Vol. XI No. 12 ~EINet News Brief ~ 13 June 2008 ~ EINet News Briefs ~ Jun 13, 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)
- UK (Oxfordshire): High-pathogenic H7N7 avian influenza confirmed
- USA: Researchers find North America still free of H5N1 avian influenza
- USA: HHS announces preparedness grants for public health, hospitals
- USA: Routine surveillance finds low-pathogenic H7N3 avian influenza in US poultry
- Indonesia: Government stops notifying global health authorities of H5N1 avian influenza cases

2. Updates

3. Articles
- Impact of Emerging Antiviral Drug Resistance on Influenza Containment and Spread: Influence of Subclinical Infection and Strategic Use of a Stockpile Containing One or Two Drugs
- Healthcare workers' attitudes towards working during pandemic influenza: A multimethod study
- Plasmid DNA-Based Vaccines Protect Mice and Ferrets against Lethal Challenge with A/Vietnam/1203/04 (H5N1) Influenza Virus
- Thermal Inactivation of Avian Influenza and Newcastle Disease Viruses in Chicken Meat

4. Notifications
- World Vaccine Congress Asia 2008
- International Meeting On Emerging Diseases and Surveillance (IMED 2009)
- HHS offers pandemic guidance on masks, antivirals

1. Influenza News

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

Bangladesh / 1 (0)
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: 383 (241).
(WHO 5.28.08 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 5.28.08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 5.28.08): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 5.20.08): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html


Europe/Near East
UK (Oxfordshire): High-pathogenic H7N7 avian influenza confirmed
The avian influenza virus that struck chickens on a farm in England this week has been identified as highly pathogenic H7N7 and is probably related to viruses that have sometimes surfaced in other European countries, British officials said on 5 June 2008. "Preliminary analysis . . . indicates that this H7N7 strain is likely to be related to viruses which have occasionally been detected in domestic poultry and wild birds elsewhere in Europe," the United Kingdom Department for Environment, Food, and Rural Affairs (DEFRA) said. DEFRA said further laboratory tests were under way. The statement did not suggest how closely related the virus may be to the H7N7 strain that caused a series of major poultry outbreaks and forced the destruction of millions of birds in the Netherlands in 2003. That virus also infected at least 89 people, causing mild conjunctivitis in most cases but killing a veterinarian.

First reported on 3 June 2008, the latest outbreak occurred on a farm near Banbury, Oxfordshire, about 80 miles northwest of London. A flock of 25,000 chickens is being culled. "The Health Protection Agency has advised that H7N7 avian flu remains largely a disease of birds and the risk to human health is low," a DEFRA statement said. The agency set up protection and surveillance zones around the outbreak site and said a full epidemiologic investigation was under way. Richard Court, the owner of the farm, said the source of the outbreak was unknown.
(CIDRAP 6.5.08)


USA: Researchers find North America still free of H5N1 avian influenza
The feared H5N1 avian influenza has yet to make it to North America in the bodies of migrating birds, researchers said on 5 June 2008. Testing of more than 16,000 migratory birds between May 2006 and March 2007 showed no evidence of the H5N1 bird flu virus, which has become entrenched in many parts of Asia and which regularly pops up in flocks in Europe, the Middle East and Africa.

The birds are infected with virtually every other known strain of influenza, said Hon Ip of the U.S. Geological Survey, National Wildlife Health Center in Madison, Wisconsin. But not the highly pathogenic H5N1 virus. "Maybe the Pacific Ocean is a nice, big biological barrier, for which I am forever grateful," Ip said. "The general avian influenza infection rate is not really different in Alaska or North America than pretty much anywhere else. In spite of H5N1's spread through most of Asia and into Africa and Europe, that spread has not come into North America," Ip added.

