Vol. IX, No. 23 ~ EINet News Briefs ~ Nov 24, 2006

2003
Viet Nam / 3 (3)
Total / 3 (3)

2004
Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)

2006
Azerbaijan / 8 (5)
Cambodia / 2 (2)
China / 12 (8)
Djibouti / 1 (0)
Egypt / 15 (7)
Indonesia / 55 (44)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 111 (75)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 258 (153).
(WHO 11/13/06 http://www.who.int/csr/disease/avianinfluenza/en/ )

Avian influenza age & sex distribution data from WHO/WPRO: http://www.wpro.who.int/sites/csr/data/data_Graphs.htm.
(WHO/WPRO 11/13/06)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 23 Nov 2006): http://gamapserver.who.int/mapLibrary/
(WHO)

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Greece: Avian influenza infection suspected in wild ducks
Greece said it found bird flu in a wild duck shot by a hunter, adding that more tests were underway. The H5 virus was confirmed in the migratory duck killed in a coastal area of the central prefecture of Fthiotida, the agriculture ministry said. Samples from the bird will be sent to the EU Reference Laboratory for avian influenza to determine whether the virus is in fact H5N1, the highly pathogenic strain. The relevant European Union authorities have also been informed. The most recent detection of H5N1 in Greece took place Jan-Feb 2006; the affected birds were wild swans in the Thessaloniki area. Even though no domestic poultry cases turned up, demand for chicken in the country took a serious blow for weeks. Authorities in Fthiotida have been advised to ban the transport of live poultry near the area where the duck was hunted. Poultry owners have been warned to keep their flocks indoors, and the public advised to alert the authorities to all bird carcass finds, the ministry said.
(Promed 11/18/06)

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South Korea: Avian influenza suspected in poultry deaths
The Agriculture Ministry said it has discovered a suspected case of bird flu at a poultry farm in Iksan, in the south west of the country. Health inspectors are now conducting tests after about 6000 of the 13 000 chickens at the farm died between 19 Nov 2006 and 22 Nov 2006, Kim Chang-seob, chief veterinary officer at the ministry, said. Kim said the government was informed of the incident, raising alarm that the large number of deaths may be an indication the virus is of a virulent strain. The discovery comes as the country is on a high bird flu alert as migratory birds fly to the Korean peninsula for the winter, the ministry said. "We have closed the farm and halted the movement of any poultry or eggs from the farm," Kim said. The ministry also issued an order to temporarily close 2 hatcheries in the area as further investigations will be conducted. A 10 km radius around the farm will be quarantined. Kim said the ministry expects to confirm whether the poultry had been infected with bird flu soon. The official said the chickens show signs of bird flu, but was careful not to speculate that it was the H5N1 strain of avian influenza. Korea reported its first outbreak of H5N1 Dec 2003. About 5.3 million chickens and ducks valued at 150 billion won (USD 161 million) were slaughtered within 4 months.
(Promed 11/24/06)

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Australia (Canberra): Influenza A (H1) kills 6 in nursing home
The ACT [Australian Capital Territory] Health Protection Service is assisting with the management of a respiratory disease outbreak at an aged care facility [the Jindalee Nursing home, Canberra]. The outbreak appeared to commence 10 Oct 2006. Cumulative counts to 16 Nov 2006 of persons affected by the respiratory disease are: 56 cases, including 7 staff members. 6 deaths (among elderly, very debilitated residents) have occurred. Denominators: 141 residents; 150 staff.

The outbreak is probably due to an influenza A virus, but is unusual, as influenza typically occurs in the middle of the year in this region. For this reason, rigorous diagnostic testing will continue to be required of cases. PCR testing of nose/throat swabs has resulted in 6 positives out of 10 samples. An H1 subtype has been detected. Sequencing results are expected 20 Nov 2006. The facility reports good influenza vaccination coverage among residents (greater than 90 per cent) and vaccination rates among staff of about 55 percent. Immunization against influenza will continue to be recommended for unvaccinated residents and staff at the facility, along with infection control and all other measures specified in the Guidelines for the Prevention and Control of Influenza Outbreaks in Residential Care Facilities. The importance of preventing spread to other institutions, the prescription of antiviral therapy (oseltamivir/Tamiflu) for all residents and staff is under way as an additional preventive measure. General practitioners in the ACT region and other doctors are being kept informed of developments.

The Australian Medical Association (AMA) warned 19 Nov 2006 that Australia's pandemic management plan lacked consistency. AMA president Mukesh Haikerwal said state governments had neglected to share their pandemic plans with doctors, and there was a lack of coordination across states and territories on the role of fever clinics and how to direct patients to the most appropriate care. Australia has spent AUD 600 million [USD 462 million] since 2003 preparing for a possible influenza outbreak.
(Promed 11/21/06, 11/22/06)

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China: Increase in rabies cases in humans and dogs
Over-sized dogs and dogs without photo identification in Beijing are being snatched by the city police to curb the spread of rabies, which has killed about 200 people a month in China this year. Human rabies fatalities nationwide surged 30 percent to 1817 in the first 9 months of 2006, according to the Chinese Center for Disease Control and Prevention. At least 10 deaths occurred in the capital, as attacks by abandoned, rabid dogs escalate. China has about 150 million pet dogs. The number has reportedly climbed 30 percent in the past 5 years. The increase has been attributed to the desire among one-child households for an extra companion and as a source of comfort for older people.

Police are killing strays before they can bite people, and ordering owners to register their pets. Beginning 1 Nov 2006, owners without a license bearing their pet's photo will face fines of up to 5000 yuan (USD 635) and the confiscation of the animal. Beijing authorities also introduced a 1-dog per owner policy and is enforcing a decade-old ban on "violent and large dogs," such as German shepherds. "There has been a significant rise in the number of human cases of rabies particularly over the last 3 years in China," said Julie Hall, WHO’s team leader for communicable diseases in Beijing. "This is something that requires action." Police are stepping up enforcement as the rate of infection rises and China is spending USD 34 billion in preparation for the 2008 Olympics in Beijing. More than 8900 unregistered dogs were nabbed in the city this year. Dog-bite injuries in Beijing are increasing by about 10 000 a year, and reached 70 000 in the first half of 2006. The trend is similar in other cities.

