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EINet Alert ~ Jan 12, 2007


*****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: Avian influenza prevention puzzle: linking knowledge, action
- EU: Tighter regulations for importing live captive birds
- Indonesia: Additional confirmed and suspected cases of avian influenza H5N1 infection in humans
- China (Anhui): Human case of avian influenza H5N1 infection
- Viet Nam: Avian influenza H5N1 spreads to fifth province
- South Korea: Poultry worker was infected with avian influenza H5N1
- Hong Kong: Avian influenza H5N1-infected bird found
- Japan (Miyazaki): Farm may have avian influenza outbreak
- Bangladesh: Undiagnosed deaths in poultry
- Azerbaijan: Undiagnosed deaths in poultry
- USA: HHS awards $102 million for new influenza drug
- USA: FDA approves refrigerated form of FluMist
- USA (Iowa): Human case of swine influenza
- Nigeria: Avian influenza suspected in poultry

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

2. Articles
- Pandemic Influenza School Closure Policies
- Influenza vaccination and risk of mortality among adults hospitalized with community-acquired pneumonia
- Avian Influenza Risk Perception, Europe and Asia
- Code-based Syndromic Surveillance for Influenzalike Illness by International Classification of Diseases, Ninth Revision
- Tropism of avian influenza A (H5N1) in the upper and lower respiratory tract

3. Notifications
- Pandemic Preparedness Planning for US Businesses with Overseas Operations
- Pandemic Planning Tool Kit
- Flu Vaccine Effectiveness: Questions and Answers for Health Professionals
- Business preparedness for pandemic influenza Summit
- Paris Anti-Avian Influenza Conference


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 / 13 (8)
Djibouti / 1 (0)
Egypt / 18 (10)
Indonesia / 56 (46)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 116 (80)

2007
Indonesia / 2 (1)
Total / 2 (1)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 265 (159).
(WHO 1/12/07 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 1/11/07)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 1/12/07): http://gamapserver.who.int/mapLibrary/

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Global: Avian influenza prevention puzzle: linking knowledge, action
An increase in human cases of H5N1 avian influenza is focusing attention on the unsolved problem of crafting influenza-prevention messages that developing-world farmers will trust and follow. Research into avian flu prevention in Cambodia underlines the difficulty, reporting that villagers did not take preventive action even when they knew how to protect themselves. The persistent mismatch between knowledge and action has researchers wondering whether blanket bans on handling and slaughtering sick poultry are impractical. Officials in Indonesia and Egypt said the latest bird flu victims were probably infected by sick poultry. Both countries have run education campaigns about the risk of acquiring bird flu. The victims were aware of the education efforts; they first denied, and then admitted, handling or slaughtering the birds.

The gap between knowing what to do and doing it is spotlighted by a dispatch in the Jan edition of Emerging Infectious Diseases. The paper reports the results of a "knowledge, attitudes and practices" survey of 460 Cambodian villagers. 97 % of the 269 households where the villagers lived kept chickens. 81% of the households had learned about avian flu and flu prevention from announcements on television; 78% had heard similar messages on the radio. 72% of the participants understood that avian flu is a fatal disease that can be transmitted to humans, 67% thought it was unsafe to touch sick or dead poultry with their bare hands, and 70% knew it was not safe to eat wild birds. Poultry had indeed died in 62% of the households in the previous 6 months. Nevertheless, 75% acknowledged touching sick or dead poultry bare-handed; 45% ate poultry that had died from illness; 33% ate wild birds; and 8% collected and ate dead wild birds. In addition, though half of the participants agreed on the importance of reporting poultry deaths to authorities, many did not report—41% because they did not know how, 31% because they had not done so in the past, and 18% because they believed it would hurt sales of their surviving birds.

