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EINet Alert ~ May 08, 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 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: Joint WTO/OIE/WHO/FAO statement on A/H1N1 influenza
- Global: Experts to discuss influenza A (H1N1) vaccine on 14 May 2009
- Global: Fewer seniors infected with influenza A (H1N1) may hint at protection
- Canada: PHA update on influenza A (H1N1)
- Canada (Alberta): Initial tests of humans on infected pig farm are negative for influenza A/H1N1
- Mexico: Negative economic impacts of influenza A (H1N1) continue
- USA: CDC update on influenza A (H1N1)
- USA: CDC revises guidance on school closures
- USA (Tennessee): Poultry on farm tests positive for low pathogenic avian influenza
- USA (Texas): Reports nation’s second death due to influenza A (H1N1)
- Mexico: Update on outbreak of influenza A/H1N1 infection
- Egypt: 68th human case of avian influenza A/H5N1 confirmed

2. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA

3. Articles
- Update: Novel Influenza A (H1N1) Virus Infections --- Worldwide, May 6, 2009
- Age-specific infection and death rates for human A(H5N1) avian influenza in Egypt
- Stockpiling Supplies for the Next Influenza Pandemic
- Emergence of a Novel Swine-Origin Influenza A (H1N1) Virus in Humans
- The Signature Features of Influenza Pandemics--Implications for Policy
- Implications of the Emergence of a Novel H1 Influenza Virus
- Triple-reassortant swine influenza A (H1) in humans in the United States, 2005-2009

4. Notifications
- EINet now linked to APEC’s website
- Information from WHO on antiviral drugs and vaccines for influenza A/H1N1
- US CDC circulates influenza A (H1N1) guidance
- Webcast: Influenza Outbreak in the Americas—International Cooperation in Response to the Spread of H1N1 Flu
- Influenza in the Asia-Pacific
- Conference: ICU Infection in an Era of Multi-Resistance

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

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1. Influenza News

Global
Cumulative number of human cases of influenza A/(H1N1)
Twenty-four countries have officially reported 2371 cases of influenza A/H1N1 infection.

Economy / Cases (Deaths)
2009
Austria/ 1 (0)
Canada/ 201 (0)
Colombia/ 1 (0)
Costa Rica/ 1 (0)
Denmark/ 1 (0)
El Salvador/ 2 (0)
France/ 5 (0)
Germany/ 10 (0)
Guatemala/ 1 (0)
Hong Kong/ 1(0)
Ireland/ 1 (0)
Israel/ 6 (0)
Italy/ 5 (0)
Mexico/ 1112 (42)
Netherlands/ 2 (0)
New Zealand/ 5 (0)
Poland/ 1 (0)
Portugal/ (1)
Republic of Korea/ 3 (0)
Spain/ 81 (0)
Sweden/ 1 (0)
Switzerland/ 1 (0)
United Kingdom/ 32 (0)
United States/ 896 (2)
Total/ 2371 (44)

(WHO 5/7/09)

One suspected case has been reported in Kosovo.
(Veratect 5/7/09)

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

2009
China/ 7 (4)
Egypt/ 17 (0)
Viet Nam/ 4 (4)
Total/ 28 (8)

***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: 423 (258).
(WHO 5/6/09 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: Joint WTO/OIE/WHO/FAO statement on A/H1N1 influenza
The following statement was issued jointly on 2 May 2009 by the Food and Agriculture Organization of the United Nations (FAO), the World Organization for Animal Health (OIE), the World Health Organization (WHO) and the World Trade Organization:

“In light of the spread of influenza A/H1N1, and the rising concerns about the possibility of this virus being found in pigs and the safety of pork and pork products, we stress that pork and pork products, handled in accordance with good hygienic practices recommended by the WHO, FAO, Codex Alimentarius Commission and the OIE, will not be a source of infection.

To date, there is no evidence that the virus is transmitted by food. There is currently, therefore, no justification in the OIE Terrestrial Animal Health Standards Code for the imposition of trade measures on the importation of pigs or their products.

However, it is important that Veterinary Authorities should collaborate with human health counterparts to monitor pig herds for any signs of unusual illness with suspected linkages to human cases of A/H1N1 influenza."
(OIE 5/5/09)

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Global: Experts to discuss influenza A (H1N1) vaccine on 14 May 2009
The World Health Organization (WHO) will convene a group of experts 14 May 2009 to advise the agency on whether to pull the trigger on production of a vaccine for the novel H1N1 swine influenza virus, a WHO official announced 6 May 2009. The experts will be asked if there's enough evidence to warrant a WHO recommendation for manufacturers to start large-scale manufacturing of a vaccine for the new virus, said Dr. Marie-Paule Kieny, director of the WHO's Initiative for Vaccine Research.

