A Personal Pre-Pandemic Plan

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While I don't have any special insight into what H5N1 will - or won't - do in the coming months, the virus continues to rack up new achievements and milestones to the point that even the mainstream media can no longer ignore it.  A few examples this week include:

The risk of a bird flu pandemic is rising - MIT Tech Review

A Bird Flu Pandemic Would Be One of the Most Foreseeable Catastrophes in History - NYT's Opinion

Scientists warn of the increased dangers of a new bird flu strain - NPR

Nothing is guaranteed, of course. We've stood on the precipice with H5N1 before, only to see it's threat recede.  But this time, the H5 virus is more widespread, and affecting a wider range of avian and mammalian hosts, than ever before. 

This time, it feels different. 

And it is always possible while we are watching H5N1 that another threat will emerge - like we saw in 2020 with COVID - that will take us by surprise. H5N1 isn't the only novel virus in the wild with pandemic potential (see CDC IRAT List), and there are plenty of other pandemic contenders not even on this list. 

While much of the world (including myself) continues to suffer from varying degrees of PTSD from the last pandemic, there are things we could - and should - be doing now to prepare for the next global health emergency. 

I'm talking individually, or as families and neighbors.  Because regardless of what governments and agencies end up doing before - or during - a pandemic, much of the day-to-day responsibility for staying healthy, and continuing to function, will fall on the individual. 

Sadly, much of the public guidance that was once promoted by the CDC and HHS on pandemic preparedness has been expunged from their websites. It's as if the first rule of pandemic preparedness in the 2020's is . . . we don't talk about pandemic preparedness. 

Buried in the CDC's archives, however, are a number of useful documents, including these from 2017:

• Get Your Household Ready For Pandemic Flu {PDF - 16 pages]
• Get Ready for Pandemic Flu: Educational Settings [PDF – 16 pages]

• Get Ready for Pandemic Flu: Workplace Settings [PDF – 16 pages]  

In addition to the advice offered in these (and other) guidance documents, I'd like to offer 5 things you can do today to prepare for a possibility of seeing another pandemic sometime in the reasonably near  future.

1.   Get, and become, a `Flu Buddy'

The first item is one we've discussed often (see Yes, We Have No Pandemic . . . But Line Up A Flu Buddy Anyway). I first fleshed out the idea in a 2008 blog called Lifelines In A Pandemic.

A `Flu Buddy’ is simply someone you can call if you get sick, who will then check on you every day (by phone, social media, or in person), make sure you have the food and medicines you need (including fetching prescriptions if appropriate), help care for you if needed, and who can call for medical help if your condition deteriorates.

Those people who care for others, like single parents, also need to consider who will take care of their dependents if they are sick.

2.  Avail yourselves of the vaccines that are available now. 

While the evidence is limited, there are some studies suggesting that getting the seasonal flu vaccine may give you some small degree of protection against the H5N1 virus.  Even if it doesn't, it may reduce your chances of having a dual infection, which could either be more serious, or even lead to a reassortant virus.

COVID remains a threat, and a dual COVID-flu infection can be worse than either one alone, so keeping current with that vaccine makes sense as well.

Since bacterial co-infections are common with influenza, getting the latest appropriate pneumonia vaccines is also a smart move.  Last year, I also updated my Tetanus shot (Tdap), and those over 75 will want to consider the RSV vaccine. 

 3.    Get a Dr. Checkup, Renew Rx Meds, & Handle any Issues

 

I'm currently a contender for a Deadpool look-a-like contest since I'm doing a (long overdue) 21-day scalp and face field treatment (Fluorouracil) following skin cancer surgery last spring.  It's not how I wanted to spend the holidays, but it seems prudent to take care of as many health issues now that I can. 

I also got my Rx meds renewed, and have laid in a stock of any OTC meds I might need.            

 4.    Stock up on PPEs or other supplies you might need

I went into COVID with an existing supply of N95 masks and gloves, and I refreshed my stocks in 2022, but if you don't already have all the N95/KN95 or other personal protective gear you would want during a pandemic, now is the time buy them. 

Once a crisis begins, it is often too late to stock up. And that goes for any preparedness supplies or gear you might desire in an emergency (Hand Sanitizers/OTC meds/etc.)

5.    Be prepared to Shelter in Place

If there was one lesson from the opening months of COVID, it is that many of us may elect - or be forced - to stay home, and avoid public places. Supply chains may be compromised, and there may be runs on `necessities' leaving some store shelves bare.

We see this every year before blizzards and hurricanes, and so it makes sense - whenever possible - to keep a stocked pantry, along with the other staples of life. Last week, in The Gift of Preparedness 2024  we looked a number of items that might make life more bearable during an extended `bug-in' situation.

The good news is, much of what you need to do now to prepare for a pandemic would hold you in good stead for any prolonged emergency or disaster.  Frankly, there is not much here I wouldn't do to prepared for hurricanes, blizzards, or earthquakes.

And if we get lucky, and no pandemic (or other emergency) occurs necessitating these preps, I'll have slept well not worrying about being unprepared. 

