EINet Alert ~ Feb 13, 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)
- China: Defends avian influenza vaccination plan despite human deaths
- Chinese Taipei: Flu vaccines not as effective in 2009 as in the past
- Indonesia: Avian influenza H5N1 detected in village on Bali
- Japan: Panasonic addresses speculation over employee pandemic order
- Viet Nam: Reports new human case of avian influenza H5N1
- Viet Nam: Avian influenza H5N1 continues to spread among poultry in the Mekong Delta
- Canada (British Columbia): Avian influenza found on second poultry farm
- USA: Senate negotiators remove pandemic funding from economic stimulus bill
- USA: Seasonal influenza activity increases
- Egypt: Young boy infected with avian influenza H5N1

2. Updates

3. Articles
- Absolute humidity modulates influenza survival, transmission, and seasonality
- Human HA and polymerase subunit PB2 proteins confer transmission of an avian influenza virus through the air
- Healthcare worker's attitudes to working during pandemic influenza: a qualitative study
- Update: Influenza Activity --- United States, September 28, 2008--January 31, 2009
- Weekly Epidemiological Bulletin available online

1. Influenza News

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

China/ 7 (4)
Egypt/ 4 (0)
Viet Nam/ 1 (0)
Total/ 8 (4)

***For data on human cases of avian influenza prior to 2009, go to:

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 407 (254).
(WHO 2/11/09 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 2/2/09)

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):


China: Defends avian influenza vaccination plan despite human deaths
China's Ministry of Agriculture on 6 Feb 2009 defended its bird flu vaccination program, stating there had been no outbreaks since June 2008 despite a number of human cases, some fatal, in 2009. Human cases and the appearance of dead wild birds in Hong Kong have caused some experts and media reports to question whether the virus is widespread but undetected in China.

A total of five people died of bird flu in China in January 2009, in regions far removed from each other and in which there were no reported cases of bird flu in birds. In addition, three others have become ill, of which two have recovered, a toddler infected in Hunan and a young man in Guizhou. Apart from the discovery of a case during routine sampling in eastern China's Jiangsu province in December 2008, Chinese testing has not detected any bird flu since June 2008.

The Ministry of Agriculture said in a report on its Web site that the strain found in Jiangsu was a variant, requiring the modification of the vaccine program in the surrounding provinces of Zhejiang, Shanghai, Anhui and Shandong.

Meanwhile, two ducks and a goose found in Hong Kong have tested positive for H5N1, the strain of bird flu that can infect humans. Hong Kong closed its Mai Po nature preserve as a precaution for 21 days from 6 Feb 2009, after a dead grey heron found there also tested positive for bird flu.

Hong Kong authorities are still testing 14 other dead birds found last week on Lantau Island. "We're checking water currents" to see if the birds were washed ashore from mainland China, a government spokeswoman said.

China has vaccinated aggressively since bird flu first reappeared among humans in Asia in 2003. But vaccination does not eliminate the virus. In 2008, China reported six outbreaks of bird flu that killed 9,000 birds and led to the culling of 590,000 birds.
(ProMED 2/7/09)


Chinese Taipei: Flu vaccines not as effective in 2009 as in the past
Influenza vaccines that proved to be effective late last year have failed to live up to expectations early this year, the Department of Health (DOH) said on 3 Feb 2009. Chou Jih-haw, Deputy Director-general of the DOH's Centers for Disease Control, said more than 3.2 million free flu shots were given to the public in the autumn and winter of 2008. "Judging from the number of influenza cases in the fourth quarter of 2008, it was significantly lower than in the same period the previous year," Chou said. "But this year [2009], tests of flu viruses on the patients showed that the results have not been as good as expected," he continued.

Chou said influenza vaccines given in autumn 2008 and the winter of 2008-09 should be effective against the H1N1 and H3N2 viruses, and tests taken from patients who were inoculated in 2008 proved their effectiveness. But in January 2009, tests found the vaccines were not protective on 70 percent of those with H1N1 viruses and 40 percent of those with the H3N2 virus. A vaccine is considered effective if it controls the virus in 80 percent to 90 percent of those inoculated. Chou would not categorize the vaccines as ineffective, however, because influenza viruses are "prone to mutation," meaning that the virus formula for producing vaccines must be changed on a yearly basis.

