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EINet Alert ~ Jan 26, 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: FAO says recent spread of avian influenza H5N1 doesn't match last year's
- Hungary: Report of avian influenza H5N1 infection in geese
- Indonesia (Jakarta): Government to ban backyard poultry
- Indonesia: New human cases of avian influenza H5N1 infection
- Thailand: Control policies against avian influenza H5N1
- Thailand (Nong Khai): Report of a new avian influenza H5N1 outbreak in poultry
- Viet Nam: Avian influenza H5N1 found in ducks in Can Tho City
- Viet Nam (Dong Thap): Ducks infected with avian influenza H5
- Japan (Miyazaki): Avian influenza H5N1 highly virulent; studies on origin
- Japan (Miyazaki): Suspected second outbreak of avian influenza H5N1 in poultry
- South Korea: Latest poultry outbreak caused by avian influenza H5N1 virus
- Hong Kong: Wild birds confirmed to have avian influenza H5N1 infection
- Australia: Launch of new surveillance project for wild birds
- Egypt: Eleventh human death from avian influenza H5N1 infection
- Nigeria (Kano): Outbreak of avian influenza H5N1

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

2. Articles
- Impact of Rapid Diagnosis on Management of Adults Hospitalized With Influenza
- Antiviral Resistance and the Control of Pandemic Influenza
- Modeling the Worldwide Spread of Pandemic Influenza: Baseline Case and Containment Interventions
- No Evidence of Avian Influenza A (H5N1) among Returning US Travelers
- Compensation for Avian Influenza Cleanup

3. Notifications
- Pandemic influenza preparedness: business continuity planning for the global healthcare industry
- Business preparedness for pandemic influenza
- CDC offers pandemic communication guidance
- Pandemic Influenza: Progress Made and Challenges Ahead
- IDSA urges requiring flu shots for healthcare workers in new 12 point plan


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
Egypt / 1 (1)
Indonesia / 5 (4)
Total / 6 (5)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 269 (163).
(WHO 1/15/07 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 1/15/07)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 1/25/07): http://gamapserver.who.int/mapLibrary/

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Global: FAO says recent spread of avian influenza H5N1 doesn't match last year's
The UN Food and Agriculture Organization (FAO) said that recent poultry outbreaks of H5N1 avian influenza have been less extensive than those a year ago but warned that many are going unreported. FAO expressed concern about recent outbreaks in China, Egypt, Indonesia, Japan, Nigeria, South Korea, Thailand, and Vietnam, but said, "The number of outbreaks in the first weeks of 2007 has been significantly lower than the epidemic waves of last year." In late 2005 and early 2006, the virus spread from East Asia to Siberia, Eastern Europe, the Middle East, and Africa. This pattern of intercontinental spread has not been repeated in recent months. "However, poultry trade and the transport of live birds could still spread the virus," it said. Juan Lubroth, a senior officer in the FAO's Animal Health Service, said, "Recent outbreaks are following a seasonal pattern and do not come as a great surprise. But we need to remain on the alert as the recent outbreaks show." Calling on governments to increase their surveillance, he said, "Unfortunately, many outbreaks remain unreported. National and international bodies are often not in a position to immediately verify rumors or reports about unconfirmed outbreaks."

Lubroth warned that banning backyard poultry would lead to illegal poultry production. His warning came less than a week after the city government in Jakarta, Indonesia, announced that backyard poultry would be banned as of Feb 1 in an effort to control avian flu. Instead of banning production, he said, authorities should encourage farmers to participate in virus control and vaccination campaigns. Given the prevalence of avian flu in Indonesia, FAO has suggested vaccination of chicks before they leave hatcheries, plus mass vaccination in heavily infected areas. FAO also said that the private sector should be more closely involved in avian influenza control campaigns.
(CIDRAP 1/23/07 http://www.cidrap.umn.edu/ ; Promed 1/24/07)

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Europe/Near East
Hungary: Report of avian influenza H5N1 infection in geese
Hungary announced an H5N1 avian influenza outbreak at a goose farm, signaling the first appearance of the disease in Europe this winter. Hungarian authorities notified the European Union of an H5N1 avian flu outbreak in Csongrad County in southeastern Hungary. The EU said veterinarians tested some geese after several deaths were reported in a 3,000-bird flock; the remaining geese were culled. Reportedly, residents said a large flock of wild ducks had passed through the area last month. Hungarian officials said they will send samples to a UK lab to confirm results. Chief veterinarian Miklos Suth said a surveillance zone was set up around the farm (3-km protection zone and 10-km surveillance zone), which is in an isolated location, making spread of the disease unlikely. Croatia banned imports of poultry from Hungary 24 Jan 2007. Hungary's first H5N1 outbreaks involved a handful of mute swans in the south-central region Apr 2006. The following June, the disease was detected on several goose farms in the same area. 26 nations in Europe reported their first H5N1 outbreaks in wild birds or poultry late 2005 and early 2006. The last previous outbreak in Europe occurred in Germany Aug 2006.
(CIDRAP 1/23/07, 1/24/07 http://www.cidrap.umn.edu/ ; Promed 1/24/07)

