EINet Alert ~ Jul 13, 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)
- Czech Republic: Confirmation of avian influenza H5N1 at 2 more farms
- Germany (Thuringia): Domestic goose test positive for avian influenza H5N1
- Australia: 3 Children die from influenza after bacterial infection in Perth
- Indonesia: Report of 81st human death from avian influenza H5N1 infection
- Viet Nam (Dien Bien, Ca Mau): New avian influenza H5N1 outbreaks in poultry
- USA: Poll shows waning concern about avian influenza in public
- USA: HHS to give states $430 million for hospital preparedness
- USA (Virginia): Turkeys may have been exposed to mild avian influenza H5N1

1. Updates
- Avian/Pandemic influenza updates

2. Articles
- Highly pathogenic avian influenza A/H5N1 in birds within the EU - Implications for Public Health
- Addressing the Need for Integration between Health and Agriculture in the Preparedness Plans in Latin America
- Avian and pandemic influenza: Progress and problems with global health governance
- Duration of Influenza A Virus Shedding in Hospitalized Patients and Implications for Infection Control

Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

Viet Nam / 3 (3)
Total / 3 (3)

Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)

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)

Cambodia/ 1 (1)
China / 3 (2)
Egypt / 19 (5)
Indonesia / 27 (23)
Laos / 2 (2)
Nigeria / 1 (1)
Viet Nam 2 (0)
Total / 55 (34)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 318 (192).
(WHO 7/11/07 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 6/29/07)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 7/12/07): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 7/3/07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.


Europe/Near East
Czech Republic: Confirmation of avian influenza H5N1 at 2 more farms
Tests confirmed the H5N1 type of the bird flu virus in poultry at 2 farms in the eastern Czech Republic, the State Veterinary Authority (SVS) said 12 Jul 2007. The virus was found at the 2 farms with 71 000 poultry, bringing the number of outbreaks in Czech farms to 4. Vets were preparing to cull all 71,000 birds on the farms 12 Jul 2007, spokesman Josef Duben said. The Czechs identified their first H5N1 bird flu case at a turkey farm in the eastern part of the country Jun 2007 (wild swans in the country had tested positive for H5N1 in the spring of 2006). The 2 farms where disease was reported 11 Jul 2007 are within a 3-km protective zone around another farm where H5N1 had been found. Vets have extended the standard 3-km protection zone and 10-km surveillance zone to include the 2 farms.
(Promed 7/12/07; CIDRAP 7/12/07)


Germany (Thuringia): Domestic goose test positive for avian influenza H5N1
A pet goose in a home for mentally handicapped people had tested positive for the H5N1 strain of bird flu and all 1200 farm and pet birds in a 3-km exclusion zone were culled as a precautionary measure. The goose was found 2 Jul 2007 in the yard of a commune for handicapped people in Wickersdorf in Thueringen in eastern Germany. The affected goose had been able to run around freely and contact with wild birds was suspected as being the cause. Amateur poultry breeders, who said their life's work been ruined by the cull, vented fury at the handicapped group, which had only moved to the village 4 weeks ago and offered animal care as a form of therapy. All the handicapped people and their care providers had been checked as well and none had been infected. Thomas Schulz, spokesman for the state health ministry of Thuringia, said that tissue tests of the hundreds of culled ducks, geese, and hens had found no more H5N1.

Thueringen had re-introduced a lock-up order for farm poultry, which must be kept indoors in areas of high-risk contact with wild birds, such as in farms near lakes and rivers. 4 German states have recently reported finding the H5N1 virus in swans and other wild birds. The number of infected birds in Germany has risen to 43, plus the pet goose. Saxony said 2 more wild swans had tested positive for H5N1 bird flu. Japan said it was banning imports of day-old chicks from Germany following the bird flu case in the pet goose.
(Promed 7/9/07; CIDRAP 7/9/07)


Australia: 3 Children die from influenza after bacterial infection in Perth
Health officials in Perth, Australia, last week advised parents to seek medical care quickly for young children with respiratory symptoms, after 3 children under age 5 died of pneumonia as a complication of "mild" influenza A (H3) infections. Paul Van Buynder, director of communicable disease control for Western Australia's health department, said Jul 6 that officials were surprised by how quickly the illness developed in the children. "While we do not want to create unnecessary panic, it is important for parents to be aware that the disease can cause serious illness within 24 hours," he said. The children who died had a streptococcal pneumonia infection, but officials have not announced what type. The cases started out as "mild influenza A infection," Van Buynder said. He said the health department found no links between the children's cases. Australia is at the peak of its flu season, and the report said hospitals in the Perth area were inundated by anxious parents bringing children with flu symptoms.

