Vietnamese Media Reports: Severe A/H9 Case Reported in Tien Giang Province - Updated (2) MOH Statements

[Michael Coston]

Vietnamese Media Reports: Severe A/H9 Case Reported in Tien Giang Province

Credit Wikipedia

#17,993


For the second time in just over 2 weeks Vietnamese state run media is reporting a severe human avian flu infection; this time it is A/(H9) - the first time a human case of this subtype has been reported in that country. While the full subtype has not been determined - unless it is a new reassortment - it is most likely H9N2.

After years of relative quiescence, in recent months we've seen a flurry of avian flu activity in Vietnam - including a fatal H5N1 case reported in late March - and just yesterday, a warning from the FAO on a new H5N1 reassortment in the Mekong Delta region.​

Although roughly 130 cases have been reported (see FluTracker's list) over the past 25 years (see ECDC/EFSA graphic below), most have been mild, and the virus is usually detected in children. Nearly 90% of all known cases have been reported by China.



While I haven't found anything posted on the Vietnamese MOH or CDC websites (yet), state run media is widely reporting on the case. First, the following (translated) report from VOV.vn (Voice of Vietnam), after which I'll have a bit more.

Tien Giang conducts emergency treatment after detecting the first case of influenza A/H9

Saturday, 16:21, April 6, 2024


VOV.VN - Information from Pasteur Institute, City. Ho Chi Minh City, just discovered the first case of Influenza A/H9 in the country in Tien Giang province. The health sector, veterinary medicine and local authorities are taking urgent measures to prevent the spread of this disease.

That is patient Nguyen Van D., 37 years old, working as a construction worker, residing in Tan Quoi hamlet, Tan Ly Dong commune, Chau Thanh district (Tien Giang province), currently being treated at the Hospital of Tropical Diseases in Ho Chi Minh City.

Tien Giang Disease Control Center has coordinated with Chau Thanh District Health Center, Tan Ly Dong Commune People's Committee, Epidemiology Department of Region VI Veterinary Department, Livestock and Veterinary Department, Agricultural Service Center Chau Thanh district verified case information, investigated epidemiology and took measures to handle the outbreak in accordance with regulations.

On March 9, the patient had fever, cough with phlegm, abdominal distention, and loss of appetite to be examined at Military Hospital 120 with a diagnosis of liver fibrosis and cirrhosis. The hospital advised the patient to be hospitalized for treatment at the Hospital. City Hospital for Tropical Diseases. HCM and found positive for Influenza AH9. Through verification, this patient 4 weeks ago only lived at home with his wife and did not leave the place of residence; Sometimes I drink alcohol with 2 other people at home. Near the house there is a slaughterhouse and live poultry trading facility.

According to the instructions of the Pasteur Institute of Ho Chi Minh City, the local health sector is handling the epidemic according to the instructions for monitoring and preventing influenza A (H5N1) and influenza A (H7N9); Coordinate with veterinary agencies at all levels to share information about the epidemic situation and coordinate to investigate and handle outbreaks, and take samples for testing on poultry in areas near the patient's home; Perform surface disinfection with Chloramin B 2% in the patient's household and surrounding area; Make a list and monitor daily health of cases who have had close contact with the patient within 14 days from the last contact for adults and 21 days for children under 15 years old.

Instruct close contacts to monitor if they have symptoms such as fever, cough, difficulty breathing, etc. to immediately report to the Health Station. Assign Tan Ly Dong Commune Health Station to monitor and monitor the health of close contacts daily within 14 days from last contact for adults and 21 days for children under 15 years old. During the monitoring period, if there are suspicious symptoms, the Health Station will notify the Tien Giang Center for Disease Control to take samples.​

As an LPAI (low path avian influenza) virus, H9N2 is not considered a `reportable' disease by WOAH (formerly the OIE), even though it is zoonotic. We've seen seroprevalence studies which suggest people with exposure to infected poultry often develop H9 antibodies, suggesting mild or asymptomatic infection.

Over the past 15 years we've watched as H9N2 has expanded its geographic range - spreading out of Asia into Europe, the Middle East and Africa. While it occasionally spills over into humans, H9N2's biggest threat may come from its unique ability to reassort with other, potentially more dangerous, avian viruses.

Its internal genes have often been found inside many HPAI viruses (including H5N1, H5N6, H7N9, and most recently zoonotic H3N8) - (see The Lancet's Poultry carrying H9N2 act as incubators for novel human avian influenza viruses).


