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EINet Alert ~ Jul 04, 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)
- Poland (Warsaw): H5N1 avian influenza vaccine causes deaths of 21 homeless, authorities suspect
- Indonesia: Cases of H5N1 avian influenza misdiagnosed as dengue fever and typhoid
- Japan: Kyoto professor creates avian influenza antibodies in ostrich eggs
- South Korea: Officials hope to declare country "bird flu free" in August
- Pakistan: Confusion surrounds suspected H5N1 avian influenza outbreak in poultry
- USA: Slumping sales spur Tamiflu deal
- East Africa: WHO official calls for regional approach to H5N1 avian influenza preparedness
- AVIAN/PANDEMIC INFLUENZA
- The Geography of Transport Systems
- Planning for Pandemic Influenza: Lessons from the Experiences of Thirteen Indiana Counties
- Toward a unified nomenclature system for highly pathogenic avian influenza virus (H5N1) Conference Summary
- Duck migration and past influenza A (H5N1) outbreak areas [letter]
- Avian influenza virus (H5N1) mortality surveillance [letter]
- At-Risk Populations and Pandemic Influenza: Planning Guidance for State, Territorial, Tribal, and Local Health Departments
- Promising Practices for Pandemic Planning: Breaking language barriers with preparedness messages
- 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: 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: 385 (243).
Avian influenza age distribution data from WHO/WPRO: http://www.wpro.who.int/sites/csr/data/data_Graphs.htm.
WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 6.19.08):
WHO’s timeline of important H5N1-related events (last updated 6.17.08):
Poland (Warsaw): H5N1 avian influenza vaccine causes deaths of 21 homeless, authorities suspect
Twenty-one homeless individuals in Poland have died after being given an unproven bird-flu virus vaccine, authorities have charged. Prosecutors have accused three doctors and six nurses of misleading the homeless individuals by telling them they were being given a new influenza vaccine rather than a vaccine for the H5N1 bird-flu virus, The Daily Telegraph said on 3 Jul 2008.
Polish Health Minister Ewa Kopacz has condemned the alleged testing and called for a permanent ban on all involved personnel from future health treatment.
"It is in the interests of all doctors that those who are responsible for this are punished," Kopacz said of 2007's testing efforts. Medical personnel involved with the vaccine trial have denied the allegations, saying the homeless participants knew the type of vaccine they were being paid to take. No definitive link has been found between the unproven bird-flu vaccine and the deaths of the homeless.
Indonesia: Cases of H5N1 avian influenza misdiagnosed as dengue fever and typhoid
Some cases of human bird flu in Indonesia have been variously misdiagnosed as dengue fever and typhoid, resulting in the late administration of drugs, a leading doctor in the country said on 20 Jun 2008.
Indonesia has had the highest number of human H5N1 cases in the world and while mortality rates are around 60 percent in other places, the figure is highest, or at 81 percent, in Indonesia.
Sardikin Giriputro, director of the Sulianti Saroso Infectious Disease Hospital in Indonesia, told an infectious disease conference in Kuala Lumpur that misdiagnoses and the late administration of drugs were partially responsible for the high mortality rates. "It (H5N1) is misdiagnosed initially as dengue, bacterial pneumonia, typhoid and upper respiratory tract infection because of similar clinical features (symptoms)," Giriputro said.
Oseltamivir, otherwise known by its brand Tamiflu, is considered the drug of choice against bird flu and Giriputro said fatalities mounted the later the drug was administered. The survival rate was very high when Tamiflu was given less than two days after the onset of symptoms, but that plunged the later the drug was given.
"It's best if given less than 24 or 36 hours after the onset of symptoms," he said. While rapid test kits are now used to diagnose the disease in animals, Giriputro said these tools were much less reliable in people.
"It depends on the viral load (in samples taken from patients)," he said, adding that test results could turn out negative even if the person was infected with H5N1, simply because there was not enough virus in samples taken. In a bid to reduce the death rate, the Indonesian government has begun distributing Tamiflu to health centers in areas where H5N1 cases have occurred. "When doctors see influenza-like illnesses and where there is evidence of contact with sick poultry, then they give Tamiflu (without waiting for laboratory results)," Giriputro said.
