Brazilian MOH: 3893 Suspected Microcephaly Cases Under Investigation

Microcephaly Incidence - Brazil Epi Week 1

#10,914


Although the full epidemiological report for week 2 has not yet been uploaded to the Brazilian MOH website, the press release below indicates 3893 suspected microcephaly cases are under investigation, an increase of 363 over last week's number.

In a normal year Brazil records fewer than 200 microcephalic births, but since October that number has skyrocketed, with more than 3800 suspected cases reported in the past few months.

While a firm connection has yet to be established, the operating assumption is these birth defects are due to maternal infection with the Zika virus, a mosquito-borne illness that began to spread in Brazil less than a year ago.


Over the past week we've seen the CDC issue a revised travel advisory , a HAN: Recognizing, Managing & Reporting ZIka Virus Infections In Travelers for clinicians, and MMWR: Interim Guidelines For Pregnant Women During A Zika Outbreak.

Registration Date: 01/20/2016 17:01:47 changed in the 20.1.2016 the 17:01:32

MICROCEFALIA

Laboratories expand 20 times the capacity for Zika tests

Ministry of Health is acquiring 500 000 PCR tests for the virus, increasing the production capacity of one thousand to 20 thousand monthly diagnostics. Newsletter registers 3,893 suspected cases of microcephaly and points the breakdown of confirmed cases and discarded
   
(SNIP)

PRESS RELEASE - The new epidemiological report released on Wednesday (20) by the Ministry of Health indicate 3,893 suspected cases of microcephaly. The notifications were registered until 16 January and took place in 764 municipalities in 21 Brazilian states. The report shows a breakdown of confirmed cases and discarded. The notified total of 224 had microcephaly confirmation, 6 confirmed the relationship with the Zika virus and other 282 were discarded. Continue research 3,381 suspected cases of microcephaly.

In total there were 49 reported deaths due to congenital malformations. These five have been confirmed for the relationship with the Zika virus, all in the Northeast, one in Ceará and four in Rio Grande do Norte. Additionally, the release also brings the laboratory investigation of a baby with microcephaly in Minas Gerais, which had the relationship with Zika diagnosed. This is the sixth confirmed the relationship of disease with the virus. These results add to the other scientific evidence obtained in 2015 and reinforce the hypothesis relationship between the Zika virus infection and the occurrence of microcephaly and other congenital malformations.

According to the report, the state of Pernambuco continues with the highest number of suspected cases (1,306), representing 33% of total registered across the country. Next are the states of Paraíba (665), Bahia (496), Ceará (216), Rio Grande do Norte (188), Sergipe (164), Alagoas (158), Mato Grosso (134) and Rio de Janeiro ( 122).

Currently, the movement of the Zika is confirmed by PCR with molecular biology technology. From the confirmation in a particular locality, the other diagnoses are made clinically, for medical assessment of symptoms. So far, they are with indigenous circulation of Zika virus 20 units of the federation. They are: Federal District, Mato Grosso do Sul, Roraima, Amazonas, Para, Rondonia, Mato Grosso, Tocantins, Maranhao, Piaui, Ceara, Rio Grande do Norte, Paraiba, Pernambuco, Alagoas, Bahia, Espírito Santo, Rio de Janeiro, São Paulo and Paraná.

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MMWR: Interim Guidelines For Pregnant Women During A Zika Outbreak

Zika Testing Algorithm - MMWR Jan 2016

#10,913


Last Friday the CDC issued a HAN advisory for clinicians on Recognizing, Managing & Reporting ZIka Virus Infections In Travelers. Yesterday the CDC's MMWR published a lengthy set of interim guidance for pregnant women during a Zika Outbreak.

These guidelines include recommendations for pregnant women considering travel to areas where Zika may be acquired and recommendations for screening, testing, and management of pregnant returning travelers.

Last week the CDC issued a travel advisory suggesting:

• Pregnant women in any trimester should consider postponing travel to the areas where Zika virus transmission is ongoing. Pregnant women who must travel to one of these areas should talk to their doctor or other healthcare provider first and strictly follow steps to avoid mosquito bites during the trip.

And as I reported earlier today, health authorities are already seeing pregnant women with travel history to Zika endemic areas return with the virus (see PAHO: Zika Marches On).

As we've seen with so many other emerging infectious diseases (MERS-CoV, Avian Flu, Dengue, etc), one of the most important steps is for patients to share their travel history with their health care provider.


