H5N1

Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050

Via The Lancet: Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050. This is very disturbing, because it's probably an underestimate. Excerpt from the long summary:

In 2021, we estimated 4·71 million (95% UI 4·23–5·19) deaths were associated with bacterial AMR, including 1·14 million (1·00–1·28) deaths attributable to bacterial AMR. Trends in AMR mortality over the past 31 years varied substantially by age and location. From 1990 to 2021, deaths from AMR decreased by more than 50% among children younger than 5 years yet increased by over 80% for adults 70 years and older. AMR mortality decreased for children younger than 5 years in all super-regions, whereas AMR mortality in people 5 years and older increased in all super-regions. 

For both deaths associated with and deaths attributable to AMR, meticillin-resistant Staphylococcus aureus increased the most globally (from 261 000 associated deaths [95% UI 150 000–372 000] and 57 200 attributable deaths [34 100–80 300] in 1990, to 550 000 associated deaths [500 000–600 000] and 130 000 attributable deaths [113 000–146 000] in 2021). 

Among Gram-negative bacteria, resistance to carbapenems increased more than any other antibiotic class, rising from 619 000 associated deaths (405 000–834 000) in 1990, to 1·03 million associated deaths (909 000–1·16 million) in 2021, and from 127 000 attributable deaths (82 100–171 000) in 1990, to 216 000 (168 000–264 000) attributable deaths in 2021. There was a notable decrease in non-COVID-related infectious disease in 2020 and 2021. 

Our forecasts show that an estimated 1·91 million (1·56–2·26) deaths attributable to AMR and 8·22 million (6·85–9·65) deaths associated with AMR could occur globally in 2050. Super-regions with the highest all-age AMR mortality rate in 2050 are forecasted to be south Asia and Latin America and the Caribbean. 

Increases in deaths attributable to AMR will be largest among those 70 years and older (65·9% [61·2–69·8] of all-age deaths attributable to AMR in 2050). In stark contrast to the strong increase in number of deaths due to AMR of 69·6% (51·5–89·2) from 2022 to 2050, the number of DALYs showed a much smaller increase of 9·4% (–6·9 to 29·0) to 46·5 million (37·7 to 57·3) in 2050. 

Under the better care scenario, across all age groups, 92·0 million deaths (82·8–102·0) could be cumulatively averted between 2025 and 2050, through better care of severe infections and improved access to antibiotics, and under the Gram-negative drug scenario, 11·1 million AMR deaths (9·08–13·2) could be averted through the development of a Gram-negative drug pipeline to prevent AMR deaths.

Sequencing-Based Detection of Avian Influenza A(H5N1) Virus in Wastewater in Ten Cities

A letter to the NEJM, published today: Sequencing-Based Detection of Avian Influenza A(H5N1) Virus in Wastewater in Ten Cities. Click or tap through for the citations and a chart.

Highly pathogenic avian influenza viruses are virulent members of the H5 and H7 subtypes of influenza A virus, cause systemic disease in avian species, and incur substantial costs to agricultural production because of the need for mass culling of infected animals. Since 1955, most avian influenza outbreaks have been caused by three lineages; one of them (a lineage that infected poultry) gave rise to the 2.3.4.4b clade, which has recently become widespread. 

On March 25, 2024, H5N1 2.3.4.4b was detected in dairy cattle herds in Texas concomitantly with herds in Michigan and Kansas. The first case in humans in 2024 was detected shortly thereafter in Texas (on March 28, 2024) in a person with exposure to symptomatic cattle. As of July 28, 2024, H5N1 had been detected in 14 human infections in 3 U.S. states (4 cattle-associated and 10 poultry-associated), 171 dairy herds across 13 states, and 94 poultry flocks across 26 states.  

Another group has reported the presence of influenza virus with an H5 hemagglutinin gene in wastewater beginning in March 2024 and has subsequently identified H5 influenza virus at 25 sites across 9 states (https://data.wastewaterscan.org/). 

Since May 2022, the Texas Epidemic Public Health Institute has been using hybrid-capture sequencing to test weekly wastewater samples in mostly urban areas in cities throughout Texas (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org) and has detected over 400 human and animal viruses to date, several of which (e.g., SARS-CoV-2, influenza virus, and mpox virus) correlate with clinical case data. 

Seasonal influenza virus serotypes H3N2 and H1N1 are routinely detected in Texas Epidemic Public Health Institute wastewater samples, and levels in wastewater have corresponded to clinical caseloads from May 2022 through the beginning of March 2024. Until that point, serotype H5N1 had not been detected (0 of 1337 wastewater samples). 

However, in samples from March 4 through July 15, 2024, H5N1 was detected in 10 of 10 cities, 22 of 23 sites, and 100 of 399 samples (Figure 1 and Fig. S1). The abundance of H5N1 sequences identified has not correlated with influenza-related hospitalizations, which declined in Texas during the spring of 2024 (Figure 1B). 

Wastewater sequences were identified as H5N1 through the use of competitive mapping to an influenza genome database. Sequences were then manually validated and documented by three independent genomics researchers. Within the set of validated H5N1 sequencing reads, there are alignments to all eight genome segments, including the PB2, HA (hemagglutinin), and NA (neuraminidase) genes, which cover more than 85% of the genome (Figure 1A). All sequencing reads best match H5N1 genomes from birds and mammals (including those identified in humans) collected since 2023 and are assigned to the 2.3.4.4b clade. 

