PAHO Epi Alert: COVID-19 During Pregnancy - 13 August 2020

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For the second day in a row (see yesterday's PAHO Epi Alert: Complications & Sequelae Of COVID-19), we have an Epidemiological Alert from PAHO (Pan American Health Organization) - this time on the risks of COVID-19 during pregnancy. 

Ten days ago in Pregnancy & COVID-19: Still More Questions Than Answers, we looked at the long and tragic history of pandemics and pregnancy, along with several recent COVID studies, including a CDC MMWR from last June entitled:

Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020

Weekly / June 26, 2020 / 69(25);769–775

Sascha Ellington, PhD1; Penelope Strid, MPH1; Van T. Tong, MPH1; Kate Woodworth, MD1; Romeo R. Galang, MD1; Laura D. Zambrano, PhD1; John Nahabedian, MS1; Kayla Anderson, PhD1; Suzanne M. Gilboa, PhD1 (View author affiliations)View suggested citation

Summary

What is already known about this topic?

Limited information is available about SARS-CoV-2 infection in U.S. pregnant women.

What is added by this report?

Hispanic and non-Hispanic black pregnant women appear to be disproportionately affected by SARS-CoV-2 infection during pregnancy. Among reproductive-age women with SARS-CoV-2 infection, pregnancy was associated with hospitalization and increased risk for intensive care unit admission, and receipt of mechanical ventilation, but not with death.

What are the implications for public health practice?

Pregnant women might be at increased risk for severe COVID-19 illness. To reduce severe COVID-19–associated illness, pregnant women should be aware of their potential risk for severe COVID-19 illness. Prevention of COVID-19 should be emphasized for pregnant women and potential barriers to adherence to these measures need to be addressed.

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The finding that Hispanic and non-Hispanic black pregnant women appear to be disproportionately affected by SARS-CoV-2 infection would suggest the impact of COVID-19 on pregnant women may be higher in some regions than in others.

Which brings us to an 8-page PAHO (Pan American Health Organization) Epidemiological Alert: COVID-19 During Pregnancy - 13 August 2020 released on August 14th. Due to its length, I've only reproduced the introduction.

Follow This LINK to download the PDF and read it in its entirety. 

Recently published results and studies based on COVID-19 surveillance data have indicated an increased risk among pregnant women of presenting with severe forms of COVID-19 and, therefore, of being hospitalized and admitted to intensive care units (ICU).

The Pan American Health Organization / World Health Organization (PAHO/WHO) requests that Member States intensify efforts to ensure access to prenatal care services, as well as to implement preventive measures to reduce morbidity and mortality associated with COVID-19 across all levels of the health system, in order to maintain the commitment to reducing maternal and perinatal mortality and the progress achieved to date.

Introduction

Countries and territories in the Region of the Americas have faced not only the inherent challenges of responding to the COVID-19 pandemic, but also the challenges of sustaining the public health achievements made thus far. These efforts are all in parallel with continuing to offer the necessary healthcare services for women of childbearing age, and particularly for pregnant women, without interruption.

The implementation of measures restricting the movement of people, and the closure of some healthcare centers, have made it difficult for pregnant women to receive the appropriate number of prenatal checks corresponding to the respective gestational age. This could potentially result in the delayed detection of issues related to the pregnancy (such as gestational diabetes or hypertension) or to the fetus directly (such as intrauterine growth restriction) and,therefore, pose a risk to both the mother and fetus.

The challenge of adopting timely corrective measures has been exacerbated by the scarcity of scientific information available regarding the effects of the SARS-CoV-2 virus on pregnancy and the fetus.

Acknowledging that the characteristics of pregnant women in the Region of the Americas may differ from that of pregnant women in Europe, some studies conducted among pregnant womenin Europe can be considered for identifying risk factors to mitigate the potential impact of COVID-19 on pregnancy and the fetus.

