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EINet Alert ~ Jul 03, 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
- Weekly update of pandemic influenza H1N1
- Cumulative number of human cases of avian influenza A/H5N1
- Global: Health officials say antiviral resistance likely in some pandemic H1N1 influenza cases
- Global: Studies show novel H1N1 influenza affects deep lung tissue, transmits fairly well
- UK: Health officials warn pandemic H1N1 influenza cases could exceed 100,000 per day by August
- Indonesia: Authorities watchful after avian influenza H5N1 virus was detected in 20 villages
- Indonesia: Announces it will ask foreign visitors to wear masks to guard against pandemic H1N1
- Saudi Arabia: Health officials ask groups at high risk for pandemic influenza H1N1 to skip hajj
- Argentina: Novel influenza A/H1N1 in pigs reported
- Argentina: Health minister resigns over handling of novel influenza H1N1 cases
- USA: CDC estimates over 1 million Americans infect with pandemic H1N1
- Egypt: 79th-81st human cases of avian influenza H5N1 reported confirmed by the WHO
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- Pandemic Vaccine Preparedness—Have We Left Something Behind?
- “Prepandemic” Immunization for Novel Influenza Viruses, “Swine Flu” Vaccine, Guillain-Barré Syndrome, and the Detection of Rare Severe Adverse Events
- The Persistent Legacy of the 1918 Influenza Virus
- Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza
- Pneumonia and Respiratory Failure from Swine-Origin Influenza A (H1N1) in Mexico
- Historical Perspective--Emergence of Influenza A (H1N1) Viruses
- Spread of a Novel Influenza A (H1N1) Virus via Global Airline Transportation
- National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza
- Weekly Epidemiological Record Bulletin
- US CDC and FDA Emergency Use Authorization Course
- Influenza in the Asia-Pacific
1. Influenza News
Weekly update of pandemic influenza H1N1
The WHO has confirmed 77,201 of influenza A/H1N1 infection, including 332 deaths. Countries with the most confirmed cases of H1N1 are detailed below.
Economy/ Cases (Deaths)
Case totals for other APEC economies
Map the spread of confirmed pandemic H1N1 influenza at http://www.who.int/csr/don/Map_20090701_1100.png.
Other APEC updates:
***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: 436 (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: Health officials say antiviral resistance likely in some pandemic H1N1 influenza cases
He characterized what occurred in the Danish patient as "drug-induced resistance" that developed when a low dose of medication was used, as opposed to the more widespread resistance that occurs when a flu virus acquires new characteristics, which has happened over the past two years with the seasonal H1N1 strain. World Health Organization (WHO) spokesman Dick Thompson said on 30 Jun 2009 that the Danish case is isolated and has no public health implications, Reuters reported. "But we must remain alert as the virus can change at any time and we must not be complacent," he added. The antiviral resistance finding will not prompt any changes in the WHO antiviral recommendations.
Roche said it is monitoring drug resistance in several countries, and officials in several nations, including the United States, are also watching for changes in the virus. The US Centers for Disease Control and Prevention (CDC) said in its most recent surveillance report, released 24 Jun 2009, that of 191 novel H1N1 isolates that have been tested for resistance to neuraminidase inhibitors, none showed resistance.
CDC recommends treatment with oseltamivir or zanamivir for all patients who have confirmed, probable, or suspected novel H1N1 infections who are hospitalized or are at high risk for complications. Carolyn Bridges, associate director of epidemiologic science in the CDC's influenza division, told National Public Radio that though the US hasn't detected any antiviral resistance in the new virus, it will likely occur here eventually. She said the novel flu virus has an "N1" gene that is very different than the "N1" of the seasonal H1N1 virus, so perhaps the pandemic virus isn't as susceptible to the antiviral resistance mutation seen with the seasonal H1N1 strain.
Global: Studies show novel H1N1 influenza affects deep lung tissue, transmits fairly well
A team from Erasmus Medical Center in the Netherlands found that the virus transmits easily between ferrets housed in cages whose walls are 4 inches apart. But a team from the Massachusetts Institute of Technology (MIT) and the US Centers for Disease Control and Prevention (CDC) found that the novel virus only transmitted well when the ferrets shared direct contact—a sign, the team said, that the new virus has not yet fully adapted to mammals.
