HK CHP: Two More Cases Of H5N6 On The Chinese Mainland

#16,225

Mainland China's summer of H5N6 avian flu continues today with yet another announcement of (2) human infections with this often deadly virus.  The first case (M,55) - as was yesterday's  fatal case - was infected in Guilin, Guangxi province in August, but remains in serious condition.  

The second case is from Chongqing Municipality (M,77), was hospitalized on September 19th, and has since died.   Both cases reportedly had contact with poultry prior to infection. 

Together these represent the 22nd and 23rd H5N6 cases reported by China since last December, which is very nearly 50% of all the cases reported by China since the virus first emerged in 2014.  This uptick in cases comes after a nearly 3-year lull in both H5 and H7 virus cases in China. 

HP closely monitors two human cases of avian influenza A(H5N6) in Mainland

The Centre for Health Protection (CHP) of the Department of Health is today (September 30) closely monitoring two human cases of avian influenza A(H5N6) in the Mainland, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

The first case involves a 55-year-old man living in Guilin in Guangxi, who had prior exposure to a live poultry market before the onset of symptoms. He developed symptoms on August 23, and was admitted for treatment on August 30. The patient is in serious condition.

The second case involves a 72-year-old man living in Chongqing Municipality, who had contact with sick poultry before onset. He developed symptoms on September 16, and was admitted for treatment on September 19. The patient has passed away.

From 2014 to date, 47 human cases of avian influenza A(H5N6) have been reported by Mainland health authorities.

"All novel influenza A infections, including H5N6, are notifiable infectious diseases in Hong Kong," a spokesman for the CHP said.

Travellers to the Mainland or other affected areas must avoid visiting wet markets, live poultry markets or farms. They should be alert to the presence of backyard poultry when visiting relatives and friends. They should also avoid purchasing live or freshly slaughtered poultry, and avoid touching poultry/birds or their droppings. They should strictly observe personal and hand hygiene when visiting any place with live poultry.

Travellers returning from affected areas should consult a doctor promptly if symptoms develop, and inform the doctor of their travel history for prompt diagnosis and treatment of potential diseases. It is essential to tell the doctor if they have seen any live poultry during travel, which may imply possible exposure to contaminated environments. This will enable the doctor to assess the possibility of avian influenza and arrange necessary investigations and appropriate treatment in a timely manner.

While local surveillance, prevention and control measures are in place, the CHP will remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments.

The public should maintain strict personal, hand, food and environmental hygiene and take heed of the advice below when handling poultry:

• Avoid touching poultry, birds, animals or their droppings;
• When buying live chickens, do not touch them and their droppings. Do not blow at their bottoms. Wash eggs with detergent if soiled with faecal matter and cook and consume the eggs immediately. Always wash hands thoroughly with soap and water after handling chickens and eggs;
• Eggs should be cooked well until the white and yolk become firm. Do not eat raw eggs or dip cooked food into any sauce with raw eggs. Poultry should be cooked thoroughly. If there is pinkish juice running from the cooked poultry or the middle part of its bone is still red, the poultry should be cooked again until fully done;
• Wash hands frequently, especially before touching the mouth, nose or eyes, before handling food or eating, and after going to the toilet, touching public installations or equipment such as escalator handrails, elevator control panels or door knobs, or when hands are dirtied by respiratory secretions after coughing or sneezing; and
• Wear a mask if fever or respiratory symptoms develop, when going to a hospital or clinic, or while taking care of patients with fever or respiratory symptoms.

​The public may visit the CHP's pages for more information: the avian influenza page, the weekly Avian Influenza Report, global statistics and affected areas of avian influenza, the Facebook Page and the YouTube Channel.

Ends/Thursday, September 30, 2021

Issued at HKT 19:51

So far, human infection with H5N6 has been primarily reported in China (and 1 from Laos), although the virus has been found in migratory birds in Vietnam, Laos, and Cambodia. As we discussed yesterday, in Taiwan & South Korea Both Warn On Fall Arrival Of Migratory Birds, how long H5N6 remains primarily a Chinese problem is unknown.

Over the past month China's CDC has published two detailed outbreak reports (see below) in their CCDC Weekly. Both of which warn that HPAI H5N6 continues to mutate and reassort, and that its threat to public health is increasing.

 

China CCDC Weekly: Genetic Characterization of Two Human A (H5N6) Viruses — Guangxi , China, 2021

CCDC Weekly: Outbreak Report - Five Independent Cases of Human Infection With HPAI H5N6 — Sichuan Province

While we haven't seen any obvious signs of human-to-human transmission of H5N6, this recent surge in human infections is the largest we've seen since the spring wave of H7N9.  And given the recent, belated announcements by the Chinese government, this outbreak could be bigger than the current numbers suggest. 

Since summer is traditionally the least active time of the year for avian flu transmission,  we'll be watching the developments in China - and its neighbors - carefully over the fall and winter months.   

CCDC Weekly Perspectives: COVID-19 Expands Its Territories from Humans to Animals

 

Zoonotic Disease Pathways

#16,224

Although the origins of the SARS-CoV-2 virus remain undefined, the available evidence suggests it likely originated in bats - jumped to an intermediate host (pangolin, palm civet, mink, etc.), where it evolve further - and then jumped to humans (see Science Perspective: The Animal Origin of SARS-CoV-2).

This is the presumed route of SARS-CoV from 2002, and MERS-CoV in 2012, and is similar to what we've seen with Nipah, Hendra, Ebola, and the Marburg virus. 

But humans have not been a dead-end host for COVID-19, as they have repeatedly transmitted the virus on to a variety of companion animals (dogs, cats, ferrets), farmed animals (mink), captive wild animals in zoos - and either directly or indirectly - into peridomestic wildlife (see USDA/APHIS: White-Tailed Deer Exposed To SARS-CoV-2 Detected In 4 States).

In early July, in EID Journal: Peridomestic Mammal Susceptibility to SARS-CoV-2 Infection, we looked at the admittedly low, but worrisome possibility that COVID could establish itself in a non-human species, either in farmed livestock or in the wild.

This could conceivably provide the virus with additional opportunities to produce new variants - something we've already seen happen in domesticated mink (see SSI Study: Denmark's Cluster-5 mink Variant Had Increased Antibody Resistance) - which might then spill back into the human population and spark additional pandemic waves.

This week China's CCDC Weekly - their version of our MMWR - published a perspective article by two Chinese scientists that readers of this blog are already familiar with - George F. Gao and Liang Wang - on the continual spread of SARS-CoV-2 from humans to other animal hosts, and the impacts that could have going forward. 