About 1.7 percent of the birds were infected, but all with low-pathogenic strains of influenza viruses, which typically do not cause disease, Ip's team reported in the Virology Journal. However, U.S. government officials have said it is inevitable that migratory birds will carry H5N1 to the Americas at some time. An estimated that 1.5 million to 2.3 million birds migrate from Asia to Alaska each year. But Ip, who worked with teams at the U.S. Department of Agriculture, the Fish and Wildlife Service and the Alaska Department of Fish and Game, says it has not happened yet. The researchers are sampling birds that ornithologists say are the most likely to have migrated recently from Asia. "Some of these viruses contain a mix of genes from both North American and Asian viruses," Ip said. "We have direct evidence that the birds are carrying back at least a relative or descendant of viruses from Asia," he added. "This confirms we are sampling from those birds that are most likely to bring H5N1 back if H5N1 was to be brought back from Asia." It also confirms that the viruses swap genes inside the birds -- a process that scientists believe gives rise to new and sometimes more dangerous strains.

The researchers have been testing birds since 2005 for H5N1, concentrating on Alaska but looking in all regions. The birds most likely to be infected with any kind of flu virus are the dabbling ducks -- species such as mallards, Ip said. This reinforces the theory that the virus spreads as birds feed in the same water in which they are defecating.
(Reuters AlertNet 6.5.08)


USA: HHS announces preparedness grants for public health, hospitals
The US Department of Health and Human Services (HHS) on 3 June 2008 announced that it is allocating states and major metropolitan areas $1.1 billion to strengthen public health preparedness and help healthcare facilities respond to emergency events such as an influenza pandemic or terrorist attack. "States and local communities need to be supported because they are on the front lines of response in a health emergency," HHS Secretary Mike Leavitt said in an HHS press release. "These funds will continue to enhance community readiness by increasing the capabilities of health departments, hospitals, and healthcare delivery systems to respond to any public health emergency."

HHS earmarked $1.1 billion for two related cooperative agreement programs: Public Health Emergency Preparedness (PHEP), administered by the Centers for Disease Control and Prevention (CDC), and the Hospital Preparedness Program (HPP), managed by the HHS Assistant Secretary for Preparedness and Response (ASPR). HHS said it allocated $704.8 million in PHEP funds to states, territories, and certain metropolitan areas, which is down from $896 million the agency granted in 2007. However, last year's amount included $175 million for pandemic influenza preparedness. Focus areas for this year's funds include:

  • Integrating public health, public, and private capabilities with other first responder systems
  • Addressing the needs of vulnerable populations in the event of a public health emergency
  • Ensuring that state, local, and tribal groups coordinate their planning on preparedness and response activities.

HHS started ramping up its funding for healthcare facility preparedness after the Sep 11 and anthrax attacks in 2001. The grant award, designed to boost surge capacity, this year is $398 million, down from $430 million in 2007. Trust for America's Health (TFAH), a nonprofit public health advocacy group, has voiced concerns about the state of hospital preparedness over the past few years in its annual reports called "Ready or Not? Protecting the Public's Health from Diseases, Disasters, and Bioterrorism." Most of the goals for the funds are the same as last year: development of or improvement in interoperable communication systems, bolstering hospital bed tracking systems, preregistration of healthcare volunteers, processes for hospital evacuations or sheltering-in-place, and fatality management. An added focus this year is strengthening community healthcare partnerships, HHS said.

In February 2008, TFAH issued an analysis of the Bush administration's budget proposals for 2009 in which it raised concerns over shrinking funding levels for public health preparedness and hospital readiness programs. Over the past five years, the funding level has been reduced by one-third, according to a TFAH press release that accompanied the analysis. At about the same time, a report from the National Association of County and City Health Officials (NACCHO) said that the cuts have impaired local preparedness efforts.
(CIDRAP 6.3.08)


USA: Routine surveillance finds low-pathogenic H7N3 avian influenza in US poultry
Tyson Foods Inc, the second largest US chicken producer, said on 3 Jun 2008 it will destroy about 15,000 chickens in Arkansas exposed to a mild strain of bird flu, and while there was no risk to human health the news sent its shares lower. The affected chickens, which will not enter the food supply, had antibodies of a mild or low pathogenic strain of bird flu called H7N3. It is the high pathogenic H5N1 strain, which has never been found in the United States, that worries scientists because it has spread to and killed people around the world.

