EID Journal: Highly Pathogenic Avian Influenza A(H5N8) Virus in Gray Seals, Baltic Sea

Gray Seals - Credit Wikipedia

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Highly pathogenic avian H5N8 (clade 2.3.4.4.) emerged over the winter of 2013-14 in South Korea, and over the next two years sparked major epizootics in North America (2014-2015) and Europe (2016-2017).

The European version proved to be a more virulent strain - the product of a reassortment over the summer of 2016 in either China or Russia - and was dubbed clade 2.3.4.4 B (see EID Journal: Reassorted HPAI H5N8 Clade 2.3.4.4. - Germany 2016).

While a few dogs were reportedly infected in South Korea by the initial strain  (see Korea Finds More Dogs With H5N8 Antibodies),  (AFAIK) we've not seen any confirmed mammalian infections with the reassorted H5N8 B clade outside of laboratory experiments (see Sci Rpts: H5N8 - Rapid Acquisition of Virulence Markers After Serial Passage In Mice).

Today, however, the EID Journal brings us evidence of HPAI H5N8 infection in two marine mammals - grey seals - recovered in the Baltic sea over the winter of 2016-17.

Seals, and other marine mammals are susceptible to a wide variety of influenza viruses, and over the years we've looked at a number of investigations involving H3N8, H10N7, and other (mostly avian) flu subtypes.

• A month ago, in BioRxIv: Avian H3N8 With Multiple Mammalian-Adaptive Mutations in a Rescued Grey Seal, recovered from Cornwall in 2017.

• In 2014, a large outbreak northern Europe (mostly Denmark and Germany & Sweden) resulted in as many as 3,000 harbor seal deaths from avian H10N7 (see Avian H10N7 Linked To Dead European Seals), prompting warnings to the public not to touch seals.

• In 2013 we saw a report (and a study) from UC Davis showing the human 2009 pandemic H1N1 virus had jumped to wild California Elephant Seals just one year after that virus emerged (see The 2009 H1N1 Virus Expands Its Host Range (Again)).

• And in November of 2011, we saw a die off of seals in New England that was eventually determined to be due to a  Mammalian Adapted avian H3N8 virus.

While harbor seals have been the most commonly affected seal species, in 2016 we looked at a seroprevalence study intriguingly suggested that grey seals may be an unrecognized natural wild reservoir for influenza A viruses (see Emerg. Microbes & Inf.: Prevalence Of Influenza A in North Atlantic Gray Seals).

The full text of today's EID dispatch is well worth reading.  I've only included a few excerpts (bolding mine), so follow the link to read it in its entirety. 

Volume 25, Number 12—December 2019
Dispatch

Highly Pathogenic Avian Influenza A(H5N8) Virus in Gray Seals, Baltic Sea

Dai-Lun Shin, Ursula Siebert, Jan Lakemeyer, Miguel Grilo, Iwona Pawliczka, Nai-Huei Wu, Peter Valentin-Weigand, Ludwig Haas1, and Georg Herrler

Abstract

We detected a highly pathogenic avian influenza A(H5N8) virus in lung samples of 2 gray seals (Halichoerus grypus) stranded on the Baltic coast of Poland in 2016 and 2017. This virus, clade 2.3.4.4 B, was closely related to avian H5N8 viruses circulating in Europe at the time.

(SNIP)

Conclusions

We report the case of a clade 2.3.4.4 B group HPAI H5N8 virus able to infect marine mammals. The isolated H5N8 seal virus showed 99%–100% identity to the avian strains that were circulating in Europe during 2016–2017. HPAI H5N8 2.3.4.4 B virus infections are associated with severe symptoms in infected waterfowl or wild birds. The AIV AR8444 strain in the EpiFLU database with the highest homology to H5N8/seal was isolated from a dead tufted duck found in Lake Plön, Schleswig-Holstein, in northern Germany. Experimental infection of ducks with the AR8444 strain resulted in a mortality rate of 33% 4–8 days postinfection (9).

(SNIP)

Studies have shown that some mutations known to enhance the transmissibility of H5N1 HPAI viruses may increase the ability of LPAI viruses to be transmitted from bird to marine mammal (11–13). These factors include the change of sialic acid receptor binding affinity (11) and adaptive mutations in the vRNP complex for replication and virus spread in the seal population (12). In the H5N8/seal isolate, we detected no molecular markers previously associated with the transmission of avian-derived influenza viruses to marine mammals (13) in the viral PB2, PB1, PA or HA segments (Table). Thus, it appears that no adaptive mutations have occurred in the gray seal analyzed in this study.

Most reports on influenza viruses in seals are related to outbreaks in harbor seals and not gray seals. However, seroprevalences against H10N7 influenza A virus were described in gray seals in the Netherlands (14). In addition, influenza A virus matrix RNA (without further characterization) was detected in swab samples of 9.0% of apparently healthy weaned gray seal pups live-captured in the North Atlantic (15). In adult seals, seroprevalence was 50%; the authors suggest a possible role of gray seals as a wild reservoir of influenza A virus.

These reports indicate that the gray seal can be infected by influenza viruses. Because we describe a naturally occurring spillover of HPAI virus to a marine mammal, future surveillance programs should continue to monitor gray seals and harbor seals as possible reservoirs of AIV.

Dr. Shin is a veterinarian at the University of Veterinary Medicine, Hannover, Germany. His primary research interest is the pathogenesis of influenza virus infection in different animal species.

Admittedly there are fewer opportunities for marine mammals to infect humans with (potentially mutated or reassorted) flu viruses; at least compared to pigs, poultry, or companion animals.

But in 2014, a study published in - Nature Communications: Respiratory Transmission of Avian H3N8 In Ferrets - raised precisely those concerns (see USGS Avian Flu in Seals Could Infect People).

A more recent study in 2016 (see Sci Rpts: Receptor Cell Binding Of Seal H3N8) has rolled back some those concerns due to finding limited binding to cells in the human trachea (as opposed to deep lung tissues), but concerns over the future evolution and mammalian adaptation of H3N8 remain.

Although we look primarily to birds and pigs as being the most likely source of the next flu pandemic, over the past 2 decades we've learned of a growing array of species that can host novel flu viruses.

