Monday, November 20, 2017

South Korea: More H5N6/H5 In wild Birds


On the heels of yesterday's announcement (see MAFRA Confirms HPAI H5N6 At Gochang Poultry Farm) we learn of a second H5N6 detection in wild birds, and a third report from the northeastern part of the country of avian H5 in the environment.
The subtype and pathogenicity of this third report has yet to be determined. 
There are also media reports that MAFRA (Korea's Ministry of Agriculture) will be taking a hard line against poultry farmers who are negligent in their biosecurity.  
Now facing a 4th consecutive year of economically devastating avian flu outbreaks, as well as hosting the Winter Olympics next February, South Korean officials are under intense pressure to contain the crisis.
 First, an excerpt from MAFRA's second confirmed H5N6 report in Suncheon, South Jeolla.

Suncheon, South Jeolla strengthen quarantine measures in accordance with the feces of wild birds Highly Pathogenic AI detection (11.20, deployment)

Chonnam Suncheon (Suncheon) wild bird feces Highly Pathogenic AI (H5N6 type) strengthening defenses of the detection measures "Key Contents" 
◇ Agriculture, Forestry, Animal Husbandry and Food respect to the wild bird feces collected from November 13, Chonnam Suncheon (Suncheon) Ministry of environmental Research overhaul is confirmed by the final result of 11.20 days Highly pathogenic AI (H5N6 type) announced that due to measures taken to strengthen defenses "avian influenza emergency action plan." Clinical observations with respect as the H5 type antigen detection for duck farmers residing in keeping Suncheon enhanced biosecurity readiness such as 11.17 days action was "wild tide flow forecasting area" setting, movement control for poultry inspection and chicken, etc. Simple test kits and ever strengthening quarantine measures when necessary 

(Continue . . . )

This next report comes from Yangyang County.  Full test results should be available in a day or two, and while LPAI H5 is a strong possibility, local officials are taking no chances.

Yangyang, Gangwon (namdaecheon) wild birds AI H5-type virus detected in the feces
(11.20, deployment) Added 2017-11-20 21:02:00
Gangwon Yangyang (namdaecheon) Bird detection type H5 AI virus in feces - AI biosecurity measures in accordance with the emergency action plan (SOP) - Agriculture, Forestry, Animal Husbandry and Food (Minister: gimyoungrok) is a wild bird feces collected from 11.16 days Gangwon Yangyang (namdaecheon) and to inform you that with respect to the intermediate test results detected H5-type virus AI * 11.20 days in the Ministry of environmental Research, AI announced that the preventative measures taken in accordance with the emergency action plan (SOP).
Set to 'wild birds current surveillance area "** for detecting the center point of a radius 10km area was to be subjected to movement control and disinfection with respect to poultry and birds bred in the area for 21 days, as well as, poultry farms and migratory doraeji, Small Stream AI enhanced biosecurity and its municipalities for such vehicles is to mobilize the Defense wide Area bangjegi announced that total take biosecurity measures, including disinfection carried out every day. * N-type and highly pathogenic whether confirmation from about 3 to 5 takes ** Chonnam Suncheon Suncheon AI detected center point within 10km poultry breeding farms surveillance against the (about 130 farmers, shallow water 15) (clinical examination or inspection) carried

Our last stop is an English language report in the business section of today's Korea Times which describes the government's plans to go after poultry farmers who are found negligent in preventing AI outbreaks.
Gov't to penalize farms for bird flu outbreak

Posted : 2017-11-20 16:50
Updated : 2017-11-20 21:40

By Lee Hyo-sik

The government plans to penalize chicken and other poultry farms infected with avian influenza if they are found to have been negligent in preventing the outbreak of the highly infectious virus, the top agriculture policymaker said Monday.

At a press briefing in Sejong, an administrative city 130 kilometers south of Seoul, Agriculture Minister Kim Young-rok said the government will consider taking legal action against Charmfre. The local poultry breeding and processing company is accused of being responsible for the latest bird flu outbreak that hit one of its affiliated farms in Gochang, North Jeolla Province.