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Asia
Indonesia (Jakarta): Government to ban backyard poultry
Government authorities in Indonesia banned backyard poultry in the country's capital after 5 human cases were reported so far this month, all in Jakarta or its suburbs. In several instances, poultry deaths were reported in the patients' neighborhoods. Residents reportedly have until Jan 31 to surrender the banned fowl, including chickens, ducks, swans, quail, and pigeons. The government promised to pay USD1.40 for each bird surrendered for culling. A fully grown chicken costs about USD 4 in Jakarta. Indonesia has resisted widespread culling in the past, despite the high number of human illnesses. Backyard farmers are often reluctant to hand over their sick or at-risk birds. The country has about 350 million backyard chickens, many of which are in Jakarta and surrounding areas.

Health Minister Siti Fadilah Supari told residents culling is urgently needed. She said 18 Jan 2007 the ban in Jakarta would be extended to 8 other provinces that had reported human infections of the H5N1 bird flu virus. Starting Feb 1, government officials will go door-to-door confiscating banned birds, the governor of Jakarta said. Officials of Bogor, a town that neighbors Jakarta, branded the culling plan unrealistic and too expensive. A number of regencies said it was difficult to conduct mass culls due to the limited availability of funds to compensate owners and the absence of necessary regulations. West Java legislators and officials of the provincial livestock husbandry office are also questioning a decrease in the supply of bird flu vaccine from the central government at a time when the virus is spreading.
(CIDRAP 1/19/07 http://www.cidrap.umn.edu/ ; Promed 1/20/07, 1/24/07)

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Indonesia: New human cases of avian influenza H5N1 infection
WHO confirmed that a 26-year-old woman (she has been reported as 19 years of age in some reports) from West Java province experienced avian flu symptoms Jan 11 and died in the hospital 8 days later. Investigators said the woman had been involved in slaughtering sick chickens before she became ill. Also, Indonesia’s health ministry announced that a 6-year-old girl recently died of H5N1 avian influenza, marking the country’s sixth case this year. The girl, from central Java, reportedly died 6 days ago in a Yogyakarta hospital. Her neighbors reportedly had dead chickens. If the girl’s case is confirmed by WHO, it will be counted as Indonesia’s 81st case and 63rd death. Indonesia has had the most human cases of the several countries with recent avian flu outbreaks.

5 people in Indonesia’s South Sulawesi province are hospitalized with possible avian flu symptoms at Wahidin Sudirohusodo hospital in Makassar. The patients, 3 of whom are children, are reportedly improving. All come from the same area, Tamamaung village in Panakkukang district, Makassar, where chicken deaths had been reported. They were sent to the hospital after coming down with high fever and breathing problems. A quick test result reportedly found that one was infected with influenza virus type A. There are also reports of suspected avian flu cases from Bandung and Semarang, Central Java. Since the beginning of Jan 2007, 5 human cases of H5N1 avian influenza have been confirmed in Indonesia, 4 of whom have died. Human cases have been reported from 8 provinces (Banten, Jakarta, West Java, East Java, Lampung, West Sumatra, North Sumatra, South Sulawesi).
(CIDRAP 1/22/07, 1/25/07 http://www.cidrap.umn.edu/ ; Promed 1/24/07, 1/25/07)

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Thailand: Control policies against avian influenza H5N1
All 16 districts in the central province have been declared disaster zones to help public health authorities with the mass culling of poultry in bird flu-prone areas. A ban on fowl movement throughout the province, especially free-range ducks from other provinces, has also been enforced. Provincial Governor Cherdpan na Songkhla, who issued the order 20 Jan 2007, said areas where bird flu had previously been confirmed, such as Bang Pahan, Phak Hai and Bang Pa-in districts, were still at risk because the virus remained dormant in water resources and residential areas. To prevent a possible new outbreak of the H5N1 virus, the Agriculture and Cooperatives Ministry has sought cooperation from the Customs Department to monitor and ban the import of poultry and breeding equipment from neighboring countries hit by avian influenza. Public health authorities are considering a new partner in China to jointly develop influenza vaccines. Public Health Minister Mongkol na Songkhla decided to look for a new Chinese biotechnology firm which could provide better technology and a larger production capacity than the Chinese firm previously targeted for the job. Dr. Mongkol in Oct 2006 called for a re-think of plans to vaccinate animals developed after the country faced a series of avian flu outbreaks since 2004. He said the virus had mutated and that it was difficult to diagnose the symptoms in new human fatalities. The bird flu policy committee, chaired by Deputy Prime Minister Kosit Panpiemras, will make a decision on limited vaccine use in bird-flu-plagued areas 29 Jan 2007. However, virologist Prasert Thongcharoen said a thorough study on the effectiveness of animal vaccines used in neighboring countries was essential before undertaking the measure here.
(Promed 1/22/07)

