Sunday, November 19, 2017

South Korea: MAFRA Confirms HPAI H5N6 At Gochang Poultry Farm


In a follow up to yesterday's report (see South Korea: H5 Avian Flu Detected At Gochang Poultry Farm) we've seen an unexpectedly rapid turnaround on the lab results, and we now know this outbreak to be due to HPAI H5N6. 

South Korea's national alert level has been raised to its highest level (`Serious'), and a temporary 48-hour nationwide ban on the movement of poultry has been ordered. This is the first outbreak of HPAI H5N6 in South Korea since early summer.
When combined with the discovery of HPAI H5N6 in wild bird in Japan last week (see Japan MOE: 2nd H5N6 Lab Confirmation & More Dead Birds Being Tested), this is a pretty good indication that HPAI H5 is once more making its way along the East Asian migratory flyways.
First the syntax challenged (translated) statement from South Korea's Ministry of Agriculture (MAFRA), after which I'll return with a postscript.

Jeonbuk Gochang duck farms confirmed highly pathogenic AI

Added 2017-11-19 09:36:00

Jeonbuk Gochang duck farms Highly Pathogenic AI diagnosis - severe stages issued 48 hours temporarily move the stop command, simultaneous nationwide sterilization chongryeok Defense Systems operation - Agriculture, Forestry and Animal Husbandry and Food (Minister: gimyoungrok) the results test for broiler ducks Jeonbuk Gochang 11.19 (Sun) confirmed today announced that a highly pathogenic avian influenza (H5N6 type).
Whilst agri-food section was taken in the last 17 days immediately found a doctor shaft first responders preventative measures against the highly pathogenic confirmed, pursued a national biosecurity measures strengthened. 12,300 broiler ducks that are bred to be a farm that was completed quickly buy foreclosure, set the room Chronicles (10km) with its center being a farm emergency measures, such as farmers surveillance, movement control.
Agri-food section was performed at the highest level of the key preventative measures following on the basis of today's afternoon held a livestock quarantine council results depending on Highly Pathogenic occur
(1) trigger the AI ​​crisis upgraded to 'serious' step in 'Caution' alerts
(2) temporarily move the stop command for 48 hours from today midnight for all poultry workers and vehicles in the country, and the national poultry farmers and livestock-related facilities in Japan disinfection carried
(3) pan-governmental aggregate power confrontation to the main road of the entire country about all domestic fowl breeding farm and the worker of North Jeolla Province Gochang County which is a nationwide domestic fowl farmhouse and a livestock raising related infrastructure simultaneous disinfecting conduct
(4) AI occurrence area for 7 days the control guard post which is established to the main road of the mobile discontinuance
(5) occurrence area and the connection area for the AI center accident control headquarters (the general manager: Pus vice minister food) and area disaster safe Countermeasures Headquarter (general manager:

The city and province governor, market munition the ward head) the establishment government holds the urgent AI anti-epidemic measure meeting where the interagency local authority organization participates to 11.20 day morning, and the government measures and occurrence situation will announce detailed contents.

While we never really know what bird flu viruses will due each fall -  they have a habit of zigging when we expect them to zag -  there are concerns that both H5N6 in Asia, and H5N8 in Europe, will return again this fall via migratory birds (see Sci Repts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission Of HPAI H5N1).
It was just about this time last year when H5N6 showed up - for the very first time - in both Japan and South Korea, while Europe's H5N8 invasion was just ramping up. 
Both avian subtypes have had months to circulate among birds in their high latitude summer roosting areas, and so we will have to remain alert for any changes in their behavior. There are also concerns that H5N6 may follow H5N8's (and H5N1's) example, and expand beyond Asia, eventually showing up in Europe or perhaps even North America.

That said, everyone expected H5N8/H5N2 to return to North America in the fall of 2015 after the worst avian epizootic in North American history the previous spring, and so far it has failed to show.
The takeaway being, avian flu subtypes - like all influenza viruses - are extremely unpredictable.
Whatever happens in the months ahead, we should be prepared to be surprised.

Thanksgiving Is National Family History Day

Note: This is an updated version of my yearly post on National Family History Day.


