|HomeAvian Influenza and EINetVirtual SymposiumHuman Avian Influenza CasesAbout APEC-EINetNewsbriefs> Browse• SearchAPEC EconomiesPeople DirectoryTeaching & LearningResearch ResourcesContact Us
EINet Alert ~ Dec 19, 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: Progress reported at WHO meeting on virus sharing
- Germany: Turkeys infected with low pathogenic avian influenza H5N3
- Bangladesh: Avian influenza H5N1 outbreak at two poultry farms
- Cambodia: 320 poultry killed after man is infected with avian influenza H5N1
- China (Jiangsu): Reports new avian influenza H5N1 outbreaks
- Chinese Taipei: Japan suspends imports due to suspected avian influenza H5N2
- India (West Bengal): New outbreak of avian influenza H5N1 among poultry
- Indonesia: Suspected avian influenza patient dies
- Russia (Belgorodskaya Oblast): Woman infected with rabies virus infection from cat
- USA: Treatment comes first in HHS antiviral guidance
- USA: Cost, resistance aired in HHS webcast on antivirals
- Egypt: Human death attributed to avian influenza H5N1
- AVIAN/PANDEMIC INFLUENZA
- Component-Specific Effectiveness of Trivalent Influenza Vaccine as Monitored through a Sentinel Surveillance Network in Canada, 2006–2007
- Using Surveillance to Evaluate Influenza Vaccine Effectiveness
- WHO discussion papers address ethical issues in pandemic influenza planning
- HHS releases report on guidance regarding employer stockpiling of antivirals
- Grand Challenges in Global Health Initiative request for proposals
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:
Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 391 (247).
Avian influenza age distribution data from WHO/WPRO:
WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 11/17/08):
WHO’s timeline of important H5N1-related events (last updated 8/14/08):
Global: Progress reported at WHO meeting on virus sharing
Representatives from more than 100 countries participated in the negotiations, and the meeting was attended by a host of observers, nongovernmental organization representatives, and industry groups. Topics for the next meeting will likely include difficult intellectual property (IP) issues related to virus-sharing and agreements on and mechanisms for sharing virus samples and ensuring benefits for countries that provide their viruses, the official said.
The meeting was the IGM's third attempt to resolve H5N1 virus sharing issues. In early 2007, Indonesia―the country that has been hit hardest by the virus―announced that it had ceased sharing virus samples with the WHO. The aim of the move was to protest what Indonesia regarded as its lack of access to vaccines and treatments made from the virus by companies in more developed nations. Indonesia has pushed for global virus-sharing policies it considers more transparent and fair to developing nations. The IGM first met in November 2007, and Indonesia and the United States recently have had bilateral talks to help clarify some of the issues, the US official said.
While continuing to withhold samples, Indonesia started sending genetic sequences of its H5N1 viruses in May 2008 to a new public database, the Global Initiative on Sharing Avian Influenza Data (GISAID), which was formed in 2006 by a group of 70 scientists and health officials to ease the sharing of H5N1 sequences. Anyone can use the database if they register and agree to share and credit the use of others' data, analyze findings jointly, publish results collaboratively, and not push IP rights issues that relate to diagnostic, drug, and vaccine developments.
The senior US official said the key element in IGM's progress last week was shifting away from discussing voluntary versus mandatory virus sharing and focusing more on a commitment to sharing. "Putting the debate into a different context was conducive," the official said, crediting the US and Indonesia for their work on a compromise.
Participants asked the WHO to work on several technical issues before the next IGM session. They include a mechanism for virus tracking, terms of reference for the WHO's collaborating centers, revisions to the material transfer agreement technical section, and the needs, priorities, and financing options for virus-sharing benefits.
Siti Fadilah Supari, Indonesia's health minister, addressed the meeting on 8 Dec 2008, the IGM's opening day. In her remarks, she recommended that the WHO consider an offer from GISAID to allow member states to use a new tracking system that it has developed to complement its new influenza sequence database. Some of the difficult IP issues that remain include defining what material may be patented and spelling out the benefits that a source country or researcher can gain in return for providing virus samples.
Germany: Turkeys infected with low pathogenic avian influenza H5N3
Avian influenza is spreading in the district of Cloppenburg. An influenza virus that poses no danger for humans has been detected in four additional holdings in Garrel and Boesel. A total of 58,000 turkeys are affected, which will be culled immediately.
