Media Report: H5N1 In Telangana Poultry

Credit Wikipeida

 

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Via the Times of India this morning, we’ve a report that H5N1 has been confirmed as the cause of numerous poultry deaths in Telangana, very near Hyderabad, and that 200,000 birds are to be culled.   First the report, then I’ll return with a bit more.

 

Telangana reports bird flu outbreak, culls poultry

Siddharth Tadepalli,TNN | Apr 14, 2015, 02.38 PM IST

HYDERABAD: The Telangana government sounded a red alert after the highly pathogenic H5N1 bird flu virus broke out in Ranga Reddy district about 20 kilometers from Hyderabad.

In wake of the outbreak, the government swung into action and initiated a process to cull about 2 lakh birds within a 10 kilometre radius and also ban sale of poultry and eggs in Hayathnagar, the main town in the district and issued an advisory to Andhra Pradesh as well.

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"Yes we confirm it as the deadly H5N1 virus and we have advised the animal husbandry department in Telangana and the government to take all appropriate measures," DD Kulkarni, joint director , High-Security Animal Disease Laboratory, Bhopal, told TOI from Bhopal.

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A month ago (see Watching India (Again) . . . .) we looked at reported H5N1 outbreaks in a town called Amethi in Uttar Pradesh, where poultry reportedly began dying en masse two weeks earlier, and according to local reports animals (dogs and crows) which consumed dead poultry also died.

 

While the account of the dogs dying was never confirmed, the OIE notification Follow-up report No. 1 filed on March 25th listed both poultry and crows as testing positive for the H5N1 virus. 

 

Last fall we also saw outbreaks of H5N1 in India’s southern Kerala state and northern Chandigarh's Sukhna Lake region.  Unlike Egypt, China, and many other Southeast Asian countries which have dealt extensively with H5N1, India has never reported a human infection.

 

Whether this is due to the clade of the virus circulating in India, the use of antivirals by cullers, less-than-comprehensive surveillance/testing & and reporting, or some other factor is unknown.  

While H5N1 remains difficult for humans to catch, and even more difficult to spread to others, the concern is that after several years during which the H5N1 threat appeared to be slowly waning, it is back this year with a vengeance. 

 

And this time it has an entourage of promiscuous and unpredictable HPAI friends like H5N8, H5N2, and H5N6.

 

So we watch outbreaks carefully for any signs that the virus is changing its behavior.

Watching India (Again) . . . .

Uttar Pradesh – Credit Wikipedia

 

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With the caveat that media reports out of India are sometimes suspect, and are often tinged with less-than-veiled jabs at the local bureaucracy, we’ve a report today of a suspected outbreak of `bird flu’  (subtype not provided, but probably HPAI H5) in a town called Amethi in Uttar Pradesh, where poultry reportedly began dying en masse two weeks ago.

According to this report, animals (dogs and crows) which consumed dead poultry have also died.

 

Culling teams have reportedly been dispatched to the region.  First a link, and some excerpts from the story, then I’ll be back with a bit more on India’s history of bird flu.

 

Bird flu alert sounded in Amethi

Mar 15, 4:27 pm

Amethi (Uttar Pradesh) Mar. 15 (ANI): The threat of a bird flu outbreak looms large on Amethi as birds have been dying mysteriously in the district for almost two weeks now.

A team of the district veterinary department was dispatched to the village after a frantic call from a villager who collected samples from various villages which were then sent to Bhopal. The samples tested positive for bird flu.

However, District Veterinary Officer, Doctor Vinod Kumar, refused to come clean on the findings of the reports.

"We received a call informing us that birds were dying in a village after which a team was rushed to the spot which found out that birds were actually dying, said Kumar, while adding "this matter is somewhat confidential" when asked about inquiry report.

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In addition to having infected more than 20 mammalian species, the H5N1 virus has been detected in more than 150 different types of wild birds (See USGS List of Species Affected by H5N1 (Avian Influenza)).

Waterfowl (ducks & geese) and gallinaceous birds (turkeys, grouse, chickens & quail) are most often associated with carriage of the H5N1 virus, but terrestrial birds such as crows, starlings, pigeons, and sparrows are also known to carry, and shed, the virus as well (see 2007’s EID Journal Role of Terrestrial Wild Birds in Ecology of Influenza A Virus (H5N1).

 

As far back as 2008, we saw reports out of India of crows dying from the H5N1 virus. A little over three years ago India was again plagued with numerous wild bird die offs that were blamed on the avian flu virus (see Media Report: H5N1 Killing Crows In Jharkhand), a phenomenon that was reported again in 2014 (see OIE: H5N1 Detected In Crows Again – India).

 

Similarly, we’ve seen reports from the field, and scientific studies (see Study: Dogs And H5N1) with warnings that `dogs are highly susceptible to H5N1 AIV and may serve as an intermediate host to transfer this virus to humans’. 

Interestingly, in  A Dog & Cat Flu Review, we saw another study suggesting that dogs were less likely to display signs of illness with H5N1 than cats, although this could be a clade-specific finding.  Dogs have also been found to be susceptible to (apparently asymptomatic) infection with the recently emerged H5N8 virus (see MAFRA: H5N8 Antibodies Detected In South Korean Dogs (Again)).

 

Last fall we saw outbreaks of H5N1 in India’s southern Kerala state and northern Chandigarh's Sukhna Lake region.  While H5N1 outbreaks occur nearly every winter in India, so far they have never reported human infections.  

Whether this is due to the clade of the virus circulating in India, the use of antivirals by cullers, less-than-comprehensive surveillance/testing & and reporting, or some other factor is unknown.   

The concern is that after a decade where the H5N1 threat appeared to be slowly waning, it is back with a vengeance, and this time it has an entourage of promiscuous and unpredictable HPAI H5 friends.  So much so that a little over two weeks ago, the World Health Organization issued a warning: WHO: H5 Currently The Most Obvious Avian Flu Threat.

 

So we watch outbreaks, such as this one in India, for any signs that the virus is changing.

