Hong Kong & Taiwan Take Notice Of Unidentified Pneumonia Outbreak In Wuhan

Wuhan pneumonia prevention and promotion - Credit Taiwan CDC

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Just before 6pm local time (5am EST), Hong Kong's CHP posted a statement on the story we've been following for the past few hours (see here and here) ; an outbreak of an - as yet - unidentified viral pneumonia in Wuhan, China.

We seem to be in echo chamber mode, as each statement adds little we hadn't heard before.

For now, there is very little solid information, beyond the fact that more than 2 dozen cases are hospitalized in Wuhan, and no cause has been identified.  We've two translated statements - the first from Hong Kong's CHP , followed by one from Taiwan's CDC.

CHP closely monitors cases of Mainland pneumonia cases

　　The Centre for Health Protection of the Department of Health is closely monitoring the pneumonia cases in Wuhan, Hubei Province today (December 31), and has contacted the National Health and Health Commission for further information.

　　According to the Hubei Provincial Health and Health Committee's announcement, Wuhan has recently confirmed multiple cases of pneumonia related to a local seafood market, "South China Seafood City." The Wuhan Municipal Health and Health Committee has launched an investigation. Currently, 27 cases have been found, of which seven are in serious condition and the rest are stable. The symptoms of the case were mainly fever, and a few patients had difficulty breathing. At present, all patients have been treated in isolation, and follow-up investigations and medical observations of close contacts are ongoing.

　　According to the announcement of Wuhan Municipal Health and Health Committee, relevant experts analyzed that the above cases were viral pneumonia. So far, the investigation has not found any obvious human-to-human transmission or infection by medical personnel. Detection of the pathogen and investigation of the cause of the infection are still ongoing.

　　Locally, the CHP has developed a series of measures to monitor and control infectious diseases, and will remain vigilant, working closely with the World Health Organization and relevant health departments to monitor the latest developments.

　　The Port Health Section of the Center for Health Protection has been implementing health monitoring measures at various entry and exit ports, and has infrared cameras to monitor the temperature of immigrants. If a case of suspected severe infectious disease is found, it will be immediately referred to a public hospital for isolation and follow-up. The Center for Health Protection has notified the Hospital Administration of the pneumonia case group in Wuhan.

　　The CHP reminds passengers that if they have respiratory symptoms, they should wear a mask and seek medical advice, and report their travel history to the doctor. The Center for Health Protection will continue to closely monitor the latest situation of Wuhan pneumonia cases, and update monitoring guidelines and testing strategies in accordance with the situation.

　　To prevent pneumonia and respiratory infections, citizens must always maintain good personal and environmental hygiene, including:

• Always keep your hands clean, especially before touching your mouth, nose, or eyes; after touching public facilities such as handrails or door handles; or when your hands are contaminated with respiratory secretions, such as after coughing or sneezing.

• When washing your hands, clean your hands with soap and water, rub your hands for at least 20 seconds, rinse with water and dry with a tissue or a cell phone. If there is no hand-washing facility or there is no obvious dirt on the hands, it is also effective to clean the hands with 70 to 80% alcohol hand rub.

• Cover your mouth and nose with paper towels when sneezing or coughing. Dispose of used paper towels in a covered dustbin, then clean your hands thoroughly.

• When symptoms of respiratory tract infection occur, surgical masks should be worn instead of going to work or school. Avoid going to crowded places and seeing a doctor as soon as possible.

　　Citizens should pay attention to the following precautions when traveling abroad:

• Avoid contact with birds or their dung, and go to wet goods markets, live poultry markets or farms.

• Avoid close contact with patients, especially those with symptoms of acute respiratory infections.

• Pay attention to food safety and hygiene, and avoid eating or drinking raw or undercooked animal products, including milk, eggs, and meat, or foods that may be contaminated with animal secretions, excreta (such as urine), or products, unless Cook, wash or peel properly.

• When you are out of the country, if you are unwell, especially if you have a fever or cough, you should wear a surgical mask, immediately notify the hotel staff or tour leader, and seek medical treatment as soon as possible.

• If you have a fever or other symptoms after returning to Hong Kong from a foreign country, you should consult a doctor immediately, tell the doctor where you have recently visited, and wear surgical masks to prevent infection.

Ends
/ Tuesday, December 31, 2019
17:55 Hong Kong time

And this from Taiwan's CDC:

In response to the outbreak of pneumonia in Wuhan, Mainland China, the CDC has continued to implement border quarantine and boarding quarantine for Wuhan inbound flights

Release Date: 2019-12-31

Regarding a number of cases of pneumonia reported in Wuhan, Mainland China, the CDC has confirmed the epidemic information to the Mainland China Centers for Disease Control and Prevention and the World Health Organization (WHO) IHR window today (31). In the evening, Lu Fang sent experts to Wuhan in response. Conducted pathogen detection and investigation of the cause of infection, and provided information released by the Wuhan Municipal Health and Health Committee on December 31, stating that 27 cases of pneumonia were recently discovered in the local area and 7 cases were critically ill. 

All of them have been treated in isolation and 2 cases have improved. The clinical manifestations are mainly fever, a few patients have difficulty breathing, and have bilateral lung infiltrative lesions. Most of the cases were operated by South China Seafood City, Jianghan District, Wuhan City. No obvious human-to-human transmission and medical staff infection have been found. Lu indicated that if there is further information, he will inform us in time.

In response to the epidemic of pneumonia in Wuhan, Mainland China, in order to prevent cases from moving abroad, China has initiated contingency measures for border quarantine in accordance with standard operating procedures, strengthened fever screening for inbound tourists, implemented travel history, occupation type, contact history of suspected cases, Inquiries about the gathering situation, health assessment and health education, the assessment of the epidemic can be effectively prevented from overseas, but for the sake of prudence, boarding and quarantine will be carried out for flights departing directly from Wuhan, Mainland China, except for proactive assessment of passenger health In addition to this situation, relevant preventive measures were also introduced to passengers on the flight.

