Monday, June 26, 2017

Bird Flu Murmurs From Thailand














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In the middle of the last decade, when H5N1 was still pretty much a Southeast Asian problem, Thailand was one of the hardest hit countries. In 2004, they reported 17 human infections and 12 deaths, coming in second to Vietnam.

They also lost more than a hundred rare tigers that year, as reported by the WHO:
In October 2004, captive tigers fed on fresh chicken carcasses began dying in large numbers at a zoo in Thailand. Altogether 147 tigers out of 441 died of infection or were euthanized. Subsequent investigation determined that at least some tiger-to-tiger transmission of the virus occurred.
By the end of 2006 - the last year Thailand reported a human infection - they had done a remarkable job controling the virus, although scattered outbreaks in poultry would be reported over the next few years.
Thailand filed their last OIE report on Avian flu in 2009.

But given their location and immediate neighbors - and the recent surge of H7N9 in China, the spread of H5N8 in Asia, Europe, and Africa, and the recent escape of H5N6 from China - it is safe to say Thailand remains on high alert for any signs of the virus.

While it may be nothing more than a timely reminder, the Thai language press overnight has been echoing a vague report referencing `sick poultry in the north', and urging increase surveillance and reporting (note: the website url mentioned in the article isn't responding right now).
(Translated)
The Department of Prevention and Control of Avian Influenza After the outbreak of the province.
Credit: manager.co.th

Mr. Sopon Mektanat, Permanent Secretary, Ministry of Public Health said that the Ministry of Public Health. Has joined with related agencies. Avian influenza surveillance is intensive and continuous. Although Thailand has not reported human infection with avian influenza in humans since 2006 to date. But there are still risks due to climate change and the movement of animals along the border. 


From the surveillance, it was found that the poultry were sick in the lower North. The Provincial Health Office ordered the Department of Disease Control together with the Department of Livestock. Send the team to investigate the swiftly moving disease into action. By integrating all agencies and all levels in the area. To maintain safety and promote self-defense awareness of the people.

The Department of Disease Control ordered 12 Disease Control Offices nationwide. And the Institute for Disease Control and Prevention. Accelerate surveillance and preparedness for avian influenza. Together with the Provincial Public Health Office Provincial Livestock Office And related agencies Practice emergency preparedness plan.
Situation of bird flu outbreak Especially high risk areas such as border areas. Dense poultry area And a lot of reptiles. People can keep track of information and advice on bird flu prevention at the Bureau of Emerging Infectious Diseases, Department of Disease Control. Http://beid.ddc.moph.go.th For more information, contact the Department of Disease Control Hotline on 1422.

Admittedly, not a lot of details here.  The `outbreak' - whatever it is - is being investigated.  Hopefully more details will be released soon.

Updating the CDC's IRAT (Influenza Risk Assessment Tool) Rankings

Credit NIAID












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Last September, before H7N9 reinvented itself (twice) in China, we looked at the CDC's ranking (see CDC: IRAT Evaluation Of Novel Avian & Swine Flu Risks) of 11 novel flu subtypes/strains that circulate in non-human hosts and are believed to possess some degree of pandemic potential.

The CDC is quick to point out the Influenza Risk Assessment Tool (IRAT) is not meant to be predictive.  As stated in their FAQ:
Can the IRAT predict a future pandemic?
No. The IRAT is an evaluative tool, not a predictive tool. Flu is unpredictable, as are future pandemics.
But the IRAT can help planners decide which viruses pose the greatest risks, so they can prioritize their efforts and investments. And ten months ago, out of the 11 viruses on the list:
Not all novel flu viruses are created equally.  Some show signs of being more likely to jump to humans than others, while some have shown more virulence in humans than others.   
A mild flu, even if it spreads easily, isn't that much of a threat to public health. But a severe flu that spreads easily, is another matter entirely. 
The CDC uses two sets of criteria to evaluate novel viruses.  One to estimate a virus's potential for sustained human-to-human transmission, and another to guage it's potential for significant impact on public health. 

