Vol. XI No. 15 ~ EINet News Briefs ~ Jul 25, 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: HealthMap, the newest global infectious disease surveillance tool, values informal sources
- Indonesia (Jakarta): H5N1 avian influenza suspected in 38-year-old man's death
- Viet Nam (Long An): Hundreds of vaccinated chickens die of H5N1 avian influenza infection
- Global: Cumulative number of human cases of avian influenza A/(H5N1)

2. Infectious Disease News
- Australia (Queensland): Anxious watch over veterinary staff in Hendra virus outbreak
- Indonesia (Bali): Officials report chikungunya outbreak
- Russia: Hemorrhagic fever with renal syndrome cases on the rise in 2008
- Russia (Moscow): First case of tularemia reported
- Russia (Krasnoyarsk): Two more young children diagnosed with Yersiniosis
- Russia (Rostov): Area seriously affected by Crimean-Congo hemorrhagic fever
- Russia (Buryatia): Number of suspected anthrax cases reaches 13, eight confirmed
- Viet Nam (Ha Giang): Contaminated meat suspected in anthrax cases
- USA (Florida): More cases of ciguatera poisoning from fish
- USA: Jalapeno pepper likely culprit in Salmonella outbreak
- USA (Georgia): E. coli outbreak continues, spreads to more states
- USA (Alabama): Eastern equine encephalitis virus infection confirmed in a baby
- USA: Measles outbreak has now reached 15 states
- USA (North Carolina): La Crosse encephalitis confirmed in two children

3. Updates
- WEST NILE VIRUS – New cases

4. Articles
- Deaths from Bacterial Pneumonia during 1918–19 Influenza Pandemic
- Protecting residential care facilities from pandemic influenza
- Bacterial Pneumonia and Pandemic Influenza Planning
- Promoting regional disaster preparedness among rural hospitals
- Phase I and II randomised trials of the safety and immunogenicity of a prototype adjuvanted inactivated split-virus influenza A (H5N1) vaccine in healthy adults.

5. Notifications
- No Ordinary Flu: Preparedness comic book in multiple languages
- PHI2008--Envisioning Options for Integrated Public Health Information Systems for Low Resource Settings: Components, Connections, Partners, Strategies
- Guidance on Allocating and Targeting Pandemic Influenza Vaccine

1. Influenza News

Global: HealthMap, the newest global infectious disease surveillance tool, values informal sources
Dr. Larry Brilliant, one of the chiefs of the World Health Organization's (WHO's) smallpox-eradication effort and now executive director of the philanthropy Google.org said, "Is it possible, or even probable, that if we better understood the complexity and magnitude of the many factors that lead to the emergence of infectious disease, that we . . . might be able to get early warning signals from satellites or webcrawlers or phone banks?" Brilliant said in March in a keynote speech at the International Conference on Emerging Infectious Diseases. "Or even better, that we could identify hotspots where newly emerging communicable diseases would arise . . . ?"

The emerging surveillance systems seek very early warnings of outbreaks by analyzing data that originates outside the public health hierarchy. The most recent entry in the field is HealthMap, created by epidemiologist John Brownstein and software developer Clark Freifeld at the Children's Hospital Boston Informatics Program. It began as a pilot project in September 2006 and is described in the July issue of Public Library of Science Medicine (and is partially supported by a grant from Google.org). It joins older nonprofit tools including ProMED, a free Web and email-service of the International Society for Infectious Diseases (ISID); official surveillance efforts by public health agencies, such as the European Union's MedISys and the Global Public Health Intelligence Network (GPHIN), operated by the Public Health Agency of Canada for the WHO; and new grassroots efforts by epidemiologists and computer scientists such as the volunteer effort WhoIsSick.org. Collectively, the new surveillance efforts give teeth to the revised International Health Regulations, which took effect a year ago. The revision formally recognized "informal sources" of disease news as worthy of attention and capable of triggering an international outbreak alert.

What the new surveillance systems share is a refusal to depend on data from public health's established reporting systems, which rely on electronic or paper reports filed by physicians or local health departments and passed layer by layer through the public health hierarchy. Those reports may be exquisitely accurate, because they originate with medical professionals, but they are slow. The new systems balance the risk of sacrificing accuracy against the need for speed, which they get by harvesting and evaluating news stories, blog posts, listserv discussions, and whatever else can be spotted by eye or scraped by a Web-crawling program.