"The infected duck farm was saddled with outdated breeding facilities and disregarded necessary quarantine precautions," Kim said. "We will carefully consider what steps to take against Charmfre. The farm will also be held accountable for the outbreak."

(Continue . . . )

Whether taking a hard line against poultry farms hit by the virus will result in better compliance, or - as we've seen in China  - will lead to coverups and the midnight dumping of infected poultry into landfills and rivers, remains to be seen.

HK CHP Notified Of Human H5N6 Infection In Guangxi Province


While human infections with HPAI H5N6 have always been sporadic, it has been a year since the last two cases (see WHO Update On 2 Recent H5N6 Cases In China) were reported from China. Those two cases brought 2016's total to 9 cases. 
Despite seeing this avian virus turn up (in poultry and wild birds) over the past 3 years in Vietnam, Laos, South Korea, Japan, Taiwan, and the Philippines - China is the only country to have reported human infections.
The reasons behind this disparity - and the recent lull in human cases - are unknown, although we do know that there are numerous genotypes of this virus in circulation (see Cell Host Microbe: Genesis, Evolution and Prevalence of HPAI H5N6 In China) and it is likely than some of these (dozens) of variants are less well adapted to human physiology than others (see Differences In Virulence Between Closely Related H5N1 Strains).

With H5N6 just confirmed in South Korean poultry after an absence of 6 months, and the virus confirmed in wild birds collected in Japan last week, the news from Hong Kong this morning - while not unexpected - is far from welcome.

CHP notified of human case of avian influenza A(H5N6) in Guangxi

The Centre for Health Protection (CHP) of the Department of Health (DH) today (November 20) received notification of an additional human case of avian influenza A(H5N6) in Guangxi from the National Health and Family Planning Commission, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

The case involved a 33-year-old man from Guigang. He developed symptoms on November 7 and was hospitalised on November 12. He is now in a critical condition. The patient had contact with live poultry and exposure to live poultry markets before the onset of symptoms.

"Based on the seasonal pattern of avian influenza viruses, their activity in the Mainland is expected to increase in winter. The public should avoid contact with poultry, birds and their droppings and should not visit live poultry markets and farms to prevent avian influenza," a spokesman for the CHP said.

From 2014 to date, 17 human cases of avian influenza A(H5N6) have been reported by the Mainland health authorities.

"All novel influenza A infections, including H5N6, are notifiable infectious diseases in Hong Kong," the spokesman said.

Travellers to the Mainland or other affected areas must avoid visiting wet markets, live poultry markets or farms. They should be alert to the presence of backyard poultry when visiting relatives and friends. They should also avoid purchasing 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 of potential diseases. 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.

While local surveillance, prevention and control measures are in place, the CHP will remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments.

The CHP's Port Health Office conducts health surveillance measures at all boundary control points. Thermal imaging systems are in place for body temperature checks on inbound travellers. Suspected cases will be immediately referred to public hospitals for follow-up.

The display of posters and broadcasting of health messages in departure and arrival halls as health education for travellers is under way. The travel industry and other stakeholders are regularly updated on the latest information.

The public should maintain strict personal, hand, food and environmental hygiene and take heed of the advice below if handling poultry:

  • Avoid touching poultry, birds, animals or their droppings;
  • When buying live chickens, do not touch them and their droppings. Do not blow at their bottoms. Wash eggs with detergent if soiled with faecal matter and cook and consume the eggs immediately. Always wash hands thoroughly with soap and water after handling chickens and eggs;
  • Eggs should be cooked well until the white and yolk become firm. Do not eat raw eggs or dip cooked food into any sauce with raw eggs. Poultry should be cooked thoroughly. If there is pinkish juice running from the cooked poultry or the middle part of its bone is still red, the poultry should be cooked again until fully done;
  • Wash hands frequently, especially before touching the mouth, nose or eyes, before handling food or eating, and after going to the toilet, touching public installations or equipment such as escalator handrails, elevator control panels or door knobs, or when hands are dirtied by respiratory secretions after coughing or sneezing; and
  • Wear a mask if fever or respiratory symptoms develop, when going to a hospital or clinic, or while taking care of patients with fever or respiratory symptoms
The public may visit the CHP's pages for more information: the avian influenza page, the weekly Avian Influenza Report, global statistics and affected areas of avian influenza, the Facebook Page and the YouTube Channel.
Ends/Monday, November 20, 2017
Issued at HKT 18:05 
         (Continue . .. )