Asia accounts for more than 80 percent of rabies cases worldwide, according to a study published in Dec in Emerging Infectious Diseases journal. In China, 103 200 people died of rabies in 4 epidemic waves between 1950 and 2004, the study's authors said. Human cases are now approaching levels not seen since the 1980s. A "fifth epidemic wave of rabies that began in the 1990s is gaining momentum," the authors said. Abandoned dogs bear much of the blame, they said. "In China it is extortionately expensive to register an animal," WHO's Hall said. Pets are often kept illegally and unvaccinated, she added, recommending that vaccination be compulsory and cheap. Initial registration costs 1000 yuan (USD 127) and includes the first rabies vaccination. The fee, including a booster shot, declines to 500 yuan in subsequent years.
(Promed 11/11/06)

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Japan: Kyoto man and Yokohama man contract rabies from Philippines
A Kyoto resident in his 60's died of rabies on his return to Japan after a stray dog bit his hand in the Philippines, the Public Health and Welfare Bureau in Kyoto announced 17 Nov 2006. The man, who fell into a coma before his death, was the first Japanese to be diagnosed with the virus in 36 years, the Health, Labor and Welfare Ministry said. According to the ministry, the man was bitten by the dog at the end of Aug 2006 and returned to Japan 1 Nov 2006. He visited a doctor in Kyoto 9 Nov 2006 with cold symptoms before developing characteristic signs of rabies such as hallucinations and a fear of water and wind. The National Institute of Infectious Diseases diagnosed the man with rabies after testing his saliva.

A Yokohama man is in serious condition, having contracted rabies after being bitten by a dog in the Philippines, the Ministry of Health, Labor and Welfare stated 22 Nov 2006. This is the second rabies case discovered in Japan in less than a week. Ministry officials responded to the resurgence of the disease by displaying posters warning about the dangers of rabies. The Ministry plans to put up the posters at airports and quarantine centers. The latest case involved a man in his 60s who normally lives in the Philippines but had temporarily returned to Yokohama. A dog in the Philippines bit him on his hand around Aug 2006. He returned to Japan Oct 2006 and fell ill Nov 2006. Tests confirmed he had contracted rabies virus infection.

WHO estimates that rabies caused 55 000 deaths in 2004, including 248 fatalities in the Philippines. Rabies, after its symptoms develop, has no known cure and a fatality rate of almost 100 percent. However, its effects can be fought through if detected early enough. Although rabies vaccination is not a requirement for entry into any country, travelers to and from rabies-endemic countries should be made aware of the risk of contracting rabies. In addition to the ever-present risk of bites from unvaccinated dogs, travelers with extensive unprotected outdoor exposure in rural areas might be at high risk even if their trip is brief.
(Promed 11/18/06, 11/22/06)

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Also, the pandemic planning report released this week, called Pandemic Planning Update III, discusses stockpiling of antiviral drugs. So far HHS has stored 16 million treatment courses of antivirals, en route to a goal of 26 million courses by the end of this year and 36 million by Mar 2007. The longer goal is to have 50 million courses by the end of 2008. HHS is buying both oseltamivir (Tamiflu) and zanamivir (Relenza) for the stockpile, according to Hall. The goal is for the stockpile to be about 80% oseltamivir and 20% zanamivir. Leavitt's planning update says HHS also has been stockpiling personal protective equipment. The government now has 73.1 million N95 respirators, used to protect healthcare workers from airborne pathogens, with another 31.8 million on order. The stockpile also contains 37.4 million surgical masks, along with face shields, gloves, and gowns. In addition to buying antivirals directly, HHS is offering a 25% cost-share to help states buy their own supplies, up to a total of 31 million courses. The report says 33 states have ordered antivirals under that program, and only 4 states don't plan to take full advantage of the subsidy.
(CIDRAP 11/16/06, 11/17/06 http://www.cidrap.umn.edu/ )

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USA: HHS awards 3 contracts for more H5N1 vaccine
The US government announced the awarding of 3 contacts to buy enough additional H5N1 avian influenza vaccine to immunize almost 2.7 million people, at a cost of $199.45 million. The Department of Health and Human Services (HHS) said the contracts are for a total of 5.3 million 90-microgram (mcg) doses of vaccine. The awards include $117.9 million to Sanofi Pasteur for 3.7 million doses, $40.95 million to Novartis for 800,000 doses, and $40.6 million to GlaxoSmithKline (GSK) for 800,000 doses. HHS said that the existing national stockpile of pre-pandemic vaccine is enough to vaccinate about 3 million people with two 90-mcg doses each. The stockpile contains 7.3 million doses, but about 1.4 million doses have begun to lose potency, leaving 5.9 million doses of full-strength vaccine. "These newest vaccine purchases supplement the existing stockpile of 5.9 million doses of H5N1 vaccine and build on the department's plans to buy enough vaccine for 20 million people," HHS said.

Sanofi Pasteur said its new contract is for a vaccine based on a clade 2 (subgroup 2) H5N1 virus. The existing stockpile is based on clade 1 viruses, which circulated and caused human cases in Thailand, Vietnam, and Cambodia in 2004 and 2005. Clade 2 viruses circulated in birds in China and Indonesia in 2003-04 and spread to the Middle East, Europe, and Africa in 2005 and 2006. In a pandemic planning update, HHS noted its intention to begin stockpiling vaccine based on clade 2 viruses, out of concern that a vaccine based on one clade won't work well against a pandemic strain stemming from a different clade. Recently, WHO cautioned governments against rushing to stockpile pre-pandemic flu vaccines, saying too many scientific uncertainties remain. They said vaccines that work against one clade may not work against others and that the level of measured immune response representing adequate protection is unknown.

