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The more H5N1 influenza continues to circulate in wild and domestic birds around the world, including here in North America, the more we have to be concerned about exposure of pets to H5N1 influenza through raw food diets. Recent documented infections in cats fed raw meat from infected birds have highlighted these concerns. For more information on the risks of H5N1 influenza from raw diets for pets and associated risk reduction measures, check out the latest quick podcast on Worms&GermsPod.

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Addendum: The Oregon Veterinary Medical Association has indicated in a release that the cat discussed below was euthanized because of the severity of disease. That’s more consistent with the severe disease that’s usually reported but I think the discussion below still applies since this seems to have been an initial primary respiratory disease presentation. It probably still shows that there can be a primary presentation that overlaps with more common presentations so we need to consider H5N1 beyond severe neuro or sudden death cases.

I’m not commenting on every new report of an H5N1 influenza spillover infection in a domestic animal because it’s not really news anymore, but that doesn’t mean they’re not concerning. Spillover infections definitely are a concern with this virus, and we expect these spillovers to continue as long as this virus is circulating in wild birds (or in large numbers of dairy cattle, as it is the the US).

Nonetheless, a recent case of H5N1 influenza in another cat in Oregon highlights something important, because it’s different from previous cases. Most reported cases of H5N1 flu in cats to date have been of severe disease, usually with neurological signs, but it’s been unclear whether this is because infected cats typically get severe neurological disease or whether we’ve only been testing the cats with severe disease. It remains unknown how often infected cats get milder disease, and that’s a really important testing consideration, for both clinical patients and surveillance testing.

Respiratory disease in very common in cats, especially outdoor cats. Knowing whether flu should be a consideration in your average cat with an upper respiratory tract infection is important for determining how they are managed in a clinic (to avoid transmission to staff and other patients) and how they should be managed at home (to avoid transmission to family members and other animals in ad around the home). 

In contrast to previously described severe cases in cats, the recent case of H5N1 in a cat from Oregon was described as having a much more typical respiratory tract infection. “A veterinarian examined the cat after it exhibited symptoms including a fever, runny nose and eyes, lethargy, difficulty breathing and loss of appetite.” Although difficulty breathing isn’t typical for a run-of-the-mill upper respiratory tract infection in a cat, it is consistent with pneumonia, which can occur secondary to any viral infection. The news report is light on clinical details, but if this case was actually was more akin to a typical pneumonia that we might see in cat secondary to other more common bugs, it (long with a few other milder cases where cats have recovered) suggests that we need to vastly expand the cats we should consider potential H5N1 flu suspects. It means we need to focus on more than just the severely ill cats with respiratory and neurological disease. At the same time, it’s tough to say how wide a net we should cast, given the commonness of mild upper respiratory tract disease in cats.

At this point, the key is flagging risk factors for exposure in these animals, including outdoor access, contact with farms and being fed raw poultry diets. In combination with respiratory tract or neurological disease, we should consider the cat an H5N1 flu suspect unless another cause is evident. 

A challenge with this is that cats with outdoor access are also the main risk group for any typical feline upper respiratory tract infection, so including them greatly expands the pool of suspects and can make practical management harder. Nonetheless, at least for now, we should probably still be flagging any outdoor or indoor-outdoor cat presenting with respiratory disease beyond the routine upper respiratory disease complex as a potential flu suspect, with corresponding considerations for testing and infection control.

Should we consider any outdoor/raw fed cat with any signs of respiratory disease a flu suspect? Maybe. It’s certainly possible that H5N1 can also cause typical flu-like disease/upper respiratory infection. I’d recommend not completely discounting it in any case, but paying particular attention the more severe the disease is, and the greater the cat’s risk of exposure.  

As with most emerging diseases, this is a fluid situation and it’s tough to figure out where to draw the line in order to balance protection and practicality. As we learn more, that line will likely move, so we must keep an eye on new developments and take reasonable measures in the interim. Personally, I always prefer to err on the side of testing more and being more aggressive at the start, and then de-escalating when we know more, but there’s also a practical limit to how far we can go with that. 

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As H5N1 avian influenza continues to spread in wild birds and spills over into domestic birds and mammals of many kinds, we’re becoming more aware of the risks to domestic mammals and there are more questions about test selection and interpretation. Fortunately, testing for H5N1 influenza is relatively straightforward.

  • For cats and dogs, the recommended samples for testing are typically oropharyngeal swabs, plus or minus nasal swabs (plus or minus other tissue samples of the animal is deceased. 

What tests are currently being run by veterinary diagnostic labs?

