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EINet Alert ~ Oct 10, 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
- Cumulative number of human cases of avian influenza A/(H5N1)
- Germany: Farm duck positive for H5N1 avian influenza
- South Korea: Low pathogenic avian influenza H5N2 found at a duck farm
- Viet Nam: Avian influenza H5N1 in 300 ducks in Nghe An province
- USA: GAO urges HHS to speed antiviral and prepandemic vaccine plans
- USA: Bacterial coinfections boosting child influenza deaths
- USA: CDC contract to improve labs' access to influenza viruses
- USA: Businesses urged to avoid pandemic planning pitfalls
- AVIAN/PANDEMIC INFLUENZA
- Molecular characterization of highly pathogenic H5N1 avian influenza viruses isolated in Sweden in 2006
- Influenza Vaccine Effectiveness Among Children 6 to 59 Months of Age During 2 Influenza Seasons
- Insights into Inflammation and Influenza
- Antigenically Distinct MF59-Adjuvanted Vaccine to Boost Immunity to H5N1
- APIC Postion Paper on Influenza Immunization of Health care Personnel
- The 7th International Bird Flu Summit
- Influenza scientist Graeme Laver dies at age 79
- First European meeting of EHESP school of public health
- Promising Practices: Pandemic Preparedness Tools
- “Simulation Exercises on Influenza Pandemic Responses in the Asia Pacific Region” booklet released
1. Influenza News
Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
***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).
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 10/6/08): 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
Germany: Farm duck positive for H5N1 avian influenza
Authorities say a duck at a farm in eastern Germany has tested positive for the H5N1 strain of the bird flu virus. The social affairs ministry in the eastern state of Saxony says the farm near Goerlitz on the Polish border has been sealed off. The ministry said on 9 Oct 2008 that the farm has more than 1000 birds, including turkeys and geese. Germany has seen several cases of bird flu in the past, most recently in December 2007.
South Korea: Low pathogenic avian influenza H5N2 found at a duck farm
A new suspected case of bird flu was found at a duck farm in South Korea, the South Korean Agriculture Ministry said 4 Oct 2008. Routine tests showed ducks at a farm in Yesan, 134 km south of Seoul, have been infected with avian influenza. Laboratory testing later confirmed low pathogenic avian influenza H5N2. However, all ducks at the farm were culled to avoid further spreading of the disease, the ministry said.
South Korea experienced a wide scale outbreak of HPAI H5N1 that started 1 Apr 2008 and was resolved on 15 May 2008. The outbreak was contained and eradicated by the application of a stamping-out policy; no vaccine was used. On 14 Aug 2008, South Korean authorities sent the World Organization for Animal Health (OIE) an official declaration, stating that "the Republic of Korea has met the requirements for the recognition as a country free from Highly Pathogenic Avian Influenza (HPAI) as of 15 Aug 2008 in accordance with Article 22.214.171.124 of the Terrestrial Animal Health Code (2006)."
Viet Nam: Avian influenza H5N1 in 300 ducks in Nghe An province
Now, bird flu is hitting two Vietnamese provinces, including Ca Mau and Nghe. According to Viet Nam's recent follow-up report (No. 21) to the World Organization for Animal Health on HPAI H5N1, dated 29 Sep 2008, outbreaks of the disease have been found in the provinces of Dong Thap, Nghe An, Kien Giang, Ben Tre, Quang Ngai, and Ca Mau Ca Mau since mid-July 2008. Bird flu outbreaks in Viet Nam, starting in December 2003, have killed or led to the culling of dozens of millions of fowl in the country.
USA: GAO urges HHS to speed antiviral and prepandemic vaccine plans
In a recent progress report to Congress on federal influenza pandemic response planning, the Government Accountability Office (GAO) recognized a host of obstacles but cited two areas that officials could make headway on: finalizing guidance on allocating antivirals and developing guidance on how to prioritize groups to receive prepandemic vaccine in the early stages of a pandemic.
Investigators looked at three response components that the GAO and outside experts have said need improvements—pharmaceutical intervention, healthcare surge capacity, and public communications. Though the GAO gave detailed status reports for all three of the areas, it made recommendations only about pharmaceutical interventions. "We believe that finalizing guidance on the use of pharmaceutical interventions will be crucial for responding to a pandemic outbreak and that the necessary guidance documents should be finalized as soon as possible," the GAO wrote.