Perspectives: COVID-19 Expands Its Territories from Humans to Animals

George F. Gao1,2, , ; Liang Wang2 

THE GLOBAL STATUS OF COVID-19 PANDEMIC

Since the discovery of a novel type of coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, also known as 2019-nCoV, or HCoV-19) (1), the causative agent of coronavirus disease 2019 (COVID-19), COVID-19 has been spread globally during a short period of time. As of August 17, COVID-19 has caused more than 206 million infections, of which more than 4 million have died worldwide (2), which is the worst pandemic caused by coronaviruses thus far. The pandemic of COVID-19 has not only posed a global threat to public health but has also thoroughly taxed medical systems and global economies.

In response to this pandemic, unprecedented efforts have been made worldwide, such as the implementation of non-pharmacological interventions (NPIs) (3) and vaccine development (4). However, several types of variants of concern (VOC) have been found gradually during the circulation of SARS-CoV-2, as the combination effects of their intrinsic characteristics of error-prone replication process, host immune pressure and other environmental factors.

Several studies have documented that these VOCs showed increased transmissibility and were more resistant to neutralization by convalescent and vaccine sera than other variants, posing a global threat to public health. Taken together, the arms race between SARS-CoV-2 evolution and human coping strategies will continue for some time to come.

THE ORIGIN OF SARS-COV-2 REMAINS A MYSTERY

For any causative agent of a pandemic, tracing the origin of the “prime criminal” is crucial for both understanding its evolution and preventing outbreaks in the future. To our knowledge, a bat-origin coronavirus RaTG13 had the most similar genome compared to SARS-CoV-2 at the whole genomic level (96.2%), although the amino acid similarity of the receptor binding domain (RBD) of the spike protein, which mediates the viral entry to human cell, was only 89.2%. RaTG13 pseudovirus could transduce cells expressing human ACE2 with low efficiency (5). Subsequently, several coronavirus genomic sequences with high similarity to SARS-CoV-2 from bats have been found in different countries (6-8). Both pseudotyped SARS-CoV-2 virus and wild SARS-CoV-2 virus could infect cells expressing ACE2 from Rhinolophus macrotis (9). 

These results indicated that SARS-CoV-2 could have more likely originated from bats. However, it is well established that intermediate hosts are needed for bat-origin coronaviruses before they acquire sufficient mutations to have the ability to infect humans, such as dromedary camels for MERS-CoV. Two groups reported that they found SARS-CoV-2-related coronaviruses in Malayan pangolins (Manis javanica) and their RBD region had a high similarity to that of SARS-CoV-2. Yet, the overall genomic similarity compared to SARS-CoV-2 were both low (<93%), which suggested pangolins were unlikely to be the intermediate host for SARS-CoV-2. So far, the mysteries of the route through which SARS-CoV-2-related coronaviruses were transmitted from bats to humans and if bats were the original reservoir host still remain unsolved.

THE SPILLOVER OF SARS-COV-2 EVENTS AND THEIR POTENTIAL MOLECULAR MECHANISMS

In addition to humans, natural infection of SARS-CoV-2 have been found in several other species of mammals via contact with COVID-19 patients, such as cats, dogs, lions and tigers in zoos, minks, and ferrets (10) (Figure 1A). Snow leopards, pumas, and gorilla also have been found to be infected with SARS-CoV-2 in nature (10) (Figure 1A). Among these spillover events, mink-related SARS-CoV-2 variants had the greatest impact, as the mink had also transmitted the SARS-CoV-2 variants back to humans and caused further community transmission (11). In order to prevent the mink-derived SARS-CoV-2 variants from continuously both circulating in the minks and spreading to humans, tens of millions of minks have been culled which also caused huge economic losses to mink-related industries. In addition to natural infection cases, several animals (e.g., rabbits, pigs, foxes, and civets etc.) have also been considered as possibly susceptible hosts of SARS-CoV-2 through infection experiments (10) (Figure 1B). Although most natural infections described above occurred in domesticated animals, far fewer cases were identified in the wild.

Recently, serosurveillance showed that antibodies against SARS-CoV-2 have been found in 40% of samples of wild white-tailed deer (Odocoileus virginianus) from USA in 2021 (12). However, antibodies were detected in only 1 and 3 samples from 2019 and 2020, respectively (12). Although it is still not known if SARS-CoV-2 in wild white-tailed deer was introduced by humans, the significant increase of positive rate of antibodies indicated that SARS-CoV-2 had been circulating in wild white-tailed deer. Due to the wide geographic distribution and large population (approximately 30 million) of wild white-tailed deer in North America, contact between human and wild white-tailed deer could be achieved by several activities such as wildlife rehabilitation, field research, practical conservation work and some wildlife-related tourism, supplemental feeding, captive cervid operations, and hunting (13). In this case, it increased the risk that SARS-CoV-2 from wildlife would spillback to humans.

Structural and functional studies identified several key sites from both SARS-CoV-2-RBD and ACE2. Mutations at these sites are closely related to the cross-species transmission of SARS-CoV-2. On SARS-CoV-2-RBD, residues 493, 498, and 501 were identified as key mutation hotpots that determine the host range. Mouse-adapted strains with N501Y mutation on RBD were isolated after 6 passages cultured in aged mice by wild type SARS-CoV-2 (14). Another 2 mutations, namely Q493K and Q498H were introduced to the S protein in mouse-adapted strains. Retrospective analysis showed that Q493K began to appear after 5 passages and, notably, Q498H dominated after only 1 passage. On ACE2, residues 41 and 42 were recognized as the critical sites for SARS-CoV-2 RBD binding. Sequence alignment showed that these two residues account for the major difference in the interaction network with SARS-CoV-2 RBD among different ACE2 orthologs (9). There are 4 combinations at these 2 sites (Y41-Q42, H41-Q42, Y41-E42, and H41-E42). Among them, Y41-Q42 combination showed the highest binding affinity to SARS-CoV-2 RBD; H41-Q42 showed much weaker; Y41-E42 was weaker than that of H41-Q42; and H41-E42 showed the weakest binding to SARS-CoV-2 RBD. In addition, K31 and K353 have been reported as a hotspot providing substantial amount of energy in receptor binding, and the mutation from K353 to A353 may abolish the binding capacity of ACE2 to SARS-CoV-2-RBD.

