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EINet Alert ~ Dec 21, 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:
1. Influenza News
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Germany: H5N1 avian influenza infection found in a backyard flock in Brandenburg, Germany
- Poland: 100,000 birds culled in latest Mazowsze, Poland outbreak, officials fear significant economic impact
- Saudi Arabia: 13,500 ostriches destroyed in most recent outbreak of H5N1 avian influenza in Saudi Arabia
- Indonesia (Banten): 47-year-old man succumbs to H5N1 avian influenza
- Indonesia: Officials investigate suspicious avian influenza cases
- Myanmar: First case of human H5N1 avian influenza infection in Myanmar confirmed
- Pakistan: Two deaths and several more potential cases have Pakistani experts searching for answers
- Benin: First H5N1 avian influenza outbreak in Benin confirmed on poultry farm
- AVIAN PANDEMIC INFLUENZA
- Protective effect of low-concentration chlorine dioxide gas against influenza A virus infection
- Evidence for a Heritable Predisposition to Death Due to Influenza
- Molecular analysis of avian H7 influenza viruses circulating in Eurasia in 1999–2005: detection of multiple reassortant virus genotypes
- Wild Bird Influenza Survey, Canada, 2005
- Identification of H2N3 influenza A viruses from swine in the United States
- Players in H5N1's debut ponder a decade's lessons
- Comments on the nonpharmaceutical interventions in New York City and Chicago during the 1918 influenza pandemic.
- Trends in influenza vaccination coverage rates in Germany over five seasons from 2001 to 2006
- Update: Influenza Activity --- United States, September 30--December 1, 2007
- Bangkok International Conference on Avian Influenza 2008: Integration from Knowledge to Control
1. Influenza News
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 340 (209). (WHO 12.18.07 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 11.12.07)
WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 12.10.07): http://gamapserver.who.int/mapLibrary/
WHO’s timeline of important H5N1-related events (last updated 12.17.07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html
Germany: H5N1 avian influenza infection found in a backyard flock in Brandenburg, Germany
A new case of H5N1 infection in poultry was confirmed on 14 Dec 2007 in the Federal State of Brandenburg in Northeastern Germany. In a backyard flock of 11 layer chickens, five animals suddenly died. Samples of two of the dead chickens were investigated at the regional laboratory in Frankfurt-Oder showing highly positive results for H5 and N1 in real-time RT-PCR (reverse transcriptase polymerase chain reaction) analyses. The samples were immediately transferred to the OIE (World Organization for Animal Health) and National Reference Laboratory for Avian Influenza at the Friedrich-Loeffler-Institut.
Real-time RT-PCR specific for Qinghai-like strains of HPAIV confirmed the presence of HPAIV H5N1 in these samples. Preliminary results of the sequencing analysis of the HA-gene showed a close relationship to HPAIV H5N1 isolates detected earlier in 2007 in Germany (HPAIV H5N1 subclade 2.2.3). Further molecular analyses are ongoing.
Poland: 100,000 birds culled in latest Mazowsze, Poland outbreak, officials fear significant economic impact
Poland is thought to be one of Europe's largest producers of poultry and poultry products, with annual exports to European markets averaging 230,000 metric tons. The announcement of previous outbreaks of bird flu caused wholesale prices for Polish poultry to drop at least 30 percent. The highly pathogenic (H5N1) avian influenza outbreak was detected at a large laying hen farm in Mazowsze Province. More than 120,000 birds were culled and 100,000 eggs were destroyed by the Veterinary Service.
The exact damage to the economy has not yet been calculated, but early indications have not been good. This is reported to be the fifth case of avian flu registered by Polish veterinary authorities since the week of 10-16 Dec 2007, when the deadly virus was discovered at three turkey farms in central Poland. A safety zone has been set up around the site to prevent the spread of the virus. The deadly bird flu virus has hit numerous locations across the bloc this year.
