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EINet Alert ~ May 23, 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)
- Global: Launch of WHO H5N1 avian influenza vaccine stockpile still awaited
- Bangladesh: Officials report country's first human case of H5N1 avian influenza infection
- Indonesia: Experts welcome Indonesia's vow to share H5N1 avian influenza data
- South Korea: Economy's H5N1 avian influenza strain closely matches Japanese cases
- South Korea: Troops mobilize to fight H5N1 avian influenza outbreak
- South Korea: Economy plans to build H5N1 avian influenza vaccine plant
- Europe: EU approves its first pre-pandemic H5N1 avian influenza vaccine
- Detection of mortality clusters associated with highly pathogenic avian influenza in poultry: a theoretical analysis
- AVIAN/PANDEMIC INFLUENZA
- Avian influenza in birds and animals
- Finding the real case-fatality rate of H5N1 avian influenza
- Options for the use of human H5N1 influenza vaccines and the WHO H5N1 vaccine stockpile
- APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems
- Health educators in Bangladesh use theater in H5N1 avian influenza prevention efforts
- Pandemic Human Influenza as the Workplace Issue
1. Influenza News
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 382(241).
Avian influenza age distribution data from WHO/WPRO:
WHO’s timeline of important H5N1-related events (last updated 5.2.08):
Global: Launch of WHO H5N1 avian influenza vaccine stockpile still awaited
At the World Health Assembly in May 2007, WHO member countries called on the WHO leadership to set up an international vaccine stockpile against H5N1 and other influenza viruses of pandemic potential. And in June 2007, the pharmaceutical company GlaxoSmithKline (GSK) pledged to donate 50 million doses of vaccine to the stockpile over three years.
In the latest report, the WHO says development of a stockpile is under way, but no doses have been acquired yet.
"At this time, a physical WHO stockpile of H5N1 vaccine does not exist, and its development will depend on several factors, including discussions with manufacturers on the terms and conditions of their donation, as well as on technical issues such as obtaining further information on the stability of vaccines," says the report, which is based on a scientific meeting held in Geneva in October 2007. The 26-page report assesses the development of H5N1 vaccines to date and discusses their possible uses, including how the planned WHO stockpile would be used. The document is titled "Options for the Use of Human H5N1 Influenza Vaccines and the WHO H5N1 Vaccine Stockpile."
In three more years, the report says, the stockpile could contain 50 million doses, or enough to vaccinate 25 million people with two doses each, which is likely to be needed to generate a good immune response.
The WHO says the contemplated uses of the stockpile are (1) to help contain the initial, localized emergence of a potential H5N1 pandemic if the event is identified early enough, and (2) to supply vaccine to countries that otherwise would have little access to it once sustained human-to-human transmission is under way.
For several reasons, vaccination alone would probably not be enough to contain a local outbreak of an emerging pandemic virus, the report says. However, "mathematical modeling approaches suggest that under certain conditions, vaccination could make a significant addition to the effects of other control actions."
Concerning the eventual size of the stockpile, the WHO states, "Based on the results of the consultation described in this report, a stockpile of approximately 100 million doses may be warranted given its potential uses."
In addition to GSK, companies that have expressed a willingness to contribute to the stockpile include Omninvest of Hungary, Baxter, and Sanofi Pasteur, the document says. The report says that at least 16 companies have H5N1 vaccines in "relatively advanced development." Studies on the vaccines so far suggest that they should be safe and effective, but their effectiveness can be confirmed only by trials in which people are exposed to H5N1 either experimentally or in an outbreak, the WHO states. The document notes that H5N1 vaccines generally elicit lower immune responses than seasonal flu vaccines do, but adjuvants boost the response. Results to date also suggest that H5N1 vaccines may protect people against strains other than the one used in the vaccine, the report says.
"Animal data suggest that vaccination by human H5N1 influenza vaccines, produced from viruses of one clade, may confer cross-reactivity against H5N1 viruses from other clades and therefore may confer protection against challenge by H5N1 viruses from other clades." In addition, this cross-reactivity "might indicate potential cross-protection against future emerging strains, but such coverage could diminish as H5N1 vaccines continue to evolve."
Bangladesh: Officials report country's first human case of H5N1 avian influenza infection
Bangladesh reported its first confirmed case of human bird flu on 22 May 2008, but said the 16-month-old victim has now recovered from the virus.
