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EINet Alert ~ Jun 19, 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: Influenza drugs determined relatively safe for pregnant and breast-feeding women
- Global: Novartis won't supply free H1N1 influenza vaccine to poor countries
- UK: Reports first death due to novel H1N1 influenza outside of the Americas
- China (Yingchang): California students in China hospitalized for novel influenza H1N1
- Japan: Announces closure of special influenza clinics
- Brazil: Experts discount claim of mutant novel H1N1 influenza virus strain
- Canada: PHA update on influenza A/H1N1
- Canada (Alberta): Blood test results provide information in pig farm influenza H1N1 case
- USA: CDC update on influenza A/H1N1
- USA: Pandemic declaration prompts CDC to engage with businesses
- USA: Hunt for novel H1N1 influenza reveals persistence of seasonal strains
- Egypt: Three new novel H1N1 cases confirmed, government vows to cull country’s remaining pigs
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- Antibodies against H5 and H9 Avian Influenza among Poultry Workers in China
- Emergence and pandemic potential of swine-origin H1N1 influenza virus
- Novel Influenza A (H1N1) Virus Infections Among Health-Care Personnel--United States, April--May 2009
- Influenza A(H1N1)v in the southern hemisphere - lessons to learn for Europe?
- US Congressional Research Services reports available online
- Interim CDC Guidance on Day and Residential Camps in Response to Human Infections with the Novel Influenza A (H1N1) Virus
- Influenza in the Asia-Pacific
1. Influenza News
Cumulative number of human cases of influenza A/(H1N1)
The WHO has confirmed 39,620 of influenza A/H1N1 infection, including 167 deaths.
Economy / Cases (Deaths)
Chinese Taipei has reported 58 confirmed cases of influenza A (H1N1) with 0 deaths. Cases from Chinese Taipei are included in the cumulative total above.
***For data on human cases of avian influenza prior to 2009, go to:
Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 433 (262).
Avian influenza age distribution data from WHO/WPRO:
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):
Global: Influenza drugs determined relatively safe for pregnant and breast-feeding women
The review may assuage concerns of women who contract novel H1N1 influenza and are worried about whether or not to use antiviral drugs. Pregnant women are at higher risk of complications than their non-pregnant peers when they catch seasonal flu. Evidence from some previous pandemics suggests they can be hit disproportionately hard by a strain of pandemic influenza.
"During the current pandemic, we shouldn't hesitate to treat those patients at increased risk," said senior author Dr Shinya Ito, head of the division of clinical pharmacology and toxicology at Toronto's Hospital for Sick Children. "In terms of risk-benefit ratio I think it's very clear that the benefit is much more significant to use the drug for pregnant women, even in the first trimester."
The authors, from the Motherisk Program at Sick Kids and the Japan Drug Information Institute in Pregnancy, examined the available data on antiviral drug use in pregnant and breast-feeding women. They admitted the evidence is limited and said it will be important to monitor what happens with antiviral drug usage by pregnant women during the pandemic. In addition to looking at reports of use filed to the drug makers after the fact, they found unpublished Japanese data that followed 90 pregnant women who took Tamiflu during the first trimester of their pregnancies. The first trimester is the period when concern is greatest that chemicals or drugs a mother is exposed to or takes could have a detrimental effect on the developing fetus. Of those women, only one gave birth to a child with a birth defect. The rate of birth defects in the general population is between 1 to 3 percent. Given that the rate among Tamiflu users isn't higher, it suggests the single case occurred by chance, not as a result of exposure to the drug.
In another study, scientists used a human placenta to see if Tamiflu introduced to the placenta would flow to the fetus. Ito said it took a high concentration of Tamiflu to see even small concentrations of drugs coming out the other end.
The authors suggested Tamiflu is probably the better choice of the two flu drugs to give pregnant women infected with this new strain of H1N1 flu, because there is more safety data on its use in pregnancy. But they said for women who are breastfeeding, either Tamiflu or Relenza could be used because only small amounts are excreted in breast milk.
The paper said neither drug appears to affect the growth or development of fetuses exposed to them in the womb. The US Centers for Disease Control and Prevention said during the week of 2 Jun 2009 that it is receiving reports that some pregnant women who catch the novel H1N1 influenza virus are refusing to take antiviral drugs out of fear it might put their fetuses at risk.
Full article available at http://www.cmaj.ca/cgi/rapidpdf/cmaj.090866.
