MERS-CoV update from BCCDCMay282015

From BCCDC:

Dear Colleagues,

Although it has been just over one week since our last bulletin, we would like to highlight a recent MERS-CoV cluster in South Korea that underscores several key aspects of emerging pathogen response, including travel history, prompt and rigorous infection control, and contact follow-up.

Last week, South Korea notified the WHO of a laboratory-confirmed case of MERS-CoV, the first travel-related case to be reported in that country. Subsequent contact tracing investigations have so far identified at least six additional laboratory-confirmed cases, including among family and healthcare-associated contacts.

The index case, an adult male in his 60s, had recently returned from travel in the Middle Eastern region. The case had no history of exposure to known risk factors for MERS-CoV in the 14 days prior to detection, but did report travel in countries where MERS-CoV is known to be circulating (i.e. United Arab Emirates, Saudi Arabia and Qatar).

Since this initial report, six secondary laboratory-confirmed cases have been reported: the wife of the index case, two patients epidemiologically linked through shared hospital exposure to the index case, two healthcare workers who provided care to the index case, and the daughter of the third case who visited her father while in hospital with the index case. One additional suspect case, a contact of the third confirmed case, traveled to China while febrile and is currently under investigation.  

Reminiscent of the SARS experience in 2003, this cluster highlights the potential for onward indigenous spread, particularly nosocomial infection, among countries receiving imported cases. To mitigate this risk, clinicians are reminded to elicit a travel history and to immediately implement respiratory precautions for suspected cases of severe acute respiratory illness (SARI) in a patient with links to affected areas in the 14 days prior to symptom onset (i.e. residence, travel history, or contact with someone with such history). Facilities should be mindful of the protection for other patients and visitors, in addition to healthcare workers, to minimize nosocomial transmission and risk. Cases should be managed in respiratory isolation with contact and droplet precautions; airborne precautions are warranted in the event of aerosol-generating procedures or conditions and/or where the index of suspicion may be raised (e.g.. because of contact with a confirmed case/cluster or comorbidity or other clinical features that may influence transmission risk).

In the event of a SARI case, please notify your local health authority/Medical Health Officer so that appropriate follow-up may be undertaken and consult a virologist or microbiologist at the BC Public Health Microbiology & Reference Laboratory (PHMRL) to arrange advance notification and direct shipping of diagnostic specimens.

Sincerely,

The Influenza and Emerging Respiratory Pathogens Team

BC Centre for Disease Control

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Emerging Respiratory Pathogens updateMay192015

From BCCDC:

As we enter the summer months and our human influenza surveillance indicators decline to inter-seasonal levels, we would like to update you on recent global trends related to emerging respiratory pathogens, including novel influenza A viruses and MERS-CoV.

HIGHLIGHTS

  • Human Infections with Avian Influenza
    • Avian Influenza A(H5N1). Egypt continues to experience a large-scale outbreak of avian influenza A(H5N1), with year-to-date case counts (n=132) exceeding prior yearly totals in that country by more than three times. In fact, the number of cases occurring between November 2014 and February 2015 in Egypt has exceeded the number of cases ever found in any country since 2003. A recent joint high-level mission, including representatives of human and animal health organizations, has assessed the current situation in Egypt and concluded based on epidemiologic and virologic features that the risk of an H5N1 pandemic has not changed appreciably, but warrants ongoing monitoring.
    • Avian Influenza A(H7N9). A third wave of human infections with avian influenza A(H7N9) appears to have subsided in China, following an expected seasonal peak in January-February. The peak of the third epidemic wave in 2014-15 was smaller in scale than the prior year’s wave in 2013-14, but the epidemiological features of cases remain similar.
  • Other Influenza
    • Swine-origin Influenza A(H1N1) variant (H1N1v). A fatal case of swine-origin influenza A(H1N1) variant (H1N1v) was reported in the United States last week. This is the second human case of H1N1v in 2015.
    • H5 Avian Influenza Outbreaks. Multiple outbreaks of highly pathogenic avian influenza (HPAI) due to H5 subtype viruses (e.g. H5N2, H5N8, H5N1) continue to be reported in domestic poultry, with 29 countries (including Canada and the Unites States) reporting HPAI H5 detections so far in 2015.
  • MERS-CoV. Sporadic MERS-CoV activity continues in Saudi Arabia and affected regions in the Middle East, driven by small-scale nosocomial outbreaks, mostly in the Riyadh region.

