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EINet Alert ~ Apr 10, 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)
- Germany: 17,000 turkeys to be culled due to low pathogenic avian influenza infection
- Poland: Health workers charged with avian influenza H5N1 fraud
- Indonesia: Family of child killed by avian influenza H5N1 in Pekanbaru (Riau) develop fever
- Japan: Study finds avian influenza H5N1 antibodies in wild raccoons
- Japan: Study tests new influenza prepandemic vaccination strategy
- Viet Nam: Avian influenza H5N1 infection confirmed in death of 3-year-old boy
- Viet Nam: Receives funds from FAO for avian influenza H5N1 preparedness
- USA: FDA approves avian influenza H5N1 rapid test
- USA (Kentucky): Confirmed low-pathogenic avian influenza on poultry farm
- Egypt: Three new avian influenza H5N1 infections confirmed in children
- Egypt: Recent avian influenza H5N1 cases prompt speculation about silent infections
- Nigeria (Oyo): Poultry farmers protest radio messages about avian influenza

2. Updates
- AVIAN/PANDEMIC INFLUENZA

3. Articles
- Intradermal influenza vaccination of healthy adults using a new microinjection system: a 3-year randomised controlled safety and immunogenicity trial
- Use of Northern Hemisphere Influenza Vaccines by Travelers to the Southern Hemisphere

4. Notifications
- Influenza in the Asia-Pacific
- Conference: ICU Infection in an Era of Multi-Resistance


1. Influenza News

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

2009
China/ 7 (4)
Egypt/ 12 (0)
Viet Nam/ 3 (3)
Total/ 22 (7)

***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: 417 (257).
(WHO 4/8/09 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 3/23/09)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 3/18/09): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 3/23/09):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Europe/Near East
Germany: 17,000 turkeys to be culled due to low pathogenic avian influenza infection
Seventeen thousand turkeys will be culled on a fattening unit in the district of Kleve after a preliminary test revealed the presence of a low-pathogenic avian influenza (LPAI) H7 virus. The H7 subtype of avian influenza is a virus with a low morbidity and mortality rate for poultry. Further samples will be investigated by the NRL (Friedrich-Loeffler-Institut) on the island of Riems and results are expected beginning 6 Apr 2009. The application of further precautionary measures, such as implementation of restriction zones, and their scope depend upon the laboratory results.
(ProMED 4/6/09)

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Poland: Health workers charged with avian influenza H5N1 fraud
Nine health workers went on trial in northern Poland Monday accused of having tested a vaccine against bird flu on nearly 200 patients without their knowledge, court officials said. The accused -- three doctors and six nurses -- are charged with "fraud, creating false documents and delivering health care without authorization" to 196 patients, judge Piotr Szadkowski of the Torun region stated.

The medical personnel are charged with administering a vaccine banned in Poland against the deadly H5N1 strain of bird flu that can be transmitted to humans. They allegedly led their patients, many of them poor and homeless, to believe they were being vaccinated against ordinary flu. Patients were reportedly paid to receive the vaccine.
(AFP 4/6/09)

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Asia
Indonesia: Family of child killed by avian influenza H5N1 in Pekanbaru (Riau) develop fever
The death of a 2-year-old child in Pekanbaru (Riau), subsequently confirmed as due to bird flu, has alarmed his family and neighbors. They are afraid that virus is still circulating and taking lives. In particular, the child's 42-year-old father has developed a high fever. The situation was reported by the Head of Monitoring and Disaster Section of the Health Service Pekanbaru, Naviri on 1 Apr 2009, while her team was inspecting the victim's house. In addition, she reported that the victim's 59- and 67-year-old grandparents had also developed a high fever. They have been treated intensively at Arifin Ahmad regional hospital and the victim's father remains in intensive care. The hospital has collected blood samples for further tests.