Follow the link below to view the full MMWR interim guidance:

Interim Guidelines for Pregnant Women During a Zika Virus Outbreak — United States, 2016

Early Release / January 19, 2016 / 65(2);1–4

Format:

Select one

• PDF [354 KB]

Emily E. Petersen, MD¹; J. Erin Staples, MD, PhD²; Dana Meaney-Delman,, MD³; Marc Fischer, MD²; Sascha R. Ellington, MSPH¹; William M. Callaghan, MD¹; Denise J. Jamieson, MD¹ (View author affiliations)

CDC has developed interim guidelines for health care providers in the United States caring for pregnant women during a Zika virus outbreak. These guidelines include recommendations for pregnant women considering travel to an area with Zika virus transmission and recommendations for screening, testing, and management of pregnant returning travelers. 

Updates on areas with ongoing Zika virus transmission are available online (http://wwwnc.cdc.gov/travel/notices/). Health care providers should ask all pregnant women about recent travel. Pregnant women with a history of travel to an area with Zika virus transmission and who report two or more symptoms consistent with Zika virus disease (acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) during or within 2 weeks of travel, or who have ultrasound findings of fetal microcephaly or intracranial calcifications, should be tested for Zika virus infection in consultation with their state or local health department. Testing is not indicated for women without a travel history to an area with Zika virus transmission. In pregnant women with laboratory evidence of Zika virus infection, serial ultrasound examination should be considered to monitor fetal growth and anatomy and referral to a maternal-fetal medicine or infectious disease specialist with expertise in pregnancy management is recommended. There is no specific antiviral treatment for Zika virus; supportive care is recommended.

Zika virus is a mosquito-borne flavivirus transmitted primarily by Aedes aegypti mosquitoes (1,2). These vectors also transmit dengue and chikungunya virus and are found throughout much of the Americas, including parts of the United States. An estimated 80% of persons infected with Zika virus are asymptomatic (2,3). Symptomatic disease is generally mild and characterized by acute onset of fever, maculopapular rash, arthralgia, or nonpurulent conjunctivitis. Symptoms usually last from several days to 1 week. Severe disease requiring hospitalization is uncommon, and fatalities are rare. Guillain-Barré syndrome has been reported in patients following suspected Zika virus infection (4–6).

Pregnant women can be infected with Zika virus in any trimester (4,7,8). The incidence of Zika virus infection in pregnant women is not currently known, and data on pregnant women infected with Zika virus are limited. No evidence exists to suggest that pregnant women are more susceptible to Zika virus infection or experience more severe disease during pregnancy.

Maternal-fetal transmission of Zika virus has been documented throughout pregnancy (4,7,8). Although Zika virus RNA has been detected in the pathologic specimens of fetal losses (4), it is not known if Zika virus caused the fetal losses. Zika virus infections have been confirmed in infants with microcephaly (4), and in the current outbreak in Brazil, a marked increase in the number of infants born with microcephaly has been reported (9). However, it is not known how many of the microcephaly cases are associated with Zika virus infection. Studies are under way to investigate the association of Zika virus infection and microcephaly, including the role of other contributory factors (e.g., prior or concurrent infection with other organisms, nutrition, and environment). The full spectrum of outcomes that might be associated with Zika virus infections during pregnancy is unknown and requires further investigation.

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Recommendations for Pregnant Women Considering Travel to an Area of Zika Virus Transmission

Because there is neither a vaccine nor prophylactic medications available to prevent Zika virus infection, CDC recommends that all pregnant women consider postponing travel to areas where Zika virus transmission is ongoing (10). If a pregnant woman travels to an area with Zika virus transmission, she should be advised to strictly follow steps to avoid mosquito bites (11,12). Mosquitoes that spread Zika virus bite both indoors and outdoors, mostly during the daytime; therefore, it is important to ensure protection from mosquitoes throughout the entire day (13). Mosquito prevention strategies include wearing long-sleeved shirts and long pants, using U.S. Environmental Protection Agency (EPA)–registered insect repellents, using permethrin-treated clothing and gear, and staying and sleeping in screened-in or air-conditioned rooms. When used as directed on the product label, insect repellents containing DEET, picaridin, and IR3535 are safe for pregnant women (14,15). Further guidelines for using insect repellents are available online (http://wwwnc.cdc.gov/travel/page/avoid-bug-bites) (11,15).

