ECDC Rapid Risk Assessment On H5N1 In Egypt

Credit ECDC

 

# 9824

 

Egypt is currently experiencing the largest outbreak of human H5N1 infections since the virus re-emerged in 2003, with roughly 115 cases reported over the past 17 weeks (see WHO H5N1 Update – Egypt).  

 

While transmission still appears to be bird-to-human, and the virus remains difficult to spread from person-to-person, this uptick is nonetheless a worrisome development.

 

Today the ECDC has released one of their detailed Rapid Risk Assessments on Egypt’s recent H5N1 outbreak.  First the summary, and then a link to, and excerpts from the document.

 

 

Rapid risk assessment: Human infection with avian influenza A(H5N1) virus, Egypt, first update

•  13 Mar 2015

Available as PDF in the following languages

EN

This document is free of charge.

Abstract

Human cases and fatalities due to influenza A(H5N1) virus continue to increase in Egypt, with cases from the country now accounting for the highest number of human cases reported worldwide.

Continuous increase of virus circulation in backyard poultry and exposure to infected poultry are most probably contributing to the increase in human cases. Whenever avian influenza viruses circulate in poultry, sporadic infections and small clusters of human cases are possible in people exposed to infected poultry or contaminated environments.

Although Egypt has reported an increased number of animal-to-human infections over the past few months, the influenza A(H5) viruses do not appear to transmit easily among people, and no sustained human-to-human transmission has been observed. As such, the risk of these viruses spreading in the community remains low.

Increased human infectivity of the circulating virus and the protection conferred by the poultry vaccines currently in use should be further investigated.

The current assessment remains that there is no risk for the general public in the EU. Travellers from the EU should avoid direct contact with poultry or poultry products when travelling to Egypt.

There is a low but ongoing and continuous risk of the virus being introduced and cases being imported into Europe and therefore both veterinary and public health authorities should maintain preparedness.

 

 

 

 

RAPID RISK ASSESSMENT Human infection with avian influenza A(H5N1) virus, Egypt

First update, 13 March 2015

 

ECDC threat assessment for the EU

Egypt has reported a dramatic increase in human cases and deaths due to A(H5N1) in recent months. During the  same period, a large increase in outbreaks among poultry has been reported, mainly related to backyard farming. A(H5N1) affects all sectors of poultry production, is detected in different bird species and circulates in all geographical areas.

The reason for the current increase in human infections is believed to be the spread of the virus within the backyard poultry population and the intensive virus circulation. There has also been speculation that increased co circulation of A(H9N2) might have contributed to the intensified spread of A(H5N1) in poultry and associated human cases in Egypt. The current joint WHO/CDC/FAO/OIE mission to Egypt will hopefully provide more information on the reason for the sharp increase in human cases. A strategy needs to be established to prevent further geographical spread.

Although the risk of an introduction of A(H5N1) into Europe via migratory birds seems to be very low, the increase in the number of outbreaks and the higher level of virus circulation in the poultry population in Egypt might increase the likelihood for A(H5N1) infections of migratory birds. In particular, migratory waterfowl are known to be potential vectors for the introduction of A(H5N1) to free areas as they undertake movements at certain times of the year. Therefore in Europe there is a theoretical risk that the virus may spread to poultry and the veterinary sector should maintain vigilance, using well-established surveillance systems for early detection, should new introductions occur.

Whenever avian influenza viruses are circulating in poultry, sporadic infections and small clusters of human cases are possible in people exposed to infected poultry or contaminated environments. Although an increased number of animal-to-human infections has been reported by Egypt over the past few months, these influenza A(H5) viruses do not appear to transmit easily among people at present. As such, the risk of these viruses spreading in the community remains low.

Human infections are related to exposure to infected poultry, with the increase in outbreaks among backyard poultry most probably contributing to the increase in human cases. Increased human infectivity of the circulating virus and protection conferred by the poultry vaccines currently in use should be further investigated. No indications of human–to-human transmission have been reported from Egypt. As such, the risk of these viruses spreading in the community remains low, and the assessment of the last ECDC Rapid Risk Assessment published on 23 December 2014 remains valid.

Although the areas where there has been transmission in poultry are mostly rural, the importation of a sporadic travel-related human A(H5N1) case into the EU is possible and public health authorities should be prepared. The risk of EU citizens being infected in Egypt is extremely low. No cases of A(H5N1) among travellers to Egypt have ever been notified. Travellers should be advised to avoid direct contact with poultry or poultry products.

ECDC Rapid Risk Assessment #15 On MERS-CoV

 

 

# 9801

 

In the wake of this weekend’s announced imported MERS case in Germany  (see Germany Reports Imported MERS Case - ex UAE), and barely two weeks since their last update, the ECDC has published their 15th Rapid Risk Assessment on the novel coronavirus threat to the EU.

 

Main conclusions and recommendations

• Since April 2012 and as of 7 March 2015, 1 082 cases (including 439 deaths) of Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported by local health authorities worldwide.
• The incidence of cases has been rising in the Arabian Peninsula in the past month. A similar pattern has been observed in previous years.
• The majority of MERS-CoV cases are still being reported from the Arabian Peninsula, specifically from Saudi Arabia, and all cases have epidemiological links to the outbreak epicentre. The source of MERSCoV infection and the mode of transmission have still not been confirmed.
• The latest importation of a case to Germany from the United Arab Emirates demonstrates the continued risk of case importation to Europe after exposure in the Middle East, especially in the context of the seasonal upsurge of cases currently observed in Saudi Arabia. However, the risk of sustained human-tohuman transmission in Europe remains very low.
• Taking into account the latest development with respect to MERS-CoV, ECDC's conclusion continues to be that the MERS-CoV outbreak poses a low risk to the EU, as stated in the previous update of ECDC's Rapid Risk Assessment on MERS-CoV, dated 23 February 2015 [1].
• National healthcare providers and public health institutions should remain prepared for a possible imported case in the EU/EEA.
• WHO recommends that probable and confirmed cases should be admitted to adequately ventilated single rooms or airborne precaution rooms. Healthcare workers caring for probable or confirmed cases of MERS-CoV infection should use contact and droplet precautions (medical mask, eye protection – i.e. goggles or face shield – gown and gloves [2]) in addition to standard precautions. Airborne precautions should be applied when performing aerosol-generating procedures.
• The advice for travellers to affected areas remains the same as in previous ECDC risk assessments.

