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EINet Alert ~ Sep 28, 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)
- Indonesia (West Java, Riau): Suspected human cases of avian influenza H5N1
- Bangladesh (Rajshahi): Avian influenza H5N1 in poultry
- Thailand (Phichit): Avian influenza H5N1 reported in poultry
- Russia (Krasnodar): 250,000 poultry to be culled after avian influenza H5N1 outbreak
- Canada (Saskatchewan): Avian influenza H7N3 detected in poultry
- USA: FDA approves sixth flu vaccine for US market

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

2. Articles
- CDC EID Journal, Volume 13, Number 9—Sep 2007
- Patient Knowledge and Attitudes about Antiviral Medication and Vaccination for Influenza in an Internal Medicine Clinic
- Impact of SARS on Avian Influenza Preparedness in Healthcare Workers
- Establishment of a UK National Influenza H5 Laboratory Network
- Preclinical In Vitro Activity of QR-435 Against Influenza A Virus as a Virucide and in Paper Masks for Prevention of Viral Transmission
- Limitations of current prophylaxis against influenza virus infection.
- H5N1 infection of the respiratory tract and beyond: a molecular pathology study
- IOM calls for new research on safety garb for health workers

3. Notifications
- Vietnam Chief Epidemiologist to Present at the 5th International Bird Flu Summit
- Symposium Invitation to Influenza Vaccine Research
- CIDRAP Database lists choice pandemic-planning resources
- Review of the DoD-GEIS Influenza Programs: Strengthening Global Surveillance and Response
- Influenza pandemic: federal executive boards' ability to contribute to pandemic preparedness
- Influenza pandemic: opportunities exist to clarify federal leadership roles and improve pandemic planning
- Correctional Facilities Pandemic Influenza Planning Checklist
- Law Enforcement Pandemic Influenza Planning Checklist


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 / 20 (5)
Indonesia / 31 (27)
Laos / 2 (2)
Nigeria / 1 (1)
Viet Nam 7 (4)
Total / 65 (42)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 328 (200).
(WHO 9/10/07 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 9/10/07)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 9/28/07): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 9/11/07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.

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Asia
Indonesia (West Java, Riau): Suspected human cases of avian influenza H5N1
An Indonesian woman suspected of being infected with bird flu has died in the West Java city of Bandung, hospital sources said 23 Sep 2007. Samples from the 30-year-old woman have been sent for testing in Jakarta. A total of 2 tests must come back positive for the H5N1 virus before a victim is confirmed as part of the official bird flu death toll in Indonesia. The woman, who died 22 Sep 2007, was showing symptoms of bird flu infection, such as fever, coughing, breathing difficulties, and low red blood count.

According to local media 24 Sep 2007,] 2 Indonesian children were in critical condition at a hospital in Riau Province with doctors strongly suspecting them of having developed bird flu symptoms. The 2 boys, ages 1 and 3, are being treated in isolated rooms at the Arifin Ahmad Hospital in the provincial capital of Pekanbaru. Reportedly they are suffering high fever and respiratory problems. Laboratory tests by the hospital indicated that the 2 patients had bird flu but further tests in Jakarta are needed for confirmation.
(Promed 9/24/07)

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Bangladesh (Rajshahi): Avian influenza H5N1 in poultry
Reportedly an avian influenza outbreak occurred in the country's northwestern Bogra district, about 105 miles from Dhaka, the capital. An official from Bangladesh's livestock department said 5,000 chickens were culled and buried at the farm. The farm has been sealed off and a 1-km (0.6 mi) area around it has been declared as an affected zone. The samples from the dead poultry have reportedly tested positive for avian influenza type H5. The virus was first detected in the country's poultry in Mar 2007. Since then, Bangladesh has reported 28 outbreaks, the last one occurring in May.
(CIDRAP 9/27/07; Promed 9/27/07)

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Thailand (Phichit): Avian influenza H5N1 reported in poultry
Government officials reported positive avian influenza H5N1 results in chickens raised by a villager in Phichit province in the northern part of the country. Local authorities have culled 90 chickens within a 1-km radius of the site and have restricted the transport of birds in the area. Preecha Ruengchan, Phichit's governor, called an urgent meeting with livestock officials. In the past, a number of provinces in Thailand, included Phichit, have reported H5N1 outbreaks. However, only 3—Mukdahan, Nong Khai, and Phitsanulok—have had outbreaks this year, according to OIE reports.
(CIDRAP 9/27/07)