Although the risk to Canadians for these emerging respiratory pathogens remains low, clinicians should remain vigilant and consult their local Medical Health Officer for advice related to diagnostic testing, infection control and follow up where a novel emerging pathogen may be suspected.

More detailed epidemiologic information, risk assessment and action and advice are provided below.

EPIDEMIOLOGICAL SUMMARY

Human Infections with Avian Influenza

Avian Influenza A(H5N1)

As of May 1, 2015, 132 human cases of avian influenza A(H5N1), including 37 deaths (case fatality: 28%), have been reported in Egypt so far in 2015, more than three times as many cases as any prior year in that country. In fact, the number of cases occurring between November 2014 and February 2015 has exceeded the number of cases ever found in any country since 2003. Of the 132 cases in Egypt so far in 2015, 115/132 (87%) were newly reported since our last bulletin to you on February 27, 2015, and covering the period January 26 to May 1, 2015.

Of these latest 115 cases, ages range from <1 to 77 years (median: 27 years), with 40 (35%) reported in children <10 years of age; 45 (39%) are male. All cases with known exposure history reported contact with poultry or poultry markets and all were hospitalized. Twenty-two deaths were reported during this period, but none occurred in children <10 years of age. Two family clusters, each comprised of two cases, are included in this total.

Although Egypt continues to report sporadic human cases of H5N1, the number of laboratory-confirmed cases decreased in April compared to the previous five months, according to the latest WHO risk assessment. The recent surge of cases since November 2014 has been attributed to a mixture of factors, including increased circulation of H5N1 in poultry compared to previous periods, lower public health risk awareness, and greater opportunities for poultry exposure due to increases in the number of small poultry farms and backyard poultry flocks and seasonality.

Preliminary laboratory investigations do not suggest any genetic changes in the virus that would increase the likelihood of transmission from animals to humans, and sustained human-to-human transmission in the community has not been observed. A recent joint high-level mission to assess the current situation in Egypt, including representatives of human and animal health organizations, has concluded that the pandemic risk from H5N1 has not appreciably changed.

Additionally in 2015 (as of May 1, 2015), 7 human cases of H5N1 have been further reported in China (n=5) and Indonesia (n=2, family cluster), for a global year-to-date tally of 139 cases, including 40 deaths (case fatality: 29%). Since 2003, a total of 840 laboratory-confirmed cases, including 447 deaths (case fatality: 53%), have been reported from 16 countries.

For an infographic of H5N1 activity (March 31), see: www.emro.who.int/images/stories/egypt/h5n1-infographic-march-2015.pdf?ua=1.

For the latest WHO risk assessment on influenza at the human-animal interface (May 1), see: www.who.int/influenza/human_animal_interface/Influenza_Summary_IRA_HA_interface_1_May_2015.pdf?ua=1.

For an executive summary of the joint high-level mission on the current H5N1 situation in Egypt, see: www.emro.who.int/images/stories/Executive_Summary_14_May_2015.pdf?ua=1.