Like with H5N1 and H7N9, human infection with H5N6 is associated with high morbidity and mortality. Although the sampling size is small (n=18), and some details are lacking, roughly half of reported H5N6 cases have died.
Hospitalized cases - which represent the `sickest of the sick'  - are most likely to be tested and reported, which means we don't have a very good handle on how many `mild' cases might fly under the surveillance radar.
While reports of human avian flu infections out of China have been absent for the past couple of months, this is the time of year - as winter sets in - we normally expect to start seeing cases.   

Although H7N9 is expected to be the big story out of China this winter, H5N6 continues to spread and evolve, making it a virus very much worth keeping our eyes on. 


Sunday, November 19, 2017

South Korea: MAFRA Confirms HPAI H5N6 At Gochang Poultry Farm


In a follow up to yesterday's report (see South Korea: H5 Avian Flu Detected At Gochang Poultry Farm) we've seen an unexpectedly rapid turnaround on the lab results, and we now know this outbreak to be due to HPAI H5N6. 

South Korea's national alert level has been raised to its highest level (`Serious'), and a temporary 48-hour nationwide ban on the movement of poultry has been ordered. This is the first outbreak of HPAI H5N6 in South Korea since early summer.
When combined with the discovery of HPAI H5N6 in wild bird in Japan last week (see Japan MOE: 2nd H5N6 Lab Confirmation & More Dead Birds Being Tested), this is a pretty good indication that HPAI H5 is once more making its way along the East Asian migratory flyways.
First the syntax challenged (translated) statement from South Korea's Ministry of Agriculture (MAFRA), after which I'll return with a postscript.

Jeonbuk Gochang duck farms confirmed highly pathogenic AI

Added 2017-11-19 09:36:00

Jeonbuk Gochang duck farms Highly Pathogenic AI diagnosis - severe stages issued 48 hours temporarily move the stop command, simultaneous nationwide sterilization chongryeok Defense Systems operation - Agriculture, Forestry and Animal Husbandry and Food (Minister: gimyoungrok) the results test for broiler ducks Jeonbuk Gochang 11.19 (Sun) confirmed today announced that a highly pathogenic avian influenza (H5N6 type).
Whilst agri-food section was taken in the last 17 days immediately found a doctor shaft first responders preventative measures against the highly pathogenic confirmed, pursued a national biosecurity measures strengthened. 12,300 broiler ducks that are bred to be a farm that was completed quickly buy foreclosure, set the room Chronicles (10km) with its center being a farm emergency measures, such as farmers surveillance, movement control.
Agri-food section was performed at the highest level of the key preventative measures following on the basis of today's afternoon held a livestock quarantine council results depending on Highly Pathogenic occur
(1) trigger the AI ​​crisis upgraded to 'serious' step in 'Caution' alerts
(2) temporarily move the stop command for 48 hours from today midnight for all poultry workers and vehicles in the country, and the national poultry farmers and livestock-related facilities in Japan disinfection carried
(3) pan-governmental aggregate power confrontation to the main road of the entire country about all domestic fowl breeding farm and the worker of North Jeolla Province Gochang County which is a nationwide domestic fowl farmhouse and a livestock raising related infrastructure simultaneous disinfecting conduct
(4) AI occurrence area for 7 days the control guard post which is established to the main road of the mobile discontinuance
(5) occurrence area and the connection area for the AI center accident control headquarters (the general manager: Pus vice minister food) and area disaster safe Countermeasures Headquarter (general manager:

The city and province governor, market munition the ward head) the establishment government holds the urgent AI anti-epidemic measure meeting where the interagency local authority organization participates to 11.20 day morning, and the government measures and occurrence situation will announce detailed contents.

