WHO: 2nd Ebola Death Reported In Goma & WHO Press Conference Audio

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After nearly 12 months and 2500 cases, two weeks ago the WHO declared the DRC Ebola Outbreak A PHEIC - a Public Health Emergency of International Concern.  While the deteriorating security situation in the region was a prime concern, so too was the recent discovery of the first case in the city of Goma.

Overnight it was reported that a second case - apparently unrelated to the first - has died in Goma, which is home to two million people.

While we await further details, this morning the WHO held a 1-year-anniversary press conference (see audio link below), which includes a lengthy Q&A with journalists.  Some of the audio is a bit muffled, but most of it can be understood.

While I cover Ebola in this blog, I don't follow it as closely as Crof at Crofsblog, who does a tremendous job of covering this outbreak on a daily basis. 

EID Journal: (Fatal) Household Transmission of Human Adenovirus Type 55 (Anhui, China)

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When it comes to severe, sometimes fatal, respiratory viral infections - influenza gets most of our attention - primarily because it is highly mutable, causes annual epidemics, and is estimated to kill more than 500,000 people each (non-pandemic) year (see The Lancet: Estimates Of Global Seasonal Flu Respiratory Mortality).
 
But a wide array of adenoviruses, rhinoviruses, coronaviruses and other non-influenza viruses cause far more human infections each year. Even during the height of the 2009 H1N1 pandemic, roughly 70% of the respiratory samples sent to the CDC for analysis were not positive for the influenza virus (see ILI’s Aren’t Always The Flu).

Graph based On CDC Flu Data early October 2009

While most of these viruses produce only mild to moderate illness, in some cases, particularly among susceptible populations, they can be deadly.

Until 2003, coronaviruses were thought to only cause mild, cold-like illnesses in humans, but that changed following the emergence of SARS in China. In 2012, a second, often fatal coronavirus emerged in the Middle East (MERS-CoV), and we are now watching other regions of the world for other threats (see Potential For Zoonotic Emergence Of Coronavirus In Latin America).

Adenoviruses - of which there are scores of known serotypes - are also a common cause of respiratory illnesses in both adults and children. Many outbreaks go unreported, however, because it is not a nationally notifiable disease; clinicians are not required to test for, or report it, to health departments or the CDC.

• Last year, we saw several high profile adenovirus outbreaks (see DOH: 2nd NJ Facility Reporting Adenovirus Outbreak & 10th Fatality At Wanaque Center and Heath Dept. Reports A Cluster Of Severe Adenovirus Cases In Upper Michigan).

• We've looked at severe adenovirus outbreaks in the past, including a multi-state outbreak of virulent serotype Ad14 a dozen years ago (see 2007 MMWR Acute Respiratory Disease Associated with Adenovirus Serotype 14 --- Four States, 2006—2007)

• In 2016, we looked at a report in the EID Journal: Human Adenovirus Associated with Severe Respiratory Infection, Oregon, USA, 2013–2014, that described a relatively large outbreak in the Pacific Northwest.

Long time readers will recall that back in 2012 there was a brief media flap over what was initially feared to be a return of SARS in China, but was quickly  identified as Ad55 (see China Denies Internet Rumor Of SARS Outbreak and China: Hebei Outbreak Identified As Adenovirus 55).

News from China is often seriously lacking in detail, and other than vague reports of `scores hospitalized', we learned very little about that outbreak.

Today, however, we have a research letter published in the EID Journal that details a household outbreak of Ad55 in Anhui province - roughly 1,000 km to the south of the Hebei outbreak - which occurred roughly 6 weeks later. 

While the Hebei outbreak wasn't mentioned in this report, the authors reported that the Anhui virus was very similar to one that sparked a serious outbreak in Shanxi Province 6 years earlier. 

First, some excerpts from the EID article, then I'll return with a bit more about the 2006 Shanxi, China outbreak.

Research Letter

Household Transmission of Human Adenovirus Type 55 in Case of Fatal Acute Respiratory Disease
 
Shuping Jing1, Jing Zhang1, Mengchan Cao, Minhong Liu, Yuqian Yan, Shan Zhao, Na Cao, Junxian Ou, Kui Ma, Xiangran Cai, Jianguo Wu, Ya-Fang Mei, and Qiwei Zhang

Abstract

We identified a case of fatal acute respiratory disease from household transmission of human adenovirus type 55 (HAdV-55) in Anhui Province, China. Computed tomography showed severe pneumonia. Comparative genomic analysis of HAdV-55 indicated the virus possibly originated in Shanxi Province, China. More attention should be paid to highly contagious HAdV-55.

