APHIS Updates HPAI Response Plan

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Primarily of interest to poultry producers, and those called upon to respond to avian flu outbreaks, the USDA's APHIS has released an update to their response plan they released last September (see AP HIS: Fall 2015 HPAI Preparedness & Response Plan).

Although the anticipated return of HPAI H5 hasn't happened yet, an entirely new HPAI virus (H7N8) did appear, resulting in the culling of 400K birds across 10 Indiana poultry farms.

And as `avian flu season' runs into early summer, there are plenty of opportunities for seeing additional outbreaks in the months ahead.

USDA Issues Updates to Highly Pathogenic Avian Influenza Fall Plan

Published: Jan 22, 2016

 

January 22, 2016 – The U.S. Department of Agriculture’s (USDA) Animal and Plant Health Inspection Service (APHIS) today issued updates to its Highly Pathogenic Avian Influenza (HPAI) Fall Plan.  The updates include additional detail around reimbursement for any virus elimination activities and the results from an August 2015 industry survey on preparedness. APHIS has also finalized its vaccination policy, which was previously released as a draft policy.  These updates will help APHIS, states, industry and producers to be even better prepared to address the HPAI virus if it returns this winter or spring.

In the original fall plan, released in September 2015, APHIS outlined its intent to use a flat rate reimbursement for virus elimination activities (cleaning, disinfecting) on infected properties.  However, the details were still being finalized.  The updated plan provides greater detail about how flat rate reimbursement will work.  APHIS will provide a flat rate to the producer, based upon the type of facility and the number of birds in the flock.  The flat rates are based upon averages and lessons learned during the spring outbreak.  They cover the cost of barn preparation, dry cleaning and heat disinfection.  The flat rates are:

• Turkey $3.55 / bird
• Layer $6.45/ bird
• Broiler $1.15 / bird (This is an estimate based on industry averages because no broiler flocks were affected in the previous outbreak)

The producer will be able to use the funds provided to do the work themselves or to hire an outside contractor.  They can also use the flat rate money to help fund alternate effective virus elimination methods after consultation with APHIS representatives.

The survey on industry preparedness was in progress when the original version of the plan was published, so APHIS is including the results in today’s update.  The survey found that the poultry industry has made important efforts in implementing preparedness and response capabilities for future HPAI cases.  However, APHIS is recommending some additional actions, such as increasing the use of premises IDs and having these entered in APHIS’ emergency database, which would greatly facilitate response activities.

The original fall plan included a draft vaccination policy, which has since been updated and finalized over the past several months to clarify a few points. The policy updates include:

• Clarifying that while USDA will cover the cost of purchasing vaccine, it will not incur the costs associated with administering the vaccine.
• Clarifying that should USDA decide to vaccinate, there may be justification for not vaccinating certain commercial subpopulations within an area, such as short-lived birds (broilers, ducks) or primary breeders that are under high biosecurity or compartmentalization
• Clarifying that surveillance testing for layer flocks would be through serological testing of vaccinates and dead bird surveillance using rRT-PCR followed by confirmatory testing at NVSL.

The changes APHIS made to the HPAI fall plan are important and support continued preparation for any future HPAI outbreak that might occur.

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CDC MMWR Early Release: Zika Spread & Possible Association With Microcephaly

Credit MMWR

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Coming off a 2pm embargo, the CDC has published two Early Release MMWR reports on the rapidly emerging Zika virus; one on the potential link between Zika and Microcephalic birth defects and the other on the rapid spread of the virus to new regions around the world.

Due to their combined length, I've only presented the link, a short description, and the summary for each MMWR report.  

Follow the link to read each in its entirety.

Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015

JANUARY 22, 2016

An outbreak of Zika virus infection was first recognized in northeastern Brazil in early 2015. By September, a sharp increase in microcephaly cases was reported from affected areas. The Brazil Ministry of Health developed a case definition for Zika virus–related microcephaly, and established a task force and a registry to investigate Zika virus–related cases of microcephaly and to describe the clinical characteristics of cases.

Summary

What is already known about this topic?

 An outbreak of Zika virus infection, a flavivirus transmitted by Aedes mosquitoes, was first recognized in northeastern Brazil in early 2015. In September, a sharp increase in the number of reported cases of microcephaly was reported in areas affected by the outbreak.

What is added by this report?
The Brazil Ministry of Health developed a case definition for Zika virus–related microcephaly (head circumference ≥2 standard deviations [SD] below the mean for sex and gestational age at birth). A task force and registry were established to investigate Zika virus–related cases of microcephaly and to describe the clinical characteristics of cases. Among the first 35 cases of microcephaly reported to the registry, 74% of mothers reported a rash illness during pregnancy, 71% of infants had severe microcephaly (>3 SD below the mean), approximately half had at least one neurologic abnormality, and among 27 who had neuroimaging studies, all were abnormal. Cerebrospinal fluid from all infants is being tested for Zika virus; results are not currently available.