While we never really know what bird flu viruses will due each fall -  they have a habit of zigging when we expect them to zag -  there are concerns that both H5N6 in Asia, and H5N8 in Europe, will return again this fall via migratory birds (see Sci Repts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission Of HPAI H5N1).
It was just about this time last year when H5N6 showed up - for the very first time - in both Japan and South Korea, while Europe's H5N8 invasion was just ramping up. 
Both avian subtypes have had months to circulate among birds in their high latitude summer roosting areas, and so we will have to remain alert for any changes in their behavior. There are also concerns that H5N6 may follow H5N8's (and H5N1's) example, and expand beyond Asia, eventually showing up in Europe or perhaps even North America.

That said, everyone expected H5N8/H5N2 to return to North America in the fall of 2015 after the worst avian epizootic in North American history the previous spring, and so far it has failed to show.
The takeaway being, avian flu subtypes - like all influenza viruses - are extremely unpredictable.
Whatever happens in the months ahead, we should be prepared to be surprised.

Thanksgiving Is National Family History Day

Note: This is an updated version of my yearly post on National Family History Day.


Every year since 2004 the Surgeon General of the United States has declared Thanksgiving – a day when families traditionally gather together - as National Family History Day, since it provides an excellent opportunity to ask about and document the medical history of relatives.
The CDC and the HHS have a couple of web pages devoted to collecting your family history, including a web-based tool to help you collect, display, and print out your family’s health history.
Document Your Family's Health History
Surgeon General's Family Health History Initiative 
Using these online tools, you can create a basic family medical history with relative ease. For those leery of using such forms, you can simply use them as a guide for creating your own. 

But before you can do this, you’ll need to discuss each family member’s medial history. The HHS has some advice on how to prepare for that talk:
Before You Start Your Family Health History

Americans know that family history is important to health. A recent survey found that 96 percent of Americans believe that knowing their family history is important. Yet, the same survey found that only one-third of Americans have ever tried to gather and write down their family's health history.
Here are some tips to help you being to gather information:
As a former paramedic, I am keenly aware of how important it is for everyone to know their personal and family medical history.  Every day emergency room doctors are faced with patients unable to remember or relay their health history, current medications, or even drug allergies during a medical crisis. 
And that can delay both diagnosis and treatment.
During a major disaster, where the power or Internet may be down, and electronic medical records unavailable - emergency physicians may literally be working in the dark. Anything you can do to shed light on your medical history could be lifesaving. 
Which is why I always keep an EMERGENCY MEDICAL HISTORY CARD – filled out and frequently updated – in my wallet, and have urged (and have helped) others in my family to do the same.

I addressed this issue at some length in a blog called Those Who Forget Their History . . . .   A few excerpts (but follow the link to read the whole thing): 
Since you can’t always know, in advance, when you might need medical care it is important to carry with you some kind of medical history at all times. It can tell doctors important information about your history, medications, and allergies when you can’t.
Many hospitals and pharmacies provide – either free, or for a very nominal sum – folding wallet medical history forms with a plastic sleeve to protect them. Alternatively, there are templates available online.
I’ve scanned the one offered by one of our local hospitals below. It is rudimentary, but covers the basics.

I’ve highlighted several other methods of creating histories in the past, some of which you may prefer.  A few excerpts (and links) from these essays. First, I’ll show you how I created and maintain histories for my Dad (who passed away several years ago) and myself.  This was featured in an essay called A History Lesson.
Today I’m going to impart a little secret that will ingratiate yourself with your doctor and not only improve the care you receive, but also reduce the amount of time you spend in the exam room. When you go to your doctor, have a brief written history printed out for him or her

I’ve created a sample based on the one I used for my Dad (the details have been changed).   It gets updated, and goes with him, for every doctor’s visit.
And his doctors love it.