While most are long shots in the pandemic generation sweepstakes, nothing says that one of these couldn't help spawn the next novel virus. A few past blogs on some these `outlier' flu hosts include:

EID Journal: Equine Influenza - A Neglected, Reemergent Disease Threat

HPAI H5Nx Clade 2.3.4.4. Shedding In Cottontail Rabbits

Back To The Bat Cave: More Influenza In Bats

mBio: Novel Reassortant Influenza A Viruses in Canines in Southern China

EID Journal: Avian H7N2 Virus in Human Exposed to Sick Cats

H9N2 Adaptation In Minks

Saudi MOH Announces 3rd & 4th MERS Case of Epi Week 44

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The recent uptick in MERS cases continues with 2 more cases announced today by the Saudi MOH - bringing October's total to 13 cases - which exceeds the combined total for August and September.  

Today's 1st case hails from Wadi Aldwasir, which you'll recall was the site of a large community & Healthcare acquired outbreak (60+ cases & 8 deaths) last spring (see WHO Update & Saudi Epidemiological Investigation Of The Wadi Aldwasir MERS Cluster).

Since that outbreak ended we've seen a smattering of MERS cases from that area - including two others this month (Epi Week 40 and Epi Week 42), all of which have been reported as `primary' cases with no stated epidemiological links.

These barebones daily updates from the Saudi MOH are always subject to  revision, but for now none of these cases is reported as `secondary',  which would indicate a cluster. 

Today's second case adds to yet another recent hot spot - Khamis Mushait - which I highlighted in yesterday's blog.  Today's case - a 55 y.o. male listed as `primary' - is either the 4th or 5th case  (see below) from the area this month.

• The first involved a 26 y.o. female listed as a `secondary case') on Oct. 10th, possibly linked to another case (M, 34) who was reported from a nearby community (Abha City, about 17 miles from Khamis Meshalt) on Oct 2nd.

• The 2nd was a 73 y.o. male listed as `primary, with unknown camel contact' on Oct. 19th.

• The third case - reported yesterday - is a 94 y.o. male, reportedly with recent camel contact. 

Community acquisition of the MERS virus outside of hospitals and healthcare facilities - and among those without recent camel contact - remains poorly understood, although environmental exposures and potential spread by mildly symptomatic or asymptomatic carriers are considered likely.

So far - despite some regional clustering of primary cases - we've not seen MERS transmit in the community the way that SARS did 16 years ago.

MERS does, however, transmit from person-to-person quite readily in close quarters - such as in hospitals and households - and we've seen studies (see 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.

So we watch these reports closely, for any signs that the status quo has changed.

Japan MAFF Confirms 47th Farm Outbreak (Saitama) Of Classical Swine Fever

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Japan has, for more than a year - been dealing with the return of Classical Swine Fever (CSF) after an absence of 26 years.  While similar in impact to ASF, CSF is caused by a different virus, and is considered a little easier to control.  

After going 3 weeks without reporting a fresh farm outbreak, today Japan's MAFF reports another CSF outbreak at a farm in Saitama Prefecture, apparently within the restricted movement area of the 46th outbreak.

Confirmation of suspected affected animals of swine fever in Saitama Prefecture, about (47 case was in Japan) 

October 30, first year of the Ministry of Agriculture, Forestry and Fisheries

A simulated case of swine fever was confirmed today at a farm in Honjo City, Saitama Prefecture, which was within the 46th restricted movement area in Japan.

We will make every effort to prevent the disease.

We ask for your cooperation to refrain from interviewing at the site because it may cause the spread of the disease.

1.Outline of the farm where it occurred

Location: Honjo City, Saitama

Breeding situation: 865

2.Background

(1) Saitama Prefecture received an on-site inspection by a livestock quarantine officer on Tuesday, October 29, after receiving a report from the farm that the pigs were showing abnormalities.

(2) On the same day, because of the suspicion of swine cholera caused by the inspection at the Livestock Hygiene Center, it was revealed that it was a simulated case of swine cholera today (Wednesday, October 30). did.

In addition to the 47 farm outbreaks, more than 1200 wild boar have been discovered infected with the virus across 10 prefectures.  The most recent OIE report adds two new prefectures (Shiga and Gunma) to the list. 

Summary of the wild boar surveillance (As of 7th October) 

• [Gifu prefecture (since 13th of September 2018)] Tested (RT-PCR): 2,324 wild boars (415 dead and 1,909 captured), Positive: 990 (310 dead and 680 captured) 
• [Aichi prefecture (since 14th of September 2018)] Tested (RT-PCR): 1,219 wild boars (42 dead and 1,177 captured), Positive: 98 wild boars (19 dead and 79 captured) 
• [Nagano prefecture (since 14th of September 2018)] Tested (RT-PCR): 368 wild boars (110 dead and 258 captured) Positive: 121 (40 dead and 81 captured) 
• [Mie prefecture (since 14th of September 2018)] Tested (RT-PCR): 523 wild boars (32 dead and 491 captured), Positive: 17 (1 dead and 16 captured)
• [Fukui prefecture (since 14th September 2018)] Tested (RT-PCR): 98 wild boars (18 dead and 80 captured), Positive: 17 (6 dead and 11 captured)
• [Toyama prefecture (since 14th September 2018)] Tested (RT-PCR): 134 wild boars (10 dead and 124 captured) Positive: 20 (9 dead and 11 captured) 
• [Gunma prefecture (since 14th September 2018)] Tested (RT-PCR): 18 wild boars (8 dead and 10 captured) Positive: 2 (0 dead and 2 captured) 
• [Saitama prefecture (since 14th September 2018)] Tested (RT-PCR): 15 wild boars (7 dead and 8 captured) Positive: 5 (2 dead and 3 captured) 
• [Ishikawa prefecture (since 14th September 2018)] Tested (RT-PCR): 175 wild boars (12 dead and 163 captured) Positive: 8 (4 dead and 4 captured) 
• [Shiga prefecture (since 14th September 2018) Tested (RT-PCR): 47 wild boars (22 dead and 25 captured) Positive: 1 (1 dead and 0 captured) 

[Other 34 prefectures (since 14th of September 2018) Tested (RT-PCR): 564 wild boars (294 dead and 270 captured) 

The territorial expansion of CSF continues in Japan, further complicating the control of this disease, and reinforces just how difficult it can be to put a biological genie back into the bottle.

CDC EID Journal: Locally Acquired Human Infection with Swine-Origin Influenza A(H3N2) Variant Virus, Australia, 2018

Swine Variant Human Cases : 2010-2018  - Credit CDC

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Although we've enjoyed a remarkably small number of human swine variant flu (H1N1v, H1N2v, H3N2v) infections this summer, over the past 15 years more than 460 cases have been confirmed in the United States, with 2/3rds of those reported in 2012. 