Of importance, a glutamic acid, instead of lysine, in position 627 of PB2 suggests that this virus has not extensively adapted to humans (see Table S2, which shows all unique single-nucleotide polymorphisms). 

The widespread detection of influenza A(H5N1) virus in wastewater from 10 U.S. cities is troubling. Although the exact origin of the signal is currently unknown, the lack of clinical burden along with genomic information suggests multiple animal sources. 

Wastewater monitoring should be considered as a sentinel surveillance tool that augments our detection of evolutionary adaptations of concern. To aid efforts to identify the source and promote efforts to mitigate the next flu pandemic, we suggest expanded, agnostic sequencing of wastewater, livestock and their products, exposed agricultural workers (including fecal and urine samples), and migrating birds along major flyways.

CDC Confirms Human H5 Bird Flu Case in Missouri

Thanks to Greg Folkers for the link to this CDC news release: CDC Confirms Human H5 Bird Flu Case in Missouri. Excerpt:

September 6, 2024 -- CDC has confirmed a human case of avian influenza A(H5) ("H5 bird flu") reported by the state of Missouri. The case was identified through that state's seasonal flu surveillance system. The specimen was forwarded to CDC for confirmatory testing per usual protocols and confirmed yesterday. An investigation into the potential exposure is ongoing by the Missouri Department of Health and Senior Services (DHSS).  

Case Information  

Missouri DHSS reports that the patient, who was hospitalized, had underlying medical conditions, was treated with influenza antiviral medications, subsequently discharged, and has recovered. There is no immediate known animal exposure. No ongoing transmission among close contacts or otherwise has been identified.  

This is the 14th human case of H5 reported in the United States during 2024 and the first case of H5 without a known occupational exposure to sick or infected animals. H5 outbreaks in cattle have not been reported in Missouri, but outbreaks of H5 have been reported in commercial and backyard poultry flocks in 2024. H5N1 bird flu has been detected in wild birds in that state in the past.  

While other novel flu cases have been detected through the country's national flu surveillance system, this is the first time that system has detected a case of H5. Targeted H5-outbreak specific surveillance has been conducted as part of ongoing animal outbreaks and has identified all the other cases. In this case, the specimen from the patient originally tested positive for flu A, but negative for seasonal flu A virus subtypes. That finding triggers additional testing.

Detection and spread of high pathogenicity avian influenza virus H5N1 in the Antarctic Region

Via Nature Communications: Detection and spread of high pathogenicity avian influenza virus H5N1 in the Antarctic Region. The abstract:

Until recent events, the Antarctic was the only major geographical region in which high pathogenicity avian influenza virus (HPAIV) had never previously been detected. Here we report on the detection of clade 2.3.4.4b H5N1 HPAIV in the Antarctic and sub-Antarctic regions of South Georgia and the Falkland Islands, respectively. 

We initially detected H5N1 HPAIV in samples collected from brown skuas at Bird Island, South Georgia on 8th October 2023. Since this detection, mortalities were observed in several avian and mammalian species at multiple sites across South Georgia. Subsequent testing confirmed H5N1 HPAIV across several sampling locations in multiple avian species and two seal species. Simultaneously, we also confirmed H5N1 HPAIV in southern fulmar and black-browed albatross in the Falkland Islands. 

Genetic assessment of the virus indicates spread from South America, likely through movement of migratory birds. Critically, genetic assessment of sequences from mammalian species demonstrates no increased risk to human populations above that observed in other instances of mammalian infections globally. 

Here we describe the detection, species impact and genetic composition of the virus and propose both introductory routes and potential long-term impact on avian and mammalian species across the Antarctic region. We also speculate on the threat to specific populations following recent reports in the area.

WHO DON: Avian Influenza A(H5N1)- Cambodia

WHO has published a new DON: Avian Influenza A(H5N1)- Cambodia. Excerpt:

Situation at a glance 

On 20 August 2024, the World Health Organization (WHO) was notified by the country’s International Health Regulations (IHR) National Focal Point (NFP) of a laboratory-confirmed case of human infection with avian influenza A(H5N1) virus (clade 2.3.2.1c) in a 15-year-old child in the Kingdom of Cambodia. 

This case is one of 10 human cases of influenza A(H5N1) infection reported in Cambodia in 2024. From 2003 to the present, 72 cases of human infection with influenza A(H5N1), including 43 deaths (case fatality ratio [CFR] of 59.7%), have been reported in the country. 

According to the IHR (2005), a human infection caused by a novel influenza A virus subtype is an event that has the potential for high public health impact and must be notified to the WHO. Based on currently available information, WHO assesses the current risk to the general population posed by this virus as low.

Financialisation: a 21st century commercial determinant of health equity

Via The Lancet Public Health: Financialisation: a 21st century commercial determinant of health equity. The summary:

In 21st century capitalism, financial markets reign supreme. The elevation of investing, trading, and speculating as a way of making profit has shifted economic power towards institutional investors and enhanced the power of financial capital.  