HealthMap, the newest entry, expands on the sources the other systems draw from: It performs fully automated Web-scraping from 14 aggregate sources that collect data from approximately 20,000 sites. It currently collects in English and machine-translates from four other languages, with three more under development. The reports it collects are automatically sifted for duplicates and mistakes, ranked by urgency, and sorted and posted by source, date, location, and disease. Its striking innovation is real-time mapping of the news it gathers. Reports are coded with latitude and longitude and "pinned" to a world map; clicking on the pins produces links to the reports that the system has gathered. The collective result—map plus links plus reports—is gathered into a single open-access Web page. The latest movement in novel reporting is the deployment of sophisticated but easy-to-use tools such as GIS-mapping for very local surveillance. It was the inspiration for WhoIsSick.org, a private project by California software engineer PT Lee that aggregates personal reports of illness into "crowdsourced" snapshots of local disease trends.

Developers of the new surveillance systems agree that incorporating local reports is the necessary next step in the systems' evolution. It may be the most challenging: Data gathered by amateurs is likely to include a higher percentage of inaccurate or irrelevant reports. But it may also be the only route by which areas with no official disease surveillance—or with tight political controls on disease reports—can share information with the rest of the world. In fact, representatives of the public health systems from 23 countries called for enhanced disease surveillance in a December 2007 "call for action," asking industrialized countries to help improve disease reporting especially in Africa and South Asia. Cell-phone text-messaging has already been used in India to report suspected cases of avian flu to provincial animal-health authorities. A new nonprofit named InSTEDD (Innovative Support to Emergencies, Diseases and Disasters) has received grants from the Rockefeller Foundation and Google.org's Predict and Prevent Initiative to bring rapid disease-reporting tools to Mekong Basin villages in Southeast Asia.

HealthMap's founders are working on a pilot project, using ProMED's volunteer moderators, that will test combining machine-harvested reports with human-evaluated ones. "The vision down the road is it would be a two-way line of communication, not just receiving or curating information [but] also inputting new data," Brownstein said. "That would be the concept that would open this up to the global community."
(CIDRAP 7.21.08)


Indonesia (Jakarta): H5N1 avian influenza suspected in 38-year-old man's death
A 38-year-old Indonesian man from a town near Jakarta has reportedly died of H5N1 avian influenza. Indonesia has said it will no longer immediately report new H5N1 cases and will instead provide periodic updates. However, details about the man's death were reported by the AP, which cited the man's brother-in-law and anonymous health workers as its sources. The man was said to have died on 10 Jul 2008 after experiencing a high fever, coughing, and breathing difficulties. "The doctor told us he died of bird flu. The tests came back positive from Jakarta," the man's brother-in-law said. The 38 year old man was from Belendung, a village 24 miles west of Jakarta, the AP reported. Residents of the area said ducks and chickens roam the streets freely, but none were reported sick or dead.

Lily Sulistyowati, a health ministry spokeswoman, said she couldn't confirm the man's death. "But we'll let the public know when we release our report at the end of the month," she said. Under the International Health Regulations, countries are obligated to promptly report human H5N1 influenza cases and other diseases regarded as a potential global health threat to the World Health Organization (WHO), which posts announcements about them and keeps an official count of illnesses and deaths. It is not clear, however, if Indonesia's health ministry has informed WHO of the case. If WHO recognizes the man's infection, it will be listed as Indonesia's 136th H5N1 case and 111th death.
(ProMED 7.19.08)


Viet Nam (Long An): Hundreds of vaccinated chickens die of H5N1 avian influenza infection
Chickens that are vaccinated against bird flu are supposed to be immune to the disease. But hundreds of chickens at a poultry farm in southern Viet Nam have died of avian influenza -- even though the farm owner had earlier reported that the birds were vaccinated against the disease, an official said on 17 Jul 2008.