What are the implications for public health practice?
The increased occurrence of microcephaly associated with cerebral damage characteristically seen in congenital infections in Zika virus-affected areas is suggestive of a possible relationship. Additional studies are warranted to confirm the association and to more fully characterize the phenotype. In addition to removing potential breeding areas for mosquitoes, pregnant women in Zika-affected areas should wear protective clothing, apply a U.S. Environmental Protection Agency (EPA)-approved insect repellent, and sleep in a screened room or under a mosquito net.

Zika Virus Spreads to New Areas — Region of the Americas, May 2015–January 2016
 
JANUARY 22, 2016
 
In May 2015, the World Health Organization reported the first local transmission of Zika virus in the Americas, with autochthonous cases identified in Brazil. In December, the Ministry of Health estimated that 440,000–1,300,000 suspected cases of Zika virus disease had occurred in Brazil in 2015

Summary

What is already known on this topic?

Zika virus is a mosquito-borne flavivirus transmitted primarily by Aedes aegypti mosquitoes. Most infections are asymptomatic, and symptomatic disease generally is mild. In May 2015, the first local transmission of Zika virus in the Region of the Americas was reported in Brazil. Following the spread of Zika virus in Brazil, there has been a marked reported increase in the number of infants born with microcephaly; it is not known how many of these cases are associated with Zika virus infection.

What is added by this report?

By mid-January 2016, local Zika virus transmission had been reported to the Pan American Health Organization from 20 countries or territories in the Region of the Americas; spread to other countries in the region is likely. Although local transmission of Zika virus has not been documented in the continental United States, infections have been reported among travelers visiting or returning to the United States, and  these likely will increase. Imported cases might result in local transmission in limited areas of the continental United States.

What are the implications for public health practice?

The best way to prevent Zika virus infection is to avoid mosquito bites by avoiding exposure and eliminating mosquito breeding areas. Until more is known, pregnant women should consider postponing travel to any area with ongoing Zika virus transmission. Health care providers should contact their state or local health department about testing patients with symptoms of Zika virus infection and a compatible travel history.

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CDC Expands Zika Travel Advisory Country List

Credit PAHO - Epi Wk 2

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Seven days ago the CDC issued a Level-II travel advisory for 14 countries and territories over the Zika Virus threat, and warned that list would likely grow. Two days ago, in PAHO: Zika Marches On, we looked at an updated list of affected countries from the Pan American Health Organization, which had increased to 20 nations and territories.

Today the CDC has released a statement adding Barbados, Bolivia, Ecuador, Guadeloupe, Saint Martin, Guyana, Cape Verde, and Samoa to the list. 

Given the speed with which this virus is spreading, it seems likely this list will continue to expand in the weeks ahead.

CDC adds countries to interim travel guidance related to Zika virus

Media Statement

For Immediate Release: Friday, January 22, 2016Contact: Media Relations, (404) 639-3286

CDC is working with other public health officials to monitor for ongoing Zika virus‎ transmission. Today, CDC added the following destinations to the Zika virus travel alerts:  Barbados, Bolivia, Ecuador, Guadeloupe, Saint Martin, Guyana, Cape Verde, and Samoa.  On January 15, CDC issued a travel alert (Level 2-Practice Enhanced Precautions) for people traveling to regions and certain countries where Zika virus transmission is ongoing: the Commonwealth of Puerto Rico, a U.S. territory; Brazil; Colombia; El Salvador; French Guiana; Guatemala; Haiti; Honduras; Martinique; Mexico; Panama; Paraguay; Suriname; and Venezuela. 

Specific areas where Zika virus transmission is ongoing are often difficult to determine and are likely to continue to change over time.

As more information becomes available, CDC travel alerts will be updated. Travelers to areas where cases of Zika virus infection have been recently confirmed are at risk of being infected with the Zika virus. Travelers to these areas may also be at risk of being infected with dengue or chikungunya viruses. Mosquitoes that spread Zika, chikungunya, and dengue are aggressive daytime biters, prefer to bite people, and live indoors and outdoors near people. 
There is no vaccine or medicine available for Zika virus. The best way to avoid Zika virus infection is to prevent mosquito bites.

Some travelers to areas with ongoing Zika virus transmission will become infected while traveling but will not become sick until they return home. Symptoms include fever, rash, joint pain, and red eyes. Other commonly reported symptoms include muscle pain, headache, and pain behind the eyes. The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon and case fatality is low. 

