CDC Statement on Marburg Cases in Rwanda

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A few hours ago, in WHO: Rwanda Reporting An Outbreak of Marburg Virus (26 cases, 8 Deaths), we looked at the initial reports of the first reported outbreak of Marburg in Rwanda.  This morning the CDC has released the following statement:

CDC Statement on Marburg Cases in Rwanda

STATEMENT

For immediate release: September 30, 2024
CDC Media Relations
(404) 639-3286
https://www.cdc.gov/media/


CDC is aware of 26 individuals with Marburg virus disease, as confirmed by the Republic of Rwanda Ministry of Health. According to the Ministry, six of those individuals have died. CDC is in communication with health officials in the Republic of Rwanda and across the region. To date, no cases of Marburg virus disease related to this outbreak have been reported in the United States, and the anticipated risk of Marburg virus disease to the general population in the United States is low.

CDC has a longstanding presence in Rwanda, having established an office there in 2002. CDC's Rwanda office works closely with the government to strengthen health systems and prevent communicable diseases, including training scientists through the Field Epidemiology Training Program (FETP), which supports Rwanda's capacity to investigate disease outbreaks. CDC has worked closely with the Republic of Rwanda to implement the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative (co-implemented by USAID). These investments and partnerships have strengthened core capabilities that can be utilized to respond to this outbreak, as well. CDC's ongoing coordination across the U.S. Government includes collaboration with the Ambassador of Rwanda and the team at post, working to address critical public health challenges in the country. CDC also has a long standing and trusted relationship with the Ministry of Health in Rwanda.

CDC has offered additional support to Rwanda. CDC is deploying subject matter experts to assist with the country's investigation and response to this outbreak. The staff will use experience from responding to outbreaks of Marburg virus disease AND similar diseases in other countries to support epidemiology, contact tracing, laboratory testing, disease detection and control along borders and hospital infection prevention and control.

Marburg virus disease is a rare, severe viral hemorrhagic fever similar to Ebola, which is spread in several countries in Africa by certain types of bats. It can cause deadly infections in people. The virus can also spread from person-to-person through direct contact with people who are sick. Healthcare workers in outbreak settings are at an increased risk of infection. Symptoms can appear suddenly and may include fever, rash, and severe bleeding.

For more information on Marburg virus disease, please visit About Marburg Disease | Marburg virus disease | CDC.

Preprint: Intelligent Prediction & Biological Validation of the High Reassortment Potential of Avian H5N1 and Human H3N2 Influenza Viruses

 

Antigenic `Shift' or Reassortment 

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Although a novel pandemic virus might emerge solely from the wild, an `easier' route would be for an avian or swine virus to reassort with an already `human-adapted' seasonal flu virus, producing a pandemic inducing hybrid.

Such reassortments are rare, but at least twice in my lifetime (1957 & 1968) a reassortment between seasonal flu and an avian flu virus - likely in a human host - produced a pandemic virus. 

• The first (1957) was H2N2, which According to the CDC `. . . was comprised of three different genes from an H2N2 virus that originated from an avian influenza A virus, including the H2 hemagglutinin and the N2 neuraminidase genes.'

• In 1968 a novel H3N2 virus emerged (a reassortment of 2 genes from a low path avian influenza H3 virus, and 6 genes from H2N2) which supplanted H2N2 - killed more than a million people during its first year - and continues to spark yearly epidemics more than 50 years later.

Note: The 2009 H1N1 pandemic - although it was a triple-reassortment containing some avian-origin genetic contributions - emerged from swine. 

We've seen other examples, which have fallen short of sparking a pandemic.  In April of 2020, during the opening of the COVID pandemic, we saw an MMWR Report on a Seasonal H3N2 & H1N1pdm09 Reassortant Infection - Idaho, 2019), involving a 13 year-old boy. 

A year earlier, in  Eurosurveillance: Novel influenza A(H1N2) Seasonal Reassortant - Sweden, January 2019, we saw another example, and the following assessment.

As part of Swedish national influenza surveillance, a seasonal reassortant influenza A(H1N2) virus with a novel genetic constellation was identified. This is the second detected seasonal A(H1N2) reassortant in a human in Europe within 1 year. Here, we describe the detection of the virus, its genetic characteristics and follow-up investigations.

Denmark reported a 3rd European case in May of 2019 (see Denmark Reports Novel H1N2 Flu Infection).

We've also seen worrying co-infections (see Chinese CDC: A Retrospective Investigation of a Case of Dual Infection by Avian A (H10N5) and Seasonal Influenza A (H3N2) Viruses), which - as far as we know - did not lead to a reassortant virus.

Some influenza A viruses appear far more likely to reassort than others, with LPAI H9N2 probably the most promiscuous virus on our radar, having contributed its internal genes to a wide array of HPAI viruses (see The Lancet's Poultry carrying H9N2 act as incubators for novel human avian influenza viruses).

