Early Reports of Flu From Around The Country

Credit CDC  - PDF Guide

#12,786


Even though it is still only late September, we are already beginning to see scattered reports of seasonal influenza across the country - easily a month earlier than usual. A few headlines from the past 24 hours (excluding the swine variant outbreak in Maryland) include:

Officials urge influenza vaccination as Colorado sees early uptick in hospitalizations - The Denver Channel

Doctors say flu season is starting earlier than usual - kgw.com ·Portland OR

An Early Start To The Flu Season | Husker Radio - Nebraska

No children under 12 allowed on Children's Hospital patient floors starting Oct. 1 - Birmingham AL

While seasonal influenza's peak may still be months away, it is not too early to get the flu shot - it takes two weeks to kick in - and to start taking winter flu hygiene (covering coughs, washing/sanitizing hands, staying home when sick) seriously.

We've seen a good deal of speculation over what kind of flu season the Northern Hemisphere can expect after the recent particularly rough flu epidemics in Australia, Hong Kong, and Southern China (see UK: NHS Warns Of A Potentially Rough Flu Season Ahead), although in truth, flu is not easily predicted.

What we do know is that H3N2 appears to be the dominant subtype right now, and years where H3N2 dominates tend to be more severe - particularly for those over the age of 65.  We also know we are coming off two relatively moderate flu seasons (see chart below), and acquired community immunity may be a bit low.

Credit CDC FluView

Despite our fixation with novel flu viruses, plain old seasonal flu kills as many as a half million people each year, and its severity can vary by more than 10-fold from one year to the next ( see MMWR: Estimates Of Yearly Seasonal Influenza Deaths).  From that 2010 report, we get estimates for the United States.

For deaths with underlying pneumonia and influenza causes (the most narrow definition of flu-related fatalities used) the models estimated a yearly average of 6,309 (range: 961 in 1986--87 to 14,715 in 2003--04) influenza-associated deaths.

Using a broader criteria (underlying respiratory and circulatory causes including pneumonia and influenza causes)  the models estimated an annual average of 23,607 (range: 3,349 in 1986--87 to 48,614 in 2003--04) influenza-associated deaths.

Seasonal flu viruses are also capable of picking up enhanced virulence due to small evolutionary changes (see EID Journal: Emergence of D225G Variant A/H1N1, 2013–14 Flu Season, Florida and When Influenza Goes Rogue), sometimes resulting in pockets of more severe disease around the world.

Simply put, the severity of the flu that arrives in Chicago or Miami this winter may differ greatly from what arrives in London, Moscow, or even Los Angeles.  

A few years ago the Census bureau reported that 1 in 4 households had just a single occupant - greater than at any time in the past century.

Currently, more than 32 million Americans live alone (see chart below), and while many of those are younger people who are waiting later to get married, a side effect of our longer lifespan and high divorce rate is that many of these single households are held by those over the age of 65.

Whether we live alone by choice or by happenstance, we all share a common vulnerability.  If we get sick, or injured, there may be no one around to notice, or to help.

As a paramedic I saw a significant number of people who lived alone who either died, or spend miserable hours or even days incapacitated and unable to call for help, due to an illness or accident.

Another vulnerable group are households with only 1 adult, and minor children.  This too is a growing demographic, with more than 5 million households falling into that category.  If the adult falls seriously ill, then even more are potentially at risk.

Because of this, starting in 2007 I floated the idea of having `flu buddies'  -   someone you can call if you get sick, who will then check on you every day (by phone or in person), fetch food or medicines for you,  and who can call for medical help if your condition deteriorates. 

While I originally envisioned this for a pandemic scenario, it is just as valid and equally  important for those who live alone during regular flu seasons.

While we all hope this year's flu season won't be anything out of the ordinary, we can do things now - like getting the flu shot, practicing good flu hygiene, and being and having one or more `flu buddies' - to reduce the impact should things turn out differently.

FluView Week 38: 32 Presumptive & Confirmed H3N2v Cases

PDF

#12,785


The swine variant flu outbreak connected to three county fairs in Maryland (see here, here, and here) continues to expand with both the Maryland Department of Health and the CDC reporting this morning a total of 32 presumptive and confirmed cases.

According to today's FluView Report, 14 cases have been fully identified as H3N2v, while an additional 18 cases have tentatively been identified as H3v (variant) influenza. 

With 34 fully identified cases thus far in 2017, and 18 more in the pipeline,  52 cases this year will easily make this the second biggest reporting year for swine variant flu in the United States. 

Given the aggressive ongoing epidemiological investigation, it would not be unexpected to see additional cases to turn up over the next week or so.

This report from today's FluView.  

Novel Influenza A Virus:

Thirty-two human infections with novel influenza A viruses were reported by two states (Delaware [1] and Maryland [31]). Fourteen of these viruses have been fully characterized and are influenza A (H3N2) variant (H3N2v) viruses; the remaining 18 viruses have tested presumptive positive for H3v at the Maryland public health laboratory and further confirmatory testing is being performed by CDC to characterize these viruses. 

All 32 patients reported exposure to swine at one of three agricultural fairs during the week preceding illness onset. Swine influenza A(H3N2) viruses were identified from respiratory samples collected from pigs at two of the three fairs. The exposure to swine at the agricultural fair reported by the Delaware resident occurred at one of the agricultural fairs in Maryland. 

Thirty of the 32 patients were children younger than 18 years and two patients were adults aged > 50 years. One of 32 patients was hospitalized but is improving. All other patients are recovering or have fully recovered from their illness. No human-to-human transmission of these viruses has been identified.

To date, CDC has confirmed a total of 34 variant virus infections in the United States during 2017. Thirty-two of these were H3N2v viruses (Delaware [1], Maryland [13], North Dakota [1], Ohio [15], Pennsylvania [1], and Texas [1]) and two were influenza A (H1N2) variant (H1N2v) viruses (Ohio [2]). An additional 18 viruses have tested presumptive positive for H3v and further analysis is being conducted at CDC (Maryland [18]).

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.

H3N2v is the most common swine variant virus reported in the United States, but is far from the only swine flu virus of concern. Co-circulating in North America are also H1N1 and H1N2 swine viruses, along with occasional reassortants like H3N1 (see J. Virol: Novel Reassortant Human-like H3N2 & H3N1 Influenza A Viruses In Pigs).

Globally the picture becomes even more complicated, with reports of other swine flu variants coming from Europe, South America, and Asia. As surveillance and testing is spotty at best, the constellation of of swine flu viruses in circulation is likely much larger and more complex than we know.

