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EINet Alert ~ Jun 15, 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: Glaxo to give 50 million doses of H5N1 vaccine to WHO
- UK (England): Low Pathogenic avian influenza H7N2 found at smallholding
- Europe: EU safety agency approves avian influenza vaccination
- Europe: EU approves Novartis's cell-based influenza vaccine
- Asia: Leaders vow to share avian influenza H5N1 samples
- Indonesia (Riau): New human case of avian influenza H5N1 infection
- Indonesia: Few Indonesians see avian influenza as threat based on survey
- Indonesia: Concerns that avian influenza H5N1 infections becoming less symptomatic in birds
- Malaysia: Suspected human cases of avian influenza H5N1 infection; outbreaks in poultry
- Myanmar: Report of new avian influenza H5N1 outbreak in farm north of Yangon
- Viet Nam: Report of 2 new avian influenza H5N1 cases; risks from free range ducks
- Viet Nam: Northern Vietnam reports new avian influenza H5N1 infections in ducks
- USA: Many Americans confused about avian influenza and food safety
- USA: HHS hears community leaders' ideas on pandemic influenza readiness
- USA: Firm wins grant for fast way to make DNA vaccines
- Egypt (Qena): More human cases of avian influenza H5N1 infection

1. Updates
- Avian/Pandemic influenza updates

2. Articles
- Inefficient Transmission of H5N1 Influenza Viruses in a Ferret Contact Model
- Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary
- Tamiflu and neuropsychiatric disturbance in adolescents

3. Notifications
- National Pandemic Influenza Exercise, Exercise Cumpston 06 Report
- APEC Avian/Pandemic influenza Documents
- Pandemic preparedness Webinar recordings


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 / 3 (2)
Egypt / 18 (5)
Indonesia / 25 (22)
Laos / 2 (2)
Nigeria / 1 (1)
Total / 50 (33)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 313 (191).
(WHO 6/15/07 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO: http://www.wpro.who.int/sites/csr/data/data_Graphs.htm. (WHO/WPRO 6/4/07)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 6/13/07): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 6/4/07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.

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Global: Glaxo to give 50 million doses of H5N1 vaccine to WHO
GlaxoSmithKline (GSK) promised to give 50 million doses of its H5N1 "prepandemic" influenza vaccine to WHO for distribution to poor countries. The vaccine will be delivered over 3 years and be enough to vaccinate 25 million people at 2 doses each, the UK–based drug company said. The announcement marks the first tangible step toward the creation of a world stockpile of H5N1 vaccines, a goal endorsed by WHO member countries. Following GSK's announcement, US-based Baxter International and the French vaccine maker Sanofi Pasteur both announced their intention to donate H5N1 vaccines to the WHO stockpile.

The idea of a global stockpile emerged after complaints by Indonesia and other developing countries about lack of access to commercial H5N1 vaccines. Indonesia, the country hit hardest by H5N1, withheld samples of the virus from the WHO from Dec 2006 until May 2007 on grounds that drug companies use the samples to make vaccines priced out of Indonesia's reach. WHO said it needs to do "detailed operational planning for the stockpile, including how and under which conditions it will be deployed, as well as regulatory aspects of the vaccine." WHO members had passed a resolution calling for the creation of a stockpile of vaccines for H5N1 and other viruses of pandemic potential. The resolution also called on WHO to set up mechanisms for the "fair and equitable distribution" of pandemic flu vaccines at "affordable prices."

GSK's vaccine includes a proprietary adjuvant (immune-stimulating chemical) and in clinical trials has induced a strong immune response at low doses. In Jul 2006 the company said 80% of volunteers showed a good immune response after receiving two 3.8-microgram doses. A typical dose of seasonal flu vaccine contains 15 micrograms of antigen for each of three flu strains. In Mar GSK said its vaccine might protect people against more than 1 strain of H5N1. The vaccine is based on a 2004 strain from Vietnam, but in a clinical trial it elicited an immune response (neutralizing antibodies) to an H5N1 strain from Indonesia.