Naviri said the health service is now engaged in data recording and surveillance around the outbreak location. Agriculture service officers of Pekanbaru, Sentot Djoko Prayitno have carried out chicken depopulation and disinfection measures within an area of 100 square meters (approximately 1000 square feet) around the victim's house.
(ProMED 4/3/09)

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Japan: Study finds avian influenza H5N1 antibodies in wild raccoons
Ten wild raccoons have been found with signs of previous H5N1 bird flu infections, according to a joint study by Tokyo University and Yamaguchi University. This is the first time mammals in Japan have been found with bird flu virus antibodies, which develop as a result of infection. Before the discovery, only birds had been found with bird flu antibodies.

The research team, which presented a paper on its findings at a conference of the Japanese Society of Veterinary Science in Utsunomiya on Saturday 4 Apr 2009, warned that infected raccoons could introduce the virus into chicken farms and noted that countermeasures were needed.

The research team collected and examined blood from 988 raccoons captured since 2005 at three locations in western Japan and one location in eastern Japan. In the blood of 10 raccoons from three of the locations, the team found antibodies that had developed after past H5N1 infections. In two of the three places, not even birds had been found with the antibodies before this time.

According to Taisuke Horimoto, an associate professor of Tokyo University's Institute of Medical Science, raccoons do not live in packs. He said the blood test this time showed that in comparison with other infectious diseases, the proportion of animals found with the H5N1 antibodies was low.

The researchers think the 10 raccoons likely were not infected by other raccoons, but by eating the carcasses of infected birds or inheriting the antibodies from a parent at birth. Raccoons are found throughout the nation. Many of them are descended from abandoned pets or have run away from zoos.
(ProMED 4/7/09)

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Japan: Study tests new influenza prepandemic vaccination strategy
The use of two vaccines made from different strains of H5N1 avian flu virus may be a promising prepandemic vaccination strategy for dealing with a potential H5N1 pandemic strain, according to a news report about a vaccine trial in Japan. In the trial, conducted by Japanese government researchers, 210 volunteers were first given a vaccine based on an H5N1 strain from Vietnam, the Mainichi Daily News reported. Three years later, the volunteers were given one of two other H5N1 vaccines, based on strains from Indonesia and China. Three weeks after the second vaccination, 67% to 96% of the volunteers were found to have immunity to the strain for which they had not been vaccinated. Also, the volunteers showed improved immunity within a week of the second vaccination.
(CIDRAP 4/7/09)

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Viet Nam: Avian influenza H5N1 infection confirmed in death of 3-year-old boy
The Ministry of Health in Viet Nam reported a new confirmed case of human infection H5N1 avian influenza virus on 8 Apr 2009. The case has been confirmed at the National Institute of Hygiene and Epidemiology (NIHE). The case is a 3-year-old boy from Chau Thanh District, Dong Thap Province. He developed symptoms on 12 Mar 2009, was hospitalized on 13 Mar 2009, and died on 19 Mar 2009. Investigations into the source of infection indicated a history of close contact with sick and dead poultry prior to the onset of symptoms.

Of the 110 cases confirmed to date in Viet Nam, 55 have been fatal.
(ProMED 4/8/09)

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Viet Nam: Receives funds from FAO for avian influenza H5N1 preparedness
The UN’s Food and Agriculture Organisation (FAO) pledged US$7.3 million to help Viet Nam prepare for any outbreaks of avian influenza on 8 Apr 2009. The money will also be used to gather evidence for a transitional strategy on H5N1 vaccination. The two projects are expected to improve the community’s awareness on bird flu and educate the public on ways to minimize the spread of the disease to humans.

The US Ambassador, Michael W Michalak, said his government would closely co-operate with the Vietnamese Government, donors and other international organizations to help agencies move from large-scale vaccination to a more sustainable strategy on bird-flu prevention.

According to the Deputy Minister of Agriculture and Rural Development, Diep Kinh Tan, outbreaks of bird-flu have occurred in Viet Nam since the end of 2003. They have seriously damaged the country’s economy and the health of its people. In 2003-04, the epidemic slashed the economic growth by 0.5 per cent, equal to about VND3 trillion ($171.4 million). More than 51 million ducks and chickens died or had to be killed.