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Recommendations for Pregnant Women with History of Travel to an Area of Zika Virus Transmission

Health care providers should ask all pregnant women about recent travel. Women who traveled to an area with ongoing Zika virus transmission during pregnancy should be evaluated for Zika virus infection and tested in accordance with CDC Interim Guidance (Figure). Because of the similar geographic distribution and clinical presentation of Zika, dengue, and chikungunya virus infection, patients with symptoms consistent with Zika virus disease should also be evaluated for dengue and chikungunya virus infection, in accordance with existing guidelines (16,17).

Zika virus testing of maternal serum includes reverse transcription-polymerase chain reaction (RT-PCR) testing for symptomatic patients with onset of symptoms within the previous week. Immunoglobulin M (IgM) and neutralizing antibody testing should be performed on specimens collected ≥4 days after onset of symptoms. Cross-reaction with related flaviviruses (e.g., dengue or yellow fever) is common with antibody testing, and thus it might be difficult to distinguish Zika virus infection from other flavivirus infections. Consultation with state or local health departments might be necessary to assist with interpretation of results (18). Testing of asymptomatic pregnant women is not recommended in the absence of fetal microcephaly or intracranial calcifications.

Zika virus RT-PCR testing can be performed on amniotic fluid (7,9). Currently, it is unknown how sensitive or specific this test is for congenital infection. Also, it is unknown if a positive result is predictive of a subsequent fetal abnormality, and if so, what proportion of infants born after infection will have abnormalities. Amniocentesis is associated with an overall 0.1% risk of pregnancy loss when performed at less than 24 weeks of gestation (19). Amniocentesis performed ≥15 weeks of gestation is associated with lower rates of complications than those performed at earlier gestational ages, and early amniocentesis (≤14 weeks of gestation) is not recommended (20). Health care providers should discuss the risks and benefits of amniocentesis with their patients. A positive RT-PCR result on amniotic fluid would be suggestive of intrauterine infection and potentially useful to pregnant women and their health care providers (20).

For a live birth with evidence of maternal or fetal Zika virus infection, the following tests are recommended: histopathologic examination of the placenta and umbilical cord; testing of frozen placental tissue and cord tissue for Zika virus RNA; and testing of cord serum for Zika and dengue virus IgM and neutralizing antibodies. CDC is developing guidelines for infants infected by Zika virus. If a pregnancy results in a fetal loss in a woman with history of travel to an area of Zika virus transmission with symptoms consistent with Zika virus disease during or within 2 weeks of travel or findings of fetal microcephaly, Zika virus RT-PCR and immunohistochemical staining should be performed on fetal tissues, including umbilical cord and placenta.

There is no commercially available test for Zika virus. Testing for Zika virus infection is performed at CDC and several state health departments. Health care providers should contact their state or local health department to facilitate testing and for assistance with interpreting results (4).

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How to Treat Pregnant Women with Diagnoses of Zika Virus Disease

No specific antiviral treatment is available for Zika virus disease. Treatment is generally supportive and can include rest, fluids, and use of analgesics and antipyretics (4). Fever should be treated with acetaminophen (21). Although aspirin and other nonsteroidal anti-inflammatory drugs are not typically used in pregnancy, these medications should specifically be avoided until dengue can be ruled out to reduce the risk for hemorrhage (4,9,17).

In a pregnant woman with laboratory evidence of Zika virus in serum or amniotic fluid, serial ultrasounds should be considered to monitor fetal anatomy and growth every 3–4 weeks. Referral to a maternal-fetal medicine or infectious disease specialist with expertise in pregnancy management is recommended.

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PAHO: Zika Marches On

 
#10,912


Five days ago the CDC issued a Level 2 (Enhanced Precautions) Travel Alert for Zika Virus for portions of South & Central America and the Caribbean, and while specifically mentioning 14 countries and territories, granted that the number of affected regions would likely expand.   

As of today, PAHO lists 20 countries and territories in the Americas with autochthonous transmission of the Zika Virus, and that number is only expected to rise.

Yesterday it was widely reported (see 2 cases of Zika virus confirmed in Miami-Dade County) that Florida's DOH had confirmed 3 recently arrived international travelers had been diagnosed with the Zika virus; two in Miami-Dade who returned from Columbia last month, and one in Hillsborough County who visited Venezuela in December.


