Myanmar Cancels Taung Byone Nat Festival Over H1N1 Flu Fears

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H1N1 lost its pandemic status, and became just another seasonal influenza virus in the summer of 2010.  While it tends to strike a younger cohort of people, and can sometimes cause serious illness, H1N1 flu seasons are generally less severe than H3N2. 

Despite all of this, in some parts of the world, H1N1 is still referred to as `swine flu' and carries a fearsome reputation.

Some of this concern is warranted, as H1N1 can be a serious infection, particularly in high risk patients. Like H3N2, H1N1 is continually evolving (see Nature Sci Rpts: Continued Evolution Of The 2009 H1N1 Virus), and for this reason a new H1N1 vaccine component (A/Michigan/45/2015 (H1N1)pdm09-like) has been added to this year's flu shot.

Last week, just as Myanmar was reporting a fresh outbreak of avian flu (see OIE Notification: H5N1 In Poultry - Myanmar), we began seeing reports of an outbreak of H1N1 in Yangon, Myanmar's largest city.   

Since then - amid a growing media frenzy - Myanmar's Ministry of Health and Sports has held daily meetings and has issued nearly a dozen press releases on the outbreak, and overnight Reuters is reporting at least 10 deaths from the virus.

While at this point there is nothing to suggest anything unusual about this H1N1 outbreak, The Irrawaddy is now reporting that the country's largest annual celebration - the Taung Byone Nat Festival - has been canceled to help prevent the spread of the virus.

H1N1 Halts Taung Pyone Nat Festival

By Zarni Mann 31 July 2017 

MANDALAY — Myanmar’s largest annual nat festival scheduled to begin on Monday in Taung Pyone near Mandalay has been cancelled over fears of spreading the H1N1 influenza outbreak currently rattling the country.

“The festival ground is always crowded and germs would spread easily, so we have decided to postpone the festival until the influenza is under control,” Mandalay Region Chief Minister U Zaw Myint Maung told reporters on Sunday.

Hundreds of thousands of people from across Myanmar flock to the annual festival in Taung Pyone village, 15 miles north of Mandalay. It is held in honor of two brothers—Min Gyi and Min Lay—who were believed to have become nat spirits after they were executed by King Anawrahta.

On Sunday, the health ministry announced 10 lives had now been claimed by the influenza from a total of 182 suspected cases since July 21. Parliament approved an urgent proposal to boost awareness of H1N1 influenza in an attempt to control the country’s outbreak last week.

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The use of NPIs - Non-Pharmaceutical Interventions -  such as the closing of schools, cancellation of large public events, and social distancing are a major part of any attempt to halt the transmission of a contagious illness like influenza.

The CDC’s Nonpharmaceutical Interventions (NPIs) web page defines NPIs as:

Nonpharmaceutical interventions (NPIs) are actions, apart from getting vaccinated and taking medicine, that people and communities can take to help slow the spread of illnesses like influenza (flu). NPIs are also known as community mitigation strategies.

You'll find an in-depth discussion of NPIs, along with excerpts from the recently released 2017 HHS Pandemic Plan, in Community Pandemic Mitigation's Primary Goal : Flattening The Curve.

In low resource countries like Myanmar - where vaccines, antivirals, and hospital beds are in limited supply - the early and judicious use of NPIs may be their most effective tool to contain this outbreak.

Zimbabwe Farm Reports 2nd Outbreak of HPAI H5N8

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Two months after Zimbabwe reported their first HPAI H5N8 outbreak, local and international media are reporting overnight that the same farm complex has been hit again.

The original outbreak only affected 1 of 8 separately managed units, which are kept a minimum of 1 km apart. Two weeks later it was reported the outbreak had spread to two other units.  All three were depopulated, sealed, and disinfected.

 While details are scant, Reuters this morning is reporting:

Zimbabwe poultry farm hit again by avian flu outbreak
Reuters Staff

HARARE, July 31 (Reuters) - A Zimbabwean poultry farm has reported a second outbreak of highly pathogenic H5N8 bird flu, two months after it first occurred, the state-owned Herald newspaper said on Monday

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HPAI H5N8 is a recent arrival to Africa, showing up for the first time last fall in both Egypt and Nigeria (see OIE Report). In January it caused a major die off of waterfowl on the shores of Lake Victoria in Uganda (see Ugandan HPAI H5 Outbreak Confirmed As H5N8). It was then confirmed in Cameroon in February, and two months later in the DRC.

While reports remain sporadic and widely scattered, H5N8 has made far greater inroads into sub-Saharan Africa over the last six months than H5N1 managed to do over the last decade.

Last year's reassortment of H5N8 (see last November's EID Journal: HPAI A(H5Nx) Viruses With Altered H5 Receptor-Binding Specificity) appears to have created a more aggressive virus with a greatly increased avian host range; one that includes (at last count) 78 species of migratory and wild birds.

These genetic changes may help explain last winter's record setting epizootic in Europe, the rapid spread of H5N8 across Europe, the Middle East, and Africa, and even its persistence this summer in Europe (see here, here, and here), long after their bird migration season has ended.

Given the migratory pathways between the Northern and Southern Hemispheres - particularly those linking Africa to Europe and Asia - we'll need to keep watch to see if H5N8 becomes established in Southern Africa, and how that might affect its evolution and spread.

Meanwhile we are less than 90 days away from the start of this fall's return of migratory birds across much of the Northern Hemisphere (see Sci Rpts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission  Of HPAI H5N1).

Study: Virulence Of HPAI H5N8 Enhanced By 2 Amino Acid Substitutions

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The big saving grace with avian HPAI H5N8 - which last winter sparked Europe's largest avian epizootic on record, while moving at the same time into the Middle East and Africa  - is that it hasn't shown any signs (yet) of being able to infect humans.

The virus that showed up in Europe last October, however, was more virulent in wild and migratory birds, and spread faster, farther, and infected more avian  species than we'd ever seen before.

Studies over the winter (see EID Journal: HPAI A(H5Nx) Viruses With Altered H5 Receptor-Binding Specificity) suggested recent evolutionary changes in the virus may have increased its host range, and its ability to spread.

HPAI H5N8, like all flu viruses, continues to evolve via reassortment and/or antigenic drift.  We know the virus underwent a major reassortment during the spring or summer of 2016 - probably in China or Russia (see EID Journal: Reassorted HPAI H5N8 Clade 2.3.4.4. - Germany 2016). 

But smaller changes due to antigenic drift can produce big effects as well, particularly if they occur in a non-avian host. 

Influenza viruses, as negative-sense single-stranded segmented RNA viruses, are notoriously sloppy replicators. Transcription `accidents' that favor replication in the host tend produce more progeny, and if biologically `fit enough', can drown out the earlier `wild type’ virus in the host. This is called host adaptation.