Japan: Kyoto professor creates avian influenza antibodies in ostrich eggs
A bird's immune system stores antibodies from its blood in eggs to protect their chicks. Tsukamoto had noted that ostriches have a strong resistance to viruses and that their eggs are 25 to 30 times heavier than those of chickens. His team developed the technique to create large quantities of antibodies that counter bird flu and human flu viruses. Test drugs for 20,000 people can be obtained from antibodies created from one egg. Another benefit is that ostriches can bear eggs for about 40 years, making it possible to provide antibodies of the same quality for an extended period of time, Tsukamoto said.
South Korea: Officials hope to declare country "bird flu free" in August
Changes to guidelines in the Ramsar Convention, a treaty aimed at protecting global wetlands, will aid understanding of H5N1 in wild birds. The new guidelines, to be presented in South Korea in late October 2008, aim to counter the threat of avian influenza by protecting wetlands inhabited by waterfowl, including improved monitoring of migrating birds and continue to isolate domestic poultry from wild birds. The guidelines also call for more sampling from many nations to better understand the relationship between migratory birds and the spread of avian influenza, and quicker reporting to the international community about species of birds infected. These new guidelines seek to encourage all countries, including developing nations, to adopt these countermeasures to further resist the global spread of H5N1 avian influenza.
Pakistan: Confusion surrounds suspected H5N1 avian influenza outbreak in poultry
They claimed that on the advice of a local Member Provincial Assembly (MPA), who favored the poultry farm owners, the Basic Livestock Officer was made a scapegoat for revealing the information and "transferred within a day as the process usually takes a month."
Earlier, the livestock department had conducted a test of poultry samples at the National Research Institute Islamabad that reportedly detected H5N1 virus in the poultry samples taken from a poultry farm in Tordher, Swabi.
In contrast to this report, the Poultry Association Swabi claimed that they had conducted a similar test of the poultry sample at the Poultry Research Institute Rawalpindi, which identified the virus as H5N9, which was not dangerous for human beings.
Meanwhile, a team of the World Health Organization (WHO) discussed the bird flu issue with the local authorities in Swabi. They discussed the signs and symptoms of the avian influenza with the healthcare providers at the two basic health units and one rural health center in the area. The local health workers were instructed to conduct daily fever monitoring of all poultry workers along with their families. As there is no isolation ward at the District Headquarters Hospital Swabi, the WHO has recommended that suspected cases of avian influenza in the area be shifted to the Khyber Teaching Hospital in Peshawar. The WHO has recommended an early disease warning system in the district to prevent outbreaks of the disease and that specific veterinary staff for bird flu investigation and surveillance in the district be sensitized, it added. Currently there is no proper surveillance system. Sources said that upon the recommendation of the WHO, about 1,700 birds at the poultry farm were culled, whereas 4,300 had already died. The birds had been supplied to the farm by a Lahore-based company.
[According to the immediate notification of Pakistan's Chief Veterinary Officer, submitted on 26 Jun 2008 to the OIE (World Organization for Animal Health), the outbreak described was diagnosed as highly pathogenic avian influenza virus serotype H5N1].
USA: Slumping sales spur Tamiflu deal
Fears of bird flu are receding and sales of the anti-flu drug Tamiflu have slumped. Now its maker is offering a deal to U.S. employers: Pay an annual fee and reserve enough to protect every worker if a new super-flu strikes.
The plan announced on 26 Jun 2008 comes as the federal government also begins a new effort to encourage many businesses to stockpile anti-flu drugs in case of a pandemic. Those private stockpiles would supplement a national stockpile that contains enough doses to treat only a fraction of the population. But stockpiling is a big upfront investment for a threat that may never arrive--and requires replacing supplies whenever drug doses expire. Roche Holding AG says its new plan would remove some of those barriers for companies otherwise interested in Tamiflu.
It would take months to custom-brew a vaccine against a new super-flu. So the government has stockpiled enough antiviral drugs, mostly Tamiflu, to treat 50 million people, and is urging states to purchase enough for 31 million more. The antiviral drugs also can be used to prevent infection before a vaccine arrives.
Until recently, federal health officials didn't recommend employer stockpiling for fear that there wasn't enough Tamiflu being produced to satisfy global demand during regular flu seasons, and to build up the pandemic stockpiles of the United States and other governments. But Roche increased global production 15-fold--and U.S. guidelines proposed earlier this month not only say that employer stockpiling is feasible, but encourage businesses to set aside enough antiviral drugs to help their workers ward off infection and stay on the job.