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Thailand (Nong Khai): Report of a new avian influenza H5N1 outbreak in poultry
Thailand's livestock authorities confirmed 23 Jan 2007 the country's second case of bird flu outbreak in 2007, saying they had detected the H5N1 virus among chickens in the northeastern border province of Nong Khai. The results of laboratory tests reportedly confirmed H5N1 virus in some 200 chickens at a poultry farm in Nong Khai. Earlier reports said that some 2000 chickens at the farm had been culled, in Si Chiangmai district, Nong Khai province, some 615 km northeast of Bangkok, bordering Laos, after 230 chickens at the farm died of unknown causes. The district has been declared an outbreak area with monitoring to prevent the illegal movement of poultry. The first bird flu outbreak of 2007 was reported 15 Jan when authorities confirmed that the H5N1 virus was found in dead ducks in northern province of Phitsanulok.

Also, 12 children and 1 man from Phichit and Ang Thong provinces are reportedly under watch after they became ill following suspicious chicken deaths in their areas. 8 of the children experienced high fevers after a chicken carcass was found in their schoolyard.
(Promed 1/24/07, CIDRAP 1/25/07 http://www.cidrap.umn.edu/ )

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Viet Nam: Avian influenza H5N1 found in ducks in Can Tho City
Bird flu has killed ducks in the southern Mekong delta's largest city of Can Tho, bringing to 8 the number of provinces in the Mekong Delta affected by recent poultry outbreaks. The virus killed 30 ducklings, and the remaining 40 ducks in the flock were culled to stop the disease. The Animal Health Department said that tests showed H5N1 had killed ducklings in Can Tho 4 days after the virus was found in neighboring Soc Trang province. The domesticated ducks had not been vaccinated. The Agriculture Ministry has ordered a new round of poultry vaccinations and sent more animal health experts to try to stem the bird flu, which has struck 7 provinces and Can Tho city in the southern rice basket region. This week, the government ordered farmers to stop ducks from roaming in the Mekong delta. The government is anxious to stop bird flu spreading ahead of the Tet Lunar New Year festival in mid-Feb 2007, when poultry is part of the traditional feast. Officials fear the disease could spread nationwide by migrating birds and through the movement of poultry, including the smuggling of chickens and ducks from neighboring countries. Reportedly, 23 people who ate ducks that died from unknown causes in Bac Lieu province have been put under surveillance.
(Promed 1/20/07; CIDRAP 1/19/07 http://www.cidrap.umn.edu/ )

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Viet Nam (Dong Thap): Ducks infected with avian influenza H5
Specimens from healthy ducks in Dong Thap province have reportedly tested positive to bird flu virus strain H5. The tested ducks are reportedly in the 3 districts of Thanh Binh, Lap Vo and Thap Muoi, and Sa Dec town. Due to the existence of the virus in healthy ducks, the risk of bird flu breaking out in Dong Thap is high, the provincial Department of Agriculture and Rural Development said, adding that the province finds it difficult to monitor the cross-border transport of poultry and quarantine fowl transported to the province. Bird flu is hitting 38 communes in 18 districts in the 7 southern localities of Ca Mau, Bac Lieu, Hau Giang, Kien Giang, Vinh Long, Soc Trang and Can Tho. Southern Tra Vinh province has not detected new bird flu outbreaks in the last 21 days, meeting criteria for announcing an end to bird flu outbreaks in its territory.
(Promed 1/22/07)

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Japan (Miyazaki): Avian influenza H5N1 highly virulent; studies on origin
The avian influenza that broke out last week at a poultry farm in Miyazaki Prefecture involved a highly virulent virus, the Agriculture, Forestry and Fisheries Ministry said 18 Jan 2007. The ministry determined the degree of virulence through a laboratory examination of virus samples taken from chickens that died of bird flu on the farm. The National Institute of Animal Health, which identified the virus as the highly pathogenic H5N1 strain 16 Jan 2007, drew the conclusion after 8 chickens inoculated with the sampled virus were dead by 18 Jan 2007. The institute will continue genetic analysis. Its latest outbreak in poultry in Japan--the fifth bird-flu case here since 2004--caused the death of 3500 birds. Inspectors from the Miyazaki Prefectural Government's task force checked bird-keeping households and homes within a 10 km radius of the farm after they finished examining the 11 poultry farms with more than 1000 chickens in the area. 10 households with at least 20 birds, including chickens and bantams [small breeds of chickens], were selected 18 Jan 2007 for on-site inspections to take blood and fluid samples.

