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Vol. XI No. 2 ~EINet News Brief ~ 25 Jan 2008 ~ EINet News Briefs ~ Jan 25, 2008


*****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)
- Iran (Mazandaran): First reports of H5N1 avian influenza in domestic birds
- UK (Dorset): Fifth swan infected with H5N1 avian influenza
- Turkey (Zonguldak): Officails confirm H5N1 avian influenza outbreak in chickens
- Ukraine (Crimea): Village placed under quarantine after H5N1 avian influenza outbreak in poultry
- India (West Bengal): Six districts now report H5N1 avian influenza outbreaks in poultry
- Indonesia (Tangerang): 30-year-old man succumbs to H5N1 avian influenza
- Indonesia (Tangerang): WHO confirms avian influenza caused 8-year-old boy's death
- Viet Nam (Tuyen Quang): WHO confirms death from H5N1 avian influenza
- USA: GAO cites barriers to antiviral, vaccine roles in pandemic
- Egypt: Avian influenza outbreak abating says Egyptian government
- Global: WHO announces avian influenza surveillance system

2. Infectious Disease News
- Global: New International Health Regulations Now in Force
- Australia: One person dead and three more fighting for their lives after contracting melioidosis
- Philippines (Cavite): Growing number of people affected by dengue fever
- Singapore: Six people infected with the chikungunya virus
- Taipei: Officials announce first case of hantavirus this year
- Chile: Two cases of hantavirus detected and a third under investigation
- Peru (Lambayeque): Officials on alert after anthrax outbreak
- USA: Heparin and saline filled flushes cause patient infections
- USA: MRSA causes concern for men who have sex with men
- USA (Massachusetts): Listeria outbreak kills three in New England
- USA (MN, IN): Undiagnosed illness affects porcine plant workers
- USA (South Dakota): Cluster of Salmonella cases found, source still unidentified
- USA (WI, CA): Investigation of illnesses leads to groud beef recall

3. Updates
- AVIAN PANDEMIC INFLUENZA
- United Nations Food and Agriculture Organization update

4. Articles
- Influenza-testing and antiviral-agent prescribing practices — Connecticut, Minnesota, New Mexico, and New York, 2006–07 Influenza Season
- Does the Effectiveness of Control Measures Depend on the Influenza Pandemic Profile?
- Planning, surveillance, and reporting for pandemic influenza: A briefing for advanced practice nurses
- Establishing a nationwide emergency department-based syndromic surveillance system for better public health responses in Taiwan
- Epidemiologic Characterization of the 1918 Influenza Pandemic Summer Wave in Copenhagen: Implications for Pandemic Control Strategies
- Patient knowledge and attitudes about avian influenza in an internal medicine clinic

5. Notifications
- APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems
- Bangkok International Conference on Avian Influenza 2008: Integration from Knowledge to Control
- WHO Influenza Virus Tracking System (interim)
- National Citizens Pandemic Alliance (USA): GetPandemicReady.org


1. Influenza News

Global
Global: Cumulative number of human cases of avian influenza A/(H5N1)
2008
Indonesia / 3 (3)
Viet Nam / 1 (1)
Total / 4 (4)

2007
Cambodia / 1 (1)
China / 5 (3)
Egypt / 25 (9)
Indonesia / 42 (36)
Laos / 2 (2)
Myanmar / 1 (0)
Nigeria / 1 (1)
Pakistan / 1 (1)
Viet Nam 8 (5)
Total / 86 (58)

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)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2) Viet Nam / 61 (19)
Total / 95 (41)

2004
Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

2003
Viet Nam / 3 (3)
Total / 3 (3)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 353 (221).
(WHO 1.21.07 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 1.11.08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 1.15.08):
http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 1.14.07):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html .

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Europe/Near East
Iran (Mazandaran): First reports of H5N1 avian influenza in domestic birds
State Veterinary Organization has announced that migratory and indigenous birds have tested positive for H5N1 bird flu virus.

"Avian flu, earlier reported for migratory swans in the Anzali International Wetland in northern Iran, has been detected among geese, ducks and domestic hens in Barzanghib village near the wetland," the Organization's chief, Mojtaba Norouzi said. "Laboratory tests in Italy confirmed that Iran's wild and native birds had been infected by the H5N1 bird flu virus."

The Organization culled domestic birds of the village to prevent the outbreak of the deadly virus in the vicinity of the wetland. With thousands of migratory geese, ducks and other wildfowl heading for the province for the winter, local authorities are on high alert, he said. Iran had officially announced an outbreak of bird flu among migratory birds in late 2005.
(ProMED 1.19.07)

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UK (Dorset): Fifth swan infected with H5N1 avian influenza
A fifth swan at a sanctuary in Dorset has tested positive for the virulent H5N1 strain of bird flu, environment department Defra has said.

A total of four mute swans found dead at the Abbotsbury Swannery, near Chesil Beach, also tested positive for the strain.

"We are expecting to have a run of positives and negatives while the virus works its way through the herd," said John Houston, of Abbotsbury Tourism. Earlier, Defra said there was currently no evidence to suggest the disease was widespread among wild birds in the area, but officials were closely monitoring the situation.

The Abbotsbury Swannery will be given the all-clear if no birds test positive for the virus after 21 days.
(ProMED 1.18.08)

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Turkey (Zonguldak): Officails confirm H5N1 avian influenza outbreak in chickens
Turkish authorities confirmed on 22 Jan 2008 the presence of the deadly bird flu virus among chickens in a village in the northern Black Sea region.

"Two days of laboratory examinations have been completed and H5N1 was detected in the chickens," the ministry's spokesman Tunc Tuncel said.

The virus was found among dead chickens that were collected from Saz village in Zonguldak province on 19 Jan 2008. The village was put under quarantine and all animal movements were halted, Muzaffer Aydemir, the Agriculture Ministry's General Director of Protection and Control, said. He said the authorities had not begun culling poultry in the region because the case looks like a limited one.

