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EINet Alert ~ Oct 24, 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)
- Global: UN says pandemic risk remains despite progress on avian influenza H5N1
- Global: World Bank says influenza pandemic could cost $3 trillion
- Global: Projected supply of pandemic influenza vaccine sharply increases
- Germany: Farm ducks positive for H5N1 avian influenza, an update
- Bangladesh: Avian influenza H5N1 detected at poultry farm
- USA: Antiterrorism rules restrict vaccine exports
- USA: Biotechnology agency demonstrates efficacy of oral avian influenza vaccine in preclinical studies
- Nigeria: Avian influenza H5N1 as dangerous as financial crisis
- Avian/Pandemic Influenza
- An avian live attenuated master backbone for potential use in epidemic and pandemic influenza vaccines
- Pandemic Preparedness in the States: An Assessment of Progress and Opportunity
- Pandemic: Potential Insurance Impacts
- The International Response to Highly Pathogenic Avian Influenza: Science, Policy, and Politics
- The 7th International Bird Flu Summit
- National strategy for pandemic influenza implementation plan: two year summary
- Blueprint for a Healthier America: Modernizing the Federal Public Health System to Focus on Prevention and Preparedness
- Conference in Egypt focusing on global plan for pandemic preparation and response
- Second Ditan International Conference on Infectious Diseases
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
Global: UN says pandemic risk remains despite progress on avian influenza H5N1
The 115-page update on the global avian influenza status and pandemic planning efforts was released in advance of an international conference on avian and pandemic flu that starts 24 Oct 2008 in Sharm el-Sheik, Egypt. The report is an analysis of survey responses that the UN's influenza coordinator compiled from 148 countries. The findings also include information that the World Bank provided on the international pledges, commitments, and expenditures for avian influenza prevention and control.
Too little testing
Pandemic plans need to include both social distancing and pharmaceutical strategies, but not all countries are prepared to apply both strategies, the report said. Some haven't established the logistical and legal provisions needed to enact social distancing measures. The UN said it found great disparities in preparedness among countries with, for example, wealthier countries more likely to have planned for pharmaceutical interventions. "Given the interdependence of countries when responding to a pandemic, preparedness within poorer countries will be a critical element of the world's readiness for the next pandemic," the report said.
Also, some individual countries have made progress on plans to maintain essential services during a pandemic, but more nations need to engage the private sector to accomplish multisector planning. The UN recommended that for 2009, countries develop protocols, frameworks, and indicators for longer-term multisector pandemic preparedness and fund the efforts through their all-hazard preparedness mechanisms. In response to reporters' questions about pandemic planning transparency, Nabarro said he's noticed more openness among some countries, such as China. However, he said he was concerned that interactions among countries were "sometimes a bit tense."
Outbreaks and surveillance
Funding is eroding
East and Southeast Asian countries received 56% of the funds, Eastern Europe and Central Asia received 22%, and Sub-Saharan Africa, the Middle East, and North Africa got 20%, according to the report. Only $125 million remains in available funding, the World Bank said. "Grant finance will continue to be needed to sustain critical capacities and actions in the medium to longer term."
Global: World Bank says influenza pandemic could cost $3 trillion
The new report increases the economic impact estimates made by the World Bank in June 2006. At that time the bank estimated GDP would drop by 3.1%, or about $2 trillion. Bank officials estimate that a "mild" pandemic, similar to the Hong Kong flu of 1968-69, could kill 1.4 million people and reduce global GDP by 0.7% in the first year. The projections for a “moderate” pandemic like that of the Asian flu in 1957-58 is that it could cause 14.2 million deaths and reduce global economic activity by 2%. The bank report also notes that some experts have estimated a death toll ranging from 180 million to 250 million in a severe pandemic.
The World Bank predicts that changes in individual behavior, such as avoiding air travel, restaurants, and mass transportation, could account for 60% of the costs during a pandemic. In the worst case, the authors estimate that air travel, tourism, restaurant business, and use of mass transit could drop 20% for the first year.
The World Bank's estimate of a 4.8% drop in GDP in a severe pandemic is slightly lower than some other estimates of the hit on the global and US economies. For example, researchers at Australian National University predicted that an "ultra" pandemic would slash global GDP by 5.5%. In 2007, the health advocacy group Trust for America's Health estimated that US economic activity would shrink 5.5% in a 1918-like pandemic. And in 2005 the Congressional Budget Office projected that a pandemic would cut the US GDP by 5%.
