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EINet Alert ~ Jun 05, 2009


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

1. Influenza News
- Cumulative number of human cases of influenza A/(H1N1)
- Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO moves closer to declaring influenza pandemic; Chan urges governments not to overreact
- Australia: Reports community spread of influenza A/H1N1 in Victoria
- India (West Bengal): New outbreak of avian influenza H5N1 in backyard poultry
- Japan: Seasonal flu vaccine for 2008/2009 has no protective effect on novel influenza A (H1N1) virus
- Canada: PHA update on influenza A/H1N1
- Mexico: Update on outbreak of influenza A/H1N1 virus infection in Mexico
- USA: CDC update on influenza A/H1N1
- USA: Analysis of influenza A/H1N1 flu response shows progress, problems
- USA (New York): Asthma leads risk factors in influenza A/H1N1 hospitalizations
- Egypt: Economy's 77th and 78th human avian influenza H5N1 cases in children

2. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA

3. Articles
- Satellite-marked waterfowl reveal migratory connection between H5N1 outbreak areas in China and Mongolia
- Managing and Reducing Uncertainty in an Emerging Influenza Pandemic
- Pig infection studies with influenza A (H1N1) associated with global epidemic in humans
- Update: Novel Influenza A (H1N1) Virus Infection--Mexico, March--May, 2009

4. Notifications
- Weekly Epidemiological Record Bulletin
- Characteristics of the emergent influenza A (H1N1) viruses and recommendations for vaccine development
- General Business and Workplace Guidance for the Prevention of Novel Influenza A (H1N1) Flu in Workers
- Influenza Pandemic--Continued Focus on the Nation’s Planning and Preparedness Efforts Remains Essential
- Influenza in the Asia-Pacific


1. Influenza News

Global
Cumulative number of human cases of influenza A/(H1N1)
69 countries have officially reported 21,940 of influenza A/H1N1 infection, including 125 deaths.

Economy / Cases (Deaths)

2009
Argentina/ 147 (0)
Australia/ 876 (0)
Austria/ 2 (0)
Bahamas/ 1 (0)
Bahrain/ 1 (0)
Barbados/ 1 (0)
Belgium/ 7 (0)
Brazil/ 28 (0)
Bulgaria/ 1 (0)
Canada/ 1795 (3)
Chile/ 369 (1)
China/ 89 (0)
Colombia/ 24 (0)
Costa Rica/ 68 (1)
Cuba/ 4 (0)
Cyprus/ 1 (0)
Czech Republic/ 1 (0)
Denmark/ 4 (0)
Dominican Republic/ 33 (0)
Ecuador/ 43 (0)
Egypt/ 1 (0)
El Salvador/ 49 (0)
Estonia/ 3 (0)
Finland/ 4 (0)
France/ 47 (0)
Germany/ 43 (0)
Greece/ 5 (0)
Guatemala/ 23 (0)
Honduras/ 34 (0)
Hungary/ 3 (0)
Iceland/ 1 (0)
India/ 4 (0)
Ireland/ 8 (0)
Israel/ 39 (0)
Italy/ 38 (0)
Jamaica/ 2 (0)
Japan/ 410 (0)
Korea, Republic of/ 41 (0)
Kuwait/ 18 (0)
Lebanon/ 3 (0)
Luxembourg/ 1 (0)
Malaysia/ 2 (0)
Mexico/ 5563 (103)
Netherlands/ 4 (0)
New Zealand/ 11 (0)
Nicaragua/ 5 (0)
Norway/ 9 (0)
Panama/ 173 (0)
Paraguay/ 5 (0)
Peru/ 47 (0)
Philippines/ 29 (0)
Poland/ 4 (0)
Portugal/ 2 (0)
Romania/ 8 (0)
Russia/ 3 (0)
Saudi Arabia/ 1 (0)
Singapore/ 12 (0)
Spain/ 218 (0)
Sweden/ 13 (0)
Switzerland/ 10 (0)
Thailand/ 8 (0)
Turkey/ 8 (0)
United Kingdom/ 428 (0)
United States/ 11,054 (17)
Total/ 21,940 (125)

(WHO 6/5/09)

