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EINet Alert ~ Jul 18, 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)
- Hong Kong: Experts fear H5N1 avian influenza poultry vaccine has lost its effectiveness
- Indonesia: Officials suspect 38-year-old cargo worker died from H5N1 avian influenza infection
- Indonesia: Reports examine country's high H5N1 avian influenza death rate
- Indonesia: Officials detail reasons for withholding H5N1 avian influenza viruses
- Japan: Study finds no behavioral effects from Tamiflu
- USA: "Dragon" protein could be key to H5N1 avian influenza vaccines and therapies
- USA: Supercomputers identify potential new drugs to combat avian influenza
- USA: Vical Inc. to present phase 1 Data For pandemic influenza DNA vaccines
- USA: GAO reports progress in state medical surge planning, still much work to be done
- Egypt: Officials declare H5N1 avian influenza endemic in country's poultry flocks

2. Updates
- AVIAN/PANDEMIC INFLUENZA

3. Articles
- Using Quality Improvement Methods To Improve Public Health Emergency Preparedness: PREPARE For Pandemic Influenza
- Clinical and Epidemiological Features of Patients With Confirmed Avian Influenza Presenting to Sulianti Saroso Infectious Diseases Hospital, Indonesia, 2005-2007
- A Global Perspective on Avian Influenza
- Towards Mutual Trust, Transparency and Equity in Virus Sharing Mechanism: The Avian Influenza Case of Indonesia
- Antiviral Drugs for the Control of Pandemic Influenza Virus
- Risk Communications: In Search of a Pandemic

4. Notifications
- PHI2008--Envisioning Options for Integrated Public Health Information Systems for Low Resource Settings: Components, Connections, Partners, Strategies
- Nipah Virus Colloquium 2008
- Community Pan-Flu Preparedness: A Checklist of Key Legal Issues for Healthcare Providers


1. Influenza News

Global
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 / 34 (26)

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 6.19.08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 6.19.08): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 7.14.08):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Asia
Hong Kong: Experts fear H5N1 avian influenza poultry vaccine has lost its effectiveness
A poultry vaccine designed to protect chickens in Hong Kong from H5 avian influenza has lost effectiveness over the past seven years of use, an expert told the Chinese media recently. Yuen Kwok-yung, who heads the microbiology department at the University of Hong Kong, said that the virus is shifting away from the Fujian strain that it was developed for. He told city officials that they must ban all live chickens from markets before the vaccine becomes completely ineffective. Tests on birds in 2005 suggested that the vaccine generated only a quarter of the antibody response it did in 2001. "It takes time for the manufacturers to produce new vaccines. Hong Kong is taking its own risk if it still has live chickens in the market," Yuen said.

In early June, animal health workers detected the virus in poultry feces at several market stalls. They did not say if the testing was done in response to sick or dead birds, and the source of the virus has not been determined. Since then, officials have banned poultry from overnight stays in the market and have proposed a total ban on live poultry in Hong Kong markets. They have offered traders and farmers compensation packages in return for surrendering their sales licenses, but the offer has angered the poultry merchants, who have said the government's offer was too low, according to previous reports.
(CIDRAP 7.10.08)

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Indonesia: Officials suspect 38-year-old cargo worker died from H5N1 avian influenza infection
An Indonesian cargo worker died of bird flu, relatives confirmed on 16 Jul 2008, raising the unofficial toll in the world's hardest hit nation to 111. The government recently started delaying announcements about bird flu fatalities, sometimes by several weeks. But health workers speaking on condition of anonymity confirmed the tests came back positive.

Asnawi Sandri, a 38-year-old father of two, died in the hospital on 10 Jul 2008, days after he came down with symptoms of the disease, including high fever, coughing and breathing difficulties, said Abdul Kadir, his brother-in-law. "The doctor told us he died of bird flu," he said. "The tests came back positive from Jakarta." Sandri lived in Belendung, a village 40 kilometers west of Jakarta, where chickens and ducks freely roam the dusty streets. But it is not clear where he contracted the H5N1 virus, with residents saying none of the poultry had fallen ill or died. Though officials took blood samples from relatives and neighbors, they have not culled any of the birds, Kadir said.