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Russia (Krasnodar): 250,000 poultry to be culled after avian influenza H5N1 outbreak
About 250 000 birds are to be culled at a poultry farm in south Russia's Krasnodar Territory following an outbreak of bird flu earlier Sep 2007, Russia's agriculture watchdog said 26 Sep 2007. A total of 170 600 birds have been slaughtered at the Lebyazh Chepiginskoye farm and the remaining 77 500 are reportedly due to be culled in the near future. On 5 Sep 2007, about 22 000 birds were culled at the farm after a regional laboratory identified the H5N1 virus in dead birds at the farm. In 2005, 1.3 million birds were culled in Russia, in 2006 the was 1.04 million, but in 2007 the figure had dropped to around 260 000.
(Promed 9/27/07)

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Americas
Canada (Saskatchewan): Avian influenza H7N3 detected in poultry
Agriculture officials in Canada announced that a highly pathogenic H7N3 strain of avian flu has been detected in chickens at a commercial poultry operation in Saskatchewan, at Regina Beach. An employee of the Canadian Food Inspection Agency (CFIA) said the birds were tested after some appeared sick or died. Gerry Ritz, Canada's minister of agriculture and agri-food, emphasized that the virus was not the lethal H5N1 strain. "This situation does not affect food safety when poultry is properly cooked," he said. "None of the infected products from this farm were destined for the human food supply." The H7N3 strain is not normally associated with serious human illness, the CFIA said.

All 50,000 birds within 1 km of the affected farm will be culled, and poultry movements have been restricted within 3 km of the farm. The agency said it is investigating the recent movement of birds, bird products, and equipment to and from the affected property. OIE reports indicate that Canada has had no other outbreaks of highly pathogenic avian flu since 2004. In that year, an H7N3 virus struck 40 commercial poultry farms in southern British Columbia's Fraser Valley, leading to the culling of more than 17 million chickens. 2 mild cases of H7 influenza in poultry workers were reported in connection with that outbreak.
(CIDRAP 9/27/07; Promed 9/28/07)

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USA: FDA approves sixth flu vaccine for US market
The Food and Drug Administration (FDA) announced the approval of an Australian-made influenza vaccine called Afluria for use in adults, raising the number of US-licensed flu vaccines to 6. The vaccine, made by CSL Limited, was approved for protecting people aged 18 and older from type A and B influenza viruses. Like most flu vaccines, Afluria contains inactivated (killed) flu viruses grown in chicken eggs. People who are allergic to eggs should not receive the vaccine. The vaccine is given as a single injection in the upper arm. It will be available in single dose, preservative-free syringes and in multiple-dose vials containing thimerosal, a mercury compound, as a preservative. CSL expects to supply up to 2 million doses of the vaccine in the US this season. FDA said CDC has estimated that the 6 vaccine makers will supply a record total of 132 million doses of flu vaccine in the US this year. CSL Biotherapies announced its filing for FDA approval of Afluria in Apr 2007. The application included the results of a phase 3, randomized, placebo-controlled clinical trial that involved 1,357 volunteers at 9 US sites. The study evaluated the safety and immunogenicity of thimerosal-free and thimerosal-containing formulations of the vaccine. FDA used its accelerated approval pathway in evaluating the vaccine.

CSL-branded flu vaccines are approved and sold in 16 countries, and the company provides bulk antigen for flu vaccines sold in 24 countries. Officials said the company has been making flu vaccines for 40 years. The bulk antigen for the vaccine is made in Australia, and this year the product will be finished and packaged in a facility in Germany. Last year CSL announced it would spend $60 million to double the capacity of the company's Melbourne, Australia, plant to 40 million doses per year, making it one of the largest flu vaccine production facilities in the world. Other injectable flu vaccines licensed in the US, with their manufacturers, are FluLaval, ID Biomedical; Fluarix, GlaxoSmithKline; Fluzone, Sanofi Pasteur; and Fluvirin, Novartis. The other licensed product is FluMist, the nasal-spray vaccine made by MedImmune.
(CIDRAP 9/28/07)