And while it can (and does) happen in the wild, it can be easily simulated in the laboratory as well, via a classic serial passage study (see chart above).

Researchers inoculate a host with a `wild type’ strain of a virus, let it replicate awhile, then take the virus from the first host and inoculate a second, and then repeat the process five, ten, fifteen times or more. Over time, the virus tends to adapt to the new host (assuming there are no species barriers to prevent it).


Last January, in Sci Rpts: H5N8 - Rapid Acquisition of Virulence Markers After Serial Passage In Mice, we looked at just this sort of experiment that showed H5N8 may not remain benign in mammals forever. The authors wrote:

These results suggest that H5N8 viruses can rapidly acquire virulence markers in mammalian hosts; thus, rapid spread as well as repeated viral introduction into the hosts may significantly increase the risk of human infection and elevate pandemic potential.

This week we've another serial passage study on HPAI H5N8 in mice that identifies two specific amino acid changes that enhance its virulence in mice (and possibly other mammals).

Of the two (PB2 E627K and HA A149V), we've run into this PB2 mutation the most often, including earlier this month in Arch. Of VIrology: Rapid Virulence Shift Of An LPAI H5N2 Virus During A Single Passage In Mice.

Birds run `hotter’ than mammals, which means avian flu viruses (which typically replicate in the avian gut) must adapt to lower temperatures if they are to succeed in human or mammalian hosts.

The E627K substitution in the PB2 protein (swapping out Glutamic acid (E) for Lysine (K)) makes an avian influenza virus better able to replicate at the lower temperatures (roughly 33C) found in the upper respiratory tract of mammals (see Eurosurveillance: Genetic Analysis Of Novel H7N9 Virus). 

The E627K substitution alone isn't enough adapt an avian virus to a mammalian host, and the virus will need help from other amino acid changes to succeed, but it is an important start.

This report (alas, the full study is behind a pay wall) comes from Infection, Genetics and Evolution.

Research paper

Virulence of an H5N8 highly pathogenic avian influenza is enhanced by the amino acid substitutions PB2 E627K and HA A149V

Haibo Wua, Xiuming Penga, Rufeng Lub, Lihua Xuc, Fumin Liua, Linfang Chenga, Xiangyun Lua, Hangping Yaoa, Nanping Wua,
https://doi.org/10.1016/j.meegid.2017.07.026Get rights and content

Highlights•

• The virulence of mouse-adapted H5N8 avian influenza virus was increased and HA(A149V) and PB2(E627K) mutations were detected.•
• Substitutions led to enhanced viral virulence, expanded tissue tropism, and increased replication kinetics in cells.•
• Continued surveillance in poultry for amino acid changes is required.
  

Abstract

A novel reassortant H5N8 highly pathogenic avian influenza (HPAI) virus was recently identified in Asia, Europe, and North America. The H5N8 HPAI virus has raised serious concerns regarding the potential risk for human infection.

However, the molecular changes responsible for allowing mammalian infection in H5N8 HPAI viruses are not clear. The objective of this study was to identify amino acid substitutions that are potentially associated with the adaptation of H5N8 HPAI viruses to mammals.

In this study, an avian-origin H5N8 virus was adapted to mice through serial lung-to-lung passage. The virulence of mouse-adapted virus was increased and adaptive mutations, HA (A149V) and PB2 (E627K), were detected after the ninth passage in each series of mice.

Reverse genetics were used to generate reassortants of the wild type and mouse-adapted viruses. Substitutions in the HA (A149V) and PB2 (E627K) proteins led to enhanced viral virulence in mice, the viruses displayed expanded tissue tropism, and increased replication kinetics in mammalian cells.

Continued surveillance in poultry for amino acid changes that might indicate H5N8 HPAI viruses pose a threat to human health is required.

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While we've no reports of human infection with HPAI H5N8, we have seen some scattered reports of H5N8 infection in dogs exposed during poultry outbreaks  (see H5N8 Antibodies Detected In South Korean Dogs (Again)), proving that natural mammalian infection is possible, even if the infection is mild or asymptomatic.

J. Virol: H9N2 Virus Isolated From Air Samples In LPMs In Jiangxi, China

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Avian influenza viruses bind preferentially to the α2-3 receptor cells that are most commonly found in the gastrointestinal tract of aquatic birds, and is believed mostly spread via infected feces. 

For that reason researchers have concentrated less on airborne spread among birds, and more on fomites and shared water sources.

Recently, however, we've seen renewed interest in aerosolized avian flu - particularly in and around Live Poultry Markets (LPMs) - where birds are housed, slaughtered, and sometimes  mechanically defeathered for the customer (see How to Aerosolize A Chicken).

In 2014, a year after the H7N9 virus emerged in China, in CDC: Risk Factors Involved With H7N9 Infection, we looked at a case-control study that pretty much nailed visiting  LPMs as the prime risk factor for infection. Since then we've seen cases whose likely exposures was cited as simply living near, or walking past an LPM.

A little over a year ago, in Detection Of Airborne H9 Nucleic Acid In Chinese Live Poultry Market, we looked at an article appearing in the Chinese Medical Journal which found ample environmental evidence of viral contamination, and reports the first positive detection of Airborne H9 (presumably H9N2) in a Chinese LPM.

Samples were cataloged and tested for influenza A viral RNA and positive samples were then analyzed to determine their (H5/H7/H9) subtype. This  detection of viral RNA is a much lower bar than isolating a live virus, and doesn't tell us about the viability of the viruses they detected.

That study found ample environmental evidence of viral contamination, and reports the first positive detection of Airborne H9 (presumably H9N2) in a Chinese LPM. Another study -  published last August - found similar results with the H5N6 virus (see J. Infection: Aerosolized H5N6 At A Chinese LBM (Live Bird Market))


Today we've a new report, again on avian H9N2, only this time they managed to isolate and sequence one of these airborne viruses.

Avian influenza H9N2 virus isolated from air samples in LPMs in Jiangxi, China

Xiaoxu Zeng†,Mingbin Liu†,Heng Zhang,Jingwen Wu,Xiang Zhao,Wenbing Chen,Lei Yang, Fenglan He,Guoyin Fan,Dayan Wang,Haiying Chen and Yuelong Shu †Contributed equally

Virology Journal201714:136

https://doi.org/10.1186/s12985-017-0800-y

© The Author(s). 2017
Published: 24 July 2017
Abstract

Background

Recently, avian influenza virus has caused repeated worldwide outbreaks in humans. Live Poultry Markets (LPMs) play an important role in the circulation and reassortment of novel Avian Influenza Virus (AIVs). Aerosol transmission is one of the most important pathways for influenza virus to spread among poultry, from poultry to mammals, and among mammals.