India Media Report: NIV Denies Mutations In H1N1

 

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Yesterday, in contrast to recent government denials (see No mutation of H1N1), we looked at an analysis by MIT: Genetic Changes In A 2014 Indian H1N1pdm09 Virus, that the authors offered as an possible explanation for the reportedly severe H1N1 season India is experiencing this winter (see press release Analysis suggests a more virulent swine flu virus in the Indian subcontinent).

 

Today, media reports are carrying denials by India’s National Institute of Virology in Pune.

 

This debate could be quickly settled were India to sequence, and make available, a comprehensive and representative sampling of recent flu isolates.  But according to the MIT article, only two samples have been deposited over the past year, and one of those was the subject of their analysis.

 

No evidence to suggest swine flu virus has mutated: NIV

New Delhi, March 12 (IANS): The National Institute of Virology on Thursday said there was no evidence to suggest that the swine flu virus in India may have mutated.

A study by the Massachusetts Institute of Technology (MIT) conducted by a team of Indian-origin scientists said swine flu has killed over 1,500 people and infected more than 27,000 people in India and the virus has acquired mutations that make it more dangerous than previously circulating strains of H1N1 influenza.

The flu virus in India seems to have acquired mutations that could spread more readily, the MIT scientists warned in the study.

Official sources at the NIV in Pune said the genetic analysis of the H1N1 isolates from the present 2015 outbreak do not show any such mutations as mentioned in the MIT publication.

The observation in the MIT report was based on gene sequence analysed for the H1N1 virus taken from a database and not from actual virus isolates from the current 2015 outbreak, the NIV sources said.

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MIT: Genetic Changes In A 2014 Indian H1N1pdm09 Virus

Flu Virus binding to Receptor Cells – Credit CDC

 

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A little over a week ago, in EID Journal: Emergence of D225G Variant A/H1N1, 2013–14 Flu Season, Florida, we re-visited one of the mutations linked to greater virulence in the (formerly pandemic, now seasonal) A/H1N1pdm09 virus.

 

This relatively rare amino acid substitution at position 225 (222 using H1 Numbering) from aspartic acid (D) to glycine (G) allows the virus to bind to receptors found deeper in the lungs, and is linked to the development of more severe pneumonia.

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A 2013 study in Influenza Other Respir Viruses called A(H1N1)pdm09 hemagglutinin D222G and D222N variants are frequently harbored by patients requiring extracorporeal membrane oxygenation and advanced respiratory assistance for severe A(H1N1)pdm09 infection linked this, and the D225N mutation to more severe respiratory symptoms.

While probably the best known, and most studied, of the virulence enhancing mutations in the pH1N1 virus, D225G/N is certainly not the only one.  And in truth, there are likely other  mutations – or combinations of amino acid substitutions – that would increase the virus’s transmissibility, replication, antiviral resistance, or pathogenicity that we don’t even know about.

 

With the D225G/N mutation, it is believed that while it increases virulence, it reduces transmissibility.   But that may simply mean that the right combination of concurrent changes hasn’t emerged to increase both . . . yet.

 

Last November, in When Influenza Goes Rogue, we looked at the long history of extreme variability between flu seasons, and the emergence of mutated, or `drifted’ viruses.  And by now everyone knows that this year we are experiencing exactly that scenario with an antigenically drifted H3N2 virus.

 

The point being that flu viruses – even seasonal flu viruses that have been around for a long time – can occasionally throw us a curve. 

 

This winter we’ve seen India reporting a large number of pH1N1 cases – which they call `swine flu’ – supposedly with an unusually high mortality rate.    We’ve seen these sorts of reports from India in the past, and so it has been difficult to determine if anything is really different about this year’s flu strain (see India swine flu toll inches towards 1500).

 

Although the numbers seem high (and likely represent only the smallest tip of much larger iceberg), in a nation of over a billion people –  millions would be expected to contract the flu in an average year - and of those, thousands would likely die. 

A couple of weeks ago, in India’s H1N1 Outbreak, we looked at some of these reports along the Indian Government’s denials that anything untoward was occurring . India’s National Institute of Virology (NIV) and their National Centre for Disease Control (NCDC) both reported No mutation of H1N1.

 

Today, however, we’ve a report that suggests (based on very limited data) that perhaps something has changed with the H1N1 virus, and that it may be affecting its transmissibility, and severity, in India.

 

First, this press release, and then a link to the study.

 

Analysis suggests a more virulent swine flu virus in the Indian subcontinent

Cell Press

A flu outbreak in India that has claimed over 1200 lives may not be identical to the 2009 North American strain, as recently reported in India. A comparative analysis conducted by scientists at the Massachusetts Institute of Technology (MIT) shows that the flu virus in India seems to have acquired mutations that could spread more readily and therefore requires deeper studies. As flu season in India winds down, the researchers call on officials to increase surveillance of this and future flu outbreaks and rethink vaccination strategies to account for potential new viruses.

The MIT analysis, which compared viral proteins important for virulence and transmissibility in the 2009 and 2014 flu epidemics, was conducted by professor Ram Sasisekharan, PhD, at the Koch Institute for Integrative Cancer Research, and his research scientist colleague Kannan Tharakaraman, PhD. It appears in the March 11 issue of the journal Cell Host & Microbe.

"It has been extensively reported in India that a virus similar to A/California/07/2009 is responsible for the current outbreak," Sasisekharan says. "Examination of the Indian H1N1 flu viruses that circulated in 2014 shows amino acid mutations that make them distinct (in terms of receptor binding, virulence, and antigenic drift) from the A/California/07/2009 virus."

"It is widely believed that the current H1N1 flu vaccine is still effective for the most part," he adds.  "Effectiveness of the current H1N1 flu vaccine is debatable, and there have been calls for updating the vaccine. The Indian H1N1 viruses that circulated in 2014 are different compared to the 2009 vaccine strain A/California/07/2009."

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This commentary (see below), which calls for greater testing and genetic sequencing on the Indian Subcontinent, notes that - despite the vastness of the Indian subcontinent, only two sequences have been deposited during 2014–2015 from India, suggesting poor surveillance and potentially limiting the response to a deadly outbreak.

