EINet Alert ~ Sep 12, 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)
- Indonesia: Confirmation of two avian influenza H5N1 cases reported earlier
- Indonesia: Supari accuses rich nations of creating influenza viruses for profit
- Laos (Luang Prabang): Report of new avian influenza H5N1 outbreak
- USA (Idaho): Low-pathogenic avian influenza H5N8 hits game farm
- Togo (Lome): Avian influenza hits poultry farm

2. Updates

3. Articles
- Emerging Infectious Diseases - Volume 14, Number 9 – September 2008
- Evaluation of two avian influenza type A rapid antigen tests under Indonesian field conditions
- Pathogenicity of Chinese H5N1 highly pathogenic avian influenza viruses in pigeons
- Dutch Patient dies from Tamiflu-resistant H1N1 virus

4. Notifications
- The 7th International Bird Flu Summit
- Pandemic Influenza Storybook: Narratives from 1918 and 1957 pandemics
- FAO-OIE-WHO Joint Technical Consultation on Avian Influenza at the Human-Animal Interface

1. Influenza News

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

Bangladesh / 1 (0)
China / 3 (3)
Egypt / 7 (3)
Indonesia / 20 (17)
Viet Nam / 5 (5)
Total / 36 (28)

***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: 387 (245).
(WHO 9.10.08 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 8.28.08): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 8.14.08): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html


Indonesia: Confirmation of two avian influenza H5N1 cases reported earlier
Indonesia's health ministry reported that two men have died of H5N1 avian influenza over the past three months, marking the government's first official announcement of human cases since early June 2008, when it said it would provide periodic updates instead of case-by-case notifications. The update—in Bahasa, the language of Indonesia—appeared on the health ministry's Web site, Bloomberg News reported. So far, the government has not posted an English version of the update on the main ministry site or that of the country's avian flu committee.

As recounted by Bloomberg, Indonesia's description of the two cases generally agreed with earlier media accounts. The health ministry said one of the two men was a 20-year-old who died on July 31, 2008. A media report in early August had described him as a 19-year-old from Tangerang, a suburb of Jakarta, who died in late July. He developed symptoms on 20 Jul, was hospitalized on 29 Jul, and died on Jul 31. Reports indicate that chickens from the case's household had died in the week preceding the onset of his symptoms and that he had slaughtered and consumed some of his stock during this period.

The health ministry said the other man was a 38-year-old truck driver from Banten province who got sick on Jul 4, 2008 and was hospitalized in Tangerang five days later. The ministry said he died on Jul 10, Bloomberg reported. Media reports in July had described him as a 38-year-old from Belendung, west of Jakarta, who died on Jul 10. Tests on samples from poultry in the man's neighborhood were pending, the ministry statement said. The health ministry also said that laboratory tests by its research center and the Eijkman Institute on samples from five provinces showed no evidence of human-to-human transmission of avian flu, Bloomberg reported.

Health Minister Siti Fadillah Supari has said the number of bird flu cases surfacing in Indonesia is on the decline. "The number of bird flu cases tends to decrease because the patients infected by the virus have received appropriate and quick medical treatment," she reportedly said 8 Sep 2008. The WHO and Ministry of Health tally of the numbers of cases and fatalities are now in agreement--of the 137 cases confirmed to date in Indonesia, 112 have been fatal.
(CIDRAP 9/9/08; Promed 9/9/08, 9/10/08)


Indonesia: Supari accuses rich nations of creating influenza viruses for profit
Indonesian health minister Siti Fadilah Supari, who is at the center of a controversy over sharing of H5N1 avian influenza virus samples, recently claimed that developed countries are creating new viruses as a means of building new markets for vaccines, according to an Agence France-Presse (AFP) report. In February 2008, Supari published a 182-page book titled Time for the World to Change: God is Behind the Avian Influenza Virus, which alleges that the United States intended to produce a biological weapon with the H5N1 virus and the World Health Organization (WHO) was conspiring to profit from H5N1 vaccines. Supari has said that wealthy nations are creating "new viruses" that are meant to infect people in poorer nations in order to help drug companies sell more vaccines, according to a Sep 7, 2008 AFP report.