Global: Novartis won't supply free H1N1 influenza vaccine to poor countries
UK: Reports first death due to novel H1N1 influenza outside of the Americas
Health officials in the United Kingdom reported Europe's first novel H1N1 flu death, in a 38-year-old Glasgow woman who reportedly had underlying health problem and died 14 Jun 2009, Scotland's Daily Record reported. The death was described as the first outside the Americas. The woman died two weeks after giving birth to a premature baby, who also died on 15 Jun 2009, according to other media reports. Scotland's tally of novel H1N1 cases stood at 496 yesterday, the government said.
China (Yingchang): California students in China hospitalized for novel influenza H1N1
Chinese officials have hospitalized six students and a teacher from a California high school in Yingchang after they tested positive for the novel H1N1 virus, the San Diego Union-Tribune reported on 15 Jun 2009. Four others from the group are also hospitalized but apparently do not have the virus. The rest of the school group, 26 students and five teachers, are quarantined at a hotel near the hospital, and all from the school have received antiviral treatment.
Japan: Announces closure of special influenza clinics
Brazil: Experts discount claim of mutant novel H1N1 influenza virus strain
The US Centers for Disease Control and Prevention (CDC) and other experts have rejected a report that a new strain of the novel H1N1 influenza virus has been identified in a Brazilian patient. Scientists at Adolfo Lutz Bacteriological Institute in Sao Paolo said they found the new strain in a local patient who has recovered, according to a Medical News Today (MNT) report, which was based on information from the institute and Agence France-Presse. The story said the scientists found "a number of discrete alterations in nucleotide and amino acid sequences" in the isolate's hemagglutinin (HA) gene. They also analyzed the matrix-protein (MP) gene and found no changes. But CDC spokesman Joe Quimby discounted the report that the isolate is a new strain.
The Brazilian researchers labeled the isolate A/Sao/Paolo/1454/H1N1. They deposited the nucleotide sequences for the HA and MP genes in GenBank under accession numbers GQ247724 and GQ250156, the MNT report said. Vincent Racaniello, PhD, a Columbia University virologist who writes Virology Blog, also dismissed the claim of a new strain. "Comparison of the amino acid sequence of the HA protein of A/Sao Paulo/1454/H1N1 with those of other isolates of the current pandemic strain reveals no alterations in the HA protein which would allow the virus to infect new hosts," Racaniello wrote. "The HA protein of this virus and many other 2009 H1N1 isolates are identical. The few amino acid differences with other 2009 H1N1 isolates are in areas that would not be expected to influence antigenicity or host range."
The MNT report said the virus came from a 26-year-old Sao Paolo man who fell ill shortly after returning from a trip to Mexico. He was hospitalized on 24 Apr 2009 and later recovered.
Canada: PHA update on influenza A/H1N1
Canada (Alberta): Blood test results provide information in pig farm influenza H1N1 case
The carpenter had just returned from a trip to Mexico when he went to do a job at the farm on 14 Apr 2009. At that point the new H1N1 virus was already circulating in parts of the Mexico, but the world was not yet aware a new flu virus was on the move.
Provincial health officials are starting to believe they may never find out how the virus made its way into the herd, the only pigs anywhere in the world to have tested positive for the new virus to this point. "Since serological [blood] tests indicated the carpenter had not had H1N1, someone else must have brought it in, but it is unlikely we will ever be able to pinpoint exactly who," says May.
Officials had earlier said several members of the family that owned the farm were sick a couple of days before the carpenter worked there briefly. Others fell ill after the pigs started to display signs of being sick, leading authorities to suggest the virus may have gone from a person to pigs and back to people. Nasal swabs taken from people on the farm tested negative, but blood samples were taken to look for antibodies to the virus. Whether that work is completed and what the tests showed if it is, has not been made public.
Recently the farmer who owned the herd announced he had destroyed his pigs, because he could not sell the animals. The farm had been under quarantine since late April 2009, when the outbreak first came to the attention of the Canadian Food Inspection Agency [CFIA].
Sporadic tests continued to find evidence of possible ongoing circulation of virus in the herd, says Dr Jim Clark, the national manager for disease control for CFIA's animal health division. Over the course of the weeks of quarantine, testing found diminishing but still present viral DNA, which may or may not have meant infectious viruses were still spreading among the pigs, Clark says.
Clark says CFIA would like to be able to determine how the pigs got infected. But he says the agency isn't getting much co-operation from human health counterparts responsible for testing the people involved. "So far we haven't been able to get a whole lot of information from them," he says, adding that while he's not sure why that is, privacy concerns may play a role.
Clark says he expects there will be other opportunities to learn about how this virus behaves when it gets into pig populations. With continued spread around the world, he suggests, "it's invariably going to result in the exposure of pigs in other countries and in other places."