Since late June 2008, several hundred of the 3,000 chickens in the flock have died at the farm in Tan Lan commune in Long An province, 50 km [31 miles] west of Ho Chi Minh City. They were tested positive for the H5N1 avian-influenza virus, said Mr. Dinh Van The, head of the province's Animal Health Department. The farm owner reported to the department that all birds in the farm had been vaccinated against bird flu, he said. "We suspect that he was not honest in his report, or that the vaccine used at the farm was of bad quality," he added. "We are investigating the case."
(ProMED 7.20.08)


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

Bangladesh / 1 (0)
China / 3 (3)
Egypt / 7 (3)
Indonesia / 18 (15)
Viet Nam / 5 (5)
Total / 34 (26)

***For data on human cases of avian influenza prior to 2008, go to: http://depts.washington.edu/einet/humanh5n1.html

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:
(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):


2. Infectious Disease News

Australia (Queensland): Anxious watch over veterinary staff in Hendra virus outbreak
The owner of a Brisbane veterinary clinic is anxiously waiting to see if more of his staff have contracted the potentially fatal Hendra virus. A nurse and a veterinarian at the Redlands Veterinary Clinic were diagnosed with the virus after treating several infected horses. Owner Dr. David Lovell said, "If we get through this weekend I get the feeling we will be on the road to recovery."

Lovell said staff had visited the nurse and veterinarian Ben Cunneen in the Princess Alexandra Hospital. "They are no way near being cured but it just means they are not deteriorating and that has to be some cause for optimism. But this is not detracting one bit from the seriousness of the condition." The veterinarian of 38 years has closed his horse practice during the crisis as eight other staff who worked closely with affected horses are monitored to see if they are incubating the bug. One of the horses was put down, another died and a third is recovering.

Cunneen and the nurse suffered flu-like symptoms from the virus, which claimed the life of trainer Vic Rail and 14 horses during the last outbreak in 1994. Brisbane Southside Population Health Unit medical officer Dr Brad McCall said the affected pair would have acquired the infection through close contact with the horses in the late stage of illness or at autopsy. There had been no evidence of person to person transmission of the virus and no risk to the wider community. Queensland Health continues to monitor seven people in Proserpine, north Queensland, who have undergone blood tests following a second outbreak of the virus. A virus-affected horse died late last week at a Cannonvale property.
(ProMED 7.20.08)


Indonesia (Bali): Officials report chikungunya outbreak
Chikungunya virus has attacked between 10 and 20 residents in RT 02, Banjar Yeh Sumbul, Yeh Sumbul, Mendoyo over the past two weeks. Most residents claimed that they did not know the cause and regarded it only as a normal fever. Symptoms occurred in residents in several households. Affected individuals reported fever and pain, especially of the hands and feet, characteristic of chikungunya virus infection. An official reported positive confirmation for chikungunya virus infection on 16 Jul 2008. Jamhuri, the chairman (mayor) of RT 02 said that the conditions between adjacent houses in the complex enabled mosquitoes to breed in this settlement. He indicated that in his area about 24 residents had experienced chikungunya virus infection symptoms, but had partly recovered.
(ProMED 7.20.08)


Russia: Hemorrhagic fever with renal syndrome cases on the rise in 2008
A second fatal case of hemorrhagic fever with renal syndrome (HFRS) has been recorded in Bashkortostan. Oleg Mavlutov, head of the Sanitary Inspectorate of Rospotrebnadzor's [Territorial Directorate of the Federal Services for Consumer Protection and Human Welfare] regional management, announced on 11 Jul 2008 that a 50-year-old resident of Ufa had died in hospital. The first fatal case of HFRS was recorded a month before in the infectious diseases hospital of Ufa. Mavlutov stated that: "From the beginning of the epidemiological season more than 400 people with HFRS [have been] recorded in Bashcortostan. This figure almost is twice that recorded last year [2007] observed Mavlutov.

The HFRS situation in Tatarstan has also worsened during 2008; 165 cases have been recorded so far this year, and one person had died. According to the Russian Epidemiological Surveillance System, last year 249 cases were reported with three deaths.
(ProMED 7.14.08 & 7.23.08)


Russia (Moscow): First case of tularemia reported
Physicians from an infectious clinical hospital have reported the first case of tularemia in Moscow in 2008. A 53-year-old Muscovite had acquired tularemia in Naro-Fominsk, a Moscow suburban area, where he was on vacation in the country. For several days he fished and collected mushrooms. Symptoms of the infection began on 26 Jun 2008 with fever and groin swelling. Self-treatment had no success. In the hospital his illness was suspected as tularemia and the diagnosis was confirmed.
(ProMED 7.23.08)


