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EINet Alert ~ Mar 23, 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 H5N1
- Global: 6 developing countries may get influenza vaccine plants
- Global: 3 countries listed as weak links in dealing with avian influenza H5N1
- Kuwait: Avian Influenza H5N1 outbreaks in poultry
- Saudi Arabia: Report of first avian influenza outbreak in fowl
- Bangladesh (Savar): Reportedly detects avian influenza in poultry
- Hong Kong: Baby infected with H9N2 avian influenza
- Indonesia: 2 new human deaths attributed to avian influenza H5N1 infection
- Japan (Kumamoto): Avian influenza H5N1 kills rare eagle
- Japan: Warning against Tamiflu use in teens
- Myanmar: UN calls for stricter controls after new avian influenza outbreak
- Pakistan (Islamabad): Avian influenza H5N1 resurfaces in birds
- Thailand (Mukdahan): Cock-fighting birds likely culprit in Mukdahan H5N1 outbreak
- Thailand: Avian influenza strain found to be resistant to amantadine
- Egypt (Aswan): New human case of avian influenza H5N1 infection
- Egypt: Vaccination efficacy questioned
- Nigeria (Kano): Avian influenza H5N1 spreads in northern Nigeria

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

2. Articles
- Pandemic could cause deep, uneven recession, group predicts
- Virus-Like Particle Vaccine Induces Protective Immunity against Homologous and Heterologous Strains of Influenza Virus
- Long-standing influenza vaccination policy is in accord with individual self-interest but not with the utilitarian optimum
- Seasonality of Influenza in Brazil: A Traveling Wave from the Amazon to the Subtropics
- Influenza (H5N1) Viruses in Poultry, Russian Federation, 2005–2006
- Genetic Characterization of HPAI (H5N1) Viruses from Poultry and Wild Vultures, Burkina Faso
- Influenza Vaccine Effectiveness among US Military Basic Trainees, 2005–06 Season

3. Notifications
- Health Insurer Pandemic Influenza Planning Checklist
- FluWorkLoss 1.0 Software to Estimate Loss of Work Days during an Influenza Pandemic
- Portable lab could revolutionize bird flu detection
- Combining poultry vaccination with other disease control measures to combat H5N1
- WHO meeting explores avian influenza H5N1 treatment issues


Global
Global: Cumulative number of human cases of avian influenza 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
China / 1 (0)
Egypt / 8 (3)
Indonesia / 6 (5)
Laos / 2 (2)
Nigeria / 1 (1)
Total / 18 (11)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 281 (169).
(WHO 3/20/07 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 3/12/07)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 3/23/07): http://gamapserver.who.int/mapLibrary/

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Global: 6 developing countries may get influenza vaccine plants
WHO said 6 developing countries are moving closer to getting their own flu vaccine manufacturing plants. "Up to 6 projects to establish in-country manufacturing capacity of influenza vaccine are in the final stage of approval following an application process which began in November," WHO said. "These projects will take place in 2 Latin American and 4 Asian countries, 3 of which have had human H5N1 influenza cases." WHO said vaccine manufacturer Sanofi Pasteur has "played a key role in transferring vaccine technology to Brazil, which will be in a position to produce vaccine next year."

Japan and the US have provided $18 million to support the effort. The announcement comes in the wake of Indonesia's statement that it will not share any more H5N1 virus samples with WHO without a guarantee of access to any vaccines based on their samples. Indonesia complained that it gets little or nothing in return for the samples, because the specimens are used to make vaccines that the countries' populations can't afford. In other efforts to ensure that developing countries will have access to vaccines in the event of a flu pandemic, WHO said it is exploring financing mechanisms to help countries buy vaccines from multinational companies. Among the proposals are a "virtual international pandemic influenza stockpile and advance purchase mechanisms to secure funds to buy vaccines for developing countries."

David Heymann, WHO's acting director-general for communicable diseases, reportedly said that certain vaccine makers might be able to transfer some manufacturing capacity to developing countries, but that it could take 10 years. He also noted that the world's total capacity for making flu vaccine is very limited. WHO has estimated capacity at no more than 350 million doses of trivalent flu vaccine. WHO released a "global pandemic influenza action plan to increase vaccine supply" in Oct 2006. Today the agency said more money is needed to keep the plan on track.
(CIDRAP 3/21/07, 3/22/07 www.cidrap.umn.edu )

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Global: 3 countries listed as weak links in dealing with avian influenza H5N1
International officials listed Egypt, Indonesia, and Nigeria as the 3 countries least able to deal with H5N1 outbreaks in birds. Bernard Vallat, head of the OIE, said, "There are still 3 countries that are not capable of managing the situation: Indonesia, Egypt and Nigeria, which harbour reservoirs of the virus that can take off elsewhere." Joseph Domenech, chief veterinarian for the UN Food and Agriculture Organization (FAO), said, "The lack of a national strategy, the lack of political involvement and the disorganization of these countries mean that lots of outbreaks, as well as human cases of the disease, arise." However, the two officials said they don't expect to see as many bird outbreaks of H5N1 this year as occurred last year. Vallat said, "On the medical level you see a reduction in terms of viral quantity. The presence of the disease in the population of wild birds is lower than last year when there was a surge in the virus." Wild birds may be growing more resistant to the virus, or the strain may be declining, Vallat said. Domenech commented that most countries have gotten faster at detecting and responding to the virus. But he said it would be unrealistic to think that the virus can be eradicated soon.
(CIDRAP 3/23/07 www.cidrap.umn.edu )

