FAO: Egypt Reports Third H9N2 Case Of 2015

 

# 10,079

 

Since we only rarely hear of it infecting humans, and it tends to produce mild to moderate illness when it does, the H9N2 avian influenza virus doesn’t get as much attention as it probably deserves. Despite its relatively benign reputation, H9N2 is a major driver of avian influenza evolution, and reassorts readily (and often) with other viruses.

 

Look at the internal genes of some of the most worrisome avian influenza viruses – H5N1, H7N9, H10N8, etc. – and you’ll find that H9N2 that has lent a good deal of its backbone – it’s internal genes – to the creation of these emerging threats. 

 

Earlier this year, the WHO warned:

 

The emergence of so many novel viruses has created a diverse virus gene pool made especially volatile by the propensity of H5 and H9N2 viruses to exchange genes with other viruses. The consequences for animal and human health are unpredictable yet potentially ominous.

 

Early last year, The Lancet carried a report entitled Poultry carrying H9N2 act as incubators for novel human avian influenza viruses by Chinese researchers Di Liu a, Weifeng Shi b & George F Gao that warned:

 

Several subtypes of avian influenza viruses in poultry are capable of infecting human beings, and the next avian influenza virus that could cause mass infections is not known. Therefore, slaughter of poultry carrying H9N2—the incubators for wild-bird-origin influenza viruses—would be an effective strategy to prevent human beings from becoming infected with avian influenza.

We call for either a shutdown of live poultry markets or periodic thorough disinfections of these markets in China and any other regions with live poultry markets.

   

And just last  January (see PNAS: Evolution Of H9N2 And It’s Effect On The Genesis Of H7N9) we looked at a study that found a new, better adapted genotype  (G57) of the H9N2 virus had emerged  – one that evades the poultry vaccines currently in use – and that it has become widespread among vaccinated Chinese poultry since 2010.

 

Globally, we’ve seen seen a fairly limited number of human infections, including a handful in China between 1998 & 1999, Hong Kong in 1999 (2 cases), 2003 (1 case), and 2007 (1 case), and December of 2013 (see Hong Kong: Isolation & Treatment Of An H9N2 Patient).   In late 2014, two mild cases were reported out of China.

 

As this virus is most common in areas where testing and surveillance are less than optimal, we really don’t know how many people end up infected by it. 

 

Although reporting out of Egypt has been inconsistent, last February (see An H9N2 Infection In Egypt & Updated H5N1 Count – FAO/EMPRES) we learned of Egypt’s first H9N2 infection. Late yesterday ProMed Mail carried the following report – gleaned from an FAO report – detailing Egypt’s third H9N2 infection.

 

Published Date: 2015-05-22 13:44:27

Subject: PRO/AH/EDR> Avian influenza, human (108): Egypt, H9N2, influenza B

Archive Number: 20150522.3378923

AVIAN INFLUENZA, HUMAN (108): EGYPT, H9N2 AND INFLUENZA B
*********************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the International Society for Infectious Diseases
http://www.isid.org

Date: Thu 14 May 2015

Source: FAO EMPRES-Animal Health, Global Early Warning System (GLEWS) [edited]
Animal Disease Threats Update

(Disease Events monitored by FAO AGAH/GLEWS between 10 May 2015 and 14 May 2015)
Egypt, confirmed additional infection with H9 LPAI in a human;

• on 29 Apr 2015, a 7-year-old male with high fever and cough tested positive for H9 on 7 May 2015;
• the sample tested positive for RNP gene, flu A, avian H9 and flu B and was negative for all other respiratory viruses;
• the investigation revealed a history of exposure to live bird market poultry. The case was cured and discharged. [MoH and FAO field officer, 12 May 2015]

Note: This is the 3rd case of H9N2 LPAI reported in humans in Egypt since January 2015. The other 2 cases were detected in 2015 in Aswan and Cairo Governorate. The latest case is the 1st recorded human case of co-infection with H9 and flu B in Egypt.

(Continue . .. )

 

While the direct threat to human health from H9N2 is currently small, its promiscuity and history of reassorting with other avian viruses makes it a serious threat, and one very much worth keeping track of.

