Saturday, April 25, 2015

CDC’s Key Facts On The New H3N2 Canine Flu

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Credit CDC - Healthy Pets Healthy People

 

# 9979

 

Two weeks ago, in Midwest Canine Influenza Outbreak Due To `New’ Korean H3N2 Virus, we learned that an outbreak of canine influenza which began a month or so ago around Chicago was due to an Asian H3N2 canine flu subtype which emerged in 2007 (see Transmission of Avian Influenza Virus (H3N2) to Dogs). 


How this emerging influenza subtype managed to jump from Korea (or perhaps China) to the United States is unclear. But now that it is here, it appears to be spreading rapidly through an immunologically naive dog population. 

 

Unlike our domestic canine H3N8 - which jumped from horses to dogs in 2004, and has circulated in North America sporadically since then - this subtype has also been shown capable of infecting cats as well (see Korea: Interspecies Transmission of Canine H3N2). 

 

Adding yet another wrinkle, this H3N2 virus appears to be of avian origin. The HA and NA of the A/canine/Korea/01/2007 (H3N2) isolate was closely related to those identified from South Korean chickens and doves in 2003.

 

As with the existing equine and canine strains of H3N8, we’ve not seen any evidence of human infection with this canine H3N2 virus. But like all influenza viruses, canine H3N2 is a continually moving target.  It can not only evolve via antigenic drift, it can also pick up entire gene segments from other flu viruses via antigenic shift (aka reassortment).

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And while rare, as any virologist will tell you – shift happens.

 

Last summer we saw evidence of just such an event, in areport appearing in the journal Epidemiology & Infection, that  found a new reassortment of the canine H3N2 virus – one that had picked up the M (matrix) gene from the 2009 H1N1 pandemic virus (see Canine H3N2 Reassortant With pH1N1 Matrix Gene) – in china.

 

When found in reassorted swine variant viruses, The CDC has speculated that `This M gene may confer increased transmissibility to and among humans, compared to other variant influenza viruses.’ – CDC HAN 2012

 

But so far, we’ve seen no evidence that this canine H3N2 can infect humans.

 

This week the CDC published a new updated FAQ file on Canine influenza, specifically addressing this newly arrived subtype, including whether it has the potential to jump to humans.  I’ve excerpted the first two segments, so follow the link to read it in its entirety.

 

 

Key Facts about Canine Influenza (Dog Flu)

What is canine influenza (dog flu)?

Canine influenza (also known as dog flu) is a contagious respiratory disease in dogs caused by specific Type A influenza viruses known to infect dogs. These are called "canine influenza viruses." Dog flu is a disease of dogs. No human infections with canine influenza have ever been reported. There are two different influenza A dog flu viruses: one is an H3N8 virus and the other is an H3N2 virus.

Can canine influenza viruses infect humans?

To date, there is no evidence of transmission of canine influenza viruses from dogs to people and there has not been a single reported case of human infection with a canine influenza virus.

However, influenza viruses are constantly changing and it is possible for a virus to change so that it could infect humans and spread easily between humans. Human infections with new influenza viruses (against which the human population has little immunity) are concerning when they occur. Such viruses could present pandemic influenza threats. For this reason, CDC and its partners are monitoring the canine influenza H3N8 and H3N2 viruses (as well as other animal influenza viruses) closely. In general, canine influenza viruses are considered to pose a low threat to humans.

  • Where did canine influenza viruses come from and how long has it been around?
  • What are signs of canine influenza infection in dogs?
  • How serious is canine influenza infection in dogs?
  • How is canine influenza spread?
  • Is there a test for canine influenza?
  • Is there a vaccine for canine influenza?
  • My dog has a cough. What should I do?
  • Where can I find more information on canine influenza virus?
  • Nepal Struck By A 7.9 Quake – Major Damage Reported (Updated)

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    UPDATED 0700 hrs EST:   The USGS has downgraded this quake to M7.8, but has revised their damage/fatality estimates upwards, with as many as 10,000 deaths possible.   This is a rapidly evolving situation, and we are only now starting to get reports from the ground.

