The Lancet Inf. Dis.: MERS-CoV Risk Factors & Determinants Of Primary, Household, & Nosocomial Transmission

Credit WHO

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We first learned that a novel coronavirus was circulating in Saudi Arabia from a September 2012 letter posted in ProMed Mail (NOVEL CORONAVIRUS - SAUDI ARABIA: HUMAN ISOLATE) by Dr. Ali Mohamed Zaki - an Egyptian Virologist working In Saudi Arabia.

Retrospective analysis, however, revealed the MERS coronavirus to have been involved in a pneumonia outbreak at a hospital in Jordan in April of that year (see Serological Testing Of 2012 Jordanian MERS Outbreak).

Although the source, and mode of transmission remained unknown, by the end of 2012, the World Health Organization reported:

Thus far, the laboratory confirmed cases have been reported by Qatar (two cases), Saudi Arabia (five cases) and Jordan (two cases). All patients were severely ill, and five have died.

As the number of human infections slowly climbed, in August of 2013 the first evidence was presented (see Lancet: Camels Found With Antibodies To MERS-CoV-Like Virus), that some camels on the Arabian peninsula had been exposed to – and likely carried - a MERS-like virus.

By December, researchers led by Marion Koopmans, DVM, PhD, head of virology at the Laboratory for Infectious Diseases at the RIVM in the Netherlands, determined that the human viruses and the camel viruses collected from a Qatari farm were almost an identical match (see The Lancet: Identification Of MERS Virus In Camels).

So close, in fact, that they were unable to determine whether the humans or the camels were infected first.

Acceptance of this MERS-camel connection in Saudi Arabia and the Middle East was slow at first, resulting in a huge backlash (see Saudi Camel Owners Threaten Over MERS `Slander’) and back peddling by officials (see Saudi MOA Spokesman: Camel Link Unproven).

After large nosocomial outbreaks erupted in Jeddah in the spring of 2014 (see chart below), the tide slowly turned, and warnings about camel contact and consumption of raw camel products were intensified.

By the summer of 2014, more than 700 cases had been reported, with the vast majority coming out of Saudi Arabia. While camel contact was considered a factor in many of these infections, it certainly wasn't responsible for all - or even most - of the cases.

Limited human-to-human transmission - particularly in households and health care facilities - was responsible for at least half of all known cases.

Additionally, a substantial number of `primary' community acquired cases - with no known exposure - were also reported, raising the possibility that mild or asymptomatic cases were flying under the surveillance radar, and occasionally transmitting the virus.

Some early blogs on that possibility include:

Study: Possible Transmission From Asymptomatic MERS-CoV Case

EID Journal: Asymptomatic MERS Infections Possibly Linked to Infected Camels

WHO Guidance On The Management Of Asymptomatic MERS Cases

EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016

Despite these concerns, asymptomatic MERS infections were practically ignored in Saudi Arabia, at least until the summer of 2015, when the WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS - without specifically naming the Saudis – chastised the response to MERS in unusually blunt terms, stating: 

The Committee further noted that its advice has not been completely followed. Asymptomatic cases that have tested positive for the virus are not always being reported as required.

Timely sharing of detailed information of public health importance, including from research studies conducted in the affected countries, and virological surveillance, remains limited and has fallen short of expectations.

Inadequate progress has been made, for example, in understanding how the virus is transmitted from animals to people, and between people, in a variety of settings. The Committee was disappointed at the lack of information from the animal sector.

Despite a substantial increase in the flow of information on MERS since then, nearly three years later a great many questions on how the virus is transmitted  - particularly in the community - remain unanswered.

What we know, what is strongly suspected, and a long list of what we still need to learn is well summarized in the following (lengthy) Lancet Infectious Diseases review, which I'm pleased to note contains a section devoted to Transmission of MERS-CoV by asymptomatic individuals.

Follow the link to read the full review.

Review

Middle East respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission

Prof David S Hui, FRCP, Prof Esam I Azhar, PhD, Yae-Jean Kim, MD, Prof Ziad A Memish, FRCP, Prof Myoung-don Oh, MD, Prof Sir Alimuddin Zumla, FRCP
Published: 18 April 2018
DOI: https://doi.org/10.1016/S1473-3099(18)30127-0

Summary

Middle East respiratory syndrome coronavirus (MERS-CoV) is a lethal zoonosis that causes death in 35·7% of cases. As of Feb 28, 2018, 2182 cases of MERS-CoV infection (with 779 deaths) in 27 countries were reported to WHO worldwide, with most being reported in Saudi Arabia (1807 cases with 705 deaths). MERS-CoV features prominently in the WHO blueprint list of priority pathogens that threaten global health security. Although primary transmission of MERS-CoV to human beings is linked to exposure to dromedary camels (Camelus dromedarius), the exact mode by which MERS-CoV infection is acquired remains undefined. 