The Department of Disease Control will continue to monitor the epidemic situation in Wuhan, Mainland China, and adjust the prevention and control according to the epidemic situation. As the local epidemic situation is not yet clear, the public is urged to receive information on unknown or unproven epidemic situations. Do not distribute or repost it at will. Article 63 of the Law on the Prevention and Control of Infectious Diseases stipulates that the spread of rumors or false information about the epidemic situation of infectious diseases, which is caused to the public or others in full, is subject to a fine of up to NT $ 3 million; and in accordance with the Law on the Maintenance of Social Order Article 63, paragraph 5, provides that those who spread rumors enough to affect public peace may be detained for less than three days or fined less than NT $ 30,000.

The Department of Disease Control stated that in addition to the flu epidemic season, winter is also a period of pneumonia. It reminds the public to take good personal hand hygiene and cough etiquette, and try to avoid crowded and airless public places. People in the Wuhan area of ​​mainland China who have fever or acute respiratory symptoms within 10 days of returning to China should take the initiative to report the 1922 epidemic prevention line and wear a mask to seek medical treatment as soon as possible. When seeking medical treatment, please actively inform the history of tourism activities, timely diagnosis notification and obtain a complete Medical care.

China: Hubei Provincial Health Committee Statement On `Unidentified' Pneumonia In Wuhan

Credit Wikipedia


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It's been about six hours since the news broke about an unidentified `viral pneumonia' outbreak in Wuhan City, the capital  of Hubei Province (see China: 27 Cases of `Atypical Viral Pneumonia' Reported In Wuhan, Hubei), and while the media and twitter are full of reports, official statements have been hard to find.

After several attempts I was finally able to access  the Hubei Provincial Health Committee's website and translate their official statement.

While it doesn't tell us any more than we already knew, it at least has the advantage of being an  `official' statement.  The facts remain essentially the same;  27 cases, 7 in serious condition.  All isolated. And the identify of the viral pathogen yet to be determined.

Municipal Health and Health Commission's briefing on the current pneumonia epidemic situation in our city

Recently, some medical institutions found that many of the pneumonia cases received were related to South China Seafood City. After receiving the report, the Municipal Health and Health Commission immediately launched a case search and retrospective investigation related to South China Seafood City in the city's medical and health institutions. Twenty-seven cases have been found, of which 7 are in serious condition, and the remaining cases are stable and controllable. Two patients are expected to be discharged in the near future.

The clinical manifestations of the cases were mainly fever, a few patients had difficulty breathing, and chest radiographs showed bilateral lung infiltrative lesions. At present, all cases have been isolated for treatment, follow-up investigations and medical observations of close contacts are ongoing, and hygiene investigations and environmental sanitation disposals for South China Seafood City are ongoing.

Wuhan organized consultations with clinical medical, epidemiological, and virological experts from Tongji Hospital, Provincial CDC, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan Infectious Diseases Hospital, and Wuhan CDC. According to the analysis of epidemiological investigations and preliminary laboratory tests, the above cases are considered to be viral pneumonia. Investigations so far have not revealed any apparent human-to-human transmission or infection by medical staff. Detection of the pathogen and investigation of the cause of the infection are ongoing.

Viral pneumonia is more common in winter and spring, and can be spread or outbreak. The clinical manifestations are fever, soreness, dyspnea in a small part, and lung infiltration. Viral pneumonia is related to the virulence of the virus, the route of infection, and the age and immune status of the host. Viruses that cause viral pneumonia are common with influenza viruses, others are parainfluenza virus, cytomegalovirus, adenovirus, rhinovirus, and coronavirus. Confirmation depends on pathogenic tests, including virus isolation, serological tests, and viral antigen and nucleic acid tests. The disease is preventable and controllable, and indoor air circulation can be prevented to prevent closed and airless public places and crowded places. Masks can be worn when going out. Symptomatic treatment is the main clinical practice, and bed rest is required. If you have the above symptoms, especially the persistent fever, you should go to the medical institution in time. (Wuhan Municipal Health Committee)

My thanks once again to the newshounds of FluTrackers (and a 0030 hrs Alert from Sharon Sanders) for a head's up on this story.   You'll find the FT thread China - 27 viral pneumonia / suspected SARS? cases in Wuhan, Hubei province - December 31, 2019, already has a half dozen reports.

China: 27 Cases of `Atypical Viral Pneumonia' Reported In Wuhan, Hubei

Wuhan - Credit Wikipedia

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While it may turn out to be something relatively innocuous , the dedicated newshounds at FluTrackers began posting numerous reports out of China a little before midnight (EST) on an outbreak of an - as yet - unidentified viral pneumonia in Wuhan; the capital and largest city (pop. 11 million) in Hubei Province.

SARS - not unexpectedly - is being widely mentioned in both Chinese and international media reports as a possible cause, but recent media reports indicate that local officials are downplaying that notion. 

This report from RTHK.HK.

          (translation)

Internal media quotes Wuhan CDC staff saying viral pneumonia case is not related to SARS

2019-12-31 HKT 14:00
Viral pneumonia broke out in Wuhan, 7 of which were critically ill. Most of the cases came from merchants in Wuhan South China Seafood City. Experts from the National Health Commission arrived in Wuhan for testing and verification. Southern Metropolis Daily quoted a staff member of the Wuhan Centers for Disease Control and Prevention as saying that it had nothing to do with SARS.