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Europe/Near East
Kuwait: Avian Influenza H5N1 outbreaks in poultry
Kuwait officials announced that another chicken in the country has tested positive for the H5N1 virus, bringing the number of infected birds to 54 since the outbreak began Feb 2007. A total of 17 outbreaks of H5N1 highly pathogenic avian influenza (HPAI) were reported to the OIE, 6 on 26 Feb 2007 and 11 just recently on 13 Mar 2007. Based on the OIE report, about 3238 backyard chickens, turkeys, geese, pigeons, falcons, guinea fowl, quails, and ducks have either died of HPAI or have been destroyed as part of Kuwait's control measures. About 4233 birds were termed susceptible. Outbreak locations were Al Farwaniyah, Al Ahmadi, Al Jarah, Hawalli, Moubarak Al Kabeer, and Al Kuwayt governates, which happen to be 5 of the 6 governorates in Kuwait. No human cases have been reported. The first case of HPAI was confirmed in 2005. Kuwait has also implemented measures to control movement inside the country, vaccinate, disinfect infected premises, and [implement] zoning for the whole country. A 3-month ban has also been imposed on urban poultry slaughtering and sales of live poultry and live poultry imports, as well as conducting health inspections of all poultry shops, closure of the zoo, and the ban of poultry in cages at schools and kindergartens.
(Promed 3/21/07 http://promedmail.org ; CIDRAP 3/19/07 www.cidrap.umn.edu )

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Saudi Arabia: Report of first avian influenza outbreak in fowl
The agriculture ministry in Saudi Arabia said that the H5N1 virus had been confirmed in samples obtained by a citizen in the eastern part of the country who reported several bird deaths at home earlier Mar 2007. The outbreak reportedly involved turkeys, parrots, peacocks, and ostriches on private land. The birds were reportedly destroyed and the site was sterilized. H5N1 avian flu has been reported in several countries near Saudi Arabia, including Egypt, Israel, Jordan, Iraq, Kuwait, and Sudan. Neighboring Kuwait has reported a spate of cases of H5N1 bird flu in fowl since 25 Feb 200], many of them in Wafra, close to the border.
(Promed 3/22/07 http://promedmail.org ; CIDRAP 3/23/07 www.cidrap.umn.edu )

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Asia
Bangladesh (Savar): Reportedly detects avian influenza in poultry
Bangladesh said 22 Mar 2007 the H5N1 bird flu virus had been detected in poultry. An outbreak struck chickens at a state-run poultry farm in Savar, near the capital, Dhaka. Government sources said farm workers had recently culled all 30,000 chickens at the farm after many of them died mysteriously. Preliminary tests at local laboratories suggested in Feb 2007 that the chickens died of Newcastle disease, but the government later sent samples to a lab in Thailand for more tests. Bangladeshi Health Minister S. M. Matium Rahman said no human cases have been reported, but citizens have been put on alert. WHO said it would work closely with Bangladesh to curb the spread of the disease. An H5N1 outbreak could devastate Bangladesh's poultry industry, which includes about 150,000 farms and does $750 million of business annually. 40 million Bangladeshis are directly or indirectly associated with poultry farming.
(CIDRAP 3/23/07 www.cidrap.umn.edu ; Promed 3/22/07 http://promedmail.org )

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Hong Kong: Baby infected with H9N2 avian influenza
Hong Kong officials confirmed 20 Mar 2007 that a 9-month-old girl is infected with the strain of avian influenza known as A/H9N2. The Hospital Authority said the baby girl has only mild symptoms but is in isolation at Princess Margaret Hospital. The same strain infected 2 girls in Hong Kong in 1999 and a 5-year-old boy there in 2003; all had mild illnesses and recovered. Thomas Tsang, head of the Hong Kong Centre for Health Protection, said the baby girl became ill Mar 4, 2007 with an upper respiratory tract infection and fever. The girl was believed to have contracted the virus from a market (where live poultry was sold) in a densely populated area. Tsang said, "Further genetic sequencing is being conducted to determine if the virus is completely of avian origin. This is an isolated case and the source of infection is being investigated. Based on previous experience, however, we will look especially into bird-to-human transmission." The Centre for Health Protection said the girl's family members were well and she had not been taken outside Hong Kong recently. Officials were taking more samples from the market and family members.

In 2004 the US National Institute of Allergy and Infectious Diseases, concerned that H9N2 could evolve into a pandemic strain, contracted with Chiron Corp. (now part of Novartis) to produce a vaccine against the virus. In Sep 2006, scientists reported that the experimental vaccine generated a good immune response in a phase 1 clinical trial. The report on the clinical trial results said H9N2 viruses are widespread in Eurasian poultry. 2 of the 3 different Asian lineages of these viruses can bind to human as well as bird cell receptors and therefore may be more likely to infect humans than other avian flu viruses are, the authors wrote.
(CIDRAP 3/20/07 www.cidrap.umn.edu ; Promed 3/20/07 http://promedmail.org )

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Indonesia: 2 new human deaths attributed to avian influenza H5N1 infection
Indonesia recently announced 2 new H5N1 avian influenza deaths. The first Indonesian fatality involves a 21-year-old woman from East Java who was previously reported to be ill with H5N1 avian flu Mar 12, 2007. Health Minister Nyoman Kandun said she died 19 Mar 2007 after 2 weeks in a hospital. The woman had reportedly cleaned an area where a neighbor had dumped dead chickens. Indonesia's second victim is a 32-year-old man who died Mar 14, 2007 in a Jakarta hospital. Indonesia's health ministry said the man kept a parrot in his home and that no other suspicious influenza-like illnesses were reported in his neighborhood. It has not been determined whether the bird was infected with bird flu.

