Cambodia’s H5N1 Surge & the `M’ Word

 

 

# 8402

 

This week officials from Vietnam, Cambodia, and the International community are meeting in Phnom Penh, Cambodia to discuss the dramatic increase in H5N1 cases in that country over the past couple of years, along with other avian flu containment and control issues (see VOA report Vietnamese, Cambodian Officials Meet Over Bird Flu Concerns).

 

While H5N1 is the immediate concern, the close proximity and spread of the H7N9 virus in China also looms large for these officials (see Vietnam Girds Against H7N9 As H5N1 Spreads).

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For reasons that are far from clear, the incidence of human infection with the H5N1 virus in Cambodia over the past couple of years far exceeds that seen in neighboring Vietnam, which – in the middle of the last decade – was the world’s hotspot for human cases.

Mash up of data from WHO & Cambodia’s MOH

 

The reporting of nearly 6 times as many human cases over the past 4 years (46 vs. 8) becomes even more dramatic when you factor in the relative populations of the two countries (Vietnam 89 million, Cambodia 15 million).  Making the rate of human infection roughly 36 times higher in Cambodia since 2011.

 

Overnight the Cambodian Daily carried a report (h/t Crof) intriguingly headlined New Mutation in Bird Flu Virus in Cambodia, which they describe as:

 

The new virus apparently mutated from two existing viruses. It was discovered around the time Cambodia reported its first human infections of 2013.

 

This `mutation’ – more properly a new genotype – isn’t well described in this media report, but appears to be one we’ve discussed previously, which was described last September in Cape Town at the Options VIII Control of Influenza Conference, in an abstract entitled:

 

A new genotype resulting from the reassortment of clade 1.1 and 2.3.2.1 at the origin of the human and animal H5N1 virus cases in Cambodia in 2013

V Duong, S Rith, SV Horm, S Ly, S Sorn, S Chuop, S Buth, R Tsuyuoka, D Laurent, B Richner, H Seng, B Sar, D Holl, P Kitsutani, S Ung, A Tarantola, T Sok , P Buchy

Background: In Cambodia since 2004, A(H5N1) virus has been detected in 39 poultry outbreaks and 32 patients (27 deaths) to May 1, 2013.  Until 2012, all  A(H5N1) strains isolated in Cambodia belonged to clades 1 and 1.1, of which six distinct lineages were identified. Lineage 1 viruses shared the same ancestor with viruses from Thailand, while all the lineages detected since 2005 were closely related to viruses detected in Southern Vietnam.

Materials and Methods: Samples were obtained between January and March 2013. The samples comprised 10 confirmed human cases, 6 poultry outbreak investigations and samples from environmental surveillance of live poultry markets. All samples included in this study tested positive for A(H5N1) virus by real-time RT-PCR. Full genome sequences were generated from 31 strains amplified after inoculation into MDCK cells, embryonated eggs, or directly from the original specimen. Phylogenetic analyses were performed using the maximum likelihood method on all the genes. Antigenic analyses were also performed using reference antisera.

Results: The phylogenetic analysis of 8 genes revealed that the 31 A(H5N1) strains isolated and sequenced in Cambodia in 2013 resulted  from reassortment between clade 1.1 and clade 2.3.2.1 viruses. While the HA and NA genes belong to the clade 1.1, genotype Z, the 6 internal genes are closely related to the viruses of the clade 2.3.2.1 (A/Hubei/1/2011-like). Antigenic analysis demonstrated a significant antigenic drift.

Conclusions: In this study we report the emergence of a new genotype of clade 1.1 A(H5N1) virus in Cambodia associated with a significant antigenic drift. The link between the emergence of this new genotype and the increase in human cases observed in 2013 is yet to be determined. 

 

Last December the  World Health Organization released their monthly Influenza at the human - animal interface report where they discussed this variant and the uptick in human cases.

(excerpts)

This might be due to improvements in surveillance and physician awareness or to a potential increased circulation of the virus in poultry. The case fatality rate among reported cases, however, has decreased (54% in 2013 compared with 90% over all previous years).

Before 2013, H5N1 viruses from clade 1.1 predominated in Cambodia. Analysis of isolates from human cases and birds from the beginning of 2013 revealed the emergence of a new H5N1 genotype resulting from the reassortment of clade 1.1 and clade 2.3.2.1 viruses.