Additionally, first cases have been confirmed in Ukraine, Venezuala, French Polynesia and the Cayman Islands. Cases have been reported in Sudan as well.
(Veratect 6/5/09; 6/4/09; 6/3/09; 6/2/09; 5/29/09)

APEC economy updates: Chile reports first novel H1N1 death in South America. Viet Nam recorded its first case of influenza A/H1N1; case is a student who reported travel to the US. China reported its first locally acquired case of H1N1. Patient had contact with travelers to the US.
(ProMED 5/31/09)

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

2009
China/ 7 (4)
Egypt/ 27 (4)
Viet Nam/ 4 (4)
Total/ 38 (12)

***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: 433 (262).
(WHO 6/2/09 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 5/6/09)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 5/10/09): 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 moves closer to declaring influenza pandemic; Chan urges governments not to overreact
The head of the World Health Organization urged governments not to overreact to global outbreaks of influenza A/H1N1 as the agency moves closer to declaring the first pandemic in four decades. Margaret Chan, the WHO’s director-general, may declare an influenza pandemic within days, said three people familiar with the organization’s plans. Chan, in an interview on 3 June 2009, said a final decision hasn’t been taken, and authorities must use the time before novel H1N1 becomes global to revise emergency plans and convey the measures to their countries’ populations.

Most pandemic plans were crafted for the H5N1 bird flu virus, deadly in three out of five cases. Swine flu, the new bug racing across the world, so far causes little more than a fever and a cough in most patients. Governments must resist the temptation to restrict travel, close borders and adopt other measures that aren’t justified, according to Chan.
(Bloomberg News 6/4/09)

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Asia
Australia: Reports community spread of influenza A/H1N1 in Victoria
Australian health officials acknowledged 3 June 2009 that the novel H1N1 influenza virus has achieved sustained community transmission in the state of Victoria, where 521 cases were reported that same day, an increase of 126 since the previous day.

The Australia Department of Health and Ageing said the pandemic response for Victoria has been raised from "contain" to "sustain." The resulting measures "will enable Victoria to more appropriately respond to the relatively higher number of cases and the sustained community transmission of the infection in Victoria," said the agency.

Australia's overall novel H1N1 case count reached 633 as of 3 June 2009, with all eight states and territories reporting cases. In addition to Victoria's cases, New South Wales has reported 70, and Queensland has reported 26. For the remaining states and the two territories, case numbers are in the single digits.

The spread of the virus in Victoria suggests that the World Health Organization's (WHO's) formal criterion for a full-fledged pandemic (pandemic alert phase 6)—sustained community transmission in more than one global region—has probably been met. The WHO has been holding off on a pandemic declaration because of concern that it may trigger undue alarm, given that the illness is mild in most cases. The agency said it would come up with a way to rate the disease's severity and provide related guidance in an effort to reduce undue alarm from a pandemic declaration.

Victoria's health minister, Daniel Andrews, said that the state's move to a modified sustain phase of its influenza plan is being done to focus on protecting vulnerable people from the virus rather than containing the virus. Vulnerable groups include seniors, students at special development schools, hospital patients, and those who have chronic illnesses.

The state will provide antiviral treatment only to those who have novel flu infections and their household contacts, require people with confirmed cases to isolate themselves for three days after starting treatment, conduct intensive surveillance in high-risk settings such as nursing homes, and enhance community surveillance for illnesses and changes in the circulating influenza strains. Schools will no longer automatically close if a student has a flu-like illness, though large numbers of confirmed cases in a school might warrant closure.

Raina MacIntyre, professor of infectious diseases and epidemiology at the University of New South Wales in Sydney, said that Victoria is the only state where sustained community transmission appears to be occurring. More than 75% of cases have occurred in children aged 5 to 18, she said.

The normal influenza season in Australia and the rest of the southern hemisphere is just getting under way, and global health officials worry that the novel flu virus could change when it circulates alongside the seasonal strains. Though weekly reports on Australia's flu season haven't yet begun, MacIntyre said so far labs are reporting that both seasonal and flu viruses are circulating.

Meanwhile, an Australian cruise ship was been turned away from New Caledonia amid fears of influenza H1N1. The Dawn Princess cruise liner was prevented from stopping after up to five people on board started showing flu-like symptoms. Swabs have been taken from the sick passengers and sent to Sydney for testing.

