Friday, August 18, 2017

CDC FluView Week 32: 3 Swine Variant Infections (OH, PA, ND)


As telegraphed by yesterday's MMWR, for the 4th week running the CDC today is reporting additional novel flu cases, all three swine variant viral infections linked to attendance of state or county fairs.  Over the past 3 weeks we've seen:
CDC FluView Week 31: 3 More H3N2v Cases Reported in Ohio
FluView Week 30: 1 Additional Swine Variant Report From Ohio - H1N2v
CDC FluView: 11 H3N2v Swine Flu Cases Reported In Ohio
Today's reports deals with 3 patients, from 3 states (Ohio, Pennsylvania, and North Dakota), although it appears the Pennsylvania case was exposed while visiting North Dakota (see yesterday's statement from the North Dakota Health Department).
Two of the cases have been identified as H3N2v, while final subtyping is awaited on the third case. Preliminary testing indicates it is an H3 variant, making H3N2v the most likely culprit.
While rare, it is worth noting we've seen other H3 viruses circulating in North America swine before (see J. Virol: Novel Reassortant Human-like H3N2 & H3N1 Influenza A Viruses In Pigs), so it will be of interest to see what the full lab report finds.

Novel Influenza A Virus:

Three human infections with novel influenza A viruses were reported by three states (North Dakota [1], Ohio [1], and Pennsylvania [1]) during week 32. All three infections were with variant viruses (influenza A viruses that normally circulate in pigs and not people are called variant viruses when detected in people.) 

Viruses from two of the infections have been fully characterized and are influenza A (H3N2) variant (H3N2v) viruses; the third infection has been characterized as an influenza A (H3) variant (H3v) virus at this time (further analysis is being performed at CDC to characterize the neuraminidase protein of this virus). 

All three patients reported exposure to swine in a fair setting during the week preceding illness onset. Two patients reported attendance at the same agricultural fair. The exposure to swine at the agricultural fair reported by the Pennsylvania resident occurred out of state. 

Two of the three patients were children younger than 18 years of age and one patient was an adult aged > 64 years. Two of the three patients were hospitalized but all have fully recovered from their illness. No human-to-human transmission of these viruses has been identified. 

To date, a total of 19 variant virus infections have been reported in the United States during 2017. Eighteen of these have been H3 variant viruses (Texas [1], North Dakota [1], Pennsylvania [1], and Ohio [15]) and one has been with an H1N2 variant virus (Ohio [1]).

Early identification and investigation of human infections with novel influenza A viruses are critical to ensure timely risk assessment and so that appropriate public health measures can be taken. Additional information on influenza in swine, variant influenza infection in humans, and strategies to interact safely with swine can be found at

While rarely as severe as avian flu in humans, swine influenza viruses nevertheless have some pandemic potential. The CDC's IRAT (Influenza Risk Assessment Tool) Rankings monitors and characterizes 14 different novel flu viruses, and has this assessment on H3N2v
H3N2 Variant:[A/Indiana/08/11]

Swine-origin flu viruses do not normally infect humans. However, sporadic human infections with swine-origin influenza viruses have occurred. When this happens, these viruses are called “variant viruses.” Influenza A H3N2 variant viruses (also known as “H3N2v” viruses) with the matrix (M) gene from the 2009 H1N1 pandemic virus were first detected in people in July 2011. The viruses were first identified in U.S. pigs in 2010. In 2011, 12 cases of H3N2v infection were detected in the United States. In 2012, 309 cases of H3N2v infection across 12 states were detected. The latest risk assessment for this virus was conducted in December 2012 and incorporated data regarding population immunity that was lacking a year earlier.
Summary: The summary average risk score for the virus to achieve sustained human-to-human transmission was in the moderate risk category (less than 6). 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 low-moderate risk category (less than 5).

For some recent blogs on Swine variant influenza, and why the CDC closely monitors these infrequent human infections, you may wish to revisit:

EID Journal: Transmission Of Swine H3N2 To Humans At Agricultural Exhibits - Michigan & Ohio 2016

Ohio: Henry County Fair Closes Pig Barn Over H1N2 Swine Flu

Second Ohio County Fair Closes Hog Barn Over Swine Flu

A Reminder About The `Other' Novel Flu Threat


Saudi MOH Announces Another MERS Case In Jeddah


After skipping a day, the Saudi MOH has another report of a MERS case (exposure under investigation) in Jeddah.  This is the 4th case announced in Jeddah - a major Hajj terminal - since the first week of August, and comes less than 10 days before the start of this year's Hajj.