As we’ve come to expect from the  ECDC, we are also provided with a number of excellent charts, graphs, and maps along with a detailed epidemiological discussion of the virus.

Worldwide situation

Since April 2012 and as of 7 March 2015, 1 082 cases (including 439 deaths) of MERS-CoV have been reported by
health authorities worldwide (Figure 1).

Current situation in Saudi Arabia

Since the last rapid risk assessment on 24 February 2015, Saudi Arabia has reported 39 additional cases and 20 deaths. The cases were reported from Riyadh (25), Khobar (3), Buaydah (3), Jeddah (2), Al Jawf (1) Hofuf (1), Najran (1), Qweyah (1), Shakra (1) and Unazah (1). Of the 36 cases with known age and gender, 67% (n=24) were male. The mean age was 56 years, ranging from 24 to 83 years for the 36 cases. Nine of  the 39 cases were classified as nosocomial transmission, while five are currently under investigation for possible nosocomial transmission. Seven of the 39 cases were healthcare workers. Three of the 39 cases reported contact with animals, one of these cases reported camel contact.
 

(Continue . . . )

 

As we’ve discussed often in the past (see here, here, and here), the lack of a well mounted case-control study by Saudi Arabia puts them, and the rest of the world, in the unenviable position of not fully understanding how this virus is spreading among humans.  

 

We know a small number of cases appear to be linked to animal (mostly camel) exposure, and a sizable chunk have been exposed at healthcare facilities, but for the vast majority of cases the route of exposure is unknown.

 

While the epicenter, and vast majority of this spring’s MERS activity will likely remain in the Middle East, we should expect that additional cases will be exported from the region, and that they can literally turn up practically anywhere in the world.

ECDC: 14th Rapid Risk Assessment On MERS-CoV

 

 

# 9747

 

Although the MERS coronavirus has yet to be declared a PHEIC (Public Health Emergency Of International Concern), it is nonetheless a worrisome, high-mortality virus that after nearly three years - and more 1,000 cases -  we still know far too little about.  

 

Recently  we’ve seen assessments from the World Health Organization (see Saudi Arabia: WHO MERS Mission Summary & WHO Summary & Risk Assessment On MERS-CoV) that discuss some of these dangerous gaps in our knowledge, and that urge the Saudis to intensify their research efforts.

 

Meanwhile, we’ve watched a steady increase in cases over the past couple of months, and already February of 2015 is the 4th most active MERS month on record. 

While cases have only emerged from on the Arabian peninsula (KSA being the most active by far), the virus has been exported to 8 European countries, and to 13 nations beyond the Middle East.  

 

With up to a 15 days incubation period, it is all to easy for someone to acquire the virus in the Middle East and travel while still asymptomatic anywhere in the world.

KSA: The Global hub of MERS – Credit ECDC

 

Accordingly the ECDC issues updated Rapid Risk Assessments from time to time (the last one was in January) where they review the epidemiology of the virus, and discuss the degree of threat the virus poses to the EU. The consensus to date remains:

 

Although importation of MERS-CoV cases to the EU remains possible, the risk of sustained human-to-human transmission in Europe remains very low.

EA few excerpts from today’s report follows, but the entire PDF is well worth downloading an reviewing.

 

Main conclusions and recommendations

Since April 2012 and as of 20 February 2015, 1 042 cases (including 419 deaths) of Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported by local health authorities worldwide.

The incidence of MERS-CoV cases has been on an increase in Saudi Arabia since December 2014. This increase parallels the increase observed in early 2014 and may be indicative of the start of a seasonal pattern. Most of the increase in the recent weeks affects Riyadh, and one third of the recent cases may have a nosocomial origin. Twelve per cent of the recent cases have reported contact with an animal or animal product. This is consistent with the transmission pattern observed in early 2014, which showed increased transmission from a primary animal source, most likely camels or camel products, amplified by nosocomial transmission.

The importation of a case in the Philippines demonstrates the possibility of importation of cases from abroad, especially in relation with healthcare workers infected while caring for patients in Saudi Arabia.

The majority of MERS-CoV cases are still reported from the Arabian Peninsula, mainly from Saudi Arabia.

The source of MERS-CoV infection and the mode of transmission have still not been confirmed.

Taking into account the latest developments with respect to MERS-CoV, ECDC’s conclusion continues to be that the MERS-CoV outbreak poses a low risk to the EU.

Because of the continued risk of cases in Europe after exposure in the Middle East, international surveillance for MERS-CoV cases remains essential. Although importation of MERS-CoV cases to the EU remains possible, the risk of sustained human-to-human transmission in Europe remains very low.

Sensitisation of healthcare staff to MERS-CoV is prudent, not only for timely detection purposes, but also in order to ensure rapid implementation of infection control measures.

Worldwide situation
Since April 2012 and as of 20 February 2015, 1 042 cases (including 419 deaths) of MERS-CoV have been
reported by health authorities worldwide (Figure 1).

CONCLUSIONS

The large surge in infections seen in the spring of 2014 was mainly due to an outbreak in Jeddah, but driven by
an increase in primary infections [8]. A similar increase is possible in spring 2015, and public health authorities in the epicentre are currently preparing appropriate response measures. In Saudi Arabia, response activities have recently been decentralised and are now managed by the regional health departments [9].

