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EINet Alert ~ Feb 09, 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)
- Netherlands, Norway: Precautionary measures advised following avian influenza in England
- Russia (Krasnodor): Outbreak of avian influenza among domestic birds
- United Kingdom (England): Avian influenza H5N1 outbreak among turkeys
- Indonesia: 2 additional human cases of avian influenza H5N1 reported
- Japan (Miyazaki): Fourth avian influenza H5N1 outbreak in 2007 in poultry
- Pakistan: New avian influenza H5N1 outbreaks among chickens and peacocks
- Turkey (Batman): Outbreak of avian influenza H5N1 suspected in chickens
- Viet Nam (Ninh Binh): Outbreak of avian influenza H5N1 suspected in chickens
- Egypt (Fayyoum): Twelfth human death from avian influenza H5N1
- Nigeria: First human death from avian influenza H5N1 confirmed

1. Updates
- Avian/Pandemic influenza updates

2. Articles
- Highly pathogenic avian influenza virus subtype H5N1 in Mute swans in the Czech Republic
- Influenza Transmissibility: A Two-Amino Acid Change in the Hemagglutinin of the 1918 Influenza Virus Abolishes Transmission
- Attitudes of health care workers to influenza vaccination: Why are they not vaccinated?
- Students Wear Masks to Try to Stop Flu
- Indonesia May Sell, Not Give, Bird Flu Virus to Scientists
- Avian Influenza A (H5N1) Age Distribution in Humans
- Bird Migration Routes and Risk for Pathogen Dispersion into Western Mediterranean Wetlands
- Effectiveness of Neuraminidase Inhibitors for Preventing Staff Absenteeism during Pandemic Influenza
- Risk for Infection with Highly Pathogenic Influenza A Virus (H5N1) in Chickens, Hong Kong, 2002
- Update: WHO-confirmed human cases of avian influenza A(H5N1) infection, 25 November 2003–24 November 2006
- Preparing for the next flu pandemic
- Role of combination antiviral therapy in pandemic influenza and stockpiling implications

3. Notifications
- Proposed US budget boosts pandemic readiness
- Report from the 2007 University of Minnesota CIDRAP Summit: Business preparedness for pandemic influenza
- OSHA releases workplace guidelines for pandemic influenza
- FAO: Avian influenza in cats should be closely monitored


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 / 2 (2)
Indonesia / 6 (5)
Nigeria/ 1(1)
Total / 9 (8)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 272 (166).
(WHO 2/6/07 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 1/29/07)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 2/6/07): http://gamapserver.who.int/mapLibrary/

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Europe/Near East
Netherlands, Norway: Precautionary measures advised following avian influenza in England
The Ministry of Agriculture of the Netherlands ordered poultry farmers throughout the Netherlands to bring all livestock indoors. Meanwhile, the Norwegian Food Safety Authority has declared parts of Norway as high-risk areas, and the public is asked to report dead wild birds to the Food Safety Authority. In the high-risk areas poultry keepers must ensure that their animals do not come into direct contact with wild birds, and gatherings and shows for domestic birds are forbidden. Owners of poultry and other birds in the high-risk areas that have not earlier registered their animals are obliged to register their animals in a central register. The heightened measures are introduced following confirmation of H5N1 avian influenza in a poultry holding in South East England.
(ProMED 2/5/07 http://www.promedmail.org )

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Russia (Krasnodor): Outbreak of avian influenza among domestic birds
The All-Russian Animals Protection Research Institute confirmed that 45 domestic birds died of bird flu at small farms in the Krasnodar territory. Anti-epizootic, preventive anti-epidemic, and disinfection measures are being taken in order to prevent bird flu from spreading, the regional consumer rights watchdog said. Seasonal flu incidence does not exceed the epidemiological threshold at this time. These newest bird flu cases are the first in the Krasnodar territory this year. In 2006 more than 300,000 birds died of bird flu at one poultry farm.
(ProMED 2/5/07 http://www.promedmail.org )

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United Kingdom (England): Avian influenza H5N1 outbreak among turkeys
Government veterinarians confirmed an outbreak of H5N1 avian influenza at a large turkey farm in Suffolk, England, marking the country's first poultry outbreak and Europe's second in 2007. The viral strain is reported to be similar to that found in Hungary Jan 2007. A World Organization for Animal Health (OIE) report said the outbreak began Jan 27, 2007 and affected 2,500 turkeys that were being raised for meat production. The farm is the largest plant operated by the company; only 1 of 22 turkey sheds was affected by the outbreak. Workers at the farm have been offered antiviral medications. Authorities initially established a 3-km restricted zone and a 10-km surveillance zone around the farm but later widened the restricted zone. The agency also banned all bird gatherings, including shows, markets, fairs, and pigeon races, until further notice.