Financialisation has introduced uncertainty in the commitment to public provision of goods and services. The behaviours of corporations focus more on profit for shareholders and senior executives to the detriment of wages, worker protections, livelihoods, and impact on prices and the environment. The practices of this financial system pose major challenges to public health and planetary health equity through the influence on social inequality, climate change, and health outcomes.  

The aim of this Viewpoint is to expand the understanding of the commercial determinants of health to explicitly include the financial system and present key plausible pathways via which the financialisation of advanced economies influences public health and planetary health equity. The global public health community must pay close attention to these key commercial determinants of health.  

It is now crucial to reduce the power of financial actors and hold financial actors accountable. Civil society groups can highlight their practices, articulate alternative visions, and hold financial actors and governments to account. Interdisciplinary research must provide a diagnosis of the financial and public health issues, and, importantly, illuminate effective pathways forward. Financial and commercial worlds must return to stakeholder primacy rather than that of the shareholder.

Excess Death Rates by State During the COVID-19 Pandemic: United States, 2020‒2023

Via AJPH: Excess Death Rates by State During the COVID-19 Pandemic: United States, 2020‒2023. The full article is paywalled, but the abstract confirms some earlier studies:

Objectives. To estimate state-level excess death rates during 2020 to 2023 and examine differences by region and partisan orientation.  

Methods. We modeled death and population counts from the Centers for Disease Control and Prevention to estimate excess death rates for the United States, 9 census divisions, and 50 states. We compared excess death rates for states with different partisan orientations, measured by the party of the seated governor and the level of partisan representation in state legislatures.  

Results. The United States experienced 1 277 697 excess deaths between March 2020 and July 2023. Almost 90% of these deaths were attributed to COVID-19, and 51.5% occurred after vaccines were available. The highest excess death rates first occurred in the Northeast and then shifted to the South and Mountain states. Between weeks ending June 20, 2020, through March 19, 2022, excess death rates were higher in states with Republican governors and greater Republican representation in state legislatures.  

Conclusions. Excess death rates during the COVID-19 pandemic varied considerably across the US states and were associated with partisan representation in state government, although the influence of confounding variables cannot be excluded.

WHO: Mpox – African Region

A Disease Outbreak News item from WHO: Mpox – African Region. Excerpt and then a comment:

Situation at a glance

On 14 August 2024, the WHO Director-General determined that the upsurge of mpox in the Democratic Republic of the Congo and a growing number of countries in Africa constitutes a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations (2005) (IHR), the highest level of alarm under the IHR. 

Here we describe the latest countries in the region newly reporting cases since the start of the multi-country outbreak in 2022. The clade Ib MPXV outbreak, which began in September 2023 in the Democratic Republic of the Congo, is having an increasing number of cases in the country and also expanding to neighbouring countries. 

Burundi, Kenya, Rwanda and Uganda have each reported their first mpox cases. Several of these cases have travel links to eastern parts of the Democratic Republic of the Congo and each of these countries has identified clade Ib monkeypox virus (MPXV). 

Based on available epidemiological data, this clade has been spreading rapidly among adults through close physical contact, including sexual contact identified within networks of sex workers and their clients. 

As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. Additionally, Cote d’Ivoire is reporting cases of clade II mpox for the first time since the start of the multi-country outbreak in 2022.

Note that I've created a list of mpox resources near the top of the right-hand column. I'll continue to add to the list.

ECDC recommends enhancing preparedness as more imported cases of clade I mpox highly likely

ECDC has issued a press release: ECDC recommends enhancing preparedness as more imported cases of clade I mpox highly likely. Excerpt:

In a new risk assessment, the European Centre for Disease Prevention and Control (ECDC) has said that it is highly likely that the EU/EEA will see more imported cases of mpox caused by the clade I virus currently circulating in Africa. However, the likelihood of sustained transmission in Europe is very low provided that imported cases are diagnosed quickly and control measures are implemented. 

Due to frequent and close travel links between the EU/EEA and Africa, ECDC recommends that EU/EEA Member States issue travel advice for people visiting or returning from areas affected by the outbreak. The likelihood of infection for people from the EU/EEA travelling to affected areas who have close contact with affected communities is high. Additionally, there is a moderate risk for close contacts of possible or confirmed imported cases into the EU/EEA.  

“As a result of the rapid spread of this outbreak in Africa, ECDC has increased the level of risk for the general population in the EU/EEA and travellers to affected areas. Due to the close links between Europe and Africa, we must be prepared for more imported clade I cases,” says Pamela Rendi-Wagner, Director of ECDC.  

Through strengthened surveillance and preparedness activities as well as the robust healthcare and response capacity in EU/EEA Member States, ECDC predicts that the impact on the EU/EEA from MPXV clade I will be low.  

ECDC recommends that public health authorities in the EU/EEA maintain high levels of preparedness planning and awareness raising activities to enable rapid detection and response of any further MPXV clade I cases that may reach Europe. Ensuring effective surveillance, laboratory testing, epidemiological investigation and contact tracing capacities will be vital to detecting cases of MPXV clade I on the continent and activating any response.  