The link between the emergence of this reassortant virus and the increase in human cases observed in 2013 is yet to be determined.

 

While the media loves to use the `M’ word (mutation), the reality is influenza viruses are constantly evolving, perpetually producing new genotypes and variants. A few thrive and spread, but most are evolutionary failures, unable to compete against more biologically `fit’ variants.

 

More than 20 clades and subclades of  the H5N1 virus have been identified since 1996, and more are to be expected. This constant evolution is something we’ve looked at often, including Moving Viral Targets & EID Journal: The Expanding Variants Of H5N1.

Evolution of H5N1  -  NOTE: Not all of these clades continue to circulate.

 

 

Although this new genotype may be behind the uptick in Cambodian H5N1 cases, there are other possibilities as well, some of which are explored in the following Radio Australia Interview  (h/t Carol@SC on the Flu Wiki).

(Transcript & MP3 Audio at the link below)

 

Rising number of bird flu cases in Cambodia under scrutiny

Updated 26 March 2014, 13:34 AEST

Cambodia reported 14 deaths last year from the bird flu strain H5N1.

(Credit: ABC)

It was the highest number of human cases in the world and more than the total that Cambodia had recorded, since H5N1 was first detected there a decade ago.

So far this year, another four Cambodians have died from avian influenza.

This week, officials from Cambodia, Vietnam and international agencies have been meeting in Phnom Penh to try to work out why the numbers are higher and what to do about it.

Reporter: Robert Carmichael

Speakers: Dr Dennis Carroll, USAID; Lotfi Allal, FAO; market vendor Ly Mey

While scattered H5N1 outbreaks continue to plague Vietnam, and the recent introduction of clade 2.3.2.1C has created a snag in their vaccination program (see Vietnam Reporting H5N1 Poultry Vaccine `Failures’), eight years ago - through a combination of massive educational and regulatory efforts - they went from being the worst afflicted country in the world to being viewed as the `poster child’ for successful bird flu containment.

 

Hopefully some of the lessons learned from that experience can be used to do the same for Cambodia.

ICAAC 2012: Streaming & Archived Videos

 

ICAAC Live Feed

 

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The 52th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) got underway today in San Francisco, and once again we’re fortunate to have videos of press conferences being webcast live and archived via MicrobeWorld’s Youtube channel.

 

You can visit MicrobeWorld for a complete schedule and links to the embedded videos, but briefly the 10 interview/press conferences scheduled over the next three days are:

 

   ICAAC Live 2012 San Francisco

Schedule

(Please note topics, guests and times are subject to change. This page may be updated frequently prior to ICAAC.)

Sunday, September 9

10:00 a.m. PDT - Seasonal Flu Vaccine and Pandemic Flu Severity

Danuta Skowronski, BC Center for Disease Control, Vancouver, BC, Canada

10:45 a.m., PDT - HIV Infection and Cardiovascular Health

Daniel Pearce, Loma Linda University, Loma Linda, CA, United States

Charles Hicks, Duke University Medical Center, Durham, NC, United States

12:00 noon, PDT - ICAAC Overview Briefing

M. Lindsay Grayson, Austin Hospital, Melbourne, Australia

• Craig E. Rubens, Seattle Children’s Hospital Research Institute, Seattle, WA
• Michael J. Pucci, Achillion Pharmaceuticals, New Haven, CT

1:00 p.m., PDT - Measles:  What's Next?

Jane Seward, Centers for Disease Control and Prevention, Atlanta, GA, United States

Gaston De Serres, Institute National de Santé Publique du Quebec, Quebec, Canada

Monday, September 10

10:30 a.m., PDT - Universal Influenza Vaccine Update

Wendy Keitel, Baylor College of Medicine, Houston, TX, United States

Zachary Shriver, Visterra, Inc., Cambridge, MA, United States

12:00 noon, PDT - Vaccine to Prevent Norovirus Infection

John Treanor, University of Rochester, Rochester, NY, United States

1:00 p.m., PDT - Do Cranberries Prevent UTIs? Suzanne Geerlings, Academic Medical Center, Amsterdam, Netherlands

2:00 p.m., PDT - ICAAC Live: This Week in Microbiology with Vincent Racaniello

Vincent Racaniello, Columbia University Medical Center, NY, United States

Michael Schmidt, Medical University of South Carolina, SC, UNited States

John Brownstein, Boston Children’s Hospital, Harvard Medical School, MA, United States