But whether farmers will admit to it is another issue. The family who owned the Alberta herd has reportedly paid a heavy price, financially and personally. Pork sales are down, even though health officials have repeatedly stressed people cannot get novel H1N1 flu from eating pork. The lengthy quarantining of the Alberta farm -- and the unfortunate outcome -- may discourage farmers from reporting flu-like symptoms in their pigs. There are a variety of influenza virus subtypes that infect pigs and outbreaks, while common, are not a long-term threat to the health of pigs.
"I think right now the production community is looking and saying 'OK, when you can tell us what you specifically want to do about the situation, then we might be in a situation to want to submit samples to find out what's going on,'" says Clark, who admits he has some sympathy for that position. "From a purely scientific perspective, I'd love all the samples in the world to be coming in and get as much background information as we can about where this virus may currently be occurring anywhere in the swine population," he says.
"On the practical side, without having a clearly defined policy that is able to get us out of the situation as quickly as possible and define all the risk factors, I'm saying 'Well, maybe I don't really want to know about too many things that are going on right now until we can get more definitive information about what we need to be concerned about.'"
USA: CDC update on influenza A/H1N1
USA: Pandemic declaration prompts CDC to engage with businesses
At a teleconference on 12 Jun 2009 for the business community, Lisa Koonin, MN, MPH, a senior adviser with the CDC's influenza coordination unit, said that because influenza viruses are so unpredictable and the pandemic may change or become more severe in the fall, now is the time for businesses to revise pandemic plans or begin developing one if they don't already have one. About 680 people called in for the conference.
Anthony Fiore, MD, MPH, a medical epidemiologist in the CDC's influenza division, said the novel flu cases and hospitalizations are hitting younger people and children the hardest. "This is much of the workforce, as well as their children," he said.
He warned that a vaccine against the new virus, if successfully developed, won't be available until October 2009 or later and probably won't be distributed through typical commercial channels. Fiore advised businesses to plan on using basic preventive measures as a fallback, such as encouraging employees to stay home when they're sick, cover their coughs, and wash their hands frequently. Employees who have risk factors for flu complications, such as asthma, cardiac conditions, or pregnancy, should be advised to seek medical care quickly if they have flu symptoms, he said. Those who don't have risk factors and experience severe symptoms should also seek care.
Employers should review their leave, pay, and benefits policies to determine if any adjustments are needed to allow employees to stay home for 7 to 10 days if they are sick with the novel flu or need to stay home to care for a sick family member, she said. Flexibility with policies will be crucial, Koonin said. For example, employers may not want to require a doctor's note when workers have been home sick, because clinics and emergency departments will likely be swamped, making it difficult for sick people to get notes in a timely manner.
She advised the group to address business continuity concerns by identifying essential business functions and critical employees, planning for staffing redundancy for key positions, and assessing supply-chain and critical input issues. Koonin added that it's a good idea for businesses to ask suppliers to provide details about their pandemic plans.
Some businesses asked the CDC for clearer guidance on how long people with novel flu infections should stay home before returning to work. Fiore said the current guidance, issued out of an abundance of caution but without much scientific data, is 7 days or 24 hours after symptoms resolve, whichever is longer. He said the CDC is actively examining its recommendation on how long to stay home and hopes to update its guidance within the next few weeks.
USA: Hunt for novel H1N1 influenza reveals persistence of seasonal strains
In the week that ended 6 Jun 2009, about 1.8% (49 of 2,681) of the flu viruses identified in lab tests reported to the Centers for Disease Control and Prevention (CDC) were seasonal viruses—either influenza A/H1N1, A/H3N2, or B, according to the CDC's latest weekly flu surveillance report. The agency says that about 89% of the isolates were the novel virus, while the rest were not subtyped. (The 89% includes 315 isolates that could not be subtyped by reference laboratories; the CDC says its own testing of those isolates nearly always shows them to be the novel virus.)
Clinicians who see patients with respiratory illnesses at this time of year usually don't test them for flu, because normally it has faded by now, said Dr. Anthony Fiore, a medical epidemiologist with the CDC's influenza branch. "Now people who don't normally look for flu are looking more than they ever have," Fiore said. "We're seeing that some of the respiratory illnesses that occur even late in the season may be due to seasonal flu viruses that we didn't appreciate in the past."
Fiore added that there has long been awareness that flu viruses continue to circulate at a low level in the summer, but the current level of testing is shedding more light on the situation.