Asked whether she could confirm Sandri's cause of death, Health Ministry spokeswoman Lily Sulistyowati said: "I can't say now whether the tests were positive or negative. . .but we'll let the public know when we release our report at the end of the month." A member of the national bird flu commission, however, reportedly confirmed that the cargo worker died of bird flu, a local health worker said.
(International Herald Tribune 7.17.08)

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Indonesia: Reports examine country's high H5N1 avian influenza death rate
Recent reports from Indonesian health officials tie the high fatality rate in human H5N1 influenza cases there to the difficulty of diagnosing the disease, late treatment with antiviral drugs, and a shortage of well-equipped hospitals. The case-fatality rate (CFR) in Indonesia, which leads the world in H5N1 cases, climbed from 63 percent in 2005 to 80 percent in 2006 and 85.7 percent in 2007, according to a report in the journal Annals Academy of Medicine Singapore. The CFR remains high so far this year, with 15 of 18 cases fatal, or 83.3 percent, according to World Health Organization (WHO) figures. By comparison, the CFR for the global total of 385 cases with 243 deaths is 63.1 percent. The fatality rate with Indonesian cases excluded is 53.2 percent (250 cases with 133 deaths, based on WHO figures).

Two reports in the Singapore journal discuss H5N1 cases in Indonesia. One, written by Indonesian Ministry of Health (MOH) officials, looks at the 116 cases, including 94 fatal ones, the country recorded from 2005 through 2007 (the article also defends Indonesia's refusal to share H5N1 virus isolates with the WHO). A second article, written by hospital physicians, profiles the 27 cases, including 21 fatal ones, treated at Sulianti Saroso Infectious Diseases Hospital in Jakarta during that period. (Both reports, including full-text links, can be found in the Articles section of this bulletin).

According to the second report, Indonesia, like most developing countries, has few primary or secondary care hospitals with the protocols, isolation rooms, or cardio-respiratory support equipment to treat patients critically ill with H5N1 influenza. "This is probably the largest single contributor to the high mortality recorded," says the report, written by Sardikin Giriputro, MD, and colleagues. The MOH report cites the infection's nonspecific early clinical features, medical providers' unfamiliarity with the disease, and the late clinical stage of patients when hospitalized as potential causes of the high mortality. But with the increasing CFR over time, it adds, "the probability of an increase in the virulence of H5N1 viruses should also be considered."

Without a fast, convenient test for H5N1 infection, the disease is difficult to diagnose, the hospital article says. The MOH report says that 71 percent of H5N1 patients in Indonesia were treated with the antiviral drug oseltamivir (Tamiflu), but only two patients received it within the recommended time frame of 48 hours after the first symptoms. Those two patients survived. The survival rate decreased as the time to start treatment increased, the report says. Because early recognition is critical, the hospital report says, "The only conceivable solution is the development of cheap, effective point-of-care tests for H5N1 influenza that are as easy to use as a pregnancy test for example. These could be used by a rural primary healthcare clinic or district hospital in any developing country. This is clearly a challenge for the global scientific community."

In other observations, the MOH report says the CFR was significantly higher among females than males—89 percent versus 73 percent; it offers no explanation for the difference. Adults had a higher CFR than children, 83 percent versus 76 percent, but the difference was not significant. The median age for all case-patients was 20 years.

The MOH report also says that 24 percent of the 116 cases "occurred in 10 clusters of blood-related family members." According to the MOH authors, less than half of all the Indonesian patients—46 percent—had an "unmistakable history of direct contact with sick or dead poultry." Another 36 percent had been near sick or dead poultry without direct contact, and the possible sources for the other 18 percent were unclear, the report says.
(CIDRAP 7.17.08)

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Indonesia: Officials detail reasons for withholding H5N1 avian influenza viruses
In a recent medical journal article, Indonesian officials detailed the rationale for their refusal to share H5N1 influenza virus samples with the World Health Organization (WHO), asserting that it was in part a response to violations of the WHO's own guidelines by scientists and laboratories. A key part of the Indonesian argument is that the WHO issued a statement in March 2005 that its reference labs should not distribute biological specimens to other organizations without permission from the country that supplied them. The report also maintains that withholding the viruses is not a violation of the International Health Regulations (IHR).