THE HOST EXPANSION OF SARS-COV-2 IS NOT OVER

The host expansion of coronaviruses was well established (15). A previous study found some ongoing mink-adapted mutations such as Y453F, F486L, and N501T in the S protein; for example, Y453F has been found to increase in hACE-2 affinity (16). Those results suggested that some ongoing mink-adapted mutations posed a huge threat to public health if they transmitted back to humans and even triggered further community transmission. Due to the fact that minks are bred in farms, large-scale slaughter of these minks can effectively prevent mink-derived SARS-CoV-2 variants from spreading and mutation accumulation in the mink population. However, similar measures could not be taken for wild animals.

Together with the fact that adaptive mutations are needed when cross-species transmission happens and then circulate among populations of the new host, more efforts are needed to survey the genetic alterations and corresponding impact of transmissibility and infectivity in humans in these novel variants from wild white-tailed deer. Since SARS-CoV-2 is going wild, many other wild animals would also be infected with SARS-CoV-2 via direct or indirect contact with wild white-tailed deer or even infected patients. Several experimental studies have demonstrated several animals could be susceptible to SARS-CoV-2, such as Egyptian fruit bats (Rousettus aegyptiacus), marmosets (Callithrix jacchus), macaques (Macaca fascicularis and Macaca mulatta), bank voles (Myodes glareolus), and North American deer mice (Peromyscus maniculatus) (10).

However, these are just the tip of the iceberg as the susceptibility of most terrestrial wild animals to SARS-CoV-2 has not been tested. In addition, the research on susceptibility of marine wildlife (especially marine mammals) to SARS-CoV-2 is still lacking. Due to frequent marine human activities (such as mariculture and marine fishing), the frequency of human contact with marine organisms is high. If some marine organisms are highly susceptible to SAR-CoV-2, there is a risk that SARS-CoV-2 could be transmitted from humans to marine organisms, and worse, SARS-CoV-2 then might spread in the marine ecosystem, which may lead to the generation of some novel SARS-CoV-2 variants with unknown threats to humans.

Therefore, it is necessary to carry out large-scale SARS-CoV-2 screening for terrestrial and marine wildlife, especially those susceptible ones, in order to monitor the status of infection and mutation of SARS-CoV-2 in wild animals, so as to formulate further prevention and control strategies. It also provides more clues to the study of the origin and cross-species transmission of SARS-CoV-2.

Acknowledgement: Dr. Kefang Liu and Mr. Linjie Li for help in collecting the references and drawing figure.

          (Continue . . . )

Just as we monitor the spread and evolution of influenza viruses carried by pigs, birds, and marine mammals due to their pandemic potential, the expansion of SARS-CoV-2 in a growing number of animals hosts will likely present a similar threat to public health going forward. 

Five weeks ago, in PNAS Research: Intensity and Frequency of Extreme Novel Epidemics, we looked at a paper that suggested that the probability of novel disease outbreaks will likely grow three-fold in the next few decades.

All reasons why, after two decades of mostly empty talk about pandemic preparedness, the world needs to prepare seriously, as if the next health crisis is imminent, and could well be worse than COVID-19.  

Because ready or not, the next pandemic is coming. 

COVID & Pregnancy: CDC Issues HAN For Pregnant Women Urging COVID Vaccination

CDC Data - An increase of 37 deaths since our last check on Aug. 12th, 2021
 

#16,223

Influenza pandemics have a long history of exacting a heavy toll on pregnant women and their unborn children (see 2009's Pregnancy & Flu: A Bad Combination), which is why the CDC has long recommended the flu vaccine for pregnant women. 

Not surprisingly, our current Coronavirus pandemic has had a similar impact, with at least 161 deaths reported among pregnant women.  I say `at least', since the CDC cautions that their data is far from complete.  

Six weeks ago the CDC updated their recommendations for COVID vaccines for pregnant women, or those who are planning to become pregnant, but the uptake of vaccine among this cohort remains low.  According to the CDC:

Data from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) in 2021 indicate that approximately 97% of pregnant people hospitalized (either for illness or for labor and delivery) with confirmed SARS-CoV-2 infection were unvaccinated.2

Vaccine hesitancy among expecting parents is not unusual - particularly given the amount of anti-vaccine rhetoric online - but scare tactics aside, we continue to see the real-world impact of COVID infection on pregnant women. 

Preprint: Impact of SARS-CoV-2 Variant on the Severity of Maternal Infection and Perinatal Outcomes

AJOG: Disease Severity, Pregnancy Outcomes and Maternal Deaths With Patients With SARS-CoV-2 - Washington State

MMWR: Two New Reports On Pregnancy & COVID-19

PAHO Epi Alert: COVID-19 During Pregnancy - 13 August 2020

With less than 1/3rd of pregnant Americans fully vaccinated against COVID, yesterday the CDC issued a HAN Health Advisory, which strongly urges all pregnant women to get the COVID vaccine, along with a media release (see CDC Statement on Pregnancy Health Advisory).

(Excerpt)

The CDC health advisory strongly recommends COVID-19 vaccination either before or during pregnancy because the benefits of vaccination for both pregnant persons and their fetus or infant outweigh known or potential risks. Additionally, the advisory calls on health departments and clinicians to educate pregnant people on the benefits of vaccination and the safety of recommended vaccines.

Some excerpts from the HAN Advisory follow.  Click the link to read it in its entirety.

COVID-19 Vaccination for Pregnant People to Prevent Serious Illness, Deaths, and Adverse Pregnancy Outcomes from COVID-19

Distributed via the CDC Health Alert Network

September 29, 2021, 12:00 PM ET

CDCHAN-00453

Summary 

The Centers for Disease Control and Prevention (CDC) recommends urgent action to increase Coronavirus Disease 2019 (COVID-19) vaccination among people who are pregnant, recently pregnant (including those who are lactating), who are trying to become pregnant now, or who might become pregnant in the future. CDC strongly recommends COVID-19 vaccination either before or during pregnancy because the benefits of vaccination outweigh known or potential risks.

As of September 27, 2021, more than 125,000 laboratory-confirmed COVID-19 cases have been reported in pregnant people, including more than 22,000 hospitalized cases and 161 deaths.1 The highest number of COVID-19-related deaths in pregnant people (n=22) in a single month of the pandemic was reported in August 2021. Data from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) in 2021 indicate that approximately 97% of pregnant people hospitalized (either for illness or for labor and delivery) with confirmed SARS-CoV-2 infection were unvaccinated.2

In addition to the risks of severe illness and death for pregnant and recently pregnant people, there is an increased risk for adverse pregnancy and neonatal outcomes, including preterm birth and admission of their neonate(s) to an intensive care unit (ICU). Other adverse pregnancy outcomes, such as stillbirth, have been reported. Despite the known risks of COVID-19, as of September 18, 2021, 31.0% of pregnant people were fully vaccinated before or during their pregnancy.3 In addition, there are racial and ethnic disparities in vaccination coverage for pregnant people.