 

Returning briefly to the World Health Organization’s blunt pandemic warning of last February:

 

Warning: be prepared for surprises

Though the world is better prepared for the next pandemic than ever before, it remains highly vulnerable, especially to a pandemic that causes severe disease. Nothing about influenza is predictable, including where the next pandemic might emerge and which virus might be responsible. The world was fortunate that the 2009 pandemic was relatively mild, but such good fortune is no precedent.

.

ProMed Mail: Dr. Memish On Saudi MERS Patient & Camel Testing

Coronavirus – Credit CDC PHIL

 

 

# 7965

In a follow up to a story which we’ve been following since yesterday (see KSA MERS Investigation: Testing The Beast, Not The Beauty & MERS-CoV: CIDRAP & Dr. Mackay On The Saudi Camel Connection), ProMed Mail has published this afternoon an email from Dr. Ziad Memish , Deputy Minister for Public Health for the Kingdom of Saudi Arabia, that provides some additional details.

 

I’ve only included some excerpts, you’ll want to follow the link to read the entire release, including commentary by the editors at ProMed.

 

 

Published Date: 2013-11-12 13:01:10
Subject: PRO/AH/EDR> MERS-CoV - Eastern Mediterranean (85): animal reservoir, camel, susp, official
Archive Number: 20131112.2051424

MERS-COV - EASTERN MEDITERRANEAN (85): ANIMAL RESERVOIR, CAMEL, SUSPECTED, OFFICIAL

A ProMED-mail post http://www.promedmail.org
ProMED-mail is a program of the International Society for Infectious Diseases http://www.isid.org

Date: Tue 12 Nov 2013
From: Ziad Memish <zmemish@yahoo.com> [edited]

The Saudi Ministry of Health [MoH] continues to follow carefully all new cases of MERS-CoV diagnosed in KSA [Kingdom of Saudi Arabia] with routine contact tracing of all contacts inclusive of family contacts and HCWs [healthcare workers] who cared for the patient. On 7 Nov 2013 the Saudi MoH reported a new case: a 43-year-old male from Jeddah, who developed symptoms on 27 Oct 2013. He sought medical treatment on 3 Nov 2013. He is currently in an intensive care unit. The patient does not have any underlying chronic disease. He has no recent travel history outside of Jeddah. He had significant contact with animals but no contact with a known positive human case. To complete the investigation extensive environmental/animal contact sources were pursued. Camels owned by the patient which were symptomatic with fever and rhinorrhea were tested for MERS-CoV and tested positive

This is the 1st time that a camel related to a case tests positive for MERS-CoV by PCR. Further testing is ongoing to sequence the patient and the camel virus and compare genetic similarity level to conclude causality.

(Continue . . .)

The Price Of Vigilance Revisited

# 7481

 

As a one-man-band using Google’s gratis blogger platform, the costs of running this blog are negligible, so I don’t seek donations or run advertisements of any sort.

 

But for larger concerns, like ProMed Mail and FluTrackers – while they offer their services to the world without charge - there are considerable expenses involved. 

 

Server costs alone can run hundreds of dollars each month.Then there are accounting fees, legal fees, filing fees, Internet access, telephone expenses. . . .

 

This morning, Dr. Ian MacKay in his Virology Down Under blog took notice of ProMed’s current fund raising drive (see ProMED in need...), and asked if I’d lend my voice to the appeal.

 

As I’ve done so in previous years (see The Price Of Vigilance), I’m happy to do so again. I’ve also written of  FluTrackers need for donations as well (see The Cost Of Fluing Business).

 

FluTrackers.com Inc. is a 501(c)(3) charity, and donations can be made via credit card or Paypal via their front page.

 

Both organizations do remarkable work, almost entirely by dedicated volunteers scattered around the world, and both could use your financial support.

Australia: Acute Flaccid Paralysis & EV71

WHO Guidance On HFMD

 

 

# 7324

 

ProMed Mail carried a report over the weekend from Professor Bruce Thorley of the National Enterovirus Reference Laboratory in Australia that described 5 recent cases of acute flaccid paralysis (AFP) in children who tested positive for the EV71 virus.

EV71 – which is most often reported in Asia and the Western Pacific region - is one of more than 60 non-polio enteroviruses that can cause human illness. While it is frequently linked to severe outbreaks of HFMD (Hand, Foot, & Mouth Disease), EV71 is capable of producing other serious neurological illnesses – including poliomyelitis-like paralysis - as well.

