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EINet Alert ~ Apr 20, 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)
- UK: Update: Cause of first avian influenza H5N1 outbreak still uncertain
- Kuwait (Wafra): Imported falcons purported source of poultry epidemic of avian influenza H5N1
- Saudi Arabia: Ministry of Health reports no threat of avian influenza outbreak
- Cambodia: Avian influenza H5N1 outbreak in birds reported to OIE
- China: Reported withholding of avian influenza H5N1 virus samples
- USA: FDA approves vaccine for avian influenza H5N1
- Algeria (Oran Wilaya Governate): First detected avian influenza case in chicken

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

2. Articles
- Summary of the second WHO consultation on clinical aspects of human infection with avian influenza A(H5N1) virus
- Difficulty in the Rapid Diagnosis of Avian Influenza A Infection: Thailand Experience
- Community Engagement: Leadership Tool for Catastrophic Health Events

3. Notifications
- Citizen engagement in emergency planning for a flu pandemic: a summary of the October 23, 2006 workshop of the Disasters Roundtable
- Bird Flu School Planning Summit Stresses Hands-On Training


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
China / 2 (1)
Egypt / 16 (4)
Indonesia / 6 (5)
Laos / 2 (2)
Nigeria / 1 (1)
Total / 28 (14)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 291 (172).
(WHO 4/11/07 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 4/11/07)

WHO’s timeline of important H5N1-related events (last updated 4/20/07):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 4/16/07):
http://gamapserver.who.int/mapLibrary/

FAO map showing outbreaks among poultry (last updated 3/26/2007):
http://www.fao.org/avianflu/en/maps.html

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Europe/Near East
UK: Update: Cause of first avian influenza H5N1 outbreak still uncertain
The final epidemiologic report on the United Kingdom's first H5N1 avian influenza outbreak says the source of the virus remains unknown but might have been contaminated turkey meat imported from Hungary. Investigators from the National Emergency Epidemiology Group explored all possible ways the virus could have arrived at the Bernard Matthews turkey farm in Suffolk in Feb 2007, the UK Department for Environment, Food and Rural Affairs (DEFRA) said. The 32-page epidemiologic report concludes that contaminated turkey meat could have been imported and that it could have come from birds that had subclinical H5N1 infections from exposure to wild birds that spread the virus to 2 Hungarian goose farms in January. The investigation, which included authorities from the European Commission and Hungary, found no evidence of undisclosed H5N1 infection in Hungary and indicated that undetected infections in turkeys there would be "a rare event," DEFRA said. DEFRA also said Bernard Matthews would be compensated 589,356 pounds (about US $1.18 million dollars) for culling its flocks to prevent the spread of the disease. According to an OIE report, the company culled 152,000 birds after the H5N1 outbreak was detected. The February H5N1 outbreak was the first among domestic poultry within English borders. In Sep 2005, H5N1 was detected in some finches that were quarantined in Sussex after importation from Taiwan. In Mar 2006 a dead mute swan that had washed up on a Scottish shore tested positive for the virus. And in Apr 2006 a low-pathogenic form of H7N3 avian influenza struck 3 English farms, leading to the culling of 50,000 poultry.
(CIDRAP 4/19/07, http://cidrap.umn.org )

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Kuwait (Wafra): Imported falcons purported source of poultry epidemic of avian influenza H5N1
The first case of avian flu in broiler chickens has been discovered in a poultry farm in Wafra, says a source at the Public Authority for Agricultural Affairs and Fish Resources (PAAAFR). Meanwhile, falcons illegally imported into Kuwait may have been the cause of an outbreak of bird flu that has forced authorities to cull about 2 million chickens. During a special debate, a number of lawmakers submitted official documents showing that several falcon shipments for royals and influential people were imported without the strict quarantine procedures. The head of the government's agriculture authority denied the allegations, insisting that all the imported falcons were properly tested and found healthy. But he admitted that a total ban on bird imports -- imposed in 2005 following the discovery of the first bird flu case in Kuwait -- was eased in Jul 2006 to allow the import of falcons. In the meantime, the Public Authority for Agricultural Affairs and Fish Resources (PAAAFR) has destroyed 180 000 eggs and 250 tons of fodder from 5 poultry farms that tested positive for bird flu virus.
(ProMED, 4/19/07, http://promedmail.org )