Based on an analysis of Indian-origin strain A/India/6427/2014, they reported finding:

 

Although there are limited Indian-origin influenza sequences available in the public database to make any causal inference on the perceived increased fatalities in India, examination of the 2014 Indian H1N1 HA sequences shows traits with potential cause for concern. Amino acid changes in specific positions in the receptor binding site (RBS) of 2009pdmH1N1 have been shown to impact glycan RBS specificity and have been linked to increased virulence and disease severity.

Among these changes, the Indian-origin strain A/India/6427/2014 contains amino acid changes T200A and D225N compared to the 2009pdmH1N1 pandemic strain. The T200A amino acid change has been shown to improve human glycan receptor-binding of 2009pdmH1N1 HA (Xu et al., 2012b). The D225N mutation has been linked to increased virulence and disease severity in patients infected by the 2009 pdm virus (Ruggiero et al., 2013).

 

A third mutation,  K166Q, was also detected and has been linked to increased severity of pH1N1 in middle-aged adults during the 2013-14 flu season (see CIDRAP Study: Middle-aged adults susceptible to recent flu virus mutation).

The lack of any recent sequencing of H1N1 viruses from India is particularly frustrating in light of recent news reports. The authors write:  It is unknown if the strain A/India/6427/2014 is still in circulation; however, the apparent severity of the current outbreak seems to suggest that it could be.

 

The entire report/commentary – which emphasizes the need for more robust and timely influenza surveillanece and sequencing data -  may be accessed at:

 

Influenza Surveillance: 2014–2015 H1N1 “Swine”-Derived Influenza Viruses from India

Kannan Tharakaraman , Ram Sasisekharan

DOI: http://dx.doi.org/10.1016/j.chom.2015.02.019

Summary

The 2014-15 H1N1 outbreak in India has reportedly led to 800 fatalities. The reported influenza hemagglutinin sequences from India indicate that these viruses contain amino acid changes linked to enhanced virulence and are potentially antigenically distinct from the current vaccine containing 2009 (Cal0709) H1N1 viral hemagglutinin.

India’s H1N1 Outbreak

 

Flu Strain Surveillance February 5th 2015  - Credit WHO

 

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While North America and most of Europe have been dealing almost exclusively with a `drifted’ H3N2 dominated flu season, parts of the Middle East and much of the Indian sub-continent have seen more of the A(H1N1)pdm09 virus this winter.

 

By nearly all accounts, essentially the same H1N1 virus that emerged in 2009, and that we saw return in the 2013-14 flu season.

Once considered a `pandemic’ flu, H1N1 is now viewed as a seasonal strain of influenza – and while it tends to strike a younger cohort than does H3N2 – it often produces a `milder’  overall flu season than H3. 

 

In the Indian press, however, H1N1 is still widely regarded as `swine flu’  or `pig flu’, and it isn’t unusual to see a heightened level of `urgency’ in their reporting on the virus.  This is ground we’ve trod before.

 

In 2012 (India’s last H1N1-heavy flu season) we saw a flurry of newspapers headlines (see Indian Expert: `Nothing Scary About Outbreak’), claiming government cover-ups of huge numbers of `swine flu’ deaths, and speculation that some (unidentified) `mutation’ in the H1N1 virus has revived its ferocity.

So prevalent were these stories that the Indian government issued a flat denial in April of 2012.

 

No Cause for panic about Pandemic Influenza A H1N1

Ministry of Health and Family Welfare

11-April, 2012 13:53 IST

The situation with respect to instances of H1N1 is well under control and is being monitored. As reported in some section of the press, the virus has not mutated to a more virulent form or changed its character.

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After a relatively quiet 2013-14 flu season, India is once again reporting high numbers of H1N1 cases and deaths, and the Indian and International press are giving it a lot of coverage.

 

Swine Flu Outbreak Kills 700 in India – Time

40 more deaths due to swine flu; number of cases cross 11000 mark - International-Times of India-Feb 19, 2015

Indian health officials urge calm as swine flu outbreak spreads – Al Jazeera

 

Although the numbers seem high (and undoubtedly represent only the smallest tip of much larger iceberg), in a nation of 1.25 billion people – tens of millions would be expected to contract the flu in an average year - and of those, tens of thousands would likely die.  

 

So it isn’t at all clear at this point that anything unusual is going on with the H1N1 virus in India. 

 

Despite persistent rumors to the contrary , India’s National Institute of Virology (NIV) and their National Centre for Disease Control (NCDC) both report No mutation of H1N1. That said, the  Health Ministry issued the following statement earlier this week, pledging an investigation.

 

Health Ministry on H1N1: Closely monitoring the situation; no shortage of drugs

 

 

As we’ve seen previously, India’s free-wheeling press isn’t shy about using infectious disease concerns to embarrass or discredit  local officials and even political parties. Over the past couple of days the Mayor of Mumbai and West Bengal’s Chief Minister have both come under fire for making what are – admittedly – some very strange assertions regarding the flu virus.

 

This from NDTV.

After Mamata Banerjee Thought it's Mosquito-Borne, Mumbai Mayor Calls Swine Flu a 'Heart Disease'

Mumbai | Veer Arjun Singh (with inputs from PTI) | Updated: February 19, 2015 23:19 IST

 

At the time when swine flu cases in the country have crossed 10,000 mark, Mumbai Mayor Snehal Ambekar today called it a "heart disease" and made a bizarre suggestion that the municipal authority will plant trees to check the disease.

"Swine flu is a heart disease... Hence, BMC will plant trees, develop gardens and parks to check swine flu," Ms Ambekar told reporters after garlanding the statue of Chhatrapati Shivaji Maharaj on the occassion of his birth anniversary in Mumbai today.

The blooper from Ms Ambedkar comes a day after West Bengal Chief Minister Mamata Banerjee was quoted saying that swine flu "mostly happens from mosquito bite".

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While it is always possible that the H1N1 virus could pick up changes that could make it more virulent as it passages through millions of hosts, this particular virus has proven remarkably stable since it emerged in the spring of 2009.