Avian Influenza A(H7N9)

Since our last bulletin to you on February 27, 2015, 85 new cases of human infection with avian influenza A(H7N9) have been reported in China, including 23 deaths (case fatality: 27%) at the time of reporting. Affected provinces include Guangdong (39), Zhejiang (23), Anhui (8), Fujian (4), Jiangsu (4), Hunan (2), Shanghai (2), Guizhou (1), Jiangxi (1), and Shandong (1). Among these recent cases, the epidemiologic profile remains similar to previous summaries. Ages range from 1 to 82 years (median: 55 years) and 63/85 (74%) are male. Of the cases with known exposure history, almost all (71/77, 92%) reported exposure to live poultry or live poultry markets. Three family clusters, each comprised of two cases, were reported, of whom four of six cases had exposure to live poultry or live poultry markets. Most cases were in severe/critical condition at the time of report; accordingly, the case fatality may increase as reporting becomes more complete.

Symptom onset dates of these latest cases range from January 21 to April 12, 2015. More than 80% of cases had onset in January-February (69/85, 81%), suggesting that the third seasonal wave of infections has subsided. Human cases of H7N9 continue to show a seasonal pattern, with case reports peaking from January to March.

As of May 1, 2015, a total of 657 laboratory-confirmed human cases and at least 261 deaths (case fatality: 40%) due to H7N9 have been reported since the start of the outbreak in February 2013. Case reports span three seasonal waves: the first wave of 135 cases (February 2013 to September 2013); a second, more substantial wave of 320 cases (October 2013 to September 2014); and an ongoing third wave of 202 cases (starting October 2014). Outside of the primarily affected area of China there have also been four imported cases reported from Taipei CDC, 13 from Hong Kong CHP, one from Malaysia MoH, and two from Canada. The majority of cases continue to be associated with exposure to infected live poultry or contaminated environments, although multiple clusters of probable close household or family transmission have also been identified. The risk of sustained human-to-human transmission in the community remains low.

In a recent epidemiological comparison of H7N9 and H5N1 viruses, researchers show that H7N9 may have a greater pandemic potential risk than H5N1, although both viruses had estimated reproductive numbers (R) below the epidemic threshold. Conversely, H5N1 was associated with a higher proportion of clusters and increased risk for infection in blood-related contacts than H7N9, suggesting that susceptibility to H5N1 is more likely limited and familial. Findings were published in Clinical Infectious Diseases: cid.oxfordjournals.org/content/early/2015/05/04/cid.civ345.short.

On April 7, the US Centers for Disease Control and Prevention (US CDC) released new antiviral treatment and chemoprophylaxis guidelines for human infections with novel influenza A viruses, including H7N9 and H5N1. This guidance recommends antiviral treatment as soon as possible for all hospitalized cases of human infection with novel influenza A viruses associated with severe human disease and for confirmed and probable outpatient cases or outpatient cases under investigation who have had recent close contact with a confirmed or probable case. In addition, recommendations for chemoprophylaxis have been adjusted. Specifically, treatment frequency dosing for oral oseltamivir or inhaled zanamivir at one dose twice daily is recommended instead of the typical antiviral chemoprophylaxis regimen (once daily). Related details are available from: www.cdc.gov/flu/avianflu/novel-av-treatment-guidance.htm and www.cdc.gov/flu/avianflu/novel-av-chemoprophylaxis-guidance.htm.

Other Influenza

Swine-origin Influenza A(H1N1) variant (H1N1v)

On May 8, the US CDC reported a fatal human case of influenza A(H1N1) variant (H1N1v) of classical swine origin in Ohio. Subsequent partial genetic sequencing conducted at the US CDC indicated that this virus is similar to H1N1 viruses currently circulating in swine. The case worked at a livestock facility that housed swine but reported no direct contact with swine in the week prior to illness onset. No further human-to-human transmission was identified.

This latest case brings the total number of H1N1v cases reported in the United States since 2005 to 18 and is the second human case of H1N1v reported in 2015. In January, a non-fatal case was reported in Minnesota.

H5 Avian Influenza Outbreaks (H5N1, H5N2, H5N3, H5N6, H5N8)

Multiple outbreaks of highly pathogenic avian influenza (HPAI) due to H5 subtype viruses continue to be reported in poultry around the globe.