Hundreds, perhaps thousands, of other cases have almost certainly escaped detection as most cases are mild to moderate, and relatively few people are tested for novel viruses (see CID Journal: Estimates Of Human Infection From H3N2v (Jul 2011-Apr 2012).

While the United States has the highest reported number of cases, there is little reason to suspect that cases aren't occurring - unnoticed - around the globe. Surveillance is spotty at best, and identifying cases is often a matter of luck.

Nevertheless, we do see occasional cases reported: 

J.O.I. : A Human Infection with a Novel Reassortant H3N2 Swine Virus in China
  
Eurosurveillance: Swine Origin H1N1 Infection Leading To Severe Illness - Italy, 2016,

Netherlands: RIVM Reports Patient With Severe Swine Variant (H1N1) Infection,

EID Journal: Reassortant EAH1N1 Virus Infection In A Child - Hunan China, 2016

Three years ago Chen Hualan - director of China's National Avian Influenza Reference Laboratory - gave an interview to Xinhua where she pegged the EA (Eurasian Avian-like) H1N1 swine virus (EAH1N1) as having perhaps the greatest pandemic potential of any of the novel viruses in circulation.

So we watch these swine-origin reassortant viruses closely, looking for signs that they might be following the same path as the 2009 H1N1 `swine flu' pandemic virus.

In the summer of 2018, in JVI: Divergent Human Origin influenza Viruses Detected In Australian Swine Populations, we looked at a report describing genetic remnants of much older human flu strains still circulating in geographically isolated swine populations in Australia. Lineages going back roughly 50 years (to H3N2 in 1968), which show unexpectedly little antigenic drift over time.

The authors went on to suggest that `. . . .  isolated swine populations can act as ‘antigenic archives’ of human influenza, raising the risk of re-emergence in humans when sufficient susceptible populations arise.'

Last February, the WHO reported the first known human swine-variant infection from Australia.

Influenza A(H3N2)v activity from 25 September 2018 to 17 February 2019
A human case of A(H3N2)v influenza virus infection was detected in Australia during routine screening of influenza positive samples. The case was a 15-year-old female with likely exposure at a livestock exhibition. This is the first documented case of a variant influenza virus human infection in Australia.

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

Phylogenetic analyses of the HA and NA genes of the Australian virus, A/South Australia/85/2018, showed that it grouped with A(H3N2) swine influenza viruses detected in Australia and Asia, which were likely derived from seasonal A(H3N2) viruses that circulated in the late 1990s. The six internal genes of A/South Australia/85/2018 were derived from A(H1N1)pdm09 viruses circulating in pigs. Antigenic characterization of this virus is pending.

All of which brings us to a dispatch, published this week in the EID Journal, that looks at this first reported Australian swine variant case, and echos some of the same concerns voiced in last summer's JVI study.

I've only posted some excerpts, so follow the link to read dispatch in its entirety.

Dispatch 

Locally Acquired Human Infection with Swine-Origin Influenza A(H3N2) Variant Virus, Australia, 2018
 
Yi-Mo Deng, Frank Y.K. Wong, Natalie Spirason, Matthew Kaye, Rebecca Beazley, Miguel Grau, Songhua Shan, Vittoria Stevens, Kanta Subbarao, Sheena Sullivan, Ian G. Barr, and Vijaykrishna Dhanasekaran 
 
Abstract

In 2018, a 15-year-old female adolescent in Australia was infected with swine influenza A(H3N2) variant virus. The virus contained hemagglutinin and neuraminidase genes derived from 1990s-like human seasonal viruses and internal protein genes from influenza A(H1N1)pdm09 virus, highlighting the potential risk that swine influenza A virus poses to human health in Australia.

Long-term circulation of influenza A viruses (IAVs) among swine poses a public health threat. The 2009 pandemic was caused by a reassortant swine influenza A(H1N1) virus with genes that originated from human and avian IAVs that had circulated among swine for several years (1,2). 

Since then, globally enhanced influenza surveillance among swine has indicated continuous introduction of human seasonal influenza viruses into swine, followed by reassortment with influenza A viruses endemic in swine (IAV-S) and persistence of many lineages in swine for several decades (3). 

Although IAV-S are normally limited to transmission among swine, since 2010, a total of 430 cases of human infection with swine-origin influenza A(H3N2) variant viruses (H3N2v) have been detected in the United States (4), primarily in young persons exposed to swine at agricultural fairs. Most patients had self-limited influenza-like illness (5). Recent data also suggest that IAV-S have been endemic to Australia for many decades, including viruses that were originally derived from human H3N2 viruses as early as 1968, pre-2009 seasonal H1N1 viruses, and influenza A(H1N1)pdm09 (pH1N1) viruses (6).

(SNIP)

Conclusions

A comparison of divergence times between the IAV-S segments from Australia showed that reassortment of endemic viruses with introduced human lineages had been continual (Appendix Figure 3), thereby potentially maintaining sustained transmission on individual swine farms. The risk for emergence of A/South Australia/85/2018-like viruses in humans is potentially high because all 6 internal protein genes are derived from human-adapted pH1N1 virus.

The human-origin HA and NA genes of A/South Australia/85/2018 were widely circulating in the human population 20–25 years ago. Hence, children probably have little or no immunity to the HA/NA of this virus, making them more susceptible to infection with this virus subtype, as in the case reported here and in children infected with swine H3N2v virus in the United States (12–14).

The genomic and antigenic properties and epidemiologic characteristics of zoonotic IAV-S are useful for identifying the potential risk for emergence and spread into the human population. These data also enable better identification of potential nationally relevant mitigation strategies, including measures such as public awareness programs and influenza vaccination of swine herds to eliminate sustained transmission of influenza virus in swine populations (15).

Our study highlights the risk to the general human population in Australia for infection with IAV-S and the need for more vigilant surveillance of swine and persons who are in close contact with swine to enable early detection and characterization of zoonotic influenza infections.

Dr. Deng leads the molecular biology group at the WHO Collaborating Centre for Reference and Research on Influenza, Melbourne, Australia. Her primary research interest is the use of novel sequencing and analysis methods to infer the epidemiology and mechanisms of evolution of zoonotic and human influenza viruses.