Human adenoviruses are associated with mild and acute respiratory infections, depending on the virus type and host immunity. Human adenovirus type 55 (HAdV-55) (1), formerly known as HAdV-11a (2), is a reemergent respiratory pathogen that has caused severe pneumonia outbreaks in military and civilian populations in Europe and Asia (2–7). However, household transmission of HAdV-55 is rarely reported. We report a case of household transmission of HAdV-55 involving 3 confirmed adult cases with 1 death. Epidemiologic, clinical, and laboratory investigations, along with whole genome sequencing, elucidate the disease progression and the pathogen origin.

During April 1–May 5, 2012, 7 household members (5 males and 2 females; 3 children and 4 adults) in Anhui Province, China sequentially experienced influenza-like symptoms, including fever, productive cough, fatigue, pharyngalgia, dyspnea, and other symptoms. The youngest patient was 4 months of age, the oldest, whom we refer to as AQ-1, was a 55-year-old man. The family lived together near a farm in a house with poor sanitary and ventilation conditions.

        (SNIP)

We isolated AQ-1’s adenovirus in culture and sequenced the genome (GenBank accession no. KP279748). Sequences for the hexon, penton base, and fiber genes were identical to those previously reported for HAdV-55. Phylogenetic analysis showed that the 3 isolates clustered closely with other strains from China (Appendix Figure 2). The genome of AQ-1’s strain had the highest nucleotide identity (99.951%) with QZ01_2011, an isolate from a military trainee in Shanxi Province, China. The second highest identity (99.948%) was with QS-DLL_2006, which caused a fatal ARD outbreak in a senior high school in Shaanxi Province, China (1, 8) (Appendix Table). We hypothesize the strain infecting AQ-1 and his family originated from Shanxi Province.

In this household transmission of ARD, the index case was a probable case because no specimens were collected to confirm virologic identification. From the timeline of illness onset in this household cluster of ARD cases (Figure), we suspect that the pathogen spread rapidly among the children and further circulated in adults who had close contact with infected children and one another.

HAdV-55 contains a 97.4% genome of HAdV-14 and a hexon from HAdV-11 (1). Since 2006, HAdV-14 has caused severe ARD in America, Europe, and Asia (8,9), with high hospitalization (38%) and case-fatality (5%) rates (10). Because the risk for infection among the close contacts may rise, more attention should be paid to these highly contagious pathogens.

Ms. Jing was a graduate student at Southern Medical University and works at Zhuhai Center for Disease Control and Prevention, Guangdong Province, China. Her research interest is the epidemiology of human adenoviruses. Jing Zhang is a PhD candidate at Southern Medical University, Guangzhou, China, whose primary research interests are genomics and evolution of human adenoviruses.

A fuller description of the 2006 Shanxi Ad 55 outbreak was published a decade ago:

Outbreak of acute respiratory disease in China caused by B2 species of adenovirus type 11.

Zhen Zhu, Yong Zhang, +13 authors Wenguo Xu
Published in Journal of clinical microbiology 2009
DOI:10.1128/JCM.01769-08

An outbreak of acute respiratory tract infection occurred in Shanxi Province, China, from March to April 2006. Of the 254 patients affected by this outbreak, 247 patients were students of a senior high school; 1 of these patients died during the outbreak. Serological tests and blood culture revealed no evidence of bacterial infection.

The results of direct reverse transcription-PCR or PCR performed with clinical specimens collected from the patients, including the sole patient who died, were positive for human adenoviruses (HAdVs) but negative for influenza virus, measles virus, rubella virus, mumps virus, parainfluenza virus, respiratory syncytial virus, and human enteroviruses. These findings were confirmed by enzyme-linked immunosorbent assay for HAdV immunoglobulin A, the conventional neutralization test, and viral isolation and identification. 

Sequencing of the entire hexon gene revealed that HdAV type 11a (HAdV-11a) belonging to the B2 species of HAdV was the etiological agent responsible for the outbreak. However, both the analysis of the phylogenetic relationship and the similarity plot indicated that the sequence of the 3' end of the hexon gene outside the hypervariable regions the HAdV-11a strain isolated in this outbreak may be a recombinant with the sequence of the HAdV-14 strain of species B2.

Although isolates of HAdV species B2 seldom cause respiratory infections, they may pose a new global challenge with regard to acute respiratory diseases; this possibility cannot be overlooked and should be carefully considered. Hence, the need to establish and improve both epidemiological and virological surveillance of HAdV infections in China should be emphasized. LESS

In addition to causing respiratory illnesses - ranging from `common cold' symptoms to pneumonia and bronchitis - adenoviruses can cause other ailments such as gastroenteritis, conjunctivitis, cystitis, and rash-associated illnesses.

Infected hosts can shed the virus for prolonged periods of time, even though they may no longer be symptomatic (cite).

Between its broad tissue tropism, and its ability to continually reinvent itself through recombination (see Sci Repts Molecular evolution of human adenoviruses), these versatile DNA viruses are well worth our continued attention.  