Up to 50% of MERS-CoV cases in Saudi Arabia have been classified as secondary, occurring from human-to-human transmission through contact with asymptomatic or symptomatic individuals infected with MERS-CoV. 

Hospital outbreaks of MERS-CoV are a hallmark of MERS-CoV infection. The clinical features associated with MERS-CoV infection are not MERS-specific and are similar to other respiratory tract infections. Thus, the diagnosis of MERS can easily be missed, unless the doctor or health-care worker has a high degree of clinical awareness and the patient undergoes specific testing for MERS-CoV. 

The largest outbreak of MERS-CoV outside the Arabian Peninsula occurred in South Korea in May, 2015, resulting in 186 cases with 38 deaths. This outbreak was caused by a traveller with undiagnosed MERS-CoV infection who became ill after returning to Seoul from a trip to the Middle East. The traveller visited several health facilities in South Korea, transmitting the virus to many other individuals long before a diagnosis was made.

With 10 million pilgrims visiting Saudi Arabia each year from 182 countries, watchful surveillance by public health systems, and a high degree of clinical awareness of the possibility of MERS-CoV infection is essential. 

In this Review, we provide a comprehensive update and synthesis of the latest available data on the epidemiology, determinants, and risk factors of primary, household, and nosocomial transmission of MERS-CoV, and suggest measures to reduce risk of transmission.

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To access the entire article, you may need to set up a (free) account.

While MERS-CoV hasn't taken off the way that SARS did in 2003, we've seen analyses (see Study: A Pandemic Risk Assessment Of MERS-CoV In Saudi Arabia) suggesting the virus doesn't have all that far to evolve before it could pose a genuine global threat.

Seven weeks ago, in the WHO List Of Blueprint Priority Diseases, we saw MERS-CoV listed among the 8 disease threat in need of urgent accelerated research and development. 

List of Blueprint priority diseases

(SNIP)

The second annual review occurred 6-7 February, 2018. Experts consider that given their potential to cause a public health emergency and the absence of efficacious drugs and/or vaccines, there is an urgent need for accelerated research and development for*:

• Crimean-Congo haemorrhagic fever (CCHF)
• Ebola virus disease and Marburg virus disease
• Lassa fever
• Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS)
• Nipah and henipaviral diseases
• Rift Valley fever (RVF)
• Zika
• Disease X

All of which makes the filling in of our substantial knowledge gaps on the MERS coronavirus a high priority.

PLoS Currents: A Psittacosis Outbreak Among Office Workers WIth Little Or No Bird Contact - UK

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As we've discussed previously, community acquired pneumonia (CAP) is the #1 cause of hospitalization of adults with an infectious disease in the United States, and yet, in more than half of the cases the type of infection (viral, fungal, bacterial) is never actually identified.

A 2015 study published in the NEJM (see The CDC’s EPIC CA-Pneumonia Study) followed 2500 cases over 5 years and found that in the majority (62%) of cases no definitive pathogenic agent was identified.

Among those that were identified – viral infections out-numbered bacterial infections by roughly 2:1.

Specifically, they found:

• one or more viruses in 530 (23%) cases
• bacteria in 247 (11%) cases
• bacterial and viral pathogens in 59 (3%) cases
• and a fungal or mycobacterial pathogen in 17 (1%) of cases

The most commonly detected pathogens were:

• Human rhinovirus (in 9% of patients)
• Influenza virus (in 6%)
• and Streptococcus pneumoniae (in 5%).

Even without a definitive diagnosis, patients can be treated empirically.   But CAP (etiology either known or unknown) inflicts a significant burden in terms of morbidity and mortality. 

When a cluster of atypical pneumonia cases is identified - in a neighborhood, or linked to a specific event, or location - an epidemiological investigation is usually mounted by public health officials.  

Over the years we've looked at many, including:

Korean CDC: S. rectivirgula Likely Cause Of Konkuk Pneumonia Outbreak

NYC Investigating Another Legionella Outbreak

WHO: Legionnaire’s Disease Outbreak – Portugal

Psittacosis Identified In Hong Kong Respiratory Outbreak

Rarely, however, do we get an insiders look at the investigation itself.

Today we have such a report, on the UK' PHE investigation of a cluster of (what was eventually determined to be) Psittacosis among office workers without obvious exposure to birds.

Psittacosis - often called parrot fever - is a relatively rare, atypical bacterial pneumonia caused by Chlamydia psittaci.  Large outbreaks are uncommon, but we've seen some small clusters of cases around the world over the past decade.

I've reproduced the abstract below, but you'll want to follow the link to read the full report on the challenges faced by these investigators. When you return, I'll have a bit more on Psittacosis, and how it once caused a panic in the United States.