Again yesterday, the Illinois State Department of Health announced two pregnant women - with recent travel to Zika endemic areas - have tested positive for the virus.

Two Illinois Residents Test Positive For Zika Virus

19th Jan, 2016

SPRINGFIELD – The Illinois Department of Public Health (IDPH) is alerting the public of the potential of contracting Zika virus while traveling abroad.  Zika virus is spread to people through mosquito bites, similar to West Nile virus or dengue fever.  While illness is usually mild and severe disease requiring hospitalization is uncommon, there is a possible link between Zika virus infection in pregnant women and subsequent birth defects.

Two pregnant Illinois residents who recently traveled to countries where Zika virus is found have tested positive for the virus.  Physicians are monitoring their health and pregnancies.

“There is virtually no risk to Illinois residents since you cannot contract Zika virus from another person, but only through the bite of an infected mosquito,” said IDPH Director Nirav D. Shah, M.D., J.D.  “But since this is a time of year when people travel to warmer climates and countries where Zika virus is found, we are urging residents, especially pregnant women, to take preventive measures when traveling in affected countries and check health travel advisories.”

(Continue . . .)

 
This is precisely the kind of scenario the CDC hopes to avoid going forward with their recently issued travel warning.


During the dead of winter mosquito activity is practically non-existent across much of the nation, and significantly dampened even here in central Florida.   Were this summer or fall, there would be greater concern over the possibility of viremic visitors `seeding' the virus into local mosquito populations and sparking local transmission.

This is how both Dengue and Chikunungya are believed to have been (temporarily) introduced into Florida's mosquito population in recent years, and local transmission has occurred (see Arboviruses: (Already) Coming To America).

With Zika, Dengue and Chikungunya all spreading rapidly across the tropical Americas, this is a threat we will undoubtedly have to deal with increasingly over the coming months and years.

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RESEP ES MAMBO COKLAT SUSU ENAK DAN LEMBUT

Resep Es Mambo Coklat Susu Enak yang Lembut - Minuman beku tradisional dengan aneka varian rasa ini sejak dahulu memang sudah sangat akrab menjadi pilihan jananan sebagai penghilang dahaga. Bahan dasar es mambo umumnya terbuat dari air, sari buah, susu atau santan, serta bermacam tambahan lainnya sehingga lebih bervariasi. Penggunaan air yang terlalu banyak akan menghasilkan es mambo yang tidak lembut, sedangkan penggunaan susu (full cream atau skim) sebagai bahan dasar dapat membuatnya menjadi creamy dan lembut.

Apabila ingin mencoba mengolahnya sendiri di rumah, berikut ini adalah cara membuat es mambo coklat susu yang enak dan mudah serta bertekstur lembut. Semakin baik kualitas bubuk coklat yang digunakan, maka cita rasa coklatnya juga akan semakin mantap.

Persiapan Bahan Es Mambo Coklat Susu

• 20 gram coklat bubuk
• 500 ml susu cair full cream
• 80 ml susu kental manis putih full cream (sekitar 2 sachet)
• 150 gram gula pasir
• 15 gram tepung maizena dilarutkan sedikit air

Cara Membuat Es Mambo Coklat Susu Lembut

1. Tuang semua bahan ke dalam panci kecuali tepung maizena, aduk rata lalu masak sambil diaduk-aduk sesekali hingga mendidih. Setelah mendidih, baru kemudian tuang larutan maizena dan terus diaduk hingga agak kental, matikan api dan biarkan dingin.
2. Setelah dingin lalu tuang dalam plastik es mambo, gunakan gelas takar atau wadah apa saja yang sekiranya mudah untuk menuangkannya. Pegang batas isi dan putar-putar plastiknya, tarik ujungnya biar memanjang lalu putar dan ikat. Simpan dalan freezer kemudian siap untuk disantap setelah beku.

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CDC H7N8 Update & Risk Assessment

Dubois County, Indiana - Credit Wikipedia

#10,911


The CDC has today published an update and human health risk assessment for the HPAI and LPAI H7N8 avian flu viruses which were detected late last week on nine poultry farms in Dubois County, Indiana.

As you'll see the assessment and the recommendations are very similar to what we saw last year with the arrival of HPAI H5. 

I've only posted about half of the statement, so follow the link to read it in its entirety. 