One such study conducted amongst a cohort of 427 pregnant women who were hospitalized with confirmed SARS-CoV-2 infection between 1 March 2020 and 14 April 2020 in the United Kingdom found that the majority of those admitted to the hospital were in the late second or third trimester of pregnancy. Overall, 233 were Black or Other ethnic minority group, 281 were overweight or obese, 175 were 35 years or older, and 145 had pre-existing comorbidities. Forty-one women admitted to the hospital required respiratory support and 5 women died.

The study indicated that 266 of the women gave birth or had a pregnancy loss; 196 gave birth at term. Twelve of 265 newborns tested positive for SARS-CoV-2 RNA, including 6 within the first 12 hours after birth. 1

In another study conducted in Spain, antibody testing for SARS-CoV-2 was conducted for 874 pregnant women consecutively attending first trimester screening trimester (between 10-16 weeks of gestation, 372 women) or delivery (502 women) between 14 April and 5 May 2020 at three university hospitals 2 in Barcelona. Seroprevalence was similar between women in the first trimester of pregnancy and women in the third trimester, suggesting a similar risk of infection; however, both the proportion of women with symptoms and the proportion of women requiring hospitalization were higher amongst those in their third trimester compared to those in the first trimester. 3

Below is a summary of the situation of pregnant women and maternal mortality in the context of COVID-19 in countries of the Region of the Americas for which information was available.

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CDC Clarifies: Recovered COVID-19 Cases Are Not Necessarily Immune To Reinfection

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Yesterday a number of media outlets reported that the CDC had suggested - in guidance released earlier this month - that recovered COVID-19 cases were likely `immune' to reinfection for at least 90 days.  Typical of the reporting is this from NBC News.

CDC suggests recovered COVID-19 patients have protection for 3 months

The update lines up with previous guidance that people who have recovered don't need to be retested for 90 days.

Given recent uncertainties expressed over the amount (and duration) of post-infection immunity one might expect to acquire, this story quickly made the rounds of major media.  

The source material comes from a short passage in the CDC's `WHEN TO QUARANTINE' guidance (below, underlining mine).

Who needs to quarantine?

People who have been in close contact with someone who has COVID-19—excluding people who have had COVID-19 within the past 3 months.

People who have tested positive for COVID-19 do not need to quarantine or get tested again for up to 3 months as long as they do not develop symptoms again. People who develop symptoms again within 3 months of their first bout of COVID-19 may need to be tested again if there is no other cause identified for their symptoms.

Quite honestly, I wouldn't have been quick to interpret this as a tacit acknowledgment of a 90-day grace period on re-infection, but I can see how some might have come away with that impression. 

While the CDC's messaging was a little kludgy, I would assume that if they had evidence of a minimum post-infection period of immunity - they'd call a press conference - not slip it quietly into a guidance doc that took 10 days for anyone to notice. 

Late last night, the CDC clarified matters in the following media statement.

Updated Isolation Guidance Does Not Imply Immunity to COVID-19

Media Statement

For Immediate Release: Friday, August 14, 2020

Contact: Media Relations

(404) 639-3286

On August 3, 2020, CDC updated its isolation guidance based on the latest science about COVID-19 showing that people can continue to test positive for up to 3 months after diagnosis and not be infectious to others. Contrary to media reporting today, this science does not imply a person is immune to reinfection with SARS-CoV-2, the virus that causes COVID-19, in the 3 months following infection. The latest data simply suggests that retesting someone in the 3 months following initial infection is not necessary unless that person is exhibiting the symptoms of COVID-19 and the symptoms cannot be associated with another illness.

People with COVID-19 should be isolated for at least 10 days after symptom onset and until 24 hours after their fever subsides without the use of fever-reducing medications.

There have been more than 15 international and U.S.-based studies recently published looking at length of infection, duration of viral shed, asymptomatic spread and risk of spread among various patient groups. Researchers have found that the amount of live virus in the nose and throat drops significantly soon after COVID-19 symptoms develop. Additionally, the duration of infectiousness in most people with COVID-19 is no longer than 10 days after symptoms begin and no longer than 20 days in people with severe illness or those who are severely immunocompromised.