Staff also said that receiving reports of related pneumonia cases is relatively common and many pathogens may cause it. Some patients have a relatively long course of disease, and there is a process of testing, which is being fully investigated. It should be announced in the past two days. According to the information circulating on the Internet, the staff said that there are many types of pneumonia, and the country will monitor it every year, saying " Don't worry at all, you can say responsibly that it has nothing to do with SARS. "

People's Daily quoted news reports that since this month, Wuhan has confirmed 27 cases of viral pneumonia, all of which are viral pneumonia or lung infections, and the authorities are conducting tests, isolation treatment and disinfection. Many people in Wuhan Hospital believe that the current cause is not clear, and it cannot be concluded that it is the SARS virus rumored online. Other severe pneumonia is more likely. Even SARS virus has a mature prevention and treatment system, and the public need not panic.

The Wuhan Municipal Health and Medical Commission's Medical Affairs and Medical Administration Department issued an urgent notice, requiring some medical institutions to make statistics and report treatment in a timely manner.

Another report, this time from Zaobao.com, provides additional `official' reassurance, citing `no significant human-to-human transmission'.  Reports suggest that the bulk of the cases so far are among merchants in Wuhan South China Seafood City, which could indicate either H-2-H transmission or a shared environmental exposure.

Wuhan Bulletin: Preliminary analysis shows no significant human-to-human transmission of viral pneumonia

Posted / December 31, 2019 2:27 PM
Update / December 31, 2019 2:45 PM

The Wuhan Municipal Health and Health Committee issued a notification on the pneumonia epidemic. The preliminary analysis of the cases was viral pneumonia. All cases have been isolated for treatment, no obvious human-to-human transmission has been found, and no medical staff infection has been found.

According to the "Beijing News" report, Wuhan Health and Health Commission has released news that 27 cases have been found, seven of which are in serious condition, and the remaining cases are stable and controllable. Two patients are expected to be discharged in the near future.

The clinical manifestations of the cases were mainly fever, a few patients had difficulty breathing, and chest radiographs showed bilateral lung infiltrative lesions.

Since we don't have a timeline indicating how long this outbreak has been going on, a lack of infected medical staff may, or may not, be significant.  `Bad news', particularly when it involves disease outbreaks, often takes time to filter out of China, and is almost always presented in the best `light'.

One of the Chinese phrases we in flublogia keep an eye out for is `非典型肺炎'  - aka Atypical Pneumonia - and it is currently lighting up Twitter and Chinese language media sources.  

Even if - as the RTHK report above suggests - that SARS is not a reasonable suspect, there are a number of other novel coronavirus contenders we are keeping an eye on in China (see PNAS: SARS-like WIV1-CoV Poised For Human Emergence).

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 - also in Hebei Province -  but it was quickly identified as Ad55 (see China Denies Internet Rumor Of SARS Outbreak and China: Hebei Outbreak Identified As Adenovirus 55).

A novel flu is also a possibility, although by now they ought to have at least narrowed it down to an influenza A virus. 

In February and March of 2013, however, several cases of `atypical pneumonia' were hospitalized in Anhui and Shanghai province, and it took several weeks before it was revealed that they were the first victims of a newly emerged avian H7N9 virus (see  China: Two Deaths From H7N9 Avian Flu).

Whatever this turns to be (and the possibilities are myriad at this point), it comes just weeks before the start of Chunyun, or the Spring Festival travel season - which begins about 15 days before the Lunar New Year (Jan 25th).

Lasting about 40 days, Chunyun marks the largest annual human migration in the world. Hundreds of millions of people - primarily in China, but also across much of Asia - will travel home (mostly via crowded rail and bus) for a traditional family gathering. 

Monitored closely every year due to its potential for spreading infectious diseases, thus far - very much like the Hajj - this period of intense travel has yet to spark a major epidemic. 

As of 0345 hrs EST, Hong Kong's CHP, Taiwan's CDC, and  Macao's government portal have not reported on these cases.  FluTrackers and I will continue to monitor Chinese language and English language reports, and we'll update this situation when more become known.

Stay tuned. 

CDFA: A Resurgence Of Virulent Newcastle Disease In Southern California Poultry

Southern California Quarantine Area

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Six months ago, California's year-long battle against Virulent Newcastle Disease - which began in May of 2018 (see APHIS: USDA Confirms Virulent Newcastle Disease In Backyard Flock - California) - appeared all but over.

After 440 cases were confirmed during the first 12 months - and more than a million birds culled - only 4 cases would be reported between June 1st and November 15th of 2019.

Newcastle disease only poses a minor threat to human health - on rate occasions causing mild flu-like symptoms and/or conjunctivitis -  but it can be up to 100% fatal in poultry, and remains a serious threat to poultry interests world wide.

An outbreak in 1971 that began in Southern California led to the culling of 12 million birds and a loss of tens of millions of dollars while the last outbreak in 2003 led to the depopulation of 3.16 million birds at a cost of $161 million (cite). 

The hard fought campaign against Newcastle in Southern California appeared to be be won until six weeks ago, when - after more than 2 months without a case -  5 new outbreaks were reported in the second half of November.  This has been followed by 14 new outbreaks in December (see chart below).

As of December 27, 2019, USDA has confirmed 470 premises in California as infected with vND, including 262 in Riverside County, 158 in San Bernardino County, 46 in Los Angeles County, 1 in Ventura County, 1 in Alameda County, and 1 in San Diego County. USDA also confirmed 1 infected premises in Utah County, Utah and 1 infected premises in Coconino County, Arizona.

A week ago, the CDFA released the the following statement on this sudden reversal.

December 23, 2019

Virulent Newcastle Disease Update from State Veterinarian Dr. Annette Jones
Over the past month, Virulent Newcastle disease cases have increased because people have violated the CDFA VND Regional Quarantine by moving infected birds or contaminated equipment and secondary spread to neighboring flocks. We now have 20 new cases under investigation, all linked to the recent Bloomington area outbreak. Most of the cases are in San Bernardino County, with two in Riverside County and one in Los Angeles County. Backyard flocks as well as retail pet/feed stores are involved.