WHO noted that 3 other vaccine producers—Baxter, Sanofi Pasteur, and Omnivest of Hungary—also have expressed a willingness to provide some doses of H5N1 vaccine to the global stockpile. Baxter's said the company intends to provide a "multiyear donation" of its candidate pandemic flu vaccine to WHO. Sanofi Pasteur, meanwhile, said it was ready to give a "significant number of doses" of H5N1 vaccine. GSK promised that, in addition to its donation, it would provide some of its H5N1 vaccine to WHO at "preferential" prices for use by countries eligible for assistance from GAVI (the Global Alliance for Vaccines and Immunization), a public-private program that provides vaccines for children in poor countries. The company noted that a precisely matched vaccine won't become available until 4 to 6 months after a pandemic strain emerges. Experts hope that if the next pandemic strain is an H5N1 variant, existing H5N1 vaccines will provide some protection, though supplies are likely to be very short.
(CIDRAP 6/13/07 www.cidrap.umn.edu )

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Europe/Near East
UK (England): Low Pathogenic avian influenza H7N2 found at smallholding
A restriction zone has been placed around a non-commercial smallholding near St Helens, Lancashire, England, following the positive tests for low pathogenic avian influenza. Some of the infected chickens had been bought from a market 7 May 2007 held in Chelford that was associated with a recent H7N2 low pathogenic bird flu outbreak in north Wales. All the farm's birds, including peacocks, have been culled. Low pathogenic avian influenza typically causes little or no clinical symptoms in infected birds. The birds included 20 chickens, 3 ducks, 3 peacocks, and some peacock chicks. A restricted zone extends 1 km from the holding, which is thought to be in Rainhill, near St Helens. People are forbidden from moving poultry or any sort of live birds or eggs through this zone. The 2 people who live on the smallholding have been testing for the disease after exhibiting flu-like symptoms but results came back negative. The animal health department is tracing movements and contacts. DEFRA is working closely with the Health Protection Agency on all potential human health aspects.
(Promed 6/8/07 www.promedmail.org/ )

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Europe: EU safety agency approves avian influenza vaccination
Vaccination programmes of poultry with approved drugs and procedures could be used to prevent outbreaks of avian influenza, the European Union's (EU's) food safety assessment agency said 6 Jun 2007. Mass vaccination is seen as one way of calming consumers' fears about the safety of the bloc's poultry flock. Consumption of poultry and poultry products plunged by as much as 70 per cent in some countries at the start of 2006 due to outbreaks in member states.

The EU authorised vaccines for poultry such as chickens and ducks meet relevant quality standards. However more study is needed before an opinion could be made about the use of vaccination for other poultry, European Food Safety Agency (EFSA) stated. According to the EFSA, monitoring strategies, combined with the use of sentinel birds in order to detect possible transmission after vaccination, must be employed to allow the detection of a possibly circulating field strain. Last year the European Centre for Disease Prevention and Control (CDPC) warned that vaccination programmes that are widely but imperfectly instituted in poultry may impede detection of human cases. Mass vaccination can also serve to disguise the presence of any H5N1 that manages to survive in innoculated flocks, and thus pose a great danger, others have argued. So far, the European Commisson and member countries have resisted calls for mass vaccination of the domestic poultry stock.

At least 3 countries -- China, Indonesia and Viet Nam -- are undertaking large-scale poultry vaccination programmes against H5N1, alongside with the mass culling of millions of birds. "If poultry immunisation is efficient and well monitored it could reduce the population burden of H5N1 in poultry and hence the risk for humans," the CDPC stated. "Equally however if it leads to the silent circulation of H5N1 in poultry it could actually increase the threat to humans in those countries and the risk of co-infection with other influenzas. Falling numbers of reported human cases in countries practicing large scale poultry immunisation may therefore be misleading." Cases of avian influenza H5N1 have occurred in wild birds in 13 member states of the EU to date: Greece, Italy, Slovenia, Hungary, Austria, Germany, France, Slovakia, Sweden, Poland, Denmark, Czech Republic and, more recently, the UK.
(Promed 6/8/07 www.promedmail.org/ )

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Europe: EU approves Novartis's cell-based influenza vaccine
The European Union (EU) has approved Novartis's seasonal influenza vaccine, Optaflu, putting the Swiss company in a position to become the first to market a flu vaccine grown in cell culture rather than eggs. The vaccine has been approved for use in all 27 EU member states plus Iceland and Norway, Novartis announced. It is expected to be available in Germany and Austria for the upcoming flu season and in the rest of the EU in 2008-09. "Optaflu marks the first major innovation in influenza vaccine manufacturing in over 50 years," Dr. Jorg Reinhardt, CEO of Novartis Vaccines and Diagnostics, said. "The use of a Novartis proprietary cell culture technology enables a faster and more flexible start-up of vaccine manufacturing, offering the potential to more quickly respond to a potential pandemic influenza threat," the company said. Flu vaccines have been produced in chicken eggs since the 1950s. Growing the viruses in cell cultures is seen as much more flexible and somewhat faster than egg-based production, which takes several months. Several companies are developing cell-based production methods. Novartis said it expects to apply next year for US approval of Optaflu. In May 2006 the US government awarded Novartis a $220 million contract to develop cell-based flu vaccines, and in Jul 2006 the company announced plans for a $600 million plant in North Carolina to produce them.
(CIDRAP 6/13/07 www.cidrap.umn.edu )