In the EU/EEA, public health authorities are prepared for the timely detection and appropriate treatment of cases in returning travellers, should the need arise. Sensitisation of first-line healthcare staff to the fact that MERS-CoV is still circulating in the Middle East is prudent, not only for timely detection purposes, but also in order to ensure rapid implementation of infection control measures.

Taking into account the latest developments with respect to MERS-CoV, ECDC’s conclusion continues to be that the MERS-CoV outbreak poses a low risk to the EU. Because of the continued risk of the importation of cases to Europe after exposure in the Middle East, international surveillance for MERS-CoV cases remains essential. Although importation of MERS-CoV cases to the EU remains possible, the risk of sustained human-to-human transmission in Europe remains very low.

 

ECDC: Rapid Risk Assessment On LPAI H7N7

# 9707

 

Up until two years ago, human infection with H7 avian viruses were both rare, and almost always mild.  Often little more than mild `flu-like’ symptoms and/or conjunctivitis. 

 

The one notable exception occurred in 2003 when a largest known outbreak of H7N7 infected 89 people, one of whom died (see Eurosurveillance Journal Human-to-human transmission of avian influenza A/H7N7, The Netherlands, 2003).

When H7N9 showed up unexpectedly in China two years ago, it was the first time we’d seen a highly pathogenic (in humans, yet LPAI in birds) H7 virus, sporting an impressive mortality rate. 

 

Suddenly H7 avian viruses were due a lot more respect.

 

But, except for the Asian H7N9 virus, the remainder of the avian H7 viruses appear to pose only a minor human health threat at this time.  Viruses can change over time, hence the need for a qualifier.

With the recent outbreak of H7N9 in UK poultry, the ECDC has produced an updated Rapid Risk Assessment on the human health risks for Europe.  First their brief summary, followed by a link to the full document, and some excerpts:

Low risk to public health in the EU from low pathogenic avian influenza A(H7N7) viruses

13 Feb 2015

On 2 February 2015, British authorities reported an outbreak of low pathogenic avian influenza virus A(H7N7) on a chicken farm in Hampshire in the United Kingdom. Culling of the birds in the affected holding has started, with restriction and surveillance zones established, and investigations into how the birds became infected have been initiated.

Three persons who had been exposed to the flock reported an influenza-like illness or conjunctivitis, however no human infections with A(H7N7) or other respiratory viruses were identified.

Groups at risk for infection include people with occupational exposure to infected poultry, e.g. during the culling and destruction process when there are outbreaks on poultry farms. However, the risk for zoonotic transmission to the general public in EU/EEA countries is considered to be extremely low.

Outbreaks in poultry holdings caused by low pathogenic avian influenza A(H7N7) viruses have been reported previously in Europe, causing infections in humans occupationally exposed to infected poultry . Such infections caused mild disease with influenza-like symptoms or conjunctivitis.

Read the risk assessment

Main conclusions and recommendations

On 2 February 2015, British authorities reported an outbreak of low pathogenic avian influenza virus A(H7N7) on a chicken farm in Hampshire in the United Kingdom. Culling of the birds in the affected holding has started, with a restriction zone established, and investigations into how the birds became infected have been initiated. The virus has been analysed genetically and does not contain key mutations associated with increased risk for zoonotic infection.

Outbreaks in poultry holdings caused by low pathogenic or high pathogenic avian influenza A(H7N7) viruses have been reported previously in Europe, as well as human infections with low pathogenic avian influenza virus  A(H7N7). Such infections generally cause mild disease with influenza-like symptoms or conjunctivitis.

The group at risk for infection includes people with occupational exposure to poultry. This group should be made aware of the clinical features of infection, and advised to alert authorities and healthcare providers about  any relevant exposure if they develop influenza-like illness or other symptoms.

There is a low risk of zoonotic transmission to people who are directly exposed to infected birds during the culling and destruction process when there are outbreaks in poultry farms. The risk can be minimised if the exercise is performed under the safety measures recommended in Directive 2005/94/EC. Persons with direct contact to infected poultry before or during culling and disposal should be monitored for symptoms, and postexposure antiviral prophylaxis should be considered.

The risk for zoonotic transmission to the general public in EU/EEA countries is considered to be extremely low.

ECDC Rapid Risk Assessment: Human Infection With H7N9

 

# 9672

 

Although it has long been considered likely to happen at some point, the recent importation of two cases of H7N9 into Canada has highlighted the risks of seeing H7N9 (or MERS-CoV, or one of the growing number of emerging novel flu subtypes), making its way out of China (or the Middle East) and flying practically anyplace else in the world. 

In addition to Canada, H7N9 cases have already been exported to Taiwan, Malaysia, and Hong Kong.

 

The ECDC has released an updated Rapid Risk Assessment, along with the following press release, that looks at the potential for seeing H7N9 arrive in Europe.

 

Although its case counts, graphs and charts are already out of date due to the bulk announcement this morning of 49 recent cases from mainland China, this RRA contains a lot of good information and is worth reviewing in its entirety.

 

 

Sporadic A(H7N9) cases imported from China possible but community-level spread unlikely

04 Feb 2015

​The first two cases of A(H7N9) in North America following travel to China highlight the possibility that imported cases to Europe are possible but community-level spread following importation is unlikely as the virus does not transmit easily among people. ECDC has updated its rapid risk assessment in light of this even but the main conclusions are not altered.

On 26 January 2015, the Public Health Agency of Canada announced the detection of influenza A(H7N9) infection in a resident of British Columbia upon return from China. The case was diagnosed through routine testing while attending a general practice with mild flu symptoms. On the 29 January 2015, a second case, with the same travel history and close contact to the first case, tested positive for influenza A(H7N9). Neither case required hospitalisation and both are recovering at home.

Since the notification of a novel reassortant influenza A(H7N9) virus on 31 March 2013, a total of 488 laboratory confirmed cases of human infection with avian influenza A(H7N9) virus, including 185 deaths, have been reported, the vast majority in China.