Raising awareness among clinicians and establishing effective case management processes once a suspected case is identified will be crucial to detecting any further cases of MPXV clade I in the EU/EEA and preventing any secondary infections. If a clade I infection is detected, the event should be promptly communicated at the EU level via EpiPulse or EWRS. ECDC recommends travellers to epidemic areas consult their healthcare provider or travel health clinic regarding eligibility for vaccination against mpox.  

The new risk assessment follows Africa CDC’s declaration of a Public Health Emergency of Continental Security and the declaration of a Public Health Emergency of International Concern by the World Health Organization.  

ECDC continues to work with local and international partners to help control the spread of mpox on the African continent. The outbreak in Africa is distinct from the global MPXV clade IIb outbreak that occurred in 2022 and which continues to circulate at low levels in Europe and globally.

WHO: Antimicrobial Resistance, Hypervirulent Klebsiella pneumoniae - Global situation

A WHO Disease Outbreak News report: Antimicrobial Resistance, Hypervirulent Klebsiella pneumoniae - Global situation. Excerpt:

Situation at a glance

In early 2024, the Global Antimicrobial Resistance and Surveillance System on Emerging Antimicrobial Resistance Reporting (GLASS-EAR) issued a request for information to assess the current global situation given the increased identification of isolates of hypervirulent Klebsiella pneumoniae (hvKp) sequence type (ST) 23 carrying resistant genes to the carbapenem antibiotics – carbapenemase genes. 

K. pneumoniae strains that can cause severe infections in healthy individuals and have been identified with increasing frequency in recent years are considered hypervirulent compared to classical strains because of their ability to infect both healthy and immunocompromised individuals and because of their increased tendency to produce invasive infections.The presence of hvKp ST23 was reported in at least one country in all six WHO Regions. 

The emergence of these isolates with resistance to last-line antibiotics like carbapenems necessitates the administration of alternative antimicrobial treatment, which may not be available in many contexts. 

WHO recommends that Member States progressively increase their laboratory diagnostic capacity to allow for the early and reliable identification of hvKp, as well as reinforce laboratory capacities in molecular testing and detection and analyses of relevant virulence genes in addition to resistance genes. 

The assessment of risk at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, track and scale of community transmission, the gap in the available data on infections, hospitalization, and the overall burden of the disease.

Colorado reports three presumptive positive H5 cases in poultry workers

A CDC news release: Colorado Reports Three Presumptive Positive H5 Cases in Poultry Workers. Excerpt and then a comment:

July 12, 2024 – The state of Colorado has announced that three people have tested presumptive positive for highly pathogenic avian influenza (HPAI) A(H5) (“H5 bird flu”) virus infection. Specimens have been sent to CDC for confirmatory testing. All of the people who tested presumptive positive experienced mild symptoms and were workers who were involved in the depopulation of poultry at a poultry facility experiencing an outbreak of the H5N1 virus that is circulating in wild birds and has been causing multistate outbreaks in dairy cows and poultry. At the state’s request, CDC is sending a team to Colorado to support their investigation, which is ongoing.  

CDC’s current risk assessment for the general public remains low. As we learn more, we will continue to assess the situation and provide updates. These preliminary results again underscore the risk of exposure to infected animals. There are no signs of unexpected increases in flu activity otherwise in Colorado, or in other states affected by H5 bird flu outbreaks in cows and poultry.

Similar cases occurred when H5N1 was spreading in Asia 20 years ago. South Korea had several such cases after poultry culls. I seem to recall that, like the American cases, they were relatively minor; most serious cases followed consumption of infected poultry meat.

Stop H5N1 influenza in US cattle now

An editorial in Science; Stop H5N1 influenza in US cattle now.

The relentless march of a highly pathogenic avian influenza virus (HPAIV) strain, known as H5N1, to become an unprecedented panzootic continues unchecked. The leap of H5N1 clade 2.3.4.4b from Eurasia and Africa to North America in 2021 and its further spread to South America and the Antarctic have exposed new avian and mammalian populations to the virus and led to outbreaks on an unrivaled scale. 

The virus has infected wild birds across vast geographic regions and caused wildlife deaths in some of the world’s most biodiverse ecosystems. Hundreds of millions of poultry have died or been culled, affecting global food security in some of the world’s poorest regions. Numerous mammalian species, including sea lions and fur animals, have been infected. Outbreaks in dairy cows in the United States have been occurring for months, seemingly unchecked in most affected states. Why is there not a greater sense of urgency to control these infections? 

Although the H5 2.3.4.4b virus seems poorly optimized for infection or spread in humans, with fewer than 20 cases since 2016, influenza leaves no room for complacency. The sheer number of infected wild birds and poultry has caused spillover infections to occur in wild carnivores, marine mammals, and farmed animals, providing additional pathways for exposure and perhaps infection in humans. The H5 virus has evolved continuously since 1996 but has never infected so many bird species nor been able to transmit to, and replicate in, cows. 

The more than 140 dairy farms in 12 US states with the virus and the detection of viral RNA in milk products in grocery stores speak for themselves. Infection in cattle creates new possibilities for direct contact between the virus and humans, and also risks the virus evolving the ability to spread in cattle, a new livestock reservoir of around 1.5 billion animals worldwide. 