This information was made available by the district authorities on 13 Dec 2008. During the previous days a total of 43,000 turkeys have been culled and destroyed. According to the veterinary authorities, the virus is spreading quickly.
Low pathogenic H5N3 influenza virus was detected on turkey fattening units. It is a mild form of bird flu, a disease sometimes called fowl plague and not the dangerous, highly aggressive virus H5N1, which is also known to affect people.
District Administrator Hans Eveslage said that all precautions are being taken to act swiftly and rapidly in the event of a further spread of the disease. How the virus was introduced is still unclear. The Agriculture Ministry of Lower Saxony had ordered to keep all poultry confined. This applies to all owners of chicken, ducks, geese, and poultry, commercial and private.
The district of Cloppenburg is one of the strongholds of poultry production in Lower Saxony. In the district, about 12 million birds are kept of which 3 million are turkeys, a district spokesman said. The extent of economic damage for farmers is, so far, not established. Direct losses, which means animals culled by order of the State veterinarian of the district, are covered by the compulsory health fund.
Bangladesh: Avian influenza H5N1 outbreak at two poultry farms
Livestock officials in reported on 17 Dec 2008 that the avian influenza H5N1 virus struck two commercial poultry farms, one in Rajshahi district, in the northwestern part of the country near the border with India, and one about 30 miles northeast of Dhaka, the capital. The country's last outbreak occurred in late September 2008, striking a different poultry farm in Rajshahi. Veterinary workers culled 3,781 birds at the two farms to contain the outbreak.
Cambodia: 320 poultry killed after man is infected with avian influenza H5N1
A 19-year-old man in Kandal province, 30 kilometers southeast of Phnom Penh, tested positive for bird flu last on 11 Dec 2008. The man fell ill after touching a dead chicken, said Ly Sovann, a health ministry expert on bird flu. The man remains hospitalized in the capital. The seven previous Cambodian victims of the disease died.
China (Jiangsu): Reports new avian influenza H5N1 outbreaks
H5N1 is considered endemic in large parts of China. Mainland China reported its last major outbreak in June 2008 when the virus struck thousands of ducks in Yashan City in Guangdong province, according to a previous report. The ministry's statement on the Jiangsu outbreak said the source of the virus might be migratory birds. Authorities are culling and vaccinating poultry in the area, have quarantined the outbreak farms, and have banned the movement of poultry and poultry products in and out of the area.
News of a fresh outbreak in China comes about a week after officials in Hong Kong announced an outbreak at a poultry farm in the special administrative region city of Yuen Long, the special administrative region's first farm-based outbreak since 2003.
In other developments in that region, public health officials in China, Hong Kong, and Macao conducted a drill on 16 Dec 2008 to test their cross-border avian flu response plan. Named "Exercise Great Wall 2008," the test involved more than 60 public health officials. The scenario involved a man and his teenage daughter who lived in Hong Kong but became infected with the H5N1 virus after visiting the man's wife in mainland China. The drill was the third such exercise under a 2005 cooperative public health emergency agreement between China, Hong Kong, and Macao.
Chinese Taipei: Japan suspends imports due to suspected avian influenza H5N2
According to the Ministry of Agriculture, Forestry and Fisheries of Japan, Taipei’s Council of Agriculture (COA) confirmed the outbreak of H5N2 virus in Taipei. Japan has stopped any poultry imports from Taipei and asked Taipei to present detailed information. Sung Hwa-tsung, director general of Bureau of Animal and Plant Health Inspection and Quarantine of COA, said they would give explanations to Japan, hoping the exports to Japan would be resumed as soon as possible.
Japan imported 5128 tons of poultry, 65 tons of products made from poultry, and 148 tons of eggs from Taipei in 2007. According to COA estimates, the value of poultry exported to Japan last year amounted to NTD 600 million (USD 18,432,000).
COA Minister Chen Wu-hsiung said in the Legislative Yuan on18 Dec 2008 that the suspected avian flu incident has caused a preliminary loss of over NTD 10 million (USD 307,672). The second special panel report will come out soon to confirm the existence of the avian flu, said Chen.