Live poultry markets
The majority of recently reported human cases are associated with exposure to infected live poultry or contaminated environments, including markets where live poultry are sold. Influenza A(H7N9) viruses continue to be detected in poultry and their environments in the areas where human cases are occurring.  Information to date does not support sustained human-to-human transmission.

At present, the most immediate threat to EU citizens is to those living or visiting influenza A(H7N9)-affected areas in China. It is advisable to avoid live bird markets and contact with live poultry and avoid consuming raw or incompletely cooked meat products and eggs.

Community-level spread in following importation into Europe is unlikely as the virus does not transmit easily among people. Nonetheless, travellers developing severe respiratory or flu-like symptoms within ten days after travel to affected areas and exposure to poultry or untreated poultry products in China should be rapidly managed and appropriately sampled for influenza testing.

                                                                           

Rapid Risk Assessment: Human infection with influenza virus A(H7N9) virus

Sample graphics from the ECDC RRA report.

ECDC Influenza Season Risk Assessment

Credit ECDC – Week 3

 

# 9642

 

While North America’s flu season is already well underway (and in some regions has already peaked), seasonal flu is getting a later - but no less strenuous start - in Europe this year.  And as we’ve seen here in the United States, the predominant flu strain in Europe this season is a `drifted’ H3N2 virus, one which has reduced the effectiveness of this year’s vaccine.

This morning ECDC released an updated Rapid Risk Assessment and summary on this year’s flu season, and  Director Dr. Marc Sprenger  tweeted:

 

First a press release summary, with links to the Rapid Risk Assessment, and then I’ll be back with a few words on the CDC & ECDC’s strong recommendations for the use of antiviral medications.

 

More severe influenza season to be expected in Europe

28 Jan 2015

Medium or high rates of influenza intensity are likely to be observed in the vast majority of EU and EEA countries, concludes ECDC annual risk assessment on influenza for the remainder of the season. The number of severe cases of influenza as well as fatal outcomes especially among older people and other risk groups can be expected to rise.

Strenuous start of this influenza season

• Influenza activity in Europe started in week 50/2014 without a particular geographic progression, affecting the Netherlands, Sweden and England first, and then followed by Iceland, Malta and Portugal.
• Children between 0 and four years of age have been the most affected age group according to primary healthcare data in almost all reporting countries, similarly as in other seasons.
• Influenza-like illness and acute respiratory infections have been increasing in adults and older people in almost all countries.
• Most of the first affected countries report greater pressure on primary healthcare services during this season compared to the peak activity in previous season.
• Among the countries reporting hospitalised influenza cases, 34 fatal outcomes were reported, two thirds of these in the elderly.

Drifted A(H3N2) viruses dominant

• Subtype A(H3N2) viruses, known to cause more severe disease, are dominant in almost all reporting European countries.
• Majority of A(H3N2) viruses analysed are antigenically distinct from the A(H3N2) virus included in the vaccine for this season.
• Reduced vaccine effectiveness is expected as a result of this mismatch between the vaccine and the circulating influenza strains.

ECDC Director, Dr Marc Sprenger, said:
“We face an influenza season that could be more severe and exert bigger pressure on health care systems than in the last few years. As each year, ECDC undertakes a risk assessment early in the season, combining a multitude of data sources and aiming to inform and strengthen EU and EEA countries in their response to the influenza epidemics.”

How to protect oneself and others from the flu

• Self-isolation when sick, hand-washing and good respiratory hygiene as well as cough etiquette remain simple yet effective measures to protect from catching or passing on influenza.
• A lower overall vaccine effectiveness due to the circulation of drifted A(H3N2) viruses is expected, however, the vaccine may still reduce complications and severe outcomes associated with this subtype of influenza viruses.
• Influenza vaccine offers good protection against the circulating A(H1N1)pdm09 viruses.

Antivirals particularly important this season

• Treatment and post-exposure prophylaxis with antivirals protects the elderly and people in other risk groups against severe influenza illness.
• The circulating viruses are susceptible to antiviral drugs oseltamivir and zanamivir.

Dr Marc Sprenger emphasizes:

“In a season dominated by a drifted A(H3N2) strain of influenza viruses, more severe illness can be expected especially among older people and those in medical risk groups. It is therefore paramount that physicians across Europe consider treatment and post-exposure prophylaxis with antivirals especially for these patients.”

The annual ECDC risk assessment of seasonal influenza aims to provide an early description of seasonal influenza in the first affected countries and to inform public health decisions to be taken to reduce the burden of seasonal influenza in 2015 in Europe.

Read full risk assessment of seasonal influenza in the EU/EEA countries, 2014-2015

More information:

Flu News Europe: weekly influenza updates
Seasonal influenza on ECDC website
Influenza maps and graphs
Follow us on Twitter: @ECDC_Flu

 

 

In Europe, even more so than in the US, antiviral drugs have been excoriated in the press; often referred to as an expensive scam on the part of the government, purportedly in cahoots with `Big Pharma’.  In the past we’ve seen Tamiflu’s ®  value questioned by Cochrane meta-studies, some prestigious medical journals, conspiracy theorists, pundits, but most often, the tabloid press.

 

Admittedly, it hasn’t helped that for many years Tamiflu’s maker -  Roche Pharmaceuticals - has refused to release all of the testing data on their best selling antiviral drug, and we’ve seen some scare articles in the popular press suggesting adverse side effects to the drug.

 

With all of this baggage, you may be wondering why the ECDC, CDC , the UK’s PHE, and many other public health agencies continue to recommend the use of influenza antivirals for influenza. 

 

Last April, in Revisiting Tamiflu Efficacy (Again), I wrote at some length on the BMJ –  Cochrane Library review Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children – that examined a subset of the scientific literature and cast doubt on its effectiveness in treating influenza.

