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Vol. XI No. 13 ~EINet News Brief ~ 27 June 2008 ~ EINet News Briefs ~ Jun 27, 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: UN official says bird biosecurity lapses could worsen food crisis
- Global: Leading international health officials say world is not ready for an influenza pandemic
- Indonesia: WHO confirms two deaths from H5N1 avian influenza infection
- Pakistan (Swabi): Government declares H5N1 outbreak; Swabi Poultry Association disagrees
- Viet Nam: FAO advises continuing vaccination program
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Hong Kong: Officials aim for complete closure of poultry industry

2. Infectious Disease News
- Philippines: Dengue on the rise, authorities step up information campaign for rainy season
- China (Shanghai): Health officials report first child death of hand, foot and mouth disease
- Indonesia: Despite control efforts, dengue is increasing in some provinces
- Philippines: Officials note high incidence of leptospirosis infection
- Russia: Dozens infected with Trichinella after eating bear meat
- Russia: Health officials see a rise in Crimean-Congo hemorrhagic fever
- Vietnam: Southern provinces hit hard by dengue
- Canada: Fraser Valley health officials identify 47 cases of mumps
- USA: Multistate outbreak of Salmonella infection from tomatoes continues
- USA (Ohio & Michigan): Multistate outbreak of E. coli infection may be linked to ground beef

3. Updates
- AVIAN/PANDEMIC INFLUENZA
- WEST NILE VIRUS (North America)

4. Articles
- Influenza Activity — United States and Worldwide, 2007–08 Season
- Virus transfer from personal protective equipment to healthcare employees’ skin and clothing
- An adjuvanted, low-dose, pandemic influenza A (H5N1) vaccine candidate is safe, immunogenic, and induces cross-reactive immune responses in healthy adults
- Immune responses of healthy subjects to a single dose of intramuscular inactivated influenza A/Vietnam/1203/2004 (H5N1) vaccine after priming with an antigenic variant
- Clinical review: Influenza pandemic — physicians and their obligations
- Tackle the problem when it gets here: pandemic preparedness among small and medium businesses
- Mitigating pandemic influenza: ethics of implementing a school closure policy
- Primary care physicians and pandemic influenza: an appraisal of the 1918 experience and an assessment of contemporary planning
- Pharmacokinetics and tolerability of Oseltamivir (Tamiflu®) combined with probenecid

5. Notifications
- PHI2008: Envisioning options for integrated public health information systems for low resource settings: components, connections, partners, strategies
- BirdFlu 2008: Avian Influenza and Human Health


1. Influenza News

Global
Global: UN official says bird biosecurity lapses could worsen food crisis
Lax biosecurity measures around poultry in some countries could lead to an increasing number of H5N1 avian influenza outbreaks that could exacerbate the global food crisis, an official from the United Nations Food and Agriculture Organization (FAO) said at an international infectious disease conference in Malaysia on 20 June 2008. Juan Lubroth, senior officer with the FAO’s infectious diseases group, made the comments during symposia on influenza in animals and people at the International Congress on Infectious Diseases (ICID), which started on 19 June 2008 in Kuala Lumpur and runs through 22 June 2008. ICID is the annual meeting of the International Society for Infectious Diseases.

Lubroth said though fewer countries have experienced recent avian flu outbreaks, numerous small outbreaks continue to occur. “It's like a boiling pot, and we need to keep the lid on that before it gets worse” he said.

He said 80 percent of the world’s poor depend on livestock for their livelihood, and poultry has been an inexpensive protein source. However, he added that about 240 million poultry have been slaughtered to control the spread of H5N1. Failure to protect the food supply of the world’s poor only makes worse the effect of rising prices of rice, corn, and other staples, Lubroth said. Global veterinary service capacity needs to be expanded, and more countries need to be transparent regarding disease surveillance and develop surveillance systems and policies to manage the disease, he said. “We fail to see that political commitment.” In the abstract that accompanied the presentation, Lubroth wrote that veterinary experts worry that government officials, in a panic over the threat to human health, are focusing nearly all of their efforts on accumulating antiviral and vaccine stockpiles, “forgetting that the origin of the malady was — and remains — a poultry problem.

These comments from the FAO seem to counter some of the recent comments from a UN official on the state of global pandemic preparedness. On 18 June 2008, David Nabarro, the UN’s influenza coordinator, listed national improvements in poultry biosecurity as a reason behind the organization’s assessment that the world is better prepared for an influenza pandemic, according to an earlier report. He also said more countries are focusing their efforts on the link between human and animal health.