Methods

In this study, air samples were collected from LPMs in Nanchang city between April 2014 and March 2015 to investigate possible aerosol transmission of AIVs. Air samples were detected for Flu A by Real-Time Reverse Transcription-Polymerase Chain Reaction (RRT-PCR). If samples were positive for Flu A, they were inoculated into 9- to 10-day-old specific-pathogen-free embryonated eggs. If the result was positive, the whole genome of the virus was sequenced by MiSeq. Phylogenetic trees of all 8 segments were constructed using MEGA 6.05 software.

Results

To investigate the possible aerosol transmission of AIVs, 807 air samples were collected from LPMs in Nanchang city between April 2014 and March 2015. Based on RRT-PCR results, 275 samples (34.1%) were Flu A positive, and one virus was successfully isolated with embryonated eggs. The virus shared high nucleotide homology with H9N2 AIVs from South China.

Conclusions

Our study provides further evidence that the air in LPMs can be contaminated by influenza viruses and their nucleic acids, and this should be considered when choosing and evaluating disinfection strategies in LPMs, such as regular air disinfection. Aerosolized viruses such as the H9N2 virus detected in this study can increase the risk of human infection when people are exposed in LPMs.

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A bit more controversial, we've also seen some evidence suggesting avian influenza viruses can be spread from farm to farm - at least over short distances - by prevailing winds (see Bird Flu’s Airborne `Division).

Just over two years ago, in CIDRAP: H5N2 Roundup & Detection In Environmental Air Samples, we looked at testing conducted by the University of Minnesota around infected poultry farms also that found evidence of airborne virus particles.

The science of all of this even has a name; aerobiology – the study of how bacteria, fungal spores, pollen and even viruses can be passively transported in the air.

The evidence of short-distance airborne spread of avian viruses in LPMs grows stronger each year, and reinforces the need to better control - or even shut down -  these live markets.   For more on the threat posed by LPMs, you may wish to revisit:

Emerg. Microbes: Dynamics Of Transmission Of H5N1 & H9N2 In Live Bird Markets - Bangladesh

Beijing Orders Closure Of Live Bird Markets To Control H7N9

The Lancet: Interventions To Reduce Zoonotic & Pandemic Risks From Avian Flu In Asia

CDC FluView: 11 H3N2v Swine Flu Cases Reported In Ohio

PDF Link

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Twice over the past couple of weeks we saw reports of county fairs in Ohio closing their pig barns when swine H3N2 was detected in exhibition pigs (see Second Ohio County Fair Closes Hog Barn Over Swine Flu).

When swine influenza viruses jump to humans, they are dubbed swine variant viruses. The CDC describes Swine Variant viruses in their Key Facts FAQ.

What is a variant influenza virus?

When an influenza virus that normally circulates in swine (but not people) is detected in a person, it is called a “variant influenza virus.” For example, if a swine origin influenza A H3N2 virus is detected in a person, that virus will be called an “H3N2 variant” virus or “H3N2v” virus.

Since the influenza subtypes that commonly circulate in swine (H1, H2 & H3) are also the same HA subtypes as have caused all of the human pandemics going back 130 years (see Are Influenza Pandemic Viruses Members Of An Exclusive Club?), swine influenza viruses are watched carefully for signs of jumping to humans.

While only rarely reported, these infections probably happen far more often than we know. But since swine variant influenza infections look like seasonal flu, and testing for swine variant viruses is only sporadically done, we don't often hear about it.

The last swine variant infection in the US was reported from Texas last May. Today the CDC has announced 11 additional H3N2v (variant) infections, all from the state of Ohio and linked to county fair attendance in the past couple of weeks.  All were mild, no one was hospitalized, and all have recovered.

Novel Influenza A Virus:

Eleven human infections with novel influenza A viruses were detected in Ohio during week 29. All 11 persons were infected with influenza A (H3N2) variant (H3N2v) viruses and reported exposure to swine in a fair setting during the week preceding illness onset. Ten of the 11 patients were children less than 18 years of age and one patient was an adult aged 50-64 years. 

None were hospitalized and all have fully recovered from their illness. No human-to-human transmission has been identified. Swine influenza A (H3N2) viruses were identified from respiratory samples collected from pigs at the same fair. Public health and agriculture officials are investigating the extent of disease among humans and swine, but no increases in influenza-like illness in the community have been reported. These 11 infections bring the total number of H3N2v infections during 2017 to 12 and the cumulative total since 2011 to 376.

Early identification and investigation of human infections with novel influenza A viruses are critical to ensure timely risk assessment and so that 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.

Last October, in MMWR: Investigation Into H3N2v Outbreak In Ohio & Michigan - Summer 2016,  we looked at the CDC's investigation into a cluster of 18 H3N2v cases across two states in August of 2016.  This was the biggest outbreak of swine variant infections we'd seen since 2012, when more than 300 cases were reported across 10 states. 

The `headline' in that report was that 16 of the 18 cases analyzed belonged to a new genotype not previously detected in humans.  Swine influenza viruses, like all flu viruses, are continually evolving.

As the state and county fair season continues over the summer and into fall, it would not be surprising to see additional, scattered reports of swine variant infection, as these venues tend to put a lot of people into close contact with pigs.

For more information on swine variant viruses, and how to protect yourself when in contact with farm animals, the CDC provides the following guides.

• Key Facts for People Exhibiting Pigs at Fairs[545 KB, 2 pages]
• Take Action to Prevent the Spread of Flu Between People and Pigs[1.3 MB, 2 pages]
• Educational Posters[389 KB, 1 page]
• Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2013.
• Reduce Your Risk (English)[22 KB, 1 page] | (Spanish)[22 KB, 1 page]
• Measures to Minimize Influenza Transmission at Swine Exhibitions, 2016 – NASAHO and NASPHV[97 KB, 8 pages]

Arch. Of Virology: Novel Reassortant H5N6 Isolated From Cats - Eastern China

 

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Until cats (both large and small) began dying in Asia from avian H5N1 back in 2004, it was generally believed that cats were relatively immune to influenza A infection. Gradually that perception has changed (see Catch As Cats Can) - particularly with regard to novel flu viruses (see Companion Animals And Novel H1N1). 

Last winter we saw a large, unprecedented outbreak of avian H7N2 among hundreds of cats in New York City animal shelters (see NYC Health Dept. Statement On Avian H7N2 In Cats) which eventually led to one human infection (link).

At almost the same time, South Korea announced the discovery of at least 3 cats infected with the H5N6 virus in Gyeonggi Province (see Korean CDC Statement On H5N6 In Cats).  MAFRA's Quarantine division immediately announced plans to test stray cats in and around multiple areas that have been hit by avian influenza. 