The Australian report also is a reminder of recent worries US health officials have had about rising numbers of young flu patients who have suffered coinfections with the sometimes-fatal Staphylococcus aureus pneumonia, in some cases involving drug-resistant strains. S aureus can cause a severe, necrotizing pneumonia that has a relatively high case-fatality rate—33% during the 1968-69 flu pandemic, US CDC said in an Apr 13 Morbidity and Mortality Weekly Report article. Evidence points to a synergistic relationship between S aureus and influenza, according to an article in the June 2006 issue of Emerging Infectious Diseases. Flu viruses appear to increase S aureus adhesion in the respiratory tract, and S aureus-specific enzymes (proteases) appear to increase flu virus replication. Also, influenza A virus strains appear to decrease destruction of S aureus by immune cells called phagocytes, making patients more susceptible to bacterial coinfection.

In May CDC issued an alert after noticing an increase in the number of S aureus infections in children with flu. CDC said that from Oct 2006 through May, 55 influenza deaths in children had been reported. 20 of the children (out of 51 for whom relevant data were available) had bacterial infections, and 16 of these were infected with S aureus. Though the number of pediatric flu deaths this past flu season was similar to the 2 previous years, CDC said the 16 deaths from S aureus pneumonia or bacteremia recorded so far reflected a sharp increase over those years. Further, of the 16 children who had S aureus infections, 11 had methicillin-resistant (MRSA) strains that are typically associated with MRSA skin infection outbreaks. CDC also noted that the children who had S aureus infections had been in good health before they got sick, but progressed rapidly to serious illness.
(CIDRAP 7/11/07)


Indonesia: Report of 81st human death from avian influenza H5N1 infection
As of 11 Jul 2007, the Ministry of Health of Indonesia has announced a new case of human infection of H5N1 avian influenza. A 6-year-old male from Cilegon, Banten province developed symptoms on 1 Jul 2007, and was hospitalized on 5 Jul 2007. He died on 8 Jul 2007. He had symptoms of high temperature, cough and breathing difficulty. Laboratory observation results indicated that he suffered leukopenia, thrombocytopenia and pneumonia. The Ministry of Health is currently investigating the source of infection. No infected poultry had been found within a radius of up to 300 meters from the boy's home. Of the 102 cases to date in Indonesia, 81 have been fatal.

Also, on 11 Jul 2007, the national committee overseeing Indonesia's bird flu fight along with UNICEF were to begin distributing 7000 protective kits to villages in Banten province, where at least 10 bird flu deaths have occurred. The kits contain gloves, masks, soap, an informational VCD (video compact disk), a banner, and booklet. About 100 000 kits were distributed in high-risk areas in May 2007. Indonesia stepped up its campaign in 2007 to battle bird flu, barring Jakarta residents from the popular practice of keeping poultry in their backyards.

Avian influenza-positive cases by Indonesian province (Province / Cases / Deaths):

West Java / 29 / 23
DKI Jakarta / 25 / 22
Banten / 13 / 11
North Sumatera / 8 / 7
East Java / 7 / 5
Central Java / 9 / 8
Lampung / 3 / 0
South Sulawesi / 1 / 1
West Sumatera / 3 / 1
South Sumatera / 1 / 1
Riau / 3 / 2
Total: 102 cases / 81 deaths
(Promed 7/9/07, 7/11/07; CIDRAP 7/9/07)