Other pandemic experts, such as Michael T. Osterholm, director of the University of Minnesota Center for Infectious Disease Research and Policy, the publisher of CIDRAP News, disagree that the world is better prepared for a pandemic and say governments have not planned for supply, medicine, and utility disruptions that could severely damage the world’s economy and worsen the impact of the disease on health. Nabarro, however, expressed concern that the virus remains entrenched in several countries, particularly Indonesia, the country that has had the highest number of human cases and deaths.
(CIDRAP 6.20.08)

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Global: Leading international health officials say world is not ready for an influenza pandemic
The world is far from being well prepared for an influenza pandemic, leading national and international health officials warned at a meeting in Malaysia last week. As the H5N1 avian influenza virus continues to thrive in birds, there is no vaccine that can provide sure protection if it evolves into a pandemic strain, and governments are paying less attention to the threat, officials said. “We are a long way from being fully prepared,” said Dr. Julie Gerberding, director of the US Centers for Disease Control and Prevention (CDC). She spoke at the International Congress on Infectious Diseases in Kuala Lumpur, Malaysia. “We do not have a vaccine that will provide universal protection, we do not have surveillance in every country, we do not have control of the virus in animal reservoirs, and we have huge gaps in our basic understanding of influenza,” Gerberding said. She warned against complacency stemming from either misplaced confidence that a solution is at hand or a belief that nothing can be done to stop a pandemic, according to reports. “Public health enemy No. 1 is the challenge of complacency and our inability to maintain a focus on threats when they are around the corner or potentially in our backyard,” she said. However, she also said much progress has been made in pandemic preparations.

David Heymann, the World Health Organization’s (WHO’s) assistant director-general for health security and environment, said governmental attention to the pandemic threat has waned. “Certainly at higher levels in many governments there is no longer the concern there was five years ago,” Heymann said. He noted that many countries have written pandemic plans and are stockpiling antiviral drugs, but he agreed with Gerberding that the world “is not prepared as far as vaccines go.”

In other news from the Malaysia conference, Heymann said a committee of experts would meet in November 2008 to discuss whether the WHO should plan to build a larger stockpile of prepandemic H5N1 vaccines. So far, two drug companies, GlaxoSmithKline and Sanofi Pasteur, have pledged to provide a total of 110 million doses of H5N1 vaccines for the WHO stockpile. The WHO has said the stockpile would be used to help battle the initial emergence of a potential H5N1 pandemic and to provide vaccine to countries that would have little access to it. Heymann said a WHO advisory committee “will determine whether or not there should be a greater stockpile or even consider vaccinating populations against H5N1 as an insurance policy.” He warned that widespread use of the vaccines could backfire if they cause serious side effects. “If they are severe, it may cause concern and might even derail activities to vaccinate in the future,” he said. Heymann said the committee would also discuss whether the prepandemic vaccines are safe and whether they provide protection against different H5N1 strains.
(ProMED 6.23.08)

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Asia
Indonesia: WHO confirms two deaths from H5N1 avian influenza infection
As of 19 Jun 2008, The Ministry of Health of Indonesia has announced two new cases of human H5N1 avian influenza infection. The cases are not linked epidemiologically. The first case is a 16-year-old female from South Jakarta, DKI Jakarta Province. She developed symptoms on 7 May 2008, was hospitalized on 12 May 2008 and died on 14 May 2008. Investigations into the source of her infection indicate exposure to sick and dead poultry. The second case is a 34-year-old female from Tangerang District, Banten Province. She developed symptoms on 26 May 2008, and was hospitalized on 2 Jun 2008 and died on 3 Jun 2008. Investigations into the source of her infection are ongoing. Of the 135 cases confirmed to date in Indonesia, 110 have been fatal. (ProMED 6.20.08)

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Pakistan (Swabi): Government declares H5N1 outbreak; Swabi Poultry Association disagrees
Pakistani authorities on 22 Jun 2008 reported a new outbreak of avian flu at a commercial poultry farm in the country’s northwest, killing thousands of birds, officials said. Tests conducted at a government-run laboratory in Islamabad confirmed the presence of H5N1 bird flu at a farm in Swabi district, local livestock department chief Ibrahim Khan said.

“The virus was detected after the owner of the farm informed us on 20 Jun 2008 that some 4,000 birds had died within the past few days,” he said. “We got the confirmation on 21 Jun 2008, sealed the farm and culled around 2,000 birds,” he said. All workers on the affected farm were examined by the ministry of health but none was found to have been affected by the virus, he added. Local health officials are monitoring surrounding farms and advised them to take precautionary measures including vaccination of birds, he said.

Swabi Poultry Association (SPA) on 25 Jun 2008 staged a protest demonstration against the District Livestock and Dairy Development Department and the National Research Institute (NRI), Islamabad, for what they called ‘mistaking an H5N9 strain for H5N1’ that caused bird flu. The association’s office-bearers said that they had conducted their own test at the Poultry Research Institute (PRI), Rawalpindi, where the strain was identified as H5N9. The association’s president, Zabiullah, demanded that the government constitute an impartial committee that should take samples for fresh tests. He warned that if the government failed to listen to their demand by 30 Jun 2008, they would hold a hunger strike camp in front of the NWFP Assembly.
(ProMED 6.23.08 & 6.27.08)

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Viet Nam: FAO advises continuing vaccination program
Viet Nam should continue to vaccinate and the program will probably be needed for the next three to five years or longer, even though this will be costly because it will have to be implemented on such a large scale, says FAO. Speaking to the press during a three-day international conference called to discuss ways of translating avian influenza research into policy, Dr. Jeff Gilbert, FAO’s avian influenza team leader in Viet Nam, said that because most of the country’s farmers do not know about biosecurity, the lack of vaccination would mean that the disease would return and Viet Nam could face significant fresh outbreaks similar to those in 2004 and 2005.