Avian Influenza H7N8 Update

January 19, 2016 -- On January 15, 2016, the United States Department of Agriculture’s (USDA) Animal and Plant Health Inspection Service (APHIS) reported detection of highly pathogenic avian influenza (HPAI) H7N8 virus in a commercial turkey flock in Dubois County, Indiana. Subsequently, APHIS reported detection of low pathogenic avian influenza (LPAI) H7N8 among 8 nearby turkey flocks*. There are nine known subtypes of avian influenza H7 viruses (H7N1, H7N2, H7N3, H7N4, H7N5, H7N6, H7N7, H7N8, and H7N9); most of these have been LPAI viruses. LPAI H7N8 virus has been detected previously in wild bird surveillance in the United States, but this is the first instance of HPAI H7N8 virus detection in poultry.

Avian influenza viruses are classified as either low pathogenic or highly pathogenic depending upon molecular characteristics of the virus and the virus’ ability to cause disease and mortality in chickens in a laboratory setting. Infection of poultry with LPAI viruses may cause no disease or mild illness (such as ruffled feathers and a drop in egg production) and may not be detected. Infection of poultry with HPAI viruses can cause severe disease with high mortality in birds. Both HPAI and LPAI viruses can spread rapidly through poultry flocks. Influenza viruses are constantly changing and LPAI H7 viruses have been known to rapidly evolve into HPAI viruses.

CDC Risk Assessment

Human infection with avian influenza viruses is rare, but can occur. Human infections with avian influenza viruses have most often occurred after unprotected close contact with infected birds or the excretions/secretions of infected birds (e.g., droppings, oral fluids). Infected birds shed virus in their saliva, mucous and feces. Human infections with avian influenza viruses can happen when enough virus gets into a person’s eyes, nose or mouth, or is inhaled. This can happen when virus is in the air (in droplets or possibly dust) and a person breathes it in, or when a person touches something that has virus on it then touches their mouth, eyes or nose. 

Human infection with avian influenza viruses has not occurred from eating properly cooked poultry or poultry products.

At this time no human infections with avian influenza H7N8 viruses have ever been reported worldwide, however other avian influenza H7 viruses have infected people sporadically, including both LPAI and HPAI H7 viruses. H7 virus infections in people have been associated with a wide range of illness from conjunctivitis only, to influenza-like illness, to severe respiratory illness.

At this time, CDC considers the risk to the general public from these H7 viruses to be low; however, because other avian influenza A H7 viruses have infected people, it is possible that human infections with these viruses could occur. Risk is dependent on exposure. People with close or prolonged unprotected contact with infected birds or contaminated environments are likely to be at greater risk of infection. It is important to note that this is an evolving situation with some uncertainty. The public health risk assessment and associated recommendations may change.

CDC Recommendations

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Xinhua: H7N9 Case In Fujian Province

Fujian Province - Credit Wikipedia

#10,910


Although I find no official notice on the Fujian Health Ministry website, Xinhua (English) News is carrying the following report of what seems to be the 1st H7N9 case in Fujian Province of this 4th epidemic season.


First the report, then I'll return with a bit more.

East China province reports 1st H7N9 case this winter

Source: Xinhua   2016-01-19  21:41:49

XIAMEN, Jan. 19 (Xinhua) -- East China's Fujian Province on Tuesday confirmed its first human infection of H7N9 bird flu virus this winter.

The patient from Zhangpu County was confirmed to have the virus on Saturday. The patient is being treated and is in stable condition, the local publicity department said.

The county authorities have ordered to halt livestock sales in three townships in a bid to reduce the risk of infection.

On Tuesday, health authorities in Shanghai said that one of the city's two confirmed H7N9 patients has basically recovered and another is no longer critical.

The two are a 59-year-old man and a 58-year-old woman. 

Editor: Xiang Bo

Fujian Province ranks #4 overall in the number of reported human H7N9 cases, with the last case reported a 5 year old girl from Quanzhou, who recovered as of May 10th, 2015. 


This year, Zhejiang Province (which leads overall) has reported the most cases with 19, followed by Guangdong Province with 5. Whatever Guangdong Province has been missing in terms of H7N9 activity has been made up for by 5 recent H5N6 infections.

Credit HK CHP - Jan 19th Report

Whether the lack of reported cases during this 4th winter in provinces like Anhui, Shandong, or Henan reflect a change in the distribution of the virus, changes in human behavior around birds, or are the result of less stringent surveillance and reporting is unknown.