Today's case is the 24th case reported during the first 18 days of August.

Yesterday the World Health Organization published a Saudi MERS update, with details on 26  case that occurred between July 4th and August 12th, 13 of which were associated with a cluster in a hospital in Al Jawf Region.

Nigeria Investigating Unknown Disease Outbreak In Kogi State


For the past couple of weeks there have been repeated reports of a fatal disease outbreak in Kwara State, Nigeria (see FluTrackers thread Oro-Ago, Nigeria: Questionable report of dozens of deaths due to undiagnosed hemorrhagic illness)

While first thought to be Lassa fever, the outbreak was dismissed as a rumor by the local government (see Kwara Government Denies Disease Outbreak in Oro Ago Community) last week. According to the government press release of August 11th:
The State’s Commissioner for Health, Alhaji Suleiman Alege, on Friday told newsmen in Ilorin, that the report is a mere rumor as the ministry has no confirmed outbreak of disease fatalities in any part of the state.
Fast forward to last night and Pathfinder at FluTrackers has picked up fresh reports (see Nigeria - ​ Mysterious illness kills 62 in Kogi) from the neighboring state of Kogi of a very similar sounding outbreak.

As is often the case, media reports don't always align, and official government reports are slow to emerge. Typical of what is being reported, this comes from Channels Television :
Nigeria: 50 Killed As Disease Hits Kogi, KwaraAn unknown illness has thrown many families in Kogi State into mourning and left health authorities with a puzzle to solve.

The state Commissioner for Health, Dr Saka Audu, told Channels Television that so far, 62 people have been killed by the illness which was initially thought to have been Lassa fever by many people.

This is because it has some symptoms that are similar to Lassa fever such as diarrhea, abdominal pain, and vomiting.

The worst hit community is Okoloke in Yagba West Local Government Area of the state. Other areas are Okunran and Isanlu-Esa – both villages in Yagba West LGA.

With over 60 people dead and Lassa fever ruled out as a cause, the government has taken samples of the disease and is hoping to identify the illness as quickly as possible to prevent more deaths, according to the commissioner.

Unlike Kwara State, the Kogi government appears to have acknowledged they have an outbreak.   This much more detailed report comes from 

Nigeria: 50 Killed As Disease Hits Kogi, Kwara

By Itodo Daniel Sule, Romoke Ahmad and Akor Ojoma

At least 50 people have been killed in the last three weeks by a yet-to-be ascertained ailment in three communities in Kogi State, the state government announced yesterday.

The affected communities are Okunran, Okoloke and Isanlu-Esa all in Yagba West local government area of the state, according to the state health commissioner Dr Saka Audu.

Authorities in neighbouring Kwara State are also investigating reports of an outbreak which allegedly claimed some lives in Oro-Ago community in Ifelodun local government area of the state.

The Oloro of Oro-Ago, Oba Tafa Dada and the President of Oro-Ago Development Union, Mr Olaniyi Olushola raised the alarm of the strange illness that hit some members of the community, especially the herders which they said claimed many lives.
But Dr Audu confirmed yesterday during a visit to the affected communities to assess the health situation, saying a technical team was earlier sent to take samples which were sent to General Hospital Irua, Edo State, for investigation.

"We are here to make sure we determine the cause of these mysterious deaths and then quickly proffer a solution to it," he said.

(Continue . . . )

Although I'll follow up when more is known, you'll get your most complete day-to-day coverage from the newshounds at FluTrackers.

China MOA Confirms H5N6 Outbreak In Quail - Guizhou Province

Credit Wikipedia


Less than three weeks after announcing a large outbreak of HPAI H5N1 in Inner Mongolia, China's Ministry of Agriculture has announced an outbreak of HPAI H5N6 in quail farms in Guizhou Province.