 

While I too lamented the lack of solid, well mounted Randomized controlled trials (RCTs) proving the effectiveness of Oseltamivir (particularly in high risk patients, or with novel flu strains), I listed a number observational studies that strongly support the effectiveness of Oseltamivir.

 

A few days later, the CDC issued their own response. I’ve posted the link and some excerpts below.  Follow the link to read their rationale in its entirety.

 

CDC Recommendations for Influenza Antiviral Medications Remain Unchanged

April 10, 2014 -- CDC continues to recommend the use of the neuraminidase inhibitor antiviral drugs (oral oseltamivir and inhaled zanamivir) as an important adjunct to influenza vaccination in the treatment of influenza. CDC’s current influenza antiviral recommendations are available on the CDC website and are based on all available data, including the most recent Cochrane report, about the benefits of antiviral drugs in treating influenza.

(Continue . . .)

 

Recommendations that were echoed a few months ago by Public Health England (see UK PHE: Revisiting Influenza Antiviral Recommendations), and that are supported by many studies I’ve written about previously, including:

 

Study: Antivirals Saved Lives Of Pregnant Women

BMJ: Efficacy of Oseltamivir In Mild H1N1

Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic

The Lancet: Effectiveness Of NAI Antivirals In Reducing Mortality In Hospitalized H1N1pdm09 Cases

CID Journal: Under Utilization Of Antivirals For At Risk Flu Patients

 

For uncomplicated influenza in a healthy individual (essentially what the Cochrane studies looked at), antivirals probably offer little value.

 

But for severe influenza, or for people at risk of complications . . .

 

While not a cure, the preponderance of evidence shows that taking antivirals early can limit the severity and duration of symptoms – and for those patients  – that could help keep them out of the hospital, and even prove life saving.

ECDC: Updated Rapid Risk Assessment On MERS-CoV

 

# 9603

 

As the total number of confirmed MERS cases closes in on 1,000 the  ECDC has produced their 13th update on the MERS coronavirus, and the risks (low at this time) it may pose to the EU.  As we’ve come to expect, along with this rapid risk assessment we also get a detailed epidemiological review of cases, discussing what we know – and what we don’t.

 

The chart above shows the major surge in cases recorded during the spring of 2014, and since we don’t know all of the factors behind that huge spike in cases, there are obviously concerns we could see a repeat performance this spring as well.

 

While dated January 15th, this report appears to have only recently been uploaded to the ECDC website.  I’ve included the summary and some excerpts from the report, but use the link to download the entire PDF.

 

Rapid Risk Assessment: Severe respiratory disease associated with Middle East respiratory syndrome coronavirus, 13th update

Main conclusions and recommendations

Since April 2012 and as of 11 January 2015, 972 cases of Middle East respiratory syndrome coronavirus (MERSCoV) have been reported by local health authorities worldwide, including 394 deaths.

The incidence of MERS-CoV cases shows a decrease after the surge in October 2014, and the majority of MERS-CoV cases are still reported from the Arabian Peninsula, mainly from Saudi Arabia.

The source of MERS-CoV infection and the mode of transmission have still not been confirmed.

Taking into account the latest developments with respect to the Middle East respiratory syndrome coronavirus
(MERS-CoV),  ECDC’s conclusion in this latest update continues to be that the assessed risk to the EU posed by the outbreak of MERS-CoV is low.

There is a continued risk of cases presenting in Europe following exposure in the Middle East and international surveillance for MERS-CoV cases remains essential. Although importation of MERS-CoV cases to the EU remains possible, the risk of sustained human-to-human transmission in Europe remains very low.

Sensitisation of healthcare staff to MERS-CoV is prudent, not only for timely detection purposes, but also in order to ensure rapid implementation of infection control measures.

Conclusions

The overview of this virus, its epidemiology, clinical features, transmission and diagnostics as well as relevant
public health measures are presented in the ECDC factsheet [8]. The source of MERS-CoV infection and the mode of transmission have still not been confirmed. Dromedary camels are a host species for the virus, and many of the primary cases in clusters have reported direct or indirect camel exposure. However, close contact with infectious camels does not always seem to result in human infections [12]. In addition, despite evidence of seropositive camels in several African countries and PCR-positive camels originating from Pakistan, no autochthonous cases arising from presumed camel contacts have been reported from outside the Middle East. This might be due to lack of diagnostic capacity in these countries. Serological screening kits are now also commercially available for both humans and camels.

The increase of human MERS-CoV cases in October 2014 is not explained by the calving or weaning of camel calves as it does not coincide with the calving and weaning seasons. The latest case reports do not suggest any link with participating in the Hajj or Umrah either. Similar to the upsurge in case numbers in April/May 2014, the increase in case numbers in Saudi Arabia in the autumn of 2014 could be linked to specific nosocomial outbreaks in Taif and Riyadh.

In 2013, WHO proposed a multi-country case-control study to assess the risk factors associated with infections of primary cases, which the affected countries agreed to embark on [13]. Results of such a study could be highly informative for disease control purposes.

The incidence of MERS-CoV cases shows a decrease after the surge in October 2014, and the majority of MERS CoV cases are still reported from the Middle East, mainly from Saudi Arabia. All cases have epidemiological links to the outbreak epicentre. The increase shows that the MERS-CoV continues to circulate, particularly in the Middle East and the risk for transmission is greatest for people in this area.

A large surge in infections seen in the spring of 2014 was mainly due to an outbreak in Jeddah, but driven by an increase in primary infections [14]. These events may be repeated in spring 2015, and therefore public health authorities in the epicentre are actively preparing appropriate responses. In Saudi Arabia, the response activity has recently been decentralised from a national command and control centre to regional health departments [15].

Also in the EU/EEA, public health authorities are prepared for timely detection and appropriate treatment of cases among returning travellers, should the need arise. Sensitisation of first-line healthcare staff to the fact that MERS CoV is still circulating in the Middle East is prudent, not only for timely detection purposes, but also in order to ensure rapid implementation of infection control measures.