By WHO's count, Indonesia has had 81 human cases of H5N1 illness, with 63 deaths. WHO has not yet recognized these 2 cases or 4 previous cases reported by Indonesia since Jan 29. Those 4 cases involved a 15-year-old girl and a 30-year-old man, reported Feb 6, and a 22-year-old woman and a 9-year-old boy, reported Feb 12, who both died of the illness. Bird flu is endemic in fowl in many of the 33 provinces in Indonesia, the world's fourth most populous country with 220 million people, and there was a sudden increase in the number of human deaths from the virus early this year after a brief lull. The country has tried to control bird flu by banning backyard fowl in Jakarta and surrounding provinces, and increasing culling.
(CIDRAP 3/19/07 www.cidrap.umn.edu ; Promed 3/16/07, 3/20/07 http://promedmail.org )

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Japan (Kumamoto): Avian influenza H5N1 kills rare eagle
The H5N1 bird flu virus killed a rare species of eagle, captured within 75 km of sites of 3 Japanese outbreaks of the virus among poultry earlier this year, the environment ministry said 19 Mar 2007. Further tests are under way to see whether it is a highly pathogenic strain of the H5N1 virus as well as genetic tests to determine its roots. Spizaetus nipalensis orientalis, or Hodgson's hawk eagle, is an endangered species in Japan. It does not migrate, and eats small birds and animals. The ministry said the adult female bird was found sick 4 Jan 2007 in Kumamoto prefecture, on Japan's southern island of Kyushu. Japan later in the month confirmed its first outbreak of the H5N1 virus since 2004 in neighboring Miyazaki prefecture, the country's biggest poultry-producing region. 2 other outbreaks have since hit Miyazaki and another occurred in the western prefecture of Okayama. A test for bird flu was positive in the eagle, followed by a later test in which the H5N1 virus was isolated, the ministry said. The ministry said it plans to resume surveillance of wild birds around the site where the bird was captured. The results of earlier tests for bird flu on samples of ducks and other wild birds taken in areas immediately surrounding the 4 outbreaks had all been negative.
(Promed 3/20/07 http://promedmail.org )

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Japan: Warning against Tamiflu use in teens
Japan's health ministry ordered the country's importer of oseltamivir (Tamiflu) to warn doctors against prescribing the drug to teens, because of continuing concerns that psychiatric symptoms might be linked to the influenza medication. The health ministry said that 2 teenagers were injured Feb and Mar 2007 when they fell from buildings after taking oseltamivir. Also, on Feb 27 a 14-year-old boy fell to his death from a condominium building where he lived in Sendai, Miyagi prefecture, a day after taking Tamiflu. A 16-year-old girl from Aichi prefecture died Feb 16 under similar circumstances. However, Roche said that clinical trials in the US and Japan have shown similar rates of psychiatric symptoms in children with influenza who took oseltamivir compared with their peers who didn't take the drug. In addition, Roche said US health insurance data from 1999 to 2006 on more than 101,000 flu patients treated with oseltamivir and more than 225,000 flu patients who didn't receive the drug revealed a lower likelihood of central nervous system events such as delirium, confusion, and hallucination in the treated patients.

Oseltamivir, a neuraminidase inhibitor, is used for flu treatment and prevention. Because world health experts regard it as the best available drug for treating a potential pandemic flu strain, US and numerous other countries are stockpiling the drug. To address concerns about possible psychiatric symptoms, Roche in Nov 2006 added a warning to its US labeling for Tamiflu that people who have the flu, particularly children, might be at increased risk for self-injury and confusion shortly after taking the drug and should be monitored for signs of unusual behavior. At that time, the US Food and Drug Administration and Roche both said the drug's contribution to the psychiatric symptoms was not known. FDA said influenza itself could contribute to some neuropsychiatric disorders. The warning was prompted by an FDA review of 103 reports of neuropsychiatric adverse events associated with oseltamivir between Aug 29, 2005, and Jul 6, 2006. Of the reports, 95 came from Japan, and about two thirds of the reports involved children and youth younger than 17. 60 of 103 were described as delirium with disturbed behavior. Some of the physicians who reported the events said that problems occurred within a day of starting treatment and quickly resolved after treatment ended. The FDA concluded it was unclear if the neuropsychiatric events were related only to the drug, only to the flu, or to both. Oseltamivir is used more widely in Japan than in the US.
(CIDRAP 3/21/07 www.cidrap.umn.edu )