The European team, however, warned that the new H1N1 is adapted enough to compete with seasonal flu strains for turf in humans. It "has the ability to persist in the human population, potentially with more severe clinical consequences," they wrote.
Both studies were published online by the journal Science on 2 Jul 2009. The article from Erasmus can be accessed at http://www.sciencemag.org/cgi/content/abstract/1177127. The MIT and CDC study is available at http://www.sciencemag.org/cgi/content/abstract/1177238.
UK: Health officials warn pandemic H1N1 influenza cases could exceed 100,000 per day by August
Health ministers warn new cases of pandemic flu could top more than 100,000 a day by the end of August, as they admitted they can no longer contain the spread of the virus. Patients with suspected symptoms will now be told to stay at home and telephone their family doctor for a diagnosis, as part of a major step change in the handling of the pandemic, in an effort to limit the spread of the infection. Anti-viral drugs will also no longer be given as a precaution to people who may have come in contact with the infection.
Andy Burnham, the Health Secretary, said that an almost doubling of cases since 26 Jun 2009 prompted the Government to move to the third and final "treatment" stage of dealing with the outbreak.
Indonesia: Authorities watchful after avian influenza H5N1 virus was detected in 20 villages
At least 20 villages in Purbalingga regency, Central Java, have been hit with cases of bird flu, forcing local authorities to remain alert to prevent it from infecting other areas, officials said on 25 Jun 2009. Purbalingga husbandry office head Hartono said the disease was first been detected in the regency in January 2009.
More than 1000 infected chickens had been culled between January and May 2009 by local authorities, he said. "We are continuing to collect data based on information from local people whose chickens have died suddenly. The tests on those birds have come back positive for bird flu," he said. The chickens were culled, and their bodies incinerated, he added. Hartono said most of the virus-infected poultry were domestic chickens that were not kept in cages. "Because local villagers traditionally have chickens roaming free, not kept in cages, bird flu has spread very quickly," he said. To curb the virus from spreading further in Purbalingga, the local authorities have set up a special team to combat bird flu."The team is already working 24 hours a day. Any time we receive a report on a dead chicken we will go to the location immediately," Hartono said. The dead chickens, he said, would be used as samples for tests.
Purbalingga has also received 240,000 doses of vaccine from the World Health Organization to help control the spread of bird flu, Hartono said. "Around 30 percent of the vaccines have already been used." The WHO has also provided Purbalingga with anti-bird flu disinfectants. "We have enough medical stocks to deal with bird flu cases. What we need to do more is improve people's awareness so they will keep their poultry cages clean," Hartono said.
Indonesia: Announces it will ask foreign visitors to wear masks to guard against pandemic H1N1
Saudi Arabia: Health officials ask groups at high risk for pandemic influenza H1N1 to skip hajj
Argentina: Novel influenza A/H1N1 in pigs reported
Argentina has reported an outbreak of influenza A/H1N1 in a commercial pig farm in the Buenos Aires region. The authorities have qualified this outbreak as "a new emerging disease" in the report. Introduction of the infection was attributed to human to animal transmission from workers at the farm who showed flu signs between 7 and 9 Jun 2009. According to the report, the farm was restocked from their own restocking system in July 2008. The infected pigs showed clinical signs up to 24 Jun 2009 and have now recovered. The report states that in a total population of over 5500 pigs (mixed ages) there was 30 percent morbidity but no mortality. (References removed.)
Full report available at http://www.defra.gov.uk/animalh/diseases/monitoring/pdf/h1n1-argentina-090626.pdf.
Argentina: Health minister resigns over handling of novel influenza H1N1 cases
In recent days Argentina has reported a disproportionate number of deaths from H1N1 compared to the United States and other countries, a spokesman for the health ministry said. Argentina has reported 26 deaths out of 1,587 infections, or a death rate of 1.6 percent. As a result, Buenos Aires along with five other provinces have declared health emergencies extending school vacations and giving the mayor the power to suspend sports and other entertainment gatherings.