A former CDC Director suggested on 3 Feb 2009 that part of the problem may be that flu viruses tend to strike Chinese Taipei between six months and two years earlier than European countries and the United States. Su Ih-jen, Director of the Division of Clinical Research of the National Health Research Institutes, said that because of the time lag, influenza vaccines produced by European and American pharmaceutical makers based on data provided by the World Health Organization could not keep up with the outbreak of flu in Asia. Su noted that with close exchanges between Chinese Taipei and mainland China, Chinese Taipei has become an outpost of influenza outbreaks.

The World Health Organization began to address the issue of different prevalent viruses in Asia and Europe in April 2008. Currently, two out of five major vaccine manufacturers have made inroads into China, and the production of Asian influenza vaccines "has become a trend," he said. Su suggested that the virus in every influenza outbreak is slightly different, and that "it can show major changes about every five years, so the effectiveness of vaccines can diminish."
(ProMED 2/6/09)


Indonesia: Avian influenza H5N1 detected in village on Bali
A 20-year-old man in Jagapati village, Badung, on the island of Bali, a place well known for cockfighting, is suspected of having contracted bird flu. A field doctor who has been treating and observing the man, said he began showing symptoms of influenza on 9 Feb 2009, just a few days after the report of a possible bird flu outbreak in the area. "We've given him Tamiflu and we'll continue to observe him every five hours," the doctor Tresna said. She added that her patient seemed to be getting better, but declined to rule out the possibility of bird flu, saying that she was still waiting for results of blood tests, which were sent to Jakarta on 9 Feb 2009.

It is the latest resurgence of avian flu in Bali since the death of a 29-year-old woman, who allegedly died after being infected by the H5N1 virus in August 2007. The virus was first detected on 4 Feb 2009, when a villager reported the sudden and nearly simultaneous death of 15 fowl to the Badung Animal Husbandry and Fisheries Agency. The dead fowl tested positive for bird flu. The agency has since culled as many as 133 fowl in the district, with further culling to continue in the days to come until all the villages' estimated 180-fowl population has been eliminated. "We have culled 133 fowl so far, including the 40 we aim to finish off today [11 Feb 2009]. We'll continue the elimination for as long as it takes," said I Made Badra, head of the Badung Animal Husbandry and Fisheries Agency, in Jagapati.

According to Badra, the resurgence of the virus was related to the wet season, which may have weakened a certain fowl's immune system enough to catch bird flu, quickly spreading to others. Another possibility, he said, was the transportation of an infected chicken from Java to Jagapati to use for cockfighting.

The Bali government has banned unlicensed live animal transportation into Bali and cockfighting, but the latter remains a staple in the island due to religious and traditional reasons. The ban on animal transportation has been fully implemented since the detection of rabies virus late last year 2008. However, Badra said there was a good chance that infected fowl escaped detection because they might have been transported before the rabies scare. "For now we'll continue to urge the public to not transport live animals into Bali," he said.
(ProMED 2/12/09)


Japan: Panasonic addresses speculation over employee pandemic order
A spokesman for Panasonic Corp. said on 12 Feb 2009 that the company had no proprietary information about any increased risk of an influenza pandemic in December 2008 when it instructed some of its overseas employees to send their families back to Japan by September.

Jim Reilly, a Panasonic spokesman based in New York City, also denied speculation that the company ordered the families to return to Japan as a cost-saving measure to mitigate the effects of the global economic downturn. However, he stated that the company realizes its move may seem unusual, given that they are the first major company to enact such a pandemic planning measure. "They realize that there are different perceptions around the world," Reilly said of Panasonic officials.

No change in pandemic risk
Masato Tashiro, MD, PhD, a virologist at Japan's National Institute of Infectious Diseases and a consultant to the World Health Organization (WHO), said that he hasn't seen any increase in the global pandemic risk. "As far as I understand, the recent situation of poultry outbreaks and human infections in China is within our prediction," he said.

Panasonic said its request to the employees was based on a review of where the H5N1 virus has been detected and an assessment of medical facilities in the areas, according to previous reports. The regions that were named align with its operational divisions, Reilly said. He reiterated that Japanese employees have been asked to send their families back from Asia (except Singapore), China, the Middle East, Africa, the Commonwealth of Independent States (the former Soviet republic states), and Latin America. Divisions that aren't subject to the repatriation request include North America, Western Europe, and Oceania (Australia and New Zealand).

He said it was difficult to determine how many people are affected, but he said that Panasonic has 60 factories and about 100,000 employees in China. The company has 307,000 employees worldwide, including 13,500 in North America.

