HK CHP: China Reports Fatal H5N1 Infection In Guangxi Province

 Credit Wikipedia

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Although it can be confusing, there are many different clades (varieties) of avian H5N1 viruses in the wild, some of which are more pathogenic to humans than others. The clade 2.3.4.4b H5N1 virus which is currently affecting poultry and wild birds - and the occasional human - in Europe and North America is not the same as its deadlier Asian cousins. 

While they share a common ancestor, the European H5N1 virus has (thus far) only produced mild or asymptomatic infections in humans, while some Asian H5 clades have a double-digit fatality rate. 

With that in mind we have a (belated) report out of Mainland China of a fatal infection with H5N1 in a 38-year-old woman from Guangxi Province.  She fell ill and was hospitalized in September, and died in October.  While the clade isn't given, based on its severity, this is almost certainly one of the Asian strains. 

China, which is dealing with a variety of internal problems (see China At The Pandemic Crossroads) is often slow to report avian flu cases - or any other `bad news' for that matter - which is why `no news' doesn't always mean `good news' when it comes to Mainland China. 

Today's report from Hong Kong's CHP follows.  I'll have a bit more after the break.

CHP closely monitors human case of avian influenza A(H5N1) in Mainland

The Centre for Health Protection (CHP) of the Department of Health is today (November 30) closely monitoring a human case of avian influenza A(H5N1) 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 38-year-old woman living in Qinzhou, Guangxi, who had exposure to live domestic poultry before onset. She developed symptoms on September 22 and was admitted for treatment on September 25. She passed away on October 18.

From 2005 to date, 54 human cases of avian influenza A(H5N1) have been reported by Mainland health authorities.

"All novel influenza A infections, including H5N1, 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/Wednesday, November 30, 2022
Issued at HKT 17:00

Although it is undoubtedly a major undercount, prior to 2021 the World Health Organization had confirmed 862 human infections with the `Asian' H5N1 virus (see chart below). Of those, 455 (52%) died. 

This doesn't include the 80+ cases of H5N6 reported by China, the 1500+ cases of H7N9, or any of the other occasional spillovers of avian flu (H9N2, H3N8, H10N8, etc.) that often go unreported.

While infections with H5N1 and H5N6 are sporadic, and H7N9 is now (at least temporarily) controlled by China's massive poultry vaccination campaign, the concern is that these viruses can intermingle, and even share genetic material, meaning that a `mild' H5N1 virus today may not remain so forever. 

Last month we saw the release of ECDC Guidance For Testing & Identification Of Zoonotic Influenza Infections In Humans In The EU/EAA, while CDC Guidance can be found HERE.

To date, all known human influenza pandemics have involved only H1, H2, and H3 viruses, and there is some debate over whether an H5 virus can actually join that exclusive club.  

But the same skepticism existed about novel coronaviruses not so many years ago, and we now know how well that turned out. 

Peru & Ecuador Report HPAI In Poultry - Peru Reports Nearly 14,000 Wild Bird Deaths - Testing Dead Sea Lions

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Fifteen days ago Peru confirmed the deepest incursion of HPAI H5 into South America to date (see Peru: SENASA Reports HPAI H5 In Pelicans) after several pelicans tested positive on "Los cangrejos" beach in Paita, nearly 1,000 miles south of the two Colombian outbreaks reported in late October.

Five days ago, in Peru: SENASA Issues Health Alert Over HPAI H5N1 In Wild Birds, we learned it was estimated that between 3,000 and 5,000 pelicans - recovered from the beaches and natural areas of Piura (bordering Ecuador), Lambayeque, and Lima - had been killed by the virus.

Earlier this week Ecuador filed a report with WOAH WAHIS on their first outbreak of HPAI H5, detected at a commercial layer farm (location not provided), where roughly 50,000 chickens had died, while in Peru a backyard flock of poultry (see below) has tested positive.

National Agrarian Health Service of Peru

SENASA keeps cases of avian influenza in domestic birds under control

Press release

November 29, 2022 - 3:53 p.m

The National Agrarian Health Service (SENASA), an entity attached to MIDAGRI, activated an epidemiological fence in the Gallito town center, San José district, Lambayeque region, to control the first outbreak of avian influenza type A subtype H5 detected in a backyard poultry farm.

Through this measure, the health authority has managed to keep the detected outbreak under control and establish permanent epidemiological surveillance in a 500-meter radius focus and a 3-km perifocus.

Timely detection is given as a result of the health alert ordered by SENASA for 180 days against positive cases of H5 avian influenza that have been registered in wild birds of the Peruvian coast and the outbreaks that occurred in the United States, Mexico, Colombia and Ecuador.

          (Continue . . . ) 

Yesterday  Peru's National Forestry and Wildlife Service (Serfor) also published a press release, one which updates the number - and variety - of wild birds killed by HPAI over the past two weeks.  And while laboratory test results are still awaited, they are also investigating the suspicious deaths of several Sea Lions.

I'll have more after the break.

National Forest and Wildlife Service

More than 13,000 wild seabirds killed by avian influenza

Press release 

• Latest SERFOR report involves several species, including more than ten thousand pelicans.

• Two specialists from Serfor traveled to Piura to take tests on sea lions. 

November 29, 2022 - 4:44 pm

 

The latest official report carried out at the national level by the National Forestry and Wildlife Service (SERFOR) shows more than 13,869 wild seabirds killed by H5N1 avian influenza, in a large part of our coastline, inside and outside of protected areas.

Of this number, it has been recorded that 10,257 are Peruvian pelicans, 2,919 are Peruvian boobies, and 614 camanay, among other species.

