EINet Alert ~ Apr 27, 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:
- This bulletin was supplemented with information from Veratect.

1. Influenza News
- Global: WHO raises level of influenza pandemic alert from phase 3 to 4
- Global: Countries outside of North America report suspected cases of swine influenza A/H1N1
- Canada: Nova Scotia confirms 4 and BC confirms 2 cases of swine influenza A/H1N1
- EU: Europe Urges Citizens to Avoid US and Mexico Travel
- UK: Increased monitoring and travel advisories due to swine flu outbreak in North America
- Europe: Netherlands, Poland & Sweden issue advisories for travelers to North America
- Asia: Governments increase surveillance for travelers and restrict pork imports
- Hong Kong: Announces tough response to swine influenza A/H5N1
- Mexico: Swine influenza A/H1N1 outbreak in three states
- USA: Federal officials declare national public health emergency
- USA: CDC launches investigation into swine influenza A/H1N1
- USA (Kansas): Announced two confirmed cases of swine influenza A/H1N1
- USA (New York City): Eight students confirmed infected with swine influenza A/H1N1
- South America: Chile, Peru, and Brazil increase surveillance at points of entry

2. Updates

This bulletin was supplemented with information from Veratect.


1. Influenza News

Global: WHO raises level of influenza pandemic alert from phase 3 to 4
The Emergency Committee, established in compliance with the International Health Regulations (2005), held its second meeting on 27 April 2009.

The Committee considered available data on confirmed outbreaks of A/H1N1 swine influenza in the United States, Mexico, and Canada. The Committee also considered reports of possible spread to additional countries, and on the advice of the Committee, the Director-General has raised the level of influenza pandemic alert from the current phase 3 to phase 4. The change to a higher phase of pandemic alert indicates that the likelihood of a pandemic has increased, but not that a pandemic is inevitable.

This decision was based primarily on epidemiological data demonstrating human-to-human transmission and the ability of the virus to cause community-level outbreaks. Given the widespread presence of the virus, the Director-General considered that containment of the outbreak is not feasible. The current focus should be on mitigation measures. The Director-General recommended not to close borders and not to restrict international travel. It was considered prudent for people who are ill to delay international travel and for people developing symptoms following international travel to seek medical attention.

The Director-General considered that production of seasonal influenza vaccine should continue at this time, subject to re-evaluation as the situation evolves. WHO will facilitate the process needed to develop a vaccine effective against A/H1N1 virus. The Director-General stressed that all measures should conform with the purpose and scope of the International Health Regulations.

The decision comes after the swine flu outbreak in North America was declared a "public health emergency of international concern." Countries around the world are asked to step up reporting and surveillance of the disease implicated in dozens of human deaths in Mexico and at least 40 non fatal cases in the US. "It would be prudent for health officials within countries to be alert to outbreaks of influenza-like illness or pneumonia, especially if these occur in months outside the usual peak influenza season," Chan said. "Another important signal is excess cases of severe or fatal flu-like illness in groups other than young children and the elderly, who are usually at highest risk during normal seasonal flu," she said.

The swine influenza A/H1N1 viruses characterized in this outbreak have not been previously detected in pigs or humans. The viruses so far characterized have been sensitive to oseltamivir, but resistant to both amantadine and rimantadine.
(ProMED 4/26/09, WHO 4/27/09, CDC 4/27/09)


Global: Countries outside of North America report suspected cases of swine influenza A/H1N1
In addition to the confirmed cases in North America, there are suspected cases reported from New Zealand, France, Israel, Hong Kong, Costa Rica, Scotland, Peru, and Germany—all involving travelers returning from Mexico. New Zealand said that 10 students who took a school trip to Mexico "likely" had swine flu. Israel said a man who had recently visited Mexico had been hospitalized while authorities try to determine whether he had the disease. French officials said 4 possible cases are under investigation. All recently returned from Mexico.

At this point in time, any individual with a history of travel to a location with known confirmed cases of the novel H1N1 virus who develops an influenza like illness (ILI) is considered a suspected cases until results from laboratory testing are available.
(ProMED 4/27/09)


Canada: Nova Scotia confirms 4 and BC confirms 2 cases of swine influenza A/H1N1
Health authorities in Nova Scotia confirmed four cases of swine flu A/H1N1 in the province. The four infected people in the Windsor area are recovering from the illness. All of them had "mild" cases of the flu. British Columbia has confirmed two cases, both mild with self limited illness.
(ProMED 4/26/09, ProMED 4/27/09)


Europe/Near East
EU: Europe Urges Citizens to Avoid US and Mexico Travel
Hoping to head off a global pandemic of swine flu that has surfaced in North America, the European Union’s health commissioner on 27 April 2009 urged Europeans to avoid traveling to the United States or Mexico if doing so is not essential.