For some vaccine makers, that would mean curtailing production of the seasonal flu vaccine for the northern hemisphere, since not all manufacturers have finished production. A WHO recommendation to do that could come in a few weeks, Kieny said. "What we've recommended for the timing at present was for all manufacturers to put everything in place to be able to start manufacturing vaccine," she said.

The US Centers for Disease Control and Prevention (CDC) and other WHO collaborating centers are developing seed strains of virus for use in H1N1 vaccines. "We expect these will be available to manufacturers most likely in the second half of May [2009]," Kieny said.

The decision whether to recommend production will depend on the accumulating epidemiologic evidence about the virus, including how much of the population is likely to get sick and how severe the illness is, she said. And if the recommendation is made, it will be up to the manufacturers to decide whether to go ahead.

"The decision is not that of WHO; the decision will be the manufacturers' to take," she said. Kieny said "the vast majority" of manufacturers would need five to six months (from the identification of the virus) to begin producing a vaccine in quantity, but a few manufacturers might be able to start providing vaccine in as little as four months.

Last week Kieny said some of the vaccine manufacturers had completed about 60% of their production of the seasonal flu vaccine and that WHO officials were talking with them about the best time to switch from making seasonal vaccine to a new H1N1 vaccine. In response to questions on 6 May 2009, she said some manufacturers might be able to make seasonal and swine flu vaccines at the same time, using different production facilities. "You can't make two vaccines in the same plant at the same time," but some companies have more than one facility, she commented.

Kieny offered an estimate today of global capacity to make a vaccine for the novel virus: somewhere between 1 billion and 2 billion doses in a year, based on an estimated seasonal vaccine capacity of about 900 million doses. Current world population is more than 6 billion.

Kieny also acknowledged that multiple unknowns will govern how many doses can be produced and how many will be needed. For one thing, most of the vaccine will have to be grown in eggs—cell-based flu vaccine production is not mature enough to make much of a contribution—and no one knows how well the vaccine virus will grow in eggs, she said.

In addition, no one yet knows what size dose will be necessary, whether an adjuvant will be needed, and whether each person will need one dose or two, Kieny reported. It's generally understood that with novel flu viruses, to which people have little or no immunity, two doses of vaccine may well be necessary. That's true of H5N1 avian influenza vaccines, Kieny noted, but she said, "We hope that one dose will be sufficient [for the new H1N1 flu virus]. Before we know that, it's very difficult to say how many doses will be available."

In other comments, Kieny reported that the WHO director-general and the secretary-general of the United Nations will meet with vaccine company executives on 19 May 2009 to discuss how to ensure "equitable access for all countries" to any H1N1 vaccine.
(CIDRAP 5/6/09)

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Global: Fewer seniors infected with influenza A (H1N1) may hint at protection
A lab test currently under development at the Centers for Disease Control and Prevention (CDC) could answer one of the novel H1N1 swine flu outbreak's most intriguing questions: why older people seem less likely to catch the new disease. The test, called an antigenic assay, will not be completed for several weeks and then will go through several rounds of double-checking. But when it can be put into use, it should also help determine who should receive a vaccine against the novel flu strain if vaccine manufacturing goes forward.

Wherever there is surveillance for the new flu, it shows that the virus strikes young adults the hardest. In Mexico, according to data released 5 May 2009 by the country's Ministry of Health, 51% of the 866 cases are younger than 20. On 6 May 2009, according to the CDC, 58% of the confirmed US cases were younger than 18.

To date there has been no way of distinguishing whether the skewed age distribution is due only to who may have first been exposed to the strain—American high school and college students on spring break, for example—or whether some other factor is at work.

"One of the questions which came up is whether most of the people traveling right now. . .tend to be younger people," Dr. Keiji Fukuda, assistant director-general for health, security, and environment at the World Health Organization said on 5 May 2009. He added: "One of the alternate possibilities of course is that it is an infection that is primarily going to younger people because there may be something about older people which is preventing them from being infected."

Scientists at the CDC have been working since the epidemic's earliest days to identify that something. They have glimpsed what are, in effect, its footprints: evidence that people aged 60 and older have a preexisting immune-system component that reacts to the novel strain of flu. The phenomenon, called cross-reactive antibody, does not mean that older people were infected in the past by this exact strain of flu. Rather, their blood contains proteins that were produced by their immune systems when they were infected by a different strain of H1N1, and that also react more weakly to the current strain.