     

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    # 9978

     

    Four years ago, in UNDP: Supercities At Seismic Risk, we looked at a United Nations Development Programme study that warned half of the world’s supercities (urban areas with 2 million – 15 million inhabitants) were at high risk of seismic activity.  From their press release:

     

    A significant number of very large cities with high population density such as Tokyo, Mexico City, Port-au-Prince, Istanbul or Kathmandu, many in developing countries with rapidly expanding population, are located near fault zones that have caused major earthquakes in the past – and most likely will again in the future.

     


    Over the past several hours Nepal has seen a cluster of a dozen strong earthquakes – topped off by an M7.9, and followed by an M6.6 – striking in the region Northwest of Kathmandu.  Fortunately, the epicenter of the strongest quake was 50 miles from the heart of Kathmandu.

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    The USGS pager system, which generates likely damage based on location, magnitude, depth, and ground shaking, has estimated between 100 and 1,000 fatalities likely occurred.   (See update above)

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    We’re just starting to get on-the-scene reports of damage and injuries, and those will be coming in for hours, if not days.  Strong aftershocks may continue for weeks as well.

     

    While Nepal is no stranger to strong quakes (M6.8 in 1988, 2011 M6.9 Sikkim Quake ) this is the strongest quake to strike the region since the M8.0+ 1934 Nepal-Bihar earthquake, which claimed at least 10,000 lives.


    The deep reds in the USGS map below show the areas most at risk of seismic activity, and as you’ll see the boundary where Northern India and the Eurasian plate meet is one the more active regions of the world.

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    Seismically active areas of the world

    Earthquakes strike without warning, and literally billions of people live on, or near seismic zones.   Millions more live within range of earthquake driven tsunamis. The ground beneath one’s feet can violently shift in an instant, making it imperative that you, your family, and your business are prepared.

     

    Working to improve earthquake awareness, preparation, and safety is Shakeout.org, which promotes yearly earthquake drills and education around the country (see NPM13: A Whole Lotta Shakeouts Going On).  If you live in one of these seismically active areas, I would encourage you to take part in these yearly drills.

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    Every home should have no less than a 72-hour supply of emergency food and water, for all of its occupants (including pets!).  This is a bare minimum, here in the United States many agencies and organizations recommend that households work towards having a 10-day supply of food, water, and emergency supplies on hand.

     

    In When 72 Hours Isn’t Enough, I highlighted  a colorful, easy-to-follow, 100 page `survival guide’ released by Los Angeles County, that covers everything from earthquake and tsunami preparedness, to getting ready for a pandemic.

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    While admittedly California-threat specific, this useful guide may be downloaded here (6.5 Mbyte PDF).

    For more information on emergency preparedness, I would invite you  to visit:

    FEMA http://www.fema.gov/index.shtm

    READY.GOV http://www.ready.gov/

    AMERICAN RED CROSS http://www.redcross.org/

    And some of my preparedness blogs, including:

    NPM14: The Advantages Of Having A Shaky Preparedness Plan

    The Gift Of Preparedness – 2014 Edition

    In An Emergency, Who Has Your Back?

    Friday, April 24, 2015

    APHIS: 3 More Minnesota Farms Hit By HPAI H5N2, 1 In Wisconsin

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    HPAI H5 Detections In North America

     

    # 9977

     

    We seem to be getting into a pattern where individual states are announcing outbreaks, but those reports are taking a couple of days to show up on the USDA’s APHIS website. 

     

    Case in point, as of yesterday Wisconsin was reporting 6 outbreaks, yet this evening’s APHIS update still only shows 4, and yesterday’s reported outbreak in Sac County, Iowa has yet to appear on their list. 

     

    It may be that APHIS is waiting for full subtype information to to come back from the lab before posting.

     

    In any event, APHIS announced three new outbreaks today in Minnesota, and one of the  Wisconsin cases we learned of yesterday morning.   Given the volume of testing going on - including ongoing surveillance of flocks within the quarantine zones surrounding infected farms - it is little wonder that the release of data is at times erratic.

     

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    Although the APHIS tally lists 7,837,073 bird now affected, there are a several farms where the numbers are still pending, and several other farms that the states have announced as being infected, but are not yet listed. 