UKHSA Reports A 2nd Imported Mpox Clade Ib Case

 

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Four weeks ago the UK became the fifth non-African nation to report an imported Mpox Clade Ib case in a recent traveler to Africa. Since then 3 house mates of this index case have become infected, and we've seen the both the United States and Canada report imported cases. 

Unlike the milder Clade II Mpox virus, which began its world tour in the spring of 2022, clade Ib is believed to be more virulent, and potentially more easily transmitted. For that reason, it has been designated a high consequence infectious disease (HCID) in the UK

Today the UK's Health Security Agency has announced a second imported clade Ib case, this time in Leeds. 

Latest update

A new case of Clade Ib mpox has been detected in England, the UK Health Security Agency (UKHSA) can confirm.   

The case was detected in Leeds and the individual is now under specialist care at Sheffield Teaching Hospitals NHS Foundation Trust. They had recently returned from Uganda, which is seeing community transmission of Clade Ib mpox. The UKHSA and NHS will not be disclosing any further details about the individual.  

The risk to the UK population remains low. We expect to see the occasional imported case of Clade Ib mpox in the UK.  

This is the fifth case of Clade Ib mpox confirmed in England in recent weeks. This case has no links to the previous cases identified. All 4 previous cases were from the same household and all have now fully recovered.   

Close contacts of the case are being followed up by UKHSA and partner organisations. Any contacts will be offered testing and vaccination as needed and advised on any necessary further care if they have symptoms or test positive. 

Professor Susan Hopkins, Chief Medical Adviser at UKHSA, said: 

It is thanks to clinicians rapidly recognising the symptoms and our diagnostics tests that we have been able to detect this new case. 

The risk to the UK population remains low following this fifth case, and we are working rapidly to trace close contacts and reduce the risk of any potential spread. In accordance with established protocols, investigations are underway to learn how the individual acquired the infection and to assess whether there are any further associated cases. 

Clade Ib mpox has been widely circulating in the Democratic Republic of Congo (DRC), Burundi, Rwanda, Uganda and Kenya in recent months. Imported cases have been detected in Canada, Sweden, India, Thailand and Germany. 

There has been extensive planning underway to ensure healthcare professionals are equipped and prepared to respond to any further confirmed cases.

Clinical Inf. Dis.: Benefit of Early Oseltamivir Therapy for Adults Hospitalized with Influenza A: An Observational Study

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During the the opening months of the COVID pandemic we found ourselves facing a novel virus with few viable pharmaceutical options. Treatments were mainly supportive (ventilation, O2, IV fluids, etc.) along with a few desperate attempts to incorporate `off-label' drugs, many of which proved to be of limited value (see WHO Solidarity Therapeutics Trial: Remdesivir, HCQ, Lopinar/Ritonavir & Interferon Disappoint).

The first coronavirus vaccine wouldn't become widely available until early 2021, and the first experimental monoclonal antibody (Bamlanivimab) didn't receive a EUA until November 2020.

Unlike with COVID, should an influenza pandemic come along we do have a number of influenza specific antivirals, although none of them come close to being a `cure'. Most are most credited with shortening the duration and severity of an influenza infection (assuming they are started early enough in the infection).  

The most widely used of these is oseltamivir (aka `Tamiflu'), which became the go-to drug nearly 20 years ago after resistance to the older drug Amantadine became insurmountable.  There are others, including I.V. Peramavir and the newer Baloxavir, but oseltamivir is the most widely prescribed oral influenza antiviral.

A number of studies have questioned oseltamivir's value over the years, citing a paucity of `gold standard’ Randomized Control Trials (RCTs) demonstrating its effectiveness. Such studies, however, can be difficult to mount since it would be unethical to deny potentially life-saving antivirals to a `placebo group'.

Instead, we've had to rely on observational studies, many of which strongly suggest that antivirals - when given early - can reduce morbidity and mortality from influenza infection.  

In December of 2012, in Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic we looked at a meta-analysis of 90 observational studies that appeared in the Journal of Infectious Diseases that spanned nearly 35,000 patients, 85% of whom has laboratory confirmed H1N1.

Their main finding was antiviral therapy - principally oseltamivir - initiated within 48 hours of onset, reduced the likelihood of severe outcomes, namely admission to a critical care unit or death, by 49 to 65%.

And of interest with H5N1 threatening, in 2010’s Study: Antiviral Therapy For H5N1, a study of outcomes of H5N1 patients who either received, or did not receive, antiviral treatment found: 

Out of 308 cases studied, the overall survival rate was a dismal 43.5%.  But . . . of those who received at least one dose of Tamiflu . . .  60% survived . . .  as opposed to only 24% who received no antivirals.

Admittedly, not a spectacular result, but most of these cases were only diagnosed and treated after several days of severe illness. 

Despite these gaps in our knowledge, the CDC continues to encourage the early use of oseltamivir in high risk influenza patients, those with severe symptoms, or those who may be exposed to avian flu. 

CDC Study: Early flu Antiviral Treatment Can Shorten Hospital Stays in Children With Flu

CDC Interim Guidance on the Use of Antiviral Medications for Treatment of Human Infections with Novel Influenza A Viruses Associated with Severe Human Disease).