The information was released by SERFOR's specialist in marine fauna, biologist Lady Amaro, who stated that official reports are made through the count that specialists from the Forestry and Wildlife Technical Administrations (ATFFS) and AgroRural have been doing. , deployed throughout the Peruvian coast, mainly in Piura, Lambayeque, Ancash, Ica, Arequipa, Moquegua, Tacna and Lima, all belonging to SERFOR.

On the other hand, it was reported that two specialists in marine fauna traveled to the department of Piura, so that they proceed to take laboratory samples from dead sea lions and wild birds in the north of our country, to determine the causes of their death. , that is, if they were infected by the virus.

Prevention

 

Because it is a highly contagious virus, people are advised not to approach seabirds or take them into their homes, in order to avoid spreading the virus, and, above all, infecting poultry or backyard birds.

Report these cases to the authorities so that they carry out the collection and care with the necessary biosecurity measures to the National Agrarian Health Service of Peru (Senasa) 946 922 469, or to the National Forestry and Wildlife Service (SERFOR) at the WhatsApp number (947 588 269).

          (Continue . . . )

The introduction of HPAI H5 to a new continent provides this avian flu virus with access to millions of immunologically naive wild birds, and to an array of LPAI viruses with which to reassort.

And as we discussed a week ago, HPAI H5 may also spill over into mammalian species with unpredictable results. We've already seen HPAI infect mink, bears, foxes, and other small terrestrial mammals in North America and in Europe, but marine mammals appear to be particularly susceptible. 

Sweden: First Known Infection of A Porpoise With Avian H5N1

UF Researchers Announce 1st Detection of HPAI H5N1 In A Bottlenose Dolphin

Maine: Seal Deaths Linked To Avian H5N1

Quebec: Seal Deaths Linked To Avian H5N1

The spread of HPAI H5 into South America is just the latest `1st' to be racked up by H5 avian flu. Over the past 12 months we've also seen:

• The first human infections (In the U.S., England and Spain)

• Its designation as a zoonotic virus by the CDC and the ECDC

• Its crossing of both the Atlantic and Pacific oceans to North America via migratory birds

• Its first detection in the Arctic (see HPAI Detected In Arctic (Svalbard) For the First Time)

• Its unusual persistence over the summer months (see Ain't No Cure For the Summer Bird Flu)

• Its Unprecedented `Order Shift' In Wild Bird H5N1 Positives In Europe & The UK

While previous incarnations of HPAI H5N1 have loomed large before - only to lose steam and recede - past performance is no guarantee of future results.

    

Clade 2.3.4.4b continues to evolve, and has become more widespread - and better adapted to year-round persistence (see Study: Global Dissemination of Avian H5N1 Clade 2.3.4.4b Viruses and Biologic Analysis Of Chinese Variants) - making it a more pervasive threat than we've seen previously.

How this plays out is anyone's guess.  But we need to be prepared to deal with new challenges ahead. 

UK APHA: Technical risk assessment for avian influenza (human health): influenza A H5N1 2.3.4.4b

APHA Interactive Avian Influenza Disease Map

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The UK's current avian epizootic began in earnest in October of 2021 - 14 months ago - with the early arrival of HPAI H5 clade 2.3.4.4b (see DEFRA: HPAI in the UK, and Europe (Preliminary Assessment), which replaced the HPAI H5N8 virus which had appeared sporadically the previous year. 

While the 2021-2022 (Oct 1st-Sept 30th) avian flu season would be the worst in UK history, its numbers have been nearly equaled in the opening 60 days of the 2022-2023 flu season. According to DEFRA:

In the United Kingdom, there have been 137 confirmed cases of highly pathogenic avian influenza (HPAI) H5N1 since 1 October 2022:

• 124 cases in England
• 9 cases in Scotland
• 3 cases in Wales
• 1 case in Northern Ireland

There have been 257 cases of (HPAI) H5N1 in England since the H5N1 outbreak started in October 2021.

This only counts captive birds or poultry.  In addition there have been literally hundreds of detections of HPAI in sick or dead wild birds (see list) across the country over the past few weeks.  

While reports of human infection with this particular clade of HPAI H5N1 are rare, we are seeing unprecedented levels of the virus in the environment, and the chances for humans to be exposed has increased markedly. 

Today the UK's APHA (Animal & Plant Health Agency) has published a technical risk assessment on the threat to human health. HPAI viruses are moving targets, of course - constantly evolving, and occasionally reassorting - which can affect the shelf life of any risk assessment.

While the APHA reassuringly finds `There is no evidence of sustained human-to-human transmission (moderate to high confidence).', they provide a number of caveats, including: 

There is insufficient information to judge the risk of asymptomatic or mild disease due to limited testing in human contacts of infected birds.

and 

There is insufficient information to assess the occurrence of limited human-to-human transmission such as transmission within households. 

As a result, this assessment states: At present there are no indicators of increasing risk to human health; however, this is a low confidence assessment. They also caution that `The risk assessment is dynamic and requires regular review during this period of unusually high levels of transmission in birds.'

In other words, the news for now is good, but it is subject to change. The full text of the risk assessment follows.

Technical risk assessment for avian influenza (human health): influenza A H5N1 2.3.4.4b

Published 29 November 2022

Applies to England

This preliminary risk assessment was undertaken using genomic analysis supplied by the Animal and Plant Health Agency (APHA) and data supplied by academic partners at an ad hoc meeting on 11 November 2022. A full technical group will be convened for ongoing risk assessment.

UK virus population

There is an increase in confirmed cases of influenza A infected birds (high confidence). In 2022, there has been year-round maintenance in indigenous wild birds, which represents a change compared to the usual seasonal pattern in which infections die out over the summer.