Agriculture authorities have culled between 150,000 and 160,000 turkeys at the farm. Authorities first speculated that the source of infection could be one of several possibilities, including an infected wild bird, human spread of the virus into Britain, for example on footwear, and infected food material. Deputy Chief Vet Fred Landeg said a possible route of infection was from imported "poultry products." The bird flu outbreak may be linked to imports from the firm's plant in Hungary, the government has said. The government confirmed that the strain of the H5N1 virus was the same strain found last month in Hungary, where an outbreak prompted the slaughter of birds. A flock of 3000 geese on the infected farm near Szentes in southern Hungary was destroyed last month after they were found to have H5N1. The company has temporarily suspended shipments to and from its Hungarian operations, pending further investigation.

Europe may see more H5N1 outbreaks in poultry this year, but the situation is not as bad as in 2006. The UN FAO expressed confidence in the capacity of authorities in the UK to adequately respond to the recent outbreak of H5N1 avian influenza at a commercial turkey farm there. The European Union discouraged any move toward banning British poultry based on this outbreak. South Korea, Hong Kong, Russia, Macedonia South Africa, Indonesia, and Japan have banned imports from Britain, and the Netherlands and Norway ordered all poultry to be taken indoors or to be secured. Ireland banned some imports and France ordered an investigation of the risks.
(CIDRAP 2/5/07 http://www.cidrap.umn.edu/ , FAO 2/7/07 http://www.fao.org , ProMED 2/2/07, 2/3/07, 2/05/07, 2/6/07, 2/8/07 http://www.promedmail.org )

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Asia
Indonesia: 2 additional human cases of avian influenza H5N1 reported
2 new human cases of H5N1 avian influenza were announced by Indonesian authorities. 1 patient is a 15-year-old girl from an upscale Jakarta neighborhood who caught a wild bird that died 2 days later, Joko Suyono, a spokesperson for the health ministry's bird flu information center, said. He said the other patient is a 30-year-old man from West Java province neighborhood where a number of chicken deaths have been reported. The West Java patient tested positive for the H5N1 bird flu virus after receiving laboratory test results from the Jakarta-based Health Research and Development Agency. His wife said that they had raised only 3 chickens in their kitchen and that they were healthy. She said dozens of her neighbor's fowl had died suddenly, however, about 500 m from their house. "My husband got seriously ill one week before being admitted to hospital," she said. If the WHO confirms the other patients' avian flu status, she will become Indonesia's 83rd case of H5N1. 6 people have died from avian influenza in Indonesia this year. Indonesia has seen 63 human deaths from the disease. To slow the spread of the disease, Indonesian authorities banned backyard poultry in Jakarta and planned to begin a massive cull throughout the urban area Feb 1, 2007. However, it's not known if any progress has been made because of widespread flooding in the city.

Meanwhile, bird flu has reemerged in Gowa regency, South Sulawesi, where about 13 000 fowl raised by local people died suddenly in 2 villages in Bontonompo district. A rapid test of the dead fowl showed they all had the H5N1 virus. The Gowa Livestock Husbandry Office has sent samples of the dead chickens' blood to the Veterinary Agency in Maros for confirmation. In a related development, the U.S. Embassy in Jakarta warned its citizens in Indonesia that cats may carry the bird flu virus. Most known cases of human infection with H5N1 have involved contact with chickens or other infected birds. But last month, experts called for closer monitoring of other animals after Indonesian scientists found the virus in cats near poultry markets.
(CIDRAP 2/6/07 http://www.cidrap.umn.edu/ , ProMED 2/6/07, 2/7/08 http://promedmail.org )

