Friday, July 22, 2016

WHO Update : H7N9 in China - July 22nd

Credit CDC


The World Health Organization has published an update on 7 H7N9 cases reported by the Chinese government between May 26th and Jun 23rd.

Normally, by late May, H7N9 cases have all but ended until the fall.  This year Hong Kong's CHP has taken special notice of these unusual `warm weather cases' and has repeatedly warned:

"In view of additional human cases reported on the Mainland with detections of human cases in previously unaffected areas in warmer months, as well as the detections of positive sample of faecal droppings of live poultry in Hong Kong and positive environmental sample in Macao in June, the public should remain vigilant. Travellers to the Mainland and other avian influenza-affected areas in the upcoming summer vacation should not visit poultry markets, and should avoid contact with poultry and their droppings."

All seven cases were reported previously, and this report adds little, except that it confirms that during this reporting period there were no new clusters.

Human infection with avian influenza A(H7N9) virus – China

Disease outbreak news
22 July 2016

On 12 July 2016, the National Health and Family Planning Commission (NHFPC) of China notified WHO of 7 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus, including 4 deaths.

Onset dates range from 26 May to 23 June. The cases range in age from 52 to 68 years, with a median age of 61 years. Of these 7 cases, 4 (57%) are male. The majority (5 cases, 71%) reported exposure to live poultry, slaughtered poultry or live poultry markets. One case has no history of exposure to poultry and the remaining case worked in a market where live poultry is sold. No human to human transmission was reported.

Cases were reported from 6 provinces and municipalities: Tianjin (2), Anhui (1), Beijing (1), Jiangsu (1), Liaoning (1) and Zhejiang (1).

Public health response

The Chinese Government has taken the following surveillance and control measures:

  •  strengthening outbreak surveillance and situation analysis;
  •  reinforcing all efforts on medical treatment; and
  •  conducting risk communication with the public and dissemination of information.

WHO risk assessment

Most human cases are exposed to the A(H7N9) virus through contact with infected poultry or contaminated environments, including live poultry markets. Since the virus continues to be detected in animals and environments, further human cases can be expected. Although small clusters of human cases with influenza A(H7N9) viruses have been reported previously including those involving healthcare workers, current epidemiological and virological evidence suggests that this virus has not acquired the ability of sustained transmission among humans. Therefore, community level spread of this virus is considered unlikely for the time being.

Human infections with the A(H7N9) virus are unusual and need to be monitored closely in order to identify changes in the virus and/or its transmission behaviour to humans as it may have a serious public health impact.

Sci Rpts: Intense Circulation Of A/H5N1 In Cambodian LBMs & Evidence Of Subclinical Human Infection

Cambodia's H5N1 surge


Between 2011 and 2014 Cambodia reported a significant surge in human H5N1 infections, primarily among young children.  In the previous 6 years (2005-2010) they had only reported a total of 10 cases, but between 2011 and 2014, they reported 46 new cases and 29 deaths. 

In 2013 we saw reports suggesting a new reassortment of H5N1 (between clade 1.1 and clade viruses) had emerged in Cambodia (see Cambodia’s H5N1 Surge & the `M’ Word), although its role in this spike in human cases remains unknown. 

Then - just as abruptly as it began - Cambodia's H5N1 surge ceased, and we've not seen a case reported there since the spring of 2014.

Whether the circulating virus mutated to a less virulent strain, or local public health education efforts were finally successful in halting transmission, or perhaps something changed with Cambodia's reporting and surveillance, is simply unknown.

Nevertheless, even without a case reported in the last 2 years Cambodia remains ranked 4th in the world with documented H5N1 cases and deaths, exceeded only by Egypt, Indonesia, and Vietnam.

Considering Cambodia's much lower population (15 million vs Egypt's 82 million and Vietnam's 89 million), the per capita rate of infection in Cambodia is nearly equal to Egypt's and more than twice that of Vietnam.

It is against this backdrop that we get the following surveillance and seroprevalence study conduced during the height of the H5N1 human outbreaks in 2013 at four live bird markets in Cambodia.

Researchers not only found an incredibly high incidence of H5N1 infected poultry (35%), they found a plethora of other LPAI subtypes (HA1, HA2, HA3, HA4, HA6, HA7, HA9, HA10 and HA11) as well. 
Seroprevalence studies also found evidence of sub-clinical H5N1 and H9N2 infection in LMB workers, and additional seroconversions were documented during the course of the 11 month study.