Taking into account the latest developments with respect to the Middle East respiratory syndrome coronavirus
(MERS-CoV), ECDC’s conclusion in this latest update continues to be that the assessed risk to the EU posed by the outbreak of MERS-CoV is low.

There is a continued risk of cases presenting in Europe following exposure in the Middle East and international surveillance for MERS-CoV cases remains essential.

Although importation of MERS-CoV cases to the EU remains possible, the risk of sustained human-to-human transmission in Europe remains very low.

 

 

You’ll note the diplomatic reminder in the Conclusion section of this report on the value of having a case-control study, an important piece of epidemiological analysis that has been long promised by the Saudi MOH (see June 2014 KSA Announces Start To Long-Awaited MERS Case Control Study), but which has yet to be delivered.

ECDC Rapid Risk Assessment On Recent Spike In Egyptian H5N1 Cases

 

# 9481

 

The recent resurgence of H5N1 in Egypt (see Egyptian MOH Update: 21st H5N1 Case Of 2014) is a reminder that as we try to deal with Ebola, MERS-CoV, and new emerging avian viruses, that the venerable H5N1 virus has not gone away. 

 

While there are no signs of increased transmissibility of the virus among humans, anytime we see a surge in human infections, the situation bears watching.

 

With 17 cases reported over roughly the past 6 weeks, the level of activity in Egypt is unusual – particularly for this time of the year.  Yesterday the ECDC released a Rapid Risk Assessment on these Egyptian cases, along with some excellent background on the virus’s transmission in Egypt.  First their summary, then some excepts from the report:

 

New ECDC RRA on avian influenza A(H5N1) in Egypt

23 Dec 2014

Avian influenza A(H5N1) has been circulating in Egypt since its introduction in 2006 and has been the source of sporadic human infections. The number of cases reported in Egypt for 2014 (12) is higher than last year but at similar levels as 2012. Given this increase, and that eight cases by date of onset were reported in November, ECDC has assessed the potential changes in the risk to public health in the EU/EEA and to European citizens in a new rapid risk assessment. 

The current risk status of this epidemic remains unchanged. In addition, considering the circulation of the virus is in areas which are not very popular as tourist destinations, the risk of EU citizens in Egypt being infected is extremely low.

The total number of human cases due to A(H5N1) is decreasing; 2014 had the lowest number of cases reported since the first cases in 2003 . The most affected countries cumulatively are Indonesia and Egypt, and Egypt and Cambodia reported most cases in 2014.

Human infections remain rare and these influenza A(H5N1) viruses do not currently appear to transmit easily among people.

Read the Rapid Risk Assessment on avian influenza A(H5N1) in Egypt, December 2014

(EXCERPTS)

ECDC threat assessment for the EU

• Human infections remain rare, and influenza A(H5N1) viruses do not currently appear to transmit easily among people. As such, the risk of community-level spread of these viruses remains low, and the assessment of the last updated ECDC Rapid Risk Assessment published on 26 February 2014 remains valid [21].

• A higher number of human cases due to A(H5N1) was reported from Egypt in November 2014. The  detection of A(H5N1) in backyard poultry with a high number of outbreaks in 2014 might be the cause for the increase in human cases, as all cases reported exposure to infected poultry prior to the onset of symptoms.

• No indication is given of human clusters or human-to-human transmission.

• Considering the circulation of the virus in non-touristic areas, the risk of EU citizens being infected is extremely low. No cases of A(H5N1) among travellers to Egypt have ever been notified.

Conclusions

The recently reported increase of human cases of A(H5N1) infection from Egypt in November 2014 might be due to an increase in the circulation of A(H5N1) in backyard poultry and exposure to infected poultry across Egypt.

Identification of such sporadic cases or small clusters are not unexpected as avian influenza A(H5N1) viruses are known to be circulating in poultry in the country. Strict control measures of infected poultry are essential to prevent zoonotic transmission and human cases. Epidemiological investigations should be performed and results communicated to the global public health community.

Human cases and outbreaks were only reported from non-touristic areas in Egypt. Travellers visiting affected areas should avoid contact to sick or dead poultry and birds.

ECDC Rapid Risk Assessment On `Drifted’ H3N2 Viruses

Credit NIAID

 

 

# 9474

 

While we often talk about seasonal strains (H1N1, H3N2, Influenza B) as if they were individual entities – in truth within each subtype there are many clades and variants - and they are all evolving over time. Geographically, these viruses can vary widely, and so the dominate strains in Europe may differ from the dominant strains in North America or Asia.

 

Over time, new, more biologically `fit’ viruses replace older strains as community immunity drives them closer to obsolesce.

 

All which makes the flu world dynamic and ever-changing, and presents a genuine challenge for vaccine manufacturers to stay ahead of. NIAID has a terrific 3-minute video that shows how influenza viruses drift over time, and why the flu shot must be frequently updated, which you can view at this link.

Over the summer it was becoming apparent that a new, `drifted’ H3N2 virus was making inroads in Europe and around the globe (see ECDC: Influenza Characterization – Sept 2014) – one that differed antigenically from this year’s H3N2 vaccine strain. 

 

In September the WHO announced a strain change for next year’s Southern Hemisphere vaccine to meet this viral challenge, but this virus emerged far too late in the year to allow changes to this fall’s Northern Hemisphere vaccine.

 

In early November, in A `Drift’ In A Sea Of Influenza Viruses, I wrote about early concerns over this year’s vaccine, and in the first week of December the CDC issued a HAN Advisory On `Drifted’ H3N2 Seasonal Flu Virus along with a warning that  Early Data Suggests Potentially Severe Flu Season.

 

Today the ECDC has issued their own Risk Assessment on this `drifted’ flu strain.

 

Rapid risk assessment: circulation of drifted influenza A(H3N2) viruses in the EU/EEA, 22 December 2014

22 Dec 2014

Available as PDF in the following languages

EN

This document is free of charge.