"There is no reason to panic. The child contracted the H5N1 bird flu virus in January 2008 but we only got confirmation from the CDC (US Centers for Disease Control) on Wednesday (21 May 2008) it was a human bird flu case," said senior government official Saluddin Khan.
Khan, who works for the livestock ministry and is coordinating Bangladesh's battle against bird flu, said the boy "has now made a complete recovery." Khan said Bangladesh's fight against the virus was "very much under control. We're destroying the birds and eggs as soon as we have any report of bird flu at any farm in the country," he said.
Bangladesh has set up isolation units at all public hospitals across the country, and officials said the government had taken adequate safety measures to tackle any new human cases of bird flu.
"Right now everything is under control. We have trained doctors and readied hospitals to tackle any new detection," said Mahmudur Rahman, who heads Bangladesh's Institute of Epidemiology and Disease Control and Research. "We successfully tackled the disease when it spread to most parts of the country in January and February of 2008. In the last 40 days there has been only one outbreak of the H5N1 virus in a farm in northern Bangladesh," added Khan.
Bangladesh, which has a population of 140 million, is the world's most densely populated country with nearly 1,000 people per square kilometer. It was first hit by bird flu in February 2007 near Dhaka, but the disease became dormant. It made a forceful comeback in January 2008 when several new districts were hit. At the outbreak's peak, some 50 of the country's 64 districts were affected by bird flu, officials said. More than a million birds were slaughtered, but the outbreaks began to subside in March 2008 as temperatures started soaring, killing the virus, officials said.
Bangladesh's poultry industry is one of the world's largest, producing 220 million chickens and 37 million ducks annually. Industry officials said the bird flu outbreak at its peak this year led to closure of 40 percent of the nation's poultry farms and left half a million workers jobless. Earlier this year, one health official said there was "a huge lack of awareness in the countryside" about disposing of poultry hit by bird flu and people were "throwing away dead chickens in open fields, canals and ponds." Also earlier this year, India suffered its third and worst outbreak of the virus among poultry in West Bengal state, which borders Bangladesh. No human cases of bird flu have been reported in India, which has also carried out massive poultry slaughters. The two nations recently agreed to pool information on bird flu after sparring over the source of the disease.
Indonesia: Experts welcome Indonesia's vow to share H5N1 avian influenza data
In early 2007 Indonesia stopped sharing H5N1 virus samples with the WHO to protest what it perceived as a lack of access to costly pandemic vaccines that companies in developed countries produce from the shared samples. The government has shared only a few samples with WHO labs since then. Though Indonesia's embargo has drawn support from some other developing countries and nongovernmental organizations, the country was widely criticized by global health officials and researchers, who have said sample sharing is crucial for tracking the evolution of the virus and developing treatments and vaccines.
"We have always promoted the sharing of influenza data, all we ask for is that it be done in a fair, transparent, and equitable manner," Supari said of Indonesia's decision to contribute sequence data to the new database, known as the Global Initiative on Sharing Avian Influenza Data (GISAID. A WHO working group has met several times to resolve the virus-sharing dispute, but has made little progress. The issue is expected to surface at the annual World Health Assembly, which started on 19 May 2008 in Geneva. However, the working group's next formal meeting is scheduled for November 2008.
Two researchers who work with H5N1 viruses say they are pleased that Indonesia, which leads the world in human H5N1 cases and deaths, will share the genetic sequences from their virus samples. However, their opinions varied on how useful the genetic sequences will be without the actual H5N1 virus isolates, which are used to make seed strains for vaccines. Richard Webby, PhD, a virologist at St Jude Children's Research Hospital in Memphis, Tenn., said that the sequences would allow researchers to track virus evolution. "It is absolutely a step in the right direction, and it allows everyone to see how the Indonesian viruses are evolving genetically," Webby said. "Unfortunately, however, our ability to accurately predict antigenic and biologic properties from sequence data alone is embarrassingly poor. So, no, it [providing genetic sequence data] is not as good as sharing viruses." Webby added that the most important aspect scientists can determine from a viral isolate that they can't learn from a sequence is antigenicity—how well a virus will cross-react with antibodies generated against other strains. "Antigenic relatedness, not genetic relatedness, is key to vaccine strain selection," he said. Also, sequence data alone can't predict the transmission and pathogenicity changes that researchers depend on to make risk assessments, Webby said.