Reassortment can also occur in humans, and with seasonal flu viruses. The possibility exists that someone could bhttps://afludiary.blogspot.com/2024/04/vietnamese-media-reports-severe-ah9.htmle co-infected with seasonal flu and H9N2, allowing a hybrid (reassortment) to emerge (see The `Other Mixing Vessel' For Pandemic Influenza).

Note quite a month ago, in Infectious Medicine: Rapid Adaptive Substitution of L226Q in HA protein Increases the Pathogenicity of H9N2 Viruses in Mice, we looked at mutations that can enhance the pathogenicity in mammals.

Given unusual severity of today's case, and the FAO Alert issued yesterday on the co-circulation of two clades of H5N1, and the emergence of a new H5N1 genotype in the Mekong Delta Region, we'll be interested to see what - if any - changes may have occurred in this virus.​

While LPAI H9N2 ranks pretty far down our pandemic threats list - at least as a standalone virus - it's ability to reassort with potentially more dangerous avian, human, and swine flu viruses make any uptick in cases worthy of our attention.​


https://afludiary.blogspot.com/2024/04/vietnamese-media-reports-severe-ah9.html

 

[Michael Coston]

Vietnam MOH Statements On A/H9 Case In Tien Giang Province

#17,994

Vietnam's Ministry of Health has published two statements on the A/H9 case reported in this blog yesterday that add a little bit to what we already knew, and illustrates how seriously they are taking this case.

Although the exact subtype has yet to be determined, this is most likely a spillover from LPAI H9N2.​

As an LPAI (low path avian influenza) virus, H9N2 is not considered a `reportable' disease by WOAH (formerly the OIE), even though it is zoonotic. We've seen seroprevalence studies which suggest people with exposure to infected poultry often develop H9 antibodies, suggesting mild or asymptomatic infection

While most human infections have been mild, the CDC has designated 2 different lineages (A(H9N2) G1 and A(H9N2) Y280) for their short list of influenza viruses with zoonotic potential (see CDC IRAT SCORE), and several candidate vaccines have been developed.​

First, the two reports from the MOH, after which we'll take a deeper look at the differences between LPAI and HPAI viruses.

Information about cases of Influenza A(H9) in Tien Giang

07/04/2024 Print article

The Department of Preventive Medicine announces a case of influenza A(H9) as follows:

Male patient, 37 years old, residing in Tan Ly Dong commune, Chau Thanh district, Tien Giang province. On March 10, 2024, the patient developed symptoms of fever and self-medicated but did not regularly. The patient came for examination and treatment at the City Hospital for Tropical Diseases. Ho Chi Minh City (BVBND) on March 16, 2024, was diagnosed with severe pneumonia suspected to be caused by a virus.​

Initial test results at the National Hospital showed positive for influenza A and had gene segments similar to influenza A virus subtype H9. The specimen was sent to the Pasteur Institute in Ho Chi Minh City for confirmation testing. On April 1, 2024, the Pasteur Institute in Ho Chi Minh City discovered a patient sample positive for influenza A subtype H9. Currently, the Institute is continuing to perform in-depth tests to determine the subgroup. The patient is currently being actively treated at Ho Chi Minh City People's Hospital.

According to the results of the epidemiological investigation, the patient's place of residence is in a poultry market, and there is a poultry market in front of the patient's house; There have been no reports of sick or dead poultry around the area where the patient's family lives. Cases in close contact with patients are listed and their health monitored; Up to now, no symptoms of respiratory infection have been detected; No outbreak of respiratory infections has been recorded in the community where the patient lives.

This is the first case of influenza A(H9) in Vietnam ever. Previously, in March 2024, in Khanh Hoa, 01 case of death due to human influenza A(H5N1) was recorded. From 2015 until now, in the Western Pacific region, 98 cases of influenza A(H9N2) have been recorded, including 2 deaths, both of which were patients with underlying diseases. Of which 96 cases were recorded in China and 02 cases were suspected in Cambodia. There is currently no evidence that influenza A(H9N2) is transmitted from person to person.

In the world, from the end of 2023 until now, the situation of avian influenza in animals has become complicated, not only recording many outbreaks of influenza in poultry in all regions but also recording its transmission. for an increasing variety of mammals. In the US, scattered cases of influenza A(H5N1) infection transmitted from livestock have been recorded in many states. In Asia, outbreaks of influenza in poultry continue to be recorded caused by many strains of influenza A virus such as H5N1, H5N6, H5N8, H3N2, H9N2, H10N3... Some countries bordering Vietnam Nam continues to record cases of avian influenza in humans including H5N1 and H9N2.