Due to the imprecise nature of translation software, it isn't entirely clear whether more than one farm was affected, but the report refers to `some farmers'

Luodian County, Guizhou province occurred poultry with H5N6 subtype highly pathogenic bird flu
Issued by: Ministry of Agriculture press office Date: 2017-08-18 14:27 Keywords: bird flu; epidemic; Guizhou

  Ministry of Agriculture press office issued August 18, Luodian County, Guizhou province occurred poultry with H5N6 subtype highly pathogenic bird flu.

  August 10, Luodian County, Guizhou province some farmers rearing of quail suspected bird flu symptoms appear, the incidence 13103, died 9752. August 13, animal disease prevention and control center in Guizhou Province diagnosed with suspected bird flu. August 18, 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 of poultry 8110. Currently, the outbreaks has been effectively controlled.

While H5N6 has been known to infect humans (n=16), it has been 9 months since the last reported case.  In the meantime, we've seen H5N6 move beyond China, Vietnam, and Laos and into South Korea, Japan, and Taiwan. 
As it has spread, it has reassorted numerous times, producing multiple genotypes (see Emerg. Microbes & Inf.: Human Infections With A Novel Reassortant H5N6).
Due to the extensive use of H5 vaccines in Chinese poultry, large outbreaks of HPAI H5 viruses in commercial flocks have become relatively rare, although there is ample evidence that these viruses continue to circulate widely as sub-clinical infections. 
Subclinical Highly Pathogenic Avian Influenza Virus Infection among Vaccinated Chickens, China). 
Study: Recombinant H5N2 Avian Influenza Virus Strains In Vaccinated Chickens 
EID Journal: Subclinical HPAI In Vaccinated Poultry – China

Seeing two `breakout' events so close together - particularly this late in the summer - is a bit unusual.
This fall China will roll out a new combination H5 + H7 poultry vaccine (see China MOA Orders HPAI H7N9 Vaccine Deployed Nationwide This Fall) which they hope will help control HPAI H5 viruses like H5N1, H5N6 and H5N8, plus the rapidly spreading LPAI and HPAI versions of H7N9.
After more than a dozen years of use in China, however, poultry vaccines have not proved to be a panacea for bird flu. For more on some of the challenges of controlling avian flu with poultry vaccines, you may wish to revisit:
Virology: Selection Of Antigenic Variants Of An H5N1 HPAI Virus In Vaccinated Chickens
New Scientist: The Downsides To Using HPAI Poultry Vaccines

PLoS Bio: Imperfect Poultry Vaccines, Unintended Results

Philippines Announces 2nd Outbreak Of HPAI H5 Avian Flu


A week after the Philippines announced their very first bird flu outbreak, their Secretary of Agriculture Manny Piñol has announced a second outbreak - in neighboring Nueva Ecija province - to the media, and on his Facebook page.

This report from the Secretary's Facebook feed.


By Manny Piñol

Two new cases of Avian Influenza have been confirmed by the Bureau of Animal Industry in Jaen and San Isidro towns of Nueva Ecija today.

The confirmation was made after.series of laboratory tests on specimens gathered from quails and layer chickens were conducted by thr Animal Diseases Detection Laboratory.

Unlike in the case of San Luis, Pampanga where a similar case was only reported three months after it as first suspected, the Nueva Ecija cases were immediately reported.

Quarantine teams were immediately established even before the laboratory tests confirmed the presence of the virus.

A 1 km. Contained radius and a 7 kilometer controlled radius were established just like in San Luis, Pampanga.

The farm in Jaen raised quails which were wiped out while the farm in Jaen is a layer poultry facility of about 20,000 heads.

Culling operations are on-going for the otherfowls in the 1-kilometer radius.

Nueva Ecija poultry population:

* layer chicken 401,894; (affected- 28k, 7%)
* broiler 3,805,135; (0%)
* Duck 502,005; (affected - 22k, 4%)
* native chicken 1,507,510; (affected - 57k, 4%)
* quail (200k)
(population & percentage of total, w/in 1km radius).

A similar report appears this morning in the Manila Times.

Bird flu spreads to Nueva Ecija but under control—agriculture chief
By The Manila Times on August 18, 2017

AGRICULTURE Secretary Manny Pinol has confirmed two cases of bird flu infection in Nueva Ecija.

In a live interview on GMA7 on Friday, Pinol said affected were the poultry farms of Jaen and San Isidro.