Adolfo Garcia-Sastre, PhD, a virologist at Mount Sinai School of Medicine in New York City, also welcomed the news about Indonesia sharing its viral sequences and voiced a more optimistic view on their usefulness.
"Sequences are very important to understand antigenicity, and even if no viruses are shared, provide the basis to make reagents to experimentally test antigenicity and pathogenicity," he said. Garcia-Sastre is also principal investigator for the Center for Research on Influenza Pathogenesis, one of six National Institute for Allergy and Infectious Diseases Centers of Excellence for Influenza Research and Surveillance.
The idea for the GISAID database was generated by a group of 70 scientists and health officials who signed a letter in the August 31, 2006, issue of Nature proposing the formation of a new consortium to promote greater sharing of H5N1 genetic sequences. Aside from concerns about potential social inequities, virus sharing has been a flashpoint for other controversies, including intellectual property rights and published credits for virus sources in scientific papers. Supari had earlier signaled Indonesia's support for the GISAID database when she announced its initial launch in March 2007. Her support for the GISAID database followed a technical meeting on the virus-sharing issue that was attended by health ministers of countries that have been hit by the H5N1 virus.
An official with GISAID, who asked not to be named, said that the database's platform for sharing H5N1 genetic sequences went live on 15 May 2008. The official confirmed that Indonesia has committed to sharing its virus data and is currently uploading its sequences into the GISAID EpiFlu database. China, Russia, and other nations are also in the process of submitting sequences, the GISAID source said.
"This global health research community will find that the GISAID platform provides a high standard of data and analysis tools that uniquely promotes responsible sharing of information," Supari said in a 2007 press release. GISAID said the public can freely access the database, which includes both human and animal H5N1 sequences, after they register and agree to share and credit the use of others' data, analyze findings jointly, publish results collaboratively, and refrain from pressing intellectual property rights issues that relate to diagnostic, drug, and vaccine developments.
South Korea: Economy's H5N1 avian influenza strain closely matches Japanese cases
Kim Jae-hong, a professor of veterinary medicine at Seoul National University, said that viruses over 99 percent genetically the same are considered the same strain. This substantiates assumptions that migratory birds spread the virus on their way north in March and April after spending the winter in Southeast Asia.
Korea saw its first case of bird flu this year at a chicken farm in Gimje on 1 April 2008. In Japan, four swans were found to be infected with bird flu on 21 April 2008. This is not the first time that the same strain of bird flu has broken out in Korea and Japan; similar findings were confirmed when bird flu was reported in the two nations in 2003 and 2006.
South Korea: Troops mobilize to fight H5N1 avian influenza outbreak
South Korea has been battling its latest outbreak of avian flu since 1 April 2008. The agriculture ministry has since reported 42 cases of bird flu at 33 places around the country. No human infections have been confirmed in South Korea, but the discovery of the H5N1 strain in the capital Seoul and other major cities has fuelled fears of possible human victims. The government is restricting the distribution and sale of live poultry for human consumption. It has already banned the butchering of chickens and other poultry at traditional markets. In the country's 2003-2004 outbreak, 5.28 million birds were culled while a 2006-2007 outbreak resulted in 2.8 million birds being destroyed.
South Korea: Economy plans to build H5N1 avian influenza vaccine plant
Europe: EU approves its first pre-pandemic H5N1 avian influenza vaccine
The European Medicines Agency has approved the adjuvanted vaccine, called Prepandrix, for marketing in all 27 EU countries, GSK said. The vaccine offers European governments the opportunity to protect their populations "in advance or at the outset of a declared influenza pandemic," the company said. The product is licensed for adults aged 18 to 60.
The EU approval comes about 13 months after the US Food and Drug Administration approved the first H5N1 vaccine for the United States, made by Sanofi Pasteur. "This vaccine marks a significant step in the world's ability to cope with an influenza pandemic," GSK CEO Jean-Pierre Garnier said.
Disease experts hope that pre-pandemic vaccines, based on existing H5N1 strains, will offer some protection against an emerging pandemic strain of H5N1 until a specific pandemic vaccine can be developed and produced, a process expected to take four to six months.