(Continue . . . )

Saudi MOH Adds Another MERS Case (Week 44) & Removes One (Week 43)

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In yesterday's MERS update I wrote:

The Saudi MOH has added their 1st MERS case of Epi Week 44 (M,43) and added a second case (apparently belatedly on Sunday) to their Epi Week 43 list (M,10). Both cases hail from Unayzah (aka`Onaizah' or `Onizah'), and both are listed as `primary'.

Today, without explanation, the 10 y.o. has been removed from the Epi Week 43 list and the case count chart (see above) has been reset to 1 for last week. 

Without more information, it is impossible to know what happened, although the lab tests for MERS are not 100% reliable (see EID Journal: Sensitivity and Specificity Of MERS-CoV Antibody Testing).

False negatives, however, are more common than false positives.

Last October, in AJIC: Intermittent Positive Testing For MERS-CoV,
we looked at a study, that found intermittent positive results for MERS-CoV on reverse-transcription polymerase chain reaction (RT-PCR) tests.  The authors (including Memish and Al-Tawfiq) wrote:

Our data indicate that 2 to 3 nasopharyngeal samples are needed to produce the highest yield of positive results for MERS-CoV. In addition, 2 negative results 48 hours apart with clinical improvement or stabilization are needed to clear patients from MERS-CoV. Evaluation of the yield of sputum samples is needed to assess the effectiveness against nasopharyngeal swabs.

Hopefully we'll find out what happened, but in the meantime the MOH has reported the second MERS case of Epi Week 44, involving a 94 y.o. male with recent camel contact

 

This is the third case reported from Khamis Mushait - and the 4th from this general region - in the month of October.

•  The first involved a 26 y.o. female listed as a `secondary case') on Oct. 10th, possibly linked to another case (M, 34) who was reported from a nearby community (Abha City, about 17 miles from Khamis Meshalt) on Oct 2nd.

•  The 2nd was a 73 y.o. male listed as `primary, with unknown camel contact' on Oct. 19th.

The Saudi MOH daily reports don't provide much in the way of details, and so we'll probably have to wait for the next WHO summary to learn if any of these cases are epidemiologically linked.

A Curious Report From Gabon

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Long-time readers of this blog know that every once in awhile we'll hear about a `mysterious' outbreak somewhere in the world, and most of the time, it will turn out to be something fairly common; measles, malaria, dengue, etc.

Every once in awhile, there will be more more to the story.

Since early yesterday evening the dedicated newshounds at FluTrackers (h/t Pathfinder) have been following (see FT thread) an unidentified medical emergency involving the captain and crew of a work boat, bound from Douala, Cameroon to Pointe-Noire in the Congo.

Last night's (translated) media report stated:

The SANDRA TIDE, a Crew boat, used to supply oil rigs, left Douala on October 21, 2019 for Pointe-Noire in Congo. On 24 October 2011 he issued distress signals off the coast of Gabon, from which the intervention of the maritime authorities allowed the evacuation of the Captain of the ship and his deputy who are in a critical health situation.

There were eight (8) crew members on board, including two (02) of Philippine nationality (the Captain and his deputy), five (5) of Cameroonian nationality and one (01) of Ghanaian nationality.

       (Continue . . . .)


Today, Pathfinder has posted the official statement from the Gabonese Ministry of Health, which - while still not identifying the cause - adds that the captain has died and his deputy is in a coma, and expands the number of crew hospitalized with various (and possibly, unrelated) symptoms.

Tuesday, October 29, 2019

Flash Infos

Press release from the Ministry of Health

Libreville, October 28, 2019 - The SANDRA TIDE, a type of boat Crew boat, used to supply oil platforms, left Douala October 21, 2019 at Pointe-Noire in Congo. On 24 October 2019, it issued a distress signal in offshore Gabon, where the intervention of the maritime authorities which helped to evacuate the ship's captain and his assistant who were in a critical health situation. There were eight board (08) including two crew members (02) of Philippine nationality (the Flight Captain and his deputy), five (05) of Cameroonian nationality and (01) of Ghanaian nationality.

Upon notification by the Base Epidemiology Health Region Maritime (Port Gentil), in charge of health surveillance, the death of the ship's captain and the hospitalization of his deputy in a coma in the intensive care unit of hospital NTCHENGUE, the Minister of Health convened a crisis in the presence of the Representative of the World Health Organization (WHO) October 26, 2019 after which it was decided to send the same day on Port-Gentil, a rapid response team. On arrival, it has integrated multisectoral crisis team set up by the Governor of the province of Ogooue Maritime.

In their initial assessment shows that the index case occurred outside the community, limiting the spread of any infectious disease. The list of contacts persons- (nurses and sailors) who approached the sick has been carefully established and daily monitoring is performed.

He was evacuated from the ship, its disinfection and observing implementation of other crew members including three (03) were eventually hospitalized for various symptoms (hiccups, fatigue, diarrhea), but without no fever.

Samples of diseased biological fluids, drinking water, sewage, food remains found on board, as swabbing conditioned air lines has been made. These samples will be analyzed by the International Center for Medical Research (CIRMF).

Following the inspection of the ship, was taken to the destruction of foodstuffs and of all litter found on board by a special unit of hygiene and sanitation service, which also ensures the incineration of personal protective equipment and all equipment used during various procedures requiring contact with patients.

This first report was communicated today, October 28, 2019 a multisectoral platform in the presence of the WHO Representative. Present at the Crisis, representatives of the Merchant Navy, the Military Health Services, Ministry of Interior, the Ministry of Foreign Affairs, infectious disease specialists and biologists.

Pending the results CIRMF, which only specify our infectious origin or not troubles plaguing the crew of SANDRA TIDE, multisectoral coordination chaired by the Governor of the province of Ogooué Maritime, we welcome the diligence, has control of the situation.

The following recommendations were made:

• strengthening epidemiological surveillance in all health facilities in Port Gentil;
• regular monitoring of all cases contacts listed;
• the strict application of individual protection measures by all healthcare professionals in contact with patients;
• urgent sent by air (Helicopter) samples taken.
  

Additional information will be provided as and when the evolution of the situation, especially when the CIRMF analysis results we will be reached.

While we must wait for results, given the short time frame, this appears to have been a thorough and well executed response.

Although I'll update this story when more information comes available, you best bet is to visit FluTrackers (I do, every day), as they have volunteers collecting and posting reports literally 24 hours a day, from all over the world.

