Tuesday, November 21, 2017

South Korea: MAFRA Testing Environmental H7N7 For Pathogenicity


















#12,913

In late September South Korea announced they would increase their surveillance and containment procedures for the expected return of avian flu this fall and winter.  Since then we've seen a growing number of reports of both LPAI H5 and H7 viruses in wild birds, or their feces, and more recently, HPAI H5N6 in wild birds and poultry. 

There are two broad categories of avian influenza; LPAI (Low Pathogenic Avian Influenza) and HPAI (Highly Pathogenic Avian Influenza).
  • LPAI viruses are quite common in wild birds, cause little illness, and only rarely death. They are not considered to be a serious health to public health. The concern is (particularly with H5 & H7 strains) that LPAI viruses have the potential to mutate into HPAI strains.
  • HPAI viruses are more dangerous, can produce high morbidity and mortality in wild birds and poultry, and can sometimes infect humans with serious result. The type of bird flu scientists have been watching closely for the past decade has been HPAI H5 (and to a lesser extent HPAI H7s & H9s).
While HPAI H5N6 is currently considered South Korea's greatest threat, the possibility of seeing new reassortant (H5 or H7) viruses is always present, and so all findings must be fully examined.

Nearly two months ago, we saw South Korean H7N7 Indentified As LPAI from samples retrieved from Yeongcheon.Today, we learn that MAFRA is testing new samples taken from Pohang, roughly 25 miles further east. 

While likely to be LPAI, given the rapid reassortment potential for avian influenza viruses, no one in South Korea can afford to take the results for granted. 
Gyeongsangbuk-do Pohang wild bird H7N7 AI virus type detected in the feces (11.21, deployment) 
Added     2017-11-21 20:49:00

Gyeongsangbuk-do Pohang (Hyeongsan River) wild bird H7N7 type AI virus detected in the 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 11.14 days Gyeongbuk Pohang (Hyeongsan River) Agriculture, Forestry and Livestock quarantine office intermediate tests AI H7N7 type virus is detected - 11.21 days against the AI ​​urgent action in accordance with the instructions (SOP) announced that take preventative measures.

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. * Check whether the highly pathogenic 11.22 days ** will Gyeongsangbuk-gu, Pohang Yeonil AI detection point with respect to the forecasting center within 10km poultry breeding farms (about 285 farmers, 150 Tianshui) (clinical examination or inspection) carried out

Zoonosis & PH: Survey Of Animal Exhibitor's KAP During Swine Variant Outbreak



















#12,912

Between 2005 and the end of 2010, the CDC  documented 19 human infections by swine origin influenza viruses (SOIV) across the United States, 12 of which were trH1N1 viruses, 6 were trH3N2, and 1 was trH1N2.
During the summer of 2011 a new strain of swine influenza  - originally dubbed trH3N2 but renamed H3N2v (swine variant influenza) – was discovered to have evolved in pigs. 
What made this virus different from the earlier trH3N2 novel strains was that it was a reassortant swine H3N2 which had acquired the matrix (M) gene from the 2009 H1N1 pandemic virus.

Over the next couple of months a handful of human infections were reported in Pennsylvania, Indiana, and Iowa - primarily among children - all with exposures to pigs at state or local fairs.

The CDC’s MMWR on November 23rd of that year detailed the Iowa cases in a dispatch called Limited Human-to-Human Transmission of Novel Influenza A (H3N2) Virus — Iowa, November 2011. 
By then  it was pretty apparent that this swine H3N2 virus had a greater affinity to human hosts than most of the other SOIVs we’d seen in the past (excluding the 2009 H1N1pdm virus).
A few more scattered cases in Minnesota and West Virginia by year's end, and the virus was given a new name WHO/FAO/OIE: Call It A(H3N2)v, which raised the total for 2011 to a dozen cases reported around the country.
This was, in all likelihood, a substantial undercount with at least one estimate putting the number 200 times greater (see CID Journal: Estimates Of Human Infection From H3N2v (Jul 2011-Apr 2012).
The following summer (2012) the floodgates opened - and while still likely badly under counted - over a little more than two months more than 300 human swine variant infections were reported across 10 states.  Again, nearly all had direct contact with pigs at state and local fairs (see CID Journal: H3N2v Outbreaks In United States – 2012).
While the number of reported swine variant infections dropped back to single digits for each of the next three years (2013, 2014, 2015) in 2016 we saw a renewed surge of cases.
An MMWR: Investigation Into H3N2v Outbreak In Ohio & Michigan - Summer 2016 revealed that 16 of the 18 cases analyzed belonged to a new genotype not previously detected in humans.