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Myanmar: UN calls for stricter controls after new avian influenza outbreak
The U.N. reported a new outbreak of bird flu in Myanmar 21 Mar 2007 and called for more stringent measures to control the spread of the H5N1 virus. The UN is providing 1.4 million dollars in assistance to help fight the disease. About 1600 chickens contracted the virus and died during at a farm in Nyaunghnapin, about 40 km north of Yangon, Myanmar's largest city, said Tang Zang Ping, the Myanmar representative for the UN’s Food and Agriculture Organization. Authorities slaughtered the farm's remaining 20 700 birds as a precautionary measure, he said. "We need to impose stricter control on the movement of poultry, poultry products, chicken feed, eggs and even the trucks that carry these materials," Tang said. The Livestock Breeding and Veterinary Department said the virus might have spread in the farm, located in Hmawyby township, through contaminated trays used to carry eggs or small birds. Chickens, ducks and quails within a 1-km radius of the farm were being monitored and that authorities imposed a ban on the sale and transport of fowl within 6 km of the outbreak. Reportedly about 960 people who had contact with fowls, as well as their family members around the outbreak areas, are still under surveillance. Myanmar has reported 2 H5N1 outbreaks in recent weeks among poultry at 2 farms on the outskirts of Yangon. Until the recent cases, Myanmar last reported an H5N1 outbreak among poultry Mar 2006. It has reported no human H5N1 cases. According to an official follow-up report sent to the OIE on 20 Mar 2007 by Myanmar's Livestock Breeding and Veterinary Department, the exact numbers of layer chickens affected by the above outbreak were the following: Susceptible -- 22 337; cases -- 1645; deaths -- 1645; destroyed -- 20 692.
(Promed 3/20/07, 3/21/07 http://promedmail.org )

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Pakistan (Islamabad): Avian influenza H5N1 resurfaces in birds
Bird flu virus has once again been detected in Islamabad, the federal capital. "The National Reference Laboratory for Avian Influenza has detected bird flu virus in 2 out of 8 crows received from different parts of the capital," Ministry of Food and Agriculture spokesman Dr Mohammad Afzal said 21 Mar 2007. He said these samples were received from a park, a garden and roadside, adding that some were also brought from Tarlai. Dr Afzal said there were chances of some other wild birds carrying the H5N1 virus. He said if a dead bird was found somewhere, it should be reported to the sanitary inspectors of the Capital Development Authority (CDA). He said people having backyard poultry or keeping fancy birds should protect their birds from coming in contact with wild birds and get them vaccinated against avian influenza. Afzal said the detection of bird flu virus had nothing to do with chicken, and it was safe to eat. The H5N1 virus first turned up in Pakistan Feb 2006, prompting the culling of 40,000 birds in North West Frontier Province. The Islamabad zoo was temporarily closed last month after 4 peacocks and a goose died of the infection.
(CIDRAP 3/23/07; 3/22/07 www.cidrap.umn.edu )

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Thailand (Mukdahan): Cock-fighting birds likely culprit in Mukdahan H5N1 outbreak
The fourth bird flu outbreak in north-eastern province of Mukdahan has been reported. The fresh bird flu outbreak was discovered in domestic chickens raised on a farm. Provincial livestock officials had culled the entire flock to prevent any possible spread of the virus. The poultry deaths were first reported Mar 9, 2007. The outbreaks are the first since late Jan 2007. The latest bird flu epidemic was most likely to have come from Sawannakhet province in Laos through illegal cock-fighting tours, officials said 20 Mar 2007. The total number of local people who had been in contact with dead poultry in 2 areas of the province's Muang district where the H5N1 virus was confirmed has risen to 9, including a livestock officer whose fighting cocks had died. Earlier, the subtype H5 was confirmed in a dead chicken in Sawannakhet, and it was highly likely the virus had spread to Mukdahan. Despite imposing stringent measures against bringing poultry, both dead and alive, and eggs to the province since the confirmation of bird flu infection in Laos, there was still smuggling along the Thai-Laos border. Poultry smuggling and illegal cock-fighting tours to Laos were 2 of the most likely channels for bird flu to have spread to the province. 7 of 8 people who had eaten a dead turkey plus the livestock officer were given Tamiflu to prevent infection. After being announced a "disease outbreak zone" 19 Mar 2007, Mukdahan livestock officials ordered "comb-search" testing for H5N1 virus in poultry in every single house within a radius of 1 km from the 2 infected areas.
(Promed 3/20/07, 3/21/07 http://promedmail.org ; CIDRAP 3/19/07 www.cidrap.umn.edu )

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Thailand: Avian influenza strain found to be resistant to amantadine
Scientists have found that a strain of the H5N1 bird flu virus circulating in Thailand is resistant to the flu drug amantadine, and they called for rigorous study of H5N1 strains to better treat human victims. While WHO has long recommended that Tamiflu be used as the first line of defense against H5N1, it said May 2006 that a "dual therapy" combining amantadine and Tamiflu may be considered in case of an outbreak. Yong Poovorawan, a medical professor at Chulalongkorn University in Bangkok, said an H5N1 strain in the central part of Thailand had become resistant to amantadine, casting more doubt over its use to fight the disease. "It would be very dangerous if we don't know the sensitivity or resistance of the strain to amantadine and we use amantadine (to treat people infected with this strain of H5N1)," Yong said.