Fast forward to June 2017, and the CDC has added two new viruses to their IRAT list (a second H7N9 [A/Hong Kong/125/2017] variant, and the recently arrived Canine H3N2) and has further refined their rankings.   
Where there were 11 last September, there are now 13. It is worth nothing that of the 13 novel viruses on this list, 10 have been added in the past 6 years. 
Below you'll find the latest rankings, with the new H7N9 virus nudging out the old version in both Emergence and Impact scores, putting both (A & B) far ahead of the pack.

https://www.cdc.gov/flu/pandemic-resources/monitoring/irat-virus-summaries.htm


Summaries on the two new entries, follow:
H3N2: [A/canine/Illinois/12191/2015]
The H3N2 canine influenza virus is an avian flu virus that adapted to infect dogs. This virus is different from human seasonal H3N2 viruses. Canine influenza A H3N2 virus was first detected in dogs in South Korea in 2007 and has since been reported in China and Thailand. It was first detected in dogs in the United States in April 2015. H3N2 canine influenza has reportedly infected some cats as well as dogs. There have been no reports of human cases.
Summary:  The average summary risk score for the virus to achieve sustained human-to-human transmission was low risk (less than 4). The average summary risk score for the virus to significantly impact public health if it were to achieve sustained human-to-human transmission was in the low risk range (less than 4).
Some past blogs on the Canine H3N2 virus include:
A Canine H3N2 Virus With PA Gene From Avian H9N2 - Korea

Canine H3N2 Reassortant With pH1N1 Matrix Gene

Virology J: Human-like H3N2 Influenza Viruses In Dogs - Guangxi, China

The bigger concern comes from the recently emerged Yangtze River Delta lineage of H7N9 (we don't have enough data yet on the risks posed by the recently emerged HPAI version).

H7N9: [A/Hong Kong/125/2017]
Low pathogenic avian influenza (LPAI) H7N9 viruses were first reported from China in March 2013. These viruses were first scored using the IRAT in March 2013 and again in April 2013, and then annually in 2014, 2015, and 2016 with no change in overall risk scores. Between October 2016 and May 2017 evidence of two divergent lineages of these viruses was detected – the Pearl River Delta lineage and the Yangtze River Delta lineage. The IRAT was used to assess LPAI H7N9 [A/Hong Kong/125/2017], a representative of the Yangtze River Delta viruses.

Summary:  A risk assessment of H7N9 [A/Hong Kong/125/2017] was conducted in May 2017. The overall IRAT risk assessment score for this virus falls into the moderate-high risk category and is similar to the scores for the previous H7N9 viruses. The summary average risk score for the virus to achieve sustained human-to-human transmission is in the moderate risk category (less than 7). The summary average risk score for the virus to significantly impact public health if it were to achieve sustained human-to-human transmission was in the moderate-high risk category (less than 8).

While IRAT can't tell us which virus will spark the next pandemic, or when that might happen, there are three major takeaways from these reports.
  1. There are a lot of novel flu threats out there with at least some pandemic potential. IRAT currently evalluates 13, but that is by no means an exhaustive list.
  2. New viruses appear to be emerging at an accelerated rate over the past decade.
  3. Viral evolution requires that these viruses be re-evaluated from time to time, as nothing is static in the flu world. A virus that ranks relatively low today might be viewed as a serious contender a year or two from now.
All very good reasons why pandemic preparedess is getting renewed attention by the CDC, the WHO, and other government and NGO agencies around the world.  You'll find some recent blogs on that below:
HHS Pandemic Influenza Plan - 2017 Update
OpenWHO: Preparedness Training For Epidemics, Pandemics & Health Emergencies

World Bank: World Ill-Prepared For A Pandemic

Are We Prepared to Help Low-Resource Populations Mitigate a Severe Pandemic?
Community Pandemic Mitigation's Primary Goal : Flattening The Curve
 

DAFF Update On HPAI H5N8 In South Africa

 