Based on phylogenetic analysis and epidemiologic studies, we understand how the disease spreads in Southern California. This highly contagious virus has been spread when people move exposed birds or equipment, or when people carry the virus to their own unfortunate flock on their hands and feet. It moves long distances as people illegally move birds or equipment. When introduced to a new area, it is amplified as the previously uninfected poultry succumb until the environmental virus load is so great, the outbreak spreads from yard to yard. Exposed poultry around a newly infected flock are the “virus amplifiers,” particularly just before they show signs of disease.

Put simply, your birds can spread the disease before they show symptoms, so the only way to stop it is to not move birds – period – if you are in the CDFA Regional Quarantine Area. 

As a reminder, last year the disease was spread from San Bernardino to LA and Riverside counties and beyond, leading to widespread highly infected areas, infected poultry farms, the death of over 1.2 million birds, and significant financial and emotional strain on poultry owners and disease control agencies.

We need your help to stop the spread of this virus and end this outbreak. Specific actions you can take to protect the poultry in your community are on the CDFA VND website in our biosecurity videos, guidance documents and links, but general keys to success include: 

• DO NOT move poultry or poultry equipment within the VND Regional Quarantine without a CDFA permit.
• DO NOT let anyone with birds near your poultry.
• DO NOT accidentally bring this virus home to your flock on your clothes, hands, feet or equipment.

Please work together to ensure we do not see this outbreak grow as it did in 2018. Stopping the spread will take the combined effort of all bird owners. Talk to your neighbors and friends. Keep Southern California safe for poultry!

Just as with epidemic diseases in humans, the risks of seeing foreign animal diseases imported into this country continue to rise as international travel, and trade, increases.

While most of these diseases don't directly impact human health, some of them - like avian influenza, Anthrax, Brucellosis, Japanese encephalitis, Crimean Congo hemorrhagic fever, and Rift Valley Fever - can pose a threat to public health.

For a long (and growing) list of notifiable animal diseases, you may wish to peruse the USDA's Notifiable Diseases and Conditions webpage.

Taiwan Reports Another Outbreak Of HPAI H5N5

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A little over 3 months ago Taiwan Reported their 1st outbreak of Avian H5N5 virus at a duck farm in Kaohsiung, a city in southern Taiwan. Initial government reports suggested this was likely a one-off event - and that the virus had not spread - but this has since proved overly optimistic.

A second outbreak occurred in adjacent Pingtung county two weeks later (see Taiwan BAPHIQ: 2nd Outbreak Of HPAI H5N5), indicating that the first detection was not (as first hoped) a solitary event and a third detection at a Taipei City Abattoir was reported in mid-October (see OIE Report).

Ten days ago we saw a 3rd outbreak at a chicken farm in Yanpu Township, while today we learn of a 4th outbreak - this time in in Tainan City - which has resulted in the culling of more than 8,000 chickens. 

This (translated) press release from the Tainan City government website:

Mayor Huang enters the period of avian flu outbreak, asks the animal protection department to actively prevent epidemics

Tainan City culled the second bird flu case chicken of the year this year (29). It was confirmed to be H5N5 subtype avian influenza. A total of 8,209 black feather chickens were culled. Tainan Mayor Huang Weizhe instructed the Agriculture Bureau ’s animal protection department to take active precautions. The epidemic has spread, and poultry farmers are required to strengthen biosecurity and epidemic prevention, implement disinfection, heat preservation and ventilation, and personnel entry and exit control of the environment inside and outside the poultry farm to prevent the epidemic from leaking and avoid the recurrence of immunity.

After receiving the active notification from the poultry farm animal owners, the Tainan Municipal Government ’s Animal Health Protection Department immediately operated in accordance with standard operating procedures, and immediately executed culling treatment when the highly pathogenic avian influenza was diagnosed. All diseased chickens on the farm were culled and transported to incineration. The furnace was destroyed, and there was no doubt that it would flow into the market. The public can safely eat poultry meat. The H5N5 avian influenza subtype detected this time is the fourth case of avian influenza cases in Taiwan this year.

The possible source is the existence of H5N2 virus in Taiwan at this stage and the reorganization of HXN5 virus carried by wild birds, but it cannot be completely ruled out. Then, it is speculated that this subtype may be transmitted from neighboring counties and cities to Tainan by means of human, vehicle and other bird and bird transmission.

Mayor Huang Weizhe said that in order to prevent the spread of the epidemic, he has instructed the Animal Health Protection Division of the Agricultural Bureau to urgently start various intensified epidemic prevention measures and mobilize veterinary manpower to conduct a comprehensive sampling inspection and epidemic visits to poultry farms within a radius of 3 kilometers around the case site. The high-risk poultry farms around the case farms are monitored, and guidance is provided to poultry farmers to strengthen protective measures to truly prevent the risk of avian influenza virus invasion, and provide disinfectants for self-prevention and disinfection of poultry farms within a radius of 3 kilometers. Continue to dispatch disinfection vehicles to strengthen the spray disinfection work in the surrounding areas of poultry farms in this city, to minimize the virus in the environment, and to avoid another epidemic in this city.

Huang Weizhe reminded that the bird flu epidemic in Taiwan continued to occur. So far this year, 82 cases of highly pathogenic bird flu have occurred. The bird flu season is now entering the winter season. The weather in the south has a large temperature difference and it has recently rained and wet. Even more in place, poultry farmers must not relax their epidemic prevention work. They must implement biosecurity measures in their poultry farms and prevent pathogens such as bird flu from invading. The Tainan City Government will also strengthen various epidemic prevention measures to assist the industry to jointly prevent the epidemic situation. Happen again.

The origins of this reassorted HPAI H5N5 virus are still under investigation, so we don't know if this  virus comes from a local reassortment, is an imported virus carried in by migratory birds, or the product of an LPAI-to-HPAI mutation.

