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Vol. XI No. 5 ~ EINet News Briefs ~ Mar 07, 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)
- Iraq (Basra): H5N1 avian influenza found in poultry
- UK (Dorset): H5N1 avian influenza discovered in dead goose
- Egypt: Three new cases of H5N1 avian influenza, one death
- Indonesia: Recent H5N1 avian influenza viruses show no mutation

2. Infectious Disease News
- Brunei Darussalam: Seminar participants hit by food poisoning
- China (Xinjiang Uygur): Measles kills 10 and sickens thousands in January 2008
- Philippines (Eastern Samar): High rates of diarrheal illness, deaths reported
- Peru: Several districts on alert in dengue epidemic
- USA (Nevada): Deadly toxin ricin found in motel room, 57-year-old occupant in critical condition
- USA (Hawaii): Local restaurant produces cluster of E. coli cases
- USA (Nevada): Unsafe injection practices associated with transmission of bloodborne pathogens
- USA (Colorado): 3-day-old baby recovers from infant botulism
- Global: Report finds highest rates ever of MDR-TB
- Philippines (Laguna): Typhoid on the rise, officials declare a state of calamity
- Russia (Chelyabinsk): 45-year-old woman dies, health officials suspect rabies

3. Updates
- AVIAN PANDEMIC INFLUENZA

4. Articles
- Effect of Surgical Masks Worn Concurrently Over N95 Filtering Facepiece Respirators: Extended Service Life Versus Increased User Burden.
- Pandemic Economics: The 1918 Influenza and Its Modern-Day Implications
- Responding to Simulated Pandemic Influenza in San Antonio, Texas
- Effects of Adjuvants on the Safety and Immunogenicity of an Avian Influenza H5N1 Vaccine in Adults
- Flu Virus Research Yields Results but No Magic Bullet for Pandemic
- Integrated Food Chain Surveillance System for Salmonella spp. in Mexico
- Presence of Clostridium botulinum spores in Matricaria chamomilla (chamomile) and its relationship with infant botulism.

5. Notifications
- APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems
- Eleventh Annual Conference on Vaccine Research
- Public Health – Seattle & King County: Business Not As Usual: Preparing for Pandemic Flu (video)
- HHS advisor, William Raub, fields online pandemic preparedness queries


1. Influenza News

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

2008
China / 3 (3)
Egypt / 3 (1)
Indonesia / 12 (10)
Viet Nam / 4 (4)
Total / 22 (18)

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: 371 (235). (WHO 3.5.07 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 2.28.08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 3.3.08): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 2.25.07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html .

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Europe/Near East
Iraq (Basra): H5N1 avian influenza found in poultry
A case of bird flu was discovered on 2 Mar 2008 in the southern Iraqi city of Basra. An Iraqi higher committee Secretariat in combating bird flu said the new discovery is in Al-Fedagiya village in the Fao area. The committee, based on the discovery, prohibited all transfers of poultry and live birds to other provinces before getting permission from local vet hospitals. The committee also issued an order prohibiting the selling and dealing of birds and poultry in the area, including taking all the precautionary measures needed. The committee also called on citizens in the area to avoid bird hunting in the area for their own safety.
(ProMED 3.4.08)

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UK (Dorset): H5N1 avian influenza discovered in dead goose
A dead goose has tested positive for the highly virulent H5N1 strain of bird flu, government scientists said.

The remains of the bird were discovered around 1km (0.6m) from Abbotsbury Swannery in Dorset, where a number of swans have been found with the disease. The Department for the Environment, Food and Rural Affairs (Defra) said the Canadian goose was the 11th wild bird in the area to test positive for H5N1. Restrictions on the movement of poultry have now been introduced in the area. Defra said the decision was based on veterinary advice. Poultry keepers will not be able to move birds from their premises except under license. A spokeswoman said that the latest case of bird flu was "not unexpected." She said H5N1 was active at a very low level among wild birds in the area, and there was no evidence of the virus in domestic poultry locally. Regular surveillance was continuing, she added, with patrols looking for dead birds. A Wild Bird Monitoring Area is in place around the affected area, where keepers are required to keep domestic poultry away from wild birds. Owners have been urged to stay vigilant and report any signs of the disease.
(ProMED 3.29.08)