USA: CDC estimates over 1 million Americans infect with pandemic H1N1
Only a tiny fraction of those million cases have been tested, Dr. Schuchat said. The estimate is based on testing plus telephone surveys in New York City and several other locales where the new flu has hit hard. A survey in New York City, she said, showed that almost 7 percent of those called had had flu symptoms during just three weeks in May when the flu was spreading rapidly through schools. If that percentage of the city has had it, then there have been more than 500,000 cases in the city alone, though most have been mild enough that doctors recommended nothing more than rest and fluids.
The flu has now spread to many areas of the country, Dr. Schuchat noted, and the CDC has heard of outbreaks in 34 summer camps in 16 states. About 3,000 Americans have been hospitalized, she said, and their median age is quite young, just 19.
The median age for deaths is somewhat higher, at 37, but that number is pushed up because while only a few elderly people catch the new flu, about 2 percent of them die as a result. Of those who die, Dr. Schuchat said, about three-quarters have some underlying condition like morbid obesity, pregnancy, asthma, diabetes or immune system problems. Even those victims, she said, “tend to be relatively young, and I don’t think that they were thinking of themselves as ready to die.”
The new flu has now reached more than 100 countries, according to the World Health Organization. The world’s eyes are on the Southern Hemisphere, which is at the beginning of its winter, when flu spreads more rapidly. Australia, Chile and Argentina are seeing a fast spread of the virus, mostly among young people, while one of the usual seasonal flus, an H3N2, is also active.
Five American vaccine companies are working on a pandemic H1N1 vaccine, Dr. Schuchat said. The CDC has estimated that once the new vaccine is tested for both safety and effectiveness, no more than 60 million doses will be available by September 2009. That means difficult decisions will have to be made about whom to give it to first.
Egypt: 79th-81st human cases of avian influenza H5N1 reported confirmed by the WHO
The Ministry of Health of Egypt has reported three new confirmed human cases of avian influenza A(H5N1). Investigations into the source of infection indicated that all three cases had close contact with dead and/or sick poultry.
The first case is a one year old boy from Domiat Governorate. His symptoms started on 1 Jun 2009. He was admitted to hospital on 2 Jun 2009, where he received oseltamivir treatment. The patient has recovered and was discharged on 9 Jun 2009.
The second case is a 4 year old girl from Dakhlia Governorate. Her symptoms started on 5 Jun 2009. She was admitted to hospital on 6 Jun 2009, where she received oseltamivir treatment. The patient has recovered and was discharged on 14 Jun 2009.
The 3rd case is a one year old boy from Kaleen District, Kefr El Sheikh Governorate. His symptoms started on 15 Jun 2009. He was admitted to Kefr El Sheikh Fever Hospital on 16 Jun 2009, where he received oseltamivir treatment and is in a stable condition.
The following websites provide the most current information and advice.
- North America
- Other useful sources
Pandemic Vaccine Preparedness—Have We Left Something Behind?
Capua I et al. PLoS Path. 26 Jun 2009. Available at http://www.plospathogens.org/article/info%3Adoi%2F10.1371%2Fjournal.ppat.1000482.
“Prepandemic” Immunization for Novel Influenza Viruses, “Swine Flu” Vaccine, Guillain-Barré Syndrome, and the Detection of Rare Severe Adverse Events
The availability of immunogenic, licensed H5N1 vaccines and the anticipated development of vaccines against “swine” influenza A(H1N1) have stimulated debate about the possible use of these vaccines for protection of those exposed to potential pandemic influenza viruses and for immunization or “priming” of populations in the so‐called “prepandemic” (interpandemic) era. However, the safety of such vaccines is a critical issue in policy development for wide‐scale application of vaccines in the interpandemic period. For example, wide‐scale interpandemic use of H5N1 vaccines could lead to millions of persons receiving vaccines of uncertain efficacy potentially associated with rare severe adverse events and against a virus that may not cause a pandemic. Here, we first review aspects of the 1976 National Influenza Immunization Programme against “swine flu” and its well‐documented association with Guillain‐Barré syndrome as a case study illustration of a suspected vaccine‐associated severe adverse event in a mass interpandemic immunization setting. This case study is especially timely, given the recent spread of a novel influenza A(H1N1) virus in humans in Mexico and beyond. Following this, we examine available safety data from clinical trials of H5N1 vaccines and briefly discuss how vaccine safety could be monitored in a postmarketing surveillance setting.