The 16-18 Jun 2008 conference was co-organized by the Vietnamese Ministry of Agriculture and Rural Development, the Food and Agriculture Organization of the United Nations (FAO), the US Department of Agriculture (USDA) and the US Agency for International Development (USAID). The conference heard bird flu-related reports by international experts, including a model outlining the risk and progress of the virus, epidemiology research on viruses on different kinds of poultry, and campaigns to raise public awareness about the disease and its prevention.

Addressing the conference, Viet Nam’s Deputy Minister of Agriculture and Rural Development Bui Ba Bong said avian influenza was temporarily under control in the country but that there was a risk the situation could change and become complicated. More research on avian influenza is necessary to bring it under control, he told the meeting, saying that more work was needed to understand the nature of the virus, how it was transmitted and on the production of a vaccine to sustainably control a pandemic and minimize virus transmission to humans. Bong said research should be combined with restructuring of the poultry sector to increase biosecurity and with strengthening of mass education and communication about the disease. He stressed the importance of research in deciding measures to effectively rein in the epidemic and warned Viet Nam to reconsider vaccination, which he said was effective but costly. Do Huu Dung, an epidemiologist in Viet Nam’s Animal Health Department, said that while statistics show that recent outbreaks are small in scale and few in numbers, they are scattered over many different areas throughout the north, the center and the south. “What we need to do is to have a sustainable vaccination strategy to maintain control over bird flu. The current government goals regarding this disease include keeping the frequency and scale of outbreaks at low level, preventing the transmission of the virus to humans and reducing the burden of vaccination on the state.”

Dr. Glibert told participants that two of the country’s biggest challenges were to improve surveillance and to change farming systems. He warned against prescriptive solutions telling people to change and called for a process-driven approach, consulting farmers to listen to their points of view and offering incentives.” So, there is push and pull. They (farmers) will be pushed by legislation but they will be pulled by giving them access to markets. Consumers may be uneasy with chicken but if they are assured that it is of good quality, and for it to be good quality it might cost a little more in a secure market chain, then they have peace of mind, and the farmer feels that he’s doing a service and getting the profit incentive to do that.”

Dr. Anni McLeod, a senior officer with FAO’s Livestock Division, sounded a word of caution about the impact of messages transmitted to people via mass media. She said studies carried out in Viet Nam were showing that repeated mass media messages were losing their effectiveness. “People have said that they hear the messages but they don't really think it’s something meant for them. They feel that they will manage in their own way, and that repeatedly hearing the same messages over and over again does not really have an impact on them.” In response, conference participants concluded that it was important to have much more personal discussion with communities about how they see risks and how they are dealing with the disease rather than constantly giving them the same message over time. “For many people in Viet Nam,” McLeod said, “avian influenza is a part of life, it’s not unusual, so we have to think about more direct ways to communicate with people, ways that are more related to their lives, and involve listening to and talking to people.”
(FAO 6.19.08)

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

2008
Bangladesh / 1 (0)
China / 3 (3)
Egypt / 7 (3)
Indonesia / 18 (15)
Viet Nam / 5 (5)
Total / 31 (24)

2007
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)

2006
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)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 20 (13)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 98 (43)

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

2003
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: 385 (243).
(WHO 6.19.08 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 6.17.08):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Hong Kong: Officials aim for complete closure of poultry industry
The poultry industry has been given an official ultimatum to accept a HKD 1 billion [USD 128.1 million] government compensation package to shut down their businesses or face an uncertain future. The city’s 469 chicken retailers have been told they must decide what to do by 24 Jul 2008 while farmers, wholesalers, and transport workers have been given until 24 Sep 2008.

Secretary for Food and Health, York Chow Yat-ngok, said this was the government’s final offer after a meeting of the Executive Council on 24 Jun 2008. As well as retailers, Hong Kong has 71 wholesalers, 50 chicken farms, and 266 transport workers who depend on the trade for their livelihood. However, if the retailers accept the buyout deal it will effectively end the businesses of the rest of the sector as well as Hong Kong’s culture of cooking live chickens. The need for central slaughtering by 2011 may also be made redundant. Chow expressed confidence that most of the retailers will accept the deal, which is more than three times the 2005 Voluntary Surrender Scheme.

Many of the traders said they can’t operate under the overnight ban and they are also considering the risk of facing another bird flu outbreak within the next few years, he said. But the government will only approve the offer when 90 percent of the trade accepts it. Another offer will not be offered in the future before central slaughtering, Chow added. A source said the government has improved the deal for retailers with an increase of almost HKD 100 million [USD 12.8 million] or over 20 percent to a total of HKD 513 million [USD 65.7 million].

A source said the increase was justified. “If we terminate the trade’s tools for living out of public health concerns, we must be more reasonable in our offer,” the source said, adding that no further increase is expected after any future negotiations. Retailers who choose to resume operation on 2 Jul 2008 must operate under an overnight ban that requires keeping live chickens in the stalls between 8 pm and 5 am. Violators are subject to a penalty of HKD 50,000 (USD 6,406) and six months’ imprisonment.
(ProMED 6.27.08)

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2. Infectious Disease News

Global
Philippines: Dengue on the rise, authorities step up information campaign for rainy season
Health officials in Caloocan City have recorded a 100-percent increase in dengue cases in the first five months of 2008, compared to the same period in 2007. The city health officer Claire Clemente said they recorded 630 cases from 1 Jan-29 May 2008. Of the 630 cases, five died. Clemente said most of the dengue victims were males. She said the city government is now stepping up its information campaign against dengue, now that the rainy season is approaching.