Influenza A H5N1 is the predominant influenza virus subtype detected in wild birds and farmed flocks in the UK (high confidence). There is diversity within the UK population of H5N1 viruses with 10 genotypes detected since October 2021, including some reassortment with low pathogenic avian influenza viruses (LPAIVs). The dominant circulating genotypes are currently AIV09 and AIV07-B2. The other currently detected genotype in poultry is AIV48, which includes genes from gull-associated influenza viruses.

Genomic surveillance is proportionate for poultry outbreaks (a genome is generated for every affected premise). There is a limited genomic surveillance sample size in wild birds, although distributed in time and space. Genomic data lags 7 to 10 days behind date of sample collection for poultry.

Extent of human exposure in the UK

Owing to the disease burden in birds, there is an increased interface between humans and infected birds (high confidence). The high number of wild birds and domestic flocks with influenza A infection also increases the likelihood of human exposures to this virus without personal protective equipment (moderate confidence).

Propensity to cause mammalian and human infection

Available surveillance data does not suggest widespread mammalian adaptation of this virus (low to moderate confidence).

Known mammalian adaptation mutations are infrequent in the available genomic data from avian viruses. There is evidence of direct spillover from birds into some mammalian species. The species affected (foxes, otters and seals) are presumed to have direct high-level exposure to infected birds based on feeding behaviour and food preferences. Few mammalian infections have been detected. The 8 available influenza genomes from these positive mammals all show the PB2 E627K substitution. This mutation is known to be acquired rapidly after infection of a mammalian host in some influenza viruses and is associated with enhanced polymerase activity.

The rapid and consistent acquisition of the PB2 mutation in mammals may imply this virus has a propensity to cause zoonotic infections and further assessment should be made of the properties of this mutation. There is an unconfirmed recent report of possible transmission between mink in Spain. Genomic data from the mink is urgently required if this is confirmed.

There is incomplete genotype to phenotype understanding and genomic data must be supplemented by in vitro and animal model studies.

There have been 4 instances of influenza A H5N1 2.3.4.4b detection in humans (one in the UK, one in the US, and 2 in Spain). There is limited asymptomatic testing of human contacts of bird cases in the UK and international surveillance is variable. Nevertheless, by comparison with other zoonotic infections including influenza viruses, this data suggests that zoonotic infections are not frequent (low confidence).

Ability to cause (a) severe infection and (b) asymptomatic infection in humans

There are no detected severe human cases associated with influenza A H5N1 (clade 2.3.4.4b) in the UK or internationally. There is insufficient information to judge the risk of asymptomatic or mild disease due to limited testing in human contacts of infected birds.

Human-to-human transmission

There is no evidence of sustained human-to-human transmission (moderate to high confidence). Subtyping surveillance in the NHS or through NHS referral to the UK Health Security Agency (UKHSA) is incomplete and could delay detection. There is insufficient information to assess the occurrence of limited human-to-human transmission such as transmission within households.

The current H5N1 2.3.4.4b viruses in UK birds react well against antisera raised against an available World Health Organization candidate vaccine virus (A/Astrakhan/3212/2020).

Assessment

The avian epidemic has passed the triggers for undertaking enhanced characterisation and surveillance. At present there are no indicators of increasing risk to human health; however, this is a low confidence assessment. The risk assessment is dynamic and requires regular review during this period of unusually high levels of transmission in birds. In vitro and animal model data is required, and detailed sentinel human infection surveillance is recommended.

Provisional triggers

Provisional triggers proposed by the ad hoc expert group are:

• change in incidence in animals
• expanded species range, particularly mammals
• increasing size of human or animal interface and the number of people exposed
• genetic features associated with human transmission
• symptomatic or asymptomatic infection in a human (evidence of replication in a human host)

Emerg. Microbes & Inf.: Epidemiology, Evolution, and Biological Characteristics of H6 Avian Influenza Viruses in China

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Among avian flu viruses, we are currently most concerned with the zoonotic threat of HPAI H5 - which is driving the largest, and most intense avian epizootic on record (see USDA/APHIS Snapshot: HPAI H5N1 In The United States) - but it is far from being the only avian flu virus on our watch list. 

In addition to other clades of HPAI H5, we've seen large outbreaks of HPAI H7 viruses, including H7N9 which infected more than 1,500 people in China between 2013-2017, killing hundreds.  

Credit FAO - Dec 5th 2017 Update

While far less deadly, we've also seen scores of human infection with LPAI H9N2, along with scattered spillover of other avian viruses (e.g. H10N8, H3N8, H7N4, H7N2, etc.). It is likely that spillovers of avian and swine variant flu viruses into humans occur far more frequently than is reported, given the lack of surveillance and testing for novel flu viruses around the globe. 

Not quite 10 years ago Taiwan's CDC Reported the 1st Human Infection With Avian H6N1 in a 20 year-old female who was hospitalized for pneumonia. The case might have gone undiagnosed were it not for the enhanced surveillance for H7N9, which had just broken out on the mainland. 

In 2014 we learned that H6N1 had jumped to Taiwanese dogs (see Taiwan: Debating The Importance Of H6N1 In Dogs), while the following year - in EID Journal: Seropositivity For H6 Influenza Viruses In China - researchers reported on a small, but significant number of people in their survey who tested positive for H6 influenza antibodies (indicating previous exposure).

H6N6 viruses have also been reported in Chinese pigs (see Pathogenicity and transmission of a swine influenza A(H6N6) virus).

Also in 2015, in Study: Adaptation Of H6N1 From Avian To Human Receptor-Binding, we saw a report citing changes the authors suggest are slowly moving the H6N1 virus towards preferential binding to human receptor cells instead of avian receptor cells

In 2020's Nature: Evolution & Pathogenicity of H6 Avian Influenza Viruses, Southern China 2011-2017, we looked at H6's increasing adaptation to mammalian physiology, and again 6 weeks ago in Study: Influenza A (H6N6) Viruses Isolated from Chickens Replicate in Mice and Human lungs Without Prior Adaptation.