Saudi Arabia: 13,500 ostriches destroyed in most recent outbreak of H5N1 avian influenza in Saudi Arabia
The outbreak of the H5N1 strain of the disease that is dangerous to humans was reported on 13 Dec 2007 evening at a farm in the Al-Kharj region, 80 km (50 mi) south of Riyadh. In November 2007, the Saudi authorities ordered nearly four million birds culled in the face of at least 14 separate outbreaks of avian influenza. There have been no reports of the disease spreading to humans.
Indonesia (Banten): 47-year-old man succumbs to H5N1 avian influenza
As of 18 Dec 2007, the Ministry of Health of Indonesia has announced the death of a previously confirmed case of H5N1 infection. The 47-year-old male from Tangerang District in Banten Province died on 13 Dec 2007.
Indonesia: Officials investigate suspicious avian influenza cases
"In the last three to four months, we have had four cases where the poultry in the victim's neighbourhoods (tested) negative for the virus," said Bayu Krisnamurthi, head of Indonesia's National Avian Influenza Committee. "The number is significant enough for us to intensify our investigations so that we could have a more accurate explanation."
"Some 20 percent of confirmed cases in 2006 were inconclusive, meaning there was no direct contact with poultry. This year (2007) the figure has been raised to 30 percent," he added.
The bird flu virus is usually transmitted to humans from infected birds, but scientists fear it could mutate into a form easily transmissible between humans, sparking a global pandemic that could kill millions.
Krisnamurthi nevertheless insisted that Indonesia had made progress in tackling bird flu, with the number of reported cases decreasing this year. In 2007, 40 cases were confirmed with 35 fatalities, compared to figures of 55 and 45, respectively, in 2006. But he also conceded that Indonesia needed more effective measures, particularly to combat bird flu in poultry. According to Krisnamurthi, even though the agriculture ministry vaccinated 70 percent of the country's farmed poultry in 2007, "the quality of the vaccine must be improved," he said.
Myanmar: First case of human H5N1 avian influenza infection in Myanmar confirmed
The case was detected through routine surveillance following an outbreak of H5N1 in poultry in the area in mid-November 2007. She developed symptoms of fever and headache on 21 Nov 2007 and was hospitalized on 27 Nov 2007. She has now recovered. Samples taken from the case tested positive for H5N1 virus at the National Health Laboratory in Yangon, and the National Institute of Health in Thailand. The diagnosis was further confirmed at the WHO Collaborating Centre for Reference and Research on Influenza, National Institute of Infectious Diseases in Tokyo, Japan.
A team from the Ministry of Health, the Ministry of Livestock and Fisheries and the WHO Economy Office are conducting investigations to confirm the source of her infection. Initial findings indicate poultry die off in the vicinity of the case's home in the week prior to the onset of illness. To date, all identified contacts of the case remain healthy and ongoing surveillance activities in the area have not detected any further cases.
Pakistan: Two deaths and several more potential cases have Pakistani experts searching for answers
News services have spoken of nine suspected cases, including four brothers (two of whom died) and two of their cousins, raising concern about possible person-to-person transmission. As reported previously, the four brothers with suspected H5N1 cases have another brother who lives in New York state and went to Pakistan to attend the funeral of a brother who died. The man, who lives in Nassau County on Long Island, reported possible H5N1 exposure on his return to the United States. After a voluntary quarantine, he was tested and cleared.
The WHO has sent a team to investigate the situation in Pakistan. Gregory Hartl, a WHO spokesman in Geneva, said there have been reports of "many more potential cases due to heightened sensitivity and enhanced surveillance."
More than 30 contacts of the suspected patients have been tested for H5N1 so far, with no positive results, Hartl said. Pakistan has had a number of H5N1 outbreaks in poultry in recent months, and the suspected human cases surfaced in the wake of culling operations.
On 18 Dec 2007, the WHO team visited a hospital that treated some of the patients in the north western city of Peshawar. They were working with doctors and nurses on how to handle suspected cases and improve infection control measures.