J, Epi & Global Health: Al-Tawfiq & Memish On Hajj Health Concerns

Credit Wikipedia

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Jaffar A. Al-Tawfiq and Ziad A. Memish - either writing together or separately - are probably the two best known and most prolific authors on the public health aspects of the Hajj, and since 2012, on the emerging MERS coronavirus.

A partial list of my past blogs highlighting their work include:

AJIC: Intermittent Positive Testing For MERS-CoV

Evaluation of a Visual Triage for the Screening of MERS-CoV Patients

Frontiers Med.: MERS-CoV In 7 Pediatric Patients

ATS: Mass Gatherings And Lessons From The Hajj

The start of this year's the Hajj (Aug 8th-14th) - the largest annual mass gathering of humans on the planet - is now only 10 days away, and so a lot of attention is currently focused on its potential public health impact.

A week ago, in UK PHE Risk Assessment & Travel Advice For MERS-CoV In Saudi Arabia, we looked at the UK's risk assessment, and in May the CDC updated their travelers Advice on the Hajj in Saudi Arabia.

While local threats like MERS-Cov are always a concern - with roughly 2 million pilgrims arriving from all corners of the globe - the most likely threats may lie in less exotic infectious diseases unknowingly brought in by visitors.

The most probable disease outbreak scenarios involve mosquito borne illnesses (like Dengue, Chikungunya, Zika & Yellow Fever), tuberculosis, mumps, measles, chickenpox, norovirus and respiratory viruses like seasonal influenza & Rhinovirus.

In 2015's EID Journal: ARI’s In Travelers Returning From The Middle East, researchers found respiratory infections are the most commonly reported illness among religious pilgrims. This study also found that:

`Pneumonia is the leading cause of hospitalization at Hajj, accounting for approximately 20% of diagnoses on admission.’

Respiratory viruses generally all look alike in their early stages, creating enough `viral noise' to make it difficult to identify and isolate those infected with more serious infections, like MERS (see BMC Inf. Dis.: Clinical Management Of Suspected MERS-CoV Cases).

Today we've an overview of the upcoming Hajj -  along with the recommended and mandatory vaccinations for its visitors - and a look at some of the evolving public health challenges this annual mass gathering presents.

I've only included some excerpts, so follow the link to read it in its entirety.  I'll have a brief postscript when you return.

The Hajj 2019 Vaccine Requirements and Possible New Challenges

Authors

Jaffar A. Al-Tawfiq1, 2, 3, *, Ziad A. Memish4, 5, 6
Accepted 5 July 2019, Available Online 25 July 2019.
DOI https://doi.org/10.2991/jegh.k.190705.001How to use a DOI? 

Abstract

Each year millions of pilgrims perform the annual Hajj from more than 180 countries around the world. This is one of the largest mass gathering events and may result in the occurrence and spread of infectious diseases. As such, there are mandatory vaccinations for the pilgrims such as meningococcal vaccines. 

The 2019 annual Hajj will take place during August 8–13, 2019. Thus, we review the recommended and mandated vaccinations for the 2019 Hajj and Umrah. The mandatory vaccines required to secure the visa include the quadrivalent meningococcal vaccine for all pilgrims, while yellow fever, and poliomyelitis vaccines are required for pilgrims coming from countries endemic or with disease activity. The recommended vaccines are influenza, pneumococcal, in addition to full compliance with basic vaccines for all pilgrims against diphtheria, tetanus, pertussis, polio, measles, and mumps. 

It is imperative to continue surveillance for the spread of antimicrobial resistance and occurrence of all infectious diseases causing outbreaks across the globe in the last year, like Zika virus, MDR-Typhoid, Nipah, Ebola, cholera, chikungunya and Middle East Respiratory Syndrome Coronavirus. 

Copyright© 2019 Atlantis Press International B.V.Open Access

This is an open access article distributed under the CC BY-NC 4.0 license (http://creativecommons.org/licenses/by-nc/4.0/).

1. INTRODUCTION

Each year millions of people from more than 180 countries gather to perform the annual Hajj pilgrimage in Makkah, Saudi Arabia. The Hajj season occurs at a fixed time each year from 8th to 13th day of the 12th month (Dhu al-Hijjah) in the Islamic calendar [1]. The Islamic/Lunar calendar is 11 days shorter than the Gregorian calendar [1]. 

This year the annual Hajj is expected to take place during August 8–13, 2019. The annual Hajj is one of the largest recurring mass gathering in the world and is the most studied mass gathering [1–8]. The number of pilgrims traveling to Saudi Arabia is based on the number of Muslims in each country and is calculated as one pilgrim per 1000 Muslims in the specific country [7]. The annual pilgrimage number had increased from 58,584 in 1920 to 3,161,573 in 2012 and of those pilgrims in 2012 about 1,752,932 were international pilgrims coming from outside Saudi Arabia [5]. 

