EINet Alert ~ May 11, 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: WHO meets to revise pandemic preparedness guidelines
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Denmark (Stenstrup): Officials report low pathogenic H7 avian influenza outbreak in poultry
- Japan (Hokkaido): Two more dead swans infected with H5N1 avian influenza
- Indonesia: Officials discuss virus sharing and NAMRU-2
- India (West Bengal): H5N1 avian influenza resurfaces in backyard poultry
- South Korea (Kyonggi): H5N1 avian influenza spreads to Seoul

2. Updates

3. Articles
- Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26–27, 2007
- Preparedness for the Spread of Influenza: Prohibition of Traffic, School Closure, and Vaccination of Children in the Commuter Towns of Tokyo
- Development and Validation of a One-Step Real-Time PCR Assay for Simultaneous Detection of Subtype H5, H7, and H9 Avian Influenza Viruses
- Simultaneous Genotyping of All Hemagglutinin and Neuraminidase Subtypes of Avian Influenza Viruses by Use of Padlock Probes
- H2N5 influenza virus isolates from terns in Australia: genetic reassortants between those of the Eurasian and American lineages
- PROMISING PRACTICES FOR PANDEMIC PLANNING: North Carolina fosters preparedness with the touch of a finger

4. Notifications
- APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems

1. Influenza News

Global: WHO meets to revise pandemic preparedness guidelines
World Health Organization (WHO) officials on 6 May 2008 kicked off a four day meeting to begin revising pandemic preparedness guidance for countries, amid warnings that the risk of an influenza pandemic has not waned since the last update. The new guidance will reflect important advances since the last guidance was issued in 2005, WHO said recently. For example, several companies are working on or have developed H5N1 vaccines, clinicians have more experience treating patients who are infected with the virus, and the new International Health Regulations specify how member nations and the WHO should respond to pandemic influenza threats.

Keiji Fukuda, coordinator for the WHO's global influenza program, in an address to about 150 expert participants, said the pandemic threat remains substantial. "We can't delude ourselves. The threat of a pandemic influenza has not diminished," he told the group. Fukuda told the group that more than 150 countries have preparedness plans, but their levels of detail vary, with some amounting only to brief statements acknowledging the risk. Fukuda said the WHO's global stockpile of the antiviral medication oseltamivir (Tamiflu) contains five million treatment courses, and the organization is developing a vaccine stockpile that will initially contain 150 million doses.

The WHO statement said working groups at the meeting will focus on topics such as disease control, surveillance, nonpharmaceutical interventions, and pandemic communications. New draft guidelines from the meeting will circulate for comments. The WHO said it expects to publish the new pandemic planning guidance by the end of the year.

Supamit Chunsuttiwat, an infectious disease expert with Thailand's health ministry who is chairing the meeting, said the pandemic influenza risk is probably expanding, and that the H5N1 virus persists on three continents and has infected humans in Indonesia, Egypt, and China this year (2008). "We are concerned that the spread through migratory birds hasn't stopped. Once the virus is established in birds it is difficult to get rid of the virus, and the risk (to humans) remains unless countries develop good control of transmission in birds," he said.
(CIDRAP 5.6.08)


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

China / 3 (3)
Egypt / 7 (3)
Indonesia / 16 (13)
Viet Nam / 5 (5)
Total / 31 (24)

Cambodia / 1 (1)
China / 5 (3)
Egypt / 25 (9)
Indonesia / 42 (37)
Laos / 2 (2)
Myanmar / 1 (0)
Nigeria / 1 (1)
Pakistan / 3 (1)
Viet Nam 8 (5)
Total / 88 (59)

Azerbaijan / 8 (5)
Cambodia / 2 (2)
China / 13 (8)
Djibouti / 1 (0)
Egypt / 18 (10)
Indonesia / 55(45)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 115 (79)

Cambodia / 4 (4)
China / 8 (5)
Indonesia / 20 (13)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 98 (43)

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

China / 1 (1)
Viet Nam / 3 (3)
Total / 4 (4)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 382(241).
(WHO 4.30.08 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO:
(WHO/WPRO 4.17.08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 5.6.08):

WHO’s timeline of important H5N1-related events (last updated 4.24.08):


Europe/Near East
Denmark (Stenstrup): Officials report low pathogenic H7 avian influenza outbreak in poultry
Veterinary officials in Denmark on 29 Apr 2008 reported a low-pathogenic avian influenza outbreak at a farm in the southern part of the country, according to a report to the World Organization for Animal Health (OIE). The outbreak site is a poultry farm in Stenstrup that housed 2,050 birds, mostly mallards but also including a few hundred other ducks and geese. All of the birds were culled. Preliminary testing revealed an H7 virus. The outbreak was identified through routine surveillance in poultry. Denmark's Veterinary and Food Administration established a restricted zone around the farm and disinfected the site. Denmark's last avian influenza outbreak occurred in July 2006 and involved a low-pathogenic H5N3 subtype.
(CIDRAP 5.5.08)


Japan (Hokkaido): Two more dead swans infected with H5N1 avian influenza
Environmental officials in Japan said on 5 May 2008 that two more dead swans from two different sites have tested positive for the H5N1 virus.