William Bishai, Johns Hopkins School of Medicine, MD, United States

Victor Nizet, University of California, San Diego School of Medicine, CA, United States

Tuesday, September 11

9:30 a.m., PDT - Antibody Therapies for C. difficile

Sylvia Wong, Donnelly Centre for Cellular & Biomolecular Research, University of Toronto, Toronto, ON, Canada

David Humphreys, UCB Pharma, Slough, United Kingdom

 

10:30 a.m., PDT - Emergence of Animal-Origin H3N2 Influenza

Lyn Finelli, CDC, Atlanta, GA, United States

11:30 a.m., PDT - The Emerging Role of Social Media in Public Health

John Brownstein, Children's Hospital Boston & Harvard Medical School, Boston, MA, United States

 

 

You can follow the ICAAC conference, and ask questions of these speakers, via Twitter by following, or using the #ICAAC hashtag, or by directing your question to @ASMNewsroom.

The Hong Kong Flu Conference

 

 

 

# 4870

 

Robert Webster Warns of Complacency

 

 

Friday marked the beginning of a 5-day International Options For The Control of Influenza (VII) conference being held in Hong Kong.

 

Organized this year by such notables as Dr. Malik Peiris, Dr. Yi Guan, and Dr. Gavin Smith of the University of Hong Kong, the roster of speakers is a veritable who’s who in the world of influenza research.

 

Conference Program

 

During the first morning session attendees heard from such familiar names as Malik Peiris, York Chow, Kennedy Shortridge, Daniel Jernigan, Sherif Zaki and perhaps the most famous of all, Dr. Robert Webster.

 

Robert G. Webster is regarded as the father of influenza virology, having correctly posited 5 decades ago that human flu's are derived from avian flu strains.

 

Webster holds the Rose Marie Thomas Chair in Virology at St. Jude Children's Research Hospital, and is also a fellow of the Royal Society of London, the Royal Society of Medicine and the Royal Society of New Zealand, and a member of the National Academy of Sciences of the United States.

 

Now in his late-70s, Dr. Webster continues his research at St. Judes Research Hospital, which has been named one of  six Centers of Excellence for Influenza Research and Surveillance funded by the National Institute of Allergy and Infectious Diseases (NIAID), a part of the National Institutes of Health.

 

Today the Associated Press is carrying a story out of this influenza conference which includes some sideline comments from Dr. Webster and others. 

 

Expert warns of complacency after swine flu fizzle

By MIN LEE (AP)

 

In it Webster is quoted as saying, "We may think we can relax and influenza is no longer a problem. I want to assure you that that is not the case."

 

Webster also predicted that the next pandemic could easily arise from a virus that moves from waterfowl to swine, and then to humans.

 

A prime candidate he fears is H5N1 -  although he cautions that we can’t say when - or if – that might happen.

 

You’ll find other quotes from Webster, along with statements by Malik Peiris and the head of WHO’s global influenza program, Sylvie Briand on future pandemic threats, and on the pandemic just past.  

 

Follow the link to read the article in its entirety.

 

Hopefully the next few days will provide us with a stream of reports out of this conference.

ICEID 2010 Slide Session Abstracts

 

 

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This is a big news week for infectious disease geeks such as myself, as the International Conference on Emerging Infectious Diseases (ICEID 2010) is underway in Atlanta, Georgia.

 

Last night , the keynotes were delivered (scheduled to appear were):

 

Thomas R. Frieden, Director, CDC

 

Anthony S. Fauci, Director, NIAID  
Emerging Infectious Diseases: A
Perpetual Challenge

 

Keiji Fukuda, Special Advisor, WHO
A Pandemic in the 21st Century:
What Can We Learn

 

And today the full schedule begins, with presentations to continue through Wednesday.

 

The CDC’s EID Journal has published a pdf file of the Silde Sessions Abstracts.  It provides brief summaries of dozens of presentations that will be delivered at this conference over the next three days.

 

Some of these abstracts are intriguing, and I’ll be highlighting a number of them this week. 

 

Along the way, I’ve no doubt we’ll get additional coverage from medical reporters in attendance (something that, alas, I am not).

 

(Click link to open)

HPA Conference: Pandemic Lessons Learned

 

 

# 4677

 

 

Last week the UK’s Health Protection Agency convened a two-day conference in London where scientists, academics and clinicians gathered to examine lessons learned from the pandemic of 2009.

