Friday, February 24, 2017

Eurosurveillance: Emergence Of A Novel Subclade Of Seasonal A/H3N2 - London

Credit NIAID


Twice each year (February & September) influenza experts from around the world meet (often electronically) to discuss recent developments in human and animal influenza viruses, and to decide on the composition of the next influenza season’s flu vaccine.  Vaccine strains must be selected for two A strains (H1N1 & H3N2) and two B strains (Victoria & Yamagata Lineage)

NIAID has a terrific 3-minute video that shows how influenza viruses drift over time, and why the flu shot must be frequently updated, which you can view at this link.

Due to the time it takes to manufacture and distribute a vaccine, these decisions must be made six months in advance, so the composition of next fall's flu vaccine is expected soon.

While we talk about 2 primary influenza A subtypes (H1N1 & H3N2) - in truth there are multiple variations of each subtype in circulation at any given time. Usually, one of these versions is dominant, but these evolving strains are constantly playing a viral game of `king of the mountain’, and the balance of power can shift quickly.

In the fall of 2014, a late arriving `drifted' H3N2 virus practically negated that year's flu vaccine's effectiveness (see CDC HAN Advisory On `Drifted’ H3N2 Seasonal Flu Virus).

Since 2009 seven distinct genetic groups have been defined for H3N2While all belong to clade 3C, they are divided into three subdivisions; 3C.1 , 3C.2, and 3C.3, with last November's ECDC Influenza Virus Characterization Report stating:

In 2014 three new subclades emerged, one in subdivision 3C.2, 3C.2a, and two in 3C.3, 3C.3a and 3C.3b , with subclade 3C.2a viruses dominating in recent months.

Yesterday's edition of  the Journal Eurosurveillance adds yet another layer of complexity to this already diverse field of H3N2 viruses. A new subclade of H3N2 - proposed as 3C.2a2 - has recently appeared in London. 

While more studies are needed - and the future spread or dominance of subclade 3C.2a2 is far from assured  - there are concerns that the current H3N2 vaccine may offer sub-optimal protection against this new strain.

Eurosurveillance, Volume 22, Issue 8, 23 February 2017
Rapid communication
Emergence of a novel subclade of influenza A(H3N2) virus in London, December 2016 to January 2017

H Harvala 1 2 , D Frampton 2 , P Grant 1 , J Raffle 2 , RB Ferns 2 3 , Z Kozlakidis 2 , P Kellam 4 , D Pillay 2 , A Hayward 5 , E Nastouli 1 3 6 , For the ICONIC Consortium 7

Correspondence: Eleni Nastouli (, Heli Harvala (

Citation style for this article: Harvala H, Frampton D, Grant P, Raffle J, Ferns RB, Kozlakidis Z, Kellam P, Pillay D, Hayward A, Nastouli E, For the ICONIC Consortium. Emergence of a novel subclade of influenza A(H3N2) virus in London, December 2016 to January 2017. Euro Surveill. 2017;22(8):pii=30466. DOI:
Received:13 February 2017; Accepted:23 February 2017

We report the molecular investigations of a large influenza A(H3N2) outbreak, in a season characterised by sharp increase in influenza admissions since December 2016. Analysis of haemagglutinin (HA) sequences demonstrated co-circulation of multiple clades (3C.3a, 3C.2a and 3C.2a1). Most variants fell into a novel subclade (proposed as 3C.2a2); they possessed four unique amino acid substitutions in the HA protein and loss of a potential glycosylation site. These changes potentially modify the H3N2 strain antigenicity.

The ongoing influenza season started early in eleven European Union countries, including England, on week 46 of 2016 [1]. The majority of reported infections have been caused by clade 3C.2a or 3C.2a1 influenza A(H3N2) viruses. The clade 3C.2a contains the current vaccine strain A/Hong Kong/4801/2014, and the first few viruses within the more recently emerged subclade 3C.2a1 were earlier shown to be antigenically matched with the vaccine component [2]. However, evidence for suboptimal vaccine effectiveness (VE) against laboratory-confirmed influenza A infection in people over 65 years-old was obtained in the first studies from Finland [3] and Sweden [4].

An outbreak of influenza A(H3N2) was first notified in our London centre on 30 December 2016. The outbreak coincided with unusually high ongoing circulation of respiratory syncytial virus (RSV) (Figure 1), and affected both patients and staff in the acute medical unit (AMU).