One of the infected swans was found on 24 Apr 2008 on the Notsuke Peninsula in eastern Japan's Hokkaido prefecture. The other, which was positive for H5N1 in preliminary tests, was found near Lake Saroma, also in Hokkaido prefecture. Prefecture officials said they inspected five chicken farms within a 30-kilometer radius around the Lake Saroma site.

In late April 2008, animal health officials conducting heightened surveillance spurred by South Korea's H5N1 outbreaks found three dead wild swans and one sick one on the shores of Lake Towada in Akita prefecture. Samples from all four of the birds were positive for the virus.
(CIDRAP 5.5.08)


Indonesia: Officials discuss virus sharing and NAMRU-2
Indonesia is trying to defend the interests of poorer nations by refusing to share bird flu samples with the West and is locked in a cultural misunderstanding over the issue, Jakarta's health minister said 7 May 2008. Siti Fadillah Supari also said in an interview that a U.S. naval medical lab based in Indonesia for research into tropical diseases was barely benefiting its host country and was not being transparent in its operations. "Poor countries sent the virus to the WHO on behalf of humanity. But it was commercialized by the WHO," Supari said.

Officials in Indonesia, the country with the highest number of human bird flu victims, have said they want to ensure equal access to any vaccines that are made against bird flu. But U.S. Health Secretary Michael Leavitt said after visiting Jakarta that Indonesia also wanted payments. Supari likened Indonesia's gripe over virus sharing to someone giving a ripe banana to someone so it could be fried to raise its value and then not giving any benefit to the person providing the banana.

"Well that's our culture, but Western culture cannot understand. Western people are used to buying the thing and after that don't feel any attachment," said Supari, who is known for being outspoken on the bird flu issue. She said that virus samples were not being sent to the WHO until a new fairer global mechanism for sharing was in place that ensured that samples sent from countries benefited them. "If the virus is from Indonesia they (WHO) must share with Indonesia, if the virus came from Vietnam they must share with Vietnam, and that also goes for Thailand."

The future of the U.S. naval lab in Jakarta would be discussed by the health, defense and foreign ministries, and the intelligence agency, Supari said. The minister said the U.S. lab had been receiving virus samples from across Indonesia, but that had been stopped. "We don't know what happened to the viruses that we sent," she said, adding the U.S. lab had also received samples from Indonesian soldiers deployed in Papua. A memorandum of understanding allowing the lab to operate in Jakarta expired two years ago and a new one is being discussed but sticking points include the number of U.S. staff that can have diplomatic immunity and an agreement over virus transfers. Supari said that the U.S. Naval Medical Research Unit No. 2, or NAMRU-2 for short, had provided Indonesia benefits for example during a dengue outbreak but not by as much as expected.

"For example, up to now malaria is still a problem, until now tuberculosis is still a problem and we don't have tools to diagnose. . .and we don't have vaccine or special treatment," she said, adding that NAMRU had also not provided research results. U.S. officials have dismissed accusations that the lab with about 170 staff it not transparent and said the facility, which has been in Indonesia since 1970 and is one of five in the world, is based in the Southeast Asian country to further studies into tropical diseases that benefits both nations.
(Reuters India 5.7.08)


India (West Bengal): H5N1 avian influenza resurfaces in backyard poultry
Veterinary workers were getting ready to cull thousands of backyard poultry to contain an outbreak of bird flu in India's eastern state of West Bengal that has struggled to control the virus since January 2008. The communist-ruled state briefly contained the outbreak by culling more than four million birds in 14 of its 19 districts, but the virus has intermittently resurfaced. Poultry sales in the state had fallen by about 70 percent in the January-March period of 2008, but traders said they were still struggling to overcome losses.

On 9 May 2008, officials said the virus had spread to the tea-growing Darjeeling district, the 15th to be hit by bird flu in 2008. "Tests in a central laboratory confirmed the recent poultry deaths from the H5N1 strain of the virus in Darjeeling district," Rajesh Pande, a senior government official said.