While we worry about a potential H5N1/Seasonal flu reassortment - and urge those who work with poultry (and now dairy cattle) to get the flu shot - no one really knows how likely a successful HPAI/Seasonal flu hybrid is to emerge.

All of which brings us to a preprint from Chinese researchers using a deep learning framework tool (HAIRANGE), which suggests that recent iterations of HPAI H5N1 virus and seasonal H3N2 are increasingly well suited for reassortment.

This is, as one might guess, a highly technical report, and one that falls well above my pay grade. 

Those with more patience, and a far better understanding of machine learning, genetics, and statistics than I, may want to read the report in full. For those less adventurous, the bottom line can be summed up as:

Based on their tools and analysis, they believe the risk of seeing an H5N1/H3N2 reassortment is relatively high. 

Follow the link to read the full report.  

Intelligent prediction and biological validation of the high reassortment potential of avian H5N1 and human H3N2 influenza viruses

Jing Li, Jun-Qing Wei, Ya-Dan Li, Sen Zhang, Shu-Yang Jiang, Yue-Hong Chen, and 6 more

This is a preprint; it has not been peer reviewed by a journal.

https://doi.org/10.21203/rs.3.rs-4989707/v1

This work is licensed under a CC BY 4.0 License

PDF

Abstract

Current highly pathogenic H5N1 avian influenza (HPAI H5N1) viruses in bovine and other mammals have been posing unprecedented risks to public health. It’s vital and urgent to assess the pandemic potential of the HPAI H5N1 virus, and the risk degree posed by the virus infection or the genome reassortment with human influenza A viruses (IAVs). 

An attentional deep learning framework here was constructed of Human Adaptive Influenza virus Reassortment using Attentional Networks based on Genome Embedding (HAIRANGE), to predict high-risk reassortment between avian and human IAVs. HAIRANGE embedded genomic contextual codons covering both RNA and protein information, biologically interpretable on viral adaptive codon contexts of IAVs, predicted accurately adaptive IAV genes and adaptive reassortment between avian and human IAVs on independent validation data sets of RNA polymerase-related genes. 

A high adaptive reassortment risk was predicted by HAIRANGE of the current bovine HPAI H5N1 viruses with human H3N2 IAVs, as has been in vitro validated with polymerase reporter assay.

 In summary, the present study provides an intelligent tool to predict high-risk IAV reassortment based on genome embedding. Current bovine HPAI H5N1 is posing high pandemic potential via possible genomic reassortment with human IAVs.

(SNIP)

Conclusion

In summary, there is a human adaption-specific genomic codon context in RNA polymerase-related genes of IAVs, with which, deep learning approaches are capable of predicting the human adaptive reassortment between avian and human IAVs. The reassortment predictor predicted a high risk of adaptive reassortment of the current bovine HPAI H5N1 virus with human H3N2 IAVs, indicating a high public health risk of bovine HPAI H5N1 virus. 

          (Continue . . . )
 

WHO: Rwanda Reporting An Outbreak of Marburg Virus (26 cases, 8 Deaths)

Marburg Outbreaks 1967-2023 : Credit CDC
 

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On Friday, Sept 27th the Rwandan MOH announced that `a few' cases of Marburg virus disease had been reported in the country, making this the first outbreak reported from that country.  While less common than Ebola, Marburg was the first of the filovirus family of hemorrhagic diseases to be recognized.

As the CDC map above illustrates, Rwanda is nestled between several countries (DRC, Uganda, Kenya, Tanzania) which have all reported cases in the past. 

This is the 5th report of Marburg in a new African nation since the summer of 2021 (see recent reports from Equatorial Guinea, Guinea, Ghana, and Tanzania), suggesting the virus is increasing its geographic range. A total of 10 African nations have now reported outbreaks.

Since 2012 the CDC has recorded 47 confirmed cases across 7 outbreaks in Africa - with 25 deaths - although additional cases are likely to have gone unrecognized or reported.  

Over the weekend the WHO African Region released a statement upping the ante from `a few' cases to 26, with 6 known fatalities.  This report indicates the virus has spread to 7 different districts (of 30), suggesting this outbreak has been ongoing for some time. 

Rwanda reports first-ever Marburg virus disease outbreak, with 26 cases confirmed
28 September 2024

Brazzaville/Kigali – Rwandan health authorities are intensifying outbreak control efforts following the detection of Marburg virus disease, with 26 cases confirmed and six deaths reported currently.

Cases of the virus have been reported in seven of the country’s 30 districts. Twenty cases are in isolation and receiving treatment, while 161 people who came into contact with the reported cases have so far been identified and are being monitored as the authorities ramp up comprehensive response measures and deepen investigation to determine the origin of the infection.

In support of the ongoing efforts, World Health Organization (WHO) is mobilizing expertise, outbreak response tools, including emergency medical supplies to help reinforce the control measures being rolled out to curb the virus. A consignment of clinical care and infection prevention and control supplies is being readied and will be delivered to Kigali in the coming days from WHO’s Emergency Response Hub in Nairobi, Kenya.