The divide between developing-world villagers' avian-flu beliefs and practices is familiar and frustrating territory to groups that work on flu control. Villagers who did not follow safe practices nevertheless had not gotten sick, leading others to conclude that eating sick and dead poultry was worth the risk. Equipment that could protect them during handling and slaughtering (rubber gloves, masks, soap, etc.) is hard to obtain. Some avian-flu prevention programs improve their success when they choose locally trusted sources to deliver flu-control messages. In addition, "We try to ask what the motivation is—why people will do this," Academy for Educational Development’s Silvio Waisbord said. "Technical messages may not work, but. . .'Protect your birds so you will have them for religious festivals,' those messages resonate with people's existing concerns." Economic incentives such as payments in exchange for preventively slaughtered birds can be a powerful persuader—the World Bank recently recommended that compensation be paid directly to farmers in cash within 24 hours of a cull.

Recently, staff at some nonprofit organizations that work on avian flu have been comparing efforts against the disease to campaigns against HIV/AIDS. Early on it became clear that blanket prohibitions on behaviors that transmit HIV would never conquer human nature, but campaigns that encouraged incremental protective steps had a chance of success. (One, the ABC campaign—from its slogan "Be Abstinent, Be faithful, use a Condom”) That risk-reduction model, advocates argue, may have a better chance of controlling avian flu than broad prohibitions that effectively order villagers to sacrifice important sources of protein and income. Whitney Pyles, avian influenza coordinator for CARE International, said the essential component is turning out to be community participation. Protective behaviors that are discussed and agreed to by a community have better adherence than solutions imposed from above by national health authorities.
(CIDRAP 1/11/07 http://www.cidrap.umn.edu/ )

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EU: Tighter regulations for importing live captive birds
EU animal health experts have tightened rules for the import of live captive birds as part of the bloc's strategy to fight bird flu. "Under the regulation agreed today, only specific countries or regions which have already been approved to export live commercial poultry will be allowed to export captive birds to the EU," the EU's executive Commission said. The list of countries approved to export live captive birds to the EU would be limited to those already approved to export live poultry to EU markets--Australia, Canada, Chile, Croatia, Israel, New Zealand and the US, along with certain states in Brazil. However, certain third countries that were geographically close to the EU would be exempt from the new rules--Andorra, Lichtenstein, Monaco, Norway, San Marino, Switzerland and Vatican City. The EU's new rules will not apply to certain types of birds, including commercial poultry and pet birds accompanying their owners, since these were already covered by separate EU laws. Exporter countries will have to prove the absence of bird flu as well as Newcastle disease virus. Birds destined for EU countries may not be vaccinated against avian flu and all imported birds will have to be individually identifiable.
(Promed 1/11/07)

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Asia
Indonesia: Additional confirmed and suspected cases of avian influenza H5N1 infection in humans
The husband and son of an Indonesian woman who was being treated for H5N1 avian influenza were hospitalized with possible cases of the same illness 11 Jan 2007, and the woman died shortly afterward. The 38-year-old woman from Tangerang, Banten Province died at Persahabatan Hospital in East Jakarta. The woman reportedly slaughtered a chicken she bought from a local market. Deaths among poultry in the neighbourhood have also recently been reported. The woman's case was first reported Jan 8, 2007. Reportedly, the woman's 42-year-old husband and their 18-year-old son were hospitalized 11 Jan 2007 with fever and signs of respiratory infection and were being tested for the H5N1 virus.

On 10 Jan 2007, a 14-year-old boy from Tangerang died of avian influenza H5N1 at the same hospital. He developed symptoms 31 Dec 2006 and was hospitalized 4 Jan 2007. Deaths among poultry in the neighbourhood have recently been reported, and he had reportedly been in contact with ducks but the source of exposure is currently still under investigation.