"The conspiracy between superpower nations and global organizations isn't a theory, isn't rhetoric, but it's something I've experienced myself," Supari reportedly said. In early 2007 Indonesia announced that it had stopped sharing H5N1 virus samples with the WHO. The country based its action on what it saw as a lack of access to pandemic vaccines that are produced by pharmaceutical companies in developed nations from the shared samples. A WHO working group formed to address the concerns of Indonesia and other developing countries has met several times to work out a virus-sharing agreement between global health officials and developing countries, but has made little progress.

In early June 2008, Supari said the government would no longer report human H5N1 cases and deaths promptly to the WHO. Media outlets reported that she planned to report cases after they were reported in the news media or only at six month intervals. Meanwhile, Amin Subandrio, a scientist who heads Indonesia's avian flu committee, said the government is also withholding the H5N1 virus from the country's own research community, according to the AFP report. "The minister of health is keeping the virus in the laboratories but they are giving no access to Indonesian scientists at the moment," he said.

Subandrio told AFP that though he supports Indonesia's concern about developing nations' lack of access to vaccine supplies and believes changes to the international virus-sharing system are needed, Supari's stances are risky. He said there is no evidence to back up Supari's claim that wealthy nations are conspiring against developing nations to boost profits for pharmaceutical companies. Likewise, Indonesian President Susilo Bambang Yudhoyono appears to support Supari's demands regarding the H5N1 virus-sharing issue, but not her conspiracy allegations, according to the AFP report.
(CIDRAP 9/8/08)


Laos (Luang Prabang): Report of new avian influenza H5N1 outbreak
A government official in Laos said the H5N1 avian influenza virus has been detected in ducks in one of the country's provinces. Yong Chanthalangsy, a foreign ministry spokesman, said the finding prompted the culling of about 7,000 birds in a 1-km radius around the site, according to a report from Agence France-Presse (AFP). He said that no suspected human cases have been identified. Reportedly, a Lao newspaper, the Vientiane Times, reported that the outbreak involved ducks in Luang Prabang province. The outbreak reportedly began on Aug 27 when ducks began to die. They have been banned from transport, trade, and consumption in the district. Several bird flu outbreaks have occurred in Laos since 2004. The most serious outbreak happened in 2007 when two human fatalities were confirmed in the capital city and northern Vientiane province. Laos' last H5N1 outbreaks occurred in February and March 2008, hitting birds at Louang Namtha province.

The country is now able to conduct its own H5N1 laboratory tests. Laos previously relied on facilities in Thailand and Vietnam, but now uses a laboratory that is under construction in Vientiane. The lab was reportedly funded by the Japanese government.
(CIDRAP 9/10/08; Promed 9/10/08)


USA (Idaho): Low-pathogenic avian influenza H5N8 hits game farm
Agriculture officials in Idaho announced that they were investigating an outbreak of low-pathogenic avian influenza at a game farm in the southwestern part of the state after a federal lab confirmed the virus in pheasants. The virus has been identified as subtype H5N8, according to a Sep 3, 2008 report that the US Department of Agriculture (USDA) filed with the World Organization for Animal Health (OIE). The farm contains about 30,000 game birds that are raised for hunting activities, the report said. Besides pheasants, the farm has chukars, partridges, and mallard ducks.

State officials quarantined the farm on Aug 29, 2008 but have not culled any birds at the site, located in Payette County. However, Larry Hawkins, a USDA spokesman, said 300 birds that the farm shipped to California for a bird dog event before the virus was detected were quarantined and culled, the Associated Press (AP) reported. The farm's owner did not report an unusual number of bird deaths, but in late August sent three dead pheasants to a lab at Pennsylvania State University for a diagnostic work-up, according to the OIE report. The lab found Pasturella and Mycoplasma in the samples. Routine tests also revealed avian influenza. Sequence testing at the USDA's National Veterinary Services Laboratory led to the H5N8 finding.