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Japan (Miyazaki): Fourth avian influenza H5N1 outbreak in 2007 in poultry
Agriculture ministry officials confirmed another poultry outbreak of H5N1 in Miyazaki prefecture. The outbreak is western Japan's fourth such outbreak in 2007. 2 other outbreaks had previously been reported in Miyazaki prefecture, while the third occurred at a farm in Okayama prefecture. There have been no reported cases of human infection from the virus in Japan. The country suffered 4 outbreaks of the H5N1 bird flu in 2004, but had been free of it until it emerged this year.
(ProMED 2/3/07 http://promedmail.org , CIDRAP 2/5/07 http://www.cidrap.umn.edu/ )

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Pakistan: New avian influenza H5N1 outbreaks among chickens and peacocks
Pakistan reported its first 2 cases of avian influenza in almost a year after finding the H5N1 bird flu virus in small flocks of chickens and peacocks. A Food, Agriculture and Livestock Ministry spokesman said all the chickens in a flock of 40 birds had died after the virus was detected in Rawalpindi, near Islamabad. The virus has also been detected in a flock of peacocks in Mansehra in North-West Frontier Province. A total of 18 birds died and the rest were slaughtered. Affected populations of backyard poultry also include other fancy birds like pheasants, pigeons, ducks and parakeets. The virus has not yet been found in commercial poultry following the latest outbreak and the government has provided farmers with enough vaccine to protect their birds. Pakistan produces 4.5 million chickens annually, while peacocks are often kept for decorative purposes and as a good luck charm to bring their owners wealth. Meanwhile, the Pakistan Medical Association Karachi Chapter expressed its fear that the lack of hygiene standards in the poultry sector might spread the disease in the country.
(ProMED 2/6/07, 2/7/07, 2/8/07 http://promedmail.org )

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Turkey (Batman): Outbreak of avian influenza H5N1 suspected in chickens
Turkey's agriculture ministry confirmed an outbreak of bird flu in the southeast of the country, just over a year after the H5N1 strain of the disease killed 4 children in the region. The ministry said that bird flu had been found in the village of Bogazkoy in the Batman province. The ministry said it believed wild birds had spread the disease. "We have put under quarantine an area of 3 square km," Batman Governor Haluk Imga reported. "We will cull nearly 1500 chickens, ducks and turkeys in that area.” Veterinary experts were making tests to determine whether the virus was the H5N1 strain. Last year, WHO confirmed 4 deaths in Turkey from H5N1, all of them children from the town of Dogubayazit near the Iranian border. 8 other Turks tested positive for the H5N1 strain but recovered.
(ProMED 2/8/07, http://promedmail.org )

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Viet Nam (Ninh Binh): Outbreak of avian influenza H5N1 suspected in chickens
Reportedly, over 100 chickens in Vietnam's northern Ninh Binh province died in the last few days. Specimens from the dead fowls from some 40 households in Nho Quan district are being tested for bird flu viruses, said Chairman of the People's Committee of the district, Nguyen Quang Van. The local Veterinary Bureau has isolated and disinfected farms having dead fowls, encouraged people to raise poultry in cages, not let them stroll, and banned egg incubation. Since late Dec 2006, a total of 7 provinces have been hit by bird flu. 4 of those provinces have detected no new bird flu outbreaks for at least 21 days, meeting the criteria for announcing an end to the outbreaks in their territory. Bird flu outbreaks in Vietnam started in Dec 2003, and have killed and led to the forced culling of dozens of millions of fowls in the country.
(ProMED, 2/3/07 http://promedmail.org )

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Africa
Egypt (Fayyoum): Twelfth human death from avian influenza H5N1
The Egyptian Ministry of Health and Population and WHO announced a new human case of avian influenza A(H5N1) virus infection. The case marks the twelfth death among 20 confirmed cases in Egypt. Egypt has the largest know cluster of human cases outside of Asia. This case was confirmed by the Egyptian Central Public Health Laboratory and by the US Naval Medical Research Unit No.3 (NAMRU-3). The 17-year-old female from Fayyoum Governorate developed symptoms 25 Jan 2007 and was initially treated for seasonal influenza. She was hospitalized 1 Feb with fever and breathing difficulties, and died 2 Feb. Investigations into the source of her exposure indicate the presence of sick and dead poultry at her home in the days prior to the onset of symptoms. It remains unknown whether the latest case is of the 294S strain, which shows “moderate” resistance to the antiviral Tamiflu, which infected 2 people in Egypt earlier this year.
(WHO 2/5/07 http://who.int/en , ProMED 2/5/07 http://www.promedmail.org)

