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EINet Alert ~ Nov 03, 2006
*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Global: WHO to report on ethical issues in pandemic planning
- Italy: Culling of hundreds of wild ducks near Grosseto after report of avian influenza
- Viet Nam: When avian flu control meets cultural resistance
- USA (New York): Low pathogenic avian influenza H5N1 detected in wild birds
- Egypt: Seventh fatal human case of avian influenza H5N1 infection
- Zimbabwe: Suspected avian influenza in ostriches
- Avian/Pandemic influenza updates
- Seasonal Influenza
- Pandemic Influenza: CIDRAP-authored overview
- Nonpharmaceutical Influenza Mitigation Strategies, US Communities, 1918–1920 Pandemic
- Anti-influenza viral prodrug oseltamivir is activated by carboxylesterase HCE1 and the activation is inhibited by anti-platelet agent clopidogrel
- Human cases of influenza A(H5N1) infection, in eastern Turkey, Dec 2005 - Jan 2006
- WHO report calls H5N1 vaccine stockpiling premature
- Emergence and predominance of an H5N1 influenza variant in China
- Third International Bird Flu Summit
- International agencies join forces to advise OIE animal health and welfare fund
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 256 (152).
Avian influenza age & sex distribution data from WHO/WPRO (as of 10/16/06): http://www.wpro.who.int/sites/csr/data/data_Graphs.htm.
Global: WHO to report on ethical issues in pandemic planning
The WHO report will stress the need to have broad public involvement in decisions and to base choices on an accurate understanding of the pandemic. WHO is not aiming for "a single set of prescriptions for all circumstances." Instead, everyone involved in planning will be dealing with "the need for trading off among a number of different ethical values." Capron cited several examples: the principle of utility, which stresses the need to "maximize welfare"; the principle of fairness, which emphasizes justice; the principle of liberty, which says individuals should be able to make their own choices as much as possible; and the principle of reciprocity, which says that people who contribute to the public good are owed something in return.
In response to a question about vaccine rationing, Capron said, "One of the things that emerged very strongly is the necessity for good ethics to rest on good facts." Some at the meeting challenged the assumption that children and elderly people will be at greatest risk, and suggested, he said, that health agencies may need "contingency plans depending on what the virus turns out to be like, how it behaves." In response to another question about vaccine allocation, Dr. Richard Heymann, the WHO director-general's acting special representative for pandemic flu, said the groups that will most need protection include health workers and their families along with police and fire fighters. As for journalists, Heymann said he hopes they can be protected too. "But it has to be decided by the local community and the countries," he added. "WHO just meets and makes broad recommendations and studies the issues."
Italy: Culling of hundreds of wild ducks near Grosseto after report of avian influenza
After the discovery of avian influenza 31 Oct 2006 in the Grosseto area, hundreds of animals will be put down. Reportedly, the N1 strain has been ruled out. In addition to the putting down of the wild ducks, a surveillance zone around the farm in question and surveillance, which will last for 3 weeks after the culling, will be established. In the zone, the entire bird population will once again be checked, even birds intended for use by single families. All the animals will have to be kept on the farms, prohibited from coming in or going out, including the birds, their eggs and chicks. All farms in rural zones will be under surveillance by the veterinary service. The culling of the farm-bred wild ducks will be carried out within a few days, and the disinfected bodies will be destroyed and buried. The owners of the animals culled will be reimbursed for the market value of the animals.
On 21 Sep 2006, Italy sent the following "final report" to the OIE: "The last case of avian influenza detected in wild birds dates back to 25 Feb 2006, in Puglia (Taranto province). Therefore, since the surveillance activity on the entire national territory has revealed no positive results for H5N1 virus, the event should be considered over. Furthermore, the active surveillance among domestic poultry on the national territory involved in the outbreak was intensified between 10 Feb and 5 Apr 2006. It was carried out on samples from 13 112 farms, and all gave negative results.”
Viet Nam: When avian flu control meets cultural resistance
The willingness of thousands of small farmers in Viet Nam to follow the government's orders does much to explain Vietnam's dramatic change of fortune on avian flu, from one of the countries hardest hit by the virus to one of the most successful in controlling it. The Vietnamese government is proud of those results, and international animal and human health experts have applauded its apparent success. Yet some of those experts caution, and interviews with farmers and consumers confirm, that Vietnam's continued success is not guaranteed—because it may depend on new and stricter government prescriptions that the populace may find hard to accept. "What is being talked about is trying to change really basic behavior that people have been engaged in all their lives," said Dr. Richard Brown, a WHO epidemiologist. As the H5N1 outbreak expands, planners worldwide are acknowledging that scientific and political efforts to control the virus will fail unless they are accompanied by willing cultural change.