“We’re rapidly setting all the critical outbreak response aspects in motion to support Rwanda halt the spread of this virus swiftly and effectively,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “With the country’s already robust public health emergency response system, WHO is collaborating closely with the national authorities to provide the needed support to further enhance the ongoing efforts.”

WHO is also coordinating efforts to reinforce collaborative cross-border measures for readiness and response in countries neighbouring Rwanda to ensure timely detection and control of the virus to avert further spread.

Although there are several promising candidate medical countermeasures that are progressing through clinical development, there is no licensed vaccine currently available to effectively combat Marburg virus disease. WHO is coordinating a consortium of experts to promote preclinical and clinical development of vaccines and therapeutics against Marburg virus disease.

Marburg virus disease is highly virulent and causes haemorrhagic fever, with a fatality ratio of up to 88%. It is in the same family as the virus that causes Ebola virus disease. Illness caused by Marburg virus begins abruptly, with high fever, severe headache and severe malaise. Many patients develop severe haemorrhagic symptoms within seven days. The virus is transmitted to people from fruit bats and spreads among humans through direct contact with the bodily fluids of infected people, surfaces and materials.

Yesterday the Rwanda MOH posted an update on Twitter/X, indicating two more fatalities. 

Eight weeks ago the WHO released their updated 2024 Pathogens Prioritization Report which lists filoviridae viruses (Ebola & Marburg) as high risk diseases for sparking a PHEIC (Public Health Emergency of International Concern).   

While most cases have occurred in central Africa, a few cases have been exported, via humans or lab animals, to other regions. The first known outbreak (in 1967) occurred at a laboratory working with green monkeys from Uganda in Marburg, Germany.

In 2019 the CDC released a list of the 56 zoonotic diseases of greatest concern to the United States, and while Ebola came in at number 16, Marburg was much further down the list at #38.

Since then, we've seen a flurry of new outbreaks, and an expansion of the virus to 5 new countries in Africa.  While this is likely to remain a regional concern, the unprecedented 2014 3-nation outbreak of Ebola taught us the folly of underestimating these viruses.

Stay tuned. 

CDC: Updated (Sept 27th) Information for Workers Exposed to H5N1 Bird Flu

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Last April - after the first confirmed HPAI H5 infection in a dairy worker - the CDC issued initial guidance on PPE (Personal Protective Equipment) for farm workers who may be exposed to suspected or confirmed HPAI infected cattle (see CDC HAN #00506) along with safety Considerations for Veterinarians working with potentially infected cats. 

In May, the CDC released Recommendations On Making PPE Available To Workers on Dairy Farms, Poultry Farms, and in Slaughterhouses.  

Even though the number of infected farm workers has grown (n=13) over the summer, the CDC has no legal authority to enforce compliance with these measures, and we've seen considerable resistance from farmers (see STAT news Farmers resist push for workers to wear protective gear against bird flu virus).

Admittedly, the recommended PPE can be unbearably hot (particularly during the summer months), can restrict movement and communication (both safety issues), and can be difficult to properly don and doff.  

While it involves some significant compromises, earlier this month the Journal of Infectious Diseases published an article calling for PPE against HPAI H5N1 to Be Adapted to Meet the Needs of Dairy Farm Workers. 

On Friday (Sept 27th) the CDC published updated guidance for farm workers (below) - and more detailed guidance for their Employers -  including several new graphics.  

I only reproduced some excerpts from a much longer guidance document (which includes donning & doffing procedures), so follow the link to read it it is entirety. 

I'll have more after the break.

Information for Workers Exposed to H5N1 Bird Flu

AT A GLANCE

H5N1 bird flu is a virus that has recently been detected for the first time in cows and can be found in poultry and other animals. The virus can infect people who work with infected animals or their byproducts (for example, raw milk), such as dairy and poultry workers. Your employer should develop a workplace health and safety plan and share it with you. This page was updated to include more details about using personal protective equipment safely.

Overview

Information for employers‎
CDC has created guidance to help your employer.

Reducing Risk for People Working with or Exposed to Animals

This H5N1 bird flu virus has been found at high levels in the milk of infected dairy cows. It has also been found in the lungs, muscle, and udder tissue of infected dairy cows. This virus has been spreading among dairy cows in multiple U.S. states and has also been found in poultry flocks. It is widespread in wild birds and has been found in some mammals, including cats. Symptoms in animals vary, with high death rates in poultry but often mild symptoms in cows, including coughing, sneezing, runny eyes or nose, or lack of appetite.

Although H5N1 bird flu usually does not infect people, there have been some infrequent cases of human infection. Confirmed cases detected in the United States to date have all been mild. However, symptoms in people can range from no or mild to severe, including death. If you work with animals or materials that could be infected or contaminated with H5N1 bird flu, you can take steps to reduce your risk of getting sick. Consult your supervisor or your employer's health and safety committee to determine how best to apply these recommendations.