Around 300 birds mysteriously died in Sukna area in the foothills of the Himalayas near the bustling town of Siliguri, he said. "The deaths are all in backyard poultry and not in any farm," Pande added. After a massive culling operation, authorities in West Bengal said in February 2008 that bird flu was under control. The World Health Organization (WHO) has described the situation in West Bengal as India's worst bird flu outbreak in poultry. India's first outbreak of H5N1 was reported in 2006. Officials in West Bengal said they were looking for people with flu-like symptoms. India has so far not reported any human infections.
(Reuters AlertNet 5.9.08)


South Korea (Kyonggi): H5N1 avian influenza spreads to Seoul
Bird flu has spread to South Korea's capital Seoul despite a massive nationwide cull that saw the slaughter of six million ducks and chickens in recent weeks, officials said on 6 May 2008.

The agriculture ministry said a case was reported at a small aviary run by Gwangjin district officials in eastern Seoul. "This was the first outbreak in Seoul. We believe it has been caused by infected pheasants that district officials purchased at an open market in the city of Seongnam south of Seoul," a ministry official said.

All 53 chickens, turkeys, and pheasants at the aviary were slaughtered, he said. "Initial blood tests showed pheasants and chickens were infected with bird flu, although the type of the virus is not yet known," he said. "Health officials are conducting blood tests to determine whether it was caused by the virulent H5N1 strain." Quarantine officials slaughtered poultry in a nearby public park and also plan to decontaminate aviaries and poultry farms in other parts of Seoul. A major theme park in southern Seoul culled 221 ducks, wild chickens and geese in its aviary. More than six million chickens and ducks have been slaughtered since the country's latest outbreak was reported on 1 April 2008, the ministry said.

The Korea Center for Disease Control and Prevention said it asked all hospitals in Seoul to keep a close eye on their patients and immediately report any suspected cases of human bird flu. The public health clinic in Gwangjin said on 7 May 2008 it had been swamped with inquiry calls or visits by residents, some with a high fever and headache, for medical checks. No bird flu infections were reported.

"They all turned out to be completely irrelevant to bird flu," Mo Hyun-Hee, head of the clinic, said. South Korea has not recorded any human cases of bird flu. A soldier taken to hospital last month was found not to have the disease. The agriculture ministry said quarantine authorities were continuing to decontaminate all aviaries and poultry farms in the city. Public access has been limited to those areas. It was also trying to trace poultry dealers and farms which had sold birds to a market at Seongnam south of Seoul, which was the suspected supplier of infected pheasants to the Gwangjin aviary.

Agriculture officials in South Korea said H5N1 avian influenza outbreaks have been reported in six of the country's nine provinces. South Korean officials said the three provinces that have not reported outbreaks are Gangweon in the northeast, North Chungcheong in the central part of the country, and Jeju, an island off the southern coast, according to a report on 3 May 2008. The H5N1 virus returned in South Korea in early April 2008 after about a year with no reported outbreaks. The virus first hit an egg producer in Gimje in North Jeolla province and quickly spread to several more farms, mostly in the southwest, before striking sites in southern and eastern areas.

In related events, North Korea announced on 5 May 2008 that it vaccinated poultry to prevent the spread of the virus from South Korea. Ri Kyong Gun, a North Korean quarantine official, said that poultry in provinces bordering South Korea received emergency vaccinations and that 1,600 observation posts had been established on the east and west coasts to monitor the movement of migratory birds.
(CIDRAP 5.5.08; AFP 5.6.08 & 5.7.08)


2. Updates


3. Articles
Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26–27, 2007
Devereaux A, et al. Chest. 2008;133:1S-7

Executive Summary
This supplement on the management of mass critical care for ill patients represents the consensus opinion of a multidisciplinary panel convened under the umbrella of the Critical Care Collaborative Initiative. Expert recommendations on this subject are needed. Most countries have insufficient critical care staff, medical equipment, and ICU space to provide timely, usual critical care to a surge of critically ill victims. If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health-care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing. As a result, United States and Canadian authorities have called for the development of comprehensive plans for managing mass casualty events, particularly for the provision of critical care. This supplement includes the following: (1) a review of current U.S. and Canadian baseline critical care preparedness and response capabilities and limitations, (2) a suggested framework for critical care surge capacity, (3) suggestions for minimum resources ICUs will need for mass critical care, and (4) a suggested framework for allocation of scarce critical care resources when critical care surge capacity remains insufficient to meet need. This supplement is intended to aid clinicians and disaster planners in providing a coordinated and uniform response to mass critical care.