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DEFRA: Preliminary Outbreak Assessment - LPAI H5N1 In Scotland

#10,909


Over the past year we've seen a number of LPAI (low path) and HPAI (high path) avian flu outbreaks across Europe  that have included several new strains of avian influenza. In December, we learned of new H5N1, H5N2, and H5N9 subtypes in France, while last summer Germany and the UK were hit by new strains of HPAI H7.

Last week Scotland reported the UK's first outbreak of 2016 (see Fife, Scotland Avian Flu Outbreak Confirmed As LPAI H5N1), and today DEFRA has published their preliminary outbreak assessment (dated, curiously, 5 days ago).

 
The virus has been identified as a European LPAI H5N1 strain, similar to those commonly carried by wild birds. They note it is unrelated to either the Eurasian HPAI H5N1 virus, or to the HPAI H5 viruses circulating in poultry in Southwest France.


The authors find there is a low, but constant risk of poultry infection by H5 and H7 avian viruses in the UK via direct or indirect contact with wild birds, and recommend continued vigilance. 

Low Pathogenic Avian Influenza (H5N1) in the UK (Scotland)
 
14 January 2016 Ref: VITT/1200 LPAI in UK
Disease Report

On January 13th, the UK confirmed an outbreak of Low Pathogenic Avian Influenza (LPAI) subtype H5N1 on a commercial broiler breeder (parent) holding in the region (parish) of Dunfermline, Scotland (OIE, 2016; see map and inset). 


The premises had a flock of approximately 40,000 57 week old housed hens. The birds were housed in 5 sheds and the operation was “all in all out”. Mild clinical signs (egg drop and inappetence) were observed; there was no increase in mortality. Disease control measures were put in place on 8 January, when suspicion was raised after the receipt of the first non-negative laboratory test results. Measures include a 1km restriction zone, culling of all poultry on the infected premises and the destruction of eggs originating in the holding placed at the company hatchery has now been completed. An epidemiological investigation is being undertaken.
 
Situation Assessment

The holding is in a low poultry density area and there are no other commercial premises in the 1km zone, but there are areas where wild birds congregate within a few kilometres. The source of infection is unknown at this stage, and disease investigations continue. In general, LPAI (H5 and H7) viruses are considered to occasionally circulate in European waterfowl. 

National surveillance programmes in Europe have shown H5 seropositive flocks of farmed anseriformes (ducks and geese) and rarely in galliformes (chickens and turkeys) (European Commission, 2005-2014), nevertheless in the last 12 months over twenty outbreaks of various LPAI strains have been reported in domestic poultry in France, Germany, Italy, Netherlands and the UK, which is an indication of high awareness and effective screening in these countries.
 
Genetic sequencing results provided by the UK National Reference Laboratory (NRL) / EU Ref Lab (EURL) confirm that this is a European strain with common ancestry with other European LPAI H5 viruses most probably deriving from similar wild bird progenitor strains. The virus is clearly distinguishable from the Eurasian origin H5N1 viruses causing disease in poultry and occasionally people in close contact with infected poultry in Asia since 2003. It is also unrelated to the HPAI viruses circulating in poultry in Southwest France.

An interrogation of TRACES, the EU trade notification system, indicate there has been no recent trade to other Member States or Third countries of live poultry, hatching eggs or day old chicks from the affected premises or the restriction zone.
 
Conclusions
 
We consider that there is a constant low risk of incursion of any notifiable avian disease into the poultry in the UK from direct or indirect contact with wild birds. Prompt reporting of disease by farmers and vets in the UK, rapid diagnosis and swift disease control measures, often in advance of final strain identification, as in this case, enable rapid eradication from the UK poultry flock. The risk to public health and food safety is negligible.
 
For exports to non-EU countries the UK has taken immediate action to ensure that, in those cases where an importing country requires national freedom from Avian Influenza (i.e. that there be no reported cases of AI within the UK), the relevant Export Health Certificates have been suspended. In most cases the principle of regionalisation has been applied to enable trade to continue from outside the restricted area.
 
This disease event emphasises the importance of maintaining vigilance and appropriate biosecurity measures at all times throughout the year on poultry premises. Livestock keepers are reminded of the requirement to report all suspect notifiable diseases. 

We will continue to report on the situation if there are any significant changes.
 

Authors
Dr Helen Roberts
Professor Ian Brown

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