In June 2008, the US Department of Health and Human Services (HHS) released draft guidance on the use of antivirals during an influenza pandemic. The agency's goal is to place 75 million treatment courses in the Strategic National Stockpile, and draft guidance proposes that the private sector stockpile 110 million additional treatment courses. The proposed guidance, developed by an interagency task force, advised that antivirals in government stockpiles be used to treat people who are ill, especially when supplies are scarce, and that antivirals for preventive use be mainly drawn from private stockpiles. The draft document did not attempt to prioritize groups.
In its other recommendation, the GAO advised HHS to release guidance for using and prioritizing prepandemic vaccine designed to protect against a pandemic virus before a vaccine closely matched to the actual pandemic strain is available. Federal officials are already stockpiling a prepandemic vaccine based on the H5N1 virus.
Also in June 2008, HHS released its official guidance on allocating pandemic vaccine, which would be developed after the start of a pandemic and designed to match the circulating strain. HHS officials project that it would take 20 to 23 weeks after the start of a pandemic to start producing the first doses. As for prepandemic vaccine stockpiles, the GAO report says HHS will oversee the distribution and administration to workers who are needed to keep society functioning until a pandemic vaccine becomes widely available. According to the report, the National Infrastructure Advisory Council has estimated that the critical workforce numbers about 20 million people, and HHS' goal is to stockpile enough to cover that number.
However, HHS has not yet released draft guidance on prioritizing target groups for prepandemic vaccines. HHS officials told GAO investigators that target groups for the prepandemic vaccine would likely resemble those for the pandemic vaccine, but would have more of a critical workforce focus. They also said that a tiered approach like that used for the pandemic vaccine would be needed only if a pandemic occurs before HHS reaches its goal of stockpiling enough for 20 million people.
The GAO said establishing target groups in advance is a key component of pandemic planning and warned that HHS could encounter problems if it doesn't issue graft guidance for prepandemic vaccines in a more timely manner. "This lack of essential information could slow the initial response at the state and local levels and complicate the general public's understanding of the necessity for rationing these interventions," the GAO wrote. Investigators also said a public comment period after the draft prepandemic vaccine allocation plan is announced is a useful step. "Public participation is an essential component for acceptance of tough decisions that will be required unless and until greater capacity or a universal vaccine can be developed," the report said.
USA: Bacterial coinfections boosting child influenza deaths
Overall, the researchers say, child deaths from influenza are relatively uncommon. There were 166 between autumn 2004 and spring 2007, according to a new national reporting system, only a few more than the 153 that occurred in the harsh 2003-04 flu season and prompted the reporting system's development. But child deaths from flu are rising, and serious complications from bacterial infections such as MRSA are playing a much larger role.
Staph infection is difficult to prevent: The bacterium lives on the skin and in the nostrils and causes disease unpredictably. But "you can't have this overwhelming catastrophic complication without also having the flu, so if you can prevent the flu, you can prevent the coinfection," Lyn Finelli, DrPH, chief of influenza surveillance at the Centers for Disease Control and Prevention (CDC), said in an interview. Finelli is lead author of the report in the October issue of Pediatrics, which is co-authored by flu and MRSA researchers from two CDC divisions. The article analyzes reports of child deaths from flu filed by 39 states and two local health departments since the CDC made child death from flu a nationally reportable illness in 2004.
The full report was featured in newsbrief number 20 (3 October 2008).
USA: CDC contract to improve labs' access to influenza viruses
"This new resource will be a significant improvement for accessing the CDC library of influenza viruses," said Dr. Nancy Cox, director of the CDC's Influenza Division. "We expect that the CDC-IRR will speed the development of better diagnostic tests, antiviral drugs, and vaccines." Once the system is set up, deputy director of the CDC's Influenza Division Dr. Daniel Jernigan said, researchers will be able to enroll in it and order materials online. A person seeking to develop a new flu diagnostic test, for example, will be able to order particular viral strains and a test kit, consisting of a standard set of viruses used to validate the test.
In the event of a flu pandemic, the CDC-IRR will serve as a source of reagents to qualified labs, CDC said. Such labs are expected to play a critical role in detecting and confirming initial cases, characterizing viruses, monitoring the course of the pandemic, and choosing vaccine strains, the agency said. Jernigan said the new system is expected to help both public health labs, which are "the first line of detection for pandemic and seasonal influenza viruses," and developers making new vaccines, antiviral drugs, and diagnostic tests.