Earlier today, in WHO: Candidate Vaccines For Pandemic Preparedness - Sept 2017, we looked at recommendations from the World Health Organization for the creation of 3 new candidate vaccine viruses (CVVs); 2 for H1N2v and 1 for H3N2v.

It may be a few weeks before we learn exactly how well these Maryland H3N2v viruses match the existing and proposed H3N2v vaccine candidates.

WHO: Candidate Vaccines For Pandemic Preparedness - Sept 2017

#12,784



As we discussed yesterday, twice each year influenza experts gather to discuss recent developments in human and animal influenza viruses around the world.

Yesterday we looked at the WHO's recommendations for next year's Southern Hemisphere seasonal flu vaccine, while today we'll look at their selections for the development of novel flu vaccines for those viruses that possess some degree of pandemic potential.

Just as there are currently more than a half dozen subclades of seasonal H3N2 jockeying for dominance in the flu world (see The Enigmatic, Problematic H3N2 Influenza Virus), there are dozens of subclades and genotypes of avian and swine flu viruses competing in the wild.

Simply put, the H5N1 virus in Egypt (Clade 2.2.1.2) isn't isn't the same as the H5N1 virus in Nigeria (Clade 2.3.2.1c), or the one in Bangladesh (Clade 2.3.2.1a).

So, when we speak of the avian H5N1 virus, or H7N9 - we are really talking about multiple  genetically distinct variants - each on their own evolutionary path. And a vaccine developed against one strain of the same subtype may not prove protective against another.

Since H5N1 emerged in 2003, three dozen H5N1 candidate vaccine viruses (CVVs) have been selected by WHO for development.  While it can be expensive, having a proven CVV already tested and approved can save months of valuable time if mass production and distribution of a vaccine is ever required.

Similarly there are 11 H7N9 CVVs, and 6 H9N2 CVVs either developed or in the pipeline. The latest report from the WHO, released yesterday, can be found at:

Antigenic and genetic characteristics of zoonotic influenza viruses and candidate vaccine viruses developed for potential use in human vaccines

28 September 2017

This summary provides a review on the zoonotic influenza virus activity and virus characterization, and describes the current status of the development of candidate vaccine viruses for pandemic preparedness purposes. It is meant to provide guidance for national authorities and vaccine companies on the selection of candidate viruses for use in vaccine development.

September 2017
pdf, 923kb

According to this latest report, since the last review (see WHO: Candidate Vaccines For Pandemic Preparedness) 6 months ago, no new H5N1, H7N9, or H9N2 viruses have appeared requiring development into new CVVs.

On the swine flu front, however, we've seen several new variants turn up, which are discussed in the following excerpts from yesterday's 14-page report:

Influenza A(H1N2) variants (v)4
 
Influenza A(H1) viruses circulate in swine populations in many regions of the world. Depending on geographic location, the genetic characteristics of these viruses differ. Human infections with swine A(H1) viruses have been documented for many years.

Influenza A(H1N2)v activity from 28 February to 25 September 2017

Two cases of A(H1N2)v were detected in the United States of America during this reporting period. Both were in children who developed mild disease following direct contact with pigs. Phylogenetic analysis of the HA gene of A/Ohio/24/2017 showed it was of the swine H1 alpha lineage similar to viruses isolated from swine in North America in recent years. A/Ohio/35/2017 had a seasonal, human-like H1 HA gene segment that belonged to the delta 2 lineage of swine influenza viruses. This HA gene is closely related to the HA genes of influenza viruses currently circulating in swine in the United States of America (Figure 2).

Antigenic and genetic characteristics of influenza A(H1N2)v viruses

Antigenic testing demonstrated that ferret antisera raised against current CVVs reacted poorly with these two A(H1N2)v viruses. The reactivity of pooled, adult human sera collected post-vaccination with the 2016-2017 vaccine was also reduced against these viruses in haemagglutination inhibition assays (Tables 4 and 5).

Influenza A(H1)v candidate vaccine viruses
 
Based on the current antigenic, genetic and epidemiologic data, new CVVs generated from A/Ohio/24/2017-like and A/Ohio/35/2017-like viruses are proposed. The available A(H1)v CVVs are listed in Table 6.

Influenza A(H3N2)v
 
Influenza A(H3N2) viruses are enzootic in swine populations in most regions of the world. Depending on geographic location, the genetic and antigenic characteristics of these viruses differ. Human infections with swine influenza A(H3N2) viruses have been documented in Asia, Europe and North America5.

Influenza A(H3N2)v activity from 28 February to 25 September 2017

Thirty one cases of A(H3N2)v were detected in the United States of America during this reporting period. The virus from one case in Texas had an HA gene belonging to the IV-A cluster, closely related to A(H3N2) viruses currently circulating in North American swine. 

The remaining cases of A(H3N2)v virus infection were identified in North Dakota [1], Pennsylvania [1], Maryland [13] and Ohio [15] from July to September following exposure to swine at agricultural fairs. With the exception of three adult cases, all others were among children twelve years of age or younger. No human-to-human transmission was identified. These A(H3N2)v viruses had HA genes derived from a seasonal human H3 virus that was probably introduced to swine by humans in 2010 (Figure 3). The viruses were closely related to A(H3N2)v viruses infecting humans in Ohio and Michigan in 2016 and viruses known to circulate in swine in the United States of America.

Antigenic and genetic characteristics of influenza A(H3N2)v viruses

Characterisation of the cluster IV-A virus revealed that ferret antisera raised against wild type viruses and CVVs reacted well with this virus. Antigenic testing of the viruses with the 2010 human-like H3 gene showed reduced inhibition by post-infection ferret antisera raised against the nearest CVV, IDCDC-RG55C, and seasonal A(H3N2) viruses. Pooled, adult post-vaccination antisera reacted with these viruses at titres that were reduced compared to those against homologous vaccine viruses. A pool of sera collected from vaccinated children showed greater reductions in titre compared with pooled adult sera (Table 7).

 Influenza A(H3N2)v candidate vaccine viruses
 
Based on the available antigenic, genetic and epidemiologic data, a new CVV based on an A/Ohio/13/2017-like virus is proposed. The available A(H3N2)v CVVs are listed in Table 8.

Since the influenza HA subtypes that commonly circulate in swine (H1, H2, H3) are also the same that have caused all of the human pandemics going back 130 years (see Are Influenza Pandemic Viruses Members Of An Exclusive Club?), they are generally regarded as having less far to `jump’ to humans than do many avian viruses. 

Which is precisely how the H1N1 pandemic virus emerged in 2009, after kicking around (and reassorting in) swine herds for a decade or longer.