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After HPAI H5N8 jumped from the West Coast to Africa to Uganda in early January, it began moving southward; making it to the shores of Lake Alfred in the DRC in May, followed by a large poultry holding in Zimbabwe in early June.
Fearing its imminent arrival, just over two weeks ago South Africa's Department of Agriculture, Forests, and Fisheries (DAFF) put South Africa On Alert For HPAI H5N8.
The official announcement came last Thursday; OIE: South Africa Reports Outbreak Of HPAI H5N8. Over the weekend DAFF published an update on the outbreak, and the steps they are taking to contain it.
MEDIA STATEMENT 24 JUNE 2017
UPDATE ON AVIAN INFLUENZA CONFIRMED IN MPUMALANGA

Highly pathogenic avian influenza (HPAI) H5N8 was confirmed in a broiler breeder site in Mpumalanga on Thursday 22 June 2017. HPAI is a rapidly spreading viral disease that can infect many types of birds and it is highly contagious. It exists naturally in many birds and canbe transmitted by coming into contact with infected animals or through ingestion of infected food or water.


The affected farm has been quarantined and culling of the affected animals has been completed. The department is conducting forward and backward tracing to trace movement of all poultry in and out of the farm in order to establish the source of the Influenza. The department has established a 30km control zone in Mpumalanga and Free State. The two Provinces are conducting surveillance in the 30km control zone for other potentially affected properties. All provinces have been notified and are on high alert.


The following control measures have been implemented to prevent spread of disease:

  • A complete standstill of movement of poultry and poultry products on the infected farm(s). Nothing is to enter or leave the farm
  • Birds at the infected sites will be euthanized humanely
  • State Vets are conducting inspections starting with all the farms within a 3 km and a further 27 km (30km) radius around the affected farm to gather information on the health status of the birds.
  • Poultry and poultry products may only move from these farms with a State Veterinary Permit
  • We have placed a General ban on the sale of live spent hens across the country until further notice
Our trading partners were formally notified of the outbreak in Mpumalanga. Trading partners require a declaration of country freedom of highly pathogenic avian influenza for trade in fresh poultry meat and unprocessed poultry products, which we are currently unable to provide due to the confirmation of HPAI on the Mpumalanga farm. Exports of processed poultry products, live chickens and fresh products from registered poultry compartments will continue depending on the requirements of the importing countries.

To date, no human cases of infection with avian influenza H5N8 have been reported, however people handling wild birds, sick or dying poultry must wear protective clothing and wash their hands with disinfectants. Meat from healthy poultry is safe for consumption as it issubjected to strict meat inspection processes at abattoirs. We urge people to avoid consumption of birds found dead, dying or sick.


No effective treatment for the disease has been found. Infected animals must be humanely destroyed and disposed of properly to prevent the disease from spreading. If you suspect yourflock has contracted the disease, quarantine the affected birds and area immediately. Notify your nearest State Veterinarian of any suspected cases.

After more than 2,000 outbreaks in Europe over the winter, a handful of outbreaks in central and South Africa may not sound like such a big deal.  But this is the first substantial introduction of HPAI H5 into the Southern Hemisphere, and that opens up possibilities for the virus whose impacts and future directions are difficult to predict. 
  • The virus may be able to meet, and reassort with, new LPAI viruses.  HPAI H5 clade 2.4.4.3. has proven itself to be highly promiscuous, and fully capable of spinning off new subtypes, as it did last winter with H5N5 and H5N6 in Europe.
  • HPAI H5N8 could find areas in interior Africa where - due to the right conditions, and/or a lack of surveillance and control measures - it could become endemic, as HPAI H5 has along the west coast of Africa and H5N1 has in Egypt. 
  • And lastly, interior and southern Africa lie under the intersection of 3 major global migratory flyways (see map below), meaning that the virus could find new directions in which to spread.

Or the virus could run roughshod for a few weeks or months - and then mysteriously disappear - just as it did in North America in 2015 (see PNAS: The Enigma Of Disappearing HPAI H5 In North American Migratory Waterfowl).

As we've seen time and again, bird flu is notorious for zigging when we expect it to zag.