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Egypt: Three new cases of H5N1 avian influenza, one death
Three new cases of avian influenza have been found in Egypt. The first case (Egypt's 44th) is a 4-year-old female from El-Edwa district, Menea governorate. She developed symptoms on 21 Feb 2008 and was hospitalized on 24 Feb 2008. She is receiving treatment and is in a stable condition. Investigations into the source of her infection indicate exposure to sick poultry in the

The second case (Egypt's 45th) was a 25-year-old female from Sennoris district, Al Fayyum governorate. She developed symptoms on 24 Feb 2008 and was hospitalized on 27 Feb 2008. Her death has now been confirmed by the Ministry of Health and Population. Investigations into the source of her infection indicate that she had contact with sick poultry prior to becoming unwell.

The third case (Egypt's 46th) is an 11-year-old male from Menof District, Menofia [Al Minufiyah] governorate. He was hospitalized with symptoms on 26 Feb 2008 and was confirmed as being infected with A (H5N1) by the Central Public Health Laboratory and NAMRU-3 on 4 Mar 2008. He remains in critical condition. Investigations into the source of his infection indicate a history of contact with sick and dead poultry. Of the 46 cases confirmed to date in Egypt, 20 have been fatal.
(ProMED 3.2.08 & 3.5.08 & 3.6.08)

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Asia
Indonesia: Recent H5N1 avian influenza viruses show no mutation
Indonesia's health ministry said that H5N1 avian influenza virus samples it sent to a World Health Organization (WHO) laboratory in the United States in February 2008 showed no signs of dangerous mutations.

On Feb 22 2008, Nancy Cox, PhD, chief of the influenza division at the US Centers for Disease Control and Prevention (CDC), said Indonesia's health ministry shipped 15 clinical samples to the CDC lab, which is a WHO collaborating facility. She said the samples were from two patients whose infections were confirmed by the WHO on 5 Feb and 12 Feb 2008. Lily Sulistyowati, spokeswoman for Indonesia's health ministry, said the CDC has run tests on the samples. "The result is it is still H5N1. It hasn't mutated, meaning it is endemic among fowl and can be transferred from fowl to human," Sulistyowati said. Since flu viruses evolve and mutate constantly, Sulistyowati apparently meant that the viral isolates showed no mutations that would enable them to spread more easily from person to person. Most human H5N1 cases have resulted from contact with poultry; person-to-person transmission of the virus has been rare.

It's unclear if the recently shared samples signal that Indonesia has unilaterally ended its boycott of the international virus-sharing system. A WHO group that met to resolve the virus-sharing issue in November 2007 failed to draft an agreement between developing nations and the developed countries that are home to the world's' largest vaccine producers.
(CIDRAP 3.5.08)

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2. Infectious Disease News
Brunei Darussalam: Seminar participants hit by food poisoning
A total of seven people were admitted to the RIPAS emergency ward on 25 Feb 2008 where they were diagnosed with food poisoning in what appears to be the result of bad 'nasi ayam' that was served to participants attending a University Brunei Darussalam (UBD) seminar. Teachers and librarians from around the nation were invited for the seminar. "They were serving food there, like nasi ayam which tasted quite good actually," said a teacher who was diagnosed with food poisoning at the emergency ward. He said participants who did not eat the nasi ayam were "okay" and were not afflicted by any of the symptoms.

"About two hours after eating it, I started feeling dizzy and had a stomach ache. I started vomiting a lot and so my wife took me to the emergency ward. It was here I met some other patients with food poisoning who also attended the seminar," said the teacher. "We have taken samples for testing and so far we know of seven people from the seminar who were infected," he said. Some 300 people attended the seminar.
(ProMED 2.29.08)

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China (Xinjiang Uygur): Measles kills 10 and sickens thousands in January 2008
An outbreak of measles killed 10 people in Xinjiang Uygur Autonomous Region in January 2008. The disease also sickened 4365 people in January 2008, a jump from 1149 cases in December 2007 when only two people died of the disease. The region's government has offered free treatment for those infected with measles and clinics are encouraging people to get their temperature tested. Patients are being isolated to avoid spread of the disease. At present, most measles cases are in children under 4 years of age, who account for 80 percent of patients.
(ProMED 2.22.08 & 2.23.08)