The reaction may be so weak that it represents only a laboratory result and not any real-world protection, Dr. Carolyn Bridges, associate director of epidemiologic science in the CDC's influenza division, cautioned. "We don't know how well that matches with clinical effectiveness; those are two different things," she said. Older people would have had ample chance to be infected by some variant of H1N1, which is named for the varieties of hemagglutinin (the "H" portion) and neuraminidase (the "N") proteins on the surface of the virus. H1N1 was the dominant strain of seasonal flu from 1918 to 1957, when it was replaced by the H2N2 strain that caused the 1957-58 pandemic.

The 1976 swine flu epidemic was caused by a different H1N1 flu, which circulated briefly and then disappeared behind the H3N2 strain that has been dominating seasonal flu since the 1968 pandemic began. In 1977, an H1N1 strain that was identical to the 1950s version suddenly appeared again—almost certainly as the result of a Russian laboratory accident—and has been part of the seasonal mix ever since.

The novel H1N1 swine flu resembles none of those prior strains. Yet in tests on blood samples that have been stored in CDC freezers from a variety of serologic surveys, as well as ones hastily contributed by academic researchers, serum from people older than 60 seems consistently to be showing a faint protective response to the new flu.

Those results have provided the impetus for the assay now being worked on at the CDC, which, when it is completed, should be able to identify people who have an immune response to the current flu. That is important because evidence of infection is the best, though most labor-intensive, indicator of how far an epidemic has spread and what ages and risk groups are most vulnerable.

But the test could be vital for determining future actions even more than past spread. A positive response could determine who might not need to be vaccinated against the new flu, if a vaccine is achieved—or more likely, who would need only a single dose because their immune system has already been primed by the prior infection. That would save a dose for another recipient, because medicine assumes that vaccination against a new strain of flu requires two doses—and that could be critical, because any vaccine that is made will likely be in limited supply.

A number of logistical challenges are holding up the test's development. Chief among them: The outbreak is too new to allow collection of the blood samples that its developers most need. "For influenza, you really need what are called 'paired serum samples'—collected from the same person, ideally 7 to 10 days from the onset of symptoms and then 2 to 3 weeks after that," Bridges said. "We are just barely at the convalescent point for the earliest cases."
(CIDRAP 5/6/09)

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Americas
Canada: PHA update on influenza A (H1N1)
The PHA has confirmed 214 human cases of influenza A (H1N1) in nine provinces. The provinces most heavily burdened are Onterio (56), British Columbia (54), Nova Scotia (53), and Alberta (33). Provinces that have not reported cases are Newfoundland, Yukon, Northwest Territories, and Nunavut.
(PHA 5/7/09)

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Canada (Alberta): Initial tests of humans on infected pig farm are negative for influenza A/H1N1
Canada's chief public health officer said the people who live on an Alberta pig farm where pigs were found to be infected with influenza A/H1N1 have tested negative for the virus.

Some pigs at the farm went off feed and showed respiratory symptoms. The Canadian Veterinary Services decided immediately to put the farm under quarantine. The sampled pigs tested positive to the "A/H1N1 virus." It was mild disease and the pigs have now recovered.

A number of people living on the unidentified pig farm experienced flu-like symptoms after the pigs fell ill and were tested to see whether they too were infected. But Dr. David Butler-Jones said tests suggest the people were not infected with the H1N1 swine virus. Butler-Jones said, though, that there may have been "sampling issues," and blood samples from the people will be tested for antibodies to look for a definitive answer on whether they were infected. He did not say how many people were tested or what he meant by sampling issues.

The pigs were thought to have been infected by a worker who had been in Mexico and was ill on his return to work in mid-April 2009. The unidentified carpenter also tested negative for the virus, but it is believed that that is because he was too far along in his recovery to be shedding virus. A nasal swab from the man was only collected after the pigs started falling sick, and that was more than 10 days after his return from Mexico. Officials intend to test his blood too, looking for antibodies to the new H1N1 swine flu virus.

The antibody test was developed at Canada's National Microbiology Laboratory, which has played a key role in the investigation into this new flu virus. It was the Winnipeg lab that determined that an unusual outbreak of severe respiratory illness in Mexico was being caused by a new swine flu virus, one US researchers had found was infecting people in the United States.

