Vol. VII, No. 04~ EINet News Briefs ~ January 30, 2004
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In this edition:
1. OVERVIEW OF INFECTIOUS-DISEASE INFORMATION
Below is a semi-monthly summary of Asia-Pacific emerging infectious diseases.
Asia, USA, Europe—Global collaboration urged to contain bird flu epidemic
But the ministers and officials saw no need to impose travel restrictions over the lethal H5N1 strain of avian influenza that can spread from poultry to humans, but is not known to spread between humans. "We advise careful monitoring and investigation to guard against possible human-to-human H5N1 transmission. Currently, such transmission has not been scientifically demonstrated, and travel advisories currently are not called for," the statement said. They also agreed to strengthen cooperation with regional and international organizations on joint research and the development of effective low-cost diagnostic test kits, vaccinations, and antiviral drugs.
Although experts said culling of infectious birds is the only feasible measure to stop transmission of avian influenza virus in humans, some affected countries were reluctant to cull their susceptible poultry. Shigeru Omi, the WHO's Western Pacific regional director, said, "Currently, the only feasible measure, in the absence of human vaccine and effective drugs, is culling of infectious birds and to improve personal hygiene. To stop transmission of avian influenza in humans, poultry suspected of being infected must be slaughtered." Officials said experts from the WHO, FAO and OIE would gather next week in Rome to discuss technical matters related to the avian influenza pandemic including development of vaccines.
Pan-Asia—ADB offers assistance and urges regional cooperation in fight against avian flu
"This is a regional issue, as viruses know no borders," Mr. Nag said. "We, as an institution, stand ready to assist our DMCs. If there is anything we learned from SARS, the more open we are, the more information we share, the better off we are to fight any impending health crisis." The avian flu virus could cost the region tens of billions of dollars if it is not curtailed, according to ADB's Assistant Chief Economist, Jean-Pierre Verbiest. He pointed out that chicken is a major staple food item in most Asian countries, particularly for the poorer segments of the population. "A major crisis in the chicken industry would reduce supply and push up prices, disproportionately affecting the poorer consumers," he said. "For several Asian countries, chicken is a major export. Thailand exports about 500 000 tons of broiler meat, mainly to Japan. This alone represents an annual value of about 1 billion USD, which is not negligible. A major crisis in the poultry industry would have quite a severe impact on some Asian economies, particularly on rural areas."
The SARS outbreak in 2003 revealed weaknesses in public health systems in several countries. In response, ADB approved grants amounting to 5 million USD to DMCs in public health surveillance, SARS prevention and control, public education, and improved capacity to assess the health and socioeconomic consequences of SARS. "About 800 000 USD of the money remains undisbursed and can be used immediately to assist in the fight against avian flu," says Erik Bloom, an ADB Social Protection Specialist. In addition, in June, ADB approved a request from Viet Nam to reallocate USD 6.17 million from an existing health sector loan to help the country's fight against SARS. Some of these funds can be used to counteract the new health threat.
Pan-Asia—WHO seeks to speed avian influenza vaccine development
"We are observing a possible pandemic situation, and we are trying to take precautionary measures in case significant human-to-human transmission takes place," said Klaus Stoehr, head of WHO's global influenza program. The prototype could be ready within two months, but after that more time would be needed to test its safety, for which they use ferrets, with the final step being clinical trials. Stoehr said 11 international companies had indicated that they were ready to take part in the clinical testing.
But in the meantime, the WHO was considering recommending that anybody exposed to infected chickens and other poultry be vaccinated against normal strains of influenza virus, Stoehr said. Although the normal [human] vaccine (the current triple vaccine comprising A (H1N1), A (H3N2), and B serotype strains) is no protection against avian influenza A (H5N1) serotype virus, officials hope such immunization campaigns can prevent any mixing of the human and avian viruses. WHO is particularly concerned about those taking part in the mass culling of birds in Thailand, Viet Nam, and China, because television images had shown many working without any sort of protective clothing. On 28 Jan 2004, a leading drug industry group said members would donate 220,000 doses of normal influenza vaccine to fight avian influenza.
East Asia—Prevention of further cases of avian influenza in humans
WHO continues to stress the need for personal protection of these workers, who are at high risk of exposure to a virus that has demonstrated its capacity to cause severe disease and deaths in humans. Recommendations about safety measures http://www.wpro.who.int/avian/docs/recommendations.asp that should be in place before the mass destruction of poultry begins have been issued. Adherence to these recommendations will reduce the likelihood that measures aimed at preventing the further spread of H5N1 infection in poultry might lead to increased transmission of the virus to humans.