A Psittacosis Outbreak among English Office Workers with Little or No Contact with Birds, August 2015

April 27, 2018 ·

John Mair-Jenkins, Tracey Lamming, Andy Dziadosz, Daniel Flecknoe, Thomas Stubington, Massimo Mentasti, Peter Muir, Philip Monk

Abstract

Introduction: On 14th August 2015 an office manager informed Public Health England of five employees known to have been diagnosed with pneumonia over the previous three weeks. We investigated to establish whether an outbreak occurred and to identify and control the source of infection.

Methods: We undertook case finding for self-reported pneumonia cases at local businesses (July-August 2015). Clinical samples from a hospitalised case were tested for common respiratory pathogens, but returned negative results. Further testing confirmed Chlamydia psittaci infection in this case (serology and PCR). We subsequently undertook C. psittaci testing for all cases, redefining them as confirmed (C. psittaci PCR or high antibody titre via serology) or probable (inconclusive C. psittaci serology). Twenty-eight day exposure histories informed descriptive epidemiological analysis. We conducted an environmental investigation at the office to identify potential sources of exposure.

Results: We identified six office workers with pneumonia; four met case definitions (three confirmed, one probable) with symptom onset between 29th July and 4th August 2015. Workplace was the only epidemiological link and only one case reported limited, indirect bird contact. Environmental investigations identified pigeons roosting near the office which were being fed by workers (none cases).

Discussion: This was a probable outbreak of psittacosis with no direct bird-to-human contact reported. Cases recovered after receiving appropriate antibiotics. Feeding of pigeons was stopped. A deep clean of office ventilation systems was conducted and workers were advised to avoid bird contact. We hypothesised that indirect environmental exposure to infected pigeons was to the source of this outbreak. This work provides evidence that health professionals should consider psittacosis in the differential diagnosis of cases of severe or atypical respiratory illness even without overt bird contact.

While the exact source of infection was not identified by these researchers, the the available evidence pointed more to a shared environmental exposure than to human-to-human transmission. 

Human infection, at least until relatively recently, has been solely attributed to direct or indirect contact with infected birds.

But in 2012, the journal Eurosurveillance carried a report called Psittacosis outbreak in Tayside, Scotland, December 2011 to February 2012, involving four family members and a health-care worker, which suggested human-to-human transmission.

The following year, in Sweden Reports Rare Outbreak Of Parrot Fever, we saw a credible report of human transmission of parrot fever, where a 75 year old man who died in Kronoberg appeared to have spread the infection to at least 8 close contacts, including healthcare personnel.

In 2014, the ECDC's Eurosurveillance Journal carried a follow up report called:

Eurosurveillance, Volume 19, Issue 42, 23 October 2014

Surveillance and outbreak reports

Multiple human-to-human transmission from a severe case of psittacosis, Sweden, January–February 2013

Proven transmission of Chlamydia psittaci between humans has been described on only one occasion previously. We describe an outbreak which occurred in Sweden in early 2013, where the epidemiological and serological investigation suggests that one patient, severely ill with psittacosis after exposure to wild bird droppings, transmitted the disease to ten others: Two family members, one hospital roommate and seven hospital caregivers. Three cases also provided respiratory samples that could be analysed by PCR. All the obtained C. psittaci sequences were indistinguishable and clustered within genotype A.

The finding has implications for the management of severely ill patients with atypical pneumonia, because these patients may be more contagious than was previously thought. In order to prevent nosocomial person-to-person transmission of C. psittaci, stricter hygiene measures may need to be applied.

While H-2-H transmission of C. psittaci now appears possible, contact with birds still appears to be the primary route of transmission (by far).

Six years ago, in How Parrot Fever Changed Public Health In America, we looked at the fascinating (and tragic) story of how a multi-state outbreak of parrot fever in 1929 - 10 years after the end to the Great Pandemic - sparked a brief national panic, and led to the deaths of several of the public health officials investigating the mysterious epidemic. 

Before it was quashed, the outbreak sparked 169 cases of parrot fever nationwide, along with 33 deaths (including Dr. Daniel S. Hatfield and Dr. William Stokes of the Baltimore Health Department, and Henry (Shorty) Anderson of the Hygienic Lab).

But out of this tragedy also came congressional funding for a new, far better equipped national public health laboratory.

One that today you know as the National Institute of Health.

Frontiers Pub. Health: The Zoonotic Threat From Four Types Of Respiratory Viruses

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Zoonotic diseases - those which originated in or are normally hosted by non-human species - but can infect humans - have been with us for many thousands of years. But their ability to spread, and opportunities to adapt to humans, likely only really took off as humans began to cluster together in communities.