The report, authored by four Indonesian scientists and officials, including Health Minister Siti Fadilah Supari, was published in the June issue of Annals Academy of Medicine Singapore. The article gives the Indonesian version of the sequence of events leading to the government's decision in January 2007 to stop sending H5N1 viruses to the WHO's reference labs. The essential reason was, and remains, the concern that samples provided freely by developing countries are used by companies in wealthy countries to develop vaccines and other products that the developing countries can't afford. Indonesia wants a guarantee that it will share in the benefits derived from the isolates it provides. "If the world continues to operate in this way, the discrepancies will become wider and wider," the article says. "The poor will become poorer and the richer become richer. It is the responsibility of all nations to change this situation."

In January 2007 the government made the "drastic decision" to withhold the specimens. Incidents that offended Indonesia began in April 2006, the report says. Scientists at international meetings started reporting results of analyses of H5N1 viruses from Indonesia, without first getting permission from, or even notifying, Indonesia. In other cases, foreign scientists who studied Indonesian viruses sent to the WHO offered to include Indonesian experts and officials as coauthors, but only "at a very late stage of the manuscript writing," according to the journal article. Another episode that played a role was the emergence in May 2006 of Indonesia's largest H5N1 case cluster—one probable and seven confirmed cases, all in blood relatives, seven of them fatal. The cluster raised fears that a pandemic was beginning. One result was that Indonesia was criticized for releasing genetic data only to a small network of researchers linked to the WHO and the CDC, the Indonesian authors wrote. In response to this "unfair" criticism, Indonesia decided that all its H5N1 virus sequence data at the CDC and Hong Kong University should be deposited in GenBank, a public database.

The Indonesian authors maintain that their policy is not a violation of the International Health Regulations (IHR) as revised in 2005. The regulations do not "literally or specifically" require countries to share biological samples related to potential public health emergencies, they argue. In their view, the IHR can be interpreted as requiring only the sharing of public health information, not biological materials.

The report also traces the series of meetings convened by the WHO to try to resolve the virus-sharing issue. At a meeting in November 2007, participants failed to reach a solution. But according to the Indonesian authors, the meeting brought an acknowledgement of a "breakdown of trust" in the global flu surveillance system and thereby "laid the foundation for a fundamental and significant change to the existing system."
(CIDRAP 7.15.08)

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Japan: Study finds no behavioral effects from Tamiflu
A Japanese health ministry official said that a government-supported study has found no evidence that the antiviral drug oseltamivir (Tamiflu) causes abnormal behavior in young people. The unnamed ministry official said the findings would be presented to the government's drug safety panel, which might withdraw a warning it issued Mar 2007 against prescribing the drug for people between ages 10 and 19. "The timing of the presentation is not decided, but we want to do it as soon as possible," the official said. The study included 10,000 people younger than 18 who were diagnosed with seasonal influenza in 2006 and 2007.

Oseltamivir, a neuraminidase inhibitor, is used to prevent and treat seasonal influenza. Because it is considered the most promising drug to date for use during an influenza pandemic, the United States and many other countries are stockpiling it. However, reports of self-injury and delirium in some Japanese children and adolescents who took the drug have raised concerns among regulators in other countries, including the United States. Some of the reported adverse events included the deaths of adolescent patients who fell from windows or balconies or ran into traffic.

Japan has also reported abnormal behaviors in young people who took zanamivir (Relenza), an inhaled neuraminidase inhibitor. However, three rounds of review by the US Food and Drug Administration (FDA) have found no evidence that oseltamivir contributed to neuropsychiataric events. Despite the findings, the FDA this spring advised Roche, the maker of Tamiflu, and GlaxoSmithKline, the maker of Relenza, to add warnings about the reported neuropsychiatric effects to the drug labels. In February 2008, the FDA and Roche sent a letter to US healthcare professionals about the labeling change. The letter acknowledged the reports, noted that the role of Tamiflu in the events had not been established, and advised that flu patients should be monitored for signs of abnormal behavior. In March 2008, Glaxo sent a similar letter to doctors regarding labeling changes for Relenza.
(CIDRAP 7.11.08)

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Americas
USA: "Dragon" protein could be key to H5N1 avian influenza vaccines and therapies
Scientists and researchers have taken a big step closer to a cure for the most common strain of avian influenza, or "bird flu," the potential pandemic that has claimed more than 200 lives and infected nearly 400 people in 14 countries since it was identified in 2003. Researchers at the U.S. Department of Energy's (DOE) Argonne National Laboratory, in conjunction with scientists from China and Singapore, have crystallized and characterized the structure of one of the most important protein complexes of the H5N1 virus, the most common strain of bird flu.