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Nigeria: First human death from avian influenza H5N1 confirmed
The government of Nigeria announced the presence of A/H5N1 avian influenza virus in a 22-year-old deceased female from Lagos. The WHO Collaborating Centre for Reference and Research on Influenza confirmed the initial positive test findings from a laboratory in Nigeria. Further investigations are under way to identify the source of her infection. All samples from contacts of the deceased have tested negative by the WHO Collaborating Centre. Nigeria is the eleventh country worldwide to suffer human fatalities from the H5N1 strain. The H5N1 virus was first detected in poultry in the country Feb 2006. Since then, more than 700,000 poultry have died of bird flu or been culled. Despite control measures, 19 of the country’s 36 states, as well as the Federal Capital Territory, have been affected. The UN FAO and WHO have formed a team to meet with health, agriculture and other officials to evaluate the situation and ensure that appropriate food safety messages are disseminated to educate the public and to avoid panic.
(FAO 2/7/06 http://www.fao.org , WHO 2/3/07 http://who.int/en , ProMED 2/3/07 http://www.promedmail.org )

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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. Read some recent reports regarding Nigeria.
- 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 upcoming avian influenza conferences.
- US CDC: http://www.cdc.gov/flu/avian/index.htm.
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/. Pandemic Flu Public Service Announcement has been released.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and journal articles.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- 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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2. Articles
Highly pathogenic avian influenza virus subtype H5N1 in Mute swans in the Czech Republic
A Nagy, et al. Vet Microbiol. 2007 Feb 25;120(1-2):9-16. Epub 2006 Oct 12.
Abstract: “In order to determine the actual prevalence of avian influenza viruses (AIV) in wild birds in the Czech Republic extensive surveillance was carried out between January and April 2006. A total of 2101 samples representing 61 bird species were examined for the presence of influenza A by using PCR, sequencing and cultivation on chicken embryos. AIV subtype H5N1 was detected in 12 Mute swans (Cygnus olor). The viruses were determined as HPAI (highly pathogenic avian influenza) and the hemagglutinin sequence was closely similar to A/mallard/Italy/835/06 and A/turkey/Turkey/1194/05. Following the first H5N1 case, about 300 wild birds representing 33 species were collected from the outbreak region and tested for the presence of AIV without any positive result. This is the first report of highly pathogenic avian influenza subtype H5N1 in the Czech Republic. The potential role of swan as an effective vector of avian influenza virus is also discussed.”

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Influenza Transmissibility: A Two-Amino Acid Change in the Hemagglutinin of the 1918 Influenza Virus Abolishes Transmission
Terrence M. Tumpey, et al. Science 2 February 2007:
Vol. 315. no. 5812, pp. 655 - 659
DOI: 10.1126/science.1136212
Abstract: “The 1918 influenza pandemic was a catastrophic series of virus outbreaks that spread across the globe. Here, we show that only a modest change in the 1918 influenza hemagglutinin receptor binding site alters the transmissibility of this pandemic virus. Two amino acid mutations that cause a switch in receptor binding preference from the human {alpha}-2,6 to the avian {alpha}-2,3 sialic acid resulted in a virus incapable of respiratory droplet transmission between ferrets but that maintained its lethality and replication efficiency in the upper respiratory tract. Furthermore, poor transmission of a 1918 virus with dual {alpha}-2,6 and{alpha}-2,3 specificity suggests that a predominant human {alpha}-2,6 sialic acid binding preference is essential for optimal transmission of this pandemic virus. These findings confirm an essential role of hemagglutinin receptor specificity for the transmission of influenza viruses among mammals."
(http://www.sciencemag.org/cgi/content/full/315/5812/655)