• Tuberculosis probably jumped to humans when we began to domesticate goats and cattle 5000 years ago.
• Measles appears to have evolved from canine distemper and/or the Rinderpest virus of cattle.
• And Influenza, as most of you know, is native to aquatic birds.

The list of zoonotic diseases is long and continues to expand, and includes such notable nasties as SARS, MERS, Babesiosis, Borrelia (Lyme), Nipah, HIV, Plague, Rabies, Hendra, Malaria, Dengue, Zika, Hantavirus, Ebola, Bartonella, Leptospirosis, Q-Fever, several flavors of avian flu and many, many others.

Over the years we've looked at this growing trend, which was largely predicted back in the mid 1990s by noted anthropologist and researcher George Armelagos of Emory University (see The Third Epidemiological Transition (Revisited)). 

Around the same time (1995), the CDC began publishing the EID Journal, a highly respected peer-reviewed journal on emerging pathogenic threats.  Today emerging disease threats, and neglected tropical diseases, are a hot topic in scores of respected journals.

In 2014, in Emerging zoonotic viral diseases  L.-F. Wang (1, 2) * & G. Crameri wrote:

The last 30 years have seen a rise in emerging infectious diseases in humans and of these over 70% are zoonotic (2, 3). Zoonotic infections are not new. They have always featured among the wide range of human diseases and most, e.g. anthrax, tuberculosis, plague, yellow fever and influenza, have come from domestic animals, poultry and livestock.

However, with changes in the environment, human behaviour and habitat, increasingly these infections are emerging from wildlife species.

While the public health burden from non-respiratory diseases (i.e. Dengue, Zika, Lyme, Malaria, rabies, Ebola, etc.) is very high, respiratory viruses - due to their ability to spread quickly, and sometimes even globally - are among the most concerning.  

We've an excellent mini-review of zoonotic respiratory disease threats, published earlier this month in Frontiers In Public Health, that looks four specific types of emerging or re-emerging threats; influenza viruses, coronaviruses, enteroviruses (EVs), and adenoviruses (Ads).

Not a complete list, of course.  But these four groups are viewed as having particularly good growth prospects.

I've only included a few excerpts, so follow the link to read the full article.

A Mini Review of the Zoonotic Threat Potential of Influenza Viruses, Coronaviruses, Adenoviruses, and Enteroviruses 

Emily S. Bailey1,2*, Jane K. Fieldhouse1,2, Jessica Y. Choi1,2 and Gregory C. Gray1,2,3,4 

1Duke Global Health Institute, Duke University, Durham, NC, United States
2Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, United States
3Global Health Research Center, Duke-Kunshan University, Kunshan, China
4Emerging Infectious Diseases Program, Duke-NUS Medical School, Singapore

During the last two decades, scientists have grown increasingly aware that viruses are emerging from the human–animal interface. In particular, respiratory infections are problematic; in early 2003, World Health Organization issued a worldwide alert for a previously unrecognized illness that was subsequently found to be caused by a novel coronavirus [severe acute respiratory syndrome (SARS) virus]. 

In addition to SARS, other respiratory pathogens have also emerged recently, contributing to the high burden of respiratory tract infection-related morbidity and mortality. Among the recently emerged respiratory pathogens are influenza viruses, coronaviruses, enteroviruses, and adenoviruses.

As the genesis of these emerging viruses is not well understood and their detection normally occurs after they have crossed over and adapted to man, ideally, strategies for such novel virus detection should include intensive surveillance at the human–animal interface, particularly if one believes the paradigm that many novel emerging zoonotic viruses first circulate in animal populations and occasionally infect man before they fully adapt to man; early detection at the human–animal interface will provide earlier warning. Here, we review recent emerging virus treats for these four groups of viruses. 

Introduction

During the last two decades, scientists have grown increasingly aware that viruses are emerging from the human–animal interface. In order to combat this increasingly complex problem, the One Health approach or initiative has been proposed as a way of working across disciplines to incorporate human, animal, and environmental health. Of particular concern are emerging respiratory virus infections; in a recent seminar given by the National Institute of Health on emerging and re-emerging pathogens, nearly 18% were respiratory viruses (1).

Among the recently emerged respiratory pathogens contributing to the high burden of respiratory tract infection-related morbidity and mortality, displayed graphically in Figure 1, are influenza viruses, coronaviruses, enteroviruses (EVs), and adenoviruses (Ads). In this report, we summarize the emerging threat characteristics of these four groups of viruses.

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Emerg. Microbes & Inf.: Genetic & Evolutionary Analysis of Emerging Canine H3N2

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Because they live in such close contact with people, companion animals - mostly dogs and cats - are uniquely positioned to serve as a bridge to introduce zoonotic diseases to humans.