PCR is the most accessible and useful test; diagnostic labs basically offer two types of influenza PCR: matrix / pan-influenza A PCR, and strain-specific PCRs (see below). Different commercial labs offer different tests or combinations of these tests, and the tests offered may also vary by species (i.e. what’s routinely done for dogs can be different from cats). Test offerings may also change over time as labs adapt to the ever-changing situation with flu in different populations. If influenza is a consideration in your patient, check with your lab regarding which tests they will run (particularly if you are submitting samples for a respiratory PCR panel) and how to interpret the results, including whether or not the test will detect H5N1 flu if that’s a concern.

Influenza A matrix PCR (aka pan-influenza A PCR)

This test will detect RNA from any / all influenza A viruses. A positive test confirms that flu virus is present, but not the strain (and not that the virus present is necessarily viable). Knowing the strain is important to understand how the animal might have been exposed and transmission risk. It’s a good first screening step, but if it’s positive we need more testing. If a cat was positive, it could mean it has a human seasonal flu strain (people sometimes infect their cats, and ’tis the season), or it could have H5N1 influenza, or another flu strain (e.g. a low pathogenicity flu strain which can cats sometimes get from wild birds, or potentially a swine flu virus if they have contact with pigs). Really rarely, but importantly, an animal could be infected with a combination of different flu viruses. Our concerns about and responses to these different scenarios are really different, so it’s important information to get. 

Strain-specific influenza PCR

These tests target specific influenza strains in different species, like canine H3N2, canine H3N8, avian H7N2 (found sometimes in cats) and human H1N1 (which can spill over sometimes into dogs and cats). It’s important to be aware that these are strain-specific tests, so an animal that just has H5N1 influenza will test negative on the H3N2 test, for example.

H5N1-specific influenza PCR 

As the name suggests, this test is specifically for H5N1 influenza, and we can be more confident in the result if that’s the strain for which we’re looking. The downside is that it won’t detect co-infections with multiple flu strains. The odds of a dog having H3N2 canine flu or H1N1 human flu and H5N1 avian flu at the same time are REALLY low, but that would be a REALLY concerning situation, so it would be nice to know. It’s more relevant when there’s higher non-H5N1 flu activity in the area as well, since that would mean there’s a greater chance of a hidden co-infection.

In order to provide the best possible information without over-testing every sample, labs will sometimes perform different tests in sequence: 

Run matrix PCR; if positive, then test for H5N1

This adds a step, but it’s usually a quick one, and we find out whether the animal has a flu virus and if so, whether its H5N1. The same issue with not identifying co-infections applies here, because there’s no testing for other flu strains.

Run matrix PCR, then test for non-H5N1 strains; if negative, then test for H5N1 

This works too. It adds a bit of extra time/work, and the more steps that are required, the greater the chance of a test error, but it gets to the same result pretty quickly and gives us a specific H5N1 result. The main theoretical issue is that we could still miss a coinfection (in this case because the H5N1 test isn’t run if any of the other strains are detected). 

Run matrix PCR, then test for non-H5N1 strains; if negative, then refer to another lab for H5N1 testing

This slows things down more and adds in some uncertainty as it requires sending the sample out for follow-up testing, which is another step where human error could affect things. It also misses co-infections.

Run matrix PCR, then test for non-H5N1 strains, then test for H5N1; if negative, stop and call it a generic influenza A positive

This isn’t ideal but still tells us a lot. In most cases nowadays, if the sample is matrix positive and negative for all the other main flu strains, it’s probably H5N1 flu, but pets can get spillover infection of other strains that aren’t included in strain-specific tests. If they stop here, it’s functionally okay but not ideal. I’d want to try to get followup testing of any matrix positive, type-specific negative samples (and would treat them as H5N1 positive until proven otherwise).

Any of these combinations would be okay for testing an animal in which there’s suspicion of H5N1 flu exposure / infection, but I’d rather have a quick H5N1-specific result in these cases, and I’d want to make sure that the lab will forward any positive sample for further genomic testing, so we can better understand the situation with H5N1 flu. 

Take home message

  • Talk to your lab to know what they can (and can’t) do in terms of testing for H5N1 flu, and follow up testing.
  • We can’t just stop at “flu positive.” Any such result needs to be scrutinized to make sure we know the strain (or strains) involved.
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TLDR: Nope.

These days I commonly get the question ”Does vaccination of dogs with available canine influenza vaccines protect them from H5N1 avian flu?” While we don’t have any hard data on this, we still have a pretty good idea of the answer.