 

You can view the program  for the conference, along with bios of the presenters, here.

 

From the Emerging Health Threats Forum we get the following report, with extensive comments and reactions from Angus Nicoll of the European Centre for Disease Prevention and Control (ECDC).

 

 

 

 

Pandemics: Europe looks ahead

Friday 25 June 2010

ECDC expert evaluates flu response, identifies weaknesses that need to be tackled for next time

 

From a European perspective “it’s hard to think of a better pandemic”, says Angus Nicoll of the European Centre for Disease Prevention and Control (ECDC). Many features of the 2009 pandemic were in Europe’s favour, he says, but adds there are still lessons to be learned about the public health responses countries planned and how well they worked.

 

Speaking at a UK Health Protection Agency conference about the public health response this week, Nicoll says that on balance, Europe managed the pandemic “moderately” well, but that countries were “lucky it was the pandemic it was.”

 

He described the advantages Europe had in tackling the pandemic — that the pandemic virus emerged in Central America from pigs, and was not a variant of the deadly Asian bird flu virus that many had feared, he explained.

(Continue . . .)

CIDRAP News: School Based Vaccination Programs

 

 

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Robert Roos, News Editor at CIDRAP, has an overview of three reports presented this week at the 44th National Immunization Conference on the effectiveness of school-based flu vaccination programs.

 

Reports support usefulness of school-based flu vaccination

Robert Roos News Editor

Apr 19, 2010 (CIDRAP News) – Some reports released during the National Immunization Conference this week support the idea that school-based influenza vaccination programs are a workable way to get flu doses into the arms and noses of more school children faster.

 

More than 120,000 New York City children received pandemic H1N1 flu vaccine doses at school in the fall of 2009, and school-based immunization against H1N1 was practiced widely in Massachusetts as well, according to abstracts of studies being presented at the Atlanta conference.

(Continue . . . )

 

 

Among the topics being discussed at this week’s conference, the website lists:

• Adolescent Immunization
• Adult Immunization
• Assessment Barriers to Vaccination
• Community and Partnerships
• Childhood Immunization
• Cultural Diversity
• Global Immunization Surveillance
• Health Communications
• Health Education Policy and Legislation
• New Vaccines and Vaccine Development
• Vaccine-Preventable Diseases
• Vaccine Safety
• Immunization Registries

When available, full-text abstracts may be accessed via the online agenda.

Conference Agenda 

Reports From Hanoi Flu Conference

 

 

# 4508

 

 

This week representatives from more than 80 countries are gathering in Hanoi, Vietnam for the 7th annual International Ministerial Conference on Animal and Pandemic Influenza. 

 

Last week we got an early look at the draft Global Report (to be amended and revised after the conference), along with an number of resource documents.

 

We are starting to get some news reports filtering out of this conference, including this one featuring David Nabarro, the UN’s Senior System Coordinator for Avian and Human Influenza, who is attending the conference electronically after his travel plans were disrupted by the Icelandic Volcano eruption. 

 

Follow the link to read the entire interview.

 

INTERVIEW-Focus shifts to mid-sized farms to stop bird flu –UN

20 Apr 2010 06:31:42 GMT

Source: Reuters

HANOI, April 20 (Reuters) - Mid-size traders and farms that sell poultry to small farmers could act as avian flu transmission hubs and there needs to be to better biosecurity at that level, a top United Nations expert said on Tuesday.

 

Bird flu outbreaks have generally been dealt with by culling birds, but health authorities were now trying to look up the supply chain to identify possible sources of infection, said David Nabarro, the U.N.'s senior coordinator for avian and pandemic flu.

 

(Continue . . . )

 

The United States has a contingent in attendance at the conference which includes representatives of the USDA, the State Department, and a name familiar to those who read this blog -the HHS’s  Dr. Bruce Gellin, Director of the National Vaccine Program Office.

 

Here is the State Department press release on this meeting.