Also, the avian flu in Miyazaki was found to be almost identical to the one that sparked an epidemic in China that has been spreading since 2005. Experts said the highly virulent strain of the virus might have been carried by migratory birds from China to Japan. The National Institute of Animal Health has been analyzing the virus after obtaining samples from dead chickens at a poultry farm in Kiyotake, Miyazaki Prefecture, in mid-Jan 2007. The test results showed that the strain found on the Kiyotake farm was at least a 99-percent match in terms of DNA sequencing with the H5N1 strain confirmed in China May 2005. The strain at the Kiyotake farm is apparently genetically different from the other H5N1 strain of avian flu that has caused outbreaks in Southeast Asia. Several thousand migratory birds have been killed by avian flu at Qinghai Lake, in the western part of China. The Ministry of Agriculture, Forestry and Fisheries is trying to determine the route of the infection that ended up killing thousands of chickens at the Kiyotake farm. The same H5N1 strain is believed to have caused an epidemic in South Korea Nov 2006.
(Promed 1/20/07, 1/24/07)

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Japan (Miyazaki): Suspected second outbreak of avian influenza H5N1 in poultry
A fresh outbreak of bird flu was suspected 23 Jan 2007 after 250 birds died at a poultry farm in southwestern Japan. The birds had reportedly died at a farm in Miyazaki Prefecture, where earlier this month the government confirmed a case of the H5N1 strain of the virus -- Japan's first such case in 3 years. Local officials were conducting tests to see whether the deaths were from bird flu. Reportedly, one of 11 tested birds was positive for avian flu, but it was not yet known if it had the H5N1 virus. Miyazaki on Japan's southernmost island of Kyushu is the country's top breeder of chickens.
(Promed 1/24/07; CIDRAP 1/23/07 http://www.cidrap.umn.edu/ )

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South Korea: Latest poultry outbreak caused by avian influenza H5N1 virus
South Korea is set to slaughter poultry after an outbreak of the H5N1 strain of bird flu, the Agriculture Ministry and health officials said 20 Jan 2007. The outbreak occurred at a chicken farm in Cheonan, about 60 miles south of Seoul, earlier this week, the fifth such outbreak since Nov 2006, said Lee Joo-won, a ministry official. "We plan to start slaughtering 273 000 poultry within a 500-meter radius of the outbreak site and destroying eggs as early as Saturday [20 Jan 2007] evening," Lee said. The ministry also said it will make a decision on whether to kill another 386 000 poultry 21 Jan 2007 while limiting the movement of about 2.16 million chickens and ducks from 90 farms within a 6-mile radius of the outbreak. South Korea culled 5.3 million birds during the last known outbreak of bird flu in 2003.
(Promed 1/22/07)

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Hong Kong: Wild birds confirmed to have avian influenza H5N1 infection
The Agriculture, Fisheries and Conservation Department (AFCD) said 22 Jan 2007 that the Japanese White-eye, the House Crow and the White-backed Munia found earlier were confirmed to be H5N1 positive after a series of laboratory tests. The carcass of the Japanese White-eye (Zosterops japonicus), was collected by AFCD staff 15 Jan 2007 on Convair Drive, San Po Kong. The House Crow and the White-backed Munia (Lonchura striata), were found 16 Jan 2007 from Lai On Estate, Sham Shui Po and at 101 ¬ 109 Boundary Street, Mong Kok, respectively. AFCD reminded the public to observe good personal hygiene.

Also, Hong Kong should tighten imports of wild birds from China, which are released en masse at Buddhist religious rites, due to the risk they could spread bird flu to poultry, experts say. 6 scaly-breasted munias--a popular species of "prayer birds" used for release in Buddhist rituals to enhance a devotee's karma--were found dead on New Year's eve, including 1 which tested positive for the H5N1 virus. Prayer bird species range from munias, Japanese white-eye, white-rumped munia and tree sparrows costing as little as HK 4 (USD 0.50) each, to the more expensive azure-winged magpies and Mongolian larks. While the Hong Kong government tightly regulates poultry imports, laws for wild bird imports are much more lax, making it a potential crack in the city's bird flu defenses. The territory banned imports of poultry from Japan 15 Jan 2007 after a fresh outbreak of bird flu there. Richard Corlett, a professor of ecology at the University of Hong Kong, said the trade in wild birds was on a much larger scale than previously thought, with at least half a million birds freed by Buddhists in 2005. The European Union passed new laws last week banning imports of wild birds. The government has not said whether it would consider a ban on wild bird imports but has urged Buddhist organizations not to release such birds in the future.
(Promed 1/24/07)