Until now, human infections with H5 viruses were mainly associated with the keeping of infected poultry. But over the past 3 months, the United States has identified human H5 cases in farmworkers associated with one of the world’s most industrialized dairy production systems. Even difficult viral adaptations can occur if there are enough opportunities for contact and replication in new host species. Adaptation of the virus to cattle must be prevented. The outbreak in cattle in the United States must therefore be brought under control quickly. 

Key measures that should be initiated or intensified immediately include surveillance of all US dairy farms by testing, for example, bulk milk for influenza virus RNA, implementation of strict quarantine for infected cattle, and restriction of within-state transport to stop the circulation of the virus in cows. Only a couple of states are attempting this currently. 

Biosecurity and hygiene measures on US dairy facilities must be enhanced to avoid virus spread and spillover infections. This should include simple and practical steps such as keeping work clothing on the farm, thoroughly decontaminating stock vehicles and equipment, ensuring restricted access and movement of personnel among premises, and providing appropriate personal protective equipment. 

Human influenza surveillance should be bolstered during the summer and before the usual human seasonal influenza wave begins in the fall. The timely development of vaccine candidates for both livestock and humans should be undertaken along with associated policies on their distribution. This is the ultimate insurance against a worst-case scenario in which viral variants emerge that spread more easily in mammals. 

Globally, surveillance of mammalian cases should be intensified and real-time genomic information on the virus should be made publicly available, especially in at-risk populations (such as pig and fur animal farms). There must be increased global awareness of data collection and data sharing on zoonotic influenza. Analyses for incursion risk and pandemic preparedness based on both genetic and phenotypic data (including identifying mammalian adaptive changes, antiviral therapeutic resistance, and diagnostic robustness) in all regions need to be substantially improved, and the detection of human infection clusters needs to be further optimized. 

National and international coordination in the spirit of a modern “One Health” approach is essential, and the quadripartite comprising the Food and Agricultural Organization of the United Nations, United Nations Environment Programme, World Health Organization, and World Organisation for Animal Health should step up to take a leading role.

Neolithic population collapse may have been caused by plague, researchers say

Via The Guardian: Neolithic population collapse may have been caused by plague, researchers say. Excerpt:

A devastating population collapse that decimated stone age farming communities across northern Europe 5,000 years ago may have been driven by an outbreak of the plague, according to research.  

The cause of the calamity, known as the Neolithic collapse, has long been a matter of debate.  

Studies based on DNA from human bones and teeth excavated from ancient burial tombs in Scandinavia – seven from an area in Sweden called Falbygden, one from coastal Sweden close to Gothenburg and one from Denmark – now suggest that disease played a central role.  

The remains of 108 people – 62 males, 45 females and one undetermined – were studied. Eighteen of them, or 17%, were infected with plague at the time of death.  

The researchers were able to chart the family tree of 38 people from Falbygden across six generations, spanning about 120 years. Twelve of them, or 32%, were infected with plague. Genomic findings indicated that their community experienced three distinct waves of an early form of plague.  

The researchers reconstructed full genomes of the different strains of the plague-causing bacterium Yersinia pestis responsible for these waves. They determined that the last one may have been more virulent than the others, and they identified traits indicating the disease could have spread from person to person to cause an epidemic.  

“We learned that the Neolithic plague is an ancestor to all later plague forms,” said Frederik Seersholm, a geneticist at the University of Copenhagen and lead author of the research, published in the journal Science.  

A later form of this same pathogen caused the Justinian Plague of the sixth century AD and the 14th-century Black Death that ravaged Europe, north Africa and the Middle East. Because the strains circulating during the Neolithic decline were much earlier versions, the plague may have produced different symptoms than those in the epidemics millennia later.  

The study demonstrated that the plague was abundant and widespread in the area examined.  

Martin Sikora, who is also a geneticist at the University of Copenhagen and a co-author of the report, said: “This high prevalence of plague indicates that plague epidemics played a substantial role in the Neolithic decline in this region. 

“Indeed, it seems plausible that the decline seen in other parts of Europe was also in some way affected by plague. We do already have evidence for plague in other megalithic sites in different parts of northern Europe. And seeing how prevalent it was in Scandinavia, I would expect a similar picture to emerge once we study these other megaliths with the same resolution.”

Cambodia: Two Takeo boys confirmed infected by H5N1 bird flu

Google Maps

Thanks to Peter O'Meagher for alerting me to this Khmer Times report: Two Takeo boys confirmed infected by H5N1 bird flu. Takeo is a province south of the capital, Phnom Penh. The 3-year-old case was reported yesterday, but not the 5-year-old. Excerpt:

The Takeo Health Department said two boys, ages three and five, have been confirmed to be infected with the H5N1 bird flu, while 29 others are still waiting for test results from the National Institute of Public Health (NIPH) and the Pasteur Institute (PI) of Cambodia.  

H5N1 is a subtype of influenza that predominantly infects birds. However, the H5N1 virus can also infect mammals that have been exposed to infected birds in some cases. In these cases, symptoms are frequently severe or fatal.  