While the findings are no threat to humans, shares of US chicken companies dropped as investors worried foreign buyers may ban US chicken. The United States exports about 16 percent of its chicken, and a loss of key overseas markets could create a glut of chicken here. There have been previous cases of mild bird flu in the United States. In 2007, government investigators found cases in 13 states. Because of the Arkansas findings the US Agriculture Department (USDA) already has suspended shipments of chicken from that state to Russia, the top overseas market for US chicken. One concern is Russia may implement a broader ban. "The Russians might say nothing or they may ban all sales from us. There is no predicting what they will do," said Paul Aho, economist with the consulting firm Poultry Perspective.

In addition to Tyson's shares, shares of top chicken producer Pilgrim's Pride Corp and smaller rival Sanderson Farms Inc also were lower on 3 Jun 2008. "By itself, the ban of exports from Arkansas doesn't necessarily change the momentum of the export business," Jonathan Feeney, Wachovia food industry analyst, said in a note to clients. He said chicken can just be exported from other states. While the stock market may be justified "to give some pause to the news," Feeney said the drop in chicken company shares seems overdone. "Honestly, it's a non-event. So far, it's not something that's reportable to any international monitoring agency like the World Organization for Animal Health (OIE)," said Toby Moore, spokesman for the USA Poultry and Egg Export Council, an industry trade group.

The Arkansas chickens were not sick and the antibodies were discovered as part of routine surveillance by the company, Tyson said. Shares of Tyson Foods fell more than nine percent on New York Stock Exchange trading on 3 Jun 2008, but by early afternoon were down about eight percent, or USD 1.44, at USD 17.01. While tests showed the birds had antibodies for the mild bird flu strain, "there was no indication the birds currently have the virus," the company said.
(ProMED 6.4.08)


Indonesia: Government stops notifying global health authorities of H5N1 avian influenza cases
Indonesia's health minister said today the government has stopped the practice of promptly notifying global health officials each time it confirms a human H5N1 avian influenza case or death, a move some say will likely hamper efforts to monitor the world's pandemic risk level. Health Minister Siti Fadilah Supari on 5 June 2008 confirmed that a 15-year-old girl from Jakarta tested positive for H5N1 avian influenza on May 13 2008 and died the next day. Indonesia's National Committee for Avian Influenza Control and Pandemic Influenza had previously listed the case as confirmed on its Web site, but the information is apparently no longer listed. The WHO, which typically confirms cases when it receives notifications from health ministries or test results from its collaborating laboratories, has not yet confirmed Indonesia's most recent case and has not commented on Supari's decision to stop sending out H5N1 case notifications. The WHO last confirmed an Indonesian H5N1 case in a three-year old boy who died on Apr 23.

Supari said that the health ministry would not send out H5N1 case confirmations until after they have been reported in the media. However, Reuters reported that the ministry will announce the death toll from the H5N1 virus only every six months. "How does it help us to announce these deaths?" Supari said. "We want to focus now on positive steps and achievements made by the government in fighting bird flu." She said that announcements of H5N1 deaths are sometimes misunderstood. "It's OK not to announce it. Sometimes they only give hurtful comments instead of helping," she said without further explanation.