In other areas of the Philippines: Bago, Silay, and Talisay had the most number of dengue cases from January-June 2008, a report submitted by Provincial Health officer Luisa Efren to the Office of the Governor stated. The report noted an uncommon rise in dengue cases in Bago City with 56 cases, Silay City with 55, and Talisay City with 52 recorded cases.
(ProMED 6.18.08)

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Asia
China (Shanghai): Health officials report first child death of hand, foot and mouth disease
The Shanghai Health Bureau on 17 Jun 2008 confirmed the city’s first pediatric death of hand, foot and mouth disease (HFMD). A two-year-old boy was sent to the Shanghai Public Health Clinic Center for treatment on the evening of 14 May 2008, where he was diagnosed as having HFMD. Emergency treatment failed and he died a few hours later, according to the bureau.

Shanghai reported 10,340 HFMD cases in the first five months of 2008. The city is not on the Health Ministry’s list of the regions worst hit by the epidemic. The ministry reported earlier last week that there were more than 176,000 HFMD cases reported nationwide in May 2008. Daily reported cases declined from 11,501 at the peak on 14 May 2008 to 3,922 on 5 Jun 2008.
(ProMED 6.17.08)

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Indonesia: Despite control efforts, dengue is increasing in some provinces
Cases of dengue fever in the Jakarta Capital again increased over the last 2 months. From April to May 2008, some 1,000 additional cases were reported. The public relations official of the Health Service of Jakarta, Tini Suryani, said on 13 Jun 2008 that during April there were at least 3,741 cases and three of them died. In May, 4,774 cases were recorded with four deaths, indicating an increase of 1,031 dengue cases in Jakarta. A member of the local government commission to control dengue, Achmad Husein Alaydrus, questioned the eradication program of the mosquito-breeding sites that has been carried out up until now. He said the program must be reviewed again. According to the Jakarta Regional Government, the eradication programs of mosquito breeding-sites are carried out for 30 minutes every Friday. This means that every Friday all office complexes must allow 30 minutes in order to carry out the elimination of mosquito-breeding sites in order to prevent dengue fever. This pattern in fact was carried out in Cuba and was successful.

In South Kalimantan Province, during the period January-May 2008, 260 residents were afflicted by dengue fever, including six who died. The number of recorded South Kalimantan residents who contracted dengue in 2007 was 1,000 people spread over 13 cities/regencies in South Kalimantan.
(ProMED 6.18.08)

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Philippines: Officials note high incidence of leptospirosis infection
The Department of Health (DOH) noted the high incidence of leptospirosis cases in the Davao Region, a deadly disease caused by Leptospira bacterium that can reside in the kidneys of rats (as well as other rodents and other animals.) Dr. Rogelio Penera, medical specialist of the DOH (Region XI), warned the public to be careful especially those in flooded areas, as urine of rodents are carried by waters. He said the bacterium could pass through open wounds in humans and is common during rainy seasons mostly in urban areas although there are also cases in rice farms where rats thrive. Because of the wide range of symptoms the infection is often wrongly diagnosed. This leads to a lower reported number of cases than the actual number of cases of leptospirosis.
(ProMED 6.26.08)

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Russia: Dozens infected with Trichinella after eating bear meat
Twenty-six people from Zabaykalye have been infected with Trichinella after eating bear meat. The majority of them are hunters and relatives and friends of hunters. According to the Russian Sanitary surveillance officer at the center of Chita, N. Rodina, 14 are from the village of Tungokochen, and 12 are from Chita. The source of the infection was bear meat, which is considered to be a special dish and which contained Trichinella. In all, 65 people, including nine children, have eaten the meat from the infected bear.

In another outbreak, 60 people have trichinellosis in Tomsk (Molodejniy Kargasokskiy district) after eating meat from a Trichinella-infected bear. It is the first time a mass outbreak of trichinellosis has been registered in Tomsk. The bear was illegally shot and slaughtered without proper veterinary inspection. A veterinarian and a local police officer are among the infected people.

(This outbreak took place in two different cities but within the same Siberian Federal District of Russia simultaneously. In both cases, bear meat was the source of the Trichinella, and it is possible that the source of the meat was the same animal. Bear meat is apparently distributed through informal supply chains without proper inspection. Trichinae are not a problem if the meat is sufficiently cooked, but if used uncooked — in sausages, for example —Trichinae can remain infective for years. The arctic strain of Trichinella, Trichinella native, is resistant to freezing.)
(ProMED 6.22.08)

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Russia: Health officials see a rise in Crimean-Congo hemorrhagic fever
A Dagestan woman has been registered as a case of Crimean-Congo hemorrhagic fever (CCHF). According to the head of the local health authority, Zoya Magometowa, the woman was bitten by a tick in her abdominal region while milking a cow on 16 Apr 2008. Two days later when her condition deteriorated, she sought medical help. The course of the patient’s disease was mild and the woman was discharged from hospital.