Russia (Krasnoyarsk): Two more young children diagnosed with Yersiniosis
Two more kindergarten-age children have been diagnosed with yersiniosis in Krasnoyarsk and the total number of cases is now 141. 22 children and two adults are still in hospital. The first cohort of children from a summer camp was hospitalized on 20 Jun 2008. The next mass outbreak of yersiniosis among children from another summer camp was registered on 23 Jun 2008 and in another outbreak that began on 27 Jun 2008, 11 children from a kindergarten were hospitalized.
(ProMED 7.18.08)


Russia (Rostov): Area seriously affected by Crimean-Congo hemorrhagic fever
According to data from the Rostov province Territorial Directorate of the Federal Services for Consumer Protection and Human Welfare, since March 2008, 53 cases of Crimean-Congo hemorrhagic fever (CCHF) as a consequence of tick bites have been recorded in the Rostov Oblast of Russia. The most seriously affected areas are the Orlov, Martinov, and Zimovnikov districts. More than 4,000 people have sought medical care following a tick bite.
(ProMED 7.18.08 & 7.23.08)


Russia (Buryatia): Number of suspected anthrax cases reaches 13, eight confirmed
Two more people have been hospitalized in Buryatia because of suspected anthrax. The number of suspected cases of anthrax has reached 13 in Buryatia. The diagnosis has been confirmed in eight of them. Animal die-off continues in the region. The testing of specimens is being carried out in Irkutsk and the results are expected soon. The first cases appeared in the beginning of July 2008 in the settlement of Bayangol.
(ProMED 7.24.08)


Viet Nam (Ha Giang): Contaminated meat suspected in anthrax cases
A total of 13 people in Meo Vac district in the northern mountainous province of Ha Giang are suspected of having caught anthrax after eating meat of sick cattle, said the director of the Ha Giang Department of Health. The health official, Hoang Ngoc Quyen, said tests conducted by the Central Institute for Hygiene and Epidemiology on 13 food poisoning cases in Meo Vac district, Ha Giang province showed some samples were positive for the anthrax bacillus. However, doctors haven't confirmed whether these people (two have died) are infected with anthrax or not. Of those, 11 showed symptoms of anthrax after eating sick cattle meat but they have recovered already.

In late June 2008, some cattle died of an unknown disease, thought to be anthrax. Some people who ate meat from the sick cattle also got sick with symptoms of anthrax. The Preventive Health Agency has asked the Ha Giang Department of Health to take urgent measures to prevent the disease and warn locals not to eat meat of sick animals.
(ProMED 7.18.08)


USA (Florida): More cases of ciguatera poisoning from fish
Numbers are increasing in Florida of people getting sick from toxic fish. The culprit is being narrowed down to grouper, as five more individuals have been diagnosed with ciguatera. This type of poisoning is caused by the consumption of certain subtropical and tropical marine fish.

In Palm Beach County, the health department has confirmed that five more people have become seriously ill from ciguatera in just one week. The health department usually only has a few cases in a year's time. In recent years, Florida has had outbreaks of ciguatera resulting from kingfish and amberjack. Other fish known to cause the illness include barracuda, snapper, jacks, mackerel and triggerfish. Even with the numbers of ciguatera rising in South Florida, the CDC has not issued any warnings against eating grouper at this time. A warning of this kind could hurt a wide range of businesses as grouper is one of the more popularly eaten fish in many restaurants.
(ProMED 7.24.08)


USA: Jalapeno pepper likely culprit in Salmonella outbreak
Call it the smoking jalapeno. After nearly two months of mystery, the USA Food and Drug Administration (FDA) has identified a jalapeño pepper that is contaminated with the same strain of Salmonella Saintpaul that has sickened more than 1,237 people in 43 states. It's the first time during this outbreak that a test has found the strain in a piece of produce. The discovery, which will be announced shortly by the FDA, was reportedly made at a packing plant in McAllen, Texas. The pepper was grown in Mexico, the source said, but was sent to the USA for sale. Authorities are not sure where it was contaminated with organism.