All of which makes the development of swine CVVs, like the ones proposed yesterday, a critical part of pandemic preparedness. For more on the global emergence of novel swine flu viruses, you may wish to revisit:

EID Journal: Transmission Of Swine H3N2 To Humans At Agricultural Exhibits - Michigan & Ohio 2016

A Reminder About The `Other' Novel Flu Threat

J. Virol: Novel Reassortant Human-like H3N2 & H3N1 Influenza A Viruses In Pigs

MMWR: Investigation Into H3N2v Outbreak In Ohio & Michigan - Summer 2016

WHO: Recommended Composition of The 2018 Southern Hemisphere Flu Vaccine

#12,783


Twice each year influenza experts gather to discuss recent developments in human and animal influenza viruses around the world, and to decide on the composition of the next influenza season’s flu vaccine.

NIAID has a terrific 3-minute video that shows how influenza viruses drift over time, and why the flu shot must be frequently updated, which you can view at this link.

Due to the time it takes to manufacture and distribute a vaccine, decisions on which strains to include must be made at least six months in advance, which means the composition of next year's Southern Hemisphere’s vaccine must be decided upon in late September.

As we've discussed often (see The Enigmatic, Problematic H3N2 Influenza Virus), coming up with a good vaccine match for seasonal H3N2 has become increasingly more difficult in recent years. 

Last winter we saw a modest level of protection (34%) against H3N2, according to the CDC's MMWR report of June 30th.

2016–17 Influenza Vaccine Effectiveness

Data collected through the U.S. Influenza Vaccine Effectiveness Network during November 28, 2016–April 14, 2017, indicate that influenza vaccination this season reduced the overall risk for influenza-associated medical visits by 42% (95% CI = 35%–48%).

Vaccine effectiveness against the predominant influenza A(H3N2) viruses was 34% (95% CI = 24%–42%) and vaccine effectiveness against influenza B viruses was 56% (95% CI = 47%–64%).

Earlier this week, we saw comments from Australia's Chief Medical Officer (see Australian CMO Statement On Flu Vaccine Effectiveness) placing some of the blame for their unusually rough flu season on `. . .   the effectiveness of the vaccines has been less than usual this year, particularly in terms of protecting the elderly against influenza A (H3N2).'

This week the World Health Organization brought together representatives from  GISRS (Global Influenza Surveillance and Response System), along with members of OFFLU (the OIE/FAO Network on Animal Influenza), and other experts to recommend what flu strains to include in next year's Southern Hemisphere flu vaccine.

Today, they've released their recommendations, which includes a new H3N2 vaccine component (A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus) which includes some of the changes we've seen in the virus (including the AA substitution N121K in the HA gene) over the past 8 months, and a switch from the Victoria Lineage B virus back to a Yamagata lineage virus for a trivalent vaccine.

Recommended composition of influenza virus vaccines for use in the 2018 southern hemisphere influenza season 

 28 September 2017

It is recommended that trivalent vaccines for use in the 2018 southern hemisphere influenza season contain the following:

• an A/Michigan/45/2015 (H1N1)pdm09-like virus;
• an A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus; and
• a B/Phuket/3073/2013-like virus.
  

It is recommended that quadrivalent vaccines containing two influenza B viruses contain the above three viruses and a B/Brisbane/60/2008-like virus. 

For more information 

Recommended composition of influenza virus vaccines for use in the 2018 southern hemisphere influenza season - full report
pdf, 183kb

There are many theories over why flu vaccines aren't as effective as we'd like, ranging from antigenic drift, to vaccine strain selection, to mutations that can occur in the (primarily egg-based) manufacturing process.

You'll find an excellent review in last week's Science Magazine article called:

Why flu vaccines so often fail

By Jon CohenSep. 20, 2017 , 2:30 PM

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

Even assuming this year's shot only provides modest protection, if an unusually severe H3N2 season materializes this winter, you'll probably want every advantage you can get.

Italy: IZSV Reports 3 More Outbreaks Of HPAI H5 & H5N8

HPAI H5 Outbreaks Since July 1st, 2017

#12,782


It's been two weeks since the last report of HPAI H5N8 from Italy's IZSV (Istituto Zooprofilattico Sperimentale delle Venezie), but today we learn of 3 more outbreaks - 2 already identified as H5N8 - and one HPAI H5 still awaiting further lab analysis. 

Today's report brings to 24 the number of outbreaks reported since July 1st, and the 40th of 2017.

The unusual persistence of H5N8 this the summer in Italy, and to a far lesser extent in Belgium, Luxembourg, France, Germany, Switzerland, and the UK (see DEFRA: Outbreak Assessment On H5N8 In Europe - Summer 2017) has raised concerns that avian flu may be becoming more of a year-round threat (see DEFRA Warns Of `Constant Risk' From Avian Flu).

Details on the latest outbreaks follow:

Avian influenza in Italy: updates

Posted: 16 September 2015 Last update: 27 September 2017

2016/2017 – H5N5, H5N8

• Outbreaks | PDF (last update: 27/09/2017)
• Maps | PDF (last update: 27/09/2017)

September 2017

27/09/2017 – On 26 September, the National Reference Laboratory for Avian Influenza and Newcastle Disease (NRL) confirmed as positive for Avian Influenza A virus subtype H5N8 a fattening turkey farm in Vicenza province (Veneto region). At the moment of the epidemiological investigation, there were 30,076 53 day-old male turkeys present at the farm. On 20 September, respiratory symptoms were detected and, in the following days, neurologic symptoms and increased mortality rates were observed.

On the same day, the NRL confirmed as positive for Avian Influenza A virus subtype H5N8 a duck farm in Vicenza province (Veneto region). Around 8.200 female ducks were present at the farm. On 24 September, an increase in mortality was observed, along with neurological symptoms. The epidemiological unit also includes an adjacent grower farm rearing various species (for a total of 3,950 birds). Control and eradication measures were applied to the whole epidemiological unit.

Still on 26 September, the NRL 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, 8,378 female turkey with 100 days-old were present at the farm. A marked increase in mortality was observed on 25 September.

Protection and surveillance zones (3 and 10 km) around all the infected holdings were defined, and control measures were implemented as provided by the Council Directive 2005/94/EC.

(Continue . . .)

As Italy and the rest of Europe continue to deal with what are presumably remnants from last winter's epizootic, we are rapidly approaching the start to this year's fall migration (see 2016's Sci Repts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission Of HPAI H5N1).

Exactly what that will bring to Europe, North America and Asia this fall is unknowable, but given last year's impact, poultry interests throughout the Northern Hemisphere should be taking steps to enhance their biosecurity before their arrival.

