H5N1

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.

MMWR: Outbreak of Highly Pathogenic Avian Influenza A(H5N1) Viruses in U.S. Dairy Cattle and Detection of Two Human Cases — United States, 2024

Via MMWR: Outbreak of Highly Pathogenic Avian Influenza A(H5N1) Viruses in U.S. Dairy Cattle and Detection of Two Human Cases — United States, 2024. The summary and abstract:

Summary

What is already known about this topic?  

Influenza A(H5) virus infection was detected in two U.S. farm workers during a multistate outbreak of A(H5N1) viruses in dairy cows; these are the first known instances of presumed cow-to-human transmission of avian influenza A viruses.  

What is added by this report?  

Approximately 350 exposed farm workers are being monitored; one of the two cases was identified via daily, active monitoring. Surveillance has identified no unusual influenza activity trends in the United States. A(H5) candidate vaccine viruses are available, and laboratory analyses indicate that A(H5N1) viruses circulating in cows and other animals are susceptible to FDA-approved antivirals.  

What are the implications for public health practice?  

Current risk to the U.S. public from A(H5N1) viruses is low; however, persons exposed to infected animals or contaminated materials, including raw cow’s milk, are at higher risk and should take precautions and self-monitor for illness. A One Health (human, animal, and environmental) approach is critical to preparing for circumstances that could increase risk to human health.

Abstract  

On April 1, 2024, the Texas Department of State Health Services reported that a dairy farm worker had tested positive for highly pathogenic avian influenza A(H5N1) virus after exposure to presumably infected dairy cattle; CDC confirmed these laboratory findings. A(H5N1) viruses were found in high concentrations in unpasteurized (raw) milk from infected cows.  

CDC is collaborating with the U.S. Department of Agriculture, the Food and Drug Administration, the Administration for Strategic Preparedness and Response, the Health Resources and Services Administration, the National Institute of Allergy and Infectious Diseases, and state and local public health and animal health officials using a coordinated One Health approach to identify and prepare for developments that could increase the risk to human health.  

Activities include monitoring of exposed persons, conducting syndromic and laboratory surveillance, planning epidemiologic investigations, and evaluating medical countermeasures. As of May 22, 2024, approximately 350 farm workers with exposure to dairy cattle or infected raw cow’s milk had been monitored.  

These monitoring efforts identified a second human A(H5) case with conjunctivitis in Michigan, which was reported on May 22, 2024. CDC considers the current risk to the U.S. public from A(H5N1) viruses to be low; however, persons with exposure to infected animals or contaminated materials, including raw cow’s milk, are at higher risk for A(H5N1) virus infection and should take recommended precautions, including using recommended personal protective equipment, self-monitoring for illness symptoms, and, if they are symptomatic, seeking prompt medical evaluation for influenza testing and antiviral treatment if indicated.  

Pasteurization inactivates A(H5N1) viruses, and the commercial milk supply is safe for consumption; however, all persons should avoid consuming raw milk or products produced from raw milk.  

Importantly, the risk to the public might change based on whether A(H5N1) viruses acquire genetic changes that increase their transmissibility to and among humans, which could increase the risk of an influenza pandemic.

Mental health and addiction health service use by physicians compared to non-physicians before and during the COVID-19 pandemic

Via PLOS Medicine: Mental health and addiction health service use by physicians compared to non-physicians before and during the COVID-19 pandemic: A population-based cohort study in Ontario, Canada. The abstract:

Background  

The Coronavirus Disease 2019 (COVID–19) pandemic has exacerbated mental health challenges among physicians and non–physicians. However, it is unclear if the worsening mental health among physicians is due to specific occupational stressors, reflective of general societal stressors during the pandemic, or a combination. We evaluated the difference in mental health and addictions health service use between physicians and non–physicians, before and during the COVID–19 pandemic.  

