I'm glad this is on the YLE radar. I'm not psychologically or physically prepared as a primary doc to do this all over again... but I agree this is different/potentially better in a lot of ways. However, a future mutant does have the potential for higher mortality rates than we saw with Covid.
The WastewaterScan website is amazing, and is actually helping me game out which viruses I might be seeing in my practice. URI right now near Philly? Probably metapneumovirus. GI bug? Probably rotavirus or norovirus, based on the sewage analysis downstream.
And at the risk of being self-referential I'll include a link to a post I did last week about H5N1 from my primary care angle. Always appreciate your guidance, and I hope this H5N1 continues to be a scenario 2 or lower.
Good question. These wastewater sheds cannot differentiate between human and animals. It's most likely animals and behaviors like milk dumping, but we definitely need more visibility into this.
Agree, though it occurs to me that a minimal volume of the animal waste of interest is deposited in municipal sewer system. I admit, this is my conjecture.
"My understanding is the Department of Health and Human Services (HHS) has proposed a new rule requiring hospitals to report data outside of an emergency. The new rule’s proposed start date is October 1.
"As someone who is at higher risk should I get Covid, I would encourage passage of continuing the rule to have hospitals report. Weekly, I check the CDC figures to see what precautions I have to take. It has been such a blessing with the low Covid numbers the last couple-three weeks to feel free not to mask all the time. Let's not go backward or pretend we do not have to think about Covid anymore. We also need the early warning should a variant take off and we have to take emergency steps again as a nation. For me personally, it is one important way I can keep myself and my family safe."
I followed the link provided to comment on the Covid reporting requirements for hospitals. The page was about Medicare and Medicaid payment rules. I did not see anything about Covid in any of the rule changes. Is this the correct place to comment?
I believe the way this works is that hospitals are only paid by Medicare if they "follow the rules". Thus they won't be reimbursed by Medicare, Medicaid, or insurance (who generally follow the Medicare approved payments), unless they continue to report covid hospitalizations.
Thanks as always Katelyn. I LOVED your "2-7% of your brainspace" guidance. That's a relief...and kinda funny, b/c who really knows what 2-7% means? :) But it surely keeps things in perspective for we lay-folk. Keep on doing!
The link works, here is the relevant part of the rules:
"Conditions of Participation Requirements for Hospitals and Critical Access Hospitals To Report Acute Respiratory Illnesses
In section X.F. of the preamble of this proposed rule, we are proposing to update the hospital and CAH infection prevention and control and antibiotic stewardship programs conditions of participation (CoPs) to extend a limited subset of the current COVID-19 and influenza data reporting requirements. These proposed reporting requirements ensure that hospitals and CAHs have appropriate insight related to evolving infection control needs. Specifically, CMS is proposing to replace the COVID-19 and Seasonal Influenza reporting standards for hospitals and CAHs with a new standard addressing acute respiratory illnesses to require that, beginning on October 1, 2024, hospitals and CAHs would have to electronically report information about COVID-19, influenza, and RSV. CMS is proposing that outside of a public health emergency"
Regarding wastewater numbers…many of our dairy farms are in rural areas that do not tie into public wastewater systems. In my region of the NY Finger Lakes where I once worked as an Ag Extension Agent, I can’t think of a single dairy farm that does not use on site agricultural waste management, including milk dumping. Of course, none of the dairies in our area are as huge as the ones in the Midwest and Texas, so they might have a different relationship with their local wastewater treatment facilities. When looking at wastewater data, how can we be confident that the collection data includes rural farms?
Thank you for sharing your perspective on pasteurized milk. It's important to consider the historical context behind pasteurization, which was indeed implemented in response to the industrialization of dairy milk production. It's true that pasteurization processes can involve the commingling of milk from multiple sources, potentially leading to issues such as the presence of HPAI DNA.
However, it's also worth noting that raw milk produced for human consumption typically comes from single dairies, reducing the risk of commingling. Additionally, small raw milk dairies often have different sourcing practices, minimizing the likelihood of exposure to certain contaminants.
Regarding HPAI, current scientific understanding suggests that it lacks the genetic markers necessary to infect humans. While precautions such as state-imposed quarantine areas are in place, trust remains a significant concern among dairy farmers.