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Asia
Asia: Leaders vow to share avian influenza H5N1 samples
In a statement released at the end of the 2-day APEC health ministers' conference, the ministers pledged to continue supporting WHO influenza surveillance with the timely sharing of virus samples. APEC's 21 members include many of the countries that have been hardest hit by avian flu, including Indonesia, China, and Vietnam. Their statement acknowledges the concerns that Indonesia and other developing countries have about equitable access to pandemic vaccines. "We aim to ensure and promote the transparent, fair, and equitable sharing of benefits arising from the generation of information, diagnostics, medicines, vaccines, and other technologies associated with the sharing of virus samples," the ministers said.

At the World Health Assembly in May 2007, WHO adopted a resolution calling for an international H5N1 vaccine stockpile, a system for fairly distributing the vaccines, and a group to draw up "terms of reference" for virus sharing. Also at the APEC meeting, a senior WHO official warned that the H5N1 virus is mutating rapidly and unpredictably. Shigeru Omi, WHO regional director for the Western Pacific, said, "The virus is already entrenched, embedded in this part of the world, and it has been very, very unstable and changeable." Omi said the virus has evolved from 2 distinct groups into 4 subgroups, adding, "And I would not be surprised to if we end up with more subclasses in the years to come," he said. Though the current mutations have not clearly increased the likelihood of human-to-human transmission, they do show that the virus is "risky", Omi said. To read more about the APEC Health Ministers meeting: http://www.apec.org/.
(CIDRAP 6/8/07 www.cidrap.umn.edu )

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Indonesia (Riau): New human case of avian influenza H5N1 infection
The Ministry of Health of Indonesia has announced a new case of human infection of H5N1 avian influenza. A 26-year-old male from Riau Province developed symptoms 3 Jun 2007, was hospitalized 6 June and died in hospital 12 June. Investigations into the source of his infection indicate exposure to sick and dead poultry. Of the 100 cases confirmed to date in Indonesia, 80 have been fatal.
(WHO 6/15/07 http://www.who.int/csr/don/2007_06_15/en/index.html )

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Indonesia: Few Indonesians see avian influenza as threat based on survey
A survey of Indonesians' attitudes about avian flu revealed that 97% were aware of the virus, but only 15% saw it as a direct threat to them or their families, the Jakarta Post reported. "Many people still say 'I know the that the disease is dangerous, but it's other people's problem, not mine,'" said Bayu Krisnamurthi, head of the Indonesian National Commission for Avian Influenza and Pandemic Preparedness, the group that released the data. Indonesians should learn from the Egyptians, who have a lower human death toll because they seek immediate medical care, he reportedly told reporters. Commission data show that the human death rate in Indonesia from June 2006 to May 2007 rose to 86.4%, from 74.5% the previous year, the Post reported. About 57% of Indonesia's avian flu patients had contact with dead or infected poultry, 29% lived near poultry farms where sick or dead poultry were reported, and 1% had contact with poultry feces, the commission said. For 13% of patients the source was not known. Only 2 of Indonesia's 33 provinces—North Maluku and Gorontalo—remain free of the disease, the report said.
(CIDRAP 6/8/07 www.cidrap.umn.edu )

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Indonesia: Concerns that avian influenza H5N1 infections becoming less symptomatic in birds
Some Indonesian officials said some poultry are getting H5N1 infections without showing signs of illness, complicating efforts to track the virus and protect humans. "From our observations during 2007 we have found that chickens infected by bird flu have not been showing the usual symptoms," said Memed Zulkaraen, director of the agriculture ministry's avian flu campaign unit. So far this year, 12,000 birds in Indonesia have died of avian flu or been culled, whereas last year about 1.75 million poultry died of the disease or were destroyed, said Musny Suatmodjo, animal health director at the agriculture ministry. Bayu Krisnamurthi, chief of Indonesia's avian flu commission, expressed concern that healthy-looking poultry could shed the virus, increasing the risk of human cases. Kisnamturthi said Indonesia has had some human cases in the absence of any sick or dead poultry in the area. Last week Krisnamurthi expressed a suspicion that the H5N1 virus has mutated in a way that enables it to jump more easily from birds to humans.