A snippet from the ProMed  report, then I’ll return with more.

 

Detection of enterovirus 71 sub-genogroup C4a in specimens from cases of acute flaccid paralysis, Australia

 

Australia conducts surveillance for cases of acute flaccid paralysis (AFP) in children less than 15 years of age as part of the national polio surveillance program funded by the Australian government.

 

From January to early May 2013, human enterovirus 71 (EV71) was detected in stool specimens from 5 of 14 (36 percent) AFP cases in children. EV71 was also detected in specimens from cases of hand-foot-mouth disease (HFMD) and non-paralytic neurological illness by members of the Enterovirus Reference Laboratory Network of Australia.

 

A phylogenetic analysis of the VP1 genomic region identified homology with the EV71 C4a sub-genogroup circulating in China and South East Asia, which has been associated with more severe neurological complications than other sub-genogroups in recent years.

(Continue . . . )

 

 

HFMD is normally a mild childhood illness, most often caused by the Coxsackie A16 virus and more rarely by Coxsackie A10 here in the United States. In recent years, we’ve seen the emergence of the Coxsackie A6 virus which has been linked to somewhat more severe HFMD cases (see MMWR: Coxsackievirus A6 Notes From The Field).

 

But Enterovirus 71 has been linked to the most severe cases of HFMD – particularly across Asia - with serious outbreaks recorded over the past 15 years in places like China, Taiwan, Malaysia, Hong Kong, and last year in both Vietnam and Cambodia (see Updating The Cambodian EV71 Story).

 

An article that appeared in early 2001 in Clinical Infectious Diseases (cite Neurological Manifestations of Enterovirus 71 Infection in Children during an Outbreak of Hand, Foot, and Mouth Disease in Western Australia Peter McMinn, Ivan Stratov, Lakshmi Nagarajan, and Stephen Davis) describes its impact this way:

 

Children <4 years of age are particularly susceptible to the most severe forms of EV71-associated neurological disease, including meningitis, brain-stem and/or cerebellar encephalitis, and poliomyelitis-like paralysis.

 

The neurological complications of EV71 infection may occasionally cause permanent paralysis or death. Several large epidemics of severe EV71 infection in young children, including numerous cases of fatal brain-stem encephalitis, have recently been reported in Southeast Asia [10–12].

 

Like other RNA viruses we monitor, EV71 is constantly evolving, creating new strains or lineages, and as a result we’ve seen repeated outbreaks over the years.

 

During the late 1990s and early 2000s, genotypes C1, C2, B3, and B4 were most commonly reported as sparking outbreaks in Malaysia, Singapore, and Taiwan.

 

By 2005 emerging genotype C4 had replaced B4 in Taiwan, while in China C4 (which had split into 2 distinct lineages, C4a and C4b) caused major HFMD outbreaks in 2007–2009 (see Phylogenetic analysis of Enterovirus 71 circulating in Beijing, China from 2007 to 2009.)

 

The spread and diversity of EV71 – Credit WHO

 

As shown in the chart above, the more aggressive C4 genotype – which first appeared in China in 1998 - has made significant inroads across much of Asia and the Western Pacific over the past 15 years. 

 

Among the challenges of controlling EV71 outbreaks are:

• No currently available vaccine
• A moving viral target, with new strains evolving and emerging over time
• Many children can carry (and shed) the virus asymptomatically (see Incidence Rates of Enterovirus 71 Infections in Young Children during a Nationwide Epidemic in Taiwan, 2008–09)
• Patients may shed virus for month or longer (see Long persistence of EV71 specific nucleotides in respiratory and feces samples of the patients with Hand-Foot-Mouth Disease after recovery)

 

For now, control and prevention are limited to promoting good hygiene, and removing children with signs of the disease from child care or school environments. 

 

This from the Queensland Health Department.

 

Transmission

EV71 infection is transmitted from person to person by direct contact with nose and throat secretions, saliva, fluid from blisters or the faeces of infected people.
The virus may continue to be excreted in the faeces for several weeks. A person is infectious for as long as the virus is present in the faeces.

Treatment

Treatment of EV71 neurological disease usually focuses on the person's symptoms. Currently there is no specific treatment.