"This is a very limited case. Only spotted in chickens of a citizen who hunts wild birds. We are sure that the virus passed to the chickens from wild birds," Aydemir said.

He said the area surrounding the village was disinfected, but no other cases have been reported so far. Consumers should not stop buying poultry products, he said, and 12 teams of veterinary and other experts were working in the area to stop the disease spreading.
(ProMED 1.22.08)

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Ukraine (Crimea): Village placed under quarantine after H5N1 avian influenza outbreak in poultry
The H5N1 strain of avian flu has been detected in fowl at a farm on Ukraine's Black Sea Crimea peninsula, emergency officials said on 18 Jan 2008. The farm in the village of Rivne had been placed under quarantine after more than 150 chickens died of the virus, the Emergency Situations Ministry said. The last registered outbreak of bird flu in Ukraine was in June 2006. No human cases have been recorded in the country.
(ProMED 1.18.08)

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Asia
India (West Bengal): Six districts now report H5N1 avian influenza outbreaks in poultry
Villagers in eastern India are continuing to eat chickens killed by bird flu and there are signs the virus may be spreading among poultry, an official said.

West Bengal animal resources minister Anisur Rahman said the situation in the affected areas was "horrible," and that more suspect cases had been reported on the state's borders with Nepal and Bangladesh. "The ignorance of villagers is one of the main hurdles. They are carrying the dead chickens without any protective gear," he said. "Most villagers are not aware of the disease. They are eating the dead chickens. Their children are playing with the infected chickens in the courtyards. It's horrible," Rahman added.

So far, six districts in West Bengal state have reported outbreaks of avian flu among poultry. Rahman said there were fears it could be spreading further afield in the state, with suspect poultry spotted in the hill resort of Darjeeling on the border with Nepal, and in several villages in Cooch Behar bordering Bangladesh, which is also fighting a bird flu outbreak.

"Blood samples of the dead poultry have been sent for tests. We are awaiting the report," he said.

The epicenter of the outbreak is Margram village, 240 km (150 miles) from the state capital Kolkata. Rahman said authorities had killed 200,000 chickens and ducks, and were planning to cull 500,000 more in the following days.

Some 30 million rupees (USD 770,000) has been set aside to compensate poultry owners — although farmers are reportedly opposing the slaughter of their birds because they want the cash immediately. Bangladesh, meanwhile, reported another outbreak near the border with India — taking the number of affected districts to 26 out of 64. Authorities have slaughtered at least 355,000 chickens, ducks, and pigeons since the first outbreak of the disease in February 2007. But experts have said some outbreaks may not have been reported, as farmers preferred to cover them up, fearing they might not be able to sell their birds in the market.
(ProMED 1.21.08)

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Indonesia (Tangerang): 30-year-old man succumbs to H5N1 avian influenza
The WHO also announced that a 30-year-old Indonesian man who was confirmed yesterday as the country's 120th-case patient died today. His age was previously reported as 32.

His death raises the WHO's fatality total for Indonesia to 98. The man was from Tangerang, a suburb of Jakarta. He fell ill on 13 Jan 2008 and was hospitalized six days later, according to yesterday's WHO statement. Investigators are trying to determine the source of his infection. The man was a sales executive at an automobile company.

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Indonesia (Tangerang): WHO confirms avian influenza caused 8-year-old boy's death
The Ministry of Health of Indonesia has announced a new case of human infection of H5N1 avian influenza. An 8-year-old boy from Tangerang District, Banten Province, developed symptoms on 7 Jan 2008, was hospitalized on 16 Jan 2008 and died in an AI referral hospital on 18 Jan 2008. Investigations into the source of his infection are ongoing, however initial reports indicate the case lived in close proximity to a chicken slaughter house.
(ProMED 1.22.08)

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Viet Nam (Tuyen Quang): WHO confirms death from H5N1 avian influenza
WHO today confirmed that a 34-year-old man from Viet Nam has died of H5N1 avian influenza.

The man, from Tuyen Quang province, about 50 miles northwest of Hanoi, got sick on Jan 10 2008, was hospitalized six days later, and died on Jan 18 2008, according to a WHO statement. He is now confirmed as the country's 102nd H5N1 case-patient and 48th death.

Investigators determined the man had contact with sick and dead poultry before he became ill, and had slaughtered and cooked chickens and geese on his backyard farm. WHO said animal health officials tested poultry from his village and found they were infected with the H5N1 virus.
(CIDRAP 1.24.08)

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Americas
USA: GAO cites barriers to antiviral, vaccine roles in pandemic
Antiviral medications and vaccines are two tools that many government and health officials hope will stall the spread of an influenza pandemic, but each strategy has daunting challenges, according to a new report from Congress's Government Accountability Office (GAO).

The report, Influenza Pandemic: Efforts Under Way to Address Constraints on Using Antivirals and Vaccines to Forestall a Pandemic, was requested by four members of Congress who head various health and homeland security committees. It was released this week on the GAO's Web site.

In its report, the GAO acknowledges that national governments and international organizations are working with pharmaceutical manufacturers to expand global production of antivirals and vaccines. However, it cites a US Department of Health and Human Services (HHS) caveat that a pandemic vaccine might play little role in the early phases of a pandemic, because it will take 20 to 23 weeks to develop and produce a targeted vaccine. Also, the GAO says it would be difficult to quickly expand antiviral production, because of the need to build new facilities, obtain production materials, and gain regulatory approval.

Weaknesses in international surveillance systems are hampering the detection of influenza outbreaks, which the GAO says could limit the ability to promptly administer or develop antivirals or vaccines.

"WHO has noted that to increase the likelihood of successfully forestalling the onset of a pandemic, surveillance in affected countries needs to improve, particularly concerning the capacity to detect clusters of cases closely related in time and place," the report states. "If early signals are not identified, the opportunity for preemptive action will be missed."