Viet Nam (Dien Bien, Ca Mau): New avian influenza H5N1 outbreaks in poultry
Bird flu has hit 2 more provinces, while several localities nationwide have met criteria for announcing an end to bird flu outbreaks in their territory. The disease, since 5 Jul 2007, killed about 500 ducks raised by 6 households in northern Dien Bien province, the Department of Animal Health under the country's Ministry of Agriculture and Rural Development said, noting that specimens from the affected poultry have tested positive for the bird flu virus H5N1. All of the ducks were 25 days old and were not vaccinated yet. On 2 Jul 2007, bird flu was also found in a flock of 14 ducks raised by a household in southern Ca Mau province's Dam Doi district, with 9 ducks affected and 5 dead; the provincial veterinary bureau has slaughtered all fowls in the affected flock. Bird flu has hit 20 Vietnamese cities and provinces since early May 2007. So far in 2007, the country has vaccinated 154.3 million fowls, including 85.6 million chickens, 65.11 million ducks, and 3.59 million white-winged ducks.
(Promed 7/12/07; CIDRAP 7/12/07)


USA: Poll shows waning concern about avian influenza in public
Only 27% of Americans describe themselves as concerned about avian influenza, down from 35% last year, according to a national survey. In an Associated Press–Ipsos Public Affairs poll released Jul 2, 2007, 41% of respondents said they were not concerned about avian flu, an increase from 31% last year. Another 34%—the same as last year—said they were moderately concerned. Only 15% of respondents said they were concerned that they or someone in their household would get sick, as compared with 24% last year. The survey questions used the terms "bird flu" and "avian flu," but not "pandemic flu."

Ipsos said the apparent drop in Americans' concern over avian flu coincides with reports from WHO that the number of human H5N1 flu cases appears to have stabilized over the past year. Through mid June, WHO had confirmed 50 human cases in 2007, compared with 115 for all of 2006. Recall of news coverage about avian flu has also declined. The number of Americans who say they have read, heard, or seen at least some coverage of bird flu is 56%, down from 74% in 2006. 62% thought US government leaders were giving enough attention to avian flu, up from 45% 2006. Only 32% thought the government should be directing more attention to the problem, down from 42% last year. One number that seems to have changed little is the share of Americans who say news about avian flu is influencing their eating habits: about 9 in 10 respondents reported there has been no change in their consumption of chicken, turkey, or eggs. The survey interviews were conducted from Jun 7-17. The poll, which included 1,438 adults, had a margin of sampling error of plus or minus 3.1 percentage points.

The apparent decline in concern about avian flu also comes at a time when the US Department of Health and Human Services (HHS) is ramping up efforts to urge Americans to prepare for a pandemic. HHS recently sponsored a summit and blog series for pandemic planning leaders and announced that it would soon provide preparedness tool kits for various groups and conduct personal preparedness communication campaigns in 5 to 10 diverse communities.
(CIDRAP 7/6/07)


USA: HHS to give states $430 million for hospital preparedness
This year's round of federal grants to states to help healthcare facilities prepare for public health emergencies totals $430 million, down from $450 million last year, the US Department of Health and Human Services (HHS) announced. The grants are intended to help hospitals and other healthcare facilities cope with emergencies that could cause mass casualties, including bioterrorist attacks, infectious disease outbreaks, and natural disasters, according to HHS. In 2002, HHS awarded $125 million to the states for hospital preparedness. This was increased to $498 million in 2003 and 2004, but was pared to $471 million in 2005 and to $450 million last year.

HHS said this year's funds are to be used to develop or improve 4 activities: interoperable communications, systems to track available hospital beds, advance registration of volunteer health professionals, and planning for "fatality management and hospital evacuation." The grants will go to territories and 4 major metropolitan areas—Chicago, Washington, Los Angeles County, and New York—as well as the states. For the states, amounts range from $1.15 million for Wyoming to $34.1 million for California. Each state is allotted a base grant of $500,000 plus an additional amount based on population, according to Marc Wolfson, spokesman for the HHS Office of the Assistant Secretary for Preparedness and Response.

HHS said this year's funding includes $15 million for the new Healthcare Facilities Partnership Program, which is designed to foster regional partnerships to enhance community and hospital preparedness. The agency will use a competitive process to award between 6 and 30 cooperative agreement awards ranging from $500,000 to $2.5 million. "The goal of the new program is to develop innovative and creative projects that can be replicated across the country," said Rear Adm. Craig Vanderwagen, MD, HHS assistant secretary for preparedness and response. "These partnerships will require close coordination among health officials from state, local and private sectors."