     

    All of which means the real number is probably in excess of 8 million birds by now, and still growing.

    North Dakota Reports 2nd Outbreak Of HPAI H5

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    # 9975

     

    Not quite two weeks after their first farm was struck in Dickey County, today the North Dakota Department of Agriculture has announced a second farm in adjacent LaMoure County as been hit by a highly pathogenic H5 virus.   Final sub typing is pending, but the expectation is that this will turn out to be HPAI H5N2.

     

     

    Avian influenza confirmed in second North Dakota flock

    Submitted April 24, 2015

    BISMARCK, N.D. – The United States Department of Agriculture’s (USDA) Animal and Plant Health Inspection Service (APHIS) has confirmed the presence of highly pathogenic H5 avian influenza (HPAI) in a commercial turkey flock in LaMoure County, North Dakota. The premises contained approximately 69,000 turkeys and also about 2,000 chickens. A presumptive positive case was first identified by the University of Minnesota’s Veterinary Diagnostic Laboratory and confirmed by the APHIS National Veterinary Services Laboratories in Ames, Iowa. This is the second case confirmed in North Dakota. A response team has been working with a Dickey County poultry farm since the first case was confirmed earlier this month.

    The State Board of Animal Health and the North Dakota Department of Agriculture are working closely with USDA-APHIS and local officials in the LaMoure County response. The premises has been quarantined and the flock will be destroyed to prevent the spread of the disease. Domestic birds in a 6-mile control zone around the affected farm will be monitored and tested; and movement is being restricted to help prevent the spread of HPAI. Birds from the flock will not enter the food system.

    There is no immediate public health concern due to this finding. The risk to people from HPAI is low despite the disease often being fatal for birds. No human infections with these viruses have been detected in the U.S.

    “We have activated the avian influenza response plan that has been in place for some time,” said North Dakota State Veterinarian Dr. Susan Keller. “It is a collaborative effort with help from federal and state agencies, local officials and poultry producers.”

    The avian influenza response team is working around the clock to control the outbreak and serve as a resource to residents. In an emergency clause, the North Dakota legislature has allotted $300,000 of federal spending authority to respond to and combat avian influenza.

    Due to the recent findings of HPAI in North Dakota and surrounding states, poultry owners should immediately report death loss to their local and state veterinarian, restrict access to their property, prevent contact between their birds and wild birds and practice enhanced biosecurity.

    Avian influenza exists in many wild birds and can be transmitted by contact with infected birds or ingestion of contaminated food and water.

    As the number of HPAI cases continue to rise across the Midwest, scientists anticipate warmer temperatures will slow the spread of the disease. Typically, influenza viruses are hampered by warm, dry conditions.

    More information about avian influenza and biosecurity recommendations is available at www.nd.gov/ndda/disease/avian-influenza and from the USDA-APHIS at www.aphis.usda.gov.

     

     

    We should get an update on other avian flu activity from the USDA’s APHIS website sometime after 5pm EST.

    CDC HAN Advisory & MMWR: HIV & HCV Among Injectable Drug Users

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    # 9974

     

    Over the past month we’ve been following the HIV and HCV outbreak in Southeastern Indiana (see Indiana Gov To Declare HIV Health Emergency In Scott County & Scott County HIV Epidemic Reaches 130 Cases) which has now grown to 142 cases. 

     

    Reportedly, at least 80% of these cases are injectable drug users, and this practice appears to be driving this epidemic.

     

    Today the CDC, along with officials from the State of Indiana, held a 50-minute-long press conference in advance of the release of a CDC HAN  message, and an early release MMWR called  Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone — Indiana, 2015.

    The MMWR describes socio-economic situation in Scott County as:

    Injection drug use in this community is a multi-generational activity, with as many as three generations of a family and multiple community members injecting together. IDU practices include crushing and cooking extended-release oxymorphone, most frequently 40 mg tablets not designed to resist crushing or dissolving. Syringes and drug preparation equipment are frequently shared (e.g., the drug is dissolved in nonsterile water and drawn up into an insulin syringe that is usually shared with others). The reported daily numbers of injections ranged from four to 15, with the reported number of injection partners ranging from one to six per injection event.