Every year since 2004 the Surgeon General of the United States has declared Thanksgiving – a day when families traditionally gather together - as National Family History Day, since it provides an excellent opportunity to ask about and document the medical history of relatives.
The CDC and the HHS have a couple of web pages devoted to collecting your family history, including a web-based tool to help you collect, display, and print out your family’s health history.
Document Your Family's Health History
Surgeon General's Family Health History Initiative 
Using these online tools, you can create a basic family medical history with relative ease. For those leery of using such forms, you can simply use them as a guide for creating your own. 

But before you can do this, you’ll need to discuss each family member’s medial history. The HHS has some advice on how to prepare for that talk:
Before You Start Your Family Health History

Americans know that family history is important to health. A recent survey found that 96 percent of Americans believe that knowing their family history is important. Yet, the same survey found that only one-third of Americans have ever tried to gather and write down their family's health history.
Here are some tips to help you being to gather information:
As a former paramedic, I am keenly aware of how important it is for everyone to know their personal and family medical history.  Every day emergency room doctors are faced with patients unable to remember or relay their health history, current medications, or even drug allergies during a medical crisis. 
And that can delay both diagnosis and treatment.
During a major disaster, where the power or Internet may be down, and electronic medical records unavailable - emergency physicians may literally be working in the dark. Anything you can do to shed light on your medical history could be lifesaving. 
Which is why I always keep an EMERGENCY MEDICAL HISTORY CARD – filled out and frequently updated – in my wallet, and have urged (and have helped) others in my family to do the same.

I addressed this issue at some length in a blog called Those Who Forget Their History . . . .   A few excerpts (but follow the link to read the whole thing): 
Since you can’t always know, in advance, when you might need medical care it is important to carry with you some kind of medical history at all times. It can tell doctors important information about your history, medications, and allergies when you can’t.
Many hospitals and pharmacies provide – either free, or for a very nominal sum – folding wallet medical history forms with a plastic sleeve to protect them. Alternatively, there are templates available online.
I’ve scanned the one offered by one of our local hospitals below. It is rudimentary, but covers the basics.

I’ve highlighted several other methods of creating histories in the past, some of which you may prefer.  A few excerpts (and links) from these essays. First, I’ll show you how I created and maintain histories for my Dad (who passed away several years ago) and myself.  This was featured in an essay called A History Lesson.
Today I’m going to impart a little secret that will ingratiate yourself with your doctor and not only improve the care you receive, but also reduce the amount of time you spend in the exam room. When you go to your doctor, have a brief written history printed out for him or her

I’ve created a sample based on the one I used for my Dad (the details have been changed).   It gets updated, and goes with him, for every doctor’s visit.
And his doctors love it.

While every history will be different, there are a few `rules’.
  • First, keep it to 1 page.     Even if the patient has an `extensive history’.   If your doctor can’t scan this history, and glean the highlights, in 60 seconds or less . . . it isn’t of much use.
  • Second, paint with broad strokes.   Don’t get bogged down in details.  Lab tests and such should already be in your chart.
  • Third, always fill in a reason for your visit.   Keep it short, your doctor will probably have 10 to 15 minutes to spend with you.   Have your questions and concerns down in writing before you get there.
  • Fourth, list all Meds  (Rx and otherwise) and indicate which ones you need a refill on.   If you have a question about a med, put a `?’ next to it.   And if you have any drug allergies, Highlight them.
  • Fifth,  Make two copies!   One for your doctor to keep, and one for you.  As you talk to your doctor, make notes on the bottom (bring a pen) of your copy.  
Once you create the basic template (using any word processor), it becomes a 5 minute job to update and print two copies out for a doctor’s visit.

The history above is great for scheduled doctor’s visits, but you also should still carry a readily available EMERGENCY Medical History Card, along with any health insurance information, in your wallet or purse..

And a couple of other items, while not exactly a medical history, may merit discussion in your family as it has recently in mine.
  • First, all adults should consider having a Living Will that specifies what types of medical treatment you desire should you become incapacitated.
  • You may also wish to consider assigning someone as your Health Care Proxy, who can make decisions regarding your treatment should you be unable to do so for yourself.
  • Elderly family members with chronic health problems, or those with terminal illnesses, may even desire a home DNR (Do Not Resuscitate) Order.
Without legal documentation, verbal instructions by family members – even if the patient is in the last stages of an incurable illness – are likely to be ignored by emergency personnel.