 

So much so that the A/California/7/2009-like virus is the same strain used in flu vaccines today. 

 

At some point A(H1N1) will drift antigenically enough as to render the old vaccine strain obsolete. The hallmark of flu viruses is that they eventually change, and H1N1 is no exception.

 

And while the concern is we’ll see a more virulent virus emerge, there is nothing that says H1N1 couldn’t just as easily evolve into a less virulent strain. 

 

Although India’s press reports on H1N1 are easy to dismiss based on their obvious hyperbole and oft times inaccurate description of the virus, anytime you have a large outbreak of flu it is worth keeping an eye on it.  

H5N1 In Northern India’s Sukhna Lake

Source Wikipedia

 

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Sukhna Lake is a man-made recreational area and wild bird preserve located at the foothills of the Himalayas, and since its construction more than 50 years ago has become a favorite overwintering ground for a variety of migratory waterfowl. 

 

In recent days local authorities have reported an unusual die off of birds, and today it has been announced that the India’s NIHSAD Lab in Bhopal had detected the H5N1 virus in a dead duck.

 

Sukhna Lake is nearly 3,000 km north of the H5N1 outbreak reported in Kerala last month (see India Orders Massive Cull Over HPAI H5 Outbreak In Ducks). Local authorities now plan to cull a small number of ducks at the lake, and are monitoring local poultry farms for any signs of infection.

 

Bird flu: Chandigarh's Sukhna Lake cordoned off

IndiaToday.in  New Delhi, December 18, 2014 | UPDATED 13:50 IST

Chandigarh's Sukhna Lake was cordoned off early on Thursday after a sample from a dead duck tested positive for the H5N1 (avian or bird flu) virus.

Police and paramilitary personnel with masks on their faces were stationed at the lake complex since early Thursday to cordon off the entire area, IANS reported.

Scores of morning walkers who throng to the lake every day and other visitors were kept away from the lake complex.

Police officials at the lake told IANS that the complex would remain out of bounds for all visitors for at least two to three days.

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India Orders Massive Cull Over HPAI H5 Outbreak In Ducks

Credit Wikipedia

 

 

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Although the BBC is reporting this outbreak as H5N1 (see India: Kerala orders culling over bird flu fears) the FAO-EMPRES report simply lists the cause as HPAI H5, a designation that is still being used in the majority of media reports coming out of India this morning.

 

Hopefully we’ll see an official statement on the subtype soon.

 

In the meantime, the agricultural minister has order a cull of as many as 200,000 birds and has ordered a halt of transport of ducks or other poultry products from the region. This from Mathrubhumi.com.

Avian flu in Kerala: More than 200,000 birds to be culled

Alappuzha: With the avian flu virus in Alappuzha and Kottayam districts and also in a few panchayats being confirmed, the government will take preventive steps to contain the disease, said ministers V S Sivakumar and K P Mohanan at a joint press meet here on Tuesday.

'We got reports from a Bhopal laboratory that H5 avian influenza virus has been identified in poultry birds in Alappuzha, Kottayam and Pathanamthitta districts. So as a precautionary measure about two lakh birds mostly ducks would be culled starting Tuesday in the affected areas,' Agriculture Minister K.P. Mohanan told reporters after a high-level meeting chaired by Chief Minister Oommen Chandy.

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The exact subtype, and clade, of this virus is yet to be determined, as it the extent of this outbreak.

 

Although it has been awhile, India is no stranger to seeing bird flu outbreaks, both in domesticated birds and in wild or migratory birds.  The H5N1 virus was first detected on the Indian sub-continent in early 2006, but sparked numerous outbreaks in the 2008-2011 timeframe.

 

Last February, in OIE: H5N1 Detected In Crows Again – India, we saw the latest in a series of terrestrial bird detections that go back to at least 2008.  

Unlike many other countries that have seen outbreaks in poultry, India has yet to report a human infection with the H5N1 virus.

India: HPAI Behind Massive Duck Die Off In Kerala

Credit Wikipedia

 

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With highly pathogenic avian flu turning up in Europe, and continual reports of outbreaks in across much of Asia (see China: H5 AI Rising), we are understandably interested whenever there is a large, unexplained bird die off anywhere in the world.

Last week the Indian press carried reports of a large, and ongoing die off of ducks in Kerala, near Kuttanad – a low lying rice growing region of Southern India - which switches over to duck farming each fall after the rice harvest is in.

 

Based on that report,  there was a die off last spring as well, and a variety of explanations have been offered – including weed killers and chemicals used in the rice paddy.  This fall, however, the die off has accelerated.

 

5,000 Ducks Die of Epidemic in Kuttanad

By Express News Service

Published: 19th November 2014 06:00 AM

(EXCERPT)

Experts from the Department of Veterinary Pathology, College of Veterinary and Animal Sciences, KVASU, Mannuthy, had reported in one of their studies in October that ‘pasteurellosis’ and ‘aflatoxicosis’ had affected the duck population in Kuttanad, and almost 250 ducks died in the outbreak.

But the farmers presented a different picture. They said the disease had killed more than 25,000 ducks in October first week. It had spread to Thakazhi, Edathua, Veeyapuram and other areas in Upper Kuttanad. This time the killer disease has appeared again in November and places like Kainakari, Nedumudi and Mankombu have been affected, they said. 

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Today the Indian press is carrying word that testing by the National Institute of High Security Animal Diseases has revealed an (undisclosed subtype) highly pathogenic avian influenza virus is behind this die off.  This from the Indian Express.

 

Tests confirm Kerala duck deaths caused by avian influenza

Written by Shaju Philip | Thiruvananthapuram | Posted: November 24, 2014 5:03 pm

Kerala Animal Husbandry Department on Monday said avian influenza virus was behind the massive death of ducks in Kuttanad region of Alappuzha district.

Reports from Alappuzha said 17,000 ducks had died in recent days. Kuttanad is Kerala’s prominent paddy-growing region, where scores of farmers are engaged in rearing duck.

