Monday, December 22, 2014

ECDC Rapid Risk Assessment On `Drifted’ H3N2 Viruses

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Credit NIAID

 

 

# 9474

 

While we often talk about seasonal strains (H1N1, H3N2, Influenza B) as if they were individual entities – in truth within each subtype there are many clades and variants - and they are all evolving over time. Geographically, these viruses can vary widely, and so the dominate strains in Europe may differ from the dominant strains in North America or Asia.

 

Over time, new, more biologically `fit’ viruses replace older strains as community immunity drives them closer to obsolesce.

 

All which makes the flu world dynamic and ever-changing, and presents a genuine challenge for vaccine manufacturers to stay ahead of. NIAID has a terrific 3-minute video that shows how influenza viruses drift over time, and why the flu shot must be frequently updated, which you can view at this link.

Over the summer it was becoming apparent that a new, `drifted’ H3N2 virus was making inroads in Europe and around the globe (see ECDC: Influenza Characterization – Sept 2014) – one that differed antigenically from this year’s H3N2 vaccine strain. 

 

In September the WHO announced a strain change for next year’s Southern Hemisphere vaccine to meet this viral challenge, but this virus emerged far too late in the year to allow changes to this fall’s Northern Hemisphere vaccine.

 


In early November, in A `Drift’ In A Sea Of Influenza Viruses, I wrote about early concerns over this year’s vaccine, and in the first week of December the CDC issued a HAN Advisory On `Drifted’ H3N2 Seasonal Flu Virus along with a warning that  Early Data Suggests Potentially Severe Flu Season.

 

Today the ECDC has issued their own Risk Assessment on this `drifted’ flu strain.

 

Rapid risk assessment: circulation of drifted influenza A(H3N2) viruses in the EU/EEA, 22 December 2014

22 Dec 2014

Available as PDF in the following languages

EN

This document is free of charge.

Abstract

Surveillance data gathered since 1 October 2014 indicate that in the first ten weeks of the 2014–15 influenza season, viruses in EU/EEA countries have been predominantly A(H3N2) rather than A(H1N1)pdm09 and type B viruses. In previous seasons, influenza A(H3N2) viruses were associated with more severe disease than A(H1N1) and type B viruses; they were also associated with several outbreaks in long-term care facilities.

These observations indicate that the 2014-15 influenza season may be associated with a greater number of cases with more severe disease, given the higher proportion of A(H3N2) strains among isolates typed to date and the early evidence of drift that is likely to be associated with reduced vaccine effectiveness.

Influenza vaccine coverage among the elderly and the risk groups in most parts of Europe is low. However, the benefits of vaccination are considerable in protecting these population groups, even if vaccine effectiveness against one of the circulating viruses may turn out to be low.

 

 

  I’ve excerpted the following from the full report:

 

Main conclusions and recommendations


Surveillance data gathered since 1 October 2014 indicate that in the first ten weeks of the 2014–15 influenza
season, viruses in EU/EEA countries have been predominantly A(H3N2) rather than A(H1N1)pdm09 and type B  viruses. In previous seasons, influenza A(H3N2) viruses were associated with more severe disease than
A(H1N1) and type B viruses; they were also associated with several outbreaks in long-term care facilities.


The recently published US CDC health alert network notification on antigenically drifted influenza A(H3N2) viruses is the first signal from a northern hemisphere country that circulating viruses will include strains that are antigenically distinct from the A(H3N2) vaccine virus, A/Texas/50/2012, which was recommended by WHO for the northern hemisphere 2014–15 season at the February 2014 strain selection meeting.


Very few influenza virus characterisations have been conducted to date in EU/EEA countries, and the majority of them have been genetic rather than antigenic. The genetic information reported so far suggests the following:

  • Influenza A(H3N2) viruses circulating in EU/EEA countries this season will be antigenically distinct from the  northern hemisphere A(H3N2) vaccine virus.
  • Early indications are that circulating A(H1N1)pdm09 viruses are antigenically similar to the vaccine virus.
  • Too few type B viruses have been characterised to date to comment on the likely effectiveness of the B/Massachusetts/2/2012 vaccine component.