The international pilgrims arrive to Saudi Arabia mainly by air and others may travel via land [4,8,9]. In previous years, there were occurrences of Hajj-related outbreaks [10–14] such as the 1987 international meningococcal disease outbreak caused by Neisseria meningitidis serogroup A [15–17], and serogroup W135 [18], and the 2000–2001 N. meningitidis outbreak [14,15]. Thus, the annual Hajj requirements are updated annually in response to the occurrence of newly emerging infectious diseases such as Middle East Respiratory Syndrome Coronavirus (MERS-CoV) [1,6,19] and the occurrence of international outbreaks such as Ebola [7,8]. The recommended vaccinations for the Hajj are updated annually [6–9,20]. 

The 2019 required and recommended vaccinations were issued by the Saudi Ministry of Health [20]. Here, we summarize the 2019 Hajj mandatory and recommended vaccinations and discuss the possible impact of newly occurring outbreaks internationally, one of the most globally spread outbreaks is measles [21–23]. 

(Continue . . . )

Six years ago, in MERS, Mass Gatherings & Public Health, we looked at some of the immense challenges that Saudi Arabia faces each year with the Hajj, that go far beyond infectious diseases. Many pilgrims arrive from countries with limited healthcare, are often elderly, and frequently have chronic diseases like diabetes, heart disease, and COPD.

A demographic commonly associated with MERS infection.

While reported MERS activity in Saudi Arabia has thankfully dropped since this year's spring surge, sporadic cases are still begin reported, and some (unknown) number of cases are undoubtedly missed by surveillance.

The good news is, MERS has shown no signs that it is ready or able to embark on a world tour, although three months ago in BMC I.D.: Epidemiological Status Of MERS-CoV - Jan 2017 to Jan 2018 the authors cautioned:

`In today’s “global village”, there is probability of MERS-CoV epidemic at any time and in any place without prior notice.'

So we'll be watching the events during - and the weeks following - the Hajj very closely.

Japan MAFF: CSF Expands To 4th Prefecture (Fukui)

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After 10 months of farm outbreaks being limited to just two Prefectures (Gifu & Aichi), last week we saw Classical Swine Fever (CSF) reported in a third (see Japan MAFF: Classical Swine Fever Expands To Mie Prefecture).

Today, a 4th Prefecture (Fukui) reports a farm outbreak, the 7th CSF farm outbreak reported in the past month from Japan.

The pace of outbreaks has picked up markedly since March, with 24 farms impacted over the past 150 days.

CSF, while similar in appearance and impact to African Swine Fever (ASF), is caused by a different virus. Both are highly contagious among pigs, and can be economically devastating for pork producers, but neither disease poses a direct human health threat.

This (translated) announcement from Japan's Ministry of Agriculture.

About confirmation (domestic 34 cases) of sickness of pig cholera in Fukui

July 29

Ministry of Agriculture, Forestry and Fisheries

Today, a case of pig cholera was confirmed at a farm in Echizen city, Fukui Prefecture, which was within 10 km of the wild boar positive confirmation point and was subject to surveillance.

We will make every effort on preventive measures against this disease.
We would like cooperation to refrain strictly from coverage on the spot as there is a risk of causing the spread of this disease.

1. Outline of outbreak farm

Location: Echizen City, Fukui Prefecture
The feeding situation: 309

2. History

(1) Fukui Prefecture received a report from the farm on Sunday, July 28 that the breeding pig had an abnormality, and conducted an on-site inspection by a livestock quarantine officer.
(2) Since examination of livestock sanitation centers raised suspicion of hog cholera, materials were sent to the National Institute of Advanced Animal Health and Research (Note) and genetic analysis was carried out today (July 29 (Monday) )), Proved to be the diseased animal of hog cholera.

(Note) Japan's only specialized research institute on animal health

3. Future response

Based on "specific livestock epidemic disease prevention policy about pig cholera", we will make sure about the following epidemic measures.

(1) We will promptly and properly implement necessary epidemic prevention measures such as killing and burning of pig breeding on the farm, and setting of movement restricted area.
(2) About farms in movement restricted area, we carry out outbreak situation check examination immediately.
(3) In order to prevent the spread of infection, we will strengthen disinfection around the outbreak farm and establish disinfection points on major roads.
(4) We dispatch a national epidemiological research team to investigate the infection route.
(5) We will make thorough early detection and early notification of this disease.
(6) We will strive to provide accurate information to producers, consumers, distributors, etc. as well as working closely with relevant government agencies.
(7) We will thoroughly provide guidance on compliance with the management standards for sanitation such as disinfection of farms and prevention of invasion of wildlife to farms.
(8) Investigate the route of infection and prevent spread, assume all possibilities for investigation.