Healthcare providers should communicate the risks of COVID-19, the benefits of vaccination, and information on the safety and effectiveness of COVID-19 vaccination in pregnancy. Healthcare providers should strongly recommend that people who are pregnant, recently pregnant (including those who are lactating), who are trying to become pregnant now, or who might become pregnant in the future receive one of the authorized or approved COVID-19 vaccines as soon as possible.

(Continue . . . )

 

For more information on COVID-19 vaccines and pregnancy, the CDC maintains the following website:

COVID-19 Vaccines While Pregnant or Breastfeeding
Updated Aug. 11, 2021
 
What You Need to Know

• COVID-19 vaccination is recommended for all people 12 years and older, including people who are pregnant, breastfeeding, trying to get pregnant now, or might become pregnant in the future.
• Evidence about the safety and effectiveness of COVID-19 vaccination during pregnancy has been growing. These data suggest that the benefits of receiving a COVID-19 vaccine outweigh any known or potential risks of vaccination during pregnancy.
• There is currently no evidence that any vaccines, including COVID-19 vaccines, cause fertility problems in women or men.
• Pregnant and recently pregnant people are more likely to get severely ill with COVID-19 compared with non-pregnant people.
• Getting a COVID-19 vaccine can protect you from severe illness from COVID-19.

(Continue . . . )

 

COCA Call Tomorrow: Evaluating and Supporting Patients Presenting With Fatigue Following COVID-19

#16,222

Yesterday the CDC held a COCA call (see CDC Recommendations for Pfizer-BioNTech COVID-19 Booster Vaccination), and tomorrow the agency will hold a second, this time on patients with Post-COVID fatigue. 

Despite the relatively good news that somewhere between 98%-99% of those infected with COVID-19 survive their illness, we continue to see disturbing data suggesting that survivors often come away with lingering - sometimes permanent - sequelae. 

Dubbed `Long COVID' or `Post-COVID Syndrome', these after-effects can range from mild or moderate - to disabling - and may potentially contribute to an early death months or years after the the initial infection.

One of the most common complaints is fatigue following COVID infection, that may last for weeks or months.  Tomorrow's COCA call will help clinicians evaluate and support patients reporting post-COVID fatigue. 

COCA Calls are often technical, and are of greatest interest to clinicians and healthcare providers, but also may be of interest to the general public.

As always, If you are unable to attend the live presentation, these (and past) webinars are archived and available for later viewing at this LINK. Details on tomorrow's presentation follow:

Evaluating and Supporting Patients Presenting With Fatigue Following COVID-19

= Free Continuing Education

Overview

During this COCA Call, presenters will discuss Post-COVID conditions (PCC), an umbrella term for the wide range of health consequences present four or more weeks after infection with SARS-CoV-2, which includes Long-COVID. It can be difficult to distinguish symptoms of fatigue and post-exertional malaise caused by PCC from symptoms that occur for other reasons. 

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) has recently published a Multi-Disciplinary Collaborative Consensus Guidance Statement on the Assessment and Treatment of Fatigue in PCC. It provides practical guidance to clinicians when assessing and treating individuals with fatigue and a history consistent with PCC. The burden of PCC is expected to reflect the disproportionate burden of infection by race, ethnicity, and socioeconomic status and to highlight ongoing inequities in healthcare. The Health Equity Work Group of the AAPM&R has developed guidance to highlight the central role that principles of diversity, equity, and inclusion play in delivering quality healthcare.

Presenters

Maureen Miller, MD, MPH
Research, Surveillance, and Management Unit
Natural History/Post-COVID Conditions Team
Epidemiology Task Force
COVID-19 Response
Centers for Disease Control and Prevention

Joseph E. Herrera, DO
Professor and System Chair of Rehabilitative Medicine
Department of Rehabilitation and Physical Medicine
Mount Sinai Health System

Monica Verduzco Gutierrez, MD
Professor and Chair of Physical Medicine and Rehabilitation
Department of Physical Medicine and Rehabilitation
UT Health San Antonio

Benjamin Abramoff, MD, MS
Assistant Professor of Clinical Physical Medicine and Rehabilitation
Department of Physical Medicine and Rehabilitation
Penn Medicine

Call Materials

None at this time
Call Details


When:
Thursday, September 30, 2021,
2:00 PM – 3:00 PM ET

Webinar Link:
https://www.zoomgov.com/j/1603742224

Passcode: 907646

Dial In:
US: +1 669 254 5252
or +1 646 828 7666
or +1 551 285 1373
or +1 669 216 1590

International numbers

One-tap mobile:
US: +16692545252,,1603742224#,,,,*907646# or +16468287666,,1603742224#,,,,*907646#

Webinar ID: 160 374 2224 Add to Calendar

Taiwan & South Korea Both Warn On Fall Arrival Of Migratory Birds

 

#16.221

One of the most important avian migratory pathways in the world is the East Asian- Australasian Flyway (EAAF), which is described (below) by the EEAFP (East Asian-Australasian Flyway Partnership), which monitors the arrival and health of migratory birds along the route each year.

The East Asian - Australasian Flyway (EAAF) stretches from the Russian Far East and Alaska, southwards through East Asia and South-east Asia, to Australia and New Zealand and encompasses 22 countries. The EAAF is home to over 50 million migratory waterbirds from over 250  different populations, including 32 globally threatened species and 19 Near Threatened species.

Although it has been the source of excitement and wonder for bird lovers every fall for uncounted eons, in recent years the annual southbound trek of migratory birds has also been associated with the arrival and spread of HPAI and LPAI viruses. 

While once the topic of heated debate (see Bird Flu Spread: The Flyway Or The Highway?). the role of migratory birds in the long-distance spreading avian influenza is now pretty much settled.  Despite protestations that `sick birds don't fly', we now know that many avian species can carry HPAI viruses asymptomatically. 

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

Which means that nations that lie beneath the major migratory flyways begin to sound the alert each fall for poultry interests to beef up their biosecurity. We've already discussed concerns over avian influenza's return this fall to Europe (see FLI Risk Assessment: Avian Flu Threat High For Germany & Europe This Fall), but the threat is very much presemt in Asia as well. 