While infection control precautions were intensified, it resulted in multiple bay closures. We suspected that the sharp increase in the number of influenza A(H3N2) infections may have been caused by the emergence of a new genetic variant of H3N2, a hypothesis investigated through next generation sequencing (NGS) of influenza A(H3N2) strains.



In our centre in London, the early start and higher intensity of the 2016/17 influenza A(H3N2) virus epidemic mirrored that of the season 2014/15 where the subtype H3N2 also predominated. During the 2014/15 season, most influenza A(H3N2) infections in Europe were shown to be caused by antigenically drifted virus variants within the new genetic subgroup 3C.2a [8]. Our genetic analysis of London A(H3N2) viruses demonstrates ongoing co-circulation of drifted variants from multiple subclades (3C.3a, 3C.2a1 and proposed 3C.2a2). 

Four or more substitutions in two or more antibody binding sites are predicted to give an antigenically different virus [9] as in our case. Although we did not observe mutations in the seven positions suggested as being responsible for major transition clusters [10], position 144 is at the flank of the RBS, and additionally recognised as antigenic [11].

Although not necessarily determining major antigenic drift, the alterations of N-linked glycosylation sites are likely to contribute to more complex conformational changes in the HA due to gain or loss of glycosylation and can thus facilitate immune escape [12]. Furthermore, any amino acid changes in the 140–146 region of HA have been shown to be characteristic for antigenically distinct viruses of epidemic significance [9,13,14]. The amino acid substitution S144K in the emerging subclade 3C.2a2 viruses together with the loss of an N-linked glycosylation site (N122D) shows potential for antigenic drift that warrants further monitoring during this ongoing season. A limitation of our study was the lack of detailed vaccination data.

Our findings in London of the rapid emergence of genetically drifted influenza A(H3N2) viruses underscore the potential for such strains to spread rapidly in hospital environments among patients and staff. Characterising emerging strains of influenza by next generation sequencing adds to the local and national monitoring of influenza trends. Further studies are needed to investigate the antigenic effects of substitutions occurring within the newly described subclade.

(Continue . . . )

WHO H7N9 Risk Assessment - Feb 2017


Yesterday the World Health Organization released a new Influenza at the human-animal interface report - one that reflects information provided by the Chinese government through February 14th of this year.  As new cases continue to be announced - and others are presumably in the `pipeline' - case totals increase almost daily.
As the chart above illustrates, H7N9 cases this winter have already exceeded anything we've seen to date, and China's winter epidemic season typically has a couple of more months to run.
The cases reported reflect the `sickest of the sick' - those ill enough to require hospitalization - and so we really don't have a good handle on how many mild or moderate cases there may be.  The assumption is that number is substantial (see Beneath The H7N9 Pyramid).

Despite this abrupt increase in cases, we've seen no evidence of sustained or efficient human-to-human transmission of the virus.  Clusters have been small, and infrequently reported.  For cases where information is known, the vast majority appear to have had recent close contact with live poultry. 
Today's report does not address the recent HPAI variant viruses detected in both Taiwan and Guangdong Province (see Two H7N9 `Variants' Isolated From Human Cases) in January, as this report was compiled prior to those announcements.  So far, we've not seen any indication that these genetic changes increase the health risk to humans.

Today's report also details two swine origin H1N1 infections in Europe, and contains a line listing of H7N9 cases.   Follow the link to read the full report.

Influenza at the human-animal interface
Summary and assessment, 17 January to 14 February 2017

  • New infections1: Since the previous update, new human infections with influenza A(H7N9) andA(H1N1)v viruses were reported.
  • Risk assessment: The overall public health risk from currently known influenza viruses at thehuman-animal interface has not changed, and the likelihood of sustained human-to-humantransmission of these viruses remains low. Further human infections with viruses of animalorigin are expected.
  • IHR compliance: All human infections caused by a new influenza subtype are required to be reported under the International Health Regulations (IHR, 2005).2 This includes any animal andnon-circulating seasonal influenza viruses. Information from these notifications is critical toinform risk assessments for influenza at the human-animal interface.