    Like many other rural counties in the United States, the county has substantial unemployment (8.9%), a high proportion of adults who have not completed high school (21.3%), a substantial proportion of the population living in poverty (19%), and limited access to health care (1). This county consistently ranks among the lowest in the state for health indicators and life expectancy (2).

     

    And the demographics of the outbreak:

     

    The age range of the 135 patients is 18–57 years (mean = 35 years; median = 32 years); 74 (54.8%) are  male. A small number of pregnant women were diagnosed with HIV infection and started on antiretroviral  therapy during pregnancy. As of April 21, no infants had tested positive for HIV. Of the 135 persons with diagnosed HIV infection, 108 (80.0%) have reported injection drug use (IDU), four (3.0%) have reported no IDU, and 23 (17.0%) have not been interviewed to determine IDU status. Among the 108 who have reported IDU, all reported dissolving and injecting tablets of oxymorphone as their drug of choice. Some reported injecting other drugs, including methamphetamine and heroin. Ten (7.4%) female patients have been identified as commercial sex workers. Coinfection with hepatitis C virus has been diagnosed in 114 (84.4%) patients

     

    Because the conditions described in Scott county are not necessarily unique to that part of the country, the CDC has issued a HAN Advisory to alert clinicians to be alert to signs of similar outbreaks in their communities, so that public health interventions can come sooner rather than later.

     

    Some excerpts from a much longer HAN Advisory follow: 

     

    Outbreak of Recent HIV and HCV Infections among Persons Who Inject Drugs

     This is an official CDC HEALTH ADVISORY

    Distributed via the CDC Health Alert Network
    April 24, 2015, 11:00 ET (11:00 AM ET)
    CDCHAN-00377

    Summary

    The Indiana State Department of Health (ISDH) and the Centers for Disease Control and Prevention (CDC) are investigating a large outbreak of recent human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID). Many of the HIV-infected individuals in this outbreak are co-infected with hepatitis C virus (HCV). The purpose of this HAN Advisory is to alert public health departments and healthcare providers of the possibility of HIV outbreaks among PWID and to provide guidance to assist in the identification and prevention of such outbreaks.

    <SNIP>

    Recommendations for Health Departments

    • Review the most recent sources of data on HIV diagnoses, HCV diagnoses (acute as well as past or present), overdose deaths, admissions for drug treatment, and drug arrests. Attributes of communities at risk for unrecognized clusters of HIV and HCV infection include the following:
      • Recent increases in the:
        • Number of HIV infections attributed to injection drug use,
        • Number of HCV infections, particularly among persons aged < 35 years;
      • High rates of injection drug use and especially prescription-type opioid abuse, drug-related overdose, drug treatment admission, or drug arrests.
    • Ensure complete contact tracing for all new HIV diagnoses and testing of all contacts for HIV and HCV infection.
    • Ensure persons actively injecting drugs or at high-risk of drug injection (e.g., participating in drug substitution programs, receiving substance abuse counseling or treatment, recently or currently incarcerated) have access to integrated prevention services,9 and specifically:
      • Are tested regularly for HIV and HCV infection (consider more frequent testing based on frequency of injection drug usage or sharing of injection equipment);
      • If diagnosed with HIV or HCV infection:
      • Are rapidly linked to care and treatment services;
      • If actively injecting drugs:
        • Have access to medication-assisted therapy (e.g., opioid substitution therapy) as well as other substance abuse services, if not already engaged,
        • Are counseled not to share needles and syringes or drug preparation equipment (e.g., cookers, water, filters),
        • Have access to sterile injection equipment from a reliable source.
      • If not HIV infected but actively injecting drugs:
        • Are referred for consideration of HIV pre-exposure prophylaxis10 and if potentially exposed within the past 72 hours (e.g., shared drug preparation or injection equipment with a known or potentially HIV-infected person) HIV post-exposure prophylaxis11,12
    • Remind venues that may encounter unrecognized infections, such as emergency departments and community-based clinical practices (e.g., family medicine, general medicine, prenatal care) of the importance of routine opt-out HIV testing as well as HCV testing per current recommendations13-15
    • Local health departments should notify their state health department and CDC of any suspected clusters of recent HIV or HCV infection.

