Monday, October 23, 2017

WHO: Plague Cases In Madagascar Increase To 1365














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With the epidemiological reports posted by Madagascar's MOH becoming increasingly convoluted - and falling even farther behind the WHO's tally of cases and deaths - it has become increasingly difficult to use them to  gauge the full extent of their pneumonic plague outbreak.
Exactly what is behind the stark (40%+) difference in cases totals being reported by the MOH and the WHO is unknown, although differences in what each consider `suspected' cases might be a factor.
Today the WHO has updated their numbers again, through October 20th, which shows an increased of 68 cases, and 4 deaths over the last 24 hours of reporting. Once again we are seeing a large increase in the number of HCWs reported as infected (n=54).


Some excerpts from today's report follow:

http://apps.who.int/iris/bitstream/10665/259352/1/OEW42-1420102017.pdf


EVENT DESCRIPTION
 
Madagascar has been experiencing a large outbreak of plague affecting major cities and other non-endemic areas since August 2017. Between 1 August and 20 October 2017, a total of 1 365 cases (suspected, probable and confirmed) including 106 deaths (case fatality rate 7.8%) have been reported. Of these, 915 cases (67%) were clinically classified as pneumonic plague, 275 (20.1%) were bubonic plague, one case was septicaemic plague, and 174 cases were unspecified. Of the 915 cases of pulmonary plague, 160 (17.5%) have been confirmed, 375 (50%) were probable and 380 (41.5%) were suspected (further classification of cases is in process). A total of 54 healthcare workers have contracted plague since the beginning of the outbreak.


Of 1 087 cases with age and sex information available, 58% (544) were children and young people aged less than 21 years, while 36% (387) were adults aged between 21 and 40 years. Male were the most affected, accounting for 57% of all cases, and have experienced a slightly higher case fatality rates in comparison to females, 9.4% to 7.7%, respectively.


Of the 1365 cases, 219 were confirmed, 520 were probable and 626 remain suspected (additional laboratory results are in process). Eleven strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.


Overall, 40 out of 114 (35.1%) districts in 14 of 22 (63.6%) regions in the country have been affected by pulmonary plague. The district of Antananarivo Renivohitra has been the most affected, accounting for 41.4% of all reported cases.


On 20 October 2017, 1 385 out of 2 293 (60.4%) contacts were followed up and provided with prophylactic antibiotics. A total of 141 contacts completed the 7-day follow up without developing symptoms.


(Continue . . . )


Italy IZSV: More Reports Of HPAI H5 In Poultry & Wild Birds















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Although Italy's IZSV (Istituto Zooprofilattico Sperimentale delle Venezie) hasn't updated their map or Outbreaks Chart since Friday, today they have posted some brief updates on HPAI H5 in poultry and in wild birds.
During the first three weeks of October Italy has reported at least 15 outbreaks of HPAI H5N8 or HPAI H5, along with several other detections in wild birds.
This heavy persistence of avian flu in Italy over the summer - and at much lower levels across other parts of Europe - is in sharp contrast to previous years when H5N8 all but disappeared in Europe and North America once spring ended (see PNAS: The Enigma Of Disappearing HPAI H5 In North American Migratory Waterfowl).

As we discussed in Avian Flu: That Was Then . . This Is Now, HPAI H5N8 has undergone dramatic evolutionary changes since 2016, and additional changes in its genetics and behavior are always possible.


Highly pathogenic avian influenza (HPAI) in Italy

2016/2017 – H5N5, H5N8

Outbreaks | PDF (last update: 20/10/2017)
Maps | PDF (last update: 20/10/2017)

October 2017

23/10/2017 – On 13 October, samples from two mute swans (Cygnus olor) found in Verbano-Cusio-Ossola province (Piedmont region), were analysed at the National Reference Laboratory (NRL) for Avian Influenza and Newcastle Disease and resulted positive to Avian Influenza subtype H5. On 17 October, NRL characterised the virus as Highly Pathogenic Avian Influenza (HPAI) virus subtype H5N8.

