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Vol. XII, No. 9 ~ EINet News Briefs ~ May 01, 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:
- ***Notice: In accordance with guidance from the World Health Organization (WHO), APEC EINet will now refer to the new strain of influenza circulating in humans as influenza A/H1N1.***
- ***This bulletin was supplemented with information kindly provided by Veratect***

1. Influenza News
- Cumulative number of human cases of influenza A/(H1N1)
- Cumulative number of human cases of avian influenza A/(H5N1)
- Global: WHO raises influenza pandemic alert to phase 5
- Global: Agencies want to remove 'swine' from influenza A/H1N1 virus's name
- Global: OIE advises against culling of pigs
- Global: Containing influenza A/H1N1 not feasible, experts say
- Netherlands: Toddler confirmed first case of influenza A/H1N1
- Germany: 2 confirmed and 5 probable influenza A/H1N1 cases in Bavaria
- China, Hong Kong: Leaders take visible approach to influenza A/H1N1
- Indonesia: 31-year-old dies, avian influenza A/H5N1 suspected
- Viet Nam: Central province woman dies of avian influenza A/H5N1
- Canada: PHA update on influenza A/H1N1
- Costa Rica: 2 confirmed, 60 suspected influenza A/H1N1 cases
- Mexico: MOH update on influenza A/H1N1
- Mexico: Influenza A/H1N1 response continues, non-essential services and businesses close for 5 days
- USA: CDC update on influenza A/H1N1
- USA: Health officials respond to pressure for tighter border measures
- USA: HHS provides guidance via PlanFirst webcast
- Egypt: Woman is country’s 68th case of avian influenza A/H5N1

2. Infectious Disease News
- Russia (Moscow): Chinese woman who died on Moscow train not infected with SARS
- Russia (Tartarstan, Mariy-El): Increased incidence of HFRS in 2009
- Thailand: Nearly 6400 people infected with chikungunya virus in 3 districts
- USA (Massachusetts): 9 university students infected with mumps
- USA (Washington DC, Virginia): Measles infections are 5th and 6th cases in the region in 2009

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- DENGUE
- CHOLERA, DIARRHEA, & DYSENTARY

4. Articles
- Swine influenza: how much of a global threat?
- Update: Drug Susceptibility of Swine-Origin Influenza A (H1N1) Viruses, April 2009
- Update: Infections With a Swine-Origin Influenza A (H1N1) Virus--United States and Other Countries, April 28, 2009

5. Notifications
- Weekly Epidemiological Record Bulletin
- CDC Guidance Documents on Influenza A/H1N1
- Free courses on preparedness from Northwest Center for Public Health Practice
- APEC Conference for the Surveillance, Treatment, Laboratory Diagnosis and Vaccine Development of Enteroviruses
- CDC Symposium on Drug-resistant and Vaccine-escape HBV Mutants

***Notice: In accordance with guidance from the World Health Organization (WHO), APEC EINet will now refer to the new strain of influenza circulating in humans as influenza A/H1N1.***

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***This bulletin was supplemented with information kindly provided by Veratect***

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1. Influenza News

Global
Cumulative number of human cases of influenza A/(H1N1)
Economy / Cases (Deaths)

2009
Austria/ 1 (0)
Canada/ 34 (0)
Denmark/ 1 (0)
Germany/ 4 (0)
Hong Kong/ 1(0)
Israel/ 2 (0)
Mexico/ 156 (9)
Netherlands/ 1 (0)
New Zealand/ 4 (0)
Spain/ 13 (0)
Switzerland/ 1 (0)
United Kingdom/ 8 (0)
United States/ 141 (1)
Total/ 365 (10)

(WHO 5/1/09)

An additional confirmed case has been reported from France (1) and Ireland (1).
Suspected cases have been reported from Barbados, Belize, Chile, Grenada, and Trinidad and Tobago.
(Veratect 5/1/09)

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

2009
China/ 7 (4)
Egypt/ 16 (0)
Viet Nam/ 3 (3)
Total/ 26 (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: 421 (257).
(WHO 4/23/09 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 4/15/09): 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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Global: WHO raises influenza pandemic alert to phase 5
To confront the spreading influenza H1N1 virus, the head of the World Health Organization (WHO) raised the agency's pandemic alert level to phase 5 on 29 Apr 2009, one notch below a full-fledged influenza pandemic, signaling that it's time for all countries to prepare. The move comes just two days after the WHO raised the alert from phase 3, where it had been for several years, to phase 4.

"Based on assessment of all available information, and following several expert consultations, I have decided to raise the current level of influenza pandemic alert from phase 4 to phase 5," WHO Director-General Dr. Margaret Chan said at a press conference. "All countries should immediately activate their pandemic preparedness plans," Chan said. "Countries should remain on high alert for unusual outbreaks of influenza-like illness and severe pneumonia.”

Officially, a phase 5 declaration means that a novel virus has caused sustained community outbreaks in two or more countries within one WHO region. In response to questions, Chan signaled that the spreading cases in Mexico and the United States (US) meet that criterion.

The criterion for phase 5 is that "first we have to demonstrate human-to-human transmission in a sustainable manner and community spread, and we've seen this definitely in Mexico, and as information has emerged from US authorities, we are also seeing that" in the US, Chan said.

Phase 6, the peak phase of the WHO pandemic scale, is defined as the time when the virus has caused sustained community outbreaks in more than one WHO region. Dr. Keiji Fukuda, the WHO's assistant director-general for health security, suggested that phase 6 may not be far off. "A pandemic means we have spread of this new virus in multiple countries and multiple regions," he said in response to a question. "If this continues, we expect it will be in other countries and other regions."