The Persistent Legacy of the 1918 Influenza Virus
Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza
Methods From March 24 to April 29, 2009, a total of 2155 cases of severe pneumonia, involving 821 hospitalizations and 100 deaths, were reported to the Mexican Ministry of Health. During this period, of the 8817 nasopharyngeal specimens that were submitted to the National Epidemiological Reference Laboratory, 2582 were positive for S-OIV. We compared the age distribution of patients who were reported to have severe pneumonia with that during recent influenza epidemics to document an age shift in rates of death and illness.
Results During the study period, 87% of deaths and 71% of cases of severe pneumonia involved patients between the ages of 5 and 59 years, as compared with average rates of 17% and 32%, respectively, in that age group during the referent periods. Features of this epidemic were similar to those of past influenza pandemics in that circulation of the new influenza virus was associated with an off-season wave of disease affecting a younger population.
Conclusions During the early phase of this influenza pandemic, there was a sudden increase in the rate of severe pneumonia and a shift in the age distribution of patients with such illness, which was reminiscent of past pandemics and suggested relative protection for persons who were exposed to H1N1 strains during childhood before the 1957 pandemic. If resources or vaccine supplies are limited, these findings suggest a rationale for focusing prevention efforts on younger populations.
Pneumonia and Respiratory Failure from Swine-Origin Influenza A (H1N1) in Mexico
Methods We used retrospective medical chart reviews to collect data on the hospitalized patients. S-OIV infection was confirmed in specimens with the use of a real-time reverse-transcriptase–polymerase-chain-reaction assay.
Results From March 24 through April 24, 2009, a total of 18 cases of pneumonia and confirmed S-OIV infection were identified among 98 patients hospitalized for acute respiratory illness at the National Institute of Respiratory Diseases in Mexico City. More than half of the 18 case patients were between 13 and 47 years of age, and only 8 had preexisting medical conditions. For 16 of the 18 patients, this was the first hospitalization for their illness; the other 2 patients were referred from other hospitals. All patients had fever, cough, dyspnea or respiratory distress, increased serum lactate dehydrogenase levels, and bilateral patchy pneumonia. Other common findings were an increased creatine kinase level (in 62% of patients) and lymphopenia (in 61%). Twelve patients required mechanical ventilation, and seven died. Within 7 days after contact with the initial case patients, a mild or moderate influenza-like illness developed in 22 health care workers; they were treated with oseltamivir, and none were hospitalized.
Conclusions S-OIV infection can cause severe illness, the acute respiratory distress syndrome, and death in previously healthy persons who are young to middle-aged. None of the secondary infections among health care workers were severe.
Historical Perspective--Emergence of Influenza A (H1N1) Viruses
On April 17, 2009, officials at the Centers for Disease Control and Prevention (CDC) confirmed two cases of swine influenza in children living in neighboring counties in California. Here we take a perspective from systems biology to review the series of evolutionary and epidemiologic events, starting in 1918, that led to the emergence of the current swine-origin influenza A (H1N1) strain (S-OIV), which is widely known as swine flu. This article is one of two historical articles on influenza A (H1N1) viruses in this issue of the Journal. Our review focuses on the key steps that characterize this viral evolution. (Excerpt with references removed.)
Spread of a Novel Influenza A (H1N1) Virus via Global Airline Transportation
National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza
American College of Emergency Physicians document available at http://www.acep.org/WorkArea/DownloadAsset.aspx?id=45781.
Weekly Epidemiological Record Bulletin
US CDC and FDA Emergency Use Authorization Course
Now available online at http://emergency.cdc.gov/training/eua/index.html.
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.
To register, go to http://mail.elsevier-alerts.com/go.asp?/bELA001/qUQEAS8/x8BATS8