Tuesday, October 17, 2017

Seychelles MOH Update On Plague - Oct 17th


While the most recent reports from Madagascar (see MOH: Confirmed & Suspected Plague Now Exceeds 800 Cases) continues to show their pneumonic plague epidemic to be out of control, the news from the Seychelles is far more positive with only their imported index case presumed positive for plague.
Although test results on some of his contacts are still awaited, all have received prophylactic antibiotics and remain asymptomatic.
 This was posted on the Seychelles MOH Facebook page about an hour ago.
Press Release: Update on Plague Alert

The Plague outbreak in Madagascar continues and remains uncontrolled. According to the latest report, currently, the epidemic is now circulating in 38 of the 114 districts of Madagascar. Antananarivo is the most affected city/district. By yesterday, (16th Oct 2017), 805 cases have been reported (595 pneumonic and 210 bubonic). There has been 74 deaths (9.2% of notified cases) 

Training in contact tracing was conducted today for 60 health care workers, red cross volunteers and other key partners by two WHO experts in conjunction with DSRU. 

Update of cases admitted on suspicion or for precautionary measure

A total of 12 people remain admitted in isolation in hospital.

  • The index patient (probable case) is still admitted on the hospital ward and has no symptoms and is stable. Today is the 9th day of treatment as per clinical guidelines, the patient is no longer infectious. He remains in isolation to complete his antibiotic course.
  •  The other eleven (11) patients in the hospital are stable on treatment and asymptomatic. This includes the foreign national.
Contact tracing and surveillance
  • The total number of people admitted at the Perseverance military academy for active surveillance remain 6. None of them has developed any symptoms.
  • Three (3) Seychellois nationals returned from Madagascar via Nairobi on Thursday 12th October. They remain well and are receiving prophylaxis and will go home if they remain asymtomatic.
  •  A French national who left Madagascar on 13th October via Reunion will remain in the facility until 19th of October.
  • Two (2) Australians who arrived on Friday 13th October from Mauritius after having spent time in Madagascar will remain in active surveillance for 7 days before being released on 19th October if they do not develop any symptoms.
  •  A total of 577 children and 63 teachers (640) at Anse Boileau Primary School and crèche have reached 7 days after last potential contact with the admitted child. They are also off passive surveillance as of today.
  • Laboratory samples were successfully shipped on Sunday evening and received on Monday afternoon by Pasteur institute France. We are now awaiting results.
  • Should anyone who is on prophylaxis develop fever, cough or other symptoms, they should contact their health centre, the Hotline 141, Dr Jastin Bibi on 2723739 or Dr Naomi Adeline 2711818.
  • Regional Health facilities (Beau Vallon, English River, Les Mamelles, Anse Boileau health centres and Anse Royale and Baie Ste Anne Hospitals) are being used to assess contact and provide prophylaxis.
  • The Public Health Authority (PHA) is reinforcing the advisory to discourage people from travelling to Madagascar for the time being. Anyone who has information that a Seychellois national is planning to travel to Madagascar should send a report to the Public Health authority or refer to CDCU.
  • Hotline 141 is active and people can call for information and advice.

China MOA: Outbreak Of HPAI H5N6 In Anhui Province


Reports out of China have been fairly subdued the past month or so - likely due to reduced late summer bird flu activity - but also likely due in part to an extended holiday (National Day Golden Week) held in the first week of October and to the politically sensitive closed-door sessions of the 19th CCP Congress, which is set to begin on the 18th. 
There is a strong tendency towards not `rocking the boat' during this once-every-five-years session of China's Communist Party's Congress, as many political fortunes could rise or fall over the next week or 10 days.
Today, however, China's MOH is reporting an outbreak of HPAI H5N6 at a poultry farm in Anhui Province.

Ma'anshan City, Anhui Province and County in poultry with H5N6 subtype highly pathogenic bird flu

Issued by: Ministry of Agriculture press office Date: 2017-10-17 16:42 Keywords: bird flu; epidemic; Anhui

  Ministry of Agriculture press office issued October 17, Ma'anshan City, Anhui Province and County in poultry with H5N6 subtype highly pathogenic bird flu.

  October 11, Ma'anshan City, Anhui Province and County, some farmers raise chickens suspected bird flu symptoms appear, the incidence of 28,650, 15,066 died. October 13, animal disease prevention and control center in Anhui diagnosed as suspected bird flu. October 17, by the National Avian Influenza Reference Laboratory confirmed the outbreaks as H5N6 subtype highly pathogenic bird flu.