He also called phase 5 "a situation in which the likelihood [of a pandemic] is very high to inevitable." Chan said, "At this stage, effective and essential measures include heightened surveillance, early detection and treatment of cases, and infection control in all health facilities. This change to a higher phase of alert is a signal to governments, to ministries of health and other ministries, to the pharmaceutical industry and the business community that certain actions should now be undertaken with increased urgency, and at an accelerated pace."

Chan said she has "reached out" to manufacturers of antiviral drugs to assess capacity and all options for boosting production and has also contacted vaccine manufacturers that can contribute to producing a pandemic vaccine. She also has talked with donor countries, the World Bank, UNITAID, and the GAVI Alliance about helping in the swine flu fight. She warned that influenza "may cause mild disease in affluent countries, but more severe disease, with higher mortality, in developing countries.”

"Above all, this is an opportunity for global solidarity as we look for responses and solutions that benefit all countries, all of humanity. After all, it really is all of humanity that is under threat during a pandemic," she stated.

Chan said the WHO will need donated antiviral drug supplies to help needy countries. The agency had an oseltamivir stockpile of 5 million doses donated by Roche, but some of those were distributed to countries threatened by avian flu, leaving roughly 3.5 million doses now. "Clearly that's not enough," she said. She said many private companies have told her they are prepared to provide resources to support the WHO's efforts to battle the pandemic.

Citing other positives, Chan said, "The world is better prepared for an influenza pandemic than at any time in history." She said preparations triggered by avian flu prompted many countries to develop and test preparedness plans, which has led to early detection of swine flu cases. She praised the responses of the Mexican, US, and Canadian governments in particular.

WHO's Mike Ryan said the response of affected countries in providing information has been "amazing," adding, "I can certainly say that the world has changed in terms of the way we work." When asked what governments should be doing now, Fukuda said they should make sure their pandemic plans are up to date and they are prepared to execute them. Further, governments should increase their disease surveillance, evaluate their ability to communicate with populations, and consider social distancing measures.

As for what individuals should do, the WHO officials repeated the oft-heard advice about handwashing and using good respiratory hygiene, but did not mention stockpiling food, water, and medicines—measures recommended by many preparedness experts.

In a WHO briefing, Fukuda said the H1N1 cases so far are generally similar to seasonal flu, but there is some evidence that diarrhea is more common than it is in seasonal flu. He said the evidence so far shows that the virus can cause a range of illness from mild to fatal. Experts still do not know why the severe cases seem to be almost entirely confined to Mexico.
(CIDRAP 4/29/09)

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Global: Agencies want to remove 'swine' from influenza A/H1N1 virus's name
To quell the notion that pigs are to blame for the swine influenza H1N1 epidemic, three international agencies said they would take the "swine" out of the virus's name and call it "influenza A/H1N1" instead.

The United Nations Food and Agriculture Organization (FAO) said on 30 Apr 2009, it has agreed with the World Health Organization (WHO) and the World Organization for Animal Health (OIE) "to no longer refer to 'swine flu' but instead to 'influenza A/H1N1.'"

Joseph Domenech, the FAO's chief veterinary officer, said that there is no evidence that the new virus is circulating in pigs in Mexico or anywhere else and that pork consumption poses no increased risk of contracting the virus. The move comes in the wake of reports that Egypt began slaughtering pigs out of the mistaken concern that they could spread the new virus to people. Some countries have banned pork from Mexico and the United States for the same reason.

The US Centers for Disease Control and Prevention (CDC) also has been trying out a new name for the virus, but without removing "swine." In Morbidity and Mortality Weekly Report and in other documents, the CDC has been referring to the virus as "swine-origin influenza A (H1N1)."

The CDC Web page dedicated to the new virus is currently labeled "H1N1 Flu (Swine Flu)." A note on the page acknowledges inconsistencies in the name: "This is a rapidly evolving situation and current guidance and other web content may contain variations in how this new H1N1 virus of swine origin is referred to. "Over the coming days and weeks, these inconsistencies will be addressed, but in the interests of meeting the agency's response goals, all guidance will remain posted and new guidance will continue to be issued." A CDC spokesman who was queried about the shifting names replied only that the name is being coordinated by the WHO.

The CDC has said the virus contains a combination of genes from North American and Eurasian swine flu strains along with avian and human flu strains. But experts quoted in Wired magazine on 29 Apr 2009 said the virus contains genetic material only from swine flu viruses. How and where the virus made the jump to humans has not yet been determined.

In announcing the name change, the international agencies did not explain how they would avoid confusion over the fact that one of the seasonal flu strains that circulates every year is also called influenza A/H1N1. An H1N1 strain is included in each year's flu vaccine, along with a strain of A/H3N2 and infuenza B.

Names such as H1N1 and H3N2 refer to influenza subtypes. The terms can be misleading, because two viruses of the same subtype may differ greatly in their ability to infect humans or other species. For example, the Asian variety of H5N1 avian flu virus is usually lethal to chickens and various other bird species. But there are other viruses that are also called H5N1 that pose little danger to birds.
(CIDRAP 4/30/09)

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Global: OIE advises against culling of pigs
The World Organization for Animal Health (OIE) strongly counsels against the culling of pigs in the current situation with A/H1N1 influenza that started in North America.

Scientific information currently available to the OIE and partner organizations indicates that this novel A/H1N1 influenza virus is being transmitted amongst humans; there is no evidence of infection in pigs, nor of humans acquiring infection directly from pigs.

Moreover, and despite the fact that the currently circulating A/H1N1 influenza virus is not simply a swine influenza virus (it has reassortant genetic material of human, avian and swine origin), it is important to note that swine influenza has not been shown to be transmissible to people through eating pig meat or other products derived from pigs.