The Ministry of Health has also confirmed a new case of human infection with the H5N1 avian influenza virus. The 22 year old woman from Banten Province developed symptoms 3 Jan 2007 and remains in hospital. An initial investigation into the source of her exposure found reports of chicken deaths near her home in the days prior to symptom onset. Of the 77 cases confirmed to date in Indonesia, 59 have been fatal. Indonesia has the world's highest avian influenza H5N1 death toll.
(WHO 1/12/07, Promed 1/7/07, 1/9/07, 1/11/07, CIDRAP 1/11/07 http://www.cidrap.umn.edu/ )

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China (Anhui): Human case of avian influenza H5N1 infection
As of 10 Jan 2007, China confirmed a case of human infection with the H5N1 avian influenza virus. The case is a 37-year-old man from Tunxi in Anhui Province. He developed fever and pneumonia 10 Dec 2006 and was hospitalized 17 Dec 2006. The patient was discharged 6 Jan 2007 and is recovering well. He was a farmer and may have kept a number of birds in his backyard. No information on possible exposure to diseased birds as the source of his infection is presently available, but an investigation is under way. Close contacts were placed under medical observation, but are all well and were released 29 Dec 2006. There has been no reported poultry outbreak in the area. Henk Bekedam, WHO's China representative said that as vaccination rates for birds improve in China, detecting avian influenza becomes harder.

Of the 22 cases confirmed to date in China, 14 have been fatal. China last reported a human case of bird flu Jul 2006, when a farmer died of H5N1 in Xinjiang. Investigation had found no history of exposure to dead or diseased birds. The man had no history of travel the month before he got sick, and no poultry outbreaks were reported near his home. The most recent reported poultry outbreaks were early Oct 2006 in Inner Mongolia and Ningxia. China has been criticized for a lack of transparency in its handling of health threats, but Bekedam said WHO was informed of the case as soon as he tested positive, and WHO praised the fact that he was tested a second time after his first tests turned up negative.
(Promed 1/10/07; CIDRAP 1/10/07 http://www.cidrap.umn.edu/ )

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Viet Nam: Avian influenza H5N1 spreads to fifth province
Avian outbreaks have spread to a fifth province, raising concern about a nationwide resurgence of the virus. The virus killed 20 chickens on a small farm in the MeKong Delta province of Vinh Long, animal health officials in Hanoi said. Since Dec 2006, the virus has also struck poultry in Ca Mau, Bac Lieu, Hau Giang, and Kien Giang provinces. Officials have blamed the outbreaks on gaps in the country's mass vaccination program and farmers' refusal to obey a ban on hatching ducks. "Our biggest problem in preventing the virus from spreading is the failure to enforce the government ban of hatching and restocking ducks," said Dinh Cong Than, director of the Kien Giang provincial department of animal health. The government instituted the ban more than a year ago, but most farmers ignored it, and government figures show that 50 million to 70 million ducks have been restocked since then. Ducks can carry the H5N1 virus without showing signs of illness. "For farmers in the Mekong Delta, rice and ducks are their biggest sources of income. It's therefore very difficult to ban them from raising ducks," Than said.

Officials from WHO and the UN Food and Agriculture Organization (FAO) are in talks with the Vietnamese government about sending experts to investigate the source of the outbreaks. Viet Nam has had no human cases since Nov 2005, though it had 93 cases with 42 deaths before that. For an interactive map of HPAI visit: http://www.oie.int/wahidprod/public.php?page=disease_outbreak_map&disease_id=15. Clicking on Vietnam will allow zooming in and viewing the respective locations of the recent outbreaks.
(CIDRAP 1/8/07, 1/10/07, 1/11/07 http://www.cidrap.umn.edu/ ; Promed 1/5/07)

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South Korea: Poultry worker was infected with avian influenza H5N1
South Korea's Health Ministry said that a poultry worker was infected with bird flu late 2006, but had not been seriously ill. The person was infected after the H5N1 outbreak that first hit poultry farms in the country Nov 2006. "We confirmed the person was positive for antibodies to bird flu," the Ministry said. The poultry worker was subject to regular testing of 26 farmers and workers involved in a mass cull of about 1.7 million fowl at 4 farms in the southwestern region following the discovery of the virus. The worker did not develop any serious illness and is now healthy. The worker took the anti-flu drug Tamiflu following the outbreak. During an H5N1 outbreak late 2003 and early 2004, 9 South Koreans were infected but none developed any major illnesses. The virus responsible for the outbreaks in South Korea (and also Japan) belongs to the V genotype of H5N1 avian influenza virus, whereas the predominant virus in East Asia belongs to the Z genotype. These genotypes are reassortants which differ in the origin of their NA genome subunit. This may be a determining factor in the apparent lack of virulence of the South Korean virus.
(Promed 1/11/07)