In North America, outbreaks of HPAI H5 in wild and domestic birds have been reported in two Canadian provinces and 17 US states to date in 2015. These outbreaks are the first due to HPAI H5 reassortants of Eurasian origin in North America, resulting from a reassortment of Eurasian H5N8 viruses with endemic avian viruses. The current H5N1 virus detected in North American birds is a new reassortant virus of mixed origin which is considered genetically distinct from the avian-origin H5N1 virus causing human infections in Egypt and parts of Asia. To date, no human cases of avian influenza have been reported associated with these recent outbreaks in North America but ongoing monitoring is warranted.

In addition to human health implications with respect to pandemic potential with opportunities for adaptation, the geographic expansion of HPAI H5 viruses has serious implications for the poultry industry. As of May 19, 2015, 29 countries have reported HPAI H5 detections to the World Organization for Animal Health (OIE) so far in 2015, including in:

  • North America
    • H5N1: Canada (British Columbia); United States (Washington)
    • H5N2: Canada (British Columbia, Ontario); United States (Arkansas, Idaho, Iowa, Kansas, Kentucky, Minnesota, Missouri, Montana, North Dakota, Oregon, South Dakota, Washington, Wisconsin, Wyoming)
    • H5N8: Canada (British Columbia); United States (California, Idaho, Nevada, Oregon, Utah, Washington)
  • Europe
    • H5N1: Bulgaria; Romania; Russia; Turkey
    • H5N8: Germany; Hungary; Italy; Netherlands; Sweden
  • Asia
    • H5N1: Bhutan; China; India; Indonesia; North Korea; Myanmar
    • H5N2: China; Chinese Taipei; Vietnam
    • H5N3: Chinese Taipei
    • H5N6: China; Hong Kong
    • H5N8: Chinese Taipei; Japan; South Korea
  • Middle East
    • H5N1: Israel; Palestine
  • Africa
    • H5N1: Burkina Faso; Egypt; Libya; Niger
    • Subtype not specified: Nigeria

 

For more information on outbreaks of HPAI due to H5 subtype viruses in North America, see: www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=29809&lang=en.

Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Since our last bulletin to you on February 27, 2015, the WHO has reported 92 additional cases of MERS-CoV. Nearly all of these cases have been reported from Saudi Arabia (88/92, 96%), with over half (47/88, 53%) reported from the Riyadh region. On March 7, Germany reported a case in an adult male who had recently returned from travelling in the United Arab Emirates (UAE). This is the third imported MERS-CoV case in Germany since the start of the outbreak in March 2012. On March 9, Qatar reported its second case of 2015 in an adult male who reported frequent contact with camels and regular consumption of raw camel milk. This month, Iran reported a case, its first since July 2014, in an adult male who was epidemiologically linked to two pilgrims with influenza-like symptoms returning from Umrah. Most recently, on May 18, the UAE reported a case in an adult male who frequently transports camels from Oman to UAE.

Among these recent 92 cases, the epidemiologic profile is similar to previous summaries. Ages range from 20 to 93 years (median: 56 years) and over three-quarters (70/92, 76%) are male. Most cases (67/92, 73%) had at least one chronic comorbidity. Over 40% of cases had no known exposure to risk factors for MERS-CoV in the 14 days prior to symptom onset. Of the 54 cases with known exposure, 26 (48%) reported exposure to a healthcare setting (including 11 who were healthcare workers), 9 (17%) were household contacts of previously identified cases, and one (the Iranian case) was epidemiologically linked to two suspect cases. Only 17 (31%) reported direct or indirect contact with camels, including consumption of raw camel milk, and one reported direct contact with sheep but not camels.

The current epidemiological pattern is consistent with earlier periods of the outbreak characterized by exposure to a primary animal source (likely dromedary camels) followed by secondary amplification in healthcare settings. Despite a small upswing in case reports at the beginning of 2015, recent nosocomial outbreaks, mostly in the Riyadh region, remain smaller in scale than prior outbreaks, likely due to improvements in infection prevention and control practices.