He urged more rigorous surveillance and study. Yong and his researchers came to the conclusion after studying the molecular structure of the strain, which has been circulating in Thailand, Cambodia and Viet Nam since 2004. However, he could not say how effective a dual Tamiflu-amantadine therapy may be, as Thailand has not tried administering such a treatment. There are 2 H5N1 strains circulating in Thailand, one in the northeast and the other in the central part of the country. Yong identified the strain in the northeast province of Nakhon Phanom as a Fujian-like strain. "From its molecular structure, we would say it is sensitive to Tamiflu and amantadine." The emergence of various strains of H5N1 is a matter of concern because each one may respond differently to different antiviral drugs and vaccines. Their findings were published in the Mar 2007 issue of the journal Emerging Infectious Diseases.
(Promed 3/21/07 http://promedmail.org )

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Africa
Egypt (Aswan): New human case of avian influenza H5N1 infection
As of 20 Mar 2007, the Egyptian Ministry of Health and Population has 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. The 2-year-old boy from Aswan Governorate developed symptoms 15 Mar 2007. He was admitted to hospital the following day where he remains in a stable condition. Reportedly, he received oseltamivir within 24 hours of becoming ill. Investigations indicate a history of contact with backyard poultry. The boy’s family contacts are under medical observation. No epidemiological link has been found between this case and that of the 10-year-old girl from the same area that was announced 19 Mar 2007. She was hospitalized Mar 13 and is in stable condition. Of the 26 cases confirmed to date in Egypt, 13 have been fatal.
(Promed 3/20/07 http://promedmail.org ; CIDRAP 3/19/07 www.cidrap.umn.edu )

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Egypt: Vaccination efficacy questioned
Egypt has detected bird flu in chickens and ducks from reportedly vaccinated flocks. This is a sign that inoculation procedures may be lacking, an animal health official said 13 Mar 2007. The official said chickens and ducks from vaccinated household flocks and in poultry farms had tested positive for the H5N1 bird flu virus in 2007 in 12 locations, and 8 of the infections were detected Mar 2007. He said all but one of the vaccinated flocks where infections occurred, were in the hard-hit Nile Delta. Ahmed Chikhaoui, the Food and Agriculture Organisation (FAO) representative in Cairo, said he was unaware of detected cases in vaccinated flocks. Officials said that the problem was likely due to improper vaccination procedures, and it was possible that the farms where infections occurred had not followed health ministry guidelines. Some farms might be vaccinating chicks at over 5 days old, which could reduce the efficacy of the vaccine. Inoculations should be done when the chicks are a day old. According to an FAO update of Jul 2006, between 50 and 60 million combined doses of H5N1 and H5N2 inactivated vaccines had been imported into Egypt up to 30 May 2006.
(Promed 3/17/07 http://promedmail.org )

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Nigeria (Kano): Avian influenza H5N1 spreads in northern Nigeria
The H5N1 bird flu virus is spreading among poultry farms around northern Nigeria`s largest city, a senior veterinary official said 18 Mar 2007. "The avian influenza virus is still spreading among poultry farms and it has so far affected 33 farms in 7 districts," said Shehu Bawa, head of Kano State`s Committee on Avian Flu. More than 80 000 birds have been culled in Kano, Bawa added. Further measures taken to check the outbreak include controls on movement of poultry and people, disinfecting farm workers and visitors, fencing off farms, and a ban on borrowing of farm implements from them. Nigeria, the continent`s most populous nation with some 140 million people, early this year reported west Africa`s first human bird flu death. A 22-year-old woman died in Lagos 17 Jan 2007 weeks after plucking and disemboweling a chicken. Bird flu was first detected on a farm in Jaji town outside the northern city of Kano in Feb 2006 from where it spread to other parts of Nigeria. Kano, northern Nigeria`s most populous city, was worst affected by the flu outbreak which ravaged 97 farms in the city resulting in the death or culling of at least 300 000 birds. Nigeria has a poultry population of about 140 million, 60 percent of which is kept by backyard farmers.
(Promed 3/17/07, 3/20/07 http://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.
- 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/.
- 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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Seasonal Influenza
Chinese Taipei
During the Feb 25 to Mar 3, 2007, the percentage of outpatient visits to sentinel physicians for influenza-like illness (ILI) has decreased by 10.9% compared with last week and is 12.6% lower than the same period in 2006. In recent 4 weeks (week 6 to 9, 2007), the respective ILI consultation rates (per 100 outpatient visits) were 4.63, 4.07, 4.05 and 3.61. Comparing to last week, the consultation rate increased in Taipei region while the remaining 5 regions reported a decreased trend. The dominant respiratory virus identified for week 6 to 9, 2007 was influenza A (H3), followed by B type. The other main respiratory viruses were Adenovirus and HSV (Herpes simplex virus). Based on reporting dates, no severe influenza case was reported in week 9. Based on onset dates, 127 severe cases have been reported cumulatively in the 2006-2007 epidemic season. Among these, 28 were confirmed, 91 were excluded, and 8 are still pending. So far this season (weeks 26, 2006 to week 9, 2007), 5 deaths have been reported.
(Taiwan IHR Focal Point 3/22/07)

