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EINet Alert ~ Dec 29, 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: Availability of new recombinant H5N1 vaccine virus
- Viet Nam: Urgent measures in Ho Chi Minh City against new bird flu outbreak
- Viet Nam (Bac Lieu, Ca Mau): Excerpts from the OIE report on avian influenza H5N1
- China: Poultry markets close in Beijing; vaccinations continue
- South Korea: Pigs, Chickens Culled As Bird Flu Spread
- Egypt: 3 new fatal cases of avian influenza H5N1

1. Updates
- Avian/Pandemic influenza updates
- Seasonal Influenza

2. Articles
- Highly Pathogenic Avian Influenza A/H5N1 – update and overview of 2006
- WHO Rapid Advice Guidelines for pharmacological management of sporadic human infection with avian influenza A (H5N1) virus


Global
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

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 / 18 (10)
Indonesia / 55 (45)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 114 (79)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 261 (157).
(WHO 12/27/06 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 11/29/06)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 12/22/06): http://gamapserver.who.int/mapLibrary/

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Global: WHO: Availability of new recombinant H5N1 vaccine virus
The WHO Global Influenza Programme is continuing to monitor the antigenic and genetic evolution of circulating H5N1 viruses and their human isolates. In Aug 2006, WHO reported that analysis of newly isolated viruses collected from animals and humans indicated that the H5 hemagglutinin (HA) genes had become genetically distinguishable from the H5N1 viruses that had previously been selected for vaccine development. There was also evidence of antigenic variation among the recent viruses. Since then, WHO Collaborating Centres (WHO CCs) and H5 Reference Laboratories have been developing new recombinant H5N1 vaccine viruses that are representative of this newly discovered genetic sub-group of clade 2 viruses.

The WHO CC in the US CDC and the China CDC have together developed a new recombinant H5N1 virus from A/Anhui/1/2005 selected from clade 2, sub-clade 3. The recombinant vaccine virus is available for distribution. The sequences of hemagglutinin and neuraminidase of the new H5N1 recombinant vaccine virus can be found on the public website of Los Alamos National Laboratory database together with all other WHO selected and developed influenza vaccine viruses for both seasonal and H5N1 influenza. Institutions, companies and others interested in pandemic vaccine development who wish to receive this recombinant vaccine virus should contact either the WHO Global Influenza Programme at or WHO CC CDC at the address: "WHO Collaborating Center for Surveillance, Epidemiology and Control of Influenza, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail stop G16, Atlanta, GA 30333, USA (fax: +1 404 639 2334; e-mail: )."

Review of the needs and the actual development of H5N1 vaccine viruses representative of circulating strains in the world are ongoing. The WHO Global Influenza Programme will continue to select, verify and develop new H5N1 candidate vaccine viruses from genetically and/or antigenically different groups of circulating viruses for the purposes of vaccine research and development.
(Promed 12/24/06)

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Asia
Viet Nam: Urgent measures in Ho Chi Minh City against new bird flu outbreak
Avian influenza H5N1 has killed 600 chickens and 2100 ducks in Khanh Binh and Khanh Hai communes, Tran Van Thoi district, Ca Mau province from 11-20 Dec 2006. The epidemic has spread to Vinh Binh commune, Hoa Binh district, Bac Lieu province. Reportedly, many local residents killed diseased poultry and threw the corpses into Hiep Hoa canal, which made the epidemic spread more rapidly among poultry breeding farms in Khanh Binh commune and others nearby. The Chairmen of the Bac Lieu and Ca Mau province People's Committees immediately announced the bird flu outbreak in Khanh Binh and Vinh Hoa communes, banning the transportation of poultry out of restricted areas, and began spraying areas of high risk. So far, the new outbreak of bird flu appeared in 3 communes of Ca Mau and Bac Lieu provinces. 1000 chickens and 7300 ducks have been culled.