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Philippines (Eastern Samar): High rates of diarrheal illness, deaths reported
At least 178 persons from the flooded city and towns of Eastern Samar were reported to be suffering from diarrhea, according to reports collated by the Office of Civil Defense in Eastern Visayas. The death toll due to flooding reached 18, the report released on 24 Feb 2008 said. The death toll is expected to climb as more reports from affected towns are received, said operation chief Rey Gozon. As flooding spawned by the relentless rain continued, diarrhea cases also rose, said Gozon. He said that diarrhea cases were detected in practically all localities in Eastern Samar, with Borongan City having 38 people afflicted with diarrhea, the highest number of cases among all areas in the province.
(ProMED 2.29.08)

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Americas
Peru: Several districts on alert in dengue epidemic
In epidemiological week six week of 10 Feb 2008, there has been notification of 1406 classical dengue cases, 59 percent from the Loreto health district. To date, 16 health directorates have reported locally acquired dengue cases. The Lima health district has reported 23 cases, of which four have been confirmed, but these have been imported from Loreto (three cases) and Ucayali (one case), areas where there are outbreaks currently. The remainder of these (Lima) cases are probable. Of these, 12 are probable classical dengue cases. They have not been outside of Lima and are currently under investigation. An analysis of the dengue epidemiological situation countrywide indicates that there are dengue epidemic alert situations in the health directorates of Loreto, La Libertad and Ucayali. There also has been a case of DHF in Loreto and in Ucayali. In the Loreto district, there has been notification of 831 classical dengue cases through epidemiological week six.
(ProMED 3.6.08)

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USA (Nevada): Deadly toxin ricin found in motel room, 57-year-old occupant in critical condition
Firearms and an "anarchist type textbook" were found in the same motel room where several vials of the deadly toxin ricin was found, police said on 29 Feb 2008. Tests conducted by the Centers for Disease Control and Prevention (CDC), confirmed the substance found in vials was ricin.

The room was previously occupied by a 57-year-old man who has been hospitalized with breathing problems and was in critical condition since 14 Feb 2008. Captain Joseph Lombardo said on 29 Feb 2008 that the book was tabbed at a spot with information about ricin. Lombardo did not give more information about the book or specify what kinds of weapons were found. Las Vegas police said there was no apparent link to terrorist activity and no indication of any spread of the deadly substance beyond the several vials of powder found in a plastic bag in the man's room on 28 Feb 2008. But what the ricin was doing there remained a mystery.

An American Medical Response paramedic crew that took the man to the hospital 14 Feb 2008 had no indication of ricin poisoning, AMR general manager John Wilson said. Greg Evans, director of the Institute for Biosecurity at Saint Louis University in Missouri, said the fact that the man suffered respiratory illness suggested he was exposed to a powder fine enough to float in the air. Multiple vials would probably contain enough ricin to sicken many people if it was spread, for example, around a buffet table or sprayed in a closed room. "If it was aerosolized in a confined space then it certainly could harm dozens of people," he said.
(ProMED 3.1.08 & 3.5.08)

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USA (Hawaii): Local restaurant produces cluster of E. coli cases
Sekiya's Restaurant in Kaimuki dumped all its food and everything disposable on 26 Feb 2008 and began to disinfect the restaurant from top to bottom after the worst outbreak of E. coli 0157:H7 in the state's history. Six customers who ate at Sekiya's suffered bloody diarrhea in December 2007 followed by a seventh in February 2008, even after the restaurant corrected health inspection violations, said Dr Paul Effler, state epidemiologist for the Health Department. The head of Hawaii's restaurant inspectors said the case shows the state doesn't have enough inspectors to keep restaurants in line. "This is not surprising," said Peter Oshiro, standards office supervisor for the state Department of Health. "We're not inspecting at the frequency we need to be. That's why we get these problems."

The customers who fell ill went to their doctors, who then ordered stool samples, Effler said. Technicians at the state laboratory created a "DNA fingerprint" of each sample that was checked against a nationwide database on the Mainland, Effler said. "They didn't match anything else on the Mainland," he said, "but they matched each other, which suggests a common source." In each of the six cases, the patients had eaten at Sekiya's within seven days of their symptoms. "This was not a coincidence," Effler said.