Takeo Health Director Nhea Sithan said yesterday that two children have been diagnosed with the H5N1 bird flu virus, while 29 people were waiting on results of blood tests from the NIPH and PI. He said that the Takeo Provincial Health Department has asked experts to cooperate with the relevant ministries to identify everyone who ate chickens that are suspected of having been infected with the H5N1 bird flu virus.  

“We have dealt with the situation in a timely manner and we’ve sent 29 people who may have been exposed to H5N1 to analyse their blood to see whether they have contracted bird flu or not,” he said.  

The director of the Takeo Provincial Production and Veterinary Office, Thai Ly, said yesterday that more than 600 chickens that were thought to be at high risk of being infected with the H5N1 virus were destroyed after the Takeo Provincial Department of Agriculture, Forestry, and Fisheries identified a case of bird flu in Por village.  

He added that according to past studies of the bird flu virus, this level of infection is unlikely to spread to other villages. However, he urged people not to eat sick or already-dead birds to avoid H5N1 infection.  

“We are calling on people to be vigilant against infection by bird flu by not eating and cooking the chickens and ducks that are sick or die from unknown causes due to the danger caused by H5N1,” he said.

Counting the dead in Gaza: difficult but essential

Via The Lancet: Counting the dead in Gaza: difficult but essential. Excerpt, with my bolding:

By June 19, 2024, 37 396 people had been killed in the Gaza Strip since the attack by Hamas and the Israeli invasion in October, 2023, according to the Gaza Health Ministry, as reported by the UN Office for the Coordination of Humanitarian Affairs. The Ministry's figures have been contested by the Israeli authorities, although they have been accepted as accurate by Israeli intelligence services, the UN, and WHO. These data are supported by independent analyses, comparing changes in the number of deaths of UN Relief and Works Agency (UNRWA) staff with those reported by the Ministry, which found claims of data fabrication implausible. 

Collecting data is becoming increasingly difficult for the Gaza Health Ministry due to the destruction of much of the infrastructure. The Ministry has had to augment its usual reporting, based on people dying in its hospitals or brought in dead, with information from reliable media sources and first responders. This change has inevitably degraded the detailed data recorded previously. Consequently, the Gaza Health Ministry now reports separately the number of unidentified bodies among the total death toll. As of May 10, 2024, 30% of the 35 091 deaths were unidentified. 

Some officials and news agencies have used this development, designed to improve data quality, to undermine the veracity of the data. However, the number of reported deaths is likely an underestimate. The non-governmental organisation Airwars undertakes detailed assessments of incidents in the Gaza Strip and often finds that not all names of identifiable victims are included in the Ministry's list. Furthermore, the UN estimates that, by Feb 29, 2024, 35% of buildings in the Gaza Strip had been destroyed, so the number of bodies still buried in the rubble is likely substantial, with estimates of more than 10 000. 

Armed conflicts have indirect health implications beyond the direct harm from violence. Even if the conflict ends immediately, there will continue to be many indirect deaths in the coming months and years from causes such as reproductive, communicable, and non-communicable diseases. The total death toll is expected to be large given the intensity of this conflict; destroyed health-care infrastructure; severe shortages of food, water, and shelter; the population's inability to flee to safe places; and the loss of funding to UNRWA, one of the very few humanitarian organisations still active in the Gaza Strip. 

In recent conflicts, such indirect deaths range from three to 15 times the number of direct deaths. Applying a conservative estimate of four indirect deaths per one direct death to the 37 396 deaths reported, it is not implausible to estimate that up to 186 000 or even more deaths could be attributable to the current conflict in Gaza. Using the 2022 Gaza Strip population estimate of 2 375 259, this would translate to 7·9% of the total population in the Gaza Strip. 

A report from Feb 7, 2024, at the time when the direct death toll was 28 000, estimated that without a ceasefire there would be between 58 260 deaths (without an epidemic or escalation) and 85 750 deaths (if both occurred) by Aug 6, 2024.

An immediate and urgent ceasefire in the Gaza Strip is essential, accompanied by measures to enable the distribution of medical supplies, food, clean water, and other resources for basic human needs. At the same time, there is a need to record the scale and nature of suffering in this conflict. Documenting the true scale is crucial for ensuring historical accountability and acknowledging the full cost of the war. 

It is also a legal requirement. The interim measures set out by the International Court of Justice in January, 2024, require Israel to “take effective measures to prevent the destruction and ensure the preservation of evidence related to allegations of acts within the scope of … the Genocide Convention”. The Gaza Health Ministry is the only organisation counting the dead. Furthermore, these data will be crucial for post-war recovery, restoring infrastructure, and planning humanitarian aid.

State of Global Air Report 2024

Via the Health Effects Institute: State of Global Air Report 2024. Click or tap through todownload the complete report. The summary:

The State of Global Air 2024 report provides a comprehensive analysis of data for air quality and health impacts for countries around the world. The analysis finds that: 

 ● Air pollution accounted for 8.1 million deaths globally in 2021, becoming the second leading risk factor for death, including for children under five years. Of the total deaths, noncommunicable diseases including heart disease, stroke, diabetes, lung cancer, and chronic obstructive pulmonary disease (COPD) account for nearly 90% of the disease burden from air pollution. 