Vietnam's success against avian flu has made the country an island of viral suppression in a sea of transmission—this year, H5N1 has recurred in Cambodia, China, Laos, Myanmar, and Thailand. And Vietnam's successful measures are stringent and strictly maintained. In Ho Chi Minh City, raising chickens in the city has been banned, and chickens raised in the countryside are inspected twice before they cross the city limits. More than 2,000 trucks pass through the checkpoints each day; if the birds' paperwork is in order, the truck carrying them is allowed to proceed along limited designated routes to slaughterhouses. If the birds do not pass inspection, they are confiscated on the spot, and taken to an incinerator.
Dr. Bui Quang Anh, the director general of the department of animal health in the agriculture ministry, pointed to the likelihood that the virus still circulates in poultry within Vietnam, and the possibility of its being carried over the Chinese border in smuggled live chickens. To counter that perceived threat, the ministry proposes strict additional prevention measures. One proposal is to permanently ban the raising of ducks, an integral component of the rice-growing economy. Another is to take poultry raising out of the hands of the backyard growers, who make up 70% of producers, and concentrate the industry in large, biosecure farms. Most controversially, for many Vietnamese, the government proposes to phase out the markets where consumers choose live birds and have them slaughtered, and substituting birds killed in a modern slaughterhouse and sold shrink-wrapped and chilled in supermarkets. The change—already instituted in Ho Chi Minh—would challenge deep-rooted food preferences, because already-dead chickens are considered less desirable. It could affect social patterns, because markets are where neighbors meet. Slaughtering and cooking chicken for ancestors is also a crucial observance during Lunar New Year.
In Vietnam's health agencies, and in the cities and villages, there are scattered signs that acceptance of anti-bird flu measures may not be complete. The 2-shot poultry vaccination campaign mandated last year inoculated approximately 160 million birds—80% of the country's total—in late 2005. But a repeat this year, meant to catch a new crop of birds, vaccinated 140 million, about 65%. And a campaign to halve the country's duck population, which stood at 60 million in 2003, has stalled at 40 million birds.
USA (New York): Low pathogenic avian influenza H5N1 detected in wild birds
The New York State Department of Environmental Conservation (DEC) announced test results which indicate that a virus found in samples collected earlier this month from wild mallard ducks in Niagara County was low pathogenic avian influenza (LPAI). LPAI has been detected several times in wild birds in North America and poses no risk to human health. The US Department of Agriculture (USDA) National Veterinary Services Laboratories (NVSL) confirmed the presence of LPAI H5N1 from 2 of 27 mallard ducks collected from the Tonawanda Wildlife Management Area in Niagara County 21 Oct 2006. This LPAI strain occurs naturally in wild birds and typically causes only minor sickness or no noticeable signs of disease in birds. These strains are common worldwide. Highly pathogenic strains of avian influenza spread rapidly and are often fatal to chickens and turkeys.
To date, USDA and US Department of Interior (DOI) have announced 12 presumptive positive and/or confirmatory test results for LPAI in 6 other states (MI, MD, PA, MT, IL and OH). In all cases, there has been no detection of Highly Pathogenic Avian Influenza (HPAI) in North America. As the expanded surveillance of wild birds for highly pathogenic avian influenza increases in the coming months, additional detections of the "North American strain" of LPAI H5N1 are expected. All suspected LPAI H5N1 detections can be viewed at: http://wildlifedisease.nbii.gov/ai/LPAITable.pdf.
To date, New York State has collected more than 845 wild bird samples for testing. No other LPAI detections have been found. Samples taken from loons and other birds found dead along Lake Ontario in recent weeks have also been tested for strains of avian influenza, but results to date have been negative. Sampling is expected to continue into February 2007 to reach a 1600-sample size goal.
Egypt: Seventh fatal human case of avian influenza H5N1 infection
A 39-year-old woman who was previously listed by WHO as Egypt's 15th H5N1 avian influenza case-patient died. She is the seventh Egyptian to die of the illness and the first fatality since May 2006. The woman is from the Nile Delta town of Samanoud, which is about 60 miles northwest of Cairo. The woman became ill Sep 30, 2006 and was hospitalized Oct 4. Her infection was confirmed 11 Oct, and she died 30 Oct. She had suffered from pneumonia and been treated with oseltamivir. Her contacts have reportedly tested negative for the virus. The WHO report said she had slaughtered and plucked about a dozen ducks after some of the flock got sick and died.
The H5N1 virus first cropped up in Egyptian poultry Feb 2006, and a series of human cases followed in Apr and May 2006. Cases in poultry resurfaced in Egypt Sep 5, 2006, when an outbreak was reported on a farm in the southern province of Sohag. Another outbreak was reported late Sep 2006 among domestic birds near Aswan, in southern Egypt. Reportedly, most commercial poultry flocks in Egypt have been vaccinated against H5N1, but only about 20% of backyard birds have been immunized. Poultry is a major source of protein in Egypt and poor families frequently breed chicken domestically in cities and rural areas to supplement their diet and income.