Scientists are conducting surveys of poultry to gauge the frequency of asymptomatic H5N1 infections, their cause and risks to people. 4 of every 5 human H5N1 cases have been fatal in Indonesia. Of 15 cases confirmed there May 2007, doctors weren't able to identify the cause of infection in 8 of them. "If there's virus circulation and the animals appear clinically healthy, then it can be a human health risk because people keep on handling those animals" without being aware of the risks, said Christianne Bruschke, a veterinarian leading an avian influenza project for the World Organisation for Animal Health [OIE]. Indonesia's vaccination program aimed at controlling poultry outbreaks may be obscuring infections, said Bruschke. The Indonesian government allocated 60 million doses of vaccine for poultry this year [2007], enough to protect about 1/5 of the 285 million chickens raised in backyards across the country.
(CIDRAP 6/11/07 www.cidrap.umn.edu ; Promed 6/13/07 www.promedmail.org/ )

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Malaysia: Suspected human cases of avian influenza H5N1 infection; outbreaks in poultry
The health ministry in Malaysia said that 5 people in 2 central states have been quarantined for suspected H5N1 infection. The patients include 3 children and 2 adults. An 11-year-old boy was isolated at a hospital in Selangor state, while the others were hospitalized in Pahang state. Chua Soi Lek, a health ministry official, said all the patients had had contact with dead chickens. He added that 16 other people who were hospitalized with flulike symptoms have tested negative for the virus. The H5N1 virus resurfaced in Malaysian poultry early this month in Selangor, marking the country's first outbreak since Feb 2006, but it has never had a confirmed human H5N1 case.

Excerpts from OIE report
Location: Selangor
Start date: 2 Jun 2007; Report date: 12 Jun 2007.
Date of previous occurrence: 22 Mar 2006.
Causal agent: highly pathogenic avian influenza virus, serotype H5N1.

Source of infection: unknown or inconclusive.
Stamping out (1-km-radius zone around the index case) and disinfection started on 6 Jun 2007, and were completed on 10 Jun 2007. The total number of birds culled was 4127, consisting of village chickens (63.17 percent), fighting cocks (16.89 percent), ducks (2.43 percent), quails (1.89 percent), and other birds (15.62 percent). Clinical and laboratory surveillance is ongoing in the surveillance zone (10-km-radius zone around the index case). Similarly, surveillance in the whole country is also ongoing.

Test: real-time reverse transcriptase/polymerase chain reaction (RRT-PCR), positive.
(CIDRAP 6/13/07 www.cidrap.umn.edu ; Promed 6/13/07 www.promedmail.org/ )

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Myanmar: Report of new avian influenza H5N1 outbreak in farm north of Yangon
Myanmar has detected the H5N1 bird flu virus among chickens on a private farm. Than Hla, an official at the Livestock Breeding and Veterinary Department, said 13 Jun 2007 the virus was detected in a small farm in Bago, 80 km north of Yangon, early this month, marking the country's first outbreak of the virus since Apr 2007. "About 28 chickens died at a private poultry farm in the outskirts of Bago starting 3 Jun 2007," said Than Hla, adding that laboratory tests confirmed 7 Jun 2007 that some of chickens were infected with H5N1. About 1000 birds from the farm have been killed as a precaution, he said. The livestock department has also kept a close watch on the area, he said, adding that the outbreak remained under control because the farm was located away from other poultry farms and residential areas. Myanmar had reported outbreaks of H5N1 bird flu in the outskirts of Yangon in Feb and Apr 2007 and had slaughtered more than 60 000 chickens and other birds. Before those cases, Myanmar last reported an H5N1 outbreak among poultry in Mar 2006. It has reported no human H5N1 cases.

Excerpts from the OIE report:
Start date: 26 Feb 2007; Report date: 09 Jun 2007.
Date of previous occurrence: 27 Apr 2006.
Causal agent: Highly pathogenic avian influenza virus; Serotype: H5N1.

Outbreak 1: Hanthawaddy ward, Bago, Bago, BAGO.
Date of start of outbreak: 02 Jun 2007.
Outbreak status: Continuing; Epidemiological unit: Farm.
Species: Birds: Susceptible: 989; Cases: 28; Deaths: 28; Destroyed: 961; Slaughtered: 0.