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1. Updates
Avian/Pandemic influenza updates
- UN: http://www.un-influenza.org/ : latest progress report available. 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. Link to supplement to Journal of Wildlife Diseases on avian influenza.
- OIE: http://www.oie.int/eng/en_index.htm.
- US CDC: http://www.cdc.gov/flu/avian/index.htm. News on federal updates.
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html.
- CIDRAP: http://www.cidrap.umn.edu/.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm. 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 28 Sep 2007 with information on H7N3 outbreak in Canada.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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Seasonal influenza updates
Influenza Activity--USA and Worldwide, May 20--Sep 15, 2007
During May 20--Sep 15, 2007, US tested 21,029 respiratory specimens for influenza viruses; 398 (1.9%) were positive. Of these, 330 (83%) were influenza A viruses, and 68 (17%) were influenza B viruses. Of the influenza A viruses, 152 (46%) were subtyped: 67 (44%) were influenza A (H1) viruses, and 85 (56%) were influenza A (H3) viruses. Influenza viruses were reported from 22 states. However, 200 (50%) of all the influenza viruses, including 63 (94%) of the 67 influenza A (H1) viruses, were reported from Hawaii, and 100 (25%) were reported from Florida. Of the 398 influenza viruses reported during the summer months, only 124 (31%) were reported during Aug and the first half of Sep. Among this subset of viruses, 105 (85%) were influenza A, and 19 (15%) are influenza B.

During May 20—Sep 15, the weekly percentage of patient visits to U.S. sentinel providers for influenza-like illness (ILI) remained below the national baseline of 2.1% and ranged from 0.6% to 1.0%. The percentage of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold. One influenza-associated pediatric death occurred during June. 2 human cases of novel influenza A were reported. Both persons were infected with swine influenza virus and were infected by handling ill pigs at a county fair in Ohio. Both recovered from their illness.

During May 20--Sep 15, influenza A (H1), influenza A (H3), and influenza B viruses cocirculated worldwide. Influenza A (H3) viruses predominated in Asia; however, influenza A (H1) and B viruses also were reported. In Africa, influenza A viruses predominated, with approximately equal numbers of influenza A (H1) and A (H3) viruses reported and a smaller number of influenza B viruses identified. In Europe and North America, small numbers of influenza A and influenza B viruses were reported. In Oceania, influenza A viruses predominated. Influenza A (H3) viruses were reported more frequently than influenza A (H1) viruses in Australia and New Caledonia; however, in New Zealand, influenza A (H1) viruses predominated. In South America, influenza A (H3) viruses were most commonly reported, although influenza B viruses also were identified.
(MMWR September 28, 2007 / 56(38);1001-1004)
http://cdc.gov/mmwr/preview/mmwrhtml/mm5638a4.htm

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2. Articles
CDC EID Journal, Volume 13, Number 9—Sep 2007
CDC Emerging Infectious Diseases Journal Sep 2007 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. Expedited articles can be viewed at: http://www.cdc.gov/ncidod/eid/upcoming.htm.

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Patient Knowledge and Attitudes about Antiviral Medication and Vaccination for Influenza in an Internal Medicine Clinic
Michael A. Gaglia, Jr. et al. Clinical Infectious Diseases. 2007;45:000 http://www.journals.uchicago.edu/CID/journal/issues/v45n9/51042/brief/51042.abstract.html
Abstract : Background. Despite the introduction of Centers for Disease Control and Prevention guidelines for their use, antiviral medications for influenza remain underutilized. Our objective in this study was to describe beliefs, attitudes, and knowledge regarding antiviral medication and vaccination for influenza among patients in an internal medicine clinic. Methods. We conducted a cross-sectional survey of adult patients in an internal medicine clinic from April through June 2006. Results. Two-hundred eighty patients completed the survey. Fifty-five percent received influenza vaccination for the most recent influenza season. Overall antiviral knowledge was poor. Of 8 antiviral knowledge questions, the mean percentage of correct answers was 40%; 1 (<1%) of the patients answered all questions correctly, and 47 (18%) answered all questions incorrectly. Only 37 (13%) of the patients reported calling their physician within 48 h after the onset of influenza-like symptoms. Patients with conditions associated with a high risk of complications from influenza were no more likely than other patients to be more knowledgeable about antiviral medication, nor were they more likely to report calling their physician within 48 h after symptom onset or to report receipt of influenza vaccination for the previous influenza season. Only 90 (37%) of the respondents were willing to pay >$20 for antiviral medication, although 205 (84%) were willing to pay something. Conclusions. Patients are ill-informed about antiviral medication and its benefits, and medication costs may present a barrier to treatment. Physicians should discuss antiviral medication with patients who are at high risk for complications from influenza before the influenza season, and education programs for physicians and patients should be developed.