Methods and findings  

We conducted a population–based cohort study in Ontario, Canada between March 11, 2017 and August 11, 2021 using data collected from Ontario’s universal health system. Physicians were identified using registrations with the College of Physicians and Surgeons of Ontario between 1990 and 2020. Participants included 41,814 physicians and 12,054,070 non–physicians. We compared the first 18 months of the COVID–19 pandemic (March 11, 2020 to August 11, 2021) to the period before COVID–19 pandemic (March 11, 2017 to February 11, 2020). The primary outcome was mental health and addiction outpatient visits overall and subdivided into virtual versus in–person, psychiatrists versus family medicine and general practice clinicians. We used generalized estimating equations for the analyses.  

Pre–pandemic, after adjustment for age and sex, physicians had higher rates of psychiatry visits (aIRR 3.91 95% CI 3.55 to 4.30) and lower rates of family medicine visits (aIRR 0.62 95% CI 0.58 to 0.66) compared to non–physicians.  

During the first 18 months of the COVID–19 pandemic, the rate of outpatient mental health and addiction (MHA) visits increased by 23.2% in physicians (888.4 pre versus 1,094.7 during per 1,000 person–years, aIRR 1.39 95% CI 1.28 to 1.51) and 9.8% in non–physicians (615.5 pre versus 675.9 during per 1,000 person–years, aIRR 1.12 95% CI 1.09 to 1.14). Outpatient MHA and virtual care visits increased more among physicians than non–physicians during the first 18 months of the pandemic.  

Limitations include residual confounding between physician and non–physicians and challenges differentiating whether observed increases in MHA visits during the pandemic are due to stressors or changes in health care access.   

Conclusions  

The first 18 months of the COVID–19 pandemic was associated with a larger increase in outpatient MHA visits in physicians than non–physicians. These findings suggest physicians may have had larger negative mental health during COVID–19 than the general population and highlight the need for increased access to mental health services and system level changes to promote physician wellness.

Chile: Health ministry reports first human case of H5N1, in north of country

I believe this is the first case of human H5N1 contracted in the Americas. Via La Nación: Minsal informa primer caso humano de gripe aviar en el norte del país.[Health ministry report first human case of avian flu in the north of the country] The full report, with my translation:

El Ministerio de Salud (Minsal) informó la tarde de este miércoles el primer caso en Chile de gripe aviar en humanos, reportado en el norte del país. 

The Ministry of health reported Tuesday afternoon on the first case in Chile of avian flu in a human, reported in the north of the country.

La persona enferma corresponde a un hombre de 53 años afectado por un cuadro de influenza grave. El paciente se encuentra estable dentro de su gravedad. 

The person is a 53-year-old man with a case of severe influenza. The patient is in serious but stable condtion.

Se indicó que se activaron los protocolos sanitarios establecidos para el manejo de esta enfermedad y se tomaron los exámenes correspondientes para su análisis por el Instituto de Salud Pública (ISP), que confirmó que se trata de influenza aviar. 

The ministry said it had activated health protocols established for control of the disease; tests were analyzed by the Institute of Public Health, which confirmed the disease was avian flu.

Se investiga la fuente de contacto y si existen antecedentes de otros afectados en el entorno del paciente. 

The source of the infection in being investigated, as well as the possibility of others' infection among the patient's contacts.

El virus H5N1 o gripe aviar es un virus que se puede transmitir desde aves o mamíferos marinos al ser humano, pero no se conocen casos de contagios de humano a humano. 

The H5N1 virus, or avian flu, can be transmitted from birds or infected marine mammals to humans, but human-to-human cases are unknown.

El Ministerio de Salud hace un llamado a la ciudadanía a no manipular aves o mamíferos enfermos o muertos e insta a los trabajadores avícolas a seguir los protocolos de seguridad correspondientes y a vacunarse contra la influenza estacional.

The Ministry of Health asked the public not to handle or touch birds of marine mammals, whether sick or dead, and asked workers in the poultry industry to follow the appropriate safety protocols and to obtaain a vaccination against seasonly influenza.

Tanzania confirms first-ever outbreak of Marburg Virus Disease

Via WHO AFRO: Tanzania confirms first-ever outbreak of Marburg Virus Disease.