One of the challenges with flu vaccination (in any species, including humans) is the lack of good cross protection between strains (e.g. H3N2 vs H1N1 vs H5N1). In general, we assume there’s little to no cross-protection, and organizations such as CDC, Public Health Agency of Canada and WHO have stated that seasonal flu vaccines don’t offer any protection to people against H5N1 flu. 

That said, theoretically there there may be a bit of protection, though it’s hard to have confidence in that based on data from older lab animal studies. One study (Rockman et al. J Virol 2013) showed that ferrets vaccinated with human seasonal flu vaccine had partial protection against challenge with H5N1 flu. They determined that this was from the H1N1 component of the vaccine, and was predominantly from the neuraminidase (N) part (H5N1 and H1N1 have the same N1). While we typically pay more attention to the H component for vaccination, the similarity in N may be useful. That means there may be some protection of people from H5N1 flu if they’re vaccinated for seasonal flu, but not a lot, and we have to be careful extrapolating too much from older studies using different types of H5N1 in lab animal models. 

Canine flu vaccines target H3N2 canine flu, plus or minus H3N8 canine flu strain. (Realistically we only care about H3N2 now, since H3N8 appears to have disappeared as of a few years ago.) Those are quite different from H5N1 avian flu in flu terms.  Since there’s no overlap in the Hs or Ns, we wouldn’t expect to even have that small theoretical cross-protection benefit. If we had an H1N1 canine flu strain, maybe there’d be some protection, but (thankfully!) we don’t.

Does canine flu vaccination help protect against flu recombination? 

Recombination (mixing) of different flu strains in the same host (human or animal) to create a new, more problematic strain is certainly a concern. We don’t want someone to be infected with seasonal flu and H5N1 flu at the same time, as that creates the potential for a new flu strain to emerge that has the hallmarks of a human flu (readily infected people, effective human-to-human transmission) but has picked up enough H5N1 bits that we don’t have protection from previous exposure or vaccination and may can cause more severe disease. So even though seasonal flu vaccines in people don’t protect against H5N1 flu, there is still benefit from reducing the human seasonal flu burden, as it in turn reduces the risk that a person will be infected with multiple flu strains at the same time, which reduces the chances of recombination.

Does the same principle apply to vaccination of dogs against canine flu? It’s a stretch. There could be some potential benefits for canine health, but probably not much benefit for public health. Canine flu is much rarer than seasonal flu is in people, so there’s less potential benefit simply because there’s less disease to prevent. There’s also less baseline protection against canine flu in dogs because it’s rare and therefore vaccination is uncommon. So from a disease transmission standpoint for dogs, a new flu strain against which they don’t have immunity isn’t that different from the current H3N2 canine flu strain, since most dogs don’t have immunity to that either.

However, there could potentially be a difference in terms of disease severity. Fatal H5N1 infections have occurred in many mammals and at least one dog, and we don’t want an H3N2/H5N1 recombinant virus that spreads nicely dog-to-dog and is more likely to cause severe disease.  The odds of that happening are extremely low, but not zero.

Also bear in mind that canine flu vaccines aim to reduce the severity of disease more than prevent infection altogether. That still might be useful, as a mildly affected dog with some degree of immunity might have a lower H3N2 viral burden, but it’s hard to say how much that would really help protect against recombination of flu viruses, even if we had more widespread vaccination in the dog population. Probably not too much.

Public health benefits would be less of a reason to promote vaccination of dogs against canine flu stains. Canine H3N2 flu poses little risk of infection of people, so a hybrid of canine H3N2 and H5N1 wouldn’t be expected to be more transmissible to people (even though it would potentially add some mammalian adaptations to an H5N1-related virus, which is definitely not the direction we want the virus to go). For dogs to be a flu “mixing vessel” of public health concern, a human flu strain would need to be involved. While dogs can occasionally be infected with human flu strains, the odds of a dog having H3N2, human seasonal flu and H5N1 at the same time are pretty low. Even then, whether or not the dog was vaccinated against H3N2 wouldn’t really affect the risk, since we’d be primarily concerned about the human flu and the H5N1 flu mixing in the dog, not whether or not H3N2 joins the party.

Should we change how we approach canine flu vaccination?

I’d mostly stick with our current approach, which is based on assessment of the risk of exposure of the dog to canine flu, and the risk of serious consequences should the dog get flu (e.g. elderly, brachycephalic, underlying heart or respiratory disease). Since there are some plausible dog health concerns about H3N2/H5N1 recombinants, I’d drop my threshold for vaccination in dogs that also have a higher risk of exposure to wild birds (or dairy farms in the US). Dogs that have a reasonable risk of exposure to both types of flu virus (canine and avian) would be higher on my list to vaccinate, but that’s a very small subset (currently), and the benefits of vaccination beyond H3N2 protection are probably very limited.