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Hong Kong: Avian influenza H5N1-infected bird found
Hong Kong officials announced that a wild bird found dead near a busy shopping district Dec 31, 2006 tested positive for H5N1 avian influenza. The infection in a scaly-breasted munia (type of finch), a species often imported from mainland China and released in religious ceremonies, marks the first case found in Hong Kong since Feb 2006. Hong Kong has reported no human H5N1 cases since 1997, when the virus first jumped to humans. The Hong Kong government has not specified if the virus was the highly pathogenic H5N1 strain. Hong Kong's Agriculture, Fisheries, and Conservation Department (AFCD) announced Jan 4, 2007 that a preliminary test for the virus was positive and confirmatory tests were being conducted. The practice of releasing these birds may be a concern, as they're not subject to the disease-prevention measures used with poultry, and sellers and buyers can come into contact with infected bird droppings.

AFCD advised the public not to release birds. The statement said pet birds imported from mainland China must come from registered farms and be accompanied by a veterinary health certificate certifying that the birds have been quarantined and have tested negative for H5. Farms on the mainland that are allowed to export birds to Hong Kong are inspected by mainland authorities and occasionally by AFCD authorities and must have had no avian flu outbreaks in the past 180 days. AFCD has enhanced checks on farms and pet shops, and physicians will be informed of the latest situation. Precautionary measures and cleaning operations have been enhanced in all Leisure & Cultural Services Department venues where birds congregate. The aviaries in Hong Kong Park, the Zoological & Botanical Gardens and Kowloon Park have been temporarily closed. All the birds are healthy. The government said its records show that 38,000 munias were imported into Hong Kong from the mainland in 2006. The scaly-breasted Munia is a resident bird in Hong Kong and has been found all over the territory (although reportedly more common in rural areas).
(CIDRAP 1/8/07 http://www.cidrap.umn.edu/ ; Promed 1/5/07, 1/7/07)

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Japan (Miyazaki): Farm may have avian influenza outbreak
Japan's Agriculture Ministry has received reports of a suspected outbreak of bird flu at a poultry farm in western Japan, 11 Jan 2007. The outbreak is suspected at a poultry farm in the western Miyazaki prefecture (state). Japan suffered outbreaks of HPAI H5N1 early 2004 in the prefectures Kyoto and Hyogo, eradicated by stamping out and disinfection. Later, it was found that several humans had been infected without serious illness. Multiple outbreaks of LPAI H5N2 were recorded in the Ibaraki prefecture during the second semester of 2005 and Jan 2006.
(Promed 1/11/07)

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Bangladesh: Undiagnosed deaths in poultry
Reportedly at least 60 chickens are dying every day in each poultry farm in Sherpur. There are about 3000 small and big poultry farms in the district having 500 to 3000 birds in each farm. Various diseases have broken out in an epidemic form in the poultry farms due to low temperature. As a result, the poultry industry in the district faces the threat of closure. Some poultry firm owners claimed that the prices of chicken fell considerably while prices of poultry feed increased greatly in the local markets in last few days.
(Promed 1/11/07)

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Azerbaijan: Undiagnosed deaths in poultry
Reportedly, a mass death of poultry has occurred in the village of Boyuk Bahmanli in the Fuzuli region. They said that mass death of poultry was observed in several yards and they appealed to the veterinary service. The reasons for the deaths are unknown. Many dead fowl were found in the water basins of the village, as well as in the ponds. State Veterinary Service will investigate. Reportedly, bird flu virus was not found in this territory during initial monitoring.
(Promed 1/11/07)