Sanofi previously won a $13 million contract Sep 2004 to make 2 million doses of H5N1 vaccine. In Sep 2005 the company won what was then listed as a $100 million contract to make more of the vaccine. The latest company statement said that contract is worth $150 million. Novartis will make the H5N1 vaccine in 2007 after production of next year's seasonal flu vaccine is finished. "The US government will determine the dosage and formulation of the final product, including potentially adding an adjuvant such as MF59, at a later date," Novartis said. Earlier this year Novartis acquired Chiron Corp., which had won a $62.5 million H5N1 vaccine contract award from HHS Oct 2005. A GSK statement said HHS may require that the vaccine include an adjuvant, which could reduce the amount of antigen needed per dose. The company said earlier that preliminary results of a clinical trial of an H5N1 vaccine with a novel adjuvant looked promising.
(CIDRAP 11/20/06 http://www.cidrap.umn.edu/ )

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USA: Norovirus outbreak suspected on trans-Atlantic cruise ship
More than 700 people aboard a trans-Atlantic cruise have fallen ill with flu-like symptoms. The outbreak, thought to be caused by a norovirus, struck people aboard the Carnival Cruise Lines' Liberty. The ship left Rome, Italy 3 Nov 2006 with about 2800 passengers and more than 1150 crew members. The boat is due in Ft. Lauderdale, USA 19 Nov 2006. "Within 24 hours of sailing, they had a lot of people sick. It has tapered off considerably over the past couple days," said David Forney of CDC. The U.S. agency flew 2 medical epidemiologists and an environmental health officer to St. Maarten, where the ship was in port 16 Nov 2006.

Noroviruses affect 23 million Americans annually, according to CDC. A dozen incidents of the illness have been reported on cruise ships so far in 2006. Spokeswoman Jennifer de la Cruz said Carnival hasn't nailed down the outbreak's origin, though she noted 2 passengers acknowledged getting sick in Rome prior to boarding. Noroviruses are enteric viruses present in the stool or vomit of infected people, and cause severe diarrhea, nausea and vomiting. The virus can be spread through the air. Most people recover with no lasting side effects. Severe dehydration can be a problem, especially for the very young, the very old and the immuno-compromised. Prevention is best achieved by thorough hand-washing. Epidemics occur frequently during winter months in situations where people congregate in close proximity such as on cruise ships.
(Promed 11/17/06)

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The government rounded up as many as 30 million birds last winter from "backyard" farms around the country and placed a ban on domestic breeding that only expired with the beginning of summer. But while the ban found partial success in urban centers, few complied in rural governorates since raising poultry often constitutes citizens' lone source of income. Egypt is home to an estimated 1.5 million poultry farmers. WHO estimates Egyptians rely on poultry for 60 percent of their animal protein intake.

Talib Ali, regional animal health and production officer for the Food and Agriculture Organization [FAO], says the actual number of bird flu cases in poultry may be higher. The new avian flu cases, he says, are reported by the government's Central Poultry Laboratory, which collected 2800 random samples from 9 governorates. An effective survey, he says, must be conducted on a wider scale and be accompanied by fair compensation for poultry owners whose chickens are destroyed. Ali says the government allocated just LE 50 million [USD 8.73 million] for compensation for 30 million culled chickens. A fair system needs to set aside at least LE 500 million for compensation, he says. Last year's outbreak of the disease raised poultry and egg prices by as much as 200 percent. Prices have since dropped gradually but have not reached pre-flu levels. Egypt's bird-flu statistics, in humans and animals, are available at the State's bird-flu web-site <http://birdflu.sis.gov.eg/html/flu01001.htm>.
(Promed 11/17/06)

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Cholera, diarrhea & dysentery
Hong Kong
The Food & Environmental Hygiene Department has ordered the temporary closure of a fish stall in San Hui Market, Tuen Mun for thorough disinfection following the discovery of Vibrio cholerae in a water sample collected from its fish tank. The water sample was collected from the stall 26 Oct 2006. Results confirmed the presence of V. cholerae O1 El Tor serotype Inaba. The Director of Food & Environmental Hygiene ordered the immediate closure of the fish stall. It will remain closed until the director is satisfied with its overall hygiene and there are no immediate health risks.
(Promed 11/10/06)

USA (South Dakota)
Almost 300 cases of shigellosis have been reported to South Dakota health officials in 2006. The outbreak started May 2006, peaked in Jul and continues. In 45 percent of the South Dakota cases, the patient was 4 years old or younger and in 11 percent of the cases, the patient was hospitalized, the state health department said. Good hygiene, hand washing and proper diapering are advised to prevent contracting the disease. (Promed 11/10/06)

USA (Wyoming)
At least 17 people in Fremont County have come down with shigellosis. "It doesn't appear that there's any large common source of food or water" causing the infections, said Tracy Murphy, the Wyoming state epidemiologist. "It's being spread now through one infected person through another." Murphy said anyone who thinks they might be infected should avoid going to school or work and should see a doctor. Wyoming has had 5-8 outbreaks of the disease in the past 5 years.
(Promed 11/10/06)

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Dengue
Chinese Taipei
Based on the notifiable disease surveillance system in Taiwan, during the 45th epidemiological week (Nov 5 to Nov 11, 2006), 137 dengue fever (DF) cases were reported in Taiwan, of which 76 were laboratory confirmed, including 1 dengue hemorrhagic fever (DHF) case. As of Nov 11, there had been 1,838 reported cases of DF nation-wide this year, of those, 742 had been confirmed, including 15 DHF cases. So far in 2006, 2 DF deaths have been reported from Kaohsiung City. The cumulative number of dengue confirmed cases has increased by 256.7 percent compared with the same period in 2005 (208 cases). Among this year’s cases, 92 were classified as imported cases and 650 were domestic cases. The origins of the imported cases were as follows: 31 from Vietnam; 17 from Indonesia; 12 from the Philippines; 10 from Thailand; 8 from Cambodia; 5 from Malaysia; 3 from India; 2 from Myanmar; 2 from Bangladesh; 1 from El Salvador; and 1 from Madagascar. Of the domestic cases, the main serotype (269 cases) of circulating DF virus is DEN-3, followed by 28 cases of DEN-2, and 1 case of DEN-1. The case distribution was mainly in southern Taiwan; in the north, there were 1 case in Taipei County and 1 case in Keelung City.