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Issues with raw diets and H5N1 influenza risk in cats (and dogs) have gotten a lot of attention in the last week or two. Like most emerging disease situations, it’s still fluid, and we’re learning more as time goes on, but we know enough at this point to at least make some basic assessments and recommendations. Here’s my current take on it.

What are the concerns with H5N1 influenza and raw diets for pets?

The unprecedented pandemic of H5N1 highly pathogenic avian influenza (HPAI) has ongoing for more than 2 years. Massive numbers of wild birds have been affected around the world. Spillover into domestic animals is an ever-present risk where this virus is circulating in wild birds, with domestic poultry being the most severely affected. Millions of domestic poultry have died or been depopulated due to infection, and spillover infections have also occurred in mammals, including many cats and at least one dog.

Recently, H5N1 influenza infection has been linked to consumption of contaminated raw meat diets in at least two cats. It’s been well established for some time that ingestion of infected birds can lead to H5N1 influenza infection in cats, based on earlier studies and field observations. It is therefore unsurprising that infections could occur if infected poultry makes its way into raw diets fed to cats, and unfortunately the infection in cats is often fatal.  The risk to dogs is less clear, but infection was reported in one dog that died shortly after close contact (chewing on) an infected bird. Dogs may be less susceptible to H5N1 influenza than cats, but they are still susceptible and infection can have dire consequences, so the same concepts apply to both species.

What types of raw diets for pets pose a risk of H5N1 influenza infection?

Poultry-based diets are the main concern, including chicken, turkey and duck, as all poultry are highly susceptible to H5N1 influenza. However, the virus is now also widespread in dairy cattle in the US, particularly in certain states (like California at the moment). Work done by the Food Safety and Inspection Service (FSIS) in the US has found no evidence of virus in retail beef samples and only very low levels of virus in samples from 1 of 185 cull dairy cows tested (the positive cow did not enter the food chain). More investigation is needed, but it is likely that viral loads in muscle of infected cattle are far less than those in poultry. Risks from beef are presumably low, but the potential for the virus to be present in meat from infected dairy cattle cannot be dismissed.

Does use of “human grade” meat in raw diets eliminate the risk?

Human grade meat does not mean pathogen-free – it only means that the meat would have been allowed for sale for human consumption based on more rigourous requirements for the animals, facilities, processing and handling. These presumably reduce, but do not eliminate,  the risk of H5N1 infected animals entering the pet food chain.  

Does high-pressure pasteurization of raw diets eliminate H5N1 influenza virus?

High pressure pasteurization (HPP) of food products uses high pressure (rather than high heat, as in cooking) to reduce contamination with bacteria and viruses. Many commercial raw diets for pets are high pressure pasteurized (which is good). The pressures achieved during this process should inactivate influenza virus, but there are no standard methods for HPP. The effectiveness of HPP depends on the pressure, temperature, and composition of the food matrix. It is unclear whether manufacturers have developed and validated the method for their wide range of diets and pathogen risks. Recalls of high-pressure pasteurized raw diets because of Salmonella contamination have been regular occurrences, and a recent infection in a cat was linked to such a diet. High pressure pasteurization should be considered a risk reduction step, not a risk elimination step.

Are frozen or freeze-dried raw diets lower risk for H5N1 influenza?

Freezing and freeze drying are effective preservation methods for viruses, so its unlikely that these methods substantially reduce the risk of viral contamination in raw diets. Ultralow freezing is used for longterm preservation of viruses, but shorter-term survival is also possible at temperatures achieved using normal freezers (-20C). A study of the survivability of H7N9 influenza on raw chicken meat (Dai et al. Lancet 2022) reported that viral infectivity was maintained for 9 days at -20C, 4 days at 4C and 4 days at 25C. This was a rather small study, so it is possible that somewhat longer survival could occur in some situations. In nature, long term (e.g. overwintering) survival of influenza virus in ice has been suspected.

While the survival kinetics of this virus with freezing are not clear, it should be assumed that the virus could survive frozen for at least a week, and possibly much longer. Freezing should not be assumed to be a risk mitigation measure for viral contamination of raw diets.

Freeze drying is a highly effective virus preservation method. Survival of virus in freeze dried food has not been assessed, but in the absence of specific evidence, it is reasonable to assume that influenza virus would survive for long periods of time in such diets.

My cat is doing well on a raw diet and I don’t want to change. What can I do?