4. Other

(1) Porcine cholera is a disease of swine and wild boar and does not infect humans. In addition, infected pig meat does not go on the market.
(2) We ask for your cooperation in the field of on-site coverage from the fact that it may cause the spread of the disease and that it may violate the privacy of farmers. In particular, coverage using a helicopter is an obstacle to epidemic prevention work, so please strictly refrain.
(3) Since we will continue to provide prompt and accurate information, we ask for your cooperation not to be confused by people such as producers or consumers due to groundless rumors.

Up until last September, Japan was one of just 35 countries (see map below) that had been certified by the OIE as being free of the disease, with their last outbreak reported in the early 1990s.  

Meanwhile, in Asia African Swine Fever continues to spread, with Vietnam reporting the heaviest losses (see FAO ASF update), but with many outside experts believing that China is drastically under-reporting their losses.

Updating 2 Outbreaks: Respiratory Illness In Virginia LTCF & iGas in Essex, UK

Credit CDC PHIL

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 A couple of weeks ago, in Fairfax Co. Va Health Advisory: Outbreak of Respiratory Illness at a Long-Term Care Facility, we began to follow reports of an as-yet-unidentified respiratory illness among residents of a long term care facility (LTCF) in Virginia.

Respiratory illness outbreaks in nursing facilities are not uncommon as the residents are usually either elderly, suffer from chronic illnesses, or are otherwise immunocompromised.

But we usually see them during the fall and winter months, not mid-summer.

On July 16, we learned there had been 3 fatalities and 23 hospitalizations among the residents of the facility, and 19 staff members had reported an ILI.  Samples had been sent to the CDC for analysis, but results were still pending.

On July 19th, it was announced that:

Additional laboratory testing from CDC has not identified a specific cause for the increase in respiratory illness. Test results showed several bacteria that are known to colonize the nose and throat and may not be the cause of infection. In addition, several specimens were positive for rhinovirus, the cause of the common cold.

On Friday, July 26th, the local Health Department declared the outbreak over, with the following brief summation:

Outbreak Investigation at Assisted Living Facility in Springfield

July 19, 2019

Update: July 26, 2019

The outbreak of respiratory illness in Greenspring has concluded, as there have been no additional cases reported since July 15. A total of 63 residents became ill within the assisted living and skilled nursing areas (Garden Ridge) during the outbreak. Several residents in the independent living sections of Greenspring became ill but the number who were sick was similar to what is expected at this time of year and there was no evidence of an outbreak affecting independent living. Despite extensive testing of multiple specimens, no specific pathogen was identified as the cause of the outbreak. The facility will initiate a gradual return to normal operations.

        (Continue . . . )
 
While the lack of a specific cause of this outbreak is disappointing, it isn't all that unusual.  In my first report on this outbreak I cautioned:

Even with the full firepower of the CDC's labs, it is possible that a definitive diagnosis may not achieved. 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.

It is worth noting that 10 days ago the Virginia Department of Health issued a general Respiratory Illness alert, citing widespread, unseasonable ILI activity. They wrote:

The reports involve different regions of the state and different diseases, including pertussis (whooping cough), influenza, Haemophilus influenzae infection, Legionnaire’s disease, and pneumonia caused by rhinovirus or human metapneumovirus.

It is possible that the reason the CDC was unable to nail down a specific cause of the Virginia LTCF outbreak is because it was due to the introduction of more than one infectious pathogen currently circulating in the community.

Essex County - Credit Wikipedia

Moving on now to the Essex County, UK outbreak of Invasive Group A Streptococcus (iGas) - which we began following more than a month ago (see UK: Essex NHS Reports Outbreak Of Invasive Group A Streptococcus - 12 deaths).

Most of the cases were receiving home healthcare visits for wound care.

While a definitive source of this outbreak is still under investigation, the NHS has taken steps to prevent potential transmission via asymptomatic carriers, and has placed community nurses in the region on prophylactic antibiotics and is working to improve hand hygiene and the use of PPEs by local nurses. 

This outbreak appears to be winding down, as there have been no new updates posted in a week.

Group A Streptococcus (iGAS) outbreak in mid Essex

Latest update - 23 July 2019

NHS Mid Essex Clinical Commissioning Group (CCG) has been informed of one new case of iGAS in mid Essex. In addition, NHS Mid Essex CCG and NHS West Essex CCG have been informed of two cases of iGAS infection within the NHS West Essex CCG boundary. Sadly, one West Essex patient has died.

Following investigation, both of the West Essex patients with iGAS infection have been linked to the mid Essex outbreak. Test results from the mid Essex patient are pending.