Those organizing culling operations in affected countries need to ensure that WHO recommendations are followed as strictly as possible. The recommendations spell out the appropriate personal protective equipment, which includes goggles and preferably N95 respirator masks, as well as specific types of protective clothing that can be either disinfected or discarded after use. Frequent handwashing is strongly recommended. WHO also recommends that effective antiviral drugs be readily available for the treatment of suspected H5N1 respiratory infections in cullers and farm workers.
N95 masks and prophylactic treatment with antiviral drugs were used to protect thousands of poultry workers and cullers during an outbreak of highly pathogenic H7N7 avian influenza in the Netherlands in 2003. During that outbreak, nearly 30 million poultry were destroyed. Although avian influenza virus caused mild illness in 83 poultry workers and members of their families, the single death in that outbreak occurred in a veterinarian who was not adequately protected.
Laboratory characterization of several viruses from humans and different species of birds has helped to compare H5N1 viruses taken from infected birds and humans in January 2004 with viruses obtained from birds several months ago. Results indicate that the virus now causing severe disease in poultry and some humans has been circulating in parts of Asia for longer than initially presumed. Up to now, laboratories in the WHO network have analyzed viruses from the current outbreaks made available by Cambodia, Japan, South Korea, and Viet Nam. Viruses from the outbreaks in Indonesia , Laos, and Thailand are expected to be available for analysis soon.
East Asia—Spread of avian influenza and migratory birds
While chickens and other domesticated fowl succumb easily to avian influenza, migratory birds are hardier and can be infected for long periods and travel great distances while showing few ill effects. The wildfowl deaths here appear to be another ominous sign of the virulence of the epidemic that scientists now fear. Pakistan announced Monday that chickens there had been infected with a mild strain of bird flu. Chickens have reportedly been dying from a mysterious illness in Myanmar , Bangladesh , and Saudi Arabia. Environmentalists here warned against trying to cull wild birds or eliminate their habitats, saying that it would not be possible to cull enough wild birds to stamp out the disease, but that a cull could endanger populations of rare species.
South Korea, Japan, Vietnam, Cambodia, Thailand and Indonesia have previously confirmed cases of type A influenza virus strain H5N1, while Taiwan (H5N2) and Pakistan (H7) have reported different, milder strains. Dr. Yeoh Eng-kiong, Hong Kong 's secretary of health, welfare and food, said he had asked officials to step up their testing of migratory birds there. On 19 Jan 2004 a single peregrine falcon was found dead near a residential development at Gold Coast, New Territories, Hong Kong. The bird carcass was submitted for laboratory testing and was found to be positive for avian influenza virus subtype H5N1. An intensive monitoring and surveillance system on all poultry farms and an extensive wild bird viral surveillance system is in place.
Two Hong Kong residents who visited their ancestral hometown in southern China early last year fell ill with avian influenza on their return, and 6 of the 14 countries bordering China or just off its shores have reported bird flu. Farmers in Thailand and Vietnam have described seeing the first cases in late October and in November, consistent with the arrival of migratory birds.
East Asia—Avian influenza A (H5N1) virus may have become more virulent
China confirmed on 27 Jan 2004 that avian influenza had killed ducks in southern Guangxi province, making it the tenth place in Asia to be afflicted with a disease that has killed eight people in the region in the last few weeks. "H5 serotype viruses are generally less fatal to ducks, so it is uncommon for so many ducks to die. This means this particular strain of avian influenza virus has become more virulent," said virologist Leo Poon from the University of Hong Kong. "This means it can cause extensive deaths in poultry, and this may in turn increase the chance of more people contracting it (if they come in direct contact with sick birds)."
Avian influenza A (H5N1) virus has devastated poultry populations wherever it has appeared, and the greatest fear is that the avian influenza A (H5N1) virus might recombine with human influenza and unleash a pandemic. Avian influenza A (H5N1) virus first jumped from chicken to human in 1997 in Hong Kong, infecting 18 people and killing six of them. Experts considered ducks to be the original host of the H5N1, although the waterfowl were usually not affected by the virus. Scientists said they could not rule out the possibility that the new, more virulent avian influenza strain might make human-to-human transmission less difficult. Although the virulence of the current strain indicates the virus has mutated, experts were divided over whether the vaccine used in Hong Kong and parts of mainland China to inoculate chickens against avian influenza is still useful. The vaccine is derived from the milder H5N2 virus.