Sunday, June 25, 2017

Taiwan Seizes 210 Bottles of Illegal Chinese `Poultry Vaccine'

Seized `Vaccine' in Wine bottles - Credit BAPHIQ

















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Although a victim of sporadic avian flu outbreaks for many years, HPAI H5N8 arrived in the island nation of Taiwan in January of 2015, immediately spun off several reassorted HPAI H5 viruses - and together - would infect more than 1,000 farms over the next 12 months.
While the level of bird flu activity dropped in 2016, and is even further reduced this year, well over 100 outbreaks have been reported since January, including the first detection of H5N6 on the island.
In Taiwan, as in most of the world, culling and quarantine are the preferred methods of controlling avian flu. Unlike in neighboring China, and a few countries like Vietnam and Egypt, avian flu vaccines for poultry are not allowed.
 
For at least a dozen years the OIE has warned that vaccination of poultry cannot be considered a long-term solution to combating  avian flu. And that “Any decision to use vaccination must include an exit strategy, i.e. conditions to be met to stop vaccination. – OIE on H7N9 Poultry Vaccines.
Unfortunately, the handful of countries that currently allow use of poultry AI vaccines have shown little signs of having that `exit strategy'.  China, 12 years into their vaccination program, two weeks ago announced plans to test a New H7N9 Poultry Vaccine In Two Provinces starting late this month.
Faced with this reality, a couple of years ago the OIE - while still discouraging their use - softened the language in their recommendations to allow: 
`In short, vaccination should be implemented when culling policies cannot be applied either because the disease is endemic and therefore widely present, or the infection in affected animals is too difficult to detect.'

As we’ve discussed previously (see PLoS Bio: Imperfect Poultry Vaccines, Unintended Results & The HPAI Poultry Vaccine Dilemma), despite more than a decade of heavy use, poultry AI vaccines have proven to be less than a panacea for bird flu.
 
Countries that have gone the vaccine route (notably China, Egypt, Vietnam, and Indonesia) continue to battle the virus. One could argue (at least in Egypt & China), that their AI problems are worse now than when they started.
The problem is that as the avian viruses evolve, poultry vaccines become increasingly less effective; often only masking the symptoms of infection.
That can allow viruses to spread silently among flocks, to continue to reassort and evolve, and potentially lead to the emergence new subtypes of avian flu (see Subclinical Highly Pathogenic Avian Influenza Virus Infection among Vaccinated Chickens, China)
Twelve years ago, the world had only one HPAI H5 virus of concern; H5N1. Now we have at least a half dozen subtypes (H5N1, H5N2, H5N3, H5N6, H5N5, H5N8, H5N9), with literally dozens of genotypes between them.
The 2015 study Recombinant H5N2 Avian Influenza Virus Strains In Vaccinated Chickens found `These results are in agreement with previous work indicating that AIVs can continue genetic evolution under vaccination pressure'.

Which is why so few countries allow their use. In the fall of 2015, as desperate poultry farmers lobbied for vaccines, Taiwan's Council Of Agriculture strongly Warned Against the Importation & Use Of AI Vaccines.   
Beyond the illegalities, the HPAI H5 viruses in Taiwan originated from Korea, and were expected to be a poor match to the Chinese R5 vaccine.
While not completely ruling out use of an AI vaccine in the future, the COA reiterated that AI vaccines were prohibited in Taiwan, and there were currently no plans to introduce them. They then warned of severe penalties for the illicit manufacture, import, processing, trafficking and use of any illegal animal drugs.

Fast forward to today, and we learn - via the COA - that 18 boxes of  `poultry vaccine' were intercepted - bound for Taiwan - at the Kinmen airport in Fujian Province. While there is considerable doubt as to the authenticity of this `vaccine' (testing is underway), when arrested, the smuggler claimed that it was `duck vaccine'.
'Tis a sad day, indeed, when you can't trust the word of a drug smuggler.  But I digress. . . .
The purported `vaccine' was repackaged into more than 200 recycled Kaoliang (sorghum wine) bottles - and according to local media reports - was discovered after one of the bottles broke, and a custom's official realized it didn't smell like alcohol.