The warning came as officials in Spain confirmed 27 April 2009 that a man hospitalized in eastern Spain had tested positive for swine flu. Authorities were also testing 17 other suspected cases across Spain, a major hub for travel between Mexico and Europe. Britain and other European Union nations had already issued travel advisories for those traveling to Mexico, but the European Union’s health commissioner went a step further on 27 April 2009 in urging Europeans to avoid nonessential trips. Europeans, she said, “should avoid traveling to Mexico or the United States of America unless it is very urgent for them.”

Other nations also imposed travel bans or made plans to quarantine air travelers over the weekend as additional confirmed cases appeared in Mexico and Canada, and at least 10 suspected cases appeared in New Zealand. Top global flu experts struggled to predict how dangerous the new A/H1N1 swine flu strain would be as it became clear that they had too little information about Mexico’s outbreak — in particular how many cases had occurred in what is thought to be a month before the outbreak was detected, and whether the virus was mutating to be more lethal, or less.
(NY Times 4/27/09)


UK: Increased monitoring and travel advisories due to swine flu outbreak in North America
Officials in the UK say they are closely monitoring the outbreak of swine flu in Mexico and the US, amid fears of a potential pandemic. The Health Protection Agency (HPA) said it was working with the government to assess any threat posed to public health in the UK.
(ProMED 4/26/09)


Europe: Netherlands, Poland & Sweden issue advisories for travelers to North America
The Dutch government's Institute for Public Health and Environment has advised any traveler who returned from Mexico since 17 April 2009 and develops a fever within four days of arriving in the Netherlands to stay at home. The Polish Foreign Ministry has issued a statement that recommends that Poles postpone any travel plans to regions where the outbreak has occurred until it is totally contained. The Stockholm-based European Center for Disease Prevention and Control said earlier 25 April 2009 it shared the concerns about the swine flu cases and stood ready to lend support in any way possible.
(ProMED 4/26/09)


Asia: Governments increase surveillance for travelers and restrict pork imports
Governments including China, Russia, and Chinese Taipei began planning to put anyone with symptoms of the swine flu virus under quarantine. Others were increasing their screening of pigs and pork imports from the Americas or banning them despite health officials' reassurances that it was safe to eat thoroughly cooked pork. Some nations issued travel warnings for Mexico and the United States.

Hong Kong and Chinese Taipei said visitors who came back from flu-affected areas with fevers would be quarantined. China said anyone experiencing flu-like symptoms within two weeks of arrival from an affected area had to report to authorities. A Russian health agency said any passenger from North America running a fever would be quarantined until the cause is determined. Philippines also indicated they may quarantine passengers with fevers who have been to Mexico.

In addition, Tokyo's Narita airport installed a device to test the temperatures of passengers arriving from Mexico. Indonesia increased surveillance at all entry points for travelers with flu-like symptoms—using devices at airports that were put in place years ago to monitor for severe acute respiratory syndrome, or SARS, and bird flu. It said it was ready to quarantine suspected victims if necessary. Hong Kong and South Korea warned against travel to the Mexican capital and three affected provinces. Russia banned the import of meat products from Mexico, California, Texas and Kansas. South Korea said it would increase the number of its influenza virus checks on pork products from Mexico and the U.S.
(ProMED 4/25/09, ProMED 4/27/09)


Hong Kong: Announces tough response to swine influenza A/H5N1
Hong Kong, the epicenter of a SARS outbreak in 2003, announced some of the toughest measures anywhere on 26 April 2009, in response to a swine flu outbreak in Mexico and the United States. Officials urged residents not to travel to Mexico, and they ordered the immediate detention at a hospital of anyone who arrived with a fever and symptoms of a respiratory illness after traveling in the previous seven days through a city with a laboratory-confirmed outbreak.

The new policy has the potential to dampen air travel across the Pacific. Hong Kong has Asia’s busiest airport hub for international travel. Ever since the 2003 outbreak of SARS, or severe acute respiratory syndrome, Hong Kong has used infrared scanners to measure the facial temperatures of all arrivals at its airport and at its border crossings with mainland China.