Increasingly cats (and dogs) are viewed as potential intermediate hosts for novel influenza viruses.

These companion animals - who often interface with wildlife - are in a unique position to serve as a conduit for zoonotic viruses to humans, even in urban settings.

Which brings us to the following study, whose details are sadly tucked behind a paywall. Luckily the abstract still provides us with a fair amount of information.

Genetic characterization of novel reassortant H5N6-subtype influenza viruses isolated from cats in eastern China

Xueliang Cao, Fan Yang,Haibo Wu, Lihua Xu

Brief Report  First Online: 21 July 2017
Abstract

Cats are susceptible to influenza A viruses and therefore may act as transmission vectors within households, posing a potential public health concern. Two novel reassortant H5N6 influenza viruses were isolated from cats in Zhejiang Province, Eastern China, in 2016.

Both viruses were characterized by whole-genome sequencing with subsequent phylogenetic analysis and genetic comparison. Phylogenetic analysis showed that these viruses received their genes from H5N6, H9N2, and H7N9 influenza viruses isolated from China. These H5N6 viruses were able to replicate in mice without prior adaptation. Our results show that continued circulation of these viruses could endanger humans.

We aren't provided with any details on this novel reassortant, other than its parental viruses (H5N6, H9N2, and H7N9).  It does, however, reaffirm that the promiscuous H5N6 virus continues to reassort with other viruses in China.

The discovery that these avian H5N6 viruses were able to replicate without adaptation in mice suggests that while these cats might have been infected through contact with infected birds, it could just as easily have come from contact with small mammals or rodents.

Over the years we've looked at the potential role of peridomestic animals (cats, dogs, rodents, small mammals, etc.) in spreading avian flu viruses, and affecting its evolution.

• In 2015, in Taking HPAI To The Bank (Vole) we looked at the susceptibility of the European bank vole to both H5 and H7 avian viruses, and concerns they may be getting past farm bio-security measures.
• Also in 2015, we looked at the expanded host range that is susceptible to infection with H5N6 in H5N6 Rising: Infecting Birds, Humans, & Even Cats.
• A little over a year ago, in Report: Skunks and Rabbits Can Catch And Shed Avian Flu, we looked at a report that suggested that infected small mammals were a plausible intermediate host, and may be part of the chain of transmission of avian flu.

More evidence that things we used to think were rare with novel influenza viruses, may be more commonplace than we know.

Italy's IZSV Reports Three More HPAI H5 Outbreaks

2017 HPAI Outbreaks - Credit IZSV

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Last week Italy's IZSV (Istituto Zooprofilattico Sperimentale delle Venezie) confirmed a pair of HPAI H5 outbreaks in Mantua Province, in northern Italy (see Italy Reports Two New Outbreaks Of H5N8), bringing their 2017 outbreak total to 19. 

Over the past couple of days three more outbreaks have been confirmed (2 as HPAI H5, 1 as HPAI H5N8).

Credit IZSV

It is very likely these HPAI H5 outbreaks will be be confirmed as H5N8 in the days to come.  A description of these latest outbreaks from the IZSV follows:

27/07/2017 – On 27 July, the National Reference Laboratory (NRL) for Avian Influenza and Newcastle Disease confirmed as positive for Avian Influenza A virus subtype H5 a fattening turkey farm in Verona province (Veneto region). At the moment of the epidemiological investigation, 12.200 turkeys (around 70 days-old) were present. The turkeys started to exhibit nervous symptoms last Sunday (23/07/2017), and the next day a slight increase in mortality was observed.

Still on 27 July, the Regional Laboratory of Lombardy and Emilia-Romagna confirmed as positive for Avian Influenza A virus subtype H5 a laying hens farm (about 120.000 birds) located in the province of Mantua (Lombardy region).

Further information on virus characterization and on the cases will be provided as soon as available.

Culling procedures for the positive fattening turkey farm in Verona (confirmed on the 25/07/2017) were concluded today, under the supervision of the Veterinary Services.
26/07/2017 – The virus detected in a fattening turkey farm in Verona province, confirmed yesterday (25/07/2017), has been characterised by the National Reference Laboratory as Highly Pathogenic Avian Influenza virus subtype H5N8.

25/07/2017 – On the evening of 24 July, an increase in mortality was reported in a fattening turkey farm in Verona province (Veneto region). On 25 July, the IZS delle Venezie confirmed the case as positive for Avian Influenza virus subtype H5. At the moment of the epidemiological investigation, 17.724 turkeys (112 days-old) were present. Starting on Sunday, a slight increase in mortality was observed in one of the five sheds at the farm. The farm is located in one of the most densely populated poultry areas in Italy.

Although this past winter's massive HPAI H5 epizootic has been over for most European countries for several months, during June and July we saw a small resurgence of outbreaks in poultry and wild birds cut a swath across Luxembourg, Belgium, and just barely into northern France (see Belgium Reports Another Outbreak of HPAI H5N8).

The UK, Finland, and the Netherlands all reported single outbreaks, while during the same time period, Italy has reported six new outbreaks.

This is a decided change over what was seen with the H5N8 virus during previous summers, when the virus all but disappeared  (see PNAS: The Enigma Of Disappearing HPAI H5 In North American Migratory Waterfowl).

The virus acquired significant changes (see EID Journal: Reassorted HPAI H5N8 Clade 2.3.4.4. - Germany 2016) during the summer of 2016, and now appears to be more virulent in wild and migratory birds (see here), and has demonstrated an ability to infect a much wider range of birds (see here).

These changes in behavior are a reminder that influenza viruses change constantly, and have a remarkable ability to adapt to new hosts, and new environments, over time.  Simply put, what we think we know about any given flu virus today, might not hold true tomorrow.

Which is why we should expect surprises going forward.

Saudi MOH Reports 2 MERS Cases Over 2 Days

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After a two-week lull, Saudi Arabia reported a single primary MERS case from Riyadh yesterday listed in stable condition, and today is reporting a single primary (with camel contact) case from Buraidah, who is listed in critical condition.

After seeing 50+ cases in June, this slowdown is welcomed given the start of this year's Hajj (August 30th) is just a little over a month away.

COCA Call Today: Zika - Updated Clinical Guidance & Recommendations for Pregnant Women and Infants

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Later today  the CDC will hold a COCA (Clinicians Outreach and Communication Activity) caall with their latest guidance and recommendations on Zika Virus infection in pregnant women and infants.

Primarily of interest to clinicians and healthcare providers, COCA (Clinician Outreach Communication Activity) calls are designed to ensure that practitioners have up-to-date information for their practices.

Follow the link below to review the different ways you can access this webinar.