CDC will continue to closely monitor the evolving science for information that would warrant reconsideration of these recommendations.

I can attest that writing clearly and concisely about a pandemic virus that we don't completely understand - without interjecting dozens of caveats or incorporating `weasel words' like `may', `might', or `could' at every turn - is a daunting task.   

And one I'm sure that - as a blogger - I've botched more than once along the way.  

As far as post-infection (or post-vaccination) immunity to SARS-CoV-2 is concerned, the jury is still out, and I suspect ultimately, the answers will be messy, and probably won't apply across the board.  

Some people will likely mount a robust (and hopefully long-lasting) immune response, and others won't.

The limited evidence we have suggests those who have mild or moderate COVID illness are likely to develop less of an immune response. And if the COVID vaccine ends up working anything like the flu vaccine, those who need the most protection (the elderly, immunocompromised, etc.) will likely derive the least benefit. 

These are all topics we've covered repeatedly over the past few months.   Some related blogs, if you missed them, include:

Imperial College London: (REACT) SARS-CoV-2 Antibody Prevalence Study - England

China: Jingzhou City Reports COVID-19 Positive Test In A Woman 6 Months After Recovery

`Forward Looking' & `Aspirational' Vaccine Press Releases

Eurosurveillance: 2 More SARS-COV-2 Seroprevalence Studies To Ponder

Kings College: Longitudinal Evaluation & Decline of Antibody Responses in SARS-CoV-2 infection

 

PAHO Epi Alert: Complications & Sequelae Of COVID-19

 

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Very early on in our COVID-19 outbreak it was apparent that this emerging coronavirus did not carry the same level of lethality as MERS-CoV, SARS-CoV, or H5N1/H7N9 avian flu in humans. The Case Fatality Rate (CFR) - at least among healthy adults - was relatively low, albeit higher than seasonal flu. 

More concerning were the high communicability and attack rates, and the lengthy hospitalization stays and slow recoveries being reported. By the end of February it was apparent we were facing a high-morbidity/low-mortality pandemic. 

One that might kill 1% of those infected, but that could often require weeks or even months for many to recover from. Twenty-five weeks ago, in Pandemics Are More Than Just About The CFR, I warned about the danger of focusing too heavily on the number of deaths, while ignoring the other negative impacts of a high-morbidity contagion. 

Sadly, until recently the media has focused primarily on the grim daily death toll, while glossing over long recoveries and often - long-term health problems and/or disability - associated with SARS-CoV-2 infection. 

Some of the adverse outcomes reported among COVID-19 survivors include:

JAMA: Two Studies Linking SARS-CoV-2 Infection To Cardiac Injury

The Lancet: Yet Another Study On Neurological Manifestations In Severe COVID-19 Patients

WHO Scientific Brief: Multisystem Inflammatory Syndrome in Children & Adolescents with COVID-19

EID Journal: Two Reports On Thrombotic Events In COVID-19 Patients

EID Journal: Pulmonary Embolism and Increased Levels of d-Dimer in COVID-19 Patients

Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young

While originally viewed as a primarily a respiratory infection, last month in Nature Med. Review: Extrapulmonary manifestations of COVID-19, we looked at just how broadly SARS-CoV-2 attacks the human body. 

https://twitter.com/KartikSehgal_MD/status/1281695760879202304

Over the past few months, we've seen cardiologists and neurologists weigh in on the potential for seeing huge increases in COVID-19 related heart failure and neurological diseases, some that may not become fully apparent for years. 

Coronavirus Disease 2019 (COVID-19) and the Heart—Is Heart Failure the Next Chapter?