Furthermore, both raw milk and breastmilk have the capacity to pass on antibodies to viruses previously encountered by the animal or person. This underscores the complex interplay between food safety, public health, and the natural immune response.
It's essential to approach discussions around food safety with an open mind and a willingness to engage with diverse perspectives and scientific evidence. Thank you for contributing to the conversation.
Thanks for this update, very useful! With the news on spread of H5N1 thru unpasteurized milk, I have the same question as some other commenters about whether to avoid US-produced raw milk cheese? And if so, how long to keep avoiding it after the current rise in avian flu infections of cattle subsides?
It would be good to address this, since while drinking unpasteurized milk is pretty rare in the US, cheese made from unpasteurized milk is widely sold. (In cheese shops & fancy groceries, anyhow).
What about raw, unpasteurized cheese that has undergone aging?
FDA regulations require a 60-day aging process for unpasteurized cheese, as the aging process may inactivate some bacteria and viruses. However, these regulations are not safety standards, and some pathogens may survive the 60-day aging process. Because we have limited research and information on whether HPAI viruses can be transmitted through raw milk or raw milk products, such as cheese, the FDA recommends that industry does not manufacture or sell raw milk or raw/unpasteurized milk cheese products made with milk from cows showing symptoms of illness, including those infected with HPAI viruses or exposed to those infected with avian influenza viruses, even if the cheese will undergo the 60-day aging process. By exposure, we generally mean cattle located on a premises with cattle with suspected or confirmed HPAI A (H5N1). Given the variety of premises sizes and the potential for state requirements, the FDA recommends producers consult with state regulatory officials and their veterinarian for further guidance. Accordingly, the FDA recommends that milk from exposed, asymptomatic cattle only be used for pasteurized milk and milk products, whether for human or animal feed channels. The FDA recommends that premises test for HPAI in pooled milk prior to resuming commerce in unpasteurized dairy products following apparent resolution of illnesses on the premises.
Unpasturized milk cheese isn’t permitted in Canada so for now, all is ok. My problem is that I have a September trip to France where there is a lot of these cheeses (yummmmm!!!!) there… and I haven’t read anything about contaminated milk, or cows in Europe… I’ll have to wait and see I guess!
This is probably a stupid question, but on the form for public comment on Covid reporting, I can't figure out which option to select in the drop-down menu for "what is your comment about"? Could someone inform me?
I spent a ridiculous amount of time on this, as long as it took to write my comment or more! I think it means 'who are you representing' more than 'what is your comment about'. I don't think it's a stupid question at all!! I ended up with "individual" as I am retired from anything health related...
Thank you! I submitted a comment at the link you suggested regarding surveillance. The relevant part in the document was buried, but I found it by reading through the whole thing. At first, I thought it might not be the correct document, because it seemed to be about a lot of other issues.
Thanks for this, but could you please clarify one thing. In one part of the post, you indicate that individuals should avoid touching wild birds to prevent contracting bird flu, but at another point, you seem to suggest that this may only apply to dead birds. Which is it? The reason I ask is that I help to on a wildlife rescue helpline, and we frequently have callers that we advise to handle injured or orphaned birds. Typically, we suggest that they wear gloves, which probably mitigates the problem. But it would be helpful to know if it is wild birds in general or dead, wild birds that are the potential problem. Thanks
Thank you so much for this update, Dr. Jetelina. I hope an H5N1 pandemic doesn’t breakout, especially now, following closely on the heels of the Covid-19 one. I still have a stockpile of N95/KN95 masks and will be in line for an H5N1 specific vaccine. But, as you note, a lotpeople will die, and I hope we can avoid this happening from the get go. Thanks, as always, for keeping us informed.
I'm glad this is on the YLE radar. I'm not psychologically or physically prepared as a primary doc to do this all over again... but I agree this is different/potentially better in a lot of ways. However, a future mutant does have the potential for higher mortality rates than we saw with Covid.
The WastewaterScan website is amazing, and is actually helping me game out which viruses I might be seeing in my practice. URI right now near Philly? Probably metapneumovirus. GI bug? Probably rotavirus or norovirus, based on the sewage analysis downstream.
