Wednesday, June 10, 2020

Forgotten Fronts & Global Blind Spots

A Dearth Of Influenza Data Reported to WHO 


While the world is - quite understandably - consumed with the COVID-19 pandemic and its knock-on economic and societal impacts, there is no reason to believe that nature's laboratory has called it quits out of a sense of fairness.  The same zoonotic and agricultural diseases that concerned us before COVID-19 are still out there, spreading and evolving.
And yet, for the past few months, surveillance and reporting on many types of disease  threats have declined and in some cases stopped altogether. 
A few weeks ago, in MERS-CoV: Forgotten, But Not Gone, I wrote about the abrupt halt in reporting by the Saudi MOH on MERS=CoV cases, with their last report in Epi Week 14. We are now in Epi Week 24, and the Saudi MOH has yet to update their case count.

In the first 14 weeks of 2020, Saudi Arabia reported 50 MERS cases.  In the last 10 weeks, they've reported none.  
Admittedly, KSA has never been enthusiastic about public reporting of cases, and we've seen the Saudis take `breaks' in reporting before (see 2018's The Saudi MOH Breaks Their Silence On MERS-CoV).  
But even during these `breaks', the World Health Organization EMRO (Eastern Mediterranean Region) continued to publish monthly MERS-CoV updates.  It is less than comforting that the last Outbreak Situation Update published by EMRO was in February, and was for January, 2020. 

The WHO did publish a Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia DON on May 5th, but it was for cases reported during the month of March. Since then, silence.

For nearly 8 years MERS-CoV has been near the top of our pandemic concern list - and given its similarity to both SARS and SARS-CoV-2 - should still be considered a credible threat. 
Yet we appear to have little or no visibility on what is happening in the most affected region in the world.
But it isn't just MERS-CoV.

Avian influenza reports - outside of a handful of H9N2 cases in China and H5N8 outbreaks in European poultry (mostly Hungary) - have practically disappeared the past few months. Admittedly, avian flu has been on the decline since China instituted its massive H5+H7 poultry vaccination campaign in 2017.

But there are areas of the world - particularly in the Middle East - where numerous HPAI H5 viruses continue to evolve and spread (see Study: Genotyping & Reassortment Analysis of HPAI H5N8 and H5N2 viruses from Egypt). 
While it is possible that avian flu around the world has gone into deep hibernation, it does stretch credulity.  
Reporting and surveillance on Seasonal Flu has apparently halted from the Middle East as well.  Normally, even during the summer, we get a weekly influenza report from the WHO EMRO Outbreaks division. 

The last update posted was more than 3 months ago:

Granted, influenza has likely been suppressed by social distancing around the globe, and hard choices have to be made during a pandemic where to allocate scarce resources. The decision to stop reporting on flu may be perfectly reasonable under the current circumstances, but that doesn't make it any less problematic.

The most recent WHO Global Flu Report (Influenza update - 368) was released on May 25th, but was based on data only up to May 10th. Before reporting a dearth of data, the WHO issues a caveat:
The current influenza surveillance data should be interpreted with caution as the ongoing COVID-19 pandemic might have influenced to varying extents health seeking behaviours, staffing/routines in sentinel sites, as well as testing priorities and capacities in Member States. The various hygiene and physical distancing measures implemented by Member States to reduce SARS-CoV2 virus transmission might also have played a role in interrupting influenza virus transmission.
Globally, influenza activity appeared to be at lower levels than expected for this time of the year. In the temperate zone of the northern hemisphere, a sharp decline of influenza activity was observed in recent weeks while in the temperate zones of the southern hemisphere, the influenza season has not started yet.
  • In the temperate zone of the northern hemisphere, influenza activity was low overall. An overall increase in excess all-cause mortality was seen across the countries of the EuroMOMO network.
  • In the Caribbean and Central American countries, no or low influenza detections were reported in most reporting countries. Severe acute respiratory infection (SARI) activity appeared to decrease in Jamaica.
  • In tropical South American countries, influenza detections were low.
  • In tropical Africa, there were no influenza virus detections reported in this period.
  • In Southern Asia, influenza like illness (ILI) and SARI activity was low in Bhutan and Nepal.
  • In South East Asia, no influenza detections were reported.
  • In the temperate zones of the southern hemisphere, influenza activity remained at inter-seasonal levels.
  • Worldwide, seasonal influenza A viruses accounted for the majority of detections.

Even today's release from the ECDC of their Influenza Characterization Report states that no antigenic analysis of submitted flu samples has been conducted since their April report:

Influenza virus characterisation - Summary Europe, May 2020
Surveillance report
10 Jun 2020
Executive summary
This is the seventh report for the 2019 2019–20 influenza season. As of week 20 /2020, 16 4 868 influenza detections across the WHO European Region ha have been reported; 73% type A viruses, with A(H1N1)pdm09 prevailing over A(H3N2), and 27% type B viruses, with 4 4 479 (98%) of 4 5 568 ascribed to a lineage being B/Victoria.
Since the April 2020 characterisation report report, eight shipments of influenza influenza-positive specimens from EU/EEA countries have been received at the London WHO CC, the Francis Crick Worldwide Influenza Centre (WIC). In total, 1 362 virus specimens, with collection dates after 31 August 2019, have been received. No influenza antigenic characterisation has been conducted during this reporting period.
I would note that in the previous (April) reportthat no influenza antigenic characterization had been conducted either.

Again, this is an observation not a criticism. Regardless of the reasons, we appear to be heading headlong towards next fall's flu season with less information than usual. 
And it isn't just zoonotic and human disease reporting that have fallen by the wayside.  
Given the pandemic driven supply chain issues, and warnings of increased food insecurity around the world (see Poverty and food insecurity could grow dramatically as COVID-19 spreads), anything that further depletes or stresses the global food supply is a serious concern.

Over the past two years we've been following the spread of African Swine Fever around the world, and its devastation of the world's pork supply.  Estimates are that between 25% and 30% of the world's pork supply has been lost to this fast moving disease. 
Although India (after considerable delay) recently confirmed their first case, reporting from Asia countries where ASF is rife has all but disappeared.
No where is this lack of reporting more evident than from the FAO's ASF reporting system, which was last updated on March 5th, with a promise of their next update to be published on March 19th. 
ASF situation in Asia update 05 March 2020, 08:00 hours; Rome
The next update will be issued in 19 March 2020

That next update is now nearly 3 months overdue.

In many cases, I'm sure local and national surveillance systems are overwhelmed by COVID-19, and are simply unable to conduct the kind of surveillance and reporting - which admittedly, has always varied in quality and quantity - as we've seen in the past.
In a few cases, I suspect there are countries and regions that are quite happy to have an excuse not to report on `inconvenient' events like ASF, MERS-COV, avian influenza, and other disease outbreaks. 
Whether `reasonable', unavoidable, or simply politically expedient, the growing gaps in disease reporting around the world leaves us all vulnerable to being blindsided again.

And the last thing we need while we are struggling to deal with COVID-19 is to find ourselves fighting a viral war on another, unexpected front.