Kerala Animal Husbandry Minister K P Mohanan said preventive steps would be soon initiated to contain the disease. The avian flu was confirmed after lab tests at National Institute of High Security Animal Diseases, Bhopal. He said veterinary kits would be disturbed in the region and if necessary, birds would be culled to prevent the disease’s spread to other regions.

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The identity of this avian flu has not been disclosed, and as of this writing I’ve found no OIE report published.  Perhaps we’ll learn more later today.

Kerala is an important over-wintering spot for scores of avian species, which flock to the warm tropical wetlands of southern India each fall. 

 

According to The Hindu  2011 report Migratory birds arrive in Kerala, most of these birds hail  from the . . . Eurasia region; Siberia, Mongolia, Kazakhstan and other area north of the Himalayan regions. Some of the birds are also from the Himalayan region.  . . .  The migratory species arriving include godwits, terns, ospreys, golden plovers, pratincoles, several species of ducks and waders like sandpipers and plovers.

There are, admittedly, a number of bird flu strains that could be behind this outbreak.  In recent months we’ve seen the emergence of HPAI H5N8, H5N3, H5N6, H10N8 and new clades of H5N1 and H7N9 (not normally pathogenic in birds) continue to emerge.

For more on this you may wish to revisit these recent related blogs:

FAO On The Potential Threat Of HPAI Spread Via Migratory Birds

Bird Flu Spread: The Flyway Or The Highway?

EID Journal: Subclinical HPAI In Vaccinated Poultry – China

Referral: Ronan Kelly On AES In India

 

 

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One of the great things about this little part of the internet called Flublogia is that we are blessed with a great many very  smart, dedicated, and talented participants.  I’ve written in the past about the work done by volunteers on the  flu forums (see Newshounds: They Cover The Pandemic Front), but they often do far more than just surf the internet and post reports.

Ronan Kelly, who is a senior moderator at FluTrackers, has devoted an incredible amount of time and effort focusing primarily on infectious diseases on the Indian Subcontinent.

 

He was recently contacted by the University of New South Wales and invited to put together a blog post on the – as yet unidentified and complicated AES (Acute Encephalitis Syndrome) epidemic– which occurs in the Northeastern states of that country every year. 

 

So, without further ado, I invite you to follow the link below to read:

 

Acute Encephalitis Syndrome Outbreaks in India – an ongoing puzzle.

By Ronan Kelly.

Ronan Kelly (USA) is a Senior Moderator at www.FluTrackers.com, with an interest in outbreaks in India.

Past history of AES in India

Acute Encephalitis Syndrome (AES) is a growing problem in India. The first major outbreak was in West Bengal in 1973 involving 700 cases and over 300 deaths. Subsequent serological studies identified the Japanese Encephalitis (JE) virus as the cause. (1,2) Between 1978 and 2007, over 100,000 cases of AES with a case fatality rate (CFR) of almost 33% were reported from 13 different states. It was widely presumed that JE was the predominant aetiological agent in these outbreaks. (3,4) However, a study of patients admitted between 1985-1988 at King George’s Medical College (now Shahuji Maharaj Medical University) in Lucknow revealed bacterial meningitis as a diagnosis in 18% of apparent AES patients with JE indicated in only 12% of cases. Measles, Mumps, Malaria also played a part to some smaller degree, but 50% of the cases remained undiagnosed. Reye’s Syndrome was not found in any case.(5) An investigation of repeated AES outbreaks in Saharanpur in the early 2000s found that children were eating beans of the Cassia occidentalis plant which was causing acute hepatomyoencephalopathy. These patients were being misdiagnosed as AES cases. Local government organized removal of the plants and provided information programs for residents. As a result, fatalities in the district dropped from around 100 per year to zero in 2010. (6,7)

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India: MSF Calls For `Rational’ Antibiotic Use In Treating TB

MSF Briefing Report

 

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Tomorrow (March 24th) is World TB Day, and the focus this year is on multidrug-resistant tuberculosis (MDR TB) (see ECDC/WHO: World TB Day - Focus On MDR & XDR Treatment Outcomes), a growing concern around the world, but no more so than in India where more than 25% of all new TB cases reported in 2012 are to be found.

 

On Friday, Médecins Sans Frontières (MSF) released a sharply worded statement admonishing the Indian government for failing to regulate the sale and use of antibiotics for the treatment of Tuberculosis.

 

They warned that the inappropriate prescribing of antibiotics risks fueling the expansion of drug-resistant TB in that nation. The following excerpts come from a press release from MSF.

 

Patients in India suffer the consequences of poor regulation of TB drugs

March 21, 2014

The Ministry of Health must act to stop drug resistance from spiralling

New Delhi/Mumbai, March 21, 2014: Immediate action from the Indian government is needed to prevent the unregulated sale and inappropriate prescription of tuberculosis (TB) drugs in the private healthcare sector, a practice that has had a significant role in the emergence of drug-resistant TB in the country, warned the international medical humanitarian organisation Doctors Without Borders/Médecins Sans Frontières (MSF) in a statement released today in advance of World TB Day.

“It is the patients who suffer the consequences of poor regulation of TB drug formulations in India. An increasing number of our patients are being diagnosed with drug resistant TB (DR-TB). We encounter a spectrum of resistance patterns which range from mono-drug-resistant TB all the way through to extensively drug-resistant TB (XDR-TB),” said Dr Simon Janes, medical coordinator with MSF in India. “This makes it even more difficult for treatment providers like MSF and the government’s TB Control Programme to accurately diagnose and treat the different forms of drug-resistant tuberculosis.”

Read the briefing report

DR-TB infections are on the rise in India. The rising incidence has made the disease more difficult and considerably more expensive to treat. The conditions for emergence of drug resistance are increasingly being linked to poor drug regulation in India.

India has the largest private TB drug market, with rampant proliferation of first-line TB drugs in a wide variety of dosages and combinations.