While admittedly, not the cheeriest topic of conversation in the world, a few minutes spent during this Thanksgiving holiday putting together medical histories could spare you and your family a great deal of anguish down the road.

WHO SitRep #11: Plague In Madagascar


Although the number of `suspected, probable, and confirmed' plague cases reported from Madagascar continues to rise, the momentum of their plague epidemic continues to decline (see epi curve below) with no new laboratory confirmed infections in nearly two weeks.
That said, additional lab-confirmed cases are not only possible - they are expected - as Madagascar's plague season often runs into April. Despite the breathless, often hyperbolic coverage by the tabloids, the overall trend is encouraging. 
At least for now.

Some excepts from the latest WHO Sitrep - with numbers current through Nov15th - follow:
WHO continues to support the Ministry of Public Health and other national authorities in Madagascar to monitor and respond to the outbreak of plague. From 6 to 15 November 2017, 149 probable (12) and suspect (137) cases of plague were reported to WHO. The date of onset of the last case of bubonic plague was 29 October and the last confirmed case of pneumonic plague was reported on 6 November.

From 1 August to 15 November 2017, a cumulative total of 2 203 confirmed, probable and suspected cases of plague, including 192 deaths (case fatality rate 9%), have been reported from 56 of 114 (49%) districts in Madagascar. Analamanga Region in central Madagascar has been the most affected, with 68% of all recorded cases. Since the beginning of this outbreak, the vast majority of cases have been treated and have recovered. As of 15 November 2017, only 6 people were hospitalized for plague. There has been no international spread outside the country.

The majority of the reported cases (1 705, 77%) have been clinically classified as pneumonic plague, 321 have been classified as bubonic plague (15%), one was septicaemic, and 176 have not yet been classified (further classification of cases is in process). Eighty-one healthcare workers have had illness compatible with plague, none of whom have died.

Of the 1 705 clinical pneumonic cases, 372 (22%) have been confirmed, 599 (35%) are probable and 734 (43%) remain suspected (additional laboratory results are in process). Twenty-five isolates of Yersinia pestis have been cultured and are sensitive to all antibiotics recommended by the National Plague Control Program.

Of the 7 270 contacts identified during this outbreak, 99% (7166) have completed their 7-day follow up and a course of prophylactic antibiotics, and eleven contacts have developed symptoms compatible with plague and became suspected cases. On 15 November 2017, 31 out of 33 (94%) contacts currently under follow-up were reached and provided with prophylactic antibiotics.

Plague is endemic on the Plateaux of Madagascar, including Ankazobe District, where the current outbreak originated. A seasonal upsurge, predominantly of the bubonic form, usually occurs yearly between September and April. This year, the plague season began earlier than usual. The current outbreak is predominantly pneumonic and is affecting both endemic and non-endemic areas, including major urban centres such as Antananarivo (the capital city) and Toamasina (a port city).

         Current risk assessment
The number of new plague cases in Madagascar has steadily declined since mid-October. From 6 to 15 November 2017, 149 probable (12) and suspect (137) pneumonic cases, 18 bubonic cases and 8 unspecified cases of plague have been reported to WHO. No confirmed cases have been reported since 6 November and, to date, no cases of plague have been reported outside of Madagascar.

While the number of new cases and hospitalizations are declining, evidence suggests that the epidemic phase of the outbreak is ending. However, WHO anticipates plague cases to be reported until the endemic plague season ends in April 2018.
Based on available information and response measures implemented to date, the potential risk of further spread of plague at national level remains high. The risk of international spread is mitigated by the short incubation period of pneumonic plague, implementation of exit screening measures and advice to travellers to Madagascar, and scaling up of preparedness and operational readiness activities in neighbouring Indian Ocean islands and other southern and east African countries. The overall global risk is considered to be low.
WHO is re-evaluating the risk assessment based on the evolution of the outbreak and information from response activities.