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Saudi Arabia: Ministry of Health reports no threat of avian influenza outbreak
The Minister of Health of the Kingdom of Saudi Arabia said Apr 15, 2007 that there was no bird flu outbreak in the Kingdom. The announcement comes after a small number of bird flu cases were reported in the Eastern Province Mar 2007. The Minister reports that the cases of bird flu “have been eliminated," and reported that preventive measures against the spread of the bird flu virus was the responsibility of the Ministry of Agriculture. The minister said that the cases discovered in the Kingdom were small, consisted of migratory birds crossing the nation’s border, and immediately contained by the Ministry of Agriculture.
(ProMED, 4/15/07 http://promedmail.org)

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Asia
Cambodia: Avian influenza H5N1 outbreak in birds reported to OIE
Cambodia submitted to the OIE on April 12, 2007, a report of an outbreak of H5N1 among a flock of 1086 susceptible birds. Authorities reported 302 cases, and that the remainder of the flock had been culled. The recorded start date of the epidemic is April 6, 2007, which is 4 days after the death of Cambodia’s seventh bird flu victim, April 2. One would have expected an earlier date than April 2 for the onset of the outbreak. But it appears as if the outbreak started the day after the 13-year-old girl died. It is therefore possible that the source of the human infection was another outbreak at an earlier time that has not been officially reported.
(ProMED, 4/15/07 http://promedmail.org )

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China: Reported withholding of avian influenza H5N1 virus samples
China has purportedly been withholding H5N1 samples from humans from WHO. Keiji Fukuda of WHO said China has not shared any human H5N1 virus samples in about a year. The country provided some H5N1 samples from birds in late 2006. Researchers need samples of the virus to monitor its evolution and spread, test for resistance to antiviral drugs, and develop vaccines. China sent its latest shipment of human H5N1 isolates to a WHO-affiliated laboratory in the spring of 2006. The newest sample in the shipment was gleaned from a patient in late 2005 or early 2006. Fukuda said that WHO has been negotiating with the Chinese health and agriculture ministries and remained hopeful that the talks would lead to a system for timely sharing of H5N1 samples.
(CIDRAP 4/16/07, http://cidrap.umn.edu )

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Americas
USA: FDA approves vaccine for avian influenza H5N1
The U.S. Food and Drug Administration (FDA) approved a human vaccine against the H5N1 influenza virus on April 17, marking the first such approval in the U.S. In a press release the agency said that, should H5N1 develop the ability to spread readily from person to person: "The vaccine may provide early limited protection in the months before a vaccine tailored to the pandemic strain of the virus could be developed and produced." The vaccine will be kept in a federal stockpile and available only through public health officials; it is approved for those 18 to 64 who are at increased risk for H5N1 exposure.

The vaccine was obtained from a human strain (a/vietnam/1203/2004 influenza virus) and consists of 2 intramuscular injections, given approximately 1 month apart. 1 multi-center, randomized, double-blinded, placebo-controlled, dose-ranging study in healthy adults, 18 to 64 years of age, investigated the safety and immunogenicity of the vaccine. A total of 103 healthy adults received a 90 microgram dose of the vaccine by injection followed by another 90 microgram dose 28 days later. In addition, there were approximately 300 healthy adults who received the vaccine at doses lower than 90 micrograms and a total of 48 who received a placebo injection. The vaccine was generally well tolerated, with the most common side effects reported as pain at the injection site, headache, general ill feeling and muscle pain. The study showed that 45 percent of individuals who received the 90 microgram, two-dose regimen developed antibodies at a level that is expected to reduce the risk of getting influenza. Although the level of antibodies seen in the remaining individuals did not reach that level, current scientific information on other influenza vaccines suggests that less than optimal antibody levels may still have the potential to help reduce disease severity and influenza-related hospitalizations and deaths. Additional information on this H5N1 influenza vaccine is being collected on safety and effectiveness in other age groups and will be available to the FDA in the near future.
(CIDRAP 4/17/07 http://cidrap.umn.edu , ProMED, 4/18/07 http://promedmail.org )