Raw diets can be cooked so that the cat receives a diet with the same ingredients but without the risk from H5N1 influenza (and other pathogens). There is no evidence that cooking reduces the health benefits of a diet. Cooking the food to an internal temperature of 165F/74C will inactivate influenza virus and other pathogens such as Salmonella.  

My cat has eaten a raw diet that’s been recalled diet. What should I do?

You should observe your cat closely and contact your veterinarian in you are concerned or your cat develops any signs of illness. Antiviral prophylaxis could be considered in particularly high-risk situations where it is likely that the cat has eaten contaminated food. This may not be the case for all recalled diets and would depend on the nature of the recall. Early signs of H5N1 influenza in cats are not well established, but often seem to be vague signs such as lethargy, malaise and decreased appetite. Rapid progression to severe disease can occur so veterinary care should be sought as soon as possible.

My cat has eaten a raw diet that’s not been recalled. What should I do?

Unless there is evidence that the diet has been implicated in disease, the odds of a problem developing are low. However, it would still be ideal to transition the cat to a cooked diet, whether that’s a commercial wet or dry diet, a home-cooked diet or cooking the cat’s current raw diet. Monitoring of your cat for illness, as above, is still indicated, as always.

What are risks to people from contact with contaminated raw diets?

The risk to people from H5N1 influenza from handling contaminated raw diets is likely quite low but not zero. Exposure could happen from inadvertent ingestion of the virus from contaminated surfaces (e.g. food prep surfaces, refrigerator, food bowls). That would likely be low level exposure, but the infectious dose of the virus is not known so it could still be relevant. There are similar risks with these diets from pathogens such as Salmonella, so good food handling practices are always warranted. These include avoiding cross-contamination with human foods and kitchen surfaces, careful cleaning and disinfection of in contact surfaces, dishes and utensils, and thorough handwashing (or use of an alcohol-based hand sanitizer) after contact with the raw diet or food bowls.

The greatest risk to people would be from exposure to a cat (or less likely a dog) infected with H5N1 influenza. An infected animal might be shedding enough virus to infect people, although the risk of this is still unclear. Any cat or dog with suspected influenza should be handled sparingly, and with use of good infection control measures, including a mask (ideally an N95 respirator) and eye protection.  

Closing thoughts

My opinions on raw diets have been pretty clear all along. I don’t think there’s any evidence that raw diets have any health benefits over an appropriate cooked diet, but raw diets come with numerous infectious disease risks. I’ve seen enough dogs and cats (and sometimes owners) sickened from raw diets to be confident in that. At the same time, I’m a realist and know that some people will continue to feed pets raw diets regardless. That’s why we have a infosheet about raw diets that includes ways to reduce the infectious disease risks for those who choose to feed them to their pets.

The current situation doesn’t really change anything for me. I’m still opposed to raw diets for pets, and this simply adds yet another layer of risk to pets and people that consume/feed them.

If someone is adamant that they are going to feed their pet a raw diet, here’s what I currently recommend:

  • Avoid diets that contain poultry (including duck)
  • Use a diet treated with high pressure pasteurization (realizing it reduces risk, but does not eliminate it)
  • Take care to avoid cross contamination of human food, and use good food handling and hygiene practices (always)
  • If your pet has been fed raw meat and gets sick, make sure your veterinarian knows about the diet so they can consider whether that might be relevant
  • Pay attention to the news and recalls so that you can stop feeding a diet if there are any known issues (but realize that we don’t typically know about any issues until one or more animals gets really sick or dies from the diet)
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Hot on the heels of the recent death of a cat in Oregon due to H5N1 influenza infection linked to a raw diet (that some raw diet proponents are trying to deflect or downplay), we have confirmation of a very similar case in California. Los Angeles County Public Health has issued a notice to avoid feeding Monarch Raw Pet Food “due to detection of H5 bird flu in product samples.” (note the plural). H5N1 was confirmed in one cat that was fed this diet and is suspected in four other cats from the same household.

The diet type was not reported, but the company’s website indicates “Our pet food is made of human grade USDA free-range poultry that is raised in the San Joaquin Valley.” Free range poultry are at increased risk of H5N1 infection from wild birds. Nonetheless, it would be interesting to know how infected poultry made it into the food chain (even the pet food chain), since H5N1 influenza usually causes widespread illness and death in domestic poultry, so it’s pretty obvious when it hits a poultry farm (and sick birds cannot be sent to slaughter).

The status of the infected cat wasn’t reported, but H5N1 infection in cats is often fatal based on what we know to date. Hopefully the cat had a milder infection, but I assume it was at least worse than a routine upper respiratory tract infection, since testing is usually limited to pets that are pretty sick.

