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EINet Alert ~ Jan 30, 2009


*****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: Avian influenza vaccination could be on the way
- Bangladesh: Reports three avian influenza H5N1 outbreaks on poultry farms
- Bangladesh: Media can play role in avian influenza prevention, workshop reminds journalists
- China: WHO confirms three new human cases of avian influenza H5N1, two deaths
- Indonesia: Avian influenza H5N1 suspected in death of 21-year-old woman
- Nepal: Man in Damak suspected of being infected with avian influenza H5N1
- Canada (British Columbia): Avian influenza outbreak on turkey farm
- USA: House-passed stimulus bill includes pandemic funding
- USA (New Jersey): Gates Foundation funds development of plant-based avian influenza vaccine
- Egypt: Two-year-old infected with avian influenza H5N1

2. Updates
- AVIAN/PANDEMIC INFLUENZA

3. Articles
- Impact of the 2004–2005 Influenza Vaccine Shortage on Pediatric Practice: A National Survey
- Face Mask Use and Control of Respiratory Virus Transmission in Households
- Time from Illness Onset to Death, 1918 Influenza and Pneumococcal Pneumonia
- Highly Pathogenic Avian Influenza Virus (H5N1) in Frozen Duck Carcasses, Germany, 2007

4. Notifications
- Weekly Epidemiological Bulletin available online
- CDC's preparedness chief named acting director


1. Influenza News

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

2009
China/ 6 (4)
Egypt/ 2 (0)
Total/ 8 (4)

2008
Bangladesh / 1 (0)
Cambodia/ 1 (0)
China / 4 (4)
Egypt / 8 (4)
Indonesia / 22 (18)
Viet Nam / 6 (5)
Total / 42 (31)

***For data on human cases of avian influenza prior to 2009, go to:
http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 403 (254).
(WHO 1/27/09 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 1/27/09)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 1/27/09): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 1/22/09):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: Avian influenza vaccination could be on the way
On 29 Jan 2009, researchers in Japan said they had developed a flu vaccine that works against multiple viruses and might prevent a deadly pandemic of bird flu mutations. According to Tetsuya Uchida, a researcher at the National Institute of Infectious Diseases, the research team has tested the vaccine on mice implanted with human genes, which confirms that it works even if flu viruses mutate. Right now, flu vaccines use proteins that cover the surface of viruses, but the protein frequently mutates to make the vaccines ineffective.

Uchida said that the newly developed vaccine is based on common types of protein inside the bodies of flu viruses as they rarely change. The viruses used are the Soviet-A and Hongkong-A, along with the H5N1 strain of bird flu. "We expect this will also be effective on new variations" of the much-feared H5N1 strain in addition to conventional flu viruses, he said.

It would mostly likely take several years to put the vaccine into practical use, said Uchida. The research team would need to confirm the vaccine's safety with further experiments on mice and possibly larger animals before tests on humans.

The study was done by researchers from the national institute, Hokkaido University, Saitama Medical University and NOF Corp., a chemicals company based in Tokyo. According to experts, influenza that affects humans is caused mostly by the Soviet-A, Hongkong-A and type B viruses. The experiment had been done with the type A viruses, but the method should also be effective on the type B, said Uchida.
(Breaking Bird Flu News 1/30/09)

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Asia
Bangladesh: Reports three avian influenza H5N1 outbreaks on poultry farms
Veterinary officials in Bangladesh reported three more avian influenza H5N1 outbreaks, including a commercial farm near the country's capital, Dhaka, according to a report from the World Organization for Animal Health (OIE).

The outbreak on the farm near Dhaka started on 7 Jan 2009 and killed 112 of 5,341 poultry. The remaining birds were culled to control the spread of the virus.

Authorities reported another outbreak that began on 11 Jan 2009 and struck backyard birds in a village in Rajshahi division in the northwestern part of the country near the border with India, killing 11 of 736 susceptible birds. Animal health workers destroyed the rest of the flock.

Another outbreak at a commercial poultry farm, this time in Chittagong division in the southernmost area of Bangladesh, began on 15 Jan 2009, killing 80 of 1,800 birds. The remaining birds were destroyed.

Bangladesh has had several outbreaks since October 2008, when the virus reemerged in late September 2008 after a four-month lull. Two states in western India that share borders with Bangladesh—Assam and West Bengal—have also battled recent H5N1 outbreaks.
(CIDRAP 1/23/09)

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Bangladesh: Media can play role in avian influenza prevention, workshop reminds journalists
Speakers at workshop for journalists in Rajshahi on 27 Jan 2009 said that the media has a vital role in preventing bird flu through objective reporting. A collective effort of all is essential in taking preventive measures against infection of avian influenza to protect the country's potential poultry farms from ruination, they said. The speakers said all concerned government and non- government organizations, as well as poultry bird farmers, should work together with media professionals to protect this sector from any adverse impact.