In other developments, German and Saudi researchers recently published a nationwide MERS-CoV serosurvey, including samples from over 10,000 individuals in 13 provinces in Saudi Arabia. Anti-MERS-CoV antibodies were detected in 0.15% (95% CI: 0.09-0.24%) of patients, with higher antibody prevalence found in men and residents of central (versus coastal) provinces. Compared to the general population, seroprevalence was 15 to 23 times higher in camel-exposed individuals, providing further evidence that camels are the primary source of MERS-CoV infection. The authors postulate that subclinical infections in healthy, younger adults may be a source of infection (i.e. human-to-human transmission) in index cases with no known camel exposure. The findings were published in Lancet Infectious Diseases: www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)70090-3/abstract.

As of May 18, 2015, the WHO has been informed of 1,118 laboratory-confirmed cases of MERS-CoV including at least 423 deaths (case fatality: 38%).

For an infographic of MERS-CoV activity (March 31), see: www.emro.who.int/images/stories/csr/documents/MERS-CoV_March_2015.pdf?ua=1.

ACTION AND ADVICE

In the event of severe acute respiratory illness (SARI) in a patient with links to affected areas in the two weeks prior to symptom onset (i.e. residence, travel history or contact with someone with such history), clinicians should notify their local health authority/Medical Health Officer. Clinicians should obtain relevant travel, animal (direct or indirect), or other contact exposure history from patients presenting with severe acute respiratory illness (SARI).

Health care workers should implement respiratory precautions immediately, and cases should be managed in respiratory isolation with contact and droplet precautions. Airborne precautions are warranted in the event of aerosol-generating procedures or conditions. Given a spectrum of illness inclusive of milder or atypical presentations, clinicians are encouraged to use their judgement and/or consult infection control for guidance around enhanced measures where the index of suspicion (e.g. based on contact, comorbidity or clustering history) and exposure risk may be higher. Facilities should be mindful of the protection of other patients and visitors, in addition to healthcare workers, to minimize nosocomial transmission and risk.

Please discuss with your local health authority/Medical Health Officer and consult a virologist or microbiologist at the BC Public Health Microbiology & Reference Laboratory (PHMRL) to arrange advance notification and direct shipping of diagnostic specimens. For diagnostic testing for suspected MERS-CoV or avian influenza, lower respiratory specimens (e.g. sputum, endotracheal aspirate, or bronchoalveolar lavage) are recommended where possible and clinically indicated. Follow strict infection prevention and control guidelines when collecting respiratory specimens.

Sincerely,

Influenza and Emerging Respiratory Pathogens Team

BC Centre for Disease Control

 

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Job posting with Northern HealthApr072015

Northern Health has a new vacancy for a Regional Manager, Communicable Disease – Prince George (Full Time).

The Regional Manager, Communicable Disease Programs is accountable for the leadership, development, planning, and strategic implementation and evaluation related to the promotion, prevention and control of Communicable Diseases and Immunization programs for NH. This role is also responsible for overseeing the application, effective utilization and ongoing enhancements of the information system that supports the delivery of selected maternal/family, early intervention and communicable disease control activities. The incumbent is responsible for creating and maintaining internal and external linkages and partnerships required for the development and delivery of Communicable Disease Programs.

You can read more about the position on the Northern Health website

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Emerging Respiratory Virus UpdateMar022015

From the BC Centre for Disease Control, February 27, 2015:

There are a number of recent trends in the field of emerging respiratory viruses (ERV), including:

1.         Upswing in MERS-CoV reports from the Middle East, primarily Saudi Arabia, since December 2014.

a.         In the context of the dramatic surge in MERS-CoV that occurred during the spring 2014, with amplification in the nosocomial setting, close monitoring through the coming weeks is warranted.

b.         See the attached graphics of MERS-CoV case reports by time and geographic mapping as illustration.

