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EINet Alert ~ May 18, 2007


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Global: World Health Assembly resolution for equitable access to medical products
- Hungary: Authorities admit link with UK avian influenza outbreak
- Bangladesh (Nilphamari, Dhaka): Continuing avian influenza epidemic among birds
- Indonesia (North Sumatra): 75th human death from avian influenza, WHO confirms 15 cases
- Indonesia: Avian influenza H5N1 samples going to WHO again
- Viet Nam: Avian influenza poultry vaccine concerns
- Viet Nam (Nghe An): Avian influenza H5N1 Outbreak continues among fowl
- USA: FDA advisory panel recommends FluMist approval for young children

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

2. Articles
- UK preparedness for pandemic influenza
- Influenza transmission: research needs for informing infection control policies and practice
- Influenza vaccination for severely multiply handicapped persons/children in the 2005-2006 season
- Modeling the Impact of Pandemic Influenza on Pacific Islands

3. Notifications
- USA: CDC and CSTE announce three-day training course on preparedness


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
Cambodia/ 1 (1)
China / 2 (1)
Egypt / 16 (4)
Indonesia / 21 (18)
Laos / 2 (2)
Nigeria / 1 (1)
Total / 43 (27)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 288 (170).
(WHO 5/16/07 http://www.who.int/csr/disease/avian_influenza/en/index.html )

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 maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 5/16/07):
http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 5/20/07):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.

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

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Global: World Health Assembly resolution for equitable access to medical products
On May 15, 17 developing countries, including Indonesia, introduced a resolution at the World Health Assembly demanding equitable access to vaccines, drugs, and other medical products derived from H5N1 samples the countries provide. The resolution also would require researchers and vaccine developers to seek informed consent from countries that contribute the viruses before using them. Sharing of avian flu virus samples is vital to the research community for developing pandemic vaccines and monitoring the virus's ability to infect humans, global spread, and resistance to drugs. WHO Director-General Margaret Chan, at a technical briefing at the Geneva meeting May 16, 2007 said WHO recognizes the concerns of developing countries and is taking several actions to ensure that they have access to affordable pandemic vaccines. However, she used strong words in a plea for unrestricted virus sharing. "If you do not share the virus with us, I want to be absolutely honest with you, I will fail you," Chan said. "I will fail you because you are tying my hands, you are muffling my ears, you are blinding my eyes." On Apr 25, 2007, WHO officials, after meeting with governments and vaccine producers, said it might be feasible to set up a world stockpile of H5N1 influenza vaccine to help ensure that developing countries have access to pandemic flu vaccines. The WHO said it would set up expert groups to discuss how to create, maintain, fund, and use an H5N1 vaccine stockpile and would continue working with member states and other partners on the problem of access to pandemic vaccines.
(CIDRAP 5/17/07, http://www.cidrap.umn.edu )

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Europe/Near East
Hungary: Authorities admit link with UK avian influenza outbreak
Hungary has admitted for the first time that it may have been the source of the deadly flu virus that caused an outbreak at a British turkey farm. Bognar Lajos, Hungary's deputy chief veterinary officer, conceded that the H5N1 virus could have gone undetected in a Hungarian turkey flock which was sent to slaughter. He said the meat might then have been exported by Bernard Matthews, the British poultry company, to its plant in Holton, Suffolk, England, before the virus-infected birds there. However, Mr. Lajos insisted that ultimately the blame for the British outbreak must lie with Bernard Matthews, which was criticized for shortfalls in its biosecurity in the wake of the scare. Until now, officials in the east European country have flatly denied that the virus could have come from Hungary. The Csongrad region of the country, Southeast of the capital Budapest, is the area in which 2 goose farms were hit by the virus Jan 2007, weeks before the same strain infected a flock of Bernard Matthews turkeys. A report into the British outbreak by the Department of Environment, Farming and Rural Affairs (DEFRA) concluded that the most plausible explanation was that the infection had been introduced to Britain through imported turkey meat from Hungary. Britain's poultry industry is still paying the price of the bird flu outbreak. Research by the analysts Nielsen shows turkey sales have fallen by 29 percent over the past 3 months while sales of frozen turkeys are down 33 percent on last year. In Hungary, however, the goose farmers affected by bird flu shortly before the British outbreak say they are still waiting for compensation. Under European legislation, member states can have half of any compensation given to farmers hit by bird flu outbreaks paid by the European Commission. A spokesman at the EC said it had received no application for compensation for either of the farms hit by the outbreak.
(ProMED 5/13/07, http://promedmail.org )