Press Institute of Bangladesh (PIB) organized the workshop titled "Bird Flu Awareness and Preparedness" at the conference hall of Rajshahi Chamber of Commerce and Industry. Approximately 35 journalists of print and electronic media including news agencies from Rajshahi and Naogaon attended the workshop.

PIB Senior Trainer Aliur Rahman and Trainer Abdul Mannan addressed the workshop as resource persons while Dr Md Jobayer of the Microbiology Department of Dhaka Medical College gave an overview of the disease and its probable causes and prevention strategies in his keynote speech.
(The New Nation 1/30/09)

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China: WHO confirms three new human cases of avian influenza H5N1, two deaths
The Ministry of Health in China has announced three new confirmed human cases of H5N1 infection. The first, a 31-year-old female from Urumqi, Xinjiang Autonomous Region, had onset of symptoms on 10 Jan 2009. She received treatment in hospital, but died on 23 Jan 2009. Investigations into the possible source of her infection indicate recent visits to a live poultry market. The local authorities are currently conducting epidemiological investigations and close contacts are being monitored. No clinical symptoms have been reported among the contacts.

The second case is a 29-year-old male from Guiyang city, Guizhou. He had onset of symptoms on 15 Jan 2009 and remains in a critical condition. Investigations into the source of his infection indicate possible exposure at a poultry market.

The third case is an 18-year-old male from Beiliu City, Guangxi Province. He had onset of symptoms on 19 Jan 2009 and died on 26 Jan 2009. Investigations into the source of his infection indicate a recent history of exposure to sick and dead poultry. Close contacts of the case are being monitored and to date all remain well.

China launched a daily bird flu reporting system for poultry and human cases on 22 Jan 2009, underscoring its concerns about potential epidemics. Provincial health and agriculture departments must report to the Health Ministry, Agriculture Ministry and the State Administration for Industry and Commerce every day on whether there have been infections in their areas. The Agriculture Ministry has also ordered increased monitoring and management of live poultry markets, especially before the Lunar New Year holiday, when people will have more contact with chickens and ducks while preparing celebratory meals.

Despite the new cases, the Health Ministry has said there was no evidence of a large-scale outbreak of bird flu. It said the illnesses were isolated, unrelated, and did not show significant mutations of the H5N1 virus. They also occurred during the cold months, which experts have determined are high season for infections.
(ProMED 1/24/09, 1/27/09)

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Indonesia: Avian influenza H5N1 suspected in death of 21-year-old woman
A 21-year-old Indonesian woman has died of suspected bird flu, a doctor said on 28 Jan 2009. The woman died on 24 Jan 2009 in Doctor Soetomo Hospital in Surabaya, East Java, after showing bird flu symptoms, said Palilingan, a doctor in the hospital's avian flu team.

"She had breathing difficulties, high fever, and lost consciousness," Palilingan stated. He said the presence of the H5N1 strain of the virus would have to be confirmed after testing of tissue samples. Two positive results are needed before Indonesian authorities confirm a human bird flu infection. A health ministry spokeswoman said the ministry had sent experts to check on the condition of poultry in the woman's village in Tulungagung district, East Java.
(ProMED 1/28/09)

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Nepal: Man in Damak suspected of being infected with avian influenza H5N1
Nepal has found a patient from Damak, eastern Nepal, who is a suspected case of human bird flu infection, the Nepali national news agency RSS reported 25 Jan 2009. Damak of Jhapa district is 320 km east of the Nepali capital Kathmandu. In mid-January 2009, the first case of bird flu in poultry was detected in Kakarbhitta of the same district.

The patient was taken to nearby BP Koirala Institute for Health Sciences (BPKIHS) in Dharan. Communication spokesperson for BPKIHS Bijay Rimal said that bird flu virus is suspected to have been found in the patient's blood sample during tests in the institute's laboratory. He said the patient's blood sample has been sent for further tests in a more sophisticated laboratory. He added that the patient was showing symptoms of bird flu infection.

Rimal, however, said it cannot be officially confirmed whether the patient is infected with bird flu yet as the institute lacked a specific lab to test bird flu. The patient has been referred to Dharan by Lifeline Hospital in Damak.