The full (open access) study is well worth reading. The link and abstract follow.

Citation: Emerging Microbes & Infections (2016) 5, e70; doi:10.1038/emi.2016.69

Published online 20 July 2016

Intense circulation of A/H5N1 and other avian influenza viruses in Cambodian live-bird markets with serological evidence of sub-clinical human infections


Srey Viseth Horm1,*, Arnaud Tarantola1, Sareth Rith1, Sowath Ly1, Juliette Gambaretti1, Veasna Duong1, Phalla Y1, San Sorn2, Davun Holl2, Lotfi Allal3, Wantanee Kalpravidh4, Philippe Dussart1, Paul F Horwood1,* and Philippe Buchy1,5,*

Correspondence: PF Horwood, E-mail:; P Buchy, E-mail:

Received 29 January 2016; Revised 13 April 2016; Accepted 25 April 2016


Surveillance for avian influenza viruses (AIVs) in poultry and environmental samples was conducted in four live-bird markets in Cambodia from January through November 2013.
Through real-time RT-PCR testing, AIVs were detected in 45% of 1048 samples collected throughout the year. Detection rates ranged from 32% and 18% in duck and chicken swabs, respectively, to 75% in carcass wash water samples.
Influenza A/H5N1 virus was detected in 79% of samples positive for influenza A virus and 35% of all samples collected. Sequence analysis of full-length haemagglutinin (HA) and neuraminidase (NA) genes from A/H5N1 viruses, and full-genome analysis of six representative isolates, revealed that the clade 1.1.2 reassortant virus associated with Cambodian human cases during 2013 was the only A/H5N1 virus detected during the year.
However, multiplex reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of HA and NA genes revealed co-circulation of at least nine low pathogenic AIVs from HA1, HA2, HA3, HA4, HA6, HA7, HA9, HA10 and HA11 subtypes.
Four repeated serological surveys were conducted throughout the year in a cohort of 125 poultry workers.
Serological testing found an overall prevalence of 4.5% and 1.8% for antibodies to A/H5N1 and A/H9N2, respectively. Seroconversion rates of 3.7 and 0.9 cases per 1000 person-months participation were detected for A/H5N1 and A/H9N2, respectively. Peak AIV circulation was associated with the Lunar New Year festival.
Knowledge of periods of increased circulation of avian influenza in markets should inform intervention measures such as market cleaning and closures to reduce risk of human infections and emergence of novel AIVs.
      (Continue . . . )

Saudi MOH Announces 1 Primary MERS Case In Buraidah


The pace of new MERS cases has slowed considerably in July with just 11 new infections in the first 3 weeks.  Most of those have been `primary' community acquired cases, with many of them coming from Najran near the Yemen border

Today we've another primary case, with no known risk exposure, this time from Al-Baraidah.

The patient is a 27 year-old male already listed in critical condition. While camel contact is often cited in primary cases, for the vast majority of community acquired cases, the source of their infection is never known.

Iraq: Bird Flu Reports From Babil Governorate

Babil Governorate - Credit Wikipedia

UPDATED (see bottom)


Despite no new filings with the OIE since last April we continue to see almost daily reports of large die offs of poultry in Iraq, with local media reports calling it `bird flu' (see More Reports Of Bird Flu Coming Out Of Iraq).

The assumption is this is H5N1 - since it has been repeatedly reported in Iraq and other Middle Eastern countries in the past - although we have no confirmation of that.

Without official reporting it is impossible to accurately judge the size and scope of these outbreaks. That said, local media have repeatedly indicated losses in the millions of birds.

Until now, the three governorates that have been most often mentioned as seeing outbreaks are Baghdad, Wasit, and Al-Qādisiyyah

Based on a slew of media reports overnight, it appears we can now add Babil Governorate (aka Babylon) to the list, as their Governor (Sadiq Madlool Hamad Jasim) today announced local outbreaks and the halt of poultry imports from outside the province.

This (translated) report from Radio Dijla. 
Babylon reveals the emergence of "bird flu" and decides to temporarily prevent the introduction of poultry

Governor of Babylon Sadiq revealed connotation, on Friday, reported cases of the disease, "bird flu" in a number of areas of the province, stressing that the health committees are currently examining these areas of non-proliferation, while noting that the province has decided to prevent the introduction of poultry them temporarily.