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Africa
Algeria (Oran Wilaya Governate): First detected avian influenza case in chicken
The first case of avian flu was detected in a hen from a domestic breeding site in the locality of Sidi El Bachir in the Oran Wilaya Governorate, 432 km West of Algiers. It is suspected to be the first case detected in Algeria. The diagnosis has been confirmed by analyses performed by the regional laboratory of veterinary services. Authorities have increased controls and preventive measures in order to prevent the propagation of the disease in humans.
(ProMED 4/14/07, 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 the Paris anti-avian influenza conference.
- 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. Latest global updates.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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Seasonal Influenza
During week 14 (April 1 – 7, 2007), influenza activity continued to decrease in the US. Data from the U.S. WHO and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories indicated a small increase in the percentage of specimens testing positive for influenza (10.9% of specimens tested positive for influenza during week 14 compared to 10.3% for week 13), although other surveillance systems indicated a decrease in influenza activity. Influenza like illness (ILI) data decreased during week 14 and was below the national baseline. 8 states reported widespread influenza activity; five states reported regional influenza activity; 13 states and New York City reported local influenza activity; the District of Columbia and 22 states reported sporadic influenza activity; and 2 states reported no activity. The number of jurisdictions reporting widespread or regional influenza activity decreased from 19 for week 13 to 13 for week 14. The percent of deaths due to pneumonia and influenza remained below baseline level.
http://cdc.gov/flu/weekly

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2. Articles
Summary of the second WHO consultation on clinical aspects of human infection with avian influenza A(H5N1) virus
19-21 March, 2007, Antalya, Turkey
Since the last meeting in Hanoi, May 2005, 8 new countries have reported human infections with avian influenza A(H5N1) viruses. Clinicians, epidemiologists, virologists and public health specialists from the countries with human cases, and experts in pulmonary medicine, critical care, and influenza attended the meeting to share their experiences. Participants agreed that standardizing care and promptly sharing clinical and treatment information are critically important to understanding the disease in humans and to improving clinical management. Observations and experiences, including unpublished data, were shared by participants during the consultation. Several conclusions regarding management of patients with H5N1 illness support and expand current WHO guidance (http://www.who.int/csr/disease/avian_influenza/guidelines/pharmamanagement/en/ind ex.html ):

• Experiences with early oseltamivir treatment suggest its usefulness in reducing H5N1-associated mortality. In addition, evidence of prolonged H5N1 virus replication indicates that treatment is warranted even with late presentation.
• As previously discussed, modified regimens of oseltamivir treatment, including two-fold higher dosage, longer duration and possibly combination therapy with amantadine (in countries where the H5N1 virus is susceptible to amantadine) may be considered on a case by case basis, especially in patients with pneumonia or progressive disease. Ideally this should be done in the context of prospective data collection.
• Corticosteroid therapy has failed so far to show effectiveness, and prolonged or high dose corticosteroids can result in serious adverse events in H5N1 patients, including opportunistic infection. Corticosteroids should not be used routinely, except for persistent septic shock with suspected adrenal insufficiency.
• Antibiotic prophylaxis should not be used. When pneumonia is present, antibiotic treatment is appropriate initially for community-acquired pneumonia according to published evidence-based guidelines. When available, the results of microbiologic studies should be used to guide antibiotic usage in patients with A(H5N1) infection.
• Therapy for H5N1-associated ARDS should be based upon published evidence-based guidelines for sepsis-associated ARDS, specifically including lung protective mechanical ventilation with low tidal volume.

The observations from the meeting will be published in greater detail, as an updated WHO guidance on H5N1 clinical management followed by a meeting summary in the form of peer-reviewed article.
(CIDRAP, http://cidrap.umn.edu )

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Difficulty in the Rapid Diagnosis of Avian Influenza A Infection: Thailand Experience
Anucha Apisarnthanarak, Rungrueng Kitphati, and Linda M. Mundy. Difficulty in the Rapid Diagnosis of Avian Influenza A Infection: Thailand Experience. Clinical Infectious Diseases 2007;44:1252-1253.
(references removed)
TO THE EDITOR—We would like to report our experience with the use of rapid tests for confirmation of avian influenza A (H5N1) infection in Thailand. During the first H5N1 infection outbreak in Thailand (1 December 2003 to 31 March 2004), nasopharyngeal specimens from 610 patients (range, 1–3 specimens per patient) were submitted to the Thai National Institute of Health. Twelve (2%) of 610 patients had confirmed H5N1 infection by RT-PCR, real-time RT-PCR, and/or viral culture results. Of these 12 patients, 7 (58%) had specimens submitted for nasopharyngeal rapid testing; 2 (28.5%) of these 7 patients had nasopharyngeal rapid test results positive for H5N1 (SD Bioline Influenza Antigen A/B [MT Promedt Consulting] and Quickvue Influenza A+B test [Quidel]). Quality-improvement initiatives identified inappropriate specimen procurement, incorrect specimen containment, or delayed specimen shipment for 4.8% of the nasopharyngeal specimens obtained. A county-wide educational program on proper specimen procurement, transport, and processing occurred from 1 April through 31 August 2004. After the educational program, 4417 patients had at least 1 specimen (range, 1–6 specimens per patient) submitted for H5N1 testing. There was a notable reduction in suboptimal specimen collections to 2.4% (P = .02). Thirteen (0.3%) of 4417 patients had H5N1 infection confirmed by RT-PCR, real-time RT-PCR, and/or viral culture results. Ten (77%) of these 13 patients had specimens submitted for nasopharyngeal rapid testing, and 3 (30%) of these 10 patients had nasopharyngeal rapid test results positive for H5N1. Of note, 1 patient with H5N1 infection received neuraminidase inhibitor >48 h before specimen collection and had negative nasopharyngeal rapid test results. Our findings have some important implications. Although physicians tend to submit multiple specimens from each index patient, and although suboptimal specimen collection and processing were identified less commonly after the educational program, we found no difference in the diagnostic yield of the rapid test. With the increase in neuraminidase inhibitor supply in Thailand, physicians tend to prescribe this medication to the index patient long before specimen collection. Because rapid diagnosis for H5N1 infection can be difficult, we emphasize the importance of treating physicians obtaining multiple adequate, deep specimens from patients before the administration of antiviral medication to the index patient.
(PMID: 17407049, http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed )

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Community Engagement: Leadership Tool for Catastrophic Health Events
Monica Schoch-Spana, Crystal Franco, Jennifer B. Nuzzo, and Christiana Usenza on behalf of the Working Group on Community Engagement in Health Emergency Planning. “Community Engagement: Leadership Tool for Catastrophic Health Events. ” Biosecurity and Bioterrorism. Volume 5, Number 1, 2007.
Abstract: Disasters and epidemics are immense and shocking disturbances that require the judgments and efforts of large numbers of people, not simply those who serve in an official capacity. This article reviews the Working Group on Community Engagement in Health Emergency Planning’s recommendations to government decision makers on why and how to catalyze the civic infrastructure for an extreme health event. Community engagement—defined here as structured dialogue, joint problem solving, and collaborative action among formal authorities, citizens at-large, and local opinion leaders around a pressing public matter—can augment officials’ abilities to govern in a crisis, improve application of communally held resources in a disaster or epidemic, and mitigate communitywide losses. The case of limited medical options in an influenza pandemic serves to demonstrate the civic infrastructure’s preparedness, response, and recovery capabilities and to illustrate how community engagement can improve pandemic contingency planning.
(CIDRAP, http://cidrap.umn.edu )

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3. Notifications
Citizen engagement in emergency planning for a flu pandemic: a summary of the October 23, 2006 workshop of the Disasters Roundtable
By Byron Mason, report by the National Research Council of the National Academies, released Apr 13, 2007. This open book page image presentation framework is a free, browsable, nonproprietary, fully and deeply searchable version of the publication. To see the full report, go to:
http://books.nap.edu/openbook.php?isbn=0309107911.
(The National Academy Press)

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Bird Flu School Planning Summit Stresses Hands-On Training
The second Bird Flu School Planning Summit, which will be launched May 21, 2007 at the Hilton Garden Inn Raritan Center in New Jersey, is meant to engage school administrators, teachers, parents, and students in an intensive, hands-on training on how to prevent, prepare for, respond to, and recover from a possible bird flu pandemic. Organized by New-Fields Exhibitions, the summit aims to encourage all community members to engage in the fight against bird flu and to prepare for a looming flu pandemic. Summit workshops start off with a clear, easy-to-remember overview of bird flu, then go on to spell out the roles and responsibilities of community members in the event of a pandemic. They also include simulation exercises that test resources against the toughest classroom, home front, and community scenarios. The summit agenda has four general topics: Learn How to Plan, Protect the Community, Know How to Respond, and Plan to Continue. Taken together, these are meant to teach participants how, in the event of a pandemic, to maintain cash flow and to continue day-to-day operations. The school planning materials equip participants with the resources to effectively collaborate, coordinate and communicate, so that they can carry on their day-to-day operations with the least disruption. These are reviewed by experts from the health and human services department, CDC, the Department of Education, and other stakeholders in the private and academic communities. The bird flu school planning conference is a part of New-Field Exhibitions continuing commitment to be responsive to the needs and expectations of communities. Last year, it organized a similar event in California. New-Fields also organized International Bird Flu Summits in Washington, DC and Geneva, attended by public health officials, scientists, and business leaders from around the world. For more information about the conference, call 202.536.5000 or visit www.new-fields.com.
(Bird Flu Summit 4/15/07)

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 apecein@u.washington.edu