2.         A third wave of avian influenza A(H7N9) activity that began in mid-October 2014 in China has shown substantial increase through December and January.

a.         Given that avian influenza viruses have distinct winter-spring seasonality, and given the substantial second wave of H7N9 activity that occurred in the spring 2014, close monitoring for a further surge through the winter/spring 2015 period is warranted.

b.         See the attached graphics of H7N9 case reports by time and geographic mapping as illustration.

c.         As previously shared, two human cases of A(H7N9) infection were reported in British Columbia in a couple recently returned from travel within China in January 2015, reinforcing the need for ongoing vigilance.

3.         A variety of other avian influenza viruses have been associated with human infections and poultry outbreaks globally in recent weeks, namely:

a.         Human cases of H5N1 and H9N2 in Egypt and H5N6 in China.

b.         Poultry outbreaks due to highly pathogenic avian influenza of the Eurasian H5 lineage including H5N1, H5N8 and/or H5N2 in Europe and Asia and newly also now in North America.

4.         Although the risk to Canadians remains low, clinicians should remain vigilant.

a.         Clinicians should obtain relevant travel, animal or other contact exposure history from patients presenting with severe acute respiratory illness and consult their local Medical Health Officer for advice related to diagnostic testing, infection control and follow up where a novel emerging pathogen may be suspected.

Further information related to these trends is provided in detail below.

 

1.         MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS (MERS-COV), MIDDLE EAST

Since our last ERV bulletin to you on November 5, 2014, 124 additional MERS-CoV cases have been reported, including at least 44 deaths. Nearly all of these recent cases have been reported in Saudi Arabia (118/124, 96%), mostly from the Riyadh region, with additional cases reported in Oman (3), UAE (1), Qatar (1), and the Philippines ex. KSA (1). Of these 124 recent cases, ages range from 22 to 99 years (median: 56 years); 76% are male; and 79% have had one or more comorbid conditions.

In January 2015, Oman reported its first case since October 2013 in a farm owner with frequent contact with animals, including camels. Two secondary cases in close contact with this index case were subsequently reported by Oman. On February 13, 2015, the Philippines reported a case in a health care worker who was likely exposed at a hospital in Riyadh, Saudi Arabia. Of note, there were no cases identified in association with the Hajj in October 2014, despite enhanced surveillance activities upon exit from the country and in the countries of the returning pilgrims. However, the recent importation of a MERS-CoV case to the Philippines emphasizes ongoing risk for returning travellers, particularly among those exposed to a recognized transmission setting (e.g. health care facility) or to animals or animal products for which the index of suspicion may be higher.

Dromedary camels are now recognized as the likely animal reservoir for MERS-CoV. However, even among those with close contact with infected camels, a recent serological study indicated no evidence of human infection, and the factors associated with possible transmission to humans remain unclear. Furthermore, among recent human cases, only about one in ten reported contact with an animal or animal product, while up to one-third may have had nosocomial exposure. This epidemiologic pattern is consistent with earlier periods of the outbreak that have been characterized by exposure to a primary animal source (likely camels or camel products) followed by amplification in health care settings. Overall, however, the risk for sustained human-to-human transmission in the community remains low.

As of February 23, 2015, the WHO has been informed of 1,026 laboratory-confirmed cases of human infection with MERS-CoV, including at least 376 deaths (case fatality 37%), since its emergence in March/April 2012. Among cases with known age or sex, an adult male predominance persists: ages range from 9 months to 99 years (median: 48 years) and 64% are male. Affected countries include: Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, UAE and Yemen in the Middle East; Algeria and Tunisia in North Africa; Austria, France, Germany, Greece, Italy, the Netherlands, Turkey and the United Kingdom in Europe; Malaysia and Philippines in Southeast Asia; and the United States of America. All cases reported outside of the Middle East have had direct exposure or an epidemiological link to persons with recent travel to affected regions in the Middle East.