Today South Korea's MAFRA issued the following (translated) alert on the early, and heavy arrival of migratory birds to the Korean peninsula, warning that now is the time to begin increasing biosecurity efforts. 

Winter migratory birds begin to arrive in earnest, strengthening poultry farms

2021.09.29 10:58:59

The Ministry of Agriculture, Food and Rural Affairs (Minister Kim Hyun-soo, hereinafter referred to as the Ministry of Agriculture, Food and Rural Affairs) announced that it will strengthen the avian influenza prevention management of poultry farming farms and migratory birds across the country as a result of a recent survey of the early arrival of winter migratory birds conducted by the Ministry of Environment (Minister Han Jung-ae).

❍ The early bird status survey of migratory birds in this winter was conducted by the National Institute of Biological Resources under the Ministry of Environment on 10 major migratory birds in Gyeonggi and Chungcheong Province for three days from Sept. 24 to Sept. 26, 21, and confirmed 38,927 birds of 83 species.

❍ Compared to last year's survey, the total population increased by 37.7%*, and in particular, ducks and geese increased by 82.5%**.

* Overall Current Status: ('Sep.) 36,309 → ('Sep.) 28,277 → ('Sep. 21) 38,927

** Status of Ducks and Geese: ('September 20) 15,714 → ('September 21) 28,685

This year, the number of highly pathogenic avian influenza in foreign wild birds has increased sharply compared to last year, and in particular, the virus type has become more active*, which is likely to lead to various high pathogenic avian influenza in Korea through migratory birds this winter.

* Wild bird detection (until August 1∼8): (Europe) '31 in 20→ '1,237 in 21, (Asia) '14 in 20 → '44 in 21

** Serum type: (Europe) '20 Year 1→ '21 Year 6 Species, (Asia) '20 Year 3 Species → '21 Year 4 Species

❍ The Ministry of Agriculture, Food and Rural Affairs and the Ministry of Environment will keep a close eye on the arrival of migratory birds this winter, and will preemptively implement quarantine management, such as controlling the access of livestock vehicles to migratory birds*, inspection of migratory birds' feces**, and disinfection, during the special quarantine period for livestock epidemics (from October to February) even if avian influenza does not occur.

* ('19) 84 points → ('20) 234 → ('21) 260 ('11%↑ over 20)

** Target migratory birds: "103 places in 20 years → "109 places in 21 years (6 certificates)

The Ministry of Agriculture, Food and Rural Affairs requested that all poultry farms in the country thoroughly follow quarantine rules to prevent the outbreak of avian influenza at a dangerous time when migratory birds begin to arrive.

❍ Emphasizing the strict implementation of the ban on outsiders from entering poultry-keeping facilities and visiting migratory birds.

❍ In addition, the government urged the government to thoroughly overhaul quarantine facilities such as nets and electric rooms and comply with anti-avian influenza prevention rules such as changing boots (shoes) for each barn and disinfecting the inside and outside of the barn.

          (Continue . . . )

Considerably further down the flyway, Taiwan is also warning on the imminent arrival of this fall's migration. 

A confirmed case of avian influenza in Yunlin Gukeng White Broiler Breeder Farm, and implement epidemic prevention measures in accordance with standard operating procedures

110-09-28

 

The Animal and Plant Inspection and Quarantine Bureau (Bureau of Inspection and Quarantine) stated today (28) that the Animal Health Laboratory notified that the white broiler breeder farm in Gukeng Township, Yunlin County was diagnosed with H5N5 subtype highly pathogenic avian influenza (active notification), and it operates in accordance with the standard According to the procedures, the Yunlin Animal and Plant Epidemiological Institute executed the culling and destruction of 17,937 white broiler breeders in the farm at 70 weeks of age, and supervised the industry to complete the cleaning and disinfection of the farm. A total of 14 cases of avian influenza have been confirmed and culled in poultry farms since 110 (6 farms of land poultry, 7 farms of geese and 1 farm of ducks).

The Bureau of Inspection and Quarantine stated that the H5N3 subtype low pathogenic avian influenza virus nucleic acid was recently detected in the wild bird row in South Korea, and the migratory birds have come to Taiwan for the winter season. The risk of new avian influenza viruses imported into foreign countries by migratory birds has increased. The industry should maintain the normal operation of bird prevention facilities in poultry farms, strengthen the cleaning and disinfection of the farms, and control the entry and exit of personnel, equipment, and vehicles in poultry farms or poultry houses to prevent the occurrence of avian influenza epidemics.

The Bureau of Inspection and Quarantine once again urged poultry farmers that there are still cases of bird flu poultry farms, and they should implement the various biosafety work of poultry farms in accordance with the "H5, H7 subtype poultry influenza prevention and control measures" announced by the local county and city government. Prevent the occurrence of bird flu. If a poultry farm is found to be inconsistent with the previous prevention and control measures, it will be fined up to NT$150,000 and improved within a time limit according to the regulations. If no improvement is made by the deadline, if highly pathogenic avian influenza is detected in the poultry on the farm, the poultry will be culled , According to the regulations, no compensation will be given.

         (Continue . . . )

Other Asian and Pacific nations and territories that will be on heightened alert this fall include Japan, Hong Kong, Vietnam, and the Philippines.   

Oceans separate North & South America from both Europe and Asia, making it difficult - but not impossible - for migratory birds from either continent to carry HPAI viruses to the Americas. In 2014-2015, the United States and Canada suffered their worst Avian epizootic on record, when HPAI H5N8 arrived from Asia. 

There are overlaps between the East Asian and the Pacific flyways in Alaska (see map below) which provide a legitimate route of entry for Asian avian flu viruses (see USGS: Alaska - A Hotspot For Eurasian Avian Flu Introductions).

Some past blogs on that possibility include:

EID Journal: Introduction of Eurasian-Origin Influenza A(H8N4) Virus into North America by Migratory Birds

USGS: Alaska Still A Likely Portal For Introduction Of Avian Viruses 

EID Journal: Reassortment in Wild Birds in Alaska before H5 Clade 2.3.4.4 Outbreaks

For North Americans, our Arctic Refuge, where more than 200 bird species spend their summers, serves as a central hub, and funnels migratory birds south each fall via all four North American Flyways.

Credit U.S. Fish & Wildlife 

Similarly, although perhaps a bit more tenuously, there are overlaps between the European and North American flyways (see PLoS One: North Atlantic Flyways Provide Opportunities For Spread Of Avian Influenza Viruses), that could provide European avian viruses a plausible path to the New World. 