"Import suspension is a standard procedure when Japan encountered suspected disease problems, but we have asked [Taipei’s] representative in Japan to engage in communication with Japanese government," said Chen.
India (West Bengal): New outbreak of avian influenza H5N1 among poultry
Indian authorities are already culling hundreds of thousands of birds in the northeastern state of Assam, where health authorities are also monitoring about 100 people who had shown signs of the virus. Those patients in Assam's Guwahati, the main city in the region, were suffering from fever and respiratory infections, symptoms of the H5N1 bird flu virus in humans. There have been no confirmed human cases of H5N1 among those patients being monitored or at any other time in India.
West Bengal officials said several hundred birds could have been found dead but disputed local media reports that as many as 5000 birds were dead. The WHO has described an outbreak of bird flu in communist-ruled West Bengal in January 2008, when more than 4 million birds were culled, the most ever in India.
An outbreak of bird flu in poultry was also detected in Malda district in March 2008, resulting in the culling of more than 50,000 birds. Authorities later said in May 2008 that the virus had been stamped out in the area.
Culling operations, which began in Guwahati in Assam in November 2008, have been expanded to nearby Meghalaya state as a precaution, authorities said on 14 Dec 2008.
Indonesia: Suspected avian influenza patient dies
The head of the Tangerang health service, Hari Heryanto, said his office could not as yet confirm if the cause of Su's death was avian influenza virus. "Her blood sample is still being examined and the result of laboratory tests is needed to confirm if the cause is really the [avian influenza] virus," he said.
The district of Tangerang which is located west of capital city Jakarta has been known as an endemic area and has recorded the highest number of bird flu cases so far, 17 cases leading to 15 deaths.
Russia (Belgorodskaya Oblast): Woman infected with rabies virus infection from cat
The cat disappeared sometime after the incident and has not been traced. On 2 Dec 2008 the woman complained of indisposition and apprehension. Her temperature rose up to 40 degrees Celsius and she exhibited symptoms of vomiting, shortness of breath, speech disability due to throat spasms, aerophobia, and sweating. Doctors at a local hospital and the city hospital made a preliminary diagnosis of rabies. She has been transferred to an intensive care unit.
People in her village who may have had contact with the ailing cat have been admitted to hospital for examination and are receiving anti-rabies prophylaxis. Veterinarians are vaccinating pet animals.
During the first 10 months of 2008, 174 laboratory confirmed cases of rabies infection of animals have been recorded in the region. The existence of a high rabies incidence among animals is causing concern. The large number of neglected animals inhabiting the streets of cities and throughout the region is also a matter of concern. In 2008, 40 percent of cases of animal bites were caused by feral cats and dogs. During the first nine months of 2008, 3600 persons sought medical treatment for animal bites. That is 15.2 percent more than in 2007. The public are reminded that immediate treatment should be sought after any animal bite. In particular hunters should be aware that wild foxes are a reservoir for rabies virus infection in this region.
USA: Treatment comes first in HHS antiviral guidance
A revised federal guidance document on the use of antiviral drugs in an influenza pandemic reaffirms that public supplies of the drugs should be reserved mainly for treating the sick and that preventive treatment for high-risk workers should rely on private supplies.
The Department of Health and Human Services (HHS) issued its draft guidance on the topic in June 2008. A revision released on 15 Dec 2008 includes no major changes but does have some new material added in response to comments, particularly on implementation problems, risks and uncertainties.
HHS also released a separate document summarizing the 28 comments it received on the draft version and presenting responses to them. At the same time, HHS released a revision of its guidance on employer stockpiling of antivirals, with no major changes. The thrust of the general guidance is that, in a pandemic, antivirals should primarily be used to treat the sick, but they should also be used to prevent illness in high-risk healthcare and emergency workers and to both prevent and treat illness in the context of initial outbreaks both in the Untied States and overseas. The guidance pertains mainly to the two licensed neuraminidase inhibitors, oseltamivir (Tamiflu) and zanamivir (Relenza).
The five main recommendations are unchanged in the revised guidance. It calls for using antivirals for the following purposes:
HHS is buying antiviral drugs for the Strategic National Stockpile, and states are stockpiling the drugs with a 25% federal subsidy. The overall goal for public stockpiles is 81 million treatment courses, including 75 million courses for treatment and 6 million for containment and for delaying the spread of pandemic flu into the United States.