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Attitudes of health care workers to influenza vaccination: Why are they not vaccinated?
Takayanagi IJ, et al. Am J Infect Control. 2007 Feb;35(1):56-61.
Abstract: “BACKGROUND: Compliance rates with influenza vaccination among health care workers (HCW) are historically low. Although a safe and effective vaccine is available, the reasons for such poor compliance are not well understood. METHODS: After a campaign encouraging HCW to vaccinate against influenza, we conducted an epidemiologic survey to evaluate the reasons for compliance and accompanied the impact of these measures (campaign and questionnaire) during the subsequent 2 years. RESULTS: Compliance rate was 34.4%. Multivariate analysis showed that "older age" (P = .008), "believing that most departmental colleagues had been vaccinated" (P < .0001), and "having cared for patients suffering from severe influenza" (P = .031) were significantly associated with compliance with influenza vaccination. The main reason given for being vaccinated was "individual protection" and, to a lesser extent, "protection for the patient." In subsequent years, compliance rates among those participating in the survey fell to 20.2% in 2004, when the only measure taken was the questionnaire, and to 12.75% in 2005, when no educational intervention was scheduled. CONCLUSION: We conclude that a better understanding of HCW's negative attitude regarding influenza vaccination is needed as are more appealing and convincing continuous education programs, to ensure motivation for influenza vaccination over a longer period.”

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Students Wear Masks to Try to Stop Flu
Hundreds of students on the University of Michigan campus are part of a research study that could change the way the world looks at influenza. Researchers are trying to determine whether wearing surgical masks and hand sanitizing can prevent the spread of flu or other respiratory illnesses. Flu hit the university late last month and students in the study have since been divided into three groups: those who only wear masks; those who wear masks and use hand sanitizer; and those who do neither. They'll fill out surveys every week, answering questions about their physical health and how often they wear the mask, which is optional outside the residence halls. The students will wear the masks until the flu outbreak has died down, but no longer than six weeks, the researchers said. Funded by the U.S. CDC, the research is the first of its kind, said Dr. Allison Aiello, a Michigan epidemiology professor who designed the study with principal investigator Dr. Arnold Monto. Scientists say the world is long overdue for a flu epidemic, one that could emerge if the bird flu in Asia mutates to spread easily among people. A pandemic could kill millions of people. Right now there's not enough research to determine whether wearing masks and washing hands would be effective during such an event, Aiello said.
(New York Times, 2/8/07. http://www.nytimes.com/aponline/us/AP-Flu-Masks.html )

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Indonesia May Sell, Not Give, Bird Flu Virus to Scientists
Indonesia, which has had more human cases of avian flu than any other country, has stopped sending samples of the virus to WHO, apparently because it is negotiating a contract to sell the samples to an American vaccine company, a WHO official said Feb 6, 2007. The strains of the H5N1 virus circulating in Indonesia are considered crucial to developing up-to-date vaccines and following mutations in the virus. The official, Dr. David L. Heymann, said the agency was “clearly concerned” about the development and was in talks with Indonesia. Dr. Heymann, the agency’s chief of communicable diseases, said he was not blaming the company involved, Baxter Healthcare of Deerfield, Ill. “But now that this has happened,” he said, “we have to sit down and figure out how to rectify it.” Indonesia signed a memorandum of agreement with Baxter today. Until recently, Indonesia had been very cooperative about releasing genetic information about H5N1 flu found in animals and humans there, said Henry L. Niman, a Pittsburgh biochemist who runs a Web site tracking the genetics of flu cases, recombinomics.com.
(New York Times, 2/7/07. http://www.nytimes.com/2007/02/07/world/asia/07birdflu.html )

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Avian Influenza A (H5N1) Age Distribution in Humans
Matthew Smallman-Raynor and Andrew D. Cliff. EID. Volume 13, Number 3–March 2007. http://www.cdc.gov/eid/content/13/3/06-0849.htm (references removed).
To the Editor: “ total of 229 confirmed human cases of avian influenza A (H5N1) were reported to the World Health Organization (WHO) from 10 countries of Africa, Asia, and Europe in the 30 months leading up to July 4, 2006. WHO has highlighted the skewed age distribution of these confirmed cases toward children and young adults, with relatively few cases in older age categories. An explanation for this age bias is currently lacking, although a range of behavioral, biological, demographic, and data-related factors may account for the observed pattern. To determine whether the statistical parameters of the case distribution can shed any light on the issue, we reviewed the age profile of patients with confirmed avian influenza A (H5N1) included in WHO's Situation Updates—Avian Influenza archive (January 13, 2004–May 18, 2006). We supplemented our review with case information from an additional WHO source; to allow for the age structure of reporting countries, we accessed age-specific population estimates for 2005 from the Population Division of the United Nations Secretariat. . .”