But since LPAI H6 viruses only rarely produce clinical illness in poultry, and are not legally reportable to the OIE (now WOAH), we are only rarely aware of their presence, or of the potential threat they may pose.

H6N6Today we've another study, published in Emerging Microbes & Infections, which characterizes the evolution and biological characteristics of H6 viruses in China, and finds additional evidence of increased adaptation to mammalian hosts. 

This is a lengthy, and detailed, research article, which deserves to be read in its entirety.  I've only posted  the abstract and a few excerpts from the discussion. Follow the link to read:

Epidemiology, evolution, and biological characteristics of H6 avian influenza viruses in China

Xiaohao Xu, Qi Chen, Min Tan, Jia Liu, Xiyan Li, Lei Yang, show all
Accepted author version posted online: 28 Nov 2022
 
https://doi.org/10.1080/22221751.2022.2151380

Abstract

H6 avian influenza virus (AIV) is one of the most prevalent AIV subtypes in birds globally. To investigate the current situation and characteristics of H6 AIVs circulating in China, we analysed the epidemiology, genetic evolution and pathogenic features of this subtype. During 2000-2021, H6 subtype AIVs spread widely through Southern China and presented high host diversity. 

On analysing 171 H6 viruses isolated during 2009-2021, dynamic reassortments were observed among H6 and other co-circulating AIV subtypes, and these generated a total of 16 different genotypes. A few H6N6 strains possessed L226 and S228 mutations of hemagglutinin (H3 numbering), which may enhance the affinity of H6 viruses to human receptors.

H6N6 viruses also exhibited divergent pathogenicity and growth profiles in vivo and in vitro. Some of the H6N6 viruses could infect mice without mammalian adaptation, and even caused death in this species. Therefore, our study H6 AIVs posed a potential threat to human healthdemonstrated that the H6 AIVs posed a potential threat to human health and highlighted the urgent need for continued surveillance and evaluation of the H6 influenza viruses circulating in the field.

(SNIP)

Discussion

In our study, the genotypic diversity of H6 viruses and 16 genotypes was revealed in the genome analysis, providing an indication of the intricate reassortment that occurs among these viruses during their active circulation with other viruses. The same characteristics were seen for the highly pathogenic avian influenza (HPAI) H5N1 virus and the H7N9 virus. For instance, during the 1997 outbreak in Hong Kong, H5N1 influenza viruses identified in this region were considered to be complicated reassortants that acquired the ability to infect and kill mammals gradually[23]. Previously, reassortment has contributed to the emergence and spread of pandemic influenza viruses in human populations[28]. However, an H3N8 AIV jumped the species barrier recently and caused acute respiratory distress syndrome in a child. Consequently, it was extremely likely to be a novel reassortant bearing certain genes from other influenza viruses[29]. Even though human-derived gene cassettes have not yet been reported in H6 AIVs, clearly, the possibility that such reassortments will occur someday exists.

H6 AIVs had been found to replicate in mice without preadaptation, but with less weight loss and an absence of death[30]. In this study, several of the H6N6 viruses caused severe clinical symptoms in mammals or eventual death. It has been demonstrated that a deletion in the NA stalk region increased the virulence of waterfowl-derived influenza viruses in poultry[26]. Interestingly, the two H6N6 isolates (JX24/09 and HN01/09), despite having totally different pathogenicities in mice (Figure 5A-B), shared the same nine amino acids deficit in this region and even possessed completely identical NA sequences. Hence, the real determinant of virulence and the molecular mechanism underlying the difference in the biological characteristics of H6 viruses deserve thorough explorations.

Moreover, molecular analysis suggested that the Q226L and G228S mutations existed in the HA proteins of our isolates and may have contributed to their increased affinity for the human-type receptor. Taken together, our findings suggest that H6 viruses pose an increasingly serious threat to public health.

In summary, given that H6 viruses have acquired the ability to replicate in mammalian hosts, we cannot rule out the possibility that they will eventually evolve into viruses with efficient transmissibility in mammals and even human populations via the accumulation of reassortments or mutations. Therefore, long-term surveillance of H6 AIVs in China is urgently needed.

         (Continue . . . )

The conventional wisdom is that H6 viruses are unlikely to pose a serious zoonotic threat, but a decade ago LPAI H7 viruses were also thought to be a weak cousin of HPAI H5N1, and incapable of producing the same level of virulence or spread in humans.

The emergence of LPAI H7N9 in China in 2013 - sporting a mortality rate (among those hospitalized) of 30% - has dispelled that notion. A severe human infection with LPAI H7N4 in China in 2018 showed this was not a fluke.

Admittedly, H6 sits pretty low on our novel flu worry list, but the more we know about these non-notifiable LPAI viruses, the less likely we are to be blindsided by a pandemic threat coming at us from out of left field.

U.S. Embassy Alert In China: Emergency Information For Americans (Nov 28th)

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Earlier today, in China At The Pandemic Crossroads, I wrote about the limited options China has for dealing with their growing COVID epidemic, and the mounting protests erupting in many Chinese cities over their long running Zero-COVID policies. 

A short while ago Sharon Sanders at FluTrackers sent me the following Embassy Alert for Americans living or visiting China, which illustrates how perilous the situation could become. 

The State Department also recently reissued a Level 3: Reconsider Travel Advisory for China. 