The OIE advises Members that the culling of pigs will not help to guard against public or animal health risks presented by this novel A/H1N1 influenza virus, and such action is inappropriate. Instead, Members should focus their efforts on appropriate disease surveillance and strengthening the general biosecurity measures applied at premises where pigs are handled and slaughtered.

The OIE is collaborating with its network of reference laboratories and collaborating centers, as well as with the World Health Organization and the UN Food and Agriculture Organization in scientific investigations on the current situation and will, if needed, issue further advice regarding biosecurity and trade measures in due course. Thanks to these current investigations, the pathogenicity (if any) of the circulating virus for animals should be known shortly and, once known, will be the subject of a further communication from the OIE.

In the meantime, Veterinary Authorities should work in collaboration with human health counterparts to monitor pig herds for any signs of unusual illness with suspected linkages to human cases of A/H1N1 influenza.
(ProMED 4/30/09)

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Global: Containing influenza A/H1N1 not feasible, experts say
“Containment is no longer a feasible option,” Dr. Keiji Fukuda, deputy director general of the World Health Organization (WHO), announced 27 Apr 2009 in Geneva after a meeting of the agency’s emergency committee on the spreading influenza A/H1N1 virus. “The world should focus on mitigation. We recommend not closing borders or restricting travel.” Many countries are still ignoring that advice. The globe is a confusing muddle of bans, advisories and alerts on some pork and some people.

On 29 Apr 2009, Homeland Security Secretary Janet Napolitano was heavily pressed in Congressional hearings to ignore the advice and close the border with Mexico. She defended her decision not to do so, saying it “would be a very, very heavy cost for what epidemiologists tell us would be marginal benefit.”

President Obama defended it too, stating that it would be “akin to closing the barn door after the horse is out.”

Experts on the global movement of flu say Dr. Fukuda, Ms. Napolitano and Mr. Obama are right. The world, they say, must bow to the inevitable: closing borders would not only fail to stop the virus, but would also cause economic collapse and possibly add to the death rate. “But it’s wrong to think we’re throwing up our hands and saying ‘Let ’er rip and let’s hope for the best,’ ” said Dr. Martin S. Cetron, director of global migration and quarantine for the Centers for Disease Control and Prevention in Atlanta. “This has all been in the national pandemic flu plan since 2007.”

Closing borders is dangerous because many goods needed in a pandemic are made abroad, said Dr. Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, including most masks, gowns and gloves, electrical circuits for ventilators and communications gear, and pharmaceutical drugs and the raw materials to make them. (For example, most suppliers of shikimic acid, the base ingredient in the antiviral drug Tamiflu, are in China.) “You cut those off and you cripple the health care system,” he said. “Our global just-in-time economy means we are dependent on others.” Much of our food is from overseas.

The fallback position, experts said, is mitigation, the use of “nonpharmaceutical measures.” They include personal ones like washing hands and wearing a mask, occupational ones like working from home or arranging care for children who are sick or whose schools close, neighborhood-level ones like closing theaters, museums or restaurants, and metropolitan-wide ones like shutting a school system or canceling a major league ballgame.
(NY Times 4/29/09)

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Europe/Near East
Netherlands: Toddler confirmed first case of influenza A/H1N1
The National Influenza Centre (NIC) of the Netherlands, a collaboration between the National Institute for Public Health and the Environment (RIVM) in Bilthoven and Erasmus MC in Rotterdam, detected the first case of influenza A/H1N1 infection in the Netherlands.

The patient is a 3-year-old child that traveled with the family from Mexico to The Netherlands on 27 Apr 2009. The child developed fever and respiratory symptoms the same evening. In compliance with national advisories, the case was notified to public health authorities. The clinical specimen was tested on 29 Apr 2009 and was found positive for influenza A. Virus isolation in eggs and cell cultures, full genome sequencing, and additional laboratory investigations are ongoing.

The patient is currently doing reasonably well, with only mild symptoms. She is receiving treatment with oseltamivir. Close contacts of the patient are on prophylactic oseltamivir, after being swabbed for virological evaluation. The contacts in the flight (same row, and two rows in either direction) are being approached by the health authorities and will be treated with antivirals and monitored if needed.
(ProMED 4/30/09)

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Germany: 2 confirmed and 5 probable influenza A/H1N1 cases in Bavaria
There are five probable cases in addition to the two confirmed cases of influenza A/H1N1 in Bavaria, according to the Bavarian health institute. These cases match the clinical profile and had contact with infected persons or have been tested positive, but the test has not been confirmed by a national reference center (RKI).

Two of the suspected cases were infected during stay in the regional hospital in Mallersdorf (ICU) with the confirmed case, who is now being treated in the university clinic of Regensburg, before the case was isolated. One is a patient who shared the room with the confirmed case in the ICU of the regional hospital, and the second patient is a nurse. Both are not severely ill and are staying at home but show the typical clinical symptoms of influenza. They are receiving Tamiflu.
(ProMED 4/30/09)

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Asia
China, Hong Kong: Leaders take visible approach to influenza A/H1N1
In the clearest sign yet of how seriously China is taking the influenza outbreak, President Hu Jintao convened a meeting on 30 Apr 2009 of the Standing Committee of the Politburo--the nine men who run China--that was immediately announced. It is rare for China’s authorities to disclose any meeting of the standing committee, and particularly to do so as soon as the meeting ended.

After struggling to cope six years ago with an outbreak of SARS, the Chinese leadership is taking a much more visible approach now to in influenza. Premier Wen Jiabao held a cabinet meeting on 28 Apr 2009 to discuss preparations for the disease and call for an interagency effort to address it. President Hu announced a few hours later that China was stepping up its inspection and quarantine procedures for people and imports of pigs and pork products. And on 29 Apr 2009, Vice Premier Li Keqiang toured the Chinese Center for Disease Control and Prevention and called for manufacturers to produce more face masks, sterilization chemicals and flu medicines.