Affected population: layer poultry (battery cage).
Control measures already applied: Movement control inside the country; Screening; Disinfection of infected premises/establishment(s); Dipping / Spraying; Quarantine; Modified stamping out; Vaccination prohibited; No treatment of affected animals.
Measures to be applied: Control of wildlife reservoirs; Zoning.

Tests and results: polymerase chain reaction (PCR), 05 Jun 2007, Positive; rapid tests, 04 Jun 2007, Negative; virus isolation, 07 Jun 2007, Positive.
(Promed 6/14/07 www.promedmail.org/ )

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Viet Nam: Report of 2 new avian influenza H5N1 cases; risks from free range ducks
Vietnamese health officials announced that 2 more patients tested positive for H5N1 avian influenza, while officials suggested that unvaccinated ducks may be to blame for Vietnam's recent rash of poultry outbreaks. Nguyen Huy Nga, director of Vietnam's preventive medicine administration, said tests at a Vietnamese laboratory confirmed that a 28-year-old man from Tranh Hoa province and a 29-year-old woman from Ha Nam province, both in the northern part of the country, were infected with the H5N1 virus.

Reportedly, the patient from Tranh Hoa got sick after eating meat from an infected duck and was released from a hospital after recovering from pneumonia-like symptoms. Reportedly, the woman from Ha Nam province was in critical condition at the Hospital for Tropical Diseases in Hanoi. Officials were trying to learn how she was exposed to the virus. If WHO confirms the 2 cases and 2 others reported by Vietnam over the past few weeks, the country's H5N1 case count will rise to 97.

In other news, Vietnam's first H5N1 case-patient in a year and a half, a 30-year-old man, left the hospital May 15, 2006. He became infected after he helped slaughter chickens for a friend's wedding. Doctors at the Bach Mai hospital said they treated him with the antiviral drug oseltamivir for 10 days instead of the standard 7 days. Doctors also said the virus was found in the man's saliva, stomach, and feces. A number of studies have reported gastrointestinal symptoms in H5N1 patients, and WHO has said that H5N1 infection is more likely to involve diarrhea than ordinary flu is.

Since early May 2007, Vietnam has battled H5N1 outbreaks in 15 provinces. The UN Food and Agriculture Organization (FAO) and Vietnamese agriculture officials recently conducted a joint investigation of outbreaks in Nam Dinh province, one of the affected areas. In a report released 2 days ago, the FAO said this year's outbreaks are occurring later in the year than expected. Historically, January and February have been the worst months for the spread of H5N1, because of high consumer demand for poultry products during Lunar New Year (Tet) celebrations and because cooler temperature have been thought to favor the virus's survival in the environment, FAO said. Investigators believe an increase in the numbers of ducks, many of which are unvaccinated, released to graze on newly harvested rice paddies are the reason for the later-than-usual spike in bird outbreaks this year. Investigators found that unvaccinated young ducks, whose breeding cycles may not have corresponded with local vaccination campaigns, were released onto the rice paddies.

"Free range duck production is an excellent system for farming, but there are risks and challenges involved," said Andrew Speedy, FAO's Vietnam representative. The agency recommends that officials ensure that all ducks are vaccinated, require hatcheries to meet basic biosecurity standards, and discourage small hatcheries. FAO said current poultry vaccines are still effective and that it was assisting the government with the study of the H5N1 virus circulating in poultry. Jeffrey Gilbert, chief technical advisor of the FAO's avian influenza program in Vietnam, said, "So far, genetic sequencing of recent viral isolates has shown no significant changes in the antigenicity of the virus."
(CIDRAP 6/11/07, 6/13/07 www.cidrap.umn.edu ; Promed 6/13/07 www.promedmail.org/ )

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Viet Nam: Northern Vietnam reports new avian influenza H5N1 infections in ducks
Bird flu spread to a duck farm in northern Vietnam 28 May - 2 Jun 2007, bringing to 16 the provinces and a city infected with the H5N1 virus, the government said 7 Jun 2007. A total of 240 ducks died in Viet Tri city, the capital of Phu Tho province during the first 4 days of Jun 2007. Health workers slaughtered the remaining 130 fowl as tests confirmed the H5N1 virus among the dead ducks, the Animal Health Department said. Phu Tho has been added to the government's bird flu watch list of 15 provinces and Can Tho city in the southern Mekong delta, following the latest outbreak. On 6 Jun 2007 veterinarians found 80 dead ducks in a flock of 1000 waterfowl in the central province of Quang Nam, one of the provinces which have reported outbreaks in birds since early May. In addition, the Animal Health Department said 3 bird flu cases in poultry were found 7 Jun 2007 and 8 Jun 2007 in the northern province of Thai Binh, which had reported outbreaks in other districts in the province.
(Promed 6/8/07, 6/13/07 www.promedmail.org/ )