These observations indicate that the 2014-15 influenza season may be associated with a greater number of cases with more severe disease, given the higher proportion of A(H3N2) strains among isolates typed to date and the early evidence of drift that is likely to be associated with reduced vaccine effectiveness.


Despite the expected low vaccine effectiveness (VE) of the A(H3N2) vaccine virus component in the vaccines administered for protection in the 2014–15 influenza season, the current tri- and quadrivalent vaccines are likely to provide protection against infection by other currently circulating influenza viruses. Even with low VE of the A(H3N2) vaccine virus components, the vaccine may ameliorate or shorten the duration of influenza disease in infected individuals and is likely to reduce the number of severe outcomes and mortality. Influenza  vaccination remains the most effective measure to prevent illness and possibly fatal outcomes.


The circulating viruses are susceptible to the antiviral drugs oseltamivir and zanamivir. Physicians should therefore always consider treatment or post-exposure prophylaxis with antivirals when treating influenza infected patients and exposed individuals in risk groups.


Influenza vaccine coverage among the elderly and the risk groups in most parts of Europe is low.

However, the benefits of  vaccination are considerable in protecting these population groups, even if vaccine effectiveness against one of the circulating viruses may turn out to be low.

Germany Adopts New Stringent Bird Flu Protection Regulations

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Lower Saxony – Near Dutch Border – Credit Wikipedia

 

# 9473

 

After the announcement on Saturday (see Germany: 2nd H5N8 Outbreak In Lower Saxony) of Germany’s 3rd farm to be impacted by the H5N8 virus, followed closely by a report of a wild duck in the eastern state of Saxony-Anhalt likewise infected, the Federal Ministry of Agriculture (BMEL) has announced new stringent regulations on the raising, sale, and transport of ducks and geese within the country.


Unlike chickens and turkeys, ducks and geese (and waterfowl in general) are less apt to show outward signs of infection with avian flu viruses, and so recent testing is now required prior to transport and slaughter.

 

The concern at this time is over the potential to spread the H5N8 virus to other poultry holdings via the transporting of asymptomatic ducks and geese, rather than any serious human health threat. 

 

This (machine translated) press release from the BMEL.

 

Press release no. 336, 22/12/14

Federal Agriculture Minister Schmidt shall express regulation for protection against avian influenza

Federal Agriculture Minister Christian Schmidt has signed a rush Regulation on Monday, with all the ducks and geese holders are obliged to examine your animal populations for the presence of avian influenza prior to transport. Only with a negative test result, the animals can be transported and slaughtered.

At the time of shipment, the sampling must not be older than seven days. The Regulation shall enter into force on Tuesday at 0.00 clock and applies nationwide by 31st March 2015th The associations of the poultry industry had promised to the Federal Ministry of Agriculture at the weekend to implement the proposed investigation obligation immediately.

"Ducks and geese, in contrast to turkeys and chickens no signs of illness, if they have been infected with the highly infectious virus H5N8. The risk of undetected infected animals are transported and the spread of disease vehicle and personal contacts may be reproduced, is therefore high, "said Minister Schmidt. "This measure is intended to protect our livestock", as Schmidt added.

In the last week of Avian Influenza Virus was first detected in a Lower Saxony turkey fattening farm and then ducks in a pig farm, also in Lower Saxony. Between the two companies was no contact. Experts have previously assumed that the most likely causes of the spread of the pathogen are migratory. As the pathogen has entered the livestock numbers, is still the subject of ongoing investigations.

There is no evidence that the H5N8 virus is transmitted to humans worldwide. Consumers should generally comply with strict kitchen hygiene rules when preparing poultry and poultry eat only cooked through. To protect against animal diseases are beyond raw meat scraps principle in your household trash and not in the organic waste still on the compost heap.

China Reports 7 Recent H7N9 Cases

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# 9472

 

 

It’s been just over two weeks since our last H7N9 notification out of China (see Guangdong, China Reports 1 (Fatal) H7N9 Case), but today Hong Kong’s CHP is reporting on seven recent cases; 4 from Xinjiang, 2 from Zhejiang, and 1 from Jiangsu Province.   Of these, four have died.

 

We aren’t seeing the kind of detail being released with these announcements (e saw during the first two waves, but perhaps that will come when the WHO publishes their updates.