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Americas
USA: HHS awards $102 million for new influenza drug
In an effort to expand the pool of antiviral drugs for influenza, the US government awarded a $102.6 million contract to BioCryst Pharmaceuticals Inc. to develop peramivir, a new neuraminidase inhibitor. Research under the contract will include tests involving the H5N1 virus and may include research on the possible preventive use of the drug. Licensed drugs in the neuraminidase inhibitor class are taken orally (oseltamivir) or by an inhaler (zanamivir). However, peramivir is under development as a parenterally administered drug, meaning it can be given through intramuscular and intravenous routes. The Department of Health and Human Services (HHS) said a parenteral neuraminidase inhibitor may be particularly useful in hospital emergency departments for treatment of patients who have life-threatening flu. Parenteral injection could permit rapid buildup of peramivir to high levels throughout the body and allow treatment of people too ill to take medications by mouth, the agency said.

BioCryst said its laboratory tests have shown that peramivir, an inhibitor of influenza A and B neuraminidases, is more potent than currently available drugs in its class and is active against antiviral-resistant flu strains. The company said high doses of injectable formulations have been safely administered to healthy people, and the drug has been found to promote survival in animals infected with the H5N1 virus. Both the intramuscular and intravenous formulations of peramivir will go through phase 2 and 3 clinical trials. The intramuscular formulation will be tested against a placebo in outpatients, and the intravenous trial will likely test peramivir against oseltamivir in hospitals. Enrollment of patients for the phase 2 trials will begin this flu season in the US, Canada, and Europe; the company has identified sites in the southern hemisphere that could be used to fill this year's phase 2 study groups or facilitate an early start on phase 3 studies. BioCryst is also identifying sites in Southeast Asia, where flu outbreaks occur year-round, that might be added to the study. The HHS contract to develop peramivir is subject to an emergency use authorization that would allow the department to stockpile the drug before approval by the Food and Drug Administration (FDA) if clinical data show it to be beneficial.
(CIDRAP 1/5/07 http://www.cidrap.umn.edu/ )

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USA: FDA approves refrigerated form of FluMist
The US Food and Drug Administration (FDA) has approved a refrigerated form of FluMist, the nasal-spray influenza vaccine, which should be more convenient for providers than the current formulation, MedImmune Inc. announced. FluMist, a live attenuated vaccine first approved in 2003, is currently approved for use in healthy children and adults from ages 5 to 49 years. The new formulation will allow healthcare providers to store the vaccine in a refrigerator rather than a freezer as now required. The new FluMist formulation, known in clinical studies as cold adapted influenza vaccine trivalent (CAIV-T), will be available for the 2007-08 flu season. MedImmune said the frozen and refrigerated formulations are free of preservatives, including thimerosal. In Jul 2006 MedImmune asked FDA to expand the age indication for the vaccine to children as young as 1 year who do not have a history of wheezing or asthma. Phase 3 trial results that MedImmune submitted to the FDA in 2006 showed that FluMist was 55% more effective than an injectable vaccine in children aged 6 months to about 5 years, according to MedImmune. FluMist was more effective against flu viruses both well-matched and poorly matched to the vaccine in the 2004-05 flu season. However, a study in the Dec 14, 2006, issue of the New England Journal of Medicine suggested that in adults, FluMist was less effective against type B influenza than the injected vaccine in the 2004-05 season. Both vaccines had similar efficacy against influenza A in adults.
(CIDRAP 1/9/07 http://www.cidrap.umn.edu/ )

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USA (Iowa): Human case of swine influenza
An eastern Iowan has tested positive for a swine flu. Dr. Patricia Quinlisk, the state's epidemiologist, said the case was detected when the patient gave a routine throat swab after coming down with flu symptoms. Lab tests confirmed the swine flu diagnosis. CDC confirmed the results. Quinlisk said the patient was not hospitalized and has since recovered. She said there was no evidence the virus has spread person to person. It was unknown how the Iowan contracted the virus. "It's hard to catch," Quinlisk said. "(Humans) are pretty resistant to it." CDC has blood tests pending on people in contact with the Iowan to determine exposure. People exposed to the virus may not develop symptoms. Pigs can transmit viruses to their human handlers, as they did in Cedar Rapids during the 1918 Spanish flu epidemic. Influenza A virus infection (H1N1 or H3N2) is common in swine in the USA (although less frequent elsewhere), and infection of abattoir workers causing mild respiratory disease is not uncommon. Constant surveillance of such events is necessary, however, for early detection of a virus with pandemic potential.
(Promed 1/8/07)