Said Royal, said that "the province issued, a book has been circulated in all Sitarat Mnavd the province to ban the introduction of poultry and birds in general to the province of Babylon, and until further notice," attributing the cause to the prevention of non-transmission of the disease from provinces where cases appeared to avian influenza. " .

He said Royal, that "the province is one of the first provinces to poultry, where the number of fields to maintain more than a thousand field is distributed in the districts of the center and areas of the province," pointing out that "the local government supports poultry as livestock

Despite repeated assurances from the Ministry of Agriculture that their bird flu problem is `under control' and all infected poultry have been destroyed, reports like these suggest Iraq's summer of bird flu is far from over.


The pattern with bird flu reports coming out of Iraq the past couple of months has been initial reports of large outbreaks followed by denials from state or local agencies, often pointing the finger at other provinces. 

True to form, the same source (Radio Dijla) that reported outbreaks in Babylon just hours ago is now reporting:

Veterinary Babylon denies the existence of bird flu in the province

Denied veterinary department in Babylon the presence of bird flu in the province.

He said a brief statement of the department , "there is no bird flu in the province of Babylon , " saying "the presence of the disease in southern Baghdad and northern Wasit only."

The House of Wasit province, announced on 12 July of this recording cases Panevlonzha birds in a number of poultry farms regions of Essaouira and Aziziyah, north of the province ,, declaring campaigns hanging around more than two and a half million birds chicken, also called on the Ministry of Health to take urgent measures to curb the spread of the disease.

the Ministry of Agriculture to stop movement of poultry between Baghdad and the provinces of Wasit to prevent the spread of bird Anfelonzha in the country


Thursday, July 21, 2016

Florida DOH Investigating Another Possible Non-Travel Related Zika Case

Broward County - Credit Wikipedia


For the second time this week the State of Florida is investigating a possible non-travel related case of Zika, this time in Broward County.

Details are scant, but the Florida DOH has released the following statement: 

July 21, 2016
Department of Health

Investigating Possible Non-Travel Related Case Of Zika In Broward County

Communications Office
(850) 245-4111

Tallahassee, Fla. — Today the Florida Department of Health announced that it is conducting an epidemiological investigation into a possible non-travel related case of Zika virus in Broward County. The investigation into the possible case in Miami-Dade County is ongoing.

The department is collaborating with the Centers for Disease Control and Prevention and will share additional details as they become available. Zika prevention kits and repellant will be available at DOH-Broward and distributed in the area under investigation. The department is also coordinating with local OBGYNs for distribution of the kits. Zika kits are intended for pregnant women. The department continues to work closely with mosquito control to ensure trapping, reduction and prevention activities are conducted in the area of investigation.

At the direction of Governor Rick Scott, State Surgeon General Dr. Celeste Philip has requested that CDC provide assistance in our investigation and response efforts by sending a medical epidemiologist to Florida to help our continued investigation into possible non-travel related Zika infection.

Residents and visitors are urged to participate in requests for blood and urine samples by the department in the  areas of investigation. These results will help the department determine the number of people affected.
(continue . . . )

Fiocruz: A Culex Mosquito With The Potential To Transmit Zika

Credit Wikipedia


With the caveat that there are a lot of different species of Culex mosquitoes - and earlier this week we saw a report that cast serious doubt on the ability of the Culex pipiens mosquito to transmit Zika -  today researchers at Brazil's FIOCRUZ Institute have announced they have found a Culex mosquito they believe has the potential to vector the Zika virus.

The mosquito in question is the Culex quinquefasciatus - aka the Southern House Mosquito - which can be found in a broad band ranging between latitudes 36° N and 36° S.

Like the Aedes mosquitoes, C. quinquefasciatus is primarily a tropical and subtropical mosquito, although it has been reported as far north as Indiana (cite) in North America and may mate with C. pipiens (Northern House Mosquito).
Today's announcement builds on earlier studies we've seen by lead researcher Constance Ayres involving Zika and the Culex  mosquito (see Fiocruz: Zika Virus Experimentally Introduced Into Culex Mosquitoes).

Today's report goes beyond simply infecting Culex mosquitoes in the lab. They have now detected naturally Zika infected Culex mosquitoes in the wild and they have shown that experimentally infected Culex mosquitoes replicate the virus about as well as does the Aedes aegypti. 