This is a topic we've covered previously. For a good summary and CDC webinar, you may wish to revisit  Family Pets, Zoonoses & An Upcoming COCA Call.

Of course, the reverse is also true, as they our pets are constantly exposed to human pathogens (see Companion Animals & Reverse Zoonosis), sometimes with tragic results (see Connecticut: Two Cases Of Fatal H1N1 In Cats).

Although there have always been some pathogens exchanged between dogs (and cats) and humans - up until 14 years ago - influenza wasn't thought to be one of them.

All that changed in 2004 when an equine H3N8 virus mutated enough to adapt to a canine host, and began to spread among greyhounds at a Florida race track (see EID Journal article Influenza A Virus (H3N8) in Dogs with Respiratory Disease, Florida).

A 96% match to the equine H3N8 virus, this canine H3N8 was believed to have jumped directly from horses to dogs without any reassortment.

Since then we've seen several more flu viruses turn up in dogs (and cats), including H5N1, H5N8, H1N1, H6N1, and H7N2.

But the most successful canine flu to date has been an avian H3N2 virus, which was first reported in South Korea in 2007(see Transmission of Avian Influenza Virus (H3N2) to Dogs).

Analysis showed that the HA and NA genes of the A/canine/Korea/01/2007 (H3N2) isolate were closely related to those identified in 2003 from chickens and doves in South Korea.

Since then we've seen numerous reports coming out of China and Korea suggesting the canine H3N2 may be adapting to other hosts, and continues to reassort with other avian and human flu viruses. Including:

A Canine H3N2 Virus With PA Gene From Avian H9N2 - Korea

Canine H3N2 Reassortant With pH1N1 Matrix Gene

Virology J: Human-like H3N2 Influenza Viruses In Dogs - Guangxi, China

Interspecies Transmission Of Canine H3N2 In The Laboratory

Canine H3N2 arrived in the United States in the spring of 2015 (see CDC Statement On H3N2 Canine Influenza In Chicago Region), and has since  spread across much of the United States in a remarkably short period of time.

While it has never been shown to infect humans, last summer the CDC added Canine H3N2 to their IRAT (Influenza Risk Assessment Tool) listing of novel flu subtypes/strains that circulate in non-human hosts and are believed to possess some degree of pandemic potential.

Over the past year or so we've looked at several studies suggesting that canine H3N2 continues to show signs of continual evolution and mammalian adaptation.

Emerg. Microbes & Infect.: Virulence, Transmissibility & Evolution of Canine H3N2 Influenza Viruses

J. Infect. Dis.: Molecular, Antigenic & Pathological Features of Canine H3N2 Influenza

J. Virology: Zoonotic Risk, Pathogenesis, and Transmission of Canine H3N2

To this growing list we can add another study, published this week in Emerging Microbes and Infections, which takes a deep look at genetic changes in the canine H3N2 virus over time, and by geographic origin.

A few excerpts from a much longer study.  Follow the link to read it in its entirety.

Genetic and evolutionary analysis of emerging H3N2 canine influenza virus

Cheng Zhang1,

Abstract

The H3N2 canine influenza virus (CIV) originated from an avian species. Since its emergence, it has circulated in multiple states and has caused pandemics among dog populations; however, no comprehensive studies have explored the causes driving these ongoing cases.

The study of the codon usage patterns of viruses can reveal the genetic changes required for the viruses to adapt to new hosts and the external environment. Here we performed a thorough genetic, evolutionary, and codon usage analysis.

We identified three evolutionary H3N2 CIV clades from a timescaled phylogenetic tree, namely, Origin, China, and Korea/USA, by principal component analysis (PCA). Additionally, we found a low codon usage bias and that mutation pressure, natural selection, and dinucleotide abundance shape the codon usage bias of H3N2 CIVs, with natural selection being more crucial than the others.

Moreover, the human codon adaptation index was similar to that of dogs (the natural host) and cats. In addition, the H3N2 CIV similarity index values were higher than those of the avian influenza virus (AIV), suggesting viral adaptation to the host.

Therefore, H3N2 CIVs may pose a potential risk to public health in the future, and further epidemiologic, evolutionary, and pathogenetic studies are required.

INTRODUCTION

Dogs should be carefully considered for their role as influenza hosts because of their close contact with humans and their influenza receptor distribution1, 2.

H3N8 and H3N2 are the current circulating subtypes of canine influenza virus (CIV) in dog populations. H3N8 CIV, which caused a pandemic in dogs, was first isolated in Florida in 20043, and there were no documented reports of CIV infections prior to 20044.

In 2008, Korea first reported H3N2 CIVs, followed by China and Thailand1, 5, 6. In April 2015, the H3N2 CIV circulating in Asia was isolated from an infected golden retriever in Cook County, Illinois. The virus has since spread to several states, causing respiratory disease in thousands of dogs across the United States4.