All of which brings us to a new study, published this week in Clinical Infectious Diseases, which reaffirms earlier studies showing the early administration of oseltamivir for influenza is associated with reduced severity and duration of infection. 

Due to its length I've only reproduced the abstract and a snippet from the PDF.  Follow the link to read it in its entirety.  I'll have a brief postscript when you return. 

Benefit of early oseltamivir therapy for adults hospitalized with influenza A: an observational study
Nathaniel M Lewis, PhD, Elizabeth J Harker, MPH, Lauren B Grant, MS, Yuwei Zhu, MD, MS, Carlos G Grijalva, MD, MPH, James D Chappell, MD, PhD, Jillian P Rhoads, PhD, Adrienne Baughman, Jonathan D Casey, MD, Paul W Blair, MD ... Show more
Clinical Infectious Diseases, ciae584, https://doi.org/10.1093/cid/ciae584
Published: 28 November 2024 Article history

PDF

Background

clinical guidelines recommend initiation of antiviral therapy as soon as possible for patients hospitalized with confirmed or suspected influenza.

Methods

A multicenter US observational sentinel surveillance network prospectively enrolled adults (aged ≥18 years) hospitalized with laboratory-confirmed influenza at 24 hospitals during October 1, 2022–July 21, 2023. A multivariable proportional odds model was used to compare peak pulmonary disease severity (no oxygen support, standard supplemental oxygen, high-flow oxygen/non-invasive ventilation, invasive mechanical ventilation, or death) after the day of hospital admission among patients starting oseltamivir treatment on the day of admission (early) versus those who did not (late or not treated), adjusting for baseline (admission day) severity, age, sex, site, and vaccination status. Multivariable logistic regression models were used to evaluate the odds of intensive care unit (ICU) admission, acute kidney replacement therapy or vasopressor use, and in-hospital death.

Results

A total of 840 influenza-positive patients were analyzed, including 415 (49%) who started oseltamivir treatment on the day of admission, and 425 (51%) who did not. Compared with late or not treated patients, those treated early had lower peak pulmonary disease severity (proportional aOR: 0.60, 95% CI: 0.49–0.72), and lower odds of intensive care unit admission (aOR: 0.24, 95% CI: 0.13–0.47), acute kidney replacement therapy or vasopressor use (aOR: 0.40, 95% CI: 0.22–0.67), and in-hospital death (aOR: 0.36, 95% CI: 0.18–0.72).

Conclusion

Among adults hospitalized with influenza, treatment with oseltamivir on day of hospital admission was associated reduced risk of disease progression, including pulmonary and extrapulmonary organ failure and death.

         (SNIP)

In a 24-hospital network in the United States during the 2022–2023 influenza season, among adult patients hospitalized with influenza, early treatment with oseltamivir started on the same day as hospital admission was associated reduced risk of disease progression, including pulmonary and extrapulmonary organ failure and death.

 

These findings support current recommendations, such as the IDSA Influenza Clinical Practice Guidelines and CDC guidance, to initiate oseltamivir treatment as soon as possible for adult patients hospitalized with influenza. 

          (Continue . . . )

While we would all prefer to have rock-solid, indisputable evidence based on well-mounted RCTs proving the effectiveness of Oseltamivir, the preponderance of evidence we have today indicates that NAIs can have a substantial positive therapeutic effect on influenza, particularly in high risk patients or with novel flu strains.

The real challenge with NAIs is getting them to patients in the first 24-48 hours of their illness.  

Even during moderately severe seasonal flu epidemics we've seen spot shortages around the country (see 2022's CDC HAN #0482: Prioritizing Antiviral Treatment of Influenza in the Setting of Reduced Availability of Oseltamivir).  

While there are plans to release oseltamivir from the national stockpile during an emergency, getting them that last mile from the pharmacy to the patient is always the toughest.

Which is why I hedge my bets by getting a flu shot every year.  It never hurts to have a plan `B'. 

California: CDPH Statement on Recall of 2nd Batch Of Raw Milk Following Bird Flu Detection

 State Laws on Sale of Raw Milk Products - Credit CDC

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For the second time this week California's Department of Public Health is warning people not to consume raw milk by Raw Farm, LLC of Fresno County, after a retail product on the shelf tested positive for the H5 virus.  

This time, the recalled lot (20241119) has a best used by date of 12/07/24. 

Customers are urged not to drink the product and to return any remaining product to the store where it was purchased.  While raw milk is legal in California (see map above), the CDPH (along with most public health entities) does not consider it safe.

With the recent introduction of the avian HPAI H5N1 virus to dairy cattle, the risks from consumption  have only increased. 

The full CDPH press release follows (along with photos of the product). 

CDPH Warns Against Drinking Second Lot of Raw Milk Following Bird Flu Detection ​

November 27, 2024
NR24-042​

Voluntary recall underway; Pasteurized milk is safe to drink​

​​What You Need to Know: CDPH is issuing another warning to Californians not to consume an additional batch of cream top, whole raw milk from Raw Farm, LLC of Fresno County due to a second detection of bird flu virus. Raw Farm, LLC issued a voluntary recall at the state’s request of the affected lot code 20241119 with a Best By 12/07/2024. Consumers should immediately return any remaining product to the store where it was purchased. Pasteurized milk remains safe to drink. 