Saturday, November 18, 2017

South Korea: H5 Avian Flu Detected At Gochang Poultry Farm


Although they raised their alert level weeks ago in anticipation of another winter's onslaught of avian flu (see last September's South Korea Ramps Up Avian Flu Quarantine Measures) so far this fall South Korea has only had to deal with multiple detections of LPAI H5 and H7 viruses in wild birds.
That lucky streak appears to be ending as this morning South Korea's MAFRA is reporting an outbreak of H5 AI (avian influenza) at an undisclosed poultry farm in Gochung County, about 300 km south east of Seoul.
The exact subtype and pathogenicity (LPAI or HPAI) won't be known until lab test results are made available next week, but quarantine and culling have already begun. The following (translated) statement comes from South Korea's Ministry of Agriculture (MAFRA).
Jeonbuk, Gochang Duck Farm [Pre-shipment inspection of slaughterhouse] Confirmation of AI medical certificate

Registration date 2017-11-18 08:35 

The Ministry of Food, Agriculture, Forestry and Livestock (Ministry of Agriculture, Forestry and Fisheries) announced on 11.18 (Saturday) that the pre-shipment inspection of the slaughterhouse duck farmhouse (rearing size: 12,300) in Gochang- AI antigen was detected. 

As a result, the local livestock pest controller has been dispatched and emergency measures have been taken by the AI ​​SOP, such as preemptive pre-emptive disposal, restriction of movement, and epidemiological investigation on the farm. * 

Whether the disease is highly pathogenic or not is expected to come on November 21st. * Physician Conversation Farm Households Current Status of Farm Households: Within 500m No poultry farmers The agriculture and commodity ministry has requested the active cooperation of the people including poultry farmers to prevent the spread of AI. Poultry farmers and wild migratory birds visited the site,

A somewhat less kludgy summary comes from this English language report in the Korea Times.
Bird flu virus detected in Gochang
Posted : 2017-11-18 16:53
The South Korean government said Saturday the avian influenza (AI) virus has been detected at a poultry farm operated by a local conglomerate located in the southern part of the country.

The Ministry of Agriculture, Food and Rural Affairs said the H5 strain of the bird flu was discovered from the farm with around 12,300 ducks in Gochang, 296 kilometers southwest of Seoul.

The government said it is currently carrying out epidemiological investigations, while slaughtering the livestock as a preventive measure.
         (Continue . . .)

South Korea, which will host the 2018 Winter Olympics Games in Pyeongchang County in less than 90 days (Feb 9th-25th), is particularly keen to contain any avian flu outbreaks in hopes of avoiding the financial impacts, and negative press, of the past three winters.   

Friday, November 17, 2017

ECDC: Guide To Revising The Influenza Pandemic Preparedness Plan


A decade ago - when H5N1 was looming as a global threat, and before the emergence of the 2009 H1N1 virus - pandemic planning was all the rage.  Every state had, or was working on a plan, and many countries around the world had produced plans, and were actually holding serious preparedness drills.
The military considered pandemic flu a national security issue, and many (mostly large) players in the private sector viewed it as an existential threat, and were developing serious business continuity plans.
While not all of these plans were created equal - some were overly optimistic on pandemic severity, and the local/state/federal government's ability to respond - at least everyone was thinking about how to deal with a severe pandemic.

Two events served to thwart this momentum.  
  • The first being the global economic crisis and downturn in 2008.  While pandemic planning and business continuity are important, it is hard to worry about the creek potentially rising when your building is already on fire. 
  • And the second was the 2009 H1N1 pandemic, which - while far from benign - was considerably less virulent than the three pandemics of the previous century.  The media, which over-hyped the virus in the beginning, then began to dismiss the pandemic as a `non-event' and heavily criticized governments and agencies for over-reacting.
After the 2009 H1N1 pandemic ended, there was a general feeling that `we'd had our pandemic, it wasn't terrible, and it would be decades before the next one hit . . . '.
The problem with that logic being that viruses don't use calendars.  The gap between the 1957 and 1968 pandemics was 11 years, while the inter-pandemic period between the 1775 and 1781-82 outbreaks was only 6 years (cite).
With the rapid growth in novel viruses with pandemic potential over the past 5 years (see Updating the CDC's IRAT Rankings) - including some (H7N9, H5N1, H5N6, MERS) with potential virulence that could exceed the 1918 Spanish Flu - over the past year we've seen  renewed interest in updating pandemic plans around the globe. 