First the (translated) press release, then I'll return with a brief post script.
Seized the mainland smuggling suspected animal vaccines, called on the industry to try to defensively, so as not to spread the disease

(Hereinafter referred to as the Prevention and Control Bureau) on June 24, said the Golden Gate Aviation Police found that people to air cargo delivery 18 boxes (a total of 210 bottles) Golden Gate sorghum wine to Taiwan, one box after the break out There is no alcoholic liquid, so check and notify the Office of the Office of the Kaohsiung Branch Kinmen quarantine police station investigation, after the sea inspection center in the central area of ​​the inspection team Kinmen mobile investigation team preliminary investigation, the public said the bottle filled with liquid system from Continental smuggled ducks with vaccines (what kind of virus or bacteria are not clear). The inspection team on the same day the people transferred to the Kinmen and Quarantine Recruitment, the relevant samples have been sampled by the Golden Gate quarantine station, in this (24) sent someone to send animal health test animal animal inspection branch identification.


The anti-crime bureau states that, according to the Animal Drug Administration Act, animal drugs are not approved by the unauthorized importation of doping, manufacturing or import of animal doping, at 1 year to 7 years imprisonment, and NT $ 450 And shall also be sentenced to a fine of not less than 6 months but not more than five years and shall be fined not more than NT $ 5 million.


The anti-crime bureau states that smuggling or the use of illegal animal vaccines has not been tested and the quality is not guaranteed. It can not only prevent the epidemic, it is more likely to spread the epidemic. The council will continue to cooperate with the prosecution and prosecution agencies, check illegal, to prevent blocking animals into the domestic market with doping.

While this appears to be an amateurish attempt to smuggle a potentially dangerous vaccine into Taiwan, had a bottle not broken, it is very possible it would have been successful.  One can't help but wonder about how many other shipments, either real or counterfeit, have already gotten through.


Nature's laboratory is fully capable of creating the next pandemic virus.  We scarcely need to be lending it a helping hand.

Saturday, June 24, 2017

WHO Avian Flu Risk Assessment - June 2017

WHO H7N9 Epi Curve - June 12th

















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Just 12 months ago H7N9 was closing out its 4th, and least impressive, epidemic wave in its short tenure in China.  After making a big splash over 2013-2014, the virus appeared on the decline (see epi curve above), despite dozens of genotypes in circulation.
But the only real constant with influenza is that it is constantly changing.
And so we find ourselves a year later watching the biggest bird flu human epidemic on record winding down, two distinct new H7N9 variants (1 LPAI, 1 HPAI) taking hold, and the virus edging closer to escaping the confines of Mainland China.

The recent surge, and continuing evolution H7N9 in China, has scientists increasingly  concerned.  A few recent blogs include:
PLoS Pathogens: Three Mutations Switch H7N9 To Human-type Receptor Specificity

EID Journal: 2 Expedited HPAI H7N9 Studies

Eurosurveillance: Preliminary Epidemiology & Analysis Of Jiangsu's 5th H7N9 Wave

The saving grace to all of this, so far at least, is that the H7N9 virus still doesn't transmit efficiently between humans. Clusters remain rare, and very few human-to-human transmissions have been observed.

Roughly once a month the World Health Organization releases an updated Influenza at the human-animal interface report that details novel human flu infections reported since the last update and provides a risk assessment.
Today's report - covering the 30 days between May 17th and June 15th - adds 47 H7N9 cases. No other avian or novel flu infections were reported during this time period.
Some excerpts from the 5-page PDF report follow, after which I'll return with a bit more.
Influenza at the human-animal interface
 

Summary and assessment, 17 May 2017 to 15 June 2017
  • New infections1: Since the previous update, new human infections with influenza A(H7N9) viruses were reported.
  •  Risk assessment: The overall public health risk from currently known influenza viruses at the human-animal interface has not changed, and the likelihood of sustained human-to-human transmission of these viruses remains low. Further human infections with viruses of animal origin are expected.
  • IHR compliance: All human infections caused by a new influenza subtype are required to be reported under the International Health Regulations (IHR, 2005).2 This includes any animal and non-circulating seasonal influenza viruses. Information from these notifications is critical to inform risk assessments for influenza at the human-animal interface.
(SNIP)

