Monday, February 20, 2017

Saudi MOH Announces 3 New MERS Cases


Although this year's numbers remain low, it is worth remembering that MERS-CoV - which emerged on the scene less than a year before H7N9 - not only has produced hundreds more human infections, but has a well documented history of producing large (mostly nosocomial) clusters of cases. 
Today KSA is reporting three new cases, two of which are `primary' with no known exposure, while the third reportedly had camel contact.

While neither virus appears ready for prime time, both continue to jump from animal hosts (camels for MERS, birds for H7N9) into the community, both continue to evolve, and both are regarded as having pandemic potential.

WHO H7N9 Update - China


Just over three months ago (Nov 17th) the WHO reported that `A total of 800 laboratory-confirmed human cases with avian influenza A (H7N9) virus infection have been reported through IHR notification since early 2013.'
Today's WHO report shows that number has jumped by over 50%, with 422 new cases reported since November.  A number which continues to rise daily.

While the vast majority of cases appear linked to poultry exposure, and we've seen very little evidence of clusters or human-to-human transmission, there is no denying this year's epidemic is more worrisome than years past. 

Today's update - which is current through February 14th - provides us with a brief summation of cases, some details on two two-person clusters, and a risk assessment which finds still that `this virus has not acquired the ability of sustained transmission among humans.'

While it does not directly address the recently announced HPAI virus variants from Guangdong Province,  they do state `Close observation of the epidemiological situation and further characterization of the most recent human viruses are critical to assess associated risk and to adjust risk management measures timely.

Human infection with avian influenza A(H7N9) virus – China
Disease outbreak news
20 February 2017 

Between 19 January and 14 February 2017, a total of 304 additional laboratory-confirmed cases of human infection have been reported to WHO from mainland China though the China National IHR focal point. 

On 19 January 2017, the National Health and Family Planning Commission of China (NHFPC) notified WHO of 111 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus. On 24 January 2017, the NHFPC notified WHO of 31 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus. On 30 January 2017, the NHFPC notified WHO of 41 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus. On 7 February 2017, the NHFPC notified WHO of 52 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus. On 14 February 2017, the NHFPC notified WHO of 69 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus.
Details of the cases
Between 19 January and 14 February 2017, the NHFPC reported a total of 304 human cases of infection with avian influenza A(H7N9). Onset dates range from 13 December 2016 to 9 February 2017. Of these 304 cases, 86 are female (28%). Cases range in age from 3 to 85 years, with a median age of 58 years. The cases are reported from Jiangsu (67), Zhejiang (53), Guangdong (32), Anhui (31), Jiangxi (27), Hunan (26), Fujian (20), Hubei (20), Sichuan (6), Guizhou (4), Henan (4), Shandong (4), Shanghai (3), Liaoning (2), Yunnan (2), Beijing (1), Hebei (1), and Guangxi (1). 

At the time of notification, there were 36 deaths, two cases had mild symptoms and 82 cases were diagnosed as either pneumonia (34) or severe pneumonia (48). The clinical presentations of the other 184 cases are not available at this time. 144 cases reported exposure to poultry or live poultry market, 11 cases have no clear exposure to poultry or poultry-related environments. 149 cases are under investigation. 

Two clusters of two-person were reported:
  • A 22-year-old female (mother of 3-year-old girl case who had symptom onset on 29 January 2017, died on 7 February 2017) reported from Yunnan province. She had developed symptom on 4 February 2017. She took care of her daughter during her daughter was sick. Both are reported to expose to poultry in Jiangxi province.
  • A 45-year-old female (previously reported on 9 January) from Sihui city, Guangdong province. She had symptom onset on 17 December 2016, and died on 24 December 2016. She was exposed to poultry. Another case was a 43-year-old female from Guangzhou city, Guangdong province. She had symptom onset on 30 December 2016 and was admitted to hospital on the same day. She is the sister of the 45-year old female described above. She took care of her hospitalized sister but also had exposure to poultry. At the time of reporting, she was suffering from pneumonia.
While common exposure to poultry is likely, human to human transmission cannot be ruled out.
To date, a total of 1222 laboratory-confirmed human infections with avian influenza A(H7N9) virus have been reported through IHR notification since early 2013.
          Public health response
Considering the increase in the number of human infections with avian influenza A(H7N9) since December 2016, the Chinese government has enhanced measures such as:
  • Strengthened early diagnosis and early treatment, treatment of severe cases to reduce occurrence of severe cases and deaths.
  • Convened meetings to further deploy prevention and control measures.
  • Conducted public risk communication and sharing information with the public.
  • The NHFPC strengthened epidemic surveillance, conducted timely risk assessment and analysed the information for any changes in epidemiology.
  • The NHFPC requested local NHFPCs to implement effective control measures on the source of outbreaks and to minimize the number of affected people.
  • The NHFPC, joined by other departments such as agriculture, industry and commerce, Food and Drug Administration, re-visited Jiangsu, Zhejiang, Anhui and Guangdong provinces where more cases occurred for joint supervision. The affected provinces have also strengthened multisectoral supervision, inspection and guidance on local surveillance, medical treatment, prevention and control and promoted control measures with a focus on live poultry market management control.
  • Relevant prefectures in Jiangsu province have closed live poultry markets in late December 2016 and Zhejiang, Guangdong and Anhui provinces have strengthened live poultry market regulations.
WHO risk assessment
While similar sudden increases in the number of human avian influenza A(H7N9) cases identified have been reported in previous years the number of cases reported during this season is exceeding previous seasons. The number of human cases with onset from 1 October 2016 accounts for nearly one-third of all the human cases of avian influenza A(H7N9) virus infection reported since 2013. 