EID Journal: Avian Influenza A Viruses among Occupationally Exposed Populations, China, 2014–2016

Credit CDC

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As discussed in my last blog, case counts picked up by public health surveillance  - while useful - generally only represent the `tip of the iceberg'  or - as in the CDC graphic above, the tip of the pyramid.

Between asymptomatic and mildly symptomatic cases who often never seek medical care, misdiagnosed patients, and cases that otherwise slip through the cracks, we never truly know how many people are infected during a disease outbreak.

During the first wave of avian H7N9 in China in the spring of 2013, roughly 135 cases were identified. But a subsequent analysis appeared in the Lancet (see Lancet: Clinical Severity Of Human H7N9 Infection) that substantially raised their estimate of the total number of H7N9 cases in China. After citing many limitations to the data, they wrote:

Our estimate that between 1500 and 27 000 symptomatic infections with avian influenza A H7N9 virus might have occurred as of May 28, 2013, is much larger than the number of laboratory-confirmed cases.

That's between a 12-fold and 200-fold increase in cases over what had been reported to that point. 

If capturing less than 1% of the cases sounds absurd, we've seen similar estimates for other novel flu strains. In 2013 (see CID Journal: Estimates Of Human Infection From H3N2v (Jul 2011-Apr 2012)- estimated that during a time when only 13 cases were reported by the CDC - that the actual number of infections was likely 200 times (or more) higher.

Results. We estimate that the median multiplier for children was 200 (90% range, 115–369) and for adults was 255 (90% range, 152–479) and that 2055 (90% range, 1187–3800) illnesses from H3N2v virus infections may have occurred from August 2011 to April 2012, suggesting that the new virus was more widespread than previously thought.

Mathematical models are worthwhile, but a better way to gauge the impact of a specific virus on a population is to conduct a seroprevalence study; to take blood samples from a cross section of society (or representing high risk groups) and to test them for virus specific antibodies.

These blood tests are not fool proof, as some infections (like MERS-CoV) can leave behind a temporary, less robust, antibody signature than others.  And with some tests, cross-reactivity with other similar viruses may skew results. 

But seroprevalence studies can give us a much better, albeit retrospective, idea of the spread of many viral infections.  Over the years we've looked at a number of them on avian flu, particularly in Asia and the Middle East. 

• 2018's J. Infect & Public Health: High Seroprevalence Of Avian Influenza H9 Among Poultry Professionals In Pakistan, found an overall seroprevalence of 50.3% against H9 viruses. 
  

• In 2016, in JID: High Seroprevalence Of H5N1 Antibodies In Indonesian Poultry Workers, we saw a study that found a remarkable 84% of the sera tested positive for antibody activity against the avian virus, despite a lack of reported serious illness among the 101 workers tested.

• Whereas in 2012, in H5N1 Seroprevalence Among Jiangsu Province Poultry Workers, we saw a study that found across three locations tested (Gaochun, Jianhu and Gaoyou counties) the percentage of workers testing positive ranged from zero (Gaochun) to 5.38% (95%CI, 2.19%–10.78%) in Gaoyou.

Adding this list, this week the CDC's EID Journal published a new seroprevalence study that looks at antibodies for a wide range of avian flu viruses (H9N2, H7N9, H5N1, H6N1, H10N8, etc.) among poultry workers in Southern and Eastern China. 

While none of their results reach the lofty heights previously reported among Indonesian and Pakistani poultry workers (see above), this study provides additional evidence of subclinical infection by a wide range of avian viruses. 

This is a lengthy, data-rich study, so follow the link to read it in its entirety.  When you return I'll have a postscript.

Volume 25, Number 12—December 2019
Research

Avian Influenza A Viruses among Occupationally Exposed Populations, China, 2014–2016
   
Chuansong Quan1, Qianli Wang1, Jie Zhang, Min Zhao, Qigang Dai, Ting Huang, Zewu Zhang, Shenghua Mao, Yifei Nie, Jun Liu, Yun Xie, Baorong Zhang, Yuhai Bi, Weifeng Shi, Peipei Liu, Dayan Wang, Luzhao Feng, Hongjie Yu, William J. Liu , and George F. Gao

Abstract

To determine the seroprevalence and seroconversion of avian influenza virus (AIV) antibodies in poultry workers, we conducted a seroepidemiologic study in 7 areas of China during December 2014–April 2016. 

We used viral isolation and reverse transcription PCR to detect AIVs in specimens from live poultry markets. We analyzed 2,124 serum samples obtained from 1,407 poultry workers by using hemagglutination inhibition and microneutralization assays. 

We noted seroprevalence of AIV antibodies for subtypes H9N2, H7N9, H6N1, H5N1-SC29, H5N6, H5N1-SH199, and H6N6. In serum from participants with longitudinal samples, we noted seroconversion, with >4-fold rise in titers, for H9N2, H7N9, H6N1, H5N1-SC29, H6N6, H5N6, and H5N1-SH199 subtypes. We found no evidence of H10N8 subtype. 

The distribution of AIV antibodies provided evidence of asymptomatic infection. We correlated AIV antibody prevalence in live poultry markets with increased risk for H7N9 and H9N2 infection among poultry workers. 

(SNIP)

Discussion

(Excerpt)

We observed higher prevalence for certain AIV subtypes and seroprevalence for certain AIV antibodies in live poultry markets, providing further evidence of cross-species transmission from birds to humans. Since the H7N9 outbreaks of 2013, consensus that AIV was transmitted from birds to humans led the government of China to implement epidemic control measures. The measures, such as closing live poultry markets during influenza season, cleaning and disinfecting live poultry markets daily, and vaccinating poultry, have effectively reduced the chances for human exposure to AIV-contaminated environments and ill poultry (38,39). Our results demonstrate that epidemic control measures aimed at live poultry markets, including their closure, can be highly effective in human AIV infection control (9,38).

Many participants with seropositivity were residents of southern and eastern provinces. Several determinants could account for this observation. First, the high density of live poultry markets, high population density, and expansive live poultry transportation network in these regions could favor large-scale and transboundary AIV spread in poultry, thereby increasing the risk for human infection (40). Second, these regions are rich in water resources, including the Yangtze and Pearl Rivers, as well as many lakes, which are natural habitats for waterfowl and wild birds that serve as natural hosts for various AIV subtypes, including H5Nx and H9N2 viruses, and that continually generate biological threats to public health (41,42). Studies suggest that migratory birds play a role in the evolution and spread of various zoonotic agents, and southeast China is located along the East Asian-Australian flyway, a migratory route for many bird species (43,44).