Importance of business preparedness
One element of Japanese culture is that the country is very prepared to address natural disasters, Reilly said. "People from outside of Japan are always impressed when they see lots of information on what to do about earthquakes," he said, alluding to a 1995 earthquake centered in Kobe that killed nearly 6,500 people and one in 1923 that killed 140,000. "Companies know the importance of continuing business," he said.

Japan's pandemic plan, posted on the health ministry's Web site, contains 14 pages of guidance on business preparedness. It urges employers to consider options for evacuating employees and their families assigned overseas in regions that experience pandemic outbreaks, minimizing travel to outbreak areas, and ensuring that returning employees and families follow quarantine guidelines.

William Raisch, executive director of the New York University International Center for Enterprise Preparedness, stated that Panasonic's action shows that some of the largest corporations still see a pandemic as a continuing and real threat. "Further, this announcement by Panasonic indicates that they are actively monitoring the prevalence of bird flu and have begun to assess the capability and access to healthcare in key elements of their supply and distribution networks," said Raisch.

Strict quarantine, mass cremation
The country's health ministry announced some new details of its pandemic plan, which includes strict quarantine measures such as shutting down all but four airports and three ports. Other plans include closing schools and conducting mass cremation of pandemic flu fatalities. The ministry said, "It is important to delay as much as possible the virus' entry through measures such as strengthening quarantine to take advantage of the special qualities of our nation as an island nation.”

Some pandemic flu experts have said that closing borders won't stem the spread of a pandemic virus and could hamper the flow of crucial supplies. Health minister Yosuke Yamaki said that Japan is updating its pandemic plan, based on public feedback collected in recent weeks.
(CIDRAP 2/12/09)


Viet Nam: Reports new human case of avian influenza H5N1
The Ministry of Health in Viet Nam has reported a new confirmed case of human infection with the H5N1 avian influenza virus. The case has been confirmed at the National Institute of Hygiene and Epidemiology (NIHE).

The case is a 23-year-old woman from Dam Ha district, Quang Ninh province. She developed symptoms on 28 Jan 2009 and was hospitalized on 31 Jan 2009. She is currently in a serious condition and is known to have had recent contact with sick and dead poultry prior to the onset of her illness. Further investigations are currently underway. Control measures have been implemented and close contacts are being identified and monitored.
(ProMED 2/9/09, 2/11/09)


Viet Nam: Avian influenza H5N1 continues to spread among poultry in the Mekong Delta
The H5N1 strain of bird flu has been reported in more localities across Viet Nam, raising fears of a possible epidemic, official reports said on 6 Feb 2009. The latest outbreak occurred on a farm in Mekong Delta's Ca Mau province, where 300 unvaccinated ducklings died of the virus, said the national animal health department.

The Hanoi-based office in its earlier reports said avian influenza had been found in ducks in nearby Soc Trang province and Nghe An province in the country's central region. In addition, southern Bac Lieu has been added to the list of bird-flu hit provinces. "Epidemics could spread easily because of cold weather and local residents' habit of letting the ducks run around in rice fields," Thanh Nien said, adding that thousands of infected poultry have died or been culled in 2009.

Early in February 2009, Viet Nam's capital Hanoi issued a ban on the widespread use of motorbikes or bicycles to transport poultry and livestock for fear it could help trigger an epidemic. However, state media has frequently reported that meat products continued to be transported by motorbike into the city daily despite the ban.

Viet Nam, which has been hit by bird flu since 2003, reported a human case in early 2009, an 8-year-old girl from northern Thanh Hoa province who has now recovered. Her 13-year-old sister died in hospital earlier but was not tested for H5N1 before the burial, health officials said.
(ProMED 2/8/09)


Canada (British Columbia): Avian influenza found on second poultry farm
Avian influenza has been found on a second poultry farm in Abbotsford, but it appears to be the same less-virulent strain as found on a farm last month, officials said on 11 Feb 2009. The virus was found on a farm within the 3 km quarantine and testing zone that was set up around another turkey farm in Abbotsford, where the disease was first detected, the Canada Food Inspection Agency (CFIA) said.

The case poses little if any threat to human health, officials said. Initial testing indicated the virus is H5 avian influenza but more testing will be needed to determine the exact strain. The first case involved H5N2, a low-pathogenic strain of the disease.