However, human infections with the avian influenza A(H7N9) virus remain unusual. Close observation of the epidemiological situation and further characterization of the most recent human viruses are critical to assess associated risk and to adjust risk management measures timely. 

Most human cases are exposed to avian influenza A(H7N9) virus through contact with infected poultry or contaminated environments, including live poultry markets. Since the virus continues to be detected in animals and environments, and live poultry vending continues, further human cases can be expected. Additional sporadic human cases may be also expected in previously unaffected provinces as it is likely that this virus circulates in poultry of other areas of China without being detected. 

Although small clusters of human cases with avian influenza A(H7N9) virus have been reported including those involving healthcare workers, current epidemiological and virological evidence suggests that this virus has not acquired the ability of sustained transmission among humans. Therefore the likelihood of further community level spread is considered low.

WHO advice
WHO advises that travellers to countries with known outbreaks of avian influenza should avoid, if possible, poultry farms, contact with animals in live bird markets, entering areas where poultry may be slaughtered, or contact with any surfaces that appear to be contaminated with faeces from poultry or other animals. Travellers should also wash their hands often with soap and water, and follow good food safety and good food hygiene practices.

WHO does not advise special screening at points of entry with regard to this event, nor does it currently recommend any travel or trade restrictions. As always, a diagnosis of infection with an avian influenza virus should be considered in individuals who develop severe acute respiratory symptoms while travelling in or soon after returning from an area where avian influenza is a concern.
WHO encourages countries to continue strengthening influenza surveillance, including surveillance for severe acute respiratory infections (SARI) and influenza-like illness (ILI) and to carefully review any unusual patterns, ensure reporting of human infections under the IHR (2005), and continue national health preparedness actions.

HK CHP Quashes H5N6 Rumors, Takes Notice Of H7N9 Variant


Between a record number of human H7N9 cases reported on the Mainland, the recent spread of HPAI H5N6 to Korea, Japan, and Taiwan, and persistent (and unverified) rumors of  `concealed cases' circulating on social media, the residents of Hong Kong are understandably a bit on edge.

So much so that today Hong Kong's CHP issued a statement denying rumors that H5N6 patients were being treated in local hospitals.

     In response to press enquiries on rumours on human cases of avian influenza A(H5N6) and related pneumonia cases in Hong Kong, the Centre for Health Protection (CHP) of the Department of Health today (February 20) clarified that no human H5N6 cases have been identified in Hong Kong to date.
     "Globally, 16 sporadic human H5N6 cases, including 11 known deaths, have been reported so far since the emergence of H5N6 in 2014 and all were in the Mainland. While most patients visited wet markets or had contact with live poultry, there is no evidence of human-to-human transmission among their close contacts. Standard precautions against avian influenza, such as strict personal, hand, food and environmental hygiene, are key to preventing H5N6 infections," a spokesman for the CHP said.
     "All novel influenza A infections, including H5N6, are statutorily notifiable infectious diseases in Hong Kong. Doctors and hospitals are reminded that any patient with acute respiratory illness or pneumonia, or at-risk exposure (including poultry workers and those with a history of visiting markets with live poultry or contact with poultry) in affected areas in the incubation period (10 days before onset), must be managed as suspected cases and immediately reported to the CHP for prompt epidemiological and laboratory investigations, disease control and transparent announcement," the spokesman said.
     "We will continue to remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments," the spokesman added.
Ends/Monday, February 20, 2017

Hong Kong did report Environmental Samples Positive For H5N6 among  bird droppings collected late last November in the Mai Po marsh.  But so far - despite its appearance in Vietnam, Laos, South Korea, Japan, Taiwan, and Hong Kong - we've only seen human infections reported from Mainland China.