Clyde W. Yancy, MD, MSc1,2; Gregg C. Fonarow, MD3,4

 

JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3575

Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms 

Emily A. Troyer, Jordan N. Kohn, and Suzi Hong

And just over a month ago,  Dr. Anthony Fauci expressed concerns that many COVID patients are suffering from a post-viral syndrome - similar to ME/CFS - which has disabled and traumatized well over a million Americans over the past 3 decades (see NIH About CFS/ME). 

We are literally just scratching at the surface of the damage this pandemic virus has caused, and may cause going forward.  

And as we go into what is likely to be a chaotic and dangerous fall,  The Psychological Impact On 1st Responders & Frontline HCWs can't be brushed aside either.  After the limited 2015 MERS-CoV outbreak ins South Korea (see Study: Burnout & PTSD Among Nurses Working During A Large MERS-CoV Outbreak - Korea, 2015) half of all nurses reported PTSD symptoms.

Regardless of the death toll, we'll be living with the physical and psychological wounds of COVID-19 for years to come. 

All of which brings us to a 16-page PAHO (Pan American Health Organization) Epidemiological Alert on Complications and sequelae of COVID-19  released on August 12th.  Due to its length, I've only reproduced the introduction.  Follow the link to download and read it in its entirety. 

More than 7 months following the first report of novel coronavirus disease (COVID-19), knowledge of the complications and sequelae of this disease has increased substantially.

Through this alert, the Pan American Health Organization / World Health Organization (PAHO/WHO) urges Member States to keep health professionals informed as new information continues to become available in order to strengthen the timely detection and proper management of COVID-19 cases, complications, and sequelae.

Introduction

Between 10 July and 10 August 2020, an additional 4,433,115 cases of COVID-19, including 114,480 additional deaths, were reported in the Region of the Americas, for a cumulative total of 10,697,800 confirmed cases of COVID-19 including 390,849 deaths. This represents a relative increase of 64% in cases and 37% in deaths compared to the number of new cases and deaths reported during the previous 4-week period (12 June to 9 July). The highest proportion of new cases were reported in the United States of America (44%) and Brazil (30%), while the highest proportion of new deaths were reported in Brazil (29%), the United States of America (26%), and Mexico (17%).

More than 7 months following the notification of the first COVID-19 cases (Joint Report of the WHO and the Government of China in February 2020) (1), there have been advances in the knowledge of the disease, including but not limited to the source of infection; the pathogenesis and virulence of the virus; transmissibility; risk factors; effectiveness of prevention measures; surveillance; diagnosis; clinical management; and complications and sequelae, amongst others. However, there remain several gaps pertaining to these factors that still require contribution from the entire scientific community.

The intense transmission of COVID-19 in most of the countries and territories of the Americas, along with evidence generated from the scientific community, has increased our knowledge of several of these factors including those related to complications and sequelae from COVID-19.

Knowledge of these factors is necessary to improve and adjust the prevention and control strategies of the pandemic.

The following is a summary of the available evidence regarding complications and sequelae of COVID-19.

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The morbidity and sequelae associated with COVID-19 not only presents a serious challenge to our already stressed health care delivery system, it can negatively affect economic recovery, supply chains, and the overall functioning of society. 

Longer term, we'll have to figure out how to care for those left permanently damaged or disabled by this pandemic. 

While COVID-19 remains a relatively low-mortality pandemic, its overall impact on individuals, and society, are far from benign. 

Imperial College London: (REACT) SARS-CoV-2 Antibody Prevalence Study - England

Credit Imperial College London

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It was a simpler time 6 months ago. 

The newly emerged SARS-CoV-2 pandemic virus was still thought of as primarily a pulmonary infection. One to which children were largely `immune', and that only rarely seriously impacted those under the age of 65.  Asymptomatic carriage and transmission was unproven and believed to be rare.

And the prevailing theory was - once infected - survivors have either long-term or life-time  protective antibodies.

The pandemic would end once `herd immunity' of  60%-80% could be achieved, and a few countries were suggesting they were already substantially on their way to that goal.

Some countries even considered adopting a passive approach (see The UK's COVID-19 Response Gamble : Business As Usual), gambling that letting the virus run its course would be less economically painful than a long, drawn out viral siege.  