The EU approval is based on studies of a version of the vaccine involving an H5N1 strain isolated in Vietnam in 2004 (a clade 1 strain), the company said. Results of animal and human studies suggest that the vaccine may also offer protection against clade 2 strains of the virus. The vaccine contains an oil-and-water adjuvant that enables it to induce what is believed to be a protective immune response at low doses, according to published results. For example, two 3.8-microgram (mcg) doses generated immune responses that met all United States and European criteria for vaccine licensing, according to findings published in August 2007 in The Lancet. By comparison, seasonal flu vaccines contain 15 mcg of antigen for each flu strain targeted.
In addition, more than 75 percent of volunteers who received two 3.8-mcg doses of the vaccine were shown to have neutralizing antibodies against a clade 2 strain of H5N1, the Lancet report said.
GSK announced last year it would donate 50 million doses of its H5N1 vaccine to the World Health Organization (WHO) to help launch an international pre-pandemic vaccine stockpile. The company said it has already sold supplies of its vaccine to the United States, Switzerland, and Finland. Officials said sales in 2007 totaled 146 million British pounds (US $284 million). The WHO said last week that at least 16 companies have H5N1 vaccines in advanced development.
Detection of mortality clusters associated with highly pathogenic avian influenza in poultry: a theoretical analysis
Avian influenza in birds and animals
Cardona CJ, Xing Z, et al. Comparative immunology, microbiology and infectious diseases. 14 May 2008 [Epub ahead of print].
Methods and results
Options for the use of human H5N1 influenza vaccines and the WHO H5N1 vaccine stockpile
Executive Summary (excerpt)
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:
With its feel of suburban comfort, Dhour village in the Harirampur Union does not look like a typical Bangladeshi town. But, like many towns in Bangladesh, Dhour is home to many small poultry farms. In most households of this village, chickens are as much at home as the residents, roaming as freely inside the houses as they move in the backyards. Safura Khatun, age 50, raises about 400 chickens on the roof of her building in an enclosed area with a tin roof. She has been in business for almost a year and a half, but she says her profits have staggered in the two months prior to 22 May 2008. “People do not want to eat chicken or eggs any more because of bird flu,” she explains. Since January 2008, Bangladesh has seen massive Avian Influenza outbreaks across the country.
Changing local practices
Others in the community are not practicing safe hygiene, however. One young poultry-handler is seen placing eggs in a pot without washing his hands or the eggs. Another enters the poultry farm without wearing a mask or washing his hands. In a nearby community, 22-year-old Rina Begum has a small backyard farm in which she used to rear twelve chickens and four ducks – until she introduced a new chicken into the same cage and all the birds died. Rina does not know if her chickens died of bird flu, but says she had never experienced such rapid mortality from disease before. She says she is aware that cases of avian influenza should be reported to local authorities, but she could not afford the cost involved. “It would have cost me one hundred taka (about $1.50) to go to the local government office. I need this money to feed my family,” she says.
Encouraging safety through theater
The National Safety Week is an annual event of Thailand’s Ministry of Labour. This year the event aimed to raise awareness of employers and workers, including concerned agencies namely government, private sector and state enterprises about occupational safety and health in the workplace. The objectives of the event were to develop workers’ quality of life, to campaign and raise awareness of people in safety at work. Dr. Tsuyoshi Kawakami, Senior Specialist in Occupational Safety and Health, ILO/Subregional Office for East Asia, talked on Pandemic Human Influenza as the Workplace Issue to promote awareness and benefits of developing preparedness plan for the business sector. Taking this opportunity and in support of the objectives of the current pilot project of ILO, four other Pandemic Human Influenza experts from Petroleum Authority of Thailand Public Company Limited (PTT), PTT Chemical Public Company (PTT Chem Plc, a subsidiary of PTT group), UNSIC, and the Ministry of Public Health were invited to share their expertise and experience in preparedness for Pandemic Human Influenza. The session aimed to raise awareness amongst the audience about Pandemic Human Influenza as the workplace issue and to encourage them to take action in preparation of future Pandemic Human Influenza at workplace level. Dr. Chaiyuth Chavalitnitikul, chair of the session, introduced to the audience the panelists and summarised key points of the speakers.