And at the risk of being self-referential I'll include a link to a post I did last week about H5N1 from my primary care angle. Always appreciate your guidance, and I hope this H5N1 continues to be a scenario 2 or lower.
https://mccormickmd.substack.com/p/bird-flu-as-seen-from-a-primary-care
thanks for the update! just to clarify— we believe the wastewater is picking up animal cases, right? NOT unchecked human spread
Good question. These wastewater sheds cannot differentiate between human and animals. It's most likely animals and behaviors like milk dumping, but we definitely need more visibility into this.
Agree, though it occurs to me that a minimal volume of the animal waste of interest is deposited in municipal sewer system. I admit, this is my conjecture.
Comment posted:
"My understanding is the Department of Health and Human Services (HHS) has proposed a new rule requiring hospitals to report data outside of an emergency. The new rule’s proposed start date is October 1.
"As someone who is at higher risk should I get Covid, I would encourage passage of continuing the rule to have hospitals report. Weekly, I check the CDC figures to see what precautions I have to take. It has been such a blessing with the low Covid numbers the last couple-three weeks to feel free not to mask all the time. Let's not go backward or pretend we do not have to think about Covid anymore. We also need the early warning should a variant take off and we have to take emergency steps again as a nation. For me personally, it is one important way I can keep myself and my family safe."
I followed the link provided to comment on the Covid reporting requirements for hospitals. The page was about Medicare and Medicaid payment rules. I did not see anything about Covid in any of the rule changes. Is this the correct place to comment?
I did also and checked OTHER, and then proceeded to make my comment. Hopefully it will be reviewed and taken seriously.
I believe the way this works is that hospitals are only paid by Medicare if they "follow the rules". Thus they won't be reimbursed by Medicare, Medicaid, or insurance (who generally follow the Medicare approved payments), unless they continue to report covid hospitalizations.
Thanks as always Katelyn. I LOVED your "2-7% of your brainspace" guidance. That's a relief...and kinda funny, b/c who really knows what 2-7% means? :) But it surely keeps things in perspective for we lay-folk. Keep on doing!
Beating the same drum, but H5N1 is extremely common in Asia and has been around for decades. Let's reach out to them for advice!
The link works, here is the relevant part of the rules:
"Conditions of Participation Requirements for Hospitals and Critical Access Hospitals To Report Acute Respiratory Illnesses
In section X.F. of the preamble of this proposed rule, we are proposing to update the hospital and CAH infection prevention and control and antibiotic stewardship programs conditions of participation (CoPs) to extend a limited subset of the current COVID-19 and influenza data reporting requirements. These proposed reporting requirements ensure that hospitals and CAHs have appropriate insight related to evolving infection control needs. Specifically, CMS is proposing to replace the COVID-19 and Seasonal Influenza reporting standards for hospitals and CAHs with a new standard addressing acute respiratory illnesses to require that, beginning on October 1, 2024, hospitals and CAHs would have to electronically report information about COVID-19, influenza, and RSV. CMS is proposing that outside of a public health emergency"
Regarding wastewater numbers…many of our dairy farms are in rural areas that do not tie into public wastewater systems. In my region of the NY Finger Lakes where I once worked as an Ag Extension Agent, I can’t think of a single dairy farm that does not use on site agricultural waste management, including milk dumping. Of course, none of the dairies in our area are as huge as the ones in the Midwest and Texas, so they might have a different relationship with their local wastewater treatment facilities. When looking at wastewater data, how can we be confident that the collection data includes rural farms?
Thank you for sharing your perspective on pasteurized milk. It's important to consider the historical context behind pasteurization, which was indeed implemented in response to the industrialization of dairy milk production. It's true that pasteurization processes can involve the commingling of milk from multiple sources, potentially leading to issues such as the presence of HPAI DNA.
However, it's also worth noting that raw milk produced for human consumption typically comes from single dairies, reducing the risk of commingling. Additionally, small raw milk dairies often have different sourcing practices, minimizing the likelihood of exposure to certain contaminants.
Regarding HPAI, current scientific understanding suggests that it lacks the genetic markers necessary to infect humans. While precautions such as state-imposed quarantine areas are in place, trust remains a significant concern among dairy farmers.