On 19 October, the National Reference Laboratory for Avian Influenza and Newcastle Disease confirmed as positive for Avian Influenza A virus subtype H5 a fattening turkeys farm in Brescia province (Lombardy region). In close proximity to the outbreak, there is another fattening turkeys farm. Due to proximity and lack of a clear separation, the two farms are being treated as a unique epidemiological unit. The unit hosted 29.640 female turkeys, at the time of confirmation. On 16 October evening, depressed sensorium was detected and, the next day, increased mortality was observed and reported to the Veterinary Services. Epidemiological investigations revealed that the affected unit had risk contacts with the fattening turkeys farm in Brescia Province confirmed as positive for HPAI H5N8 on 9 October.


On 19 October, NRL confirmed as positive for Avian Influenza A virus subtype H5 another fattening turkeys farm located in Brescia province (Lombardy region). The farm hosted 8.945 male turkeys, at the time of confirmation. On 17 October evening, depressed sensorium was detected and, the next day, increased mortality was observed and reported to the Veterinary Services.


On 20 October, the virus isolated in the last two outbreaks were characterised by the NRL as Highly Pathogenic Avian Influenza (HPAI) virus subtype H5N8.


19/10/2017 – On 17 October, the National Reference Laboratory (NRL) for Avian Influenza and Newcastle Disease confirmed as positive for Avian Influenza A virus subtype H5N8 a backyard flock in Padua province (Veneto region). In the premises were present five laying hens. Furthermore, six swans were resident in the property pods, which were frequented by wild mallards (Anas platyrhynchos). An increase in mortality was observed on 13 October, when two swans were found dead. Culling procedures of Gallinaceous birds were concluded on 18 October.

On the same day, NRL confirmed as positive for Avian Influenza A virus subtype H5N8 another backyard flock in Padua province (Veneto region). The flock consisted of eight geese and 34 ducks. Wild mallards (Anas platyrhynchos) used to frequent the pods located in the premise, and, in this way, came into contact with the flock. On 13 October, an increase in mortality was observed in the flock. Culling procedures have already been completed.


Lastly, NRL characterised as Highly Pathogenic the viruses isolated in the last outbreaks in Lombardy region.

With the fall migratory bird season in full swing, and fresh reports over the weekend of HPAI H5 turning up in Russia, Germany & Bulgaria, poultry interests throughout Europe are being urged to fortify their biosecurity measures.

OIE Notification: Two Outbreaks Of HPAI H5 in Bulgaria


















#12,847


Over the weekend we saw reports of avian H5 reported in the Rostov region of Russia, along with reports of HPAI H5N8 Detected In Wild Duck Near NL Border, to which we can add the following OIE notification of two outbreaks of HPAI H5 in Bulgaria.

One outbreak is reported from a farm in Stefanovo in the northeastern region of Dobric, while the other is reported in a backyard in Uzundzhovo. No word yet on the full subtype.



http://www.oie.int/wahis_2/public/wahid.php/Reviewreport/Review?page_refer=MapFullEventReport&reportid=25082

As this is the time of the year we would expect the arrival of migratory birds carrying H5N8 (or possibly other reassorted HPAI H5 viruses), any uptick in reports is worth noting. 

Pandemic Unpreparedness Revisited
















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As we head once more into an uncertain avian flu season - with three different H7N9 threats growing in China, and HPAI H5N8 and H5N6 expected to make new inroads across Asia, Europe, Africa and potentially North America this winter- the number of pandemic threats is greater than at any time I can recall.
Four days ago, in Cell Host & Microbe: HPAI H7N9 Lethality & Transmission In Ferrets, we looked at a somber assessment of the evolution (and pandemic potential) of the recently emerged HPAI H7N9 virus. 
Since then we've seen dozens of media reports on this growing threat, with perhaps CIDRAP's report by Lisa Schnirring (see Study details pandemic potential of latest H7N9 flu strains) my favorite.

While others (excluding the usual tabloid press) presented the facts well enough, Lisa's coverage ended with this all too familiar cautionary note from Dr. Michael Osterholm.  

World not prepared for H7N9 threat


Michael Osterholm, PhD, MPH, director of the University of Minnesota's Center for Infectious Disease Research and Policy (CIDRAP) said the study's findings bolster concerns that experts already have about H7N9. "The study is another very stark reminder that we could be sitting on top of a global time bomb with H7N9," he said. CIDRAP is the publisher of CIDRAP News.