Prevention

Good hygiene is the single most effective way of preventing the spread of EV71 infection. Hands should be washed thoroughly in soap and water for at least 20  seconds and then dried thoroughly. It is important to wash hands after going to the toilet, touching soiled linen or articles, changing nappies and before preparing or eating food. Teach children to wash their hands effectively before eating or drinking and after going to the toilet.

Control

Children with hand foot and mouth disease should be excluded from child care and schools until all blisters have healed.

Children with enterovirus 71 neurological disease should be excluded from childcare/school until they have a written medical clearance from a doctor or public health unit confirming that the virus is no longer being excreted in their faeces.

 

A growing problem, in 2009 China reported 1,155,525 HFMD cases, including 13,810 severe cases and 353 deaths. Among laboratory confirmed cases, EV71 was responsible for 41% of cases, 82% of severe cases, and 93% of the deaths (cite WHO HFMD Guide Pg.6). 

 

Numbers that illustrate just how big an impact this normally `mild’ childhood disease can have.

 

For more on HFMD, including the more severe Enterovirus-71 (EV-71), you may wish to revisit the following blogs:

 

The Emerging Threat Of EV71

China: A Recombinant EV-71

HFMD Rising In China

China Sounds Alert Over EV-71 Virus

ProMed: Update From Dr. Ziad Memish On Coronavirus Cases

Coronavirus – Credit CDC PHIL

 

 

# 7233

 

In a follow up to two earlier blogs today (see Branswell: Saudi Coronavirus Cluster Increases To 13 & Update On Novel Coronavirus Cases) that increased the size of the cluster of cases to 13, and deaths to 7, we have the actual notification email from Dr. Ziad Memish published in ProMed Mail.

 

Subject: PRO/AH/EDR> Novel coronavirus - Eastern Mediterranean (18): Saudi Arabia
Archive Number: 20130505.1693290

NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (18): SAUDI ARABIA

************************************************************
A ProMED-mail post  http://www.promedmail.org

ProMED-mail is a program of the
International Society for Infectious Diseases

http://www.isid.org

Date: Sunday, May 5, 2013, 11:18 PM
From: Ziad Memish <zmemish@yahoo.com>
Subject: Urgent follow up re nCOV cluster in Alhassa KSA

Dear colleagues,

As a follow up to the most recently reported 10 case cluster of nCOV in Alhasa in the Eastern Province of KSA. Our investigation is still ongoing and we picked up 3 more cases:

• Case 11: 62 year old female with multiple comorbidities. Start of symptoms [19 Apr 2013] and deceased [3 May 2013]
• Case 12: 71 year old male with multiple comorbidities. Start of symptoms [15 Apr 2013], deceased [3 May 2013]
• Case 13: 58 year old female with comorbidities. Start of symptoms [1 May 2013] and currently ventilated in critical but stable condition.

So far there is no apparent community transmission and transmission seem linked to one HCF [health care facility].

We will keep you posted on progress

 

(Continue . . .)

 

While lacking in specifics, the reference to there being no community transmission, and that transmission is linked to a single healthcare facility, suggests that most of these cases acquired the infection while in the hospital.

 

ProMed Mail’s Editors commented (excerpt):

 

. . .  "So far there is no apparent community transmission and transmission seem linked to one HCF [health care facility]" supports a conclusion that this outbreak is a nosocomial outbreak, and the reason that all confirmed cases to date have had existing comorbidities is that they were presumably infected with the nCoV while hospitalized in this HCF for other pre-existing illnesses.

 

You may recall that the first known cluster of this novel coronavirus occurred just over a year ago at a hospital in Zarqua, Jordan. Two of those cases were eventually lab confirmed out of a cluster of at least 11 people (including 8 HCWs) with undiagnosed severe pneumonia. Two people died.  (See ECDC Report and FluTrackers Thread)

HPA: Not Investigating `4th’ Coronavirus Case

 

Coronavirus – Credit CDC PHIL

# 6963

 

A follow up to a blog on Thursday (Branswell: Possible 4th NCoV Case In UK Cluster), Professor Nick Phin at the HPA has written to ProMed Mail, to clarify that:

 

“ . . . we would like to confirm that the HPA is not currently investigating any 4th possible case associated with the UK cluster of novel coronavirus.”