​Sacramento – The California Department of Public Health (CDPH) is issuing a second warning to Californians to not consume raw milk produced and packaged by Raw Farm, LLC of Fresno County due to a detection of bird flu virus in a second retail sample. At the state’s request, the company has issued a voluntary recall of the affected milk lot code number 20241119 with a Best By date of 12/07/2024 printed on the packaging. 

No human bird flu cases associated with the product have been detected. As the state continues to investigate the link between bird flu detections in retail raw milk and the ongoing spread of bird flu in dairy cows, poultry, and sporadic human cases, consumers are strongly urged to not consume any of the affected raw milk. Customers should immediately return any remaining product to the retail point of purchase. 

The California Department of Food and Agriculture (CDFA) was onsite at Raw Farm’s milk processing facility today, November 27, collecting additional samples of stored bulk tank milk and bottled products. Results from that additional testing are pending. 

As with the testing that led to the November 24 voluntary recall notice, the Santa Clara County Public Health Laboratory tested raw milk products from retail stores in their county as a second line of consumer protection. The county identified bird flu in this second sample of raw milk purchased at a retail outlet. 

Risks Associated with Raw Milk 

​Public health experts have long warned consumers against consuming raw milk or raw milk products due to elevated risks of foodborne illness. Outbreaks due to Salmonella, Listeria monocytogenes, toxin producing E. coli, Brucella, Campylobacter, and many other bacteria have all been reported related to consuming raw dairy products. Raw milk products are not pasteurized, a heating process that kills bacteria and viruses such as bird flu. ​

Pasteurized milk and milk products are safe to consume because the heating process kills pathogens, including bird flu, that can cause illness. 

Drinking or accidentally inhaling raw milk containing bird flu virus may lead to illness. In addition, touching your eyes, nose, or mouth with unwashed hands after touching raw milk with bird flu virus may also lead to infection. Symptoms of bird flu infection in humans include eye redness or discharge, cough, sore throat, runny or stuffy nose, diarrhea, vomiting, muscle or body aches, headaches, fatigue, trouble breathing and fever. Anyone who has consumed these specific products, and is experiencing these symptoms, should immediately contact their health care provider or local health department.

California Regularly Tests Raw Milk 

As part of the state’s bird flu response, testing of raw milk from dairies has been increased to help prevent raw milk consumers from getting the virus. Once bird flu was found in California dairy herds, the California Department of Food and Agriculture (CDFA) began regular testing of raw milk in bulk tanks. In response to these recent positive tests from two retail raw milk batches, CDFA followed up with immediate additional sampling and testing at Raw Farm. 

Pasteurized Milk is Safe to Drink 

Pasteurized milk is safe to drink. Pasteurization, one of the most significant scientific food safety discoveries in human history, is the process of heating milk to specific temperatures for a certain length of time to kill many microorganisms and enzymes that lead to spoilage and illness. Pasteurization kills the bird flu virus and other harmful germs that can be found in raw milk. CDPH advises consumers not to drink raw milk or eat raw milk products due to the risk of foodborne illnesses. ​

About Bird Flu 

Since early October, California has reported 29 confirmed human cases of bird flu, 28 of whom had direct contact with infected dairy cows. No person-to-person spread of bird flu has been detected in California or the U.S. To date, all cases have reported mild symptoms (primarily eye infections), and none have been hospitalized. Because bird flu viruses can change and gain the ability to spread more easily between people, public health officials have provided preventive measures and are monitoring animal and human infections carefully. ​

Protecting Public Health 

California continues to take swift and comprehensive action in response to the detection of bird flu in dairy cows across the Central Valley, demonstrating a strong commitment to public health and worker safety. While the overall risk to the public remains low, the state is prioritizing containment efforts, raising public awareness, and providing resources to those at higher risk. Key initiatives include the distribution of personal protective equipment (PPE), increased testing, and robust surveillance of infected areas. 

Through coordinated efforts between agencies like CDPH, the California Department of Food and Agriculture, and CalOES, California is leading a cross-agency response that includes multilingual outreach to dairy and poultry workers, a targeted social media campaign to promote preventive practices, and media interviews to keep the public informed. Additionally, the state is ensuring that farm workers have access to additional doses of seasonal flu vaccine from the Centers for Disease Control and Prevention (CDC) to reduce concurrent flu risks. 

Specifically, the state is: 

• Working with local, state, and federal partners to monitor bird flu in farm animals and people who work closely with poultry and dairy cows. 
• Distributing protective gear to dairy farms and workers who have contact with infected dairy cows or raw milk to reduce the risk of getting bird flu. 
• Helping ensure individuals with symptoms of or exposure to bird flu have access to testing and treatment. ​
• Conducting timely public education efforts to ensure those impacted have information about bird flu. 