Avian Influenza Viruses

Avian influenza A(H5) viruses

Current situation:

Since the last update, no new laboratory-confirmed human cases of influenza A(H5) virus infection were reported to WHO. Influenza A(H5) subtype viruses have the potential to cause disease in humans and thus far, no human cases, other than those with influenza A(H5N1) and A(H5N6) viruses, have been reported to WHO. According to reports received by the World Organisation for Animal Health (OIE), various influenza A(H5) subtypes continue to be detected in birds in West Africa, Europe and Asia. There have also been numerous detections of influenza A(H5N8) viruses in wild birds and domestic poultry in several countries in Africa, Asia and Europe since June 2016. For more information on the background and public health risk of these viruses, please see the WHO assessment of risk associated with influenza A(H5N8) virus here.

Avian influenza A(H7N9) viruses

Current situation:

During this reporting period, 305 laboratory-confirmed human cases of influenza A(H7N9) virus infection were reported to WHO from China. Case details are presented in the table in the Annex of this document. For additional details on these cases and public health interventions, see the Disease Outbreak News, and for analysis of recent scientific information on the A(H7N9) influenza virus, please see a recent WHO publication here.

1 For epidemiological and virological features of human infections with animal influenza viruses not reported in this assessment, see the yearly report on human cases of influenza at the human-animal interface published in the Weekly Epidemiological Record.
2 World Health Organization. Case definitions for the four diseases requiring notification in all
circumstances under the International Health Regulations (2005).

As of 14 February 2017, a total of 1223 laboratory-confirmed cases of human infection with avian influenza A(H7N9) viruses, including at least 380 deaths3, have been reported to WHO (Figure 2). According to reports received by the Food and Agriculture Organization (FAO) on surveillance activities for avian influenza A(H7N9) viruses in China4, positives among virological samples continue to be detected mainly from live bird markets, vendors and some commercial or breeding farms.

Risk Assessment:

1. What is the likelihood that additional human cases of infection with avian influenza A(H7N9) viruses will occur? Most human cases are exposed to the A(H7N9) virus through contact with infected poultry or contaminated environments, including live poultry markets. Since the virus continues to be detected in animals and environments, further human cases can be expected. Additional sporadic human cases of influenza A(H7N9) in other provinces in China that have not
yet reported human cases are also expected.

2. What is the likelihood of human-to-human transmission of avian influenza A(H7N9) viruses? Even though small clusters of cases have been reported, including those involving healthcare workers, current epidemiological and virological evidence suggests that this virus has not acquired the ability of sustained transmission among humans, thus the likelihood is low.

3 Total number of fatal cases is published on a monthly basis by China National Health and Family Planning Commission.
4 Food and Agriculture Organization. H7N9 situation update.

3. What is the risk of international spread of avian influenza A(H7N9) virus by travellers? Should infected individuals from affected areas travel internationally, their infection may be detected in another country during travel or after arrival. If this were to occur, further community level spread is considered unlikely as this virus has not acquired the ability to transmit easily among humans.
          (Continue . . . .)

Thursday, February 23, 2017

Korean CDC Cautions Travelers To China Over H7N9


Between their close proximity to, and cultural ties with Mainland China, it comes as little surprise that tens of thousands of travelers enter South Korea daily from China. 

A little more than a month ago - in advance of the Lunar New Year's travel surge - we saw the Korean CDC Warn Travellers To China Over H7N9 During Seollal.  

At that time, China was reporting 140 H7N9 cases in this 5th winter epidemic, a number that has roughly tripled (to 430) over the past 30 days.

Today Korea's CDC has issued a new warning, and outlines stiff penalties for travelers who fail to   submit a health-status checklist to the quarantine station when entering or returning to Korea.  You can read an English language media report in the JoongAng Daily (see Koreans warned about lethal bird flu in China), and I've posted the (translated) statement below: 

Chinese AI (H7N9) surge case

◇ Poultry contact caution when traveling in China dangerous area
◇ Submit a health status questionnaire when entering China, within 10 days after contact with poultry. If fever and respiratory symptoms occur, contact the Public Health Center or ☏1339 (Disease Control Headquarters Call Center)
◇ Medical institutions should report suspicious patients thoroughly

□ The cases of H7N9 * AI (avian influenza) human infections in China are rapidly increasing in China, so the Chinese travelers have been urged to avoid contact with poultry during their travels and to protect themselves from handwashing .