U.S. MISSION CHINA STATEMENT TO AMERICAN CITIZENS

November 28, 2022
By U.S. MISSION CHINA

The United States has no higher priority than the safety, health, and well-being of American citizens overseas. We are actively working with and assisting our citizens experiencing challenges related to the recent rise of COVID-19 infections in China. The People’s Republic of China (PRC) authorities have expanded COVID-19 prevention restrictions and control measures as outbreaks occur. These measures may include residential quarantines, mass testing, closures, transportation disruptions, lockdowns, and possible family separation. Ambassador Burns and other Mission officials have regularly raised our concerns on many of these issues directly with senior PRC officials and will continue to do so.

We encourage all U.S. citizens to keep a 14-day supply of medications, bottled water, and food for yourself and any members of your household.

The Mission remains in close contact with American citizens, including through multiple messages updating the community. In order to receive these messages, Americans are strongly encouraged to register in the Smart Traveler Enrollment Program (STEP) at https://step.state.gov/ . Americans should also visit the Department of State’s China Country Information website for the latest regarding travel conditions.

In case of emergency, please reach out to the Embassy or Consulate General day or night for your area by calling +(86)(10) 8531-4000. Further information can also be found at https://china.usembassy-china.org.cn/contact/, Twitter (@USAmbChina and @USA_China_Talk ), Weibo (@美国驻华大使馆 ), WeChat (@美国驻华大使馆 ), or by email:

Embassy Beijing: BeijingACS@state.gov

Consulate General Guangzhou: GuangzhouACS@state.gov

Consulate General Shanghai: ShanghaiACS@state.gov

Consulate General Shenyang: ShenyangACS@state.gov

Consulate General Wuhan: WuhanACS@state.gov

CDC FluView Week 46: 35 States Reporting High or Very High ILI Activity

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The CDC - due to the Thanksgiving Holiday - belatedly published Friday's weekly FluView report this morning, and 5 more states have been added to the High or Very High category since week 45. Although the nation is ensnared in a viral soup of RSV, COVID, and influenza, ILI rates are the highest in week 46 that we've seen since the H1N1 pandemic of 2009. 

We often seen a `bounce' in influenza following the Thanksgiving or Christmas holidays, and it seems likely that we will see the same following this past week's heavy travel season.  The bulk of influenza detections have been H3N2, which generally hits older people harder than does H1N1. 

While the CDC estimates that 2,900 people have already been killed by influenza this year, they also report that 12 children have died from flu-related illness.  This, sadly, is undoubtedly an undercount (see 2018's Why Flu Fatality Numbers Are So Hard To Determine).

The Key Points from today's update:

• Seasonal influenza activity is elevated across the country.
• Of influenza A viruses detected and subtyped this season, 78% have been influenza A(H3N2) and have been 22% influenza A(H1N1).
• Five influenza-associated pediatric deaths were reported this week, for a total of 12 pediatric flu deaths reported so far this season.
• CDC estimates that, so far this season, there have been at least 6.2 million illnesses, 53,000 hospitalizations, and 2,900 deaths from flu.
• The cumulative hospitalization rate in the FluSurv-NET system is higher than the rate observed in week 46 during every previous season since 2010-2011.
• The majority of influenza viruses tested are in the same genetic subclade as and antigenically similar to the influenza viruses included in this season’s influenza vaccine.
• An annual flu vaccine is the best way to protect against flu. Vaccination helps prevent infection and can also prevent serious outcomes in people who get vaccinated but still get sick with flu.
• CDC recommends that everyone ages 6 months and older get a flu vaccine annually. Now is a good time to get vaccinated if you haven’t already.
• There are also prescription flu antiviral drugs that can be used to treat flu illness; those need to be started as early as possible.

It isn't too late to get a flu shot, and face masks and hand sanitizer can add prudent additional layers of protection.  

If you do get sick, stay home and call your doctor to see if an antiviral would be appropriate.

WHO: Please Call It Mpox

 Credit Wikipedia 

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As I've written often in the past, the name `monkeypox’ is more than a little misleading. 

While the virus was first detected (in 1958) in laboratory monkeys, further research has revealed its primary host likely to be rodents or possibly squirrels. Humans can contract it in the wild from an animal bite or direct contact with the infected animal’s blood, body fluids, or lesions.

But for the past 65 years, the name has stuck, both in the vernacular, and in scientific literature. As have the names of the two major clades (West Africa and Congo Basin), named after the regions where they were first identified. 

In June, following the high profile international outbreak of the virus, a group of international scientists called for renaming the virus (and its clades) in a position paper called Urgent need for a non-discriminatory and non-stigmatizing nomenclature for monkeypox virus. 

Last August, in WHO: Expert Group Assigns New Names For Monkeypox Clades, we saw the WHO announce new  designations (clade I and clade II) for the (formerly Congo Basin and West African) clades of the Monkeypox virus.

Today the WHO has announced a `preferred' replacement for the term `Monkeypox', to be phased in over the next 12 months; Mpox. 

WHO recommends new name for monkeypox disease

28 November 2022
News release
Geneva, Switzerland 

Following a series of consultations with global experts, WHO will begin using a new preferred term “mpox” as a synonym for monkeypox. Both names will be used simultaneously for one year while “monkeypox” is phased out.

When the outbreak of monkeypox expanded earlier this year, racist and stigmatizing language online, in other settings and in some communities was observed and reported to WHO. In several meetings, public and private, a number of individuals and countries raised concerns and asked WHO to propose a way forward to change the name.

Assigning names to new and, very exceptionally, to existing diseases is the responsibility of WHO under the International Classification of Diseases (ICD) and the WHO Family of International Health Related Classifications through a consultative process which includes WHO Member States.