Dr. Guan Yi, a microbiologist at Hong Kong University, said that China and India will face particular challenges in coping with swine flu because both countries have more than a billion people, many of them living close together. “We need to believe this virus has a chance to go to every corner of the world--the only question is how fast,” he said.

Heavy news media attention to the issue in Hong Kong, where the government is holding daily televised briefings, may have also raised awareness of the disease in mainland China. Extensive and growing Internet traffic, phone calls and actual visits increasingly bind the two populations together.

Hong Kong has now confirmed a case of H1N1 from a patient who had recently travelled to Mexico. Hong Kong has imposed a 7-day quarantine on about 200 guests and staff members of a hotel where a Mexican man who tested positive for swine flu stayed, according to ChannelNewsAsia.com. Authorities were also trying to trace passengers who were on the man's flight from Shanghai. A Hong Kong hotel was the launching pad for the international spread of SARS in 2003.
(NY Times 4/30/09, 5/1/09; CIDRAP 5/1/09)

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Indonesia: 31-year-old dies, avian influenza A/H5N1 suspected
A 31-year-old bird flu patient died on 22 Apr 2009 at Arifin Achmad hospital in Pekanbaru. He died after being treated intensively at a special isolation room for suspected bird flu patients. According to Azizman Saad -- head of Bird Flu Control Team Arifin Achmad Hospital -- the patient died due to sudden lung failure. The Arifin Achmad hospital is still waiting for blood and throat swab sample test results.

This fatality is the second suspected bird flu case recorded in Arifin Achmad hospital in April 2009. A 2 1/2 year-old toddler died on 26 Mar 2009. Further blood tests showed a positive result for bird flu.
(ProMED 4/26/09)

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Viet Nam: Central province woman dies of avian influenza A/H5N1
A 23-year-old woman from Thanh Hoa Province died of bird flu on 22 Apr 2009, Viet Nam's fourth fatality from the disease this year, the Health Ministry confirmed on 24 Apr 2009.

Nguyen Huy Nga, head of the ministry's Bureau of Preventive Health and Environment, said the victim was from Quan Hoa District in the central province. Though the bureau confirmed the victim had been infected with the H5N1 avian influenza virus, no birds had been affected by the disease in the area recently. The woman was admitted to Quan Hoa General Hospital on 16 Apr 2009 before being transferred to Thanh Hoa General Hospital in critical condition on 21 Apr 2009. She was suffering from pleural and pericardial effusion and kidney failure at the time.

A team from the National Institute of Hygiene and Epidemiology and local health authorities failed to find any trace of bird flu in Thien Phu Commune, where the woman lived.
(ProMED 4/26/09)

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Americas
Canada: PHA update on influenza A/H1N1
Number of confirmed cases by province:
Alberta: 8
British Columbia: 15
Nova Scotia: 14
New Brunswick: 1
Quebec: 1
Ontario: 12
Total: 51

Canada has not reported any deaths due to influenza A/H1N1.
(PHA Canada 5/1/09)

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Costa Rica: 2 confirmed, 60 suspected influenza A/H1N1 cases
The government issued an emergency decree on 28 Apr 2009 to allow the government and public institutions to move resources to provide assistance where it is most needed and gives the ministerio de Salud the authority to order a quarantine if necessary.

There are more than 60 suspected and two confirmed cases of influenza A/H1N1 in Costa Rica. The ministra de Salud, María Luisa Avila, said the country's medical system is prepared for more cases.
(Inside Costa Rica 4/30/09)

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Mexico: MOH update on influenza A/H1N1
Cases:
Total Severe Acute Respiratory infection Influenza A(H1N1) suspected: 1918
Total probable cases of Influenza A(H1N1): 286
Total confirmed cases of Influenza A(H1N1): 99

Deaths:
Total deaths Influenza A(H1N1) suspected: 84
Total deaths Influenza A(H1N1) confirmed: 8
(ProMED 4/30/09)

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Mexico: Influenza A/H1N1 response continues, non-essential services and businesses close for 5 days
In Mexico, the influenza A/H1N1 outbreak’s epicenter, new cases and the death rate were leveling off as of 30 Apr 2009, the country's top medical officer said. Health authorities said they have confirmed 300 influenza A/H1N1cases and 12 deaths due to the virus. "The fact that we have a stabilization in the daily numbers, even a drop, makes us optimistic," Mexican Health Secretary Jose Angel Cordova said. "Because what we'd expect is geometric or exponential growth. And that hasn't been the situation."

Mexico's health secretary, Jose Angel Cordova, said three more influenza A/H1N1 deaths were confirmed, bringing Mexico's confirmed toll to 15. He said Mexico's total sickened rose by 43, to 343.

As recently as 29 Apr 2009, Mexico's health secretary said there 168 suspected deaths due to influenza A/H1N1 and almost 2,500 suspected cases. Mexican officials have stopped updating that number and say those totals may have been inflated.

Cordova said Mexicans with flu symptoms are now seeking medical attention quickly, and suspected cases are getting treatment even before the virus is confirmed, preventing deaths and limiting the virus' spread. "If the treatment is given the first day, the patient is practically not contagious," Cordova said.

Cordova said outreach efforts to families of confirmed cases are turning up relatively few other cases. Mexico shut down all but essential government services and private businesses 1 May 2009, the start of a five-day shutdown that includes a holiday weekend. Schools are also closed through 5 May 2009.