From their report: 
Besides the detection of virus in these tissues (intestine, and salivary gland), saliva samples were investigated expelled by mosquitoes infected by quantitative RT-PCR. The viral load found in two species ( Aedes aegypti  and  Culex quinquefasciatus ) was similar. 

While important findings -  that suggest this species of Culex has at least the potential to transmit Zika - it doesn't tell us how much of a role (if any) this species actually plays in the transmission of the virus to humans in the wild. 

The report states:

From the data obtained will require additional studies to assess the potential participation of Culex in the spread of zika virus and its role in the epidemic. The current study is very important, since the vector control measures are different.
Until the results of new evidence, the zika epidemic control policy will remain guided by the same guidelines, with its central focus on the control of  Aedes aegypti .

A h/t to Sharon Sanders for the link, the full (translated) announcement from FIOCRUZ follows.


Fiocruz identifies Culex in Recife with the potential to transmit the virus zika

Oswaldo Cruz Foundation (Fiocruz)

Unpublished research conducted by the Oswaldo Cruz Foundation (Fiocruz) detected the presence of zika virus in mosquito  Culex quinquefasciatus  (the popular muriçoca or house mosquito) collected in the city of Recife. This finding confirms the species as a potential vector of the virus that zika, a situation which, according to scientific literature, had not been proven to date.

The survey was conducted by Fiocruz Pernambuco in the metropolitan area of Recife, where the population of Culex quinquefasciatus is about twenty times greater than the population of  Aedes aegypti . Preliminary results of field research identified the presence of  Culex quinquefasciatus  naturally infected zika virus in three of the 80 pools * (groups) of mosquitoes analyzed to date. In two of these samples they were not fed mosquitoes, indicating that the virus was widespread in the insect body and not in a recent power in an infected host.

The technique used in the experiment was quantitative RT-PCR based detection of RNA (genetic material) virus. The material of these positive pools was used to isolate the circulating virus strains in Reef, in cell culture, where it was observed cytopathic effect induced in the cells - i.e., destruction or damage of vero cells was observed, which proves the presence viral activity.

The collection of mosquitoes was made based on the addresses of the reported cases of zika in the cities of Recife and Arcoverde, obtained from the Health Department of Pernambuco State (SES-PE). The total number of mosquitoes examined in the study was approximately 500. The aim of the project is to compare the role of some species of mosquitoes in Brazil of arbovirus transmission. Priority was given to zika virus because the epidemic of the disease in Brazil and its connection with microcephaly.

In the laboratory stage, in order to investigate the vector competence of the species  Culex quinquefasciatus  and  Aedes aegypti , mosquitoes were fed a mixture of blood and viruses, allowing the monitoring of pathogen replication process within the insect. There were two mosquito infections each infection with two different virus concentrations (104 and 106) of Ziku BRPE243 / 2015 lineage. "The smallest simulates viremia condition of a real patient. Then the mosquitoes were collected at different times: at time zero (after infection), three days, seven days, 11 and 15 days after virus infection, "says Constance Ayres, coordinator of the study.

A control group with mosquitoes fed on blood without the virus, was also maintained. Each mosquitoes was dissected to extract the intestine, and salivary gland tissues that present barriers to the development of the virus. The procedure takes place so that, if species vector is not at a given moment the development of the virus is blocked by the mosquito. However, if it is vector, virus replication occurs, spreads in the insect body and just infecting the salivary gland, from which can be transmitted to other hosts during the blood meal, the release of saliva containing virus. According Constancia, from the third day after artificial feeding has been possible to detect the presence of the virus in the salivary glands of both species of mosquito investigated. After seven days, it was observed the peak of infection in the salivary glands which was confirmed by electron microscopy.

Besides the detection of virus in these tissues (intestine , and salivary gland), saliva samples were investigated expelled by mosquitoes infected by quantitative RT-PCR. The viral load found in two species ( Aedes aegypti  and  Culex quinquefasciatus ) was similar.

From the data obtained will require additional studies to assess the potential participation of Culex in the spread of zika virus and its role in the epidemic. The current study is very important, since the vector control measures are different. Until the results of new evidence, the zika epidemic control policy will remain guided by the same guidelines, with its central focus on the control of  Aedes aegypti .

* A pool of mosquitoes consists of 1 to 10 mosquitoes collected in each location, separated by sex and species