Sharon Sanders, editor-in-chief of FluTrackers, a well-known Web message board that focuses on avian flu developments, said that Indonesia's decision to delay H5N1 notifications will obscure what is happening there, which negatively affects the world's ability to prepare for a pandemic. She said Indonesia's news blackout would likely have the opposite effect from what the government apparently intends. "Now, there will be intense speculation and generation of rumors surrounding suspicious deaths that have similar symptoms to H5N1 infections," Sanders said. "False rumors of an H5N1 outbreak have the potential to be even more economically devastating than a government-confirmed outbreak."
(ProMED 6.5.08)


2. Updates
  • UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP recently launched a new web site for information on fund management and administrative services and includes the website of the Central Fund for Influenza Action. This site also includes a list of useful links to governments, international agencies, NGOs, and scientific organizations.
  • WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The Influenza Virus Tracking System is now live and can be accessed by the public at: www.who.int/fluvirus_tracker.
  • UN FAO: http://www.fao.org/avianflu/documents/key_ai/key_book_preface.htm Read the first installment of a major new and wide-ranging overview of avian influenza that has just been released by FAO.
  • OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
  • US CDC: http://www.cdc.gov/flu/avian/index.htm. View weekly US Flu Activity Report at: http://www.cdc.gov/flu/whatsnew.htm .
  • The US government’s Web site for pandemic/avian flu: http://www.pandemicflu.gov/. View the factsheet "Control of Pandemic Flu Virus on Environmental Surfaces in Homes and Public Places" at: http://www.pandemicflu.gov/plan/individual/panfacts.html .
  • CIDRAP: http://www.cidrap.umn.edu/ See Pandemic preparedness tools: Find more than 130 peer- reviewed practices from 22 states and 33 counties aimed at furthering pandemic preparedness.
  • PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to National Influenza Centers in PAHO Member States.
  • US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds and poultry. (UN; WHO; FAO, OIE; CDC; CIDRAP; PAHO; USGS)


    3. Articles
    Impact of Emerging Antiviral Drug Resistance on Influenza Containment and Spread: Influence of Subclinical Infection and Strategic Use of a Stockpile Containing One or Two Drugs
    McCaw JM, et al. PLoS ONE 3(6): e2362. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0002362

    Wide-scale use of antiviral agents in the event of an influenza pandemic is likely to promote the emergence of drug resistance, with potentially deleterious effects for outbreak control. We explored factors promoting resistance within a dynamic infection model, and considered ways in which one or two drugs might be distributed to delay the spread of resistant strains or mitigate their impact.

    Methods and Findings
    We have previously developed a novel deterministic model of influenza transmission that simulates treatment and targeted contact prophylaxis, using a limited stockpile of antiviral agents. This model was extended to incorporate subclinical infections, and the emergence of resistant virus strains under the selective pressure imposed by various uses of one or two antiviral agents. For a fixed clinical attack rate, R0 rises with the proportion of subclinical infections thus reducing the number of infections amenable to treatment or prophylaxis. In consequence, outbreak control is more difficult, but emergence of drug resistance is relatively uncommon. Where an epidemic may be constrained by use of a single antiviral agent, strategies that combine treatment and prophylaxis are most effective at controlling transmission, at the cost of facilitating the spread of resistant viruses. If two drugs are available, using one drug for treatment and the other for prophylaxis is more effective at preventing propagation of mutant strains than either random allocation or drug cycling strategies. Our model is relatively straightforward, and of necessity makes a number of simplifying assumptions. Our results are, however, consistent with the wider body of work in this area and are able to place related research in context while extending the analysis of resistance emergence and optimal drug use within the constraints of a finite drug stockpile.

    Combined treatment and prophylaxis represents optimal use of antiviral agents to control transmission, at the cost of drug resistance. Where two drugs are available, allocating different drugs to cases and contacts is likely to be most effective at constraining resistance emergence in a pandemic scenario.
    (CIDRAP 6.4.08)


    Healthcare workers' attitudes towards working during pandemic influenza: A multimethod study
    Draper H. BMC Public Health. 2008;8:192 http://www.biomedcentral.com/1471-2458/8/192/abstract

    Healthcare workers (HCWs) will be key players in any response to pandemic influenza, and will be in the front line of exposure to infection. Responding effectively to a pandemic relies on the majority of medical, nursing, laboratory and hotel services staff continuing to work normally. Planning assumes that during a pandemic normal healthcare service levels will be provided, although it anticipates that as caseloads increase only essential care will be provided. The ability of the NHS to provide expected service levels is entirely dependent upon HCWs continuing to work as normal.