Inhabitants of Volgograd Oblast have contracted CCHF. The Healthcare Committee of the Volgograd Oblast said that two cases of Crimean-Congo hemorrhagic fever (CCHF) were registered in the region on 16 Jun 2008. Both cases have been confirmed by laboratory tests. Since the beginning of spring 334 tick bites have been registered in Volgograd Oblast.

The first case of CCHF has been registered in the Astrakhan Oblast. According to the regional administration of Rospotrebnadzor a 24-year-old woman from Ikryaninskaya region contracted the infection. She has been admitted to a local hospital. Overall 783 people have sought medical treatment because of tick bites in this region in 2008 and half of them were children. The corresponding figure for 2007 was 631.
(ProMED 6.13.08 & 6.20.08)

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Vietnam: Southern provinces hit hard by dengue
Around 5,000 cases of dengue fever have hit southern provinces. The number is expected to rise in Tien Giang, Ca Mau and Bac Lieu, among others. The incidence of dengue so far in 2008 has doubled to 1,000 cases over the same period in 2007, according to Ca Mau Province’s Preventative Health Center. The epidemic is set to increase in the remaining weeks of June 2008, according to Hoang Hai Dang, the center’s deputy head.

Tran Van Thoi, Nam Can and Tran Van Thoi General Hospitals in Ca Mau Province were operating past full capacity due to a surge of new patients. Tien Giang Province was also hit hard, with more than 1,000 cases in Go Cong Dong, Cai Lay and Cho Gao Districts and My Tho City. A lack of pesticides and concrete methods for preventing the disease for locals is to blame for the disease's spread, according to health officials in the delta.
(ProMED 6.22.08)

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Americas
Canada: Fraser Valley health officials identify 47 cases of mumps
Health officials are reminding all children and adults to make sure their immunizations are up to date after an outbreak of 47 cases of mumps in the eastern Fraser Valley, most of them in Chilliwack. “Certainly, the number of cases is unusual,” said Dr. Nadine Loewen of the Fraser Health Authority. She said in 2007, there were 11 cases in the area but none in 2003 and 2005, and the second largest outbreak of 34 cases dates back to 1997.

The virus, which affects the salivary glands and causes swollen cheeks, among other symptoms, has affected all ages, from a two-year-old to a 59-year-old, said Loewen. It’s likely a person who wasn’t immunized against mumps picked up the virus in Alberta, where there is also an outbreak, and spread it to others who weren’t immunized. There are also sporadic cases in Abbotsford, Agassiz and Mission, and officials are determining whether they’re connected to the Chilliwack outbreak.
(ProMED 6.15.08)

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USA: Multistate outbreak of Salmonella infection from tomatoes continues
Since April 2008, 652 persons infected with Salmonella (enterica serotype) Saintpaul with the same genetic fingerprint have been identified in 34 states and the District of Columbia. These were identified because clinical laboratories in all states send strains from ill persons to their State public health laboratory for characterization. The increase in reported ill persons since the last update is not thought to be due to a large number of new infections. The number of reported ill persons increased mainly because some states improved surveillance in response to this outbreak and because laboratory identification of many previously submitted strains was completed.

In particular, one new state, Nevada reported ill persons. The number of ill persons identified in each state is as follows: Arkansas (3 persons), Arizona (34), California (8), Colorado (5), Connecticut (4), Florida (1), Georgia (14), Idaho (3), Illinois (45), Indiana (9), Kansas (9), Kentucky (1), Maryland (18), Massachusetts (14), Michigan (4), Missouri (12), New Hampshire (1), Nevada (4), New Jersey (4), New Mexico (79), New York (18), North Carolina (1), Ohio (3), Oklahoma (17), Oregon (5), Pennsylvania (5), Rhode Island (2), Tennessee (5), Texas (293), Utah (2), Virginia (21), Vermont (1), Washington (1), Wisconsin (5), and the District of Columbia (1).

Among the 325 persons with information available, illnesses began between 10 Apr 2008 and 13 Jun 2008. Patients range in age from less than 1 to 99 years; 50 percent are female. At least 71 persons were hospitalized. No deaths have been officially attributed to this outbreak. Only three persons infected with this strain of S. Saintpaul were identified in the country during the same period in 2007.
(ProMED 6.25.08)

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USA (Ohio & Michigan): Multistate outbreak of E. coli infection may be linked to ground beef
The CDC said on 24 Jun 2008 outbreaks of E. coli (O157:H7) in Michigan and Ohio are linked, and health officials in both states suspect the outbreak was caused by ground beef. Health officials in Michigan said on 24 Jun 2008 more than half of the 15 people in the state with confirmed E. coli cases reported purchasing ground beef from Kroger Food Stores, the largest USA grocery chain. “We were notified today that E. coli illnesses reported in Michigan and Ohio have been linked to products purchased in some of our stores in those states,” said Kroger spokeswoman Meghan Glynn. She said the illnesses were reported between 31 May 2008 and 8 Jun 2008. “Any ground beef sold during that period is no longer available in our stores,” Glynn said.