The virus seems to trace back only to the pheasant pen, which contains about 1,000 birds, the report said. Bill Barton, a veterinarian with Idaho's Department of Agriculture, said the pheasants were kept in an outside pen that was covered with plastic mesh. He said they could have been exposed to the virus from wild birds that flew or roosted overhead. Barton said the findings of the investigation will determine how long the birds should be quarantined and if culling is necessary, the AP reported. He said authorities are testing birds at farms within a 2-mile radius of the site and disinfecting the affected game farm.
(CIDRAP 9/5/08)


Togo (Lome): Avian influenza hits poultry farm
The health ministry announced that avian influenza has been confirmed at a poultry farm in the village of Agbata, near the capital Lome, the Associated Press (AP) reported. The statement did not say if the virus was the highly pathogenic H5N1 strain. The government's Web site said samples from dead chickens were reportedly sent to laboratories in Ghana and Italy to identify the virus subtype. The outbreak site is a poultry farm in the southern part of the country that contained more than 4,500 birds. The ministry did not say how many died, but noted that more than 80% of those that were sick died.

Togo's agriculture and livestock ministry tightened a ban on poultry import and stepped up control efforts at ports, markets, and borders with Ghana, Benin, and Burkina Faso, Reuters reported. In late August 2008, two chickens from a poultry market in Benin that were tested during routine surveillance tested positive for the H5N1 virus, according to previous reports. Togo's last H5N1 outbreaks occurred in June 2007 at poultry farms, according to reports from the World Organization for Animal Health (OIE).
(CIDRAP 9/10/08)


2. Updates
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services and includes the website of the Central Fund for Influenza Action. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The Influenza Virus Tracking System can be accessed at: www.who.int/fluvirus_tracker.
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help hospital administrators and state and local health officials prepare for the next influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.pandemicflu.gov/. View archived Webcasts on influenza pandemic planning.
- CIDRAP: http://www.cidrap.umn.edu/ See information on the upcoming “Avoiding the Big 7 Pandemic-Planning Mistakes” Webinar (October 9, 2008).
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/level.php?lang=en&component=19&item=1. The Portal is a developing project for the operation of product networks and information services, for specialists, authorities and the general public.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds and poultry.


3. Articles
Emerging Infectious Diseases - Volume 14, Number 9 – September 2008
The September 2008 issue online at: http://www.cdc.gov/ncidod/eid/. Influenza articles included in this edition are:

- Y. Uchida et al. Highly Pathogenic Avian Influenza Virus (H5N1) Isolated from Whooper Swans, Japan.
- T. Leslie et al. Knowledge, Attitudes, and Practices regarding Avian Influenza (H5N1), Afghanistan
- A.P. Newman et al. Human Case of Swine Influenza A (H1N1) Triple Reassortant Virus Infection, Wisconsin


Evaluation of two avian influenza type A rapid antigen tests under Indonesian field conditions
Loth L et al. J Vet Diagn Invest. 2008 Sep;20(5):642-4.

Abstract. The current study evaluated the test characteristics of 2 commercially available rapid antigen tests for highly pathogenic avian influenza. Diagnostic specimens were collected from free-ranging village chickens in Indonesia. A total of 174 healthy, sick, and dead birds were included in the study. The relative diagnostic test sensitivity and the relative diagnostic test specificity were calculated by using real-time reverse transcription polymerase chain reaction (RT-PCR) as the confirmatory diagnosis. The AnigenR Rapid AIV Ag test had a relative diagnostic sensitivity of 0.69 (95% confidence interval [CI]: 0.56-0.80) and a relative diagnostic specificity of 0.98 (95% CI: 0.93-0.99). The Flu Detect(TM) Antigen Capture test strip had a relative diagnostic sensitivity of 0.71 (95% CI: 0.58-0.82) and a relative diagnostic specificity of 0.98 (95% CI: 0.93-0.99). These tests are a valuable tool for the Indonesian avian influenza control program by reliably and quickly detecting Influenza A virus from oropharyngeal swabs from sick or dying chickens.