Authorities in Ho Chi Minh City have initiated emergency measures to prevent the epidemic from spreading to the city. Accordingly, many quarantine stations have been reinforced to control the poultry transported into the city. Staff at the quarantine stations will be on duty all day and night with modern preventive equipment. All the slaughterhouses in the city will be carefully checked.
(Promed 12/25/06)

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Viet Nam (Bac Lieu, Ca Mau): Excerpts from the OIE report on avian influenza H5N1
Information received 19 Dec 2006 from Dr. Bui Quang Anh, Director, Department of Animal Health, Ministry of Agriculture and Rural Development, Hanoi: Report date: 19 Dec 2006. Identification of agent: highly pathogenic avian influenza virus type H5N1. Date of start of event: 6 Dec 2006. Clinical disease: yes. Nature of diagnosis: clinical and laboratory. Description of the outbreaks: 2 outbreaks were reported in villages in Bac Lieu province, (Hoa Binh division) and Ca Mau province Tran Van Thoi village 19 Dec 2006. The first outbreak included 4450 susceptible ducks, 3550 cases and deaths in addition to 900 destroyed and no slaughtered ducks. In Ca Mau province, there were 4500 susceptible birds, with 2523 cases and deaths in addition to 1500 destroyed and no slaughtered birds.

Affected population: outbreak in Vinh Binh: unvaccinated 1-month-old ducks; outbreak in Rach Lum B: unvaccinated chickens and ducks older than 1 month. Laboratory where diagnostic tests were performed: Region VII Animal Health Office. Results; real-time RT-PCR was positive 19 Dec 2006. Source of outbreaks or origin of infection: unknown or inconclusive.
(Promed 12/25/06)

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China: Poultry markets close in Beijing; vaccinations continue
Chinese press reports confirm that the temporary closure of Beijing's live poultry markets, instituted Nov 2005, has been made permanent. The decision was announced by the city's Agriculture Bureau 14 Dec 2006. Although this announcement applies to Beijing municipality only, it follows the release of State Council Document #89 (2006) requiring ". . . large cities to gradually eliminate market sale and slaughter of live poultry." Beijing appears to have been first to act on the State Council's national directive. Beijing's Agriculture Bureau also announced that all districts of the city must continue to implement RE-1 strain and RE-4 strain immunizations. RE-1 is described as the original H5N1 strain while RE-4 is described as "H5N1 mutated strain." China's avian influenza vaccines have been described in the document "Poultry avian influenza vaccination in China”, published Oct 2006 by the Veterinary Bureau of the Ministry of Agriculture, P.R. China; http://www.agri.gov.cn/ztzl/gdztzl/P020061023368529330005.pdf.

There is also an FAO listing of available vaccines worldwide, including the Chinese ones; see below. According to the Chinese document, there are 4 vaccines applied in China against HPAI:

1. The inactivated vaccine (subtype H5N2 strain). (FAO table: Strain: A/Turkey/England/N-28/73 subtype H5N2, Low pathogenicity. Type: Inactivated monovalent).
2. The recombined inactivated vaccine (subtype H5N1), "Re-1 strain;" (FAO table: Strain: A/Goose/Guandong/1996, Subtype H5N1. Type: Low pathogenicity Inactivated monovalent).
3. Recombined fowl pox vector gene engineered vaccine (subtype H5); (FAO table: Strain: A recombinant virus from A/Goose/Guangdong/1996 and human influenza vaccine virus H5N1. Type: live recombinant avian pox virus vectored H5).
4. Recombined live vaccine against Avian Influenza and Newcastle Disease. (FAO table: Strain: A recombinant avian pox virus expressed H5 from A/Goose/Guangdong/1996. Type: Live vectored vaccine based on the insertion of the avian influenza H5 gene into the lentogenic Newcastle disease live vaccine strain La Sota).