Of note, a 2012 study showed that a novel H3N1 virus infecting dogs arose by reassortment of a human-origin H1N1 influenza virus and an avian-origin H3N2 CIV. In addition, a 2015 study showed that a novel CIV reassortant, H3N2, containing the polymerase acidic (PA) genomic segment from the H9N2 pandemic avian influenza was isolated from a dog in South Korea.

These developments suggest that dogs may play critical roles as mixing vessels and reservoirs of avian-origin H3N2 CIVs7.

Therefore, canines carrying H3N2 CIV may transmit the virus to other species with whom they have frequent close contact, including humans8. In addition, companion animals may pose a potential public health risk. Although no H3N2 CIV human infections have been reported, the increasing number of new H3N2 CIV cases in the United States and East Asia, as well as the quick evolution of the virus, calls for detailed genetic analysis of emerging H3N2 CIVs to understand and estimate the risk of CIV adapting to humans.

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While it may seem a bit of a long shot that the next influenza pandemic will come from companion animals, it was 17 months ago we were monitoring an outbreak of avian H7N2 at several NYC animal shelters, infecting more than 450 cats . . . and one veterinarian.

EID Journal: Characterization Of A Feline Influenza A(H7N2) Virus

For now avian H7N2 and canine H3N2 don't appear ready for prime time, but they - like all influenza viruses - continue to evolve and adapt, and at some point one of them could accrue the right genetic changes to pose a genuine threat.  

For more on the potential companion animals to serve as intermediate hosts for emerging influenza viruses, for canines you may wish to revisit Study: Dogs As Potential `Mixing Vessels’ For Influenza, and for felines Catch As Cats Can. 

Saudi MOH Reports 1 MERS Case

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For the past 3 months daily reporting of MERS cases from the Saudi MOH has become increasingly erratic, with batches of days posted - often every 5 to 7 days - frequently omitting days entirely.

So far in April, the MOH has reported on just 18 of 26 days, skipping the 3rd, 5th, 11th, 19th, 21st, 23nd, 24rd and 25th. 

While it is likely many of these dates had no MERS activity, on many days where reports are posted, they likewise report no activity.  So the reasons behind these gaps are unknown.

This mornings batch update covers 7 days, but only provides 3 daily reports. Only one - the 22nd - shows activity; a new case in Al Qunfudhah, and a recovery in Najran.

Two days ago Crof carried a media report Saudi Arabia: A MERS case in critical condition of a new case, but obviously not the one reported, as it was of a 60 y.o. from Al Ahsa.

Today marks exactly 3 months since the last WHO DON (with a line listing of cases) was published on Saudi MERS cases, which is the longest gap I've seen in years.

We have seen monthly WHO EMRO summary Reports (see here and here), but their case counts have differed sharply from the Saudi MOH reports.

As concerning as this gap in reporting is  - the good news is -  we've still seen no signs of any sustained or efficient transmission of the MERS virus outside of health care facilities.

But with the holy month of Ramadan now less than 3 weeks away (May 16th) - which will bring with it a surge in international religious pilgrims second only to the Hajj - some better reporting from the MOH would be welcome. 

South Korea Lowers Bird Flu Alert Status To `Caution'

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As in Europe, Japan and South Korea saw the arrival of a reassorted HPAI H5N6 virus in place of the HPAI H5N8 virus which had dominated the previous three winters.  And like Europe, they saw a much less intense bird flu season than the the winter of 2016-17.

Part of this success - at least in South Korea - was likely due to the enhanced biosecurity put in place last fall in order to prevent outbreaks during their hosting of the XXIII Olympic Winter Games last February. 

But part of it seems due to HPAI H5N6 not being quite as robust of a threat as was H5N8.  That could change over time, of course. 

After a month without an outbreak in commercial poultry, we learn from this Yonhap report that MAFRA has lowered the alert level from `Serious' to `Caution'.

S. Korea lowers bird flu alert status

By Yonhap

Published : Apr 26, 2018 - 11:20

South Korea has downgraded its bird flu alert status and lifted a movement ban on local poultry farms as no additional cases have been reported in over a month, the agriculture ministry said Thursday.

The Ministry of Agriculture, Food and Rural Affairs said it lowered the avian influenza alert status from "serious" to "caution" and released a standstill order on farms in 20 regions.

South Korea strengthened bird flu quarantine measures to prevent further spread of the animal disease since the first outbreak at a duck farm in North Jeolla Province in November. Since then, a total of 22 cases broke out up until March 17 and 6.54 million poultry were culled, according to the ministry.