Our study had several limitations. Despite serious efforts to collect samples from the same participants during follow-up sampling, movement of vendors and poultry workers from target poultry markets reduced the possibility of obtaining paired samples. In addition, the relatively small sample size and use of only 1 location for the control group, Beijing in 2015, could be potential sources of bias.

In conclusion, our study provides serologic evidence of subclinical human AIV infection in an occupationally exposed population of poultry workers and corresponding AIV infection risk factors.

Because novel influenza viruses continue to emerge, our results show the need for enhanced etiologic surveillance of AIVs in live poultry markets and humans. Implementing poultry vaccination would also reduce human infection risk. Finally, our results demonstrate the need for active surveillance to foresee dynamic AIV epidemics and inform influenza vaccine development.

Dr. Quan was a medical doctor at the National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China during the study. His primary research interests include etiology and serology of influenza viruses and other emerging and reemerging viruses.

Despite the reassuring lack of avian flu reports out of China - due in large measure to their massive H5+H7 poultry vaccination campaign which began in 2017 - the avian flu threat has not gone away.

New viruses can emerge fairly often, and older subtypes can - over time - evolve far enough away from the existing vaccine to re-emerge.

Last April, in OFID: Avian H5, H7 & H9 Contamination Before & After China's Massive Poultry Vaccination Campaign, we saw evidence that other avian viruses - particularly H9N2 - have surged in the wake of the H5+H7 vaccination campaign.


And lastly, the remarkable transparency displayed by China during the first two waves of H7N9 (2013-2014) has given way to more cryptic, and less frequent, updates over the past few years.

All of which means that while we enjoy this lull, we shouldn't assume it will last forever.

Saudi MOH Reports 2nd Primary MERS Case In 3 Days In Unayzah

Credit Wikipedia

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The Saudi MOH has added their 1st MERS case of Epi Week 44 (M,43) and added a second case (apparently belatedly on Sunday) to their Epi Week 43 list (M,10).  Both cases hail from Unayzah (aka`Onaizah' or `Onizah'), and both are listed as `primary'.

Primary cases are those that occur in the community, with no known contact with an infected person, and since many have no recent camel contact, often we have no clue as to how they were exposed.

While not unheard of, MERS infections (particularly `primary cases') reported among children or adolescents are exceedingly rare (see chart below). 

Credit WHO EMRO

Today's case is the 11th so far for the month of October, which represents nearly a tripling of cases over what was reported in September (n=4).

Questions remain, however, over just how sensitive the Saudi surveillance system really is.

Between asymptomatic or mild cases, atypical presentations, and less than 100% reliable laboratory testing (see EID Journal: Sensitivity and Specificity Of MERS-CoV Antibody Testing), it has long been assumed we are only hearing about some fraction of the number of actual infections.

• In November of 2013, we looked at a study published in The Lancet Infectious Diseases, that estimated for every case identified, there are likely 5 to 10 that go undetected. 
• In 2015, when Saudi Arabia had recorded fewer than 1200 MERS cases, a seroprevalence study (see Presence of Middle East respiratory syndrome coronavirus antibodies in Saudi Arabia: a nationwide, cross-sectional, serological study by Drosten & Memish et al.,) suggested nearly 45,000 might have been infected.  
• A 2016 study (see EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016) suggested that as much as 60% of severe Saudi MERS cases go undiagnosed. 
• Just over a year ago, in Evaluation of a Visual Triage for the Screening of MERS-CoV Patients, we looked at a study of the Saudi MERS triage system - to decide who to isolate and test as a potential  case - that found it severely lacking. 

While MERS-CoV activity is down compared to 3 or 4 years ago - primarily due to better infection control in Saudi Hospitals - we've seen studies (see 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.

So we watch upticks like we're seeing this month closely, for any signs that the virus is getting its act together.

Indonesia: More Conflicting Reports of Pig Deaths From `Hog Cholera'

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For nearly 3 weeks we've been following multiple reports of pig deaths in Indonesia (see here, and here) - a nation that is surrounded by countries reporting African Swine Fever outbreaks (see map above) - but as of yet, has not confirmed ASF themselves.

Tests are apparently still `pending', and most media outlets continue to call these outbreaks `Hog Cholera', which normally refers to Classical Swine Fever (CSF), not African Swine Fever. 

African Swine Fever (`Demam Babi Afrika' in the Indonesian Language), is barely mentioned on the Indonesian Ministry of Agriculture Website (Kementan), with a single cautionary report published earlier this month indicating authorities are preparing for its potential arrival.

Over the weekend, however, there have been multiple media reports and a couple of government announcements - that while not exactly  confirming ASF - add to the suspicion that the viral culprit may be African Swine Fever.

On Friday, the Tobasa Kabupaten (District) website posted this (translated) announcement, which suggests ASF, although it falls short of announcing official test results.

October 25, 2019

Appeal Related Disease ASF government Toba Livestock Pigs

by Rikkardo Simamora

Society Toba Samosir (Toba) encouraged the pig disease ASF (African Swine Fever) are more prevalent.

The following appeal through the district government Toba Toba Head of Food Security, Darwin Sianipar, Friday (10/25/2019).

ASF disease is contagious and deadly disease in pigs caused by African swine fever virus.

ASF was originally brought from East Africa to Georgia by contaminated pork products such as sausages and meatballs, and spread to Japan, even in Japan has seized a packet of sausages from a traveler from China.

And now that virus to the countries of Asia and Indonesia, terkhususnya to Toba Samosir. Food Security Office of Toba Samosir appealed to all communities Toba Samosir for: Viewing and observe each animal the pig does have signs of swine diseases ASF (African Swine Fever).

(Continue . . . )

The following day the same regency released a report which describes an ASF-like outbreak, but never expressly names it.  

October 26, 2019

278 TAIL CATTLE PIGS IN Tobasa virus CHOLERA

by mctobasa

Balige, MC Tobasa- Regency (Regency) Toba Samosir (Tobasa) through the Department of Agriculture and Fisheries is very quick to respond to the rise of the death of pigs in several regencies / cities in North Sumatra province last few months, which has mengkwatirkan, disturbing and harmful to society in particular pig farmers and traders.

While the deaths of pigs that occurred in Dairi, Humbang Hasundutan, Medan, Deli Serdang, Karo, North Tapanuli, has reached 1,417 tails in early October 2019, stated Head of the Department of Agriculture and Fisheries, represented by the Head of Livestock Robert Aruan in office on Friday (10/25/2019).