Access the entire World Bank report: http://siteresources.worldbank.org/EXTAVIANFLU/Resources/EvaluatingAHIeconomics_2008.pdf.
Global: Projected supply of pandemic influenza vaccine sharply increases
"With influenza vaccine production capacity on the rise, we are beginning to be in a much better position vis-à-vis the threat of an influenza pandemic," Dr Marie-Paule Kieny, Director of the Initiative for Vaccine Research at WHO said on 23 Oct 2008. "However, although this is significant progress, it is still far from the 6.7 billion immunization courses that would be needed in a six month period to protect the whole world." "Accelerated preparedness activities must continue, backed by political impetus and financial support, to further bridge the still substantial gap between supply and demand," she said.
In 2008, manufacturers have been able to step up production capacity of trivalent (three viral strains) seasonal influenza vaccines to an estimated 565 million doses, from 350 million doses produced in 2006, according to the International Federation of Pharmaceutical Manufacturers & Associations. According to experts working in this field, the yearly production capacity for seasonal influenza vaccine is expected to rise to 1 billion doses in 2010, provided corresponding demand exists.
This would help manufacturers to be able to deliver around 4.5 billion pandemic influenza vaccine courses because a pandemic vaccine would need about eight times less antigen, the substance that stimulates an immune response. Vaccine production capacity is linked to the amount of antigen that has to be used to make each dose of the vaccine. Scientists have recently discovered they can reduce the amount of antigen used to produce pandemic influenza vaccines by using water-in-oil substances that enhance the immune response.
The progress was reported at the first meeting of a WHO Advisory Group on pandemic influenza vaccine production and supply. The Global Action Plan Advisory Group, an independent, international committee of ten members, met at WHO headquarters one year after eight new strategies to increase pandemic influenza vaccine were identified and published in the WHO Global pandemic influenza action plan to increase vaccine supply.
Germany: Farm ducks positive for H5N1 avian influenza, an update
Highly pathogenic avian influenza virus H5N1 has been detected in clinically healthy ducks in a mixed poultry holding in Saxony, Germany. Thirty oropharyngeal swabs from geese and ducks had been sampled for routine monitoring purposes. A single duck tested positive for HPAIV H5N1, and the cleavage site sequence was confirmed as GERRRKKR*GLF on 9 Oct 2008. Subsequently, 157 additional duck samples were obtained and revealed a further 24 H5N1 positives, of which nine had sufficient viral loads to be confirmed as HPAIV. All poultry were culled. No more cases have been detected in contact farms or in wild bird samples obtained from this region.
Preliminary sequence and phylogenetic analysis of the HA gene from four duck samples gave evidence for a representative of a cluster 2.2 sublineage, which had been detected in spring 2006 in Southern Germany. In fact, a virus from a tufted duck (R1240/06; Starick et al., 2008) found in 2006, 40 km away from the present outbreak location is very closely related. So far, there are no records for the presence of viruses of this sublineage after May 2006 in Germany or Europe. In summary, the data suggest a very recent introduction of HPAIV H5N1 into this farm from an as yet unknown source.
Bangladesh: Avian influenza H5N1 detected at poultry farm
Bangladesh authorities said on 19 Oct 2008 that they have detected fresh bird flu at a poultry farm four months after the virus was last reported in the country. Livestock department spokesman Salahuddin Khan said at least 300 birds were destroyed in a farm in the northern Naogaon district last week after the H5N1 strain of avian influenza was detected.
"We have already taken extra surveillance measures across the country," he said. "Farmers have been told to step up bio-security." Bangladesh was hit by bird flu in February 2007, and the virus made another comeback in January 2008. At the outbreak's peak, some 50 of the country's 64 districts were affected, and more than a million birds were slaughtered.
Officials said the outbreak was a warning for the country's poultry industry, which generates about $1.5 US per year. Bangladesh's poultry industry is one of the world's largest, producing 220 million chickens and 37 million ducks annually. Industry officials said the bird flu outbreak at its peak in early this 2008 led to the closure of 40 percent of the nation's poultry farms and left half a million workers jobless. The country also reported its first confirmed case of human bird flu in May 2008, but the government said the 16-month-old baby who contracted the virus had recovered.