Dr Jeremy McAnulty from New South Wales Health says the ship has not been to any novel H1N1 infected countries, but they are still being cautious. "We've learnt a lot from cruise ships and transmission of diseases over the last few years, but also particularly in the past week or so," he said. "We're working to identify people who may have had infections on board to help determine whether it was swine flu or something else." The ship is now heading back to Sydney and will arrive on 5 Jun 2009.

Cruise ships have been in the spotlight since late May 2009, when about 3000 passengers and crew on board the Dawn Princess were not allowed to leave the ship on its return to Sydney because four passengers displayed mild flu symptoms. The passengers and crew were then allowed to disembark but told to remain in home isolation until the all clear was given.

Then cases of novel H1N1 appeared on the P&O cruise ship Pacific Dawn, which docked in Sydney on 1 Jun 2009. The 1800 passengers on the ship were cleared of the virus and were allowed to disembark, although three crew members were confirmed to have the virus. Passengers on the ship's previous cruise were found to have H1N1. On 1 Jun 2009, the chief executive of Carnival Cruises, which runs P&O, said passengers might be screened before they boarded the ship for its next cruise to the South Pacific.
(ProMED 6/3/09; CIDRAP 6/3/09)

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India (West Bengal): New outbreak of avian influenza H5N1 in backyard poultry
A fresh outbreak of the highly pathogenic avian influenza has been reported in West Bengal. About 20 backyard poultry birds were reported dead on 20 May 2009 in the rural areas of Uttar Dinajpur in West Bengal, not far from the Assam and Bangladesh border.

It was confirmed that the birds died of avian influenza A/H5N1 on 25 May 2009. The animal husbandry department formally notified the World Organisation of Animal Health (OIE) of the outbreak of bird flu in the area on 28 May 2009. It also told OIE that measures such as curbs on the movement of poultry products and screening and culling of domestic poultry in a 3 km radius around the outbreak spots have already been taken.

No vaccination or treatment of the affected birds has been performed, as part of the government's strategy to tackle bird flu. The places of infection would be disinfected.

This outbreak of bird flu occured about six months after the last outbreak of this disease in Hajo, Rajabazar, and Kamrup areas of Assam. About 325 birds died of H5N1 infection at that time. The first outbreak of bird flu in India occurred in Navapur and Uchchal around the Maharashtra and Madhya Pradesh border in February 2006. Since then, there have been several outbreaks in different parts of the country, causing huge economic losses to the poultry industry. The organized poultry industry is currently believed to be worth over Rs 30,000 crores (approx. USD 6.4 billion).

Following successful containment of the disease in the epicentres of infection between 2006 and 2008, India formally declared itself bird flu-free country on 4 Nov 2008. But this status did not last long. Barely three weeks later, the disease resurfaced in the Kamrup (rural) district of Assam.
(ProMED 6/2/09)

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Japan: Seasonal flu vaccine for 2008/2009 has no protective effect on novel influenza A (H1N1) virus
As of 29 May 2009, a total of 367 confirmed cases of human infection with a novel influenza A (H1N1) virus had been reported to the Japanese Ministry of Health, Labour and Welfare (MHLW) [1]. The preliminary outbreak investigation report from National Institute of Infectious Diseases, Tokyo, Japan has provided important data on the effectiveness of pre-seasonal vaccination on the new strain [2].

They investigated 43 RT-PCR confirmed cases reported from Kobe City. Their median age was 17 years which ranged from 5 to 44 years. Among them, 42 reported the status of pre-seasonal vaccination for 2008/2009 season and the coverage was 52.4 percent. According to MHLW's estimation, the coverage of influenza vaccine among Japanese population was 53.7 percent for those aged less than 13 years, 23.1 percent for those aged 13 to 64 years, and 58.8 per cent for those aged over 64 years during the 2008/2009 season [3]. Taking account of the population age structure, 27.9 per cent of Japanese people aged 5 to 44 years are estimated to have been vaccinated for seasonal influenza virus. This indicates that vaccine coverage among confirmed cases is no less than that of the population average.