"They want to go through the records in the hospital for the last month or two to see if there's been any upsurge in respiratory cases that weren't identified as H5N1 but which could actually be cases," said Hartl.
The team will look to see which patients could have been exposed to the virus by infected birds and also whether human-to-human transmission could have occurred. Hartl said increased awareness has led to more people with flu-like symptoms being checked.
"What this is showing is that they're taking everything very, very seriously," Hartl said. "Surveillance has been enhanced, more people are reporting cases and more people have been sensitized on the heath care worker side of the need to notice."
A second team of health experts were on their way to Pakistan on 19 Dec 2007 to analyze samples from suspected bird flu cases to determine how the virus spread and whether human-to-human transmission may have occurred. The experts from the United States Naval Medical Research Unit No. 3 in Cairo, scheduled to arrive on 20 Dec 2007, were expected to retest samples already gathered from a number of patients who were positive for the H5N1 bird flu virus in initial government analysis. Once the cases are confirmed, work will begin to piece together how the victims became infected.
Benin: First H5N1 avian influenza outbreak in Benin confirmed on poultry farm
Tests in Italy have confirmed the first poultry outbreaks of H5N1 avian influenza in the West African country of Benin.
Agriculture Minister Robert Dovonou said suspected cases found on two farms earlier this month were confirmed by the World Organization for Animal Health (OIE) in Padua, Italy. The farms are north of Porto Novo, the capital, and in Cotonou, the commercial capital, both in Benin's southern coastal strip. Benin is surrounded by countries that have faced poultry outbreaks within the last two years: Nigeria, Togo, Niger, and Burkina Faso. Nigeria has had one human H5N1 case. Ivory Coast and Ghana are other West African states that have had poultry outbreaks.
Benin officials reported the two suspected outbreaks to the OIE on 5 Dec 2007, saying 100 birds had died and 245 had been killed to stop the outbreak. Most of the birds were chickens, but eight turkeys were among affected poultry on the Cotonou farm. Health experts have expressed concern that Benin's Voodoo priests could be at risk for avian flu because of their practice of tearing out the throats of live chickens in ritual sacrifices.
AVIAN PANDEMIC INFLUENZA
- UN: http://www.un-influenza.org/ : latest news on avian influenza. 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 4-6 Dec 2007 International Ministerial Conference on Avian and Pandemic Influenza.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm
- US CDC: http://www.cdc.gov/flu/avian/index.htm. Updated news from December 2007.
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/. Use the toolkit to prepare your community for a possible flu pandemic.
- 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 the avian influenza portal.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)
As of 10 Dec 2007, 30 countries had reported H5N1 cases in birds this year, compared with 54 in 2006, the FAO reported. This year five countries have reported their first outbreaks: Bangladesh, Benin, Ghana, Saudi Arabia, and Togo. Except for sporadic outbreaks in wild birds, most of the H5N1 cases this year occurred in domestic poultry, such as chickens, turkeys, geese, ducks, and quail.
The H5N1 outbreaks seemed to follow a seasonal pattern, in line with evidence that cooler temperatures are more favorable to influenza viruses. The FAO said outbreak numbers in 2007 were high between January and April, declined until September, and then started rising again in November and December.
Increased awareness and improved disease surveillance have enabled countries such as India, Romania, Malaysia and Turkey to detect and control the spread of the H5N1 virus, the FAO reported. However, the disease persists in Asia, Africa, and Europe and poses a risk for countries that have controlled outbreaks in the past and those that have not experienced infections yet, the organization stated.
The FAO said Indonesia is still having a large number of H5N1 outbreaks in poultry, which largely reflects a new "participatory disease search" program designed to detect infections in backyard poultry. The program, with support from the FAO, is operating in 162 districts and nine provinces.