Mexico City's notoriously clogged avenues were clear, crime was down and the smog dropped to levels normally seen only on holidays. Mexico is using the shutdown to determine whether to extend or ease emergency measures.
(AP 5/1/09)

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USA: CDC update on influenza A/H1N1
States/ Cases (Deaths)
Arizona/ 4( 0)
California/ 13 ( 0)
Colorado/ 2 (0)
Delaware/ 4(0)
Illinois/ 3 (0)
Indiana/ 3 (0)
Kansas/ 2 (0)
Kentucky/ 1 (0)
Massachusetts/ 2 (0)
Michigan/ 2 (0)
Minnesota/ 1 (0)
Nebraska/ 1 (0)
Nevada/ 1 (0)
New Jersey/ 5 (0)
New York/ 50 (0)
Ohio/ 1 (0)
South Carolina/ 16 (0)
Texas/ 28 (1)
Total/ 141 (1)

Additional confirmed case has been reported from Virginia.

The United States government has declared a public health emergency in the United States. The Center for Disease Control and Prevention’s (CDC) response goals are to reduce transmission and illness severity and provide information to help health care providers, public health officials and the public address the challenges posed by this emergency. CDC is issuing and updating interim guidance daily in response to the rapidly evolving situation. CDC's Division of the Strategic National Stockpile (SNS) continues to send antiviral drugs, personal protective equipment, and respiratory protection devices to all 50 states and U.S. territories to help them respond to the outbreak. The influenza A (H1N1) virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir. In addition, the federal government and manufacturers have begun the process of developing a vaccine against this new virus.

CDC updated information can be found at http://www.cdc.gov/h1n1flu/index.htm.
(US CDC 5/1/09; Veratect 5/1/09)

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USA: Health officials respond to pressure for tighter border measures
Top US officials responsible for managing the nation's response to the influenza A/H1N1 outbreak faced increasing pressure to implement more aggressive measures at the Mexico border and reveal more details about the status of a vaccine on 29 Apr 2009.

Two officials testified at the Senate homeland security hearing: Janet Napolitano, secretary of the Department of Homeland Security (DHS), designated as the lead federal official in influenza epidemic response, and Anne Schuchat, MD, interim deputy director for the Centers for Disease Control and Prevention's (CDC's) science and public health program.

Questions from Senators
Sen Susan Collins, R-Maine, ranking member of the Senate Committee on Homeland Security and Governmental Affairs, praised the government's overall level of preparedness but said the committee has expressed concerns over the past few years about the nation's ability to provide mass medical care, procure needed countermeasures, and coordinate border-related medical issues, such as travelers with multidrug-resistant tuberculosis (MDR TB), between federal departments.

She asked Napolitano about the number of US influenza A/H1N1cases that have had links to Mexico travel and whether the heavy volume of daily traffic across the border should prompt the DHS to reconsider passive surveillance measures that are in place and evaluate if tools such as temperature scanners could help identify more sick patients at ports of entry.

"I'm not advocating closing borders," Collins said. "But I am advocating a stepped-up medical presence and use of technology—even if it's not perfect."

Napolitano said so far that the DHS travel recommendations—it has discouraged nonessential travel to Mexico—have been guided by scientific findings and the public health community. She added that though surveillance is called "passive," border control agents visually inspect incoming travelers, question them about symptoms and recent illnesses, and isolate and test those who appear to be sick.

Schuchat told legislators that the focus of mitigation strategies is on where US illnesses are being reported and on patients' families and the communities that surround them. She suggested that greater efforts at the border might divert from those efforts. CDC officials have also said that containment strategies aren't workable, because the virus has already spread extensively.

Vaccine progress
Lawmakers asked how the CDC was progressing with preparing a vaccine against the influenza A/H1N1 virus. Schuchat said that if every step goes smoothly with production and testing, a vaccine could be ready by September. However, she said vaccine production can be problematic.

The vaccine against the H5N1 avian influenza virus has been somewhat disappointing, because a large amount of antigen is needed for a protective effect, and two doses are needed. Also, Schuchat said some flu viruses don't grow very well during production.

She said the decision about making a vaccine and giving the vaccine will be two separate decisions, both with many factors to weigh, particularly given the problems that occurred with the vaccine during the 1976 swine influenza outbreak. Napolitano said President Obama's $1.5 billion request to the Senate appropriations committee includes money for vaccines, more antivirals, and public health activities. "That's a rough estimate gauged on perhaps having to purchase more antivirals. The initial request from the president will be sculpted to be best used," she said.
(CIDRAP 4/29/09)

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USA: HHS provides guidance via PlanFirst webcast
At the Department of Health and Human Services (HHS) PlanFirst webcast on 30 Apr 2009, Kathleen Sebelius, HHS secretary, said federal guidance advises individual schools to close for a week when a student has a suspected or confirmed influenza A/H1N1 infection. She said some entire districts are closing, which runs counter to suggested protocol.

In addition, federal officials are not recommending that Americans stockpile food and water in response to the outbreak, she said. She urged the public to take measures to limit disease transmission such as hand washing and covering coughs, and she advised parents to make contingency plans in the event of school closures.