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Africa
Nigeria: Avian influenza suspected in poultry
New cases of bird flu have been recorded on 2 farms in north-western Nigeria, officials say, a year after the disease was first found there. Reportedly local officials had culled 1070 chickens. Some of the infected birds were found in a backyard farm in Katsina town. There are fears that 2 other farms may be infected. "We've heard it, but we are not yet sure. . ." said Ayokanmi Osinlu, spokesman for Nigeria's health minister. There have been no human victims in Africa's most populous country since the H5N1 strain was first recorded early in 2006. The UN had expressed concerns about the Nigerian government response to the disease, as poultry are still being moved around by local farmers despite an official quarantine and promised compensation for infected birds.
(Promed 1/11/07)

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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). Also, http://www.irinnews.org/Birdflu.asp provides information on avian influenza in order to help the humanitarian community.
- 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.
- 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 52nd epidemiological week (Dec 24 to 30, 2007), the percentage of outpatient visits to sentinel physicians for influenza-like illness (ILI) has increased by 5.4% compared with last week and is 54.1% higher than the same period in 2005. During weeks 49th to 52nd, the respective ILI consultation rates (per 100 outpatient visits) were 4.17, 4.53, 5.35 and 5.64. Comparing to the last week, the consultation rate decreased in Taipei region, while the remaining 5 regions reported an increasing trend. The dominant respiratory virus identified by National Influenza Center and CDC Collaborating Labs for week 49th to 52nd was influenza B virus. The other main respiratory viruses were Adenovirus and HSV (Herpes simplex virus). To date, 31 clusters have been reported this influenza season. Based on reporting dates, 12 additional severe influenza cases were reported in week 52nd. Based on onset dates, 40 severe cases have been reported cumulatively in the 2006-2007 epidemic season. Among these, 7 were confirmed, 15 were excluded, and 18 are still pending. So far this season (weeks 26th to 52nd), 1 death has been reported.
(Taiwan IHR Focal Point 1/9/07)

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2. Articles
Pandemic Influenza School Closure Policies
Laura H. Kahn. EID Journal Home > Volume 13, Number 2–February 2007. (references removed)
http://www.cdc.gov/eid/content/13/2/06-1109.htm#1
To the Editor: “. . .The US Department of Health and Human Services' checklist regarding school closures gives conflicting messages. For example, it recommends that schools stay open during a pandemic and develop school-based surveillance systems for absenteeism of students and sick-leave policies for staff and students. It also recommends developing alternate procedures to ensure the continuity of instruction in the event of district-wide school closures. These vague recommendations may reflect the paucity of data to recommend school closure. To assess the current status of school closure decisions in the United States, I conducted an internet survey of all 50 state health commissioners during the spring of 2006. I asked the respondents 2 questions: "Who makes the school closure decisions in your state?" and "What absenteeism rate, if any, would prompt a school in your state to close during a typical influenza year and/or during a pandemic influenza year?" Of the 44 responding states, I found that school closure decisions were primarily a local-level responsibility in half. Of these 22 states, closure decisions would be made either on a school-by-school or a school district–by–school district basis. Only 6 states indicated that school closure decisions would be made at the state level, and 16 states would have decisions made jointly at the state and local levels. For a typical influenza season, only 6 states indicated that they close schools if a certain absenteeism rate due to illness were reached. For 5 of these states, the absenteeism rates ranged from 10% to 30%; the sixth state said its schools would close if the rates were anywhere from 7% to 31%. However, only 1 state reported a threshold absenteeism rate for closure during an influenza pandemic. Another state said that it was developing an absenteeism rate that would prompt closure for pandemic influenza. Forty-two states did not have threshold absenteeism rates that would prompt school closures during an influenza pandemic. . .I therefore think a national policy, or at least specific national guidelines, should be developed jointly by the Centers for Disease Control and Prevention and the Department of Education, so that states' school districts can develop rational, coherent, and coordinated closure plans to protect children and communities during an influenza pandemic.”