    Recommendations for Healthcare Providers

    • Ensure all persons diagnosed with HCV infection are tested for HIV infection,16 and that all persons diagnosed with HIV infection are tested for HCV infection.17
    • Ensure persons receiving treatment for HIV and/or HCV infection adhere to prescribed therapy and are engaged in ongoing care.
    • Encourage HIV and HCV testing of syringe-sharing and sexual partners of persons diagnosed with either infection.
    • Report all newly diagnosed HIV and HCV infections to the health department.
    • For all persons with substance abuse problems:
      • Refer them for medication-assisted treatment (e.g., opioid substitution therapy) and counseling services,
      • Use effective treatments (e.g., methadone, buprenorphine), as appropriately indicated.
    • For any persons for whom opioids are under consideration for pain management:
      • Discuss the risks and benefits of all pain treatment options, including ones that do not involve prescription analgesics.
      • Note that long-term opioid therapy is not associated with reduced chronic pain.18
    • Contact the state or local health department to report suspected clusters of recent HIV or HCV infection.

    (Continue . . .)

    BMJ Open: Protectiveness (Or Lack, Thereof) Of Reusable Cloth Medical Masks

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    Cloth Masks used during the 1918 Pandemic

     

    # 9973

     

    Over the years we’ve looked repeatedly at the relative protectiveness of PPEs - personal protective equipment (N95s, PAPRs, disposable med/surgical masks) - but due to their rare usage in the developed world, have only infrequently addressed the use of washable cloth or cotton masks, whose use remains ubiquitous in developing countries.

     


    Cloth facemasks went the way of the Dodo bird in U.S. healthcare settings decades ago, replaced by inexpensive disposable surgical masks. Cloth masks are still used by many HCWs – particularly in low resources settings - around the world and would likely be embraced by the public during a pandemic.

     

    While the level of protection they provide to the wearer has been long debated (see NIOSH Webinar: Debunking N95 Myths & The Great Mask Debate Revisited), given their low cost and the fact that they don’t have to be individually `fitted’, disposable surgical masks are routinely worn by HCWs. 

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    In the developing world, however, disposable PPEs are a luxury that few hospitals can afford. Reusable cloth masks and gowns are frequently employed, even when dealing with highly infectious diseases like measles, novel influenza, or hemorrhagic fevers. 

    In the event of a localized epidemic (or worse, a pandemic), disposable PPEs will be quickly be in very short supply. 

    At one time the HHS estimated the nation would need an impossible 30 billion masks (27 billion surgical, 5 Billion N95) to deal with a major pandemic (see Time Magazine A New Pandemic Fear: A Shortage of Surgical Masks).


    So the question becomes, just how protective are cloth (reusable) face masks?

     

    According to a study, published yesterday by the BMJ Open Journal, is `not very’.    In fact, there is some evidence they may actually increase infection risks.

    First a link to the study (again by Chughtai, Seale & MacIntyre, et al.), and some excerpts from the abstract and the UNSW press release.   

     

    BMJ Open 2015;5:e006577 doi:10.1136/bmjopen-2014-006577

     

    A cluster randomised trial of cloth masks compared with medical masks in healthcare workers

    C Raina MacIntyre1, Holly Seale1,  Tham Chi Dung2,  Nguyen Tran Hien2,  Phan Thi Nga2,  Abrar Ahmad  Chughtai1,  Bayzidur Rahman1,  Dominic E Dwyer3,  Quanyi Wang4

    Published 22 April 2015

    Abstract

    Objective The aim of this study was to compare the efficacy of cloth masks to medical masks in hospital healthcare workers (HCWs). The null hypothesis is that there is no difference between medical masks and cloth masks.

    Setting 14 secondary-level/tertiary-level hospitals in Hanoi, Vietnam.

    Participants 1607 hospital HCWs aged ≥18 years working full-time in selected high-risk wards.

    Intervention Hospital wards were randomised to: medical masks, cloth masks or a control group (usual practice, which included mask wearing). Participants used the mask on every shift for 4 consecutive weeks.