MAFRA: South Korean H7N7 Indentified As LPAI

#12,781


Two days ago (see Reports of HPAI H5N6 In Vietnam, H7N7 In South Korea) we saw reports of the environmental detection of avian H7N7 in bird feces in North Gyeongsang Province, 344 km south of Seoul.  

While LPAI was suspected, we've been waiting for laboratory confirmation.

Result of close inspection of Yeoncheon wild bird feces in Gyeongbuk Province, according to the diagnosis of low-pathogenic AI (H7N7 type) 

Date Released 2017-09-28 10:10:00

The Ministry of Food, Agriculture, Forestry, Livestock and Livestock Food and Beverage (minister Kim Young-rok) said that the Environmental Science Institute conducted a detailed inspection on the AI that was found in the feces of wild birds in the village of Yeongcheon in Yeongcheon, Kyongbuk Province on September 25, and the result was H7N7, And that the area that was set for the area was released.

However, the Ministry of Agriculture, Forestry and Livestock and Livestock and Livestock Food and Livestock has urged the poultry farmers nationwide to thoroughly prevent AI from taking into account the time of migratory birds movement and the special prevention period ('17 .10.1 ~ '18 .5.31) It plans to strengthen the forecast for wild birds.

After three consecutive years of devastating HPAI H5 outbreaks, and with China's H7N9 virus making fresh inroads in the north of that country over the summer, South Korea is understandably on alert for any new incursions of avian flu via migratory birds. 

LPAI H7 viruses are common in wild birds, and are normally not a threat, but when they are introduced into large poultry populations have the potential to mutate in to a highly pathogenic (HPAI) strain.

Yesterday's report (see South Korea Ramps Up Avian Flu Quarantine Measures) is a reflection of just how seriously South Korea regards this threat. 

Vietnam Reports Another Outbreak Of HPAI H5N6

#12,780

On Tuesday we saw a report of an outbreak of H5N6 in Kon Tum Province, Vietnam - the first in that country since last April. Today, numerous Vietnamese media outlets are carrying reports of a small H5N6 outbreak in Ha Tinh City, nearly 500 km to the north. 

H5N6 avian influenza outbreak appeared in Ha Tinh city

Ha Tinh news

Leaders of the Department of Livestock and Veterinary Medicine Ha Tinh information, the unit has coordinated with the authorities of Ho Chi Minh City. Ha Tinh destroyed 250 ducks of Mr. Tran Van Nam's household (street 9, Daiai ward) due to H5N6 infection.

Earlier, on September 24, when he flocked to the duck field, Mr. Nam discovered some dead, then some other children showed signs of eating less, eyes are lethargic, ruffled feathers, convulsions and death. Shortly thereafter, Nam informed the local authorities and authorities to take measures.

By taking samples, the Department of Animal Husbandry and Veterinary Ha Tinh confirmed, his brother duck house positive for H5N6 influenza virus.

In order to control and not spread the disease spread, the authorities and local authorities have destroyed the above mentioned poultry, spraying chemicals, sprinkling lime powder in cages, vaccination surround...

Previously, H5N1 avian flu has also occurred in a commune in Ky Anh district, forcing authorities to destroy more than 2,000 sick and dead poultry.

Posted by: baohatinh

Fourteen years ago Vietnam was one of the first countries to be affected by the H5N1 virus, and for a time, lead the world in human cases and deaths; reporting 90 cases and 39 deaths over a 2 year period (2004-2005).

Through a program of aggressive culling, poultry vaccination, and public education, by 2006 they’d gone from being the worst afflicted country in the world to being viewed as the `poster child’ for successful bird flu containment.  Human cases, and outbreaks - while they still occurred - were dramatically reduced.

Although H5N1 would return sporadically over the years, and HPAI H5N6 showed up in the summer of 2014 for the first time, we've not seen a human avian flu infection reported from Vietnam since two H5N1 cases were reported in 2014. 

But success in containing bird flu can be fleeting, and with H5N1, H5N6, and H5N8 seemingly well entrenched in migratory birds that ply the East Asian flyway, and growing concerns that H7N9 will eventually follow suit and break out of China, Vietnam remains at risk of seeing new, and potentially devastating avian flu outbreaks.

Delaware DPH Reports An H3N2v Case Likely Linked To Maryland Fair

http://nasphv.org/Documents/AnimalExhibitsSafety.pdf

#12,779


In what appears to be a spillover from Maryland's fair-related clusters of swine H3N2v infections (see Maryland DOH: 20 Presumptive Positive & Confirmed H3N2v Cases), Delaware is reporting their first case involving a female Sussex County resident (< 18 yrs old) who had recent contact with pigs at a Maryland country fair.

This from Delaware.gov.

DPH Announces Delaware Flu Case Likely Related to Contact With Pigs At County Fair in Maryland

Date Posted: Wednesday, September 27th, 2017

DOVER – The Delaware Division of Public Health (DPH) announced today the state’s first laboratory-confirmed case of a variant influenza virus (in this instance H3N2v) in a female Sussex County resident under age 18, who had close contact with pigs at a county fair in Maryland. The case is mild and the individual is recovering. No additional information will be released on the individual to protect her privacy.

Any individual who visited a Maryland County fair within the last seven to ten days, had contact with pigs, and has subsequently developed flu symptoms after their last exposure, should call their medical provider to discuss the potential need for a flu test.

When an influenza virus that normally infects pigs is found in people, it is called a “variant” influenza virus. While it is not possible to determine exactly where the individual contracted the variant flu, also commonly known as the “swine flu”, the Maryland Department of Agriculture has been investigating the appearance of this virus in pigs at the fairs in Charles and Frederick Counties. The Delaware resident reportedly had close contact with pigs at the Anne Arundel County Fair, the first suspected case of variant influenza from that event. Today the Maryland Department of Health announced “presumptive” positive cases of variant flu in Maryland residents who had close contact with pigs at the Anne Arundel County Fair as well.

         (Continue . . . .)


Earlier this summer we saw a similar case reported from Pennsylvania where the patient was exposed and infected at a fair in North Dakota (see CDC FluView Week 32: 3 Swine Variant Infections (OH, PA, ND)). A reminder how easily flu can cross borders.

While limited human-to-human transmission of H3N2v has been reported in the past, outbreaks have yet to develop `legs', and have quickly died out after infected pig exposures were eliminated.

The concern, of course, is that these swine viruses are not only varied, they continue to evolve - and as we saw with swine H1N1 in 2009 - have the potential to better adapt to human physiology. 

While generally less severe than  avian flu in humans, swine influenza viruses are nevertheless viewed as having some pandemic potential. The CDC's IRAT (Influenza Risk Assessment Tool) Rankings monitors and characterizes 14 different novel flu viruses, and has this assessment on H3N2v. 