USA: Businesses urged to avoid pandemic planning pitfalls
Osterholm and Sandman told the group that business pandemic planners face tough challenges, not only in managing problems caused by the financial markets, but also in keeping the preparedness momentum going amid "pandemic planning fatigue." Sandman said he has detected a shift in the business pandemic planning approach over the past 6 months to what he calls "an island of preparedness." Over the past few years, many businesses had the mindset that each firm must do its share and that firms would prepare together, he said. "For a while that was working, but then interest waned."
Now, Sandman said, more businesses seem to deciding what to do on their own to cope when an influenza pandemic strikes. "If other islands appear, you can build bridges," he said, adding that the shift in focus is disappointing but has important planning ramifications.
Seven mistakes to avoid
On news monitoring, Osterholm said now is the time to establish trustworthy sources for news about pandemic developments. He said governments won't always be the best sources because some might have political or economic reasons for keeping a lid on disease outbreak news. Sandman advised Webinar participants to keep certain media tendencies in mind. "Typically, on the road to a pandemic they overplay small problems but they tend to underplay big ones," he said.
Also, he said groups such as the World Health Organization and the Centers for Disease Control and Prevention won't be the first to sound a pandemic warning; their roles will more likely be to "certify" that one exists. Besides monitoring these official sources, a helpful information strategy is to track sources that report and attempt to clarify rumors, which could contain some of the earliest information about an emerging pandemic, Sandman said.
Including employees can pay off
Osterholm and Sandman both urged businesses not to dilute their pandemic planning efforts by including them in all-hazards disaster planning, but both acknowledged that not all companies have the resources to do both, particularly during tough economic times. Osterholm asked the participants to remember that a pandemic is different because it will strike in waves and that a global outbreak could sever weak global supply chains. Sandman said that from a practical standpoint, business pandemic planners may have an easier time getting upper management support for an all-hazards planning approach. "It's better than nothing, and it's being more ready than we are now," he said.
Using fear effectively
- 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.
(UN; WHO; FAO, OIE; CDC; CIDRAP; PAHO; USGS)
Molecular characterization of highly pathogenic H5N1 avian influenza viruses isolated in Sweden in 2006
Kiss, Istvan et al. Virology Journal. Oct 2008; 5(113). http://www.virologyj.com/content/5/1/113.
Results. The presence of two sub-lineages of HP H5N1 AIVs in Sweden in 2006 was further confirmed by the phylogenetic analysis of approximately the 95% of the genome of twelve isolates that were selected on the base of differences in geographic location, timing and animal species of origin. Ten of the analyzed viruses belonged to sub-clade 2.2.2. and grouped together with German and Danish isolates, while two 2.2.1. sub-clade viruses formed a cluster with isolates of Egyptian, Italian, Slovenian, and Nigerian origin. The revealed amino acid differences between the two sub-groups of Swedish viruses affected the predicted antigenicity of the surface glycoproteins, haemagglutinin and neuraminidase, rather than the nucleoprotein, polymerase basic protein 2, and polymerase acidic protein, the main targets of the cellular immune responses. The distinctive characteristics between members of the two subgroups were identified and described.
Conclusion. The comprehensive genetic characterization of HP H5N1 AIVs isolated in Sweden during the spring of 2006 is reported. Our data support previous findings on the coincidental spread of multiple sub-lineage H5N1 HPAIVs via migrating aquatic birds to large distance from their origin. The detection of 2.2.1. sub-clade viruses in Sweden adds further data regarding their spread in the North of Europe in 2006. The close genetic relationship of Swedish isolates sub-clade 2.2.2. to the contemporary German and Danish isolates supports the proposition of the introduction and spread of a single variant of 2.2.2. sub-clade H5N1 avian influenza viruses in the Baltic region. The presented findings underline the importance of whole genome analysis.
Influenza Vaccine Effectiveness Among Children 6 to 59 Months of Age During 2 Influenza Seasons
Design. Case-cohort study estimating effectiveness of inactivated influenza vaccine in preventing inpatient/outpatient visits (emergency department [ED] and outpatient clinic). We compared vaccination status of laboratory-confirmed influenza cases with a cluster sample of children from a random sample of practices in 3 counties (subcohort) during the 2003-2004 and 2004-2005 seasons.