The good news is that food-associated H5N1 influenza risks are totally avoidable… just don’t feed pets raw diets. The cost:benefit calculus is pretty easy since this virus kills cats and there are no health benefits of raw diets. More information about raw meat-based diets for pets (beyond the risk of H5N1 flu) can be found in the Worms & Germs / OAHN Raw Meat Diets infosheet, available on the Worms & Germs Resources – Pets page.

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The Oregon Department of Health has issued a warning to pet owners about contaminated raw pet food after H5N1 avian influenza virus was detected in turkey-based raw (and frozen raw) pet food from Morasch Meats. Testing was performed after the death of an indoor cat from H5N1 flu in Washington County, Oregon. The virus from the cat and from the pet food were a genetic match, making a solid link between the two. The pet food company is voluntarily recalling some of their Northwest Naturals diets.

This highlights (yet another) risk posed by poultry-based raw pet food at the moment in areas like the US where H5N1 flu is actively circulating. There could also potentially be risk of H5N1 contamination of raw pet food made with beef, if the meat came from infected US dairy cattle. Risks could also extend to other raw pet food formulations if there is cross-contamination from these higher-risk ingredients.

There are no health benefits to raw diets beyond a properly formulated cooked (be it commerical or homemade) diet. H5N1 flu is now yet another potential threat to animals fed raw diets. The risk may extend to owners as well, through exposure to virus from handling food, and potentially from infected pets (especially cats, but we still don’t know the level of cat-to-human transmission risk).

We have seen foodborne H5N1 influenza infection in cats in multiple situations, often resulting in fatal disease. Foodborne disease probably helps explain some of the earlier reports of H5N1 in indoor cats, and in that respect it’s good to have an idea of how all these infections are occurring. The more infections we can’t explain, the more we worry about serious issues like unknown human (owner) infections with subsequent human-to-cat transmission. I’d much rather be able to attribute cases to straightforward food-associated transmission than have to explore other transmission pathways, or think that there may be silent human-associated spread.

The mitigation approach here is simple: just avoid raw pet food diets (especially poultry-based diets).

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A presumptive case of H5 avian influenza has been reported in a teenager from British Columbia. Confirmatory testing is underway. Very little additional information has been released, so it’s hard to say how surprising and concerning it is. Information vacuums like this often lead to excessive speculation, but information sharing has to be balanced with privacy of medical information, and we don’t have an automatic right to know everything about a case immediately. It also takes time to properly investigate a case, and there’s often (understandable) reluctance to release very preliminary findings where there are still a lot of unknowns. Hopefully some reliable details will be released soon as the investigation continues.

A few key things that we’d like to know include:

  • What was the source of the virus in this person? The government release indicates “The source of exposure is very likely to be an animal or bird, and is being investigated by B.C.’s chief veterinarian and public health teams.” The lack of a specific statement that this was linked to a known poultry infection has led some to questionable messaging. A ProMedMail report said “Based on the details provided, it would seem the individual did not have direct contact with infected cows or poultry” which seems to be a questionable (bordering on irresponsible) overstatement at this early point in the investigation. It might be true, but it’s way to early to raise concerns about unknown exposure routes, especially given there are active cases of H5N1 in poultry in this region.
  • What strain is the virus in the person? Presumably it’s the circulating wild bird strain (vs the strain circulating in dairy cattle in the US, or another strain from wild birds, or imported from overseas), but knowing more details about the strain and whether it has any relevant mammalian adaptations is important.
  • Have there been any additional human cases? This takes time to determine, but it’s important to know whether this was a single isolated event with no human-human transmission, part of a cluster associated with common animal contact (e.g. on a poultry farm), or whether there was any downstream human-to-human transmission. So far, no other human infections have been identified.
  • How serious was the illness in this person? The press release only indicates that the person “is receiving care at BC Children’s Hospital.” While there’s public interest in knowing how severe the infection is, that’s personal medical information, but hopefully some information will be released at some poiny. Infections in people associated with the H5N1 strain in the US have been mild, and hopefully that’s the case here too.

Ultimately, it remains to be seen if this was a rare but expected spillover to a person with known direct contact with infected birds (the most common and most reassuring scenario) or something else. The less it fits that scenario and the harder it is to explain the infection, the greater the concern.