How Bird Flu Spreads 

• Touching the eyes, nose, or mouth with unwashed hands after contact with raw milk from an infected cow, or other contaminated items or surfaces. 
• Raw milk from an infected cow splashed into eyes, nose, or mouth. 
• Drinking raw milk from a cow infected with bird flu virus. ​

More Resources ​

• For the latest information on the state’s bird flu response, visit CDPH’s Bird Flu webpage and CDFA’s H5N1 Bird Flu Virus in Livestock​ site. 
• For information on the national bird flu response, see CDC's Bird Flu Response Update. 
• For work-related questions or complaints related to bird flu, contact the Cal/OSHA Call Center in English or Spanish at 1-833-579-0927. Employers can contact the California Occupational Health and Safety Division at 800-963-9424 for a free consultation to strengthen their illness and injury safety program. ​
• Farmers should contact the California Department of Food and Agriculture’s bird flu hotline at 866-922-2473 if they suspect their animals are infected with bird flu.

Photo Credit CDPH

 

USDA Adds 25 More H5 Infected Herds From California (n=461)

 

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Yesterday the USDA announced 38 new cattle herd infections in California - down from the previous week - but today, they've added 25 more bringing this week's total of 63.  California now reports 461 infected herds, which is 68% of the nation's total. 

Since most states are not testing bulk milk, or dairy cows, aggressively we don't really know how widespread the virus is in American livestock.  It is worth noting that only 90 days ago, California was confident they didn't have the virus.

This lack of testing extends to wildlife as well.  The USDA's list of wildlife H5N1 detections (see below) has barely budged in more a month, as only a few states have submitted samples since the summer. 

After 194 submissions between May and July of this year, we've seen only 14 submissions (see list below) over the past 16 weeks. 

Why the vast majority of the reports have come from northern states isn't clear, although it may come down to differences in climate and terrain (swamps vs. forests vs. deserts), and the fact that some states may be looking harder than others.

Admittedly, mammals - including domestic cats - often die in remote and difficult to access places where their carcasses are quickly scavenged by other animals, meaning most never discovered or tested. And of course, some of these animals are likely to survive the infection, and are never tested.

But we need more surveillance of wildlife, not less.  Particularly since spillovers to mammals could potentially lead to a more mammalian adapted virus. 

While ignorance may be bliss, it can be expensive too. 

Hong Kong Conducts Coordinated Avian Flu Drill `Amazonite'

 
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Hong Kong - which was ground zero for SARS in 2003 - and has dealt with with multiple imported human cases of both H5N1 and H7N9 avian flu in the past - held a major drill today to prepare for the next potential health crisis. 

Dubbed exercise `Amazonite', today's drill follows a Nov. 7th table top exercise.

Details on this drill, and additional pictures from the exercise, come from the HK CHP website.  I'll have more on drills and tabletop exercises after the break.

Credit HK CHP

Exercise "Amazonite" enhances Government's response to human case of avian influenza (with photos)

The Centre for Health Protection (CHP) of the Department of Health (DH), in collaboration with relevant government departments, today (November 27) conducted a public health exercise, code-named "Amazonite", to enhance its response capabilities in dealing with a human case of avian influenza infection, and to strengthen the execution and co-ordination abilities of the DH and relevant departments in response to a human case of avian influenza, in order to enhance awareness among stakeholders on the handling of public health emergencies.

The exercise consisted of two parts. The ground movement exercise today was held at the Cheung Sha Wan Temporary Wholesale Poultry Market. Under the exercise simulation, the CHP had received a notification from the Hospital Authority (HA) about a woman with avian influenza A (H5N1) virus infection, and commenced epidemiological investigations immediately. The investigations revealed that the patient was a chicken stallholder at a wet market. The CHP co-ordinated with relevant departments to conduct on-site investigations and risk assessment, and implement control measures at the patient's residential building, the market where she worked, the wholesale poultry market, and related chicken farms. The ground movement exercise tested the capability of the CHP and relevant departments to carry out investigation and control measures, which included contact tracing and prescription of prophylactic antiviral therapy; chicken, environmental and sewage sampling; culling of chickens and disinfecting environmental. Approximately 30 personnel from four government departments participated in this ground movement exercise, along with over 30 experts from the Mainland, Macao and Singapore health authorities, who were invited to attend as observers.

The expert observers also attended the exercise briefing held at the CHP in the morning before the ground movement exercise, and visited the Lai Wan Market in the afternoon after the ground movement exercise to learn about the design features of new-style poultry stalls in the market.

The first part of the exercise, conducted on November 7, was a table-top exercise in which four relevant government departments and the HA discussed and co-ordinated the response measures required in a simulated scenario when a local human case of avian influenza A (H5N1) was reported in Hong Kong.

"This exercise provided a valuable opportunity for relevant government departments and the HA to test the response capabilities of stakeholders in the handling of a human case of avian influenza. The DH has held 30 similar exercises in the past, simulating the situation with cases such as measles, plague, Middle East Respiratory Syndrome and Ebola virus disease to enhance the community and healthcare personnel's awareness of possible epidemics, and keep them alert and prepared," the spokesman for the CHP said.

Avian influenza is caused by influenza A viruses that mainly affect birds and poultry, such as chickens or ducks. Some avian influenza viruses can infect and spread to other animals, such as mammals, as well. Humans mainly become infected with avian influenza virus through direct contact with infected animals or contaminated environments.