It is too early to reach a conclusion about a possible negative effect, yet it is already obvious that pre-seasonal vaccine for 2008/2009 season has no protective effect on disease from the novel influenza A (H1N1) strain among the Japanese population. This finding should be valuable information for public health policy makers preparing for coming winter season.

References:
1. Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan. Novel Influenza A (H1N1), Laboratory confirmed cases in Japan.
http://idsc.nih.go.jp/disease/swine_influenza_e/index.html
2. National Institute of Infectious Diseases, Kobe Institute of Health. Interim report on clinical presentation of the novel influenza A (H1N1) cases reported from Kobe City.
http://idsc.nih.go.jp/disease/swine_influenza_e/idsc_e2009/clinical_epi_kobe.html
3. Japanese Ministry of Health, Labour and Welfare. Report on the estimated demand for influenza vaccination for 2008/2009 season.
http://www.mhlw.go.jp/shingi/2008/06/dl/s0618-9f.pdf (available in Japanese only)

Submitted by Dr. Motoi Suzuki
(ProMED 5/30/09)

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Americas
Canada: PHA update on influenza A/H1N1
PHA has confirmed 1795 human cases of influenza A (H1N1) in 12 provinces/territories, including two deaths in Ontario and death in Alberta. Provinces most heavily burdened are Onterio (894) and Quebec (346). The only territory that has not reported cases is Newfoundland.
(PHA 6/3/09)

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Mexico: Update on outbreak of influenza A/H1N1 virus infection in Mexico
As of 3 June 2009, Mexico has reported 5,029 confirmed cases of infection, including 97 deaths. Other APEC economies affected by this virus are: United States (10,053 cases, including 17 deaths), Canada (1530 cases, including 2 death), New Zealand (10 cases), Japan (385 cases), Korea (41 cases), China (69 cases), Hong Kong (10) Thailand (2 cases), Malaysia (2 cases) Chile (313 cases), Peru (40 cases), Chinese Taipei (14 cases), Australia (501 cases), Philippines (16 cases), Russia (2 cases), Viet Nam (3 cases) and Singapore (9 cases).

President of Mexico, Felipe Calderon has lifted the sanitary contingency. Nevertheless, preventive sanitary measures will remain constant. One of the most affected sectors is tourism. As a result, on 25 May 2009 the Mexican Government launched the promotion campaign “Vive México” in order to boost the Mexican economy and regain the confidence of national and international visitors. As part of this campaign, several companies will launch special offers and discounts to attract tourists from abroad, while Mexico’s destinations and sites will be promoted within the country and around the world by Mexican figures from entertainment, sports and culture. This program will be granted with an investment of 1,200 million pesos.

On 25 May 2009, the government of Japan donated 25 thermal cameras to be installed at bus terminals as part of the control measures. Furthermore, Japan stopped requesting visas for Mexican travelers.

For further information visit:

www.prevencioninfluenza.gob.mx/
www.sre.gob.mx
www.sectur.gob.mx
www.economia.gob.mx

(Mexico MOE 6/3/09)

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USA: CDC update on influenza A/H1N1
The CDC has confirmed 13,217 cases of influenza A (H1N1) in all states including Washington, DC and Puerto Rico. Twenty-seven deaths have been attributed to the virus—New York (8), Illinois (5), Arizona (4), Texas (3), Utah (2), Connecticut (1), Michigan (1), Missouri (1), Virginia (1), and Washington (1). States most heavily burdened are Wisconsin (2217), Texas (1670), and Illinois (1357).
(CDC 6/5/09)

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USA: Analysis of influenza A/H1N1 flu response shows progress, problems
A coalition of health policy groups offered a "good news, bad news" evaluation of the US response to the novel H1N1 influenza epidemic so far on 4 June 2009.

The good news: The experience has shown that years of pandemic preparation have paid dividends, particularly with regard to coordination, communication, antiviral drugs, and vaccine development. The bad news: The outbreak has pointed up the serious limitations of the financially strapped public health sector, suggesting that it would be overwhelmed in a more severe and widespread epidemic.

The report was produced by Trust for America's Health (TFAH), a nonprofit, nonpartisan advocacy group in Washington, DC, in collaboration with the Center for Biosecurity at the University of Pittsburgh Medical Center and the Robert Wood Johnson Foundation. "It was clear in our report that all the pandemic planning and preparedness efforts over the past several years have improved our ability to respond to an outbreak, but it was also clear that the situation didn't test the limits of our response," said Jeff Levi, PhD, executive director of TFAH.