Glynn said Ohio and Michigan health authorities have not identified the supplier or the specific type of ground beef that caused the illnesses. “We purchase our ground beef from major suppliers in the industry and we are working with federal, state, and local agencies to identify the supplier,” she said. As of 23 Jun 2008, the CDC said it had confirmed 24 cases of E. coli that shared the same genetic fingerprint and characteristics, indicating they were related. Of those 24, the CDC said 11 cases were reported in Michigan and 13 in Ohio; 14 people have been hospitalized, and one has developed a type of kidney failure called hemolytic-uremic syndrome, the CDC said. No deaths have been reported.
(ProMED 6.25.08)

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

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WEST NILE VIRUS (North America)
Canada: No WNV human cases or virus detected in birds reported

USA (Newly reported for the period 9-24 Jun 2008) States reporting WNV detected: Arkansas, Connecticut, Missouri, North Dakota, Puerto Rico, and Utah

States reporting new human cases: California and North Dakota. Total human cases for 2008: 13 with no fatalities.
(ProMED 6.27.08)

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4. Articles
Influenza Activity — United States and Worldwide, 2007–08 Season
MMWR Weekly, 2008;57(25):692-697
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5725a5.htm?s_cid=mm5725a5_e

Introduction
During the 2007-2008 influenza season, influenza activity peaked in mid-February 2008 in the United States and was associated with greater mortality and higher rates of hospitalization of children aged 0-4 years, compared with each of the previous 3 seasons. In the United States, influenza A (H1N1) was the predominant strain early in the season; influenza A (H3N2) viruses increased in circulation in January 2008 and predominated overall. While influenza A (H1N1), A (H3N2), and B viruses co-circulated worldwide, influenza A (H1N1) viruses were most commonly reported in Canada, Europe, and Africa, and influenza B viruses were predominant in most Asian countries. This report summarizes influenza activity in the United States and worldwide during the 2007-2008 influenza season (30 Sep 2007 to 17 May 2008).
(ProMED 6.27.08)

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Virus transfer from personal protective equipment to healthcare employees’ skin and clothing
Casanova L, et al. Emerging Infectious Diseases. 2008 Aug; [Epub ahead of print]
http://www.cdc.gov/eid/content/14/8/pdfs/08-0085.pdf

Introduction
Caring for patients with communicable diseases places healthcare workers (HCWs) at risk. Infected HCWs may not only incur serious illness or death themselves but may spread infection to others. Methods to prevent HCW infections include vaccination, hand hygiene, and isolation of patients with communicable diseases.

A key aspect of patient isolation is proper use of personal protective equipment (PPE) to protect HCWs from pathogen exposure during patient care. PPE includes use of barriers (gowns, gloves, eye shields) and respiratory protection (masks, respirators) to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. The importance of PPE was underscored in the recent outbreak of severe acute respiratory syndrome (SARS). HCWs accounted for ≈20% of cases; failure to properly use PPE was a risk factor for HCW infection.

This outbreak raised concern that HCWs could contaminate their skin or clothes with pathogens during PPE removal, resulting in accidental self-inoculation and virus spread to patients, other HCWs, or fomites. The Centers for Disease Control and Prevention (CDC) addressed this concern by designing a protocol to minimize contamination to the wearer during PPE removal (Figure 1). However, the effectiveness of this protocol in preventing self-contamination has not been validated. To determine if removing PPE according to the CDC protocol prevents viral contamination of the wearer, a human challenge study was undertaken using a nonpathogenic virus.
(CIDRAP 6.24.08)

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An adjuvanted, low-dose, pandemic influenza A (H5N1) vaccine candidate is safe, immunogenic, and induces cross-reactive immune responses in healthy adults
Levie K, et al. The Journal of Infectious Diseases. 2008;198:000–000
http://www.journals.uchicago.edu/doi/abs/10.1086/590913

Background
To protect a naive global population against pandemic influenza, pandemic vaccines should be effective at low antigen doses, because of limited manufacturing capacity.

Methods
In a multicenter, randomized, blind-observer phase 1 trial, groups of 50 healthy young adults received 2 doses, 21 days apart, of influenza A/Vietnam/1194/2004 NIBRG-14 (H5N1) vaccine containing 1.9, 3.8, 7.5 or 15 μg of hemagglutinin with oil-in-water emulsion adjuvant or 7.5 μg of hemagglutinin without adjuvant. Safety was monitored to day 42. Homologous hemagglutination-inhibition (HI) and microneutralization titers were determined after each vaccination. Cross-reactivity against A/Indonesia/05/2005 RG2 was tested after the second vaccination.

Results
No vaccine-related significant or serious adverse events occurred. Injection site reactions, but not systemic reactions, were more frequent with adjuvant than without. Even with only 1.9 μg of hemagglutinin plus adjuvant, 72% of subjects had HI titers 1:32 after 2 doses. This proportion was 81%-89% with higher adjuvanted doses but was only 34% without adjuvant. Adjuvanted vaccine induced cross-neutralizing antibodies in 39%-65% of samples, versus 7% without adjuvant.

Conclusions
The emulsion-adjuvanted pandemic influenza vaccine candidate was safe, immunogenic, and induced cross-reactive antibodies. This adjuvanted 1.9-μg candidate is the lowest effective dose tested to date. This could have a major impact on prepandemic vaccination strategies with stockpiled batches of vaccine.
(CIDRAP 6.24.08)

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Immune responses of healthy subjects to a single dose of intramuscular inactivated influenza A/Vietnam/1203/2004 (H5N1) vaccine after priming with an antigenic variant
Goji NA, et al. The Journal of Infectious Diseases. 2008;198:000–000.
http://www.journals.uchicago.edu/doi/abs/10.1086/590916

Background
We administered a single dose of influenza A/Vietnam/1203/2004 (H5N1, clade 1) vaccine to subjects who had received 2 doses of influenza A/Hong Kong/156/1997 (H5N1, clade 0) vaccine in 1998.