"According to the World Health Organization (WHO) and health authorities outside Hong Kong, as of November 2024, more than 900 human cases of avian influenza A (H5N1) have been reported worldwide. So far this year, an increasing number of related cases were reported globally than previous years, with most of them reported from the United States. Locally, avian influenza is one of the statutory notifiable infectious diseases in Hong Kong. Since 1997, a total of 22 human cases of avian influenza A (H5N1) have been recorded in Hong Kong, among which seven had died. The most recent case was recorded in 2012. Although there is no evidence of genetic mutations in the avian influenza A (H5N1) virus that are associated with increased infectivity among people, the WHO has indicated that the global mortality rate of human cases of avian influenza A (H5N1) in the past 20 years has exceeded 50 per cent. We shall stay vigilant and get prepared to prevent and combat the disease," the spokesman said.

For more information on avian influenza, the public may visit the CHP's thematic page on avian influenza.

Ends/Wednesday, November 27, 2024
Issued at HKT 19:45

Eighteen years ago - during the first ominous flare up of H5N1 - pandemic drills like this were very common, and they were held at national, state, and local levels.  Every nation (and every U.S. state and Federal Agency) crafted a pandemic plan, and table top exercises were held regularly. 

Some of these plans, and drills, were better conceived than others, of course.  Far too many envisioned a `mild' pandemic, or focused on delivering unlikely-to-be-available vaccines (see No Such Thing As A `Planacea').

But they did raise awareness, and sometimes they showed where the rocks were, should another 1918-style pandemic come along.  In 2009, we got our pandemic, but it was unusually mild (except for those who died from it), and interest in pandemic planning, and drills, gradually declined.

COVID in 2020 reaffirmed that severe pandemics still happened, and we are starting to see some movement towards preparing for the `next' pandemic, including:

• Last March the WHO released a 110-page document to assist member nations in preparing, or updating, their plans to deal with a novel respiratory pathogen pandemic (Link).

• A number of nations, including Japan and the EU, have contracted for small quantities of pre-pandemic H5 vaccines, and Finland has begun offering them to High Risk Groups.

• Last June South Korea CDC Released a Revised ‘Influenza Pandemic Preparedness and Response Plan’ and here in the United States ASPR released their pandemic influenza preparedness and response strategy. 

• In July Japan's Ministry of Health Unveiled Revised Pandemic Plans, and  PAHO IRIS released a 9-page document on Developing Respiratory Pathogen Pandemic Preparedness Plans.

But these are the exceptions, not the rule, and we aren't seeing anywhere near the commitment to preparing for the next pandemic that we saw in the first decade of this 21st century. 

For some, perhaps it feels unnecessary, for others, too much of a reminder of 2020-2021.

But the clock keeps ticking, and we are moving inexorably towards the next global health crisis. While the following sage advice is nearly 20 years old, it is just as true today as it was in 2006:

“Everything you say in advance of a pandemic seems alarmist.  Anything you’ve done after it starts is inadequate." - Michael Leavitt,  Former Secretary of HHS

Reminder: Thanksgiving Is National Family History Day

Free Online Tool From HHS to Collect Family HX

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One of the perils of blogging is that over time embedded links to outside sources no longer function.  This year as been particularly bad following major upgrades/revamping of both the CDC and WHO websites, where even some of their internal links go nowhere.

Normally, the day before Thanksgiving I re-post my `Thanksgiving Is National Family History Day'  blog, with links and quotes from the CDC, the HHS, and the Office of the Surgeon General.  This year, those links are all dead.  

So, starting over . . . 

Every year since 2004 the Surgeon General of the United States has declared Thanksgiving – a day when families traditionally gather together - as National Family History Day, since it provides an excellent opportunity to ask about and document the medical history of relatives.

As a former paramedic, I am keenly aware of how important it is for everyone to know and have access to their personal and family medical history.

During routine visits with your doctor, knowing your family history can provide important information regarding your care.  Under more urgent conditions, emergency room doctors are often faced with patients unable to remember or relay their health history, current medications, or even drug allergies during a medical crisis. 

Which is why I always keep an EMERGENCY MEDICAL HISTORY CARD – filled out and frequently updated – in my wallet, and have urged (and have helped) others in my family to do the same.

I addressed this issue at some length in a blog called Those Who Forget Their History . . . . A few excerpts (but follow the link to read the whole thing):

Since you can’t always know, in advance when you might need medical care it is important to carry with you some kind of medical history at all times. It can tell doctors important information about your history, medications, and allergies when you can’t.

Many hospitals and pharmacies provide – either free, or for a very nominal sum – folding wallet medical history forms with a plastic sleeve to protect them. Alternatively, there are templates available online.

I’ve scanned the one offered by one of our local hospitals below. It is rudimentary, but covers the basics.

Since family gatherings are common over the holidays, Thanksgiving is often an ideal time to ask family members about their medical history.  The HHS even provides a free, online tool, for organizing and storing (on your own computer) this information. 

The CDC offers the following advice on collecting and sharing family medical histories.