(Major deviations from what is appropriate for kitchen hygiene have been observed in this situation. However, one might have expected not just O157 disease, but rather a variety of food-associated diseases to be found. What is missing from this report is the analysis of a food history among the seven affected people as compared with a control group who did not get ill. Such an analysis may go a long way in establishing the presumed food reservoir involved here.)
(ProMED 2.28.08)

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USA (Nevada): Unsafe injection practices associated with transmission of bloodborne pathogens
The Southern Nevada Health District is advising patients who received injected anesthesia medication at the Endoscopy Center of Nevada (700 Shadow Lane) of a risk for possible exposure to hepatitis C and other bloodborne pathogens. The health district is recommending that patients who had procedures requiring injected anesthesia at the clinic between March 2004 and 11 Jan 2008 contact their primary care physicians or health care providers to get tested for hepatitis C as well as hepatitis B and HIV. The health district received notification of three acute cases of hepatitis C in January 2008 and has identified a total of six cases to date; five of the cases had procedures requiring injected anesthesia on the same day. Following a joint investigation with the Nevada State Bureau of Licensure and Certification (BLC) and with consultation from the Centers for Disease Control and Prevention, the health district determined that unsafe injection practices related to the administration of anesthesia medication might have exposed patients to the blood of other patients. The exposures did not result from the [other] medical procedures performed.

Most people infected with hepatitis C virus do not develop symptoms and do not know that they have been infected. As a result, these infections would not have been reported to the health district. An infection with hepatitis C that results in the patient developing symptoms (acute disease) is rare, so it is an unusual occurrence that brought this problem to the attention of the health district. On average, two cases of acute hepatitis C are reported each year in Clark County; six cases have been identified in relation to this investigation.

A syringe (not a needle) that was used to administer medication to a patient was reused on the same patient to draw up additional medication. The process of redrawing medication using the same syringe could have contaminated the vial from which the medicine was drawn with the blood of the patient. The vial, which was not labeled for use on multiple patients, was then used for a second patient (with a clean needle and syringe). If that vial was contaminated with the blood of the first patient, any subsequent patients given medication from that vial could have been exposed to bloodborne pathogens.

Investigation of the clinic identified common practices that would allow disease to be transmitted in this manner. The unsafe injection practices associated with these cases were identified during the investigation conducted in mid-January 2008. The injection practices that led to the exposure have been corrected, so no new patient exposures should be occurring. As it can take several months for the symptoms of hepatitis C to appear, additional cases might be identified despite no ongoing transmission of disease. The investigation revealed practices that could have exposed patients to the blood of another patient. Officials are also concerned about the potential transmission of hepatitis B and HIV due to these unsafe injection practices.
(ProMED 2.28.08)

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USA (Colorado): 3-day-old baby recovers from infant botulism
A 3-day-old baby from El Paso County fell ill with a rare strain of infant botulism in January 2008. The boy has since recovered and was discharged from the hospital and botulism generally has no lasting effects. Only one child, a two day old, is known to have suffered botulism at an earlier age.

There are three main kinds of botulism: foodborne, wound, and infant. In each case, bacteria produce a neurotoxin that can cause paralysis, muscle weakness, and other serious symptoms. The foodborne version occurs when the toxin is pre-formed and ingested in a food product. In infant botulism and in wound botulism, the toxin is produced in situ. Infant botulism, the commonest kind of botulism in the USA, represents about two-thirds of all cases.

The El Paso County child had a rare strain known as type F, one of just 10 such cases worldwide. The strain type is insignificant to patients, who experience the same symptoms and outcomes regardless of the type, said Dr Bernadette Albanese, medical director for the health department. Type F appears to be associated with younger infants than other strains, she said. In 2005, the most recent year for which national statistics are available, there were 145 cases of botulism nationally, 96 in infants. Colorado had only one that year. In 2008, there have been two cases in Colorado, both infants. The other was in Douglas County.
(ProMED 2.25.08)

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Global: Report finds highest rates ever of MDR-TB
Multidrug-resistant tuberculosis (MDR-TB) has been recorded at the highest rates ever, according to a new report published on 26 Feb 2008. The report presents findings from the largest survey to date on the scale of drug resistance in tuberculosis. The report, "Anti-tuberculosis drug resistance in the world," is based on data collected between 2002 and 2006 on 90,000 TB patients in 81 countries. It found that extensively drug-resistant tuberculosis (XDR-TB), a virtually untreatable form of the respiratory disease, has been recorded in 45 countries. The report also found a link between HIV infection and MDR-TB. Surveys in Latvia and Ukraine found nearly twice the level of MDR-TB among TB patients living with HIV compared with TB patients without HIV.