Zika Virus: Updates to Clinical Guidance and Recommendations for Pregnant Women and Infants

Free Continuing Education 

Date:Thursday, July 27, 2017

Time: 2:00-3:00 pm (Eastern Time)
Please join the COCA Call webinar with digital audio, video and presentation formats from a PC, Mac, iPad, iPhone or Android device: https://cdc.zoom.us/j/974205265

If you cannot join through digital audio, you may join by phone in listen-only mode: 1 646-558-8656 or 1 408-638-0968

Passcode: 974 205 265
International numbers are available: https://cdc.zoom.us/zoomconference?m=CqA0lsuOx1-A-2DyDfmtSQIpZlwB6X8G

 Overview

CDC has updated its interim guidance for pregnant women with possible exposure to Zika virus to include separate recommendations for pregnant women with symptoms and pregnant women without symptoms. In addition, CDC recently released its latest findings from the Zika pregnancy and infant registries on pregnancy outcomes for pregnant women with Zika virus infection in the U.S. territories and has new updates for healthcare providers on pediatric ophthalmologic findings in infants with possible congenital Zika virus exposure. During this COCA Call, clinicians will learn about the recent updates to CDC’s interim guidance for pregnant women with possible exposure to Zika virus; hear about the latest findings on pregnancy outcomes in the U.S. territories, based on the Zika pregnancy and infant registries; and receive new information on pediatric ophthalmologic findings to assist in caring for patients based on currently available data.

Russia: Rosselkhoznadzor Finds More HPAI Contaminated Meat In Retail Stores

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During April and May we followed a number of outbreaks of HPAI H5N8 in western Russia (see here, here, and here), with the largest reported at one of Russia's biggest turkey producing facilities in Rostov (see Link).

By mid-May Russia's Federal Service for Veterinary and Phytosanitary Surveillance (Rosselkhoznadzor) announced that HPAI Contaminated Poultry Had Been Shipped To At Least 9 Regions Of Russia.

During May and June we saw numerous reports of contaminated meat being found in the food chain (see Rosselkhoznador Investigation Into HPAI Contaminated Meat Distribution & Sale), along with allegations of illegalities on the part of Rostov's Regional Veterinary Laboratory which was charged with testing these products and overseeing the issuance of food safety certificates.

Although reports of bird flu outbreaks have diminished over the past two months, we continue to see scattered reports of the discovery of contaminated meat in the food chain.  Today, we get this out of Vladivosiok:

In Primorye, discovered and thwarted the realization of retail chains products with the genome of avian influenza

According to Rosselkhoznadzor (Moscow), at this year's poultry farms of the Rostov region LLC "Evrodon-South" observed mass death of turkey stock. In selected pathological material was discovered gene of influenza A virus of birds, and identified the H5 subtype. In this regard, all terupravleniya Rosselkhoznadzor and veterinary services of the Russian Federation was ordered to strengthen the veterinary control measures in respect of products from this manufacturer, as well as for enterprises and commercial organizations that have economic ties with it.

In this regard, the Office of Rosselkhoznadzor for the Primorsky Krai and the Sakhalin Oblast unscheduled inspections of a number of wholesale food stores, retail chains and stores the Primorsky Territory was organized in order to prevent trafficking and sale of dangerous poultry products.

In the course of supervisory activities the inspectors Rosselkhoznadzor in Vladivostok in one of the hypermarkets and large food warehouse was discovered products produced on the affected bird flu Rostov company. Immediately after the discovery of potentially unsafe poultry meat has been placed on isolated storage, precluding any unauthorized traffic.

Conducted FGBU "Maritime Interregional Veterinary Laboratory" Rosselkhoznadzor tests have shown that 2 tons of steaks of turkey, who were in the wholesale food warehouse, as well as 300 kg of products of turkey meat in assortment (splint, ase, steak, medallions, sets for fire , wings and steaks), found in urban hypermarket, contains the genetic material of the virus avian influenza A, subtype H5.

Subsequently conducted FGBU "Federal Center for Animal Health" Rosselkhoznadzor (ARRIAH) testing of selected production samples confirmed the presence in them of the influenza virus genome of birds.

However, without waiting for the results ARRIAH, all dangerous products were destroyed (burned) its owners at the complex for the destruction of bio-waste "Factor-Primorye" Vladivostok under the control of Rosselkhoznadzor inspectors.

As previously reported, in May of this year, inspectors Rosselkhoznadzor, in collaboration with the staff of the department of economic security and countering corruption Russian Ministry of Internal Affairs for the city of Vladivostok in the Soviet area was prevented by turnover and, accordingly, the implementation of the population of 3 tons of turkey genome with avian influenza, produced at the plant OOO "Evrodon" Rostov region. Dangerous products have been found on one of the wholesale food warehouses and subsequently destroyed (burned).

While HPAI H5N8 isn't as big of a health concern as H5N1 or H5N6 - both of which have a track record of infecting humans - this illustrates how easily avian flu can make its way into some country's food supply.

A little over a month ago, in Appl Environ Microbiol: Survival of HPAI H5N1 In Infected Poultry Tissues, we looked at the viability (via viral isolation) of H5N1 in experimentally infected chicken's feathers, muscle tissue, and liver stored at various temperatures ( +4°C or +20°C).

Refrigerated (+4°C) feathers retained viable virus for 8 months, tissue for 6 months, and in the liver for nearly 3 weeks. But even at the higher temperature (68F), the virus remained viable for a month in feathers, and just under 3 weeks in muscle tissue.

Beyond contaminated food concerns, this sort of prolonged viral persistence provides opportunities for dead birds in the wild to infect scavengers, and reinforces the need for people in contact with dead birds to take safety precautions.

HK Flu Express Wk 29: Influenza Activity Remains At A Very High Level

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Fourteen weeks ago Hong Kong's CHP declared the end of last winter's mild flu epidemic, with their Flu Express Week 15 reporting a `low level' of flu activity by mid-April. Two weeks later, quite unexpectedly, the Hong Kong CHP Reported A Late Season Flu Surge, and reinstated their enhanced surveillance for severe seasonal influenza.

Since then we've seen a nearly continuous rise in severe seasonal flu cases - mostly H3N2 - which has claimed more than two hundred lives, and has severely impacted Hong Kong's hospital system. 

While Hong Kong is known for having a biphasic or `double peaked’  flu season, their heaviest activity usually occurs from February–April with a less severe season in mid to late summer (see Seasonality of Influenza A(H3N2) Virus: A Hong Kong Perspective (1997–2006).

This summer's flu epidemic has lasted longer, and has been far more severe, than their last two flu epidemics (see chart at top of blog), and shows no signs of abatement. According to the latest Hospital Authority Hospital Key Statistics daily report, inpatient occupancy rates range from 96% to 124% across 17 local hospitals.