Domestically, according to information from the Department of Animal Health - Ministry of Agriculture and Rural Development, influenza A(H9N2) virus was previously detected circulating in poultry flocks. This is a low-virulence avian influenza virus that usually causes mild symptoms and does not cause mass deaths of poultry. However, humans can still be infected and contract avian influenza A(H9N2) if they contact and use infected poultry and poultry products.

Currently, it is the changing season, and unusual weather changes are favorable conditions for pathogens to develop, increasing interactions between influenza virus strains along with the risk of infection to animals. mammals, the Ministry of Health said that in the near future there is still a potential risk of transmitting avian influenza virus strains to humans.

There is currently no specific treatment for avian influenza in humans and no vaccine to prevent the disease. To proactively prevent and control influenza transmitted from poultry to humans, people need to well implement the following measures:

1. Do not eat poultry or poultry products that are sick, dead or of unknown origin; Make sure to eat cooked food and drink boiled water; Wash hands with soap before eating.

2. Do not slaughter, transport, buy or sell poultry and poultry products of unknown origin; Limit contact, slaughter, and eating of wild animals, especially birds.

3. When discovering sick or dead poultry, absolutely do not slaughter and use it, but must immediately notify the local authorities and veterinary unit in the area.

4. Poultry farmers, traders, transporters and slaughterers absolutely comply with routine disease prevention measures;

5. Encourage wearing masks when entering live poultry markets or live poultry trading areas; Wash your hands with soap after contact with poultry or after going to the market.

6. When you have flu-like symptoms such as fever, cough, chest pain, difficulty breathing, go to a medical facility immediately for timely consultation, examination and treatment.

For detailed information, contact: Department of Preventive Medicine, Ministry of Health.​

Strengthen the prevention and control of bird flu from spreading to humans

07/04/2024​

On April 2, 2024, the Pasteur Institute in Ho Chi Minh City reported a case of influenza A(H9) in a 37-year-old male patient, residing in Tan Ly Dong commune, Chau Thanh district, Tien Giang province. This is the first human case of influenza A(H9) infection recorded in Vietnam to date. Previously, in March 2024, in Khanh Hoa, 01 case of death due to human influenza A(H5N1) was recorded. From 2015 until now, in the Western Pacific region, 98 cases of influenza A(H9N2) have been recorded, including 2 deaths, both of which were patients with underlying diseases. Of which 96 cases were recorded in China and 02 cases were suspected in Cambodia. There is currently no evidence that influenza A(H9N2) is transmitted from person to person.

According to information from the Department of Animal Health - Ministry of Agriculture and Rural Development, avian flu epidemics are still sporadically recorded in poultry flocks in many localities across the country. Besides, this is currently the season change period and the weather has many unusual changes that are favorable for the development of avian influenza virus. Therefore, there is always a potential risk of bird flu infection to humans.

To proactively prevent avian influenza from infecting humans, on April 6, 2024, the Department of Preventive Medicine sent an urgent dispatch to the Department of Health of Tien Giang province and the Pasteur Institute of Ho Chi Minh City requesting attention. direct some content as follows:

1. The Director of the Department of Health is interested in directing affiliated units to urgently implement the following key contents:

• Organize investigation of the source of infection and thoroughly handle the outbreak; Strengthen surveillance to detect new cases- Guide and support localities in confirmatory testing of specimens from suspected human cases and handle outbreaks according to regulations.
• Consider training to improve local capacity in monitoring, detecting, investigating and handling avian influenza outbreaks in humans as well as providing guidance on coordination with the veterinary sector.
• Guide and support localities in developing media messages and deploying communications on avian flu prevention and control.

Editorial board of the website of the Department of Preventive Medicine, be ready to collect, quarantine, and treat according to regulations of the Ministry of Health and direct the Center for Disease Control to promptly deploy epidemic prevention and control measures.

• Closely coordinate with the agricultural sector and local authorities in monitoring and early detection of influenza outbreaks in poultry, promptly sharing information and coordinating to thoroughly handle outbreaks.
• Strengthen propaganda on measures to prevent transmission of avian influenza to humans, especially in areas with sick and dead poultry and high-risk areas.
• Prepare drugs, supplies, chemicals, and means to promptly support localities in implementing measures to handle outbreaks.
• Implement coordination in the prevention and control of diseases transmitted from animals to humans according to the provisions of Joint Circular No. 16/2013/TTLT-BYT-BNN&PTNT dated May 27, 2013 of the Ministry of Health and the Ministry of Health. Agriculture and rural development; Report on infectious diseases according to Circular No. 54/2015/TT-BYT dated December 28, 2015 of the Minister of Health to the Department of Preventive Medicine, phone: 04.38456255, fax: 0437366241, email: baocaobtn@gmail. com.