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Asia
Bangladesh (Nilphamari, Dhaka): Continuing avian influenza epidemic among birds
Bangladesh authorities are struggling to combat bird flu as it spreads across farms in the impoverished country, with a leading expert warning the situation is "very grave." First detected at a farm in late Mar 2007, near the capital Dhaka, it has so far infected more than 40 farms in 11 districts, prompting authorities to cull 151 000 birds. The technical adviser to the Bangladesh Poultry Association said that the situation was worse than the government described. There have been a lot of unreported bird flu deaths in farms and cover-ups, a leading poultry industry expert said. The virus has been observed not only on farms, but also in domestic birds and fowls. Reporting on farms is apparently poor; farmers are purportedly not reporting bird flu deaths to government authorities for fear of losses in their farms and pressure by adjoining farms. A farm in the northern Nilphamari district was the latest to be infected with the virus May 11, 2007. More than 3000 chickens and ducks were culled. So far, there have been no reports of human infection in Bangladesh. The country is home to hundreds of thousands of poultry farms employing more than a million people. It had already banned imports of live birds from more than 50 countries, including neighbouring India and Myanmar, after outbreaks were detected there. Since the start of the current epizootic in Bangladesh on February 5, 2007, the authorities have reported twelve outbreaks to the OIE, and additional information about 9 additional outbreaks.
(ProMED, 5/13/07, http://promedmail.org )

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Indonesia (North Sumatra): 75th human death from avian influenza, WHO confirms 15 cases
An Indonesian woman who tested positive in preliminary tests for human bird flu has died. This death pushed the country's death toll from the disease to 76, the world's highest. The 26 year old woman was 4 months pregnant with her 2nd child. She died at a hospital in Medan, North Sumatra, early on May 13. She began to show symptoms of bird flu infection 11 days ago, and was treated initially at home, then moved to 2 different hospitals before she died. Reportedly, 3 out of the 5 chickens owned by the victim’s family and 2 pigeons died suddenly 2 weeks ago. The family burned the dead birds but ate the remaining chickens. On May 16, 2007, WHO confirmed 15 additional cases, including 13 deaths, of human infection with H5N1 avian influenza that occurred in Indonesia from the end of Jan 2007 up to the present and has updated its table of confirmed human cases accordingly. WHO had previously required external confirmation of laboratory results from Indonesia, but following a formal on-site assessment of the capacity of the national laboratory in Jakarta to diagnose H5 avian influenza viruses, WHO will now accept the results from the national laboratory, in collaboration with the Eijkman Institute, without further external confirmation. 7 of these newest 15 confirmed cases had been exposed to sick or dead poultry; the source of infection is unknown for 8 cases. Publication of these data removes the discrepancy between the number of human cases of avian H5N1 influenza recognized by the Indonesian Ministry of Health and the number confirmed by WHO. The number of human cases of avian H5N1 influenza in Indonesia is now accepted as 96, which includes 76 deaths. The global total of confirmed cases is now computed as 306, including 185 deaths.
(ProMED 5/13/07, 5/14/07, 5/17/07 http://promedmail.org, WHO 5/16/07, http://who.int/en, CIDRAP 5/13/07, 5/15/07, 5/16/07, http://www.cidrap.umn.edu )

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Indonesia: Avian influenza H5N1 samples going to WHO again
Indonesia's health minister announced May 17, at the World Health Organization's annual meeting that the country has resumed sending H5N1 avian influenza virus samples to WHO, appearing to end a 5-month standoff over developing countries' access to vaccines. "I am pleased to announce to all of you that Indonesia has resumed sending its H5N1 specimens to the WHO collaborating center in Tokyo," Siti Fadilah Supari said at the World Health Assembly in Geneva. Dick Thompson, a WHO spokesman in Geneva, confirmed that Indonesia recently began sending samples to the WHO collaborating center in Tokyo. Indonesia stopped sending its H5N1 samples to the WHO Dec 2006 and in Feb 2007 announced it would send no more until it received assurances that the strains would not be used by private companies to make vaccines that the country couldn't afford.
(CIDRAP 5/15/07, http://www.cidrap.umn.edu, ProMED 5/18/07, http://promedmail.org )