Between 2014 and 2017 HPAI H5N8 - which originated in ducks in China - spread faster and further via migratory birds than any other bird flu virus on record.  Arriving first in South Korea, then North America and Europe, then moving on to the Middle East, West Africa, and finally to South Africa. 

A reminder that what happens with avian influenza in Europe or Asia can quickly become a global problem. And with the recent rise of zoonotic H5N6 in China, and the recent zoonotic status afforded H5N8, that could maker for an eventful fall and winter ahead.

Stay tuned. 

HK CHP Monitoring Another (Fatal) Human H5N6 Infection On the Mainland

 

#16,220

China's summer of H5N6 continues with another (belated) report of a fatal H5N6 case from Guangxi Province involving a 26-year-old woman from Guilin, who fell ill in mid-August - was hospitalized on August 19th - and has subsequently died. 

While frustrating, it is not unusual for Mainland China to `slow roll' the release of bad news - particularly when it comes to novel virus outbreaks - which they tend to treat as national security issues.

This mindset led to the disastrous SARS-CoV cover-up of 2002-2003, chronic late reporting of H7N9 cases over the past decade (see Tracking H7N9: A Game Of Very Incomplete Information), and the delays in admitting they were dealing with a communicable disease outbreak in Wuhan in 2019. 

There was a period of time - right after the emergence of H7N9 in the spring of 2013 - when China seemed almost eager to share information about the disease and provided daily, detailed reports on outbreaks.  That window of openness began to erode in 2014 and 2015. 

Today's report - which comes via a notification from Hong Kong's CHP - increases to 21 the number of H5N6 cases reported in the last 10 months. To put that number in perspective, it took 6 years for the first 24 cases to be announced by China. 

 

CHP closely monitors human case of avian influenza A(H5N6) in Mainland

 

The Centre for Health Protection (CHP) of the Department of Health is today (September 29) closely monitoring a human case of avian influenza A(H5N6) in the Mainland, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

The case involves a 26-year-old woman living in Guilin in Guangxi, who had contact with live domestic poultry before the onset of symptoms. She developed symptoms on August 14 and was admitted for treatment on August 19. The patient has passed away.

From 2014 to date, 45 human cases of avian influenza A(H5N6) have been reported by Mainland health authorities.

"All novel influenza A infections, including H5N6, are notifiable infectious diseases in Hong Kong," a spokesman for the CHP said.

Travellers to the Mainland or other affected areas must avoid visiting wet markets, live poultry markets or farms. They should be alert to the presence of backyard poultry when visiting relatives and friends. They should also avoid purchasing live or freshly slaughtered poultry, and avoid touching poultry/birds or their droppings. They should strictly observe personal and hand hygiene when visiting any place with live poultry.

Travellers returning from affected areas should consult a doctor promptly if symptoms develop, and inform the doctor of their travel history for prompt diagnosis and treatment of potential diseases. It is essential to tell the doctor if they have seen any live poultry during travel, which may imply possible exposure to contaminated environments. This will enable the doctor to assess the possibility of avian influenza and arrange necessary investigations and appropriate treatment in a timely manner.

While local surveillance, prevention and control measures are in place, the CHP will remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments.

The public should maintain strict personal, hand, food and environmental hygiene and take heed of the advice below when handling poultry:

• Avoid touching poultry, birds, animals or their droppings;
• When buying live chickens, do not touch them and their droppings. Do not blow at their bottoms. Wash eggs with detergent if soiled with faecal matter and cook and consume the eggs immediately. Always wash hands thoroughly with soap and water after handling chickens and eggs;
• Eggs should be cooked well until the white and yolk become firm. Do not eat raw eggs or dip cooked food into any sauce with raw eggs. Poultry should be cooked thoroughly. If there is pinkish juice running from the cooked poultry or the middle part of its bone is still red, the poultry should be cooked again until fully done;
• Wash hands frequently, especially before touching the mouth, nose or eyes, before handling food or eating, and after going to the toilet or touching public installations or equipment, such as escalator handrails, elevator control panels or door knobs, or when hands are dirtied by respiratory secretions after coughing or sneezing; and
• Wear a mask if fever or respiratory symptoms develop, when going to a hospital or clinic, or while taking care of patients with fever or respiratory symptoms.

The public may visit the CHP's pages for more information: the avian influenza page, the weekly Avian Influenza Report, global statistics and affected areas of avian influenza, the Facebook Page and the YouTube Channel.

Ends/Wednesday, September 29, 2021
Issued at HKT 17:00

NNNN

This sudden uptick in cases - most of which have occurred over the summer months, normally a slow time for avian flu - has not gone unnoticed by China's CDC.  

Over the past month their CDC has published two detailed outbreak reports (see below) in their CCDC Weekly.  Both of which warn that HPAI H5N6 continues to mutate and reassort, and that its threat to public health is increasing. 

China CCDC Weekly: Genetic Characterization of Two Human A (H5N6) Viruses — Guangxi , China, 2021

CCDC Weekly: Outbreak Report - Five Independent Cases of Human Infection With HPAI H5N6 — Sichuan Province

While China's massive H5+H7 poultry vaccination campaign, launched in the summer of 2017,  has been a great success - particularly against H7N9 - this recent surge in H5N6 suggests that virus may now be spreading asymptomatically in vaccinated poultry (see OFID: Avian H5, H7 & H9 Contamination Before & After China's Massive Poultry Vaccination Campaign), increasing its risk of transmission to humans.

While H5N6 hasn't shown the ability to transmit efficiently from human-to-human, its high (roughly 50%) Case Fatality Rate - combined with its continual evolution - makes this virus one to watch. 

Czech Republic Reports H5 Bird Flu Outbreak

 

The last 5 Avian Flu Seasons Compared - Credit ECDC

#16,219

Every fall, migratory birds which have spent their summers in cooler high latitude nesting regions - and are the primary reservoir host for avian influenza viruses - begin their yearly journey to warmer climes for the winter.  

And so each September, we begin to monitor reports of outbreaks of HPAI along their migratory routes (see map above). 

Two weeks ago, in FLI Risk Assessment: Avian Flu Threat High For Germany & Europe This Fall, we looked a the prospects for seeing another bad avian influenza epizootic in Europe, which takes on additional significance after last year's announcement of the first known human infections with HPAI H5N8 (see Russian Media Reports 7 Human Infections With Avian H5N8).