  After the outbreak, according to the relevant local prevention plans and technical specifications, adhere to the prevention and control law, science and prevention and control, really good job epidemic disposal, have been culling and safe disposal 30 196 poultry. Currently, the outbreaks has been effectively controlled.

The last big outbreak of H5N6 in China was announced 2 months ago (see China MOA Confirms H5N6 Outbreak In Quail - Guizhou Province).

Study: Experimental Infection Of Dogs With HPAI H5N1 & HPAI H5N6


When it comes to the spread and evolution of influenza A viruses -  birds, pigs, and humans top our list of primary hosts - but over the years we've also looked at a growing list of other (presumably less important) players in the flu world.
That Touch Of Mink Flu (H9N2 Edition)
Taking HPAI To The Bank (Vole)
Report: Skunks and Rabbits Can Catch And Shed Avian Flu
SwAM: European Seal Deaths Continue From H10N7 Flu
While the opportunities for a bank vole or a seal to transmit avian influenza to humans are admittedly limited, the same cannot be said for companion animals like dogs and cats.
Since the early 2000's it has become apparent that both canines and felines are susceptible to a variety of influenza A viruses (see HPAI H5: Catch As Cats Can), with 2015's transmission of avian H7N2 to a veterinarian in New York City and the recent arrival of a new canine H3N2 virus to North America from Asia bit of a wake up call. 
While canine H3N2 (a formerly avian virus) has not been shown to infect humans, numerous reports coming out of China and Korea suggest it may be adapting to other hosts, and that it continues to reassort with other avian and human flu viruses. Including:
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

Interspecies Transmission Of Canine H3N2 In The Laboratory

Two months ago we looked at a study (see J. Virology: Zoonotic Risk, Pathogenesis, and Transmission of Canine H3N2) where researchers created and tested canine H3N2 - pdmH1N1 reassortants, and concluded some `may pose a moderate risk to public health and that the canine host should be monitored for emerging IAVs'.
But dogs (and cats) can also be exposed to novel HPAI viruses like H5N1 and H5N6 in the wild.
In 2014 we saw multiple reports of farm dogs infected with HPAI H5N8 in South Korea (see Korea Finds More Dogs With H5N8 Antibodies) while over the summer we saw a report from the Arch. Of Virology: Novel Reassortant H5N6 Isolated From Cats - Eastern China.

In April of this year, in J. Vet. Sci.: Experimental Canine Infection With Avian H5N8, we saw a study published in the Korean Journal of Veterinary Science, where researchers inoculated dogs with the 2014 Korean strain of HPAI H5N8, in order to document its pathogenicity and ability to be transmitted to other dogs. 
While producing only mild illness in these experimental animals, 2 of 4 that were inoculated shed small quantities of the virus and seroconverted, and at least one contact dog became infected. The authors wrote that these dogs appeared only weakly infected and the virus didn't appear fully adapted to a canine host.
All of which brings us to a new study, published this past week in Transboundary and Emerging Diseases, where researchers experimentally infected dogs with two different clades of HPAI H5N1 (1.1.2  & and clade H5N6.

While the bulk of the study is behind a paywall, we get the highlights from the abstract below:

Experimental infection of clade 1.1.2 (H5N1), clade (H5N1) and clade (H5N6) highly pathogenic avian influenza viruses in dogs.


Since the emergence of highly pathogenic avian influenza (HPAI) H5N1 in Asia, the haemagglutinin (HA) gene of this virus lineage has continued to evolve in avian populations, and H5N1 lineage viruses now circulate concurrently worldwide. 

Dogs may act as an intermediate host, increasing the potential for zoonotic transmission of influenza viruses. Virus transmission and pathologic changes in HPAI clade 1.1.2 (H5N1)-, (H5N1)- and (H5N6)-infected dogs were investigated. 

Mild respiratory signs and antibody response were shown in dogs intranasally infected with the viruses. Lung histopathology showed lesions that were associated with moderate interstitial pneumonia in the infected dogs. In this study, HPAI H5N6 virus replication in dogs was demonstrated for the first time. 

Dogs have been suspected as a "mixing vessel" for reassortments between avian and human influenza viruses to occur. The replication of these three subtypes of the H5 lineage of HPAI viruses in dogs suggests that dogs could serve as intermediate hosts for avian-human influenza virus reassortment if they are also co-infected with human influenza viruses.