Travelers to these areas should monitor for symptoms or illness upon return. If they become ill, they should tell their healthcare professional where they have traveled and when.

Until more is known, and out of an abundance of caution, CDC continues to recommend that pregnant women and women trying to become pregnant take the following precautions:

• 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 professional first and strictly follow steps to avoid mosquito bites during the trip.
• Women trying to become pregnant should consult with their healthcare professional before traveling to these areas and strictly follow steps to prevent mosquito bites during the trip. 

Guillain-Barré syndrome (GBS) has been reported in patients with probable Zika virus infection in French Polynesia and Brazil. Research efforts will also examine the link between Zika and GBS.

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MMWR: Dengue Outbreak In Hawaii

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Although Florida and Texas have both seen minor outbreaks of dengue fever over the past few years, Hawaii is presently seeing the largest outbreak to date, with 230 cases reported on the Big Island over the past few months.

The following is the latest update from the Hawaiian State Department of Health.

Dengue Fever – Hawaii Island Outbreak

The Hawaii Department of Health (HDOH) is investigating a cluster of locally-acquired cases of dengue fever on Hawaii Island (the Big Island). Dengue is not endemic to Hawaii. However, it is intermittently imported from endemic areas by infected travelers. This is the first cluster of locally-acquired dengue fever since the 2011 outbreak on Oahu.  The Big Island and the rest of Hawaii remain safe destinations for visitors and residents.

As of January 21, 2016*:


Since the last update, HDOH has identified 6 new cases of dengue fever.  Currently, as many as 3 of the confirmed cases to date are potentially infectious to mosquitoes. All others are no longer infectious.

Of the confirmed cases, 208 are Hawaii Island residents and 22 are visitors.

188 cases have been adults; 42 have been children. Onset of illness has ranged between 9/11/15 – 1/16/16.

As of today, a total of 962 reported potential cases have been excluded based on test results and/or not meeting case criteria.

Yesterday the CDC's MMWR published a Notes From The Field report on this outbreak, which covers the opening six weeks of this outbreak.  At that time 117 Dengue infections had been identified.

Notes from the Field: Outbreak of Locally Acquired Cases of Dengue Fever — Hawaii, 2015

Weekly / January 22, 2016 / 65(2);34–35

David Johnston, MPH¹; Melissa Viray, MD¹; Jenny Ushiroda¹; A. Christian Whelen, PhD¹; Rebecca Sciulli¹; Remedios Gose¹; Roland Lee¹; Eric Honda¹; Sarah Y. Park, MD¹ (View author affiliations)

On October 21, 2015, the Hawaii Department of Health (HDOH) was notified of a positive dengue immunoglobulin M (IgM) antibody result in a woman residing on Hawaii Island (also known as the Big Island). The patient had no history of travel off the island, and other family members reported having similar signs and symptoms, which consisted of fever, headache, myalgias and arthralgias, and a generalized erythematous rash. HDOH initiated an investigation to identify any additional cases and potential exposure sources. On October 24, HDOH received report of a group of mainland U.S. visitors who had traveled together on Hawaii Island, including several who had developed a febrile illness. Additionally, on October 27, HDOH was notified of an unrelated person, also on Hawaii Island, with a positive dengue IgM result. As of November 26, 2015, HDOH had identified 107 laboratory-confirmed cases of dengue fever (1), with dates of onset ranging from September 11 to November 18, 2015 (Figure).

(SNIP)

All travelers, whether visitors to the state of Hawaii or returning residents, should consult with and advise their health care providers regarding their recent travel if they develop illness within 2 weeks of their return home. All health care providers, especially those in Hawaii, should be familiar with and alert for signs and symptoms of dengue fever, as well as for other more common infections such as leptospirosis, which sometimes mimics dengue infection. 

Additionally, health care providers should know the warning signs and management of potential severe dengue (i.e., dengue hemorrhagic fever) (1). It is important for all persons, and especially for state of Hawaii residents and those on Hawaii Island, to avoid exposure to mosquitoes, eliminate potential mosquito breeding locations from their property, and protect themselves from mosquito bites.

The arrival of Dengue to Hawaii undoubtedly occurred in much the same way that Zika arrived in Brazil, Chikungunya arrived in the Caribbean, and Dengue turned up in South Florida. 

Carried in (unknowingly) by an infected traveler - one who may very well have been asymptomatic or only mildly ill.

Although humans are usually only viremic for a week or 10 days - during this window they are capable of infecting local mosquitoes who partake in a blood meal, even if they aren't symptomatic (see PNAS: Asymptomatic Humans Transmit Dengue Virus To Mosquitoes).