Within several days, state health departments will have the ability to identify the new H1N1 strain in their own labs instead of sending suspect isolates to the Centers for Disease Control and Prevention (CDC), acting CDC Director Dr. Richard Besser said on 30 Apr 2009. Test versions of the new diagnostic tool are being tried out by the New York and California health departments and will be pushed out to the remaining states if the tests are satisfactory.
(CIDRAP 4/30/09)

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Africa
Egypt: Woman is country’s 68th case of avian influenza A/H5N1
The Ministry of Health announced that a 34-year-old woman from Tanta city, Al Gharbiyah governorate in the Nile Delta is the 68th case of human H5N1 avian influenza infection in Egypt. The woman began to show symptoms on 21 Apr 2009 and was admitted to hospital on the same day. She had contact with infected domestic poultry. She is receiving Tamiflu (oseltamivir) treatment and the ministry says that her condition is stable.
(ProMED 4/24/09)

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2. Infectious Disease News

Asia
Russia (Moscow): Chinese woman who died on Moscow train not infected with SARS
The Chinese woman who died on the Blagoveshchensk-Moscow train did not have severe acute respiratory syndrome (SARS) or dangerous types of influenza stated Gennady Onishchenk, Head of the Federal Supervision Agency for Customer Protection and Human Welfare of the Russian Federation (Rospotrebnadzor), on 17 Apr 2009.

"Biopsies of lungs, intestines, and brain of the deceased woman have shown no evidence of infection by SARS virus, [influenza] viruses of the H1, H3 and B flu types, nor the highly pathogenic H5, H7 and H9 strains [of influenza virus]," stated the Chief Public Health Physician.

The 24-year-old Chinese citizen died suddenly on 15 Apr 2009. By the decision of local public health officials, the carriage in which she was travelling was disconnected from the train at the Zuyevka station in the Kirov Region on the same day. The train car was sent for disinfection and the 51 passengers and two conductors of the train's second car were taken to the local infectious diseases hospital.
(ProMED 4/17/09)

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Russia (Tartarstan, Mariy-El): Increased incidence of HFRS in 2009
A marked increase in hemorrhagic fever with renal syndrome (HFRS) has been observed in the Republic of Tatarstan. Since the beginning of 2009, two people have died as a result of HFRS infection in Naberezhnye Chelny and the Almetyevsky district of the republic. The incidence of HFRS has increased 14-fold in comparison with the same period in 2008.

During the first three months of 2008, there were 32 HFRS cases, whereas during the same period in 2009, a total of 436 cases of HFRS have been recorded. According to Rospotrebnadzor (the Federal Health and Welfare Authority), a significant increase in HFRS incidence was observed in 2008. A 3.5-fold increase was recorded, and there were nine deaths. Specialists associate the current situation with a significant growth in the rodent vector population.

Meanwhile, during the first quarter of 2009, 44 cases of HFRS were recorded in the Republic of Mariy-El. The incidence rate is 6.3 per 100,000 inhabitants, 7 times higher than during the same period of 2008.
(ProMED 4/22/09, ProMED 4/26/09)

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Thailand: Nearly 6400 people infected with chikungunya virus in 3 districts
A total of 6379 people have been infected with the insect-borne chikungunya virus since the beginning of 2009, a senior public health official said on 29 Apr 2009. Doctor Sanphet Ritthiraksa, a specialist in preventive medicine in the Songkhla Public Health Office, stated that it was difficult to control the outbreak because of mosquitoes in rubber plantations and frequent rains in the province.
(ProMED 4/29/09)

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Americas
USA (Massachusetts): 9 university students infected with mumps
The number of Northeastern University students suspected of being sick with mumps rose to nine, with one suffering symptoms sufficiently severe to require hospitalization, Boston public health authorities said. The students bear the signs of the viral illness, including facial swelling, fever, headaches, muscle pain, fatigue, and loss of appetite. The virus can spread via coughing, sneezing, or talking. All nine students are undergraduates, and they range in age from 18-22, said university spokesman Mike Armini.

To contain the spread of the disease, which in rare cases can lead to brain inflammation and deafness, Northeastern and disease specialists from the Boston Public Health Commission have urged the ill students to avoid crowds and stay in their rooms. Some of the students live in on-campus dormitories while others reside off campus. "All of their roommates, if they have roommates, are being tested," Armini said. "And if there's a need to provide an individual room for someone, that will be done."

Northeastern authorities estimate that 99 percent of the student body is immunized, and shots are being offered to the handful who are not. Although the vaccine provides protects most people, it fails to provide full protection for 10 to 20 percent of those who receive it, disease specialists estimate.
(ProMED 4/19/09)

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USA (Washington DC, Virginia): Measles infections are 5th and 6th cases in the region in 2009
The fifth and sixth cases of measles have been reported in the Washington DC (DC) area. One case in Prince William County is the first sign of the disease in Virginia in 2009. The Virginia Department of Health announced one case on 21 Apr 2009, a day after DC officials reported finding the highly infectious disease in a local man who contracted it during a recent three week trip to India. There is no known link between the two cases, nor are they connected to the others in the region, health officials said. The source of the measles virus in the Virginia resident has not been identified.

Measles cases are uncommon in the United States because vaccinations are required of most schoolchildren and foreign-born individuals who become US citizens. Outbreaks often begin when an unimmunized person visits a country where the disease is still prevalent and then returns with the infection. The virus is usually spread through sneezing and coughing and can remain in the air or on surfaces for two hours.

The other measles cases were in Montgomery County, Maryland. In February 2009, a man contracted measles while traveling abroad and then infected a co-worker. That employee visited Shady Grove Adventist Hospital in March 2009, where he infected an 8-month-old baby. A fourth man learned he had measles earlier in April 2009, but his case is not related to the others.
(ProMED 4/21/09, ProMED 4/22/09)

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3. Updates
INFLUENZA A/H1N1
The following websites provide the most current information and advice.

- WHO
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 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
Pandemic Influenza Preparedness and Response - A WHO Guidance Document http://www.who.int/csr/disease/influenza/pipguidance2009/en/index.html
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: 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: Influenza A/H1N1 page: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promed.org
(WHO; US CDC; MOH Mexico; PHAC; PAHO; CIDRAP; ProMED)

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AVIAN 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.
- 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/ Access their Swine Influenza website at http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/index.html. - 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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DENGUE
Australia (North Queensland)
The Red Cross Blood Service says the dengue fever epidemic in north Queensland is straining the state's blood supplies. The service can only use plasma from donor blood collected in dengue affected areas because there is no way to test red blood cells and platelets for the virus.