China (Guangxi)—First official case of avian influenza confirmed
China (south)—WHO asks China to account for two tourist deaths in early 2003
An 8-year-old Hong Kong girl fell ill and died in southeast China's Fujian province in February 2003 while visiting her family. Her father died 12 days later after returning to Hong Kong, and post-mortem specimens showed he had come down with the H5N1 strain of the bird flu virus, which has claimed ten lives in Vietnam and Thailand. The WHO last week asked the Chinese health authorities for more details about this case, although it has warned about making any premature link between the deaths and the current bird flu outbreak.
China earlier this week confirmed bird flu had been discovered at a duck farm near its border with Viet Nam. Suspected cases of bird flu have also been detected in central China 's Hubei and Hunan provinces. Local officials said those cases have been provisionally confirmed as bird flu. February 2003's two deaths are the only recent bird flu-related fatalities linked to China that the WHO knows about. The WHO received relatively little attention because China, Hong Kong, and eventually the rest of the world soon became preoccupied with the outbreak of SARS.
China (south)—WHO Update of probable and laboratory-confirmed SARS cases
A third person, a 35-year-old businessman, fulfils the WHO laboratory case definition for probable SARS described in “WHO SARS Reference and Verification Laboratory Network: Policies and Procedures in the Inter-Epidemic Period”. He has tested positive for SARS-CoV infection at a national reference lab in China and on preliminary serological tests performed by WHO SARS International Reference and Verification Network laboratories in Hong Kong. He was discharged from hospital on 21 Jan 2004. As with the 32-year-old television journalist with laboratory-confirmed SARS-CoV infection, none of the known contacts of the 20-year-old woman or the 35-year-old man have developed a SARS-like illness. All of the health care workers attending these patients have remained well. These cases highlight the need for continued vigilance and epidemiological enquiry as to the source of infection.
Serological test results in non-epidemic periods should be interpreted with some caution. False positive test results for SARS-CoV can result from current or past infection with other human or animal coronaviruses. Laboratory investigations resulting in positive tests for SARS-CoV should therefore be interpreted in the context of the clinical and epidemiological findings before any large-scale public health action is initiated. For these reasons, WHO recommends independent verification of positive results reported by national reference laboratories in one or more WHO SARS Reference and Verification Network laboratories during the inter-epidemic period.
Surveillance for people with fever and respiratory illnesses has been intensified in Guangdong and other provinces of China since the SARS epidemic. It is likely that people with respiratory illness will be investigated for SARS over the coming weeks, as symptoms of SARS resemble those of several other respiratory diseases, including many that are more frequent during the winter. These recent cases show that surveillance enhancement in China is working.
A joint team of WHO and Chinese experts has been investigating possible sources of infection. There is some circumstantial evidence that the waitress was infected from contact with Himalayan palm civets. Samples collected from cages that housed civets at the restaurant where the waitress worked have tested positive for traces of the SARS-CoV. However, evidence that civets transmit SARS-CoV to humans remains inconclusive. As the period of observation among contacts of the two confirmed and one probable case of SARS has ended with no additional cases, these events are not considered a global public health threat.
China ( Guangdong )—WHO clarification on recent SARS investigation
The joint mission, from 9 to 16 Jan 2004, did not yield a definite source of infection in any of the cases, and the investigation continues. Still, there were several intriguing findings, including some pertaining to possible animal reservoirs of the SARS coronavirus. Some media reports have oversimplified these findings, WHO said. WHO experts took samples from cages that housed civet cats at an animal market as well as the restaurant where the waitress worked. A number of these samples tested positive for traces of the SARS coronavirus. This would add to recent studies by scientists in Guangdong and Hong Kong that point to the civet cat as a reservoir of the SARS coronavirus. However, it is still unclear exactly whether or how civets transmit the SARS coronavirus to humans. It is also possible that other animal species are reservoirs and may be able to transmit the SARS coronavirus, but these species have not been conclusively identified so far. Much more study needs to be done on animal reservoirs of the SARS coronavirus, and WHO encourages China and the international community to fund and conduct such research. So far, there is no indication as to what caused the infection in the first case, the television producer, and in the third case, the businessman.
There is no conclusive evidence so far that these three cases represent a "milder" disease or a new strain of SARS. The three patients have displayed milder symptoms than some of the more severe cases in the 2003 outbreak; however, these are only three cases, and do not represent the spectrum of cases seen in 2003. There were relatively mild cases during the 2003 outbreak as well. These three people are young, and it was seen in 2003 that many younger patients recovered faster.