About 73 million courses are currently in federal and state stockpiles, according to HHS's response to comments on the guidance. It also says "many federal agencies" are "acquiring additional stockpiles to support prophylaxis as recommended in the guidance," but it does not list the amounts of these supplies.
Like the draft version, the revised guidance says that antivirals for preventive treatment of healthcare workers and others will have to come mostly from supplies bought by private organizations and businesses for their employees.
HHS says the 28 comments it received on the draft guidance came from public health workers, healthcare providers, healthcare organizations, the pharmaceutical industry, business associations, public health organizations, and labor groups, among others.
The agency added two significant pieces to the guidance in response to comments. One addresses implementation difficulties, mainly concerning barriers to the stockpiling of antivirals for health and emergency workers; the other deals with risks and uncertainties, such as antiviral resistance and treatment effectiveness.
The whole report can be accessed at http://pandemicflu.gov/vaccine/antiviral_use.html.
USA: Cost, resistance aired in HHS webcast on antivirals
The Department of Health and Human Services (HHS) released two guidance documents recently, one on antiviral use in general and one on employer stockpiling of antivirals. The general guidance says national and state antiviral stockpiles will be reserved mainly for treating the sick in a pandemic. It says that healthcare and emergency workers likely to be exposed to the sick should receive preventive anitiviral treatment, with the doses provided by their employers. The guidance on employer stockpiling supports the general guidance, recommending that businesses and organizations that employ workers likely to be exposed to infection provide prophylactic antiviral treatment for them. It also says that critical infrastructure employers should strongly consider providing antiviral prophylaxis for essential workers.
In the 17 Dec 2008 HHS "PlanFirst" webcast, Dr. Benjamin Schwartz, said the retail costs of the two recommended antivirals, oseltamivir (Tamiflu) and zanamivir (Relenza), range from about $50 to $80 per treatment course. It may be possible for some groups, particularly healthcare organizations, to buy the drugs at a much lower cost through their state health department, but this would be limited to groups working with health departments as part of state pandemic planning, said Schwartz, who is senior science advisor with HHS's National Vaccine Program Office.
The other option for organizations seeking to buy antivirals, Schwartz said, is to participate in manufacturer programs that permit groups to reserve a supply by paying a small annual fee per treatment course. The manufacturer keeps the doses up to date, and in the event of a pandemic, the buyer pays the wholesale price for delivery of the product. Both Roche, maker of Tamiflu, and GlaxoSmithKline, maker of Relenza, offer such programs. "It could almost be looked at as pandemic insurance," Schwartz said.
However, the cost of an antiviral program is more than just the per-regimen amount, HHS officials said. Workers who will receive the drugs will need medical screening, and there will be storage and dispensing costs as well.
The HHS acknowledges the risk that a pandemic virus develops resistance to the antiviral drugs. Schwartz noted that one of the three subtypes of seasonal influenza, A/H1N1, recently has shown increased resistance to oseltamivir. "What is the implication of this?" Schwartz said. "I have to emphasize that this one virus is largely resistant, whereas other flu viruses that are circulating and the avian H5N1 virus remain susceptible to Tamiflu and Relenza. The types of changes, the mutations that have made the H1N1 virus resistant are unlikely to occur in a pandemic virus, so therefore we have not changed our recommendations for planning and stockpiling."
The national stockpile of antivirals is about 80% oseltamivir and 20% zanamivir, according to HHS. The reason it's divided this way, said Schwartz, is that oseltamivir as an oral drug spreads throughout the body, whereas zanamivir is inhaled and therefore may work best in the respiratory tract. "So there may be a theoretical benefit to Tamiflu," he said. "Tamiflu may also be a little bit easier to stockpile and there's a little more flexibility with use because you can go down to a lower age." Oseltamivir is approved for treatment and prophylaxis in persons 1 year and older; zanamivir is approved for treatment of those aged 7 years and older and for prophylactic use in those aged 5 years and up.
Egypt: Human death attributed to avian influenza H5N1
The Ministry of Health and Population of Egypt has announced a new human case of avian influenza H5N1 virus infection. The case is a 16-year-old female from Assuit Governorate, Upper Egypt whose symptoms began on 8 Dec 2008. She was initially hospitalized at the district hospital on 11 Dec 2008 and then transferred to the Assuit University Hospital on 13 Dec 2008 where she died on 15 Dec 2008. Investigations into the source of her infection indicate a recent history of contact with sick and dead poultry.