Authorities have launched a second-phase program to prevent the possible spread of bird flu in Jhapa district in eastern Nepal, where the disease was traced in chickens. Officials at the Ministry of Agriculture and Cooperatives said thousands of chickens and other birds were culled and poultry products destroyed in Mechinagar Municipality, Jhapa, some 320 km east of Kathmandu, during the first phase of the anti-bird flu drive.

The second-phase, which will continue for three months, will include cleaning programs in sensitive places like poultry firms and sales stores. The government issued a bird flu alert in Mechinagar on 16 Jan 2009. Meanwhile, as part of the anti-bird flu surveillance, the Home Ministry has banned transportation of live birds and poultry products in buses and other public vehicles.
(ProMED 1/25/09, 1/26/09)

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Americas
Canada (British Columbia): Avian influenza outbreak on turkey farm
Tests have confirmed an outbreak of bird flu at a turkey farm near Vancouver, but it appeared to be a less virulent strain and posed little risk to humans, officials said on 24 Jan 2009. More than 50,000 birds on the Abbotsford, British Columbia, farm will be destroyed to ensure the avian influenza virus does not spread to other farms, the Canadian Food Inspection Agency (CFIA) said.

Tests on sickened birds showed they had H5 avian influenza, but it will be another day or more before the exact strain of the virus is known and its pathogenicity, the agency said. Pathogenicity indicates the severity of the illness to the birds. Preliminary tests indicated that it was a low pathogenic strain, it said. "Nobody has been infected by the virus," said Elizabeth Brodkin, medical officer of the Fraser Health Authority.

Twenty-three farms within 3 km of the farm in British Columbia's Fraser Valley are under quarantine as officials check to make sure their flocks have not been infected. Officials said the farm had followed all the rules designed to stop and control the disease.

The area had bird flu outbreaks in 2004 and 2005. The 2004 outbreak forced authorities to kill about 17 million farmed birds to stop the disease from spreading.

The inspection agency said it was moving quickly to cull the turkeys to avoid a repeat of 2004, when the virus mutated to a highly pathogenetic form before the outbreak was contained. The outbreak resulted in two human infections, one with low pathogenic H7N3 subtype isolated and one with high pathogenic H7N3 subtype isolated. This is not the subtype implicated in the current outbreak, however.
(ProMED 1/24/09, 1/26/09)

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USA: House-passed stimulus bill includes pandemic funding
On 28 Jan 2009, the US House of Representatives passed an $819 billion economic stimulus bill that included funding for pandemic influenza and bioterrorism countermeasures, and now the Senate will debate its version of the measure, which also includes spending on some of the same items.

President Barack Obama and several Democratic legislators have hailed the public health spending provisions as a way to create jobs and boost the productivity of the American workforce. However, some lawmakers oppose spending provisions, particularly those aimed at government departments.

The House bill includes $900 million for biomedical advanced research and development, pandemic flu, and cyber security to help the nation better prevent or respond to a natural or man-made biological threat, according to a 15 Jan 2009 statement from Trust for America's Health (TFAH), a nonprofit health advocacy group in Washington, DC.

The House plan also includes $3 billion for disease prevention, including funding for state and local health departments and immunization programs, and $20 billion for health information technology. In 2008, a TFAH expert panel reported that the country faces annual $20 billion shortfalls in critical public health program funding across state, local, and federal levels.

The Senate bill includes $870 million to complete funding for the nation's pandemic influenza plan. It also includes $5.8 billion for prevention and wellness efforts, including $600 million to boost the healthcare, and $5 billion toward the modernization of health information technology.

TFAH said the Senate's stimulus bill includes funding to modernize the nation's capacity to respond to a pandemic outbreak, along with equipment and medications to detect, contain, and treat pandemic influenza. Yesterday the House passed its stimulus measure by a 244-to-188 margin, with Republicans unanimously opposing the bill. It's unclear how the bill will fare in the Senate, where Democrats have a slimmer majority.
(CIDRAP 1/29/09)

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USA (New Jersey): Gates Foundation funds development of plant-based avian influenza vaccine
A nonprofit research group in Newark has received an $8.7 million grant from the US’s largest foundation to continue development of a plant-based vaccine for bird flu.

The Fraunhofer Center for Molecular Biotechnology expects to add at least ten Ph.D.-level scientists to its staff of 80 to help move its vaccine candidate toward clinical trials in humans. The grant builds on a $2.6 million award to Fraunhofer two years ago from the Bill & Melinda Gates Foundation to find potential flu vaccines.