Lack of oversight from the drug regulatory authority - the Drug Controller General of India (DCGI) - has made even basic treatment of drug-sensitive TB difficult to monitor. In the face of so many different formulations available in pharmacies across the country, ensuring the correct prescription of first-line TB drugs in the private sector is almost an impossible task for the Central TB Division (CTD).

As a result, poor compliance to World Health Organization (WHO) treatment guidelines is common among private doctors. TB patients being treated by private doctors in India might be facing a grave risk of developing drug-resistant TB due to irrational prescribing practices or indiscriminate use of non-WHO-recommended drug regimens.

“In our experience of working in India since 1999, we have seen prescriptions from private health providers that were completely inappropriate. For example we have seen many prescriptions that prescribe three out of the four first-line TB drugs in combination with a quinalone (antibiotic)”, said Dr Homa Mansoor, the TB Medical Referent for MSF India. “The alarm on drug resistance has been sounded, and the Health Ministry must act now to address this public health crisis."

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This coming week will no doubt bring many more reports on the challenges, and the progress being made, in the battle against TB.  For more on World Tuberculosis Day, the WHO has released the following brochure:

Reach the 3 million: Find. Treat. Cure TB

Authors:
WHO. Stop TB Partnership. The Global Fund to Fight AIDS, TB and Malaria

Publication details

Number of pages: 17
Publication date: March 2014
Languages: English

Downloads

Brochure: Reach the 3 million
pdf, 1.72Mb

 

While currently the biggest antibiotic-resistance crisis in India, TB is far from being the only concern.

 

Three and a half years ago The Lancet published a study (see NDM-1: A New Acronym To Memorize)  by Walsh, Toleman, Livermore, et al. that sounded the alarm on the emergence and growing prevalence of the NDM-1 enzyme on the Indian sub-continent.

 

Of particular concern, this NDM enzyme is carried by a plasmid – a snippet of portable DNA  - that can be easily transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

Six months after the first Lancet article - in April, 2011 - the same researchers published another study that found the NDM-1 enzyme in 4% of New Delhi’s sampled drinking water sources, and 30 per cent of the sewage tested. Most alarmingly, the researchers also identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.

 

The rise of antibiotic resistance - including these emerging NDM enzymes - has long been linked to the overuse and misuse of antibiotics. A practice that is still widespread in many parts of the world, but has been particularly rampant on the Indian sub-continent.

 

After years of delay and debate, India this month finally placed restrictions on the sale of antibiotics without a prescription (see Times of India report 46 drugs under strict prescription norm), although pharmacists are already chaffing under the rules (see Pharmacists oppose sales record rule), and it remains to be seen just how effective these new rules will end up being.

 

Short of seeing an extremely high mortality influenza pandemic, it is hard to envision a looming medical crisis more dire than the growing threat of antimicrobial resistance. The World Health Organization, the ECDC, and the CDC all consider the spread of antibiotic resistant organisms to be a major public health concern.

 

For a more complete look at the complex issues of antibiotic resistance, and the dearth of new drugs on the horizon, I can think of no resource better than Maryn McKenna’s superb book (and recent winner of the 2013 June Roth Memorial Book Award, American Society of Journalists and Authors)  Superbug: The Fatal Menace of MRSA.

And while I dabble in the issues of antibiotic resistance, undoubtedly the best coverage can be found on Maryn’s Superbug blog.

OIE: H5N1 Detected In Crows Again – India

Indian House Crow – Photo Credit Wikipedia

 

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While China, Cambodia, Vietnam, and South Korea have garnered most of the avian flu headlines this winter, the H5N1 virus remains endemic in other countries as well, including much of Asia and parts of the Middle East.  In many of these regions, surveillance and reporting is less than optimal, so the true extent of this virus is hard to measure.

 

Although debate over the incidence and importance of wild birds spreading the avian flu virus remains contentious (see India: The H5N1 & Migratory Birds Debate), we have often seen wild and migratory birds test positive for the H5N1 virus.   

 

In addition to having infected more than 20 mammalian species, the H5N1 virus has been detected in more than 150 different types of wild birds (See USGS List of Species Affected by H5N1 (Avian Influenza)).

 

Waterfowl (ducks & geese) and gallinaceous birds (turkeys, grouse, chickens & quail) are most often associated with carriage of the H5N1 virus, but terrestrial birds such as crows, starlings, pigeons, and sparrows are also known to carry, and shed, the virus as well (see 2007’s EID Journal  Role of Terrestrial Wild Birds in Ecology of Influenza A Virus (H5N1).

 

As far back as 2008, we saw reports out of India of crows dying from the H5N1 virus. A little over two years ago India was again plagued with numerous wild bird die offs that were blamed on the avian flu virus (see Media Report: H5N1 Killing Crows In Jharkhand).

 

By mid-December of 2011 the Indian Veterinary Research Institute (IVRI), Bhopal, confirmed that the H5N1 virus was behind at least some of these deaths. (see EpiSouth eweb_195_15_12__11.pdf). Over the next few months, even more reports came in, involving thousands of dead birds (see The Kolkata Crow Mystery & H5N1: A Murder Of Crows) that spread across several northern states.

 

On February  6th, 2012 official notification was made to the OIE of H5N1 virus detections in crows from four states; Jharkhand, Maharashtra, Orissa, and Bihar.

 

While India has reported a number of H5N1 outbreaks in Poultry since then - and at least one die off in pigeons (see Nov. 2012 Pigeon Droppings) - reports of the virus in wild birds have been noticeably absent the past 18 months.

 

At least, until this week, when the OIE was notified of two dead house crows from Keonjhar District, in Orissa state in Eastern India that were found to be infected with the virus.

 

 

Two dead house crows may not seem terribly important, but as the study below indicates, changes in the behavior of the virus in the wild can sometimes be a tip off that something is changing with the virus. This from just last October, in the Archives of Virology:

 

Investigating a crow die-off in January–February 2011 during the introduction of a new clade of highly pathogenic avian influenza virus H5N1 into Bangladesh

Salah Uddin Khan, LaShondra Berman, Najmul Haider, Nancy Gerloff, Md Z. Rahman, Bo Shu, Mustafizur Rahman, Tapan Kumar Dey, Todd C. Davis, Bidhan Chandra Das . . . .