          (SNIP)

Wear PPE

Wear PPE when in contact with or around dairy cows, raw milk, other animals, or surfaces and other items that might be contaminated. You may need more PPE than what you use for your normal duties. Your employer should provide the recommended PPE at no cost. Ask your supervisor if you have questions about what type of PPE to wear or when or how to use it. Putting on and removing PPE should occur during work hours.

View Larger Download

(SNIP)

While wearing PPE

• Avoid touching yourself above your chest, especially your eyes, mouth, or nose, after touching any contaminated material
• Do not eat, drink, touch your phone, smoke, vape, chew gum, dip tobacco, or use the bathroom
• Work in pairs and pay closer attention to your surroundings for hazards such as animal movement
• Protect yourself from heat stress

• Learn the symptoms and risk factors, first aid, and prevention for heat-related illness.
• Work with a buddy and observe each other for signs of heat-related illness.
• Take frequent breaks to rest and hydrate in a cool clean area after removing dirty PPE. This is important because removing PPE to take a drink while you are still working could exposure you to virus that could make you sick.
• Stay hydrated and avoid alcohol and drinks with high caffeine or sugar.
• Understand how certain medicines may increase the risk of heat-related injury and talk to a healthcare worker for help.

           (SNIP)

Know your rights

Federal law entitles you to a safe workplace. Your employer must keep your workplace free of known health and safety hazards. You have the right to speak up about hazards without fear of retaliation. See the Occupational Safety and Health Administration's Worker Rights and Protections page or more information

(Continue . . . ) 

 
I expect some of these recommendations (e.g. Do not eat, drink, touch your phone, smoke, vape, chew gum, dip tobacco, or use the bathroom while wearing PPEs) are going to be a hard sell to employees, assuming employers are willing to implement these measures. 

The updated guidance for Employers is much longer, and far more detailed, although it is worth noting that the word `should' appears 40 times (see brief excerpt below), which generally indicates a recommendation, not a requirement.

To protect workers who might be exposed, employers should update or develop a workplace health and safety plan. Employers are encouraged to use a health and safety committee that includes representatives from both management and workers to develop the plan. Helpful guidance and consultation on developing a workplace health and safety plan is available from the Occupational Safety and Health Administration (OSHA) and through your local agriculture extension office. Employers should conduct a site-specific hazard assessment to identify potential exposures based on job tasks and locations and use the hierarchy of controls to identify controls to reduce or eliminate hazards including exposure to novel influenza A viruses. The Hazard Assessment Worksheet for Dairy Facilities can help identify dairy workplace hazards and prioritize controls including PPE needed for protection. Protecting Poultry Workers from Avian Influenza (Bird Flu) can help identify poultry workplace hazards and prioritize controls.

Employers should ensure workers are protected from being exposed to the virus if workers have direct or close physical contact with:

• Any animals that are confirmed or potentially infected, including birds, dairy cows, and other livestock 

• Feces, urine, or litter from these animals

• Raw (unpasteurized) milk from these animals

• Any animals that have died, including birds and livestock
• Viscera or udders from lactating dairy cattle
• Surfaces and water (for example, ponds, waterers, buckets, pans, troughs) on farms with potentially infected animals that might be contaminated with animal waste or waste milk

         (Continue . . . )

While the CDC cites OHSA regulations, there are no HPAI H5N1 specific rules on the books.  From the OSHA site:

There is no specific OSHA standard covering avian influenza viruses; however, the General Duty Clause, Section 5(a)(1) of the Occupational Safety and Health (OSH) Act of 1970, 29 USC 654(a)(1), which requires employers to furnish to each worker "employment and a place of employment, which are free from recognized hazards that are causing or are likely to cause death or serious physical harm" may be cited where uncontrolled occupational hazards are present and no other OSHA standard is applicable to address those hazards.

OSHA's Avian Flu landing page also uses the word `should':

People who work in operations with poultry (including eradication of sick birds), cattle and other livestock (dairy, meatpacking, etc.) and their byproducts (viscera, raw milk, etc.) should take extra precautions to reduce the risk of H5N1 exposure and illness.

I'll leave the finer legal distinctions between `should' and `must', and what constitutes a `. . . place of employment, which are free from recognized hazards that are causing or are likely to cause death or serious physical harm', to the lawyers and the courts.

While it is important to have the `best practices' laid out by the CDC, for now it still appears largely up to the individual farm owner and/or operator whether, or to what extent, they are willing to follow these recommendations. 

And so far, they haven't shown much enthusiasm in doing so.

#Natlprep: Vigilance Is The Key

 

Note: This is the 28th day of National Preparedness Month. Follow this year’s campaign on Twitter by searching for the #NatlPrep #BeReady or #PrepMonth hashtags.

This month, as part of NPM24, I’ll be rerunning some updated preparedness essays, along with some new ones.

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Thirty-six hours after Helene made landfall in north Florida, more than 3 million customers remain without power across 10 states (SC, GA, NC, FL, VA, KY, WV, IN, TN), tens of thousands of families are displaced due to flood waters or damage, and rebuilding for some will take months or even years. 