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Australia: Launch of new surveillance project for wild birds
Graham Burgess from James Cook University in Australia is launching a 3-year surveillance project to monitor birds, especially waterfowl, in north Queensland for their potential to transmit H5N1 to Australia. Between one to ten percent of the waterfowl in Queensland are expected to carry some form of avian influenza, but the highly pathogenic H5N1 has not been found in Australia or in nearby Papua New Guinea. Dr. Burgess has stated that it is not likely that infected wild birds will be the way that H5N1 is introduced into Australia.
(USGS 1/19/07 http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp )

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Africa
Egypt: Eleventh human death from avian influenza H5N1 infection
As of 22 Jan 2007, Egypt announced a new human case of avian influenza A(H5N1) virus infection. The case was confirmed by the Egyptian Central Public Health Laboratory and by the US Naval Medical Research Unit No.3 (NAMRU-3). The 27-year-old woman from Beni Sweif Governate developed symptoms 9 Jan 2007 and died in hospital 19 Jan 2007. Initial investigations indicate the presence of sick and dead poultry at her residence in the days prior to the onset of illness. Of the 19 cases confirmed to date in Egypt, 11 have been fatal. The other 8 have recovered.
(Promed 1/20/07, 1/23/07)

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Nigeria (Kano): Outbreak of avian influenza H5N1
The H5N1 strain of bird flu has resurfaced in Kano, northern Nigeria's commercial capital. In the last 2 months it has reportedly been confirmed that at least 7 poultry farms in the city have tested positive for bird flu, resulting in the culling of about 10 000 birds. Katsina and Sokoto, 2 northern states, have recorded outbreaks of a disease suspected to be avian flu. Laboratory tests are still being conducted. Kano was worst affected by the bird flu outbreak since the disease was first detected on a farm in Jaji Feb 2006. According to Nigeria's Department of Veterinary Research, since the bird flu outbreak began Feb 2006, a total of 945 862 birds have been lost, of which 602 160 were culled. Bawa blamed migratory birds from Europe for the outbreak in Nigeria, although improved bio-security measures by farmers helped in minimizing its spread.

Also, officials are investigating 2 suspected human H5N1 cases. A mother and daughter from Lagos, Nigeria’s largest metropolitan area, died within 2 weeks of eating chicken bought from a live-chicken market. The father of the family said that after one of the chickens they bought died mysteriously, the family slaughtered the rest. Reportedly WHO was awaiting test results on the woman, her daughter, and a chicken.
(Promed 1/24/07; CIDRAP 1/25/07 http://www.cidrap.umn.edu/ )

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1. Updates
Avian/Pandemic influenza updates
- UN: http://influenza.un.org/. UN response to avian influenza and the pandemic threat. 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.
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html. 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
Seasonal influenza activity in APEC economies
During weeks 51-52, overall influenza activity worldwide remained low, except in the US.

Canada. Localized activity of influenza A was reported in parts of Canada during weeks 51–52, with an overall influenza-like illness (ILI) consultation rate below the expected range for the time of year.

USA. Influenza activity increased during weeks 51–52 and was widespread. The overall ILI consultation rate was above the national baseline, but the percentage of deaths due to pneumonia and influenza remained below the baseline level. During week 52, 82% of the influenza viruses detected were influenza A and 18% influenza B. Of the A viruses subtyped, 95% were influenza A(H1) and 5% A(H3) viruses.

Other Reports. During weeks 51–52, low influenza activity was reported in Hong Kong (H1, H3 and B), Japan, and Russia (H1, H3 and B). Mexico reported no influenza activity.
(WHO http://www.who.int/csr/disease/influenza/update/en/ 1/16/07)

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2. Articles
Impact of Rapid Diagnosis on Management of Adults Hospitalized With Influenza
Ann R. Falsey, Yoshihiko Murata, and Edward E. Walsh.
Arch Intern Med. 2007;167:(doi:10.1001/archinte.167.4.ioi60207).
Abstract: “Background: Rapid influenza testing decreases antibiotic and ancillary test use in febrile children, yet its effect on the care of hospitalized adults is unexplored. We compared the clinical management of patients with influenza whose rapid antigen test result was positive (Ag+) with the management of those whose rapid antigen test result was negative or the test was not performed (Ag0). Methods: Medical record review was performed on patients with influenza hospitalized during 4 winters (1999-2003). Hospital policy mandated influenza testing (antigen or culture) for all patients with acute cardiopulmonary diseases admitted from November 15 through April 15. A subset of patients participated in an epidemiological study and had reverse-transcriptase polymerase chain reaction or serologic testing performed. Clinical data from Ag+ and Ag0 patients were compared. Results: Of 166 patients with available records, 86 were Ag+ and 80 were Ag0. Antibiotic use (74 [86%] of 86 patients vs 79 [99%] of 80 patients; P = .002) was less and antibiotic discontinuance (12 [14%] of 86 patients vs 2 [2%] of 80 patients; P=.01) was greater in Ag+ compared with Ag0 patients. No significant differences in antibiotic days, length of hospital stay, or antibiotic complications were noted. Antiviral use (63 [73%] of 86 patients vs 6 [8%] of 80 patients; P<.001) was greater in Ag+ than Ag0 patients. Antigen status was independently associated with withholding or discontinuing antibiotics in multivariate analysis. Of 44 Ag+ patients deemed low risk for bacterial infection, 27 continued to receive antibiotics despite positive influenza test results. These patients more commonly had pulmonary disease and had significantly more abnormal lung examination results (P = .005) compared with those in whom antibiotics were withheld or discontinued. Conclusions: Rapid influenza testing leads to reductions in antibiotic use in hospitalized adults. Better tools to rule out concomitant bacterial infection are needed to optimize the impact of viral testing.”
http://archinte.ama-assn.org/cgi/content/abstract/167.4.ioi60207v1