Methods
Thirty-seven subjects previously vaccinated with a baculovirus-expressed recombinant hemagglutinin A/Hong Kong/156/1997 vaccine in 1998 received a single intramuscular dose of 90 μg of inactivated subvirion A/Vietnam/1203/2004 vaccine in 2006. Serum antibody was measured before vaccination and 28 and 56 days after vaccination. Antibody responses were compared with those measured after one or two 90-μg doses in H5-naive subjects.

Results
On day 28 after a single dose, the geometric mean titer (GMT) of hemagglutination-inhibition antibody in primed subjects was 64.0 (95% confidence interval [CI], 37.8-108.5), with 68% responding (4-fold increase in antibody level to a titer of 1:40). In contrast, H5-naive subjects who received two 90-μg doses had a day 56 (28 days after the second dose) GMT of 27.7 (95% CI, 20.3-38.0), with only 43% responding.

Conclusions
This study suggests that priming can result in immune responses to a single dose of an antigenically variant strain of H5N1 influenza virus and could be a useful strategy for pandemic control.
(CIDRAP 6.24.08)

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Clinical review: Influenza pandemic — physicians and their obligations
Anantham D, et al. Critical Care. 2008;12:217.
http://ccforum.com/content/12/3/217/abstract

Abstract
An influenza pandemic threatens to be the most lethal public health crisis to confront the world. Physicians will have critical roles in diagnosis, containment and treatment of influenza, and their commitment to treat despite increased personal risks is essential for a successful public health response. The obligations of the medical profession stem from the unique skills of its practitioners, who are able to provide more effective aid than the general public in a medical emergency. The free choice of profession and the societal contract from which doctors derive substantial benefits affirm this commitment. In hospitals, the duty will fall upon specialties that are most qualified to deal with an influenza pandemic, such as critical care, pulmonology, anesthesiology and emergency medicine. It is unrealistic to expect that this obligation to treat should be burdened with unlimited risks. Instead, risks should be minimized and justified against the effectiveness of interventions. Institutional and public cooperation in logistics, remuneration and psychological/legal support may help remove the barriers to the ability to treat. By stepping forward in duty during such a pandemic, physicians will be able to reaffirm the ethical center of the profession and lead the rest of the healthcare team in overcoming the medical crisis.
(CIDRAP 6.24.08)

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Tackle the problem when it gets here: pandemic preparedness among small and medium businesses
Watkins RE, et al. Qualitative Health Research. 2008;18(7):902-912.
http://qhr.sagepub.com/cgi/content/abstract/18/7/902

Abstract
Globally, governments and health authorities are preparing for pandemic influenza and producing resources to promote preparedness planning; however, there is little information available to inform the design of strategies to promote preparedness. Three focus groups were conducted to identify and to describe beliefs and perceptions about pandemic influenza and response planning among small and medium business owners and managers. Most participants were not concerned about the risk of pandemic influenza, and none had engaged in any planning for a pandemic. Findings show that participants were uncertain of the modes of transmission of pandemic influenza and what precautions could be taken prior to, or in the event of, a pandemic. Among the most important findings was participants' perceived inability to effectively prevent or control the spread of influenza within their workplace. These findings have important implications for the design of communication strategies to promote preparedness.
(CIDRAP 6.22.08)

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Mitigating pandemic influenza: ethics of implementing a school closure policy
Berkman BE. Journal of Public Health Management & Practice. 2008;14(4):372-378.
http://www.jphmp.com/pt/re/jphmp

Abstract
Pandemic influenza response plans have placed a significant emphasis on school closures as a community mitigation strategy. However, school closures raise serious ethical concerns, many of which have been largely overlooked. First, evidence of this intervention's efficacy has not yet been firmly established, calling into question whether it will be useful against the threat. Second, school closures have the potential to create serious adverse consequences, which will disproportionately affect vulnerable populations. Thus, policy makers should focus on gathering more evidence about the efficacy of school closures and on strengthening communication and transparency about the strengths and weaknesses of any school-closure plan that they decide to adopt. Policy makers should also consider intermediate options, such as partial school closures, which might provide ways to reap many of the benefits of school closings, while minimizing the costs. Finally, policy makers must labor to ensure that the benefits and the burdens of any interventions are distributed equitably.
(CIDRAP 6.20.08)

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Primary care physicians and pandemic influenza: an appraisal of the 1918 experience and an assessment of contemporary planning
Lauer J, et al. Journal of Public Health Management & Practice. 2008;14(4):379-386.
http://www.jphmp.com/pt/re/jphmp/