As usual, social media has a big camp amplifying “the end is near” messaging. While it’s not good news, there’s nothing here yet that raises a lot of concern, beyond the fact that every human exposure and human infection is playing with fire, as it creates more opportunities for this virus to change and adapt to people. As I’ve said before, I’m not really concerned about the currently circulating strain of H5N1 from a human health standpoint, since it rarely causes disease in people, typically causes mild disease when it does, and is not well adapted for human-to-human spread. I’m concerned about what this virus could do if it becomes more adapted to humans, with an ability to spread effectively between people and cause more severe disease. We need to do all we can to contain it, limit spillover infections and address those that occur promptly, but we need to maintain some perspective at the same time.

Presumably more information will be released soon to help us better understand this situation.

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A lot of infectious disease events get over-hyped by the media, which makes it a bit surprising that this case has flown a bit under the radar. It’s not a sign of an impending “influenza apocalypse,” but it’s a warning sign that more may be going on lately with flu viruses than we’ve been able to observe directly.

The CDC has confirmed a case of H5 influenza infection of a person in Missouri who had no reported contact with animals of any kind. The virus has only been identified as H5 or H5Nx, which means they have not confirmed the N-type, so we can’t say if it’s the same as the H5N1 influenza that has been circulating in wild birds since 2022, or in dairy cattle in the US since spring 2024. It’s surprising that the N-type has not been determined yet, since the infection was detected over 2 weeks ago – but knowing the strains that are circulating in the US right now, I’d say it’s almost certainly H5N1. (Sometimes sample quality can impede the effectiveness of molecular diagnostics too.)

Human H5N1 infections linked to the ongoing massive multiyear avian influenza outbreak have been rare. There have been just 14 reported H5 infections in people in the US so far in 2024, despite a huge amount of potential exposure, particularly among livestock and poultry workers. All previous human infections have been linked with direct and close contact with infected animals.

Rare spillover infections like these are largely expected when there’s lots of disease in animals. The worry is the potential for the virus to change to become amenable to human-to-human spread, so finding a human infection like the one in Missouri with no direct link to animals raises a lot of concern. The source of exposure in this case has not been determined. Details are sparse, but the person was reportedly hospitalized and recovered, and H5N1 testing was done as part of ongoing surveillance.

How could a person get H5N1 without animal contact?

  • Unreported animal contact, possibly due to incomplete history taking, or poor recall or unwillingness to report contact on the part of the patient for some reason)
  • Contact with a surface contaminated by an infected animal
  • Ingestion of contaminated food products

We hope the source of infection in this case was one of those. Hopefully they queried all animal contacts, not just birds and cattle, since we’re also concerned about infection from susceptible species that can bridge bird, cattle and and human populations (particularly cats).

Otherwise, we get concerned about the last option:

  • Contact with another infected person

As has been pretty common, details have been slow in being released. More information is needed about the person’s history, including whether the person had any human contacts that were high risk for exposure (e.g. worked with infected animals), and the genome of the virus to see if it’s consistent with the circulating avian strain, the strain that jumped to dairy cattle, or something different, and whether the strain has any genetic markers that indicate it could be more adept at spreading person-to-person. Missouri hasn’t reported H5N1 in cattle, but it’s circulating in wild birds, with spillover into poultry and backyard chickens. Missouri doesn’t have a huge dairy industry, but there are still lots of dairy cattle around and it doesn’t sound like there’s been much testing (a report in July said that only 17 of the state’s approximately 16,000 dairy cattle had been tested), so we can’t rule out local dairy cattle (or unpasteurized milk) as a source either.

Hopefully this is an oddball infection that died out when the person recovered, i.e. they got infected somehow but didn’t pass it on to anyone else. However, even if that’s the case, this event demonstrates why we need to have comprehensive and nimble influenza surveillance.

  • If the infection is indirect linked to dairy cattle (by finding the dairy cattle strain in the person), it shows again that the US has to take dairy cattle infections more seriously. H5N1 in dairy cattle should be containable with short term but aggressive movement restrictions, testing and infection control measures – short term pain for long term gain. Fewer infected farms are being reported lately, which is great, but it’s still spreading across the country. The longer the outbreak lasts, the greater the chances of interspecies spillover and for the virus to adapt to a new host.
  • If the infection is somehow linked to wild birds, that’s a tougher situation, since controlling the virus in wildlife populations is challenge, to put it mildly.

This case was detected as part of surveillance program. That’s great, in that surveillance found something important and led to an action: an investigation of possible sources and a warning that there could be more. The not-so-great part is that few people with flu-like disease get tested at all, including for H5N1 influenza. If human-to-human spread is occurring, it could easily slip under the radar if there’s insufficient testing happening. That’s particularly true if most infected people only get mild disease, as they’re even less likely to get tested. We don’t know whether this was a lucky detection of a very rare situation, or a more common problem that’s been flying under the radar. Only more time and testing will tell us that.

