#14,043
On Thursday we saw the first reported H5N1 human infection since September of 2017 anywhere in the world (see Nepal: (Unconfirmed) Media Reports Of 1st H5N1 Death) - which occurred in late March - but was only lab confirmed this week.
As the map above indicates, HPAI H5N1 began moving north from Northeastern India (see India: More H5N1 Bird Deaths At Bihar Zoo) - presumably carried by migratory birds - last December and was reported in Nepal in March.
To date, the OIE reports 11 poultry outbreaks in Nepal (see OIE Follow up Report #5).Last night CIDRAP linked to the WHO SEARO (South East Asia Regional Office) statement on the human H5N1 infection reported in Nepal, which I've produced in full below.
Interestingly, there is no mention of this patient having a history of poultry exposure (which does not exclude the possibility), nor is a location cited. Media accounts on Thursday, however, had mentioned Nepal's Kavrepalanchok district - which is roughly 20 miles S.E. of Kathmandu.
The healthcare delivery system for most of the people of Nepal is rudimentary at best - often provided by midwives and nurses in under-equipped rural health outposts - and it is not uncommon to have to travel some distance to see a doctor.
The CIA Factbook describes the nation's economy as:
Nepal is among the least developed countries in the world, with about one-quarter of its population living below the poverty line. Nepal is heavily dependent on remittances, which amount to as much as 30% of GDP. Agriculture is the mainstay of the economy, providing a livelihood for almost two-thirds of the population but accounting for less than a third of GDP. Industrial activity mainly involves the processing of agricultural products, including pulses, jute, sugarcane, tobacco, and grain.(snip)
Massive earthquakes struck Nepal in early 2015, which damaged or destroyed infrastructure and homes and set back economic development. Although political gridlock and lack of capacity have hindered post-earthquake recovery, government-led reconstruction efforts have progressively picked up speed, although many hard hit areas still have seen little assistance. Additional challenges to Nepal's growth include its landlocked geographic location, inconsistent electricity supply, and underdeveloped transportation infrastructure.
You can view Nepal's healthcare metrics at the WHO Global Health Observatory (GHO) data website. Given the level of surveillance and testing available in the region, it is a wonder this case was actually detected (see 2013's Nepal: Human H5N1 Testing (Or Lack Thereof)).
The WHO statement follows, after which I'll have a short postscript.
Information on Avian Influenza A (H5N1) Identified in Human in Nepal
May 2 | Kathmandu
On March 24, 2019, a 21-year-old male was admitted in hospital with symptoms of fever and cough. Throat swab sample was sent to National Public Health Laboratory (NPHL) – the National Influenza Center (NIC) of Nepal - to confirm suspected Influenza infection on March 25, 2019, and antiviral medication (Oseltamivir) was started from the same day, provided from Epidemiology and Disease Control Division (EDCD). The patient died in hospital following respiratory complications while undergoing treatment on March 29, 2019.
NPHL confirmed influenza A infection. For identification of the specific subtype, the sample had to be sent to the NIC of Japan which is a WHO Collaborating Center for Influenza. Information on the confirmation regarding Influenza A (H5N1) infection in the patient by the laboratory in Japan was received by EDCD – the national focal point for IHR in Nepal - on April 30, 2019. This is the first reported human case of Influenza A (H5N1) in Nepal. No additional case of infection with this virus has been reported by NPHL since then.
Influenza A (H5N1) virus usually infects birds leading to death. Very rarely this virus spreads from birds to humans. According to World Health Organization (WHO), a total of 860 human cases have been reported since 2003 with more than 50% mortality rate following infection with this virus. Human to human spread of this viral infection has not been substantiated till date.
Follow-up actions by the Ministry of Health & Population (MoHP), Government of Nepal:
1. Information on this event, in line with International Health Regulations (IHR) 2005 needs to be shared by Nepal to other member states through WHO. Hence, the National Focal Point IHR for Nepal has formally reported this event to WHO.
2. MoHP, along with the WHE Teams of the WHO Country Office for Nepal and WHO South East Asia Regional Office, has initiated a detailed case investigation. In collaboration, the Ministry of Agriculture and Livestock Development, WHO, concerned stakeholders (INGO/ NGO), and MoHP will strengthen surveillance, comprehensive epidemiological investigation, and risk assessment for containment of Influenza.
3. Risk communication messages on preventive measures are being disseminated.
Preventive measures
The following preventive measures would reduce the risk of Influenza A (H5N1) Infection:
• Wash hands frequently and properly,
• Take due care of personal hygiene,
• Maintain cleanliness of surroundings,
• Use gloves and masks while handling domestic poultry and other birds,
• Avoid preparing or eating raw or undercooked poultry products,
• Handle raw poultry hygienically and cook all poultry and poultry products (including eggs) thoroughly before eating,
• Keep children away from the dead or sick birds,
• Avoid contact with domestic birds (poultry) that appear ill or have died,
• Avoid contact with high-risk environments such as live/wet poultry/animal markets and poultry farms, and any free-ranging or caged poultry,
• Avoid contact with surfaces that appear to be contaminated with feces from wild or domestic birds,
• Avoid close contact with people with respiratory symptoms (cough, sneezing & cold),
• Travelers returning from areas affected by avian flu outbreak in domestic/wild birds should report to local health services if respiratory symptoms (cough, sneezing & cold) suspecting Avian Influenza.
Do's & Don’ts for persons experiencing flu like symptoms (fever, cough, malaise, muscle pain, diarrhea):
• Wash hands regularly with proper drying of the hands,
• Cover mouth and nose when coughing or sneezing. If using tissues, dispose of them correctly,
• Self-isolate early if feeling unwell, feverish, and having other symptoms,
• Visit hospital or Contact to doctors immediately, if you experience any flu like symptoms,
• People with direct contact with sick poultry to be vigilant to notice the occurrence of the illness early and seek treatment early,
• Do not take medicines without doctor’s prescriptions,
• Always use masks, goggles, gloves, gown, and cap when near infected patients and always wash hands with soap and water or use hand sanitizer.
While this is the first reported H5N1 infection since Indonesia's fatal case in 2017, the surveillance and testing challenges described above are not unique to Nepal, and are quite common across much of Asia and Africa where the virus circulates.
Even in countries with the proven ability to test for the virus - like China, Egypt, and Indonesia - the assumption is many cases are missed.In 2016's EID Journal: H5N1 In Egypt, the authors suggested - while Egypt has only reported just under 360 cases - that there may have been tens (perhaps, hundreds) of thousands of human H5N1 infections in Egypt over the past decade.
They based their assumption on a limited serological study that found antibodies for H5 in roughly 2% of the people tested. Even more remarkably, this study found 5.6% to 7.5% seroprevalance of antibodies to H9N2, an even less commonly reported human infection.While hundreds of thousands of infections in Egypt may be a stretch, a global total of just 860 cases across 16 nations over 20 years is almost certainly an under count as well.
As we've seen in the past, `no news' isn't necessarily `Good news'.Sometimes it just means than nobody is looking in the right places.