USA: Antiterrorism rules restrict vaccine exports
A recent Associated Press (AP) report revealed that, in the name of preventing biological attacks, the United States has rules barring the exportation of vaccines for avian influenza, smallpox, yellow fever, and many other pathogens to five countries classified as sponsors of terrorism. Under Department of Commerce rules, vaccines for a long list of viruses, bacteria, and biological toxins cannot be exported to Cuba, Iran, North Korea, Sudan, and Syria unless they obtain a special export license, which can take weeks.
Pandemic flu vaccines are not restricted under the rules. But the Department of Commerce confirmed that Cuba, Iran, and Sudan are subject to a ban on pandemic flu vaccines as part of general US trade embargoes covering nearly all products. Those embargoes are based on "broader foreign policy reasons," said Kevin Kurland, a spokesman for the department's Bureau of Industry and Security.
The list of pathogens subject to the rules includes many viruses, some of which are little known and some of which there is no vaccine for. A list of animal pathogens covered by the restrictions includes highly pathogenic avian flu viruses. Bacterial pathogens on the restricted list include anthrax and the microbes that cause tularemia and plague. Not on the list are the causes of common vaccine-preventable diseases, such as measles, mumps, rubella, chickenpox, and seasonal influenza. It can take up to 40 days for a country to obtain an export license for a restricted product. But he said humanitarian needs are considered, and licenses can be granted much faster in emergencies.
Rules go back to 1990s
Disease and bioterrorism experts say there is little reason to think that exporting the vaccines would increase the risk of biological attacks, but a Commerce Department official reportedly defended them. "Legitimate public health and scientific research is not adversely affected by these controls," Assistant Commerce Secretary Christopher Wall stated. Concerning avian flu vaccines for poultry in particular, Wall declined to explain what kind of threat they pose, but said there are valid reasons for taking steps to ensure they "do not fall into the wrong hands."
Bill Hall, an HHS spokesman, said HHS is not usually consulted about trade sanctions, even when they involve medical products. "The United States government currently requires a license for the export from the US of a wide range of goods, products, and services to Cuba, Iran, and Sudan as part of its overall foreign policy," Hall commented. "Although these licensing requirements cover exports of medical products such as human influenza vaccine, HHS is not routinely consulted on the foreign policy decisions to impose sanctions on exports of U.S. goods to state sponsors of terrorism, even including medical products such as vaccines. "In the meantime, HHS is working closely with the Department of Commerce and other government agencies to determine the most effective and humane actions the US government could take to help protect global public health, regardless of the nation or nations involved."
Vaccines into weapons?
Regarding avian flu vaccines, Ian Ramshaw, an immunology and biosecurity expert at Australian National University in Canberra said, "I can think of no scientific reason how a terrorist organization could use such a vaccine for malicious intent. I personally think it's a rather silly attitude and the U.S. is probably going overboard as it has in the past with many of its bioterrorism initiatives."
Infectious disease expert Michael T. Osterholm, director of the University of Minnesota Center for Infectious Disease Research and Policy, said he doesn't see the logic behind the restrictions either. "There really isn't any reason that using the vaccine to create the agent would be a concern," he said. "The only potential implication is if you had individuals working on [weaponizing] the agent, by vaccinating them you could protect them so they could work on it." He observed that the idea of weaponizing the H5N1 avian flu virus, for example, is not a concern, since the virus does not easily infect humans or spread easily from person to person. The virus could be used as a weapon against poultry, "but that's not about the vaccine," he said. "So I don't understand the logic about this at all. Anywhere in the world you can reduce the potential for these diseases, we should do that," Osterholm said.
USA: Biotechnology agency demonstrates efficacy of oral avian influenza vaccine in preclinical studies
Delivery of flu vaccine via a capsule rather than an injection offers critical advantages, particularly in the case of a pandemic. The Vaxart vaccine formulation can withstand ambient temperatures, enabling emergency distribution methods that avoid the transmission risks associated with centralized vaccination clinics. In the developing world, where medical providers and supplies are scarce, oral vaccination will reduce costs, as well as needle reuse and consequent cross-infection.