Bangladesh (Rajbari)—Undiagnosed deaths—disease spreads fear and grief
But experts have said the disease, which produces high fever, headache, vomiting, and spells of unconsciousness, is like nothing they have seen. Samples have been sent to the U.S. Centers for Disease Control for analysis. Dr. Jahangir Hossain, an expert at the International Center for Diarrhoeal Diseases Research, Bangladesh, said the "symptoms suggest the disease could be encephalitis." A doctor at a hospital in Goalando village said the worst of the outbreak might be over. Village school head master Habibur Rahman said the disease had spread fear. "Primary schools have been closed, and attendance in higher schools has dropped sharply since the outbreak of the unknown disease," he said.
Authorities believe it is not the bird flu sweeping across Asia. There were only a few poultry farms in Goalando and no poultry disease have been reported in Bangladesh. The Bangladesh Poultry Industries Association said checks had confirmed no bird flu in Bangladesh .
Russia (Karachayevsk-Cherkessia)—30 people contract hepatitis A in one village
Russia (Udmurtia)—Predicted increase in hemorrhagic fever with renal syndrome (HFRS)
USA --Low perceived risk of avian influenza
The World Health Organization has warned that the spread of the avian influenza to poultry in Japan, South Korea, Cambodia, Taiwan, Indonesia, Pakistan, Laos, and most recently China could result in an epidemic rivaling the 2003 SARS outbreak. Dr. Gerberding said the CDC was working with two other WHO laboratories to develop a human vaccine for the current Asian strain of avian influenza viruses. The latest avian influenza virus strain exhibited sequence differences form the strain that killed six people in Hong Kong in 1997 and 1998.
CDC said it had told doctors to check whether patients with flu symptoms had traveled to Asia . Imported exotic birds were being quarantined. "Right now the risk here appears to be very low, but we are taking a number of steps, because this could be a very serious problem if the epidemic in Asia is not contained," Dr. Gerberding said.
USA ( Washington, Idaho )—BSE (Mad Cow Disease) Update
Animal Plant Health Inspection Service (APHIS) has focused tracing efforts on finding the significant animals; those that were possibly exposed to the same feed source as the index cow. At this time, all of the animals that were imported from the same herd of origin in Canada as the index cow are being treated as significant animals. APHIS is using all tools available to identify specific significant animals, including all available identification methods and even bio-forensic testing if necessary. Since BSE is not a contagious disease spread through animal contact, these efforts can be focused on finding the individual significant animals. There is no scientific reason to restrict movements of entire herds or anything more than a group of potential significant animals. Once an animal in a herd is confirmed not to be a significant animal, it will be removed from the hold order. This will decrease the impact on individual producers and help streamline the investigation to keep the focus on the individual significant animals as necessary.
Senior U.S. government officials are continuing talks with trading partners and this week are meeting with officials in Japan, the Philippines, Hong Kong and South Korea to discuss BSE related issues. Specific trade information can be found at http://www.aphis.usda.gov/lpa/issues/bse/bse_trade_ban_status.html
Additional information on BSE can be obtained by visiting the USDA website at: http://www.usda.gov/BSE
Past BSE updates can be viewed at: http://www.aphis.usda.gov/ .
USA-Canada—BSE (Mad Cow Disease)—Need for joint process
USA ( Texas )—Targeted cattle TB testing reveals infected dairy herd
"Targeted, intensive herd testing is a major component of Texas' plan for regaining our cattle TB-free ranking, which was downgraded in 2002. Finding an infected herd this early in the testing effort indicates we are on the right track," said Dr. Bob Hillman, Texas' state veterinarian and executive director for the TAHC. He assured consumers that milk from the infected herd is safe to drink, because the required, routine pasteurization kills TB bacteria. Dr. Hillman explained that, in late December 2003, the Hamilton County dairy was quarantined by the TAHC after a number of animals reacted to TB skin tests. TAHC veterinarians collected tissue from several of the dairy animals and forwarded the samples for confirmation testing to the National Veterinary Services Laboratory (NVSL) in Ames, Iowa. "Lab results in mid-January 2004 confirmed the preliminary diagnosis, and we are working with the dairy owner to determine the most appropriate way to deal with the infected herd," he said.
Dr. Hillman said similar testing is underway in California, New Mexico, and Michigan—other states that have lost their TB-free ranking. An infected herd also was confirmed in Arizona in mid-January 2004. "Most often, the first case of cattle TB in a state is detected at slaughter, when meat inspectors examine carcasses and collect tissues for laboratory testing from potentially infected animals," said Dr. Hillman. "This is an effective method for routine surveillance. However, because of the resurgence of TB in Texas dairy and seedstock herds during the past few years, a more aggressive surveillance program was needed to supplement the slaughter surveillance program and identify infected herds quickly."