On 6 May 2009, Canadian officials announced the Winnipeg lab had completed full virus sequencing of three sample viruses, two from Canadian swine flu cases and one from Mexico. They say the viruses are virtually identical. The full genetic sequences of viruses retrieved from the pigs have not yet been completed. That work is being done at the National Centre for Foreign Animal Diseases, the National Microbiology Laboratory's animal health counterpart.

Experts will be keen to study the genetic sequences of the viruses isolated from the pigs to determine whether there are any mutations that arose when the virus went back into swine. Butler-Jones said the sequences of those viruses will be posted in open access databases once the work is done.
(ProMED 5/5/09, ProMED 5/7/09)

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Mexico: Negative economic impacts of influenza A (H1N1) continue
Mexico is returning to normal operations, but a five-day lockdown ordered by the government to try to slow the influenza's spread cast a pall on the normally exuberant Cinco de Mayo celebrations. Mexican Finance Minister Agustin Carstens said the outbreak could knock as much as half a percentage point off growth in 2009.

Furthermore, influenza A (H1N1) continued to spark trade and diplomatic quarrels. An AeroMexico plane picked up dozens of Mexicans stranded in China after they were quarantined there. Mexican President Felipe Calderon condemned the measure as discrimination against his compatriots. Singapore also issued orders to quarantine sick travelers.

In addition, Mexico told the World Trade Organization it was "deeply disappointed" by what it called "divisive measures" applied by some WTO members against its pork products. "Mexico urgently requests all its trading partners to eliminate any restrictive measures established on Mexican products, which are not in accordance with the scientific information available," the government said.

U.S. and Canadian pig and pork exports have also been hit by bans that rattled the $26 billion-a-year global pork industry, in which Mexico, the United States and Canada are among top exporters.
(Reuters 5/5/09)

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USA: CDC update on influenza A (H1N1)
The CDC has confirmed 896 cases of influenza A (H1N1) in 41 states. Two deaths, both in Texas, have been attributed to the virus. States most heavily burdened are Illinois (204), California (106), New York (98), Texas (91), and Massachusetts (71). The states that have not reported cases are Alaska, Arkansas, Mississippi, Montana, North Dakota, South Dakota, Vermont, West Virginia, and Wyoming.
(CDC 5/7/09)

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USA: CDC revises guidance on school closures
The Centers for Disease Control and Prevention (CDC) revised its novel H1N1 influenza (swine flu) guidance for schools on 5 May 2009, urging schools and parents to identify and isolate sick children rather than close schools when cases are identified or suspected.

The new recommendations are based on a new understanding of disease severity, which is now seen as less than originally thought and appears to be more in line with that of seasonal influenza, the CDC said. However, the CDC's recommendations allow for local flexibility, particularly when many student and faculty absences interfere with school functioning.

Health and Human Services (HHS) Secretary Kathleen Sebelius said that the guidance was developed in close collaboration with the Department of Education. It seeks to balance the importance of school attendance with the safety and security of students, she said.

Isolating sick kids, relieving closure burdens
According to the updated guidance, students, faculty, and staff who have influenza-like illness (fever with a cough or sore throat) should stay home, except for seeking medical care, for at least seven days, even if symptoms have already resolved. Those who appear ill at the beginning of or during the school day should be isolated and sent home.

The initial guidance, issued 1 May 2009, advised schools with confirmed or suspected cases to close for up to 14 days, depending on the scope and severity of illness.

The number of school closures as of 5 May 2009 was relatively small, according to the Department of Education—726 of the nation's more than 100,000 schools. "Still, this has been a significant disruption for hundreds of thousands of students at those schools, their families, teachers and school leaders," the department said. "Following CDC’s guidance, those schools may reopen as soon as possible, and most of those students will be able to return to class."

"Hopefully, this will alleviate some of the burden on workers and parents," Sebelius said. However, she added that changing the school closure recommendations isn't an indication that health officials know what course the novel virus will take. "There are aggressive efforts underway to learn more," she said. Some jurisdictions—including Minnesota and the Seattle—recently revised their school closure policies to reflect the new strain's apparent similarity to seasonal flu.

The rationale for softening the school-closure guidance was that the previous policies weren't practical or effective because the virus is already circulating widely in the community and because many people with mild illnesses aren't seeing their doctors or being diagnosed with the new strain.
(CIDRAP 5/5/09)

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USA (Tennessee): Poultry on farm tests positive for low pathogenic avian influenza
Birds on a farm in Giles County in Tennessee have been found to have the avian influenza virus. An official commented the virus poses no threat to human health. Two poultry houses belonging to one farm in Giles County are infected with the avian influenza virus.