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Viet Nam: Avian influenza poultry vaccine concerns
In Apr 2007, Vietnamese authorities halted the use of an Italian vaccine against bird flu strain H5N9 for geese, as the liquid serum had settled into layers of distinct colors inside the sealed bottles. In response, Merial, the Italian company that sold the vaccines, said the phenomenon is normal and the bottles must be shaken before use, a fact indicated on the bottle instructions. Before the ban, the Vietnamese Ministry of Health and Merial's distributor in Viet Nam, Viphavet, also had a disagreement over the quantity of vaccine the country would order. The vaccine is distributed in 500 ml-serum bottles, which contain 1000 doses (the ministry bought 9 million doses in 2006). This packaging format is suitable for the crowded farms in the north of the country. In the south, however, the farms are small and households raise just a few geese each. Southern localities protested they could not use the large volume of doses being supplied, prompting the ministry to ask Merial to repackage the doses in smaller vials. Viphavet did not officially reply whether it had agreed to the new bottling protocol, and by that time, the serum had settled into layers, purportedly making it difficult for it to be blended back.
(ProMED 5/14/07, http://promedmail.org )

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Viet Nam (Nghe An): Avian influenza H5N1 Outbreak continues among fowl
Viet Nam's central Nghe An province, which detected an outbreak among fowls early May 2007, has faced a new one, a local veterinary official reported May 13, 2007. Close to 1300 out of flocks of 3800 ducks raised by 3 households in Hung Nguyen district, Nghe An, were found dead 9 May 2007. Samples from dead poultry have tested positive to bird flu virus strain H5. Earlier this month, specimens from ducks raised by a household in Dien Chau district, Nghe An, tested positive to H5. Among the flock of 610 ducks, 246 died between May 1 and 4. Nghe An is the only locality in Viet Nam currently affected by bird flu, the official said. Bird flu outbreaks in Viet Nam, starting Dec 2003, have killed and led to the forced culling of dozens of millions of fowls in the country. Viet Nam is actively vaccinating fowls against bird flu viruses to prevent potential outbreaks, the official said, noting that a total of 111 million poultry in 60 cities and provinces have been vaccinated so far this year. This is the 58th HPAI outbreak in Viet Nam reported since the start of the renewed epizootic on December 6 2006. There have been no confirmed human cases of H5N1 avian influenza in Viet Nam since mid-Nov 2005, when Viet Nam led the world with a total of 42 deaths attributable to H5N1 influenza.
(ProMED, 5/13/07, http://promedmail.org )

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Americas
USA: FDA advisory panel recommends FluMist approval for young children
A US Food and Drug Administration (FDA) advisory panel unanimously agreed May 16, 2007 that FluMist, a nasal spray vaccine against seasonal flu, is safe and effective in children 2 years of age and older. The live-virus vaccine, which is manufactured by Gaithersburg, Maryland-based MedImmune, is already FDA-approved for 5- to 49-year-olds. The company has filed a supplemental biologics licensing application (sBLA) to expand its use to children younger than 5 years of age. In a 15-0 decision, the panel of outside experts supported the vaccine's use for children 2 and older who do not have a history of wheezing. The FDA, which is expected to make a decision by the end of May, is not required to follow the panel's recommendations. The panel voted 9-6 for the vaccine's safety and benefits for children between 12 to 59 months without wheezing history and 12-3 against using the nasal spray in children between 6 to 23 months, according to MedImmune. A recent international study published in the New England Journal of Medicine showed children between 6 and 11 months who received FluMist had more hospitalizations and slightly more wheezing than those who got the standard vaccine. However, the same study, which was conducted in the 2004-2005 flu season, revealed 55% fewer cases of flu in the children who received the FluMist. FluMist vaccine has been on the market since 2003. It is effective against influenza A and B viruses; side-effects of the vaccine based on results from placebo-controlled clinical trials have included runny nose, sore throat, cough, headache, and chills.
(CIDRAP 5/17/07, http://www.cidrap.umn.edu )