The Argonne study focused on H5N1's RNA polymerase protein, which contains three subunits: PA, PB1 and PB2. After performing X-ray crystallography on the protein crystals, the researchers saw a surprising resemblance in the protein structure's image. "When we mapped out the PA subunit, it looked very much like the head of a dragon," said Argonne biophysicist Andrzej Joachimiak. "One domain looked like the dragon's brains, and the other looked like its mouth."

During RNA replication the phase during which the virus "reproduces" all three of the subunits of the protein assemble themselves in a particular configuration. In order for this congregation to take place, the researchers determined the end of the PB1 subunit has to insert itself and bind to the "dragon's mouth" part of the PA subunit. This unexpected relationship between the two subunits could inspire a number of different therapies or vaccines for H5N1 that rely on muzzling the "dragon's" jaws with another molecule or chemical compound that would block the PB1 subunit's access to the PA site, according to Joachimiak. "If we can put a bit in the dragon's mouth, we can slow or even potentially someday stop the spread of avian flu," he said. "Since we are talking about a relatively small protein surface area, finding a way to inhibit RNA replication in H5N1 seems very feasible."

The results of the study will be reported in an upcoming issue of Nature and can be found online at http://dx.doi.org/10.1038/nature07120.
(Medical News Today 7.16.08)

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USA: Supercomputers identify potential new drugs to combat avian influenza
Like most viruses, the ones that cause flu are armed with an amazing ability to rapidly change their spots. In the case of avian or "bird flu," new strains are popping up all the time and rendering old medicines and vaccines practically useless, which is bad news if you're trying to prevent a possible world-wide epidemic. Now scientists have called upon the power of massive supercomputers to stay ahead of the changes and help keep a fresh supply of anti-virus treatments on hand for public health efforts. One University of California, San Diego team has isolated more than two dozen promising and novel compounds. In some cases, the compounds appeared to be equal or stronger inhibitors than the currently available anti-flu remedies. "If those resistant strains begin to propagate, that's when we're going to be in trouble, because we don't have any anti-virals active against them," said Rommie Amaro, a UC San Diego chemist and member of the research team. "So, we should have something as a backup, and that's exactly why we're working on this."

Using computers at the San Diego Supercomputing Center and the National Center for Supercomputing Applications in Urbana-Champaign, Ill., the group ran complex programs to mimic the movements of a particularly wiggly protein called neuraminidase 1 (or N1), which the avian flu virus uses to spread infection to new cells. As the proteins changed shape according to physical laws, the computers picked up a "hot pocket" that appeared to be quite dynamic and flexible and therefore a target for medicines aimed at stopping the infection process. According to the researchers, the computer simulations represent an advance over other types of 3-D studies, such as crystallography, because they are able to capture a protein's constant twitching and jiggling in a sort-of motion picture instead of snap shots of the receptor at rest.

The team conducted a "virtual screen" of 1,883 compounds selected from the National Cancer Institute Diversity Set, using a computational tool called AutoDock. About 27 compounds showed significant promise, all having potentially the same or stronger bonding affinity with N1 than currently available anti-flu drugs like Tamiflu and Relenza. "The general idea is that we will be able to make a better drug through the strategic targeting of multiple active site pockets," said Amaro. Binding to more than one site by way of a chemical "bridge" can increase a drug's potency. The research now moves into the lab, where the compounds will undergo testing against the actual virus.
(U.S. News and World Report 7.14.08)

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USA: Vical Inc. to present phase 1 Data For pandemic influenza DNA vaccines
Vical Incorporated announced the scheduled presentation of preliminary human safety and immunogenicity data from a Phase 1 trial of the company's Vaxfectin(R)-formulated H5N1 pandemic influenza DNA vaccines on 17 July 2008, at the IBC Life Sciences Next Generation Vaccines conference (National Harbor, MD). Vical's Vice President of Vaccine Research, Larry R. Smith, Ph.D., will present preliminary safety and immunogenicity results from this first human trial of vaccines formulated with the company's patented Vaxfectin(R) adjuvant. Results from this trial will drive the next steps in the company's H5N1 pandemic influenza vaccine program and could expand collaborative opportunities for both the Vaxfectin(R) adjuvant and the Vical DNA vaccine technology.