    This study is designed as a two-phase multi-method study, incorporating focus groups and a questionnaire survey. In phase one, qualitative methods will be used to collect the views of a purposive sample of HCWs, to determine the range of factors associated with their responses to the prospect of working through pandemic influenza. In phase two, the findings from the focus groups, combined with the available literature, will be used to inform the design of a survey to determine the generalisability of these factors, enabling the estimation of the likely proportion of HCWs affected by each factor, and how likely it is that they would be willing and/or able to continue to work during an influenza pandemic.

    There are potentially greater than normal health risks for some healthcare workers working during a pandemic, and these workers may be concerned about infecting family members/friends. HCWs will be as liable as other workers to care for sick family members and friends. It is vital to have information about how motivated HCWs will be to continue to work during such a crisis, and what factors might influence their decision to work/not to work. Through the identification and subsequent management of these factors it may be possible to implement strategies that will alleviate the concerns and fears of HCWs and remove potential barriers to working.
    (CIDRAP 6.2.08)


    Plasmid DNA-Based Vaccines Protect Mice and Ferrets against Lethal Challenge with A/Vietnam/1203/04 (H5N1) Influenza Virus
    Lalor PA, et al. The Journal of Infectious Diseases. 2008;197(12):1643-1652 http://www.journals.uchicago.edu/doi/abs/10.1086/588431

    Plasmid DNA (pDNA) vaccines represent an alternative to conventional inactivated influenza vaccines that are likely to experience supply constraints during a pandemic. Several Vaxfectin-formulated pDNA vaccines were tested in mice and ferrets for efficacy against a lethal challenge with the highly pathogenic A/Vietnam/1203/04 (H5N1) influenza virus strain; the vaccines encoded influenza A virus hemagglutinin (HA), and/or nucleoprotein (NP), and M2 protein. Complete protection from death and disease was achieved in mice and ferrets with 2 doses of a Vaxfectin-formulated vaccine containing H5 HA, NP, and M2 plasmids and in ferrets with only 1 dose. A Vaxfectin-formulated vaccine containing NP and M2 pDNA provided significant protection against death in mice and provided some benefit in ferrets (i.e., 17% survival, delayed time to illness and death, and significant reduction in viral load compared with that in negative control animals). These experiments support the clinical testing of pDNA vaccine candidates that may ultimately increase global vaccine supply options during pandemics.
    (CIDRAP 6.4.08)


    Thermal Inactivation of Avian Influenza and Newcastle Disease Viruses in Chicken Meat
    Thomas C, et al. Journal of Food Protection. 2008;71(6):1214-1222. http://www.ingentaconnect.com/content/iafp/jfp/2008/00000071/00000006/art00015

    Avian influenza viruses (AIV) and Newcastle disease viruses (NDV) of high pathogenicity cause severe systemic disease with high mortality in chickens and can be isolated from the meat of infected chickens. Although AIV and NDV strains of low pathogenicity are typically not present in chicken meat, virus particles in respiratory secretions or feces are possible sources of carcass contamination. Because spread of AIV and NDV is associated with movement of infected birds or their products, the presence of these viruses in chicken meat is cause for concern. This study presents thermal inactivation data for two viruses of high pathogenicity in chickens (AIV strain A/chicken/Pennsylvania/1370/1983 and NDV strain APMV-1/chicken/California/S0212676/2002) and two viruses of low pathogenicity in chickens (AIV strain A/chicken/Texas/298313/2004 and NDV strain APMV-1/chicken/Northern Ireland/Ulster/1967). Under the conditions of the assay, high-pathogenicity AIV was inactivated more slowly in meat from naturally infected chickens than in artificially infected chicken meat with a similar virus titer. In contrast, high-pathogenicity NDV was inactivated similarly in naturally and artificially infected meat. Linear regression models predicted that the current U.S. Department of Agriculture-Food Safety and Inspection Service time-temperature guidelines for cooking chicken meat to achieve a 7-log reduction of Salmonella also would effectively inactivate the AIV and NDV strains tested. Experimentally, the AIV and NDV strains used in this study (and the previously studied H5N1 high-pathogenicity AIV strain A/chicken/Korea/ES/2003) were effectively inactivated in chicken meat held at 70 or 73.9°C for less than 1 s.
    (CIDRAP 6.3.08)