WHO, in accordance with the ICD update process, held consultations to gather views from a range of experts, as well as countries and the general public, who were invited to submit suggestions for new names. Based on these consultations, and further discussions with WHO’s Director-General Dr Tedros Adhanom Ghebreyesus, WHO recommends the following: 

• Adoption of the new synonym mpox in English for the disease.
• Mpox will become a preferred term, replacing monkeypox, after a transition period of one year. This serves to mitigate the concerns raised by experts about confusion caused by a name change in the midst of a global outbreak. It also gives time to complete the ICD update process and to update WHO publications.
• The synonym mpox will be included in the ICD-10 online in the coming days. It will be a part of the official 2023 release of ICD-11, which is the current global standard for health data, clinical documentation and statistical aggregation.
• The term “monkeypox” will remain a searchable term in ICD, to match historic information.

Considerations for the recommendations included rationale, scientific appropriateness, extent of current usage, pronounceability, usability in different languages, absence of geographical or zoological references, and the ease of retrieval of historical scientific information.

Usually, the ICD updating process can take up to several years. In this case, the process was accelerated, though following the standard steps.

Various advisory bodies were heard during the consultation process, including experts from the medical and scientific and classification and statistics advisory committees which constituted of representatives from government authorities of 45 different countries.

The issue of the use of the new name in different languages was extensively discussed. The preferred term mpox can be used in other languages. If additional naming issues arise, these will be addressed via the same mechanism. Translations are usually discussed in formal collaboration with relevant government authorities and the related scientific societies.

WHO will adopt the term mpox in its communications, and encourages others to follow these recommendations, to minimize any ongoing negative impact of the current name and from adoption of the new name.

While the WHO released a Best Practices for the Naming of New Human Infectious Diseases position paper in 2015, there are literally thousands of existing viruses and/or diseases with problematic names (think: Ebola, Rift Valley Fever, Nipah, West Nile Virus, MERS-CoV, etc.).

But renaming an existing virus isn't as easy as it might sound. First, you need a consensus from an international committee, and even once that can be agreed upon, there are going to be negative impacts.

To start, the continuity of scientific and medical literature (going back decades) would disrupted. While researchers today might be mindful enough to conduct two searches (new name & old name), over time some of this data could be `lost', or misplaced, or simply ignored.

Add in the revamping of medical and insurance billing codes (on an international scale), the awkwardness for the public (and the press) when a new name is adopted ("X: the virus formerly known as . . . "), and any changes are going to take time to take effect.

Despite the `Best practices' mentioned above - which discourages the practice - we continue to see new viruses (see J. Virus Erad: A Review Of The Langya Virus Outbreak in China, 2022) named after the place where they were discovered. 

China At The Pandemic Crossroads

China's Reported COVID Cases - Credit Our World In Data

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While any numbers we get out of China must be taken with a very large grain of salt - as their government tightly controls the release of any `negative news' - the trends depicted in the above chart are probably reasonably representative of the relative intensity and spread of COVID on the Mainland. 

Aside from the initial outbreak in Wuhan nearly 3 years ago, and a noticeable spike after a more transmissible Omicron wave arrived 12 months ago, China's Zero-COVID policy has - until recently - kept COVID largely under control. 

But that level of control has come at great cost; to their economy, the government's image, and to the hundreds of millions of people forced to live under draconian lockdown and forced quarantine rules.  

While successful in the short-term, China's endgame with this virus is difficult to fathom. The SARS-CoV-2 virus shows no signs of going away, and despite the roll out of a vaccine in 2020, the vast majority of China's population has likely gained (or retained) very little immunity to COVID over the past 3 years.

Two weeks ago, in China: Beijing Relaxes Some Zero-COVID Regulations Even As Cases Continue To Rise, daily cases were reported by China to be running about 10,000 a day.  Today, China's National Health Commission reports more than 40,000 cases (symptomatic & asymptomatic) for the 1st time. 

While it is anyone's guess what the true size of China's outbreak really is, the fact that they are admitting to a quadrupling of cases in 2 weeks is telling. 

The newer Omicron variants (BQ.1.1, XBB, etc.) are many times more transmissible than the original Wuhan strain, and are highly evasive of any previously acquired immunity, allowing them to spread even under China's rigorous Zero-COVID policies. 

Reports of rare mass protests across China (see here, here, and here) are simultaneously being suppressed by China's government, and championed by social media and the Western press, making it difficult to gauge how much of an impact they may actually have. 

What is more evident is that China is at a crossroads with COVID, with very few palatable options. 

With more than a billion people with little or no immunity - if they relax their Zero-COVID policies they risk a tsunami of cases - which would further undermine their economy, overwhelm their healthcare services, and potentially destabilize the region by threatening the power of President Xi Jinping and the Communist Party. 

But even if they keep their COVID policies largely intact, they appear to be rapidly losing ground to the virus, meaning that any decision to maintain Zero-COVID could well become moot in the weeks ahead.

Another concern is that no one really knows what could happen if multiple Omicron variants are allowed to spread rapidly across hundreds of millions of immunologically naive Chinese.  Initially hospitalization would soar and deaths would rise, but other possibilities include:

• New, potentially more dangerous Omicron recombinants may emerge, which could revitalize the pandemic both in China, and around the globe.  It is even possible that we could see another major antigenic leap in the virus, such as we saw with Omicron a year ago. 

• Many rural Chinese live in close proximity to farm animals, which could provide additional routes for SARS-CoV-2 to spillover into other species, again with unpredictable results (see WHO/FAO/OIE Joint Statement On Monitoring SARS-CoV-2 In Wildlife & Preventing Formation of Reservoirs).

• At the very least, China's economy, and by extension - much of the world's supply chain - could suffer for months to come should a major epidemic shut down manufacturing. 

• It is fair to say that the political, societal, and economic impacts - both in China and around the world - from any of these events could be enormous. 

While a `soft-landing' from China's Zero-COVID policies may still be possible, it is hard to see how that can happen without a massive, and highly effective, vaccine campaign first. 