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Bird Migration Routes and Risk for Pathogen Dispersion into Western Mediterranean Wetlands
Elsa Jourdain et al. EID. Volume 13, Number 3–March 2007. http://www.cdc.gov/eid/content/13/3/365.htm
Abstract: “Wild birds share with humans the capacity for moving fast over large distances. During migratory movements, birds carry pathogens that can be transmitted between species at breeding, wintering, and stopover places where numerous birds of various species are concentrated. We consider the area of the Camargue (southern France) as an example to highlight how ad hoc information already available on birds' movements, abundance, and diversity can help assess the introduction and transmission risk for birdborne diseases in the western Mediterranean wetlands. Avian influenza and West Nile viruses are used as examples because birds are central to the epidemiology of these viruses.”

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Effectiveness of Neuraminidase Inhibitors for Preventing Staff Absenteeism during Pandemic Influenza
Vernon J. Lee and Mark I. Chen. EID. Volume 13, Number 3–March 2007. http://www.cdc.gov/eid/content/13/3/449.htm
Abstract: “We used a deterministic SEIR (susceptible-exposed-infectious-removed) meta-population model, together with scenario, sensitivity, and simulation analyses, to determine stockpiling strategies for neuraminidase inhibitors that would minimize absenteeism among healthcare workers. A pandemic with a basic reproductive number (R0) of 2.5 resulted in peak absenteeism of 10%. Treatment decreased peak absenteeism to 8%, while 8 weeks' prophylaxis reduced it to 2%. For pandemics with higher R0, peak absenteeism exceeded 20% occasionally and 6 weeks' prophylaxis reduced peak absenteeism by 75%. Insufficient duration of prophylaxis increased peak absenteeism compared with treatment only. Earlier pandemic detection and initiation of prophylaxis may render shorter prophylaxis durations ineffective. Eight weeks' prophylaxis substantially reduced peak absenteeism under a broad range of assumptions for severe pandemics (peak absenteeism >10%). Small investments in treatment and prophylaxis, if adequate and timely, can reduce absenteeism among essential staff.”

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Risk for Infection with Highly Pathogenic Influenza A Virus (H5N1) in Chickens, Hong Kong, 2002
Nina Y. Kung et al. EID. Volume 13, Number 3–March 2007.
http://www.cdc.gov/eid/content/13/3/412.htm
Abstract: “We used epidemiologic evaluation, molecular epidemiology, and a case-control study to identify possible risk factors for the spread of highly pathogenic avian influenza A virus (subtype H5N1) in chicken farms during the first quarter of 2002 in Hong Kong. Farm profiles, including stock sources, farm management, and biosecurity measures, were collected from 16 case and 46 control chicken farms by using a pretested questionnaire and personal interviews. The risk of influenza A (H5N1) infection was assessed by using adjusted odds ratios based on multivariate logistic regression analysis. Retail marketing of live poultry was implicated as the main source of exposure to infection on chicken farms in Hong Kong during this period. Infection control measures should be reviewed and upgraded as necessary to reduce the spread of influenza A (H5N1) related to live poultry markets, which are commonplace across Asia.”

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Update: WHO-confirmed human cases of avian influenza A(H5N1) infection, 25 November 2003–24 November 2006
“It is 3 years since WHO began recording human cases of infection with avian influenza A(H5N1). A description of 205 laboratory confirmed cases occurring up to 30 April 2006 found that 90% of cases were in people aged <40 years, that the overall case-fatality rate was 56%, that the median interval from illness onset to hospitalization was 4 days, and that the median duration from illness onset to death was 9 days. This article is a brief follow-up summary of that initial epidemiological description. A total of 51 additional human cases of H5N1 have been confirmed since that time; outbreaks in birds continue to be reported worldwide. . .”
(WHO 2/9/07 http://www.who.int/wer/2007/wer8206.pdf )