Furthermore, both raw milk and breastmilk have the capacity to pass on antibodies to viruses previously encountered by the animal or person. This underscores the complex interplay between food safety, public health, and the natural immune response.
It's essential to approach discussions around food safety with an open mind and a willingness to engage with diverse perspectives and scientific evidence. Thank you for contributing to the conversation.
This blog post is well researched and explains the mechanisms behind why HPAI is not considered a food-borne pathogen. https://www.colemanscientific.org/blog/2024/4/7/where-is-the-evidence
Thanks for this update, very useful! With the news on spread of H5N1 thru unpasteurized milk, I have the same question as some other commenters about whether to avoid US-produced raw milk cheese? And if so, how long to keep avoiding it after the current rise in avian flu infections of cattle subsides?
It would be good to address this, since while drinking unpasteurized milk is pretty rare in the US, cheese made from unpasteurized milk is widely sold. (In cheese shops & fancy groceries, anyhow).
What about cheese made from unpasturised milk? I suspect there might be a risk here too.
I suspect you're right based on what I read. From the FDA: https://www.fda.gov/food/milk-guidance-documents-regulatory-information/questions-and-answers-regarding-milk-safety-during-highly-pathogenic-avian-influenza-hpai-outbreaks#rawmilkcheese
What about raw, unpasteurized cheese that has undergone aging?
FDA regulations require a 60-day aging process for unpasteurized cheese, as the aging process may inactivate some bacteria and viruses. However, these regulations are not safety standards, and some pathogens may survive the 60-day aging process. Because we have limited research and information on whether HPAI viruses can be transmitted through raw milk or raw milk products, such as cheese, the FDA recommends that industry does not manufacture or sell raw milk or raw/unpasteurized milk cheese products made with milk from cows showing symptoms of illness, including those infected with HPAI viruses or exposed to those infected with avian influenza viruses, even if the cheese will undergo the 60-day aging process. By exposure, we generally mean cattle located on a premises with cattle with suspected or confirmed HPAI A (H5N1). Given the variety of premises sizes and the potential for state requirements, the FDA recommends producers consult with state regulatory officials and their veterinarian for further guidance. Accordingly, the FDA recommends that milk from exposed, asymptomatic cattle only be used for pasteurized milk and milk products, whether for human or animal feed channels. The FDA recommends that premises test for HPAI in pooled milk prior to resuming commerce in unpasteurized dairy products following apparent resolution of illnesses on the premises.
Unpasturized milk cheese isn’t permitted in Canada so for now, all is ok. My problem is that I have a September trip to France where there is a lot of these cheeses (yummmmm!!!!) there… and I haven’t read anything about contaminated milk, or cows in Europe… I’ll have to wait and see I guess!
This is probably a stupid question, but on the form for public comment on Covid reporting, I can't figure out which option to select in the drop-down menu for "what is your comment about"? Could someone inform me?
I spent a ridiculous amount of time on this, as long as it took to write my comment or more! I think it means 'who are you representing' more than 'what is your comment about'. I don't think it's a stupid question at all!! I ended up with "individual" as I am retired from anything health related...
Ah, that makes a lot more sense! Thank you!!
Thank you! I submitted a comment at the link you suggested regarding surveillance. The relevant part in the document was buried, but I found it by reading through the whole thing. At first, I thought it might not be the correct document, because it seemed to be about a lot of other issues.
Thanks for writing this! It was very informative.
Thanks for this, but could you please clarify one thing. In one part of the post, you indicate that individuals should avoid touching wild birds to prevent contracting bird flu, but at another point, you seem to suggest that this may only apply to dead birds. Which is it? The reason I ask is that I help to on a wildlife rescue helpline, and we frequently have callers that we advise to handle injured or orphaned birds. Typically, we suggest that they wear gloves, which probably mitigates the problem. But it would be helpful to know if it is wild birds in general or dead, wild birds that are the potential problem. Thanks
Thank you so much for this update, Dr. Jetelina. I hope an H5N1 pandemic doesn’t breakout, especially now, following closely on the heels of the Covid-19 one. I still have a stockpile of N95/KN95 masks and will be in line for an H5N1 specific vaccine. But, as you note, a lotpeople will die, and I hope we can avoid this happening from the get go. Thanks, as always, for keeping us informed.