According to Giles County EMA Director Barry Whitt, the case first appeared on 27 Apr 2009. State officials came in and ran tests on some of the birds and made their determination on 29 Apr 2009. Mr Whitt says that the outbreak is confined to the two barns that are located on the same property.

"This particular strain is confined to the animals only and is not spread to people," says Mr Whitt. "The public is not in any danger." Mr Whitt is coordinating with state officials on the next step to take. The EMA Director says that the plan is for the state to provide the chemicals and the manpower to clean and decontaminate the area. The Giles County Fire and Rescue Decontamination crew will supply equipment and assistance when the clean-up begins. Mr Whitt said that he will be meeting with state officials to determine when the clean-up will begin.
(ProMED 5/5/09)

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USA (Texas): Reports nation’s second death due to influenza A (H1N1)
Texas reported the nation's second death from the novel influenza A (H1N1) virus, in a woman from Cameron County who had a chronic health condition. According to an update posted on the Texas Department of State Health Services (TDSHS) website, she died earlier during the week of 3 May 2009. The first US death from the new flu strain also occurred in Texas, a 22-month-old boy from Mexico City.
(CIDRAP 5/5/09)

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Mexico: Update on outbreak of influenza A/H1N1 infection
Background
In April an outbreak of a new strain of human Influenza A/H1N1 virus was detected in Mexico. As of today (May 7th, 2009), Mexico has reported 1204 laboratory confirmed human cases of infection, including 44 deaths. Other APEC economies affected by this virus are: United States (642 cases, 2 deaths), Canada (201 cases), Hong Kong, China (1 case, a Mexican), New Zealand (5 cases), and Republic of Korea (2 cases).

Immediate response of the Mexican authorities and transparency in information sharing with relevant fora and countries have been among the main features of Mexico’s management of this crisis. This has given other countries the opportunity to monitor for the new virus and thus protect their citizens.

Actions
Since late April, the Mexican government has implemented measures to avoid contagion, according to World Health Organization (WHO) and APEC recommendations, some of them are:
i) social distance measures, such as suspension of scholar activities from all levels , as well as other activities and events which involve the gathering and contact of people--such as sports, entertainment, and religious events;
ii) economic activities not considered strategic were suspended from May 1 to 5;
iii) it was recommended -in some cases made compulsory- to use facemasks, constantly wash hands, avoid close contact with other people, and try to remain at home;
iv) installation of devices to identify people with high temperature and possible symptoms of Influenza A/H1N1, in airports and other public transportation venues;
v) schools and other public places have been disinfected;
vi) transparency and thorough communication both at national and international levels has been an outstanding practice during this emergency.

To prevent an epidemic outbreak, Mexico has a reserve of a million of antiviral treatments to face any emergency related to respiratory illness-like.

Current Situation
There is a notable control of the virus spread in Mexico; consequently, authorities have instructed citizens to gradually resume scholarly and economic activities. Notwithstanding, strict sanitary measures have to be observed, and there are ongoing actions to detect possible new cases, such as the deployment of provisional health convoys all over the country to offer immediate medical attention to persons.

Understanding that these measures have had an economic impact, the Ministry of Finance announced economic incentives to contribute to the recovery of the economy, specifically fiscal and financial measures have been recently announced, mainly to support small and medium enterprises (SMEs) and tourism.

By the same token, Mexico has demanded its trading partners both at the World Trade Organization (WTO) and bilaterally, to eliminate unjustifiable barriers to trade that some countries have imposed against Mexican goods, particularly on swine products, that lack scientific evidence. In this regard, Mexico recently circulated among APEC economies the communication sent to the Committee on Sanitary and Phytosanitary Measures of the WTO, which mentions the joint statement of the United Nations Food and Agriculture Organization (FAO), the World Organization for Animal Health (OIE), the World Health Organization (WHO) and the WTO, reaffirming that there is no evidence to date that the A/H1N1 virus is transmitted by food.

Likewise, Mexico regrets profoundly any kind of discriminatory actions against Mexican nationals carried out by some authorities, such as those related to travel restrictions. Particularly, considering that the Influenza virus AH1/N1 is present in more than 20 countries. The WHO has expressed that there is no rationale for limiting travel, since these measures would have very little effect on stopping the spread of the virus and would be highly disruptive to the global community.

Support from APEC economies
APEC economies have shown their solidarity with Mexico, and have not hesitated in sending medical devices, other equipment, and medicines to support Mexico. They have also received financial aid and technological support. Mexico deeply thanks Canada, People’s Republic of China, Japan, Republic of Korea and United States for their priceless help.