It is also not clear whether the same packing plant, which has not been named by the FDA, also packs tomatoes. The FDA first suspected tomatoes as the cause of the salmonella outbreak and warned consumers on 7 Jun 2008 to avoid certain types of tomatoes. It lifted that warning during the week of 14-18 Jul 2008. Because people continued to get sick after the tomato warning, the FDA and the CDC shifted their investigation to jalapeno and serrano peppers, which sick people had also reported eating. For the FDA, which was under public and political pressure to find the cause of the salmonella outbreak, the discovery of a smoking pepper is a big breakthrough.
(ProMED 7.21.08)


USA (Georgia): E. coli outbreak continues, spreads to more states
A sixth state, Georgia, has reported illnesses related to the latest Escherichia coli [O157] contaminated beef scandal. On 17 Jul 2008, Kentucky, New York, and Indiana were added to the list that had previously only included Ohio and Michigan, where Kroger supermarkets sold bad beef from Nebraska Beef Ltd. The latest outbreak, which was first noted in late May 2008, now has sickened at least 45 people. It is only the latest in a string of recalls of beef in recent months.
(ProMED 7.18.08)


USA (Alabama): Eastern equine encephalitis virus infection confirmed in a baby
Baldwin County Health Department has confirmed the first case of eastern equine encephalitis [EEE] virus infection in a baby. The Health Department detected EEE virus infection in two sentinel chickens in the Orange Beach area back in June 2008 and one sentinel chicken in Gulf Shores.

Health officials say it's important to limit your exposure to mosquitoes to avoid EEE virus infection. Environmentalist Rachel Beck recommends keeping repellant on hand when you are outdoors.

Mosquito-borne viruses like EEE and West Nile virus are transmitted from bird to mosquito to bird. When birds become scarce, sometimes mosquitoes will take blood from mammals like humans and horses. That's how humans and horses become ill. Although there are vaccines available for horses, there is no vaccine for West Nile or EEE viruses available to humans.
(ProMED 7.17.08)


USA: Measles outbreak has now reached 15 states
The largest measles outbreak in the United States in more than a decade has now spread to a total of 15 states. Cases first began popping up in May 2008, when more than 70 people in a dozen states came down with the illness. According to federal health officials, most of those who contracted measles were not vaccinated against the highly contagious virus. The Centers for Disease Control and Prevention (CDC) said the outbreak has been traced to travelers who became sick overseas, returned home, and then spread it to others.

Health officials are warning against the trend of parents not immunizing their children, saying that failing to do so could have devastating effects on the health of the country and world as a whole. According to experts, outbreaks and epidemics will continue throughout the developed world. In June 2008, British health officials said that measles had become an epidemic there for the first time since the mid-1990s due to parents not immunizing their children. Dr. Larry Pickering of the CDC said, "Until better global control is achieved, cases will continue to be imported into the United States and outbreaks will persist as long as there are communities of unvaccinated people."

This outbreak comes just eight years after the virus was declared virtually dead in the US, thanks to a vaccination program which began in the 1960s. According to the CDC, states with reported cases now include: Arizona, Arkansas, California, Georgia, Hawaii, Illinois, Louisiana, Michigan, Missouri, New York, New Mexico, Pennsylvania, Virginia, Wisconsin and Washington state, and Washington, D.C.
(ProMED 7.11.08)


USA (North Carolina): La Crosse encephalitis confirmed in two children
The season's first two cases of the mosquito-borne illness La Crosse encephalitis have been confirmed in two children in western North Carolina. Both children, one in Haywood County and one in Transylvania County, are recovering after contracting the virus. La Crosse is the commonest mosquito-borne virus affecting North Carolinians and is largely confined to western North Carolina. There were 10 reported cases of the virus in North Carolina last year [2007]. The disease is rarely fatal, but a child from Transylvania County did die as a result of infection in 2001.
(ProMED 7.17.08)


3. Updates


Date: 6 - 12 Jul 2008: no WNV human cases
Date: 1 Apr-22 Jul 2008: no WNV detected in birds reported.

Date: 16 - 22 Jul 2008

States newly reporting WNV detected: Colorado, Connecticut, New Jersey, New York, North Carolina, Ohio, Virginia and Washington.

States newly reporting new human cases: Colorado, Louisiana and Utah.

Total human cases for 2008: 43 with no fatalities.
(ProMED 7.23.08)


Since the beginning of May 2008, four travelers from Bali have had dengue confirmed soon after arrival in north Queensland, Australia. All four were probably viraemic whilst in north Queensland, and all four were confirmed as having dengue serotype 3. This indicates that dengue 3 is currently circulating in destinations frequented by travelers/tourists in Bali. The only other importations into north Queensland from Bali this year were two travelers with confirmed serotype 4 dengue in March 2008.
(ProMED 7.21.08)