This year, we've seen another jump in swine variant cases, with 65 novel swine variant infections reported as of November 3rd (see CDC FluView Wk 43: Three More Swine Variant Virus Infections (CO, NE, MI), second only to 2012's record setting outbreak. 


While most of these infections have been mild or moderate, a couple of deaths have been reported since 2012, along with a number of hospitalizations. The CDC takes these zoonotic infections seriously, and their Influenza Risk Assessment Tool (IRAT) lists H3N2v as having moderate pandemic potential. 
The CDC has published a number of guidance documents for animal exhibitors, venues, and visitors to agricultural exhibits and has sponsored a Public Health Youth Agriculture Education Program, but it isn't easy convincing people that activities that up until recently were considered low risk, suddenly now carry a significantly higher degree of danger.
All of which brings us to a fascinating report on KAP (Knowledge, Attitude & Practices) in animal exhibitor's households during last summer's H3N2 outbreak in Michigan and Ohio. I've only included a few excerpts from the open-access report, so follow the link to read it in its entirety.


ORIGINAL ARTICLE
Do animal exhibitors support and follow recommendations to prevent transmission of variant influenza at agricultural fairs? A survey of animal exhibitor households after a variant influenza virus outbreak in Michigan

Authors
R. J. Stewart, J. Rossow, J. T. Conover, E. E. Lobelo, S. Eckel, K. Signs, M. G. Stobierski, S. C. Trock, A. M. Fry, S. J. Olsen and M. Biggerstaff

First published: 16 November 2017Full publication history
DOI: 10.1111/zph.12425 View/save citation
Cited by (CrossRef): 0 articles Check for updates
 

Funding information

This work was supported by the Centers for Disease Control and Prevention.

Summary

Influenza A viruses circulate in swine and can spread rapidly among swine when housed in close proximity, such as at agricultural fairs. Youth who have close and prolonged contact with influenza-infected swine at agricultural fairs may be at increased risk of acquiring influenza virus infection from swine. Animal and human health officials have issued written measures to minimize influenza transmission at agricultural exhibitions; however, there is little information on the knowledge, attitudes, and practice (KAP) of these measures among animal exhibitors. 


After an August 2016 outbreak of influenza A(H3N2) variant (“H3N2v”) virus infections (i.e., humans infected with swine influenza viruses) in Michigan, we surveyed households of animal exhibitors at eight fairs (including one with known H3N2v infections) to assess their KAP related to variant virus infections and their support for prevention measures. Among 170 households interviewed, most (90%, 151/167) perceived their risk of acquiring influenza from swine to be low or very low. 

Animal exhibitor households reported high levels of behaviours that put them at increased risk of variant influenza virus infections, including eating or drinking in swine barns (43%, 66/154) and hugging, kissing or snuggling with swine at agricultural fairs (31%, 48/157).

Among several recommendations, including limiting the duration of swine exhibits and restricting eating and drinking in the animal barns, the only recommendation supported by a majority of households was the presence of prominent hand-washing stations with a person to monitor hand-washing behaviour (76%, 129/170). 

This is a unique study of KAP among animal exhibitors and highlights that animal exhibitor households engage in behaviours that could increase their risk of variant virus infections and have low support for currently recommended measures to minimize infection transmission. Further efforts are needed to understand the lack of support for recommended measures and to encourage healthy behaviours at fairs.