To prevent future epidemics, Viet Nam has mobilized government, party, and state leaders from grassroots up to directly supervise the implementation of campaigns on vaccination, disinfection, and hygiene. Up to date, the government has spent more than $130 million from the state’s budget to prevent the epidemic.
(Viet Nam News Agency 4/9/09)

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Americas
USA: FDA approves avian influenza H5N1 rapid test
On 7 Apr 2009, the US Food and Drug Administration (FDA) cleared a new, more rapid test for the detection of influenza A/H5N1 for marketing. The test, called AVantage A/H5N1 Flu Test, detects influenza A/H5N1 in throat or nose swabs collected from patients who have flu-like symptoms. The test identifies in less than 40 minutes a specific protein (NS1) that indicates the presence of the influenza A/H5N1 virus subtype. Previous tests cleared by the FDA to detect this influenza A virus subtype can take three or four hours to produce results.

“This test is an important tool to help quickly identify emerging influenza A/H5N1 infections and reduce exposure to large populations,” said Daniel G. Schultz, M.D., director of the FDA’s Center for Devices and Radiological Health. “The clearance of this test represents a major step toward protecting the public from the threat of pandemic flu.”

In clinical studies, the test correctly identified the absence of infection in more than 700 specimens. In addition, the test correctly detected the presence of influenza A/H5N1 virus subtype in 24 cultured specimens from infected patients.
(FDA 4/7/09)

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USA (Kentucky): Confirmed low-pathogenic avian influenza on poultry farm
State and federal authorities are investigating a finding of suspected non-pathogenic or low-pathogenic avian influenza in a single broiler/breeder poultry farm in western Kentucky. The strain poses minimal risk to human health and is not the high pathogenic strain associated with human and poultry deaths in other countries.

State Veterinarian Robert C. Stout has quarantined the farm, which produces hatching eggs for Perdue Farms Inc. Perdue plans to cull 20,000 chickens in two houses on the farm. "The state and federal government and Perdue are acting aggressively to contain and eliminate the disease," Dr. Stout said. "There is no evidence that any infected poultry are in the human food supply as a result of this infection. We will do what is necessary to minimize the disruption to overseas trade." The Kentucky Department of Agriculture is conducting surveillance on backyard flocks within a two-mile radius of the farm.

A minimal drop in egg production at the farm was noticed in mid-March 2009. Perdue's veterinary services laboratory took samples from chickens at the farm and found antibodies for avian influenza. Testing by the National Veterinary Services Laboratory in Ames, Iowa resulted in a presumptive positive finding for the H7 strain. Subsequent testing by NVSL and the Breathitt Veterinary Center in Hopkinsville confirmed the finding.

No virus has been isolated, and no poultry deaths have been found in connection with the infection. Avian influenza is not transmitted through eggs. Low-pathogenic avian influenza causes little if any illness in poultry and is rarely fatal to poultry.
(ProMED 4/5/09)

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Africa
Egypt: Three new avian influenza H5N1 infections confirmed in children
The Ministry of Health of Egypt has reported three new confirmed human cases of avian influenza.

The first case is a 2-year-old boy from Kom Hamada District, El Behira governorate. He developed symptoms on 27 Mar 2009 and was admitted to Naaora Fever Hospital on the 30 Mar 2009, where he was started on oseltamivir the same day. He remains in a stable condition.

The second case is also a 2-year-old boy from the same district and was detected through the investigation around the above-mentioned case. He developed symptoms on 31 Mar 2009 and was admitted to Damanhor Fever Hospital on 1 Apr 2009, where he was started on oseltamivir the same day. He remains in a stable condition.

Both boys had contact with sick/dead poultry prior to illness onset. Close contacts of both boys have been identified, and none have shown symptoms of the infection.

The third case is a 6-year-old boy from Shubra El Khema District, Qaliobia (Al Qalyubiyah) governorate. He developed symptoms on 22 Mar 2009 and was admitted to Ain Shams University Hospital on 28 Mar 2009, where he was started on oseltamivir on 3 Apr 2009. He was exposed to sick/dead poultry prior to illness onset. He remains in critical condition.