Since last week an additional 67 severe cases, and 47 deaths, have been recorded due to flu-related illness. With 255 deaths since May 5th, this summer's flu outbreak has claimed 6 times the number of lives caused by Hong Kong's 2017's winter flu (n=41). 

Although a few indicators have slowed slightly over the past week, it is too soon to say whether Hong Kong has reached the peak of their epidemic. The CHP warns to expect a `high level' of flu activity over the coming weeks.

Some excerpts from today's Flu Express report, and the I'll return with a bit more.

FLU EXPRESS

Flu Express is a weekly report produced by the Respiratory Disease Office of the Centre for Health Protection. It monitors and summarizes the latest local and global influenza activities.

Local Situation of Influenza Activity (as of Jul 26, 2017)
Reporting period: Jul 16 – 22, 2017 (Week 29)

• The latest surveillance data showed that the local influenza activity remained at a very high level in the past week. It is foreseen that the influenza activity will remain at a very high level in the coming weeks.
• The Centre for Health Protection (CHP) has collaborated with the Hospital Authority (HA) and private hospitals to reactivate the enhanced surveillance for severe seasonal influenza cases (i.e. influenza-associated admissions to intensive care unit or deaths) among patients aged 18 or above since May 5, 2017. As of Jul 26, 361 severe cases (including 252 deaths) were recorded. Separately, 18 cases of severe paediatric influenza-associated complication/death (including three deaths) (aged below 18 years) were recorded in the same period.
• Apart from adopting personal, hand and environmental hygiene practices against respiratory illnesses, those members of the public who have not received influenza vaccine may get the vaccination as soon as possible for personal protection.

(SNIP)

Surveillance of severe influenza cases

(Note: The data reported are provisional figures and subject to further revision)

Since the activation of the enhanced surveillance for severe influenza infection on May 5, 2017, a total of 379 severe cases (including 255 deaths) were recorded cumulatively (as of Jul 26) (Figure 9). These included:

• 361 cases (including 252 deaths) among adult patients aged 18 years or above. Among them, 316 patients had infection with influenza A(H3N2), 21 patients with influenza A(H1N1)pdm09, 13 patients with influenza B and 11 patients with influenza A pending subtype. 131 (36.3%) were known to have received the influenza vaccine for the 2016/17 season. Among the 252 fatal cases, 113 (44.8%) were known to have received the influenza vaccine. In the winter season in early 2017, 66 adult severe cases (including 41 deaths) were filed.
• 18 cases (including three deaths) of severe paediatric influenza-associated complication/ death. Sixteen (88.9%) cases did not receive the influenza vaccine for the 2016/17 season. To date in 2017, 26 paediatric cases (including four deaths) were filed.

Enhanced surveillance for severe seasonal influenza (Aged 18 years or above)

In week 29, 65 cases of influenza associated ICU admission/death were recorded (including 39 deaths), which was lower than 72 cases (including 52 deaths) recorded in week 28. In the first 4 days of week 30 (Jul 23 to 26), 37 cases of influenza associated ICU admission/death were recorded, in which 29 of them were fatal.

Surveillance of severe paediatric influenza-associated complication/death (Aged below 18 years)

 In week 29, four cases of severe paediatric influenza-associated complication were reported. In the first 4 days of week 30 (Jul 23 to 26), one case of severe paediatric influenza-associated complication was reported. The case details are as follow:

            (Continue . . .)


We have been following similar, albeit less severe, reports from other regions of eastern Asia (see Taiwan's Summer H3N2 Epidemic Continues Near Peak and Macao, Hong Kong & Guangdong Province All Reporting Heavy Flu Activity) in recent weeks. 

Getting good numbers out of Mainland China is difficult, but Sharon Sanders of Flutrackers has been monitoring media reports in their China Seasonal Flu Tracking forum and has posted the following threads in the past few days.

China - Pediatric flu patients up significantly in July in Heyuan, Guangdong province - July 27, 2017

China - Recent high incidence of flu patient overcrowding in Hengfeng, Jiangxi Province - July 26, 2017

China - Major hospitals in Dongguan reporting overcrowding due to flu patients - up 20-30% in July - Guangdong province - July 21, 2017

The cause of this year's out-of-season heavy flu activity remains unclear, although several theories have been advanced, including waning late-season effectiveness of last year's flu vaccine, and a possible antigenic change in the H3N2 virus.


For more on those possibilities, you may want to revisit these recent blogs:

The Enigmatic, Problematic H3N2 Influenza Virus

Hong Kong: HKU Experts Call For Deploying Prophylactic Tamiflu To Avert Crisis

J. Clin. Vir.: Ιnfluenza A(H3N2) Genetic Variants In Vaccinated Patients In Northern Greece

Texas DSHS: Probable Local Zika Infection In South Texas

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Last October - although no local cases had been reported at the time - Texas health officials warned of a heightened risk of locally acquired Zika infection in six specific south Texas counties (Cameron, Hidalgo, Starr, Webb, Willacy, and Zapata).

Subsequently 6 local cases were detected in Brownsville (Cameron County) in November and December. 

In April, as temperatures warmed, the DSHS updated their Testing Recommendations for Rio Grande Valley. Today, as a result of that enhanced surveillance, Texas Health authorities announced the detection of their first (likely) locally acquired Zika infection of 2017. 

Health officials find probable local Zika infection

News Release
July 26, 2017

The Texas Department of State Health Services and Hidalgo County Health and Human Services have determined a Hidalgo County resident who previously had a Zika infection was most likely infected in Texas. Because the individual has not recently traveled outside the area or had any other risk factors, the infection was probably transmitted by a mosquito bite in South Texas sometime in the last few months. Laboratory testing shows the individual is no longer at risk of spreading the virus to mosquitoes.

Thousands of Zika tests have been done since a DSHS recommendation in April expanded testing of pregnant women and people with Zika symptoms in six South Texas counties. The additional testing led to the identification of this infection, the first this year that appears to have been transmitted by a mosquito in Texas. There is no evidence of ongoing Zika transmission in the state at this time, but public health officials are continuing to conduct human and mosquito surveillance to find any future Zika infections as early as possible.

Hidalgo County Health and Human Services has alerted health care providers, reminding them of the testing recommendations, and DSHS and the county are asking everyone in the area to be aware of the most common Zika symptoms: rash, fever, joint pain and eye redness. People should contact their provider about testing if they experience a rash plus one of the other symptoms.

Local officials have also responded by increasing mosquito control and surveillance activities and going door-to-door to share information about Zika and ensure pregnant women and people with symptoms have had the appropriate testing.