Then the hospital ICUs began to fill rapidly, and deaths began to rise to politically untenable levels, and courses were quickly reversed. 

Since then it has become apparent that COVID-19 is a far more insidious disease, affecting not only the lungs, but the heart, the brain, and other organs (see Nature Med. Review: Extrapulmonary manifestations of COVID-19).  Children were starting to show up in ICUs with a severe inflammatory syndrome, and evidence of asymptomatic transmission was mounting. 

Even worse, by April early assumptions about long lasting acquired immunity were beginning to fray around the edges (see COVID-19: From Here To Immunity). The assumption that we could achieve herd immunity - either via natural infection or a vaccine - was increasingly being questioned.

Since then, additional studies have raised even more concerns.

Kings College: Longitudinal Evaluation & Decline of Antibody Responses in SARS-CoV-2 infection

Eurosurveillance: 2 More SARS-COV-2 Seroprevalence Studies To Ponder

The Lancet: Prevalence of SARS-CoV-2 in Spain (ENE-COVID)

Less than a month ago, the Journal Nature published. 

         (Excerpt)

16 July — Antiviral antibodies peter out within weeks after infection

Key antibodies that neutralize the effects of the new coronavirus fall to low levels within months of SARS-CoV-2 infection, according to the most comprehensive study yet.

(SNIP)

However, in most people, antibody levels began to fall about a month after symptoms appeared, sometimes to nearly undetectable levels — raising questions about the durability of vaccines designed to promote the production of neutralizing antibodies.

(Continue . . . ) 

As I pointed out in my blog at the the time. 

 `. . . nAb titers aren't the only measure of potential post-infection immunity, as the role of T-Cells in fighting this virus is poorly understood.  Still, these results give pause, as it suggests many people - particularly those who had a mild first illness - may become susceptible to re-infection within months of recovery.'

While the amount and duration of antibody protection one gets following infection remains unclear, the other half of the herd immunity equation is the percentage of the population that has been exposed (or eventually, vaccinated) and now carries detectable SARS-CoV-2 antibodies. 

In an attempt to answer that question in England - one of the hardest hit countries in Europe - Imperial College London in conjunction with the NHS has conducted a SARS-CoV-2 antibody prevalence study on over 100,000 adults who used an at-home self-administered antibody test kit between June 20 and July 13.

These test kits are described in a ICL news article called Biggest study on antibody finger-prick tests identifies promising kits by Justine Alford, which found the Fortress test had a high specificity (98.6%), and moderate sensitivity (84%). 

In other words, the test reliably detects antibodies 84% of the time and correctly identified the absence of antibodies 98.6% of the time.  When combined with its ease of use, this test was selected for the antibody prevalence study. 

The results of the actual study were released today, in the form or a pre-print article, a press release from Imperial College London, and a release from the UK's Department of Health and Social Care.

Highlights of this study's findings include:

1. Roughly 6% of the UK Population has likely been infected with SARS-CoV-2
2. Highest rates of infection were detected in London
3. People of Black or Asian (mainly South Asian) ethnicity were most affected
4. 1/3rd of positive cases were reported as asymptomatic.
5. An infection fatality ratio of 0.90%

First stop, the abstract from the 20-page study:

Antibody prevalence for SARS-CoV-2 following the peak of the pandemic in England: REACT2 study in 100,000 adults

Ward H1,2,6, Atchison C1,2, Whitaker M1 , Ainslie KEC1,3, Elliott J1 , Okell L1,3, Redd R1 , Ashby D1 , Donnelly CA1,3,4, Barclay W2,5 , Darzi A7 , Cooke G2,5,6 , Riley S1,3, Elliott P1,2,6,8

Abstract 

Background 

England, UK has experienced a large outbreak of SARS-CoV-2 infection. As in USA and elsewhere, disadvantaged communities have been disproportionately affected. 