Positives and negatives are sprinkled through the 10 lessons presented in the report, titled "Pandemic Flu Preparedness: Lessons from the Frontlines." Many of them repeat TFAH messages about the need to restore and strengthen the nation's public health infrastructure.

Investments prove wise
The first finding was that federal, state, and local planning efforts of recent years "enabled public health officials to react to the outbreak effectively and keep the public informed. Investments in antiviral stockpiles and enhanced vaccine manufacturing capacity also proved to be prudent."

At the press briefing, David Fleming, MD, director of Seattle and King County Public Health, strongly endorsed that conclusion. He said Seattle officials had thought through many of the issues and stockpiled medications. In particular, "Telling citizens we had sufficient supplies of Tamiflu [oseltamivir] went a long way" to help the situation, said Fleming, a peer reviewer for the report.

He said that by the time the outbreak began, private antiviral supplies were "essentially zero," because it was the end of the regular flu season. "We dipped into our local reserve [of antivirals] and made those available to people through our public health clinics," which resulted in moderate but not overwhelming use, he added.

Nationally, only modest amounts of stockpiled antivirals have been used, since relatively few people have been infected, said Thomas V. Inglesby, MD, deputy director of the Center for Biosecurity and a co-author of the report. But he said the stockpiles gave people confidence in their ability to help the sickest patients, adding, "I think the investment is widely seen to have been wise."

Lack of resources exposed
The second lesson cited in the report is that public health departments didn't have enough resources to carry out their carefully made plans. "Capacity to track, investigate and contain cases of H1N1 has been hampered due to lack of resources," the document states. "For instance, CDC [Centers for Disease Control and Prevention] and state laboratory testing was days to more than a week behind the on-the-ground reality."

Fleming said the national surveillance picture was 1 to 2 weeks behind what was happening on the ground. In Seattle, some schools that had possible cases were closed and then reopened before the CDC confirmed and reported a single local case of the novel flu, he said.

He also said a key part of Seattle's response to the novel flu was using public health nurses to educate school and daycare authorities about the outbreak. Ironically, many of the nurses were due to receive layoff notices two weeks after the start of the flu outbreak.

A third finding was that, though the outbreak was mild, healthcare systems in some areas were "overwhelmed." In many hospitals, emergency departments were flooded by the "worried well," and some outpatient clinics had inadequate personal protective equipment and "a limited understanding of infection control measures."

Need for flexibility, good communication
Another lesson was that the outbreak underlined that pandemic plans must be adaptable. It notes that pandemic planning has focused on the threat of the virulent H5N1 avian influenza and often has assumed that the United States would have six weeks of lead time before an emerging pandemic strain overseas reached US shores. Instead, the novel H1N1 outbreak featured a generally mild virus emerging in North America. As for public communication, the report gives US leaders good grades, saying the president and other authorities conveyed consistent, accurate information about hand hygiene, respiratory etiquette, and the need to stay home when sick. Leaders also helped dispel rumors, such as concerns about the safety of imported Mexican foodstuffs.

Other lessons
Other early lessons from the epidemic, the report says, include the following:
- Where schools were closed because of the outbreak, parents had to scramble to find alternative child care arrangements.
- The lack of sick leave caused problems. There were reports of people with flu-like symptoms going to work because they had no sick leave, which is true for 48% of American workers, said Levi. Also, some parents sent sick children to school because they couldn't stay home to care for them.
- Communication between the public health system and medical providers fell short, as many private practitioners complained that they did not receive CDC guidance documents in a timely fashion.
- The World Health Organization's (WHO's) pandemic alert system was not well-matched with the realities of the H1N1 outbreak. (WHO's alert phases are based strictly on the geographic spread of the virus, not the severity of disease. The agency said this week it would come up with a severity scale in an effort to reduce confusion.)
- International coordination posed some problems: Against WHO advice, some countries closed their borders to Mexican citizens or banned pork from the United States and Mexico.