The idea that dogs could be a `mixing vessel - producing a hybrid human-avian (or human-swine) reassorted virus - is something we've looked at before (see Study: Dogs As Potential `Mixing Vessels’ For Influenza). 
While perhaps not the most likely host for viral reassortment -  is is certainly plausible. 
With H5N6's breakout performance in Asia last year, and the huge strides H5N8 has made in the past year (see ECDC/EFSA Joint Report: Avian Influenza Overview Oct 2016–Aug 2017) the potential threat that these viruses pose to non-avian species cannot be ignored (see J. Virulence Editorial: HPAI H5N8 - Should We Be Worried?).

It is worth noting that - while currently quantified as a relatively low-risk virus -  over the summer the CDC added Canine H3N2 to their IRAT (Influenza Risk Assessment Tool) listing of novel flu subtypes/strains that circulate in non-human hosts and are believed to possess some degree of pandemic potential. Their evaluation reads:
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).

Monday, October 16, 2017

Madagascar MOH: Confirmed & Suspected Plague Now Exceeds 800 Cases


We've the first update from Madagascar's Ministry of Health since the 14th, posted on the BRGNC Madagascar website. The number of cases continues to increase, adding 195 cases and 11 deaths since Saturday's report.
The percentage of cases presenting as pneumonic plague - which can be transmitted as a respiratory infection - continues to run very high, at nearly 74%.  Normally Bubonic plague - which is transmitted by flea bites - makes up over 80% of cases.
I've only translated and posted portions of today's update, so follow the link to read it in its entirety.


 Group Date Time: 16 Oct. 2017 - 20:00
The plague epidemic is currently affecting 38 districts, 17 Regions of Madagascar.

Generally, 805 cases of plague were notified, 595 of which were pulmonary and 210 bubonic forms.
The report shows 74 deaths, with a national case fatality rate of 9.2% (the number of deaths with the total number of reported cases).

Among these notified cases:

- 62 are confirmed according to the results of the Pasteur Institute of Madagascar (IPM);
- 367 are probable according to the rapid diagnostic test (TDR);
- 377 are suspect cases.

(Source: Ministry of Public Health - 16 October 2017)

The following figure shows the distribution of the plague situation (by District) recorded until now.

- To reduce the risk of the spread of the plague epidemic, 13 out of 38 Affected districts have started to implement the sanitary control at the and at the exit of the city. It should be noted that the road axis is part of a favorable to the transmission of plague of pulmonary forms. The BNGRC, through appeals with the local authorities of the Districts affected, reinforces its recommendation to make this system more operational. A supply in personal protective equipment (PPE) is very necessary for a better implementation of this device.
- The Ministry of Public Health has increased awareness, disinfection, disinsectisation and border controls (remote flash thermometer) of affected districts in the Vatovavy Fitovinany, Boeny, Atsinanana, Analamanga, Itasy, Bongolava, Betsiboka, Atsimo Andrefana, Alaotra Mangoro and Sava.
- The Ministry of Tourism continues, today, the sensitization of the hotels in the Region of Analamanga and also supports the cities of Ambatondrazaka and Moramanga in terms of sanitation activity.
- The Ministry of Public Health and the WHO are preparing the equipment and specialized equipment at the level of 38 Districts for the benefit of managers and health personnel at the local level.
- WHO:
- supports the DVSSE (Directorate of Health Surveillance and Monitoring Epidemiology) in the management of epidemic and follow-up data of contacts. A total of 2,838 contacts out of 93 cases of pulmonary recorded in the Regions of Analamanga, Atsinanana and Upper Matsiatra.
- has just concluded a partnership agreement with the Malagasy Red Crossfor the implementation of activities related to dignified burials andin regions affected by the epidemic.
- 4 Plague Treatment Centers (CTP) are already operational, of which 3 inthe city of Antananarivo and 1 in Toamasina. These TCOs are supported by WHO,UNICEF, Médecins du Monde, ACF and Médecins sans frontières of Belgium.