Methods 

National REal-time Assessment of Community Transmission-2 (REACT-2) seroprevalence study using self-administered lateral flow immunoassay (LFIA) test for IgG among a random population sample of 100,000 adults over 18 years in England, 20 June to 13 July 2020. 

Results 

Completed questionnaires were available for 109,076 participants, yielding 5,544 IgG positive results and adjusted (for test performance), re-weighted (for sampling) prevalence of 6.0% (95% CI: 5.8, 6.1). Highest prevalence was in London (13.0% [12.3, 13.6]), among people of Black or Asian (mainly South Asian) ethnicity (17.3% [15.8, 19.1] and 11.9% [11.0, 12.8] respectively) and those aged 18-24 years (7.9% [7.3, 8.5]).

Care home workers with client-facing roles had adjusted odds ratio of 3.1 (2.5, 3.8) compared with non-essential workers. One third (32.2%, [31.0-33.4]) of antibody positive individuals reported no symptoms. Among symptomatic cases, the majority (78.8%) reported symptoms during the peak of the epidemic in England in March (31.3%) and April (47.5%) 2020.

We estimate that 3.36 million (3.21, 3.51) people have been infected with SARS-CoV-2 in England to end June 2020, with an overall infection fatality ratio of 0.90% (0.86, 0.94).

Conclusion 

The pandemic of SARS-CoV-2 infection in England disproportionately affected ethnic minority groups and health and care home workers. The higher risk of infection in these groups may explain, at least in part, their increased risk of hospitalisation and mortality from COVID-19. 

Next stop, a lengthy news article from Imperial College London.

Largest study on home coronavirus antibody testing publishes first findings

by Justine Alford13 August 2020

More than 100,000 people across England have tested themselves for SARS-CoV-2 antibodies at home as part of a major research programme.

Led by Imperial College London, the REACT (REal Time Assessment of Community Transmission) study is using antibody finger-prick tests to track past infections and monitor the progress of the pandemic. It’s the first nation-wide antibody surveillance study to be rolled out across England using self-testing at home.

 

The findings, available in a non-peer-reviewed report submitted to medRxiv, show that slightly under 6% of the population had antibodies to the virus and had likely previously had COVID-19 by the end of June, an estimated 3.4 million people. London had the highest numbers at over twice the national average (13%), while the South West had the lowest (3%).

Key workers in care homes and health care were among those most likely to have already been infected with the coronavirus. And Black, Asian and minority ethnic (BAME) individuals were between two and three times as likely to have had COVID-19 compared to white people.

(Continue . . . )

And finally, a lengthy press release from the UK government can be accessed at:

Largest home antibody testing programme for COVID-19 publishes findings

Findings published by Imperial College London today suggest that 6% of the population in England, around 3.4 million people, have been infected with COVID-19.

Published 13 August 2020

From:Department of Health and Social Care

There remain an awful lot of unknowns here.  

• First, only adults were tested, and the prevalence of detectable antibodies may be different in children.  
• Second, while innovative, the home test kit only has an 84% sensitivity. 
• Third, and most importantly, we still don't know whether the presence of detectable antibodies indicates immunity, and if it does, for how long that immunity might last. 

What is clear is that roughly 94% of the British population have either yet to be infected, or were infected and did not produce detectable antibodies, leaving the UK - and likely the rest of the world -  a very long way from achieving anything close to herd immunity. 

Australia: Victoria Reports (2) Outbreaks of LPAI H5N2

 

 Victoria State - Credit Wikipedia

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Not quite two weeks ago Victoria agricultural officials announced the detection of a highly pathogenic (HPAI) H7N7 virus at an egg farm in Lethbridge, Victoria. Six days ago, in Australia: 2nd Victoria Farm Hit By HPAI H7N7, we learned of a second outbreak at a nearby farm.

Because of increased surveillance in the region, two more farms have been found to be infected with another - low path (LPAI) - strain; H5N2. 