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The Colorado Department of Public Health and Environment recently released information about 6 cats in the state diagnosed with H5N1 influenza. Some aspects of these cases are totally unsurprising, others raise a lot of questions.

Colorado has been hit hard by H5N1 in dairy cattle, with over 50 herds affected since the spring, but they’ve also taken a more proactive response than many areas. This report covers the 6 cats that have been identified (so far) in 2024.

Let’s start with the totally unsurprising.

One cat was from an infected dairy farm.

  • Duh. That one’s easy to explain.

Three were “known indoor/outdoor cats that hunted mice and/or small birds as prey and also spent time indoors with their owners.”

  • These aren’t too surprising either. When the virus is circulating in birds, species that prey on birds are likely to get exposed.
  • Genomic evaluation of the virus will help tell us if the strains in these cats are consistent with those circulating in local birds (as they should be), versus the slightly different strains circulating in cattle (hopefully not).

Now to the unexpected cases. These are the most interesting and important cases, and they illustrate some major gaps in our understanding and approach to this virus.

Two cats were indoor cats with no known exposure to H5N1.

  • These cats didn’t have contact with birds or dairy cattle.
  • Presumably they also didn’t have contact with any person known to have had H5N1 (as there are still few enough of those cases) or contact with high risk people like dairy or poultry farm workers, but that’s not explicitly stated.
  • I also presume the authorities took a good enough history to make sure “indoor” really meant “indoor,” since “indoor” is sometimes an aspiration for cats, not a lifestyle. (Veterinarians are all too familiar with “indoor” cats that have been hit by a car or gotten into a fight with some kind of wildlife.)

So how did two “indoor” cats get exposed to the H5N1 virus?

A few potential, but still unlikely, possibilities come to mind:

  • Close contact with aerosols from infected birds or bird feces through window screens?
  • Close contact with aerosols from infected mammals (e.g. other cats) through window screens?
  • Birds that snuck into the house?
  • Unidentified infected humans?
  • Contaminated material from outside tracked in on someone’s shoes or clothes?
  • Raw food? (Including possibly raw milk?)

The latter, in the form of raw diets, has been shown to be a risk factor in a few outbreaks in cats, so we can’t dismiss it. However, the odds of a raw diet containing meat from an infected bird in Colorado are really low. So, I think potential causes are still wide open at this point. Genomic analysis should help determine if the virus from these cats is most consistent with the strain in dairy cattle or circulating avian strains.

These cases also highlight something else: surveillance bias. If you don’t test, you don’t find. If testing is focused (or restricted to) cats with known high risk contacts, we can get into a self-fulfilling prophecy of “cats only get infected if they have risk factor X.” The two unexpected cases in indoor cats show that we might need to throw a wider surveillance net, both to find more infected cats and to understand how this virus is being spread.

The disease presentation is also important. Five of the six cats had “an initial complaint of lethargy and inappetence, followed by progressive respiratory signs in some and fairly consistent progressive neurologic signs in most.” It’s not clear how disease progressed in the sixth cat, or if it was perhaps found dead. Consider that if testing focuses on cats with neurological disease, we’ll bias ourselves to thinking that this virus always causes neurological disease. I’m not sure at this point whether H5N1 infection usually causes serious neurological disease or whether the cats with serious neurological disease are just the small subset that we test for H5N1. If those are the only cats we test (perhaps as a secondary test when the cat was a rabies suspect and has tested negative for that virus first), then we’re not going to understand the true picture.

We need better and broader surveillance. I get worried when the focus of testing is on a narrow population. Yes, it’s lower yield to test outside those known high risk groups, but when we have lots of knowledge gaps, we sometimes have to go on fishing expeditions.

What does this tell us?

  • If H5N1 is in birds or cattle, cats can get exposed.
  • H5N1 can cause serious neurological disease in cats. Maybe that occurs in a minority of infected cats, or maybe it occurs in most. We just don’t know yet.
  • Not all cats with H5N1 will have known exposure to infected dairy cattle or birds. We need to do more testing to figure out what’s happening.
  • Infections in cats seem to be rare, but can be fatal, so we need to pay attention.

The risk posed by cats to people and other animals is completely unclear at this time. Some earlier data suggested that cats could have pretty high viral loads in respiratory secretions, so I think we have to assume that infected cats pose some transmission risk. That doesn’t mean we should panic or not try to treat them, but we should make sure we use good infection control practices around suspected and confirmed cases.