The service's Tony Bourke says Townsville and Cairns normally produce 14 percent of the state's donor blood supply, with donations required from other regions over coming months. "It's about 750 a week and 60 platelets a week that we're having to supply from other parts of Queensland and occasionally we're receiving support from other states as well," he said.
(ProMED 4/19/09)

Malaysia
A total of 16,684 dengue fever cases were recorded up to 18 Apr 2009 with 40 deaths in Malaysia, compared with 11,386 cases and 29 deaths over the same period in 2008, the Health Ministry said on 23 Apr 2009. Dengue cases increased 8 percent between 12-18 Apr 2009, from 794 cases recorded the previous week (5-11 Apr 2009) to 859 cases.

The ministry said that one death due to dengue fever was reported during the week 12-18 Apr 2009, bringing the death toll in the country due to the disease to 40 people in 2009.

The increase in dengue cases was reported in northern Penang state (35 cases), the Federal Territories of Kuala Lumpur and Putrajaya (18 each), central Selangor state (18), southern Johor state (10), eastern Sarawak state (4), and one each in northern Perlis state, eastern Sabah state, and central Negri Sembilan state, it said. A total of 85 dengue hotspots had been identified with 82 of the localities, or 96 percent, in Selangor, while the remaining were in Johor, Kuala Lumpur, Putrajaya, and Sarawak.
(ProMED 4/28/09)

Viet Nam
Recent unseasonal rains have caused dengue fever outbreaks to rise sharply in Ho Chi Minh City (HCMC). Since February 2009, the city's Children's Hospital No.1 has received 30 to 35 patients with dengue fever per day. From the beginning of April 2009, the figure has risen to 80 patients per day. The Tropical Diseases Hospital received more than 150 patients with dengue fever during the week of 12 Apr 2009, an increase of 100 percent compared with the same period in 2008.

HCMC districts 8, Thu Duc, Tan Binh and Tan Phu are worst hit, with cases of dengue fever up by as much as 300 percent over the same period in 2008, says Nguyen Dac Tho, deputy director of the city's Health Preventive Center. Mr. Tho has instructed local health officials to take precautionary measures against the disease, as well as warn residents to remain vigilant and contain the epidemic.
(ProMED 4/19/09)

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CHOLERA, DIARRHEA, & DYSENTARY
Indonesia
The West Nusa Tenggara Health Office has declared a cholera outbreak, which has killed two residents and infected 255 others in East Lombok regency. "The decision to declare the extraordinary occurrence was taken because of casualties and the number of people infected by the disease jumped over the last two weeks," I Ketut Pasek, head of the local health office, said on 22 Apr 2009. The cholera outbreak was recorded to have infected residents in five of the 20 districts in the regency since 14 Apr 2009.

"Most of those infected by the disease are adults, only several of them were children below five," Pasek said, adding that the two who died suffered from acute dehydration and were not treated in time.
(ProMED 4/29/09)

Malaysia
Fifty people, including one child, suspected of having cholera have been admitted to the hospital, said Hospital Tengku Ampuan Rahimah director Dr Ghazali Hasni Md Hassan. One patient is confirmed with cholera and is still receiving treatment at the hospital.

"We are investigating another 14 patients to see they are also down with cholera or just suffering from food poisoning," he stated after Selangor Police Chief Datuk Khalid Abu Bakar visited the hospital in conjunction with the 202nd Police Day celebration. Dr Ghazali said the patients were from various locations in Klang and Shah Alam and were sent to the hospital after consuming contaminated food.
(ProMED 4/29/09)

Viet Nam (Hanoi)
Local authorities closed four dog meat shops in Hanoi after confirming that the first cholera patient of 2009 had eaten at one of the restaurants, said an official in the capital. All four of the venues received their dog meat from the same supplier, said Nguyen Huu Khiem, chairman of the Xuan Dinh Commune People's Committee in Ha Noi. The man ate dog meat, shrimp sauce, and uncooked vegetables prior to becoming ill. The patient was discharged from hospital after his condition improved, said Khiem.

"There is substantial risk of another cholera outbreak this year [2009]," said Nguyen Huy Nga, director of the Department of Preventive Medicine and a health ministry spokesman. "We have asked local governments to be on high alert to prevent the spread of summer epidemics."
(ProMED 4/29/09)

Viet Nam (Dong Nai)
An acute diarrhea outbreak occurred in southern Dong Nai Province's Xuan Loc District and affected more than 500 locals, but is now under control officials say. Cao Trong Nguong, director of the southeastern province's Preventive Health Department, said 26 Apr 2009 that they had taken water samples in the area for testing and conducting blood tests on local residents.

According to the Xuan Loc District Preventive Health Bureau, the outbreak began on 20 Apr 2009 in Gia Ui Village of Xuan Tam Commune and Trang Tao Village of Xuan Thanh Commune. It spread quickly and caused a total of 513 people to suffer diarrhea, fever, and vomiting.
(ProMED 4/29/09)

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4. Articles
Swine influenza: how much of a global threat?
The Lancet. 2 May 2009; 373(9674): 1495. Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60826-6/fulltext.

Editorial
On April 27, WHO raised its pandemic alert level from phase 3 to phase 4 after human cases of a novel H1N1 swine influenza A virus spread quickly around the world from its origin in Mexico. Concern over the virus—a hybrid of human, pig, and avian influenza—started mounting internationally last week following outbreaks of influenza-like illnesses in Mexico and other countries. As of April 28, according to WHO, Mexico had 26 laboratory confirmed human cases of swine influenza A (H1N1). (Excerpt.)