Vidadi Yusibov, Fraunhofer's executive director, said the latest grant shows the foundation believes Fraunhofer's technology -- which makes vaccine materials by coaxing plants into producing certain proteins -- can yield commercially viable vaccines. The grant "will help us to establish all the processes of making a suitable product you can take into human trials," Yusibov said.

The Fraunhofer research is targeting the H5N1 virus, and the group is working with commercial partner iBioPharma Inc., a Newark biotech firm that has an exclusive license on Fraunhofer's plant-based technology. Fraunhofer has also worked with the Gates Foundation to develop vaccines for sleeping sickness and malaria.

"It is essential that new vaccines reach the people who need them most," said Doug Holtzman, senior program officer for the Gates Foundation. "If successful, this project could help developing countries respond quickly to outbreaks of influenza and other infectious diseases to significantly limit their impact on vulnerable populations."
(The News Journal 1/30/09)

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Africa
Egypt: Two-year-old infected with avian influenza H5N1
Egypt's Health Ministry says a two-year-old child is Egypt's 53rd case of bird flu since the H5N1 virus appeared in the North African country in 2006. The child, from the northern province of Menoufiya, was admitted to the hospital on 23 Jan 2009 with an elevated temperature and sore throat and was immediately treated with the anti-flu drug Tamiflu, says spokesman Dr. Abdel Rahman Shahine. The boy is in stable condition. Like most of Egypt's victims of the disease, the child was in regular contact with domestic fowl.

Egypt has had the highest number of human cases after Indonesia and Viet Nam. On 16 Dec 2008, a teenager was the 23rd death in the country from bird flu since March 2006.
(ProMED 1/25/09)

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2. Updates
AVIAN/PANDEMIC INFLUENZA
- 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)

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3. Articles
Impact of the 2004–2005 Influenza Vaccine Shortage on Pediatric Practice: A National Survey
McQuillan L et al. Pediatrics. Feb 2009; 123(2): e186-e192. Available at http://pediatrics.aappublications.org/cgi/content/abstract/123/2/e186.

Background. A severe influenza vaccine shortage occurred during the 2004–2005 influenza season because of the loss of all vaccine made by Chiron (Emeryville, CA) for US distribution.

Objectives. The objectives of this study were to assess among pediatricians nationally: (1) influenza vaccine-delivery strategies; (2) reported vaccine shortages and factors associated with experiencing shortages; and (3) the impact of shortages on vaccine redistribution, patient referral, and clinical practice, including patient prioritization.

Methods. A survey was administered in March 2005 through June 2005 to 427 pediatricians who participated in a national network representative of the American Academy of Pediatrics membership.

Results. Our response rate was 82%. Thirty-nine percent of the pediatricians had a computerized method for identifying patients at high risk needing vaccination. Ninety-four percent and 79% reported giving high-priority to children 24 months old with high-risk conditions and children 6 to 23 months old, respectively, whereas 41% gave high-priority to household contacts and caregivers of children <6 months old. Forty-three percent reported experiencing shortages of vaccine for patients at high risk, whereas only 14% ordered Chiron vaccine. In multivariate analyses, ordering vaccine from Chiron and ordering Aventis Pasteur (Lyon, France) vaccine solely from a vaccine distributor were associated with experiencing a shortage. Forty-eight percent of respondents obtained additional vaccine from another source, most frequently the public health sector, whereas 37% reported selling or giving away vaccine. In addition, 47% referred patients at high risk elsewhere for vaccination, primarily to public health clinics. Forty-nine percent reported having unused vaccine remaining at the end of the season.

Conclusions. Although few pediatricians ordered Chiron vaccine, substantial influenza vaccine shortages were reported, highlighting the tenuousness of injectable influenza vaccine supplies for children. The extensive redistribution of vaccine suggests that cooperative efforts between the private and public sectors were widespread. Efforts to vaccinate patients at high risk during shortages would be aided by better systems to identify and recall these patients.

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Face Mask Use and Control of Respiratory Virus Transmission in Households
MacIntyre CR et al. Emerg Infect Dis. Feb 2009; 15(2). Available at http://www.cdc.gov/eid/content/15/2/233.htm.