The double-blind, placebo-controlled, dose-escalation trial was conducted in approximately 100 healthy volunteers age 18 to 45 at three U.S. clinical sites. The trial was designed to assess safety and immunogenicity following intramuscular vaccination with needle and syringe or with the Biojector(R) 2000 needle-free injection system in different cohorts, and to evaluate monovalent and trivalent Vaxfectin(R)-formulated DNA vaccines at various doses.

Vical's monovalent vaccine contains a plasmid (a closed loop of DNA) encoding the hemagglutinin (HA) surface protein from the H5N1 influenza virus strain, A/Vietnam/1203/04. It is designed primarily to elicit antibody responses against the H5 protein, but could elicit T-cell responses against H5 as well. Vical's trivalent vaccine contains the H5 plasmid plus separate plasmids encoding consensus sequences of two highly-conserved influenza virus proteins: nucleoprotein (NP) and ion channel protein (M2). The trivalent vaccine is designed to elicit a combination of T-cell and antibody responses against all three proteins. Both vaccines are formulated with the company's Vaxfectin(R) adjuvant, which has demonstrated effectiveness with a variety of DNA vaccines in multiple animal models as well as dose-sparing and immune-enhancing ability in animals with a conventional seasonal influenza vaccine.
(Medical News Today 7.15.08)

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USA: GAO reports progress in state medical surge planning, still much work to be done
The Government Accountability Office (GAO) released a status report on 14 Jul 2008 on progress states have made toward preparing for a flood of people needing medical care in the wake of an event such as a terrorist attack or an influenza pandemic. The 59-page report, requested by various US Senate and House members, looked at four main components of medical "surge" readiness: increasing hospital capacity, pinpointing alternative care sites, enlisting medical volunteers, and planning for altered standards of care. The GAO also examined how federal departments have helped states make medical surge preparations, as well as what states have done for themselves. Lastly, investigators asked states what concerns they have about their medical surge planning.

GAO auditors found that of 20 states that were surveyed, many have made progress on three of the key components of medical surge planning: increasing hospital capacity, determining alternative care sites, and recruiting volunteer staff. However, only seven of them had adopted or were developing altered standards of medical care in response to a mass-casualty event. [Full text: http://www.gao.gov/new.items/d08668.pdf ].
(CIDRAP 7.14.08)

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Africa
Egypt: Officials declare H5N1 avian influenza endemic in country's poultry flocks
Officials in Egypt on 7 Jul 2008 filed a report with the World Organization for Animal Health (OIE) on several H5N1 outbreaks that have occurred in the country since February 2008 and formally declared that the disease is endemic in Egyptian poultry flocks. The report said Egypt will now file updates on its H5N1 outbreaks only every six months. News about poultry outbreaks in Egypt has been sparse this year, though the country reported a handful of human cases in February, March, and April 2008.

According to the latest OIE report, covering the months February though mid June 2008, Egypt has had 19 new outbreaks since the last update. Seven of them occurred after 1 May 2008. The most recent one was a small outbreak in Luxor that affected backyard chickens, geese, and ducks. About half of the most recent outbreaks occurred in backyard flocks; five occurred at live bird markets and four struck commercial farms, three of which housed layer chickens. Most of the outbreaks were along the Nile River delta.
(CIDRAP 7.10.08)

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

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3. Articles
Using Quality Improvement Methods To Improve Public Health Emergency Preparedness: PREPARE For Pandemic Influenza
Lotstein D, et al. Health Affairs. 2008;27(5):w328-w339
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.5.w328v1