Advanced Head Robert, cases of livestock deaths have occurred in the District Silaen Tobasa district. And to this day the number of deaths has reached 278 pig tails, and much more in a state hospital.

"The last condition pig deaths have occurred in the District Tampahan as much as 6 tails and District Balige 14 tails".

Head Robert Also explain that the disease is caused by a virus that is easily transmitted through direct contact with sick pigs, excretions and secretions of animals / fases, urine and semen stud. While Through indirect contact is through products derived from pigs, people in contact with sick pigs, equipment for stables, cattle contaminated freight cars (Swill feeding).

(Continue . . . )

While I can find no official confirmation (or OIE Report), a couple of media outlets have now started calling these outbreaks ASF. First, this (translated) report from Infopublik:

Livestock Disease Asian Pig Swine Fever Hit Tobasa

Sunday, October 27th, 2019 | 21:19 pm |

By MC KAB Toba Samosir

Balige, InfoPublik - Outbreaks of disease affecting pigs types of African Swine Fever (ASF) spread to almost all districts in Toba Samosir (Tobasa), North Sumatra.

The disease has signs of them, a high fever in cattle, lack of appetite, vomiting and difficulty breathing, diarrhea and paralysis and difficulty walking, and raised spots spots around the thighs, abdomen and neck pigs.

In response to this situation, the Government of Toba Samosir through the Department of Food Security and the Department of Agriculture issued an appeal to the public to be able to watch and observe each animal, and report to the relevant department if it is found that attack symptoms to be given a minimum of anticipatory action to minimize the risk.

(Continue . . . )

And this one from Faseberita:

Beware of breeders Advised ASF Virus Spreading

Tobasa, FaseBerita.ID - Outbreaks of swine disease known as African Swine Fever (ASF) is estimated to have arrived in Asia, including Indonesia. ASF disease is contagious and deadly disease in pigs.

It is directly addressed by the Government of Toba Samosir (Regency Tobasa) through the Food Security Agency (Ketapang). Where the Head of Darwin Sianipar Tobasa appealed to all communities in order to observe and examine every cattle feed pigs, is already contracted deadly.

(Continue . . . .)

Other media reports, such as this one dated today from Sinar Indonesia, suggest ASF could be the cause, but caution that:

"We have not been able to conclude whether for HOQ Cholera virus or other viruses. We are still waiting for lab results that have been sent to the Center of Animal Husbandry in Medan and Bogor," he explained.

The jury may still be out, but ASF continues to be a prime suspect.

Indonesia is primarily a muslim country, but produces roughly 8 million pigs a year, primarily for consumption by ethinic Chinese and Christian tribes. 

While the economic impact of ASF in Indonesia would be limited compared to that sustained by larger pork consuming nations, its arrival would signal yet another substantial geographic expansion of the disease.

Stay tuned.

Grid Down Solar Solutions On A Budget

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Later today California's PG&E - for the 3rd time in 3 weeks - will shut off power to a large area of Northern California, in an attempt to avoid sparking additional wildfires during a forecasted  high wind event.  

As many as 2 million customers may be without power for 48 hours or longer.  And by the look of things, this is a problem that is likely to be repeated  for years to come.

Having been a user of solar power for more than 30 years, including in off-the-grid settings (aboard two cruising sailboats), and living in Hurricane country, where prolonged power outages are common, I've crafted some inexpensive solar power hacks to make life more bearable when the grid goes down.

No, I don't have a $30,000 whole house solar setup; one which feeds power back to the electric company for a credit on my power bill.  While that may make economic sense for some, it isn't practical for me.

And most of those setups lack one all-important ingredient; a way to provide power to your home when the power grid is down.  Without a charged (and solar rechargeable) battery system, even with thousands of dollars worth of solar panels on your roof, you're dead in the water.

The argument against maintaining a battery bank has always been the cost (often $10K-25K), and the fact that they require maintenance, and can wear out over time.  For most people that doesn't make sense.

But that is only if you want to run your whole house (still, only for a limited number of hours), off your solar-rechargeable batteries. There are solutions for a fraction of the cost, that can at least run LED lights, fans, radios, and keep your cell phones, tablets, and laptop computers charged.

No, you won't be running your A/C, or big screen TVs, freezers or refrigerators.  But you won't be dropping $25K to 50K, either. 

At its simplest, a solar panel battery setup is very easy to build.  You can buy everything you need for $200 to $300, and can install it in a day.  As shown below, all you will have is a 12 volt power source (battery), but add a cheap inverter, and you can have 120 volts. 

Most solar panels generate 14 to 17 volts, enough to charge a 12 volt battery, and their ability to charge is rated in watts. A small 15-watt panel generates 15 watts of electricity at roughly 15 volts each hour. This is roughly the equivalent of 1 amp of charging per hour into your battery. 

Larger (more expensive) panels may produce 30, 40, 80, 120 watts of power (or more). For each 15 watts, think (roughly) 1 additional amp/hr. A 60-watt panel would therefore generate about 4 amps per hour during prime sunlight hours (usually about 5 to 6 hours a day).

The very good news is the cost of solar panels has dropped dramatically in recent years. You can often find a 100 watt panel now for less than $1 a watt. Figure another $100 for a deep cycle 12 volt battery, a $20 charge controller, and a $30 inverter, and you've got a bare bones system.

You can, of course, expand this system with additional solar panels, a bigger bank of batteries, and a more powerful inverter. A substantially more robust system might run you between $500 and $1000. 

Or, if your needs are modest (as are mine), you can go even smaller.

Earlier this summer I wrote about some less powerful off the shelf solutions, and detailed how I built a sub-$100 battery backup for my home (see Preparedness: Some Emergency Power Solutions).  Some excerpts from that blog:

The first, easiest, and least expensive option is to buy one or more solar powered USB batteries (see below). While the most limited in terms of what they can power (and for how long), these are ideal for those who need a light weight bug-out friendly solution, or for anyone who isn't comfortable with the more complex systems that follow.

Battery, Solar Panel, Fan & Light - About $50.

A 10,000 milliamp battery with (3 fold) solar panel, a USB fan, and USB LED light. The beauty of this system is it will fit in a bug out bag, weighs about 2 lbs, and while the solar charging will be slow and you'll have to be judicious with their use, it should keep phones, lights, Tablets, MP3 players, and fans going for a few days.  Longer if you don't need the fan.