“Tests to date indicate that the strain of avian influenza on the new premises is also low pathogenic and similar to the original strain identified on the index premises,” the agency said. Forty-three poultry farms in the Fraser Valley east of Vancouver have been placed under quarantine for testing because of the discovery. Twelve thousand breeding chickens on the latest farm will have to be destroyed because of the virus. Last month’s discovery of the virus led to the destruction of 60,000 turkeys.

CFIA said it is not known yet how the birds at the second farm became infected and they are not aware of any connection between the two farms. The cause of the first outbreak has also not been determined, but experts have speculated the commercial birds contracted the virus from wild birds that frequent the area.
(Reuters 2/11/09)


USA: Senate negotiators remove pandemic funding from economic stimulus bill
Bipartisan work on the Senate's version of the economic stimulus bill on 6 Feb 2009 cut $870 million in pandemic planning provisions from the list of spending proposals, according to a report from Congressional Quarterly (CQ) Today. Critics questioned whether or not increasing the nation's pandemic vaccine stockpile would increase jobs. The House stimulus bill allocates $900 for pandemic flu funding. After the Senate passes its version, a conference will meet to resolve differences between the two bills.
(CIDRAP 2/9/09)


USA: Seasonal influenza activity increases
The US Centers for Disease Control and Prevention (CDC) said on 6 Feb 2009 that five states reported widespread flu activity during the week of 25-31 January 2009, up from two states the previous week. The states are Colorado, Delaware, New York, Texas, and Virginia. Almost all (97.4%) influenza A/H1N1 samples that have been tested showed resistance to oseltamivir. New York City reported one flu-related pediatric death.

The influenza surveillance update is available at http://www.cdc.gov/flu/weekly/.
(CIDRAP 2/6/09)


Egypt: Young boy infected with avian influenza H5N1
An Egyptian boy has contracted the bird flu virus, the Health Ministry stated on 8 Feb 2009, the second such case in the last week and the 55th case since the virus reached Egypt in 2006. The 18-month-old boy from the province of Minia in central Egypt first showed symptoms on 6 Feb 2009 after coming into contact with dead birds and was admitted to hospital the following day. He was administered the antiviral drug Tamiflu and is now in a stable condition, the health ministry said.

Egypt is one of the only countries affected by bird flu that does not offer compensation for farmers when poultry is destroyed, which many experts say is the best way to ensure rapid detection of new outbreaks. Approximately 5 million Egyptian households depend on poultry as a main source of food and income.

Infection with the H5N1 avian influenza virus was confirmed by the Egyptian Central Public Health Laboratory. The case was confirmed by the World Health Organization on 10 Feb 2009.
(ProMED 2/8/09, 2/10/09)


2. Updates
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services and includes the website of the Central Fund for Influenza Action. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The (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.


3. Articles
Absolute humidity modulates influenza survival, transmission, and seasonality
Shaman J and M Kohn. Proc Natl Acad Sci. 9 Feb 2009. Available at http://www.pnas.org/content/early/2009/02/09/0806852106.abstract.

Influenza A incidence peaks during winter in temperate regions. The basis for this pronounced seasonality is not understood, nor is it well documented how influenza A transmission principally occurs. Previous studies indicate that relative humidity (RH) affects both influenza virus transmission (IVT) and influenza virus survival (IVS). Here, we reanalyze these data to explore the effects of absolute humidity on IVT and IVS. We find that absolute humidity (AH) constrains both transmission efficiency and IVS much more significantly than RH. In the studies presented, 50% of IVT variability and 90% of IVS variability are explained by AH, whereas, respectively, only 12% and 36% are explained by RH. In temperate regions, both outdoor and indoor AH possess a strong seasonal cycle that minimizes in winter. This seasonal cycle is consistent with a wintertime increase in IVS and IVT and may explain the seasonality of influenza. Thus, differences in AH provide a single, coherent, more physically sound explanation for the observed variability of IVS, IVT and influenza seasonality in temperate regions. This hypothesis can be further tested through future, additional laboratory, epidemiological and modeling studies.


Human HA and polymerase subunit PB2 proteins confer transmission of an avian influenza virus through the air
Van Hoeven N et al. Proc Natl Acad Sci. 11 Feb 2009. Available at http://www.pnas.org/content/early/2009/02/11/0813172106.abstract.