Given that there were roughly 300 outbreaks reported over the winter of 2016-17, this has been a much milder year. 

In year's past, South Korea assumed that avian flu was only a fall/winter threat, and stopped - or at least greatly curtailed - their monitoring programs for the summer.   

After persistent outbreaks in June of last year, South Korea announced their Move To Year-Round AI Prevention, and so while reduced, the threat of further outbreaks is not eliminated.

As we've seen in the past, often very big `bird flu years' are followed by one or more less severe seasons.  Sometimes this happens globally (see chart below), and sometimes it is a regional phenomenon.

All of which means, while this year's slowdown in avian flu activity around the world has been welcome, it isn't guaranteed to last.

Sweden & Finland Report HPAI H5N6 In Wild Birds

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The reassorted HPAI H5N6 virus, which arrived in Northern Europe for the first time in December of last year, continues to turn up sporadically in wild birds, with the bulk of reports coming from the UK, Netherlands, Finland and Sweden. 

While nowhere near as prevalent as was HPAI H5N8 during the epizootic of 2016-17, it has nonetheless make a bigger showing than did H5N8 during its inaugural visit to Europe in 2014-15. 

With migratory birds heading to northern latitudes for their summer roosting, the risks of seeing avian flu outbreaks in poultry or wild birds along their migratory routes is elevated.


Two reports.  First  a translated report from Finland's EVIRA.

Eat bird H5N6 avian influenza in Sauvon

04/25/2018

Southwest Finland has repeatedly found bird flu from birdwatch. H5N6-type avian influenza causing high pathogenic or high mortality to birds was now detected in the sea-bird found dead in Sauvos. To prevent infections, poultry and domestic birds must be kept inside or protected from contact with wild birds until the end of May.

The eel was found in the Savo region last Wednesday (18 April). The bird flu virus diagnosis in Kotka was confirmed by the Finnish Food Safety Authority's Evia study.

Due to the spring migration of birds, the risk of infection with avian influenza is particularly high. At the end of March, H5N6 avian influenza was found in the eel seen from Parainen, Southwest Finland. During the first part of the year, high pathogenic H5N6 bird flu virus has been found in wild birds and poultry farms, Sweden, Germany, Denmark, the Netherlands and the United Kingdom. All the birds have had to stop the infected farms.

Avian influenza viruses are poorly infected with humans, and infection usually requires close contact with diseased wild birds, poultry or their secretions. Europe's H5N6-type avian influenza found in Europe is never known to be infected with humans.

And from neighboring Sweden, we get this translated report from the Swedish Board of Agriculture (Jordbruksverket).

New cases of bird flu - still important with good poultry care routines
 
Press Release • Apr 26, 2018 10:04 CEST

Three new cases of H5N6 bird flu have been identified after analysis at the National Veterinary Office (SVA). It is about a sea eagle, a pigeon hut and a buzzard found in the areas surrounding Mörrum and Bromölla in southern Sweden. This virus has not been found to present a risk to humans, unlike the H5N6 virus that circulates in Asia.

"In order to avoid spreading to poultry, it is important that poultry producers and hobby farmer owners have good contingency routines," said Karin Åhl, chairman of the unit for horse, poultry and game at the Swedish Agriculture Agency.

- The H5N6 is still circulating in wild bird populations in the country and we do not know how extensive the spread is. It is likely that new cases of wild birds will be detected, and there is still a risk of infestation of the bird of birds. Therefore, we would like to remind you that it is always important to protect your domestic birds from direct and indirect contact with wild birds, "says Karl Ståhl, Deputy State Psychologist at SVA.

The virus is closely related to H5N8, which circulated among wild birds in Sweden in 2016 and 2017, and also caused outbreaks in poultry. While the H5N8 has been massive in large parts of Europe, the H5N6 has not been reported to the same extent, nor has it been associated with the same mortality.

Available naturally among wild birds

In February 2018, a H5N6 bird flu was detected at a sea eagle and a snake on the Blekinge coast. Thereafter, additional cases have been found in a hobby crew in Uppsala County and two sea ears in Blekinge.

Bird flu exists in many varieties and is highly contagious between birds. Milder variants of the virus are found naturally among wild birds, especially in marine birds. Protection level 1 applies in Sweden, which means that poultry may go out, but feed and water should be given under roof or under outdoor protection.

It is important to have good care routines and to prevent direct and indirect contact with wild birds as far as possible. Animal owners should pay attention and contact the vet if poultry show increased mortality, changes in feed and water consumption, egg production reduction or impaired general condition.

General hygiene rules

• Ensure that only those who care for the domestic birds have access to the zoos.
• Keep clean around houses and enclosures.
• Be sure to observe the routines at the hygiene limits.
• Wash hands after contact with birds.
• After a foreign visit, you should not be in contact with domestic birds until after 48 hours.