The data presented are from studies measuring the effectiveness of an orally-administered avian flu vaccine designed by Vaxart scientists using the company's proprietary modular platform. The Vaxart vaccine (ND1) comprises a non-replicating chimeric adenovirus-5 vector, or delivery vehicle, engineered to express avian flu hemaggluttinin (HA) and a TLR3 ligand as a vaccine adjuvant. "Injected vector-based vaccines that deliver a target pathogen protein have shown excellent potency in animal models, but their application has been limited in humans because the immune system typically responds to the vector rather than the target," said Dr. Tucker. "By using oral delivery of a non-replicating vector with a potent adjuvant, we achieve a robust immune response that is focused on the targeted pathogen rather than the delivery vehicle. This approach addresses the problems that have plagued vector-based vaccination and also allows us to create different vaccines simply by switching out the antigen."
Nigeria: Avian influenza H5N1 as dangerous as financial crisis
A representative of the United Nations in Nigeris, Dr Joyce Ijoro, has asserted that the impact of bird flu on the nation’s system is as strong as any major crisis in the financial sector. Speaking at an Animal and Human Influenza (AHI) workshop organized by the International Organisation for Migration (IOM) on the Social Mobilization of Migrant Poultry Workers, Traders and Transporters in Maiduguri, Ijoro said, “Avian influenza would be a major economy issue if its epidemic ever happened in Nigeria, as many Nigerians depend on poultry economically and on account of food.”
Ijoro said bird flu threat should be made a policy issue at all tiers of government in Nigeria, urging participants at the workshop to take the message to groups concerned with policy management, especially as they relate to agriculture and poultry. AHI Project Assistant, IOM Nigeria, Mr James Atusue, said organizers of the workshop were ready to work with both general and UN stakeholders to give towards a consolidated conflict plan for avian and human pandemic preparedness, specifically by addressing the needs of migrants and mobile populations in Nigeria.
- 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)
An avian live attenuated master backbone for potential use in epidemic and pandemic influenza vaccines
Hickman D et al. J Gen Virol 89 (2008); 2682-2690. Available at http://vir.sgmjournals.org/cgi/content/full/89/11/2682.
Abstract: The unprecedented emergence in Asia of multiple avian influenza virus (AIV) subtypes with a broad host range poses a major challenge in the design of vaccination strategies that are both effective and available in a timely manner. The present study focused on the protective effects of a genetically modified AIV as a source for the preparation of vaccines for epidemic and pandemic influenza. It has previously been demonstrated that a live attenuated AIV based on the internal backbone of influenza A/Guinea fowl/Hong Kong/WF10/99 (H9N2), called WF10att, is effective at protecting poultry species against low- and high-pathogenicity influenza strains. More importantly, this live attenuated virus provided effective protection when administered in ovo. In order to characterize the WF10att backbone further for use in epidemic and pandemic influenza vaccines, this study evaluated its protective effects in mice. Intranasal inoculation of modified attenuated viruses in mice provided adequate protective immunity against homologous lethal challenges with both the wild-type influenza A/WSN/33 (H1N1) and A/Vietnam/1203/04 (H5N1) viruses. Adequate heterotypic immunity was also observed in mice vaccinated with modified attenuated viruses carrying H7N2 surface proteins. The results presented in this report suggest that the internal genes of a genetically modified AIV confer similar protection in a mouse model and thus could be used as a master donor strain for the generation of live attenuated vaccines for epidemic and pandemic influenza.
Pandemic Preparedness in the States: An Assessment of Progress and Opportunity
This paper presents an overall assessment, based on our observations and an analysis of the information provided by workshop participants, of the current level of pandemic preparedness in the states. It focuses specifically on preparedness in four sectors or disciplines that are common to all states: health care, commerce, education and public safety. The paper also describes several areas in which additional, focused work can reap immediate benefits not only for pandemic preparedness but for any catastrophic event.
Pandemic: Potential Insurance Impacts
The British insurance market Lloyd's released a report on the possible effects of a pandemic on the insurance industry. The report says a pandemic on the scale of 1918's could reduce economic activity by anywhere from 1% to 10%. "Economic impacts are likely to occur and a pandemic as severe as 1918 may lead to a global recession with reductions of between 1% and 10% of GDP," it states. "These may impact the general business environment."
The Lloyd's report also cautions against assuming that the 1918 pandemic necessarily represents the "worst case" event. "1918 may not be a worst case," the report says. "It is certainly true that the 1918 event was extreme relative to other pandemics in history. However many published 'worst case' scenarios take 1918 as a base. There is a danger that we over optimize to this one scenario. There are other forms of pandemic than influenza, some have higher case mortality. Pandemic preparedness should consider a range of scenarios to ensure plans are appropriately flexible."