Full text of report available at http://healthyamericans.org/assets/files/pandemic-flu-lesson.pdf.
(CIDRAP 6/4/09)

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USA (New York): Asthma leads risk factors in influenza A/H1N1 hospitalizations
The New York City Department of Health (NYCDH) on 4 June 2009 detailed risk factors that were present among the 152 residents who were hospitalized for novel influenza. At least 85% had one or more underlying health condition. The most common ones were asthma (41%), being younger than 2 years old (18%), having a compromised immune system (13%), and heart disease (12%). Pregnancy, diabetes, and chronic organ system disorders were also reported among those who were hospitalized.
(CIDRAP 6/4/09)

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Africa
Egypt: Economy's 77th and 78th human avian influenza H5N1 cases in children
The Ministry of Health of Egypt has reported a new confirmed human case of avian influenza A (H5N1) on 1 Jun 2009. The case is a 4-year old female child from the Kafr el-Sheikh District of Kafr el-Sheikh Governorate. Her symptoms started on 30 May 2009 with fever, cough, and sore throat. She was admitted to Kafr el-Sheikh Fever Hospital on 31 May 2009. The patient received oseltamivir [Tamiflu] and is in a stable condition. Investigations into the source of infection indicated that she had close contact with dead and sick poultry. The case was confirmed by the Egyptian Central Public Health Laboratories.

A spokesperson for Egypt’s health ministry indicated that 39 people have been hospitalized with suspected infections. Previously, the ministry confirmed on 30 May 2009, the 77th infection with H5N1 virus. A baby girl, aged 14 months, contracted the highly pathogenic avian A (H5N1) influenza virus; she was in contact with domestic birds in a village located in Daqahliya, north Cairo, the ministry's spokesman Dr Abdulrahman Shahin said.

The baby was hospitalized on 26 May 2009 suffering from bird-flu-like symptoms including high temperature, running nose, and respiratory disorder. She was diagnosed as H5N1-positive and has been treated with the antiviral drug Tamiflu (oseltamivir), Dr Shahin said. The patient is being relocated to Manshiyat Al-Bakri Hospital, Cairo for further medication, he added.

Egypt's national tally of the disease is 78, with the death toll amounting to 27 since the outbreak of the highly contagious virus in February 2006. The National Higher Commission against Bird Flu has adopted a new preventive methodology to control the spread of H5N1. The methodology involves the medical and municipal authorities as well as the mass media.
(ProMED 6/3/09, 6/2/09, 5/31/09)

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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 Canada: 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
Satellite-marked waterfowl reveal migratory connection between H5N1 outbreak areas in China and Mongolia
Prosser DJ et al. International Journal of Avian Science. 18 May 2009. Available at http://www3.interscience.wiley.com/journal/122389147/abstract?CRETRY=1&SRETRY=0.

ABSTRACT
The role of wild birds in the spread of highly pathogenic avian influenza H5N1 has been greatly debated and remains an unresolved question. However, analyses to determine involvement of wild birds have been hindered by the lack of basic information on their movements in central Asia. Thus, we initiated a programme to document migrations of waterfowl in Asian flyways to inform hypotheses of H5N1 transmission. As part of this work, we studied migration of waterfowl from Qinghai Lake, China, site of the 2005 H5N1 outbreak in wild birds. We examined the null hypothesis that no direct migratory connection existed between Qinghai Lake and H5N1 outbreak areas in central Mongolia, as suggested by some H5N1 phylogeny studies. We captured individuals in 2007 from two of the species that died in the Qinghai Lake outbreaks and marked them with GPS satellite transmitters: Bar-headed Geese Anser indicus (n = 14) and Ruddy Shelduck Tadorna ferruginea (n = 11). Three of 25 marked birds (one Goose and two Shelducks) migrated to breeding grounds near H5N1 outbreak areas in Mongolia. Our results describe a previously unknown migratory link between the two regions and offer new critical information on migratory movements in the region.

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Managing and Reducing Uncertainty in an Emerging Influenza Pandemic
Lipsitch M et al. NEJM. 27 May 2009. Available at http://content.nejm.org/cgi/content/full/NEJMp0904380.