Based on the analysis of the survey data, WHO estimates there are nearly half a million new cases of MDR-TB a year, which is about five percent of nine million new TB cases of all types. The highest rate was recorded in Baku, the capital of Azerbaijan, where nearly a quarter of all new TB cases (22.3 percent) were reported as multidrug-resistant. Proportions of MDR-TB among new TB cases were 19.4 percent in Moldova, 16 percent in Donetsk in Ukraine, 15 percent in Tomsk Oblast in the Russian Federation, and 14.8 percent in Tashkent in Uzbekistan. These rates surpass the highest levels of drug resistance published in the last WHO report in 2004. Surveys in China also suggest that MDR-TB is widespread there. "TB drug resistance needs a frontal assault. If countries and the international community fail to address it aggressively now we will lose this battle," said Dr Mario Raviglione, director of the WHO Stop TB Department. "In addition to specifically confronting drug-resistant TB and saving lives, programs worldwide must immediately improve their performance in diagnosing all TB cases rapidly and treating them until cured, which is the best way to prevent the development of drug resistance."

WHO estimates that USD 4.8 billion is needed for overall TB control in low- and middle-income countries in 2008, with USD one billion for MDR-TB and XDR-TB. But there is a total finance gap of USD 2.5 billion, including a USD 500 million gap for MDR-TB and XDR-TB. "The threat created by TB drug resistance demands that we fill these gaps, as laid out in the Global Plan to Stop TB, a roadmap for halving TB prevalence and deaths compared with 1990 levels by 2015," said Dr Marcos Espinal, executive secretary of the Stop TB Partnership. "The Plan also calls for another imperative -- sufficient resources for research to find new diagnostics, new drugs effective against resistant strains and an effective TB vaccine."
(ProMED 2.28.08)

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Philippines (Laguna): Typhoid on the rise, officials declare a state of calamity
More than 1400 people have displayed typhoid symptoms in less than a month in a city near the Philippine capital, prompting authorities to declare a state of calamity, health officials said on 5 Mar 2008. Extra medical teams have been sent to assist doctors and conduct disease surveillance in Calamba, Health Secretary Francisco Duque said. Of 1477 people with typhoid symptoms, 436 have been treated in the city's six hospitals and the rest in local community health centers since 16 Feb 2008, said Dr. Dennis Labro, spokesman for the city's health office. Only 37 of those cases have been confirmed with blood tests because the typhoid test is expensive, Labro said. "So far there are no reported deaths," he added.

The outbreak was concentrated in five adjacent villages in Calamba, about 34 miles from Manila, and the salmonella bacteria that caused the illness may have been spread via the water system, based on the speed at which the outbreak grew, he said. But Labro was hopeful that the outbreak was under control. "There are still cases coming in, but these are fewer in number compared to the past few days," he said. Labro also said the city's 50-bed government-run hospital was so swamped when the outbreak peaked 25-27 Feb 2008 that corridors were used to accommodate patients. The city declared a state of calamity 3 Mar 2008, allowing it to immediately withdraw emergency funds for antibiotics and intravenous drips, he said. The Red Cross and the health department also sent medicine and doctors.
(ProMED 3.5.08)

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Russia (Chelyabinsk): 45-year-old woman dies, health officials suspect rabies
A suspected case of rabies in a 45-year-old woman was reported in the village of Baturinskovo in February 2008. The deputy of regional public health stated that the woman had been bitten by a fox in November 2007. The animal was found later to have been infected with rabies. The woman did not present for medical treatment at the time. Subsequently, she became critically ill and was admitted to an intensive care unit, where she died on 15 Feb 2008. The cause of her death has yet to be confirmed.
(ProMED 2.24.08)

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

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4. Articles
Effect of Surgical Masks Worn Concurrently Over N95 Filtering Facepiece Respirators: Extended Service Life Versus Increased User Burden.
Raymond R. Journal of Public Health Management and Practice. 14(2):E19-E26, March/April 2008.