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Antiviral Resistance and the Control of Pandemic Influenza
Marc Lipsitch et al. PLoS Medicine Vol. 4, No. 1, e15
doi:10.1371/journal.pmed.0040015.
Abstract: “Background: The response to the next influenza pandemic will likely include extensive use of antiviral drugs (mainly oseltamivir), combined with other transmission-reducing measures. Animal and in vitro studies suggest that some strains of influenza may become resistant to oseltamivir while maintaining infectiousness (fitness). Use of antiviral agents on the scale anticipated for the control of pandemic influenza will create an unprecedented selective pressure for the emergence and spread of these strains. Nonetheless, antiviral resistance has received little attention when evaluating these plans. Methods and Findings: We designed and analyzed a deterministic compartmental model of the transmission of oseltamivir-sensitive and -resistant influenza infections during a pandemic. The model predicts that even if antiviral treatment or prophylaxis leads to the emergence of a transmissible resistant strain in as few as 1 in 50,000 treated persons and 1 in 500,000 prophylaxed persons, widespread use of antivirals may strongly promote the spread of resistant strains at the population level, leading to a prevalence of tens of percent by the end of a pandemic. On the other hand, even in circumstances in which a resistant strain spreads widely, the use of antivirals may significantly delay and/or reduce the total size of the pandemic. If resistant strains carry some fitness cost, then, despite widespread emergence of resistance, antivirals could slow pandemic spread by months or more, and buy time for vaccine development; this delay would be prolonged by nondrug control measures (e.g., social distancing) that reduce transmission, or use of a stockpiled suboptimal vaccine. Surprisingly, the model suggests that such nondrug control measures would increase the proportion of the epidemic caused by resistant strains. Conclusions: The benefits of antiviral drug use to control an influenza pandemic may be reduced, although not completely offset, by drug resistance in the virus. Therefore, the risk of resistance should be considered in pandemic planning and monitored closely during a pandemic.” http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040015

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Modeling the Worldwide Spread of Pandemic Influenza: Baseline Case and Containment Interventions
Vittoria Colizza et al. PLoS Medicine Vol. 4, No. 1, e13
doi:10.1371/journal.pmed.0040013.
Abstract: “Background: The highly pathogenic H5N1 avian influenza virus, which is now widespread in Southeast Asia and which diffused recently in some areas of the Balkans region and Western Europe, has raised a public alert toward the potential occurrence of a new severe influenza pandemic. Here we study the worldwide spread of a pandemic and its possible containment at a global level taking into account all available information on air travel. Methods and Findings: We studied a metapopulation stochastic epidemic model on a global scale that considers airline travel flow data among urban areas. We provided a temporal and spatial evolution of the pandemic with a sensitivity analysis of different levels of infectiousness of the virus and initial outbreak conditions (both geographical and seasonal). For each spreading scenario we provided the timeline and the geographical impact of the pandemic in 3,100 urban areas, located in 220 different countries. We compared the baseline cases with different containment strategies, including travel restrictions and the therapeutic use of antiviral (AV) drugs. We investigated the effect of the use of AV drugs in the event that therapeutic protocols can be carried out with maximal coverage for the populations in all countries. In view of the wide diversity of AV stockpiles in different regions of the world, we also studied scenarios in which only a limited number of countries are prepared (i.e., have considerable AV supplies). In particular, we compared different plans in which, on the one hand, only prepared and wealthy countries benefit from large AV resources, with, on the other hand, cooperative containment scenarios in which countries with large AV stockpiles make a small portion of their supplies available worldwide. Conclusions: We show that the inclusion of air transportation is crucial in the assessment of the occurrence probability of global outbreaks. The large-scale therapeutic usage of AV drugs in all hit countries would be able to mitigate a pandemic effect with a reproductive rate as high as 1.9 during the first year; with AV supply use sufficient to treat approximately 2% to 6% of the population, in conjunction with efficient case detection and timely drug distribution. For highly contagious viruses (i.e., a reproductive rate as high as 2.3), even the unrealistic use of supplies corresponding to the treatment of approximately 20% of the population leaves 30%–50% of the population infected. In the case of limited AV supplies and pandemics with a reproductive rate as high as 1.9, we demonstrate that the more cooperative the strategy, the more effective are the containment results in all regions of the world, including those countries that made part of their resources available for global use.”
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040013