HPAI H5 viruses - particularly those of clade 2.3.4.4. - have shown a propensity to reassort with other local LPAI viruses. 

During Europe's 2016-2017 avian H5N8 epizootic, we saw a handful of `spinoff' reassortants, including an HPAI H5N5 (see ESA: Epidemiological Update On H5N8/H5N5 In Europe). While H5N5 briefly appeared in nearly a dozen countries, it appeared to fizzle after the spring of 2017, with another reassortment - H5N6 - returning the following year in both Asia and Europe.

Normally, after three months and 4 outbreaks, we'd have a better idea of the genetic make up of a newly emerged virus than we have right now.  Hopefully that information will be forthcoming sooner rather than later.

ICYMI: The Passing Parade - Pt. 5

Note: During the last half of December, and the first week of January, news and new journal articles are often in short supply. During this time I like to do a review of research papers we've looked at over the past year.  

You'll find the first 4 entries in this year's series here, here, here, and here. 

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Last May - while we were following the 2nd unusual detection of H1N2 in Europe in a year, the first (and only) admission of African Swine Fever in North Korea,  the spread of an unusually virulent LPAI H3N1 among Belgian poultry, an imported case of Monkeypox in Singapore, and Nepal's 1st H5N1 human infection -  we also looked at a number of research articles, including:

Emerg. Microbes & Inf.: Bactrian Camels Shed Large Quantities of MERS-CoV After Experimental Infection

Bactrian Camel – Credit Wikipedia

Dromedaries and Bactrian camels share some limited geographic regions, so the potential of MERS-CoV spreading to Bactrian camels - and thereby extending its threat to other human populations - is obviously a concern.

A 2015 Research letter in the EID Journal  reassuringly found an Absence of MERS-Coronavirus in Bactrian Camels, Southern Mongolia, November 2014.

In this new study, published in Emerging Microbes & Infections, researchers from NIAID and the Department of Biomedical Sciences at Colorado State University, inoculated two Bactrian camels and monitored them for nasal shedding and seroconversion.

Despite the current lack of field evidence of MERS-CoV infection in Bactrian camels, this study demonstrates that Bactrian camels can be readily infected and shed large quantities of virus in nasal secretions. If MERS-CoV were to be introduced into populations of Bactrian camels, we would expect that a potential endemic and sustained pattern of infection may result and they could act as a reservoir, similar to dromedaries, potentially exposing associated human communities to infection.

Hong Kong CDW: A Review of Psittacosis in 2018-2019

Psittacosis - often called parrot fever - is a rarely reported, atypical bacterial pneumonia caused by Chlamydia psittaci. The CDC cites an average of 10 cases of Psittacosis reported each year in the US, although many others may go undiagnosed. 

Hong Kong, with a population of roughly 7 million, reported psittacosis infections last year (n=17) at a per capita rate roughly 70 times greater than the United States, and has already reported 7 cases in the first 4 months of 2019.

Human infection, at least until recently, has been solely attributed to direct or indirect contact with infected birds. But in 2012, the journal Eurosurveillance carried a report called Psittacosis outbreak in Tayside, Scotland, December 2011 to February 2012, involving four family members and a health-care worker, which suggested human-to-human transmission.

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

This blog covers not only the Hong Kong review, but several other pertinent scientific reports.  

Eurosurveillance: The re-emergence of HPAI H7N9 Human Infection in Mainland China, 2019

Following China's massive H5+H7 poultry vaccination campaign of 2017, we saw the incidence of human infection with H7N9 plummet. In April of 2017, China reported their first confirmed case in a year, and in this Eurosurveillance report we learn that re-emergent virus has accrued a number of worrisome mutations during this lull.       

The H7N9 viruses isolated from the patient, and poultry from around his home, carried changes in the HA that may reduce the effectiveness of current vaccines, and a number of mutations that may increase adaptation to mammalian hosts.

From the report:

No H7N9 human cases was reported since February 2018. However, in late March 2019, we identified one HPAI H7N9 human case with fatal outcome, and HPAI H7N9 viruses with high genome identity to those of the case were detected from environmental samples. Together, these HPAI H7N9 viruses formed a subclade which exhibited a long genetic distance to the previously reported HPAI H7N9 viruses (Figure 1). 

This report suggests that H7N9 viruses might still circulate in poultry at a low level in limited locations. In addition, several immune escape mutations, which had not been detected in previously reported HPAI H7N9 viruses, occurred in the HA1 proteins of these viruses (Table 1). The antigenic features of these HPAI H7N9 viruses may differ from the current HPAI H7N9 candidate vaccine strain.

We saw additional evidence of worrisome changes to the H7N9 virus a week ago in  EID Journal: Antigenic Variant of Highly Pathogenic Avian Influenza A(H7N9) Virus, China, 2019

CDC: Guidance for Human Infections with Swine Flu Viruses

While 2019 proved to be a relatively quiet year, over the past 15 years we've seen more than 460 confirmed human infections with these swine-origin viruses, mostly associated with pig exposure at county and state animal exhibits.

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.

In May, the CDC released updated interim guidance for clinicians who may see suspected swine-variant influenza cases and a CDC Expert commentary was published by Medscape (link).

PNAS: Low Ambient Humidity Impairs Barrier Function & Innate Resistance Against Influenza Infection

Photo Credit PHIL (Public Health Image Library)

   
Although largely anecdotal, there is growing evidence suggesting that raising the humidity inside homes, offices, and health care facilities might be a reasonably effective NPI (Non-pharmaceutical Intervention) during times of heightened flu activity (see PLoS One Humidity as a non-pharmaceutical intervention for influenza A).

Most of the research on this topic has centered on the viability of the flu virus at lower humidity levels, but the impact of lower ambient humidity on the host's ability to fight off infection may also play a role.