Collect and share your family health history

Are you ready to collect your family health history but don't know where to start? Here's how!

• Talk to your family. Write down the names of your close blood relatives from both sides of the family: parents, siblings, half-siblings, grandparents, aunts, uncles, nieces, and nephews. Talk to these family members about what conditions they have or had, and at what age the conditions were first diagnosed. You might think you know about all of the conditions in your parents or siblings, but you might find out more information if you ask.
• Ask questions. To find out about your risk for chronic diseases, ask your relatives about which of these diseases they have had and when they were diagnosed. Questions can include
  • Do you have any chronic diseases, such as heart disease or diabetes, or health conditions such as high blood pressure or high cholesterol?
  • Have you had any other serious diseases, such as cancer or stroke? What type of cancer?
  • How old were you when each of these diseases and health conditions were diagnosed? (If your relative doesn't remember the exact age, knowing the approximate age is still useful.)
  • What is our family's ancestry? From what countries did our ancestors come to the United States?
  • What were the cause and age of death for relatives who have died?
• Record the information and update it whenever you learn new family health history information. My Family Health Portrait, a free web-based tool, is helpful in organizing the information in your family health history. My Family Health Portrait allows you to share this information easily with your healthcare provider and other family members.
• Share family health history information with your healthcare provider. If you are concerned about diseases that are common in your family, talk with your healthcare provider at your next visit. Even if you don't know all of your family health history information, share what you do know. Family health history information, even if incomplete, can help your healthcare provider decide which screening tests you need and when those tests should start.
• Share your medical and family health history with your family members. If you have a medical condition, such as cancer, heart disease, or diabetes, be sure to let your family members know about your diagnosis. If you have had genetic testing done, share your results with your family members. If you are one of the older members of your family, you may know more about diseases and health conditions in your family, especially in relatives who are no longer living. Be sure to share this information with your younger relatives so that you may all benefit from knowing this family health history information.

And lastly, a couple of other items that - while not exactly a medical history - may merit discussion in your family as it has in mine (see His Bags Are Packed, He’s Ready To Go).

• First, all adults should consider having a Living Will that specifies what types of medical treatment you desire should you become incapacitated.
• You may also wish to consider assigning someone as your Health Care Proxy, who can make decisions regarding your treatment should you be unable to do so for yourself.
• Elderly family members with chronic health problems, or those with terminal illnesses, may even desire a home DNR (Do Not Resuscitate) Order. Without legal documentation, verbal instructions by family members – even if the patient is in the last stages of an incurable illness – are likely to be ignored by emergency personnel.

While admittedly, not the cheeriest topic of conversation in the world, a few minutes spent during this Thanksgiving holiday putting together medical histories could spare you and your family a great deal of anguish down the road. 

Canada: B.C. Govt Statement on Human Influenza Case

YouTube Video Link
 

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B.C. Provincial Health officer Dr. Bonnie Henry held a lengthy press conference (video link) this afternoon providing the first update on the B.C. teenager infected with H5N1 in two weeks. The patient remains in critical, but stable, condition and is apparently on ventilator or other assisted breathing.

After an extensive investigation, including contract tracing and testing of HCWs, monitoring friends an and family, and testing more than 2 dozen animals, they have been unable to find the source of the virus, or any indication of onward transmission.

Much like our Missouri case from last August, the source of this teenager's infection may never be known.  For now, the investigation appears to be at a dead-end, but will be reopened if new information appears.

The statement from the B.C. Government follows:

Final update on human avian influenza case in B.C.

News Release

Victoria

Tuesday, November 26, 2024 11:15 AM

An extensive, multi-agency public-health investigation into an avian influenza case involving a B.C. teenager has identified no additional cases nor evidence of human-to-human transmission.

The goals of the investigation were to identify any contacts who may have had exposure to the teenager, determine the source of exposure, and ensure that there was no risk of new infections from either the teenager or animal sources. The investigation also included testing of household pets, birds and other animals from nearby premises, and environmental (soil, water) testing.

To date, all tests on humans, animals and environmental samples related to this investigation have been negative for influenza H5. While it is reassuring that no further cases have been identified, officials have also not been able to definitively identify the source of the young person’s infection.

The investigation has determined the teenager was infected with the same strain of influenza H5N1 currently circulating in wild birds and poultry in B.C. (Clade 2.3.4.4b, Genotype D1.1).  Advanced testing at the BC Centre for Disease Control (BCCDC) Public Health Laboratory determined the whole genome sequence of the virus most closely matches that of wild birds found in the Fraser Valley area in October and was not directly related to outbreaks at poultry farms in B.C.

“Our thoughts continue to be with this young person as they remain in critical condition, and their family,” said Dr. Bonnie Henry, B.C.’s provincial health officer. “I am confident in the extensive public health investigation that was led by the Fraser Health team in partnership with the BCCDC Public Health Laboratory, our partners at BC Children’s Hospital and the chief veterinary officer. Though we have not been able to determine definitively the source of exposure, we were able to rule out many potential risks and ensure there are no further cases related to this young person.”