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Impact of SARS on Avian Influenza Preparedness in Healthcare Workers
D.K.P. Tam et al. Infection. 2007 Sep 19; [Epub ahead of print] http://springerlink.com/content/p731537x50157273
Abstract: Background SARS was an unprecedented outbreak which brought about 1,755 infections and 302 deaths in Hong Kong. The similarity of SARS and avian influenza prompted us to examine the relationship between SARS experience and preparedness on a potential avian influenza outbreak. Methods A self-administered questionnaire was delivered to nurses in Hong Kong to assess their attitude towards avian influenza; risk perception, and their relationships with previous level of exposure to SARS patients. Results Nine hundred and ninety-nine respondents were included in data analysis. About half of them perceived there would be an avian influenza outbreak in Hong Kong. The majority accepted a personal risk of infection in the course of their work (72.7%), and prepared to take care of patients infected with avian influenza (84.0%). Respondents were classified into two groups: high exposure (44.1%) and low exposure (55.9%) as defined by having worked in SARS ward or hospitals. High exposure nurses were less likely to avoid patients, less inclined to change their job if they were required to take care of infected patients, and had therefore a more positive attitude towards an impending avian influenza epidemic. About half of the nurses had frequent involuntary recalls of incidents relating to SARS, the frequency of which was positively correlated with knowing a person suffering from long-term complications of SARS. Conclusion Healthcare workers who had been actively involved in SARS work were more “positive” in responding to the impending avian influenza epidemic. Whether the level of preparedness can be sustained would need to be further explored.

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Establishment of a UK National Influenza H5 Laboratory Network
Martin D. Curran et al. J Med Microbiol 56 (2007), 1263-1267; DOI: 10.1099/jmm.0.47336-0.
http://jmm.sgmjournals.org/cgi/content/abstract/56/10/1263
Abstract: Avian (H5N1) influenza continues to pose a significant threat to human health, although it remains a zoonotic infection. Sensitive and robust surveillance measures are required to detect any evidence that the virus has acquired the ability to transmit between humans and emerge as the next pandemic strain. An integral part of the pandemic planning response in the UK was the creation in 2005 of the UK National H5 Laboratory Network, capable of rapidly and accurately identifying potential human H5N1 infections in all regions of the UK, and the Republic of Ireland. This review details the challenges that designing molecular detection methods for a rapidly evolving virus present, and the strategic decisions and choices required to ensure successful establishment of a functional national laboratory network, providing round the clock testing for H5N1. Laboratory partnerships have delivered improved real-time one-step multiplex PCR methodologies to ensure streamlined testing capable of not only detecting H5 but also a differential diagnosis of seasonal influenza A/B. A range of fully validated real-time PCR H5 confirmatory assays have been developed to run in parallel with a universal first-screening assay. Regular proficiency panels together with weekly surveillance runs, intermittent on-call testing for suspect cases of avian flu in returning travellers, and several outbreaks of avian influenza outbreaks in poultry that have occurred since 2005 in the UK have fully tested the network and the current diagnostic strategies for avian influenza. The network has clearly demonstrated its capability of delivering a confirmed H5N1 diagnosis within 3–4 h of receipt of a sample, an essential prerequisite for administration of the appropriate antiviral therapy, effective clinical management, disease containment and implementation of infection control measures. A functional network is an important means of enhancing laboratory capability and building diagnostic capacity for a newly emerging pandemic of influenza, and is an essential part of pandemic preparedness.

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Preclinical In Vitro Activity of QR-435 Against Influenza A Virus as a Virucide and in Paper Masks for Prevention of Viral Transmission
Oxford JS et al. Am J Ther. 2007 Sep-Oct;14(5):455-61.
Abstract: Prophylaxis against influenza is difficult, and current approaches against pandemics may be ineffective because of shortages of the two proven classes of antivirals in the face of a large-scale infection. Herbal/natural products may represent an effective alternative to conventional attempts to protect against infection by avian influenza virus. QR-435, an all-natural compound of green tea extract and other agents, has been developed to provide protection against a wide range of viral infections. The antiviral activities of several QR-435 preparations as well as QR-435 (1) green tea extract were tested against A/Sydney/5/97 and A/Panama-Resvir 17 strains of avian influenza virus H3N2 by means of an assay based on Madin-Darby canine kidney cells. Toxic effects of QR-435 formulations on these cells were also evaluated as were the virucidal properties of a commercially available mask impregnated with QR-435. The efficacy of a QR-435/mask combination was compared with that of the QR control/mask combination, an untreated mask, and no mask. QR-435 had significant in vitro activity against H3N2 at concentrations that were not associated with significant cellular toxic effects. The antiviral activity of QR-435 (1) was similar to that of QR-435. Masks impregnated with QR-435 were highly effective in blocking the passage of live H3N2 virus. These preclinical results warrant further evaluation of the prophylactic use of QR-435 against viral infection in humans.