Pinol assured the public, however, that the spread of the bird flu strain, identified as H5, was under control.

The strain is the same type as the one found in San Luis, Pampanga where the first outbreak was reported.
         (Continue . . . ) 

A week after announcing that samples had been sent to labs in Australia for subtyping it still isn't clear exactly what type of HPAI H5 the Philippines authorities are dealing with.  There were initial denials of it being H5N1, but nothing more precise has been announced.
While H5N8 and H5N6 are the two most obvious suspects, the Asian lineage of HPAI H5 has shown a remarkable ability to reassort with local LPAI viruses. Over the past three years we've seen H5N2, H5N3, H5N5, and H5N9 viruses emerge - at least temporarily - in areas where HPAI H5 has visited. 
Hopefully we'll get an exact subtype, and a more precise genetic characterization, soon.

Thursday, August 17, 2017

MMWR Reports 3 More Novel Flu Infections (ND, OH, PA)



Although details remain scant, we have confirmation of at least 3 additional novel flu infections (1 each in OH, PA, & ND) reported in today's MMWR Notifiable Diseases and Mortality Tables. This brings the number of cases reported in the past 30 days to 18, and 2017's total to 19.
We should get additional details in tomorrow's FluView, but for now we have the following statement from the North Dakota Health Department reporting two - not one - novel flu cases linked to a local county fair.

One was a local resident, while the other was an out-of-state visitor.

North Dakota Department of Health Reports First Variant Influenza Case
BISMARCK, N.D. – The North Dakota Department of Health (NDDoH) reports a confirmed case of variant influenza A H3N2v in a child with exposure to pigs. Influenza viruses that normally circulate in pigs are called variant influenza when the virus is found in people.
Variant influenza viruses are different from typical circulating human influenza A viruses. 
Most cases of variant influenza occur during summer months in people who raise pigs, or who had contact with pigs at agricultural events like fairs. Influenza viruses do not typically move readily between people and pigs, so variant influenza cases are rare.

Symptoms of variant influenza are similar to those of seasonal flu and include fever, cough, sore throat, headache, muscle aches and lack of appetite. People seeing a health care provider for a respiratory illness should let their provider know if they have had recent exposure to pigs. Providers should alert the NDDoH if they suspect variant influenza.

“This is the first time a North Dakota resident has tested positive for variant influenza,” said Jill Baber, an epidemiologist with the NDDoH. “The child visited the North Dakota State Fair in Minot and had direct contact with pigs. The child was hospitalized, but has since been released and is recovering.” A second case associated with the State Fair, in a non-North Dakota resident, has also been identified.

(Continue . . . )

I've found no information on the Pennsylvania and Ohio cases, although there were reports late yesterday that a Child has tested positive for Influenza A after showing A pig at the Henry County Fair, which Closed their Pig Barn Over H1N2 Swine Flu earlier this week.  
Further testing is underway to determine the subtype of the child's infection, so it may or may not be connected to today's report.
Earlier today, in EID Journal: Transmission Of Swine H3N2 To Humans At Agricultural Exhibits - Michigan & Ohio 2016, we looked at the risks of novel flu transmission in these types of venues, including from healthy-looking pigs.
Most years fewer than a dozen `swine variant' infections are reported in the United States, mostly involving farm or livestock workers. Most are mild, but it is likely that many others go undiagnosed.
During the summer of 2012 we saw our largest outbreak to date, with 10 states reporting more than 300 confirmed cases, nearly all linked to county or state fair attendance (see H3N2v Update: CDC Reports 52 New Cases, Limited H2H Transmission).

With state and county fair season continuing over the summer and into fall, it would not be unexpected to see additional, scattered reports of swine variant infection. While most cases are mild, the CDC pays close attention whenever a flu virus jumps species. 

CDC Assessment

Sporadic infections and even localized outbreaks among people with variant influenza viruses may occur. All influenza viruses have the capacity to change and it's possible that variant viruses may change such that they infect people easily and spread easily from person-to-person. The Centers for Disease Control and Prevention (CDC) continues to monitor closely for variant influenza virus infections and will report cases of H3N2v and other variant influenza viruses weekly in FluView and on the case count tables on this website