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Influenza vaccination and risk of mortality among adults hospitalized with community-acquired pneumonia
Kimberly A. Spaude et al. Vol. 167 No. 1, January 8, 2007. Archives of Internal Medicine. http://archinte.ama-assn.org/cgi/content/abstract/167/1/53
Abstract: “Background Influenza vaccination has been shown to reduce illness and all-cause mortality in vulnerable populations through the prevention of influenza infection. Attenuation of the severity of illness by vaccination has been reported for respiratory tract infections due to bacterial pathogens and would represent an important additional health benefit of influenza vaccination. We evaluated the impact of prior influenza vaccination on in-hospital mortality and other health outcomes among hospitalized adults with community-acquired pneumonia (CAP). Methods Consecutive individuals hospitalized with CAP during "influenza season" (November to April, 1999-2003) at hospitals operated by Tenet HealthCare were identified using a database constructed to improve quality of patient care. Associations between vaccination status and all-cause in-hospital mortality were evaluated using logistic regression models. Results Among 17 393 adults hospitalized with CAP during the study period, 1590 (19% of those with recorded vaccine status) had a history of influenza vaccination in the current or most recent influenza season. Vaccine recipients were less likely to die in hospital of any cause than individuals without vaccination (odds ratio, 0.30; 95% confidence interval, 0.22-0.41). These effects remained significant after adjustment for the presence of comorbid illnesses and pneumococcal vaccination (adjusted odds ratio for death, 0.61; 95% confidence interval, 0.43-0.87) and under widely varying assumptions about individuals with missing vaccination status. Conclusions Prior influenza vaccination was associated with improved survival in hospitalized patients with CAP during influenza season. This observation, if confirmed by other studies, would represent an important additional benefit of enhanced influenza vaccine coverage.”

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Avian Influenza Risk Perception, Europe and Asia
Onno de Zwart et al. EID. Volume 13, Number 2–February 2007.
http://www.cdc.gov/eid/content/13/2/288.htm
Abstract: “During autumn 2005, we conducted 3,436 interviews in European and Asian countries. We found risk perceptions of avian influenza to be at an intermediate level and beliefs of efficacy to be slightly lower. Risk perceptions were higher in Asia than Europe; efficacy beliefs were lower in Europe than Asia.”

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Code-based Syndromic Surveillance for Influenzalike Illness by International Classification of Diseases, Ninth Revision
Nicola Marsden-Haug et al. EID. Volume 13, Number 2–February 2007. http://www.cdc.gov/eid/content/13/2/207.htm
Abstract: “With the spread of avian influenza, use of automated data streams to rapidly detect and track human influenza cases has increased. We performed correlation analyses to determine whether International Classification of Diseases, Ninth Revision (ICD-9), groupings used to detect influenzalike illness (ILI) within an automated syndromic system correlate with respiratory virus laboratory test results in the same population (r = 0.71 or 0.86, depending on group). We used temporal and signal-to-noise analysis to identify 2 subsets of ICD-9 codes that most accurately represent ILI trends, compared nationwide sentinel ILI surveillance data from the Centers for Disease Control and Prevention with the automated data (r = 0.97), and found the most sensitive set of ICD-9 codes for respiratory illness surveillance. Our results demonstrate a method for selecting the best group of ICD-9 codes to assist system developers and health officials who are interpreting similar data for daily public health activities.”

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Tropism of avian influenza A (H5N1) in the upper and lower respiratory tract
J M Nicholls et al. Nat Med. 2007 Jan 7; [Epub ahead of print].
http://www.nature.com/nm/journal/vaop/ncurrent/abs/nm1529.html
Abstract: “Poor human-to-human transmission of influenza A H5N1 virus has been attributed to the paucity of putative sialic acid 2-3 virus receptors in the epithelium of the human upper respiratory tract, and thus to the presumed inability of the virus to replicate efficiently at this site. We now demonstrate that ex vivo cultures of human nasopharyngeal, adenoid and tonsillar tissues can be infected with H5N1 viruses in spite of an apparent lack of these receptors.”