* H7N9 AI is different from H5N6 and H5N8, which are currently prevalent in domestic birds. There were no poultry epidemics or human cases in Korea
The number of human cases of AI (H7N9) in China has soared in recent years, with a total of 429 people * since Oct. 16, and has already exceeded three times the number of patients (121) in the past season.

* There were 1,227 deaths (426 (tentative) deaths) in the world from December 13 to February 18, 2005, with a mortality rate of 34.7%

○ China has seasonal epidemic of AI (H7N9) human infection every year from October to April after the first case of human infection in 2013.

The AI ​​(H7N9) virus is infected through contact with infected poultry or wild birds in the live poultry market. It is known that the inter-human transmission is limited to family members, medical staff, etc., Although it is likely to enter, it is estimated that the spread possibility is low.

  • ∙ AI (H7N9) Human infections are expected to continue through live poultry market and infected poultry
  • ∙ There is a report of incidence in medical staff, but the possibility of continuous transmission among people is low.
  • ∙ It is possible to spread between countries through travelers, but the possibility of spreading in the community is low

□ The Disease Control Headquarters is in cooperation with the Ministry of Foreign Affairs to issue SMS text messages for prevention and notification of AI human infection during departure to Chinese travelers *

* Daily average entry from China ('16): 25,956 (aircraft), 7,110 (ship)

○ Polluted areas in China are designated on a regular basis according to the status of AI human infection, and information on contaminated areas is posted on the homepage of the Disease Control Headquarters.

* As of February, 17th, polluted area (14 areas): Zhejiang Province, Guangdong Province, Jiangsu Province, Fujian Province, Shanghai City, Hunan Province, Anhui Province, Shandong Province, Beijing City, Hebei Province, Hubei Province, Jiangxi Province, Guizhou Province,
** Polluted areas are designated according to the expansion of the area.

○ According to the revised quarantine law, when the immigration officer does not report the health status questionnaire to the quarantine officer after visiting the contaminated area, he / she paid special attention because the fine of 7 million won is applied.

○ In addition, the people traveling to China can get guidance on infection prevention areas and infection prevention areas in China at the 'International Travel Disease Information Center' on the 3rd floor of Incheon International Airport. .
□ The Disease Control Headquarters confirms the infectious disease information of the travel destination through the homepage of the Disease Control Headquarters (, mobile before overseas travel,

○ When entering the country, check whether you are visiting a contaminated area, fill out a health status questionnaire, submit it to the quarantine officer,

○ After entry, if you have fever and respiratory symptoms within 10 days of contact with poultry in a contaminated area, you should also contact the Public Health Center or ☏1339 (Disease Control Headquarters Call Center).
□ Disease Control Headquarters can actively report to the Korean Medical Association, the Korean Hospital Association, and related professional medical organizations so that patients can come in from overseas or come to Korea at any time, so that AI (H7N9) The Ministry of Health, Labor and Welfare said that the Ministry of Health, Welfare and Environment (MOEHRC) will prepare the diagnosis and diagnosis within 24 hours.

1. Chinese AI (H7N9) Human Infection Status
2. Chinese traveler AI human infection prevention
3. Q & A about AI Human Infection
4. Number of beds available at the country's designated sound pressure bed

Catalonia Reports H5N8 Outbreak At Duck Farm In Girona

Credit Wikipedia


Earlier this week the autonomous community of Catalonia reported the discovery of  H5N8 in a stork found dead in the Natural Park of the Aiguamolls de l’Empordà, Girona.  Today, their Ministry of Agriculture, Livestock, Fisheries & Food reports the discovery of the H5N8 virus at a duck farm, also in the province of Girona.

This is the first poultry outbreak reported within the borders of Spain. In January two wild ducks were found dead in the lake Las Navas de Fuentes, Palencia, Castile and León.