Large gaps in pandemic preparedness still remain, and if H7N9 triggers a pandemic, the vaccine would likely play a limited role, he said.

Osterholm added that little work has been done to create strong global supply chains of the critical supplies and services that would be needed to battle pandemic flu, and he predicted critical shortages of drugs and equipment such as respirators if the next global flu threat is even close to the severity of the 1918 pandemic virus.

Despite decades of forewarning and the near inevitability of seeing another 1918-style pandemic, the world remains woefully unprepared.  And this isn't just one person's opinion. This is a message that has been repeated nearly every year by governments and organizations since I began blogging about pandemic flu 12 years ago.
While there was a decided international push for pandemic preparedness at all levels (public, private, community and individual) in the middle of the last decade - much of the momentum was lost after the H1N1 pandemic proved less severe than first feared.
Last May, in World Bank: World Ill-Prepared For A Pandemic, we looked at a 131-page working paper from The World Bank, that warned that far too many nations have let pandemic preparedness slide, and that the world remains unprepared to face even a moderately severe pandemic.

A conclusion not unlike that reached in 2015 by a World Bank Poll: Majority Believe World Is Not Ready For A Pandemic, and by a 2011 WHO Panel: World Ill-Prepared To Deal With A Pandemic.

In 2015, we looked at an 84-page Bipartisan Report of The Blue Ribbon Study Panel On Biodefense that looked at our nation’s vulnerability to the triple threat of a biological attack, an accidental release, or naturally occurring pandemic with a highly pathogenic biological agent.   
Their conclusion?  We aren't anywhere near ready.
None of this is to suggest that some progress hasn't been made. The WHO continues to expand their library of Candidate Vaccines For Pandemic Preparedness, surveillance - at least in some areas of the world - has improved, and newer antivirals are in the pipeline.


But the number, and variety of global disease threats continues to expand.  While novel influenza is at the top of that list, it is far from the only threat on our radar. MERS-CoV and SARS, Nipah and Hendra, Monkeypox, and a short list of hemorrhagic viruses all make the list.
And of course, there's always Virus X - the one we don't know about yet.
I can't tell you what will spark the next severe pandemic, or when it will happen. Only that each day that passes brings us closer to that day.  And when it comes, it will likely happen swiftly, with scant warning and little time to prepare.

A little over a decade ago, in Quotable Quotes, we looked at some statements by government officials on what an H5N1 pandemic might look like.  A small sampling includes:
[A pandemic] is an absolute certainty. When it comes to a pandemic we are overdue and we're under-prepared. -- Mike Leavitt, former Secretary, US Health and Human Services

Short of thermonuclear war, I have a hard time imagining anything in my lifetime that would be as horrible. -- Laurie Garrett, US Council on Foreign Relations Senior Fellow for Global Health

There would be no mutual aid, we'd have to take care of this ourselves. --Former Florida Governor Jeb Bush February 15, 2006
Although the threat today is more centered on H7N9 than H5n1 - like with earthquakes, hurricanes, blizzards and tornadoes - we ignore the inevitability of another severe pandemic at our own peril.

All of which makes this a very good time for local and state governments, businesses, organizations and even individuals to drag out, dust off, and take a hard look at their old pandemic plans (or create a new one if need be).

The HHS/CDC has recently done just that, with the release last April of a revised CDC/HHS Community Pandemic Mitigation Plan - 2017 followed in June with the release of their HHS Pandemic Influenza Plan - 2017 Update.
Although a welcomed update to the US government's pandemic plan, as in politics - all pandemics are local
While the federal government deals with a pandemic on the macro level (coordinating the development of a vaccine, the release of antiviral stockpiles, among other things), it will fall largely upon local communities, hospitals, school districts, businesses, and individuals to deal with the brunt of an outbreak. 

One of the nation’s leaders in pandemic and disaster planning is Public Health - Seattle & King County.  In 2008 they produced a 20 minute film called Business Not As Usual, designed to help introduce businesses to the core concepts of pandemic planning.