The CHP also published the following announcement, which indicates the four imported cases they've seen this year did not have the recently divulged HPAI mutation (see Taiwan CDC: January's Imported H7N9 Case Carried HPAI Mutation).

     The Centre for Health Protection (CHP) of the Department of Health is today (February 20) closely monitoring three additional human cases of avian influenza A(H7N9), including one death, in Guizhou, Guangxi and Shandong, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

     According to the Health and Family Planning Commission (HFPC) of Guizhou Province, a patient aged 45 in Qiandongnan is under management. The Guangxi Zhuang Autonomous Region HFPC reported that a female patient aged 41 in Nanning has died, and she had been involved in selling live poultry in market before onset. In addition, the HFPC of Shandong Province reported on a female patient aged 48 in Qingdao.

     "We noted the Guangdong Provincial Center for Disease Control and Prevention reporting differences in H7N9 viruses isolated from human cases. While we will closely monitor the virus activity, genetic analysis reveals that H7N9 viruses from human cases in Hong Kong have had no significant changes so far, nor has there been evidence of resistance to oseltamivir (Tamiflu). We will continue to liaise and share gene sequences with other health authorities by established arrangements," a spokesman for the CHP said.

     There is a likely risk that environments with live poultry in the Mainland might be contaminated with avian influenza viruses. Travellers to the Mainland or other affected areas must avoid visiting wet markets, poultry markets or farms. They should be alert to the presence of backyard poultry when visiting relatives and friends. They should also avoid purchase of live or freshly slaughtered poultry, and avoid touching poultry/birds or their droppings. They should strictly observe personal and hand hygiene when visiting any place with live poultry.

     Travellers returning from affected areas should consult a doctor promptly if symptoms develop, and inform the doctor of their travel history for prompt diagnosis and treatment. It is essential to tell the doctor if they have seen any live poultry during travel, which may imply possible exposure to contaminated environments. This will enable the doctor to assess the possibility of avian influenza and arrange necessary investigations and appropriate treatment in a timely manner.

Ends/Monday, February 20, 2017

Issued at HKT 17:00

Taiwan CDC: January's Imported H7N9 Case Carried HPAI Mutation

Taiwan in relation to China


While its ultimate impact and importance are far from certain, the `big' avian flu story over the weekend was the announcement from Guangdong Province's CDC of  Two H7N9 `Variants' Isolated From Human Cases.  Also detected in local poultry, these variant viruses appear to have acquired the HA genetic markers that change them from low path (LPAI) to high (HPAI) in birds. 

Unlike all of the other avian flu viruses we are following, H7N9 is the only LPAI virus (essentially benign in birds) that can cause serious - even fatal - illness in humans. 

Today Taiwan's CDC is announcing that their 5th imported H7N9 case from late January (see Taiwan CDC Announces An Imported H7N9 Case)- who remains hospitalized in critical condition - carried a virus with similar changes to its HA gene.  A case they described as `. . . . a 69-year-old man with a history of contact in Yangjiang, Guangdong Province, China, with no bird or suspected history of illness.'

Additionally, Taiwan reports his infection shows signs of antiviral resistance (Tamiflu (c) & Relenza (c)), although this may have been the result of a `spontaneous' mutation in the patient while undergoing treatment.

So far, these reported changes to the HA gene only appear to affect its pathogenicity in birds, and we've seen no indication that it increases the risk to humans.   The caveat being, information is often slow to come out of China and it is impossible to predict where this variant's evolutionary path will ultimately take it. 

Meanwhile, this third human case from Guangdong Province suggests this new variant may be biologically `fit' enough to have some `legs'.  Epidemiologists are no doubt scrambling to determine the size and scope of its spread.

Mutations occur constantly in flu viruses, but only rarely do they convey a significant evolutionary advantage. Most are neutral, or even detrimental to the virus's survival. While it is too soon to predict how this one will impact H7N9's course, no one is taking it lightly.

This (translated) announcement from Taiwan's CDC.

