Friday, January 30, 2015

FluView Week 3: Senior Hospitalizations Soar & H1N1v In Minnesota


  *** Correction ***  H1N1v was inadvertently listed as H3N2v in original post – Mea culpa.


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Since we’ve got a drifted `H3N2’ virus running rampant across much of the northern hemisphere, an unusually vigorous outbreak of H5N1 in Egypt, our regular winter H7N9 mini-epidemic in China, avian HPAI H5 viruses spreading impressively internationally, and even a pair of imported H7N9 cases in Canada this week  . . .it makes perfect sense that the latest MMWR & FluView would include news of an uncharacteristically out-of-season H1N1v infection in Minnesota as well.

H1N1v is  a swine H1N1 virus - that when it jumps to humans - gets the `variant’ tag.


Although telegraphed in yesterday’s MMWR, the following announcement appears in today’s FluView Report.

Novel Influenza A Virus:

One human infection with a novel influenza A virus was reported by the state of Minnesota. The person was infected with an influenza A (H1N1) variant (H1N1v) virus, and has fully recovered from their illness. No ongoing human-to-human transmission has been identified and the case patient reported contact with swine in the week prior to illness onset.

Early identification and investigation of human infections with novel influenza A viruses are critical in order to evaluate the extent of the outbreak and possible human-to-human transmission. Additional information on influenza in swine, variant influenza infection in humans, and strategies to interact safely with swine can be found at

Over the past few years we’ve watched as several swine variant influenza viruses (H1N1v, H1N2v or H3N2v) have made tentative jumps into the human population (see Keeping Our Eyes On The Prize Pig) and each summer the CDC has issued advice on preventing infection at county and state fairs (see Measures to Minimize Influenza Transmission at Swine Exhibitions, 2014).

We’ve not seen many reported cases the past couple of years, but during the summer of 2012 more than 300 cases were detected, with Indiana and Ohio accounting for roughly 80% of the cases. 


Illnesses were usually mild or moderate (1 fatality was recorded), and infection usually occurred in the summer and fall and was associated with attendance of local and state fairs where pigs were being shown.  Of course, some people have contact with swine all year round, and so while uncommon, it isn’t terribly surprising that someone would contract H3N2v during the winter.

What is surprising is that it  - like we saw with H7N9 in Canada earlier this week – this novel virus was detected against the background noise of a particularly nasty H3N2 influenza season. 


While occasional cases are not particularly alarming,  we keep an eye on these swine variant viruses because research has shown there to be only limited community immunity against them (see CIDRAP: Children & Middle-Aged Most Susceptible To H3N2v).

Of more immediate concern is this year’s seasonal flu activity, which remains brisk across much of the country, although in some states are seeing a drop in cases. 


Hospitalization rates for the elderly (65+) are the highest ever recorded since the CDC began tracking that data in 2005, and the CDC continues to remind providers of value of early administration of antiviral medications (see Antiviral Letter to Providers).


This from today’s FluView Report.


2014-2015 Influenza Season Week 3 ending January 24, 2015

All data are preliminary and may change as more reports are received.


During week 3 (January 18-24, 2015), influenza activity remained elevated in the United States.

  • Viral Surveillance: Of 23,339 specimens tested and reported by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories during week 3, 4,651 (19.9%) were positive for influenza.
  • Novel Influenza A Virus: One human infection with a novel influenza A virus was reported.
  • Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was above the epidemic threshold.
  • Influenza-associated Pediatric Deaths: Five influenza-associated pediatric deaths were reported.
  • Influenza-associated Hospitalizations: A cumulative rate for the season of 40.5 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported.
  • Outpatient Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) was 4.4%, above the national baseline of 2.0%. All 10 regions reported ILI at or above region-specific baseline levels. Puerto Rico and 29 states experienced high ILI activity; New York City and seven states experienced moderate ILI activity; six states experienced low ILI activity; eight states experienced minimal ILI activity; and the District of Columbia had insufficient data.
  • Geographic Spread of Influenza: The geographic spread of influenza in Puerto Rico and 44 states was reported as widespread; the U.S. Virgin Islands and five states reported regional activity; and the District of Columbia, Guam, and one state reported local activity.