Frankly, this video should be required viewing for every businesses owner, manager, and employee.

You’ll also find a long list of preparedness resources available on this page as well:
 General resources:
Business and government preparedness:
Community Based Organization (CBO) preparedness:
Personal preparedness:

 Another excellent resources comes from TFAH (Trust for America’s Health)


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Credit TFAH It's Not Flu As Usual Brochure


If you are an employer, you should know that OSHA considers it your responsibility to provide a safe workplace – even during a pandemic - and has produced specific guidance on preparing workplaces for an Influenza Pandemic  along with Guidance for Protecting Employees Against Avian Flu.

https://www.osha.gov/Publications/influenza_pandemic.html
 

 
Frankly, few businesses could survive a prolonged shutdown due to a pandemic. Which is why pandemic planning should be part of their overall business continuity and recovery plan. A couple of good resources worth checking out are The Business Continuity Daily and Cambridge Risk Perspectives, both of which provide daily reviews of current threats and advice on preparedness.

Ready.gov
urges that individuals and families take the following steps before a pandemic as well.
Before a Pandemic
  • Store a two week supply of water and food.
  • Periodically check your regular prescription drugs to ensure a continuous supply in your home.
  • Have any nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, fluids with electrolytes, and vitamins.
  • Get copies and maintain electronic versions of health records from doctors, hospitals, pharmacies and other sources and store them, for personal reference. Get help accessing electronic help records.
  • Talk with family members and loved ones about how they would be cared for if they got sick, or what will be needed to care for them in your home.


Having the supplies to treat flu at home will be essential during a pandemic, as most hospitals will be clogged, with only the `sickest of the sick' likely to be admitted. As with flashlights, batteries, and ice before a hurricane, the store shelves will be quickly wiped clean of flu supplies in the opening days of a pandemic.
As an aside, I would add a box of vinyl exam gloves, hand sanitizer, and a small supply of surgical (or N95) masks to any home flu kit. 
And now is an excellent time to discuss with family and friends who will act as your Flu Buddies people you can call on if you get sick, who will then check on you every day, make sure you have the medicines you need, help care for you if needed, and who can call for medical help if your condition deteriorates.
Frankly, these are individual and family preparations that would hold you in good stead during any flu season - not just during a pandemic.
Admittedly we could easily go years, or even decades, before the next pandemic strikes. Or, it could begin somewhere in the world tomorrow. Like earthquakes along fault lines, and tornadoes in Tornado Alley, pandemics are inevitable. The timing is really the only question.
For a family or an individual - if you are well prepared for a flood, an earthquake, or a hurricane - you are probably in pretty good shape to deal with a pandemic.  Unfortunately, fewer than half of all American households are so prepared.
Businesses, health care facilities, and government agencies will find that their disaster plans will need to consider pandemics a bit more specifically. I could go on, but I'll simply close with one more quotable quote from 2006, one that sums up the pandemic preparedness dilemma in a nut shell.

“Everything you say in advance of a pandemic seems alarmist.  Anything you’ve done after it starts is inadequate."- Michael Leavitt,  Former Secretary of HHS


Saturday, October 21, 2017

WHO SitRep #5: Plague In Madagascar
















#12,845


The most recent update posted on Madagascar's MOH website - released yesterday (October 20th) - still shows 911 plague cases, and 95 deaths, but a situation report from the World Health Organization released on the same date provides a tally more than 40% higher. 
The  reasons behind this discrepancy aren't immediately apparent, but - assuming the WHO's numbers are right - reports of a slowdown in cases (based on MOH reported numbers) earlier this week may have been premature.
Some excerpts from the WHO SitRep #5 follow:


Situation Update

Madagascar has been experiencing a large outbreak of plague affecting major cities and other non-endemic areas since August 2017. Between 1 August and 19 October 2017, a total of 1 297 cases (suspected, probable and confirmed) including 102 deaths (case fatality rate 7.9%) have been reported. Of these, 846 cases (65.2%) were clinically classified as pneumonic plague, 270 (20.8%) were bubonic plague, one case was septicaemic plague, and 180 cases were unspecified (further classification of cases is in process). Of the 846 cases of pulmonary plague, 91 (10.8%) have been confirmed and 407 (48.1%) were probable.
Between 1 August and 15 October 2017, a total of 793 specimens were analysed by the Institut Pasteur de Madagascar (IPM). Of these, 126 (15.9%) have been confirmed either by polymerase chain reaction (PCR) or bacteriological culture, 242 (30.5%) were probable after testing positive on rapid diagnostic tests (RDT) and 425 (53.6%) remain suspected (additional laboratory results are in process). Eleven strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.
Overall, 33 out of 114 (30%) districts in 14 of 22 (63.6%) regions in the country have been affected by pulmonary plague. The district of Antananarivo Renivohitra has reported the largest number of pulmonary plague cases, accounting for 63.6% of all the cases.
On 19 October 2017, 1 621 out of 2 470 (65.6%) contacts were followed up and provided with prophylactic antibiotics. A total of 372 contacts completed the 7-day follow up without developing symptoms.
Plague is endemic on the Plateaux of Madagascar, including Ankazobe District where the current outbreak originated. There is a seasonal upsurge, predominantly of the bubonic form, which occurs every year, usually between September and April. The plague season began earlier this year and the current outbreak is predominantly pneumonic and is affecting non-endemic areas including major urban centres such as Antananarivo (the capital city) and Toamasina (the port city).
There are three forms of plague, depending on the route of infection: bubonic, septicaemic and pneumonic (for more information, see the link http://www.who.int/mediacentre/factsheets/fs267/en/).
Current risk assessment
 
While the current outbreak began with one large epidemiologically linked cluster, cases of pneumonic plague without apparent epidemiologic links have since been detected in regions across Madagascar, including the densely populated cities of Antananarivo and Toamasina. 


Due to the increased risk of further spread and the severe nature of the disease, the overall risk at the national level is considered very high. The risk of regional spread is moderate due to the occurrence of frequent travel by air and sea to neighbouring Indian Ocean islands and other southern and east African countries, and the observation of a limited number of cases in travellers. This risk is mitigated by the short incubation period of pneumonic plague, implementation of exit screening measures in 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.

The risk assessment will be re-evaluated by WHO based on the evolution of the situation and the available information.

Germany: Media Reports Of HPAI H5N8 Detected In Wild Duck Near NL Border



















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While I've not found an official statement yet, German and Dutch media outlets are reporting the discovery of an HPAI H5N8 infected duck in Osterwald, very near Germany's border with the Netherlands.

A couple of the reports include:

Bird flu found just over the German border, "Pray that too bad '

Saturday, October 21, 2017 | 11:31 Last updated: 21-10-2017 | 11:43
The Influenza A virus subtype H5N8 bird flu virus was identified in a wild duck in the German municipality Osterwald, about thirty kilometers from Almelo and Hardenberg. Ben Dellaertplein of AVINED, the general contact for the poultry and egg sectors, calls for vigilance.

"The message has been confirmed by the German government," Dellaertplein said in a telephone response. In a three-kilometer radius there are no poultry farms. No containment has been set.
(Continue . . . )

Influenza A virus subtype H5N8 highly pathogenic avian influenza in wild duck near Almelo

Friday, October 20, 2017
Modified: Saturday, October 21, 2017

In a wild duck in the municipality Osterwald German Bentheim 25 kilometers from Almelo highly pathogenic avian Influenza A virus subtype H5N8 identified.

The Friedrich-Löffler-Institute (FLI) has officially confirmed infection, Avined reports Friday 20 October. The discovery came to light on the basis of the German wild bird monitoring program. In a radius of three kilometers around the site are no poultry farms. No containment has been set.
(Continue . . . )

Since we've seen scattered reports of HPAI H5N8 in west and central Europe over the summer (see last August's Germany Finds H5N8 In 3 Dead Swans and Switzerland: OIE Notified Of 2 More H5N8 Outbreaks In Waterfowl) - all apparently lingering remnants from last winter's epizootic - today's announcement doesn't necessarily herald a new fall incursion of the virus.

But with the imminent arrival of millions of migratory birds from Russia and China, reports such as these will undoubtedly have Europe's already battered poultry industry on high alert for just such a repeat event.