Avian influenza A(H7N9) viruses

 
Current situation: During this reporting period, 47 laboratory-confirmed human cases of influenza A(H7N9) virus infection were reported to WHO from China. Among these cases, one cluster of cases were reported; both cases in the cluster had exposure to live poultry. Cases were reported from Shaanxi province for the first time and cases had likely exposure in Inner Mongolia for the first time as well.
1 For epidemiological and virological features of human infections with animal influenza viruses not reported in this assessment, see the yearly report on human cases of influenza at the human-animal interface published in the Weekly Epidemiological Record. Available at: www.who.int/wer/en/
2 World Health Organization. Case definitions for the four diseases requiring notification in all
circumstances under the International Health Regulations (2005). Available at: www.who.int/ihr/Case_Definitions.pdf 3 WHO Cumulative number of confirmed human cases of avian influenza A(H5N1) reported to WHO tables. Available at: www.who.int/influenza/human_animal_interface/H5N1_cumulative_table_archives/en/


Case and cluster details are presented in the table in the Annex of this document. For additional details on these cases, public health interventions, and the highly pathogenic avian influenza (HPAI) A(H7N9) viruses, see the Disease Outbreak News.


As of 15 June 2017, a total of 1533 laboratory-confirmed cases of human infection with avian influenza A(H7N9) viruses, including at least 592 deaths4, have been reported to WHO (Figure 1). The number of human infections with avian influenza A(H7N9) viruses and the geographical distribution of human cases in the fifth epidemic wave (i.e. onset since 1 October 2016) is greater than in any earlier wave.
This suggests that the virus is spreading, and emphasizes that further intensive surveillance and control measures in both the human and animal health sectors are crucial. However, the number of reported confirmed cases has continued to decline over the past few weeks indicating that the peak of cases this wave was reached in mid-February 2017.

According to reports received by the Food and Agriculture Organization (FAO) on surveillance activities for avian influenza A(H7N9) viruses in China, positives among virological samples continue to be detected in poultry from live bird markets, commercial and backyard farms. The agricultural authorities in China have also announced plans to commence vaccination of domestic poultry in certain areas against infection with avian influenza A(H7) viruses beginning in July.5


(Continue . . . .)
 
Although eerily quiet now, just a year or two ago the  WHO considered H5 viruses the most obvious pandemic threat, particularly after Egypt's record setting H5N1 outbreak in the spring of 2015 and the emergence and global spread of H5N8, the reports of a new virus - H5N6 - infecting people and poultry in China. 
Like H7N9, those viruses continue to spread and evolve, and while reported human infections have been few and far between over the past year, they could easily stage a comeback just as H7N9 has over the past 8 months. 
H7N9 is viewed, rightfully so, as having the greatest pandemic potential right now (see Updated CDC Assessment On Avian H7N9 and NPR: A Pessimistic Guan Yi On H7N9's Evolution).
But influenza posesses remarkable evolutionary speed - where generations are measured in minutes or hours, not years or decades - and abrupt changes can occur literally overnight via viral reassortment.
Which means that we could just as easily be blindsided by a different mutated bird flu subtype, one of the many H1, H2, or H3 swine flu viruses in ciruculation around the globe, or something else that isn't even on our radar right now.

Despite the strides that have been made in the identification and understanding of novel flu viruses, less than a month ago in World Bank: World Ill-Prepared For A Pandemic, that organization warned that far too many nations have let pandemic preparedness slide, and that the world remains ill-prepared to face even a moderately severe pandemic.

Friday, June 23, 2017

A Dearth Of Recent Reports From The Saudi MOH

Screen Shot of MOH Today - 9:45 am EST


 
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The screenshot above - taken at 0945 EST today - shows that after reporting 50+ cases in the 1st 18 days of June - the Saudi MOH hasn't updated their MERS surveillance page in several days.  

For some reason, they posted 2 updates for the 19th - and while the links state no new cases, the first report for that date lists 1 asymptomatic case in Riyadh.  The last report, dated the 19th, appears to be from the 20th, and lists 2 recoveries.

Since then, we've seen no new updates.  
With this being the last week of Ramadan, it is possible the MOH is working short staffed.  Hopefully after tomorrow (the end of Ramadan), the MOH will catch us up, and resume regular daily reporting.