Pathogenicity of Chinese H5N1 highly pathogenic avian influenza viruses in pigeons
Beibei Jia et al. Arch Virol. 2008 Sep 9. [Epub ahead of print] http://www.springerlink.com/content/tt6381x466751614/

Abstract. It has long been thought that pigeons are resistant against H5 highly pathogenic avian influenza (HPAI) viruses. Recently, however, highly pathogenic H5N1 avian influenza viruses have demonstrated distinct biological properties that may be capable of causing disease in pigeons. To examine the susceptibility of domestic pigeons to recent H5N1 viruses, we inoculated pigeons using H5N1 viruses isolated in China from 2002 to 2004. Within 21 days following inoculation, all pigeons had survived and fully recovered from temporary clinical signs. However, seroconversion assays demonstrated that several viruses did in fact establish infection in pigeons and caused a certain amount of viral shedding in the oropharynx and cloaca. There was not, however, a definitive relationship between viral shedding and viral origin. Viruses were also inconsistently isolated from various organs of pigeons in infected groups. Pathological examination revealed that the infection had started as respiratory inflammation and caused the most severe lesions in the brain in later stages. These results indicate that pigeons are susceptible to the more recent Asian H5N1 HPAI and could be a source of infection to other animals, including humans.


Dutch Patient dies from Tamiflu-resistant H1N1 virus
Amid concern about rising resistance to oseltamivir (Tamiflu) in influenza A/H1N1 viruses, a Dutch team reported the death of a leukemia patient who was infected with an H1N1 virus that was resistant to the antiviral drug. In a letter in this week's New England Journal of Medicine (NEJM), the authors said the case suggests that oseltamivir-resistant H1N1 viruses can cause disease, despite evidence from animal studies that the resistance mutation makes the viruses much less dangerous. The letter said the man's virus was also resistant to amantadine, an older antiviral drug.

On Aug 20, 2008, the World Health Organization (WHO) reported that 31% of influenza A/H1N1 isolates from 16 countries that conducted recent tests carried the H274Y mutation, which confers resistance to oseltamivir. Resistance levels ranged from 100% (10 of 10 isolates) in Australia to 13% (4 of 32 isolates) in Chile. Researchers have found the oseltamivir-resistant H1N1 virus in 35 countries, including the United States and Canada. The spread of the oseltamivir-resistant H1N1 virus has puzzled experts because it has not been clearly linked to treatment with the drug.

In the case report, the authors wrote that a 67-year-old man who was on chemotherapy in a 3-year battle with chronic lymphocytic leukemia was hospitalized with shortness of breath, a dry cough, and fever. On his second hospital day, he experienced acute respiratory failure, and his physicians placed him on a ventilator and started empirical antibiotic treatment. The patient had patchy lung infiltrates, and tests on samples from his respiratory tract showed he had influenza A/H1N1.

On the sixth hospital day the man received oseltamivir, but by day 13 physicians discontinued the drug because sequence analysis of the virus revealed the H274Y mutation and there was no decrease in the viral load. The authors reported that the mutation was found in samples obtained before the patient began oseltamivir therapy. Records revealed that he had had no contact with patients who were taking oseltamivir.

On the 15th hospital day the man's doctors prescribed amantadine, and after a few days his neutrophil count increased, a sign of bone marrow recovery, the group reported. On day 20 doctors took the patient off the ventilator and instituted zanamivir treatment. However, two days later the man had respiratory failure again, and his medical team put him back on the ventilator and discontinued zanamivir therapy. By day 26 physicians detected no influenza virus, but did note that sequence analysis showed an amantadine-resistance mutation in the viral M2 protein (L26F). They wrote that recovery of the immune system was probably responsible for clearing the virus, because the patient had received only three doses of zanamivir.

A repeat CT scan on day 28 showed that pulmonary infiltrates had progressed. Because of the man's poor prognosis, the ventilator was removed on day 34, and he died three days later. The authors cited animal studies indicating that oseltamivir resistance leaves H1N1 viruses "severely compromised." Despite these reports, they wrote, "the case we describe suggests that this oseltamivir-resistant virus can be pathogenic, at least in an immunocompromised patient."