 ● In 2021, more than 700,000 deaths in children under 5 years were linked to air pollution; this represents 15% of all global deaths in children under five. 

As in previous years, the State of Global Air 2024 report and accompanying website provides comprehensive data on the levels and trends in air quality and health for every country in the world. This State of Global Air report was produced in partnership with UNICEF. 

In the State of Global Air 2024 interactive app, you can explore, compare, and download data and graphics reflecting the latest air pollution levels and associated burden of disease for over 200 individual countries, territories, and regions, as well as track trends from 1990 to 2021.

See also this Guardian story on the report.

WHO: Human infection caused by avian Influenza A(H5N2)—Mexico

A WHO DON: Human infection caused by avian Influenza A(H5N2)- Mexico. Excerpt:

Situation at a glance

On 23 May 2024, the Mexico International Health Regulations (IHR) National Focal Point (NFP) reported to PAHO/WHO a confirmed fatal case of human infection with avian influenza A(H5N2) virus detected in a resident of the State of Mexico who was hospitalized in Mexico City. This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally and the first avian H5 virus infection in a person reported in Mexico.  

Although the source of exposure to the virus in this case is currently unknown, A(H5N2) viruses have been reported in poultry in Mexico.  

According to the IHR (2005), a human infection caused by a novel influenza A virus subtype is an event that has the potential for high public health impact and must be notified to the WHO. Based on available information, WHO assesses the current risk to the general population posed by this virus as low.  

Description of the situation  

On 23 May 2024, the Mexico IHR NFP reported to PAHO/WHO a confirmed case of human infection with avian influenza A(H5N2) virus detected in a 59-year-old resident of the State of Mexico who was hospitalized in Mexico City and had no history of exposure to poultry or other animals. The case had multiple underlying medical conditions. The case’s relatives reported that the case had already been bedridden for three weeks, for other reasons, prior to the onset of acute symptoms.  

On 17 April, the case developed fever, shortness of breath, diarrhoea, nausea and general malaise. On 24 April, the case sought medical attention, was hospitalized at the National Institute of Respiratory Diseases “Ismael Cosio Villegas” (INER per its acronym in Spanish) and died the same day due to complications of his condition.  

Results from Real-Time Polymerase Chain Reaction (RT-PCR) of a respiratory sample collected and tested at INER on 24 April indicated a non-subtypeable influenza A virus. On 8 May, the sample was sent for sequencing to the Laboratory of Molecular Biology of Emerging Diseases Center for Research in Infectious Diseases (CIENI per its acronym in Spanish) of INER, which indicated that the sample was positive for influenza A(H5N2).  

On 20 May, the sample was received at the Institute of Epidemiological Diagnosis and Reference (InDRE per its acronym in Spanish) of the Mexico National Influenza Centre, for analysis by RT-PCR, obtaining a positive result for influenza A. On 22 May, sequencing of the sample confirmed the influenza subtype was A(H5N2).  

No further cases were reported during the epidemiological investigation. Of the 17 contacts identified and monitored at the hospital where the case died, one reported a runny nose between 28 and 29 April. Samples taken from these hospital contacts between 27 and 29 May tested negative for influenza and SARS-CoV 2. Twelve additional contacts (seven symptomatic and five asymptomatic) were identified near the case's residence. Samples of pharyngeal exudate, nasopharyngeal swabs and serum were obtained from these individuals.  

On 28 May, the InDRE reported that all twelve samples from contacts near the patient's residence tested negative for SARS-CoV-2, influenza A and influenza B, as determined by RT-PCR. The results of the serological samples are pending.  

In March 2024, a high pathogenicity avian influenza A(H5N2) outbreak was detected in a backyard poultry farm in the state of Michoacán, which borders the State of Mexico where the case was residing  

Additionally, in March 2024, an outbreak of low pathogenicity avian influenza (LPAI) A(H5N2) was identified in poultry in Texcoco, State of Mexico, and a second outbreak of LPAI A(H5N2) in April in the municipality of Temascalapa in the same state. Thus far, it has not been possible to establish if this human case is related to the recent poultry outbreaks.  

A study describing the continuous circulation of low pathogenicity avian influenza H5N2 viruses in Mexico and spread to several other countries was published in 2022 (2).

Implications of food ultra-processing on cardiovascular risk considering plant origin foods: an analysis of the UK Biobank cohort

Via The Lancet Regional Health—Europe: Implications of food ultra-processing on cardiovascular risk considering plant origin foods: an analysis of the UK Biobank cohort. The summary:

Background  

Comprehensive research evidence is lacking on the role of ultra-processed foods (UPF) in the relationship between the consumption of plant-sourced foods and their impact on cardiovascular disease (CVD) outcomes. This study aims to assess CVD risk associated with the dietary contribution of food groups that consider both plant or animal origin and food processing categories, within a large cohort of British adults.  

Methods  

Data from the UK Biobank participants (40–69 y) who completed at least two 24-h dietary recalls between 2009 and 2012 (n = 126,842; median follow-up: 9 y), with subsequent data linkage to hospital and mortality records, were used. Food groups were classified as either plant-sourced or non-plant/animal-sourced foods. These groups were further divided into non-UPF and UPF, and expressed as a percentage of total energy intake.  

