Medical Contact Group Newsletter

From Airfinity’s curated analysis of various health and media sources and from the ECDC (European Centre for Disease Prevention and Control) Weekly Communicable Disease Threats Report:

• The outbreak of highly pathogenic avian influenza (HPAI) A(H5N1) in cattle is still ongoing, with 69 farms affected across nine states of the US.
• As of today, there have been three human cases of avian influenza A(H5N1) reported in workers at US dairy farms with infected cows.
• No meat from affected dairy cows has entered the food supply.
• To date, routine population-based surveillance has not detected any increase in community rates of respiratory infections.

• Hospitals in the US are no longer required to report COVID-19 hospitalisations. Meanwhile, reported COVID-19 oral antiviral uptake and COVID-19 hospitalisations correlate well with SARS-CoV-2 wastewater concentration, indicating that wastewater can provide suitable metrics.

• There has been a global post COVID-19 pandemic resurgence of pertussis, also known as whooping cough. Pertussis is caused by a highly contagious bacterium and typically has a cyclical pattern returning every 3 to 5 years, varying by country. Whooping cough is preventable with a 3-dose vaccine (which also includes diphtheria and tetanus) given to small children, but recent vaccine hesitancy has resulted in an unexpected comeback of the disease. Since vaccine coverage is lowest in Africa and Oceania, these continents could be at highest risk.

• Measles cases have been detected in at least 118 countries worldwide since the start of the year.  According to the US CDC, travellers to areas where measles has been surging  are at risk if they have not been fully vaccinated at least two weeks prior to departure or have not had measles in the past. The majority of measles cases imported into the US have occured in unvaccinated residents who became infected during international travel.

• Thirteen cases of invasive meningococcal disease (IMD) serogroup W have been reported from France, Norway, UK, and US. The cases are epidemiologically linked to religious practices in the Umrah zones in the Kingdom of Saudi Arabia (KSA). International spread of IMD associated with mass gatherings during pilgrimages in the KSA has been reported in the past. Vaccination against meningococcus is recommended for those travelling to KSA to perform Umrah and for Hajj pilgrims – this year, the annual Islamic Hajj pilgrimage will take place between 14 and 19 June.

We start with cabin air research:

- In response to the question: “Is there evidence of exposure to chemical contaminants in cabin air that could have long-term health impacts, either from acute exposures or due to long-term low level exposures including mixtures, e.g., of volatile organic compounds (VOCs)?”, the UK Committee on the Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) issued earlier in April a Statement on Aircraft Cabin Air Quality. You can read it here: https://cot.food.gov.uk/sites/default/files/2024-04/Aircraft%20Cabin%20Air%20statement%202024%20Acc%20V%20SO_0.pdf

You will also find a non-technical summary here: https://cot.food.gov.uk/Statement%20on%20Aircraft%20Cabin%20Air%20Quality%20%E2%80%93%20Non-technical%20Summary

The Committee assessed the new evidence, since their previous 2007 Statement. “Overall, the COT concluded that the concentrations of the chemical contaminants (organophosphates, VOCs including as mixtures, carbon monoxide and CO₂) reported in aircraft cabin air are unlikely to cause adverse health effects in aircrew following acute or long-term exposures. However, there is still limited information about the levels of chemicals in cabin air following smoke or fume events.”

- More specifically in relation to smoke or fume events, a team led by researchers from the Ruhr University Bochum Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, published their work – also known as the FUSE II study - on biomonitoring of VOCs and organophosphorus (OP) flame retardants in commercial aircrews after “fume and smell events“. They assessed exposure to VOCs and OPs in 375 aircrew members after self-reported “fume and smell events”, as well as in 88 persons of the general population. Twenty blood and urine parameters were analysed. They concluded that “comparative VOC and OP analyses in biological samples of a large number of aircrew members and controls suggest that exposures are similar in both groups and generally low”. You can read the article in full here: https://authors.elsevier.com/sd/article/S1438-4639(24)00062-2

- In the same field, here is a reminder of the ANSES (French Agency for Food, Environmental and Occupational Health & Safety) report published at the end of last year - an extensive review of the scientific literature, as well as of the grey literature and of health data from the French national occupational disease surveillance and prevention network. The ANSES reached the same conclusion as the US National Research Council (NRC) in 2002: “there is a low level of evidence for the existence of a syndrome specifically linked to exposure to various polluting substances or breakdown products from aircraft engine or hydraulic fluid leaks”. More research is ongoing.  Short summary in English here: https://www.anses.fr/en/content/health-flight-crew-members . If you would like to review the details, look up the Medical Contact Group email of 20-Dec-2023.

From Airfinity’s curated analysis of various health and media sources and from the ECDC (European Centre for Disease Prevention and Control) Weekly Communicable Disease Threats Report:

• All indicators point to elevated but decreasing influenza activity in Europe. SARS-CoV-2 activity has remained low in Europe as well.

• The COVID-19 burden is in decline in the US and Japan.

• RSV activity has continued to decrease to low levels in most reporting countries worldwide.
• A total of four cases of avian influenza A(H9N2) have been reported in children in mainland China in February-March. H9N2 infections are usually related to contact with poultry or their environments. They are typically mild and affect children.