It takes the confluence of a several conditions - a viremic visitor, a competent vector like the Aedes mosquito, the right weather/climatic conditions, and usually a dense population - but when the conditions are right, sustained local transmission (albeit sometimes only temporarily) can occur.

With Zika, Chikungunya, and Dengue making substantial inroads into the Americas, Southeast Asia, and the Pacific - all areas with a substantial tourist trade - the ability for these viruses to hop a plane and turn up in Europe, North America, and other regions where they are not currently active continues to grow.

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Saudi MOH Announces 2 MERS Cases

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We've seen a very quiet December and January with regards to MERS reports from Saudi Arabia, but today the MOH announces two new cases, both supposedly having had (1 direct and 1 indirect) camel contact.

Although there is no overriding `season' for MERS, late winter and spring are viewed as times of heightened concern, primarily because of so many young - virologically naive - camels born over the winter.

While camel contact no doubt contributes to the `reseeding' of the virus into the human population, by far most people are infected by contact with infected individuals, often in hospital or health care settings. 

For the majority of `primary' cases (those that occur in the community when there is no known exposure to a healthcare facility or to a known human case), the risk exposure remains unknown.

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ECDC Rapid Risk Assessment On Zika Virus Epidemic

Credit ECDC

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The ECDC has published a 20 page, data-rich, overview and analysis on the Zika virus called  Rapid Risk Assessment: Zika virus disease epidemic: potential association with microcephaly and Guillain-Barré syndrome (first update).

As we've come to expect from the ECDC, it is comprehensive, well documented, and makes an invaluable reference.  

You'll want to download to read and keep this PDF file handy, as it is simply too large to excerpt the full  gist here.


You'll find sections devoted to genetic lineage and possible changes to the Zika virus (see AFD Blog Paper: Zika Adaptations To Humans Helped Spark Global Spread), the risks from blood transfusion, advice to international travelers and their doctors, and of course the two big (and as yet, unanswered) $64 questions:

Risk of microcephaly and other congenital central nervous system malformations

To date, health authorities have reported eight adverse pregnancy outcomes and/or other congenital CNS malformations with laboratory confirmation of Zika virus in amniotic fluid, placenta or foetal tissues. In addition, information on six cases of Zika virus detection in newborns from the Paraíba State with partly severe congenital malformations has been recently published. All fourteen reported cases have history of exposure in Brazil.

After performing a retrospective analysis following the alert from Brazil, the health authorities of French Polynesia reported an increase from an average of one case annually to 17 cases of CNS malformations in foetuses and infants during 2014–2015, following a Zika virus outbreak in 2013–2014.

No cases of microcephaly or other CNS malformations potentially related to Zika virus have been reported from other countries of Americas and Caribbean affected by Zika virus outbreaks. However, autochthonous transmission of Zika virus did presumably not start before the last trimester of 2015 in most of these countries, and the prospective monitoring of congenital malformations will support the evaluation of the association with Zika virus infections.


In summary, the evidence regarding a causal link between Zika virus infections during pregnancy and congenital CNS malformations is growing, although the available information is not yet sufficient to confirm it. The definitions of suspected cases applied in the epidemiological surveillance protocol for Brazil are broad and will capture many healthy children who are within the normal variation as well as children with medical conditions that are unrelated to Zika virus infections. The cases identified with the surveillance protocol will need to be further investigated and assessed, and many will have to be followed over time. It is expected that many of the suspected cases will be reclassified and discarded. So far, no results have been made public from the epidemiological studies that reportedly are ongoing and may substantiate or disprove the association between intra-uterine Zika virus infections and congenital lesions in CNS.

Risk of Guillain–Barré syndrome
 

No new scientific evidence about the association of GBS and Zika virus infection has been published since the ECDC RRA published on 10 December 2015. Two new countries, El Salvador and Venezuela (according to media), have reported an unusual increase above the baseline, concomitant with the development of Zika outbreaks in the country. This observation supports a temporal and spatial association as that seen in French Polynesia.

The bottom line is, despite a growing body of evidence, there is not yet conclusive proof that microcephalic births or the rise in GBS are due to Zika virus infection.  For now, however, it remains the most likely culprit.

With no vaccine, no specific treatment, and far too many unanswered questions - the immediate focus is on prevention. 

Better mosquito control, limiting personal exposure to mosquitoes, and taking steps (using repellents, wearing long sleeved shirts, etc.) to prevent mosquito bites will be the best way to limit the spread of Zika, along with Dengue and Chikungunya.

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