Kuta has been hit by dengue fever; 15 of the 23 cases reported have been laboratory confirmed. An outbreak of dengue fever has become an epidemic in the Kundur North subdistrict. In one month, 23 cases have been reported in the Karimun RSUD (regional hospital), and 15 were said to be positive. Although the disease caused no deaths, this outbreak made the community very anxious and more careful. The intensity of the outbreak in the subdistrict has increased recently. There have been three dengue foci in the Kundur North Subdistrict, in the Urung, Urung Barat, and Sebele districts.
(ProMED 7.15.08)

During epidemiological week (EW) 26 (22-28 Jun 2008), the Directorate General of Epidemiology reported 52 cases of classical dengue, with 96 per cent of the cases reported by regional health directorates (DIRESAs). The cumulative national total of reported dengue cases is 8,791 through EW 26 [2,049 cases laboratory confirmed, and 4,834 listed as probable]. The cumulative incidence in the country as of EW 26 is 24.7 [dengue cases] per 100,000 population.
(ProMED 7.15.08)

Viet Nam
Ho Chi Minh City and the Mekong Delta are also in the grip of a dengue fever outbreak, with many hospitals overloaded with cases. HCMC Preventive Health Department deputy director Nguyen Dac Tho said about 4,000 cases of dengue fever had been reported in the city in the first six months of 2008, with about 100 new cases recorded every week.

Thu Duc District has reported the highest number of dengue fever cases. Dang Hai Dang, deputy director of Ca Mau Province Preventive Health Department, said the number of patients with dengue fever in his province in June 2008 was nearly double the number reported in the first five months of this year 2008. Tran Van Thoi District has been hardest hit, with 600 cases reported so far in 2008, followed by the U Minh and Thoi Binh districts, and Ca Mau Town, he said. At the Children's Emergency Department of Ca Mau General Hospital, two or three patients share each bed.

The tropical disease, transmitted by the [Aedes aegypti] mosquito, has claimed four lives in Ca Mau Province in 2008. Soc Trang Province has the highest number of cases, with more than 1,900 cases reported so far in 2008. The provincial hospital's children department often struggles to cope with the influx of dengue patients. In Tien Giang Province, more than 1,400 cases of the disease have been reported in 2008. One death, a 7 year old boy, was also reported. Between 300 and 700 cases each of dengue fever have been reported in the Mekong Delta provinces of Dong Thap, Bac Lieu, Kien Giang, and Ben Tre.

Ho Chi Minh City's Pasteur Institute has run prevention and treatment training courses for health officials from Soc Trang, Ca Mau, Bac Lieu, and Hau Giang provinces. Ca Mau's health agency staff have been touring the province to advise residents on how to prevent the disease. The health departments of Soc Trang, Dong Thap, Kien Giang, and HCMC have launched mosquito eradication programs.
(ProMED 7.15.08)


4. Articles
Deaths from Bacterial Pneumonia during 1918–19 Influenza Pandemic
Brundage JF, et al. Emerg Infect Dis. 2008 Aug; [Epub ahead of print].

Deaths during the 1918–19 influenza pandemic have been attributed to a hypervirulent influenza strain. Hence, preparations for the next pandemic focus almost exclusively on vaccine prevention and antiviral treatment for infections with a novel influenza strain. However, we hypothesize that infections with the pandemic strain generally caused self-limited (rarely fatal) illnesses that enabled colonizing strains of bacteria to produce highly lethal pneumonias. This sequential-infection hypothesis is consistent with characteristics of the 1918–19 pandemic, contemporaneous expert opinion, and current knowledge regarding the pathophysiologic effects of influenza viruses and their interactions with respiratory bacteria. This hypothesis suggests opportunities for prevention and treatment during the next pandemic (e.g., with bacterial vaccines and antimicrobial drugs), particularly if a pandemic strain–specific vaccine is unavailable or inaccessible to isolated, crowded, or medically underserved populations.
(CIDRAP 7.18.08)


Protecting residential care facilities from pandemic influenza
Nuno M, et al. PNAS. published online before print July 22, 2008.