 

One farm is in Lethbridge, near the original H7N7 outbreak, while the other is in Bairnsdale, Victoria.

As a general rule, LPAI (low path) viruses are of less concern than HPAI viruses. But LPAI H5 and H7 viruses both have the ability to mutate into highly pathogenic strains if allowed to circulate in poultry. Therefore all H5 and H7 viruses - regardless of pathogenicity - are reportable to the OIE. 

This is the first occurrence of LPAI H5N2 in Australia since 2013, and 7,500 turkeys will be culled.  The OIE report can be found at this Link.

Agriculture Victoria has issued specific warnings to poultry holders in the region.

Neither of these avian flu viruses rank very high on our zoonotic worry list, although both have at least  some human health `potential'.  For now, these are mainly threats to poultry interests. 

The discovery of LPAI H5N2 likely came about due to the enhanced scrutiny of poultry in the region following the HPAI H7N7 outbreak two weeks ago. 

While bird flu reports have been relatively subdued the past few months, Russia recently reported HPAI H5N8 in Chelyabinsk Oblast, Russia, the Philippines reported HPAI H5N6, and Vietnam reported HPAI H5N1. 

The OIE's Key Messages from their most recent HPAI Report (Jul 10th-30th) reads:

Key messages 

In the reporting period, 3 new HPAI outbreaks were reported in domestic birds in Asia and Africa involving 2 different HPAI subtypes namely H5N6 and H5N8. In addition, 81 HPAI outbreaks in poultry and non-poultry are still ongoing in America, Europe, Asia and Africa involving different HPAI namely H5, H5N1, H5N5, H5N6, H5N8, H7N3 and H7N9. 

• Outbreaks of H5N1, H5N6 and H7N9 are still continuing in a few Asian countries with the Philippines reporting recurrence of new H5N6 outbreaks.
• In Chinese Taipei, H5N5 subtype has continued to be reported since September 2019
• South Africa experienced recurrence of H5N8 new outbreaks with ongoing outbreaks still continuing. The outbreak situation of H5N8 which was reported in European countries in poultry and/or wild birds have declined and only one outbreak of H5N8 is ongoing in Bulgaria. It is more likely that the source of infection in these outbreaks is contact with wild birds and followed by limited local spread.
• USA reported an outbreak of HPAI H7N3 in commercial poultry this year. The premises has an epidemiological link to another premises affected recently by low pathogenic avian influenza (LPAI) H7N3. A comprehensive epidemiological investigation and enhanced surveillance is ongoing in the affected area.

Veterinary Authorities in the affected countries have responded to contain outbreaks in poultry with stamping out measures, heightened surveillance, and recommendations to poultry owners to increase biosecurity.

The OIE Standards, and the transparency of reporting through the OIE’s World Animal Health Information System, provide the framework for Veterinary Services to implement effective surveillance, reporting, and controls for avian influenza. Wild bird surveillance can indicate periods of heightened risk, and at these times measures to improve on-farm biosecurity may reduce the likelihood of exposure of poultry

Given our recent preoccupation with COVID-19, unsurprisingly we've seen a noticeable drop in global disease surveillance and reporting (see A Disturbing Dearth Of Data), including on avian flu, seasonal influenza, and MERS-CoV. 

One can't help but wonder what other emerging disease threats we are missing, that are evolving or spreading undetected around the world. 

China: Jingzhou City Reports COVID-19 Positive Test In A Woman 6 Months After Recovery

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With the caveat that this is an anecdotal report, and details are scant, we have a report - issued by the Jingzhou City government - indicating that a 68 year-old woman who was infected with COVID-19 more than six months ago, has tested positive again for the virus. 

At this point we don't know if this is a reactivation of a dormant virus, or a re-infection, although Chinese officials are quick to call it a `rejuvenation' of the virus (not a new case).

This isn't the first time we've seen patients test positive again after supposedly being `cured' (see Feb 27th's Osaka Japan: `Recovered' Patient Tests Positive For COVID-19), but most of the time these cases tested positive again within a few weeks following `recovery', suggesting they were more likely the result of testing failures or relapses than re-infection. 