Perspective
The early phases of an epidemic present decision makers with predictable challenges that have been evident as the current novel influenza A (H1N1) virus has spread. The scale of the problem is uncertain when a disease first appears but may increase rapidly. Early action is required, but decisions about action must be made when the threat is only modest--and consequently, they involve a trade-off between the comparatively small, but nearly certain, harm that an intervention may cause (such as rare adverse events from large-scale vaccination or economic and social costs from school dismissals) and the uncertain probability of much greater harm from a widespread outbreak. This combination of urgency, uncertainty, and the costs of interventions makes the effort to control infectious diseases especially difficult.

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Pig infection studies with influenza A (H1N1) associated with global epidemic in humans
An EU funded study through an EU project consortium coordinated by VLAWeybridge. 29 May 2009. Available at http://ec.europa.eu/food/committees/regulatory/scfcah/animal_health/background_doc_point1_en.pdf/

Preliminary summary
Study aims
To investigate infection dynamics, clinical outcome, pathogenesis, host susceptibility and transmissibility of influenza A (H1N1) [associated with global epidemic in humans, hereafter referred to as influenza A (H1N1)] in pigs.

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Update: Novel Influenza A (H1N1) Virus Infection--Mexico, March--May, 2009
US Centers for Disease Control and Prevention. MMWR. 5 June 2009; 58(21); 585-589. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5821a2.htm?s_cid=mm5821a2_e.

On April 12, 2009, Mexico responded to a request for verification by the World Health Organization (WHO) of an outbreak of acute respiratory illness in the small community of La Gloria, Veracruz. During April 15--17, the Mexico Ministry of Health received informal notification of clusters of rapidly progressive severe pneumonia occurring mostly in Distrito Federal (metropolitan Mexico City) and San Luis Potosi. In response, on April 17, Mexico intensified national surveillance for acute respiratory illness and pneumonia. During April 22--24, novel influenza A (H1N1) virus infection, previously identified in two children in the United States, was confirmed in several patients. This report updates a previous report on the outbreak in Mexico and summarizes public health actions taken to date by Mexico to monitor and control the outbreak. During March 1--May 29, national surveillance identified 41,998 persons with acute respiratory illness; specimens from 25,127 (59.8%) patients were tested, of which 5,337 (21.2%) were positive for novel influenza A (H1N1) virus infection by real-time reverse transcription--polymerase chain reaction (rRT-PCR). As of May 29, 97 patients with laboratory-confirmed infection had died. Epidemiologic evidence to date suggests that the outbreak likely peaked nationally in late April, although localized cases continue to be identified. (Excerpt with references removed.)

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4. Notifications
Weekly Epidemiological Record Bulletin
WHO. 5 June 2009; 84(23): 213-236. Available at http://www.who.int/wer.

Includes:
Human infection with new influenza A (H1N1) virus: Mexico, update, March-May 2009
Meeting of the immunization Strategic Advisory Group of Experts, April 2009 - conclusions and recommendations

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Characteristics of the emergent influenza A (H1N1) viruses and recommendations for vaccine development
WHO guidance document released 26 May 2009
Available at http://www.who.int/csr/resources/publications/swineflu/H1N1Vaccinevirusrecommendation26May2009.pdf.

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General Business and Workplace Guidance for the Prevention of Novel Influenza A (H1N1) Flu in Workers
US CDC guidance document released 30 May 2009
Available at http://www.cdc.gov/h1n1flu/guidance/workplace.htm

This guidance is to help employers with employees in OSHA's Lower Risk (Caution) Zone: those employees who have minimal occupational contact with the general public and other coworkers (for example, office employees).

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Influenza Pandemic--Continued Focus on the Nation’s Planning and Preparedness Efforts Remains Essential
US Government Accountability Office report. 3 June 2009. Available at http://www.gao.gov/new.items/d09760t.pdf.

Why GAO Did This Study
As the recent outbreak of the H1N1 (swine flu) virus underscores, an influenza pandemic remains a real threat to our nation and to the world. Over the past three years, GAO has conducted a body of work to help the nation better prepare for a possible pandemic. In a February 2009 report, GAO synthesized the results of this work, pointing out that while the previous administration had taken a number of actions to plan for a pandemic, including developing a national strategy and implementation plan, much more needs to be done, and many gaps in preparedness and planning still remain.

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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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 apecein@u.washington.edu