Impacts

  • Influenza viruses can spread rapidly among swine at agricultural fairs, and youth who participate in these events may be at increased risk of acquiring influenza viruses due to their close and prolonged contact with infected swine.
  • Despite recommendations to minimize the transmission of influenza viruses from swine to humans, our survey found that animal exhibitors engaged in behaviours that put them at increased risk of acquiring variant influenza virus, including eating and drinking in swine barns, and hugging, kissing or snuggling with swine during agricultural fairs.
  • In our survey, there was little support among households of animal exhibitors for most measures recommended to minimize transmission of influenza from swine to humans. Additional efforts to educate youth animal exhibitors about the risk of infection and benefit of prevention practices may be necessary to increase support for and adherence to recommendations.
The reluctance among animal exhibitors to adopt more stringent infection control procedures is not unlike the push back we've seen among poultry farmers in Asia, and camel owners in Saudi Arabia, who can't quite get their heads wrapped around the idea that their beloved animals could potentially carry a disease that could infect them. 
And, as a serial cat owner (who owns who is a matter for debate), I understand that.
I'm just as guilty of treating my beloved feline companion like a furry family member, even though there is an (admittedly low) potential for cross species disease transmission (see PHE: Transmission Of Bovine TB From Felines To Humans - UK and  Avian H7N2 Virus in Human Exposed to Sick Cats).
But disease threats change over time. And no disease evolves faster, or has greater pandemic potential, than influenza.
Meaning we must either acknowledge these emerging disease threats and learn to avoid them, or suffer the consequences.

Monday, November 20, 2017

CDC Update: Candida Auris - November 2017


















#12,911


Not quite a year and a half ago (June 24th, 2016) the CDC issued a Clinical Alert to U.S. Health care facilities about the Global Emergence of Invasive Infections Caused by the Multidrug-Resistant Yeast Candida auris.

C. auris is an emerging fungal pathogen that was first isolated in Japan in 2009. It was initially found in the discharge from a patient's external ear (hence the name `auris').  Retrospective analysis has traced this fungal infection back over 20 years.
Since then the CDC and public health entities have been monitoring an increasing number of cases (and hospital clusters) in the United States and abroad, generally involving bloodstream infections, wound infections or otitis (see September update).
Adding to the concern:
  1. C. auris infections have a high fatality rate
  2. The strain appears to be resistant to multiple classes of anti-fungals  
  3. This strain is unusually persistent on fomites in healthcare environments.
  4. And it can be difficult for labs to differentiate it from other Candida strains 

Last last week the CDC updated their C. Auris surveillance page, where they now show 157 confirmed cases and 29 probable cases, across 10 states (California was added this month). The number of colonized asymptomatic cases has risen to 212.


On This Page

Candida auris is an emerging fungus that presents a serious global health threat. C. auris causes severe illness in hospitalized patients in several countries, including the United States. Patients can remain colonized with C. auris for a long time and C. auris can persist on surfaces in healthcare environments. This can result in spread of C. auris between patients in healthcare facilities.

Most C. auris cases in the United States have been detected in the New York City area and New Jersey. Strains of C. auris in the United States have been linked to other parts of the world. U.S. C. auris cases are a result of inadvertent introduction into the United States from a patient who recently received healthcare in a country where C. auris has been reported or a result of local spread after such an introduction.
 
While the number of confirmed and probable clinical cases continues to climb at a steady rate, the largest increase over the past few months has been in the number of colonized asymptomatic carriers detected via targeted screening.

Last August the CDC promoted the first ever Fungal Disease Awareness Week, and presented a COCA call webinar called Tackling an Invasive, Emerging, Multi-drug Resistant Yeast: Candida auris — What Healthcare Providers Need to Know, which is now archived and available online.

CIDRAP's Antimicrobial Stewardship Project (ASP) also held an hour long webinar (see below), which is now available on the CIDRAPASP Youtube channel.


https://www.youtube.com/watch?v=gCO7kWdnbkY
 (Note: you'll find more than a dozen other on-topic videos available on this channel as well).
 For more on this emerging fungal pathogen, you may wish to revisit:

MMWR: Ongoing Transmission of Candida auris in Health Care Facilities
MMWR: Investigation of the First Seven Reported Cases of Candida auris In the United States

mSphere: Comparative Pathogenicity of UK Isolates of the Emerging Candida auris

South Korea: More H5N6/H5 In wild Birds














#12,910


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





















 #12,909


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




















#12,908


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.