Mass casualty events occur frequently worldwide. Fortunately, the vast majority of these do not generate overwhelming numbers of critically ill victims. Attention to mass critical care, however, has been stimulated by the severe acute respiratory syndrome epidemic of 2002–2003, recent natural disasters, concern for intentional catastrophes, and the looming threat of a serious influenza pandemic. To guide preparedness for such events, the Task Force for Mass Critical Care (hereafter referred to as the Task Force) was convened. It comprised 37 experts from fields including bioethics, critical care, disaster preparedness and response, emergency medical services, emergency medicine, infectious diseases, hospital medicine, law, military medicine, nursing, pharmacy, respiratory care, and local, state, and federal government planning and response. Several members of the Critical Care Collaborative initiated the project and assembled a steering committee for project development and administration. Members of this steering committee included representatives from the organizational members of the Critical Care Collaborative as well as several unaffiliated North American disaster experts. This steering committee then selected members of the broader Task Force on the basis of their expertise and experience.
(CIDRAP 5.6.08)


Preparedness for the Spread of Influenza: Prohibition of Traffic, School Closure, and Vaccination of Children in the Commuter Towns of Tokyo
Yasuda H, et al. Journal of Urban Health. Published online: 1 May 2008

In Greater Tokyo, many people commute by train between the suburbs and downtown Tokyo for 1 to 2 hours per day. The spread of influenza in the suburbs of Tokyo should be studied, including the role of commuters and the effect of government policies on the spread of disease. We analyzed the simulated spread of influenza in commuter towns along a suburban railroad, using the individual-based Monte Carlo method, and validated this analysis using surveillance data of the infection in the Tokyo suburbs. This simulation reflects the mechanism of the real spread of influenza in commuter towns. Three measures against the spread of influenza were analyzed: prohibition of traffic, school closure, and vaccination of school children. Prohibition of traffic was not effective after the introduction of influenza into the commuter towns, but, if implemented early, it was somewhat effective in delaying the epidemic. School closure delayed the epidemic and reduced the peak of the disease, but it was not as effective in decreasing the number of infected people. Vaccination of school children decreased the numbers not only of infected children but also of infected adults in the regional communities.
(CIDRAP 5.5.08)


Development and Validation of a One-Step Real-Time PCR Assay for Simultaneous Detection of Subtype H5, H7, and H9 Avian Influenza Viruses
Monne I, et al. Journal of Clinical Microbiology. 2008;46(5):1769-1773

Among the different hemagglutinin (HA) subtypes of avian influenza (AI) viruses, H5, H7, and H9 are of major interest because of the serious consequences for the poultry industry and the increasing frequency of direct transmission of these viruses to humans. The availability of new tools to rapidly detect and subtype the influenza viruses can enable the immediate application of measures to prevent the widespread transmission of the infection. In this study, a novel one-step real-time reverse transcription-PCR (RRT-PCR) was developed to detect simultaneously the H5, H7, and H9 subtypes of AI viruses from clinical samples of avian origin. The sensitivity of the RRT-PCR assay was determined by using in vitro-transcribed RNA and 10-fold serial dilutions of titrated AI viruses. High sensitivity levels were obtained, with limits of detection ranging from 101 to 103 RNA copies and from 101 50% egg infectious dose (EID50)/100 µl to 102.74 EID50/100 µl with titrated viruses. Excellent results were achieved in the intra- and interassay variability tests. The comparison of the results with those obtained from the analysis of 725 avian samples by means of the reference method (virus isolation [VI]) showed a high level of agreement. To date, this is the first real-time PCR protocol available for the simultaneous detection of AI viruses belonging to subtypes H5, H7, and H9, and the results obtained indicate that this method is suitable as a routine laboratory test for the rapid detection and differentiation of the three most-important AI virus subtypes in samples of avian origin.
(CIDRAP 3.6.08)


Simultaneous Genotyping of All Hemagglutinin and Neuraminidase Subtypes of Avian Influenza Viruses by Use of Padlock Probes
Gyarmati P, et al. Journal of Clinical Microbiology. 2008;46(5):1747-1751