Pneumonia and Influenza (P&I) Mortality Surveillance:

During week 3, 9.1% of all deaths reported through the 122 Cities Mortality Reporting System were due to P&I. This percentage was above the epidemic threshold of 7.1% for week 3.

Pneumonia And Influenza Mortality

Influenza-Associated Pediatric Mortality:

Five influenza-associated pediatric deaths were reported to CDC during week 3. Four deaths were associated with an influenza A (H3) virus and occurred during weeks 53, 1, 2, and 3 (weeks ending January 3, January 10, January 17, and January 24, 2015, respectively). One death was associated with an influenza A virus for which no subtyping was performed and occurred during week 1.

A total of 61 influenza-associated deaths have been reported during the 2014-2015 season from New York City [1] and 24 states (Arizona [1], Colorado [2], Florida [2], Georgia [1], Indiana [1], Iowa [3], Kansas [2], Kentucky [3], Louisiana [2], Michigan [1], Minnesota [4], Missouri [1], North Carolina [2], Nevada [3], New York [1], Ohio [5], Oklahoma [4], Pennsylvania [1], South Carolina [1], South Dakota [1], Tennessee [4], Texas [7], Virginia [3], and Wisconsin [5]).
Additional data can be found at:

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Influenza-Associated Hospitalizations:

Between October 1, 2014 and January 24, 2015, 11,077 laboratory-confirmed influenza-associated hospitalizations were reported. The overall hospitalization rate was 40.5 per 100,000 population. The highest rate of hospitalization was among adults aged ≥65 years (198.4 per 100,000 population), followed by children aged 0-4 years (38.2 per 100,000 population). Among all hospitalizations, 10,690 (96.6%) were associated with influenza A, 290 (2.6%) with influenza B, 29 (0.3%) with influenza A and B co-infection, and 62 (0.5%) had no virus type information. Among those with influenza A subtype information, 3,016 (99.7%) were A(H3N2) virus and nine (0.3%) were A(H1N1)pdm09.

Clinical findings are preliminary and based on 1,729 (15.6%) cases with complete medical chart abstraction. The majority (93.7%) of hospitalized adults had at least one reported underlying medical condition; the most commonly reported were cardiovascular disease, metabolic disorders, and obesity. There were 230 hospitalized children with complete medical chart abstraction, 94 (40.9%) had no identified underlying medical conditions. The most commonly reported underlying medical conditions among pediatric patients were asthma, obesity, neurologic disorders and immune suppression. Among the 173 hospitalized women of childbearing age (15-44 years), 47 were pregnant.

Additional FluSurv-NET data can be found at: and


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Despite its reduced effectiveness, the CDC continues to recommend that people get the flu shot – partially because it may provide some modicum of protection against this drifted flu strain, and partly because we often see a wave of Influenza B late in the flu season, and the shot can help protect against that virus.


Beyond that, practicing good flu hygiene remains your best strategy for staying well; Staying home when sick, washing your hands, covering your coughs, and disposing of your tissues properly .

Saudi Arabia Reports 2 New MERS Cases


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Saudi Arabia’s intermittent outbreak of winter MERS cases continues today after a couple of days with no reports, with two new cases , bringing January’s total to 20.


Yesterday, in anticipation of seeing more cases later in the spring, the CDC’s MMWR posted a  MERS Epidemiological Update & Guidance document for clinicians, public health, and the public.

Guangdong’s H5N6 Patient Recovers


Credit Wikipedia


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Normally the recovery of a single avian flu patient wouldn’t rate a separate blog entry, but since this is only the second human H5N6 case diagnosed - and the first one was fatal (see Sichuan China: 1st Known Human Infection With H5N6 Avian Flu) - the recovery of the 58-year old man diagnosed last December from Guangdong Province is not only good news, it is newsworthy.