Indonesia's reluctance to share human H5N1 samples with the international community, because of its concerns that the country will not have access to the resulting pandemic vaccines, has further weakened global surveillance efforts in humans, the GAO authors write. Likewise, surveillance of influenza in animals also has shortcomings, the GAO reports. For example, outbreak definitions and reporting methods vary by country, and some countries, such as Djibouti and Uganda, lack the capacity to collect, transport, or identify animal influenza samples.

Nonexistent or poor distribution networks in many countries will hamper the release of antiviral or vaccine stockpiles, the GAO warns, citing one of its earlier investigations that found 10 of 17 countries reviewed didn't have plans for mobilizing medical countermeasure stockpiles. A lack of distribution networks is particularly an obstacle to antiviral utilization, because experts recommend that the drugs be taken within 48 hours of symptom onset, the GAO says.

To best utilize antivirals and vaccines, health officials need a reliable, fast diagnostic test to identify patients who have H5N1 infections, the report states. Though the CDC awarded four companies $11.4 million to develop new diagnostic tests, the agency estimates that approval and commercialization of the devices will take two or three years.
(CIDRAP 1.24.08)

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Africa
Egypt: Avian influenza outbreak abating says Egyptian government
Egypt's Supreme Committee to Combat Bird Flu said on 19 Jan 2008 that infection rates among poultry in farms and homes had dropped sharply since the second week of January. It said this was largely due to a public awareness campaign and the intensification of vaccination initiatives.

On the week of 14-18 Jan 2008, Cabinet spokesman Magdi Radi said 60 percent of poultry reared domestically had been vaccinated and that the government was stepping up efforts, especially in rural areas, to complete vaccination of the remaining 40 percent of poultry. Radi also said epidemiological surveillance had been completed in the governorates of Dahaklia, Behera, Giza, Fayyoum, and Gharbiyah. At the same time, Nasr El-Sayed, an adviser at the Ministry of Health, said that since the beginning of January 2008 fewer suspected human cases of bird flu had been admitted to hospitals.

However, Amany Nakhla, regional planning assistant for avian flu in the Cairo office of the UN Office for the Coordination of Humanitarian Affairs (OCHA), warned against a slackening in the awareness phase. She said 15 new suspected human cases of bird flu from the Delta area had been under medical surveillance since 16 Jan 2008.

In stepping up its public awareness campaign on bird flu, the government is cooperating with WHO. Zuhair Hallaj, the WHO country representative, said that although the media campaign had been slow in 2007, positive steps had been taken to improve the communication strategy.

The high population density, popular dependence on poultry for income and as nutrition, limited slaughter-house capacity, as well as the large number of households keeping poultry in their backyards meant there were many challenges to the successful control of the virus.

Nasser said, for example, that it was difficult to convince people to have their poultry vaccinated. "Many people still refuse the inoculation and culling of birds so we need a lot of human resources and teams to move from house to house to look for the [domestically reared] birds," he said.

Ibrahim Kerdany, WHO spokesman for the Eastern Mediterranean region, said the media campaigns were channelled through traditional media outlets (newspapers, TV and radio) in the affected and high-risk governorates, and especially through media centres affiliated to Egypt's State Information Service (SIS).
(ProMED 1.22.08)

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Global: WHO announces avian influenza surveillance system
Countries affected by H5N1 avian influenza have sent material containing 734 H5N1 virus isolates to the WHO over the past five years, and from now on the public will be able to track particular isolates that have been submitted and what is being done with them, according to WHO.

An online chart published by WHO on 21 Jan 2008 shows that countries submitted 8763 samples from humans and animals from 2003 through 2007, and 734 H5N1 viruses were isolated from those samples. WHO needs the isolates so it can monitor the virus's evolution, potential for human transmissibility and susceptibility to antiviral drugs. Viet Nam contributed the most H5N1 isolates: 375, derived from 1199 samples. But Indonesia provided the second most: 171 isolates derived from 4774 submitted samples.

On 24 Jan 2008, WHO unveiled an online system to provide information on H5N1 specimens shared with the WHO through its Global Influenza Surveillance Network. The system permits anyone to search for particular isolates by date of submission, source country, host species and several other variables. The system provides a page of detailed information for each isolate, including a list of all the laboratories to which the virus has been distributed, including pharmaceutical companies. WHO describes the current system as an interim version. At this point it contains most of the viruses and clinical specimens that have been submitted to WHO since 24 Nov 2007, plus all H5N1 viruses that have been developed into vaccine viruses, according to a WHO statement. Information on the remaining viruses submitted since 24 Nov 2007 is being added to the system.

Both the tracking system and the country-by-country report are results, at least in part, of Indonesia's concerns about the fairness and openness of the WHO system for the sharing, monitoring and use of influenza viruses. A WHO statement on 22 Jan 2008 said the tracking system was developed following the intergovernmental meeting on flu virus sharing that was held 21-23 Nov 2007 in Geneva. At the meeting, a WHO working group tried unsuccessfully to resolve Indonesia's concerns about sending H5N1 specimens to WHO. The country pushed for rules forbidding the commercial use of H5N1 samples, such as for vaccine development, without the source country's permission. But no agreement was reached. The November meeting and other discussions in 2007 were held in response to a resolution passed at WHO's World Health Assembly in May 2007. The resolution called on the WHO director-general to come up with a system for equitable sharing of the benefits of flu-virus sharing, to set up an international stockpile of vaccines for H5N1 and other potential pandemic viruses, and to revise the "terms of reference" for international sharing of flu viruses.

The WHO chart of H5N1 viruses submitted in the past five years says 13 isolates were selected for development into vaccines. So far, eight engineered viruses derived from these isolates, "suitable for vaccine development and production, are available for distribution," WHO reports. The agency says 292 institutions have received one or more copies of the eight engineered viruses, and 46 institutions have received "wild-type" vaccine viruses. Numerous other countries besides Viet Nam and Indonesia have submitted samples that yielded H5N1 isolates over the years, according to WHO. For example, Hong Kong submitted 380 specimens that yielded four isolates, China (other than Hong Kong) submitted 26 samples with 22 isolates, Egypt sent 758 specimens with 26 isolates, and Turkey provided 335 specimens with six isolates.
(ProMED 1.24.08)

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2. Infectious Disease News

Global
Global: New International Health Regulations Now in Force
New International Health Regulations (IHR) designed to halt the spread of dangerous diseases and other threats-are now in force. The chief aim of the regulations is to reduce the time it takes to identify an illness or other public health threat (including chemical and radiological hazards) with potential international impact and to mobilize a more timely and effective response.