UNDCP continues to monitor the international H7N9 flu epidemic and virus epidemics, the people to the Chinese mainland should be vigilant, not near birds and personal hygiene protection measures

The Illness Control Agency on February 13 from February 4 this year, the first confirmed H7N9 outside the case moved to the case of the successful separation of the virus, and on February 15 to complete the whole gene sequence analysis, the relevant sequence message was on February 16 to provide farmers The committee was regularly distributed to the global GISAID website to share with the world, and today the meeting was confirmed by the Expert Advisory Committee on Influenza Advisory Committee.
The results showed that the H7N9 influenza virus was isolated from the case, and its erythrocyte lectin (HA) and neuraminidase (NA) protein gene were similar to H7N9 influenza virus isolated from China. Other internal protein gene combinations Compared with the current virus is slightly different, may be a new genotype, the birds with high pathogenicity, but no enhancement of birds or human transmission ability of the mutation.

The Agency has said that the addition of three basic amino acids to the H7N9 virus isolated from the case of the HA protein cleavage may improve its pathogenicity in poultry. In addition, further gene sequence analysis showed that the NA protein of the virus has a mutation, anti-viral agents such as influenza and Ruileansa drug resistance, experts speculate that the treatment process may be selected from the drug resistance virus. 

The Department of Health (DH) immediately informed the care team as a treatment reference when the virus resistance was detected on February 15, and the current case is still in serious hospitalization. UNDCP and COA will keep abreast of trends in the international human and bird H7N9 virus epidemic strains, strengthen immediate epidemic surveillance and virus surveillance, and today announced the update of the new clinical guidelines for influenza A influenza A to ensure that people health.

In the near future, the first case of domestic H7N9 outside the case into the case of epidemic prevention and other concerns, the Commission reiterated that the case on January 25 entry to Taiwan, the first time that is due to fever by the airport quarantine officers to seize and open medical advice orders recommended medical treatment , The case on the same day medical treatment and the next day to a medical center when the doctor suspected H7N9 flu mild, and immediately informed the seizure, indicating that the quarantine station or physician have a high degree of vigilance and good monitoring responsibility, no delay notification or misdiagnosis situation. In addition, the health unit is also active in daily understanding of the case; the other case after the diagnosis, that is, all relevant contacts to investigate and book, for close contacts are given appropriate health education and open independent health notice. The total number of contacts related to a total of 141 people, were on February 13 to lift the tube.

According to the World Health Organization in April 2013 issued by the epidemic news ( content, the first batch of Chinese mainland H7N9 cases in Shanghai 2 cases, 1 case of Anhui, 3 people between the onset time Between 19 February and 15 March 2013, all cases developed severe pneumonia. These cases until March 29 to obtain the Chinese Center for Disease Control and Prevention laboratory confirmed H7N9 flu, from the onset to the diagnosis of up to 13 to 38 days. It is not true that the World H7N9 first appeared in Shanghai, where the local medical institutions confirmed and completed the virus.

China has accumulated 426 cases of H7N9 flu cases since the beginning of this season (October 1, 2016), has exceeded the calendar year, the number of cases in Jiangsu Province, 124 cases, 75 cases of Zhejiang Province, Guangdong Province, 47 cases and 45 cases of Anhui Province Many cases of poultry, live poultry market exposure history, to more than 50 years of age groups. Global cumulative since 2013, 1,224 cases, the World Health Organization (WHO) update as of January 16 this year, cumulative 359 deaths.

At present, China is still at the peak of H7N9 flu, people need to go to be vigilant, and should comply with the "5 to 6 no" principle, "5 to": poultry and eggs to cooked food, to wash the bottom of soap, To wear a mask for medical treatment and to inform the occupation and contact history, long-term contact with birds to be vaccinated against influenza, to a balanced diet and appropriate exercise; "6 no": not raw poultry eggs or products, not smuggling and purchase Unknown birds and birds, do not touch or feed migratory birds and birds, do not wild and free to abandon the birds, not to keep birds and other livestock mixed, not to the air is not in circulation or crowded places.

Sunday, February 19, 2017

KSA Announces 2 MERS Cases


Although they can happen anytime during they year, during late winter and spring we tend to see an uptick in  MERS cases with camel exposure.   It has been theorized that young camels - usually born early in the year - are immunologically naive, and are therefore more likely to  acquire the virus and transmit it to humans.

Theory or not, of the 10 cases reported by by Saudi Arabia during this month of February, 7 are listed as `Primary (Camel Contact)', including 2 cases announced today.