"The guidance for this year's program includes new performance measures, one of which requires the submission of timely and complete data from grantees," he commented. In addition, Wolfson said, "There is an ambitious evaluation plan for this year that includes a number of studies and reports." One of these will be a book of state preparedness profiles, including data on hospital preparedness and other dimensions, such as hazards and vulnerability.
(CIDRAP 7/11/07)


USA (Virginia): Turkeys may have been exposed to mild avian influenza H5N1
The US Department of Agriculture (USDA) confirmed that turkeys from a Virginia farm carried antibodies indicating possible past exposure to a mild form of H5N1 avian influenza virus. Virginia's agriculture department had announced Jul 9 that samples collected during routine preslaughter testing initially showed the birds had antibodies to an H5 virus. John Clifford, the USDA's chief veterinary officer, said tests at the National Veterinary Services Laboratories (NVSL) indicated that the antibodies correspond to an H5N1 subtype. "There have been no signs of illness or death in the birds, indicating that this is not the highly pathogenic H5N1 virus that has spread through birds in Asia, Europe, and Africa," Clifford stated. The NVSL will run further tests to better identify the virus the birds may have been exposed to.

So far, tests suggest that the antibodies detected correspond to the low-pathogenic North American strain of H5N1, which usually causes only minor illness or no noticeable signs in birds. Several thousand poultry samples collected from other poultry operations near the affected Shenandoah Valley turkey farm have all tested negative for avian influenza, which further suggests that the antibodies found in the turkeys involve a common avian flu virus that poses no threat to humans, Clifford said. When the USDA expanded its avian flu testing program for wild birds beyond Alaska in 2006, several birds, such as a green-winged teal in Delaware and mallard ducks in Illinois and Michigan, tested positive or were presumed positive for the mild North American H5N1 strain. In a fact sheet on the low-pathogenic H5N1, the USDA said the strain was detected in apparently healthy wild birds as long ago as 1975. In 2002, antibodies to the same strain were found in samples from Michigan turkeys, but the virus could not be isolated. After Virginia officials announced the antibody findings, Richard Wilkes, the state veterinarian, banned all bird sales and exhibitions until Jul 30, 2007 and restricted the application of poultry litter on fields in 17 counties.
(CIDRAP 7/12/07)


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.
- 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 about the International Technical Meeting on Highly Pathogenic Avian Influenza and Human H5N1 Infection.
- OIE: http://www.oie.int/eng/en_index.htm.
- 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/.
- 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. Updated 5 Jul 2007.


2. Articles
Highly pathogenic avian influenza A/H5N1 in birds within the EU - Implications for Public Health
Influenza Team, European Centre for Disease Prevention and Control.
Eurosurveillance weekly releases, Vol 12, Issue 7. 5 Jul 2007. http://www.eurosurveillance.org/ew/2007/070705.asp#0
(References removed)
"Since the later part of June 2007, three European Union (EU) Member States (Czech Republic, Germany, and France) have recorded cases of highly pathogenic avian influenza (HPAI) of the subtype A/H5N1 in bird populations. On 21 June, authorities in the Czech Republic confirmed an outbreak of HPAI A/H5N1 in a domestic poultry flock in the Pardubicky region in the centre of the country. A few days later a second infected flock, located 4km from the first, was identified through the enhanced surveillance of flocks in the area that was introduced after discovery of the first infected premise. Subsequently, virus was isolated from a wild bird (swan) found dead on 28 June in the Jihomoravsky region in south of the country, near the border to Austria. At almost the same time, on 26 and 28 June, German authorities reported that HPAI A/H5N1 had been identified in wild birds in two locations in Germany; six wild birds (five swans and one Canada goose) in Bavaria in southern Germany, and three wild swans in Saxony in eastern Germany. On 5 July, France also confirmed the first occurrence this year of three wild swans infected with influenza A/H5N1. They were found in the Mosel region in the north-east of France. Samples from the infected birds from all three countries were identified as part of the EU supported active surveillance programme for avian influenza in wild birds, which requires all EU Member States to test wild birds for avian influenza viruses in order to provide an early warning of the presence of the virus in the EU. . ."