Revisions of the regulations have been in the works for several years, but the 2003 SARS epidemic and concerns about a possible influenza pandemic have given new urgency to the revised rules. The new regulations were approved by the World Health Assembly in 2005 and officially came into force in 2007.

Under the old rules, PAHO/WHO member countries were only officially required to notify outbreaks of cholera, plague and yellow fever. Under the new regulations, countries must report, verify and respond to any event that is potentially a "public health emergency of international concern."

The change reflects concerns about new kinds of international health threats and the fact that new diseases have been emerging at the rate of about one per year in the past four decades. The new International Health Regulations (IHR) mean expanded roles and responsibilities for countries and for PAHO/WHO. The rules spell out four main tasks that countries must undertake:

  • Establish a national IHR focal point, which must be available 24/7 for official information exchange with PAHO/WHO.

  • Develop a national plan for building the country's capacities in surveillance and response.

  • Upgrade laboratory capacity to be able to identify dangerous pathogens.

  • Improve capacities for field investigation, social mobilization, and case management.

  • Countries have two years to formally assess how capable they are in all these areas and to develop action plans for getting up to par. After that, they have three years to implement the action plans.
The regulations also allow a two-year extension beyond the initial five years for countries that need it. But, says Dr. Marlo Libel, PAHO regional communicable diseases advisor, "We think PAHO member countries will be up and running well within the five-year period."
(PAHO 1.7.08)

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Asia
Australia: One person dead and three more fighting for their lives after contracting melioidosis
A person has died and three more are fighting for their lives in intensive care after contracting melioidosis in the Top End. A further seven people have been diagnosed with the tropical disease this wet season, but have since been treated. One case was a visitor who developed the disease after returning to their home interstate.

DHCS Centre for Disease Control director Vicki Krause warned that more people, "This is a serious disease; every year we have people dying from melioidosis," she said. "We just want people to be reasonable and know they live in an environment where this bacteria is in the soil, particularly after rains."

Melioidosis is caused by the bacteria Burkholderia pseudomallei. It killed five people in the Territory during the last Wet, and more than 30 cases were reported.

Dr. Krause said the bacteria lives below the soil's surface during the dry season but after heavy rainfall can be found in surface water and mud. She said it can also become airborne, and people are more at risk after cyclonic weather.
(ProMED 1.23.08)

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Philippines (Cavite): Growing number of people affected by dengue fever
The municipal government of Bacoor, Cavite has declared a dengue outbreak because of the growing number of people afflicted with the disease. Based on records, a total of 53 residents were admitted to hospitals due to dengue from August 2007 up to this month January 2008. Of these patients, five died because of the disease.
(ProMED 1.13.08)

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Singapore: Six people infected with the chikungunya virus
The Ministry of Health said on 17 Jan 2008 that six people in Singapore have been infected by the mosquito-borne chikungunya virus.

"This is the first instance of local transmission of the disease. Previous cases were imported, where patients caught the virus overseas and brought it back to Singapore," a Ministry of Health spokeswoman said.

To date, two patients have been admitted to the isolation ward of the Communicable Disease Centre. All six patients were living in close proximity to each other in the southeastern part of the city-state. "It's still a localized infection at the moment," she added. The Ministry of Health has begun to screen people living or working in the same area.
(ProMED 1.18.08)

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Taipei: Officials announce first case of hantavirus this year
The Department of Health (DOH) in Taipei announced on 11 Jan 2008 the first case of hantavirus hemorrhagic fever on the island this year.

Lin Ting, deputy director of DOH's Centers for Disease Control, said the patient, a 46-year-old businessman who travels frequently to Inner Mongolia in China, had contact with rats when he was disposing of rats he trapped on a sticky plate last month in Inner Mongolia.

The man developed a fever on 12 Dec 2007 and had difficulty urinating by 15 Dec 2007. He sought treatment at a Mongolian hospital. His condition turned for the better after dialysis. He returned to Taipei on 5 Jan 2008 and checked into a hospital on 7 Jan 2008. The CDC confirmed that he had contracted the virus.
(ProMED 1.19.08)

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Americas
Chile: Two cases of hantavirus detected and a third under investigation
So far in 2008, two people have been infected with hantaviruses and a third suspected case is under investigation.

The Ministry of Health provided details that in the Araucania Region a 34-year-old man died on 7 Jan 2008 due to this fatal disease that affects the respiratory system. Also in January 2008 a 37-year-old agricultural worker with a life-threatening illness, was admitted to the intensive care unit of the Talca Hospital in the Maule Region. In the Biobio Region, a rural resident from Nube was admitted to the Guillermo Grant Hospital awaits tests to determine if he has been infected by this fatal virus, which is transmitted by excretions of the long-tailed rat.
(ProMED 1.19.08)

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Peru (Lambayeque): Officials on alert after anthrax outbreak
The death of a 26-year-old farmer on 14 Jan 2008, was attributed to anthrax. According to Victor Torres, the head of the Regional Epidemiology Directorate in Lambayeque, the farmer, who lived in the village of Valle Hermoso, caught the disease from a goat. At the time of the man's death, two other people that had been exposed to the goat meat had also been infected with the disease; a 19-year-old woman and a 25-year-old man who were admitted into Las Mercedes de Chiclayo Hospital. Since then, five more people in the region of Lambayeque have been found to also be infected with anthrax. A 35-year-old woman and her 8-year-old son, who also live in the village of Valle Hermoso, were admitted into Las Mercedes de Chiclayo Hospital 14 Jan 2008. The Regional Health Directorate in Piura issued an epidemic alert on 16 Jan 2008. This alert came after the Regional Council of Lambayeque unanimously approved to declare the region in a state of sanitary emergency.
(ProMED 1.16.08 & 1.17.08)