2. Comrade Director of the Pasteur Institute of Ho Chi Minh City is interested in directing affiliated units to urgently implement the following key contents:

• Continue to investigate, monitor and track close contacts of cases, promptly detect new cases.
• Continue to perform in-depth tests to determine virus subtypes.
• Guide and support localities in confirmatory testing of specimens from suspected human cases and handle outbreaks according to regulations.
• Consider training to improve local capacity in monitoring, detecting, investigating and handling avian influenza outbreaks in humans as well as providing guidance on coordination with the veterinary sector.
• Guide and support localities in developing media messages and deploying communications on avian flu prevention and control.

Editorial board of the website of the Department of Preventive Medicine​

Since we use acronyms like HPAI (Highly Pathogenic Avian Influenza) and LPAI (Low Pathogentic Avian Influenza) frequently - and they don't mean exactly what they sound like they mean - a long-time reader has asked for a deeper dive.

The terms HPAI and LPAI refer to a virus's pathogenicity in poultry as determined by specific laboratory tests. It has little to do with its impact on human health. HPAI viruses often produce severe disease in poultry in as little as 48 hours, while LPAI viruses typically cause few, if any, signs of illness.​

Agriculture's big concern with LPAI H5 and H7 viruses is their known ability to spontaneously mutate into HPAI viruses after they have been introduced into a poultry flock (see graphic below). We've yet to see this occur with any other avian subtypes.



While it is true that up until a dozen years ago LPAI viruses were thought to pose less of a public health threat, the LPAI H7N9 outbreak in China (2013-2017) - with a CFR that approached 40% (among hospitalized cases) - changed that perception.


Since then, we've seen roughly 130 confirmed LPAI H9N2 cases around the world, and a smattering of other LPAI human infections, including A(H6), A(H7), A(H9), and A(H10) viruses. A partial list includes:

• In 2013 a 20-year-old college student on Taiwan as hospitalized with LPAI H6N1 pneumonia (see Taiwan CDC: Epidemiological Analysis Of Human H6N1 Infection).
  • The following year we learned that a number of dogs on the island tested positive as well (see EID Journal: Influenza A(H6N1) In Dogs, Taiwan)

• In addition to H7N9, we've seen a number of LPAI H7 spillovers around the world including;
  • NYC's 2016 dramatic H7N2 outbreak in cats, and spillover into animal shelter workers (see J Infect Dis: Serological Evidence Of H7N2 Infection Among Animal Shelter Workers, NYC 2016)
  • 3 mild cases of LPAI H7N7 in Italy in 2013 (see ECDC Update & Assessment: Human Infection By Avian H7N7 In Italy).
  • In 2006 1 person in the UK was confirmed to have contracted H7N3, and the following year, 4 people tested positive for H7N2 – both following local outbreaks in poultry.
  • The Fraser Valley H7N3 outbreak of 2004 resulted in at least two human infections, as reported in this EID Journal report: Human Illness from Avian Influenza H7N3, British Columbia.
  • And in 2003 a large outbreak of H7N7 (89 confirmed, 1 fatality) in the Netherlands – with nearly all reported cases having very mild (often just conjunctivitis) symptoms.

• We've also seen scattered LPAI H10 human infections in Egypt, Australia, and China, including:
  • Last JanuaryA Fatal Case of H3N2 and H10N5 Mixed Infection Discovered in Zhejiang Province
  • China has reported several LPAI H10N3 cases since 2021 (see The Lancet Microbe: Novel H10N3 Avian Influenza Viruses - a Potential Threat to Public Health).
  • A small number of LPAI H10N7 infections were was reported in Egypt in 2004 (see Avian Influenza Virus A (H10N7) Circulating among Humans in Egypt) and Australia in 2010 (see EID Journal: Human Infection With H10N7 Avian Influenza).
  • LPAI H10N8 has been reported in a small number of people with severe pneumonia with respiratory failure, including a few deaths, in China since 2013 (see EID Journal Human Infection with Influenza Virus A(H10N8) from Live Poultry Markets, China, 2014).

While we are understandably keeping a close watch on HPAI H5N1, LPAI viruses are quite capable of jumping to humans, and causing equally severe illness.

And since they tend to cause few symptoms in poultry or wild birds, and are often not considered legally `reportable' diseases, they have the potential to fly under our radar.​

Even if most don't appear to be as deadly as H5N1, even a 2% CFR (Case Fatality Rate) pandemic would make COVID pale in comparison. And that is something the world remains poorly prepared to deal with.


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