 Starts the slaughter of 17,000 ducks operation and activate the measures foreseen in the emergency plan before an avian influenza focus
Since the government is acting as quickly as possible to minimize the risks for the sector
Avian influenza is a disease that affects birds and such specific virus is transmissible to humans
The Central Veterinary Laboratory of Algete in Madrid last night confirmed an outbreak of avian influenza, the H5N8 type, a farm breeding ducks outdoors for fattening the municipality of San Gregory, Gironès. This was announced today the Minister of Agriculture, Livestock, Fisheries and Food, Meritxell Serret, at a press conference in Barcelona.
In this situation, Serret said that the Department has implemented quickly, under the precautionary principle, the measures, according to European directive on emergency plan before an outbreak of avian influenza: signed sacrifice all farm animals, a total of 17,327 ducks and triggered all security measures in the protection zone within a radius of 3 km. In this sense, they fixed the six poultry farms that are in this radius (all Gironès) and veterinary inspections have begun to know what their health status.
The fact that the type of virus matches the stork meeting Tuesday and we are in a zone of high migratory birds, and therefore contact with wild birds is the first hypothesis of possible infection. To determine the precise origin will study the Animal Health Research Centre (CRES).
Meanwhile, traceability is studying this operation and are applying the highest veterinary controls to prevent and detect other possible sources.
In Catalonia Tuesday confirmed an outbreak stork found dead in the Natural Park of Aiguamolls. It was determined a radius of 3 km protection and they immobilize three poultry farms that are in this radius, which is also still being analyzed by veterinarians. Moreover, it has established a ban on hunting wild birds in a radius of 10 km and the levels of surveillance in wild birds through the Corps of Rural Agents.
From 28 October 2016 and so far 781 have been reported in Europe focus highly pathogenic avian influenza in poultry, captive birds and 38 in 972 wild birds.
The H5N8 virus affects only birds and not transmitted to people
The Secretary of Public Health, Dr. John Plaster, also present at the press conference, pointed out that we have a virus that does not affect public health, since the H5N8 is not transmissible to humans as secured from different European organizations.
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Chinese Premier Briefed On H7N9 - Urges Shut Down Of Poultry Markets

#12, 255

While hard information on China's 5th epidemic wave of H7N9 is slow to emerge, for the third day in a row the Chinese government is reporting on high level meetings being held over the status and control of their record-setting H7N9 epidemic.  
Yesterday we looked at a national video conference held by China's MOA, while on Tuesday we saw the NHFPC National Video Conference on the epidemic.

Today, China's Premier Li Keqiang was briefed on the epidemic, and afterwards he reportedly urged live poultry markets to shut down.  The following (translated) excerpt describing today's meeting comes from a report posted on the Central Government's website (

The meeting pointed out that this year China's H7N9 epidemic compared with previous years earlier, the number of cases increased. All regions and relevant departments in accordance with the Party Central Committee and State Council, the effective implementation of joint defense control.
The next step is to open the transparent and timely release of the authority of the information, to prevent panic, to guide poultry practitioners and the public to do protection.
Two to do a good job in case treatment, to minimize the severity and death cases. Enrich the power of treatment, to ensure drug supply, the relevant treatment costs into health insurance.
Third, we must strengthen the epidemic monitoring and early warning, to strengthen the regulation of live birds and farms, strict implementation of live poultry market closed, disinfection, quarantine and other systems, found cases or detection of the source of the city and county as soon as possible to close the live poultry market, Kill and other measures. Severely punish the illegal transport, operation, slaughter and other acts.
Fourth, we must implement the "scale farming, centralized slaughter, cold chain transport, chilled listing" new model to promote the upgrading of poultry industry.

The move away from live bird markets to `chilled' or frozen chicken has been attempted before, but has always been met with strong public resistance.  Even after Beijing Ordered Closure Of Live Bird Markets To Control H7N9 late last week, many poultry markets apparently remain open.

In the past hour Reuters is reporting:
China's premier urges poultry markets to shut as bird flu fears grow
China's Prime Minister urged local authorities to shut down live poultry markets in places affected by the H7N9 bird flu virus which killed 79 people in January, a statement from China's cabinet said.

Chicken prices sank to their lowest level in more than a decade last week and concerns about H7N9 deepened after global health authorities said the strain had evolved into a more severe form for birds.
          (Continue . . .) 

Despite ample evidence that the closure of live bird markets dramatically reduces the spread of H7N9 (see The Lancet: Poultry Market Closure Effect On H7N9 Transmission), China has been unusually slow to react to this year's epidemic.  

Hopefully this week's flurry of high profile meetings is an indication that China is intent on taking a more proactive stance in fighting this epidemic.

ESA: HPAI H5N8 in Africa


Although its impact has been relatively small to date, the arrival of HPAI H5N8 to Sub-Saharan Africa this winter raises genuine concerns over the future spread, and continued evolution, of clade HPAI H5 viruses.