Today it is the ECDC's turn, with their release of a 26-page technical document designed to assist EU member nations as they update and revise their pandemic plans.  Some excerpts follow, but you'll want to download the entire PDF file.
ECDC: Guide To Revising The Influenza Pandemic Preparedness Plan
During the past decade, the 53 Member States of the WHO European Region, 31 of which are part of the European Union/European Economic Area, invested considerably in pandemic preparedness. This came in the wake of global threats posed by (re-)emerging diseases such as avian influenza A(H5N1) and A(H7N9), the SARS outbreak of 2003, and the outbreak of MERS (Middle East respiratory syndrome) which began in 2012. Adequate preparedness is also a national obligation under the International Health Regulations (2005) and the EU Decision on serious cross-border threats to health (No 1082/2013/EU).

The first pandemic since 1968 occurred in 2009, caused by a new strain of influenza A(H1N1) of swine origin. The virus spread rapidly around the globe and caused only mild disease in the majority of cases. However, severe disease and deaths occurred in a significant number of people, mostly in the same groups that are at risk of complications due to seasonal influenza infection, but also in other risk groups and even in previously healthy individuals. It has been estimated that in the first year of the pandemic between 151 000  and 475 000 deaths worldwide were attributable to influenza. Healthcare services, particularly critical care units, were often stretched to their limits, and early recognition and treatment of severe disease could be life-saving.

The 2009 pandemic tested national plans, and in the aftermath many countries and international organisations evaluated their preparedness and response activities. European countries, particularly in the western part of the Region, were generally better prepared for the 2009 pandemic than most countries. But when confronted with a milder pandemic than was expected, even the better prepared countries experienced gaps in their surveillance  and healthcare systems. Their planning assumptions were not flexible enough, they faced difficult communications and logistics issues with respect to pandemic vaccines, and often failed to establish effective communication lines with front-line healthcare responders.

An evaluation performed by the WHO Regional Office for Europe in collaboration with the WHO Collaborating Centre for Pandemic Influenza and Research, University of Nottingham, United Kingdom, showed that pandemic preparedness activities undertaken prior to the 2009 pandemic were useful in the response to the pandemic, and guidance from WHO and ECDC was critical in the preparedness phase. However, a global review of the functioningof the International Health Regulations and the response to the pandemic by both countries and WHO came to the conclusion that the ‘world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.’ 

The recommendations of this review have been only partially implemented, and the world has since been confronted with the failure to respond rapidly – and on the scale needed – to prevent the largest outbreak of Ebola ever recorded. As a result, the 69th World Health Assembly agreed to reform the WHO emergency response arrangements. It also agreed that the full implementation of the IHR core capacities by all Member States must be accelerated. In 2016, the new WHO Health Emergencies Programme was established (

A future influenza pandemic is inevitable, although it cannot be predicted when it will happen nor how severe it will be. Since the stress on the non-healthcare sectors was limited during the 2009 pandemic, only limited experience has been gained in multisectoral coordination. Business continuity which will be crucial in a more severe pandemic.

Earlier findings from European assessments and exercises show that there are still weaknesses in those areas. Since 2009, only thirteen countries in the WHO European Region have published revised pandemic preparedness plans (as of July 2017). This document therefore takes into account:

  • the need for all countries to review and revise as necessary their pandemic plans based on the lessons learned from the 2009 pandemic and WHO guidance on pandemic influenza risk management
  • (see: influenza_risk_management_update2017/en/);
  • the need for continuous integration of pandemic preparedness with preparedness for other public health emergencies, in line with the International Health Regulations, Decision No. 1082/2013/EU, and in light ofshrinking resources;
  • the need to develop plans for different scenarios of severity with more emphasis on national risk assessment to inform pandemic response; and
  • the need to revise the ‘WHO/Europe and ECDC Joint European Pandemic Preparedness Self-Assessment Indicators’ and develop a planning document that is useful to all Member States.
Description of the guide
Pandemic planning can be divided into 12 key areas. For each key area, the rationale and a list of good practice requirements for effective pandemic preparedness are provided.