Zimbabwe: Suspected avian influenza in ostriches
Avian/Pandemic influenza updates
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html. Link to the report: “Influenza research at the human and animal interface”.
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Read “EMPRES WATCH: Evolution of Highly Pathogenic Avian Influenza type H5N1 in Europe: review of disease ecology, trends and prospects of spread in autumn-winter 2006”.
- OIE: http://www.oie.int/eng/en_index.htm. Basic information about the upcoming conference (20-22 Mar 2007), “Vaccination, a tool for the control of avian influenza” is available.
- US CDC: http://www.cdc.gov/flu/avian/index.htm
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html. Information on avian influenza: http://www.hc-sc.gc.ca/dc-ma/avia/index_e.html.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and journal articles.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- American Veterinary Medical Association: http://www.avma.org/public_health/influenza/default.asp. New updates: USDA expands plan for low-pathogenic avian influenza.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Very frequent news updates.
(WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; AVMA; USGS)
New Zealand. As reported during previous weeks, influenza A(H3N2) activity remained regional until week 36, then rapidly declined and was reported as sporadic.
Others. During weeks 35–40, low influenza activity was reported in Australia (A and B), Hong Kong (H1, H3 and B), Mexico (H3 and A), and USA (A and B). In week 40, Japan and Philippines reported no influenza activity.
Pandemic Influenza: CIDRAP-authored overview
Updated Oct 27, 2006 with new information on infection control, particularly mask and respirator guidance. Sections include: Agent; Laboratory Testing for Influenza; General Considerations; Historical Perspective; Pandemics of the 20th Century; Lessons from Past Pandemics; The Current H5N1 Threat; Vaccine Development; Use of Antiviral Agents; Nonpharmaceutical Interventions; Pandemic Preparedness Planning; Hospital Pandemic Preparedness Planning; Infection Control Considerations; References.
(CIDRAP http://www.cidrap.umn.edu/ )
Nonpharmaceutical Influenza Mitigation Strategies, US Communities, 1918–1920 Pandemic
Abstract: “We studied nonpharmaceutical interventions used to mitigate the second, and most deadly, wave of the 1918–1920 influenza pandemic in the United States. We conclude that several small communities implemented potentially successful attempts at preventing the introduction of influenza.”
Anti-influenza viral prodrug oseltamivir is activated by carboxylesterase HCE1 and the activation is inhibited by anti-platelet agent clopidogrel
Human cases of influenza A(H5N1) infection, in eastern Turkey, Dec 2005 - Jan 2006
Of the 4 case-patients described in the report who died, all were teenagers, while all the survivors were younger children, aged 3 to 9 years. "This reflects closely the global situation where the highest case-fatality rate (73%) has been observed in the 10-19-year age group," the article says. Turkey was the first country outside Southeast Asia to have human cases. The report discusses 10 cases that occurred in the provinces of Van and Agri late Dec 2005 and Jan 2006 and were investigated by WHO epidemiologists. The 2 other confirmed cases in Turkey were in other provinces.
A total of 21 human H5N1 cases had been reported in Jan 2006 on the basis of tests in a Turkish lab. But WHO recognized only 12 cases that were confirmed by a UK reference lab. The 10 cases covered in the report included three family clusters, one involving 3 cases and two involving 2 each. But investigators concluded that person-to-person transmission in the families was unlikely, because in each family the members fell ill within about a 2-day period, indicating they all contracted the virus from a common environmental source. Although all 3 family clusters occurred near one another and within a 2-week period, "field investigations provided no evidence of human-to-human transmission between households," the report says. The families had had no interactions, and the children attended different schools.
Investigation indicated that close exposure to infected poultry was the primary risk factor for infection. All the patients had been exposed to poultry, and at least 5 were known to have had contact with sick or dead poultry. The 3 families that had multiple cases had been sheltering their poultry indoors.
WHO report calls H5N1 vaccine stockpiling premature
The experts agreed that the seriousness of the present situation, including the risk that a pandemic virus might emerge, is not likely to diminish in the future. The report also warns that if the H5N1 virus becomes a pandemic strain, it could remain as lethal for humans as it is now. The current case-fatality rate, with 256 cases and 152 deaths, is 59%. If the virus becomes more transmissible by acquiring genes from a human-adapted flu virus, its deadliness "would most likely be reduced." But if it remains "a wholly avian virus" that adapts to humans through a series of mutations, it could remain as deadly as it is now, the experts say.