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3. Notifications
Pandemic Preparedness Planning for US Businesses with Overseas Operations
In the event of pandemic influenza, businesses will play a key role in protecting employees’ health and safety as well as limiting the negative impact to the economy and society. The US Government has created a guide to help U.S. businesses with overseas operations prepare and implement pandemic business continuity. This is a list of suggestions and can serve as a starting point for developing a comprehensive plan. The checklist highlights actions applicable to businesses of all sizes, although each item does not necessarily apply to every overseas business. Checklist sections include:
• Plan for maintaining business continuity during and after a pandemic
• Plan for the impact of a pandemic on the lives and welfare of your employees
• Establish policies and guidelines to be implemented during a pandemic to avoid creating policies on demand” in the midst of a pandemic
• Determine resources required to fulfill actions in your pandemic plan
• Create an emergency communications system
• Work to coordinate with external organizations and your community
• Prepare for post-pandemic scenarios
(Pandemicflu.gov 1/5/07)

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Pandemic Planning Tool Kit
A document from the Ontario Chamber of Commerce, released Jan 9, 2007. Sections include: “Introduction; Protecting Yourself Against Influenza; What You Can Do For Your Employees; What Is A “Business Continuity” Pandemic Plan?; Where Can I Find Out More Information?; Contact Phone Numbers; Preparedness Checklist for your Business.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Flu Vaccine Effectiveness: Questions and Answers for Health Professionals
This new document from the CDC provides answers to the following questions:
• How is influenza vaccine effectiveness measured?
• Why does influenza vaccine effectiveness vary?
• How effective is the inactivated influenza vaccine (IIV)?
• How effective is the live attenuated influenza vaccine (LAIV)?
• How does vaccine efficacy/effectiveness (VE) compare between live attenuated vaccine and inactivated vaccine?
• What information is necessary for yearly surveillance of vaccine effectiveness?
• What types of vaccine effectiveness studies are being conducted by CDC now?
(CDC 1/11/07 http://www.cdc.gov/flu/professionals/vaccination/effectivenessqa.htm )

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Business preparedness for pandemic influenza Summit
CIDRAP's second annual summit Feb 5-6, 2007, in Orlando, Florida, USA. The summit will gather leaders in business, government, and healthcare for a timely and practical discussion on how to effectively and efficiently prepare businesses for pandemic influenza. Traditional business risk mitigation, security and disaster response plans for naturally occurring and terrorism-related events are insufficient in preparing a business for pandemic influenza. What remains untested and unclear for executives responsible for private-sector pandemic preparedness is how other companies and organizations will respond. How stable will today’s public utilities be? Will companies that supply critical parts or services be able to deliver? How many employees will be able to come to work? These unknowns can be confounding enough to bring preparedness activities to a halt.

By attending the 2007 Summit, you will: 1) Discover risk-communication techniques to help combat “pandemic fatigue”; 2) Learn how to run meaningful business preparedness tabletop scenario exercises; 3) Gain access to the scientific and business facts necessary to gain "buy in" with internal and external constituents; 4) Benchmark your organization’s pandemic preparedness to discover how your budget allocations and major decisions stack up against others'.

For more information visit: https://programs.regweb.com/metro/cidrap07/1/
(CIDRAP http://www.cidrap.umn.edu/ )

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Paris Anti-Avian Influenza Conference
Paris (France), 31 May - 1 Jun 2007. www.isanh.com/avian-influenza/
After the great success of Paris Anti-Avian influenza 2006, the 2007 edition aims to bring again together the world specialists in the field in order to make a focus on avian influenza after the epidemic in 2006 and to discuss about the latest scientific advances, especially on new therapeutic targets for treatment and prevention (vaccines) in humans and animals, and the strategies to avoid a human pandemic by treating and preventing the epizootic.

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 apecein@u.washington.edu