Brazzaville/Dar es Salaam – Tanzania today confirmed its first-ever cases of Marburg Virus Disease after laboratory tests were carried out following reports of cases and deaths in the country’s north-west Kagera region.  

Tanzania’s National Public Health Laboratory analysed samples to determine the cause of illness after eight people developed symptoms including fever, vomiting, bleeding and renal failure. Five of the eight cases, including a health worker, have died and the remaining three are receiving treatment. A total of 161 contacts have been identified and are being monitored.  

“The efforts by Tanzania’s health authorities to establish the cause of the disease is a clear indication of the determination to effectively respond to the outbreak. We are working with the government to rapidly scale up control measures to halt the spread of the virus and end the outbreak as soon as possible,” said Dr Matshidiso Moeti, World Health Organization (WHO) Regional Director for Africa.  

WHO is supporting the Ministry of Health to deploy an emergency team to Kagera to carry out further epidemiological investigations. The emergency team will focus on active case finding in the community and local health care facilities to identify more contacts and provide them with appropriate care.  

While Tanzania has never previously recorded a Marburg case, it has had to respond to other health emergencies including COVID-19, cholera and dengue within the past three years. A strategic risk assessment conducted by WHO in September 2022 showed that the country is at high to very high risk for infectious diseases outbreaks.   

“The lessons learnt, and progress made during other recent outbreaks should stand the country in good stead as it confronts this latest challenge,” said Dr Moeti. “We will continue to work closely with the national health authorities to save lives.”  

Marburg virus disease is highly virulent and causes haemorrhagic fever, with a fatality ratio of up to 88%. It is in the same family as the virus that causes Ebola virus disease. Illness caused by Marburg virus begins abruptly, with high fever, severe headache and severe malaise. Many patients develop severe haemorrhagic symptoms within seven days. The virus is transmitted to people from fruit bats and spreads among humans through direct contact with the bodily fluids of infected people, surfaces and materials.  

There are no vaccines or antiviral treatments approved to treat the virus. However, supportive care – rehydration with oral or intravenous fluids – and treatment of specific symptoms, improves likelihood of survival.

Chinese doctors and nurses reportedly told to work while infected as Covid surges

Via The Guardian: Chinese doctors and nurses reportedly told to work while infected as Covid surges. Excerpt:

Chinese doctors and nurses are being told to keep working even when infected with Covid-19, staff and residents reported, as the virus rips through the population in the wake of eased restrictions.  

Some hospitals in Beijing have up to 80% of their staff infected, but many of them are still required to work due to staff shortages, a doctor in a large public hospital in Beijing told Reuters, adding he had spoken to his peers at other big hospitals in the capital.  

All operations and surgeries had been cancelled at his hospital unless the patient was “dying tomorrow”, he said, declining to be named due to the sensitivity of the subject.  

A senior World Health Organization official said on Wednesday that China’s flare-up started “long before” restrictions were lifted, but since the sudden shift in policy major cities in Beijing appear to have experienced a huge surge in cases of Covid-19. Authorities have said it is “impossible” to measure, since most people are not being tested.  

“The explosion of cases in China had started long before any easing of the zero-Covid policy,” WHO emergencies chief Michael Ryan said on Wednesday. “There’s a narrative that, in some way, China lifted the restrictions and all of a sudden, the disease is out of control,” he added at the UN health agency’s headquarters in Geneva.  

“The disease was spreading intensively because the control measures in themselves were not stopping the disease.”  

In Sichuan, a doctor surnamed Li told Reuters that their tertiary hospital was “overwhelmed with patients”.  

“There are 700, 800 people with fever coming every day,” Li said. “We are running out of medicine stocks for fever and cold. A few nurses at the fever clinic were tested positive, there aren’t any special protective measures for hospital staff and I believe many of us will soon get infected.”  

Claims of rampant infections among hospital staff are also spreading across social media. One Chongqing resident said primary care in their city had “imploded”.  

“80% of the newly admitted patients in our small third-level respiratory department in a remote city are positive,” they wrote on Weibo.  