Guangdong The first H5N6 bird flu patient rehabilitation

(O-Vision) at 19:57 on January 30 2015

(Macau Radio News) Guangdong The first H5N6 bird flu patient rehabilitation, quarantine has been lifted. 59-year-old male patient, on March 4 disease, symptoms of fever and cough, followed by isolation and treatment in Guangzhou, was in critical condition. This is the first case in Guangdong, is also the world's first two confirmed cases of H5N6, the first case case patients from Sichuan, was the death last May. (Liang Shuting Huangcai Chan)


While H5N1 and H7N9 are probably still the two avian viruses of greatest concern, the avian flu field has been rapidly expanding the past few years. Over the past year four new avian viruses – H10N8, H5N8, H5N3 & H5N6 – have emerged, and we don’t have a good handle on how much of an impact they will ultimately have.


H5N8 has certainly shown the ability to travel well, having already shown up in Europe, North America and Asia, but so far it doesn’t appear to infect humans.   H10N8 and H5N6 have only made a few appearances, but have infected and killed a handful of people. 


How all of these viruses will interact (and evolve) is something we are going to have to watch closely over the coming months and years.  For now, the good news is none of these avian viruses appears capable of transmitting efficiently from human to human, and they remain primarily a threat to birds and the poultry industry.

Taiwan Bird Flu: Eating Chicken Is Safe – Raw Raw Raw!


Credit China Times


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One of last year’s genuinely `bad ideas’ came from Saudi Arabia, where for a time it became a thing to post pictures of people kissing camels in order to prove that `beauty’  did not spread the MERS coronavirus. 


While there is no evidence that anyone died from this practice, it nonetheless undermined their public health’s messaging on MERS prevention, which recommends wearing masks and gloves around camels.


Today, in the midst of Taiwan’s worst avian flu outbreak (in poultry) in a decade, with more than 500 farms affected and well over 1.5 million birds culled, we have an ill advised PSA emerge from the Taipai City council meeting where several people apparently ate raw chicken in solidarity with the embattled poultry producers  to prove it’s safety.

Given the general prevalence of Campylobacter, E. coli  and Salmonella in raw poultry, exposure to bird flu may be the least of the dangers of consuming chicken tartare. 

But desperate economic times apparently call for desperate measures.  This from the China Times.


Taiwan members of the bird flu outbreak Taipei, raw chicken leg chicken farmers (photo)

16:22 on January 30, 2015 source: China News Network to the engagement (0)

 Beijing, January 30, according to Taiwan's China Times reported bird flu outbreaks spread throughout the island, people can smell chickens, chicken raising business plunge, several Taipei City councilors 29th came out to support farmers, Mr Lin Ruitu followed by eating raw chicken meat, called "to be a human Guinea pig, eat to see if any deviations from the".

It was reported that the Tipei City Council on 29th "save chicken farmers" activities, a number of city councillors to attend solidarity speaker Wu Bizhu said in Taipei, she will tell "Government" in the fight against bird flu at the same time, don't forget the chicken farmers livelihoods.

Reports said Mr llyr was eating raw chicken leg, in places someone exclaim, discourage, but Lin Ruitu insisted, before eating says "to dip soy sauce or eat."

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Forget the soy sauce, what this dish needs is a nice combination oseltamivir-penicillin-imodium dipping sauce.

H7N9 Confirmed In 2nd B.C. Patient


Credit Wikipedia

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On Monday we learned of the first known imported case of H7N9 into North America (see PHAC Statement On Canada’s Imported H7N9 Case) when a woman, recently returned from China with her husband, developed flu-like symptoms and was tested by her doctor in Vancouver.  


Her husband briefly developed flu-like symptoms as well, and also suspected as having been infected. Neither were sick enough to be hospitalized, self-isolated at home, and are now recovered.


Last night it was announced that the husband’s tests had come back positive for H7N9 infection. He developed symptoms about a day before his wife, suggesting they had a shared exposure, but the exact route of their infection remains unknown.  