H3N2 Variant:[A/Indiana/08/11]

Swine-origin flu viruses do not normally infect humans. However, sporadic human infections with swine-origin influenza viruses have occurred. When this happens, these viruses are called “variant viruses.” Influenza A H3N2 variant viruses (also known as “H3N2v” viruses) with the matrix (M) gene from the 2009 H1N1 pandemic virus were first detected in people in July 2011. The viruses were first identified in U.S. pigs in 2010. In 2011, 12 cases of H3N2v infection were detected in the United States. In 2012, 309 cases of H3N2v infection across 12 states were detected. The latest risk assessment for this virus was conducted in December 2012 and incorporated data regarding population immunity that was lacking a year earlier.

Summary: The summary average risk score for the virus to achieve sustained human-to-human transmission was in the moderate risk category (less than 6). The summary average risk score for the virus to significantly impact public health if it were to achieve sustained human-to-human transmission was in the low-moderate risk category (less than 5).

For some recent blogs on Swine variant influenza, and why the CDC closely monitors these infrequent human infections, you may wish to revisit:

EID Journal: Transmission Of Swine H3N2 To Humans At Agricultural Exhibits - Michigan & Ohio 2016

A Reminder About The `Other' Novel Flu Threat

J. Virol: Novel Reassortant Human-like H3N2 & H3N1 Influenza A Viruses In Pigs

MMWR: Investigation Into H3N2v Outbreak In Ohio & Michigan - Summer 2016

Maryland DOH: 20 Presumptive Positive & Confirmed H3N2v Cases

#12,778

The outbreaks of swine H3N2 influenza in pigs at several Maryland County Fairs, and the spillover of H3N2v infections to fair goers we've been following for the past 6 days (see Monday's report  Maryland Dept. of Ag.: 11 Pigs At Frederick County Fair Test Positive For Influenza A) continues to expand with the announcement tonight from the Maryland Department of Health that 20 human cases have been detected and a 3rd county fair has been involved.

Tonight's announcement effectively doubles this year's swine variant infection count to 40, cementing 2017 as the second most active year on record (albeit far below 2012's record 307 cases). 

While swine variant infections are generally either mild or of moderate severity, the CDC takes these outbreaks seriously. The CDC's Risk Assessment on H3N2v and other swine variant viruses reads:

CDC Assessment

Sporadic infections and even localized outbreaks among people with variant influenza viruses may occur. All influenza viruses have the capacity to change and it's possible that variant viruses may change such that they infect people easily and spread easily from person-to-person. The Centers for Disease Control and Prevention (CDC) continues to monitor closely for variant influenza virus infections and will report cases of H3N2v and other variant influenza viruses weekly in FluView and on the case count tables on this website

We may get more details on Friday when the newest CDC FluView report is released.  In the meantime, we have the following press release from the Maryland Department of Health.

Flu virus detected in guests at Anne Arundel, Frederick fairs 

Five individuals presumptively positive for H3N2v strain, none hospitalized
Baltimore, MD (September 27, 2017) – The Maryland Department of Health has presumptively identified the influenza virus strain H3N2v (variant flu) in five individuals who had close contact with pigs at the Anne Arundel County Fair and The Great Frederick Fair. None of the five infected people has developed serious illness or has been hospitalized. The investigation into variant flu is ongoing. Updated case count information can be found on the Department of Health’s website. 

Test results from sick pigs at the Great Frederick Fair have been confirmed as the subtype H3N2, according to the Maryland Department of Agriculture. Ninety-five pigs remain in isolation at the fairgrounds. Additionally, three farms in Frederick County have been placed on a hold order in relation to this outbreak. The effected farms had pigs at the Great Frederick Fair that were discharged prior to the detection of the virus. Nasal swabs from those pigs have been sent out for further testing.

Officials have lifted the hold order at Charles County Fair. The swine barn at the fairgrounds will be completely broken down to allow thorough cleaning and disinfection. The Anne Arundel County fair ran concurrently, and there were no reports of pigs displaying illness at those fairgrounds. 

The Calvert County Fair is the last of the Maryland county fairs scheduled for the season. Swine exhibits at this event were cancelled last week by order of the Secretary of Agriculture out of an abundance of caution. 

Health officials recommend that people with influenza-like illness contact their healthcare provider and inform them if they have had pig contact within the past seven days. Providers are advised to contact their local health departments if they suspect variant flu in their patients to coordinate appropriate testing with their local health department. 

Influenza is an infection caused by an influenza virus that can affect people and other animals, including pigs and birds. Symptoms for the H3N2v influenza strain are the same as for those of seasonal flu, and they include fever and respiratory symptoms, such as sore throat and cough. Historically, there is limited human-to-human transmission from this strain of variant flu. The treatment recommendations for this strain of influenza are the same as for seasonal flu. 

Certain people are at higher risk for complications of influenza, including children under 5, the elderly, pregnant women and those with chronic heart, lung, liver, kidney and neurologic conditions or immunosuppression. The spread of influenza, including the possible spread of H3N2v, between humans can be prevented by:

• Avoiding close contact with sick people;
• Limiting contact with others as much as possible if you are sick to keep from infecting them and staying home from work or school if you are sick until you are fever free for 24 hours without fever reducing medicines;
• Covering your nose and mouth with a tissue when you cough or sneeze and dispose of the tissue immediately after use;
• Washing your hands often with soap and water or alcohol-based hand rub, if soap and water are not available;
• Avoiding touching your eyes, nose and mouth;
• Cleaning and disinfecting surfaces and objects that might be contaminated with such germs as the flu; and
• Getting the seasonal influenza vaccine when it becomes available. Although it is not effective against H3N2v, it is protective against other common strains of influenza.
  

The spread of influenza between pigs and humans can be prevented by:
Washing your hands frequently with soap and running water before and after exposure to pigs;

Never eating, drinking or putting things in your mouth while occupying areas where pigs are present;

• Considering avoiding exposure to pigs and swine barns this year, especially if sick pigs have been identified and if you are high risk of complications from influenza;
• Watching your pig for signs of illness and calling a veterinarian if you suspect it might be sick;
• Avoiding close contact with pigs that look or act ill; and
• Avoiding contact with pigs if you are experiencing flu-like symptoms.

Additional information from the Centers for Disease Control and Prevention regarding Swine Influenza/Variant Influenza Viruses is available here. 

Influenza viruses do not affect the safety of properly cooked pork. As with any raw meat, pork should always be properly handled and cooked to eliminate a range of food safety concerns.

Last month, in EID Journal: Transmission Of Swine H3N2 To Humans At Agricultural Exhibits - Michigan & Ohio 2016, we looked at the risks of novel flu transmission in these types of venues, including from healthy-looking pigs.