 

Of particular note, we’ve now seen 8 cases reported this fall from the far western Xinjiang Uyghur Autonomous Region, an area far removed from the rest of the H7N9 activity we’ve seen, and a region that did not report any activity during the first two waves.


First the Hong Kong CHP report, then I’ll return with a bit more.

22 December 2014

CHP notified of seven additional human cases of avian influenza A(H7N9) in Mainland 

The Centre for Health Protection (CHP) of the Department of Health (DH) today (December 22) received notification of seven additional human cases of avian influenza A(H7N9) in Xinjiang Uyghur Autonomous Region (Xinjiang) (four cases), Zhejiang (two cases) and Jiangsu (one case) from the National Health and Family Planning Commission.

The patients comprise five men and two women aged from 36 to 81. Four of them (three from Xinjiang and one from Jiangsu) died while two of them (one from Xinjiang and one from Zhejiang) are currently in serious condition. The remaining case from Zhejiang is now in mild condition and did not require hospitalisation.

To date, 454 human cases of avian influenza A(H7N9) have been confirmed in the Mainland in Zhejiang (141 cases), Guangdong (111 cases), Jiangsu (59 cases), Shanghai (42 cases), Hunan (24 cases), Fujian (23 cases), Anhui (17 cases), Jiangxi (eight cases), Xinjiang (eight cases), Beijing (five cases), Shandong (five cases), Henan (four cases), Guangxi (three cases), Jilin (two cases), Guizhou (one case) and Hebei (one case).

(Continue . . .)

 

While there have now been 454 human cases reported, no one really knows how many people have contracted the H7N9 virus.  Some cases (as in the Zhejiang case above) are mild, and are unlikely to be detected.   There are some estimates that put the real number of symptomatic cases in the tens of thousands (see Clinical severity of human infections with avian influenza A(H7N9) virus, China, 2013/14).

 

Whatever the real number, for now – based on the paucity of secondary cases among contacts of known cases - the virus does not show signs of transmitting efficiently from human to human.  Most infections appear to be the result of direct contact with infected birds.

 

The concern is that the H7N9 virus continues to evolve, reassort, and mutate as it spreads in China.  Over the summer, in Eurosurveillance: Genetic Tuning Of Avian H7N9 During Interspecies Transmission, we saw a study that identified at least 26 different genotypes of the virus in circulation.  The authors warned:

 

Overall, due to the genetic tuning procedure, the potential pandemic risk posed by the novel avian influenza A(H7N9) viruses is greater than that of any other known avian influenza viruses.

 

Added to this threat, over the past 12 months several new H5 viruses have emerged that will be competing for king of the viral hill this winter in China, including H5N8, H5N6, and H5N3.  How all of these viruses will mix and mingle over the next few months is an open question.

For more on the evolution of avian flu viruses in China, you may wish to revisit:

Study: H5 Clade 2.3.4.6 Receptor Binding
An Avian Flu Assessment From The Chinese Academy of Sciences
An Avian Flu Primer

Sunday, December 21, 2014

‘Tis The Coronary Season

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# 9471

 

If history is any gauge the three deadliest coronary days of the year will occur over the next two weeks; Christmas day, the day after Christmas, and New Year’s Day.   Events that are commonly called `Christmas Coronaries’ or `Hanukkah Heart Attacks’.

 

Fifteen years ago, a study looked at the rate of heart attacks in the United States, and found that Acute Myocardial Infarctions (AMIs) run as much 53% higher during the winter months than than during the summer.

 

Seasonal distribution of acute myocardial infarction in the second National Registry of Myocardial Infarction.

Spencer FA, Goldberg RJ, Becker RC, Gore JM.

 

While cold weather combined with strenuous physical activity (like clearing snow from sidewalks) has often been blamed for this spike, even in balmy Southern California, studies have shown a 33% increase in heart attacks over the holidays (see below).

When Throughout the Year Is Coronary Death Most Likely to Occur?

A 12-Year Population-Based Analysis of More Than 220 000 Cases

Robert A. Kloner, MD, PhD; W. Kenneth Poole, PhD; Rebecca L. Perritt, MS

Non-climate related factors – like over indulgence in food and alcohol, diminished activity levels, forgetting to take prescription medicines, and combined holiday stressors like shopping, running up debt, traveling, meal preparation, and the angst that comes from dysfunctional family gatherings are likely contributors to this yearly spike. 