Abstract

We investigated unusual crow mortality in Bangladesh during January-February 2011 at two sites. Crows of two species, Corvus splendens and C. macrorhynchos, were found sick and dead during the outbreaks. In selected crow roosts, morbidity was ~1 % and mortality was ~4 % during the investigation. Highly pathogenic avian influenza virus H5N1 clade 2.3.2.1 was isolated from dead crows.

All isolates were closely related to A/duck/India/02CA10/2011 (H5N1) with 99.8 % and A/crow/Bangladesh/11rs1984-15/2011 (H5N1) virus with 99 % nucleotide sequence identity in their HA genes. The phylogenetic cluster of Bangladesh viruses suggested a common ancestor with viruses found in poultry from India, Myanmar and Nepal. 

<SNIP>

Continuation of surveillance in wild and domestic birds may identify evolution of new avian influenza virus and associated public-health risks.

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As the H5N1 virus continues to evolve into new clades or strains, its behavior across various species is likely to change as well. Two years ago, in Differences In Virulence Between Closely Related H5N1 Strains, we looked at a study that found that genetically similar strains can exhibit significantly different pathogenicity in specific hosts.

 

Making any perceived change in how the virus presents or spreads worth noting.

India: Testing Suspected MERS-CoV Case

 

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When it comes to entertainment value, the Indian press is hard to beat, but their seldom-restrained style of reporting has taught me to favor a `watchful waiting’ attitude when it comes to their coverage of infectious diseases.

 

With that caveat, we’ve a report overnight (h/t FluTrackers) that a 40-y.o. man - recently returned from an extended stay in Saudi Arabia - has been hospitalized with signs of fever and pneumonia in Chinchpokli, a suburb of south Mumbai.

 

The patient was initially tested for H1N1, but those results came back negative (note: It isn’t clear what other types of flu were tested for).  Nevertheless, he has been placed on oseltamivir (Tamiflu ®), an antiviral therapy specifically for influenza, and is said to be `responding well’.

 

Patient samples have been sent to India’s National Institute of Virology (NIV) in Pune, for testing for MERS-CoV.  We should have some results in the next 24 hours.

 

Assuming the article is correct, and the patient is responding to oseltamivir, then that lessens (but does not obviate) the chances that this patient is infected with MERS. 

 

The latest CDC HAN Update On MERS-CoV reminds clinicians that patients can sometimes harbor dual infections; MERS and Influenza, or some other respiratory infection.

 

CDC has changed its criteria for who should be evaluated for MERS-CoV. In the previous guidance (HAN 348, dated June 7, 2013), CDC did not recommend MERS-CoV testing for people whose illness could be explained by another etiology. The new guidance states that, in patients who meet certain clinical and epidemiologic criteria, testing for MERS-CoV and other respiratory pathogens can be done simultaneously and that positive results for another respiratory pathogen should not necessarily preclude testing for MERS-CoV.

 

Here then is the link to the Times of India report on this suspected case. 

 

40-year-old man Mumbai's first suspected Gulf virus case

Sumitra Deb Roy, TNN | Aug 15, 2013, 01.28 AM IST

MUMBAI: In the first suspected case of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the city, a Vashi resident has been quarantined at Kasturba Hospital in Chinchpokli.

The viral respiratory illness, termed deadly because of a 60% mortality rate, is currently wreaking havoc in Gulf countries.

The 40-year-old man was admitted to the hospital's ward 30, meant for infectious diseases, on Wednesday afternoon with complaints of fever and a progressing pneumonia (inflammation of lungs). The patient had returned to India on August 12 after spending 35 days in Saudi Arabia.

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Regardless of how this particular case turns out, we need to get used to seeing these types of reports, as millions of devout Muslims are scheduled to converge on Saudi Arabia for the Hajj in October and many will return home with some kind of respiratory illness. 

Unless and until MERS-CoV becomes more transmissible, the vast majority of these cases will undoubtedly test negative for the coronavirus.

 

But it is only through detailed surveillance and testing that we can know whether the threat from this novel coronavirus is changing.

Pigeon Droppings

 

Bihar State – Credit Wikipedia

 

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Last winter India was plagued with numerous stories of wild bird die offs that were largely blamed on the avian flu virus (see Media Report: H5N1 Killing Crows In Jharkhand).

 

By mid-December the Indian Veterinary Research Institute (IVRI), Bhopal, confirmed that the H5N1 virus was behind at least some of these deaths. (see EpiSouth eweb_195_15_12__11.pdf).

 

Over the next few months, more reports came in, involving thousands of dead birds (see The Kolkata Crow Mystery & H5N1: A Murder Of Crows) that spread across several northern states.

 

While it is fair to say that the H5N1 virus was widely suspected, it is not clear how many were actually confirmed by laboratory testing.

 

On February  6th,2012 official notification was made to the OIE of H5N1 virus detections in crows from four states; Jharkhand, Maharashtra, Orissa, and Bihar.

 

By the end of spring, reports of fresh H5N1 outbreaks in poultry - and wild bird die offs - came to a close in India, and the subject of bird flu dropped off the front pages.  With the return of fall weather, however, the bird flu virus is back in the news (see Bangalore, India: H5N1 in Turkeys).

 

And today we’ve  a report – once again from Bihar – of a fresh bird die-off, although this time the victims are not crows, but pigeons.

 

At this point, no testing has been done, so the cause of this die off is not known.  H5N1 is a possibility, but by no means is it the only one.

 

Pigeons are generally regarded as being far less susceptible to the H5N1 virus than many other bird species (see Role of Terrestrial Wild Birds in Ecology of Influenza A Virus (H5N1), but they are not completely immune.