Among other Asian hot spots for the disease, Vietnam reported H5N1 outbreaks in 22 provinces in May, the FAO reported. It said the disease appears to be endemic in Bangladesh. China had H5N1 outbreaks in Tibet in March, Hunan province in May, and Guangdong province in September, the agency said. In addition, routine surveillance detected the virus in March and April in the southern Chinese provinces of Fujian, Guangdong, Hunan, Hubei, Sichuan and Chongqing, the FAO reported. Also, wild bird deaths were reported in Hong Kong but not in mainland China.
The only Middle Eastern country reporting an H5N1 outbreak so far this year has been Saudi Arabia, which had its first cases in March, followed by several outbreaks near Riyadh in November. In Africa, four countries have reported H5N1 outbreaks in 2007, and the FAO said the virus is considered endemic in Egypt and possibly in Nigeria.
"Several countries in West, Central, South and North Africa are at risk of becoming infected, and early warning, surveillance, and preventive measures should urgently be taken," the organization reported. Eight European countries have reported H5N1 outbreaks in 2007, the FAO noted.
Protective effect of low-concentration chlorine dioxide gas against influenza A virus infection
Ogata N, Shibata T. J Gen Virol 89 (2008), 60-67; DOI 10.1099/vir.0.83393-0 http://vir.sgmjournals.org/cgi/content/abstract/89/1/60
Abstract: Influenza virus infection is one of the major causes of human morbidity and mortality. Between humans, this virus spreads mostly via aerosols excreted from the respiratory system. Current means of prevention of influenza virus infection are not entirely satisfactory because of their limited efficacy. Safe and effective preventive measures against pandemic influenza are greatly needed. We demonstrate that infection of mice induced by aerosols of influenza A virus was prevented by chlorine dioxide (ClO2) gas at an extremely low concentration (below the long-term permissible exposure level to humans, namely 0.1 p.p.m.). Mice in semi-closed cages were exposed to aerosols of influenza A virus (1 LD50) and ClO2 gas (0.03 p.p.m.) simultaneously for 15 min. Three days after exposure, pulmonary virus titre (TCID50) was 102.6±1.5 in five mice treated with ClO2, whilst it was 106.7±0.2 in five mice that had not been treated (P=0.003). Cumulative mortality after 16 days was 0/10 mice treated with ClO2 and 7/10 mice that had not been treated (P=0.002). In in vitro experiments, ClO2 denatured viral envelope proteins (haemagglutinin and neuraminidase) that are indispensable for infectivity of the virus, and abolished infectivity. Taken together, we conclude that ClO2 gas is effective at preventing aerosol-induced influenza virus infection in mice by denaturing viral envelope proteins at a concentration well below the permissible exposure level to humans. ClO2 gas could therefore be useful as a preventive means against influenza in places of human activity without necessitating evacuation.
Evidence for a Heritable Predisposition to Death Due to Influenza
Abstract: Animal model studies and human epidemiological studies have shown that some infectious diseases develop primarily in individuals with an inherited predisposition. A heritable contribution to the development of severe influenza virus infection (i.e., that which results in death) has not previously been hypothesized or tested. Evidence for a heritable contribution to death due to influenza was examined using a resource consisting of a genealogy of the Utah population linked to death certificates in Utah over a period of 100 years. The relative risks of death due to influenza were estimated for the relatives of 4,855 individuals who died of influenza. Both close and distant relatives of individuals who died of influenza were shown to have a significantly increased risk of dying of influenza, consistent with a combination of shared exposure and genetic effects. These data provide strong support for a heritable contribution to predisposition to death due to influenza.