Abstract
This multidisciplinary research project examined the role of primary care physicians in past pandemic flu responses and current planning efforts. Project researchers gathered and synthesized historical research, state and federal planning documents, and interview-based data. The 1918 influenza pandemic presented one model from which to understand the role played by physicians during a large-scale disease outbreak, and the challenges they faced. Contemporary planning documents were assessed for their inclusion of primary care physicians. Literature reviews and interviews comprised the principal sources of information. Findings included the following: (1) primary care physicians do not have the time to engage fully in pandemic planning activities; (2) physicians are willing to serve during a pandemic; however, government support and the availability of resources will affect their level of involvement; (3) communities should develop plans for coordinating local physicians who will allow alternative care sites to be functionally staffed; and (4) full coordination of physicians is not possible under the US healthcare system.
(CIDRAP 6.20.08)

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Pharmacokinetics and tolerability of Oseltamivir (Tamiflu®) combined with probenecid
Holodniy M, et al. Antimictobial Agents and Chemotherapy. Published ahead of print, 16 June 2008.
http://aac.asm.org/cgi/content/abstract/AAC.00047-08v1

Abstract
Oseltamivir is an inhibitor of influenza virus neuraminidase, which is approved for treatment and prophylaxis against influenza A and B. In the event of an influenza pandemic, oseltamivir supplies may be limited; thus, alternative dosing strategies for oseltamivir prophylaxis should be explored. Healthy volunteers were randomized to a 3-arm, open label study and given 75 mg oral oseltamivir q24h (group 1), 75 mg oseltamivir q48h combined with 500 mg probenecid QID (group 2), or 75 mg oseltamivir q48h combined with 500 mg probenecid BID (group 3) for 15 days. Pharmacokinetic data, determined using noncompartmental methods, and safety data are reported. Forty-eight subjects completed the pharmacokinetic analysis. The study drugs were generally well tolerated except for one case of reversible grade-4 thrombocytopenia in group 2. Calculated 90% confidence intervals for the geometric mean ratios between Groups 2 and 3 vs. Group 1 were outside the bioequivalence criteria boundary (0.80-1.25) at 0.63 - 0.89 for Group 2 vs. 1 and 0.57 - 0.90 for Group 3 vs. 1. Steady state oseltamivir carboxylate apparent oral clearance (L/hr) was significantly less in groups 2 (7.4, 6.08-8.71) and 3 (7.19, 6.41-7.98) versus group 1 (9.75 6.91-12.60) (p < 0.05 for both comparisons [ANOVA]). The (arithmetic) mean 48 hr concentration (C48) for Group 2 was not significantly different compared to Group 1 C24 (42 ± 76 vs. 81 ± 54 ng/mL; P = 0.194), but was significantly less for Group 3 versus Group 1 C24 (23 ± 26 vs. 81 ± 54 ng/mL; P=0.012). Alternate day dosing of oseltamivir plus four times daily probenecid achieved trough oseltamivir carboxylate concentrations adequate for neuraminidase inhibition in vitro; and this combination should be studied further.
(CIDRAP 6.18.08)

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5. Notifications
PHI2008: Envisioning options for integrated public health information systems for low resource settings: components, connections, partners, strategies
http://www.gpphi.org/conferences


Dates: 18-19 September 2008
Location: Seattle, WA, USA
Venue: Bell Harbor International Conference Center

PHI2008 will be hosted by Global Partners in Public Health Informatics (GPPHI) at the Center for Public Health Informatics (CPHI) at the University of Washington, Seattle, WA, USA. The idea of creating a partnership of governmental and non-governmental organizations, academic institutions and companies to define and develop a vision for addressing health challenges in low-resource settings through information and communications technologies was first articulated at PHI2007: Building a Global Partnership in Public Health Informatics. PHI2007 brought together nearly 200 individuals from across the globe, who created the impetus for the Global Partners in PHI.

The Rockefeller Foundation recently funded the UW Center for Public Health Informatics to begin the planning process for the Global Partners organization. That process will take place over the coming year through an invitational meeting on Public Health Informatics at the Rockefeller Foundation conference center in Bellagio, Italy as well as at the second annual GPPHI meeting — PHI2008 — to be held in September 18-19, 2008 at the Bell Harbor Conference Center, Seattle, Washington, USA. The theme for the PHI2008 meeting is “Envisioning Options for Integrated Public Health Information Systems for Low Resource Settings: Components, Connections, Partners, Strategies.”

Program:

  • Keynote addresses by leading international experts
  • Plenary presentations:
  • National approaches from countries leading the development of integrated public health information systems
  • Creative approaches to collecting and linking data and systems to improve public health practice
  • Strategies for compiling and delivering contextually relevant information for decision support
  • Poster sessions presenting research and applied methodologies and results from public health informatics interventions in low-resource settings throughout the world
  • Panelist discussions of funding opportunities for research and applications development
  • Information exchange and networking opportunities

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BirdFlu 2008: Avian Influenza and Human Health
http://www.libpubmedia.co.uk/Conferences/BirdFlu2008/Home.htm


Date: 10-11 September 2008
Location: Oxford, UK
Venue: St. Hilda's College

The first Oxford avian influenza conference, BirdFlu2008, will address most aspects of basic and applied research on avian influenza viruses and their potential health and socio-economic impact on humans. The conference is aimed at bringing together leading experts from academia and industry, veterinarians, postdoctoral researchers, graduate research students, physicians and doctors, research managers and policy makers. Thus this event will provide an international forum to discover the latest research directions and thinking in this field in academic and commercial settings, to exchange data and ideas and to develop new collaborative links.

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 apecein@u.washington.edu