Abstract The influenza virus genes that confer efficient transmission of epidemic and pandemic strains in humans have not been identified. The rapid spread and severe disease caused by the 1918 influenza pandemic virus makes it an ideal virus to study the transmissibility of potentially pandemic influenza strains. Here, we used a series of human 1918-avian H1N1 influenza reassortant viruses to identify the genetic determinants that govern airborne transmission of avian influenza viruses. We have demonstrated that the 1918 HA gene was necessary for efficient direct contact transmission, but did not allow respiratory droplet transmission between ferrets of an avian influenza virus possessing an avian polymerase subunit PB2. The 1918 PB2 protein was found to be both necessary and sufficient for airborne transmission of a virus expressing the 1918 HA and neuraminidase. Also, it was found that influenza viruses that were able to transmit efficiently in ferrets were able to replicate efficiently at the lower temperature (33 °C) found in the environment of mammalian airway. These findings demonstrate that the adaptation of the HA and PB2 proteins are critical for the development of pandemic influenza strains from avian influenza viruses.


Healthcare worker's attitudes to working during pandemic influenza: a qualitative study
Ives J et al. BMC Pub Health. 12 Feb 2009; 9(56). Available at http://www.biomedcentral.com/1471-2458/9/56/abstract.


Background. Healthcare workers (HCWs) will play a key role in any response to pandemic influenza, and the UK healthcare system's ability to cope during an influenza pandemic will depend, to a large extent, on the number of HCWs who are able and willing to work through the crisis. UK emergency planning will be improved if planners have a better understanding of the reasons UK HCWs may have for their absenteeism, and what might motivate them to work during an influenza pandemic. This paper reports the results of a qualitative study that explored UK HCWs' views (n=64) about working during an influenza pandemic, in order to identify factors that might influence their willingness and ability to work and to identify potential sources of any perceived duty on HCWs to work .

Method. A qualitative study, using focus groups (n=9) and interviews (n=5).

Results. HCWs across a range of roles and grades tended to feel motivated by a sense of obligation to work through an influenza pandemic. A number of significant barriers that may prevent them from doing so were also identified. Perceived barriers to the ability to work included being ill oneself, transport difficulties, and childcare responsibilities. Perceived barriers to the willingness to work included: prioritising the wellbeing of family members; a lack of trust in, and goodwill towards, the NHS; a lack of information about the risks and what is expected of them during the crisis; fear of litigation; and the feeling that employers do not take the needs of staff seriously. Barriers to ability and barriers to willingness, however, are difficult to separate out.

Conclusions. Although our participants tended to feel a general obligation to work during an influenza pandemic, there are barriers to working, which, if generalisable, may significantly reduce the NHS workforce during a pandemic. The barriers identified are both barriers to willingness and to ability. This suggests that pandemic planning needs to take into account the possibility that staff may be absent for reasons beyond those currently anticipated in UK planning documents. In particular, staff who are physically able to attend work may nonetheless be unwilling to do so. Although there are some barriers that cannot be mitigated by employers (such as illness, transport infrastructure etc.), there are a number of remedial steps that can be taken to lesson the impact of others (providing accommodation, building reciprocity, provision of information and guidance etc). We suggest that barriers to working lie along an ability/willingness continuum, and that absenteeism may be reduced by taking steps to prevent barriers to willingness becoming perceived barriers to ability.


Update: Influenza Activity --- United States, September 28, 2008--January 31, 2009
US Centers for Disease Control and Prevention. MMWR. 13 Feb 2009; 58(5): 115-119. Available at http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5805a4.htm.

From September 28, 2008, to January 31, 2009, influenza activity remained low in the United States but began to increase at the end of January. Thus far during the 2008--09 influenza season, influenza A viruses have predominated and are antigenically related to the 2008--09 influenza vaccine strains. Oseltamivir resistance has been detected in nearly all of the influenza A (H1N1) viruses tested so far during the 2008--09 season, with high levels of adamantane resistance among influenza A (H3N2) viruses. This report summarizes U.S. influenza activity since the last update and reviews interim recommendations for the use of influenza antiviral medications. (References removed.)


Weekly Epidemiological Bulletin available online
WHO. 13 February 2009; vol. 84(6): p49-56. Available at http://www.who.int/wer.

Contents of this issue
49 Outbreak news– Ebola Reston in pigs and humans, Philippines
50 Cholera outbreak, Zimbabwe
52 Case definitions for the 4 diseases requiring notification to WHO in all circumstances under the International Health Regulations (2005)
56 Corrigendum
56 WHO web sites on infectious diseases