Molecular analysis of avian H7 influenza viruses circulating in Eurasia in 1999–2005: detection of multiple reassortant virus genotypes
Abstract: Avian influenza infections by high and low pathogenicity H7 influenza viruses have caused several outbreaks in European poultry in recent years, also resulting in human infections. Although in some cases the source of H7 strains from domestic poultry was shown to be the viruses circulating in the wild bird reservoir, a thorough characterization of the entire genome of H7 viruses from both wild and domestic Eurasian birds, and their evolutionary relationships, has not been conducted. In our study, we have analysed low pathogenicity H7 influenza strains isolated from wild and domestic ducks in Italy and southern China and compared them with those from reared terrestrial poultry such as chicken and turkey. Phylogenetic analysis demonstrated that the H7 haemagglutinin genes were all closely related to each other, whereas the remaining genes could be divided into two or more phylogenetic groups. Almost each year different H7 reassortant viruses were identified and in at least two different years more than one H7 genotype co-circulated. A recent precursor in wild waterfowl was identified for most of the gene segments of terrestrial poultry viruses. Our data suggest that reassortment allows avian influenza viruses, in their natural reservoir, to increase their genetic diversity. In turn this might help avian influenza viruses colonize a wider range of hosts, including domestic poultry.
Wild Bird Influenza Survey, Canada, 2005
Introduction: To provide baseline information about the strains and distribution of influenza viruses in Canadian wild ducks and to respond to the emergence of highly pathogenic avian influenza (HPAI) type H5N1 in Asia, Europe, and Africa, Canada’s Interagency Wild Bird Influenza Survey was initiated in July 2005. The goals of the survey were to identify avian influenza viruses in wild ducks in Canada and to detect HPAI strains early. We report the results of real-time reverse transcriptase–PCR (RRT-PCR) analysis.
Results: Of 4,268 wild ducks sampled in Canada in 2005, real-time reverse transcriptase–PCR detected influenza A matrix protein (M1) gene sequence in 37 percent and H5 gene sequence in 5 percent. Mallards accounted for 61 percent of samples, 73 percent of M1-positive ducks, and 90 percent of H5-positive ducks. Ducks hatched in 2005 accounted for 80 percent of the sample.
Identification of H2N3 influenza A viruses from swine in the United States
Abstract: Although viruses of each of the 16 influenza A HA subtypes are potential human pathogens, only viruses of the H1, H2, and H3 subtype are known to have been successfully established in humans. H2 influenza viruses have been absent from human circulation since 1968, and as such they pose a substantial human pandemic risk. In this report, we isolate and characterize genetically similar avian/swine virus reassortant H2N3 influenza A viruses isolated from diseased swine from two farms in the United States. These viruses contained leucine at position 226 of the H2 protein, which has been associated with increased binding affinity to the mammalian alpha-2,6Gal-linked sialic acid virus receptor. Correspondingly, the H2N3 viruses were able to cause disease in experimentally infected swine and mice without prior adaptation. In addition, the swine H2N3 virus was infectious and highly transmissible in swine and ferrets. Taken together, these findings suggest that the H2N3 virus has undergone some adaptation to the mammalian host and that their spread should be very closely monitored.
Introduction: Dr. Keiji Fukuda still remembers the intense emotions that tumbled through his mind as he waited to board his hastily scheduled flight out of Atlanta. His destination was Asia. In Hong Kong, a newly identified avian influenza virus, recently dubbed H5N1, was making people desperately ill. His objective was not the first-ever case of H5N1 in humans; that had surfaced eight months earlier, killing a three-year-old child. Instead, the focus of his emergency trip was the second and third cases, soon to grow to 18. The new illnesses were the signal that international health authorities had been dreading since that first case: evidence that the new flu's ability to sicken and kill humans was not a mysterious anomaly but a true and sustained threat.
"After the first case, there were a lot of questions, because there had never been any H5 infections in humans before," Fukuda said recently. "But once we had a second case, there were no more thoughts of lab contamination or error. The potential implications of an outbreak were immediately apparent."