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Limitations of current prophylaxis against influenza virus infection.
Guralnik M et al. Am J Ther. 2007 Sep-Oct;14(5):449-54
Abstract: Avian influenza has been a source of worldwide concern since Hong Kong authorities detected the first outbreak in 1997. Mainly as a result of poultry-to-human transmission, more than 200 cases of infection in humans have been attributed to the A/H5, A/H7, and A/H9 viral subtypes, with a case fatality rate for A/H5N1 infections exceeding 50%. A mutant or reassortant virus capable of efficient human-to-human transmission can set off a pandemic. Increased attention to prophylaxis against viral infection has identified several potentially complementary approaches: nonpharmacologic measures (eg, travel restrictions), vaccination, chemotherapeutic agents, and herbal/natural products. All have significant limitations that point out the need for additional modalities. Herbal/natural products, particularly those based on green tea extract, offer promise as adjuncts or alternatives to current interventions and warrant further evaluation in well-controlled human trials.

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H5N1 infection of the respiratory tract and beyond: a molecular pathology study
Jiang Gu et al. The Lancet 2007; 370:1137-1145. DOI:10.1016/S0140-6736(07)61515-3.
http://www.thelancet.com/journals/lancet/article/PIIS0140673607615153/abstract
Abstract: Background. Human infection with avian influenza H5N1 is an emerging infectious disease characterised by respiratory symptoms and a high fatality rate. Previous studies have shown that the human infection with avian influenza H5N1 could also target organs apart from the lungs. Methods. We studied post-mortem tissues of two adults (one man and one pregnant woman) infected with H5N1 influenza virus, and a fetus carried by the woman. In-situ hybridisation (with sense and antisense probes to haemagglutinin and nucleoprotein) and immunohistochemistry (with monoclonal antibodies to haemagglutinin and nucleoprotein) were done on selected tissues. Reverse-transcriptase (RT) PCR, real-time RT-PCR, strand-specific RT-PCR, and nucleic acid sequence-based amplification (NASBA) detection assays were also undertaken to detect viral RNA in organ tissue samples. Findings. We detected viral genomic sequences and antigens in type II epithelial cells of the lungs, ciliated and non-ciliated epithelial cells of the trachea, T cells of the lymph node, neurons of the brain, and Hofbauer cells and cytotrophoblasts of the placenta. Viral genomic sequences (but no viral antigens) were detected in the intestinal mucosa. In the fetus, we found viral sequences and antigens in the lungs, circulating mononuclear cells, and macrophages of the liver. The presence of viral sequences in the organs and the fetus was also confirmed by RT-PCR, strand-specific RT-PCR, real-time RT-PCR, and NASBA. Interpretation. In addition to the lungs, H5N1 influenza virus infects the trachea and disseminates to other organs including the brain. The virus could also be transmitted from mother to fetus across the placenta.

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IOM calls for new research on safety garb for health workers
An Institute of Medicine (IOM) committee that studied issues concerning personal protective equipment (PPE) for healthcare workers in an influenza pandemic is calling for renewed efforts to learn how influenza viruses spread, promote proper use of PPE, and improve the equipment itself. The 12-member panel’s mission was to recommend research directions, government agency roles, and policy changes, but not to issue guidelines about PPE use during a pandemic. The group's 192-page peer-reviewed report was released Sep 18, 2007. More than 13 million US workers are employed in healthcare, according to the report, and public health officials worry that in a pandemic, medical staff won't report to work if they don't feel they're adequately protected. The report explores what is known and where research gaps exist concerning influenza transmission, use of PPE among healthcare workers, and PPE design, testing, and certification.

Flu transmission studies badly needed:
Most studies on influenza transmission were conducted before 1970, and the report says more research should be done to build on earlier findings and apply new technologies, which include airborne-particle size analyzers and polymerase chain reaction (PCR) assays. Advances in fields such as aerobiology and mathematical modeling could also contribute to the study of seasonal and avian influenza. The group recommends that the US Department of Health and Human Services (HHS), in collaboration with other partners, lead a focused research effort to better understand the transmission and prevention of seasonal and avian influenza.

The global research network would:
Identify and rank research questions, as well as suggest potential study designs; Prioritize funding for short-term (1 to 3 years) laboratory and clinical studies on seasonal influenza transmission and prevention, focusing on the efficacy of different PPE items; Develop evidence-based research protocols and implementation plans for clinical studies during an influenza pandemic.