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2. Articles
Pandemic could cause deep, uneven recession, group predicts
An influenza pandemic as severe as the great flu of 1918 could cost the US $683 billion and plunge the American economy into the second-deepest recession since World War II. If rates of illness and death matched those of 1918—when one third of the population fell ill and 2.5% of those who were sickened died—US production of goods and services could shrink 5.5% in a year, according to an analysis released by the Trust for America's Health (TFAH). States whose economies depend on tourism and entertainment would be hit hardest, with losses as large as 8% of their economic production. "Businesses, governments, schools and other sectors could all face serious disruptions," said Jeff Levi, PhD, executive director of the TFAH. The TFAH report, "Pandemic Flu and Potential for U.S. Economic Recession," is the latest in a string of analyses that have attempted to forecast the potential economic impact of a pandemic as severe as the 1918 onslaught. In Dec 2005, the Congressional Budget Office predicted that a 1918-like pandemic would cut US gross domestic product (GDP) by 5% in a year, while a milder pandemic similar to the worldwide flu of 1968 would shrink the GDP 1.5%. A team from the Australian National University has set the impact of what they call an "ultra" pandemic at 5.5% of GDP in a year, while an analysis by BMO Nesbitt Burns Cooper, a brokerage firm, has forecast a loss of up to 6%. In Nov 2005, the Asian Development Bank predicted a loss of 2.3% to 6.5% of GDP just in Asia.

The TFAH analysis combines predictions of death rates and loss of productivity. Demand for arts, entertainment, and recreation is likely to drop by 80%, the report estimates, compared with 67% for transportation and warehousing and 10% for agriculture, mining, construction, manufacturing, finance, and education. The hardest-hit states are likely to be those whose economies rely on entertainment, tourism, and food service, the report says. Entertainment mecca Nevada would fare the worst, losing 8% of its GDP and $9 billion in a single year. Nevada would be closely followed by other high-tourism states: Hawaii, Alaska, Wyoming, and Nebraska. The states at the lowest risk of major losses would be those with diverse economies, as well as those that depend on the services most likely to be in use during a pandemic, such as healthcare and government. Leading the list of least-impacted places is Washington, DC, which would risk 4.62% of its GDP and lose potentially $3.8 billion. Close behind come Maryland, Virginia, New York, and Massachusetts. TFAH recommends a menu of actions to mitigate a pandemic's potential economic impact, from improving state pandemic plans to encouraging continuity planning for business sectors as well as individual businesses. It will be particularly important to address the healthcare needs of the underinsured and uninsured who may forgo healthcare or come to work while ill.

TFAH statement with link to full report: http://healthyamericans.org/reports/flurecession/
(CIDRAP 3/22/07 www.cidrap.umn.edu )

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Virus-Like Particle Vaccine Induces Protective Immunity against Homologous and Heterologous Strains of Influenza Virus
Fu-Shi Quan, et al. Journal of Virology, April 2007, p. 3514-3524, Vol. 81, No. 7. http://jvi.asm.org/cgi/content/abstract/81/7/3514
Abstract: “Recurrent outbreaks of highly pathogenic avian influenza virus pose the threat of pandemic spread of lethal disease and make it a priority to develop safe and effective vaccines. Influenza virus-like particles (VLPs) have been suggested to be a promising vaccine approach. However, VLP-induced immune responses, and their roles in inducing memory immune responses and cross-protective immunity have not been investigated. In this study, we developed VLPs containing influenza virus A/PR8/34 (H1N1) hemagglutinin (HA) and matrix (M1) proteins and investigated their immunogenicity, long-term cross-protective efficacy, and effects on lung proinflammatory cytokines in mice. Intranasal immunization with VLPs containing HA induced high serum and mucosal antibody titers and neutralizing activity against PR8 and A/WSN/33 (H1N1) viruses. Mice immunized with VLPs containing HA showed little or no proinflammatory lung cytokines and were protected from a lethal challenge with mouse-adapted PR8 or WSN viruses even 5 months postimmunization. Influenza VLPs induced mucosal immunoglobulin G and cellular immune responses, which were reactivated rapidly upon virus challenge. Long-lived antibody-secreting cells were detected in the bone marrow of immunized mice. Immune sera administered intranasally were able to confer 100% protection from a lethal challenge with PR8 or WSN, which provides further evidence that anti-HA antibodies are primarily responsible for preventing infection. Taken together, these results indicate that nonreplicating influenza VLPs represent a promising strategy for the development of a safe and effective vaccine to control the spread of lethal influenza viruses.”

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Long-standing influenza vaccination policy is in accord with individual self-interest but not with the utilitarian optimum
Galvani AP, Reluga TC, Chapman GB. Proc Natl Acad Sci U S A. 2007 Mar 16; [Epub ahead of print] http://www.pnas.org/cgi/content/abstract/0606774104v1
Abstract: “Influenza vaccination is vital for reducing infection-mediated morbidity and mortality. To maximize effectiveness, vaccination programs must anticipate the effects of public perceptions and attitudes on voluntary adherence. A vaccine allocation strategy that is optimal for the population is not necessarily optimal for an individual. For epidemic influenza, the elderly have the greatest risk of influenza mortality, yet children are responsible for most of the transmission. The long-standing recommendations of the Centers for Disease Control follow the dictates of individual self-interest and prioritize the elderly for vaccination. However, preferentially vaccinating children may dramatically reduce community-wide influenza transmission. A potential obstacle to this is that the personal utility of vaccination is lower for children than it is for the elderly. We parameterize an epidemiological game-theoretic model of influenza vaccination with questionnaire data on actual perceptions of influenza and its vaccine to compare Nash equilibria vaccination strategies driven by self-interest with utilitarian strategies for both epidemic and pandemic influenza. Our results reveal possible strategies to bring Nash and utilitarian vaccination levels into alignment.”