In an attempt to better quantify the size of this outbreak, the Maryland Department of Health  issued a letter to clinicians on Friday with guidance for testing and reporting.

While not everyone who catches the flu will seek medical attention or be tested, this could result in additional cases being uncovered in the days ahead.  And while Maryland's fair season is coming to an end, it would not be entirely surprising if we see reports from other states in the weeks to come. 

Stay tuned. 

Australian CMO Statement On Flu Vaccine Effectiveness

#12,777


Although I am well aware of its limitations, I get the flu vaccine every fall, and I urge others to consider doing so as well.  Whether through blind luck, the protective effects of the flu shot, or my maniacal  use of hand sanitizer outside the home, I've managed to avoid the flu (and any other respiratory infection) for the past 8 years, and have hopes of increasing that streak again this winter. 

But the flu shot doesn't guarantee 100% protection. In fact, depending on the recipient's age, immune health, and the current strain of influenza in circulation, the flu shot's effectiveness can often drop below 50%. 

This is hardly a new revelation, as five years ago Michael Osterholm and his group at CIDRAP released their 160-page Comprehensive Influenza Vaccine Initiative (CCIVI) report that called for the creation of more efficient vaccine technology (see CIDRAP: The Need For `Game Changing’ Flu Vaccines).

And we have seen some small improvements, including the move to a quadrivalent vaccine, and for those over 65, the availability of Fluzone High-Dose Seasonal Influenza Vaccine and starting last year, the introduction of FLUAD™: An Adjuvanted Flu Vaccine Option For Those Over 65.

But seasonal flu is an agile adversary, and with the required 6 months lead time to produce and deploy a vaccine, the virus can sometimes mutate away from the vaccine strain. That doesn't necessarily negate the vaccine's effectiveness, but it can reduce it. 

While we've seen pretty good vaccine effectiveness (VE) numbers against H1N1, and influenza B, as we discussed two months ago in The Enigmatic, Problematic H3N2 Influenza Virus, the track record against seasonal H3N2 has been less successful.

The problem is, H3N2 has split into numerous subclades, which co-circulate and battle constantly for dominance.  New mutations - like N171K and N121K have recently appeared - and their impact on this year's vaccine effectiveness is being examined.

Yesterday, in Seasonal influenza circulation patterns and projections for Sep 2017 to Sep 2018 by Trevor Bedford & Richard Neher, published on BioRxIv, seasonal H3N2's evolution was described as:

H3N2: H3N2 continues to diversify with many coexisting clades, all of which carry several amino acid mutations at previously characterized epitope sites. The majority of viruses fall into the 3c2.a clade which has been dominating globally for >3 years, but 3c3.a viruses continue to persist. The common ancestor of circulating H3N2 viruses is now more than 5 years old, which is rare for H3N2. Despite extensive genetic diversity, serological assays suggest limited, but non-zero, antigenic evolution. We expect multiple competing clades within 3c2.a to persist into the future with no clear immediate winner 

And therein lies the problem; H3N2 a diverse, meandering subtype of seasonal flu, without one distinctly dominant strain to design a vaccine against.  How well this year's vaccine works will depend in large portion, to what `flavor' of H3N2 visits your neighborhood this winter.

By now, everybody knows that Australia has come off their worst flu season in recent memory, and there are concerns that we could see a similarly rough season ahead in the Northern Hemisphere (see UK: NHS Warns Of A Potentially Rough Flu Season Ahead).

Today Australia's Chief Medical Officer has issued a statement which cites a lower than usual VE against H3N2 - particularly among the elderly - as a contributing factor to this year's high mortality rate.

27 September 2017

Statement from the Chief Medical Officer on seasonal influenza vaccines

The Australian Government is committed to immunisation and to ensuring Australia has the best possible vaccination program underpinned by sound evidence and effective vaccines.

The National Immunisation Program (NIP) provides free seasonal influenza vaccines to those most at risk of influenza and its complications. The program is demand driven, which means any eligible individual can access a free vaccine. In 2017, over 4.5 million doses have been distributed to meet the current take up of eligible Australians for the free vaccine.

Currently only around 70% of eligible Australians currently take up the free vaccine. The Australian Government strongly encourages the approximately 2.5 million eligible Australians, who do not currently have the vaccine, to be vaccinated and will make available sufficient vaccine to meet demand each year.

Each year, seasonal influenza causes significant mortality and morbidity in the Australian community. The virus is extremely complex and dynamic which means a new vaccine is required every year but also makes it very difficult to manufacture and distribute influenza vaccines each year.

2017 has been characterised by high levels of influenza A (H3N2) which disproportionately affects the elderly. We have seen reports of high numbers of deaths in nursing homes this year and also amongst healthy adults. These are tragic events which underscore the message that influenza is a serious disease and that vaccination is absolutely critical for protecting individuals and the community.

We do know that the 2017 vaccines have had a relatively good match with circulating strains, which provides the best opportunity for protection. There is, however evidence that the effectiveness of the vaccines has been less than usual this year, particularly in terms of protecting the elderly against influenza A (H3N2).

The quadrivalent seasonal influenza vaccines supplied through the NIP are similar to those supplied in like countries (eg: the United Kingdom) and also on the private market.

To be supplied through the NIP, vaccines must be registered by the Therapeutic Goods Administration and recommended by the Pharmaceutical Benefits Advisory Committee (PBAC). These processes ensure vaccines are safe and effective. In addition, competitive tendering arrangements have meant the Australian Government has been able to achieve value for money when purchasing vaccines – that is good news for the Australian community.

Of the vaccines supplied internationally specifically for the elderly, one (a high dose formulation) is not registered in Australia and the other (an adjuvanted vaccine) does not have an up to date registration in Australia. The PBAC has not yet received a submission for either vaccine.

The Australian Government has been carefully monitoring vaccine effectiveness for seasonal influenza vaccines and is committed to exploring enhanced vaccination program arrangements through the NIP, including the use of advanced vaccines for those aged 65 years and over into the future.

Media contact: email: news@health.gov.au

Unlike in the United States, the FluZone High Dose and FluAd Adjuvanted  vaccines were not licensed, or available in Australia.  Whether that would have made much of a difference is unknown, although the CDC does say:

Why is a higher dose vaccine available for adults 65 and older?

Human immune defenses become weaker with age, which places older people at greater risk of severe illness from influenza. Also, ageing decreases the body’s ability to have a good immune response after getting influenza vaccine. A higher dose of antigen in the vaccine is supposed to give older people a better immune response, and therefore, better protection against flu.