Dr. Thomas Tsang, the controller of the Hong Kong government’s Center for Health Protection, said any traveler who had passed through a city with laboratory-confirmed cases and who arrived in Hong Kong with a fever and respiratory symptoms would be intercepted by officials and sent to a hospital for testing. Dr. York Chow, Hong Kong’s secretary for health and food, asked residents to watch the news for reports of which American states had outbreaks and discouraged travel to those states, but he reserved his strongest warning for travel to Mexico. The Hong Kong government will also amend its health regulations to make it mandatory for any health professional to alert the government of any suspected cases of swine flu, he said. One legacy of SARS is that Hong Kong may now be better prepared for a flu pandemic than practically anywhere else in the world.
(NY Times 4/26/09)


Mexico: Swine influenza A/H1N1 outbreak in three states
The Government of Mexico has reported three separate swine influenza A/H1N1 events. In the Federal District of Mexico, surveillance began picking up cases of influenza-like illness (ILI) starting 18 March 2009. The number of cases has risen steadily through April 2009 and the president assumed emergency powers to deal with the crisis, which has killed at least 81 people and infected about 1,300 others. As of 23 April 2009 there were at least 854 cases of pneumonia from the capital. Of those, 59 have died. In San Luis Potosi, in central Mexico, 24 cases of ILI, with three deaths, have been reported. And from Mexicali, near the border with the United States, four cases of ILI, with no deaths, have been reported. Of the Mexican cases, 18 have been laboratory confirmed in Canada as swine influenza A/H1N1, while 12 of those are genetically identical to the swine influenza A/H1N1 viruses from California.

The majority of these cases have occurred in otherwise healthy young adults. Influenza normally affects the very young and the very old, but these age groups have not been heavily affected in Mexico. Mexican officials have closed schools through 6 May 2009, though many schools were closed anyway for the Cinco de Mayo holiday. The US Embassy in Mexico has suspended all visa and nonessential citizen services from 27 Apr 2009 until 30 Apr 2009 as a precautionary measure.
(WHO 4/24/09, CIDRAP 4/26/09, NY Times 4/25/09)


USA: Federal officials declare national public health emergency
US federal officials said 26 April 2009 that the Department of Health and Human Services (HHS) is declaring a public health emergency. John Brennan, the president's homeland security adviser, said an interagency body of federal officials is meeting daily to regularly update President Obama and to help coordinate the national response to the swine flu outbreak. He said Janet Napolitano, secretary of the Department of Homeland Security (DHS) is the lead federal official, according to the nation's pandemic influenza plan.

Despite the involvement of many federal agencies in disease response activities, Brennan said each American has a role to play. "Clearly we all have individual responsibilities, such as good hygiene, if you're feeling sick stay home, and using commonsense measures," he said.

In addition to frequent hand washing and staying home when sick, Richard Besser, acting CDC director, advised people who are ill to avoid air travel and public transportation. People should start thinking of their own personal preparedness, he said. "They need to think about what they would do if this ramps up in their community," he said. Besser said the CDC will be releasing additional guidance to help communities and schools respond to additional cases.

Dr. Anne Schuchat of the CDC said developing and producing a specifically matched vaccine will take several months. One possibility under discussion is to include a swine flu antigen in the next seasonal flu vaccine, noted Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases. The new virus could replace one of the three strains in the vaccine, or it could be added, resulting in a quadrivalent (four-strain) vaccine.

Federal response steps
Napolitano said the public health emergency declaration is a routine measure that allows the federal government to free up state and local personnel and resources to respond to the outbreak. She said it also allows the government to release to states 25% of the 50 million antiviral treatment courses in the Strategic National Stockpile. The Department of Defense will also preposition its 7-million course antiviral stockpile.

The US Department of Agriculture (USDA) is monitoring and testing the nation's food supply for swine flu–related issues. The USDA is screening and testing livestock to monitor any developments. US Customs and Border Patrol is ensuring that employees working at its border stations have enough personal protective equipment, and the department's agents are conducting passive surveillance among patients arriving from Mexico at US borders. Passengers are being asked if they're sick, and those that report illness are referred for further screening. Similar measures have been implemented at the Transportation Security Administration. CDC's Schuchat said the agency is preparing "yellow cards" to give to travelers at airports. The cards will contain information about signs and symptoms suggesting possible swine flu.
(CIDRAP 4/26/09)


USA: CDC launches investigation into swine influenza A/H1N1
Human cases of swine influenza A/H1N1 virus infection have been identified in the United States. Below is the current case count for the US as reported by the US Centers for Disease Control and Prevention:

US human cases of swine flu infection
State: # of laboratory confirmed cases
California: 7 cases
Kansas: 2 cases
New York: 28 cases
Ohio: 1 case
Texas: 2 cases
Total count: 40 cases (as of 27 April 2009)

CDC investigations are ongoing to determine the source of the infection and whether additional people have been infected with swine influenza viruses. CDC is working very closely with state and local officials in California, Texas, as well as with Mexico, Canada and the World Health Organization.