 

(Note: Newer products now have 20,000 and 25,000 milliamp batteries and larger (4 fold) solar panels)

Following our recent week-long power outage from Hurricane Irma in 2017, I've given this exact setup to several friends. It's cheap, lightweight, and dead simple to use. I have a couple of them myself, tucked in my bug out bags.

Following Irma I've also built a couple of `portable' power banks, which I keep constantly charged using a trickle charger. These weigh about 30lbs each, so they aren't exactly `backpack friendly',  but they provide considerable more power than the USB batteries pictured above.

Although a full sized deep cycle battery can be used, to save my aching back I've elected to go with smaller, lighter, and less expensive lawn mower batteries. I built two, which allow me to charge one (using a solar panel), while I draw power from the other.

Note:  Solar power purists right now are probably foaming at the mouth, as the standard lead-acid batteries I'm using are not ideal for this type of system. And if I were designing a permanent off-grid system, I would agree. But this is for emergency standby power, not long-term use, and so I've elected to go with the most accessible, and least expensive options.

I keep these on a shelf on my (well ventilated) screened lanai and check the water levels every few weeks. In two years, I've added distilled water once.

Small (10 watt to 20 watt) solar panels can be had for under $40, which should be adequate for the smaller batteries. If you go with the bigger deep cycle batteries, consider getting a bigger panel with a charge controller.

While none of these solutions will provide enough power to run major appliances, central heat and air, or other high wattage devices, they can make life a little easier when the grid goes down.  

And you'll be surprised how much you'll appreciate the simple things - like having lights, a fan, your cell phone, or a radio - after the grid has been down for 24 hours. 

And you don't have to live in California, or in hurricane country, to find yourself unexpectedly in the dark.

Between our ageing infrastructure (see ASCE report card on America’s infrastructure), natural disasters like earthquakes and severe weather, disruptions caused by solar flares (see NASA: The Solar Super Storm Of 2012), and even cyber attacks (see DHS: NIAC Cyber Threat Report - August 2017), the odds are that a prolonged outage is in your future. 

Not quite a year ago, in NIAC: Surviving A Catastrophic Power Outage, we looked at a NIAC (National Infrastructure Advisory Council) 94-page report that examines the United State's ability to respond to and recover from a widespread catastrophic power outage.

https://www.hsdl.org/?view&did=819354

While the solar hacks presented above won't make life luxurious during a prolonged power outage, the could make life a little less miserable.  And that, to me, is worth doing.

CDC Early Release MMWR & Telebriefing On Acute Lung Injuries LInked To Vaping (Oct 25th)

Credit CDC

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The CDC's investigation into unexplained acute pulmonary illnesses linked to using e-cigarettes (see CDC Clinical Action: Unexplained Vaping-Associated Pulmonary Illness) continues, and as of this week at least 1605 cases have been identified, and 34 deaths.

Although the numbers remain relatively low - and this week's increase is smaller than previous weeks -  it is too soon to know if the trajectory of this outbreak is leveling off.

There are also concerns over how this winter's cold and flu season will affect numbers, as viral infections could exacerbate (or be exacerbated by) pre-existing lung damage from vaping.

While THC containing vape `juice'  has been implicated in a large number of cases, 10% of cases (self) report only using nicotine based products. The jury is still out on what substance - or substances - are inflicting acute lung damage among those using e-cigs.

First a link, and a brief summary from this week's MMWR release.

E-cigarette Use, or Vaping, Practices and Characteristics Among Persons with Associated Lung Injury — Utah, April–October 2019

Weekly / October 25, 2019 / 68(42);953–956

On October 22, 2019, this report was posted online as an MMWR Early Release.

Nathaniel Lewis, PhD1,2; Keegan McCaffrey2; Kylie Sage, MS2; Chia-Jung Cheng, PhD2; Jordan Green, MPH2; Leah Goldstein2; Hillary Campbell2; Deanna Ferrell, MPH2; Nathan Malan, MPH2; Nathan LaCross, PhD2; Alejandra Maldonado, PhD2; Amy Board, PhD1; Arianna Hanchey, MPH3; Dixie Harris, MD4; Sean Callahan, MD5; Scott Aberegg, MD5; Ilene Risk, MPH6; Sarah Willardson, MPH7; Amy Carter8; Allyn Nakashima, MD2; Janae Duncan, MPA2; Cindy Burnett, MPH2; Robyn Atkinson-Dunn, PhD2; Angela Dunn, MD2

Summary

What is already known about this topic?

An outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI) of unknown source is ongoing in the United States.

What is added by this report?

Medical abstractions were completed for 79 Utah patients, 53 of whom were interviewed. Almost all patients reported using tetrahydrocannabinol (THC)-containing vaping cartridges. Most patients were hospitalized, half required breathing assistance, many reported preexisting respiratory and mental health conditions, and many identified as current or former smokers of combustible marijuana or tobacco. Most THC-containing products, acquired from six patients and, tested at Utah Public Health Laboratory, contained vitamin E acetate.

What are the implications for public health practice?

At present, persons should not use e-cigarette, or vaping, products containing THC. In addition, because the specific cause or causes of lung injury are not yet known and while the investigation continues, persons should consider refraining from use of all e-cigarette, or vaping, products.

(Continue . . . .)

The most recent outbreak numbers:

Updated October 24, 2019 at 1:00 PM EDT

What We Know 

 

About the Outbreak:

• As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory.
  • Thirty-four deaths have been confirmed in 24 states
  • Latest outbreak information is updated every Thursday.

About Patient Exposure:

• All EVALI patients have reported a history of using e-cigarette, or vaping, products.
  • THC is present in most of the samples tested by FDA to date, and most patients report a history of using THC-containing products.
  • The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak.

What We Don't Know

• At this time, FDA and CDC have not identified the cause or causes of the lung injuries in these cases, and the only commonality among all cases is that patients report the use of e-cigarette, or vaping, products.
• No one compound or ingredient has emerged as the cause of these illnesses to date; and it may be that there is more than one cause of this outbreak. Many different substances and product sources are still under investigation. The specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown at this time

         (Continue .  .  .)


And lastly, we have the audio file and transcript from the CDC's (approx. 40 mins) Telebriefing (Friday, 1pm) on this outbreak:

Transcript of CDC Telebriefing: Lung Injury Investigation

Press Briefing Transcript

Friday, October 25, 2019

Audio recording [MP3 – 6 MB]

Please Note: This transcript is not edited and may contain errors.