• We've seen `relapses' before with another severe coronavirus (see Korean Govt. Statement On MERS Patient `Relapse’ and Isolation). In this case, the patient had significant comorbidities, which may have led to a longer-than-normal carriage of the virus.

• False negative COVD-19 test results have been common enough (see Problematic Lab Testing For The Novel Coronavirus) that last spring Hubei Province required self-isolation for an additional 14 days for cases following release from the hospital. 

What makes today's case a little different is the nearly 6 months gap between being declared free of the virus and testing positive again. While this doesn't exclude the possibility of long-term carriage and reactivation of the virus, it does makes reinfection a scenario worth considering. 

First the initial (translated) report by Jingzhou City on Weibo, followed by a state media report.  After which I'll return with more.

Xinhuanet is reporting:

In Jingzhou, Hubei, a case of rejuvenation after a new crown patient diagnosed in February this year was cured

2020-08-12 16 :10: 24Source : CCTV News Client

According to the report of the New Crown Pneumonia Epidemic Prevention and Control Headquarters in Jingzhou City, Hubei Province on the 12th, on August 9, a 68-year-old female retired worker from Lianhe Street, Jingzhou Development Zone, was hospitalized due to illness. The new crown virus nucleic acid test was positive. The woman was The patient with new coronary pneumonia diagnosed on February 8 was cured again after a few months. It is not a new case.

At present, the patient is treated in isolation again, and all contacts have been tested negative for nucleic acid, and his residence and activity area have been thoroughly disinfected, and the risk is completely controlled. There is no evidence that there is a risk of transmission of Fuyang cases. The citizens are requested not to panic, believe or spread rumors. Remind the general public that personal protection should also be emphasized under normal circumstances.

If, as local officials are insisting, this is a case of reactivation after six months of dormant carriage of the virus, then COVID-19 could have some interesting surprises ahead.  

The `no evidence of a risk of transmission' from a reactivated case sounds more like hope than reason, but even if true, this raises new questions about the long-term individual health impacts of infection. 

The `other' possibility is that this woman was re-exposed to the virus, and was reinfected.

Admittedly, the case for this being a new infection is flimsy at best. Not only would this woman have to have been re-exposed during a time when the Chinese are reporting only a handful of new cases each day, she'd have to have lost any acquired immunity after just 6 months. 

Waning immunity after 6 months, however, is not much of a stretch given some of the serological studies we've seen. 

Kings College: Longitudinal Evaluation & Decline of Antibody Responses in SARS-CoV-2 infection

The Lancet: Prevalence of SARS-CoV-2 in Spain (ENE-COVID)

COVID-19: From here To Immunity (Take Two)

Less than a month ago, Nature published the following news article :

(Excerpt)

16 July — Antiviral antibodies peter out within weeks after infection

Key antibodies that neutralize the effects of the new coronavirus fall to low levels within months of SARS-CoV-2 infection, according to the most comprehensive study yet.

(SNIP)

However, in most people, antibody levels began to fall about a month after symptoms appeared, sometimes to nearly undetectable levels — raising questions about the durability of vaccines designed to promote the production of neutralizing antibodies.

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So the timing, at least, would seem plausible for a re-infection. As to the likelihood of her being re-exposed to the virus, that requires data that only China knows with any certainty.  

A genomic sequence analysis of this patient's virus - comparing it to the virus that was circulating in China in late January - could provide better insight into what is happening here.  Whether that will be done, and shared by Chinese officials, is anyone's guess. 

If this turns out to be a one-off, or exceedingly rare occurrence, then it probably doesn't matter which scenario (relapse or reinfection) has occurred.  

But if, over the next few months, we start seeing a significant number of similar reports - both from China and around the world - then we'll know that COVID-19 has yet another curve ball to throw at us. 

Stay tuned.