The DOH has come under some pressure this year because the outbreak has exceeded the maximum targets set at the beginning of Oct 2006 of "under 500 dengue fever cases and zero deaths from the disease." The DOH has already pooled the resources of local and central governments to assist in disinfecting and spraying pesticides in affected areas. Incentives to report dengue fever cases will be in place from now to the end of the year. An outpatient doctor who reports a dengue fever case will be rewarded TWD 1000 [USD 31], while an inpatient doctor be awarded TWD 3000 [USD 92] for every case reported.
(Taiwan IHR Focal Point 11/17/06; Promed 11/15/06)

Philippines
The Department of Health has declared a dengue outbreak in Cabuyao, Laguna, after it confirmed a rise in the incidence of dengue inside a relocation site here, the provincial health officer, Dr. Alsaneo Lagos, said 8 Nov 2006. He said from zero in 2005, there have been over 10 incidents of confirmed dengue cases inside the 53-hectare Southville Housing Project. He said, however, that of 10 reported dengue deaths, only 3 have been confirmed as caused by dengue virus. 2 of the victims were children aged 3 and 5 who died in a Mandaluyong hospital recently. "We declared a dengue outbreak based on the recommendations and findings of the DoH. . ." Lagos said. He added that 8 more victims, all of them children, are still confined in several hospitals. "We will put up a screening center inside the relocation site. We will monitor the whole area everyday until we can clear it of dengue," Lagos said. Aside from regular monitoring, Lagos said they have activated the "Brigade Against Mosquito Larvae" to eliminate mosquito breeding grounds.
(Promed 11/15/06)

Viet Nam
Reportedly, Viet Nam's southern Mekong Delta has so far this year witnessed 37 deaths caused by dengue fever, up 30 percent over the same period in 2005. An Giang is the hardest-hit province in the delta, with 9 fatalities. Over the past 4 weeks, some 4000 local people in the delta suffered from dengue fever. In the province alone, over 800 people contracted the disease. An Giang and some other provinces like Dong Thap are hit hard by dengue fever because weather conditions there and residents' habits of storing water in containers at their houses favor the breeding of mosquitoes, the disease's transmitter. Local healthcare agencies are asking residents in localities nationwide, especially those in the southern region, to frequently clean up the environment around their accommodations. Viet Nam reported 49 400 cases of dengue fever infection, including 51 fatalities in 2005, down 32.7 percent and 49.5 percent respectively from 2004.
(Promed 11/15/06)

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West Nile Virus
USA
Human Cases have been reported from:
State / Neuroinvasion* / *West Nile* fever** / Other*** / Total **** / Fatalities
Alabama / 7 / 0 / 0 / 7 / 0
Arizona / 47 / 56 / 38 / 141 / 6
Arkansas / 21 / 5 / 0 / 26 / 0
California / 78 / 178 / 11 / 267 / 6
Colorado / 60 / 250 / 0 / 310 / 4
Connecticut / 7 / 2 / 0 / 9 / 1
District of Columbia / 0 / 1 / 0 / 1 / 0
Florida / 3 / 0 / 0 / 3 / 0
Georgia / 2 / 5 / 1 / 8 / 1
Idaho / 111 / 730 / 6 / 847 / 11
Illinois / 117 / 70 / 24 / 211 / 9
Indiana / 26 / 7 / 42 / 75 / 3
Iowa / 21 / 13 / 2 / 36 / 0
Kansas / 17 / 13 / 0 / 30 / 4
Kentucky / 5 / 1 / 0 / 6 / 1
Louisiana / 87 / 77 / 0 / 164 / 0
Maryland / 7 / 1 / 2 / 10 / 0
Massachusetts / 2 / 1 / 0 / 3 / 0
Michigan / 41 / 2 / 5 / 48 / 4
Minnesota / 30 / 35 / 0 / 65 / 3
Mississippi / 84 / 89 / 0 / 173 / 10
Missouri / 47 / 12 / 1 / 60 / 3
Montana / 12 / 21 / 1 / 34 / 0
Nebraska / 41 / 176 / 0 / 217 / 1
Nevada / 34 / 75 / 14 / 123 / 1
New Jersey / 2 / 2 / 1 / 5 / 0
New Mexico / 3 / 5 / 0 / 8 / 0
New York / 8 / 4 / 0 / 12 / 2
North Dakota / 20 / 117 / 0 / 137 / 1
Ohio / 35 / 11 / 0 / 46 / 4
Oklahoma / 26 / 18 / 3 / 47 / 5
Oregon / 6 / 48 / 8 / 65 / 0
Pennsylvania / 8 / 1 / 0 / 9 / 2
South Dakota / 38 / 75 / 0 / 113 / 3
Tennessee / 15 / 2 / 0 / 17 / 1
Texas / 205 / 101 / 0 / 305 / 26
Utah / 55 / 101 / 0 / 156 / 5
Virginia / 0 / 0 / 4 / 4 / 0
Washington / 0 / 3 / 0 / 3 / 0
West Virginia / 1 / 0 / 0 / 1 / 0
Wisconsin / 11 / 9 / 0 / 20 / 1
Wyoming / 15 / 40 / 10 / 65 / 2
TOTALS / 1355 / 2356 / 176 / 3887 / 120