People throughout the Rio Grande Valley and Texas should continue to protect themselves from mosquito bites by

• Using EPA-approved insect repellent every time they go outside.
• Using air conditioning or window and door screens that are in good repair to keep mosquitoes out.
• Limiting outdoor activities during peak mosquito times.
• Covering exposed skin with long pants and long-sleeved shirts whenever possible.
• Removing standing water in and around homes, including in trash cans, toys, tires, flower pots and any other containers so mosquitoes can’t lay their eggs.
• Using a larvicide in water that can’t be drained to keep mosquitoes from developing into biting adults.
  

Texas previously had six locally-transmitted cases of Zika in Brownsville in November and December 2016. More information on Zika for the public and health care providers is available at TexasZika.org.

J. Clin. Vir.: Ιnfluenza A(H3N2) Genetic Variants In Vaccinated Patients In Northern Greece

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Last Saturday in The Enigmatic, Problematic H3N2 Influenza Virus we looked at the nearly 50 year history and growing diversity of the H3N2 virus in humans, and recent reports of an emerging subclade 3C.2a1 with amino acid (aa) substitutions (including N121K) that may have adversely affected the influenza Vaccine's Effectiveness (VE) over the last winter's flu season.

Influenza viruses evolve via two well established routes; Antigenic drift & Antigenic Shift (reassortment).

Shift requires the co-infection of a host with two different influenza viruses which then swap chunks of their genetic code, creating a new `reassorted' virus (see NIAID Video: How Influenza Pandemics Occur). 

While viable reassortments are rare, as any virologist will tell you . . . Shift Happens.

Far more common is Antigenic drift, which is driven by replication errors that are common with single-stranded RNA viruses (see NIAID Video: Antigenic Drift).  While most of these biological accidents are evolutionary failures, every once in a while a more biologically `fit' virus is produced, and it is able to compete with its parental viruses.

This is the reason why influenza vaccines must be updated so often. 

Unfortunately, it takes six months to create and produce enough influenza vaccine for each flu season, and during this time the virus continues to evolve. For the northern hemisphere, vaccine strain selections must be made in February (see WHO: Recommended Composition Of 2017-2018 Northern Hemisphere Flu Vaccine).

Despite this production lag, most years the vaccine is still a pretty good match. But as we saw in the 2014-2015 flu season, sometimes the virus is able to evade the vaccine (see CDC HAN Advisory On `Drifted’ H3N2 Seasonal Flu Virus).

We never know just how good a match the vaccine will be until well into the flu season. Starting about six months ago we began to get interim reports on last year's vaccine effectiveness (VE). 

• Here in the United States, we saw a modest level of protection (34%) against H3N2, according to the CDC's MMWR report of June 30th.
• Similarly, last February a Eurosurveillance report  Interim estimates of 2016/17 vaccine effectiveness against influenza A(H3N2), Canada, January 2017 DM Skowronski  et al. found an adjusted VE of 42%.

But at the same time we've been seeing reports of much lower VE - particularly among those over 65 - who were infected with some recently emerging variants of the H3N2 virus (see Changes in genetically drifted H3N2 influenza A viruses and vaccine effectiveness in adults 65 years and older during the 2016/17 season in Denmark),

Today we've another study, this time from Greece, focusing on genetic variants of the H3N2 virus isolated from both vaccinated  and unvaccinated patients during the last flu season.

Among those who were unvaccinated, H3N2 subclade 3C.2a - which is recognized as a pretty good antigenic match to last year's vaccine - was most commonly detected.  But among those who received the flu vaccine last year, the emerging subclade 3C.2a1 was far most common, suggesting it may be better at evading the vaccine.

Ιnfluenza A(H3N2) genetic variants in vaccinated patients in northern Greece

A. Melidou'Correspondence information about the author A. MelidouEmail the author A. Melidou Email the author A. Melidou , G. Gioula, M. Exindari , E. Ioannou, K. Gkolfinopoulou, T. Georgakopoulou, S. Tsiodras, A. Papa 

DOI: http://dx.doi.org/10.1016/j.jcv.2017.07.003
 
Highlights

    •Common aa substitutions T135K and D122N on viral antigenic and glycosylation sites.
    •These variant strain has been observed in vaccinated patients.
    •Possible antigenic drift in northern Greek A(H3N2) circulating viruses.
    •Continuous monitoring of A(H3N2) evolution and circulation of variant strains is essential to monitor their effect on vaccine effectiveness.

Abstract
 
Background

Influenza A(H3N2) viruses predominated during the influenza 2016/2017 season and showed extensive genetic diversification. A high vaccination failure rate was noticed during the 2016/17 season in Greece, especially among the elderly.

Objectives

The scope of the study was to investigate the genetic characteristics of A(H3N2) circulating viruses and viruses detected in vaccinated patients.

Study design

Virus samples originated from vaccinated and unvaccinated patients, obtained at the National Influenza Centre for northern Greece. Phylogenetic analysis and comparison of the haemagglutinin gene of the viruses to the vaccine virus A/Hong Kong/4801/2014 was performed.

Results

The majority of analysed viruses are clustering in the genetic clade 3C.2a, and in a newly emerged subclade, designated as 3C.2a1. The highest proportion of viruses detected in vaccinated patients fell into a distinct subcluster within the 3C.2a1 subclade, which is characterised by the amino acid substitutions N122D and T135 K in haemagglutinin.

Conclusions

Viruses that belong to the 3C.2a clade are generally considered to resemble antigenically to the northern hemisphere vaccine component A/Hong Kong/4801/2014 that was recommended by WHO to be included also into the 2017/18 vaccine.

However, viruses belonging to a specific 3C.2a1 subcluster was extensively circulating in northern Greece and among vaccinated individuals. Both substitutions carried by this strain were located on antigenic sites and caused losses of N-linked glycosylation sites of the virus, which could potentially affect viral antigenicity. Further studies are needed to determine the antigenicity of this variant strain and its possible implication in vaccine effectiveness.

The 64$ question is which subclade of H3N2 will dominate the northern hemisphere this fall and winter.  Clade 3C.2a should be a pretty good match to this fall's vaccine, while there are nagging questions over the vaccine's effectiveness against some variants of clade 3C.2a1.

The most recent Influenza Virus Characterization from the ECDC  - based on very limited virus sampling this summer - writes:

Genetic characterization

For specimens collected between weeks 21/2017 and 26/2017, genetic characterization of 3 viruses has been reported. Two were B/Yamagata lineage viruses and one fell into the A(H3N2) 3C.2a1 subclade defined by N171K amino acid substitution, often with N121K, in the haemagglutinin.

Viruses in this clade have been antigenically similar to the vaccine component clade (3C.2a), but both clades are evolving rapidly with the emergence of several virus clusters defined by additional amino acid substitutions in the haemagglutinin, thereby requiring continued monitoring of antigenic characteristics. See also the WHO CC London February 2017 report.

As we go into each year’s flu season, we are always presented with a  `Forrest Gump’ moment, as we never really know what we are going to get.  This year appears no different.