"Businesses that provide goods or services essential to community health, safety, or well-being have an obligation to plan and prepare for continued operations in the event of a pandemic," say the guidelines.
Roche already has sold varying amounts of Tamiflu to more than 300 U.S. businesses, said George Abercrombie, chief executive of Hoffman-La Roche Inc., the company's U.S. arm.
Under the new program, others companies could reserve Tamiflu instead of buying and storing it themselves. They would pay a yearly fee of $6 for every 10 capsules to be set aside in Roche storage and delivered within 48 hours of demand. Upon delivery, companies would pay the going wholesale price, currently $74 per 10-pack. If a pandemic had begun, the price conceivably could spike. But Abercrombie rejected that as "a bit of a cynical view," adding, "that is not the way our company operates."
In January, Roche announced that sales of Tamiflu had dropped 19 percent to $1.92 billion, as government stockpiling in wake of bird-flu fears eased. Abercrombie said on 26 Jun 2008 that production has been scaled back because of abundant supply--governments around the world had ordered 215 million courses of therapy out of 400 million available--but could ramp up again if necessary.
East Africa: WHO official calls for regional approach to H5N1 avian influenza preparedness
A World Health Organization (WHO) official has called for a regional approach in addressing the risk of avian influenza in east Africa.
Rita Njau is the WHO’s acting director of preventive services in Tanzania. Njau said that east Africa’s major bodies of water contribute to the risk of an avian flu outbreak. “The threat is quite real. . .Migratory birds take this path twice a year as they migrate either from the southern or northern hemisphere. So we do have a potential threat” (of an outbreak), she said.
She said in 2006, when there was an avian flu pandemic in East Asia, WHO took the lead in setting up a task force with relevant institutions within Tanzania to address the threat. The WHO “also worked with other United Nations (UN) agencies and a committee was set up to discuss how to prepare and handle such potential emergencies.” She added, “There were actually two parallel task forces ready to tackle the situation as it would arise.”
Njau said WHO has contingency plans and has learned from what happened in Sudan, where there was an avian flu case. She stressed the importance of getting information to the people so that they know what to do in case of an outbreak.
Njau said more needs to be done about getting East African countries to cooperate in efforts to prevent avian flu. “I don’t think we have done as much as we should. There are no concrete plans for East Africa as a region. But there are plans to look at the issue (avian flu) as an East African problem. These plans involve looking at it holistically as a region problem instead of looking at it country by country.” WHO and other UN agencies have provided technical and financial support to the countries in the region. Most of this support is in technical expertise and testing and detection kits.
The Geography of Transport Systems
Transportation and Pandemics – Chapter 9, Application 4.
Rodrigue JP, et al. (2006), New York: Routledge, 284 pages.
The relationships between transportation and pandemics involves two major sequential dimensions:
Transportation as a vector
Continuity of freight distribution
Planning for Pandemic Influenza: Lessons from the Experiences of Thirteen Indiana Counties
Toward a unified nomenclature system for highly pathogenic avian influenza virus (H5N1) Conference Summary
The continuing geographic expansion and rapid evolution of HPAI subtype H5N1 virus across 3 continents is hindering control and eradication efforts in affected countries and raising public health concerns about a potential influenza pandemic. Since 1997, when the virus was discovered to cause disease and death in humans in Hong Kong, researchers have monitored the movement of the virus from region to region. Its molecular evolution has been characterized to better understand the spread of the virus and thus help prevent its perpetuation in poultry populations. Specific mutations and reassortment events that may enhance the virus's ability to infect and be transmitted to humans have also been scrutinized. Therefore, much effort has been spent to delineate the emerging lineages of the HPAI viruses (H5N1) from their earliest known progenitor, A/goose/Guangdong/96 (Gs/GD). From this ancestral virus, numerous lineages have evolved and because of rapid transcontinental spread, numerous publications have used different names to classify similar (if not identical) groups of viruses within the Gs/GD-like lineage. As a result, discussion and comparison of virus isolates have been hindered by a lack of uniformity in nomenclature, often leading to confusion in the interpretation of research results. The now routine practice of genome sequencing has also dramatically increased the sequence information available for analyses, adding to the complexity of examining the evolutionary relationships among HPAI virus (H5N1) isolates.