As we discussed prior to landfall, some of the worst damage has occurred hundreds of miles inland, long after the system had been downgraded to a tropical storm.  And with rivers and streams still rising, and with weakened dams and levees still under pressure, the disaster is far from over. 

Losses may run into the tens of billions of dollars, and yet, it could have been much worse. Had Helene tracked just 80 miles further to the east, the entirety of the west coast of Florida would have taken a horrendous blow, and several major cities might be uninhabitable (as was New Orleans in 2005), for weeks or months. 

Adding insult to injury, this morning the National Hurricane Center has an area marked for possible development of yet another tropical system (see map at top of blog) sometime next week.   While it stands at only a 40% probability - and it may fizzle - it bears watching. 

This from this morning's 2 am Tropical Weather Outlook:

Hurricane season runs for two more months, but powerful Nor'easters and blizzards can ravage the eastern seaboard from early fall though spring.  Each year more than 1,000 tornadoes rip across the American south and mid-west. 

And earthquakes, fires, floods - and even another pandemic  - can occur at anytime with little or no warning.  It is a never-ending cycle.

In 2023, the United States recorded a record 28  Billion-dollar weather/climate disasters. 

For the past 20 years the United States has designated September as National Preparedness month, and since 2007 I've used this blog to help promote better individual and community preparedness.  As a former paramedic - and then a live-aboard sailor for > 15 years - I've learned first hand the value of being prepared to deal with emergencies. 

While no one can be completely prepared for every contingency, even a little preparedness can go a long ways towards mitigating risks.  

The time to improve your preparedness is now, before the next threat appears on the horizon. But it shouldn't be a one-and-done exercise. Ideally, preparedness is a permanent state of mind and/or lifestyle that you'll work to continually improve. 

Each year FEMA conducts a nationwide poll on preparedness, and they released their 2023 survey last December. Even though these are self-reported assessments, and `being prepared' means different things to different people, they report some small progress over the past 12 months.

It is a mixed bag, however.  More people have assembled supplies, but fewer people report practicing emergency drills or habits.  More have learned their evacuation routes, but fewer have made a plan.  And while more have tested a family communication plan, fewer report having signed up for alerts or warnings. 

I don't know where the next big disaster will occur, or when.  I only know that natural disasters are becoming bigger and more common, and the next one (even if we only consider the United States) may only be days or weeks away. 

While you can't be prepared for every eventuality, the most common scenarios involve interruptions in services (power, water, internet, banking, etc.); which may last hours, days, or even weeks.

Having basic preps (food, water, first aid kit, emergency radio, etc.) can go a long way towards easing the misery.

The goal of #NatlPrep is to foster a culture of national preparedness, and to encourage everyone to plan and be prepared to deal with an event where they can go at least 72 hours without electricity, running water, local services, or access to a supermarket.

These are, of course, minimum goals.  I consider 2 weeks a far more prudent goal. 

 So . . . if a disaster struck your region today, and the power went out, stores closed their doors, and water stopped flowing from your kitchen tap for the next 7 to 14 days . . . you are you ready with:

• A battery operated NWS Emergency Radio to find out what was going on, and to get vital instructions from emergency officials
• A decent first-aid kit, so that you can treat injuries
• Enough non-perishable food and water on hand to feed and hydrate your family (including pets) for the duration
• A way to provide light when the grid is down.
• A way to cook safely without electricity
• A way to purify or filter water
• A way to handle basic sanitation and waste disposal. 
• A way to stay cool (fans) or warm when the power is out.
• A small supply of cash to use in case credit/debit machines are not working
• An emergency plan, including meeting places, emergency out-of-state contact numbers, a disaster buddy, and in case you must evacuate, a bug-out bag
• Spare supply of essential prescription medicines that you or your family may need
• A way to entertain yourself, or your kids, during a prolonged blackout

If not, you've got some important work to do. A good place to get started is by visiting Ready.gov.  

Some past blogs that may help you get started include:

#NatlPrep: Emergency Preparedness For Kids & Teens

#Natlprep: Cultivating Preparedness - One Gift At A Time

#NatlPrep: When Evacuation Is The Better Part of Valor

#NatlPrep: Disaster Buddies - The Most Important Prep Of All

CDC Updates The Missouri H5 Case (Sept 27th) - 4 More Symptomatic HCWs

Credit CDC

Note:  After 18 hours without internet due to Hurricane Helene (which passed well to my west), I'm back online, none the worse for wear.  Sadly I can't say the same for millions of others who took a much more direct hit.  

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The on-going saga of symptomatic contacts with the Missouri H5 case from last August continues this afternoon with the revelation in this week's CDC H5N1 update that Missouri has notified them of  4 more symptomatic Health Care Workers who were in contact with the index case. 

As you'll recall, two weeks ago we learned of Two Symptomatic Contacts; one a close family member, and the other a HCW. The family member was not tested, and the HCW tested negative for influenza (test type not specified). 

A week later (Sept 21st) a 3rd Symptomatic Contact Announced, again an HCW, who was not tested. 