* Cases with neurologic manifestations (such as WN encephalitis, meningitis, and myelitis).
** Cases with no evidence of neuroinvasion.
*** Cases for which insufficient clinical information was provided.
**** Total number of human cases of WNV illness reported by state and local health departments.
(Promed 11/16/06)

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Preparing for an influenza pandemic
Nov 20, 2006 supplement of the Medical Journal of Australia is devoted entirely to the subject of preparing for an influenza pandemic. http://www.mja.com.au/public/issues/185_10_201106/suppl_contents_201106.html
(CIDRAP http://www.cidrap.umn.edu/ )

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Influenza-related articles from the Lancet
The December 2006 issue of Lancet has several influenza-related articles of interest: “Surveillance for avian influenza in human beings in Thailand”; “Averting avian influenza pandemic: SOS from a developing country”; “Displaced populations and pandemic influenza”. http://www.cmaj.ca/current.shtml.
(CIDRAP http://www.cidrap.umn.edu/ )

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Influenza-related articles from the Canadian Medical Association Journal
The 21 Nov 2006 issue of CMAJ has several influenza-related articles of interest: “Laboratory diagnosis of human infection with avian influenza”; “Pandemic triage: the ethical challenge”; “Development of a triage protocol for critical care during an influenza pandemic”. http://www.cmaj.ca/current.shtml Majury A et al. CMAJ. 2006 Nov 21;175(11):1371.
(CIDRAP http://www.cidrap.umn.edu/ )

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HHS issues planning guide for mass casualty events
The Department of Health and Human Services (HHS) has released a new medical care guide to help community leaders plan for and respond to mass casualty events such as an influenza pandemic or a terrorist nuclear attack: http://www.ahrq.gov/research/mce/mceguide.pdf. The guide, published by the HHS Agency for Healthcare Research and Quality (AHRQ), describes an array of shortages healthcare workers will face, such as of hospital beds and ambulances, and gives specific recommendations for planners, such as providing offsite care and using taxis, buses, and private cars to transport sick or injured patients.

"To be effective in their planning efforts, local, state, and regional leaders need to be aware of the latest research, tools, and models available," said AHRQ Director Carolyn Clancy in a Nov 16 AHRQ press release. "With the publication of this new community planning guide, our nation's preparation and response efforts are strengthened by bringing needed focus on advance planning for mass casualty events." The guide expands on an earlier AHRQ publication, released Apr 2005, which outlined altered standards of medical care in a mass casualty setting. The new document, a collaboration between AHRQ and the Office of Public Health Emergency Preparedness, consists of papers written by experts on 6 topics: ethical considerations, legal issues, prehospital care, hospital and acute care, alternative care sites, and palliative care.

Several potential problem areas are highlighted, such as a complex emergency medical services (EMS) system and lack of standardized EMS disaster training. The guide emphasizes that hospitals will face surge capacity problems. To handle the overflow, the AHRQ recommends that officials start making plans to provide care in alternate locations such as mobile medical facilities and nonhospital buildings. The report provides planning checklists and tips for making wise use of limited medical resources. For example, the section on alternative care sites describes how difficult it would be to provide oxygen and suggests a possible solution. A centerpiece of the report is a case study on pandemic influenza. The authors list preparations for and responses to each stage of a pandemic, from the current prepandemic period to increased and sustained transmission in the US. For example, during the worst stage of a pandemic, the authors suggest a "bed czar" be appointed to monitor the supply of hospital beds and equipment and make assignments based on availability.
(CIDRAP 11/20/06 http://www.cidrap.umn.edu/ )

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Pandemic influenza: science to policy
Nov 20, 2006 report from The Royal Society and the Academy of Medical Sciences. http://www.acmedsci.ac.uk/images/pressRelease/Pandemic.pdf
Section 1 provides a background to previous influenza pandemics, an introduction to avian and pandemic influenza, the current concerns about transfer of H5N1 avian influenza into humans and preparedness for a pandemic. Section 2 discusses avian influenza, covering viral reservoirs, the transmission and surveillance of disease, vaccines for avian influenza and facilities for research. Section 3 gives an overview of the epidemiology and surveillance of influenza, both before and during a pandemic. Section 4 discusses antivirals – their use in the UK, stockpiling, delivery, resistance, and the need for new antiviral agents. Section 5 examines human vaccination including the use of seasonal influenza vaccines, current H5N1 vaccines and the production of pandemic vaccines, and it identifies further research that is needed. Section 6 examines the public health measures that are required during a pandemic. It covers the planning and preparation needed, delivery in a pandemic and post-pandemic evaluation. Section 7 describes the use of science in policymaking, including the processes for obtaining scientific advice. It also discusses cross-governmental and international coordination and communication. Section 8 lists the report’s recommendations.
(CIDRAP http://www.cidrap.umn.edu/ )

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H5N1 influenza--continuing evolution and spread
Webster RG and Govorkova EA. N Engl J Med. 2006 Nov 23;355(21):2174-7. http://content.nejm.org/cgi/content/full/355/21/2174?query=TOC
“There is no question that there will be another influenza pandemic someday. We simply don't know when it will occur or whether it will be caused by the H5N1 avian influenza virus. But given the number of cases of H5N1 influenza that have occurred in humans to date (251 as of late September 2006) and the rate of death of more than 50%, it would be prudent to develop robust plans for dealing with such a pandemic. The epicenters of both the Asian influenza pandemic of 1957 and the Hong Kong influenza pandemic of 1968 were in Southeast Asia, and it is in this region that multiple clades of H5N1 influenza virus have already emerged. The Asian H5N1 virus was first detected in Guangdong Province, China, in 1996, when it killed some geese, but it received little attention until it spread through live-poultry markets in Hong Kong to humans in May 1997, killing 6 of 18 infected persons (see map and time line). The culling of all poultry in Hong Kong ended the first wave of H5N1, but the virus continued to circulate among apparently healthy ducks in the coastal provinces of China. . .”
(CIDRAP http://www.cidrap.umn.edu/ )