“From December 8, when the first positive patient was allowed to be admitted, to today, December 13, at least half of the medical staff in our department were infected. At the beginning the infected were allowed to go home to rest, but now as long as it is not very serious symptoms, they are not allowed to go home.”

Bilateral pneumonia outbreak in Tucumán, Argentina

Thanks to Giuseppe Michieli for tagging me in a tweet about this news release from the Ministry of Public Health in the province of Tucumán, Argentina: El ministerio de Salud Pública informó sobre la situación sanitaria del brote de neumonía bilateral (Ministry of Public Health reports on the health situation of the outbreak of bilateral pneumonia). Excerpt from the Google translation, lightly edited:

In a new press conference, the head of the Health Portfolio, Dr. Luis Medina Ruiz, reported the death of a 70-year-old patient and the identification of 3 employees of the sanatorium experiencing the same outbreak.

In this regard, the minister announced: “The sanatorium informed us of the death of a 70-year-old patient who was hospitalized there, we needed the family to know first to be able to communicate it. In addition, we identified 3 more employees of the private agent who began with symptoms around August 20 to 23 (that is, they correspond to the same outbreak and place of contagion in principle). That is why at this moment 3 more people are added to the 6 initial patients”.

Regarding the 70-year-old patient who died today, the minister stated: “She was hospitalized and she underwent surgery for a gallbladder problem. She was re-operated twice. From then on, an infectious pulmonary disease took place, the date of which coincides with the onset of symptoms in the other patients, around August 20. Although it is not yet clear which came first, at first she was considered patient zero, but she is under study based on the deepening of the analyses that are being carried out”.

At the same time he added: “We informed about the 3 identified employees. One of them is a 40-year-old pharmacy assistant and she was hospitalized a few days ago in a public hospital with a fever. In the active search that we are carrying out, especially in health personnel, we detected that it is a person who has non-severe bilateral pneumonia with an oxygen requirement under study. The other person is a 44-year-old nurse; she is at her home and we are following her evolution, since her clinical condition does not warrant hospitalization. The third case is a 30-year-old nurse with comorbidities, who was admitted to hospital this morning. His symptoms began around the same days and on the date he was present to be evaluated, at which time we decided to hospitalize him."

Following this line, the official explained that these three people have bilateral pneumonia as a clinical characteristic and have in common the origin of the focus, the epidemiological link with the 6 initial patients. The criterion of incorporating them as suspected patients to the outbreak in principle is based on the employment relationship with the sanatorium, bilateral pneumonia and that with all the study panels its etiology has not yet been found.

“Last night and this morning we had information from the Malbrán Institute and so far all the studies that we had as negative -for Covid, Hantavirus and some strains of Legionella- are also giving negative results there. We continue to carry out the research protocol for blood cultures, sputum cultures, urine cultures and all the viruses and bacteria that we have available in the province. We are in direct communication with Minister Carla Vizzotti, who is available, as well as all the epidemiology and infectious disease teams of the Nation, we are working as a large medical board in which we all participate with the information we have, there are hypotheses of the etiology that are being put on the table, although what we have specifically is the common origin and evolution of the disease”, he added.

Will COVID force public health to confront America's epic inequality?

Via Nature, an important article by Amy Maxmen: Will COVID force public health to confront America's epic inequality? Excerpt:

On a hazy day in November, Hardeep Singh received a text message from the COVID-19 testing system at Foster Farms poultry company saying that his mother had tested positive for the coronavirus.  

He got the alert because his mother, a 63-year-old line worker at one of the company’s meat-packing plants in California’s San Joaquin Valley, doesn’t speak English and doesn’t own a smartphone.  

Singh couldn’t reach her as she continued to handle chicken parts alongside her co-workers. Her supervisors didn’t tell her, either. In fact, they assigned her more shifts for the week.  

Singh broke the news to her that evening, and convinced her not to return to work, where she might spread the infection to others. But he couldn’t reach anyone at the company for another five days, to ask whether she qualified for paid time off while she isolated.  