Addressing the Need for Integration between Health and Agriculture in the Preparedness Plans in Latin America
Cristina Schneider et al. The Rural Development Unit of the Interamerican Development Bank's Sustainable Development Department coordinated with the Pan American Health Organization's Veterinary Public Health Units. Washington, DC May 2007 - No. RUR-07-02 http://www.iadb.org/sds/doc/rur-avianandhumanpandemicinfluenza.pdf
Contents: Executive Summary; Introduction; The Link between Animal and Human Health; Avian Influenza, the Current Threat; Actors in the Preparedness to a Possible Pandemic, with Emphasis on Health and Agriculture Sectors; At the global level - At the regional level - At the national level; Importance of Intersectoral Action; Evaluation of the Integration between Health and Agriculture; Preparedness Plans in Latin America; Methodology - Analysis - Percentage of integration, demographic, socio-economic and aviculture-related aspects; Percentage of positive responses for each question and categories of integration activity; Main Conclusions from the Analysis; Recommendations on how to Improve the Integration of Health and Agriculture in Avian and Pandemic Influenza Preparedness Plans in the Region of the Americas; Strategies to Operationalize the Recommendations.

". . .The objective of this document is to review if this integration exists in countries of the Americas, and in particular if and how it is reflected in the preparedness plans against avian and human pandemic influenza. For that purpose, we present a quick review of the link between animal and human health, and characteristics of the latest threat, Avian Influenza. We then define intersectoral action and its importance in this context, with specific public health measures at the interface between animal and human health that are most important for the prevention and control of zoonoses. These measures are reflected in the subsequent analysis, by subregion, of the intersectoral integration. Our diagnosis then leads us to a series of recommendations on how to improve intersectoral action in the context of Avian Influenza, but with a broader impact on the prevention and control of all zoonotic diseases. . ."


Avian and pandemic influenza: Progress and problems with global health governance
K. Lee and D. Fidler. Global Public Health, Volume 2, Issue 3 July 2007 , pages 215 - 234
Abstract: "Globalization has intensified the health risks posed by pandemic influenza. Effective governance to prepare for, and respond to, a pandemic depends on four key functions: surveillance, protection, response, and communication. Although the global nature of the threat posed is recognized, efforts to strengthen cooperation have only made limited progress. Disease surveillance and communication have benefited from new technologies and harnessing the capacities of both state and non-state actors. The protection and response functions, however, remain focused on domestic populations and are characterized by uncoordinated and, at times, competitive strategies. Global governance of influenza requires strengthening in order to prevent actions that undermine the need to protect the health of all populations."


Duration of Influenza A Virus Shedding in Hospitalized Patients and Implications for Infection Control
Surbhi Leekha et al. Infection Control and Hospital Epidemiology, volume 28 (2007), page 000.
Abstract: "OBJECTIVE. To assess the duration of shedding of influenza A virus detected by polymerase chain reaction (PCR) and cell culture among patients hospitalized with influenza A virus infection. SETTING. Mayo Clinic (Rochester, Minnesota) hospitals that cater to both the community and referral populations. METHODS. Patients 18 years old and older who were hospitalized between December 1, 2004, and March 15, 2005, with a laboratory-confirmed (ie, PCR-based) diagnosis of influenza A virus infection were consecutively enrolled. Additional throat swab specimens were collected at 2, 3, 5, and 7 days after the initial specimen (if the patient was still hospitalized). All specimens were tested by PCR and culture (both conventional tube culture and shell vial assay). Information on demographic characteristics, date of symptom onset, comorbidities, immunosuppression, influenza vaccination status, and receipt of antiviral treatment was obtained by interview and medical record review. Patients were excluded if informed consent could not be obtained or if the date of symptom onset could not be ascertained. RESULTS. Of 149 patients hospitalized with influenza A virus infection, 50 patients were enrolled in the study. Most patients were older (median age, 76 years), and almost all (96%) had underlying chronic medical conditions. Of 41 patients included in the final analysis, influenza A virus was detected in 22 (54%) by PCR and in 12 (29%) by culture methods at or beyond 7 days after symptom onset. All 12 patients identified by culture also had PCR results positive for influenza A virus. CONCLUSION. Hospitalized patients with influenza A virus infection can shed detectable virus beyond the 5- to 7-day period traditionally considered the duration of infectivity. Additional research is needed to assess whether prolonging the duration of patient isolation is warranted to prevent nosocomial outbreaks during the influenza season."