    Main outcome measure Clinical respiratory illness (CRI), influenza-like illness (ILI) and laboratory-confirmed respiratory virus infection.

    Results The rates of all infection outcomes were highest in the cloth mask arm, with the rate of ILI statistically significantly higher in the cloth mask arm (relative risk (RR)=13.00, 95% CI 1.69 to 100.07) compared with the medical mask arm. Cloth masks also had significantly higher rates of ILI compared with the control arm. An analysis by mask use showed ILI (RR=6.64, 95% CI 1.45 to 28.65) and laboratory-confirmed virus (RR=1.72, 95% CI 1.01 to 2.94) were significantly higher in the cloth masks group compared with the medical masks group. Penetration of cloth masks by particles was almost 97% and medical masks 44%.

    Conclusions This study is the first RCT of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Further research is needed to inform the widespread use of cloth masks globally. However, as a precautionary measure, cloth masks should not be recommended for HCWs, particularly in high-risk situations, and guidelines need to be updated.

     

    Public Release: 22-Apr-2015

    Cloth masks -- dangerous to your health?

    University of New South Wales

    The widespread use of cloth masks by healthcare workers may actually put them at increased risk of respiratory illness and viral infections and their global use should be discouraged, according to a UNSW study.

    The results of the first randomised clinical trial (RCT) to study the efficacy of cloth masks were published today in the journal BMJ Open.

    The trial saw 1607 hospital healthcare workers across 14 hospitals in the Vietnamese capital, Hanoi, split into three groups: those wearing medical masks, those wearing cloth masks and a control group based on usual practice, which included mask wearing.

    Workers used the mask on every shift for four consecutive weeks.

    The study found respiratory infection was much higher among healthcare workers wearing cloth masks.

    The penetration of cloth masks by particles was almost 97% compared to medical masks with 44%.

    Professor Raina MacIntyre, lead study author and head of UNSW's School of Public Health and Community Medicine, said the results of the study caution against the use of cloth masks.

     (Continue . . . )

     

     

    The recommendation by MacIntyre et al. is that Health care workers not rely on reusable cloth masks, as their use is associated with an increased risk of infection. The authors list a number of limitations to this study, however, and it isn’t at all clear whether wearing cloth masks was detrimental to HCWs. 

     

    They only showed that  the lowest rates of infection were in the medical mask group, while the highest rates were seen in those wearing the cloth masks. 

     

    And it must be stated that not all cloth masks are created equal (nor are all disposable surgical masks) in terms of quality, fit, and filtration.  Additionally, the question as to whether cloth masks have a legitimate role for the public during an epidemic – as a protection of last resort – is not addressed in this study.  

     

    In 2006, the IOM published a report entitled Reusability of Facemasks During an Influenza Pandemic: Facing the Flu, which addressed the issue of `improvised’ masks during a pandemic, and while not exactly endorsing them, accepts the will likely be necessary.

     

    Regulatory standards require that a medical mask should not permit blood or other potentially infectious fluids to pass through to or reach the wearer’s skin, mouth, or other mucous membranes under normal conditions of use and for the duration of use. It is not clear that cloth masks or improvised masks (e.g., towels, sheets) can meet these standards.

    Without better testing and more research, cloth masks or improvised masks can not be recommended as effective respiratory protective devices or as devices that would prevent exposure to splashes.

    However, these masks and improvised devices may be the only option available for some individuals during a pandemic. Given the lack of data about the effectiveness of these devices in blocking influenza transmission, the committee hesitates to discourage their use but cautions that they are not likely to be as protective as medical masks or respirators. The committee is concerned that their use may give users a false sense of   protection that will encourage risk-taking and/or decrease attention to other hygiene measures.

     

    Given that supplies of disposable masks in this interpandemic period are plentiful, and their cost is minimal (< .10 each), it isn’t such a bad idea to put back a few boxes of surgical masks in your family’s emergency stockpile, rather than being forced to rely on homemade improvised masks.


    But all stockpiles are finite, and if I were down to only having cloth masks at my disposal, I would still  bank on the idea that wearing any mask beats wearing none at all.