Abstract

Surveillance data gathered since 1 October 2014 indicate that in the first ten weeks of the 2014–15 influenza season, viruses in EU/EEA countries have been predominantly A(H3N2) rather than A(H1N1)pdm09 and type B viruses. In previous seasons, influenza A(H3N2) viruses were associated with more severe disease than A(H1N1) and type B viruses; they were also associated with several outbreaks in long-term care facilities.

These observations indicate that the 2014-15 influenza season may be associated with a greater number of cases with more severe disease, given the higher proportion of A(H3N2) strains among isolates typed to date and the early evidence of drift that is likely to be associated with reduced vaccine effectiveness.

Influenza vaccine coverage among the elderly and the risk groups in most parts of Europe is low. However, the benefits of vaccination are considerable in protecting these population groups, even if vaccine effectiveness against one of the circulating viruses may turn out to be low.

 

 

  I’ve excerpted the following from the full report:

 

Main conclusions and recommendations

Surveillance data gathered since 1 October 2014 indicate that in the first ten weeks of the 2014–15 influenza
season, viruses in EU/EEA countries have been predominantly A(H3N2) rather than A(H1N1)pdm09 and type B  viruses. In previous seasons, influenza A(H3N2) viruses were associated with more severe disease than
A(H1N1) and type B viruses; they were also associated with several outbreaks in long-term care facilities.

The recently published US CDC health alert network notification on antigenically drifted influenza A(H3N2) viruses is the first signal from a northern hemisphere country that circulating viruses will include strains that are antigenically distinct from the A(H3N2) vaccine virus, A/Texas/50/2012, which was recommended by WHO for the northern hemisphere 2014–15 season at the February 2014 strain selection meeting.

Very few influenza virus characterisations have been conducted to date in EU/EEA countries, and the majority of them have been genetic rather than antigenic. The genetic information reported so far suggests the following:

• Influenza A(H3N2) viruses circulating in EU/EEA countries this season will be antigenically distinct from the  northern hemisphere A(H3N2) vaccine virus.
• Early indications are that circulating A(H1N1)pdm09 viruses are antigenically similar to the vaccine virus.
• Too few type B viruses have been characterised to date to comment on the likely effectiveness of the B/Massachusetts/2/2012 vaccine component.
  

These observations indicate that the 2014-15 influenza season may be associated with a greater number of cases with more severe disease, given the higher proportion of A(H3N2) strains among isolates typed to date and the early evidence of drift that is likely to be associated with reduced vaccine effectiveness.

Despite the expected low vaccine effectiveness (VE) of the A(H3N2) vaccine virus component in the vaccines administered for protection in the 2014–15 influenza season, the current tri- and quadrivalent vaccines are likely to provide protection against infection by other currently circulating influenza viruses. Even with low VE of the A(H3N2) vaccine virus components, the vaccine may ameliorate or shorten the duration of influenza disease in infected individuals and is likely to reduce the number of severe outcomes and mortality. Influenza  vaccination remains the most effective measure to prevent illness and possibly fatal outcomes.

The circulating viruses are susceptible to the antiviral drugs oseltamivir and zanamivir. Physicians should therefore always consider treatment or post-exposure prophylaxis with antivirals when treating influenza infected patients and exposed individuals in risk groups.

Influenza vaccine coverage among the elderly and the risk groups in most parts of Europe is low.

However, the benefits of  vaccination are considerable in protecting these population groups, even if vaccine effectiveness against one of the circulating viruses may turn out to be low.

ECDC Rapid Risk Assessment: Plague In Madagascar

 

# 9416

 

A couple of weeks ago, in WHO: Plague Returns To Madagascar, we looked at what has become an annual occurrence – a spike in plague cases on that island country of 22 million people.  Plague (Yersinia Pestis) is a bacterial infection transmitted by fleas, carried by infected rats. 

 

The most common presentation is Bubonic plague, however in rare cases, Pneumonic Plague may develop, where the victim develops severe pneumonia and may spread the disease from human-to-human by coughing.

 

Even the United States sees a handful of cases each year, primarily in the Western states (see Colorado DPH Statement On 4 Cases Of Plague). Since plague is fairly easily treated with antibiotics, it is pretty well controlled in the developed world.

 

Yesterday the ECDC published a Rapid Risk Assessment on the most recent outbreak in Madagascar, which has begun earlier in the fall than usual.  As we’ve come to expect, it provides excellent historical context and background information on the disease.

The risk beyond Madagascar is considered low, and the risk on that island is primarily in the higher elevations (above 800 m), where the disease has become well entrenched in the local rat population.  There have been at least two recent cases reported in the heavily populated capital of Antananarivo, which has increased concerns.

 

First, a look at the latest ECDC Communicable Disease Threat’s update, then a link to the Rapid Risk Assessment.

 

Plague outbreak - Madagascar – 2014

Opening date: 24 November 2014 Latest update: 27 November 2014

Epidemiological summary

Since January 2014 and as of 5 December, 138 cases of plague including 47 deaths (CFR 34%) have been reported. Two percent of the reported cases have been of the pneumonic form. Sixteen districts of seven regions of Madagascar are affected.

Two cases including one death have been reported in the capital, Antananarivo, from two densely populated neighbourhoods.

Web sources: WHO | Media |

ECDC assessment
Cases of bubonic and pneumonic plague are not unexpected events in Madagascar. However, the recent occurrence of cases in the capital city highlights the risk of a rapid spread of the disease when occuring in densely populated areas with poor sanitation and a weak healthcare system.

Based on information currently available to ECDC, the risk of contracting plague for EU travellers to the affected area in Madagascar is considered to be unchanged and very low. The risk to visitors is very limited if they limit the risk of contact with rats and fleas.

Actions

ECDC published a rapid risk assessment on 5 December 2014.