• Avian influenza A(H5N1) has been detected for the first time in US mammalian livestock – in goats in a Minnesota farm. Cases of highly pathogenic avian influenza (HPAI) have been detected in dairy cows in farms in Kansas, Texas, and New Mexico. At this stage, there is no concern about the safety of the commercial milk supply.

• Measles continues to surge in parts of Europe, with the highest number of cases in the UK, Romania, and Austria. A surge of measles is also ongoing in North America, with a vaccine shortage in Canada due to increased demand. Elsewhere, DRC and Kyrgyzstan, among other countries in Africa and Asia, are also facing significant outbreaks. Cases of measles have been reported so far this year in a total of 83 countries globally.

• Over half a million cases of malaria have been reported recently in Madagascar. Risk is expected to remain very high into April.

• So far this year, approximately 70.000 cases of chikungunya have been reported worldwide, in a total of 16 countries, namely in the Americas (11), Asia (4), and Africa (1).

• Since the beginning of 2024 over two million dengue cases and over 500 dengue-related deaths have been reported globally – see the ECDC Three-month dengue virus disease case notification rate per 100.000 population (Dec 2023-Feb 2024) map below:
  
  

From Airfinity’s curated analysis of various health and media sources and from the ECDC (European Centre for Disease Prevention and Control) Weekly Communicable Disease Threats Report:

• The burden of COVID-19 has begun to decline in the US and across Europe, while increasing in Mexico as the COVID-19 winter wave continues.

• JN.1 seems to be the current dominant variant in almost all G20 nations. Notable exceptions are Japan, South Korea and China, where JN.1 is rising but EG.5.1.1 remains dominant, and Russia, where XBB.1.16 is still dominant.

• In December 2023, the WHO classified JN.1 as a Variant of Interest (VOI) due to its rapidly increasing spread. Current evidence, meanwhile, shows that the risk to public health from this strain at the global level is low. JN.1 is a sublineage of BA.2.86.1 and contains the L455S mutation in the spike protein, which is associated with very high immune escape but significantly attenuated infectivity. In vitro data suggest that vaccines are still effective against JN.1.

• In most of Europe, rates of respiratory illness in the community remained elevated and at levels above baseline. Seasonal influenza is now circulating at higher levels than SARS-CoV-2 and respiratory syncytial virus (RSV).

Here is another update carrying on from last week. In the previous update I introduced to you the French Agency for Food, Environmental and Occupational Health & Safety (ANSES) report on cabin air quality and occupational health of air crew, which you can access here https://www.anses.fr/fr/system/files/AIR2019SA0075Ra.pdf (in full, in French) and here https://www.anses.fr/en/content/health-flight-crew-members  (short summary in English).

The report concludes that there is a low level of evidence for the existence of a syndrome specifically linked to exposure to various polluting substances or breakdown products from aircraft engine or hydraulic fluid leaks, and that there is no consensus to date around whether “aerotoxic syndrome” corresponds to an actual nosological entity (i.e. a syndrome or a disease).

The ANSES report also addressed the potential effects of irregular hours and ionising radiation. Here is a sum-up of the report’s conclusions.

Published data regarding commercial airline pilots and cabin crew confirm a lower incidence of a number of malignancies than in the general population, in particular cancer of the lungs, bladder, kidney, colon, brain and mouth. The incidence of testicular, colorectal and thyroid cancer was found to be similar to that in the general population, while the small number of published studies and failure to take into account potential but relevant confounding factors do not allow for a conclusion regarding the risk of prostate or breast cancer.

From Airfinity’s curated analysis of various health and media sources and from the ECDC (European Centre for Disease Prevention and Control) Weekly Communicable Disease Threats Report:

• On December 4^th, JN.1 was officially designated as a variant by the UKHSA. The variant is a sublineage of BA.2.86.1 and contains the L455S mutation in the spike protein, which is associated with very high immune escape but significantly attenuated infectivity. First detected in Luxembourg, JN.1 is believed to have evolved from the Pirola variant (BA.2.86), which itself stems from the Omicron sub-variant. According to the WHO, Pirola and its variants accounted for 17% of the Sars-CoV-2 sequences uploaded to the global database GISAID. By the beginning of December, more than half of these sequences were of JN.1.
• In vitro data suggest that vaccines are still effective against JN.1 (UKHSA).
• In Europe, SARS-CoV-2 continued to circulate at higher levels than seasonal influenza and respiratory syncytial virus (RSV). Countries have been reporting a mix of increasing and decreasing trends for SARS-CoV-2 activity.
• ECDC: UKHSA have published an update on the recently reported human case of swine influenza virus A(H1N2) variant infection, detected in England. The person resides in an area where several pig farms are located. No human-to-human transmission has been detected so far. The occurrence of sporadic human cases following exposure to pigs is expected due to the high prevalence of swine influenza viruses in the pig population.
• Seventeen countries from Asia, Europe and North America, have reported cases of atypical pneumonia amongst children.
• Bangladesh has reported its highest Nipah virus burden for eight years, with the virus detected in breast milk for the first time.
• The Philippines has reported a 5-fold increase in chikungunya incidence compared to the same period last year, while dengue incidence is declining.