Given the speed of COVID's spread in China right now, that seems increasingly unlikely.  

Stay tuned, what happens in China over the next few weeks or months may very well impact the rest of the world in 2023 and beyond.  

ECDC Risk Assessment On 2022 FIFA World Cup In Qatar

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Even when we are not in the midst of a COVID pandemic, mass gathering events like Carnival in Rio, the Super Bowl, Mardi Gras, Chunyun (aka the Chinese New Year), the Summer & Winter Olympics, Umrah and the Hajj pose public health challenges not only for the host country, but for the world at large. 

In all of these events hundreds of thousands - sometimes millions - of people travel from all over the world to spend a few days or a week in a common, usually crowded, location where they can easily exchange viruses - both common and exotic - before returning home. 

While COVID - and more exotic threats like MERS-CoV, Ebola, or Avian Flu - are often the first things we think of, most infectious illnesses acquired during these mass gathering/migration events are far more common; seasonal flu, pneumonia, vector borne infections (Zika, CHKV,  Dengue, Malaria,Yellow Fever, etc.), norovirus, etc.

• In 2010, in The Impact Of Mass Gatherings & Travel On Flu Epidemics , we looked at a study  published in BMC Public Health, that looked at and attempted to quantify the impacts of mass gatherings and holiday travel on the spread of an influenza epidemic.
• And in 2011, in Viruses With A Ticket To Ride, we looked at a study that  appeared in BMC Infectious Diseases, that looked at the incidence of ARI (Acute Respiratory Infection) presenting within 5 days of train or tram travel in the UK. They found that recent  bus  or  tram  use  within  five  days  of  symptom  onset  was  associated  with  an  almost  six-fold  increased  risk  of  consulting  for  ARI.
• The  EID Journal: Respiratory Viruses & Bacteria Among Pilgrims During The 2013 Hajj found 8 of 10 pilgrims tested showed nasal or throat acquisition of respiratory pathogens during their pilgrimage, and another study by the same author found the most common cause of hospitalization during the Hajj is pneumonia (20%).  
  

Since many viruses have relatively long incubation periods (7-10 days), or may present mildly or asymptomatically in some people, it is not unusual to see these diseases transported unwittingly around the world. 

Infected travelers likely brought the West Nile Virus to the United States in 1999, introduced Chikungunya to the Americas in 2013, spread seasonal flu viruses every year, and helped to efficiently disperse COVID, the 2009 H1N1 influenza pandemic, and this year's Monkeypox viruses around the globe.

Between our concurrent COVID pandemic, the recent surge in RSV infections around the globe, and the return of an aggressive H3N2 flu strain this year - with 1.5 million visitors expected - the  FIFA World Cup being held over the next 3 weeks in Qatar is well poised to make its own contribution to the spread of infectious diseases this year.

The ECDC has published a Risk Assessment, and we have a journal pre-proof from New Microbes and New Infections called Infection risks associated with the 2022 FIFA world cup in Qatar to look at.  First, from the ECDC:

Mass gathering monitoring - the FIFA World Cup 2022 Qatar

Overview:

The 2022 FIFA World Cup is taking place between 20 November and 18 December 2022 in Qatar. Thirty-two countries are participating in this event, including nine EU Member States: Belgium, Croatia, Denmark, France, Germany, the Netherlands, Poland, Portugal, and Spain. A total of 64 matches will take place in eight stadiums spread across five Qatari cities. It is expected that approximately 1.5 million football fans from around the world will travel to Qatar during this event, some of them staying outside of the country. The FIFA Fan Festival will take place at the Al Bidda Park in Doha, and will be open every day of the tournament from 19 November to 18 December.

As of 24 November 2022, ECDC and networking partners, through epidemiological surveillance, have detected no events of public health concern in Qatar, its neighbouring countries and the countries participating in the 2022 FIFA World Cup. Four retrospective cases of MERS-CoV were reported in Saudi Arabia.

One signal that may be of interest was detected in a country participating in the World Cup, but does not pose a threat in relation to this event: on 23 November 2022, a fatality related to the ongoing shigellosis outbreak in Tunisia was reported. Previously, the Tunisian Ministry of Health issued a recommendation to apply hand-hygiene measures amid an upsurge of shigellosis cases (number not specified) among children since September 2022.

Here we provide a short epidemiological summary related to global or regional public health threats from infectious diseases:

COVID-19: Since the beginning of the pandemic and as of 17 November 2022, the Qatar Ministry of Public Health (Qatar MoPH) has reported 474 883 SARS-CoV-2 positive cases including 684 deaths. Qatar has a relatively high vaccination rate for COVID-19 with 98.86% of eligible individuals being fully vaccinated with the primary series (Qatar MoPH, WHO), and there is a decreasing trend in the number of COVID-19 cases in Qatar since late September 2022. From 1 November 2022, visitors are no longer required to present a negative COVID-19 PCR or rapid antigen test result before travelling to Qatar.

MERS-CoV: No new cases have been reported in Qatar during the monitoring week 14–17 November 2022. Overall in 2022, there were two cases of MERS-CoV reported in Qatar, and 25 cases since 2012. WHO reported four additional MERS-CoV cases in Saudi Arabia, detected from 29 December 2021 to 31 October 2022. The most recent case was reported on 9 November 2022. Overall, globally over 2 600 cases of MERS-CoV have been reported since 2012.

Monkeypox: No new cases have been reported in Qatar since September 2022. Overall, five cases of monkeypox were reported in Qatar in 2022, and the first case was imported.