Egypt: Three new novel H1N1 cases confirmed, government vows to cull country’s remaining pigs
As the number of confirmed cases of the A/H1N1 influenza virus continued to climb in Egypt, the government vowed to redouble its efforts to hunt down the country's last surviving pigs. Assistant Health Minister Nasr al-Sayid on 12 Jun 2009 confirmed three new cases of the disease.
Al-Sayid said the three new cases had come from Canada, Sweden, and the United States, and that they had been taken to hospital for isolation and treatment, Egypt's official Middle East News Agency (MENA) reported.
The Ministry of Health said the three cases brought the total number of confirmed cases of novel H1N1 flu in Egypt to 15. And as new confirmed infections continued to trickle in, the Egyptian government redoubled its efforts to hunt down the country's last remaining pigs. Samaha said the government had so far killed 15,000 pigs, and that it expected to kill all remaining Egyptian swine by the end of next week.
Later, officials maintained that culling pigs was less about reducing H1N1 risks and more an effort to improve public health generally. Many of the country's large pig farms are in "garbage cities" that segregate recyclable materials from organic matter, 30% of which is fed to the pigs. However, outside experts wonder why officials have not offered a more pressing concern: preventing reassortment between H5N1 and novel H1N1 viruses. Last week, a four-year-old girl from the Nile Delta province of Daqahliya became the 27th person to die of bird flu H5N1 in Egypt. Hers was the 72nd confirmed case of that virus in the country, MENA said.
The following websites provide the most current information and advice.
- North America
- Other useful sources
Antibodies against H5 and H9 Avian Influenza among Poultry Workers in China
Wang M et al. NEJM. 11 June 2009; 360(24): 2583-2584. Available at http://content.nejm.org/cgi/content/full/360/24/2583/.
Emergence and pandemic potential of swine-origin H1N1 influenza virus
Novel Influenza A (H1N1) Virus Infections Among Health-Care Personnel--United States, April--May 2009
Soon after identification of novel influenza A (H1N1) virus infections in the United States in mid-April 2009, CDC provided interim recommendations to reduce the risk for transmission in health-care settings. These included recommendations on use of personal protective equipment (PPE), management of health-care personnel (HCP) after unprotected exposures, and instruction of ill HCP not to report to work. To better understand the risk for acquiring infection with the virus among HCP and the impact of infection-control recommendations, CDC solicited reports of infected HCP from state health departments. As of May 13, CDC had received 48 reports of confirmed or probable infections with novel influenza A (H1N1) virus; of these, 26 reports included detailed case reports with information regarding risk factors that might have led to infection. Of the 26 cases, 13 (50%) HCP were deemed to have acquired infection in a health-care setting, including one instance of probable HCP to HCP transmission and 12 instances of probable or possible patient to HCP transmission. Eleven HCP had probable or possible acquisition in the community, and two had no reported exposures in either health-care or community settings. Among 11 HCP with probable or possible patient to HCP acquisition and available information on PPE use, only three reported always using either a surgical mask or an N95 respirator. These findings suggest that transmission of novel influenza A (H1N1) virus to HCP is occurring in both health-care and community settings and that additional messages aimed at reinforcing current infection-control recommendations are needed. (Excerpt with references removed.)
Influenza A(H1N1)v in the southern hemisphere - lessons to learn for Europe?
Outside the tropics, influenza infections show seasonal patterns which depend on the latitude but appear not to be influenced by longitude. The factors influencing this seasonality are not yet fully understood, but indoor crowding, lower temperatures, decreased humidity and reduced levels of sunlight are believed to influence both transmission and host susceptibility. Seasonal influenza typically occurs between November and March in the northern hemisphere, and between April and September in the southern hemisphere. However, a temporal overlap of influenza activity between both hemispheres has been described. In tropical regions influenza occurs year-round; it remains unclear whether tropical regions serve as reservoir for the epidemics in both hemispheres. (References removed.)
US Congressional Research Services reports available online
The 2009 Influenza A(H1N1) “Swine Flu” Outbreak: US Responses to Global Human Cases, 26 May 2009
Available at http://assets.opencrs.com/rpts/R40588_20090526.pdf.
Potential Farm Sector Effects of 2009 H1N1 “Swine Flu”: Questions and Answers, 20 May 2009
The 2009 Influenza A(H1N1) Outbreak: Selected Legal Issues, 6 May 2009
Interim CDC Guidance on Day and Residential Camps in Response to Human Infections with the Novel Influenza A (H1N1) Virus
This document provides interim guidance on suggested means to reduce the spread of the novel influenza A (H1N1) virus in day, residential, or overnight camp settings. Recommendations are interim, based on current knowledge of the H1N1 outbreak in the United States, and may be revised as more information becomes available.
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