Abstract
Growing concern over the availability of respiratory protective devices (eg, filtering face piece respirators), in the face of the probable extreme demand brought on by a pandemic influenza, has prompted the suggestion that useful life of N95 filtering face piece respirator can be extended by the concurrent use of a surgical mask as an outer protective barrier over the respirator. Personal protective equipment generally places a strain on the user, and the detrimental physiological and psychological burdens normally imposed by respirator use could be magnified by the addition of an extra layer of protection such as a surgical mask. The issue of this potentially increased burden of the concurrent use of a surgical facemask with an N95 filtering face piece respirator is investigated to afford users the necessary information to make informed decisions Regarding the use of this respiratory personal protective equipment in the face of large-scale outbreaks of respiratory pathogens.
(CIDRAP 3.1.08)

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Pandemic Economics: The 1918 Influenza and Its Modern-Day Implications
Garrett T. Federal Reserve Bank of St. Louis Review, March/April 2008, 90(2), pp. 75-93. http://research.stlouisfed.org/publications/review/08/03/Garrett.pdf


Abstract
Many predictions of the economic and social costs of a modern-day pandemic are based on the effects of the influenza pandemic of 1918. Despite killing 675,000 people in the United States and 40 million worldwide, the influenza of 1918 has been nearly forgotten. The purpose of this paper is to provide an overview of the influenza pandemic of 1918 in the United States, its economic effects, and its implications for a modern-day pandemic. The paper provides a brief historical background as well as detailed influenza mortality statistics for cities and states, including those in the Eighth Federal Reserve District, that account for differences in race, income, and place of residence. Information is obtained from two sources: (i) newspaper articles published during the pandemic and (ii) a survey of economic research on the subject.
(CIDRAP 3.2.08)

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Responding to Simulated Pandemic Influenza in San Antonio, Texas
Miller G, et al. Infect Control Hosp Epidemiol 2008;29:320–326
http://www.journals.uchicago.edu/doi/abs/10.1086/529212

Objective
To describe the results of a simulation study of the spread of pandemic influenza, the effects of public health measures on the simulated pandemic, and the resultant adequacy of the surge capacity of the hospital infrastructure and to investigate the adequacy of key elements of the national pandemic influenza plan to reduce the overall attack rate so that surge capacity would not be overwhelmed.

Design
We used 2 discrete-event simulation models: the first model simulates the contact and disease transmission process, as affected by public health interventions, to produce a stream of arriving patients, and the second model simulates the diagnosis and treatment process and determines patient outcomes.

Setting
Hypothetical scenarios were based on the response plans, infrastructure, and demographic data of the population of San Antonio, Texas.

Results
Use of a mix of strategies, including social distancing, antiviral medications, and targeted vaccination, may limit the overall attack rate so that demand for care would not exceed the capacity of the infrastructure. Additional simulations to assess social distancing as a sole mitigation strategy suggest that a reduction of infectious community contacts to half of normal levels would have to occur within approximately 7 days.

Conclusions
Under ideal conditions, the mix of strategies may limit demand, which can then be met by community surge capacity. Given inadequate supplies of vaccines and antiviral medications, aggressive social distancing alone might allow for the control of a local epidemic without reliance on outside support.
(CIDRAP 2.28.08)

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Effects of Adjuvants on the Safety and Immunogenicity of an Avian Influenza H5N1 Vaccine in Adults
Bernstein DI, Edwards KM, et al. The Journal of Infectious Diseases 2008;197:667–675
http://www.journals.uchicago.edu/doi/abs/10.1086/527489

Background
Influenza A H5N1 viruses pose a significant threat to human health.

Methods
We conducted a multicenter, randomized, double-blind study in 394 healthy adults. Subjects were randomly assigned to receive 2 intramuscular doses of either saline placebo; influenza A/Vietnam/1203/2004(H5N1) vaccine alone at 45, 30, or 15 μg per dose; vaccine at 15 or 7.5 μg per dose with MF59; or vaccine at 30, 15, or 7.5 μg per dose with aluminum hydroxide. Subjects were followed up for safety and blood samples were obtained to determine antibody responses.

Results
The vaccine formulations were well tolerated but local adverse effects were common; the incidence of these effects increased in a dose-dependent manner and was increased by the addition of adjuvants. The addition of MF59 increased the antibody response, whereas the addition of aluminum hydroxide did not. The highest antibody responses were seen in the group that received 15 μg of vaccine per dose with MF59, in which 63% of subjects achieved the predetermined endpoint (hemagglutination-inhibition titer 40) 28 days after the second dose, compared with 29% in the group that received the highest dose (45 μg per dose) of vaccine alone.