While every history will be different, there are a few `rules’.
  • First, keep it to 1 page.     Even if the patient has an `extensive history’.   If your doctor can’t scan this history, and glean the highlights, in 60 seconds or less . . . it isn’t of much use.
  • Second, paint with broad strokes.   Don’t get bogged down in details.  Lab tests and such should already be in your chart.
  • Third, always fill in a reason for your visit.   Keep it short, your doctor will probably have 10 to 15 minutes to spend with you.   Have your questions and concerns down in writing before you get there.
  • Fourth, list all Meds  (Rx and otherwise) and indicate which ones you need a refill on.   If you have a question about a med, put a `?’ next to it.   And if you have any drug allergies, Highlight them.
  • Fifth,  Make two copies!   One for your doctor to keep, and one for you.  As you talk to your doctor, make notes on the bottom (bring a pen) of your copy.  
Once you create the basic template (using any word processor), it becomes a 5 minute job to update and print two copies out for a doctor’s visit.

The history above is great for scheduled doctor’s visits, but you also should still carry a readily available EMERGENCY Medical History Card, along with any health insurance information, in your wallet or purse..

And a couple of other items, while not exactly a medical history, may merit discussion in your family as it has recently in mine.
  • First, all adults should consider having a Living Will that specifies what types of medical treatment you desire should you become incapacitated.
  • You may also wish to consider assigning someone as your Health Care Proxy, who can make decisions regarding your treatment should you be unable to do so for yourself.
  • Elderly family members with chronic health problems, or those with terminal illnesses, may even desire a home DNR (Do Not Resuscitate) Order.
Without legal documentation, verbal instructions by family members – even if the patient is in the last stages of an incurable illness – are likely to be ignored by emergency personnel.

While admittedly, not the cheeriest topic of conversation in the world, a few minutes spent during this Thanksgiving holiday putting together medical histories could spare you and your family a great deal of anguish down the road.

WHO SitRep #11: Plague In Madagascar


Although the number of `suspected, probable, and confirmed' plague cases reported from Madagascar continues to rise, the momentum of their plague epidemic continues to decline (see epi curve below) with no new laboratory confirmed infections in nearly two weeks.
That said, additional lab-confirmed cases are not only possible - they are expected - as Madagascar's plague season often runs into April. Despite the breathless, often hyperbolic coverage by the tabloids, the overall trend is encouraging. 
At least for now.

Some excepts from the latest WHO Sitrep - with numbers current through Nov15th - follow:
WHO continues to support the Ministry of Public Health and other national authorities in Madagascar to monitor and respond to the outbreak of plague. From 6 to 15 November 2017, 149 probable (12) and suspect (137) cases of plague were reported to WHO. The date of onset of the last case of bubonic plague was 29 October and the last confirmed case of pneumonic plague was reported on 6 November.

From 1 August to 15 November 2017, a cumulative total of 2 203 confirmed, probable and suspected cases of plague, including 192 deaths (case fatality rate 9%), have been reported from 56 of 114 (49%) districts in Madagascar. Analamanga Region in central Madagascar has been the most affected, with 68% of all recorded cases. Since the beginning of this outbreak, the vast majority of cases have been treated and have recovered. As of 15 November 2017, only 6 people were hospitalized for plague. There has been no international spread outside the country.

The majority of the reported cases (1 705, 77%) have been clinically classified as pneumonic plague, 321 have been classified as bubonic plague (15%), one was septicaemic, and 176 have not yet been classified (further classification of cases is in process). Eighty-one healthcare workers have had illness compatible with plague, none of whom have died.

Of the 1 705 clinical pneumonic cases, 372 (22%) have been confirmed, 599 (35%) are probable and 734 (43%) remain suspected (additional laboratory results are in process). Twenty-five isolates of Yersinia pestis have been cultured and are sensitive to all antibiotics recommended by the National Plague Control Program.

Of the 7 270 contacts identified during this outbreak, 99% (7166) have completed their 7-day follow up and a course of prophylactic antibiotics, and eleven contacts have developed symptoms compatible with plague and became suspected cases. On 15 November 2017, 31 out of 33 (94%) contacts currently under follow-up were reached and provided with prophylactic antibiotics.