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Update: Drug Susceptibility of Swine-Origin Influenza A (H1N1) Viruses, April 2009
US Centers for Disease Control and Prevention. MMWR. 28 Apr 2009; 58(Dispatch); 1-3. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a1.htm?s_cid=mm58d0428a1_x.

Since April 21, 2009, CDC has reported cases of respiratory infection with a swine-origin influenza A (H1N1) virus (S-OIV) that is being spread via human-to-human transmission. As of April 28, the total number of confirmed S-OIV cases in the United States was 64; these cases occurred in California (10 cases), Kansas (two), New York (45), Ohio (one), and Texas (six). The viruses contain a unique combination of gene segments that had not been reported previously among swine or human influenza viruses in the United States or elsewhere. Viruses from 13 (20%) of 64 patients have been tested for resistance to antiviral medications. To date, all tested viruses are resistant to amantadine and rimantadine but are susceptible to oseltamivir and zanamivir. The purpose of this report is to provide detailed information on the drug susceptibility of the newly detected S-OIVs, which will aid in making recommendations for treatment and prophylaxis for swine influenza A (H1N1) infection. These data also will contribute to antiviral-resistance monitoring and diagnostic test development. (Excerpt with references removed.)

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Update: Infections With a Swine-Origin Influenza A (H1N1) Virus--United States and Other Countries, April 28, 2009
US Centers for Disease Control and Prevention. MMWR. 28 Apr 2009; 58(Dispatch); 1-3. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm?s_cid=mm58d0428a2_x.

Since April 21, 2009, CDC has reported cases of respiratory infection with a swine-origin influenza A (H1N1) virus (S-OIV) transmitted through human-to-human contact. This report updates cases identified in U.S. states and highlights certain control measures taken by CDC. As of April 28, the total number of confirmed cases of S-OIV infection in the United States had increased to 64, with cases in California (10 cases), Kansas (two), New York (45), Ohio (one), and Texas (six). CDC and state and local health departments are investigating all reported U.S. cases to ascertain the clinical features and epidemiologic characteristics. On April 27, CDC distributed an updated case definition for infection with S-OIV. (Excerpt with references removed.)

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5. Notifications
Weekly Epidemiological Record Bulletin
WHO. 1 May 2009. 84(18): 149-160. Available at http://www.who.int/wer.

Contents of this issue:
149 Outbreak news--Swine influenza
149 Swine influenza: frequently asked questions
151 Psychological health

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CDC Guidance Documents on Influenza A/H1N1
Interim Guidance for Clinicians on Identifying and Caring for Patients with Swine-origin Influenza A (H1N1) Virus Infection:
http://www.cdc.gov/h1n1flu/identifyingpatients.htm.
Released 4/29/09.

This document provides interim guidance for clinicians who might provide care for patients with swine-origin influenza A (H1N1) or suspected swine-origin influenza A (H1N1) virus infection. It will be periodically updated as information becomes available.

Interim Guidance for Screening for Swine-Origin Influenza A (H1N1) by State and Local Health Departments, Hospitals, and Clinicians in Regions with Few or no Reported Cases of Swine Influenza A (H1N1):
http://www.cdc.gov/h1n1flu/screening.htm.
Released 4/29/09.

This document provides interim guidance for state and local health departments, hospitals, and clinicians in regions with few or no reported cases of swine-origin influenza A (H1N1) (S-OIV) regarding which patients to evaluate for possible infection with swine influenza A (H1N1).

CDC Health Update: Interim Guidance—Children and Pregnant Women who may be Infected with Swine-Origin Influenza Virus: Considerations for Clinicians:
http://www.cdc.gov/h1n1flu/HAN/042809.htm.
Released 4/28/09.

This document is CDC interim guidance for clinicians on how to care for children and pregnant women who may be infected with a new influenza virus of swine origin that is spreading in the U.S. and internationally. Children and pregnant women are two groups of people who are at high risk of serious complications from seasonal influenza.

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Free courses on preparedness from Northwest Center for Public Health Practice
The Northwest Center for Public Health Practice (NWCPHP) offers free risk communication modules that are useful for preparedness practitioners. Practitioners can benefit by taking the time to brush up or improve their current skills.

Emergency Risk Communication for Public Health Professionals:
http://nwcphp.org/training/courses-exercises/courses/risk-communication

Emergency Distribution of Pharmaceuticals:
http://nwcphp.org/training/courses-exercises/courses/emergency-distribution-pharmaceuticals

Workforce Resiliency:
http://nwcphp.org/training/courses-exercises/courses/workforce-resiliency

Introduction to Outbreak Investigation:
http://nwcphp.org/training/courses-exercises/courses/outbreak-investigation

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APEC Conference for the Surveillance, Treatment, Laboratory Diagnosis and Vaccine Development of Enteroviruses
Location: Chinese Taipei; Date : May 14-15, 2009

Chinese Taipei would like to invite all APEC members to participant in this conference which will be held in Taipei on May 14-15, 2009. The deadline for the registration is 10 April 2009. For the further information, please contact with Conference Secretariat Ms Ying- Chen Cheng (Amelia) by e-mail at amelia@mpat.org.tw or by telephone at 886-2-2321-2362 ext 20.

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CDC Symposium on Drug-resistant and Vaccine-escape HBV Mutants
Location: Atlanta, Georgia, USA
Venue: CDC Royal Campus
Dates: 4-5 Jun 2009
Registration is free

Program and online registration details available at http://www.cdc.gov/hepatitis/hbvsymposium2009.

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 apecein@u.washington.edu