Today, more than a month after the index case was hospitalized, and > 3 weeks since the index case was confirmed with HPAI H5, we learn of 4 more symptomatic HCWs.  Unfortunately, no timely PCR testing was done on any of these cases. 

Admittedly, given the delays in identifying the index case, by the time the state's epidemiological investigation was launched it was probably too late to do effective PCR testing. Hopefully serological tests (still pending) will shed more light on these cases. 

It is entirely possible - perhaps even likely - that these respiratory infections were unrelated to the H5 case.  But the optics on this are bad, and getting worse with every delayed revelation.

The following is part of this week's CDC update.  Follow the link to read it in its entirety. 

Missouri Case Update

Missouri continues to lead the investigation into that state's only reported H5 case with technical assistance from CDC in Atlanta. As CDC learns new information from Missouri about its investigation, we are sharing it as quickly as possible in this space to help keep the public up to date. The Missouri Department of Health and Senior Services has not, to date, identified ongoing transmission among close contacts of the case, first reported on September 6, 2024. 

Missouri identified two health care workers who were exposed to the hospitalized case before droplet precautions were instituted (i.e., higher risk exposure) and subsequently developed mild respiratory symptoms (among 18 workers with this higher risk exposure); one tested negative for influenza by PCR, as previously reported, and the second provided a blood specimen for testing by CDC for potential influenza A(H5N1) antibodies. 

Missouri has since identified four additional health care workers who later developed mild respiratory symptoms. One of these workers was in the higher risk category and provided a blood specimen for H5 antibody testing. Three of these workers are among 94 workers who were exposed to the hospitalized case of avian influenza A(H5) after droplet precautions were instituted (i.e., lower risk exposure); blood specimens for those who became symptomatic have been collected for H5 antibody testing at CDC. 

Aside from the one health care worker reported to have tested negative for influenza by PCR, the five remaining exposed health care workers had only mild symptoms and were not tested by PCR for respiratory infections. PCR testing would have been unreliable at the time of discovery of these individuals' prior symptoms. The health care worker monitoring effort has been part of the ongoing investigation as previously reported. Results of serology testing at CDC on the positive case and their previously identified household contact are still pending. 

To date, only one case of influenza A(H5N1) has been detected in Missouri. No contacts of that case have tested positive for influenza A(H5N1). CDC continues to closely monitor available data from influenza surveillance systems, particularly in affected states, and there has been no sign of unusual influenza activity in people, including in Missouri.

New Round Of Free COVID Tests: Online Ordering Now Available

 

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As announced earlier this month, the United States government has begun to offer a new round of free COVID tests, with each household eligible for 4 tests.  Shipping of tests will begin at the end of September. 

Place Your Order for Free At-Home COVID-19 Tests

As of late September 2024, residential households in the U.S. are eligible for another order of #4 free at-home tests from USPS.com.

Here's what you need to know about your order:

Each order includes #4 individual rapid antigen COVID-19 tests (COVIDTests.gov has more details about at-home tests, including extended shelf life and updated expiration dates)

Orders will ship free, starting September 30, 2024


NOTE: Image of tests is only representative.


Expiration Dates Extended

Tests may show “expired” dates on the box, but FDA has extended those dates; see the full list of extended expiration dates.

EID Journal: Emerging Monkeypox Virus Sublineage C.1 Causing Community Transmission, Vietnam, 2023

Mpox Virus - Credit CDC PHIL

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While DNA viruses (like Mpox) often evolve at a slower rate than RNA viruses (like influenza or SARS-CoV-2), they are far from static, and longer chains of infection (or infecting different host species) can help promote faster evolution (see Evolution of monkeypox virus from 2017 to 2022: In the light of point mutations).

Another study - published just 3 months before the 2022 international outbreak of Mpox Clade II - warned of the potential for Monkeypox to spread (see PLoS NTD: The Changing Epidemiology of Human Monkeypox—A potential threat?).

Just last year, in Mpox Virus: Its Molecular Evolution and Potential Impact on Viral Epidemiology by Xi Yu et al., the authors wrote:

The evolution of zoonotic infections to become more transmissible or virulent in humans is a key cause for concern. Particularly, regarding OPXVs such as MPXV, there is concern about the risk that they could evolve into infections capable of causing another smallpox-like pandemic.

Last year we also saw the emergence of a  a new, and reportedly more dangerous clade Ib Mpox virus in the DRC, and more recently its spillover (along with the older clade I & clade II virus) into neighboring countries, which prompted the WHO to declare a second Mpox PHEIC last Month.

At the same time, we are seeing increasing reports of clade II outbreaks (see WHO Mpox Situation Report #37), which cited Europe and the Western Pacific region as reporting large increases in the last reporting month (August). 

Just as clade I continues to evolve, so do clade II viruses.  And at a surprisingly brisk rate.

 

Which brings us to a new dispatch, published yesterday in the CDC's EID Journal, which describes a cluster of an emerging C.1 sublineage of Mpox (Clade IIb) in Vietnam, which produced particularly harsh symptoms (including several deaths) among heavily immunocompromised individuals. 