H5N8 belongs to an expandng family of viruses that have shown a remarkable ability to reassort with local LPAI viruses, generating new genotypes, and new subtypes (e.g. H5N5, H5N2, H5N1, etc.).

Last week's FLI: Updated Risk Assessment On HPAI H5 warned specifically that:

`Generation of reassortants always must be expected when different high and low pathogenic influenza viruses are circulating in one population.'

H5N8 first appeared in Nigeria last November (see OIE Report), caused a major die off of waterfowl on the shores of Lake Victoria in Uganda last month (see Ugandan HPAI H5 Outbreak Confirmed As H5N8), and was confirmed in Cameroon just last week.

Reports of H5N8 have been more common in northern Africa (Egypt & Tunisia) and the Middle East (Iran, Israel), but given the lack of surveillance, testing, and reporting from much of Africa, it is likely there are other outbreaks we simply haven't heard about.  

France's ESA (Epidemiosurveillance Santé Animale) posted the following (translated) update yesterday.  Follow the link for all of the maps, charts, and links. 

Homes and cases of HPAI H5N8 in Africa: point situation 


Submitted by Alizé MERCIER on 22. February 2017 - 9:34.

Sleep international health (VSI) ESA platform - France

Source: Data updated on 21.02.2017 (inclusive) FAO OIE WAHIS & Empres-i

A virus highly pathogenic avian influenza (HPAI) H5N8 is currently circulating in Asia, Europe and Africa. In Africa, outbreaks and cases were reported officially in Egypt, Tunisia, Nigeria, Uganda and Cameroon (Figure 1 & Table 1). 

In Egypt, the virus HPAI H5N8 was detected for the first time November 30, 2016 in two coots Coot ( Fulica atra ) found dead in Dumyat (source: OIE). Following this first case, an epidemiological surveillance system was implemented in 45 sites placed on the path of migratory birds, with sampling done on wild and domestic birds. The virus was then detected repeatedly within poultry (mainly ducks (unspecified species)) with ten declared areas from late December to early February (source: FAO Empres-i).

Tunisia is located on the main corridor of migration of wild birds traveling to Africa from Europe (source: OIE). In Tunisia, the first case of H5 HPAI was reported on 1 st December 2016 at 17 coots Coot ( Fulica atra ) and 13 Wigeon ( Anas penelope ) found dead in the north of the country in the Ichkeul National Park ( source: OIE). The Reference Laboratory Padova (Italy) then confirmed that the virus was directly related to HPAI H5 virus clade (this clade including the H5N8 virus). Phylogenetic analysis is ongoing according to the latest OIE report dated February 20, 2017.

In Nigeria, a first outbreak was reported December 17, 2016 (home dating of 19 November 2016) in Kano in outdoor rearing of 250 birds (guinea fowl, turkeys and pigeons) with morbidity and 6% mortality. The owner had bought his birds at a local market. Another outbreak was reported February 8, 2017 (home dating of 11 January 2017) in Kano in a poultry market following the collection of tracheal samples from four live ducks.

In Uganda, two cases of HPAI H5N8 on winged Tern ( Chlidonias leucopterus ) reported January 13, 2017 and, for each notification, 600 cases of 1000 susceptible birds (source: OIE). These statements correspond to high mortalities of wild birds (including wild ducks) on the shores of Lake Victoria. According to the OIE, many wild and domestic birds continue to die of the virus, threatening more than 30 million domestic birds in the country. Another outbreak was reported in a breeding (unspecified species) in Masaka, and a mixed marriage (affecting both wild and domestic birds) in Kalangala with over 4000 domestic and wild birds (species unspecified) found dead (source: OIE / FAO Empres-i).

In Cameroon, the first cases of HPAI H5N8 was declared February 14, 2017 (event start date of January 2, 2017) in the north of the country within a 107 breeding peacocks ( Pavo cristatus ) - which 103 were infected and died (96.3% mortality) - also including 10 ducks and 14 chickens (source: OIE).

It is noteworthy that despite the put monitoring systems in place in many countries (whether in Africa or in Europe), the AI ​​case detection in wild birds is difficult, which may lead to under-detection . Furthermore, other HPAI viruses, including viruses HPAI H5, also circulating in Africa. For example, the H5N1 virus was detected in the last month within farms in several African countries such as Burkina Faso, Cameroon, Nigeria, Ivory Coast, Ghana and Niger ( source: Promed).