The International Response to Highly Pathogenic Avian Influenza: Science, Policy, and Politics
This example highlights the complex trade-offs involved in policy processes around avian influenza. These are intensely political, pitting different interests and groups of actors against each other. Public image, business interests and poor people’s livelihoods are all involved in a complex mix. And the science often is so uncertain that firm decisions based on exact predictions and precise measures are impossible. Judgments – normally political judgments – are made, and these are necessarily highly contextual. Media pressure, political effectiveness, implementation capacity and geopolitical positioning all come into the picture. Thus, in order to understand the politics of the international policy response to avian influenza, we must explore an intersecting story of virus genetics, ecology and epidemiology with economic, political and policy machinations in a variety of places – from Hong Kong to Washington, to Jakarta, Cairo, Rome and London. This paper offers one, necessarily partial and incomplete, view of the story over the last decade – and particularly the last few years when over $2 billion of public funds have been mobilized.
The 7th International Bird Flu Summit
November 13-14, 2008
Monte Carlo Resort
Las Vegas, Nevada, USA
This summit is designed to help you understand the threats of avian flu pandemic in your country, as well as meet your planning requirements -on time, under budget, and with a minimum of disruption to your operations.
Confirmed speakers include:
An updated full agenda and additional information is available on the event website at: http://www.new-fields.com/birdflu7/index.php.
National strategy for pandemic influenza implementation plan: two year summary
The actions [included] are reproduced from the Implementation Plan. Each action is followed by a summary of progress, in italics, prepared by relevant departments and agencies for this report. The status of each action is indicated directly after the action number. A determination of “complete” indicates that the measure of performance has been met but does not necessarily mean that work on the action has ended; in many cases work is ongoing. A determination of “in progress” indicates that the measure of performance has not yet been met and additional work is being done to meet the appropriate standard.
Blueprint for a Healthier America: Modernizing the Federal Public Health System to Focus on Prevention and Preparedness
Drawing on the expertise of more than 150 health experts, Trust for America's Health (TFAH), a nonprofit health advocacy group in Washington, DC, released a report on 21 Oct 2008 designed to help the next president and Congress reform the public health system to improve the nation's health and emergency preparedness.
Jeff Levi, PhD, executive director of TFAH, stated that the country is losing ground on battling preventable diseases such as diabetes and obesity and could stall in its efforts to prepare for a pandemic or other public health emergency. "We believe Americans deserve better, and these problems place us at a competitive disadvantage," he said in introducing the 119-page report. Levi said the report, "Blueprint for a Healthier America: Modernizing the Federal Public Health System to Focus on Prevention and Preparedness," contains recommendations that came from a yearlong consensus-building effort among the 150 experts. The report also includes a number of public opinion surveys on Americans' perceptions of natural disaster and disease threats.
Levi emphasized that the TFAH "blueprint" proposes a public health and preparedness strategy that doesn't depend solely on the federal government but envisions critical roles for state and local governments. He said some of the key themes of the blueprint are holding funding recipients accountable for progress and results and making prevention a cornerstone of the nation's health, not just an afterthought.
In the report, TFAH projects a $20 billion annual shortfall in funding for critical public health problems. Establishing a stable funding stream though various options outlined in the report would require increases of $12 billion at the federal level and $8 billion at state and local levels.
The report urges the next administration to ensure that emergency preparedness is part of the health reform debate. Levi told reporters that strengthening surge capacity is "the single biggest and hardest issue for health preparedness." To make best use of federal resources, TFAH recommends that the next administration designate a single official at HHS to oversee all emergency preparedness activities and ensure coordination across other federal agencies that have a role in preparedness.
Among several specific suggestions for influenza pandemic preparedness, TFAH recommends developing a "Pandemic Vaccine Research and Development Master Plan," setting more ambitious goals for producing a pandemic vaccine, streamlining the licensing process for flu vaccines, implementing a nationwide system to track the use, safety, and efficacy of vaccines, and increasing the federal stockpile of antiviral drugs to enable it to treat 25% of the population.
Conference in Egypt focusing on global plan for pandemic preparation and response
An international conference where thousands of experts and distinguished scholars from around the world gather in the heart of China to engage in the discussion of the prevention policy for infectious diseases. Additional information is available at http://www.bjditan.org.