APEC and Mexico’s response to the Influenza A/H1N1
The actions taken by Mexico are in line with the APEC recommendations such as those included in the “Functioning Economies in Times of Pandemic, APEC Guidelines”, which refers to integrated planning and preparedness; coordination and cooperation with other economies; constant communication and information; maintaining essential services as well as the operations of financial and banking activities; and ensuring the movement of people through border control, quarantining, surveillance and screening measures designed to comprehensively address containment and infection issues while limiting the impact on trade in most goods and services.

The Mexican quick response and action to combat the virus alerted other countries to identify cases of Human Influenza A/H1N1, otherwise it would have taken longer for the international community to act.

As President of Mexico Felipe Calderón has said, in this war against the attack of the Human Influenza, Mexico is in the frontline of the battle, and from this trench, Mexico is preventing infection not only among Mexicans but among people all over the world.

Therefore, Mexico counts on the coordinated work and collaboration from member economies and different international actors to overcome this enormous challenge. (Mexico Ministry of Economy 5/6/09)

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Africa
Egypt: 68th human case of avian influenza A/H5N1 confirmed
The Ministry of Health of Egypt has reported the new suspected human case of avian influenza is now confirmed. The case is a 34-year-old female from Tanta District, Gharbia Governorate. Her symptoms began on 21 Apr 2009, and she was hospitalized at Tanta Fever Hospital on 21 Apr 2009, where she was started on oseltamivir. She is in a stable condition.

Infection with H5N1 avian influenza was confirmed by the Egyptian Central Public Health Laboratory on 23 Apr 2009 and subsequently confirmed by the U.S. Naval Medical Research Unit No. 3 (NAMRU-3). Investigations into the source of this infection indicate a history of close contact with dead and sick poultry prior to becoming ill.

Of the 68 cases confirmed to date in Egypt, 23 have been fatal.
(ProMED 5/6/09)

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2. 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
Map of the spread of influenza A/H1N1: http://www.who.int/csr/don/GlobalSubnationalMaster_20090507_1800.png.

- 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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3. Articles
Update: Novel Influenza A (H1N1) Virus Infections --- Worldwide, May 6, 2009
US Centers for Disease Control and Prevention. MMWR. 8 May 2009; 58(17): 453-458. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5817a1.htm?s_cid=mm5817a1_e. (references removed)

Since mid-April 2009, CDC, state and local health authorities in the United States, the World Health Organization (WHO), and health ministries in several countries have been responding to an outbreak of influenza caused by a novel influenza A (H1N1) virus. In March and early April 2009, Mexico experienced outbreaks of respiratory illness subsequently confirmed by CDC and Canada to be caused by the novel virus. The influenza strain identified in U.S. patients was genetically similar to viruses isolated from patients in Mexico. Since recognition of the novel influenza A (H1N1) virus in Mexico and the United States, as of May 6, a total of 21 additional countries had reported cases, with a total of 1,882 confirmed cases worldwide. Several WHO member states are conducting ongoing investigations of this worldwide outbreak, and WHO is monitoring and compiling surveillance data and case reports. On April 29, WHO raised the level of pandemic alert from phase 4 to phase 5, indicating that human-to-human spread of the virus had occurred in at least two countries in one WHO region. This report provides an update of the initial investigations and spread of novel influenza A (H1N1) virus worldwide.

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Age-specific infection and death rates for human A(H5N1) avian influenza in Egypt
Dudley JP. Eurosurveillance. 14(18). Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19204.

Abstract
The age-specific infection and death profiles among confirmed human cases of influenza A(H5N1) infection in Egypt differ markedly from those recorded in other countries. The case fatality rate among human H5N1 cases in Egypt is 34 percent, versus an average of 66 percent in other countries. In Egypt, children younger than 10 years comprise 48 percent of reported cases, nearly twice the global average of approximately 25 percent, and no H5N1 fatalities have been confirmed among individuals in this age group as of 23 Apr 2009. Females outnumber males among confirmed H5N1 cases by a factor of nearly 2:1, and 90 percent of reported fatalities in Egypt have been females. The evident age and sex biases in morbidity and mortality among H5N1 cases in Egypt are phenomena that warrant further investigation and analysis.

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Stockpiling Supplies for the Next Influenza Pandemic
Radonovich LJ et al. Emerg Infect Dis. June 2009 [epub ahead of print]. Available at http://www.cdc.gov/eid/content/15/6/pdfs/08-1196.pdf.