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1. Updates
Avian/Pandemic influenza updates
- UN: http://influenza.un.org/. UN response to avian influenza and the pandemic threat. Also, http://www.irinnews.org/Birdflu.asp provides information on avian influenza in order to help the humanitarian community.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html.
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html.
- OIE: http://www.oie.int/eng/en_index.htm. Link to upcoming 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/. New updates released.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html. New travel Health Advisory: Avian Influenza A (H5N1) released.
- 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
USA
During week 19 (May 6 – 12, 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 decrease in the number of specimens testing positive for influenza. The percentage of visits for ILI to sentinel providers remained at similar levels during week 19 compared to week 18 and was below the national baseline for the eighth consecutive week. One state reported local influenza activity; the District of Columbia, New York City, and 30 states reported sporadic influenza activity; and 19 states reported no influenza activity. The percent of deaths due to pneumonia and influenza has remained below baseline levels for the entire influenza season to date.
(CDC http://www.cdc.gov/flu/weekly/ )

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2. Articles
UK preparedness for pandemic influenza
Editorial, BMJ 2007;334:965-966.
Devolving responsibility for implementation to local authorities may not be the best policy.
“In the worst case scenario, a pandemic of influenza in the United Kingdom would cause 750 000 excess deaths. In the short term, gross domestic product could fall by some 0.75%, and in the longer term the cost to the nation could be around £170. On March 16 2007, the Department of Health and the Cabinet Office jointly published a new draft plan for pandemic flu. The plan builds on and replaces the October 2005 plan. It is supported by a range of additional documents related to acute hospitals, health care in the community, an "operational and strategic framework" for adults in social care, guidelines for staff in social care settings, ambulance services, and an ethical framework. Some documents offer strategic guidance, some offer operational guidance, and others guidance for individuals. Comments are requested on all draft documents. . .”
http://www.bmj.com/cgi/content/extract/334/7601/965

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Influenza transmission: research needs for informing infection control policies and practice
The recent attention devoted to human influenza in the context of a possible pandemic has identified a surprising number of research gaps, some of which concern issues of fundamental importance for preventing or reducing transmission. Important unresolved questions include: Is there significant pre-symptomatic (transmission from people who will become sick with influenza before they develop symptoms) and/or asymptomatic spread (transmission from people who are infected but never develop symptoms)? How is influenza transmitted? E.g. how much transmission takes place through indirect contact, and what is the relative contribution of aerosol transmission under normal conditions? How effective, practical and acceptable are some of the more stringent measures suggested by some authorities for infection control in high-risk and lower-risk settings, especially in places where people with influenza are being cared for? In health-care settings in particular, will people follow the stricter recommended measures, and will they be able to do their jobs whilst adhering to the more demanding recommendations?

Section Headings:
Pre-symptomatic and asymptomatic spread
Indirect transmission
Contact transmission
Control Measures
Prevention and infection control strategies for health-care settings
(Influenza Team, European Centre for Disease Prevention and Control,
http://www.eurosurveillance.org/ew/2007/070510.asp#1 )

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Influenza vaccination for severely multiply handicapped persons/children in the 2005-2006 season
Otsuka T, Fujinaka H, et al. Vaccine. 2007 Apr 11; [Epub ahead of print].
Abstract: “In this study, we report the effectiveness of trivalent inactivated influenza vaccination (TIV) for severely multiply handicapped persons/children (SMHPs) in the 2005-2006 season. In 77 SMHPs, A/New York/55/2004 (H3N2) which was the changed vaccine-strain showed significant differences in the geometric mean titers (P<0.05) and seroprotection rates (P<0.01) between pre- and post-vaccination. A/New Caledonia/20/99 (H1N1) and B/Shanghai/361/2002, which were the unchanged vaccine-strains, showed no significant differences. We defined the potential responders as those who can achieve 1:40 or more hemagglutination inhibition (HAI) titer after vaccination with any vaccine-strain. Therefore, the rate of potential responders is equivalent to the rate of seroprotection, estimated to be 40-60% among the SMHPs and >80% among the control group in this study. In the SMHPs, even potential responders could only achieve limited HAI titers (1:40-80) even after repeated vaccination. In contrast, the control group showed higher HAI titers compared to the SMHPs for the unchanged vaccine-strains caused by the priming effect. These data suggest that it might be difficult for SMHPs (including potential responders) to achieve the priming effect by the current TIV. Consequently, they cannot obtain a booster effect.”