All these 4 vaccines are developed by the National Avian Influenza Reference Laboratory. The FAO tabled list covers 43 worldwide-available HPAI vaccines against various AI serotypes. 29 of them are H5 vaccines. See the FAO table at: http://www.fao.org/ag/againfo/programmes/en/empres/vaccine_producers.htm.
(Promed 12/26/06)

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South Korea: Pigs, Chickens Culled As Bird Flu Spread
Quarantine officials culled more than 4000 pigs and 2000 chickens in Asan 24 Dec 2006, South Chungchong province, the site of the latest outbreak of avian influenza. Quarantine officials were dispatched 24 Dec 2006 to cull 4177 pigs from one pig farm located within a 500m radius of the outbreak site and 2000 chickens from one farm located about 3-km away. "Although pigs were originally exempted as subjects for quarantine measures along with dogs, since they are vulnerable to respiratory diseases and might transmit a transformed strain of the virus, we have decided to cull pigs within a 500-meter radius of the infected zone," said an official from the Ministry of Agriculture and Forestry.

Quarantine officials have collected 1000 samples of excrement from migratory birds near affected areas to find out whether the virus is present in them. In addition, they have blocked the transportation of rice straw in farmlands located near the habitats of migratory birds in the region. Experts have been claiming that feeding rice straw to cows from farmlands near habitats of migratory birds should be blocked since the possibility that migratory birds could be the source of the bird flu has not been ruled out yet. 100 tons of rice straw from farmlands that are located near habitats of migratory birds have been supplied to farmlands nearby to be fed to their livestock on a daily basis until the government's move. The government has also banned the movement of chickens, ducks and eggs within a 10-km radius of the affected area. South Korea reported 3 separate outbreaks of the disease before the latest incident in Asan, about 90 km south of Seoul. The first outbreak was reported 22 Nov 2006 in Iksan, North Cholla Province.
(Promed 12/25/06)

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Africa
Egypt: 3 new fatal cases of avian influenza H5N1
As of 27 Dec 2006, the Egyptian Ministry of Health and Population has informed WHO of 3 new human cases of avian influenza A(H5N1) virus infection. All 3 cases belong to 1 extended family in Gharbiyah province, 80 km northwest of Cairo. While being transferred to and cared for at the country's designated avian influenza hospital, a 30-year-old female, a 15-year-old girl and a 26-year-old male died. The cases reportedly had contact with sick ducks. The latest death was in the 26-year-old male, who died 27 Dec 2006. It was the 10th death from bird flu in Egypt since an outbreak of the virus started Feb 2006. The other 9 deceased were all females.

Clinical specimens from the 3 cases tested positive for avian influenza A(H5N1) virus by the Egyptian Central Public Health Laboratory. The virus was also detected in specimens from 2 of the 3 patients by US Naval Medical Research Unit No. 3 (NAMRU-3) in Cairo. The samples will be sent to the WHO Collaborating Centre for further testing, including virus characterization. The Egyptian Ministry of Health and Population is conducting further investigations and has initiated public health measures. All fowl at the infected house and neighboring ones were culled. The other family members remain healthy and have been placed under close observation.

Up to 30 million birds have been culled in Egypt, causing an estimated loss of USD one billion to the poultry industry. Active surveillance for poultry is ongoing in 1202 villages, where 22 289 samples were collected and 44 positive sites were detected. Egypt's last follow-up report on highly pathogenic avian influenza to the OIE was sent 16 Dec 2006 -- http://www.oie.int/eng/info/hebdo/A_CURRENT.HTM#Sec7. In the Middle East, the disease is also known to be present in Iran, Iraq, Israel, Gaza and the West Bank.

Judging from the gender ratio of infections in Egypt, women are more at risk of avian influenza contagion than men, said Hamdi Abdel Wahed, a media official at the Health Ministry. All of the 8 deaths that have occurred in Egypt as a result of avian flu have been among women. "The reason for this is that women in the countryside are traditionally in charge of looking after domestically kept birds, which are the most likely to be infected with bird flu," Abdel Wahed said. The majority of infections and all of the deaths in Egypt have been among people who reared birds domestically as opposed to on farms. In response to the risk of infection from rearing birds at home, the government banned domestic poultry rearing in urban centers. However, the country's health authorities did not impose similar restrictions in rural areas where domestic breeding is more widespread. The greater proneness of women to fatal infection in rural areas of Egypt is probably due to their greater exposure to infection, since they are responsible both for the rearing of poultry and the preparation of food.
(Promed 12/24/06, 12/25/06, 12/27/06, 12/28/06)