See the attached graphics of MERS-CoV case reports by time and geographic mapping as illustration.

2.         AVIAN INFLUENZA A(H7N9), CHINA

Since November 5, 2014, 151 human infections with avian influenza A(H7N9) have been reported, including at least 32 deaths. Of the 103/151 recent cases with known age and gender, ages range from <1 to 83 years (median: 55 years) and 66% are male.

Of the recently reported cases, all were likely exposed in affected regions of China, including two cases reported in British Columbia, Canada, in a couple who had recently returned from travelling in China and three unrelated cases reported in Hong Kong with recent travel to mainland China. Affected provinces in China include: Guangdong (63), Fujian (36), Zhejiang (17), Jiangsu (13), Xinjiang UAR (7), Shanghai (4), Anhui (2), Jiangxi (2), Guizhou (1), and Shandong (1).

To date, there have been 608 laboratory-confirmed human cases of avian influenza A(H7N9) infection, including at least 204 deaths (case fatality 34%). Case reports continue to show a seasonal pattern, peaking in January to March with sporadic cases reported during summer months. The first wave (February to September 2013) included 136 cases; the second wave (October 2013 to September 2014) included 320 cases; and the third wave (since October 2014) has included 152 cases to date. The majority of cases continue to be among older, adult men and almost all with a known exposure history have reported exposure to live poultry or live poultry markets. To date, however, at least 17 family clusters have been identified, each comprised of 2-3 cases. Notwithstanding these limited instances of possible close contact transmission, the risk of sustained human-to-human transmission in the community remains low.

See the attached graphics of H7N9 case reports by time and geographic mapping as illustration.

 

3.         OTHER AVIAN INFLUENZA

a.         Avian Influenza A(H5N1). Since September 2014 and as of January 26, 2015, 51 human infections with highly pathogenic avian influenza (HPAI) A(H5N1), including 20 deaths, have been reported in Egypt, including at least three clusters each involving two to three cases. More recent estimates suggest that the number of human infections with A(H5N1) in Egypt since September 2014 now exceeds 100 cases, the majority with onset between December 2014 and February 2015. Of the 51 cases identified up to January 26, ages range from 1 to 65 years (median: 20 years), and 39% are male indicating a very different age and gender profile from that of H7N9 in China. Almost all cases reported exposure to sick or dead poultry, most notably backyard flocks. Preliminary investigations did not detect changes in the viruses isolated from recent cases compared to previous isolates.  Avian influenza A(H5N1) viruses are known to circulate in poultry in Egypt, and this country has historically been one of the most affected by the A(H5N1) outbreak. Since 2003, about one-third of the human cases globally have been reported in Egypt. Cumulatively, 777 human cases of A(H5N1) have been reported to the WHO from 16 countries, including 428 deaths (case fatality 55%) since 2003.

b.         Avian Influenza A(H5N6). On February 9, 2015, the National Health and Family Planning Commission (NHFPC) of China reported a fatal human infection with avian influenza A(H5N6) in a 44-year-old male in Yunnan Province. The patient had a history of exposure to dead birds and developed symptoms in late January. This is the third reported human infection with an A(H5N6) virus. Two human cases of A(H5N6), including one fatality, were previously reported in China in 2014.

c.         Avian Influenza A(H9N2). On February 10, 2015, Egypt reported its first human case of avian influenza A(H9N2) in a 3-year-old male. The patient had a history of contact with backyard poultry and developed symptoms in mid-January. Two human cases of A(H9N2), one in a child and one in an elderly adult and both mild, were previously reported in China in 2014 and prior to that, in total, H9N2 has been associated with a dozen or more recognized human cases, primarily in China (but also Bangladesh), mostly (but not exclusively) in children and with mild illness. Influenza A(H9N2) is a low pathogenic avian influenza (LPAI) virus usually associated with mild or absent disease in birds that is endemic in poultry China. It has been considered by some experts as a scaffold for the generation of new reassortant viruses in poultry, donating gene segments to A(H7N9), A(H5N1), and other avian influenza virus subtypes. For this reason, careful monitoring of this subtype and its geographic spread is warranted.