More information

The Swedish Agricultural Agency's information on bird flu

On preventive measures for those who keep poultry and birds in captivity

SVA's information on bird flu

Public Health Information on bird flu 

Although Europe has gotten off pretty easy this winter - like its predecessor H5N8,  H5N6 has shown considerable persistence in wild birds - and it now in the process of returning the northern breeding grounds for the summer, possibly to further evolve or reassort with other viruses. 

Last summer, the $64 question was whether H5N8 would return in the fall, or something else.  In the end, we got something new; a reassorted HPAI H5N6 virus.  

Once again this summer, we'll be waiting to see what returns in the fall.

Illinois Reports 4th Death Related to Synthetic Cannabinoids

#13,289

Despite weeks of media coverage and warnings from public health officials we continue to see new cases of severe bleeding - and sometimes death - from the recreational use of adulterated Spice/K2.  

While most of the cases have been in Illinois, yesterday we learned that cases have been reported from 8 other states.

In addition to updating their case count, yesterday Illinois's Department of Public Health (IDPH) announced the fourth death related to this cluster of poisonings.  First the latest tally, then the announcement:

Synthetic Cannabinoids

As of April 24, 2018, IDPH has received reports of 153 cases, including four deaths, linked to an outbreak, since March 7, 2018; cases report using synthetic cannabinoid products before suffering from severe bleeding.

***Numbers are provisional and subject to change; IDPH will update the website everyday at 1:30pm, for the duration of the outbreak***

Fourth Death Related to Synthetic Cannabinoids

24th Apr, 2018

 

SPRINGFIELD – The Illinois Department of Public Health (IDPH) is reporting the fourth death connected to synthetic cannabinoid use.  The most recent death was a woman in her 30s in central Illinois.  Two men, one in his 20s and another in his 40s, have also died in central Illinois.  A Chicago-area man in his 20s also passed away.  More than 150 people in Illinois in 13 counties have been sickened by synthetic cannabinoids laced with rat poison.

“We continue to see new cases of individuals experiencing severe bleeding after using synthetic cannabinoids,” said IDPH Director Nirav D. Shah, M.D., J.D.  “Like so many other drugs, synthetic cannabinoids are addictive and people are not able to give them up.  Alternatively, they think that it won’t happen to them because they know their dealer or trust wherever they purchased the drugs.  If you know someone who uses synthetic cannabinoids, tell them these are deadly products and try to help them get treatment.”

Individuals who have been sickened by the synthetic cannabinoids have reported coughing up blood, blood in the urine, severe bloody nose, bleeding gums, and/or internal bleeding.  A chemical found in rat poison, brodifacoum, prevents blood from clotting, resulting in severe bleeding.  High doses of vitamin K, up to 30 tablets a day for up to six months, can help restore the blood’s ability to clot.

Because of the large amount of vitamin K needed, the long duration of treatment, and costs up to thousands of dollars per patient, IDPH started discussions with key stakeholders to find a solution with no financial burden on patients.  IDPH recently received a massive donation of nearly 800,000 tablets of vitamin K from the Bausch Foundation and Valeant Pharmaceuticals.  This donation will allow every individual who has experienced severe bleeding to receive lifesaving treatment free of charge.

Synthetic cannabinoids are human-made, mind-altering chemicals that are sprayed on to dried plant material.  These chemicals are called cannabinoids because they act on the same brain cell receptors as the main active ingredient in marijuana.  The health effects from using synthetic cannabinoids can be unpredictable, harmful, and deadly.

People should not use synthetic cannabinoids, but if they have used these drugs and have severe, unexplained bleeding or bruising, call 911 or take them to the emergency department.

More information is available at http://dph.illinois.gov/topics-services/prevention-wellness/medical-cannabis/synthetic-cannabinoids.

As mentioned previously, we've seen a heavy toll from these synthetic cannabinoids in the past. A few blogs include.

• Synthetic Cannabinoids Associated With Severe Illness, Stroke & Psychosis
• NH Governor Declares State Of Emergency Over `Spice’ Overdoses.
• MMWR: Adverse Health Effects Related to Synthetic Cannabinoid Use

On Monday, in San Diego: 6 Cases Of Wound Botulism Among Injection Drug Users, we looked at another spike in bad outcomes from the use of a different adulterated drug; black tar heroin. 

While just last month, in CDC COCA Webinar: Public Health Responses to Opioid Overdoses Treated in Emergency Departments, we looked at data from emergency departments around the country showing that the U.S. opioid overdose epidemic continues to worsen.

In the 1970s, when I was a young paramedic, drug overdoses and related deaths were very common.  We saw them almost daily.

Sadly, it appears that very little has changed in the past 40 years.