 

U.S. Joins Health and Agriculture Ministers at International Meeting in Hanoi to Address Ongoing Pandemic Preparedness

Office of the Spokesman

Washington, DC

April 19, 2010

---

U.S. Department of Agriculture Under Secretary for Marketing and Regulatory Programs Edward Avalos, Assistant Secretary of State for Oceans and International Environmental and Scientific Affairs Dr. Kerri-Ann Jones, and Deputy Assistant Secretary for Health at Health and Human Services Dr. Bruce Gellin, are leading the U.S. delegation to the International Ministerial Conference on Animal and Pandemic Influenza (IMCAPI) in Hanoi, Vietnam, April 19-21. Assistant Secretary Jones serves as U.S. Special Representative on Avian and Pandemic Influenza.

 

The three-day conference is being hosted by the Government of Vietnam, with support from the U.S. Agency for International Development, the United Nations, and the European Commission. Representatives from foreign governments and international organizations around the world are attending the meeting to explore how best to combat pandemic influenza and bring greater attention to the interconnection between animal and human health, including the challenges that animal and pandemic influenza pose to the global community.

(Continue . . .)

 

I expect well get more over the next day or two.

UN: Global Report on Animal and Pandemic Influenza (Draft)

 

 

 

# 4499

 

Later this month public health officials from more than 80 countries will meet in Hanoi for the 7th annual International Ministerial Conference on Animal and Pandemic Influenza.  

 

Today we get an early look at the draft Global Report (to be amended and revised after the conference), along with an number of resource documents.

 

 

April 2010 Global Report on Animal and Pandemic Influenza
April 2010

• Synopsis: Animal and Pandemic Influenza - a Framework for Sustaining Momentum (557.18 Kb)
• International Financial and Technical Assistance (1,422.10 Kb)
• Resource Paper 1: Animal and Pandemic Influenza (1,414.29 Kb)
• Resource Paper 2: H5N1 Highly Pathogenic Avian Influenza (791.47 Kb)
• Resource Paper 3: Preparedness for Global Health Threats (452.79 Kb)
• Resource Paper 4: Understanding the potential impacts and drivers of global health threats (705.40 Kb)
• Methodology Acronyms and Glossary (110.17 Kb)

 

 

From the United Nations News Centre, we get this overview including comments by David Nabarro, the UN’s Senior System Coordinator for Avian and Human Influenza. 

 

The dangers from H5N1, and other zoonotic diseases, has not gone away and the UN urges continued momentum to combat these threats.

 

 

New UN study urges sustained momentum to tackle human, animal influenza threats

David Nabarro, Senior UN System Coordinator for Avian and Human Influenza

14 April 2010 – While there has been substantial global progress towards pandemic preparedness in recent years, it is vital to maintain that momentum to respond effectively to existing and possible future threats, according to a new study by the United Nations and the World Bank.

 

“Continued global vigilance for infectious disease outbreaks and pandemics is of critical importance for health security and well-being,” says the report, entitled “Animal and pandemic influenza: a framework for sustaining momentum.”

 

The report notes that an estimated 75 per cent of new human diseases originate in animals and an average of two new animal diseases with cross-over capabilities emerge every year.

 

The emergence of three major epidemiological events into the first decade of the new century – SARS, H5N1 avian influenza and H1N1 pandemic influenza – is an indication of the rate at which threats may continue to arise, it adds.

 

“Sustaining momentum,” states the report, “will require a strategic use of resources and a move away from emergency response-driven projects and special, single-focus initiatives, to long-term capacity-building.”

 

The report will be taken up by delegates from over 80 countries when they meet at the International Ministerial Conference on Animal and Pandemic Influenza, which will be held in Hanoi, Viet Nam, from 20 to 21 April.

 

“This is a really significant conference,” David Nabarro, Senior UN System Influenza Coordinator, told reporters in New York, noting that the gathering will take stock of where the world is with regard to bird flu and the H1N1 virus, review preparedness and consider lessons learned from countries with successful control efforts.

 

The threats from bird flu and H1N1 are not over yet, he noted, stressing the need for further measures to ensure an effective global response.

 

“We have to find ways to put the work on bird flu and on pandemics more into the routine business of ministries of health and ministries of agriculture, into the routine work of disaster preparedness units in countries,” he stated. “And so an important element of the discussions in Hanoi will be the way forward.”

 

Part of the work in Hanoi, he added, will be to consider whether or not extra preparedness is necessary to ensure that those who look after animal health and those that look after human health are working together well enough to prepare for disease threats that come from animals.

 

A key question, he noted, is: “Are we well enough organized as a world to be prepared for diseases that can jump from the animal kingdom and lead to sickness and possibly quite widespread suffering among humans?”