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USA: Heparin and saline filled flushes cause patient infections
AM2 PAT, Inc, notified healthcare professionals and patients of a nationwide recall of all lots of both heparin and normal saline pre-filled flushes. These products are distributed under two brand names, Sierra Pre-Filled Inc and B. Braun. The products are sold in 3 ml and 5 ml sizes for Heparin and 3 ml, 5 ml, and 10 ml sizes for normal saline. One lot of heparin IV flush syringes was contaminated with Serratia marcescens, which has resulted in patient infections. This type of bacterial infection could present a serious adverse health consequence that could lead to life-threatening injuries and/or death.
(ProMED 1.22.08)

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USA: MRSA causes concern for men who have sex with men
In a study published online by the journal Annals of Internal Medicine, the bacteria (multidrug-resistant MRSA clone US300) seemed to be spread most easily through anal intercourse but also through casual skin-to-skin contact and touching contaminated surfaces. The authors warned that unless microbiology laboratories were able to identify the strain and doctors prescribed the proper antibiotic therapy, the infection could soon spread among other groups and become a wider threat. The new strain seems to have "spread rapidly" in gay populations in San Francisco and Boston, the researchers wrote, and "has the potential for rapid, nationwide dissemination" among gay men. The study was based on a review of medical records from outpatient clinics in San Francisco and Boston and nine medical centers in San Francisco. Among gay men in the study, MRSA was spread by skin contact, causing abscesses and infection in the buttocks and genital area. The new strain is closely related to earlier ones. Both are known as MRSA USA300. The strain is much more difficult to treat because it is resistant not just to methicillin, but also many more of the antibiotics used to treat the earlier strains, said Dr. Henry F. Chambers, an author of the new study. The new strain contains a plasmid called pUSA03.

"This particular clone is resistant to at least three other drugs, clindamycin, tetracycline and mupirocin," Dr. Chambers said in a telephone interview. Of the alternatives recommended by the C.D.C. and the Infectious Diseases Society of America, trimethoprim-sulfamethoxazole (Bactrim), clindamycin and a tetracycline, "this strain is resistant to two of those three," he added. "In addition, the new strain is resistant to mupirocin, which has been advocated for eradicating the strain from carriers."
[Full Text: http://www.annals.org/cgi/content/full/0000605-200802190-00204v1]
(ProMED 1.19.08)

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USA (Massachusetts): Listeria outbreak kills three in New England
Investigators probing the source of a listeria outbreak said on 17 Jan 2008 the strain that killed three people was found at a dairy processing plant in central Massachusetts. But officials have not yet determined exactly where the milk was contaminated.

"We know that there's a problem in that plant and we have connected the patients to the products to the plant, now it would be nice to know exactly how that happened, but that is part of the ongoing investigation," said Dr Alfred DeMaria, state director of communicable disease control.

Since June 2007, three elderly men have died after drinking bacteria-contaminated milk from the Whittier Farms plant in Shrewsbury, about 35 miles (56.3 km) west of Boston. The same strain of listeria sickened a pregnant woman, who then miscarried. A second woman also was sickened after drinking milk from the plant. No new cases have been identified and health officials say the public health risk is low.
(ProMED 1.18.08)

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USA (MN, IN): Undiagnosed illness affects porcine plant workers
The discovery that two Indiana pork-plant workers apparently developed symptoms of the same mystery illness that struck meatpackers in Austin, Minnesota, may be a significant break in a case that has baffled disease investigators for a month.

Like the workers in Minnesota, those at the Indiana plant were stationed near a powerful air-compression system used to blow brains out of pig heads during processing, said health officials. The process, which is no longer being used at either plant, exposes workers to floating particles of blood and brain that investigators theorize could have made them sick.

Dr. Jennifer McQuiston, an investigator for the CDC (US Centers for Disease Control and Prevention), cautioned that it's too early to be sure the cases in Minnesota and Indiana are connected. "They're in the process of tracking down this information," she said. "We're trying to learn all we can."

The Indiana workers were identified after investigators began inspecting packing plants across the country after the Minnesota cases came to light. The CDC has looked into slaughtering practices in 25 large pork-processing plants in 13 states. Officials from United Food and Commercial Workers (UFCW), the union that represents workers at Quality Pork Processors (QPP) in Austin, said they polled local packing house unions across the country about processing practices. So far 12 workers at the QPP plant in Austin have been identified as having the same collection of symptoms. Initially, health officials said the symptoms fit an extremely rare disease called CIDP (chronic inflammatory demyelinating polyneuropathy). But after further testing they backed off of that diagnosis, and now say the illness is a new syndrome.
(ProMED 1.18.08)

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USA (South Dakota): Cluster of Salmonella cases found, source still unidentified
Rapid City is at the center of a state and federal investigation into a salmonella outbreak that sickened people in South Dakota and at least three other states. So far, health officials have confirmed 22 cases of a specific strain of the bacterial-borne intestinal disorder in the four states. All of South Dakota's 11 cases, nine adults and two children, were in the Black Hills area. Of the 11 victims six were hospitalized, five at Rapid City Regional Hospital.

Additional confirmed cases of the Newport strain since the late-December 2007 announcement brought the total in South Dakota and three other states to 22 cases and prompted state health officials to issue another news release on 14 Jan 2008.

"On the surface, it looks like 22 different cases, but they have a molecular fingerprint that's almost exactly the same,"said state epidemiologist Lon Kightlinger of the South Dakota Department of Health in Pierre said 14 Jan 2008. "So we're looking for commonality in them."