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Americas
USA: Many Americans confused about avian influenza and food safety
A nationwide survey indicates that many Americans have misconceptions about food safety issues related to avian influenza, researchers from Rutgers University said. Researchers from the Food Policy Institute at Rutgers New Jersey Agricultural Experimental Station conducted the survey to gauge the public's knowledge about H5N1 avian influenza and determine how Americans would respond if the virus were found in US poultry. The research team interviewed 1,200 adults by telephone between May 3 and Jun 5, 2006. Investigators used random-digit dialing to select survey participants from all 50 states. They first asked a series of questions to gauge respondents' overall awareness of avian flu and how the disease spreads and is prevented. Then they asked what respondents would do if the threat of avian influenza increased, particularly regarding poultry buying and consumption.

Though Americans seem to be aware of avian influenza, they are uncertain of food-related transmission risks. While more than two-thirds of the survey respondents believed that the avian flu virus is present in the uncooked meat of infected poultry, less than half understood that proper cooking kills the virus. Further, when asked what they would do if the H5N1 virus turned up in US chickens, 40% of respondents said they would stop eating chicken products, rather than limiting their risk by using proper cooking and food handling procedures. The researchers said this result is consistent with findings among European consumers. Among other misconceptions, many Americans believe it's easy to identify H5N1-contaminated raw meat. Respondents said they would turn away from chicken products if a wild bird with the H5N1 virus was found in the US or if poultry outbreaks were reported in Canada or Mexico. Though consumers' actual behavior often differs from what they predict it will be, the research group concluded that domestic poultry consumption would drop dramatically if avian flu emerged in the US. Targeted messages to consumers should include information on the safety of the US poultry supply, food handling techniques to avoid cross-contamination, and properly cooking chicken to at least 165ºF, the researchers said.
(CIDRAP 6/12/07 www.cidrap.umn.edu )

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USA: HHS hears community leaders' ideas on pandemic influenza readiness
A hundred leaders from the business, healthcare, faith, and civic communities met with US Department of Health and Human Services (HHS) officials to discuss how to motivate the public to prepare for an influenza pandemic. The Pandemic Influenza Leadership Forum was linked with an online effort by HHS to engage community leaders in talking about pandemic preparedness. On May 22, 2007 the agency launched a pandemic leadership blog, which continues through Jun 27, to stimulate discussions and public feedback. During the leadership forum, HHS employees "live blogged" the event, adding several detailed blog postings describing the presentations and breakout sessions.

HHS Secretary Mike Leavitt said the goal was to share ideas on how local leaders can promote the importance of personal preparedness. Personal preparedness "is a message that needs to surround everyone. They need to hear it from their pastors, from their employers, from their physicians, and from everyone in a position of responsibility," Leavitt said. Despite uncertainty about when a pandemic will strike, Leavitt said, "Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate." He said, "We need to reach out to everyone with words that inform, but not inflame. We need to encourage everyone to prepare, but not panic.” Stephanie Marshall, director of pandemic communications for HHS, said the agency would launch 2 more personal-preparedness promotion efforts. Later this summer officials will release tool kits, tailored to 4 different sector (business, healthcare, faith, and civic), that leaders can use to teach people more about pandemic flu and what they can do to prepare.

HHS officials urged participants to communicate to their communities that it is critical for everyone to prepare for possible pandemic flu. Participants were urged to encourage people to (1) store extra food and other daily supplies to make it easier to stay home for a prolonged period of time, (2) learn and practice proper hand washing, (3) use safe cough and sneeze techniques to limit the spread of illnesses, and (4) stay home and avoid others during illness.
(CIDRAP 6/14/07 www.cidrap.umn.edu )

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USA: Firm wins grant for fast way to make DNA vaccines
Vical Inc. has been awarded a USD 6 million federal grant to develop a DNA vaccine manufacturing process that the company says may dramatically speed up production of vaccines for influenza and other diseases. In announcing the grant Jun 1, 2007, the company said its process has "the potential to produce several million doses of vaccines in a matter of days." Vical President Vijay Samant said the company's RapidResponse system is designed to allow fast, large-scale production of DNA vaccines at low cost and is ideal for responding to emerging diseases such as pandemic flu. The system uses polymerase chain reaction (PCR) to make small segments of DNA, called linear expression cassettes that include only the DNA sequences essential for the vaccine. Conventional flu vaccine production involves growing the target virus in eggs, which takes several months. Several companies are working on producing flu viruses or pieces of them in cell cultures, a process said to be more flexible and somewhat faster than egg-based production.