Strategies to promote routine PPE use:
In analyzing PPE utilization by healthcare workers, the group noted that despite recommendations and high-risk settings, many employees don't wear the gear when they should. Healthcare institutions should do more to promote a "culture of safety" regarding PPE use by their employees. Recommendations for boosting PPE use in healthcare workers include: Emphasizing appropriate PPE use in patient care settings as well as in healthcare management, accreditation, and training; Identifying and sharing best practices for improving PPE compliance; the authors recommend that the CDC and Agency for Healthcare Research and Quality (AHRQ) support and evaluate demonstration projects on improving PPE adherence; Researching the human factors and behavioral issues related to PPE use, an effort that could be supported by agencies such as NIOSH, the National Institutes of Health (NIH), and AHRQ.

Raising the bar for PPE design and testing:
Several of the group's recommendations focus on improving PPE design, testing, and certification. More rigorous premarket testing is needed to ensure that PPE products work well in clinical settings, the authors assert. Evidence-based standards and comparison ratings should be developed for PPE items. In a letter prefacing the report, Lewis Goldfrank, chair of the committee, wrote that the Food and Drug Administration's (FDA's) standards for evaluating and approving PPE are not as high as for the drugs or vaccines it regulates. Several federal agencies have important roles in supporting effective use of PPE, and more coordinated efforts are needed to harmonize requirements and expedite all the development and implementation steps, the IOM committee says. Though the committee wasn't asked to consider PPE for family members and others who will provide home care or want to protect themselves during a pandemic, the report points out some difficulties in that area. For example, new respirator designs that minimize or remove the need for fit testing would be beneficial, and PPE sold in retail stores is subject to limited regulation.
(CIDRAP 9/26/07)

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3. Notifications
Vietnam Chief Epidemiologist to Present at the 5th International Bird Flu Summit
New Fields Exhibitions announces that the Chief Epidemiologist of Vietnam will reveal a comprehensive country report on avian influenza, at the 5th International Bird Flu Summit Sep 27-28. Dr. Van Dang Ky is from the Ministry of Agriculture and Rural Development, and has published a Handbook on Avian Influenza Control and Prevention. The summit will be held in Las Vegas, Nevada. Leaders from a broad range of industries will meet with distinguished scientists, public health officials, law enforcers, first responders and other experts around the world. The event will also address the threat of the bird flu outbreak and the possibility of human-to-human transmission of H5N1 strain. Attendees will discuss the best practices to create solid business continuity plans for their companies and organizations in order to prepare for, respond to, and survive a pandemic. The 5th International Bird Flu Summit draws on the successes of the 4 previous summits. For more information visit www.new-fields.com.
(New-Fields 9/21/07)

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Symposium Invitation to Influenza Vaccine Research
We are writing to invite you to attend a 1-day Symposium on "Influenza Vaccine Research", held at the Fred Hutchinson Cancer Research Center Oct 15, 2007. There will be presentations and discussions about current research from leaders around the world. With this Symposium, VIDI is enabling leaders in this field of research to build the Influenza vaccine community as well as direct future research. The Symposium is being held as the second in a series of four symposiums sponsored by the recently formed Vaccine and Infectious Disease Institute within the Hutchinson Center. Space is limited so if you are able to attend this event, please register no later than Oct 4 at: http://www.fhcrc.org/science/vidi/event.html

Betz Halloran and Ira Longini, Organizers & Chairs, Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center

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CIDRAP Database lists choice pandemic-planning resources
Public health officials looking for ideas and tools to help them prepare for an influenza pandemic can find an online collection of peer-reviewed resources on PandemicPractices.org. The site describes and links to 130 "promising practices" from 4 countries, 22 states, and 33 counties. It was developed by CIDRAP and the Pew Center on the States. "Compiled as a resource to save communities and states time and resources, the database enables public health professionals to learn from each other and to build on their own pandemic plans," states CIDRAP and Pew. Jim O'Hara, director of health policy at the Pew Charitable Trusts, said "Communities across the country are facing the challenge of translating broad requirements into local action, often with limited resources. This database is an excellent tool to help public health officials inform their own pandemic planning and may save valuable time and resources that would be spent crafting strategies from scratch." The site describes approaches that communities have developed to address 3 key tasks: altering standards of clinical care, communicating effectively about pandemic flu, and delaying and reducing the impact of a pandemic. Specific topics cover a wide range, from triage of possible flu patients and reopening closed hospitals to guidance for schools, isolation and quarantine strategies, and mortuary planning.