 

 

RAPID RISK ASSESSMENT

Plague outbreak, August–November 2014, Madagascar

4 December 2014

Main conclusions and recommendations

In Madagascar an outbreak of plague has been evolving since 31 August 2014; as of 16 November 2014,
40 people have died from the disease.

The ongoing plague outbreak in Madagascar with 119 cases reported to the World Health Organization (as of
16 November 2014) was not an unexpected event. However, the recent occurrence of two cases in
Antananarivo, Madagascar’s capital, poses a potential risk of a rapid spread of the disease due to the city’s high population density, poor sanitation, deficient garbage collection, and the overall weakness of the healthcare
system.

Despite the risk of further spread, the risk of contracting plague for EU travellers to the affected area in
Madagascar is considered to be very low.

The local authorities are experienced in responding to plague outbreaks and have set up a control coordination committee with dedicated funding to support response measures. There is no restriction of movement in and out of Antananarivo, where the two urban cases occurred, which is consistent with the standard response to plague outbreaks in Madagascar.

Resistance of Yersiniapestisto antibiotics seems very limited. However, circulating strains are monitored to
provide accurate public health information on Y. pestis antimicrobial susceptibility.

WHO does not recommend any travel or trade restrictions based on the current information available for this
outbreak.

(Continue . . . )

 

ECDC Updated Rapid Risk Assessment On H5N8

H5N8 – A long way from home

 

# 9354

 

A week ago – when there was but one outbreak (in Germany) of HPAI H5N8 in Europe – the ECDC issued a Rapid Risk Assessment for EU Countries, noting that:

 

The public health threat from this event is considered very low. To date, no human infections with this virus have ever been reported world-wide and the risk for zoonotic transmission to the general public in the EU/EEA countries is considered to be extremely low.

 

While that basic public health assessment has not changed, the situation on the ground has. 

 

Since then there have been at least three more H5 or H5N8 outbreaks reported in European poultry, with the latest being a second farm in the Netherlands today.  While we await confirmation that this latest outbreak is the same subtype as the others, the ECDC has published an updated Risk Assessment.

 

The entire PDF is 7 pages in length, and so I’ve only reproduced portions below. Click the link to download the entire report:

RAPID RISK ASSESSMENT

Outbreaks of highly pathogenic avian influenza A(H5N8) in Europe

Updated 20 November 2014

(EXCERPTS)

ECDC threat assessment for the EU

To date, no human infections with this virus have ever been reported worldwide and the risk of zoonotic transmission to the general public in EU/EEA countries is considered to be extremely low. However, this event is another indication of the widespread circulation and continuous re-assortment of avian influenza viruses, and specifically H5 viruses in animal populations, which continues to pose a long-term risk of human influenza
pandemics.

Investigations in the countries concerned have been initiated to determine how the virus entered the affected holdings. Germany reported that no live poultry or poultry meat from the affected holding has been shipped to other regions of Germany, other EU Member States or third countries. To date, there is no epidemiological evidence that avian influenza can be transmitted to humans through the consumption of cooked food, notably poultry meat and eggs.

The German reference laboratory for avian influenza viruses reported that the virus is detectable using EU recommended laboratory methods (M 1.2 and H5). However, further adjustments of these methods could still improve performance. Optimising test performance in the context of the newly emerged strain can enhance test sensitivity when supporting outbreak investigations. This needs to be balanced against broad sensitivity of assays for application in wider passive and active surveillance programmes where the virus subtype(s) is unknown. 

 

The National Influenza Centres are assessing whether the available validated assays are sufficiently sensitive for detection of the A(H5N8) viruses in humans and they should be contacted if there is suspicion of human infection.

In order to prevent virus spread, Directive 2005/94/EC [12] requires that Member States have contingency  ]plans detailing measures for the killing and safe disposal of infected poultry, feed and contaminated equipment as well as the procedures and methods for cleaning and disinfection. Reinforcing biosecurity  measures to prevent contact between domestic poultry and wild birds is expected to reduce the risk of infection if wild birds are identified as a source of infection.

The Directive also requires the development of contingency plans for the control of avian influenza in poultry and birds in collaboration with public health and occupational health authorities to ensure that persons at risk are sufficiently protected from infection. Personal protective equipment, and in particular respiratory protection, should be considered. Persons at risk are mainly those in direct contact with/handling diseased birds and poultry, or their carcasses (e.g. farmers, veterinarians and labourers involved in the culling).

Vaccination with seasonal influenza vaccine is recommended for exposed workers having contact with birds and poultry to avoid the possibility of co-infection with human and avian influenza viruses and to reduce the risk of reassortment.

Persons in direct contact with infected poultry before or during culling and disposal, including poultry workers,
should be monitored for ten days, in order to document possible related influenza-like symptoms, fever or conjunctivitis. Local health authorities may consider actively monitoring these groups. Administration of  antiviral prophylaxis for exposed persons as recommended for A(H5N1) can be considered as a  precautionary measure depending on the local risk assessment (i.e. intensity of exposure) and in the context of the start of seasonal influenza in the EU to prevent reassortment [21].

Conclusions

There is wide diversity in the re-assorted avian influenza viruses circulating among wild bird populations across Asia. The ability of this highly pathogenic avian influenza virus to sub-clinically infect a broad range of wild birds increases the risk of geographical spread and subsequent outbreaks, as observed in South Korea. Therefore, ongoing monitoring and testing of wild birds and domestic poultry in the EU plays an important role in the detection of further virus incursion.

It remains unclear how a highly pathogenic avian influenza virus A(H5N8) was simultaneously introduced into holdings in Germany, the Netherlands and the UK. The ongoing investigations into the transmission chain may provide important information for the prevention of further outbreaks in the EU.

It is important to remain vigilant, identify early transmission events to humans and ensure active surveillance of
exposed workers at the affected holdings for human health complaints, particularly during and after culling  operations. As a minimum, exposed workers should be instructed to report health complaints (passive monitoring).