Findings  

Every 10 percentage points increase in plant-sourced non-UPF consumption was associated with a 7% lower risk of CVD (95% CI 0.91–0.95) and a 13% lower risk of CVD mortality (0.80–0.94). Conversely, plant-sourced UPF consumption was associated with a 5% increased risk (1.03–1.07) and a 12% higher mortality (1.05–1.20). The contribution of all UPF was linked to higher CVD risk and mortality, and no evidence for an association between contribution of all plant-sourced foods and CVD incidence and mortality was observed.  

Interpretation  

The dietary contribution of plant-sourced non-UPF inversely linked to CVD risk, while plant-sourced UPF contribution showed a positive association. Recognizing the role of food processing is crucial for favourable CVD outcomes, even in plant-sourced diets.

See also this report in The Washington Post.

"Nearly 7500 deaths per day": Commercial Determinants of Noncommunicable Diseases in the WHO European Region

WHO has published Commercial Determinants of Noncommunicable Diseases in the WHO European Region. Click or tap through to download the report as a 139-page  PDF. The abstract:

This report highlights the substantial impact of commercial determinants on noncommunicable diseases (‎NCDs)‎ in the WHO European Region. Nearly 7500 deaths per day in the Region are attributed to commercial determinants, such as tobacco, alcohol, processed food, fossil fuels and occupational practices. These commercial products and practices contribute to 25% of all deaths in the Region. 

The report’s chapters systematically explore various facets of how commercial interests exacerbate NCDs and key strategies used by commercial actors to negatively influence NCD-related policies at the national and international level. The report also provides selected case studies from the Region to illustrate key strategies and outcomes of industry influence on health policies. 

The report then calls for urgent and coordinated action to address the commercial determinants of NCDs. It advocates for building coalitions based on the values of equity, sustainability, and resilience. Public health actors are urged to develop competencies in economic and legal frameworks, enforce transparency, and manage conflicts of interest effectively.  

The report underscores the need for robust financial reforms and strict regulation to curb industry power and protect public health. By implementing these strategies, the Region can accelerate progress towards global NCD targets and Sustainable Development Goals by 2030.

WHO: Avian Influenza A (H9N2)—India

A WHO DON: Avian Influenza A (H9N2)- India. Excerpt:

Situation at a glance  

On 22 May 2024, the International Health Regulations (IHR) National Focal Point (NFP) for India reported to WHO a case of human infection with avian influenza A(H9N2) virus detected in a child resident of West Bengal state in India. This is the second human infection of avian influenza A(H9N2) notified to WHO from India, with the first in 2019. The child has recovered and was discharged from hospital.  

According to the IHR (2005), a human infection caused by a novel influenza A virus subtype is an event that has the potential for high public health impact and must be notified to the WHO. Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through contact with infected poultry or contaminated environments. Human infection tends to result in mild clinical illness.  

Based on available information, further sporadic human cases could occur as this virus is one of the most prevalent avian influenza viruses circulating in poultry in different regions. With the currently available evidence, WHO assesses the current public health risk to the general population posed by this virus as low.  

However, the risk assessment will be reviewed should further epidemiological or virological information become available.  

Description of the situation  

On 22 May 2024, WHO received a notification from the IHR NFP regarding a human case of avian influenza A(H9N2) virus infection in West Bengal state, India.  

The patient is a 4-year-old child residing in West Bengal state. The case, previously diagnosed with hyperreactive airway disease, initially presented to the paediatrician with fever and abdominal pain on 26 January 2024. On 29 January, the patient developed seizures and was brought to the same paediatrician. On 1 February, the patient was admitted to the pediatric intensive care unit (ICU) of a local hospital due to the persistence of severe respiratory distress, recurrent high-grade fever and abdominal cramps. The patient was diagnosed with post-infectious bronchiolitis caused by viral pneumonia.  

On 2 February, the patient tested positive for influenza B and adenovirus at the Virus Research and Diagnostic Laboratory at the local government hospital. The patient was discharged from the hospital on 28 February 2024. On 3 March, with a recurrence of severe respiratory distress, he was referred to another government hospital and was admitted to the pediatric ICU and intubated.  

On 5 March, a nasopharyngeal swab was sent to the Kolkata Virus Research and Diagnostic Laboratory and tested positive for influenza A (not sub-typed) and rhinovirus. The same sample was sent to the National Influenza Centre at the National Institute of Virology in Pune for subtyping. On 26 April, the sample was sub-typed as influenza A(H9N2) through a real-time polymerase chain reaction.  On 1 May, the patient was discharged from the hospital with oxygen support.  

Information on the vaccination status and details of antiviral treatment were not available at the time of reporting. The patient had exposure to poultry at home and in the surroundings. There were no known persons reporting symptoms of respiratory illness in the family, the neighbourhood, or among healthcare workers at health facilities attended by the case at the time of reporting.  

This is the second human infection of avian influenza A(H9N2) virus infection notified to WHO from India, with the first in 2019. Further sporadic human cases could occur as this virus is one of the most prevalent avian influenza viruses circulating in poultry in different regions.