Plague is endemic on the Plateaux of Madagascar, including Ankazobe District, where the current outbreak originated. A seasonal upsurge, predominantly of the bubonic form, usually occurs yearly between September and April. This year, the plague season began earlier than usual. The current outbreak is predominantly pneumonic and is affecting both endemic and non-endemic areas, including major urban centres such as Antananarivo (the capital city) and Toamasina (a port city).

         Current risk assessment
The number of new plague cases in Madagascar has steadily declined since mid-October. From 6 to 15 November 2017, 149 probable (12) and suspect (137) pneumonic cases, 18 bubonic cases and 8 unspecified cases of plague have been reported to WHO. No confirmed cases have been reported since 6 November and, to date, no cases of plague have been reported outside of Madagascar.

While the number of new cases and hospitalizations are declining, evidence suggests that the epidemic phase of the outbreak is ending. However, WHO anticipates plague cases to be reported until the endemic plague season ends in April 2018.
Based on available information and response measures implemented to date, the potential risk of further spread of plague at national level remains high. The risk of international spread is mitigated by the short incubation period of pneumonic plague, implementation of exit screening measures and advice to travellers to Madagascar, and scaling up of preparedness and operational readiness activities in neighbouring Indian Ocean islands and other southern and east African countries. The overall global risk is considered to be low.
WHO is re-evaluating the risk assessment based on the evolution of the outbreak and information from response activities.

Saturday, November 18, 2017

South Korea: H5 Avian Flu Detected At Gochang Poultry Farm


Although they raised their alert level weeks ago in anticipation of another winter's onslaught of avian flu (see last September's South Korea Ramps Up Avian Flu Quarantine Measures) so far this fall South Korea has only had to deal with multiple detections of LPAI H5 and H7 viruses in wild birds.
That lucky streak appears to be ending as this morning South Korea's MAFRA is reporting an outbreak of H5 AI (avian influenza) at an undisclosed poultry farm in Gochung County, about 300 km south east of Seoul.
The exact subtype and pathogenicity (LPAI or HPAI) won't be known until lab test results are made available next week, but quarantine and culling have already begun. The following (translated) statement comes from South Korea's Ministry of Agriculture (MAFRA).
Jeonbuk, Gochang Duck Farm [Pre-shipment inspection of slaughterhouse] Confirmation of AI medical certificate

Registration date 2017-11-18 08:35 

The Ministry of Food, Agriculture, Forestry and Livestock (Ministry of Agriculture, Forestry and Fisheries) announced on 11.18 (Saturday) that the pre-shipment inspection of the slaughterhouse duck farmhouse (rearing size: 12,300) in Gochang- AI antigen was detected. 

As a result, the local livestock pest controller has been dispatched and emergency measures have been taken by the AI ​​SOP, such as preemptive pre-emptive disposal, restriction of movement, and epidemiological investigation on the farm. * 

Whether the disease is highly pathogenic or not is expected to come on November 21st. * Physician Conversation Farm Households Current Status of Farm Households: Within 500m No poultry farmers The agriculture and commodity ministry has requested the active cooperation of the people including poultry farmers to prevent the spread of AI. Poultry farmers and wild migratory birds visited the site,

A somewhat less kludgy summary comes from this English language report in the Korea Times.
Bird flu virus detected in Gochang
Posted : 2017-11-18 16:53
The South Korean government said Saturday the avian influenza (AI) virus has been detected at a poultry farm operated by a local conglomerate located in the southern part of the country.

The Ministry of Agriculture, Food and Rural Affairs said the H5 strain of the bird flu was discovered from the farm with around 12,300 ducks in Gochang, 296 kilometers southwest of Seoul.

The government said it is currently carrying out epidemiological investigations, while slaughtering the livestock as a preventive measure.
         (Continue . . .)

South Korea, which will host the 2018 Winter Olympics Games in Pyeongchang County in less than 90 days (Feb 9th-25th), is particularly keen to contain any avian flu outbreaks in hopes of avoiding the financial impacts, and negative press, of the past three winters.