Nigerian CDC Update On Monkeypox


For nearly a week we've seen little or no official word from their CDC on the suspected Monkeypox outbreak in Nigeria (see last Monday's Nigerian CDC Activates Emergency Operation Centre As Suspected Monkeypox Cases Rise), although social media (and some local news sources) have been filled with increasingly hyperbolic and lurid reports, along with wild conspiracy theories.
Today, however, we have an official update from the Nigerian CDC which confirms 3 cases from Bayelsa State - while announcing negative results for 12 other cases
They concluded - based on these tests - that `the most likely source of infection is a primary zoonotic transmission, from an animal, with secondary person-to-person transmission.
They also report `a total of 43 other SUSPECTED cases have been reported from eight other States (Akwa Ibom, Cross River, Ekiti, Lagos, Enugu, Nasarawa, Rivers, and FCT)'. Four cases from Lagos State have already tested negative, and it is expected that many of these cases will test negative as well.   
Monkeypox is rare in West Africa, and the last confirmed case in Nigeria was in 1978.  

According to the CDC:There are two distinct genetic groups (clades) of monkeypox virus—Central African and West African. West African monkeypox is associated with milder disease, fewer deaths, and limited human-to-human transmission.  
The more severe form of Monkeypox is most commonly found in the Central Africa countries of the DRC and the CAR - where outbreaks have been on the rise for years - presumably because smallpox vaccinations (which provided up to 85% protection) were halted in the late 1970s. 
As the percentage of vaccinated members of the community dwindles, the risks of outbreaks is only expected to increase (see 2010 PNAS study Major increase in human monkeypox incidence 30 years after smallpox vaccination campaigns cease in the Democratic Republic of Congo).

Here then is the Nigerian CDC's Statement in full:

Press Release: HMH Update On Monkeypox Monday, October 16, 2017

UPDATE ON MONKEYPOX - Government Confirms Three Cases

On the 22nd of September 2017, the Nigeria Centre for Disease Control (NCDC) received a report of a suspected case of Monkeypox virus disease from the Niger Delta University Teaching Hospital (NDUTH), Okolobiri, Bayelsa State. The Bayelsa State Ministry of Health initiated an outbreak investigation and response, supported by a team from NCDC, which was immediately deployed to the state.

As at 13th of October 2017, there were 17 SUSPECTED cases reported from Yenagoa LGA in Bayelsa State. We have received laboratory confirmation for Monkeypox virus from three of these cases from the WHO Regional Laboratory in Dakar, Senegal. Samples from 12 others from Bayelsa were negative, and we are awaiting two results.

With these results, the Monkeypox outbreak in Yenagoa has been confirmed with laboratory evidence. The most likely source of infection is a primary zoonotic transmission, from an animal, with secondary person-to-person transmission.

Since our initial announcement, a total of 43 other SUSPECTED cases have been reported from eight other States (Akwa Ibom, Cross River, Ekiti, Lagos, Enugu, Nasarawa, Rivers, and FCT). Of these, four cases from Lagos have also been tested and confirmed to be negative for the Monkeypox virus. We expect that many of these cases being reported from other states in Nigeria are not caused by the Monkeypox virus, but we will continue to investigate all those cases that fit the case definition.

Further laboratory tests using whole genome sequencing are being carried out by the Africa Centre for Genomics and Infectious Diseases in Redeemers University Ede, Ogun State.

Monkeypox is largely a self-limiting disease, from which all suspected patients that have been reported to date are doing well clinically. Even before this confirmation, all the necessary public health measures have been put in place and will continue to be implemented.

The Federal Ministry of Health through the Nigeria Centre for Disease Control has established an Emergency Operations Centre and will continue to co-ordinate the response across States and test samples from other cases. NCDC will also continue to support all states in their response and will keep the public informed as the situation evolves.

Measures that can be taken to prevent infection with Monkeypox virus include avoiding contact with squirrels, rats and similar animals, especially when these animals are sick or found dead in areas where the Monkeypox virus is circulating. The public is advised to always wash hands with soap and water after contact with animals or when caring for sick relatives.

Monkeypox begins with fever, headache, muscle aches, and exhaustion before the rash on face, palms and soles appears and lymph nodes swell (lymphadenopathy). The incubation period (time from infection to symptoms) for is usually 7-14 days but can range from 5-21 days.

Nigerians are advised to remain calm and supportive of public health authorities, avoid self-medication and report to the nearest health facility if feeling unwell or notice any of the above symptoms in anyone around you. It is important to note that there has been no confirmation of Monkeypox in any other part of the country, and it is likely that many of the other cases being reported are not caused by the Monkeypox virus. Nigerians should continue to be vigilant at all times.