The patients affected are older members of the community receiving treatment for wounds in care homes or in their own homes.

As a result of the mid and West Essex cases, the total number of people affected by the iGAS outbreak is now 35 and 13 people have sadly died*.

NHS Mid Essex CCG has set up an incident management team which is working closely with NHS West Essex CCG and partners to manage the outbreak. Public Health England will advise what control measures need to be implemented in West Essex where patients are affected by iGAS.

*Of the 35 patients affected by the iGAS outbreak in mid and West Essex, 31 are confirmed cases and four are probable.

Background (Updated on 23 July):

Those affected within this iGAS outbreak are older people in Braintree District and the neighbouring area in West Essex, Chelmsford City and Maldon District. The majority of patients were receiving treatment for wounds, with some in care homes but most in their own homes.

Earlier in July 2019, Public Health England undertook Whole Genome Sequencing to investigate differences and similarities in the DNA sequence of the iGAS bacteria collected from patients within the mid Essex outbreak. This method allows Public Health England to check which iGAS cases are genetically linked and which are not. This is done by analysing the DNA sequence of each bacterial sample.

The Whole Genome Sequencing confirmed that the single case of iGAS in Basildon in 2018 and single case of iGAS in Southend in February 2019, previously thought to be part of the mid Essex outbreak, are not. These two cases appear to be isolated cases of iGAS that can arise in the community and have now been removed from the outbreak investigation.

Any further information from the Whole Genome Sequencing work will be shared in future updates.

(Continue . . . .)

While we always hope for a definitive, unambiguous resolution to outbreaks such as these, often we are left with something less, although it is not for the lack of trying on the part of public health officials. 

Future updates on both of these events are still possible, however.  

For now they both serve as cautionary tales on the importance of maintaining good `flu & hand hygiene' all-year round, particularly when dealing with the most vulnerable members of our society; the elderly, the immunocompromised, or those with chronic illnesses.

Deja Flu: Pigs With Swine Influenza At Fowlerville Family Fair (Michigan)

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On a Sunday morning almost exactly a year ago (July 29th, 2018) I posted  Michigan: Pigs At Fowlerville Family Fair Test Positive For Swine Flu, an outbreak which would result in at least two human infections (see Michigan DOH: 2 People Test Positive For Influenza After Contact With Infected Swine).

Although the public health threats from swine influenza viruses are believed limited, they are not zero. The concern is that these viruses are constantly evolving, and over time they may gain additional transmissibility and/or virulence.

The CDC's general risk assessment of these swine variant (H1N1v, H1N2v, H3N2v) 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

Late yesterday the Livingston County Health Department announced that pigs once again at the Fowlerville Family Fair have tested positive for swine influenza - and while no human illnesses have been reported - issued the following statement.

FOR IMMEDIATE RELEASE

Swine Flu Confirmed in Pigs at Fowlerville Family Fair

HOWELL, Michigan. – (July 27, 2019) The Michigan Department of Agriculture and Rural Development (MDARD) identified pigs at the Fowlerville Family Fair that tested positive for swine flu.

The Fowlerville Fair Board isolated infected pigs to prevent additional exposure. Infected pigs began showing symptoms in the afternoon of Thursday, July 25 and laboratory results were confirmed late Friday afternoon. 

The fair is scheduled from July 22-July 27. At this time, all pigs have been removed from the fairgrounds and there are no reported human illnesses.

The Livingston County Health Department (LCHD), in coordination with the Fowlerville Fair Board and Michigan State University Extension, are reaching out to exhibitors and their families who participated at the Fowlerville Family Fair that may have been in close contact with the infected pigs. 

The LCHD is also instructing healthcare providers in the area to watch for patients presenting with respiratory symptoms who report exposure to swine or who visited the swine barn. In addition any individuals who attended the fair and were exposed to the pigs who begin to have influenza like symptoms should contact LCHD. 

Swine flu can spread quickly between pigs and while rare, can pass to humans through droplets in the air when sick pigs cough or sneeze. Human symptoms of swine flu are similar to those of seasonal flu and can include fever, cough, runny nose, and sometimes body aches, nausea, vomiting, or diarrhea.

Symptoms usually appear within three days of exposure but can occur up to 10 days. Sometimes swine flu causes severe disease even in healthy people, such as pneumonia, which may require hospitalization.

People who are at high risk of developing complications if they get swine flu include children younger than five years of age, people 65 years of age and older, pregnant women, and people with certain chronic health disease, such as asthma, diabetes, heart disease, weakened immune systems, and neurological conditions.

Currently, there is no vaccine for swine flu and the seasonal flu vaccine will not protect against swine flu; however, antiviral drugs, such as Tamiflu and Relenza, are effective in treating swine flu. These antivirals are only available through prescription by a healthcare professional.