Singh’s mother ended up being among the more than 400 employees at the plant who were diagnosed with COVID-19 last year, and one of about 90,000 cases linked to food-production facilities and farm work across the United States. Because the sector feeds Americans and powers part of the US economy, agricultural workers such as Singh’s mother have been considered essential workers during the COVID-19 pandemic.  

That important role comes at a cost. One study1 found that food and agricultural workers in California had an almost 40% increased risk of dying last year, compared with the state’s general population. And within that imbalance lies another contrast. Latinx food and agriculture workers experienced a nearly 60% increase in deaths compared with previous years; the increase for white workers was just 16%.  

The reasons for such disparities, say public-health researchers, include discrimination, low wages, limited labour protections and inadequate access to health care, affordable housing and education. These are some of the ‘social determinants of health’, a concept that has been around for at least 150 years, but which has gained recognition during the pandemic.

Physical, psychological and cognitive profile of post-COVID condition in healthcare workers, Quebec, Canada

Via medRxiv: Physical, psychological and cognitive profile of post-COVID condition in healthcare workers, Quebec, Canada. This could have serious implications for healthcare systems around the world. The abstract:

Importance Most adults with COVID-19 do not require hospitalization, but the subsequent risk of post-COVID condition, including associated psychological and cognitive dysfunction, remains poorly understood among non-hospitalized versus hospitalized cases.  

Objective To assess the prevalence and duration of post-COVID condition, including physical, psychological and cognitive symptoms.  

Design Case series and case-control study between December 2020 and May 2021  

Setting Healthcare workers in Quebec, Canada  

Participants Eligible cases were symptomatic healthcare workers with PCR-confirmed COVID-19 between July 2020 and May 2021. Among 17,717 contacted cases, 6061 (34%) participated. A random sample of symptomatic healthcare workers with negative PCR result between November 2020 and May 2021 served as controls. Among 11,498 contacted controls, 4390 (38%) participated.  

Exposures In multivariable models, sociodemographic and clinical characteristics, as well as vaccine history, were evaluated as potential risk factors. Prevalence ratios compared self-reported cognitive dysfunctions (difficulty concentrating; difficulty organizing oneself; forgetfulness; loss of necessary items) among cases with post-COVID condition to controls, adjusting for psychological distress and fatigue.  

Outcomes Post-COVID condition was defined by symptoms persisting ≥4 weeks or ≥12 weeks after COVID-19 onset.  

Results Four-week and 12-week post-COVID condition prevalences of 46% (2,746/5,943) and 40% (653/1,746), respectively, were observed among non-hospitalized cases and 76% (90/118) and 68% (27/37), respectively, among hospitalized cases. Hospitalization, female sex and age were associated with higher risk.  

A substantial proportion of non-hospitalized cases with 4-week post-COVID condition often or very often reported cognitive dysfunction, including concentration (33%) or organizing (23%) difficulties, forgetfulness (20%) and loss of necessary items (10%), with no decline at 12 weeks. All four aspects of cognitive dysfunction were 2.2 to 3.0 times more prevalent among cases with post-COVID condition than in controls, but also independently associated with psychological distress and fatigue.  

Conclusions and relevance Post-COVID condition may be a frequent sequela of ambulatory COVID-19 in working-age adults, with important effects on cognition. With so many healthcare workers infected since the beginning of the COVID-19 pandemic, the ongoing implications for quality healthcare delivery could be profound should cognitive dysfunction and other severe post-COVID symptoms persist in a professionally-disabling way over the longer term.  

Question How common and long-lasting are the physical, psychological and cognitive effects of post-COVID condition in healthcare workers, both hospitalized and non-hospitalized?  

Findings The prevalence of post-COVID condition was 46% at 4 weeks and 40% at 12 weeks among non-hospitalized cases and 76% and 68% among hospitalized cases. One third of non-hospitalized healthcare workers with post-COVID condition reported cognitive impairment, which was independently associated with persistent physical symptoms, but also psychological distress and fatigue.  

Meaning Persistent cognitive and other professionally-disabling sequelae of COVID-19 in essential workers could have critical implications for quality healthcare delivery during and after the pandemic.