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No Evidence of Avian Influenza A (H5N1) among Returning US Travelers
Justin R. Ortiz et al. EID. Volume 13, Number 2–February 2007.
Abstract: “We reviewed reports to the Centers for Disease Control and Prevention of US travelers suspected of having avian influenza A (H5N1) virus infection from February 2003 through May 2006. Among the 59 reported patients, no evidence of H5N1 virus infection was found; none had direct contact with poultry, but 42% had evidence of human influenza A.”
http://www.cdc.gov/eid/content/13/2/294.htm

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Compensation for Avian Influenza Cleanup
Sayako Kanamori and Masamine Jimba. EID. Volume 13, Number 2–February 2007. (references removed)
To the Editor: “. . .Preemptive culling creates a major concern with regard to compensation. In Nigeria, for example, affected farmers have yet to be compensated >50 million Nigerian Naira (>US$ 0.4 million) because of the ministry's cash flow problems. On the other hand, US poultry farmers who participate in a US Department of Agriculture (USDA) program to prevent the spread of disease would be fully compensated for loss of poultry and equipment if even a low-pathogenic strain of avian influenza was found in the United States. This rule not only strengthens US protection against avian influenza but also minimizes any negative effect on the US poultry trade. As discussed by the World Bank, the situations of these 2 countries raise several questions: Who should pay the compensation? For what should compensation be paid? Who should be compensated? With regard to the first question, each country's government is an exclusive funding source. However, in Nigeria, the amount of compensation overwhelms the government's capacity. Some countries, like Australia, may get additional funding from alternative sources such as private sectors, regional economic groups, or international funds. Because national resources are often scarce, most developing countries must rely on international donors for a great deal of the funding for compensation programs.

The response to the second question, extent of compensation, varies. In Nigeria, farmers are partially compensated for loss of poultry; however, in the United States, farmers who are part of the USDA program are fully compensated for loss of poultry and equipment. Setting the amount of compensation is difficult and can affect the outcome of culling efforts. In Thailand, to take advantage of the program in which compensation was perceived as high, some farmers reportedly moved infected poultry into previously uninfected areas. In Vietnam, where compensation was perceived as low, culling compliance was poor.

The last question, who should be compensated, seems straightforward for the United States, where only farmers who participate in the USDA program would be fully compensated. However, H5N1 does not affect only farmers who sign up for such a program. And not all poultry are raised in commercial operations, especially in developing countries. In Thailand, for example, >80% of infected poultry are reportedly raised in backyards. Reasonable assumptions are that those backyard farmers do not honestly report dying poultry or that they rush sick and dying poultry to market, causing the disease to spread. Additional questions revolve around potential compensation for those who are involved in the poultry industry but who do not own poultry (e.g., poultry processing plant operators and their staff). Because each country's needs and circumstances differ, building a coherent plan for tackling HPAI is difficult. However, each stakeholder should consider compensation as part of an overall package of prevention, preparedness, and response strategies toward controlling and preventing the spread of HPAI. Because H5N1 does not respect international boundaries, donors worldwide should step forward to support the most affected and vulnerable developing countries.”
http://www.cdc.gov/eid/content/13/2/341.htm

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3. Notifications
Pandemic influenza preparedness: business continuity planning for the global healthcare industry
Report from the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA), released Jan 22, 2007:
“Many organisations have business continuity plans in place to address the impact of a crisis on their continuing operations. While these plans are likely to cover a variety of scenarios, it is important that they are reviewed and updated to address the specific case of an influenza pandemic. Unlike other crises, an influenza pandemic could result in a peak employee absenteeism rate of 30% – 50% and last for an extended period of time. Therefore, pharmaceutical manufacturers’ continuity plans must focus on maintaining the manufacture and supply of essential medicines to patients and communities around the world during an influenza pandemic. This paper outlines the key areas that pandemic influenza business continuity plans should address. The IFPMA recommends that members develop detailed plans to address the issues covered in this paper, and publish a non-confidential overview on their websites to enhance confidence and demonstrate their preparedness to key stakeholders: employees, governments, suppliers, customers, health care professionals and local communities. . .”
http://www.ifpma.org/documents/NR6468/IFPMABusinessContPlanningHCIndustryJan2007.pdf

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Business preparedness for pandemic influenza
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: https://programs.regweb.com/metro/cidrap07/1/. Also, CIDRAP has an article 1/24/07 about the summit: http://www.cidrap.umn.edu/cidrap/content/influenza/biz-plan/news/jan2407summit.html.
(CIDRAP http://www.cidrap.umn.edu/ )

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CDC offers pandemic communication guidance
There's no standard playbook on communicating with the public during an influenza pandemic, but CDC is working to educate public health officials and businesses about how to tailor successful messages. Barbara Reynolds, a CDC public affairs specialist and crisis communications expert, said that engaging the public during a pandemic will be a different problem than those encountered in any other type of crisis because communicators will be enlisting the public's help in reducing illness and death. The 3 most important components to include in messages to the public or employees in the event of a pandemic are empathy, some type of action to take, and respect, she said.