Setting. Counties encompassing Rochester, New York, Nashville, Tennessee, and Cincinnati, Ohio.
Participants. Children aged 6 to 59 months seen in inpatient/ED or outpatient clinic settings for acute respiratory illnesses and community-based subcohort comparison.
Main Exposure. Influenza vaccination.
Main Outcome Measures. Influenza vaccination status of cases vs subcohort using time-dependent Cox proportional hazards models to estimate VE in preventing inpatient/ED and outpatient visits.
Results. During the 2003-2004 and 2004-2005 seasons, 165 and 80 inpatient/ED and 74 and 95 outpatient influenza cases were enrolled, while more than 4500 inpatient/ED and more than 600 outpatient subcohorts were evaluated, respectively. In bivariate analyses, cases had lower vaccination rates than subcohorts. However, significant influenza VE could not be demonstrated for any season, age, or setting after adjusting for county, sex, insurance, chronic conditions recommended for influenza vaccination, and timing of influenza vaccination (VE estimates ranged from 7%-52% across settings and seasons for fully vaccinated 6- to 59-month-olds).
Conclusion.In 2 seasons with suboptimal antigenic match between vaccines and circulating strains, we could not demonstrate VE in preventing influenza-related inpatient/ED or outpatient visits in children younger than 5 years. Further study is needed during years with good vaccine match.
The emergence of highly pathogenic avian influenza H5N1 viruses in Asia and their spread globally have delivered a timely reminder of the public health and clinical challenges an influenza pandemic would pose. It is remarkable how little patient-oriented clinical research has been conducted over the past 30 years on a disease that could cause such extensive loss of life. There is currently a single oral drug for the treatment of influenza (the neuraminidase inhibitor oseltamivir) and no licensed parenteral drugs, although these are being developed. Lethality caused by the H5N1 influenza virus is partly attributed to a “cytokine storm” in the lung, mediated by prostaglandin E2 (PGE2). A recent study shows that mice infected with the virus and treated with an antiviral agent and a PGE2 inhibitor are better able to survive than mice treated with an antiviral agent alone.
Antigenically Distinct MF59-Adjuvanted Vaccine to Boost Immunity to H5N1
Letter to the Editor: Antigenically distinct avian influenza A (H5N1) viruses are widely dispersed. Clade 1 H5N1 viruses previously predominated in Indochina. Indonesian, Eurasian, and African viruses are clustered in a clade 2 group, with antigenically distinct sublineages. Clade 0 viruses caused influenza outbreaks in Hong Kong in 1997 but have not been isolated since then. To reduce shortfalls in vaccine supply at the onset of the next pandemic, advance stockpiling of vaccine has been suggested. Because of antigenic evolution of H5N1, current vaccines may be suboptimally matched to the actual pandemic virus. Proactive priming may induce immune memory, allowing low-dose vaccination to induce rapid cross-protection when needed.
APIC Postion Paper on Influenza Immunization of Health care Personnel
The Association for Professionals in Infection Control and Epidemiology released a paper on their position pertaining to policies around vaccinating health care professionals for influenza.
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/
Influenza scientist Graeme Laver dies at age 79
First European meeting of EHESP school of public health
EHESP school of public health organizes its first European meeting during a large exhibition on epidemics at La Cite des Sciences. This conference will gather health professionals, deciders, and citizens organizations. They ask for competencies from masters of public health (MPH). Topics of interest include how to train people to be able to propose and implement solutions in various domains such as long term care and dependence in a city, prevention of obesity in a large company, prevention and control of emerging infectious diseases in a European region. This two-day meeting will open discussions on the role of citizens and the media in this context. Is Europe ready to face an influenza pandemic? Should Europeans be prepared against a vector-borne disease?
Organised by Ecole des Hautes Etudes en Sante Publique (EHESP school of public health), jointly with La Cite des Sciences et de l'Industrie, in collaboration with Pasteur Institute, Association of School of Public Health in the European Region (ASPHER), French CDC (InVS), European Centre for Disease Prevention and Control (ECDC), Societe française de sante publique (SFSP).
For more information http://www.ehesp.fr/journees-europe-102008/
Promising Practices: Pandemic Preparedness Tools
“Simulation Exercises on Influenza Pandemic Responses in the Asia Pacific Region” booklet released