With the caveat that the following study was done using mice - which may or may not fairly represent a human response - researchers have found that lower ambient humidity can impair `. . . mucociliary clearance, innate antiviral defense, and tissue repair function'. 

Earlier this year, the World Health Organization declined to recommend modifying humidity as an effective environmental NPI during a pandemic. 

J. Gen. Virology: Mutations in PB2 and HA Enhanced Pathogenicity of H4N6 Avian Influenza Virus in Mice

LPAI H4N6 - which while common in wild and migratory birds - has also been found in Chinese, Canadian (1999) and American swine (see Virology: Detection & Characterization Of Avian H4N6 In Midwestern Swine (2015)), and has been increasingly on our radar. 

In August of 2017, in Cell: Avian-to-Human Receptor-Binding Adaptation by Influenza A Virus Hemagglutinin H4, researchers presented evidence that avian H4N6 viruses can adapt to human receptor cells while in a swine host (using the 1999 Canadian isolate).

This study, published in the Journal of General Virology, takes the H4N6 virus and runs it through a classic serial passage study. After just 12 passages a virulent mouse-adapted virus emerged, with four significant mutations appearing in PB2 (E158K and E627K) and HA (L331I and G453R, H3 numbering).

The E627K substitution in the PB2 protein (swapping out Glutamic acid (E) for Lysine (K)) makes avian influenza viruses better able to replicate at the lower temperatures (roughly 33C) found in the upper respiratory tract of mammals. 

Although the two HA mutations did not individually raise the pathogenicity of the virus, they did so in concert . . . at least in mice.

CDC: The 8 Zoonotic Diseases Of Most Concern In The United States

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

Emerging infectious diseases are considered such an important threat that the CDC maintains as special division – NCEZID (National Center for Emerging and Zoonotic Infectious Diseases) – to deal with them.

The zoonotic diseases of most concern in the U.S. are:

• Zoonotic influenza

• Salmonellosis

• West Nile virus

• Plague

• Emerging coronaviruses (e.g., severe acute respiratory syndrome and Middle East respiratory syndrome)

• Rabies

• Brucellosis

• Lyme disease

Although the CDC targeted just 8 zoonotic diseases of greatest concern in their press release, the full One Health Zoonotic Disease Prioritization report, characterizes 57 zoonotic threats to the United States.

Gansu Health Commission Report On Brucellosis Outbreak At Veterinary Research Institute

Credit Wikipedia

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Three weeks ago, in  China: Outbreak Of Brucellosis Reported At Veterinary Research Institute - Gansu Province,  we saw the first of two high profile (and epidemiologically linked) Brucellosis outbreaks, involving upwards of 100 people.  

The second outbreak, reported 3 days later, came from more than 1300 miles to the Northeast, this time in at the Harbin Veterinary Research facility (see China: Second Outbreak Of Brucellosis Reported (Harbin Veterinary Research).

Brucellosis is a bacterial disease of livestock that can also infect humans. While rarely fatal, it can cause serious and prolonged illness, with symptoms that may may include recurrent fevers, endocarditis, and neurological symptoms.

Three strains of Brucella (Brucella abortus, Brucella melitensis & Brucella suis) have been listed as Select Agents - pathogens that have been deemed to pose a significant biological hazard - and could potentially be used as bioterrorism agents (against both humans and livestock).

All of which makes finding the source of these outbreaks of great importance, particularly since the number of exposed individuals has continued to grow. 

The Health Commision of Gansu Province has recently published a preliminary report that blames a biopharmaceutical company which was producing a Brucellosis vaccine  - and sits in close proximity to the Lanzhou Veterinary Research Institute - for a prolonged, unintentional release of the bacteria into the environment, apparently due to the use of expired disinfectants. 

I've translated and posted some excerpts from a much longer report below.

Report on Investigation and Disposal of Brucella Antibody Positive Event in Lanzhou Institute of Veterinary Medicine, Chinese Academy of Agricultural Sciences

Release time: 2019-12-26 22:00:00 source: office visits: 76615

First, the event summary

On November 28, 2019, two students from the Lanzhou Veterinary Research Institute of the Chinese Academy of Agricultural Sciences (hereinafter referred to as the Lanzhou Veterinary Research Institute) technical team for the prevention and control of foot-and-mouth disease detected Brucella antibodies. On November 29, the number of Brucella antibody-positive members in the team increased to four. Subsequently, the students of the team collectively tested for Brucella antibodies, and successively detected antibody-positive personnel, which led to the worry of all the students studying there. Students go to the hospital or CDC for Brucella antibody testing.

As of 16:00 on December 25, a total of 671 preliminary screening tests for serum Brucella antibodies in students and staff of Lanzhou Institute of Veterinary Research had been conducted, and a total of 181 cases of positive antibodies had been confirmed by laboratory review tests. Except for one antibody-positive person who had clinical symptoms, the rest were asymptomatic and disease-free.

(SNIP)

The investigation team mainly composed of national, provincial and municipal experts implemented the biological safety management system of Lanzhou Veterinary Research Institute and the adjacent Zhongmu Lanzhou Biopharmaceutical Factory, the operation and maintenance of facilities and equipment, and the bacterial toxin species, and the collection, use, and preservation of experimental samples A comprehensive investigation was conducted on the research and production of Brucella, research and production of Brucella. The laboratory building of Lanzhou Institute of Veterinary Medicine, laboratory animals, staff canteens, serum specimens retained during postgraduate admission since 2016, and the surrounding areas of Zhongmu Lanzhou Biopharmaceutical Factory The environment and relevant personnel conducted sampling tests.

Synthesizing the results of investigations and surveys in various aspects, the expert group believes that: from July 24 to August 20, 2019, Zhongmu Lanzhou Biopharmaceutical Factory used expired disinfectants during the production of Brucella vaccine for veterinary use, resulting in exhaust emissions from the production of fermentation tanks. The sterilization is not complete, and the exhaust gas carrying the bacterial fermentation broth forms a bacterial aerosol.