 

Earlier this year (see WHO Updates H5N1 In Egypt & Indonesia), two human H5N1 deaths in Indonesia were linked to direct contact with pigeons. Other pigeon-related cases from the past include:

 

•  In February of 2006, a 14 year-old pigeon handler in Iraq reportedly died from H5N1
• The April 2006 CDC's EID Journal Avian Influenza H5N1 in Naturally Infected Domestic Cats, describes a domestic cat that died after eating an infected pigeon. 
• In May of 2006, a 39 year-old man died after reportedly cleaning pigeon feces from blocked roof gutters at his home.

 

 

Any mass bird die off in an area where the H5N1 virus is endemic is worthy of investigation, but there are many other diseases that can kill pigeons. The Paramyxovirus (PMV) which has recently caused such a stir among pigeon fanciers in Australia and Newcastle virus are just two.

 

And pigeons (along with other terrestrial birds) may be affected by environmental factors, such as pesticides, and contaminated feed.

 

With all of these caveats, here is the report from the Times of India, which includes the somewhat unusual speculation from a veterinarian that faulty `mobile phone towers’ may be responsible for these deaths.

 

 

Over 500 pigeons drop dead in Bihar village

IANS | Nov 5, 2012, 05.41PM IST

PATNA: More than five hundred pigeons suddenly dropped dead at a village in Bihar's Bhagalpur district over the last four days, causing residents, some of them pigeon-keepers, to fear that something was amiss.

District officials are still to visit the site and conduct an inquiry.

Over 500 pigeons died mysteriously in Bath village near Sultanganj in Bhagalpur, about 250 km from the state capital.

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The history in India has been that officials are often slow to investigate reports of bird deaths, in poultry, and in the wild. Often, by the time an investigation is launched, the birds have been incinerated or are too decomposed, to examine.

 

So we’ll have to wait to see what, if any, answers are forthcoming on this event.

India: The H5N1 & Migratory Birds Debate

Credit U.S. Fish and Wildlife Service

 

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One of ongoing debates in the world of avian influenza is over exactly how much of a role migratory birds play in the spread of highly pathogenic H5N1.  

 

Bird enthusiasts tend to point to the poorly managed poultry trade as being the main source of the spread of bird flu while those in the poultry industry are often quick to blame migratory birds.

 

Over the years we’ve studies that either implicate migratory birds in the spread of the virus, or minimizes their role (see  India: The Role Of Migratory Birds In Spreading Bird Flu).

 

Personally, I see no reason why these positions should be mutually exclusive.  As far as I can tell, both are important factors in the spread of the virus.

 

But the debate goes on, often heatedly.

 

The recent outbreak of H5N1 in India (see  Bangalore: More Poultry Culled Due To H5N1) at a government poultry farm is very near Hesaragatta lake - a man-make reservoir and winter nesting ground for migratory birds that has fallen into disrepair in recent years from a lack of water. 

 

Reportedly, the number of birds that now visit every year is greatly reduced.

 

Nevertheless, several thousand birds continue to stop over at Hesaragatta lake each winter, and that has prompted local officials to suggest that migratory birds are to blame for the current outbreak.

 

A position that local ornithologists are taking serious umbrage over.

 

First a link to the article from DNA (Daily News & Analysis) that attempts to exonerate wild birds as carriers of the H5N1 virus, then I’ll return with some comments of my own.

 

Experts debunk migratory birds theory

Published: Thursday, Nov 1, 2012, 15:50 IST
By Aishhwariya Subramanian | Place: Bangalore | Agency: DNA

The hunt for the elusive cause of the avian influenza outbreak at Central Poultry Development Organisation & Training Institute (CPDOTI) on Tuesday saw officials of animal husbandry department blaming migratory birds for carrying the virus. But ornithologists have debunked the theory despite animal husbandry officials stating that the Hesaraghatta Lake close to CPDOTI facility which attracts migratory birds was the culprit for the outbreak.

(Continue . . . )

 

The arguments being made by the experts interviewed in this article are basically two pronged. 

 

• The first seems to be the old canard that `sick birds don’t fly’
• The second is the reduced number of migratory birds arriving at the reservoir in recent years.

 

While it’s true that wild birds that acquire the virus, sicken, and die are less likely to transfer the virus across long distances, the `sick birds don’t fly’  stance ignores the fact that in migratory waterfowl, the H5N1 is often an asymptomatic infection.

We’ve looked at asymptomatic waterfowl as reservoirs of the virus a number of times in the past, including:

Reservoir Ducks

Webster On China's `Silent' Bird Flu Infections

Mallard Ducks Found To Be Asymptomatic To Bird Flu Virus

We’ve also witnessed the geographic spread of new clades of the H5N1 virus in migratory waterfowl, and the apparent importation of H5N1 into Hong Kong, Japan, and South Korea by the arrival of migratory birds in the past.

 

EID Journal: H5N1 Branching Out

Study: The Role Of Migratory Birds In Spreading Bird Flu

Egrets, They’ve Had A Few . . .

Japan: Hooded Crane Positive For H5N1

Wild Birds Eyed As Likely Source Of Hong Kong Bird Flu Outbreak

FAO: On The Trail Of Avian Influenza

 

 

The second argument, that the number of migratory birds arriving each year at Hesaragatta lake has recently dropped may reduce the odds that birds brought the virus to Bangalore, but it certainly doesn’t eliminate the possibility.

 

The bottom line - it just takes one infected bird to arrive and introduce the virus to the environment.

 

None of which tells us how the H5N1 virus made it to a government poultry operation in Bangalore, but it does help put migratory birds as carriers of avian flu into better perspective.

 

Lest bird lovers cry `fowl’, the role of poultry producers in the spread of avian flu – including, but not limited to: poor biosecurity, overcrowded conditions, covering up reports of illnesses or deaths among birds, and smuggling – are well documented in this blog, and elsewhere.

 

While migratory birds appear to have a role in introducing avian flu viruses to new regions, poorly run poultry operations obviously help to amplify and spread these viruses further.

 

The fact that this debate is unresolved nearly a decade after the re-emergence of H5N1 in 2003 underscores the need for better research and surveillance, both in migratory birds and in poultry operations.

 

 

Until we can clearly understand the various mechanisms by which this virus is spread, the prospects of halting outbreaks in the future remain slim.