While the risk of transmission to humans is considered low, last May the CDC Added Zoonotic Avian A/H5N8 To Their IRAT List, and we've seen several cautionary reports on the growing zoonotic potential of H5N8 (see V. Evolution: Genomic Evolution, Transmission Dynamics, and Pathogenicity of Avian H5N8 Viruses Emerging in China, 2020). 

While there have already been a few scattered reports of avian influenza in China, and central Russia, today we have the following report from the Czech Republic State Veterinary Agency.

09/28/2021

Avian influenza has returned to the Czech Republic, and a new outbreak is in the Příbram region

A new outbreak of bird flu has been confirmed in the Czech Republic after more than four months. It is located in small poultry farming in the village of Trhové Dušníky in the Příbram region in the Central Bohemian Region. The source of the infection is probably wild waterfowl.

The breeder reported the death of five geese from his small breed. There were also 16 hens and 11 ducks in it. Clinical signs typical of avian influenza were observed in one of the ducks. The veterinary inspectors immediately started an investigation in the breeding, took preliminary measures and sent the dead pieces to the State Veterinary Institute in Prague for examination. This subsequently confirmed H5 bird flu. The determination of pathogenicity and the precise determination of the subtype of infection is awaited. The breeder did not rule out that the poultry in the breeding came into contact with wild water birds.

The remaining poultry in the farm was killed this morning. A three-kilometer protection zone and a ten-kilometer surveillance zone will be defined around the outbreak. In these zones, emergency veterinary measures will be announced to restrict poultry movements, inventories of poultry farms and banning of mass events such as stock exchanges or bird shows which pose a high risk of spreading poultry diseases and banning of poultry and bird shows or exchanges. which pose a high risk of spreading the disease.

Avian influenza is a dangerous viral infection of domestic chickens, turkeys, waterfowl, feathered game, exotic birds and wild birds. Avian influenza viruses are commonly found in wild birds and are transmitted mainly through faeces. Therefore, the infection is most often caused by ingestion of feed or water contaminated with the faeces of infected birds. Highly pathogenic avian influenza viruses cause high morbidity and high mortality in birds. In poultry farming, this causes significant direct and indirect economic losses.

The basic preventive measures are (if possible) poultry farming in closed buildings and prevention of contact with wild birds. For holdings where it is not possible to secure an enclosure, measures must be taken to minimize the risk of contamination of water, feed and litter by wild bird droppings, such as placing water and feed under a canopy, preventing poultry from moving in wild water bodies. birds. Another possible measure is the networking of enclosures, etc. Any suspicion of the occurrence of the disease, which is an increased mortality of poultry, a sudden decrease in laying or feed intake, must be reported to the regional veterinary administration.

This year, 37 outbreaks of bird flu in poultry farms and one outbreak in captive birds were gradually declared in the Czech Republic. The first outbreak this year was confirmed on 22 January in small-scale poultry farming in the village of Dlouhá Lhota near Tábor in the South Bohemian Region. Gradually, 37 more outbreaks in farms were added, which were located both in unregistered small farms and in commercial farms. The last outbreak in Mladá Boleslav - Čejetice was confirmed on 18 May. Since July 26, the Czech Republic has been officially free of bird flu.

Petr Majer

Deputy JRC Spokesman

Whether this turns out to be a blip on our bird flu radar, or the vanguard of a new wave of avian flu this winter for Europe, remains to be seen. It is not unusual to see a year-or-two lull in avian flu activity following a big year, like we saw in 2020-2021. 

In addition to last year's H5N8 epizootic, we've also seen a rise in human H5N6 infections in China, the first known Human Avian H10N3 Infection In China, an as-yet unconfirmed report of human H5N1 infections in Nigeria (see The ECDC On The Recent Nigeria H5N1 Report Of Suspected Human Infections).

Avian influenza viruses are constantly changing, and as new clades and subtypes emerge, it is expected that some of these variants will either gain or lose virulence, transmissibility, or biological fitness. Over time, wild birds may become immune to some HPAI strains, or vaccines may alter patterns of spread.

Which means we never know what the next fall migration will bring. While Asia and Europe are at greatest risk, we've seen major avian epizootics strike North America in the past as well. 

Just as in Europe, there is a need to bolster biosecurity here in the United States (see H5Nx: Why North America Must Remain Alert).  

The USDA has some advice on how to Defend The Flock at the website below.

For more on how avian flu strains from Asia and Europe might arrive in North America, you may wish to revisit:

EID Journal: Introduction of Eurasian-Origin Influenza A(H8N4) Virus into North America by Migratory Birds

PLoS One: North Atlantic Flyways Provide Opportunities For Spread Of Avian Influenza Viruses

EID Journal: Reassortment in Wild Birds in Alaska before H5 Clade 2.3.4.4 Outbreaks

Japan To End COVID State Of Emergency On September 30th

 

#16,217

With COVID cases down 90% over the past month in Japan - and Prime Minister Yoshihide Suga poised to step down after barely a year in office - Japan’s government announced today that their 6-month-long State of Emergency over COVID will end in Tokyo and 18 other prefectures later this week. 

A link to an English Language report from Kyoto News:

Japan decides to end COVID-19 state of emergency as cases fall 

KYODO NEWS - 1 hour ago - 19:14

Tokyo - The Japanese government on Tuesday formally decided to lift the COVID-19 state of emergency covering Tokyo and 18 other prefectures, as well as the quasi-state of emergency in other areas, as infections have declined from their peak.

When the measures end on Thursday, it will be the first time since April 4 that none of the country's 47 prefectures has been under a state of emergency or quasi-state of emergency.

          (Continue . . . )

Restrictions will be eased over the next month - with local Prefectures controlling the timing - but the hope is society can return to a more `normal' existence, and revitalize their economy. 

Of course, this was the plan in Singapore up until this past weekend (see Singapore Reinstates Some Societal Restrictions As COVID Hospitalizations Surge), after cases jumped 20-fold (see chart below) in less than a month.

In mid-July, the UK abolished most of their restrictions - and so far at least -  while their cases haven't exploded, they continue to average  > 30,000 new cases per day (see chart below).  Whether they can keep cases at this level (or lower) through the winter is unknown.

While there are obvious economic, political, and societal reasons to want to declare victory and move on - pandemics typically come in multiple waves - and we can never be completely sure whether the last wave was really the last wave. 

Since COVID isn't likely to disappear completely, the test will be how well healthcare delivery systems are able to cope this winter, when they are likely to be faced not only with COVID cases, but with influenza as well. 

Stay tuned. 

