Mandy Cohen, who led North Carolina’s response to the COVID-19 pandemic, is facing her first major test as director of the federal Centers for Disease Control and Prevention — rising concerns about the spread of avian influenza.

Cases of H5N1, a strand of what is popularly known as bird flu, have been confirmed in North Carolina and nine other states, affecting more than 80 herds of dairy cattle since March. The outbreak has led to a handful of human infections; at least three farm workers in Texas and Michigan contracted the virus through exposure to sick cows.

Although the exact origin of the outbreak is unknown, the CDC believes it was caused by cows ingesting “feed contaminated with feces from wild birds” that were infected with the virus. Hundreds of thousands of animals in the Southern Hemisphere have died after being exposed to H5N1, which is carried by migratory birds that can carry the virus without getting as sick.

There have been no documented cases of avian influenza spreading from person to person, but that could change as the virus evolves. On June 5, the World Health Organization reported that a new strand, H5N2, had been linked to the death of a Mexico City man who had no known exposure to infected livestock.

Cohen was appointed last July to run the CDC. Before that, she served as secretary of the N.C. Department of Health and Human Services from 2017 to 2021. She addressed on June 6 the possibility of the H5N1 outbreak becoming an epidemic during her participation in the Association of Health Care Journalists’ annual conference in Manhattan.

“What we’re seeing right now is different than what we were experiencing when we first experienced COVID,” she said. “Avian flu is something we’ve been studying and preparing for for decades, as opposed to COVID, which is a completely novel virus: … we did not have tests, we did not have treatment, we did not have vaccines.”

Using COVID tools

The CDC is better equipped to handle H5N1, according to Cohen. She said the agency has tests that can detect it, antiviral drugs to treat infection and “multiple vaccine candidates waiting in the wings.”

“What is also different in this moment are tools that we built for COVID, we’re using for avian things — like our ability to get real time information about what’s happening in every emergency room in the country,” Cohen said. She added that 90 percent of hospitals provide the agency with real-time data that help scientists spot “unusual patterns” in virus cases.

North Carolina’s syndromic surveillance system, NC DETECT, tracks people who report to emergency departments complaining of flu-like illnesses, among other symptoms. The system played a major role during the pandemic of feeding information to state and federal officials in tracking the progress of COVID along with flu.

Cohen said wastewater monitoring systems created to track the spread of the coronavirus are now being used to map cases of avian influenza.

In North Carolina, DHHS’ wastewater tracking system aggregates data from dozens of sewage sites across the state, keeping tabs on the average number of virus particles per person. According to the DHHS website, the system collects wastewater samples twice per week, then performs laboratory analysis to determine the amount of virus present.

While wastewater monitoring systems were used to track COVID, they can be tweaked to track other diseases where people shed virus in their feces, such as influenza.

Cohen also said CDC staff are using a “beefed-up genomic program” to see “how the virus is changing and how we might need to step up our response.”