Abstract
Many public health departments seek to improve their capability to respond to large-scale events such as an influenza pandemic. Quality improvement (QI), a structured approach to improving performance, has not been widely applied in public health. We developed and tested a pilot QI collaborative to explore whether QI could help public health departments improve their pandemic preparedness. We demonstrated that this is a promising model for improving public health preparedness and may be useful for improving public health performance overall. Further efforts are needed, however, to encourage the robust implementation of QI in public health.
(CIDRAP 7.15.08)

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Clinical and Epidemiological Features of Patients With Confirmed Avian Influenza Presenting to Sulianti Saroso Infectious Diseases Hospital, Indonesia, 2005-2007
Giriputro S, et al. Ann Acad Med Singapore. 2008;37:454-7
http://www.annals.edu.sg/PDF/37VolNo6Jun2008/V37N6p454.pdf

Introduction
Since the first human cases of H5N1 avian influenza virus infection were detected in Indonesia in 2005, the Sulianti Saroso Infectious Diseases Hospital in Jakarta has managed 27 confirmed cases from September 2005 to December 2007.

Materials and Methods
We reviewed the clinical and epidemiological data of these patients.

Results
Clinical and radiological features were not specific. Most patients were young and had indirect contact with infected poultry. The majority of cases presented to the Infectious Diseases hospital late when the patients already had features of the systemic inflammatory response syndrome (SIRS). The mortality was high at 77%.

Conclusion
There is clearly an urgent need for better field diagnostics and therapeutics for the management of this emerging pathogen.
(CIDRAP 7.15.08)

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A Global Perspective on Avian Influenza
Ong A, et al. Ann Acad Med Singapore. 2008;37:477-81
http://www.annals.edu.sg/PDF/37VolNo6Jun2008/V37N6p477.pdf

Abstract
Global public health security is both a collective aspiration and a mutual responsibility that demands cooperative action at all levels. The expansion of the current H5N1 avian influenza enzootic and its incursion into human health presents a real and significant threat of an influenza pandemic. The world has for the first time an unprecedented opportunity for pandemic preparation. Current global efforts to tackle the H5N1 pandemic threat are centered around the framework of the International Health Regulations (2005) that requires countries to openly share disease intelligence including clinical samples, viruses, and epidemiological information. Present international initiatives also seek to establish more equitable allocation and sharing mechanisms for developing countries, of therapeutic resources, public health interventions and other broadbased support in the event of a pandemic. To be sustainable, country preparatory efforts need to be integrated within wider national emergency preparedness frameworks and emphasize the strengthening of basic capacities in disease surveillance, outbreak response and health systems that can respond to a range of public health emergencies. Such capacity building represents permanent investments in health that will have enduring benefits beyond a pandemic. Preparations must also go beyond the health sector; greater promotion of intersectoral cooperation and an adoption of a whole-of-society approach to preparation is recommended. Broad collaboration is vital in addressing the complex challenge posed by influenza to our collective security.
(CIDRAP 7.15.08)

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Towards Mutual Trust, Transparency and Equity in Virus Sharing Mechanism: The Avian Influenza Case of Indonesia
Sedyaningsih ER, Supari SF, et al. Ann Acad Med Singapore. 2008;37:482-8
http://www.annals.edu.sg/PDF/37VolNo6Jun2008/V37N6p482.pdf

Introduction
As the country hardest hit by avian influenza, both in poultry and in human, Indonesia’s decision to withhold samples of avian influenza virus A (H5N1) has fired up a global controversy. The objective of this paper is to describe the position taken by Indonesia in the events leading to the decision and in those conducted to resolve the situation.

Methods
The sources for this paper are the Indonesian human influenza A(H5N1) case reports and study results, summaries, minutes and reports of national and international meetings of virus sharing, and other related Indonesian and WHO documents.

Results
The International Health Regulations 2005 have been applied in different ways based on different interpretations. While one party insists on the importance of free, non-conditional, virus sharing for risk assessment and risk response, Indonesia – as supported by most of the developing countries – stresses on the more basic principles such as sovereignty of a country over its biological materials, transparency of the global system, and equity between developed and developing nations.