The database provides a brief description of each resource along with comments from the reviewers and links to the resource. The database can be searched by state or topic and by area of special interest, such as materials translated into multiple languages, materials for vulnerable populations, and tool kits for schools. Items for the database were gathered through a combination of Web-based research, targeted surveys, interviews with key public health leaders, and collection of material at conferences, said Amy L. Becker, the project coordinator at CIDRAP. She said more than 200 practices were considered.
(CIDRAP 9/24/07)

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Review of the DoD-GEIS Influenza Programs: Strengthening Global Surveillance and Response
3 times during the 20th century the human population suffered pandemic influenza disease caused by particularly virulent strains. The most famous—and the most deadly—of these was the 1918 pandemic known as the “Spanish flu,” which caused an estimated 50 million deaths worldwide, including nearly half a million in the United States. It has been nearly 40 years since the last major pandemic, the “Hong Kong flu” of 1968, but the threat of a new pandemic remains quite real. The influenza strain known as H5N1 is especially worrisome, for instance, as more than half the human cases that have occurred have been fatal. Although H5N1 is persisting in causing disease among chickens and other poultry in parts of China and Southeast Asia, the virus does not (as yet) pass easily from one human to another. Most of the human cases have resulted from close handling of infected birds. 1 of the first lines of detection of a possible influenza pandemic is the Department of Defense Global Emerging Infections Surveillance and Response Program (DoD-GEIS), which maintains a global influenza surveillance network. In 2006, spurred in part by concerns about the H5N1 virus, Congress allocated $39 million in supplemental funding for DoD-GEIS to improve this surveillance network by upgrading the capabilities of its domestic and overseas laboratories. Afterward, DoD-GEIS management asked the Institute of Medicine to form a committee that would evaluate how well DoD-GEIS had spent the supplemental funds. In addition, IOM was asked to assess more generally the effectiveness of the entire program. The report of that committee, Review of the DoD-GEIS Influenza Programs: Strengthening Global Surveillance and Response, offers a mainly favorable assessment of DoD-GEIS efforts to date and offers some suggestions for future improvements.
(IOM http://www.iom.edu/CMS/3783/38416/46343.aspx 9/25/07)

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Influenza pandemic: federal executive boards' ability to contribute to pandemic preparedness
GAO Senate testimony: Located in 28 cities with a large federal presence, the FEBs are interagency coordinating groups designed to strengthen federal management practices and improve intergovernmental relations. The FEBs bring together the federal agency leaders in their service areas and have a long history of establishing and maintaining communications links, coordinating intergovernmental activities, identifying common ground, and building cooperative relationships. The boards also partner with community organizations and participate as a unified federal force in local civic affairs. OPM, which provides direction to the FEBs, and the boards have designated emergency preparedness, security, and safety as an FEB core function and are continuing to work on a strategic plan that will include a common set of performance standards for their emergency support activities. Although not all FEB representatives agreed that the boards should play an expanded role in emergency service support, many of the FEB representatives cited a positive and beneficial working relationship with FEMA. As one of their emergency support activities, the FEBs and FEMA, often working with the General Services Administration, host emergency planning exercises and training for federal agencies in the field.

The FEBs’ emergency support role with its regional focus may make the boards a valuable asset in pandemic preparedness and response. The distributed nature of a pandemic and the burden of disease across the nation dictate that the response will be largely addressed by each community it affects. As a natural outgrowth of their general civic activities and through activities such as hosting emergency preparedness training, some of the boards have established relationships with, for example, federal, state, and local governments; emergency management officials; first responders; and health officials in their communities. Some of the FEBs are already building capacity for pandemic influenza response within their member agencies and community organizations by hosting pandemic influenza training and exercises. The communications function of the FEBs is also a key part of their emergency support activities and could be an important asset for pandemic preparedness and response.

The FEBs, however, face key challenges in providing emergency support, and these interrelated issues limit the capacity of the FEBs to provide a consistent and sustained contribution to emergency preparedness and response. First, their role is not defined in national emergency plans, which may contribute to federal agency officials being unfamiliar with their capabilities. In addition, with no congressional appropriations, the FEBs depend on host agencies and other member agencies for their resources. This has resulted in inconsistent funding for the FEBs nationwide and creates uncertainty for the boards in planning and committing to provide emergency support services.
(GAO 9/28/07 http://www.gao.gov/new.items/d071259t.pdf )