 

But increasingly influenza and other respiratory infections have been linked to this seasonal increase in heart attacks.

 

In 2012, in Study: Influenza And Heart Attacks, we looked at research that appeared in the Journal of Infectious Diseases that suggested Influenza - and other acute respiratory infections - can act as a trigger for heart attacks. The same issue carried an editorial called Increasing Evidence That Influenza Is a Trigger for Cardiovascular Disease.

 

Influenza Infection and Risk of Acute Myocardial Infarction in England and Wales: A CALIBER Self-Controlled Case Series Study

Charlotte Warren-Gash, Andrew C. Hayward1, Harry Hemingway2, Spiros Denaxas2, Sara L. Thomas3, Adam D. Timmis5, Heather Whitaker6 and Liam Smeeth4

In 2010, in CMAJ: Flu Vaccinations Reduce Heart Attack Risk we saw what would turn out to be a controversial study (see Vaccine/Heart Attack Study Questioned) that strongly suggested that those over the age of 40 who get a seasonal flu vaccine each year may reduce their risk of a heart attack by as much as 19%.

 

Last year (October 2013), in JAMA: Flu Vaccine and Cardiovascular Outcomes, we looked at a meta-analysis of  5 published and 1 unpublished randomized clinical trials involving  6735 patients – that found among those who had previously had a heart attack, the receipt of a flu vaccine was linked to a 55% reduction in having another major cardiac event in the next few months.

 

So the idea that heart attacks may be linked to influenza infection is hardly new.

 

In late October of this year, the Texas Heart Institute published this article, suggesting that tens of thousands of cardiac deaths could be prevented if every high-risk cardiac patient got the flu shot each year.

 

Research Shows Flu Can Trigger Heart Attacks

Influenza vaccinations could prevent thousands of deaths from heart disease

People who are at risk of heart disease should receive the influenza vaccine every autumn. Research shows that influenza epidemics are associated with a rise in deaths from heart disease and that flu can actually trigger the heart attacks that result in death.

However, only about 60 percent of people in the U.S. who ought to have a flu vaccination actually have one, said Mohammad Madjid, MD, MSc, a senior research scientist at the Atherosclerosis Research Lab of the Texas Heart Institute.

(Continue . . . )

 

If their hypothesis is correct – given the expected reduced effectiveness of this year’s flu vaccine (see CDC HAN Advisory On `Drifted’ H3N2 Seasonal Flu Virus) and the rising tide of H3N2 influenza across the country – the next couple of weeks could prove very busy for the nation’s EMS crews and Coronary care units.


But regardless of the effectiveness of this year’s flu shot, and influenza’s effects on cardiovascular events, even on an `average day’ roughly 1,000 people suffer a Sudden Cardiac Arrest (SCA) in the United States.

 

This from the Heart Rhythm Association:

  • Sudden Cardiac Arrest (SCA) is a leading cause of death in the United States, claiming more than 350,000 lives each year.
  • Approximately 92% of those who experience sudden cardiac arrest do not survive.
  • SCA kills more than 1,000 people a day, or one person every 90 seconds

 

What the people who witness these events do in the first few minutes can mean the difference between life and death for the stricken individual. Luckily, hands-only CPR (cardio-pulmonary resuscitation) is easier to do than ever before, and there are thousands of AEDs (automated external defibrillators) stationed in public venues across the nation.

 

With a little bit of training, you have the potential to save someone’s life.

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While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.  To learn how to use an AED, you can use this online training module  I wrote about in CPR Skills & AED Simulator.  A  CPR class only takes a few hours, can be fun, and is well worth the effort.  

 

To find a local CPR course contact your local chapter of the American Red Cross, the American Heart Association, or (usually) your local fire department or EMS can steer you to a class.

 

Of course, despite your best efforts, many SCA victims will not survive. It isn’t at all like on TV, where 75% of  recipients of CPR survive.  Even when cardiac arrests occur inside a hospital, the survival to discharge rate is less than 40%. Outside the hospital, the odds of seeing a good outcome are lower.