    4. Notifications
    World Vaccine Congress Asia 2008

    Dates: 2-5 June 2008
    Location: Singapore
    Venue: Grand Hyatt

    World Vaccine Congress Asia 2008 is an annual meeting place where vaccine buyers and sellers, health authorities, financing institutions, regulators, big and small vaccine producers and manufacturers, technology providers and other stakeholders come together to discuss industry trend, market and partnership opportunities, new vaccines and new technology innovations across Asia.

    Meet vaccine experts from NGOs (e.g. Bill & Melinda Gates, PATH, WHO, IVI) and top vaccine companies such as Green Cross, 9Bio, Novartis, Intercell, Dynavax, Sanofi Pasteur, CNBG, AdImmune, NasVax, Vaxine, Serum Institute of India, IVAC, Shantha Biotechnics, Panacea Biotec and more


    International Meeting On Emerging Diseases and Surveillance (IMED 2009)

    Dates: 13-16 Feb 2009
    Location: Vienna, Austria
    Venue: Hilton Hotel

    Emerging infectious diseases are at the center of the world’s attention. The threats of pandemic influenza and bioterrorism, and the realization that new infectious diseases may be recognized at any time, in any place, have dramatically raised our awareness. What are the most important emerging disease threats? How can we quickly detect their occurrences in order to respond in a timely and appropriate way?

    ProMED, the Program for Monitoring Emerging Diseases, is pleased to invite you to the International Meeting on Emerging Diseases and Surveillance 2009. Along with our co- sponsors, the European Centers for Disease Control, the World Organization for Animal Health, the European Commission, and the Wildlife Conservation Society, we are developing a conference that will bring together the public health community, scientists, health care workers and other leaders in the field of emerging infectious diseases. The meeting will embrace the ‘One Medicine, One Health’ concept recognizing that, just as diseases reach across national boundaries, so do they transcend species barriers. We therefore welcome the full participation of both the human and animal health communities.

    IMED 2009 will be organized by the International Society for Infectious Diseases, which has over 20 years experience in planning and implementing international biomedical meetings. Because of the enthusiastic response to the inaugural meeting, IMED 2007, which attracted over 600 participants from 65 countries, IMED 2009 will expand to 3 full days of sessions and include more opportunities for oral presentations of submitted abstracts.

    Abstract Submission: The deadline for abstract submission is December 1, 2008.

    Target Audience: ProMED-mail participants, physicians, veterinarians and other health care workers, public health workers, scientists, pharmaceutical and biotechnology industry, journalists, other interested persons.
    (ProMED 5.19.08)


    HHS offers pandemic guidance on masks, antivirals

    Proposed pandemic preparedness guidance released by the federal government recommends that people wear face masks if they have to go into crowds during an influenza pandemic and says critical infrastructure businesses should consider stockpiling antiviral drugs, among various other suggestions. The guidance from the US Department of Health and Human Services (HHS) also spells out a role for preventive use of antiviral drugs in a pandemic but says that antivirals used preventively will have to come mainly from private stockpiles, because government stockpiles will be used mostly for treating the sick. HHS released three draft guidance documents, covering the use of face masks and respirators by individuals and families, antiviral use during a pandemic, and considerations on antiviral drug stockpiling by employers. The agency is inviting public comments on all of them and says none as yet represents established policy.