DNA vaccines contain small pieces of the target pathogen's genetic material instead of a killed or weakened form of the virus. In a separate project, Vical is developing an H5N1 avian flu vaccine that is produced in cell culture, but the RapidResponse process represents a step beyond that, the company said. "The new RapidResponse platform does not use any type of cell-based process. It's a chemical synthesis enzyme reaction," Alan Engbring, Vical's executive director of investor relations, said. In initial research, a single 2-microgram dose of the PCR-produced vaccine protected mice from a lethal dose of H3N2 flu virus, a common human subtype. The company said the RapidResponse process could potentially be scaled up without adding to production time, "conceivably allowing production of hundreds of millions of doses of DNA vaccine during the earliest stages of an outbreak." For the H5N1 vaccine, Escherichia coli is used to produce a plasmid, or loop of DNA, containing genetic material from the target virus. Production time is "measured in weeks"—faster than with egg-based production, but slower than what the RapidResponse system promises to make possible.
(CIDRAP 6/14/07 www.cidrap.umn.edu )

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Africa
Egypt (Qena): More human cases of avian influenza H5N1 infection
A 4-year-old Egyptian girl was reported to have H5N1 avian influenza, as WHO confirmed that a 10-year-old girl from the same area died of the illness 2 days ago. The Egyptian health ministry said the 4-year-old girl (36th case of avian influenza infection in Egypt), from Qena governorate in southern Egypt, was hospitalized with fever and breathing difficulty 10 Jun 2007. Officials said she had been exposed to birds sick with suspected flu. The 10-year-old girl, also from Qena, was listed in critical condition when her illness was reported Jun 8, 2007. WHO said she fell ill Jun 1 and was hospitalized on the Jun 6. There was evidence that she had been exposed to dead birds. The 2 latest cases were the first in Egypt in about 2 months. The country had 16 cases earlier this year. Egypt is the worst hit nation outside East Asia. Most Egyptian cases have occurred in the northern part of the country, but 10 of the past 12 cases have been in the hotter south. Many of the victims have come into contact with infected dead birds, which occurs mostly near their homes. Around 5 million households in Egypt depend on poultry as a main source of food and income and the government has said this makes it unlikely the disease can be eradicated. The government still finds it hard to enforce restrictions on the movement and sale of live poultry.
(CIDRAP 6/11/07, 6/13/07 www.cidrap.umn.edu ; Promed 6/9/07, 6/13/07 www.promedmail.org/ )

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1. Updates
Avian/Pandemic influenza updates
- UN: http://influenza.un.org/. UN response to avian influenza and the pandemic threat. Also, http://www.irinnews.org/Birdflu.asp provides information on avian influenza in order to help the humanitarian community.
- 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. Read the article on ducks and avian influenza.
- 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/. Read about the Pandemic Flu Leadership Forum and Blog.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html.
- CIDRAP: http://www.cidrap.umn.edu/. Pandemic preparedness Webinar recordings available for purchase.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm. The website has been updated, with link to National Influenza Centers in PAHO Member States.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Updates for Hong Kong, Bangladesh, and Indonesia, 15 Jun 2007.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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2. Articles
Inefficient Transmission of H5N1 Influenza Viruses in a Ferret Contact Model
Hui-Ling Yen et al. Journal of Virology, July 2007, p. 6890-6898, Vol. 81, No. 13. http://jvi.asm.org/cgi/content/abstract/81/13/6890
Abstract: “The abilities to infect and transmit efficiently among humans are essential for a novel influenza A virus to cause a pandemic. To evaluate the pandemic potential of widely disseminated H5N1 influenza viruses, a ferret contact model using experimental groups comprised of one inoculated ferret and two contact ferrets was used to study the transmissibility of four human H5N1 viruses isolated from 2003 to 2006. The effects of viral pathogenicity and receptor binding specificity (affinity to synthetic sialosaccharides with 2,3 or 2,6 linkages) on transmissibility were assessed. A/Vietnam/1203/04 and A/Vietnam/JP36-2/05 viruses, which possess "avian-like" 2,3-linked sialic acid (SA) receptor specificity, caused neurological symptoms and death in ferrets inoculated with 103 50% tissue culture infectious doses. A/Hong Kong/213/03 and A/Turkey/65-596/06 viruses, which show binding affinity for "human-like" 2,6-linked SA receptors in addition to their affinity for 2,3-linked SA receptors, caused mild clinical symptoms and were not lethal to the ferrets. No transmission of A/Vietnam/1203/04 or A/Turkey/65-596/06 virus was detected. One contact ferret developed neutralizing antibodies to A/Hong Kong/213/03 but did not exhibit any clinical signs or detectable virus shedding. In two groups, one of two naïve contact ferrets had detectable virus after 6 to 8 days when housed together with the A/Vietnam/JP36-2/05 virus-inoculated ferrets. Infected contact ferrets showed severe clinical signs, although little or no virus was detected in nasal washes. This limited virus shedding explained the absence of secondary transmission from the infected contact ferret to the other naïve ferret that were housed together. Our results suggest that despite their receptor binding affinity, circulating H5N1 viruses retain molecular determinants that restrict their spread among mammalian species.”