 

While there are no guarantee of success, early and coordinated action taken by bystanders (calling 911, starting CPR, using AED if available) can substantially improve the SCA’s chances of survival. 

 

For more on heart attacks, and CPR, you may wish to visit some of these earlier blogs.

 

Deadlier Than For The Male

Survivability Of Non-Shockable Rhythms With New CPR Guidelines

Fear Of Trying

NPM11: Early CPR Saves Lives

Saturday, December 20, 2014

Media Reports Of New H5N1 Cases In Egypt

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# 9470

 

The Egyptian Ministry of Health webpage hasn’t mentioned H5N1 in more than 2 weeks, but we continue to see news reports of new cases announced by the Health Ministry.  On Wednesday, we saw reports from the Egyptian Media: 18th H5N1 Case Of 2014, 14 of whom had been announced since the middle of November.


On Friday there were vague reports of a 3 year-old infected who would have made #19, but since we’d just seen a 3 year old reported, it wasn’t certain that this was a fresh case.  

 

Keeping track, based purely on syntax challenged machine translated news reports, is always an `iffy’ proposition. Fair enough to say that new cases continue to pop up. Today, multiple media sources are reporting the 20th confirmed case – that of a 42 year-old woman from Sohag, who apparently first fell ill on December 4th, was hospitalized on the 12th, and transferred to a new hospital today.

 

Offered without endorsement are the following reports from http://www.masrawy.com and http://w-youm.com

 

Health: avian flu patients rising to 20 in. These prevention methods

Saturday, December 20, 2014, 05: 53 pm

Health: avian flu patients rising to 20 in. These ways of preventing bird flu patients rising for 20 cases

The Ministry of health and population has announced the positive test results for HIV N5H1, old lady, 42, of parit buntar Sohag governorate.

The Ministry said via a statement posted Saturday that it began to show symptoms on 4/12/2014 went for treatment at the Hospital of viruses of Sohag on 15/12/2014 which was suffering from a fever – nominated – cough with suspicion in the case and reported the situation of birds in backyard and booked the chest having double pneumonia and her health status and average hospital released the Abbasid on 20/12/2014.

Bringing the total number of cases of bird flu in 2014 so far 20 cases (8 cases of healing, 3 cases under treatment, 9 deaths).

(Continue . . . )

 

«Health» announce new bird flu Case in Sohag

11: 07 pm-2014/12/20

The Ministry of health and population has announced the positive results of the bird flu virus (N5H1) old lady 42 years from parit buntar Sohag governorate, where symptoms began on 4 December, and went to seek treatment at the Hospital of viruses of Sohag on 15/12/2014, which was experiencing (fever nominated cough), and is suspected in the case, according to the situation of birds in backyard and was booked, and chest showed a double pneumonia and her health Medium, and the case has been transferred to a hospital in abassiya on 20/12/2014.

Bringing the total number of cases of bird flu in 2014 so far 20 cases (8 cases of healing, 3 cases under treatment, 9 deaths).

(Continue . . . )

Germany: 2nd H5N8 Outbreak In Lower Saxony

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Emmsland – Lower Saxony – Near Dutch Border – Credit Wikipedia

 


# 9469



Detections of highly pathogenic H5N8 – an avian flu subtype practically unknown a year ago – continue with another farm in Germany reporting the virus.  This is the third German farm in just over a month to report an outbreak.

 

We’ve also seen this highly mobile avian flu virus abruptly show up in North America, Japan, and Italy this week, likely spreading via migratory birds.   

 

While H5N8 is not currently believed to pose a serious human health threat, and is primarily a concern for poultry producers, H5 avian viruses are notoriously unstable and difficult to control. So this rapid geographic expansion of H5N8 bears watching.

 

This report from NRC.NL

 

Bird flu in Germany, again near Dutch border

News

In the German Meppen, that near the Dutch border is, is a second case of bird flu at a duck farm discovered. It comes to the dangerous variant H5N8.

Meppen is located in Lower Saxony, Germany, about 35 kilometres from Emmen.

Control in other companies

The Ministry of agriculture in Hannover reports that all 10,000 birds are culled. In a radius of 3 km are checked poultry farms. In that area are still 18 poultry farms with a total of 180,000 animals. For the time being applies a transport ban at this time.

(Continue . . .)