Kightlinger declined to name the other states involved, but noted that one is a South Dakota border state and the other two are "far flung." Because of the molecular similarities of the cases, the states and the Centers for Disease Control and Prevention [CDC] in Atlanta are investigating for links.
(ProMED 1.15.08)

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USA (WI, CA): Investigation of illnesses leads to groud beef recall
Rochester Meat Company, a Rochester, Minnesota firm, is voluntarily recalling approximately 188,000 pounds (85.28 tons) of ground beef products because they may be contaminated withE. coli O157:H7, the USA Department of Agriculture's Food Safety and Inspection Service (USDA-FSIS) announced on 12 Jan 2008. The problem was discovered through an investigation initiated by the Wisconsin Department of Health and Family Services and the California Department of Public Health into five illnesses in Wisconsin and one illness in California. The ground beef products subject to recall were produced on 30 Oct 2007, and 6 Nov 2007. The products subject to recall were shipped to distributors nationwide for further distribution to restaurants and food service institutions. These products were not available for purchase by consumers in retail establishments.
(ProMED 1.14.08)

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3. Updates
AVIAN PANDEMIC INFLUENZA
UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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United Nations Food and Agriculture Organization update
Outbreaks of H5N1 avian influenza in 15 countries since December 2007 are a potent reminder that the virus is still a global threat, the United Nations Food and Agriculture Organization (FAO) warned today, as officials in Thailand announced they found the disease in poultry again after a six-month lapse.

The FAO statement said the heightened outbreak activity calls for close monitoring and strong control efforts. Recently affected countries include Bangladesh, Benin, China, Egypt, Germany, India, Indonesia, Iran, Israel, Myanmar, Poland, Russia, the Ukraine, Turkey and Viet Nam. Most outbreaks have occurred in poultry, including chickens, turkeys, geese and ducks. However, a few of the outbreaks — those in China, Poland, and the United Kingdom—involved wild birds. Worrisome spots include Indonesia, Bangladesh and Egypt, where the virus has become deeply entrenched despite major efforts to control the spread of the virus, said Joseph Domenech, the FAO's chief veterinary officer, in the FAO statement. "The virus has not become more contagious to humans but has managed to persist in parts of Asia, Africa and probably Europe. It could still trigger an influenza pandemic."

Despite all of the developments that raise concerns, Domenech said his group has seen some positive trends. "Globally, much progress has been achieved in keeping the H5N1 virus under control. We are better prepared to deal with the disease than we were three years ago," he said in the FAO statement. "Surveillance, early, detection and immediate response have improved, and many newly infected countries have managed to eliminate the virus from poultry."

The outbreak in Thailand is not included in the FAO's total, but Thai livestock officials announced that the H5N1 virus was detected in Nakhon Sawan province in the northern part of the country, about 188 miles north of Bangkok. However, a report that Thai officials filed with the World Organization for Animal Health (OIE) said the H5 virus has been confirmed and that final test results are pending. According to the OIE report, over 50,000 birds were destroyed.

Domenech discussed aspects of outbreaks in several countries:

  • He said India is struggling to control its worst-ever H5N1 outbreak. The virus has now spread to nine of West Bengal state's 19 districts and the outbreak's reach is within 18 miles of Calcutta, India's third-largest urban area.

  • Indonesia is one of the hardest hit countries in terms of avian outbreaks and human cases. The FAO said the virus has struck 31 of 33 provinces since 2004. Domenech said new H5N1 virus strains have emerged in Indonesia, which means current poultry vaccines may not fully protect against the disease. He said the Indonesian government and the FAO, along with FAO and OIE reference laboratories, are instituting a virus-monitoring program to further examine the problem.

  • Avian influenza outbreaks seem to be worsening in Bangladesh, where surveillance and control programs have not prevented the virus from spreading to 21 of 64 districts, the FAO statement said. The FAO said it is strengthening its presence in Bangladesh to support government efforts to control the disease.

  • Egypt had some early success with vaccination campaigns on commercial poultry farms, but its control efforts may have slacked off, because the disease has now reappeared in industrial poultry farms and has spread more widely throughout the country, the FAO reported. Outbreak reporting, disinfection, culling, movement control, and biosecurity all need to be improved in Egypt, Domenech said, adding that the FAO is working closely with the government to strengthen disease detection, control, and communication. He also said potential changes in the H5N1 virus strains warrant further investigation.

  • West African countries Benin, Ghana, Nigeria, and Togo all reported H5N1 outbreaks in 2007, the FAO report said. Domenech said that though the Nigerian government launched intense efforts to control the disease in poultry, virus circulation in the country still threatens neighboring countries. He said the FAO will continue working with the Nigerian government to boost disease control measures.

  • In Europe, where Germany, Poland, Russia, and the United Kingdom recently reported outbreaks, disease detection and immediate response were very effective, particularly in the European Union countries, Domenech said.
(CIDRAP 1.24.08)

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4. Articles
Influenza-testing and antiviral-agent prescribing practices — Connecticut, Minnesota, New Mexico, and New York, 2006–07 Influenza Season
CDC. MMWR Weekly. January 25, 2008 / 57(03);61-65

Influenza is a major cause of morbidity and mortality in the United States, with an average of 36,000 deaths attributed to the disease annually (1). Patients with influenza-like illness (ILI) often are evaluated by their primary-care physicians (PCPs). Antiviral therapy initiated within 48 hours of ILI symptom onset can shorten the course of influenza illness; antiviral therapy also is used as chemoprophylaxis for influenza, particularly in institutions and communities (2). Early laboratory diagnosis and knowing when influenza is circulating in the community can guide effective clinical management. To assess influenza-testing and antiviral-agent prescribing practices during the 2006–07 influenza season, personnel at four of 10 Emerging Infections Program (EIP) sites with influenza hospitalization surveillance surveyed PCPs. This report describes the results of that survey, which indicated that 69.0% of the PCPs administered influenza tests to patients who had ILI during the influenza season and 53.8% prescribed antiviral agents, including two (i.e., amantadine and rimantadine) no longer recommended by CDC. Health agencies, medical societies, and continuing medical education organizations should advance programs for physicians that increase awareness of recommendations regarding appropriate influenza testing and use of antiviral agents.
(Read more at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5703a1.htm )

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Does the Effectiveness of Control Measures Depend on the Influenza Pandemic Profile?
Kerneis S, et al. PloS One. 2008; 3(1): e1478. doi:10.1371/journal.pone.0001478 http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0001478

Background
Although strategies to contain influenza pandemics are well studied, the characterization and the implications of different geographical and temporal diffusion patterns of the pandemic have been given less attention.