None of these patient’s close contacts have developed symptoms, and given H7N9’s incubation period, authorities believe it unlikely any additional cases will arise in Canada linked to this event.


This from Helen Branswell.


H7N9 bird flu case confirmed in 2nd B.C. patient

Couple believed to have contracted virus in recent trip to China

By Helen Branswell, The Canadian Press Posted: Jan 29, 2015 9:24 PM PT Last Updated: Jan 29, 2015 9:28 PM PT

A British Columbia man has been confirmed as Canada's second case of H7N9 bird flu.

The unidentified man and his wife are believed to have contracted the virus during a recent trip to China.

They are the first North Americans known to have been infected with this virus.

B.C.'s deputy provincial health officer says the positive test result was confirmed late Thursday by the National Microbiology Laboratory in Winnipeg.

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It is remarkable that these cases were diagnosed at all, given their mild symptoms and their occurring during the midst of a very busy regular flu season. 


While 30% of known H7N9 cases have died, this is essentially the mortality rate among those sick enough to be hospitalized and tested.  Unknown is how many mild or moderate cases occur each winter in China, that are never picked up by surveillance.

That two travelers should return from China with mild symptoms suggests that mild or moderate cases are more common than we know .Something that the researchers at the University of Hong Kong have been saying for the past 18 months.


In Lancet: Clinical Severity Of Human H7N9 Infection) we saw a study that proposed, after roughly 130 cases were confirmed in the spring of 2013, that:


Our estimate that between 1500 and 27 000 symptomatic infections with avian influenza A H7N9 virus might have occurred as of May 28, 2013, is much larger than the number of laboratory-confirmed cases.


How accurate these estimates are is unknown, but it is highly likely that the official case counts under-represent the real burden of H7N9, perhaps by a sizable margin.


Somewhat more reassuring, we’ve seen a relatively low number of family clusters or contacts of known cases test positive for the virus, suggesting a low human-to-human transmission rate.  For now, direct contact with infected birds is believed the primary route of infection.


That said, a study published earlier this week (see EID Journal: H7N9 Antibodies In Close Contacts Of Known Cases) looked at 225 close contacts of confirmed H7N9 cases in China, and found 22 (9.8%) with elevated HI H7N9 antibody titers (>1:40). 

All of these seropositive contacts were asymptomatic.


All of which means we still have major gaps in our understanding of how fast and how far this virus is spreading in China.  And given the amount of travel to and from Asia, we should not be surprised to see future introductions of H7N9, and other novel flu viruses, to North America.

Thursday, January 29, 2015

MMWR: MERS Epidemiological Update & Guidance


Coronavirus – Credit CDC PHIL


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While all eyes right now are on our current flu season, and the merry band of novel flu viruses harassing people and poultry operations on four continents (Africa, Asia, Europe, North America) - if last year is any indication - in a few months the MERS coronavirus will be making headlines as well.


As the chart below from today’s MMWR illustrates, MERS seems to blossom in the spring, although exactly why is still up for grabs.  The most popular theory involves the winter calving of camels. Young camel are the most susceptible to the virus, and are believed a likely conduit to pass it on to humans.

FIGURE. Number of cases of Middle East respiratory syndrome coronavirus infection reported by the World Health Organization,* by month of illness onset — worldwide, 2012–2015The figure is an epidemiologic curve showing the number of cases of Middle East respiratory syndrome (MERS) coronavirus infection reported by the World Health Organization, by month and year of illness onset, worldwide during 2012-2015. The majority (504) of the 956 MERS cases were reported to have occurred during March-May 2014.


As both a `head’s up’ and an overview, today the MMWR has published a brief epidemiological review of the MERS coronavirus.