A subtyping assay for both the hemagglutinin (HA) and neuraminidase (NA) surface antigens of the avian influenza virus (AIV) has been developed. The method uses padlock probe chemistry combined with a microarray output for detection. The outstanding feature of this assay is its capability to designate both the HA and the NA of an AIV sample from a single reaction mixture. A panel of 77 influenza virus strains was tested representing the entire assortment of the two antigens. One hundred percent (77/77) of the samples tested were identified as AIV, and 97% (75/77) were subtyped correctly in accordance with previous examinations performed by classical diagnostic methods. Testing of heterologous pathogens verified the specificity of the assay. This assay is a convenient and practical tool for the study of AIVs, providing important HA and NA data more rapidly than conventional methods.
(CIDRAP 3.6.08)


H2N5 influenza virus isolates from terns in Australia: genetic reassortants between those of the Eurasian and American lineages
Kishida N, et al. Virus Genes. 3 May 2008 [Epub ahead of print]

To investigate the prevalence of influenza viruses in feral water birds in the Southern Hemisphere, fecal samples of terns were collected on Heron Island, Australia, in December 2004. Six H2N5 influenza viruses were isolated. This is the first report of the isolation of the H2 subtype from shore birds in Australia. Phylogenetic analysis revealed that the M gene belonged to the American lineage of avian influenza viruses and the other genes belonged to the Eurasian lineages, indicating that genetic reassortment occurs between viruses of Eurasian and American lineages in free flying birds in nature.
(CIDRAP 3.3.08)


PROMISING PRACTICES FOR PANDEMIC PLANNING: North Carolina fosters preparedness with the touch of a finger

CIDRAP's Promising Practices: Pandemic Influenza Preparedness Tools (www.pandemicpractices.org) online database showcases peer-reviewed practices, including useful tools to help others with their planning. This article is one of a series exploring the development of these practices

Prodding citizens to prepare for pandemics and other disasters is a constant challenge, but public health officials in North Carolina have a creative approach that didn't require thinking outside the box, but rather inside of it—in the form of touch-screen computer kiosks.

In North Carolina, natural disaster isn't just an abstract concept to the state's residents, said Bill Furney, communication coordinator of North Carolina's office of Public Health Preparedness and Response (PHPR), which resides in the state's division of public health and is funded by the US Centers for Disease Control and Prevention.

"North Carolina is an equal-opportunity state for disasters. We have everything—tornados, landslides, flooding, and hurricanes," he said. PHPR developed the "Be Ready!" disaster preparedness kiosks in 2006 as a way to help the state's seven Public Health Regional Surveillance Teams spread the message about emergency preparedness, said Furney.

The seven surveillance teams were created after the 11 Sept 2008 terrorist attacks to respond to terrorism activities, infectious disease outbreaks, and natural disasters. He said PHPR needed a way to stir more interest in emergency preparedness brochures. "We could have printed a bazillion materials, but what is it that makes people want to read?" he said, adding that offering a kiosk component could grab the public's attention and lure them to look at the collateral materials.

According to PHPR, kiosks are a useful educational tool because they:

  • Provide an interactive experience, which can help users retain the information
  • Allow users to select information they want at their own pace
  • Serve a range of languages and reading levels
  • Encourage action with a clear, consistent message
  • Bring critical information to citizens
With an initial budget of $50,000, PHPR selected SmartVista, a technology company based in Morrisville, NC, to provide the hardware, which consists of portable, touch-screen computers, then worked with the company on the content, which includes some materials from federal agencies such as the Department of Homeland Security and a series of public service announcements on disaster preparedness that had just been released by the Ad Council, Furney said. Pandemic influenza is covered, along with several natural and manmade disasters. The presentation is offered in both English and Spanish.

PHPR has eight kiosks, one for the main office and one for each of the seven regional surveillance teams. The kiosks are available to county and city public health departments, which use them at health fairs, county fairs, conferences, clinics, and other events. The devices are especially popular during the fall county fair season and during spring observances for public health month and week.

"This gives us the ability to provide a service to counties, which wouldn't necessarily be able to afford or coordinate this on their own," Furney said. He said it's rewarding watching people use the kiosks.

"The kids love it, and their parents will follow up on what they're doing," Furney said. "It really is a 'gee whiz' kind of technology that people will gravitate toward, but it's also functional." The kiosk devices allow public health officials the opportunity to cost-effectively offer interactive presentations on other topics, and Furney said that PHPR has recently installed a pandemic-specific module on the machines. So far, the biggest obstacle to using the kiosks in the field is keeping all of the devices maintained and repaired, Furney said. North Carolina's PHPR was recognized for its "Be Ready!" kiosks when the National Public Health Coalition awarded the group its 2006 silver excellence award in the new media (outsourced) category.
(CIDRAP 5.5.08)


4. 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 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 five 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.