Does the higher dose vaccine produce a better immune response in adults 65 years and older?

Data from clinical trials comparing Fluzone to Fluzone High-Dose among persons aged 65 years or older indicate that a stronger immune response (i.e., higher antibody levels) occurs after vaccination with Fluzone High-Dose. Whether or not the improved immune response leads to greater protection has been the topic on ongoing research. A study published in the New England Journal of Medicine indicated that the high-dose vaccine was 24.2% more effective in preventing flu in adults 65 years of age and older relative to a standard-dose vaccine. The confidence interval for this result was 9.7% to 36.5%. A separate study published in The Lancet Respiratory Medicine reported that more immunogenic, high-dose vaccines can reduce the number of hospital admission for people aged 65 years or older, especially those living in long-term care facilities. The study compared hospitalization rates among more than 38,000 residents of 823 nursing homes in 38 states during the 2013-14 flu season.

The CDC and its advisory committee do not recommend these enhanced vaccines over the getting the regular flu shot, and their use is linked to a slight increase in (generally mild) adverse effects, so those over 65 will want to consult their doctor.  

While we can't know what kind of flu season lies ahead, the epidemics in Australia, Hong Kong, and Southern China over the past 5 months may give us an advance indicator of what we can expect.

As always, even for those who do get the flu shot, the smart money is on practicing good flu hygiene (washing hands, covering coughs & sneezes, staying home when sick) all throughout the flu and cold season.

And if you do fall ill, early administration of antivirals - particularly for those at high risk of complications - can reduce both the length and severity of infection.  

South Korea Ramps Up Avian Flu Quarantine Measures

#12,776

In the wake of yesterday's report on the detection of avian H7N7 in wild bird feces - and being only days away from Korea's three day fall harvest festival Chuseok (this year, October 4th-6th) - the government is visibly stepping up their avian flu control and containment program. 

First this report from Yonhap News, then I'll return with a bit more:

Korea steps up bird flu quarantine measures

By Yonhap

 Published : Sept 27, 2017 - 11:28 

South Korea will step up quarantine measures against bird flu ahead of the long holiday as a suspected case was reported in the country's southern region, the Ministry of Agriculture, Food and Rural Affairs said Wednesday.

The ministry said an H7N7 strain of avian influenza was found in wild bird droppings that were collected in Yeongcheon, 344 kilometers southeast of Seoul on Sept. 13. 

Following its discovery, health authorities issued a warning that banned local poultry farms from entering the wintering grounds of migratory birds and ordered the disinfection of farms adjacent to the site.

The ministry said it will implement strengthened quarantine measures in the coming weeks, as many people are expected to take trips around the country during the Chuseok holiday, which runs from Sept. 30 to Oct. 9. 
The National Institute of Environmental Research will further look into the dropping sample to figure out whether it is a highly pathogenic virus strain or a milder version. The results will be announced Sept. 27, the ministry said. 

(Continue . . . )

Since January 2014, the South Korean poultry industry has been hammered by hundreds of HPAI H5N8 and - starting in 2016 -  HPAI H5N6 outbreaks, which have resulted in the loss of tens of millions of birds. 

As we discussed a few weeks ago in South Korea To Move To Year-Round AI Prevention - while we still see the majority of bird flu activity during the cooler months of the year - the expected summer lull across many temperate regions has become less pronounced.  

As an example, in June of this year - after several months of little or no activity - we saw a fresh surge of activity and South Korea: MAFRA Confirms HPAI H5N8, Raises Alert Level To Maximum. In Europe, H5N8 sporadic H5N8 activity has continued throughout the summer, with Italy being particularly hard hit. 

This year yet another emerging avian flu virus  - HPAI H7N9 - has China's neighbors on edge, with its rapid spread out of Guangdong Province last spring (see China's Nervous Neighbors). As with HPAI H5, HPAI H7 virus appears to be traveling via migratory birds. 


After three consecutive years of heavy bird flu loses, a multi-hospital MERS epidemic in the summer of 2015, a fipronil contaminated egg scandal last month - and with the 2018 Winter Olympics Games to be held in Pyeongchang County next February - the South Korean Government is understandably keen to shut down any new crisis before it can get out of hand.

In recent years South Korea has become a harbinger of sorts, often reporting their first bird flu outbreaks (or detections in wild birds or the environment) several weeks before other countries along the East Asian Flyway.

All of which means we'll be keeping a very close eye on South Korea in the weeks to come.

Reports of HPAI H5N6 In Vietnam, H7N7 In South Korea

#12,775


With October only days away, this is the time of year when we start looking for an uptick in bird flu reports - partially because of cooler autumn temperatures - and partially because in the fall migratory birds head south from their high latitude summer roosting grounds.

Today we've two media reports of avian flu activity; one from Vietnam and one from  South Korea.

First from Vietnam, which hasn't reported an outbreak of H5N6 since April, we get the following report:

Appear outbreak of influenza A / H5N6 in poultry in Kontum

SGGP 26/09/2017 16:29 GMT+7

26-9, Livestock and Veterinary Station (T-TY) Dak Ha district (Kon Tum) officially tested specimens from the Animal Health Agency Region 5. The result, the samples were taken nearly 4,700 poultry on the family Tran Duc Hoa positive for influenza virus A / H5N6.

Earlier, on 22-9, nearly 4,700 poultry son of Mr. Tran Duc Hoa family (living in Thanh Xuan village, Dak Ngoc commune, Dak Ha District, Kon Tum) was sick and dead simultaneously. Immediately after receiving the report, Station T-TY Dak Ha district took samples sent for testing at the Regional Veterinary Authority 5 (Dak Lak).

In 26-9, immediately after receiving the test results, Station T-TY Dak Ha district administration in collaboration with Dak and his family Ngoc Hoa organized destruction of entire 4,700 birds (ducks, geese, chickens) and 3,000 eggs. At the same time, T-TY Station district veterinary officer appointed to coordinate local authorities continue to monitor the outbreak; guide farmers to conduct disinfection, management of landfills and poultry.

This is the 2nd time in 2 consecutive years, influenza A / H5N6 appeared in poultry Hoa of his family. Earlier, in May 1-2016, influenza A / H5N6 has also appeared on the 2,100 poultry, prompting his family Hoa to destroy, damage more than 140 million.

HONG NAM

H5N6 first appeared in Vietnam in the summer of 2014, and we've seen sporadic outbreaks there - and in Laos - since then.   H5N1 still plagues the region (see Vietnam: Thousands Of Vaccinated Chickens Die Of Suspected H5N1) and Vietnam hopes to deploy a locally produced - and hopefully more effective - vaccine next year.