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Preparing for the next flu pandemic
Wei Shen Lim et al. BMJ 2007;334:268-269 (10 February), doi:10.1136/bmj.39101.628715.80.
http://www.bmj.com/cgi/content/extract/334/7588/268 (References removed).
“In the past three years, the incidence of infection with the H5N1 variant of avian flu has increased in humans in southeast Asia during periods corresponding to winter and spring in the northern hemisphere. More cases of H5N1 infection in humans increase the chances that the virus will adapt towards efficient transmission between humans and therefore of a flu pandemic. The United Kingdom is well advanced in its preparations for a flu pandemic. The British Infection Society, British Thoracic Society, Health Protection Agency, and Department of Health have recently developed and published provisional guidelines on the clinical management of pandemic flu. These guidelines cover the clinical management of children and adults with flu during a pandemic. In interpandemic years when influenza is circulating in the community, presentation with acute fever and new (or in chronic lung disease, worsening) cough is highly predictive of flu in adults. . .”

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Role of combination antiviral therapy in pandemic influenza and stockpiling implications
Sotirios Tsiodras et al. BMJ 2007;334:293-294 (10 February), doi:10.1136/bmj.39105.428981.BE. http://www.bmj.com/cgi/content/extract/334/7588/293 (References removed).
“We currently have two classes of drugs that are effective against influenza viruses: the M2 ion channel inhibitors (amantadine and rimantadine) and the neuraminidase inhibitors (oseltamivir, zanamivir). Although ion channel inhibitors are effective against several subtypes of influenza A viruses, they are not being widely stockpiled for a future influenza pandemic. This is because they cause unacceptable side effects and their use is associated with a rapid emergence of resistance without any demonstrable reduction in transmissibility or pathogenicity. Resistance of influenza A viruses to amantadine is increasing worldwide, and the US Centers for Disease Control and Prevention recommended against the use of ion channel inhibitors for treatment or prophylaxis during the 2005-6 influenza season. Policy makers and some medical experts thus consider ion channel inhibitors inappropriate as first line treatment or prophylaxis for pandemic influenza. We believe their role should . . .”

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3. Notifications
Proposed US budget boosts pandemic readiness
The Bush administration's new budget proposes adding funds for pandemic preparedness while cutting some support for bioterrorism and local preparedness, drawing mixed reviews from national public health groups. The budget proposes a spending plan for the fiscal year that begins Oct 2008. It proposes $1.2 billion in new funds to improve pandemic preparedness, which includes $870 million to develop a pandemic vaccine, according to a Department of Health and Human Services (HHS) budget report. The budget proposal includes $82 million for avian influenza programs, including domestic surveillance of poultry and migratory birds for H5N1 avian flu, the USDA said. A budget increase of $16 million has been requested to design a new Consolidated Poultry Research Center in Athens, Ga., which will become the USDA's primary center for conducting key research on exotic and emerging avian diseases, the HHS said.

The nonprofit health advocacy group Trust for America's Health (TFAH) commended the Bush administration for the additional pandemic influenza funding. However, it said the president's proposal would cut $185 million from funds earmarked for upgrading state and local capabilities and hospital readiness, which would undermine bioterrorism and public health readiness. The cuts would leave public health preparedness funding more than 25% below 2005 levels, TFAH said. Richard Hamburg, director of government relations at TFAH, said, "We are cutting core boots-on-the-ground support for emergency disaster response, leaving the country at unnecessary levels of risk." The American Public Health Association, the world's largest public health association, also applauded the increased proposed funding for pandemic influenza initiatives, but called some of the cuts to the CDC devastating, particularly the elimination of Preventive Health and Health Services Block Grants.
(CIDRAP 2/7/07 http://www.cidrap.umn.edu/ )

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Report from the 2007 University of Minnesota CIDRAP Summit: Business preparedness for pandemic influenza
Corporate America is showing signs of a growing recognition of the threat of an influenza pandemic, but the concern is not yet a major topic in executive suites, according to recent surveys by a business consultant. The survey was of human resources executives from about 150 companies, risk executives from 20, and financial executives from about 50. All were Fortune 1,000 companies. Executives reported increased recognition of the pandemic threat, but were relatively optimistic about their companies' preparations. More than half of the human resource execs, 52%, said their companies had adequate plans to protect themselves, up from only 14% last year, and 45% said the companies were confident of their ability to manage a pandemic, versus 18% a year ago.