Influenza Update—Summary of global influenza surveillance (to 10 January 2004 )
In Viet Nam there have been 5 laboratory-confirmed cases of infection with A(H5N1) virus. All have died. On 6 January, WHO announced influenza pandemic preparedness Phase 0 Level 2. Several countries have reported outbreaks of highly pathogenic influenza A(H5N1) in poultry. This is of great concern as frequent transmission of avian influenza viruses to humans increases the possibility for genetic reassortment with circulating human influenza strains and the possibility of a new influenza pandemic caused by such reassortant viruses. A WHO team has been sent to Viet Nam to investigate the outbreaks and WHO Collaborating Centres for Reference and Research on Influenza and some national reference laboratories are conducting antigenic and genetic analysis of the H5N1 viruses isolated from human and birds during the recent outbreaks in Asia . Results will guide WHO in preparing prototype viruses for pandemic vaccine production and providing diagnostic test kits for H5N1 viruses to national influenza centres.
Reports from individual countries:
Emerging Infectious Diseases (EID)—Special SARS issue
For further information, please see: http://www.cdc.gov/ncidod/eid/
Day Care-—Related Outbreaks of Rhamnose-Negative Shigella sonnei—Six States, June 2001–March 2003
For more information, please see: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5303a5.htm
Measles Outbreak Associated with an Imported Case in an Infant—Alabama , 2002
For more information, please see: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5302a3.htm
Human Death Associated with Bat Rabies—California, 2003
For more information, please see: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5302a4.htm
Avian Influenza—Latest information on the recent Influenza A (H5N1) outbreak:
The latest information from CDC: http://www.cdc.gov/flu/avian/index.htm
CDC SARS Guidance updated:
For further information, please see: http://www.cdc.gov/ncidod/sars/updatedguidance.htm
The Institute Of Medicine: Learning from SARS: Preparing for the Next Disease Outbreak
In response to the SARS epidemic and its lingering consequences, the Institute of Medicine 's Forum on Microbial Threats convened a scientific workshop in the fall of 2003 to consider the lessons that might be drawn from the origin, spread, and eventual control of the first outbreak. “Learning from SARS: Preparing for the Next Outbreak” presents an overview of the workshop's proceedings, including presentations from the workshop and an overall summary and assessment of the issues that were raised. Separate papers address topics including the response to SARS by public health systems within individual countries; the biology of the SARS coronavirus and related coronaviruses in animals; the economic and political fallout of the SARS epidemic; quarantine law and other public health measures that apply to combating infectious diseases; and the role of international organizations and scientific cooperation in halting the spread of SARS. Together these materials provide an illuminating survey of findings from last year's epidemic, along with an assessment of what might be needed in order to contain any future outbreaks of SARS or other emerging infections. The summary is currently available online at www.nap.edu. For more information, please contact Katherine Oberholtzer at firstname.lastname@example.org.
International Conference on Emerging Infectious Diseases
International Conference on Women and Infectious Diseases
WHO launches plan to jointly fight TB and HIV
A key element will be to rapidly expand voluntary HIV testing and counseling in TB programmes, with the aim of identifying and referring more than half a million TB patients who are HIV positive for ARV treatment in the next two years. With additional training for health workers, TB programmes will also assist in HIV prevention, ARV distribution and patient care.
TB case-finding will also be intensified in high HIV prevalence settings by introducing screening and testing for TB into HIV/AIDS service delivery points.
The launch of the “Interim Policy on Collaborative TB/HIV Activities” guidelines coincides with the fourth round call for proposals by the Global Fund to Fight AIDS, TB and Malaria. The deadline for submissions is April 2004. The interim policy will enhance proposals which address the dual epidemic of TB and HIV. Already, the Global Fund has committed US$ 2.1 billion over two years to programmes in 120 countries. Forty million people are currently infected with HIV, and 5 million more are infected every year. According to WHO, one third of the world's population is now infected with the TB bacillus, with more than 8 million people developing the active disease and two million dying of it each year.
Toolkit for HIV prevention among mobile populations
The Chinese version of “Toolkit for HIV prevention among mobile populations” is intended for managers and implementers of HIV prevention programs in locations where there is an association between mobility and HIV vulnerability. It outlines how HIV transmission can be prevented among mobile people as well as among people who live in stable communities affected by mobility. For these program managers, the toolkit presents useful guidelines that will help them to ensure that all aspects of effective HIV prevention programs are occurring in their location. Program managers may find it helpful to become part of a network of HIV prevention workers in their own country. These types of assistance are available in each country of the Greater Mekong Subregion (GMS), through national AIDS programs and HIV prevention programs designed to address the associations between mobility and HIV vulnerability.
The Chinese version of this publication can be downloaded at: http://www.hiv-development.org/publications/Tool-Kit_cn.htm
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