During the production period, the main wind direction in the area is southeast wind. Positive, causing a Brucella antibody positive event at Lanzhou Veterinary Research Institute. The incident was an accidental incident, an exposure that occurred in a short period of time. 

The production plant of Brucella vaccine in China Mulan Lanzhou Biopharmaceutical Factory that caused the incident has ceased production on December 7, 2019.

Since December, Lanzhou University students and faculty members have successively detected antibody positives. At present, a total of 3365 people have been tested. 22 positive Brucella antibodies have been detected with a positive rate of 0.65%. After an epidemiological investigation, 6 of them had In July of this year, he had all activities in Lanzhou Zoological Research Institute, and the remaining positive people were in line with the epidemic trend of brucellosis in Chengguan District of Lanzhou City.

(Continue . . . .)

The report describes Zhongmu Lanzhou Biopharmaceutical Factory as :

. . .  one of the earliest established veterinary vaccine production plants in China. It is a designated manufacturer of compulsory immunized animal disease vaccines issued by the Ministry of Agriculture and Rural Affairs. The Production License is valid. 22 veterinary drug approval numbers issued by the Ministry of Agriculture and Rural Affairs have been obtained, including 2 live brucellosis vaccines, S2 and A19 strains, respectively.

Since 2016, all batches of live brucellosis vaccines produced by Zhongmu Lanzhou Biopharmaceutical Factory have been approved. In 2019, 5 batches of live brucellosis vaccines were randomly selected for quality inspection.

While this appears to answer the question of how nearly 200 people were exposed to Brucellosis (and potentially others, not yet tested in the area), it doesn't explain why a licensed vaccine manufacturer would use expired disinfectants for months, and be unaware they were contaminating their neighbors with a potentially deadly biological agent.

Stay tuned, as there may be additional fallout from this incident in the weeks to come.

ICYMI: The Passing Parade - Part 4

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With news reports and fresh studies often in short supply during the holidays, each year at this time I review some of the infectious disease papers we looked at during the past year.  Too often these studies are published, and then quickly lost in the never-ending deluge of new data.

During the month of April, while we were watching a mystery outbreak in a mining town in Guyana, increasing MERS cases in Saudi Arabia, China's one and only H7N9 case of the year, multiple outbreaks of Equine Influenza around the globe, and another (failed) attempt to have Ebola in the DRC declared a PHEIC (Public Health Emergency of International Concern), we also looked at:

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

While Equine (H3N8) influenza is not currently regarded as a zoonotic threat, it jumped species (to dogs) roughly 16 years ago and has since been show capable of infecting cats (see Equine influenza A(H3N8) virus infection in cats). A review of the history of (H3 & H7) equine influenza suggests it has jumped species - including to humans - in the past, and could do so again. 

From the Abstract:

Equine influenza virus (EIV) is a common, highly contagious equid respiratory disease. Historically, EIV outbreaks have caused high levels of equine illness and economic damage. Outbreaks have occurred worldwide in the past decade. The risk for EIV infection is not limited to equids; dogs, cats, and humans are susceptible.

This is a scenario we looked at previously in 2018 in Equine H3N8: Looking At A long-shot In The Pandemic Sweepstakes. Canine and equine flu are of particular interest because the H3N8 and H3N2 subtypes they carry are similar to pandemic strains of the past .

OFID: Avian H5, H7 & H9 Contamination Before & After China's Massive Poultry Vaccination Campaign

During the summer of 2017 China implemented an emergency experimental poultry vaccination program using a new H5+H7 vaccine, in hopes of stemming the rising tide of H7N9 (and to a lesser extent) H5N6 human infections that threatened a pandemic.

While successful beyond anyone's expectations, vaccines don't always halt disease transmission -sometimes they only suppress it - and that can allow `vaccine escape' variants to evolve and spread (see last week's EID Journal: Antigenic Variant of Highly Pathogenic Avian Influenza A(H7N9) Virus, China, 2019).

Surveillance in Zhejiang Province (China) showed a 90% reduction in H7 virus activity following the vaccination program, but detection of H5 viruses remains pretty much unchanged, while the prevalence of H9N2 viruses had increased significantly. 

The authors concluded:

Despite the sharp decrease in H7 subtype prevalence, reduction measures for avian influenza virus circulation are still imperative, given the high type A prevalence and the increase in H9 subtype contamination across different sampling places and types.

Emer. Microb. & Inf.: Avian Flu Co-Infection in Poultry - Cambodia, 2017–2018 

Credit CDC

Cambodia has a long history of HPAI H5N1 outbreaks in poultry, and human infections, going back to early in the last decade.  In March and early April of this year, both HPAI H5N6 and a new H7N4 virus - similar to one that infected a woman in China in 2018 - were reported to be circulating in Cambodia as well. 

This research letter, published in Emerging Microbes & Infections, describes recent AI surveillance results, and quantifies the level and types of co-infections, found in Cambodian poultry. 

From the Abstract: 

Cambodian LBMs have high levels of AIV circulation, with 30–50% of ducks and 20–40% of chickens testing positive. Intense circulation of A/H5N1 and other avian influenza viruses in Cambodian live-bird markets with serological evidence of sub-clinical human infections.

Concerningly, a multitude of high and low pathogenic AIVs circulate concurrently. Previous studies suggest peak AIV circulation corresponds to the dry season (November to May) especially around Lunar New Year (LNY) celebrations when poultry consumption is highest.

Not unexpectedly, more than 90% of the co-infections reported involved the highly promiscuous H9N2 virus, which - while it has some pandemic potential on its own (see CDC IRAT Score) - is more infamous for lending its internal genes to many of the HPAI viruses of greatest concern today (see The Lancet's Poultry carrying H9N2 act as incubators for novel human avian influenza viruses).