Health care workers are strongly advised to always practice universal precautions while handling patients and/or body fluids at all times. They are also urged to be alert, be familiar with the symptoms of Monkeypox and maintain a high index of suspicion. All suspected cases should be immediately reported to the Local Government Area or State Disease Surveillance and Notification Officers.

More information on the disease can be found in the advisory note on the NCDC website: http://ncdc.gov.ng/news/106/05-october-2017-%7C-monkeypox-advisory.

However, in case of any suspected case, please call the Emergency Operations Centre on +2348148216538.

Professor Isaac F Adewole, FAS, PSPSP, FRCOG, Dsc (Hons)

Honourable Minister of Health,


ECDC/EFSA Joint Report: Avian Influenza Overview Oct 2016–Aug 2017


Last year Europe experienced their worst avian epizootic in history with the arrival of a recently reassorted HPAI H5N8 virus carried in by migratory birds from Russia and China, which resulted in the loss of millions of birds across nearly all of Europe.

According to this report, between 19 October 2016 and 31 August 2017 (based on ADNS):
  • 1,197 H5 HPAI outbreaks were reported in poultry or captive birds in 20 MSs 1,188 A(H5N8), 8 A(H5N5) and 1 A(H5N6);
  • 1,470 H5 HPAI events were reported in wild birds in 23 MSs: 1,458 A(H5N8) HPAI and 12A(H5N5);
  • 65 H5 LPAI outbreaks were reported in poultry and/or captive birds in 4 MSs, and 1 H7 LPAI outbreak was reported in poultry in France

This newly evolved H5N8 virus not only spread faster and farther than any other HPAI virus on record - it had considerably greater impact on wild and migratory birds than any previous subtype we've seen (see Avian Flu: That Was Then . . This Is Now).

Meanwhile, in Asia, HPAI H5N6 appears to be following in H5N8's footsteps, breaking out of China and turning up in South Korea, Japan, Taiwan, and the Philippines over the past 12 months - sparking concerns that it might one day turn up in Europe (or North America) as well.
And unlike H5N8, H5N6 has a track record of infecting humans.
Today, the ECDC, along with the EFSA (European Food Safety Authority) has released a 101 page report on last year's epizootic, which specifically cautions that H5N6 could become a threat to Europe at some time in the future. 
This is an extraordinarily detailed and lengthy report which looks at global avian flu activity over the past year, not just in Europe.  I've only begun to scratch the surface of this 101 page PDF file, but expect it to be a very useful reference in the months to come.
Follow the link to download the full report.

ECDC/EFSA joint report: Avian influenza overview October 2016–August 2017

surveillance report
The A(H5N8) highly pathogenic avian influenza (HPAI) epidemic occurred in 29 European countries in 2016/2017 and has been the largest ever recorded in the EU in terms of number of poultry outbreaks, geographical extent and number of dead wild birds. 

Multiple primary incursions temporally related with all major poultry sectors affected but secondary spread was most commonly associated with domestic waterfowl species. A massive effort of all the affected EU Member States (MSs) allowed a descriptive epidemiological overview of the cases in poultry, captive birds and wild birds, providing also information on measures applied at the individual MS level. 

Data on poultry population structure are required to facilitate data and risk factor analysis, hence to strengthen science-based advice to risk managers. It is suggested to promote common understanding and application of definitions related to control activities and their reporting across MSs. 

Despite a large number of human exposures to infected poultry occurred during the ongoing outbreaks, no transmission to humans has been identified.
Monitoring the avian influenza (AI) situation in other continents indicated a potential risk of long-distance spread of HPAI virus (HPAIV) A(H5N6) from Asia to wintering grounds towards Western Europe, similarly to what happened with HPAIV A(H5N8) and HPAIV A(H5N1) in previous years. 

Furthermore, the HPAI situation in Africa with A(H5N8) and A(H5N1) is rapidly evolving. Strengthening collaborations at National, EU and Global levels would allow close monitoring of the AI situation, ultimately helping to increase preparedness. No human case was reported in the EU due to AIVs subtypes A(H5N1), A(H5N6), A(H7N9) and A(H9N2). Direct transmission of these viruses to humans has only been reported in areas, mainly in Asia and Egypt, with a substantial involvement of wild bird and/or poultry populations. It is suggested to improve the collection and reporting of exposure events of people to AI.