    Masks and respirators

    The guidance on use of masks and respirators generally echoes advice issued by the Centers for Disease Control and Prevention in May 2007 but uses firmer language, changing "may" to "should" in several instances. The document says the most important precautions for preventing flu are to limit close contact with others and use good hygiene. The specific recommendations on masks and respirators are as follows:

    1. Those who must go into crowded settings during a pandemic should wear a face mask to protect themselves from others' coughs and sneezes and to protect others from their own respiratory droplets. Even though most people out in public won't be sick, those who are infected can shed virus before they have symptoms, the guidance notes.
    2. Those who must have close contact with someone who has pandemic flu should wear an N-95 respirator certified by the National Institute of Occupational Safety and Health. N-95 respirators are devices that fit tightly to the face and are designed to stop 95 of small airborne particles.
    3. People sick with pandemic flu should wear a mask when they must be in contact with others. The guidance suggests that it would be reasonable for each household to stockpile 20 respirators. In addition, people who have to commute on public transit might want to buy 100 face masks, plus some more for use in other crowded settings and at home. HHS estimates the cost of stockpiling the recommended number of respirators and masks at $35 to $70 per household. The report notes that the Food and Drug Administration (FDA) has cleared many face masks, though none specifically for use by children. Also, the FDA recently cleared the first respirators intended for use by the public during a public health emergency such as a pandemic, it says. However, there are no respirators designed for children.

    General guidance on antivirals
    The proposed recommendations on use of antiviral drugs replace advice that was developed in 2005 as part of the HHS pandemic preparedness and response plan. The recommendations were prepared by an interagency group that included state, local, and tribal public health agencies as well as HHS. The proposed guidance recommends prophylactic antivirals for several groups, but it says the supplies used for that purpose "will depend largely on private sector organizations and businesses purchasing and stockpiling antiviral drugs for their employees." The document recommends that government antiviral supplies "be prioritized for treatment of all persons who may benefit from therapy," without attempting to put certain groups ahead of others. Further, it states, "Treatment is preferred to prophylaxis in settings of limited antiviral drug supply; targeting some antiviral drug supply for prophylaxis and prioritizing treatment for certain groups would raise significant ethical and logistical challenges." The working group recommends that antivirals be used for:

    1. Containing initial pandemic outbreaks overseas and in the United States with treatment and post-exposure prophylaxis (PEP) for people exposed to the virus and those in areas where exposure may occur
    2. Reducing introduction of infection into the United States as part of control efforts at the borders
    3. Treating people with pandemic flu who seek care early in their illness and would benefit from treatment
    4. Prophylaxis for high-risk healthcare and emergency services workers
    5. Providing PEP for low-risk healthcare and emergency workers, immunocompromised people, and those living in group settings such as nursing homes and prisons

    Further, the report says businesses that provide essential goods and services—critical infrastructure businesses—"should strongly consider antiviral prophylaxis for critical workers." Other employers may consider providing antivirals to protect their workers and maintain operations.

    Employer stockpiling of antivirals

    The guidance on antiviral stockpiling by employers underlines the recommendation that critical infrastructure employers should consider stockpiling, but it "does not establish the requirement or expectation that all employers stockpile antiviral drugs." The document makes clear that employers generally won't be able to obtain antivirals from government stockpiles: "Despite expanding recommendations for antiviral drug use, there are no current plans for a commensurate expansion of public sector stockpiles, and employers will have to take the lead role for protection of their workforce if these recommendations are to be implemented." The report says businesses may want to buy antivirals for the following purposes:

    1. To provide prophylaxis for frontline healthcare and emergency workers
    2. To protect workers who are needed to maintain essential community services
    3. To provide early treatment for workers who fall ill
    4. To protect overseas employees and operations in areas where federal pandemic response activities will not reach.
    (CIDRAP 6.3.08)