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Modeling the Impact of Pandemic Influenza on Pacific Islands
Wilson N, Mansoor O, Lush D, Kiedrzynski T. Emerg Infect Dis [serial on the Internet]. 2005 Feb [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol11no02/04-0951.htm (edited)
Excerpt: Many Pacific Island countries and areas have been severely impacted in influenza pandemics. The 1918 pandemic killed substantial proportions of the total population: Fiji 5.2%, Tonga 4.2% to 8.4%, Guam 4.5%, Tahiti 10%, and Western Samoa 19% to 22%. Thirty-one influenza pandemics have occurred since the first pandemic in 1580; another one is likely, if not inevitable. The potential use of influenza as a bioweapon is an additional concern. The scale of an influenza pandemic may be projected on the basis of the available historical data that have been built into a computer model, e.g., FluAid. FluAid uses a deterministic model to estimate the impact range of an influenza pandemic in its first wave. Given the lack of accessible data for specific Pacific Island countries and areas, the default values used in FluAid were used for the proportion of the population in the high-risk category for each age group, for the death rates, hospitalizations, and illness requiring medical consultations. Economy-specific population data were obtained from the Secretariat of the Pacific Community, and hospital bed data were obtained from the World Health Organization (WHO). The FluAid model was supplemented by a model of an 8-week pandemic wave and modeling of hospital bed capacity. he results indicate that at incidence rates of 15% and 35%, pandemic influenza would cause 650 and 1,530 deaths, respectively, giving crude death rates of 22 to 52 per 100,000. Most deaths (83%) would occur in the high-risk group, 60% of whom would be 19-64 years of age, and 22% would be >65 years of age. Additionally, 3,540 to 8,250 persons would be hospitalized, most of whom (78%) would not have high-risk conditions. Also, 241,000 to 563,000 medical consultations would occur. Most (87%) consultations would be for patients without high-risk conditions (50% birth-18 years of age and 46% 19-64 years of age). If the death rate is in the range suggested by the model, this outcome would make it the worst internal demographic event since the 1918 influenza pandemic for many Pacific Island countries and areas. The upper end is considerably lower than for the 1918 pandemic, which suggests that the range indicated is reasonably plausible. Although relatively high, the death toll from pandemic influenza would still be less than the typical annual impact for some Pacific Island countries and areas from other infectious diseases (including malaria and diarrheal diseases) and from such fundamental determinants of health status such as poor sanitation, poor diet, and tobacco use.
http://www.cdc.gov/ncidod/EID/vol11no02/04-0951.htm

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3. Notifications
USA: CDC and CSTE announce three-day training course on preparedness
A three-day training course which provides a standardized curriculum to state and local public-health responders about how to identify and control human infections and illness associated with avian influenza A (H5N1) was announced May 15 by CDC and the Council of State and Territorial Epidemiologists (CSTE). Information about the course, entitled "CDC/CSTE Rapid Response Training: The Role of Public Health in a Multi-Agency Response to Avian Influenza in the United States" is available at http://www.cste.org/influenza/avian.asp. To date, no H5N1 cases in birds or humans have been found in the US or any other country in the Western Hemisphere. However, in parts of Asia, Africa and Europe, the H5N1 virus has caused widespread infections and deaths in poultry and 291 human illnesses, resulting in 172 deaths. Public-health officials around the world consider H5N1 to be the greatest current pandemic influenza threat. CDC provided $2 million in funding to CSTE to support development of the materials, to support the in-person trainings, to adapt the materials for on-line access, and to assist states in replicating the response training in their states using this curriculum.
(CDC, 5/15/07, http://www.cdc.gov/od/oc/media/pressrel/2007/r070515.htm )

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