The entire statement can be viewed at ProMed Mail at the following link:

 

NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (08): UNITED KINGDOM, 4TH CASE, NOT

The Price Of Vigilance

 

 

 

# 5143

 

 

As most of you know, I along with others in Flublogia depend heavily on the volunteer newshounds on the flu forums, and on ISID’s ProMED Mail surveillance system, for much of the infectious disease news we get each day.

 

These entities are not government supported, and rely instead on the generosity of their members and the public. 

ProMED Mail each year at this time asks for financial help to support their reporting network. I’ve just made a small donation, and I would ask that my readers consider doing the same.

 

 

Similarly, FluTrackers is an all-volunteer flu forum that requires about $400 a month to keep going. Most months, those costs have come out of the owner’s pocket.  

 

 

Both are tax-exempt, nonprofit organizations, and both serve as important early warning systems for infectious disease outbreaks.

 

I know money is tight this holiday season.

 

But if you appreciate the work being done by these volunteers, I would hope you would consider making a small contribution to help them continue their work in 2011.

Newshounds Watching Tripura

 

 

# 4779

 

 

 

Three days ago Shiloh on FluTrackers posted an article from The Hindustan Times on a deadly outbreak of a `mystery disease’ in the northeastern Indian state of Tripura that had reportedly claimed the lives of 20 children.

 

 

Unknown diseases kill 20 kids in Tripura
Indo-Asian News Service
Agartala, June 25, 2010
 
Last Updated: 16:15 IST(25/6/2010)

At least 20 children have died in the past 10 days following the outbreak of various unknown viral and tropical diseases in a remote tribal-dominated village in Tripura, officials in Agartala said on Friday.

 

"The children mostly died at their homes in remote Kangrai tribal village along the Tripura-Mizoram border in northern Tripura," doctors and officials who visited the affected areas told reporters at divisional headquarters Kanchanpur.

 

Many other children and elders also fell ill. Some were admitted to the sub-divisional hospital.

(Continue . . .)

 

 

Reports of `mystery fevers’ and illness are common out of India and surrounding countries as many villages are remote, and without adequate medical care.  

 

Often, assuming we do get a diagnosis, these outbreaks are attributed to Japanese Encephalitis, Malaria or some other vector borne disease that is endemic in the region. Sometimes food poisoning or a tainted water source is blamed.

 

Occasionally, in this part of the world, outbreaks of something more exotic occur, such as the Nipah virus. And while no human cases have been recorded in India as yet, this is also an area that has seen H5N1 in poultry.

 

So naturally, the newshounds are paying attention to reports of any `mystery disease’ out of that region.

 

Over the last 72 hours Alert, Treyfish, Ironorehopper, and RoRo have all added to this ongoing thread on Flutrackers, with more than a dozen additional reports from various news outlets.

 

The reports are somewhat confused and conflicting, with various estimates of deaths ranging from 24 to nearly 100.  The symptoms described are too vague to allow much speculation as to the cause.

 

ProMed Mail  was notified, and they’ve printed several of these reports and issued an RFI (Request for Information) as well.   I’ve excerpted their comment below.

 

 

UNDIAGNOSED ILLNESS - INDIA: (TRIPURA), REQUEST FOR INFORMATION
***********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

<SNIP>

 

The description of the symptoms of the illness is not sufficiently precise to indicate whether this outbreak has been caused by a novel pathogen such as Nipah virus or a more familiar agent such as avian (H5N1) or pandemic (H1N1) influenza virus, Japanese encephalitis virus, or malaria which may be prevalent in the area, or a combination of agents. ProMED-mail would welcome any additional information from the region.

 

Regardless of what ends up being the cause of this outbreak, this is illustrative of the terrific work being done by the volunteer newshounds on the flu forums.

 

They spend countless hours searching hundreds of newsfeeds every day, looking for any hint of an unusual outbreak of a disease in humans or animals.  And they do this not only in English, but in dozens of other languages as well. 

 

I’ve written often of my gratitude to these tireless troops.  I literally couldn’t do half what I do without their efforts.

 

For more on how they go about their formidable task, you might wish to read Newshounds: They Cover The Pandemic Front.

 

When we get more information, I’ll try to update it here.  But to follow in real time, you may wish to check on this FluTrackers thread.