Communicators need to show empathy within the first 30 seconds of a crisis message. "If not, they won't hear your message because they're so overwrought with their emotions," said Reynolds. During a pandemic, a public health communicator's job is to help people manage their emotions so that they can still function and not be "hopeless or helpless," Reynolds said. She outlined several mistakes to avoid, such as: Mixed or late messages: When it's critical to send a message quickly, "Don't worry about grammar or punctuation," she said. Paternalism: "It's not reasonable to tell people to not be afraid. Address that they are afraid, then give them information that may help alleviate that fear," Reynolds said. Ignoring rumors or myths: The longer rumors are allowed to circulate, the more likely they are to take hold. Power struggles between government agencies, which erode pubic confidence in crisis response.

Communities and businesses should be planning their communications strategies now for scenarios such as the first H5N1 avian flu outbreak in poultry on US soil, she said. Withholding information during a pandemic is risky, Reynolds said, because honesty and openness during a crisis help build the public's trust. She said news reporters are more likely to interpret events themselves when they have fewer facts and less background information. Public health communicators should also be careful not to unnecessarily or unconsciously link people or things to specific health threats.
(CIDRAP 1/23/07 http://www.cidrap.umn.edu/ )

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Pandemic Influenza: Progress Made and Challenges Ahead
The update statement by Dr. Julie L. Gerberding, Director of CDC, includes topics on: ongoing domestic and international surveillance, other preparedness initiatives in 2006, and examples of CDC actions planned for 2007 and beyond. It also describes the agency's progress towards the President's National Strategy for Pandemic Influenza.
(CDC 1/24/07 http://www.cdc.gov/about/news/2007/01/gerberding-testimony-avian.htm )

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IDSA urges requiring flu shots for healthcare workers in new 12 point plan
Influenza shots should be mandatory for healthcare workers, and public health officials should think of seasonal flu as a dress rehearsal for pandemic flu, the Infectious Diseases Society of America (IDSA) said as it unveiled a 12-point plan to strengthen the nation's preparedness. IDSA's recommendations laud the government for the $6 billion allocated so far to pandemic preparedness and the Dec 2006 passage of the Pandemic and All-Hazards Preparedness Act. "But most of the work remains ahead of us, and we need to keep attention focused on what needs to be done," said Andrew Pavia, chair of the IDSA National and Global Public Health Committee. Investments in pandemic influenza planning can help public health officials better manage seasonal flu, said Kathleen M. Neuzil, chair of IDSA's Pandemic Influenza Task Force. Stabilizing vaccine production and distribution for seasonal influenza will lay the groundwork for an effective response when a pandemic strain emerges, she said. Though the US government has allocated more than $6 billion to pandemic planning, most of the money is one-time emergency funding that falls short of what's needed to support long-term national, state, and local efforts, IDSA said.

The strongest language in the IDSA's proposals was aimed at boosting seasonal flu immunization rates among healthcare workers. The current rate for this group is about 40%, ISDA report says. IDSA recommends that healthcare workers be required to receive flu shots unless they decline, for religious or philosophical reasons or because of a medical contraindication. Other recommendations are aimed at supporting the development of new vaccines and improving the supply and selection of antiviral medications. The US should serve as a catalyst for a well-financed international effort to quickly develop pandemic influenza vaccines, the report says. IDSA envisions the effort as a large public-private partnership. IDSA supports using incentives for the pharmaceutical industry to develop flu vaccines and treatment. The group emphasizes that antibiotic innovations should also be a focus of pandemic flu planning, because patients who have severe influenza often develop lethal secondary bacterial infections. Planning for mass casualty events and updating plans for distributing vaccines and antivirals are other major themes of the IDSA's recommendations.

Among suggestions for protecting the healthcare workforce during a pandemic, IDSA proposes that Congress establish a compensation fund to help those who are injured by a pandemic influenza vaccine given during an emergency, as well as liability protection for healthcare workers following altered standards of care, consistent with local and national recommendations, during a public health emergency. Other recommendations include developing and testing community mitigation measures, improving flu surveillance, and strengthening leadership and communication.
(CIDRAP 1/25/07 http://www.cidrap.umn.edu/ )

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 apecein@u.washington.edu