This C.1 sublineage appears to have emerged in China in 2023 (see Nature Phylogeny and molecular evolution of the first local monkeypox virus cluster in Guangdong Province, China), but has since spread both regionally and internationally.  

You'll find the link and some excerpts from the report below, but you'll want to read it in its entirety (warning: some graphic content). I'll have a postscript when you return. 

Volume 30, Number 11—November 2024
Dispatch
Emerging Monkeypox Virus Sublineage C.1 Causing Community Transmission, Vietnam, 2023

Huynh Thi Thuy Hoa, Nguyen Thanh Dung , Le Manh Hung, Nguyen Thi Thu Hong, Vo Truong Quy, Nguyen Thi Thao, Nguyen Trong Duy, Hoang Truong, Tran Minh Hoang, Nguyen Thi Thanh, Mai Pham Hong Phuoc, Truong Ngoc Trung, Nguyen Nhut Thong, Nguyen Duc Huy, Vu Thi Kim Thoa, Vo Trong Vuong, Ngo Tan Tai, Huynh Kim Nhung, Dao Phuong Linh, Pham Thi Ngoc Thoa, Lam Minh Yen, Tran Ba Thien, Truong Hoang Chau Truc, Le Kim Thanh, Nguyen Thi Han Ny, Vo Tan Hoang, Nghiem My Ngoc, Dinh Nguyen Huy Man, Louise Thwaites, Tsublineage C.1 ran Tan Thanh, Nguyen Van Vinh Chau, Guy Thwaites, Nguyen To Anh, and Le Van Tan

Abstract

We studied a community cluster of 25 mpox cases in Vietnam caused by emerging monkeypox virus sublineage C.1 and imported into Vietnam through 2 independent events; 1 major cluster carried a novel APOBEC3-like mutation. Three patients died; all had advanced HIV co-infection. Viral evolution and its potential consequences should be closely monitored.


To date, most globally reported mpox sequences have come from Europe and North America, where sustained human-to-human transmission has resulted in explosive mpox outbreaks, especially in 2022 (1). A hallmark of the monkeypox virus (MPXV) strain responsible for the ongoing global outbreaks is its high evolution rate, which is driven by the host APOBEC3 (apolipoprotein B mRNA editing enzyme, catalytic polypeptide 3) deaminases, causing a dinucleotide change from TC to TT (2). 

In addition, persons with advanced HIV might experience more severe outcomes (3) and delayed viral clearance, resulting in the emergence of new variants, as has been observed with SARS-CoV-2 (4). However, this possibility has not been well studied for MPXV infection (5).

Vietnam reported its first mpox cases in late 2022 in 2 female travelers returning from United Arab Emirates (6). No additional cases were reported until September 2023, when mpox was diagnosed in a 33-year-old man in Dong Nai Province in southern Vietnam (7). This case marked the start of ongoing community transmission in Vietnam, where the mpox vaccine has not been deployed.

Despite the ongoing challenges of mpox, existing literature has been dominated by reports from Europe and North America, where most cases have been reported (1). We therefore studied the longitudinal clinical, laboratory, and virological features in mpox patients admitted to a tertiary referral hospital in Ho Chi Minh City, Vietnam, in 2023. We also sought to study virus evolution in persons with advanced HIV over the course of hospitalization.

(SNIP)

Our findings emphasize that, although MPXV infections are usually self-limiting, severe clinical complications and death can occur, especially in persons with advanced HIV (3,8). Detecting MPXV in ETA and CSF samples is unusual, although it has been reported previously (3), and this finding supports further study of mpox pathogenesis.

The responsible viruses belonged to sublineage C.1, lineage B.1 of clade IIb, and were imported into Vietnam through 2 independent events, as demonstrated by their phylogenetically forming into 2 different clusters.

Sublineage C.1 has only recently emerged and caused local transmission in China (9). In addition, C.1 sequences from various countries in Asia, Europe, and the Americas have been deposited to GISAID (https://www.gisaid.orgExternal Link), demonstrating its global dispersal.

Those collective findings point to a rapid evolution of MPXV, of which the host APOBEC3 has been shown to be a main driver (2). Alternatively, immune suppression or antivirals might also enable intrahost evolution, as observed in a recent study (5). Similar findings were documented in our metagenomics datasets of longitudinal samples. However, subsequent Sanger sequencing failed to confirm those original findings, likely attributed to sequencing artifacts, emphasizing the importance subsequent Sanger sequencing–based confirmatory experiments.

The tight cluster on the global phylogenetic tree of the 13 sequences sharing 2 nonsynonymous substitutions suggested that those patients shared a transmission network, supporting findings from a recent report (10). Because direct skin-to-skin contact plays a key role in MPXV transmission, public education campaigns should raise awareness about behaviors that increase the risk for MPXV exposure (11). Vaccination remains the most effective tool to control mpox outbreaks (12).