Of the 51 avian influenza H5N1 cases confirmed to date in Egypt, 23 have been fatal. Her death is the first bird flu fatality in Egypt since April 2008, and the first of the current winter season. The virus, which first appeared in Egypt in February 2006, tends to be less active in summer. Egypt has been the worst hit country outside of Asia.
About 5 million households in Egypt depend on poultry as a main source of food and income. The government has said this makes it unlikely the disease can be eradicated despite a large-scale poultry vaccination program.
- 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 (interim) 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. Epidemiological updates on the avian influenza outbreak in Hong Kong available at http://www.oie.int/wahis/public.php?page=single_report&pop=1&reportid=7609 and the outbreak in India at http://www.oie.int/wahis/public.php?page=single_report&pop=1&reportid=7606.
- 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/ Find more than 150 peer-reviewed practices from 25 US states and 37 cities and counties aimed at furthering pandemic preparedness in public health and allied fields.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- 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)
Component-Specific Effectiveness of Trivalent Influenza Vaccine as Monitored through a Sentinel Surveillance Network in Canada, 2006–2007
Skowronski DM et al. J Infect Dis. 16 Dec 2008. Available at http://www.journals.uchicago.edu/doi/full/10.1086/595862?cookieSet=1.
Background. Trivalent inactivated influenza vaccine (TIV) is reformulated annually to contain representative strains of 2 influenza A subtypes (H1N1 and H3N2) and 1 B lineage (Yamagata or Victoria). We describe a sentinel surveillance approach to link influenza variant detection with component-specific vaccine effectiveness (VE) estimation. Methods. The 2006–2007 TIV included A/NewCaledonia/20/1999(H1N1)–like, A/Wisconsin/67/2005(H3N2)–like, and B/Malaysia/2506/2004(Victoria)–like components. Included participants were individuals 9 years of age who presented within 1 week after influenzalike illness onset to a sentinel physician between November 2006 and April 2007. Influenza was identified by real-time reverse-transcriptase polymerase chain reaction and/or culture. Isolates were characterized by hemagglutination inhibition assay (HI) and HA1 gene sequence. VE was estimated as 1 – [odds ratio for influenza in vaccinated versus nonvaccinated persons].
Results. A total of 841 participants contributed: 69 (8%) were 65 years of age; 166 (20%) received the 2006–2007 TIV. Influenza was detected in 337 subjects (40%), distributed as follows: A/H3N2, 242 (72%); A/H1N1, 55 (16%); and B, 36 (11%). All but 1 of the A/H1N1 isolates were well matched, half of A/H3N2 isolates were strain mismatched, and all B isolates were lineage-level mismatched to vaccine. Age-adjusted estimated VE for A/H1N1, A/H3N2, and B components was 92% (95% CI, 40%–91%), 41% (95% CI, 6%–63%), and 19% (95% CI, －112% to 69%), respectively, with an overall VE estimate of 47% (95% CI, 18%–65%). Restriction of the analysis to include only working-age adults resulted in lower VE estimates with wide confidence intervals but similar component-specific trends.
Conclusions. Sentinel surveillance provides a broad platform to link new variant detection and the composite of circulating viruses to annual monitoring of component-specific VE.
Using Surveillance to Evaluate Influenza Vaccine Effectiveness
WHO discussion papers address ethical issues in pandemic influenza planning
I. Equitable access to therapeutic and prophylactic measures
II. Isolation, quarantine, border control, and social distancing measures
III. The role and obligations of health care workers during an outbreak of pandemic influenza
IV. Pandemic influenza and response―translational issues for governments
Papers are available at
HHS releases report on guidance regarding employer stockpiling of antivirals
Grand Challenges in Global Health Initiative request for proposals
The goal of this Request for Proposals (RFP) is to select and commission research on strategies that will facilitate the implementation and appropriate use in the developing world of technologies that arise from the GCGH projects related to diagnostics, modified insect vectors, nutritionally enhanced foods, and vaccine delivery. Visit WWW.MRCGLOBAL.ORG/RFP for further information. The deadline to submit proposals is January 16, 2009.