For all three of the cases reported above, infection with H5N1 avian influenza virus was tested positive by the Egyptian Central Public Health Laboratory and subsequently confirmed by the U.S. Naval Medical Research Unit No. 3 (NAMRU-3). Egypt has reported eight human infections since 1 Mar 2009.
(ProMED 4/4/09, ProMED 4/8/09)

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Egypt: Recent avian influenza H5N1 cases prompt speculation about silent infections
The recent series of H5N1 avian influenza cases in Egyptian children yet very few in adults has raised concern that some Egyptians may be getting infected without getting sick, according to a Reuters news report published 8 Apr 2009.

John Jabbour, a World Health Organization (WHO) emerging diseases specialist based in Cairo, said the Egyptian government and the WHO are planning a study to find out if subclinical or asymptomatic cases have been occurring. Jabbour said the occurrence of asymptomatic cases would be worrisome because it could give the undetected virus more time to mutate in human hosts.

"If there is any subclinical case in Egypt, the aim is to treat immediately to stop the reproduction of the virus," he told Reuters. "Because whether [through] mutation or reassortment, this will lead to the pandemic strain."

All but two of the 12 Egyptians infected with H5N1 in 2009 have been children under age 3. In the same period in 2008, most of the seven Egyptian case-patients were adults and older children, the report said.

Jabbour said the string of cases in children without similar cases in adults had prompted the questions whether adults were being infected without falling ill. He said the Egyptian study would involve testing the blood of people who were potentially exposed to infected birds but had not gotten sick.

Tim Uyeki, MD, a medical epidemiologist in the Influenza Division at the US Centers for Disease Control and Prevention, said that limited studies in several countries over the past few years have found relatively little serologic evidence of asymptomatic or unrecognized cases of H5N1 virus infection. When the H5N1 virus first infected humans in Hong Kong in 1997, there were two studies in which investigators looked for H5N1 antibodies in people who had potentially been exposed to the virus, Uyeki said. One study focused on 293 poultry cullers, of whom only nine (3%) were found to have H5N1 antibodies, indicating past infection. In the other study, involving 1,525 poultry workers, an estimated 10% had antibodies.

More recent studies "have either found no evidence of H5N1 virus infection or very low seroprevalence of H5N1 antibodies, around 1% or less, among different exposed populations," Uyeki said. "Since H5N1 virus strains continue to evolve, there's a continued need for these studies in people who have contact with poultry in countries where H5N1 virus strains are circulating in birds, since the risk of transmission to exposed persons could change." Uyeki also noted that subclinical infection with seasonal influenza virus is known to occur. "But how that relates to H5N1 is unclear," he said.
(CIDRAP 4/8/09)

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Nigeria (Oyo): Poultry farmers protest radio messages about avian influenza
Poultry farmers in Nigeria's Oyo state recently lodged a protest against a local radio station that has been airing messages about how to prevent the spread of avian influenza, the Daily Sun, a Nigerian newspaper, reported on 3 Apr 2009. The farmers claimed that chicken and eggs sales have dropped significantly over the four to six months that the prevention message has aired. The farmers threatened to topple the radio station's transmission tower unless the spots, sponsored by an international development agency, were stopped. However, the radio station manager has vowed to keep the public service announcements on air.
(CIDRAP 4/3/09)

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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
Intradermal influenza vaccination of healthy adults using a new microinjection system: a 3-year randomised controlled safety and immunogenicity trial
Beran J et al. BMC Med. 2 April 2009; 7(13). Available at http://www.biomedcentral.com/1741-7015/7/13/abstract.

Abstract (provisional)
Background. Intradermal vaccination provides direct and potentially more efficient access to the immune system via specialised dendritic cells and draining lymphatic vessels. We investigated the immunogenicity and safety during 3 successive years of different dosages of a trivalent, inactivated, split-virion vaccine against seasonal influenza given intradermally using a microinjection system compared with an intramuscular control vaccine.