The report says that vaccine development results so far "have not been promising," in part because H5N1 viruses have branched off into a number of diverse subgroups, and vaccines that seem to work against one clade don't work well against others. Scientists also need to determine which adjuvant (general immune system stimulant) works best and to define what kind of observed immune response indicates an adequate level of protection against the actual virus. Experts say the idea of intradermal injection (injecting vaccine just under the skin instead of into muscle) as a way to stretch vaccine supplies "does not look promising and is not likely to be suitable for worldwide use." The document cites an urgent need for international standards for evaluating the efficacy of pandemic vaccines. "On such an important matter, it is unwise to leave assessments of appropriate vaccines to competing manufacturers," it states.
Some other observations and recommendations in the wide-ranging report are as follows:
Emergence and predominance of an H5N1 influenza variant in China
WHO criticized the Chinese Ministry of Agriculture 1 Nov 2006 for not informing the global community of the emergence of a new sub-lineage of the H5N1 avian flu virus, hoarding virus samples and for not doing enough to contain the spread of H5N1 in poultry. WHO's top representative for China, Dr. Henk Bekedam, also suggested the Ministry may be selectively reporting findings of H5N1 in poultry, only alerting the world when large outbreaks occur. International regulations require that any finding of a highly pathogenic avian influenza virus in domestic poultry must be reported to the World Organization for Animal Health.
The critical comments -- from both Bekedam and Dr. Julie Hall, an infectious diseases expert in WHO's China office -- were triggered by an article published in the journal Proceedings of the National Academy of Sciences outlining the emergence of a new sub-lineage of the H5N1 virus. The researchers said the new variant was first isolated in Fujian province Mar 2005 and since then has rapidly crowded out other subgroups of H5N1 viruses in southern China, spreading as well to Malaysia, Thailand, Hong Kong and Laos. It has triggered human cases in China and Thailand. "It's so sad that we haven't got that information or those viruses from the Ministry of Agriculture and we have to rely on research groups in Hong Kong and the United States to provide that information," Hall said. She and Bekedam confirmed that virus samples the Ministry of Agriculture promised to share with the world last March and which China said were cleared for export late Sep 2006 probably [?] haven't yet left the country. The laboratories that conduct influenza testing and surveillance for WHO need sample viruses to track the characteristics of the virus and to ensure that prototype human vaccines are up to date.
In contrast, China's Ministry of Health has been forthcoming, WHO officials said, sharing 5 virus samples over the last 12 months. One of those sample viruses was used to make a seed strain for a human vaccine WHO thinks might be effective against the Fujian-like strain. But without sample Fujian-like viruses to test, it cannot be sure, Hall said. Bekedam said WHO is aware that the Ministry of Agriculture has been conducting the kind of surveillance that was done by the authors of the article. That suggests either the Ministry knew of the new variant and didn't share the news with the global community, or its surveillance isn't as thorough as it needs to be, he said. Bekedam said the article is also proof that China's efforts to contain the virus need to be enhanced. And he suggested the country's poultry vaccine manufacturers should urgently update the strains in their vaccines to include the Fujian-like virus--if they haven't already done so.
The Chinese government said it has found no evidence of a new strain of H5N1 in its southern provinces and said 2 Nov 2006 that there was no need to share virus samples with WHO. China rejected the report, saying there was no evidence of major changes to the virus since 2004. The point was not whether there were major differences in virus strains, Hall said: it was about being able to keep abreast of changes, however minute, to better understand how the virus is developing.
Third International Bird Flu Summit
The Third International Bird Flu Summit will take place in Geneva, Switzerland, 14-15 November 2006. The purpose of the summit is to prepare the World to fight this potentially infectious disease. WHO, FAO, Institut Pasteur and European Food Safety Authority officials will speak at the Summit. For more information, visit: http://www.new-fields.com/birdflu3/index.asp.
(Bird Flu firstname.lastname@example.org )
International agencies join forces to advise OIE animal health and welfare fund
So far, the Fund has received US$13 million, which is being used for economic studies, identification of priority investments, “training of trainers”, and the evaluation of veterinary services in 15 pilot countries. The European Commission has also announced that it will make a contribution for promoting animal welfare activities by helping countries implement OIE's animal welfare guidelines. The fund was created by an OIE resolution in 2004 to help them strengthen their capacity for dealing with animal health and welfare. When the avian influenza crisis struck, the OIE, FAO and WHO advocated the use of this facility to promote good governance worldwide so that countries can improve early detection and respond more rapidly to animal disease outbreaks, including those that can affect humans. A particular emphasis is on developing countries. “When dealing with animal health governance and emergencies, it is crucial to have a mechanism between partner international organisations and donors for synergies and better routing of limited resources”, the OIE Director General, Dr Bernard Vallat said.