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Seasonality of Influenza in Brazil: A Traveling Wave from the Amazon to the Subtropics
Wladimir J. Alonso et al. Am J Epidemiol. 2007 Mar 16; [Epub ahead of print] http://aje.oxfordjournals.org/cgi/content/abstract/kwm012v1
Abstract: “Influenza circulation and mortality impact in tropical areas have not been well characterized. The authors studied the seasonality of influenza throughout Brazil, a geographically diverse country, by modeling influenza-related mortality and laboratory surveillance data. Monthly time series of pneumonia and influenza mortality were obtained from 1979 to 2001 for each of the 27 Brazilian states. Detrended time series were analyzed by Fourier decomposition to describe the amplitude and timing of annual and semiannual epidemic cycles, and the resulting seasonal parameters were compared across latitudes, ranging from the equator (+5°N) to the subtropics (–35°S). Seasonality in mortality was most pronounced in southern states (winter epidemics, June–July), gradually attenuated toward central states (15°S) (p < 0.001), and remained low near the equator. A seasonal southward traveling wave of influenza was identified across Brazil, originating from equatorial and low-population regions in March–April and moving toward temperate and highly populous regions over a 3-month period. Laboratory surveillance data from recent years provided independent confirmation that mortality peaks coincided with influenza virus activity. The direction of the traveling wave suggests that environmental forces (temperature, humidity) play a more important role than population factors (density, travel) in driving the timing of influenza epidemics across Brazil.”

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Influenza (H5N1) Viruses in Poultry, Russian Federation, 2005–2006
Aleksandr S. Lipatov et al. EID. Volume 13, Number 4–April 2007. http://www.cdc.gov/eid/content/13/4/539.htm
Abstract: “We studied 7 influenza (H5N1) viruses isolated from poultry in western Siberia and the European part of the Russian Federation during July 2005–February 2006. Full genome sequences showed high homology to Qinghai-like influenza (H5N1) viruses. Phylogenetic analysis not only showed a close genetic relationship between the H5N1 strains isolated from poultry and wild migratory waterfowls but also suggested genetic reassortment among the analyzed isolates. Analysis of deduced amino acid sequences of the M2 and neuraminidase proteins showed that all isolates are potentially sensitive to currently available antiviral drugs. Pathogenicity testing showed that all studied viruses were highly pathogenic in chickens; for 3 isolates tested in mice and 2 tested in ferrets, pathogenicity was heterogeneous. Pathogenicity in mammalian models was generally correlated with Lys at residue 627 of polymerase basic protein 2.”

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Genetic Characterization of HPAI (H5N1) Viruses from Poultry and Wild Vultures, Burkina Faso
Mariette F. Ducatez et al. EID. Volume 13, Number 4–April 2007. http://www.cdc.gov/eid/content/13/4/611.htm
Abstract: “Genetic analysis of highly pathogenic avian influenza (H5N1) viruses from poultry and hooded vultures in Burkina Faso shows that these viruses belong to 1 of 3 sublineages initially found in Nigeria and later in other African countries. Hooded vultures could potentially be vectors or sentinels of influenza subtype H5N1, as are cats and swans elsewhere.”

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Influenza Vaccine Effectiveness among US Military Basic Trainees, 2005–06 Season
Jennifer K. Strickler et al. EID. Volume 13, Number 4–April 2007. http://www.cdc.gov/eid/content/13/4/617.htm
Abstract: “Virtually all US military basic trainees receive seasonal influenza vaccine. Surveillance data collected from December 2005 through March 2006 were evaluated to estimate effectiveness of the influenza vaccine at 6 US military basic training centers. Vaccine effectiveness against laboratory-confirmed influenza was 92% (95% confidence interval 85%–96%).”

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3. Notifications
Health Insurer Pandemic Influenza Planning Checklist
In the event of an influenza pandemic, national and regional health insurers will have several key responsibilities: protecting their employees’ health and safety, providing coverage and related services to their enrollees, and coordinating access to care through the provider community. Pandemic influenza planning is critical and will help limit the negative impact on our economy and society. To assist health insurers in their efforts, the Department of Health and Human Services (HHS) and CDC have developed a checklist. It identifies important, targeted activities health insurers can do now to prepare for a pandemic. This checklist is organized according to business-related, employee-related, and communications-related activities. Please consider incorporating these pandemic-specific elements into your current all-hazards business continuity plan. Checklist Sections are: Plan for the impact of an influenza pandemic on your business; Plan for the impact of an influenza pandemic on your employees and establish policies to be implemented during a pandemic; Communicate, educate, and provide resources for employees and enrollees; Modify business practices and policies to be implemented during an influenza pandemic; Coordinate with external organizations and help your community.
http://pandemicflu.gov/plan/workplaceplanning/healthinsurer.html

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FluWorkLoss 1.0 Software to Estimate Loss of Work Days during an Influenza Pandemic
Illness rates during an influenza pandemic are likely to be 2 to 5 times higher than during a typical influenza season. To maintain continuity of essential operations, public health officials, policy makers, health-care facilities managers, and business leaders must plan for influenza-related work absences during an influenza pandemic. FluWorkLoss is a software program that allows estimation of the potential number of days lost from work because of an influenza pandemic. Users can change nearly all input values, such as the number of work days assumed lost when a worker becomes ill or the number of work days lost because a worker stayed home to care for a family member. Users also can change the length and virulence of the pandemic model so that a range of possible effects can be estimated. FluWorkLoss provides a range of estimates of total work days lost, and graphic illustrations of work days lost by week and percentage of total work days lost to influenza-related illnesses. FluWorkLoss and other pandemic planning tools is available, free of charge, at http://www.pandemicflu.gov/plan/tools.html. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5611a5.htm
(MMWR March 23, 2007 / 56(11);256)