Stay tuned.

Taiwan's Summer H3N2 Epidemic Continues Near Peak

Credit Taiwan's Flu Express Week 28

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While not as severe as what is being reported in Hong Kong (see HKU Experts Call For Deploying Prophylactic Tamiflu To Avert Crisis) - after a lackluster winter flu season - Taiwan has been dealing with its own out-of-season summer flu surge since early May.    

Like Hong Kong, their current epidemic is primarily due to H3N2. Two weeks ago, Taiwan's CDC announced that their flu had peaked, and was beginning to decline.

While that trend continues, today Taiwan's CDC warns that flu continues near its peak, and  announced that over the past week local ERs saw more than 106,000 flu cases, 101 were diagnosed as `severe', and that 13 people died from flu-related illness.

Domestic influenza epidemic continues to decline, but still in the epidemic peak, people do not take it lightly

UNDCP said the domestic influenza flu epidemic for three consecutive weeks of decline, the other influenza and severe cases and confirmed cases also decreased for 2 weeks; but the number of influenza treatment is still more, and continued severe cases, the overall epidemic is still popular peak, To remind people to ignore the symptoms of influenza, such as signs of severe risk, please seek medical attention as soon as possible to reduce the risk of concurrent serious illness, and please keep a good hand and respiratory health, and the implementation of sick at home to rest.

According to the monitoring data, the number of visits was 106,005 last week (July 16 to July 22), down 8.6% from the previous week (115,987 person-times) and has been falling for 3 consecutive weeks. The upper respiratory tract / The number of cases reported in the past three weeks was flat, but the number of new notifications was lower than that in mid to late June, among which 16 were positive for influenza test, and the population was densely located (12). Laboratory data showed that H3N2 was predominantly in community epidemic virus type, and only about 9% of influenza virus was detected in influenza B virus. The antigenicity monitoring data showed that 95% H3N2 virus coincided with the influenza vaccine group.

101 cases of influenza infection last week to determine the case, to determine the number of cases for 2 consecutive weeks of decline, the case of infection type to H3N2 for more; another 13 cases of severe death cases, the age of onset ranging from 54 to 96 years old, Have a chronic history, infection type 11 cases of H3N2 and 2 cases of type B. July 1, 2016 so far accumulated 1,194 cases of influenza complicated with severe cases, of which 121 died. At present, the flu epidemic has been the highest point, showing a downward trend, according to the trend of the epidemic over the years, the number of new cases of severe disease is expected to slow down with the mild epidemic after the decline.

The KPC reiterates its appeal that if people have flu-like symptoms, please go to the nearest public influenza influenza antiviral contract clinic for medical treatment, to avoid concentrating on the emergency hospital, where the doctor to determine compliance with the use of public drug use conditions, without fast screening, The use of public anti-viral agents; but if there are breathing difficulties, rapid, cyanosis (hypoxia), blood sputum or sputum thickening, chest pain, changes in consciousness, hypotension and other signs of influenza risk, you should try to the largest hospital for treatment The Information can be found on the UNDG Global Information Network (influenza area) (http://www.cdc.gov.tw) or by calling the Free Epidemic Prevention Line 1922 (or 0800-001922).

The exact reasons behind this summer's unusually severe flu in Hong Kong, Macao, Taiwan, and (reportedly) Southeast China isn't known, although last week researchers at the University of Hong Kong suggested it might be due to small mutation in the virus (see The Enigmatic, Problematic H3N2 Influenza Virus).

Mutation or not, this is a reminder that seasonal influenza can be quite deadly, and that it doesn't always follow the `rules'.

Turkish Media Reporting large Die Offs Of Poultry - Facilities Quarantined

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With the dual caveats that a decade ago Turkey had quite a bad time with hundreds of outbreaks of H5N1 (including a dozen human infections and four deaths) - and that their press can be a bit hyperbolic on the subject of bird flu (Kuş Gribi) - overnight numerous Turkish media outlets are reporting on large poultry die offs in the eastern part of the country.

A few (translated) headlines include:

Bird Flu Panic in Kars! Kaz hundreds darkly dying 

Avian flu is going back to the nightmare?  

Bird flu suspected in Kars: Quarantine decision was taken    

It should be noted that the quarantining towns and poultry facilities has long been a part of Turkey's bird flu control playbook (see 2007 Turkey: Three Villages Quarantined? & Turkey : 4 More Villages Quarantined, & 2008 Turkey Quarantines Three Villages). 

A pattern which should make today’s headlines and story slightly less urgent sounding that it might at first appear.  At this point, bird flu (subtype not provided) is only suspected.  

The following syntax-challenged media report (cobbled together using 2 different translators) indicates that the poultry deaths began in Kars 10 days ago, and that the town of Ardahan - 60 km further north - is also reporting poultry deaths.

Both towns are located within about 30 km of the Georgian and Armenian borders.  

Kars and Ardahan in bird flu alert: Facility were quarantined

Internal News Service -
July 25, 2017

In the last 10 days in Kars headquarters and villages, the goose and poultry deaths took place in succession, and many facilities were quarantined. A large number of poultry were killed in Ardahan, no doubt bird flu.

The deaths of poultry living in Kars in 10 days, the authorities took action. Bird-blowing is, of course, putting a large number of poultry into living birds.

According to the EHA; In the last 10 days in Kars headquarters and the villagers, the deaths of goose and poultry were followed by the authorities. The teams affiliated to the Provincial Directorate of Food, Agriculture and Livestock put the geese in vigorous state by quarantining their districts in the Mezra village of the center. It was learned that the samples taken from the animals were sent with a lot of people, especially Erzurum to be examined.

On the other hand, the citizens who claimed that the poultry had died, claimed that their animals were killed by bird flu.

The alarm in Ardahan

In Ardahan, a large number of poultry were slaughtered by birds in the branches of the Provincial Directorate of Food, Agriculture and Livestock and the Directorate of Animal Health Branch.

Suspected Bird flu in poultry in the city, officials are alarmed. Directorate for food, agriculture and livestock and animal health branch teams, wearing special clothing, some businesses in the neighborhood suspected Central Ardahan Habeeb seen goose, chicken, duck and Turkey has culled poultry as animals.

The markets ' bird flu ', the outdoor areas in neighboring provinces of unsupervised brought sold poultry caused by citizens who claim "brought from the outside, ducks and poultry are sold. That the authorities do not intervene. But without test chickens in the village, collecting without the vaccine without analysis. We also we sin, i.e. the citizen is cut off, "he said.

Sales of poultry in public areas on the Peddler who citizens protests started to escape by leaving the area where they are located.

We'll have to await official word from the FAO or OIE to know if HPAI is the true cause of these bird deaths.