Julie Gerberding, MD, director of CDC, challenged health and business leaders to stay focused on the "marathon" of preparing for an influenza pandemic. Gerberding said CDC has come up with a list of 1,600 tasks under the heading of pandemic preparedness. The recent publication of guidance on community mitigation (nonpharmaceutical) measures was just one of those. Preparedness requires careful planning—distasteful as it may be—followed by exercises to test the plans, Gerberding went on to say. Last week the CDC conducted a major exercise that was very instructive, she said. The 24-hour live exercise—not a tabletop simulation—involved about 1,000 people, with 150 people staffing the CDC operations center.
(CIDRAP 2/7/07 http://www.cidrap.umn.edu/ )

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OSHA releases workplace guidelines for pandemic influenza
The US Department of Labor's Occupational Safety and Health Administration (OSHA) unveiled new workplace safety and health guidance that will help employers prepare for an influenza pandemic. Developed in coordination with the Department of Health and Human Services (HHS), Guidance on Preparing Workplaces for an Influenza Pandemic provides general guidance for all types of workplaces, describes the differences between seasonal, avian and pandemic influenza, and presents information on the nature of a potential pandemic, how the virus is likely to spread and how exposure is likely to occur. The guidance divides workplaces and work operations into 4 risk zones, according to the likelihood of employees' occupational exposure to pandemic influenza. Recommendations for employee protection are presented for each of the 4 levels of anticipated risk and include engineering controls, work practices and use of personal protective equipment such as respirators and surgical masks and their relative value in protecting employees. The Labor Department/HHS guidance also encourages employers to prepare a plan to deal with a depleted workforce during a pandemic.
(OSHA Press Release 2/6/07, www.osha.gov )

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FAO: Avian influenza in cats should be closely monitored
Cats can become infected with the highly lethal H5N1 avian influenza virus, but at present there is no scientific evidence to suggest that there has been sustained transmission of the virus in cats or from cats to humans, FAO said. As a precautionary measure, FAO recommended that in areas where the H5N1 virus has been found in poultry or wild birds, cats should be separated from infected birds until the danger has passed. On commercial poultry premises cats should even be kept indoors. The agency advised against killing cats as a virus control option because there is nothing to suggest that cats are transmitting the virus in a sustained way. Removing cats could lead to a surge in rodents such as rats, which are an agricultural pest and often transmit diseases to humans.

Unconfirmed reports that H5N1 infection has been detected in a high prevalence in cats in Indonesia has caused some alarm. The scavenging cats were sampled in the vicinity of poultry markets in Java and Sumatra where outbreaks of H5N1 avian influenza had recently occurred. This is not the first time that cats have been infected as previous incidents in Thailand, Iraq, the Russian Federation, the European Union and Turkey show. Cats can become infected by feeding on sick domestic or wild birds; they can develop severe to fatal disease and excrete the virus from the respiratory and digestive tracts. “This raises some concern not only because cats could act as intermediary hosts in the spread of the H5N1 virus between species but also because growth in cats might help the H5N1 virus to adapt into a more highly infectious strain that could spark an influenza pandemic,” said FAO Assistant Director-General Alexander Müller.

“Findings reported from Indonesia in January, however, suggest that around 80 percent of cats in outbreak areas have not been infected. This is rather encouraging because it indicates that cats are unlikely to constitute a reservoir of virus infection. Cats are more likely to be a dead-end host for the H5N1 virus,” said Peter Roeder, FAO Animal Health Officer. FAO said that cats should be closely monitored for any H5N1 infection. “Any unusual mortality in cats should spark a suspicion of H5N1. Infection in cats could be an early warning signal for the virus. The observation of cats should therefore become part of surveillance systems in affected areas,” Roeder said.

FAO will start field studies in areas in Java where the H5N1 virus is prevalent and where cats have died to investigate their role in disease transmission. This research will be extended to other parts of Indonesia and elsewhere. “We also need experimental studies to better understand the biology of H5N1 infection in cats, including most importantly the duration of virus shedding by infected animals,” Roeder said. FAO will collaborate with scientific institutions in affected countries and international research centres.
(FAO 2/8/07 http://www.fao.org/newsroom/en/news/2007/1000490/index.html )

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