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Portable lab could revolutionize bird flu detection
Animal health experts are meeting in Vienna to discuss new mobile rapid-detection technology that experts say could revolutionize the fight against bird flu and many other livestock diseases. Researchers, scientists and manufacturers will discuss the development and potential of portable devices to study samples and discover the cause of death in birds. The kit could even be adapted to detect the strain of bird flu, including H5N1. Moreover, such systems could easily be adapted to send results to a main control centre, allowing a much faster response to an outbreak. The talks are part of a US$500 000 coordinated research project being implemented by the Joint FAO/IAEA Programme, a partnership between FAO and the International Atomic Energy Agency. Further project activities will include field-testing of devices, identifying areas for initial deployment and exploring future funding sources. Quicker testing and reporting of bird flu would mean experts saving crucial time identifying the source of outbreaks and so increase the chances of containing their spread. The devices can also be adapted to detect other animal diseases. The main device under discussion at the meeting is a US$1 000 mobile test system and reader the size of a small portable television.

The main testing tools in the past 30 years have been laboratory based, including the ELISA (Enzyme Linked Immunosorbent Assay) technique. More modern technologies deploy what is known as the PCR (Polymerase Chain Reaction) technique, whereby a tiny amount of DNA is amplified and read. This method would be used for the mobile device. “The genius here is that such mobile testers can be used by anyone, with the most basic training,” says John Crowther of the Joint FAO/IAEA Programme’s Animal Production and Health section. The discussions will be attended by representatives from China, Nigeria, the United Kingdom, US, Sweden, the Netherlands, Austria, Ghana, Burkina Faso, South Africa, Viet Nam, the Philippines and Australia, as well as international bodies and commercial concerns from Europe and the US.
(FAO 3/19/07 http://www.fao.org/newsroom/en/news/2007/1000517/index.html )

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Combining poultry vaccination with other disease control measures to combat H5N1
Vaccinating poultry, combined with several other control instruments, is an important tool in the battle against the H5N1 virus, according to an international scientific conference. Around 400 experts reviewed the recent experiences and achievements of vaccination programmes carried out worldwide. The conference was organized by the World Organisation for Animal Health (OIE), the UN Food and Agriculture Organization (FAO) and the Istituto Zooprofilattico Sperimentale delle Venezie (IZSVe), with the support of the European Commission. Fighting the disease in poultry is essential to decrease the amount of virus in the environment and thus reduce the risk of human infection. The conference recommended that poultry should be vaccinated against avian influenza, particularly in endemic countries and when other control measures such as stamping out, movement controls of poultry and biosecurity cannot stop the spread of the virus. A successful vaccination campaign depends mainly on the use of high quality vaccines complying with OIE standards, appropriate infrastructure to ensure the rapid and safe delivery of vaccines (cold chain), monitoring of vaccinated flocks, movement control of poultry, and adequate financial resources. Efficient veterinary services complying with OIE standards on quality and evaluation is also very important for the suspension of the use of vaccination. Any vaccination policy should include an exit strategy so that countries do not rely on costly long-term vaccination campaigns. The tools differentiating infected from vaccinated animals are recommended in the field when possible.

There are no elements indicating human health implications related to the vaccination of poultry and to the consumption of poultry products from vaccinated animals. The conference called upon the commercial poultry industry to reinforce its engagement in the control of avian influenza under the supervision of national veterinary authorities. A call to international donors for the funding of vaccination in endemic countries, with particular focus on backyard poultry, was also made.

The conference urged the development and funding of more research in the following fields: Development of new and improved vaccines; Development of new vaccines that combine protection against H5N1 with the control of other poultry diseases; Design of cost-effective delivery systems, particularly for small-holders and backyard farmers; Development of a vaccination decision support model; Data sharing of vaccination programmes conducted under field conditions; Impact of vaccination on production consumption and trade; Impact of mass culling programmes on valuable poultry genetic material. Participants of the Verona conference also proposed to develop communication strategies to improve the vaccination coverage, to avoid possible market shocks and to apply basic biosecurity measures.
(FAO 3/22/07 http://www.fao.org/newsroom/en/news/2007/1000527/index.html )

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WHO meeting explores avian influenza H5N1 treatment issues
Health experts gathered at a WHO conference in southern Turkey to discuss findings in patients who have H5N1 infections and identify areas for future research on treatment. The meeting, a follow-up to one held in Hanoi in 2005, is intended to seek support from doctors for a proposed WHO system for collecting data on H5N1 cases. Doctors would be asked to submit standardized clinical information on their patients who have H5N1 infections, which would allow WHO to track disease patterns and treatment efficacy. Some health experts who attended the meeting said they supported Indonesia's stance on withholding H5N1 samples until it receives assurance that it and other developing nations will have access to pandemic flu vaccines.
(CIDRAP 3/19/07 www.cidrap.umn.edu )

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 apecein@u.washington.edu