Conclusions
A 2-dose regimen of subvirion influenza A (H5N1) vaccine was well tolerated. The antibody responses to 15 μg of A/H5 vaccine with MF59 were higher than the responses to 45 μg of vaccine alone.
(CIDRAP 3.1.08)

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Flu Virus Research Yields Results but No Magic Bullet for Pandemic
Normile D. Science 29 February 2008;319(5867):1178 – 1179
http://www.sciencemag.org/cgi/content/summary/319/5867/1178

Introduction
Just a couple of years ago, scientists, public health officials, and journalists were nervously tracking every move of the deadly H5N1 avian influenza virus, fearing that a few simple mutations might give it the ability to spread readily among humans, sparking a global pandemic that could kill tens of millions. But since alarms were sounded when the virus started spreading in earnest among birds in late 2003, the dreaded pandemic hasn't come. "I'm less worried about this virus than I was 5 years ago," says virologist Robert Webster of St. Jude Children's Research Hospital in Memphis, Tennessee.

But H5N1 hasn't gone away--and increasingly, say scientists, the virus appears to be here to stay. "H5N1 is going to be with us for a long time," says Les Sims, a veterinary consultant based in Palm Cove, Australia, continuing to devastate poultry flocks and posing an ongoing threat to human health.
(CIDRAP 2.29.05)

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Integrated Food Chain Surveillance System for Salmonella spp. in Mexico
Zaidi MB, Calva JJ, et al. Emerg Infect Dis [serial on the Internet]. 2008 Mar
http://www.cdc.gov/eid/content/14/3/429.htm

Abstract
Few developing countries have food-borne pathogen surveillance systems, and none of these integrates data from humans, food, and animals. We describe the implementation of a 4-state, integrated food chain surveillance system (IFCS) for Salmonella spp. in Mexico. Significant findings were 1) high rates of meat contamination (21.3%–36.4%), 2) high rates of ceftriaxone-resistant S. Typhimurium in chicken, ill humans, and swine (77.3%, 66.3%, and 40.4% of S. Typhimurium T isolates, respectively), and 3) the emergence of ciprofloxacin resistance in S. Heidelberg (10.4%) and S. Typhimurium (1.7%) from swine. A strong association between Salmonella spp. contamination in beef and asymptomatic Salmonella spp. infection was only observed in the state with the lowest poverty level (Pearson r = 0.91, p<0.001). Pulsed-field gel electrophoresis analysis of 311 S. Typhimurium isolates showed 14 clusters with 102 human, retail meat, and food-animal isolates with indistinguishable patterns. An IFCS is technically and economically feasible in developing countries and can effectively identify major public health priorities.
(CIDRAP 2.26.08)

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Presence of Clostridium botulinum spores in Matricaria chamomilla (chamomile) and its relationship with infant botulism.
Bianco MI, et al. Int J Food Microbiol 2008 Feb 10;121(3):357-60. Epub 2007 Nov 17

Abstract
Nowadays, infant botulism is the most important form of human botulism in some countries. This illness affects infants younger than 52 weeks of age. The infection occurs in the intestinal tract; therefore, ingestion of Clostridium botulinum spores with food is proposed. In some countries, people use chamomile tea as a household remedy for intestinal colics and given this tea to infants. Chamomile can be contaminated with C. botulinum and could be a vehicle of its spores. Our aim was to study the prevalence and spore-load of C. botulinum in chamomile. We analyzed 200 samples; the 7.5% of them were contaminated with botulinum spores. However, prevalence of these spores was significantly higher in chamomile sold by weight in herbal stores (unwrapped chamomile) than prevalence in chamomile sold in tea bags (p=0.0055). The spore-load detected in all positive samples was 0.3-0.4 spores per gram of chamomile. We identified C. botulinum types A, B, and F in the 53.3%, 6.7%, and 13.3%, respectively. Chamomile (principally, unwrapped chamomile) is a potential vehicle of C. botulinum spores, and ingestion of chamomile tea could represent a risk for infant botulism.
(CIDRAP 2.10.08)

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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 influenza 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 video clip 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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Eleventh Annual Conference on Vaccine Research
http://www.nfid.org/conferences/vaccine08/
Venue:
Baltimore Marriott Waterfront Hotel
Location:
Baltimore, Maryland
Date:
May 5 - May 7, 2008