For each key area, or requirement under a key area, countries may:

  • add requirements, indicators or outcomes for determining if a key area or requirement has been covered or implemented, or if progress has been made;
  • indicate changes that have been made to their pandemic plans after the 2009 pandemic;
  • provide to the WHO Regional Office for Europe and ECDC examples of good practice which may be shared with other countries; and
  • include questions to be addressed for each key area.
         (Continue . . . .)

Six months ago, in World Bank: World Ill-Prepared For A Pandemic, we saw the latest in a long line of assessments stating that a severe pandemic would test our modern medical system, society, and economy in ways that few can truly comprehend.  
While no amount of planning can fully prepare us for a severe pandemic, every little bit - undertaken by governments, the private sector, and even individuals - can help lessen the impact.
For more on pandemic preparedness, you may wish to revisit a few of these recent blogs.
WHO: Candidate Vaccines For Pandemic Preparedness - Sept 2017
#NatlPrep : Pandemic Planning Considerations

Upcoming Webinar: The Strategic National Stockpile
Are We Prepared to Help Low-Resource Populations Mitigate a Severe Pandemic?

Thursday, November 16, 2017

Italy: IZSV Reports 3 More HPAI H5N8 Outbreaks


The pace of HPAI H5 outbreaks in Italy continues to rise, with 15 outbreaks reported in the first half of November. Nearly as many as were reported in the first half of the year (n=17).

In mid-July we began to see a resurgence in H5N8 in northern Italy, with monthly totals to date running:
Jan-Jun     -  16 Outbreaks
July        -   6 Outbreaks
August      -  13 Outbreaks 
September   -   6 Outbreaks
October     -  23 Outbreaks  
November    -  15 Outbreaks (thru 15th)
In addition to these poultry outbreaks, there have been a number of detections in wild birds as well.  Today, we've three more outbreaks reported by Italy's IZSV (Istituto Zooprofilattico Sperimentale delle Venezie), bringing the total for 2017 to 79.

Highly pathogenic avian influenza (HPAI) in Italy
2016/2017 - H5N5, H5N82016 - H7N72014/2015 - H5N8, H5N12013 - H7N7

2016/2017 – H5N5, H5N8

    Outbreaks | PDF (last update: 15/11/2017)
    Maps | PDF (last update: 15/11/2017)

November 2017

16/11/2017 – On 10 November, IZSLER confirmed as positive for Avian Influenza A virus subtype H5 a laying hen farm in Brescia province (Lombardy region). At the time of confirmation, the farm housed 54,664 birds. The farm is located at approximately 500 m from the duck farm confirmed as positive for HPAI on 3 November (67th outbreak). Samples were taken after observing an increase in mortality on 9 November. The outbreak was extincted on 14 November.

On 10 November, IZSLER confirmed as positive for Avian Influenza A virus subtype H5 a broiler farm in Brescia province (Lombardy region). At the time of confirmation, 13,335 birds were present in the farm. On 10 November, an increase in mortality was observed and reported to the Veterinary Services. The outbreak was extincted on 14 November.

On 10 November, IZSLER confirmed as positive for Avian Influenza A virus subtype H5 another laying hen farm in Brescia province (Lombardy region). The farm is located within 600 metres from 75th outbreak, confirmed as positive earlier on the same day. The farm hosted 17,199 birds at the time of confirmation. On 10 November, an increase in mortality in one shed out of two was observed, together with a slight decrease in feed intake and a marked drop in egg production. On 15 November, the outbreak was extincted.
On 14 November, the National Reference Laboratory (NRL) for Avian Influenza and Newcastle Disease characterised as Avian Influenza A virus subtype H5N8 the viruses isolated in the last three outbreaks.

This heavy persistence of avian flu in Italy over the summer and into the fall - and at much lower levels across other parts of Europe - is in sharp contrast to previous years when H5N8 all but disappeared in Europe and North America once spring ended (see PNAS: The Enigma Of Disappearing HPAI H5 In North American Migratory Waterfowl).

As we discussed in Avian Flu: That Was Then . . This Is Now, HPAI H5N8 has undergone dramatic evolutionary changes since 2016, and additional changes in its genetics and behavior are always possible.