Early treatment works best and may be especially important for people with a high-risk condition. Individuals exposed to the pigs at the fair who begin to show symptoms should see their healthcare provider and inform them of possible exposure.

Below are some steps you can take to protect yourself and prevent the spread of any illness:

• Avoid close contact with sick people.
• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it and wash your hands.
• Wash your hands often with soap and water. If soap and water are not available, use an alcohol-based hand rub.
•  Refrain from eating or drinking in livestock barns or show rings.
• Do not take toys, pacifiers, cups, baby bottles, strollers, or similar items into pig areas.
• Anyone who is at high risk of serious flu complications and is planning to attend a fair should avoid pigs and swine barns.
• void touching your eyes, nose, and mouth. Germs spread this way.
• If you are sick, stay home from work or school until your illness is over.
• Avoid contact with pigs if you have flu-like symptoms. 
• Wait seven days after your illness started or until you have been without fever for 24 hours without the use of fever-reducing medications,whichever is longer.
• Get an annual influenza vaccination.

For questions, please contact the LCHD Nurse on Call line at 517-552-6882 and leave your name and phone number and someone will return your call as soon as possible

So far, this summer has been pretty quiet on the swine flu front, with only one other case reported in 2019 (see CDC FluView Week 21: 1 Novel (H1N1v) Flu Infection - Michigan)- reported last May in an adult > 65 years of age (also) from Michigan, who, a bit unusually, reported no recent contact with live pigs.

Earlier this year the CDC released updated Guidance for Human Infections with Swine Flu Viruses so that clinicians would know how to treat, and report, suspected cases.  This update also included an Expert Medscape Commentary.

In the fall of 2017, we looked at an EID Journal Dispatch (Transmission Of Swine H3N2 To Humans At Agricultural Exhibits - Michigan & Ohio 2016), that found while widespread illness in pigs was only rarely reported, surveillance revealed an average prevalence of influenza A in fair pigs of  77.5%.  

This study cautioned that this suggests `. .  . that subclinical influenza A infections in pigs remain a threat to public health (3).'

In other words, healthy looking pigs can carry, and transmit swine-variant viruses.  We saw similar findings in a 2012 study (see EID Journal: Flu In Healthy-Looking Pigs).

For more on Swine-variant influenza viruses - both in the United States and around the world - you may wish to revisit the past blogs:

Trop. Med & Inf. Dis.: Mammalian Pathogenicity and Transmissibility of H1 Swine Variant Influenza

BMC Vet.: Novel Reassortant H1N2 & H3N2 Swine Influenza A Viruses - Chile

J. Virology: Pathogenesis & Transmission of H3N2v Viruses Isolated in the United States, 2011-2016

JVI: Divergent Human Origin influenza Viruses Detected In Australian Swine Populations

The `Other' Novel Flu Threat We'll Be Watching This Summer

Emerg. Infect. & Microbes: Novel Triple-Reassortant influenza Viruses In Pigs, Guangxi, China

DEFRA: Avian Flu Activity In Europe (Update #6)

#14,216


After a slow build up which started in 2003, between 2015 and 2017 we saw a crescendo of avian flu activity around the globe.  A few highlights include:

• In the spring of 2015 Egypt reported the largest human outbreak of H5N1 on record (EID Dispatch: Increased Number Of Human H5N1 Infection – Egypt, 2014-15)
• That same spring, North America saw their largest avian epizootic in history, due to the arrival,  reassortment, and spread of HPAI H5 (see A Midsummer’s HPAI H5 Snapshot).
• Over the winter of 2016-2017, Europe saw its largest avian epizootic ever, when yet another reassorted virus arrived from either Russia or China (see EID Journal: Comparison of 2016–17 and Previous Epizootics of HPAI H5 In Europe).
• And in the spring of 2017, following the emergence of new H7N9 strains, we saw largest human epidemic of avian flu on record in China (see WHO Avian Flu Risk Assessment - June 2017).

But for the past 24 months, avian flu activity has fallen dramatically around the world.  There have been a few hot spots, like India and Bulgaria. But for the most part, all has been quiet on the Eastern and Western front.

China's major decline in avian flu activity since 2017 is undoubtedly primarily due to their massive H5+H7 poultry vaccination campaign, which was initiated during the summer of 2017 and continues to this day.

As for the North American and European lulls, major bird flu seasons are often followed by one or more less active years (see chart below), likely due (in part)  to acquired immunity in wild birds, and enhanced biosecurity measures taken by poultry interests.

As China has long been a prolific source of new avian flu viruses (see EID Journal: Predicting Hotspots for Influenza Virus Reassortment), their recent vaccine-induced lull has likely helped curb outbreaks around the globe.