From Airfinity’s curated analysis of various health and media sources and from the ECDC (European Centre for Disease Prevention and Control) Weekly Communicable Disease Threats Report:

• H5N1 avian influenza has been detected in poultry farms in more European countries, namely Hungary, Croatia and the Netherlands (see also the previous MCG update).

• Pakistan has confirmed its fifth wild poliovirus infection in a toddler. This is relevant in that there is an ongoing effort worldwide to completely eradicate polio.  More about the Global Polio Eradication Initiative here: https://polioeradication.org/  A good analogy from not so long ago is the successful eradication of smallpox which was declared in 1980, three years after the last natural case had occurred in Somalia  – more here https://www.cdc.gov/smallpox/history/history.html .

• Another outbreak of cholera, this time in the Dominican Republic.

• The US FDA has just approved the world's first chikungunya vaccine.

• On 23 November 2023, the World Health Organization (WHO) published a Disease Outbreak News (DON) about clusters of undiagnosed pneumonia in school-aged children in the Beijing and Liaoning regions in China.

Chinese authorities responded to WHO’s request to share more data on the current situation of respiratory illnesses in the country. The data shared showed an increase in paediatric hospitalisations due to Mycoplasma pneumoniae since May this year, as well as rising incidence of other common community respiratory viruses since October, namely adenovirus, respiratory syncytial virus (RSV) and influenza. M. pneumoniae meanwhile, seems to be the leading cause of surging paediatric respiratory illness in China. COVID-19 levels have been declining and the rates of infection with adenovirus, and RSV are at lower levels than M. pneumoniae.

From Airfinity’s curated analysis of various health and media sources.

• From today a total of 34 countries have shared SARS-CoV-2  B.A.2.86 genome sequences. The spike protein in this variant contains 34 additional mutations compared to its BA.2 predecessor, but does not appear to be more dangerous. As this variant has been detected in all those countries with a high sequencing rate, it can be assumed to be widespread. In recent weeks, a related variant, JN.1 (with the L455S mutation), has been identified which has concerning immune-evasion properties. JN.1 was detected in the US in September and has also been identified in 11 other countries but, according to the US CDC, for now makes up less than 0.1% of SARS-CoV-2 viruses. The CDC said initial data suggest that updated COVID vaccines will help protect against BA.2.86, and it expects a similar effect against JN.1.

• Across the US, wastewater data continues to show decreasing COVID-19 burden. Though still high, hospital admissions have stabilised in the last week, while the UK has shown a decrease in most indicators including hospital patient numbers and test positivity. In Japan also, the number of new COVID-19 cases has been decreasing for seven consecutive weeks. Meanwhile, in Germany cases continue to rise and it is unclear whether this wave will peak soon.

• The epicentre of deadly bird flu outbreaks seems to have shifted from Asia to Europe and Africa: https://www.nature.com/articles/s41586-023-06631-2 . Avian influenza has been detected in agricultural settings across the US, Canada, Mexico, Europe (Norway, Poland, Romania, Bulgaria) and Mozambique, while in southern Brazil, over 500 sea lions have been found dead due to avian influenza. The disease has been detected for the first time in Antarctica in skuas (a scavenging bird) on Bird Island in South Georgia, as reported by the British Antarctic Survey. It is likely that avian influenza was spread by birds returning from their migration to South America, where cases are high.

• The spread of cholera now appears to be slowing in Zimbabwe.

• Earlier this month yellow fever reemerged in Guinea after three years of absence: 178 cases and four deaths have been reported in the East Central district of Dabola.

• Dengue continues surging throughout the world and coming to places that had never had it, from the US to Chad in Central Africa. In Europe, a total of seven clusters (35 cases) of autochthonous dengue virus transmissions have been reported so far in mainland France (from the ECDC Communicable Disease Threats Report (week 42). Cases of dengue fever have also increased to 66 in Italy, and a second locally acquired case has been reported in Catalonia, Spain.

• A locally acquired West Nile virus infection has been confirmed for the first time in the Czech Republic since 2019, when two cases were reported. In Europe, the transmission area of West Nile virus has expanded in recent years due to climate change, with a case reported this year as far north as Berlin.

• While no further Nipah virus infections have been confirmed in Kerala since mid-September, a bat surveillance survey has detected Nipah virus antibodies in Pteropus bat species in 14 states in India, indicating a wider presence of the virus and possibilities of outbreaks across the country.

• On a different note, an interesting alert related to floor heating systems: Legionella can establish itself in the biofilm that forms on the inside of water pipes, where it can reproduce when conditions are favourable. Testing of different types of water distribution cabinets by researchers at the Norwegian science institute SINTEF has led to the conclusion that cabinets that combine the distribution of both domestic tap water and water for floor heating pose a risk for Legionnaires' disease. The floor heating system gives off heat that causes the temperature in the cabinet to rise to as much as 40 °C, offering the best possible temperature range for Legionella.