Methods. In a randomised, partially blinded, controlled study, healthy volunteers (1150 aged 18 to 57 years at enrolment) received three annual vaccinations of intradermal or intramuscular vaccine. In Year 1, subjects were randomised to one of three groups: 3ug or 6ug haemagglutinin/strain/dose of inactivated influenza vaccine intradermally, or a licensed inactivated influenza vaccine intramuscularly containing 15ug/strain/dose. In Year 2 subjects were randomised again to one of two groups: 9ug/strain/dose intradermally or 15ug intramuscularly. In Year 3 subjects were randomised a third time to one of two groups: 9ug intradermally or 15ug intramuscularly. Randomisation lists in Year 1 were stratified for site. Randomisation lists in Years 2 and 3 were stratified for site and by vaccine received in previous years to ensure the inclusion of a comparable number of subjects in a vaccine group at each centre each year. Immunogenicity was assessed 21 days after each vaccination. Safety was assessed throughout the study.

Results. In Years 2 and 3, 9ug intradermal was comparably immunogenic to 15ug intramuscular for all strains, and both vaccines met European requirements for annual licensing of influenza vaccines. The 3ug and 6ug intradermal formulations were less immunogenic than intramuscular 15ug. Safety of the intradermal and intramuscular vaccinations was comparable in each year of the study. Injection site erythema and swelling was more common with the intradermal route.

Conclusions. An influenza vaccine with 9ug of haemagglutinin/strain given using an intradermal microinjection system showed comparable immunogenic and safety profiles to a licensed intramuscular vaccine, and presents a promising alternative to intramuscular vaccination for influenza for adults younger than 60 years. Trial registration: Clinicaltrials.gov NCT00703651.

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Use of Northern Hemisphere Influenza Vaccines by Travelers to the Southern Hemisphere
US Centers for Disease Control and Prevention. MMWR. 3 April 2009; 58(12): 312. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5812a4.htm.

The influenza season in temperate climates extends from October through March in the northern hemisphere and from April through September in the southern hemisphere. Recent studies indicate that influenza viruses can circulate throughout the year in the tropics and that influenza is the most frequently acquired vaccine-preventable disease among those traveling to tropical and subtropical countries. Influenza outbreaks have been reported among persons who travel from the northern hemisphere to the southern hemisphere and among persons from the northern hemisphere on group tours. To reduce the risk for influenza during travel, the Advisory Committee on Immunization Practices (ACIP) recommends that persons from the northern hemisphere who are recommended for annual vaccination or who want to avoid influenza illness but have not yet received the 2008--09 influenza vaccine should consider being vaccinated 1) before travel to the southern hemisphere during influenza season, 2) before travel to the tropics at any time of year, or 3) when traveling as part of a tour group that includes persons from areas where influenza circulates during April--September (e.g., the southern hemisphere). Vaccine formulations for each hemisphere are updated yearly but might differ according to virus surveillance information from each hemisphere. (Excerpt with references removed.)

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4. Notifications
Influenza in the Asia-Pacific
The Lancet Conferences
Date: August 21-23, 2009
Location: Qingdao, China

The Lancet and The Lancet Infectious Diseases have joined forces to develop a conference that will enable leaders in their fields to present and discuss management of influenza with key health administrators, experts from the medical and scientific communities, and industry representatives. We hope the meeting will provide valuable insight into fundamental public health and operation strategies to bring about change within the Asia-Pacific.

Register now and take advantage of the early bird discount until May 31, 2009. To register, go to http://mail.elsevier-alerts.com/go.asp?/bELA001/qUQEAS8/x8BATS8

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Conference: ICU Infection in an Era of Multi-Resistance
Dates: 4-6 Jun 2009
Location: Chicago, Illinois, USA
Venue: The Palmer House Hilton

Infectious diseases are the second leading cause of death worldwide. In fact, many new and reemerging microbial threats, such as severe acute respiratory syndrome (SARS), avian influenza virus, and West Nile fever continually challenge intensive care providers.

The conference will:
- Discuss infectious disease guidelines for the control and/or prevention of infectious diseases;
- Develop methods/strategies for identifying patients with a potential risk for contracting antibiotic-resistant infections;
- Identify appropriate drug or drug/therapy combinations for combating antibiotic-resistant infections;
- Evaluate hospital and ICU team management strategies for superbugs and foreseeable antibiotic-resistant infections of the future.

Additional information and online registration available at http://www.sccm.org/Conferences/Topics/Summer_Conference/Pages/default.aspx.

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 apecein@u.washington.edu