It is widely believed that protecting health care facilities against outbreaks of pandemic influenza requires pharmaceutical resources such as antivirals and vaccines. However, early in a pandemic, vaccines will not likely be available and antivirals will probably be of limited supply. The containment of pandemic influenza within acute-care hospitals anywhere is problematic because of open connections with communities. However, other health care institutions, especially those providing care for the disabled, can potentially control community access. We modeled a residential care facility by using a stochastic compartmental model to address the question of whether conditions exist under which nonpharmaceutical interventions (NPIs) alone might prevent the introduction of a pandemic virus. The model projected that with currently recommended staff–visitor interactions and social distancing practices, virus introductions are inevitable in all pandemics, accompanied by rapid internal propagation. The model identified staff reentry as the critical pathway of contagion, and provided estimates of the reduction in risk required to minimize the probability of a virus introduction. By using information on latency for historical and candidate pandemic viruses, we developed NPIs that simulated notions of protective isolation for staff away from the facility that reduced the probability of bringing the pandemic infection back to the facility to levels providing protection over a large range of projected pandemic severities. The proposed form of protective isolation was evaluated for social plausibility by collaborators who operate residential facilities. It appears unavoidable that NPI combinations effective against pandemics more severe than mild imply social disruption that increases with severity.
(CIDRAP 7.22.08)


Bacterial Pneumonia and Pandemic Influenza Planning
Gupta RK, et al. Emerg Infect Dis. 2008 Aug; [Epub ahead of print].

Pandemic influenza planning is well under way across the globe. Antiviral drugs and vaccines have dominated the therapeutic agenda. Far less work has been conducted on stockpiling and planning for deployment of antimicrobial drugs against secondary bacterial pneumonia, a cause of substantial illness and death in previous pandemics and epidemics. In the event of a pandemic, effective antimicrobial drug measures are expected to substantially benefit public health. We address issues regarding use of antimicrobial drugs as stocks of individual agents are diminished and the role of resistance surveillance in informing such policy. Furthermore, vaccination with polysaccharide and conjugate pneumococcal vaccines is considered as part of a pandemic strategy. Most illness and death from influenza are likely to occur in developing countries, where neuraminidase inhibitors and vaccines may be neither affordable nor available; thus, compared with industrialized countries, the benefits of treating bacterial complications in developing countries may be substantially greater.
(CIDRAP 7.18.08)


Promoting regional disaster preparedness among rural hospitals
Edwards JC, et al. The Journal of Rural Health. 2008;24(3):321-5.

Context and Purpose
Rural communities face substantial risks of natural disasters but rural hospitals face multiple obstacles to preparedness. The objective was to create and implement a simple and effective training and planning exercise to assist individual rural hospitals to improve disaster preparedness, as well as to enhance regional collaboration among these hospitals.

The exercise was offered to rural hospitals enrolled with the Rural and Community Health Institute of the Texas A&M University System Health Science Center, and 17 participated. A 3-hour tabletop exercise emphasizing regional issues in a pandemic avian influenza scenario followed by a 1-hour debriefing was implemented in 3 geographic clusters of hospitals. Trained emergency preparedness evaluators documented observations of the exercise on a standard form. Participants were debriefed after the exercise and provided written feedback.

Observations included having insufficient staff for incident command, facility constraints, the need to further develop regional cooperation, and operational and ethical challenges in a pandemic.

The tabletop exercise gave evidence of being a simple and acceptable tool for rural medical planners. It lends itself well to improving medical preparedness, analysis of weak spots, development of regional teamwork, and rapid response.
(CIDRAP 7.22.08)


Phase I and II randomised trials of the safety and immunogenicity of a prototype adjuvanted inactivated split-virus influenza A (H5N1) vaccine in healthy adults.
Nolan TM, et al. Vaccine. 2008;26(33):4160-7.

The primary objective was to evaluate the safety and immunogenicity of a prototype inactivated, split-virus H5N1 (avian influenza A) vaccine. A secondary objective was to assess the cross-reactivity of immune responses to two variant clade 2 H5N1 strains.

In two randomised, dose comparison, parallel assignment, multicentre trials conducted in Australia, healthy adult volunteers received two doses of 7.5 μg or 15 μg H5 haemagglutinin (HA) vaccine ± AlPO4 adjuvant (phase I trial; N = 400) or two doses of 30 μg or 45 μg H5 HA with AlPO4 adjuvant (phase II trial; N = 400). Revaccination with a booster dose was offered 6 months after dose 2 (phase I trial only). Main outcome measures were the change in immunogenicity at each follow-up visit from baseline, measured using HA inhibition (HI) and virus microneutralisation (MN) assays, and the frequency and nature of adverse events (AEs). Computer generated tables were used to randomly allocate treatments; participants and investigators were blinded to treatment allocation.