Singapore Reinstates Some Societal Restrictions As COVID Hospitalizations Surge

 

#16,216

Three months ago Singapore made headlines by announcing plans to treat COVID much as they treat influenza (see Singapore preparing road map for living with Covid-19); no longer as a pandemic, but as an endemic virus. 

With daily cases consistently in the low-to-mid double digits for months, they believed restrictions on gatherings - particularly for those fully vaccinated - could be eased over the month of August.  Lockdowns would become a thing of the past, and life - and the economy - could return to `normal'.

The Delta variant, however, had other plans (see chart below), with Singapore yesterday reporting their highest one-day total of cases (n=1939) since the pandemic began. Of note, cases began their upward trajectory in mid-August, when restrictions on indoor dining, and group sizes, were eased. 

As a result, today Singapore's MOH announced a 1 month `Stabilization Phase' - to run from today through October 24th - with increased restrictions on social gatherings put back in place, in order to keep their current outbreak from getting completely out of hand. 

As part of this plan, in order to reduce the growing burden on local healthcare delivery services, the MOH is advising that most people can safely recover at home, and that only those with serious illness will be hospitalized. 

Some excerpts from a much longer statement from the MOH, followed by a graphic reflecting the changes follow.  I'll have a brief postscript after the break. 

STABILISING OUR COVID-19 SITUATION AND PROTECTING OUR OVERALL HEALTHCARE CAPACITY

24TH SEP 2021

Singapore entered the Preparatory Stage of our transition journey to a COVID-19 resilient nation on 19 August 2021. We ramped up our healthcare and response capacity as daily cases increased. We also introduced Home Recovery, as most of the cases, especially younger or vaccinated individuals, have mild symptoms or are asymptomatic and can stay at home to recover.

2. However, daily cases started to rise exponentially from end of August 2021. While the number of COVID-positive individuals who become severely ill – i.e., requiring oxygen supplementation and intensive care unit (ICU) – remains within expectations, the number of individuals with mild symptoms has increased very rapidly. This has put a strain on our overall healthcare and response system and on our healthcare workers, as many COVID-positive individuals with mild symptoms are seeking medical attention at our hospitals when it might not be necessary.

3. While we have been advising individuals with mild COVID-19 symptoms that it is appropriate to recover at home, we understand the anxiety of some individuals to want to seek medical attention at hospitals. The protocols and processes for home recovery are also new, and we are still improving the system as people are adjusting to them. There have also been service lapses as the numbers on Home Recovery increased, which added to their anxiety. We are ironing out the teething issues with the Home Recovery programme, and in the coming few weeks, will further ramp up our care facilities to handle more cases.

4. Most infection cases are mild in symptoms or asymptomatic and home recovery is the most appropriate care protocol for them. But if the overall number of cases continues to rise rapidly, we are also likely to see a growing number of infected persons, especially among the elderly, who do need hospital care. Hence, there is a need to slow down community transmission. We will thus be tightening our community safe management measures until our overall healthcare and response capacity has been appropriately augmented.

Updates on Local COVID-19 Situation

5. The large majority (98%) of cases were asymptomatic or had mild symptoms. This is due to our high vaccination coverage, which is now at 82% of the population who have completed their full regimen. Of the 254 cases with severe illness in the last two weeks, a disproportionate 48% were unvaccinated with the remainder being vaccinated individuals with co-morbidities. This ratio needs to be understood in the context of more than 80% of our population being fully vaccinated, indicating a vaccine efficacy against severe illnesses that is still around 80% to 90%, with the elderly and individuals with co-morbidities among the vaccinated making up the 10% to 20% who remain susceptible despite vaccination.

6. The number of persons requiring ICU is rising at the same rate as our overall case numbers, albeit with a lag. We had 21 new cases in ICU in the past week, as compared to 9 in the preceding week.

Right-siting Patients for Appropriate Care

7. The most appropriate care management protocol for fully vaccinated individuals aged 12 to 69 years will continue to be recovery at home[1]. These individuals are less likely to fall severely ill and there is no need for them to be cared for in our hospitals. Similarly, parents with infected children aged 2 to 11 years who choose to home recovery may also do so after their children have been assessed in our hospitals for suitability to do so.

8. To make best use of our hospital facilities and beds, and allow our hospitals to care for both their COVID-19 patients as well as the many other non-COVID patients requiring hospital care, we will be admitting those who are stable but do require closer monitoring to appropriate intermediate care facilities where their care and close monitoring needs will be met.

9. Patients with co-morbidities, with a risk of potentially developing severe illness, but who are otherwise asymptomatic or mildly symptomatic will be closely monitored at Community Treatment Facilities (CTFs), which are being set up progressively islandwide. These CTFs will be closely partnered with our hospitals so that there will be seamless escalation protocols for such patients to be conveyed from the CTF to an acute hospital expeditiously for further treatment when necessary. This is similar to the existing protocol for Community Care Facilities (CCFs), but with a higher level of medical care at the CTFs to ensure that these patients who are stable but at higher risk of serious illness are cared for with the appropriate level of medical manning and supporting equipment.

Safe Management Measures for Stabilisation Phase

10. If the infection continues at its current trajectory, we can expect to reach a daily count of 3,200 and beyond within the next 2 weeks. Beyond that, there is a range of possibilities, but we cannot rule out cases doubling further. To minimise the strain on our overall healthcare capacity, we will have to tighten measures before that happens. We would like to thank Singaporeans for reducing their level of activity and interactions in the past two weeks. We do not need to return to a Heightened Alert. But we have to do more to scale back social interactions further in order to slow down community transmissions and allow for better stability. The following measures will take effect from 27 September 2021 through 24 October 2021. We will review the measures two weeks after implementation and adjust these based on the community situation then. Please refer to Annex A for details.

Permissible Group Sizes

11. Permissible group sizes for social gatherings will be reduced from a maximum of 5 persons to a maximum of 2 persons. Correspondingly, the maximum number of unique visitors per household will be reduced to 2 per day. Individuals should continue to limit their overall number of social gatherings to not more than 1 per day, whether to another household, or meeting with friends and family members in a public place.

(Continue . . .) 

Singapore has one of the highest vaccination rates in the world (> 80%), which is why COVID deaths so far (n=78) have been remarkably low. Deaths, however, are a lagging indicator, and are expected to rise substantially over the next few weeks.

In mid-September Singapore began offering COVID booster shots to seniors, which they hope will help stem the tide of rising infections.  

While this setback will hopefully be a temporary one for Singapore, it is another reminder that edicts notwithstanding, the Coronavirus is still calling the shots.