ECDC assessment:

As is often the case with mass gathering events, during the 2022 FIFA World Cup in Qatar visitors may be most at risk of gastrointestinal illnesses and vaccine-preventable infections. Thus, travellers from the EU/EEA going to the event are advised to be vaccinated according to their national immunisation programme, and to ensure that they are vaccinated against seasonal influenza and have taken updated boosters for COVID-19, as recommended by respective national authorities. It is recommended to employ standard hygiene measures including regular handwashing with soap, drinking safe water (bottled, chlorinated or boiled before consumption), eating thoroughly cooked food and carefully washing fruits and vegetables with safe drinking water before consumption; and staying at home or in a hotel room when sick. The risk for EU/EEA citizens becoming infected with communicable diseases during the 2022 FIFA World Cup in Qatar is considered low if travellers observe the suggested measures before, during and after the event.

Actions:

The ECDC Epidemic Intelligence team is monitoring this event in collaboration with global partners between 14 November and 22 December 2022.

From Jaffar A. Al-Tawfiq et al. we get this discussion:

Infection risks associated with the 2022 FIFA world cup in Qatar

Jaffar A. Al-Tawfiq, Philippe Gautret, Patricia Schlagenhauf 

PII: S2052-2975(22)00107-X  DOI: https://doi.org/10.1016/j.nmni.2022.101055 

(EXCERPT)

The Qatar ministry of health (QMoH) had released COVID-19 guidance and indicated that “currently there will be no vaccination requirement” [16]. Visitors are also not required to have pre-departure SARS-CoV-2 testing. The availability of effective COVID-19 vaccines and boosters should be utilized by visitors to Qatar to prevent the occurrence of COVID-19 during mass gatherings, at least in at risk attendees.

However, the emergence of variants of SARS-CoV-2 for which vaccine efficacy might be reduced, is seen as a major threat to ending the COVID-19 pandemic and points to the occurrence of outbreaks in MGs. Previous successful Qatari experience in organizing a major football match held outside during the pandemic (Amid Cup Footbal Final of Qatar) under strict control is reassuring [17].

Another possible respiratory tract illness is the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). MERS-CoV had caused multiple hospital outbreaks in Saudi Arabia [18] and had caused limited number of cases in Qatar and the pattern was sporadic [19]. Epidemiologic data from Qatar showed the occurrence of of 28 cases of MERS (incidence of 1.7 per 1,000,000 population) and most cases had a history of contact with camels [20].

Thus, people with greater risk of developing severe disease are advised to avoid contact with dromedary camels, drinking raw camel milk or camel urine, or eating meat that has not been properly cooked [21].

Another infectious disease risk challenge at this time, is the occurrence of a multi-state monkeypox virus outbreak around the globe with the potential implication for MGs [22]. The number of reported cases to WHO is 79,641 as of 16 Nov 2022 [23]. One major difficulty with this virus is the difficulty in rapid detection of suspected cases, isolation of infected individuals and management of cases and contacts especially in large uncontrolled crowds [22]. To date, the State of Qatar had not reported any cases of monkeypox.

However, in the neighboring countries there had been limited number of cases (8 cases in Saudi Arabia, and 16 cases in United Arab Emirates) (Figure 2) [24]. The main transmission mode of the disease in the current outbreak is through close contacts, including notably sexual relations and the respiratory route plays a less important role if any [25]. Thus, it is important to avoid situations that put the individuals at risk of acquisition of monkeypox.

(SNIP)

In conclusion, the infectious disease risks associated with the FIFA World Cup 2022 this year in Qatar are dominated by the global concern about the ongoing COVID-19 pandemic with emergence of new variants and the threat of vaccine escape [32,33] and the occurrence of multistate outbreak of monkeypox.

Although in recent months, the trajectory of monkeypox cases points to decreasing numbers, this risk is still a significant challenge in the context of a football World Cup and possible sexual encounters.. Qatar, the hosting country, had made the health sector in the country ready for such occurrence. Continued surveillance and studies of the effect of MGs on the transmission of infectious disease continue to be an important aspect of MGs.

Novel technologies such as illness tracking Apps can [34] be considered for this and other large sporting and cultural events and should be employed to provide useful data for future MGs and enable recommendations for infectious disease prevention.

          (Continue . . . ) 

Although these assessments reassuringly cite the low number of MERS-CoV cases reported by Qatar (n=28) to date, we've seen a good deal of evidence that MERS-CoV is badly under-reported.  In their latest Update: Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Saudi Arabia, the World Health Organization cautioned:

The number of MERS-CoV cases reported to WHO has substantially declined since the beginning of the ongoing COVID-19 pandemic. This is likely the result of epidemiological surveillance activities for COVID-19 being prioritized, resulting in reduced testing and detection of MERS-CoV cases. 

In addition, measures taken during the COVID-19 pandemic to reduce SARS-CoV-2 transmission (e.g. mask-wearing, hand hygiene, physical distancing, improving the ventilation of indoor spaces, respiratory etiquette, stay-at-home orders, reduced mobility) are also likely reduce opportunities for onward human-to-human transmission of MERS-CoV.

However, the circulation of MERS-CoV in dromedary camels is not likely to have been impacted by these measures. Therefore, while the number of reported secondary cases of MERS has been reduced, the risk of zoonotic transmission remains.

Even before the COVID pandemic, we'd seen estimates that the vast majority of MERS cases go undiagnosed (or unreported) in the Middle East (see EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016). 

Admittedly, the chances of seeing an outbreak of MERS-COV come out of this venue are probably pretty low.  And while it might have some impact on the generation and spread of one or more new COVID variants, directly linking them to this event might be difficult or impossible. 

After nearly 3 years of pandemic lockdowns and social distancing, people understandably want to mingle, socialize, and travel. We are essentially social creatures, and the forced isolation of the past three years has exacted a heavy toll.  

But mass gathering events provide target-rich environments for all types of opportunistic infectious diseases - meaning that like it or not - we must be prepared for the unexpected.