Methodology/Main Findings
Using a well-documented metapopulation model incorporating air travel between 52 major world cities, we identified potential influenza pandemic diffusion profiles and examined how the impact of interventions might be affected by this heterogeneity. Clustering methods applied to a set of pandemic simulations, characterized by seven parameters related to the conditions of emergence that were varied following Latin hypercube sampling, were used to identify six pandemic profiles exhibiting different characteristics notably in terms of global burden (from 415 to >160 million of cases) and duration (from 26 to 360 days). A multivariate sensitivity analysis showed that the transmission rate and proportion of susceptibles have a strong impact on the pandemic diffusion. The correlation between interventions and pandemic outcomes were analyzed for two specific profiles: a fast, massive pandemic and a slow building, long-lasting one. In both cases, the date of introduction for five control measures (masks, isolation, prophylactic or therapeutic use of antivirals, vaccination) correlated strongly with pandemic outcomes. Conversely, the coverage and efficacy of these interventions only moderately correlated with pandemic outcomes in the case of a massive pandemic. Pre-pandemic vaccination influenced pandemic outcomes in both profiles, while travel restriction was the only measure without any measurable effect in either.

Conclusions
Our study highlights: (i) the great heterogeneity in possible profiles of a future influenza pandemic; (ii) the value of being well prepared in every country since a pandemic may have heavy consequences wherever and whenever it starts; (iii) the need to quickly implement control measures and even to anticipate pandemic emergence through pre-pandemic vaccination; and (iv) the value of combining all available control measures except perhaps travel restrictions.
(CIDRAP 1.24.08)

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Planning, surveillance, and reporting for pandemic influenza: A briefing for advanced practice nurses
Hoffman DF, Nannini A. Journal of American Academy of Nurse Practitioners. 2008;20(1):11-16
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1745-7599.2007.00284.x

Purpose
To provide advanced practice nurses (APNs) with information necessary to participate in pandemic influenza planning and response. Key epidemiological terms and pandemic alert designations are reviewed. Influenza surveillance activities at the local, state, and national levels are summarized. Responsibilities of the APN are discussed, and resources are provided.

Conclusions
Recent public health emergencies have brought to light the need for APNs to become educated regarding emergency planning and response. APNs should be familiar with terminology, current activities, and potential responsibilities.

Implications for practice
Resources presented in this article will help prepare APNs to participate in planning and response activities for pandemic influenza.

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Establishing a nationwide emergency department-based syndromic surveillance system for better public health responses in Taiwan
Wu TJ, King CC, et al. BMC Public Health. 2008;8:18. doi:10.1186/1471-2458-8-18
http://www.biomedcentral.com/1471-2458/8/18

Background
With international concern over emerging infectious diseases (EID) and bioterrorist attacks, public health is being required to have early outbreak detection systems. A disease surveillance team was organized to establish a hospital emergency department-based syndromic surveillance system (ED-SSS) capable of automatically transmitting patient data electronically from the hospitals responsible for emergency care throughout the country to the Centers for Disease Control in Taiwan (Taiwan-CDC) starting March, 2004. This report describes the challenges and steps involved in developing ED-SSS and the timely information it provides to improve in public health decision-making.

Methods
Between June 2003 and March 2004, after comparing various surveillance systems used around the world and consulting with ED physicians, pediatricians and internal medicine physicians involved in infectious disease control, the Syndromic Surveillance Research Team in Taiwan worked with the Real-time Outbreak and Disease Surveillance (RODS) Laboratory at the University of Pittsburgh to create Taiwanas ED-SSS. The system was evaluated by analyzing daily electronic ED data received in real-time from the 189 hospitals participating in this system between April 1, 2004 and March 31, 2005.

Results
Taiwanas ED-SSS identified winter and summer spikes in two syndrome groups: influenza-like illnesses and respiratory syndrome illnesses, while total numbers of ED visits were significantly higher on weekends, national holidays and the days of Chinese lunar new year than weekdays (p<0.001). It also identified increases in the upper, lower, and total gastrointestinal (GI) syndrome groups starting in November 2004 and two clear spikes in enterovirus-like infections coinciding with the two school semesters. Using ED-SSS for surveillance of influenza-like illnesses and enteroviruses-related infections has improved Taiwanas pandemic flu preparedness and disease control capabilities.

Conclusions
Taiwanas ED-SSS represents the first nationwide real-time syndromic surveillance system ever established in Asia. The experiences reported herein can encourage other countries to develop their own surveillance systems. The system can be adapted to other cultural and language environments for better global surveillance of infectious diseases and international collaboration.
(CIDRAP 1.18.08)

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Epidemiologic Characterization of the 1918 Influenza Pandemic Summer Wave in Copenhagen: Implications for Pandemic Control Strategies
Andreasen V, et al. The Journal of Infectious Diseases. 2008;197:270¨C278 http://www.journals.uchicago.edu/doi/abs/10.1086/524065

Background
The 1918¨C1919 A/H1N1 influenza pandemic killed 50 million people worldwide. Historical records suggest that an early pandemic wave struck Europe during the summer of 1918.

Methods
We obtained surveillance data that were compiled weekly, during 1910¨C1919, in Copenhagen, Denmark; the records included medically treated influenza©\like illnesses (ILIs), hospitalizations, and deaths by age. We used a Serfling seasonal regression model to quantify excess morbidity and mortality, and we estimated the reproductive number (R) for the summer, fall, and winter pandemic waves.

Results
A large epidemic occurred in Copenhagen during the summer of 1918; the age distribution of deaths was characteristic of the 1918¨C1919 A/H1N1 pandemic overall. That summer wave accounted for 29%¨C34% of all excess ILIs and hospitalizations during 1918, whereas the case©\fatality rate (0.3%) was many©\fold lower than that of the fall wave (2.3%). Similar patterns were observed in 3 other Scandinavian cities. R was substantially higher in summer (2.0¨C5.4) than in fall (1.2¨C1.6) in all cities.