Vietnam's biggest avian flu concern remains the incursion of H7N9 out of China, which was reported within 100 km of their northern border last spring (see H7N9 Inches Closer To Vietnam's Northern Border).

Meanwhile, from South Korea we get this report on the environmental detection of H7N9 (pathogenicity to be determined) in North Gyeongsang Province.

Avian flu virus found in bird excretions in rural city

2017/09/26 22:21 

SEOUL, Sept. 26 (Yonhap) -- A South Korean provincial government said Tuesday that the avian influenza (AI) virus had been found in bird excretions in the southern part of the country.

The government of North Gyeongsang Province said the H7N7 strain of avian influenza was detected in the excretions of wild birds in Yeongcheon, 344 kilometers south of Seoul.

The Ministry of Agriculture, Food and Rural Affairs will check to see if the virus is highly pathogenic by Friday though most of the H7N7-type viruses found in North Gyeongsang Province have turned out to be weakly pathogenic, the provincial government said.

The Gyeongbuk government and Yeongcheon city have designated everything within a 10 kilometer radius of the virus detection point under quarantine, banning poultry farms from relocating hens, ducks and geese until the examination is completed.

In the Gyeongbuk area, a highly pathogenic strain of avian flu broke out in November last year.

(END)

You may recall that South Korea Reported both LPAI H7N7 & H7N2 In Wild Birds in December of 2016, an event which was overshadowed by the arrival and rapid spread of HPAI H5N6 though South Korea's poultry industry.

 
There are two broad categories of avian influenza; LPAI (Low Pathogenic Avian Influenza) and HPAI (Highly Pathogenic Avian Influenza).

• LPAI viruses are quite common in wild birds, cause little illness, and only rarely death. They are not considered to be a serious health to public health. The concern is (particularly with H5 & H7 strains) that LPAI viruses have the potential to mutate into HPAI strains.
• HPAI viruses are more dangerous, can produce high morbidity and mortality in wild birds and poultry, and can sometimes infect humans with serious result. The type of bird flu scientists have been watching closely for the past decade has been HPAI H5 (and to a lesser extent HPAI H7s & H9s).

Before the middle of the last decade, there was no uniform requirement to report or track LPAI infections. That changed in 2006 when the OIE made reporting of all H5 & H7 viruses mandatory.

The finding of LPAI H7 viruses in Korean wild birds is therefore not terribly surprising, and under normal circumstance would scarcely warrant a mention.

But with the feared return of highly promiscuous and mutable clade 2.3.4.4. H5N6 and/or H5N8 this fall, and very dangerous HPAI & LPAI H7N9 viruses spreading next door in China, the addition of  H7N7 to South Korea's constellation of circulating avian flu viruses is a complication they could probably do without.

#NatlPrep: Radiological Emergencies

Credit CDC PHE

Note: This is day 26 of National Preparedness Month . Follow this year’s campaign on Twitter by searching for the #NatlPrep hash tag.
 
This month, as part of NPM17, I’ll be rerunning some edited and updated older preparedness essays, along with some new ones. 

#12,774


Until very recently, the notion that Americans might have to deal with a radiological emergency sounded like something out of the Cold War era (1950s to the 1980s), when multiple Soviet warheads were targeted on every major U.S. city and nuclear annihilation seemed all but unavoidable.

Today, while we’ve pulled back from that brink and have reduced our nuclear stockpiles by 80%, there still remain a variety of threats, including from terrorist organizations and rogue nations with limited nuclear capability.

Other radiological threats exist due to deliberate acts, accidents and natural disasters.  One need look only as far as the Fukushima disaster of 2011 or Chernobyl in 1986 to see how quickly a radiological emergency can affect a large population.
 
This from the CDC’s PHE website:

A radiological or nuclear incidents occurring within the U.S. homeland or elsewhere could take a number of forms, including: contamination of food or water with radioactive material; placement of radiation sources in public locations; detonation of radiological dispersal devices that scatter radioactive material over a populated area; an attack on a nuclear power plant or a high-level nuclear waste storage facility; or an improvised nuclear device.

The CDC's Emergency Preparedness and Response website lists 6 different types of potential radiological emergencies.

Types of Radiation Emergencies

Radiation emergencies may be intentional (e.g., caused by terrorists) or unintentional. Below are some examples of different types of radiation emergencies. Click on the icons to find out what to do if a radiation emergency happens in your area.

Nuclear Emergencies

• A nuclear emergency involves the explosion of a nuclear weapon or improvised nuclear device (IND).
• The explosion produces an intense pulse of heat, light, air pressure, and radiation.
• Nuclear explosions produce fallout (radioactive materials that can be carried long distances by the wind).
  

Dirty Bomb or Radiological Dispersal Device (RDD)

• A dirty bomb (also known as a radiological dispersal device) is a mix of explosives such as dynamite, with radioactive powder or pellets.
• A dirty bomb cannot create an atomic blast.
• When the explosives are set off, the blast carries radioactive material into the surrounding area.
  

Radiological Exposure Device (RED)

• A radiological exposure device (also called a hidden sealed source) is made of or contains radioactive material.
• REDs are hidden from sight to expose people to radiation without their knowledge.
  

Nuclear Power Plant Accident

• An accident at a nuclear power plant could release radiation over an area.
• Nuclear power plants have many safety and security procedures in place and are closely monitored by the Nuclear Regulatory Commission (NRC)
  

Transportation Accidents

• It is very unlikely that a transportation accident involving radiation would result in any radiation-related injuries or illnesses.
• Shipments involving significant amounts of radioactive material are required to have documentation, labels, and placards identifying their cargo as radioactive.
  

Occupational Accidents

• Radiation sources are found in a wide range of settings such as health care facilities, research institutions, and manufacturing operations.
• Accidents can occur if the radiation source is used improperly, or if safety controls fail.

The point of this blog is not to convince you that you should be preparing specifically for a radiological emergency - since being well prepared for far more common emergencies will cover most of your bases - but rather that you and your family should know what to do if a radiological release occurs.

The three basic tenants of radiation safety are:

Follow this link to review specifics on each of these topics, where you'll find a variety of information and helpful infographics - like the one below on decontamination - on what to do.

While a radiological hazard may be far down your list of `probable’ threats, being generally well prepared to shelter in place - and having a little bit of knowledge -  can go a long way towards protecting you and your family, even during a radiation emergency. 

For more on `all hazards’ preparedness, I’d invite you to visit: 

FEMA http://www.fema.gov/index.shtm
READY.GOV http://www.ready.gov/
AMERICAN RED CROSS http://www.redcross.org/

And for more on sheltering in place, you may wish to revisit:

When 72 Hours Isn’t Enough