All formulations were well-tolerated; no unexpected serious adverse events were reported. Two doses of 30 μg or 45 μg H5 HA adjuvanted formulations elicited the highest immune responses, with considerable MN antibody (≥1:20) persistence up to 6 months post-vaccination. The 7.5 and 15 μg formulations (±adjuvant) were less immunogenic than the higher dose formulations; HI and MN antibody titres decreased to near pre-vaccination levels at 6 months but were restored to post-dose 2 levels after the booster dose. Immune responses in the phase I trial demonstrated modest levels of cross-protective MN antibodies against two currently circulating, distinct clade 2 H5N1 strains.

Two doses of prototype 30 μg or 45 μg aluminium-adjuvanted, clade 1 H5N1 vaccines were immunogenic and well-tolerated with considerable 6-month antibody persistence. The prototype H5N1 vaccine also elicited modest levels of cross-protective MN antibodies against variant clade 2 H5N1 strains [ClinicalTrials.gov identifiers: NCT00136331, NCT00320346; Funding: CSL Limited, Australia].
(CIDRAP 7.21.08)


5. Notifications
No Ordinary Flu: Preparedness comic book in multiple languages

To promote pandemic flu preparedness, Public Health - Seattle & King County has developed a 12-page comic book on pandemic flu. Targeting readers of all ages, this story tells the tale of a family’s experience of the 1918 influenza pandemic. It also explains the threat of pandemic flu today, illustrates what to expect during a pandemic (such as school closures), and offers tips to help households prepare. You can order copies (or download) all 12 language versions of the comic (PDF format) at the above link.
(CIDRAP 7.23.08)


PHI2008--Envisioning Options for Integrated Public Health Information Systems for Low Resource Settings: Components, Connections, Partners, Strategies

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."


  • 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


Guidance on Allocating and Targeting Pandemic Influenza Vaccine

Effective allocation of pandemic influenza vaccine will play a critical role in preventing influenza and reducing its effects on health and society when a pandemic arrives. The specific type of influenza that causes a pandemic will not be known until it occurs. Developing a new vaccine in response will take several months and pandemic vaccine may not be available when cases first occur in the United States. Moreover, once vaccine production begins, it will not be possible to make enough new vaccine to protect everyone in the early stages of a pandemic.

The U.S. Government is taking steps to minimize the need to make vaccine allocation decisions by supporting efforts to increase domestic influenza vaccine production capacity. Significant funding is being provided to develop new vaccine technologies that allow production of enough pandemic influenza vaccine for any person in the United States who wants to be vaccinated within six months of a pandemic declaration. Until this goal is met, Federal, State, local and tribal governments, communities, and the private sector will need guidance on who should be vaccinated earlier during the pandemic to best protect our people, communities, and country.

Issues to consider in drafting guidance on pandemic influenza vaccination are different and more complex than in developing recommendations for annual vaccination against seasonal influenza. In contrast with seasonal influenza, during a pandemic nobody in the population is likely to have immunity to the virus, many more people will become ill, and rates of severe illness, complications and death are likely to be much higher and more widely distributed throughout the population. The greater frequency and severity of disease will increase the burden on health care providers and institutions and may disrupt critical products and services in health care and other sectors. National and homeland security could be threatened if illness among military and other critical personnel reduces their capabilities. Because the needs that must be addressed by pandemic vaccination differ from seasonal influenza vaccination, the guidance on vaccination differs as well.

This guidance is intended to provide strong advice to support planning an effective and consistent pandemic response by States and communities. Nevertheless, it is important that plans are flexible as the guidance may be modified based on the status of vaccine technology, the characteristics of pandemic illness, and risk groups for severe disease – factors that will remain unknown until a pandemic actually occurs. Vaccination will be only one of several tools that can be used to fight the spread of influenza when a pandemic emerges. Additional approaches include non-pharmaceutical public health measures in communities, businesses, and households to reduce and slow the spread of infection; using antiviral medications for treatment and prevention; using facemasks and respirators in appropriate settings; and washing hands and covering coughs and sneezes. These strategies will be the initial mainstay of a pandemic response before vaccine is available and continue to have important effects throughout a pandemic. Guidance around vaccine use is meant to be applied in conjunction with and in the context of these other pandemic response efforts. More information about pandemic planning and response measures is provided at www.pandemicflu.gov.
(CIDRAP 7.23.08)