The remarkable pace of biotechnology discovery is continuing unabated. New cytokines are identified, immune regulatory pathways unraveled, promising adjuvants reported, and investigational products revealed to have high degrees of protection for humans against viral diseases not yet vaccine preventable. The tools of vaccination are also being applied therapeutically for various cancers and chronic conditions. The Annual Conference on Vaccine Research provides high quality, current reports of scientific progress featured in both invited presentations and submitted abstracts. The disparate fields covered in both human and veterinary vaccinology encourage valuable cross-fertilization of ideas and approaches among researchers otherwise focused on specific diseases or methods. The Conference has become the largest scientific meeting devoted exclusively to research on vaccines and associated technologies for disease prevention and treatment through immunization. The Eleventh Annual Conference promises to maintain this tradition as the premier venue for cutting edge topics and issues. International experts will lead seminars and panel discussions on topical areas of basic immunology, product development, clinical testing, regulation, and other aspects of vaccine research. Opportunities for networking and scientific collaboration critical to advancing vaccine science and development will be available through audience discussions, poster presentations, meet the expert breakfast sessions, sponsored exhibits, and evening ceremonies and receptions.

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Public Health – Seattle & King County: Business Not As Usual: Preparing for Pandemic Flu (video)
http://www.metrokc.gov/health/pandemicflu/video/

This training video explains the effects of a possible pandemic, the importance of social distancing, business planning, and preventing food and energy shortages.

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HHS advisor, William Raub, fields online pandemic preparedness queries
http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/feb1908wiki.html
By Lisa Schnirring


FluWiki, an online resource and community forum, has its finger on the pulse of pandemic influenza planning issues and avian flu news, but on 19 Feb 2008 it featured something unusual: a dialogue with a top federal science advisor who's directly involved in the government's pandemic preparations. William Raub, PhD, science advisor to Health and Human Services (HHS) Secretary Mike Leavitt, fielded six multipart questions from the FluWiki community, covering issues such as vaccine prioritization, food and medication stockpiling, the federal government's role in pandemic planning, and how HHS plans to publicize the role of community mitigation measures.

Sharing responsibility
One of the themes that emerged from the dialogue is that federal officials strongly believe that pandemic planning should be a shared responsibility. Leavitt has often warned against total reliance on the federal government in the event of a pandemic. Raub wrote, "To the extent that potential partners refuse to apply their talents and assets unless the federal government foots the bill, they are abdicating their responsibility and thereby placing their communities at higher risk than need be." However, he also wrote that citizens can expect the federal government to play a prominent role in pandemic planning, focusing on areas that it is uniquely positioned to manage, such as vaccine and antiviral stockpiling, providing financial and technical assistance to states, and boosting domestic vaccine development and production.

FluWiki members asked Raub if funeral directors and other mass-casualty personnel, as well as their families, would be considered a priority in the federal vaccine allocation plan. He responded that a federal working group is evaluating public comments it received, which included concerns about mass-casualty workers, and that the group will release an updated plan within the next several months. Responding to questions about vaccine development, Raub wrote that most experts believe that a viable pandemic vaccine using DNA or other emerging technologies is more than five years away, but that HHS is currently reviewing contract proposals for advanced development of a DNA vaccine.

Antiviral stockpiling
When questioned about the government's stance on antiviral stockpiling by individuals, Raub wrote that HHS has concerns about misuse of the drugs and the possibility of greater use leading to antiviral resistance. However, he said an experiment with antibiotic medical kits for bioterrorism events produced promising results and that HHS would assess the design and feasibility of a similar antiviral medical kit. On another antiviral topic, the FluWiki community asked if federal efforts to induce states to build their own antiviral stockpiles by purchasing the drugs with federal subsidies amount to an "unfunded mandate." "States . . . can provide antiviral drugs for their citizens at 30 cents on the dollar," Raub wrote. "Some see the offer as being 30% empty. I see it as 70% full."

Another query dealt with how local groups can promote community mitigation plans without clear messages from the government about the importance of measures such as school closures. Raub responded that the challenge in engaging the public is more difficult than it was two years ago, because the public's' interest in avian flu seems to have diminished.

"The Web site Pandemicflu.gov will remain the lynchpin of our messaging machinery. But we recognize that we need multiple modalities to promulgate and reinforce preparedness messages," Raub responded. He added that HHS values the input from FluWiki's online community.
(CIDRAP 2.19.08)

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 apecein@u.washington.edu