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Positive emotional style predicts resistance to illness after experimental exposure to rhinovirus or influenza A virus
Cohen S, Alper CM, Doyle WJ, Treanor JJ, Turner RB. Psychosom Med. 2006 Nov 13; [Epub ahead of print].
http://www.psychosomaticmedicine.org/cgi/content/abstract/01.psy.0000245867.92364.3cv1
Abstract: “Objective: In an earlier study, positive emotional style (PES) was associated with resistance to the common cold and a bias to underreport (relative to objective disease markers) symptom severity. This work did not control for social and cognitive factors closely associated with PES. We replicate the original study using a different virus and controls for these alternative explanations. Methods: One hundred ninety-three healthy volunteers ages 21 to 55 years were assessed for a PES characterized by being happy, lively, and calm; a negative emotional style (NES) characterized by being anxious, hostile, and depressed; other cognitive and social dispositions; and self-reported health. Subsequently, they were exposed by nasal drops to a rhinovirus or influenza virus and monitored in quarantine for objective signs of illness and self-reported symptoms. Results: For both viruses, increased PES was associated with lower risk of developing an upper respiratory illness as defined by objective criteria (adjusted odds ratio comparing lowest with highest tertile = 2.9) and with reporting fewer symptoms than expected from concurrent objective markers of illness. These associations were independent of prechallenge virus-specific antibody, virus type, age, sex, education, race, body mass, season, and NES. They were also independent of optimism, extraversion, mastery, self-esteem, purpose, and self-reported health. Conclusions: We replicated the prospective association of PES and colds and PES and biased symptom reporting, extended those results to infection with an influenza virus, and "ruled out" alternative hypotheses. These results indicate that PES may play a more important role in health than previously thought.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Clinicians raise questions about respirator use in pandemic
In October, HHS issued new interim guidance saying that the use of N95 respirators, designed to stop 95% of small airborne particles, is "prudent" for medical workers providing direct care for patients with confirmed or suspected pandemic fu and is recommended when caring for patients with pneumonia. HHS also said that respirator use is prudent for support workers who have direct contact with patients. The recommendations were a departure from guidance in the HHS pandemic influenza plan released last year, which urged healthcare workers to wear simple surgical masks, designed to block large respiratory droplets, for routine care of pandemic flu patients. Both documents recommend use of N95 protection during procedures likely to generate airborne infectious particles.

Michael Bell, associate director for infection control in the CDC's Division of Healthcare Quality Promotion, emphasized that the new HHS guidance is not intended to change how clinicians respond to patients who have seasonal influenza. He said the difference in recommendations between seasonal and pandemic influenza stems from uncertainty about inherent immunity to a pandemic flu strain and potential shortages of antiviral medication and vaccines in a pandemic. He predicted that recommendations about respirator use will continue to evolve as researchers learn more about flu virus particle size and virulence. Another useful thing the recent HHS respirator recommendations do is to make a distinction between respirator use and use of negative-pressure isolation rooms, Bell said. The HHS guidance states that negative-pressure isolation is not required for routine care of patients with pandemic influenza, though such rooms should be used whenever possible for performing aerosol-generating procedures such as inhalational intubation. If negative-pressure rooms aren't available, it is prudent to perform such procedures in private rooms with the door closed or other enclosed areas, the document says.

Bell said HHS officials and other healthcare groups are brainstorming about how to stimulate more production of N95 respirators. "The companies are concerned about liability. They want to be free of that before they produce mass quantities," he said. Bell said HHS probably won't recommend N95 respirators to the general public unless people are caring for family members or neighbors who have pandemic influenza.
(CIDRAP 11/16/06 http://www.cidrap.umn.edu/ )

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FluMist called safe, effective for kids with asthma
For children and adolescents with asthma, the intranasal influenza vaccine FluMist was as safe as and more effective than an injectable vaccine in a phase 3 trial of young people aged 6 to about 17 years. The study involved 2,229 children at 145 sites in 12 European countries and Israel. In the double-blind study, conducted during the 2002-03 flu season, children received either trivalent injectable inactivated influenza vaccine (TIV) or cold-adapted influenza vaccine, trivalent (CAIV-T). CAIV-T is an investigational refrigerated form of FluMist, designed to be easier to handle than the current version, which must be stored frozen. FluMist uses a live but weakened virus.

Currently, TIV is the only vaccine approved for use in high-risk children and adolescents, including those who have asthma. Young people with asthma are at increased risk for complications from respiratory infections and are more likely to be hospitalized when they have seasonal influenza. They are also more likely to experience asthma exacerbations after being sick with seasonal flu. In the new study, for the strains of influenza that the vaccines were designed for, FluMist was 35% more effective than the injected vaccine (flu attack rates: CAIV-T, 4.1%; TIV, 6.2%). Against all influenza subtypes, CAIV-T was 31.9% more effective than TIV. There were no significant differences between the two groups in the incidence of asthma exacerbations, mean peak expiratory flow rates, asthma symptom scores, or nighttime awakening scores. Slightly more patients who received CAIV-T reported runny nose or congestion (66.2% vs 52.5%), and about 70% of those who received TIV reported injection site reactions.

The authors said their results are consistent with a similar study involving children aged 6 to 71 months who had a history of recurrent respiratory tract infections. "Although the reasons for higher observed relative efficacy for CAIV-T were not evaluated in these trials, induction of innate and specific mucosal immunity, as well as other factors, may play a role," they wrote. Despite strong recommendations that high-risk children, including those with asthma, receive an annual flu shot, many children with asthma don't receive them. Earlier studies have shown that major barriers to vaccinating high-risk children are physicians' failure to recommend the vaccine and parents' lack of knowledge about their child's risk of serious complications from the flu. Interventions, such as reminder systems, are needed to improve physician and parent awareness about the importance of annual vaccinations for children with asthma.