Van der Vries E et al. Fatal oseltamivir-resistant influenza virus infection. N Engl J Med 2008 Sep 4;359(10):1074-76. http://content.nejm.org/cgi/content/full/359/10/1074
(CIDRAP 9/5/08)


4. Notifications
The 7th International Bird Flu Summit
November 13-14, 2008 in Las Vegas, Nevada. The two-day event will draw on first-hand best practices to create solid business continuity plans that companies and organizations need to prepare for, respond to, and survive a pandemic. Public Health Officials, top leaders and key decision-makers of major companies representing a broad range of industries will meet with distinguished scientists, law enforcers, first responders, and other experts to discuss pandemic prevention, preparedness, response and recovery at the two day summit.

Discussions topics: Surveillance and Data Management; Preparing Communities Strategies; Local Partnership and Participation; Delivery of Vaccine and Antiviral Medication; National Pandemic Influenza Medical Countermeasure; Socio Economic Impact on Poultry Industry; Benefit-risk Assessment: Public Health, Industry and Regulatory Perspectives; Prevention Education Efforts and Risk Communication; Command, Control and Management; Emergency Response Management; Business-Based Planning; School-Based Planning; Community-Based Planning and more.

New Fields http://www.new-fields.com/birdflu7/
1001 Pennsylvania Avenue, NW
6th Floor South
Washington, DC 20004
Tel: (202) 536-5000; Fax: 202.280.1239; email: sharon.villalon@new-fields.com


Pandemic Influenza Storybook: Narratives from 1918 and 1957 pandemics
The need for the Pandemic Influenza Storybook became evident as the Centers for Disease Control and Prevention (CDC) conducted Crisis and Emergency Risk Communication (CERC) throughout the country for public health professionals involved with a variety of emergency response communications activities. The “Basic” CERC course debuted in 2002 and two additional modules have been added; “Leaders for Leaders” and “Pandemic Influenza”. The storybook is a resource tool for the latter module for certified CERC trainers and trainees. The online storybook contains narratives from survivors, families, and friends who lived through the 1918 and 1957 pandemics. Additionally, stories from the 1968 pandemic will be added to this resource as they become available.

The 1918 influenza pandemic killed more than 50 million people worldwide including an estimated 675,000 people in the United States, and it is one of the touchstones for today’s public health preparedness initiatives. The 1957 Influenza Pandemic caused at least 70,000 U.S. deaths and 1–2 million deaths worldwide. Improvements in scientific technology made it possible to more quickly identify that pandemic when compared with the 1918 event. These first-person and family accounts contained herein provide an intimate, personal view of the 1918 and 1957 pandemics that goes beyond the staggering statistics associated with those events and, therefore, can help planners re-energize their efforts and fight preparedness fatigue and apathy.


FAO-OIE-WHO Joint Technical Consultation on Avian Influenza at the Human-Animal Interface
7-9 Oct 2008; Verona, Italy.
The animal and public health sectors have generated data and expertise in their respective areas, but there is room for closer cooperation between the two sectors and the promotion of shared use of the accumulated data. This joint technical consultation will be a milestone towards better global understanding of avian influenza risks at the human-animal interface. It will offer a forum for sharing the benefits of research and surveillance efforts in both fields, and will provide a valuable opportunity to discuss how tools and systems might be developed and further adapted for broader application at this interface.

The Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE) and the World Health Organization (WHO), with support from the Istituto Zooprofilattico Sperimentale delle Venezie (IZSVe) and the EC-funded project FLUTRAIN, have called this technical consultation to:

- identify critical virological characteristics for the emergence of zoonotic and pandemic viruses
- evaluate external factors affecting the evolution and emergence of a pandemic strain, and identify monitoring mechanisms for pandemic strain emergence
- identify likely modes of transmission and exposure sources for zoonotic infection with avian influenza viruses
- maximise outcome of ongoing research and preparedness efforts and identify gaps in knowledge
- identify next steps for further integrated data collection, analysis and research
(FAO http://www.fao.org/avianflu/documents/Announcement_Verona.pdf )