J. Inf. Pub. Health: Diagnostic Delays in MERS Coronavirus Patients & Health Systems

MERS - like most viral illnesses - can present with a wide spectrum of symptoms - ranging from mild to severe - and are often clinically indistinguishable from other, more common and routine respiratory infections.

This, along with Intermittent Positive Testing For MERS-CoV and the Saudi's heavy reliance on a reportedly flawed Visual Triage System for the Screening of MERS-CoV Patients, has led to multiple instances where patients not diagnosed early, which can delay treatment and increase the chances of nosocomial transmission.

From the Abstract:

The health-system delay in identifying a MERS-CoV case may be attributed to the delay in the virus recognition in medical institutions [6] and to the limited awareness among healthcare-workers [11], as a survey conducted on 1216 healthcare-workers revealed that only 47.6% of the physicians and 30.4% of the nurses were aware that some infected patients had no symptoms [11].

Also diagnosis of MERS-CoV [3] and medical care for patients with MERS-CoV [12] remain major challenges in healthcare facilities. Further understanding on the causes of patient and health-system delay is needed, as it can be used as a modifiable factor to reduce diagnostic delay and to improve the diagnostic process.

Access Microbiology: Inter-Species Transmission of Avian Influenza Virus to Dogs 

Over the years we've followed the work of Dr. Daesub Song - and many others - on potential for seeing a novel flu spread by companion animals such as dogs and cats. In 2011 we looked at a study (by Dr. Song, et al.) on the Interspecies Transmission of Canine H3N2 to domestic cats in Korea.

A year later (2012) Dr. Song and company were back with another study (see Interspecies Transmission Of Canine H3N2 In The Laboratory) that looked at laboratory transmission of the canine H3N2 virus to cats, and to (a far lesser degree), ferrets.

In November of 2018, in EID Journal: Canine Influenza Virus A(H3N2) Clade with Antigenic Variation, China, 2016–2017, we learned of the emergence and rapid spread of an antigenically distinct canine H3N2 virus with signs of additional mammalian adaptation in China.

This paper, again by Dr. Song, et al. , is a review of what we've learned over the past decade on the interspecies transmission of canine influenza. Very much worth reading.

JVI: Aerosol Transmission of Gull-Origin Iceland Subtype H10N7 Influenza A Virus in Ferrets

In 2004 the first known human H10 infections (see Avian Influenza Virus A (H10N7) Circulating among Humans in Egypt) were reported, followed in 2012 by a limited outbreak among workers at a chicken farm in Australia (see in EID Journal: Human Infection With H10N7 Avian Influenza).

Most of these avian flu infections were mild or asymptomatic, but in late 2013 a new H10N8 virus emerged in Mainland China (see Lancet: Clinical & Epidemiological Characteristics Of A Fatal H10N8 Case) infecting three people, killing at least two. 

While human cases of H10 infection haven't been reported since early 2014, these avian viruses continue to turn up in aquatic mammals, often producing significant mortality (see PLoS One: Pathology Of A/H10N7 In Harbor Seals).  

Which brings us to the following abstract, published in the Journal of Virology (full article behind paywall), that reports that a `. . . . gull-origin H10N7 virus can be transmitted between ferrets through the direct contact and aerosol routes, without prior adaptation.'

The Air That We Breathe (Out)


Not the only way to spread the Flu - Photo Credit PHIL

Evidence continues to mount that pre-symptomatic (and presumably asymptomatic) flu carriers are able to share their viruses with others simply via their normal exhaled breath.

No sneezing, coughing or fever required.

Over a year ago in PNAS: Infectious Virus Exhaled In Breath Of Symptomatic Seasonal Flu Cases, we looked at study that showed coughing and sneezing are not required to spread the flu virus.

A new paper - presented to the European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) in Amsterdam last April - documents the apparent stealth transmission of influenza by pre-symptomatic carriers in a hospital setting.

Hospital study finds substantial proportion of patients and healthcare workers shed flu virus before symptoms appear

New research examining influenza transmission in a tertiary hospital finds that a substantial proportion of patients and healthcare works shed the flu virus before the appearance of clinical symptoms. The findings, being presented at this year's European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) in Amsterdam, Netherlands (13-16 April), raise the possibility that current influenza infection control measures may not be enough to protect healthcare workers and patients during routine care in hospitals. 

C.I.D.: Influenza A Reinfection in Sequential Human Challenge

Although we know that the effectiveness of influenza vaccines can wane over time, it has been widely believed that once you are naturally infected with a specific influenza virus, you will carry lifelong - or at least long-lasting - immunity to that specific virus.

This `acquired immunity' is also expected to extend to antigenically similar viruses, although things get much murkier once even minor changes to the virus begin to accrue.

In a nutshell, in this study researchers exposed a small group of healthy volunteers to a specific H1N1 virus, and recorded their subsequent infections and immune responses.

A year later, they repeated this virus challenge on the same group (n=7) with the exact same virus, expecting their residual immunity would protect them, but found instead that at least 3 - and possibly 5 - of the 7 were reinfected with the exact same virus.

          The authors wrote:

Conclusion

The data presented in this report demonstrate that sequential infection with the identical influenza A virus can occur and suggest it may not be rare. These data raise questions about immune memory responses in an acute superficial respiratory mucosal infection and their implications in development of broadly protective influenza vaccines. Further investigation of these observations is warranted.

While many studies simply add to or build upon what was known before, in the case of the last one in this series, we saw a completely unexpected result.  One that could have major implications for the eventual development of a `Universal Flu Vaccine'  (see J.I.D.: NIAID's Strategic Plan To Develop A Universal Flu Vaccine).

While I can't predict what the next decade will bring, I'm confident there will be more than a few surprises along the way.