Fleming DM, et al. Comparison of the efficacy and safety of live attenuated cold-adapted influenza vaccine, trivalent, with trivalent inactivated influenza virus vaccine in children and adolescents with asthma. Pediatr Infect Dis J 2006;25(10):860-9.

Dombkowski KJ, et al. Effect of missed opportunities on influenza vaccination rates among children with asthma. Arch Pediatr Adolesc Med 2006;166(9):966-71.
(CIDRAP 11/17/06 http://www.cidrap.umn.edu/ )

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Reports show difficulty of diagnosing H5N1 cases
2 new reports on human cases of H5N1 avian influenza that occurred in Turkey and Indonesia show that the illness proved difficult to diagnose. A report on 8 cases in Turkey and a similar report on 8 Indonesian cases, published in the Nov 23 New England Journal of Medicine, says many of the patients tested negative the first time around, even on polymerase chain reaction (PCR) tests.

The Turkish report describes 8 of the 12 confirmed cases the country has had so far. All 8 patients—4 of whom survived—were treated at a hospital. The patients included sets of 3 and 2 siblings, and 7 lived in the same community. The hospital tested a total of 290 patients for avian flu during the outbreak, using a rapid influenza test, enzyme-linked immunosorbent assay (ELISA), and real-time PCR. All the rapid and ELISA test results were negative. 4 of the 8 case-patients initially had negative results on all 3 tests, using nasopharyngeal specimens. Because the patients were severely ill, the tests were repeated using tracheal aspirate specimens, and the real-time PCR tests then were positive. Tests of nasopharyngeal specimens established the diagnosis in the other 4 patients. "Before H5N1 infection was diagnosed in the 8 patients, a total of 8 real-time PCR tests, 12 rapid influenza tests, and 12 ELISA tests were negative," the article states.

The Indonesian report covers 3 family clusters of H5N1 cases that occurred between Jun and Oct 2005 and included the country's first cases. The clusters consisted of 3 cases in Tangerang, Java; 2 cases in Bintaro, Java; and 3 in Lampung, Sumatra. 4 of the 8 patients died. All rapid tests on the patients were negative, and many reverse-transcriptase PCR tests were negative, particularly with nasal specimens. Throat swabs were more likely to test positive on RT-PCR than nasal swabs were.

The Turkish authors write, "Because of the difficulties in detecting H5N1 infection, repeated testing from nasopharyngeal swabs or deep tracheal-aspiration samples in patients who are strongly suspected of having H5N1 infection should be performed even if tests of initial nasophyaryngeal swabs are negative." Also, the Indonesian report says that the source of infection for the first patient in 2 of the clusters was never identified. The 3 patients in the first cluster reported no contact with birds, other animals, or sick people other than family members before they fell ill. In the second cluster, patients reported no contact with birds, other animals, or sick people, but the index patient used fertilizer containing chicken droppings that tested positive for H5N1. The report says limited person-to-person transmission could not be ruled out in the first 2 Indonesian clusters, since the patients had no other known exposures to the virus.

3 of the 4 Indonesian patients who recovered were children (aged 4, 5, and 9) who had mild disease. This resembles the pattern in Hong Kong's 1997 H5N1 outbreak, in which most children who were infected had relatively mild disease. The Indonesian authors write that the clusters in Indonesia and Turkey, as well as others in Hong Kong, Vietnam, Thailand, China, and Azerbaijan, "raise questions as to whether genetic or other factors may predispose some persons to H5N1 virus infection or to severe disease." They add that more investigation is needed to understand "the role of mild cases in the epidemiology of this disease and whether genetic, behavioral, immunologic, and environmental factors may contribute to case clustering."

Oner AF, et al. Avian influenza A(H5N1) infection in eastern Turkey in 2006. N Engl J Med 2006 Nov 23;355(21):2179-85.
http://content.nejm.org/cgi/content/full/355/21/2179?query=TOC

Kandun IN, et al. Three Indonesian clusters of H5N1 virus infection in 2005. N Engl J Med 2006 Nov 23;355(21):2186-94. http://content.nejm.org/cgi/content/full/355/21/2186?query=TOC
(CIDRAP 11/22/06 http://www.cidrap.umn.edu/ )

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Salmonella enteritidis on the rise in chickens
Sampling by the US Department of Agriculture (USDA) over the last 5 years has shown a 4 fold increase in the number of broiler chicken carcasses contaminated with Salmonella enterica serotype enteritidis, a strain previously associated mainly with eggs. The findings, published in the Dec issue of Emerging Infectious Diseases (EID), do not necessarily signal an overall increase in the risk of chicken-related Salmonella infection, but they appear to reinforce other evidence about the emergence of S enteritidis in chicken. The authors, led by Sean F. Altekruse of the USDA, note that 2 recent US case-control studies from the Foodborne Diseases Active Surveillance Network (FoodNet) associated eating chicken with sporadic human infections with S enteritidis. Though the overall incidence of human salmonellosis was lower in 2005 than in the mid 1990s, FoodNet indicated the incidence of S enteritidis infections was about 25% higher.

The USDA researchers tested rinse water samples collected from 2000 through 2005 at plants that slaughter broiler chickens. Eligible poultry processors were randomly selected for sampling, which involved collecting rinse water used on 1 chilled broiler chicken carcass per day for 51 days. Over the 6-year study, researchers identified 280 S enteritidis isolates from 51,327 broiler rinses; the annual number of isolates rose from 23 in 10,057 samples in 2000 to 120 in 9,592 samples in 2005. As a proportion of all Salmonella strains found, S enteritidis increased from 2.5% in 2000 to 7.7% in 2005. The proportion of establishments that had positive tests increased from 17 of 197 (9%) in 2000 to 47 of 187 (25%) in 2005. In addition, the number of states where the strain was found increased from 14 in 2000-2002 to 24 in the ensuing 3 years.