How long that happy state of affairs will last is anyone's guess, but as the following cautionary DEFRA Situation Assessment (#6) - dated the 19th, but published on Friday - points out: we shouldn't get too comfortable with it.

First some excerpts from a longer report, then I'll return with a postscript. 

Updated Situation Assessment #6
Highly pathogenic avian influenza in Europe

19 July 2019
Ref: VITT/1200 HPAI in Europe

Disease report

Although there have been no new outbreaks reported in Europe in the past month, or indeed since April, here we update the situation in Russia, Bulgaria and Europe since January 2019 with a summary of the outbreaks in the Middle East and central Asia.

There were relatively few highly pathogenic avian influenza (HPAI) virus outbreaks in Europe this last winter (2018/19) when compared to H5N6 in the winter of 2017/18 and the exceptional H5N8 epizootic in 2016/17. Indeed, between October 2018 and January 2019 there were only 18 HPAI outbreaks in poultry in Europe (15 in Bulgaria and three in west Russia) and just two wild bird events, both involving birds of prey in Denmark.

Our last outbreak assessment (dated 21 January 2019) provided an update on the ongoing H5/H5N8 outbreaks in Denmark, Russia and Bulgaria. 

(SNIP)

Situation assessment

In the period year to date there has been a very low level of activity in Europe and primarily associated with within sector spread and not through new primary introductions from wild birds. However the dynamics of threat from new incursions to Europe primarily mediated through wild birds is a constant, but carries uncertainties hence variability from one season to another. 

HPAI events can occur throughout the year in Europe including in the summer months, but detection is only possible where there is clinical disease or high mortality. HPAI viruses remain endemic in many parts of south-east Asia and some strains could be present in the wild bird breeding areas in northern Russia, where some intermingling could occur with water bird species that will winter in western Europe this autumn. 

In particular, there is overlap of the East Atlantic, Central Asian and East Asian bird migration flyways in the summer breeding sites in northern Russia. Thus, there is a pathway from the HPAI-endemic regions of south-east Asia to western Europe (Lee et al.2015).

The outbreaks in the Middle East and central Asia likely represent spread with commercial poultry and although the wild bird risk may well be very low still, these outbreaks may be relevant to Europe.

Conclusion
 
The OIE/FAO international reference laboratory/UK national laboratory at Weybridge has the necessary ongoing diagnostic capability for these strains of virus, whether low or high pathogenicity AI and continually monitors changes in the virus.

Currently the risk of HPAI in wild birds in the UK is LOW (i.e. no change). Although there have been no HPAI outbreaks in the UK this year and only a few in Europe (namely Bulgaria in April), this cannot be taken as reassuring regarding the risk for incursions this coming winter. This can be linked to the fact that there may be now more limited immunity in the wild bird population to H5 viruses, with a large susceptible population of hosts in the form of juvenile birds migrating to the UK every autumn.

Furthermore, as can occur every year, the current virus strains are continually evolving especially in central and eastern Asia where they circulate more freely and may be changing to escape the existing immunity at population level. Spread of such viruses amongst migratory waterfowl whilst on their breeding grounds in the far north of Russia in the summer is a mechanism that is well defined and could reoccur during 2019.

The north-east migration pathway to Europe and the UK is of key importance and it is possible that H5N6 could re-emerge this autumn in western Europe. The diversity of strains and virus genetic mixing events together with weather conditions and wild bird immunity make predictions on HPAI spread risk not possible at the present time.

However taking historical events into account years/seasons of relatively low activity can be followed by those of high activity.

Therefore, we recommend that all poultry keepers stay vigilant and make themselves aware of the latest information on gov.uk, particularly about recommendations for biosecurity and how to register their flocks using the simplified forms now available.

We will continue to report on any updates to the situation and in particular any changes in disease distribution or wild bird movements which may increase the risk to the UK.

(Continue . . . )

Last November the WHO issued a similar warning (see WHO: Migratory Birds & The Potential Spread Of Avian Influenza), and while Europe and Asia were largely spared, Egypt saw the arrival of a newly reassorted H5N2 virus, and India and Nepal saw outbreaks of H5N1.

The major migratory bird flyways shown below - along with scores of minor pathways not depicted - serve as a global interstate highway for avian influenza viruses.  While primarily north-south conduits, there is enough overlap to allow for east-west movement as well.

A study, published in 2016 (see Sci Repts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission Of HPAI H5N1), suggests that waterfowl pick up new HPAI viruses in the spring (likely from poultry or terrestrial birds) on their northbound trip to their summer breeding spots - where they spread and potentially evolve -  and then redistribute them on their southbound journey the following fall.

All of which means that - despite the relative quiescence of the past 24 months - this fall we'll be once again on the lookout for any signs of renewed avian flu activity around the world, and the potential for seeing new reassortant viruses in the mix.