Faced with increasing concerns about the likelihood of an influenza pandemic, healthcare systems have been challenged to determine what specific medical supplies that should be procured and stockpiled as a component of preparedness. Despite publication of numerous pandemic planning recommendations, little or no specific guidance about the types of items and quantities of supplies needed has been available. The primary purpose of this report is to detail the approach of 1 healthcare system in building a cache of supplies to be used for patient care during the next influenza pandemic. These concepts may help guide the actions of other healthcare systems.

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Emergence of a Novel Swine-Origin Influenza A (H1N1) Virus in Humans
Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. NEJM. 7 May 2009. Available at http://content.nejm.org/cgi/content/full/NEJMoa0903810.

ABSTRACT
Background. On April 15 and April 17, 2009, novel swine-origin influenza A (H1N1) virus (S-OIV) was identified in specimens obtained from two epidemiologically unlinked patients in the United States. The same strain of the virus was identified in Mexico, Canada, and elsewhere. We describe 642 confirmed cases of human S-OIV infection identified from the rapidly evolving U.S. outbreak.

Methods. Enhanced surveillance was implemented in the United States for human infection with influenza A viruses that could not be subtyped. Specimens were sent to the Centers for Disease Control and Prevention for real-time reverse-transcriptase–polymerase-chain-reaction confirmatory testing for S-OIV.

Results. From April 15 through May 5, a total of 642 confirmed cases of S-OIV infection were identified in 41 states. The ages of patients ranged from 3 months to 81 years; 60% of patients were 18 years of age or younger. Of patients with available data, 18% had recently traveled to Mexico, and 16% were identified from school outbreaks of S-OIV infection. The most common presenting symptoms were fever (94% of patients), cough (92%), and sore throat (66%); 25% of patients had diarrhea, and 25% had vomiting. Of the 399 patients for whom hospitalization status was known, 36 (9%) required hospitalization. Of 22 hospitalized patients with available data, 12 had characteristics that conferred an increased risk of severe seasonal influenza, 11 had pneumonia, 8 required admission to an intensive care unit, 4 had respiratory failure, and 2 died. The S-OIV was determined to have a unique genome composition that had not been identified previously.

Conclusions. A novel swine-origin influenza A virus was identified as the cause of outbreaks of febrile respiratory infection ranging from self-limited to severe illness. It is likely that the number of confirmed cases underestimates the number of cases that have occurred.

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The Signature Features of Influenza Pandemics--Implications for Policy
Miller MA et al. NEJM. 7 May 2009. Available at http://content.nejm.org/cgi/content/full/NEJMp0903906.

Perspective
Vast amounts of time and resources are being invested in planning for the next influenza pandemic, and one may indeed have already begun. Data from past pandemics can provide useful insights for current and future planning. Having conducted archeo-epidemiologic research, we can clarify certain "signature features" of three previous influenza pandemics — A/H1N1 from 1918 through 1919, A/H2N2 from 1957 through 1963, and A/H3N2 from 1968 through 1970 — that should inform both national plans for pandemic preparedness and required international collaborations.

Past pandemics were characterized by a shift in the virus subtype, shifts of the highest death rates to younger populations, successive pandemic waves, higher transmissibility than that of seasonal influenza, and differences in impact in different geographic regions. Although influenza pandemics are classically defined by the first of these features, the other four characteristics are frequently not considered in response plans. (Excerpt.)

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Implications of the Emergence of a Novel H1 Influenza Virus
Belshe RB. NEJM. 7 May 2009. Available at http://content.nejm.org/cgi/content/full/NEJMe0903995.

Editorial
In this issue of the Journal, there are two reports of recent transmissions of swine influenza viruses in humans. One group of viruses, described by Shinde et al., are triple reassortants of viruses from pigs, humans, and birds, called triple-reassortant swine influenza A (H1) viruses, which have circulated in pigs for more than a decade. The other group, described by the Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team, is a recent reassortant of the triple-reassortant swine influenza A (H1) viruses and a Eurasian swine influenza virus, resulting in the swine-origin influenza A (H1N1) virus (S-OIV), currently being transmitted among humans.

The two groups of viruses behave very differently. Triple-reassortant swine influenza A (H1) viruses are found in pigs and may occasionally be transmitted to humans but have not spread efficiently from human to human. S-OIV, in contrast, is not currently known to be epidemic in pigs (although pigs may be infected by exposure to humans), but it is exhibiting human-to-human transmission and has spread to several countries. Both viruses are H1 hemagglutinin viruses, which appeared in humans and swine in 1918 and have subsequently evolved, in both species, into divergent H1 viruses. The current situation is not "1918 again," it is "1918 continued," in that we are still being infected with remnants of the 1918 pandemic influenza virus. (Excerpt with references removed.)