Abstract
Many countries are stockpiling face masks for use as a nonpharmaceutical intervention to control virus transmission during an influenza pandemic. We conducted a prospective cluster-randomized trial comparing surgical masks, non–fit-tested P2 masks, and no masks in prevention of influenza-like illness (ILI) in households. Mask use adherence was self-reported. During the 2006 and 2007 winter seasons, 286 exposed adults from 143 households who had been exposed to a child with clinical respiratory illness were recruited. We found that adherence to mask use significantly reduced the risk for ILI-associated infection, but <50% of participants wore masks most of the time. We concluded that household use of face masks is associated with low adherence and is ineffective for controlling seasonal respiratory disease. However, during a severe pandemic when use of face masks might be greater, pandemic transmission in households could be reduced.

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Time from Illness Onset to Death, 1918 Influenza and Pneumococcal Pneumonia
Klugman KP et al. Emerg Infect Dis. Feb 2009; 15(2). Available at http://www.cdc.gov/eid/content/15/2/346.htm.

Letter to the Editor
Brundage and Shanks have studied time to death from the onset of influenza symptoms during the 1918 pandemic in military and civilian populations and found a median time to death of 7–11 days. They argue that these data support the idea that the deaths may be predominantly due to bacterial superinfection after the acute phase of influenza. We observed a similar 10-day median time to death among soldiers dying of influenza in 1918, a finding consistent with the time to death for a bacterial superinfection, specifically pneumococcal bacteremic pneumonia.

The major bacterial pathogen associated with influenza-related pneumonia in 1918 was Streptococcus pneumoniae. Neither antimicrobial drugs nor serum therapy was available for treatment in 1918. To further analyze the time course of death from influenza in relation to that of pneumococcal pneumonia in 1918, we examined data collected by Tilghman and Finland from the pre–antimicrobial drug era of the 1920s and 1930s. The Figure shows the distribution of time from onset of illness to death due to influenza-related pneumonia in 1918 compared with time to death due to untreated pneumococcal pneumonia in the 1920s and 1930s. The Figure indicates a close concordance of the times to death. Similar times to death do not prove the specific bacterial etiology of the 1918 deaths. However, pneumococcal bacteremia was associated with most of the pneumonia deaths reported by Tilghman and Finland, and most 1918 influenza-related deaths were due to bacterial pneumonia. Also, up to 50% of patients dying from pneumonia in 1918 had pneumococcal bacteremia. These similar times to death provide additional evidence that the influenza-related pneumonia deaths during the 1918 influenza pandemic were largely due to the pneumococcus. (References removed.)

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Highly Pathogenic Avian Influenza Virus (H5N1) in Frozen Duck Carcasses, Germany, 2007
Harder TC et al. Emerg Infect Dis. Feb 2009 ; 15(2). Available at http://www.cdc.gov/eid/content/15/2/272.htm.

Abstract
We conducted phylogenetic and epidemiologic analyses to determine sources of outbreaks of highly pathogenic avian influenza virus (HPAIV), subtype H5N1, in poultry holdings in 2007 in Germany, and a suspected incursion of HPAIV into the food chain through contaminated deep-frozen duck carcasses. In summer 2007, HPAIV (H5N1) outbreaks in 3 poultry holdings in Germany were temporally, spatially, and phylogenetically linked to outbreaks in wild aquatic birds. Detection of HPAIV (H5N1) in frozen duck carcass samples of retained slaughter batches of 1 farm indicated that silent infection had occurred for some time before the incidental detection. Phylogenetic analysis established a direct epidemiologic link between HPAIV isolated from duck meat and strains isolated from 3 further outbreaks in December 2007 in backyard chickens that had access to uncooked offal from commercial deep-frozen duck carcasses. Measures that will prevent such undetected introduction of HPAIV (H5N1) into the food chain are urgently required.

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4. Notifications
Weekly Epidemiological Bulletin available online
WHO. 31 January 2009; vol. 84(5): p37-40. Available at http://www.who.int/wer.

Contents of this issue
Global Advisory Committee on Vaccine Safety, 17-18 December 2008

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CDC's preparedness chief named acting director
Richard E. Besser, MD, who formerly directed terrorism preparedness and emergency response at the US Centers for Disease Control and Prevention (CDC), was named as the agency's acting director. Besser replaces Julie L. Gerberding, MD, MPH, who had led the agency since July 2002 and stepped down as President Barack Obama took office last week.

Besser took the helm of the agency Jan 22. He had been director of the CDC Coordinating Office for Terrorism Preparedness and Emergency Response since August 29, 2005, according to Glen Nowak, CDC media relations director. Nowak said Besser was appointed acting CDC director by Charles Johnson, acting secretary of the Department of Health and Human Services (HHS). Former Sen. Tom Daschle has been nominated as HHS secretary but has not yet been confirmed.

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 apecein@u.washington.edu