Conclusions

We report the clinical, laboratory, and virological findings in 25 mpox patients infected with an emerging sublineage C.1 that was imported into Vietnam through 2 independent events; 1 major cluster carried a novel APOBEC3-like mutation concerning virus assembly. MPXV evolution and its potential consequences should be closely monitored. Clinicians should be aware of unusual skin lesions in patients with advanced HIV.

Dr. Hoa is a senior infectious disease specialist at the Ho Chi Minh City Hospital for Tropical Diseases. Her research interests focus on infectious diseases, including mpox.

         (Continue . . . )

We have a long history of underestimating viruses, thinking that the way they behaved yesterday, and the day before that, tells us how they will behave tomorrow and all the days that follow.  It may be comforting, but that isn't how viruses - and disease outbreaks - work. 

• Swine origin H1N1 circulated in pigs for a decade before it suddenly acquired the ability to transmit efficiently in humans, and sparked the 2009 H1N1 pandemic.

• Ebola had never sparked a regional outbreak in Africa because it was thought `too virulent to spread', until it caused a year-long 3-nation outbreak in 2014, killing tens of thousands. 

• In early 2020, many `experts' predicted the end of the COVID pandemic within a matter of months', citing its `low mutation rate', and the benefits of `herd immunity'.  

• Until 2022, Mpox had only rarely been exported outside of Africa, and all outbreaks were quickly contained.  But over the summer of 2022, tens of thousands of cases were reported in scores of nations, and today more than 106,000 cases have now been confirmed. 

• And until 6 months ago, few scientists would have guessed that HPAI H5N1 could spread across more than a dozen states in dairy cows.

With viruses, we should expect the unexpected.  But somehow, we always seem to be caught flat-footed, shocked, and unprepared.  

Regardless of whether Mpox has what it takes to spark a major global public health crisis, somewhere out there - in a bat, or a pig, or a bird - there is a virus that someday will accrue the right mutations to put the world at grave risk. 

And when that day comes, we'd better have more prepared than just an excuse that `No one could have predicted this would happen. . . . ' 

NHC: Helene Now A Hurricane - Rapid Intensification Expected Before Landfall

 

#18,318 

Tropical Cyclone Helene was upgraded this morning by the National Hurricane Center to a CAT 1 hurricane, and is expected grow larger, and more powerful, before making landfall late tomorrow in the Florida panhandle.   

The 11 am discussion predicts:

Although the storm is expected to pass well to the west of Tampa Bay, significant storm surge is expected from Englewood north to where the storm crosses the coast. 

Helene is expected to be a very large and dangerous category 3 storm at landfall, and preparations to protect life and property should be completed by early Thursday. Impacts may be felt overnight further down the state. 

Power outages may be widespread and prolonged across much of Florida, and southern Georgia.  while the winds may quickly diminish, inland flooding - sometimes hundreds of miles from landfall - can be devastating.

The Key Messages from the NHC follow:

While I'll be doing usual hurricane preparedness blogs - and I follow (and recommend) Mark Sudduth's Hurricane Track, and Mike's Weather page - your primary source of forecast information should always be the National Hurricane Center in Miami, Florida.

These are the real experts, and the only ones you should rely on to track and forecast the storm.

 If you are on Twitter, you should also follow @FEMA, @NHC_Atlantic, @NHC_Pacific and @ReadyGov, and of course take direction from your local Emergency Management Office.

For more Hurricane resources from NOAA, you'll want to follow these links.

HURRICANE SAFETY

• NWS: Hurricane Safety Tips and Resources
• NOAA Education: Hurricane Safety, explained
• Ocean Today: Hurricane Safe videos
• CDC: Hurricanes and COVID-19
• CDC: Public Shelters During COVID-19

ADDITIONAL RESOURCES

• Delivering the Right Message: Understanding Forecasts & Impacts
• Current NHC Forecast
• Ready.gov
• #HurricaneStrong

California: USDA Reports 6 More Dairy Herds Infected With HPAI H5 (n=40)

 #18,317

On the heel's of Monday's update (see California: Number of Infected Dairy Herds Double (n=34) Over the Weekend), today the USDA has announced 6 more infected herds, bringing California's confirmed total to 40. 

As of this writing, there is no new update on the CFDA website, but previous cases have been discovered primarily due to targeted testing of dairies which have had connections with, or are in close proximity to, already confirmed positive sites.

No statewide mandatory testing of bulk milk (such as we've seen in Colorado) appears to be in place, so it is unknown how widespread the virus truly is in California's livestock.  

The latest cases (which provide no description of size or location) include:

Testing of bulk milk, or dairy cows, remains largely on a voluntary basis (except prior to interstate transport) in most states.  Unfortunately, HPAI in cattle continues to be treated as more of an economic or political problem, than a legitimate public health concern. 

Even if it turns out there is little direct risk to humans from infected cows, the virus continues to spread from livestock into other species (cats, mice, voles, even back into birds), and where that eventually leads is anyone's guess. 

Stay tuned.