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Triple-reassortant swine influenza A (H1) in humans in the United States, 2005-2009
Shinde V et al. NEJM. 7 May 2009. Available at http://content.nejm.org/cgi/content/full/NEJMoa0903812.

ABSTRACT
Background. Triple-reassortant swine influenza A (H1) viruses — containing genes from avian, human, and swine influenza viruses — emerged and became enzootic among pig herds in North America during the late 1990s.

Methods. We report the clinical features of the first 11 sporadic cases of infection of humans with triple-reassortant swine influenza A (H1) viruses, occurring from December 2005 through February 2009, until just before the current epidemic of swine-origin influenza A (H1N1) among humans. These data were obtained from routine national influenza surveillance reports and from joint case investigations by public and animal health agencies.

Results. The median age of the 11 patients was 10 years (range, 16 months to 48 years), and 4 had underlying health conditions. Nine of the patients had had exposure to pigs, five through direct contact and four through visits to a location where pigs were present but without contact. In another patient, human-to-human transmission was suspected. The range of the incubation period, from the last known exposure to the onset of symptoms, was 3 to 9 days. Among the 10 patients with known clinical symptoms, symptoms included fever (in 90%), cough (in 100%), headache (in 60%), and diarrhea (in 30%). Complete blood counts were available for four patients, revealing leukopenia in two, lymphopenia in one, and thrombocytopenia in another. Four patients were hospitalized, two of whom underwent invasive mechanical ventilation. Four patients received oseltamivir, and all 11 recovered from their illness.

Conclusions. From December 2005 until just before the current human epidemic of swine-origin influenza viruses, there was sporadic infection with triple-reassortant swine influenza A (H1) viruses in persons with exposure to pigs in the United States. Although all the patients recovered, severe illness of the lower respiratory tract and unusual influenza signs such as diarrhea were observed in some patients, including those who had been previously healthy.

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4. Notifications
EINet now linked to APEC’s website
Access current and archived EINet bulletins via the APEC website at http://www.apec.org/.

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Information from WHO on antiviral drugs and vaccines for influenza A/H1N1
Antiviral drugs may reduce the symptoms and duration of illness due to influenza A (H1N1) infection, just as they do for seasonal influenza. They also may contribute to preventing severe disease and death. Influenza A (H1N1) is a new virus and only a small number of people with the infection have been treated for it with antiviral drugs. WHO is in touch with public health authorities and clinicians in affected countries and is gathering information about how effective the drugs are.

Full WHO antiviral guidance available at http://www.who.int/csr/disease/swineflu/frequently_asked_questions/swineflu_faq_antivirals/en/index.html.

Work is under way to develop a vaccine for the influenza A (H1N1) virus. Influenza vaccines generally contain a dead or weakened form of a circulating virus. The vaccine prepares the body’s immune system to defend against a true infection. For the vaccine to protect as well as possible, the virus in it should match the circulating “wild-type” virus relatively closely. Since this H1N1 virus is new, there is no vaccine currently available made with this particular virus. Making a completely new influenza vaccine can take five to six months.

More frequently asked questions answered at http://www.who.int/csr/disease/swineflu/frequently_asked_questions/vaccine_preparedness/en/index.html

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US CDC circulates influenza A (H1N1) guidance
Interim CDC Guidance for Colleges, Universities, and Post-secondary Educational Institutions in Response to Human Infections with Novel Influenza A (H1N1) Virus
Available at http://www.cdc.gov/h1n1flu/guidance/guidelines_colleges.htm.

Interim guidance to assist state and local health departments in developing programs for migrant and seasonal farm workers in response to human infections with novel influenza A (H1N1) virus
Available at http://www.cdc.gov/h1n1flu/guidance/migrant_farmworkers_doh.htm.

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Webcast: Influenza Outbreak in the Americas—International Cooperation in Response to the Spread of H1N1 Flu
The Woodrow Wilson International Center for Scholars convened a webcast discussion on 5 May 2009 regarding the international response to influenza A H1N1. The panel of experts commended international efforts to contain the H1N1 influenza and noted the severity of the virus seems to be less than first perceived; however, they warned that the upcoming flu season in Southern Hemisphere could bring a second, perhaps more dangerous, round of infections.

The video archive of the event is available at http://www.wilsoncenter.org/index.cfm?fuseaction=events.event&event_id=530892.

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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

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