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Influenza pandemic: opportunities exist to clarify federal leadership roles and improve pandemic planning
GAO Congressional testimony: The administration has taken an active approach to this potential disaster by, among other things, issuing a National Strategy for Pandemic Influenza (Strategy) in November 2005, and a National Strategy for Pandemic Influenza Implementation Plan (Plan) in May 2006. However, much more needs to be done to ensure that the Strategy and Plan are viable and can be effectively implemented in the event of an influenza pandemic. Key federal leadership roles and responsibilities for preparing for and responding to a pandemic continue to evolve and will require further clarification and testing before the relationships of the many leadership positions are well understood. Most of these leadership roles involve shared responsibilities and it is unclear how they will work in practice. Because initial actions may help limit the spread of an influenza virus, the effective exercise of shared leadership roles and responsibilities could have substantial consequences. However, only one national, multi-sector pandemic-related exercise has been held, and that was prior to issuance of the Plan.

The Strategy and Plan do not fully address the characteristics of an effective national strategy and contain gaps that could hinder the ability of key stakeholders to effectively execute their responsibilities. Specifically, some of the gaps include:

• The Strategy and Plan do not address resources, investments, and risk management and consequently do not provide a picture of priorities or how adjustments might be made in view of limited resources.
• State and local jurisdictions were not directly involved in developing the Plan, even though they would be on the front lines in a pandemic.
• Relationships and priorities among action items are not always clear.
• Performance measures are focused on activities that are not always linked to results.
• The linkage of the Strategy and Plan with other key plans is unclear.
• The Plan does not contain a process for monitoring and reporting on progress.
• The Plan does not describe an overall framework for accountability and oversight and does not clarify how responsible officials would share leadership responsibilities.
• Procedures and time frames for updating and revising the Plan were not established.

These gaps can affect the usefulness of these planning documents for those with key roles to play. Also, the lack of mechanisms for future updates or progress assessments limit opportunities for congressional decision makers and the public to assess the extent of progress being made or to consider what areas or actions may need additional attention. Although the Homeland Security Council (HSC) publicly reported on the status of action items in December 2006 and July 2007, it is unclear when the next report will be issued or how much information will be released.
(GAO 9/28/07 http://www.gao.gov/new.items/d071257t.pdf )

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Correctional Facilities Pandemic Influenza Planning Checklist
Planning for pandemic influenza is critical for ensuring a sustainable health care delivery system within correctional facility settings. The Department of Health and Human Services (HHS) has developed the following checklist to help prison and jail systems to self-assess and improve their preparedness for responding to pandemic influenza. Given the differences among systems, individual facilities should adapt this checklist to meet their unique needs. This checklist should be used as one tool in developing an overall pandemic influenza plan for correctional systems as well as individual facilities. Responsible officials should incorporate information from State, regional and local health departments and emergency management agencies/authorities into the system and individual facility pandemic influenza plan. An additional benefit of this planning is that it can be used for other types of disaster preparedness. All contact information specified below should include the names, titles, and contact information (i.e., office phone and cell phone numbers and e-mail and physical addresses) for individuals or organizations. These sheets should be provided to the system-level office (for prison and large jail systems).

Checklist sections: Develop a pandemic influenza preparedness and response plan; Elements of an Influenza Pandemic Plan for Each System and Facility Should Include the Following.
(http://pandemicflu.gov/plan/workplaceplanning/correctionchecklist.html )

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Law Enforcement Pandemic Influenza Planning Checklist
In the event of pandemic influenza, law enforcement agencies (e.g., State, local, and tribal Police Departments, Sheriff’s Offices, Federal law enforcement officers, special jurisdiction police personnel) will play a critical role in maintaining the rule of law as well as protecting the health and safety of citizens in their respective jurisdictions. Planning for pandemic influenza is critical. To assist you in your efforts, the Department of Health and Human Services (HHS) has developed the following checklist for law enforcement agencies. This checklist provides a general framework for developing a pandemic influenza plan. Each agency or organization will need to adapt this checklist according to its unique needs and circumstances. The key planning activities in this checklist are meant to complement and enhance your existing all-hazards emergency and operational continuity plans. Many of the activities identified in this checklist will also help you to prepare for other kinds of public health emergencies. Information specific to public safety organizations and pandemic flu preparedness and response can be found at http://www.ojp.usdoj.gov/BJA/pandemic/resources.html. For further information on general emergency planning and continuity of operations, see www.ready.gov.

Checklist Sections: Develop a pandemic influenza preparedness and response plan for your agency or organization; Plan for the impact of a pandemic on your employees; Plan for providing services to the public during a pandemic; Plan for coordination with external organizations and help your community
(http://pandemicflu.gov/plan/workplaceplanning/lawenforcement.html )

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