d.         Avian Influenza Outbreaks in Poultry: Europe, North America and Asia. Since November, several poultry outbreaks due to highly pathogenic avian influenza (HPAI) viruses, including A(H5N1), A(H5N2), and A(H5N8), have been reported to the World Organization for Animal Health (OIE) from Europe, and Asia and newly also from North America. These reports include the first detections of HPAI Eurasian lineage H5 viruses in North America reported in British Columbia in December and January 2014, likely introduced through the mixing of migratory birds where flyways intersect and culminating in reassortant strains including Eurasian and North American lineage viral gene segments. To date, no human cases of avian influenza have been reported associated with these recent outbreaks but ongoing monitoring is warranted.

4.         ACTION AND ADVICE

In the event of severe acute respiratory illness (SARI) in a patient with links to affected areas in the two weeks prior to symptom onset (i.e. residence, travel history or contact with someone with such history), clinicians should notify their local health authority/Medical Health Officer. Travel history (direct or indirect) is critical to elicit from SARI patients.

Health care workers should implement respiratory precautions immediately, and cases should be managed in respiratory isolation with contact and droplet precautions. Airborne precautions are warranted in the event of aerosol-generating procedures or conditions. Given a spectrum of illness inclusive of milder or atypical presentations, clinicians are encouraged to use their judgement and/or consult infection control for guidance around enhanced measures where the index of suspicion (e.g. based on contact, comorbidity or clustering history) and exposure risk may be higher. Facilities should be mindful of the protection of other patients and visitors, in addition to healthcare workers, to minimize nosocomial transmission and risk.

Please discuss with your local health authority/Medical Health Officer and consult a virologist or microbiologist at the BC Public Health Microbiology & Reference Laboratory (PHMRL) to arrange advance notification and direct shipping. For diagnostic testing for suspected MERS-CoV or avian influenza, lower respiratory specimens (e.g. sputum, endotracheal aspirate, or bronchoalveolar lavage) are recommended where possible and clinically indicated. Follow strict infection prevention and control guidelines when collecting respiratory specimens.

5.         OTHER USEFUL RESOURCES

MERS-CoV:

Latest ECDC Rapid Risk Assessment (February 23, 2015):

http://www.ecdc.europa.eu/en/publications/Publications/MERS_update_14-Feb2014.pdf

Latest WHO Summary of Current Situation, Literature Update and Risk Assessment (February 5, 2015):

http://www.who.int/csr/disease/coronavirus_infections/mers-5-february-2015.pdf?ua=1

WHO statement on the Eighth Meeting of the IHR Emergency Committee regarding MERS-CoV (February 5, 2015):

http://www.who.int/mediacentre/news/statements/2015/8th-mers-emergency-committee/en/

H7N9:

Latest ECDC Epidemiological Update (February 12, 2015):

http://www.ecdc.europa.eu/en/press/news/_layouts/forms/News_DispForm.aspx?List=8db7286c-fe2d-476c-9133-18ff4cb1b568&ID=1167

Latest ECDC Rapid Risk Assessment (February 2, 2015):

http://ecdc.europa.eu/en/publications/Publications/RRA-Influenza-A-H7N9-update-four.pdf

Latest WHO Risk Assessment (October 2, 2014):

http://www.who.int/influenza/human_animal_interface/influenza_h7n9/riskassessment_h7n9_2Oct14.pdf?ua=1

Other Influenza Virus

WHO Issues Statement on Volatility of Influenza Viruses: http://www.who.int/influenza/publications/warningsignals201502/en/   

Previous ERV Bulletins of the BCCDC:

http://www.bccdc.ca/dis-cond/DiseaseStatsReports/EmergingRespiratoryVirusUpdates.htm

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