To address these issues, an international group of scientists and collaborators, referred to as the H5N1 Evolution Working Group, was convened at the Options for the Control of Influenza VI Conference in June 2007 in Toronto, Ontario, Canada. Their goal was to develop a unified nomenclature system for the classification of HPAI viruses (H5N1) belonging to the Gs/GD-like virus lineage. The initiative, which was encouraged and approved by 3 international agencies (the World Health Organization), the World Organization for Animal Health [OIE], and the Food and Agriculture Organization), set out to unify the nomenclature system to simplify interpretation of sequence and surveillance data from different laboratories and to remove stigmatizing labeling of HPAI virus (H5N1) clades by geographic reference.
Duck migration and past influenza A (H5N1) outbreak areas [letter]
The garganey (Anas querquedula) is the most numerous duck migrating between Eurasia and Africa: ≈2 million gather in the wetlands of Western Africa every northern winter. We report on a spatial correlation between the 2007 migration path of a garganey monitored through satellite telemetry and areas that had major HPAI (H5N1) outbreaks from 2005 through 2007.
Avian influenza virus (H5N1) mortality surveillance [letter]
At-Risk Populations and Pandemic Influenza: Planning Guidance for State, Territorial, Tribal, and Local Health Departments
Public health agencies function to convene and collaborate with community partners in order to protect and promote the health of the population within their jurisdiction. They have a vital role in coordinating key activities that bring together a multitude of partners. In a public health emergency such as pandemic influenza, this convening role is integral to providing guidance and coordination among the people who put support activities into action. Both CDC and ASTHO recognize that many entities have work in progress to develop plans and procedures for at-risk populations in emergencies. This guidance differs from those projects because of its singular focus on pandemic influenza. While many of the recommendations provided in this guidance will be applicable to all-hazards planning, specific considerations come into play in an influenza pandemic that cannot be addressed in all-hazards planning.
Influenza pandemics are widespread events that affect all jurisdictions. They occur over extended periods of time, affect the entire country, and may include a series of waves rather than one isolated outbreak. During a severe pandemic, hospitals and other healthcare centers are likely to be overwhelmed with patients, and business may experience a substantial reduction in staff. This guidance offers public information and recommendations to health departments on how they can provide support to at-risk populations in such an event. Although not the primary audience, community-based organizations (CBOs), faith-based organizations (FBOs), non-profit service providers, businesses, etc, will also find the guidance useful for identifying key areas where they should collaborate with the public health departments to reach at-risk populations.
After the Sep 11 terrorist attacks, officials in some of Minnesota's largest public health departments identified a big gap in their communications strategy: They had few options for getting important health and safety information to diverse state residents who speak limited English. A coalition of communications officials from state, county, and local health and service agencies came together to form the Emergency and Community Health Outreach (ECHO), with the goal of reaching limited–English-proficiency (LEP) groups with vital health and safety information. "In a crisis, you have to have the media," said Lillian McDonald, executive director of ECHO. McDonald had worked in broadcast media for several years before she signed on in 2003 to convene a group of public information officers to devise ways to bring preparedness information to LEP populations. "But the mainstream media wouldn't touch this."
Viewership has expanded threefold, to about 9,500 in the Twin Cities metropolitan area, she said. "Word of mouth has been unbelievable," she said. ECHO recently expanded its coverage across Minnesota through additional public television affiliates. Now, nearly all of the state can access the ECHO broadcasts.
One of the keys to ECHO's acceptance in the LEP populations has been customizing each topic for each language by featuring native-speaking on-air personalities and expert guests. "We're giving communities their own voice—we're creating bridges," she said.
Expanding reach with different formats
Phone messages change monthly and, during nonemergency times, feature seasonal advice, for example avoiding foodborne illnesses during summer months. On ECHO's Web site, viewers can access current and past programs. In addition to the array of languages offered on the television programs, the phone messages are also offered in Russian, Arabic, Oromo, and English. The system also sends fax and e-mail health alerts to community organizations that work with Minnesota's LEP populations. McDonald said despite little money for advertising, publicizing the various components of ECHO hasn't been difficult, given the involvement of communications officials in the system. "Word of mouth has been unbelievable," she said.
Moving toward greater sustainability
McDonald said one promising avenue is for ECHO to become a nonprofit group under the arm of the AMC's nonprofit research foundation. She said ECHO has submitted the proposed arrangement to the Internal Revenue Service and hopes it is approved.
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."
The 1st annual 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 in the field from both 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.