Update on the Epidemiology of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection, and Guidance for the Public, Clinicians, and Public Health Authorities — January 2015


January 30, 2015 / 64(03);61-62

Brian Rha, MD1, Jessica Rudd, MPH1, Daniel Feikin, MD1, John Watson, MD1, Aaron T. Curns, MPH1, David L. Swerdlow, MD2, Mark A. Pallansch, PhD1, Susan I. Gerber, MD1 (Author affiliations at end of text)

CDC continues to work with the World Health Organization (WHO) and other partners to closely monitor Middle East respiratory syndrome coronavirus (MERS-CoV) infections globally and to better understand the risks to public health. The purpose of this report is to provide a brief update on MERS-CoV epidemiology and to notify health care providers, public health officials, and others to maintain awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula.*

MERS-CoV was first identified and reported to WHO in September 2012 (1). As of January 23, 2015, WHO has confirmed 956 laboratory-confirmed† cases of MERS-CoV infection, which include at least 351 deaths. All reported cases have been directly or indirectly linked through travel or residence to nine countries: Saudi Arabia, the United Arab Emirates, Qatar, Jordan, Oman, Kuwait, Yemen, Lebanon, and Iran. In the United States, two patients tested positive for MERS-CoV in May 2014, each of whom had a history of fever and one or more respiratory symptoms after recent travel from Saudi Arabia (2). No further cases have been reported in the United States despite nationwide surveillance and the testing of 514 patients from 45 states to date.

The majority (504) of the 956 MERS cases were reported to have occurred during March–May 2014 (Figure). However, WHO continues to receive reports of MERS cases, mostly from Saudi Arabia.§ From August 1, 2014, through January 23, 2015, WHO confirmed 102 cases, 97 of which occurred in persons with residence in Saudi Arabia, including three travel-associated cases reported by Austria, Turkey, and Jordan; of the remaining cases, two cases were in persons from Qatar, and three cases were in persons from Oman.

CDC continues to recommend that U.S. travelers to countries in or near the Arabian Peninsula protect themselves from respiratory diseases, including MERS, by washing their hands often and avoiding contact with persons who are ill. If travelers to the region have onset of fever and symptoms of respiratory illness during their trip or within 14 days of returning to the United States, they should seek medical care. They should call ahead to inform their health care provider of their recent travel so that appropriate isolation measures can be taken in health care settings. Health care providers and health departments throughout the United States should continue to consider a diagnosis of MERS-CoV infection in persons who develop fever and respiratory symptoms within 14 days after traveling from countries in or near the Arabian Peninsula, and be prepared to detect and manage cases of MERS.

Recommendations might change and be updated as additional data become available. More detailed travel recommendations related to MERS, including general precautions posted by WHO for anyone visiting farms, markets, barns, or other places where animals are present, are available at

The website also lists more specific WHO recommendations for persons with diabetes, kidney failure, or chronic lung disease, and immunocompromised persons, that include avoiding contact with camels.¶ Guidance on the evaluation of patients for MERS-CoV infection, infection control, home care and isolation, and clinical specimen collection and testing is available on the CDC MERS website at

Treatment is supportive; no specific treatment for MERS-CoV infection is available. WHO has posted guidance for clinical management of MERS patients at Web Site Icon.

1Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC; 2Office of the Director, National Center for Immunization and Respiratory Diseases, CDC (Corresponding author: Brian Rha,, 404-639-3972)

  1. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med 2012;367:1814–20.
  2. Bialek SR, Allen D, Alvarado-Ramy F, et al. First confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States, updated information on the epidemiology of MERS-CoV infection, and guidance for the public, clinicians, and public health authorities—May 2014. MMWR Morb Mortal Wkly Rep 2014;63:431–6.

* Countries considered in the Arabian Peninsula and neighboring include: Bahrain; Iraq; Iran; Israel, the West Bank and Gaza; Jordan; Kuwait; Lebanon; Oman; Qatar; Saudi Arabia; Syria; the United Arab Emirates; and Yemen.

† Confirmatory laboratory testing requires a positive polymerase chain reaction test result on at least two specific genomic targets for MERS-CoV or a single positive target with sequencing on a second.

§ Additional information available at Web Site Icon.

¶ Additional information available at Web Site Icon.