"Enteritidis in broilers is noteworthy given the increase in human Salmonella enteritidis infection rates in the US and recent findings that eating chicken is a new and important risk factor for sporadic infection," the authors state. They point to a recent FoodNet report that showed a strong association between infection with S enteritidis phage types 8 and 13 and eating chicken. "The possible emergence of these 2 phage types in broiler chickens suggests that industry should implement appropriate Salmonella enteritidis controls for broiler chickens," they write. To read the article: http://www.cdc.gov/ncidod/EID/vol12no12/06-0653.htm
(CIDRAP 11/22/06 http://www.cidrap.umn.edu/ )

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Persons at high risk for influenza-related complications and severe disease, including: children aged 6--59 months, pregnant women, persons aged >50 years, persons of any age with certain chronic medical conditions; and persons who live with or care for persons at high risk, including: household contacts who have frequent contact with persons at high risk and who can transmit influenza to those persons at high risk, and health-care workers.

Although influenza vaccination is recommended before or early in the influenza season, persons who are not vaccinated early (particularly those in the recommended groups) should seek vaccination as soon as possible throughout the fall and winter months; influenza viruses can circulate anytime during Nov--Apr. To help raise awareness regarding the importance of influenza vaccination throughout the influenza season, the Department of Health and Human Services, CDC, the National Influenza Vaccine Summit, and other partners have designated Nov 27--Dec 3 as National Influenza Vaccination Week. Free materials are available at http://www.cdc.gov/flu/gallery. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5546a4.htm
(MMWR November 24, 2006 / 55(46);1254)

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Satellite Broadcast: Adult Immunization 2006
CDC and the Public Health Training Network will present the satellite broadcast and webcast, "Adult Immunization 2006" Dec 7, 2006, at noon EST. The 2.5-hour broadcast will outline vaccine-preventable diseases among adults in the US, highlight the 2006--2007 Adult Immunization Schedule, and describe strategies to improve adult vaccination coverage levels. The program will include a discussion of vaccines routinely recommended for adults, including influenza, pneumococcal, Tdap, human papillomavirus, and herpes zoster. The program also will address vaccines recommended for health-care workers and identify resources for vaccine recommendations for international travel. Participants nationwide can interact with course instructors via toll-free telephone lines during a live question-and-answer session. Additional information about the program is available at http://www2.cdc.gov/phtn/adult-imm06/default.asp. No registration is necessary to access the webcast via an Internet connection. The webcast will be available until Jan 8, 2007, and will become available as a self-study DVD and Internet-based program Feb 2007.
(MMWR November 24, 2006 / 55(46);1254)

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IMED 2007 Plenary Speakers Announced
Conference Location: Vienna, Austria; Dates: 23-25 Feb 2007
The program for the International Meeting on Emerging Diseases and Surveillance (IMED 2007) is nearly finalized. This meeting is the first such meeting co-sponsored by ProMED (along with OIE, WHO Regional Office for Europe, and the European CDC). The outstanding plenary speakers are:

• Dr. James Hughes is Director, Program in Global Infectious Diseases; Associate Director, Southeastern Center for Emerging Biologic Threats, Emory University School of Medicine and Rollins School of Public Health; and former director of the National Center for Infectious Diseases at CDC.
• Dr. William Karesh has directed the Field Veterinary Program for the Wildlife Conservation Society since its inception in 1989. He is Chief of Party, Global Avian Influenza Network for Surveillance for wild birds, and Co-chair, IUCN Species Survival Commission - Veterinary Specialist Group.
• Dr. David L. Heymann is the Acting Assistant Director-General for Communicable Diseases and Representative of the Director-General for Pandemic Influenza and the Representative of the Director-General for Polio Eradication at WHO.
• Dr. Adriano Duse is Academic Head and Chief Specialist, Department of Clinical Microbiology and Infectious Diseases, NHLS and School of Pathology of the University of the Witwatersrand, South Africa.

IMED 2007 will bring together the public health community, scientists, health care workers, and other leaders in the field of emerging infectious diseases. The meeting will include poster and oral presentations of submitted abstracts. In addition to the plenary speakers, there are over 20 confirmed speakers on a wide range of emerging disease and surveillance issues. For more information visit: http://imed.isid.org. The abstract deadline is 1 Dec 2006, and the early registration deadline is 22 Dec 2006.
(Promed 11/14/06)

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62nd INCDNCM Conference
Location: Madison, Wisconsin, USA; Dates: 12-14 Aug 2007.
The International Conference on Diseases in Nature Communicable to Man (INCDNCM) is pleased to announce its 62nd Annual Meeting at the University of Wisconsin, Madison, Wisconsin.

INCDNCM conferences are multidisciplinary and include topics on viral, rickettsial, bacterial, parasitic, and prion-related diseases acquired from natural sources, including animals, contaminated water or food supplies, arthropod vectors and other sources. Presentations are typically 10-15 minutes in length and can describe epidemiological, clinical, ecological, diagnostic or laboratory-related aspects of the above diseases. Student presentations are encouraged. The focus of the meeting is to present information from clinical, epidemiological, research and diagnostic areas primarily related to zoonotic diseases, both current and emerging. This meeting is especially suited to public health practitioners and healthcare workers, such as laboratorians, epidemiologists, veterinarians, infectious disease specialists, medical health officers, researchers and students, who have an interest in zoonotic infections and wish to present their findings either orally or through posters sessions. For additional information: http://www.union.wisc.edu/INCDNCM/index.html and http://www.union.wisc.edu/conferences/.
(Promed 11/15/06)

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