Guangdong CDC: Two H7N9 `Variants' Isolated From Human Cases

Credit NIAID


Throughout its relatively short (4 year) reign, we've watched H7N9's evolution closely for signs that it might be evolving into a more dangerous pathogen.  During that time we've seen its genetic diversity grow rapidly through continual reassortment with other avian viruses (particularly H9N2), antigenic drift, and its passage through a variety of host species.
A process dubbed `genetic tuning’ by the authors of a paper that appeared in Eurosurveillance back in 2014 (see Genetic Tuning Of Avian H7N9 During Interspecies Transmission).

With this diversity we've also seen some subtle (sometimes regional) changes in H7N9's behavior, something which was the topic of last December's  MMWR: Assessing The 4th Epidemic Wave Of H7N9 In China, where researchers warned of `the continued geographic spread, identification of novel reassortant viruses, and pandemic potential of the virus' - stating that `using the Influenza Risk Assessment Tool (10), CDC found that A(H7N9) virus has the highest potential pandemic risk of any novel influenza A viruses that have been assessed.' 
But the two constants with H7N9 until now have been its low pathogenicity in birds and its lack of sustained transmission in humans.
Today we've a brief announcement from Guangdong's CDC that two virus samples collected from human hosts last month suggest one of those constants may be changing; its pathogenicity in birds.

While the ultimate significance and impact of this discovery remains unclear, this is another sign that the H7N9 virus continues to evolve in unexpected ways.  First the (translated) announcement, then I'll be back with a bit more.

H7N9 virus mutant was found in human cases from China

Release Date: 2017-02-19 Views: Contributed by: Information Department of Publicity: Office Font: Big Middle Small

In January 2017, Guangdong Provincial Center for Disease Control and Disease on the two cases of human infection H7N9 cases were isolated virus gene sequencing analysis, found in the two strains of hemagglutinin link peptide position of the gene insertion mutation occurred, the test results Has been confirmed by the National Center for Viral Disease National Influenza Center.

I center experts to judge and communicate with the relevant experts in the agricultural sector that H7N9 virus in the hemagglutinin link peptide position of the gene insertion mutation, suggesting that the virus mutation to the highly pathogenic virus against birds; the second is based on the virus Sequence analysis results have not yet appeared in the mutant virus that has increased resistance to human infectivity, virulence and interpersonal communication.

Two cases of disease before the incidence of bird exposure history, and in the exposure of poultry birds have occurred in the phenomenon of death. At present, a case has been cured, another case is still in treatment. All the 105 cases of close contact after two weeks of medical observation, were not fever, cough and other symptoms.

H7N9 virus is a influenza virus, one of its main features is prone to gene reassignment and mutation. Some mutations may lead to the virus on the human appeal, virulence and interpersonal communication ability enhancement, so the virus variation has been widely concerned about the domestic and foreign.

It is understood that the agricultural sector laboratory also from Guangdong, four poultry specimens found similar to the variation of the virus. China's health care system will work together with the agricultural sector, the common source of the virus, the scope of the impact of in-depth study, and continue to strengthen the monitoring of H7N9 virus, in time to find any possible variation.

The results have been communicated to the World Health Organization.

China Center for Disease Control and Prevention
Although capable of causing serious (even fatal) illness in humans, H7N9 has - at least until now - been strictly an LPAI (Low Pathogenic Avian Influenza) virus in birds. As such, it has been very difficult to identify and contain in domesticated or wild bird populations.
A change to an HPAI virus might make identification in poultry flocks easier  (potentially a good thing) - but could also serve as an evolutionary `bridge' to other changes; changes that might negatively  impact how it behaves in mammalian hosts. 
Admittedly, I've employed a lot of `weasel words' here, since we simply don't know where this new fork in H7N9's evolutionary road will lead. The fact that it has been detected in both humans and poultry in Guangdong Province, however, suggests it isn't just some `spontaneous' dead end mutation. 
But until we learn more we won't know how biologically `fit' these variants really are. 

Interestingly, on Friday Science Magazine ran a story (see Bird flu strain taking a toll on humans) with an interview with renown virologist Dr. Guan Yi from the University of Hong Kong, which seems to have telegraphed this discovery. 
"It is too late to contain the virus in poultry," Guan says. He predicts that the virus will continue to spread in China's farms, possibly evolving into a strain that would be pathogenic for poultry. Authorities have culled more than 175,000 birds this winter to stamp out local outbreaks of H7N9 and other avian flu strains. Further spread of H7N9 "will naturally increase human infection cases," Guan says. 
While today's announcement doesn't necessarily move H7N9 closer to becoming a pandemic strain, it is a reminder how labile and unpredictable influenza viruses can be. 

Stay tuned.