Laboratory testing has found the swine influenza A (H1N1) virus susceptible to the prescription antiviral drugs oseltamivir and zanamivir and has issued interim guidance for the use of these drugs to treat and prevent infection with swine influenza viruses. CDC also has prepared interim guidance on how to care for people who are sick and interim guidance on the use of face masks in a community setting where spread of this swine flu virus has been detected. This is a rapidly evolving situation and CDC will provide new information at http://www.cdc.gov/swineflu/investigation.htm.
(CDC 4/27/09)


USA (Kansas): Announced two confirmed cases of swine influenza A/H1N1
The Kansas Department of Health and Environment (KDHE) announced 25 April 2009 that two cases of swine flu have been confirmed in Kansas involving two adults residing in the same household. Neither of the patients was hospitalized--one is still ill and one is recovering. One of the patients had recently traveled to Mexico. Both persons became ill with the same unique (H1N1) strain of swine flu that has been identified in Mexico, California, and Texas. Individuals who have been in contact with the patients are being interviewed and tested. Local health departments and hospitals in Kansas are being continuously updated and provided with information about the swine flu virus.

Prior to the recent outbreak in Mexico and the US, since 2005 12 cases of human infection with swine influenza had been reported to CDC. Swine flu infections in humans are rare, but are related to close proximity to infected pigs. Neither of the current patients in Kansas reported having contact with pigs.
(ProMED 4/26/09)


USA (New York City): Eight students confirmed infected with swine influenza A/H1N1
Tests show that eight students are likely to have contracted the human swine flu virus that has struck Mexico, officials in New York City said on 24 April 2009. The students were among about 100 at a preparatory school who became sick in the last few days, said Dr. Thomas R. Frieden, New York City’s health commissioner. All the cases were mild, no child was hospitalized, and no child was seriously ill.

CDC confirmed the eight cases as swine influenza A/H1N1 on 26 April 2009. Fearing a panic that might tax local health facilities, Dr. Frieden urged New Yorkers not to go to a hospital if they had typical mild cold or flu symptoms. If they are seriously ill, especially with lung problems, they should seek medical attention promptly, he said, because antiflu drugs work best if taken in the first 48 hours. Because of fears of the H5N1 avian flu, both New York City and the US have had detailed pandemic emergency plans in place since 2005, as well as stockpiles of emergency supplies and flu drugs. Dr. Frieden said that for such an emergency, the city had extra hospital ventilators, huge reserves of masks and gloves and “millions of doses of Tamiflu,” an antiflu drug that thus far appears to work against the new swine strain.
(NY Times 4/25/09)


South America: Chile, Peru, and Brazil increase surveillance at points of entry
Chilean authorities ordered a sanitary alert that included airport screening of passengers arriving from Mexico. No cases of the disease have been reported so far in the country, deputy health minister Jeanette Vega said, but those showing symptoms will be sent to a hospital for tests. In Peru, authorities will monitor travelers arriving from Mexico and the US and people with flu-like symptoms will be evaluated by health teams, Peru's Health Ministry said. Brazil will "intensify its health surveillance in all points of entry into the country," the Health Ministry's National Health Surveillance Agency said Measures will also be put in place to inspect cargo and luggage, and to clean and disinfect aircraft and ships at ports of entry. Venezuela advised its citizens to postpone travel to affected areas of Mexico and the US.
(ProMED 4/26/09, ProMED 4/27/09)


2. Updates
The following websites provide the most current information and advice.

Swine influenza: http://www.who.int/csr/disease/swineflu/en/index.html
Swine influenza frequently asked questions: http://www.who.int/csr/swine_flu/swine_flu_faq_26april.pdf
Phase of pandemic alert: http://www.who.int/csr/disease/avian_influenza/phase/en/index.html
Interim WHO guidance for the surveillance of human infection with swine influenza A(H1N1) virus:
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
International Health Regulations (IHR) at http://www.who.int/ihr/en/index.html.

- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: http://www.pandemicflu.gov
MOH Mexico: http://portal.salud.gob.mx/index_eng.html
PHAC: http://www.phac-aspc.gc.ca/media/nr-rp/index-eng.php
PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm

- Other useful sources
CIDRAP: http://www.cidrap.umn.edu/