk groups. It is therefore paramount that physicians across Europe consider treatment and post-exposure prophylaxis with antivirals especially for these patients.”

The annual ECDC risk assessment of seasonal influenza aims to provide an early description of seasonal influenza in the first affected countries and to inform public health decisions to be taken to reduce the burden of seasonal influenza in 2015 in Europe.

Read full risk assessment of seasonal influenza in the EU/EEA countries, 2014-2015

More information:

Flu News Europe: weekly influenza updates
Seasonal influenza on ECDC website
Influenza maps and graphs
Follow us on Twitter: @ECDC_Flu

 

 

In Europe, even more so than in the US, antiviral drugs have been excoriated in the press; often referred to as an expensive scam on the part of the government, purportedly in cahoots with `Big Pharma’.  In the past we’ve seen Tamiflu’s ®  value questioned by Cochrane meta-studies, some prestigious medical journals, conspiracy theorists, pundits, but most often, the tabloid press.

 

Admittedly, it hasn’t helped that for many years Tamiflu’s maker -  Roche Pharmaceuticals - has refused to release all of the testing data on their best selling antiviral drug, and we’ve seen some scare articles in the popular press suggesting adverse side effects to the drug.

 

With all of this baggage, you may be wondering why the ECDC, CDC , the UK’s PHE, and many other public health agencies continue to recommend the use of influenza antivirals for influenza. 

 

Last April, in Revisiting Tamiflu Efficacy (Again), I wrote at some length on the BMJ –  Cochrane Library review Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children – that examined a subset of the scientific literature and cast doubt on its effectiveness in treating influenza.

 

While I too lamented the lack of solid, well mounted Randomized controlled trials (RCTs) proving the effectiveness of Oseltamivir (particularly in high risk patients, or with novel flu strains), I listed a number observational studies that strongly support the effectiveness of Oseltamivir.

 

A few days later, the CDC issued their own response. I’ve posted the link and some excerpts below.  Follow the link to read their rationale in its entirety.

 

CDC Recommendations for Influenza Antiviral Medications Remain Unchanged

April 10, 2014 -- CDC continues to recommend the use of the neuraminidase inhibitor antiviral drugs (oral oseltamivir and inhaled zanamivir) as an important adjunct to influenza vaccination in the treatment of influenza. CDC’s current influenza antiviral recommendations are available on the CDC website and are based on all available data, including the most recent Cochrane report, about the benefits of antiviral drugs in treating influenza.

(Continue . . .)

 

Recommendations that were echoed a few months ago by Public Health England (see UK PHE: Revisiting Influenza Antiviral Recommendations), and that are supported by many studies I’ve written about previously, including:

 

Study: Antivirals Saved Lives Of Pregnant Women

BMJ: Efficacy of Oseltamivir In Mild H1N1

Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic

The Lancet: Effectiveness Of NAI Antivirals In Reducing Mortality In Hospitalized H1N1pdm09 Cases

CID Journal: Under Utilization Of Antivirals For At Risk Flu Patients

 

For uncomplicated influenza in a healthy individual (essentially what the Cochrane studies looked at), antivirals probably offer little value.

 

But for severe influenza, or for people at risk of complications . . .

 

While not a cure, the preponderance of evidence shows that taking antivirals early can limit the severity and duration of symptoms – and for those patients  – that could help keep them out of the hospital, and even prove life saving.