Conclusions
The Copenhagen summer wave may have been caused by a precursor A/H1N1 pandemic virus that transmitted efficiently but lacked extreme virulence. The R measured in the summer wave is likely a better approximation of transmissibility in a fully susceptible population and is substantially higher than that found in previous US studies. The summer wave may have provided partial protection against the lethal fall wave.
(CIDRAP 1.15.08)

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Patient knowledge and attitudes about avian influenza in an internal medicine clinic
Gaglia MA, Rothberg MB, et al. Public Health. 2008 Jan 16 [Epub ahead of print]

Background
Avian influenza is an emerging threat to public health, but little is known about how the public perceives this threat. The objective of this study was to describe beliefs, attitudes and knowledge regarding avian influenza among patients in an internal medicine clinic.

Methods
Four hundred adult patients in an internal medicine clinic received the survey between April and June 2006.

Results
The most common sources of information about avian influenza were local and national television news (74%), cable news (51%) and newspapers (50%). The mean percentage of correct answers to seven questions regarding knowledge of avian influenza was 49%. Multivariable linear regression using the percentage of correct answers to these questions as the primary outcome showed that: (1) college education, Internet and cable news as sources; (2) income greater than $75,000; and (3) receiving an influenza vaccine in the last influenza season were positively associated with knowledge. Having a viral upper respiratory infection on the day of the survey was negatively associated with knowledge. However, greater knowledge was not associated with more positive attitudes regarding possible public health interventions in a pandemic setting. Although 42% of patients were worried about avian influenza, only 22% trusted the Government to contain its spread. Most patients were willing to wear a mask (82%), be quarantined (78%) or undergo mandatory vaccination (55%).

Conclusions
Knowledge about avian influenza was poor in this mainly college-educated sample, but most patients had positive attitudes towards public health control measures that would be used in a pandemic scenario. Further studies are needed to inform education strategies and pandemic influenza planning.
(CIDRAP 1.16.08)

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5. Notifications
APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems
APEC EINet is pleased to host a special videoconference on pandemic inluenza preparedness. This videoconference is a follow-up to our first “virtual symposium”, which was conducted in January 2006 with great success (participating economies were Australia, Canada, China, Korea, Philippines, Singapore, Chinese Taipei, Thailand, USA, and Viet Nam). You can view a five-minute videoclip of our previous virtual symposium at: http://depts.washington.edu/einet/symposium.html. Our upcoming videoconference will be held in late May 2008. It will take place during the evening hours of 29 May in the Americas and in the morning hours of 30 May in Asia, for approximately 3.5 hours. Our objective is to describe how private and public sectors in the APEC region can cooperate and work effectively to prepare for and respond to an influenza pandemic.

Through this videoconference, we hope to promote regional information sharing and collaboration to enhance pandemic preparedness. In order to improve preparedness regionally, it is vital to understand how each economy in the region is undertaking this task. In this process, EINet will:

  1. Bring together economies in a dynamic, real-time discussion on preparedness through the collaboration of the health and the business/trade sectors, with a focus on critical systems continuity.

  2. Share specific examples of current practices — e.g. scenario exercises, communication drills and policy evaluation.

  3. Use innovative technologies (e.g. Access Grid) for real-time, virtual interchange, enhancing their utility for future collaboration and response in the event of a pandemic.
Videoconferencing offers an alternative to in-person conferencing. It cuts down on the time and cost of traditional conferences requiring long-distance travel. Simultaneous communication with multiple sites is possible, with numerous visualization options. Real-time web-based information exchange is also possible, and, during an actual pandemic, the virtual medium would be a safe way to communicate when international travel is limited or prohibited.

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Bangkok International Conference on Avian Influenza 2008: Integration from Knowledge to Control

http://www.biotec.or.th/AIConf2008/home/index.asp
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 world 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, as you can find in the details of this announcement. On behalf of the Scientific and Organizing Committees, it is our pleasure to invite you to participate in this meeting, which will certainly be fruitful to your important roles in our defense against this frightening disease.

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WHO Influenza Virus Tracking System (interim)
http://www.who.int/fluvirus_tracker

WHO is developing an electronic system to track influenza A(H5) viruses that have been shared by Member States with WHO through the Global Influenza Surveillance Network (GISN). The tracking system, currently available in an interim version, indicates which H5N1 viruses/specimens have been shared with WHO, where they are located, analyses that have subsequently been conducted, further development into H5N1 vaccine viruses and recipients of the vaccine viruses and other viruses. Improvement of the interim system is ongoing and it is anticipated that this system will be upgraded in the future. The interim system contains data for the majority of viruses and clinical specimens that have been shared with WHO from 24 November 2007 onwards, as well as all H5N1 viruses that have been developed into vaccine viruses.

Data entry of the remaining viruses and clinical specimens (from 24 November 2007 onwards) is ongoing.

Currently the data entry is conducted by WHO Collaborating Centers, WHO H5 Reference Laboratories, and regulatory laboratories which are involved in the WHO H5N1 vaccine virus selection and development process.
(CIDRAP 1.22.08)

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National Citizens Pandemic Alliance (USA): GetPandemicReady.org
http://www.getpandemicready.org/

GetPandemicReady.org was created by members of a grassroots, volunteer organization called the National Citizens Pandemic Alliance (NCPA). The NCPA is a group of concerned citizens committed to personal preparation and community resiliency as the foundation for getting though a pandemic. Members of the NCPA used their own experiences and extensive research to gather practical and time-efficient advice to help families prepare for a pandemic. This site has preparedness information relating to water, food, hygiene, emergency basics, confort, safetey, concerns of special populations, infants and toddlers, staying healthy, and treating influenza.
(CIDRAP 1.23.08)

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 apecein@u.washington.edu