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1. Updates
Avian/Pandemic influenza updates
- UN: http://influenza.un.org/. UN response to avian influenza and the pandemic threat; managed by UN System Influenza Coordination (UNSIC).
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html.
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Documents from the International Conference on Avian Influenza in Mali are available.
- OIE: http://www.oie.int/eng/en_index.htm. Link to “Vaccination: a tool for the control of avian influenza”; various updates under “Highlights”.
- US CDC: http://www.cdc.gov/flu/avian/index.htm. Link to OPLAN
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/. The public is also being asked to comment on vaccine prioritization.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html. Check out the highlights from the Canadian Pandemic Influenza Plan for the Health Sector.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and journal articles.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Global updates.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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Seasonal Influenza
Chinese Taipei
Based on the sentinel surveillance system in Taiwan, during the 50th epidemiological week (Dec 10 to 16), the percentage of outpatient visits to sentinel physicians for influenza-like illness (ILI) has increased by 8.6% compared with last week and higher than the same period in 2005. In recent 4 weeks (weeks 47th to 50th), the respective ILI consultation rates (per 100 outpatient visits) were 3.61, 3.87, 4.17 and 4.53. In week 50th, the Kaohsiung-Pingtung region reported a decrease from the previous week, while the remaining 5 regions reported an increasing trend. During weeks 47th to 50th, Taiwan CDC’s laboratory tested specimens collected from sentinel physicians and most of the virus isolates turned out to be influenza B. Besides these, other main respiratory viruses detected included Adenovirus and HSV (Herpes simplex virus). Based on reporting dates, 2 additional severe influenza cases were reported in week 50th. 21 severe cases have been reported cumulatively in the 2006-2007 influenza season: 3 were confirmed, 12 were ruled out, and 6 were pending. This report can also be found on Taiwan CDC’s website: http://www.cdc.gov.tw/en/index.asp.
(Taiwan IHR Focal Point 12/26/06)

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2. Articles
Highly Pathogenic Avian Influenza A/H5N1 – update and overview of 2006
From the Influenza team (influenza@ecdc.eu.int), European Centre for Disease Surveillance and Control, Stockholm, Sweden. http://www.eurosurveillance.org/ew/2006/061221.asp#1
Sections include: Avian influenza 2006: human situation; Animals still source of human infections; Continuing evolution of the viruses; Discussion.

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WHO Rapid Advice Guidelines for pharmacological management of sporadic human infection with avian influenza A (H5N1) virus
Schunemann HJ et al. Lancet Infect Dis. 2007 Jan;7(1):21-31.
Abstract: "Recent spread of avian influenza A (H5N1) virus to poultry and wild birds has increased the threat of human infections with H5N1 virus worldwide. Despite international agreement to stockpile antivirals, evidence-based guidelines for their use do not exist. WHO assembled an international multidisciplinary panel to develop rapid advice for the pharmacological management of human H5N1 virus infection in the current pandemic alert period. A transparent methodological guideline process on the basis of the Grading Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to develop evidence-based guidelines. Our development of specific recommendations for treatment and chemoprophylaxis of sporadic H5N1 infection resulted from the benefits, harms, burden, and cost of interventions in several patient and exposure groups. Overall, the quality of the underlying evidence for all recommendations was rated as very low because it was based on small case series of H5N1 patients, on extrapolation from preclinical studies, and high quality studies of seasonal influenza. A strong recommendation to treat H5N1 patients with oseltamivir was made in part because of the severity of the disease. Similarly, strong recommendations were made to use neuraminidase inhibitors as chemoprophylaxis in high-risk exposure populations. Emergence of other novel influenza A viral subtypes with pandemic potential, or changes in the pathogenicity of H5N1 virus strains, will require an update of these guidelines and WHO will be monitoring this closely.”

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 apecein@u.washington.edu