Conclusions
This event demonstrates the unresolved imbalance between the affluent high-tech countries and the poor agriculture-based countries. Regional, global and in-country meetings must continue to be conducted to find solutions acceptable to all.
(CIDRAP 7.17.08)

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Antiviral Drugs for the Control of Pandemic Influenza Virus
Sugrue RJ, et al. Ann Acad Med Singapore. 2008;37:518-24
http://www.annals.edu.sg/PDF/37VolNo6Jun2008/V37N6p518.pdf

Abstract
In the advent of an influenza virus pandemic it is likely that the administration of antiviral drugs will be an important first line of defense against the virus. The drugs currently in use are effective against seasonal influenza virus infection, and some cases have been used in the treatment of patients infected with the avian H5N1 influenza virus. However, it is becoming clear that the emergence of drug-resistant viruses will potentially be a major problem in the future efforts to control influenza virus infection. In addition, during a new pandemic, sufficient quantities of these agents will need to be distributed to many different parts of the world, possibly at short notice. In this review we provide an overview of some of the drugs that are currently available for the treatment and prevention of influenza virus infection. In addition, basic research on influenza virus is providing a much better understanding of the biology of the virus, which is offering the possibility of new anti-influenza virus drugs. We therefore also review some new antiviral strategies that are being reported in the scientific literature, which may form the basis of the next generation of antiviral strategies during a future influenza virus pandemic.
(CIDRAP 7.15.08)

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Risk Communications: In Search of a Pandemic
K U Menon. Ann Acad Med Singapore. 2008;37:525-34
http://www.annals.edu.sg/PDF/37VolNo6Jun2008/V37N6p525.pdf

Abstract
This paper explores the difficulties in managing risk communications in the face of uncertainty of an avian flu pandemic over a protracted period. The communications effort has also been made more difficult by the confusion and cacophony in the media and claims by experts and politicians worldwide. While Singapore secured much praise for its handling of the severe acute respiratory syndrome (SARS) just 4 years earlier which threatened its very existence as a nation-state, it also had to “unlearn” and “unfix” assumptions and mindsets that grew out of that experience. A protracted crisis of uncertainty has also raised difficult questions of sustaining public awareness and alertness. Compounding these problems is the seemingly high reliance of Singaporeans on Government to manage the crisis at all stages. Risk communications has become a crucial necessity in an increasingly troubled world and evokes contradictions for many in medicine and public health – calling on governments to raise the alarm whilst also calming fears at the same time. It is hoped that Singapore’s experience throws up some useful lessons for other countries. The basic principles of risk communications employed are in line with the best practices adopted by many other countries. The experience may also contribute to the ongoing and somewhat contentious debate on whether the manner in which Singapore manages the information flow can be replicated or applied by other states and cultures.
(CIDRAP 7.15.08)

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4. 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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Nipah Virus Colloquium 2008
http://nipah.um.edu.my

Dates: 20-21 Oct 2008
Location: Kuala Lumpur, Malaysia
Venue: University Malaya

In conjunction with the 10th anniversary of the discovery of Nipah virus and in remembrance of the outbreak, a colloquium will be held at University Malaya in Kuala Lumpur, Malaysia on 20-21 Oct 2008. Renowned Nipah virus experts have been invited to describe their latest research, offer an historical perspective of the outbreak and share their personal experiences during the outbreaks. It is hoped that the meeting will help foster closer research collaboration between Nipah virus researchers and generate consensus views on areas concerning Nipah virus that need greater research efforts.
(ProMED 7.10.08)

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Community Pan-Flu Preparedness: A Checklist of Key Legal Issues for Healthcare Providers
Community Pan-Flu Preparedness: A Checklist of Key Legal Issues for Healthcare Providers, co-sponsored by the Centers for Disease Control and Prevention, will address and reflect the perspectives of the myriad professionals along the continuum of healthcare and public health legal preparedness regarding legal impediments, gaps and implementation challenges in the event of a pandemic or other such wide scale disaster.

You can obtain a free copy of the Checklist at:
http://www.healthlawyers.org/Content/NavigationMenu/Public_Interest_and_Affairs/Public_Information_Series/Pan-Flu08.pdf or by emailing Daozhong Jin to request a print copy.
(CIDRAP 7.15.08)

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 apecein@u.washington.edu