He came to that realization somewhere over the Atlantic, 10 years ago this month. December 2007 marks the 10th anniversary of the revelation that a potentially pandemic strain of flu had emerged for the first time in years, and of the start of unprecedented scientific cooperation and commercial expansion — and political disagreement. To mark the occasion, CIDRAP News asked some of the key players in the 1997 emergency response to recall their reactions as the Hong Kong outbreak developed and to reflect on the weaknesses H5N1 exposed in public health and medicine, as well as the unexpected gifts it brought.
Abstract: A recent, comprehensive study of non-pharmaceutical interventions in 43 U.S. cities during the 1918 influenza pandemic may be influential in determining what actions policy makers take in the event of another pandemic. However, serious questions about this study have been raised. This commentary by historian John Barry, with an introduction by Michael Osterholm, elaborates on those questions and their implications.
(John Barry also published a detailed account of the influenza pandemic of 1918 entitiled, The Great Influenza: The epic story of the daeadliest plague in history.)
Update: Influenza Activity --- United States, September 30--December 1, 2007
During September 30--December 1, 2007, influenza activity remained low in the United States.
One case of novel influenza A infection was reported from Michigan during the week ending November 3, 2007; a child aged 18 months was infected with swine influenza A (H1N2) virus in August 2007 after attending an agricultural event where swine were exhibited. The child walked through a barn containing pigs but was reported to have had no direct contact with the animals. The child recovered from the illness; no contacts of the child were reported to be ill.
For the week ending December 1, 2007, pneumonia and influenza (P&I) was listed as an underlying or contributing cause of death for 6.1 percent of all deaths reported. This percentage is below the epidemic threshold of 6.4% for that period. During the 2007--08 influenza season, the weekly percentage of deaths attributed to P&I has ranged from 5.7 percent to 6.1 percent. The percentage of deaths attributed to P&I exceeded the epidemic threshold for 3 consecutive weeks during September 30--October 20 but has remained below the epidemic threshold since the week ending October 27. To date, no influenza-associated pediatric hospitalizations have been reported this season. For children aged 0--17 years, the influenza-associated hospitalization rate was 0.006 per 10,000. For children aged 0--4 years and 5--17 years, the rates were 0.01 and 0.003 per 10,000, respectively. One influenza-associated pediatric death occurring during the 2007--08 season has been reported to CDC through the National Notifiable Diseases Surveillance System.
Bangkok International Conference on Avian Influenza 2008: Integration from Knowledge to Control
Date: 23-25 January 2008
Location: The Dusit Thani, Bangkok, Thailand
The Bangkok International Conference on Avian Influenza 2008: Integration from Knowledge to Control is organized by the National Center for Genetic Engineering and Biotechnology (BIOTEC), the National Science and Technology Development Agency (NSTDA) and many allied organizations in Thailand, aiming to provide a forum that scientific experts and scientists working in affected areas can share knowledge, experiences and expertise. The forum will provide ample opportunities for knowledge, particularly those learned during the last three years, to find their ways to applications and controls. It will also facilitate international understanding and collaboration, which is obviously essential for handling this global threat. To facilitate this NSTDA will provide a number of travel funds for the students and scientists in developing, especially the affected countries, Thailand. Because of this many of world leading scientists already committed to participate.
Vaccine Allocation: Join the Discussion Who gets vaccinated first in a flu pandemic? Doctors? Paramedics? Kids? The elderly? It’s the central question posed in a series of public forums seeking input on a draft plan that spells out how vaccines will be allocated in the early days of a flu pandemic. In recent months public meetings were held in communities across the U.S. to gather feedback. Meanwhile, the draft plan was posted in the Federal Register asking the public to review it and submit comments.
To further the discussion, the CDC, ASTHO, and NACCHO are sponsoring a Web dialogue to let experts, federal officials and the public learn from one another by sharing information, ideas and perspectives. This is an excellent opportunity for interested participants to post their views and concerns and propose constructive solutions related to pandemic flu vaccinations.
Join the discussion at: http://www.webdialogues.net/cs/panflu-engage-home/view/di/104?x-t=home