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary
http://www.nap.edu/catalog/11917.html#toc
Book from Board on Global Health and Institute of Medicine released Jun 11, 2007.
By: Stanley M. Lemon, Margaret A. Hamburg, P. Frederick Sparling, Eileen R. Choffnes, and Alison Mack, Rapporteurs, Forum on Microbial Threats. Sections include: “Front Matter”, “Summary and Assessment”, “Learning from Pandemics Past”, “Planning for Pandemic Influenza”, “Strategies for Disease Containment”, “Ethical Issues in Pandemic Planning and Response”, and appendices.

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Tamiflu and neuropsychiatric disturbance in adolescents
Simon R J Maxwell. BMJ 2007;334:1232-1233 (16 June), doi:10.1136/bmj.39240.497025.80.
http://www.bmj.com/cgi/content/extract/334/7606/1232
“In March 2007 the Japanese authorities advised against prescribing oseltamivir (Tamiflu, Roche) to adolescents aged 10-19 years. This unusually severe measure resulted from the separate suicides of two 14 year olds who jumped to their deaths while taking oseltamivir; 52 other deaths (14 in children or adolescents) have been associated with the same drug. So far, similar action has not followed in Europe. When a regulatory authority warns doctors not to prescribe a drug but decides not to retract its marketing authorisation prescribers and patients are entitled to be concerned and a little confused. Oseltamivir is a sialic acid analogue that inhibits influenza type A and type B neuraminidase, the viral enzyme that allows the release of virus from infected cells. Its main licensed indications are the treatment of flu, short term postexposure prophylaxis after contact with a diagnosed case of flu, and more prolonged (up to six weeks) "seasonal" . . .”

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3. Notifications
National Pandemic Influenza Exercise, Exercise Cumpston 06 Report
Exercise Cumpston 06 was the first major event of its kind conducted by the Department of Health and Ageing. The aim was to exercise the capacity and capability of the Australian health system to prevent, detect and respond to an influenza pandemic. This document provides an evaluation report on the exercise. Released by the Australian Department of Health and Ageing report released Jun 7, 2007: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/ohp-cumpston-report.htm

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APEC Avian/Pandemic influenza Documents
The APEC Health Ministers’ Meeting was held in Sydney, Australia, 8 Jun 2007. APEC Health Ministers met over two days to consider issues that include strategies for cooperation in dealing with pandemic and other pathogenic communicable diseases. The following are available from the APEC website (www.apec.org ):

- Opening comments and keynote address from the Chair of the APEC Health Ministers' Meeting and Australia's Minister for Health, Tony Abbott
- Health Ministers Meeting Outcomes Statement

Also available is information on the upcoming Workshop on Sharing Experiences with the Management of the Avian Influenza H5N1 Threat in Bangkok, Thailand, Jun 18-20, 2007.

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Pandemic preparedness Webinar recordings
Pandemic preparedness Webinar recordings available for purchase from the CIDRAP Business Source. The following recordings are available at: http://online.krm.com/iebms/coe/coe_p1_all.aspx?oc=10&cc=00279763P

September 2006: Planning for Pandemic Influenza: Will Your Organization Be Prepared?
April 2007: Pandemic Preparedness for Human Resources: Designing and Implementing Effective Policies
June 2007: Beyond Checklists: Developing and Implementing Business Plans for Pandemic Influenza

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 apecein@u.washington.edu