While this was the first case of H5N1 in a person in B.C. and the first acquired in Canada, there have been a small number of human cases in the U.S. this year, including one reported in a child in California last week.

Health, animal and environmental partners across B.C. have also been working together and with the Canadian Food Inspection Agency and other national and U.S. partners to respond to the increased detections of H5N1 avian influenza in poultry farms and wild birds in the province since early October.

Prevention measures

To protect yourself against avian influenza, the following prevention measures are recommended:

• Stay up to date on all immunizations, especially the seasonal flu vaccine.
• Do not touch sick or dead animals or their droppings and do not bring sick wild animals into your home.
• Keep your pets away from sick or dead animals and their feces.
• Report dead or sick birds or animals.
• For poultry or livestock, contact the Canadian Food Inspection Agency (CFIA) Animal Health office: https://inspection.canada.ca/en/about-cfia/contact-cfia-office-telephone
• For pets, contact your veterinarian or call the BC Animal Health Centre at 1 800 661-9903
• For wild birds, contact the BC Wild Bird Mortality Line: 1 866 431-2473
• For wild mammals, contact the BC Wildlife Health Program: 1 250 751-7246

If you have been exposed to sick or dead birds or animals or work on farm where avian influenza has been detected, watch for symptoms of influenza-like illness. If you get symptoms within 10 days after exposure to sick or dead animals, tell your health-care provider that you have been in contact with sick animals and are concerned about avian influenza. This will help them give you appropriate advice on testing and treatment. Stay home and away from others while you have symptoms.

About avian influenza

Avian influenza viruses occur naturally among wild aquatic birds and spread easily from bird to bird. Since 2022, there has been unprecedented global spread of avian influenza caused by the H5N1 virus. While it mostly affects birds, it can affect other animals too. In addition to cases reported in wild birds and poultry farms in North America, the virus has infected mammals including dairy cattle, foxes, skunks, marine mammals and more. There have also been isolated reports of H5N1 detections in goats and in a pig in the United States. There have also been reports of cases in humans, notably following exposure to infected animals.

In B.C., H5N1 has been detected in wild birds, on poultry farms and among small wild mammals, including skunks and foxes. Most cases have been reported during migration season when wild birds carrying the virus are in high numbers in B.C. Since the beginning of October 2024, at least 54 infected poultry premises have been identified in B.C., along with numerous wild birds testing positive.

In B.C. and Canada, there have been no cases reported in dairy cattle and no evidence of avian influenza in samples of milk.

Influenza viruses are adaptable and can change when strains from humans or different animal species mix and exchange genetic information. Avian influenza could become more serious if the virus develops the ability to transmit from person to person, with potential for human-to-human transmission.

USDA: H5 Infected Herds Reach 650 Nationwide As California Adds 38 More Herds (n=436)

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While not as big of a leap as we saw last week, over the weekend California reported another 38 infected herds (as of Friday, Nov 22nd), bringing their total to 436 herds, nearly 40% of the state's 1,100 dairy herds. 

What we don't know is what percentage of farms have actually been tested, or how many of those farms have tested negative. 

While California remains the center of attention, testing of bulk mild and/or dairy cows remains sporadic, and largely voluntary, across much of the country.  

A few states (Colorado, Arkansas, Massachusetts, Oklahoma, and most recently Pennsylvania) have ordered mandatory testing, but for the most part `Don't test, don't tell' remains the order of the day.

Yesterday the USDA also updated their confirmed poultry outbreaks (as of Nov 22nd), adding 6 more outbreaks across 5 states.  

Over the past 30 days the U.S. has reported more than 60 outbreaks in flocks (backyard & commercial), resulting in the loss of more than 10 million birds. 

Over that same time period 261 herds of cattle have tested positive, although the number of affected cows is never disclosed. 

Meanwhile, seemingly undeterred by our biosecurity measures, H5N1 marches on. 

Referral: MedCram On Avian Flu Mutations That Favor Human Transmission

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As a blogger without a degree, I rely heavily on the skills and knowledge of others. One of the my favorite sources of reliable medical information is MedCram, which synthesizes important medical information (primarily for clinicians and medical students) into remarkably clear online lectures.

I've been a fan (and a subscriber) for years, and use it often just to bone up on medical topics I'm interested in. While they have a paid tier, they also have an extensive YouTube Channel with more than 1.5 million subscribers and over 550 of these presentations.

Two weeks ago we learned that the critically ill teenager in British Columbia had been infected with the D1.1 genotype, which is similar to the genotype that infected > 12 poultry workers in Washington State.  

A week ago, however, we learned that initial sequencing had revealed ambiguous mutations at several key sites (Q226 and E190) in the HA gene, although their significance - and when they occurred - wasn't clear.

Yesterday Professor Roger Seheult, MD released a relatively short (12 min) review of what we know about the sequences from the B.C. case, titled: H5N1 Mutations Detected in Canadian Case Favor Human Transmission. 

Highly recommended.

We've not had an update from the B.C. Provincial Health officer Dr. Bonnie Henry on the condition of this teenager since Nov 12th, but there is a press briefing scheduled for this afternoon (2pm EST, 11am PST), where hopefully we'll learn more.