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Vol. XII, No. 15 ~ EINet News Briefs ~ Jul 24, 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 APEC update of pandemic influenza (H1N1) 2009
- Cumulative number of human cases of avian influenza A/(H5N1)
- Global: WHO offices issue pandemic H1N1 influenza surveillance updates
- Global: Southern hemisphere sees H3N2 seasonal influenza variant threatening vaccine mismatch
- Global: VACCINE UPDATE—Trials aim to inform mass vaccination programs for pandemic H1N1 influenza
- Global: VACCINE UPDATE—WHO recommends use of adjuvants to maximize global pandemic H1N1 influenza vaccine resources
- Global: VACCINE UPDATE—Predictions that it may take much longer to produce adequate amounts of pandemic influenza H1N1 vaccine
- UK: Commercial pig farm worker in Britain contracts pandemic H1N1 influenza
- UK: Pandemic advice sows confusion among pregnant women
- China (Hunan): CORRECTION—27th human avian influenza H5N1 infection reported on 15 Jul 2009 was in error
- Argentina: Government declares health emergency, pandemic H1N1 influenza found in pigs
- Canada (Alberta): Inspectors caught pandemic H1N1 influenza while investigating pig farm outbreak
- USA: Malicious software poses as pandemic influenza H1N1 update from CDC
- USA (Washington): Seattle volunteers sought to test pandemic H1N1 influenza vaccine

2. Infectious Disease News
- China (Shandong): 2009 outbreak of hand, foot and mouth disease continues
- New Zealand: Measles outbreak raises question of faulty vaccine
- South Korea: Hundreds contract skin disease at mud festival
- USA (Maine): Year on year increase in Lyme disease in both 2007 and 2008
- USA (Tennessee): 2009 sees spike of Rocky Mountain spotted fever

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- DENGUE

4. Articles
- Neurologic Complications Associated with Novel Influenza A (H1N1) Virus Infection in Children--Dallas, Texas, May 2009
- Investigation of the first cases of human-to-human infection with the new swine-origin influenza A (H1N1) virus in Canada
- Pandemic influenza preparedness in Latin America: analysis of national strategic plans

5. Notifications
- WHO revises its reporting requirement for pandemic H1N1 virus infection
- US CDC’s Questions & Answers: Novel H1N1 Influenza Vaccine
- European CDC’s Interim Risk Assessment for pandemic H1N1 influenza
- Business continuity training exercise available online
- Weekly Epidemiological Record Bulletin
- International Swine Flu Conference

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

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1. Influenza News

Global
Weekly APEC update of pandemic influenza (H1N1) 2009
Singapore reports three deaths due to pandemic H1N1 influenza infection. All of the cases had pre-existing illnesses. Canada reports a decline in influenza like illness during the week of 13 Jul 2009, suggesting possible reduction in community transmission. Canada reports its first case of oseltamivir (Tamiflu) resistance; the patient was a 60-year-old man whose infection was treated with antivirals. Japan also reports its second case of antiviral resistance; the patient had no ties to the first reported case.
(CIDRAP 7/20/09; ProMED 7/22/09)

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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/ 41 (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: 436 (262).
(WHO 7/1/09 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 6/30/09)

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 offices issue pandemic H1N1 influenza surveillance updates
The World Health Organization (WHO) recently posted surveillance and status updates for regions where the pandemic H1N1 is just gaining a foothold, including the Mideast, Africa, and parts of Asia and the Pacific, which showed Southeast Asia as the hardest hit of those areas.

Most public health experts say the number of lab-confirmed H1N1 cases greatly underestimates the true burden of the disease, and the WHO on 16 Jul 2009 discontinued its global case counts, saying the updates were becoming less useful as a surveillance tool and that reporting all of the confirmed cases was placing a great burden on countries experiencing widespread transmission. However, it said it would provide regular updates on the spread of pandemic flu in newly affected countries.

In the Mideastern locations included in the WHO's Eastern Mediterranean region, 890 lab-confirmed cases have so far been reported in 19 countries, according to an update posted on 22 Jul 2009 on the WHO's regional Web site. The WHO said 257 cases were locally transmitted. Egypt is the only country in the region that has reported a death from the novel H1N1 virus. Saudi Arabia has the most cases in the Mideast, 232, followed by Egypt with 157, Lebanon with 79, and Palestine with 78. The only countries in the region that have not reported a confirmed case so far are Pakistan and Somalia.

Meanwhile, 12 of the 46 countries included in the WHO's Africa region have reported 174 lab-confirmed cases with no deaths, the WHO reported on 21 Jul 2009. South Africa has reported the most cases, 119, followed by Kenya with 22. The WHO said it has activated regional and subregional crisis management teams and that stockpiles of pandemic medications have been dispatched to all of the countries.

In Southeast Asia, 5,684 lab-confirmed novel H1N1 cases have been reported in 7 of 11 countries included in the WHO's Southeast Asia region, according to a 20 Jul 2009 update. Thailand leads with 5,120 cases, followed by India (308) and Indonesia (172). All of the region's deaths have been reported from Thailand, which has linked 32 fatalities to the virus. So far, four countries in the region have not reported any confirmed cases: Bhutan, North Korea, Maldives, and Timor-Leste.

Meanwhile, the WHO's Western Pacific regional office said on Jul 21 that the pandemic H1N1 influenza is now dominant in Singapore and Taiwan. Health officials in Taiwan report the novel H1N1 now accounts for 88% of all circulating flu strains, and officials in Singapore report that the new virus makes up 53% of all reported flu cases. Two of the 37 jurisdictions covered in the WHO's Western Pacific region have reported their first novel H1N1–related deaths: Guam and Tonga. Fifty-five deaths from the virus have been reported from the region, most of which are from Australia.

In related news, the WHO warned yesterday that the pandemic H1N1 virus is a threat to patients with immunosuppressive diseases such as HIV/AIDS, which it said is a particular concern for Western Pacific countries, in which people suffering from the diseases have less access to antiretroviral therapy than those in other parts of the world. The WHO recommended that country pandemic preparedness plans address the needs of people living with HIV/AIDS.
(CIDRAP 7/23/09)

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Global: Southern hemisphere sees H3N2 seasonal influenza variant threatening vaccine mismatch
Laboratory experts in the southern hemisphere are reporting the circulation of a drifted strain of the seasonal H3N2 flu virus, raising the threat of a vaccine mismatch for the northern hemisphere's upcoming flu season, the Canadian Press reported 23 Jul 2009. Officials, overwhelmed by handling a deluge of pandemic H1N1 samples, are not sure how common the variant is. The new variant has been seen on a number of continents, though it still remains a minority member of the H3N2 family, according to experts at the World Health Organization and the U.S. Centers for Disease Control. It was first identified in March 2009 by researchers in British Columbia, Canada.
(CIDRAP 7/23/09; Canadian Press 7/23/09)

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Global: VACCINE UPDATE—Trials aim to inform mass vaccination programs for pandemic H1N1 influenza
A flurry of innovative vaccine trials is in the offering as governments and regulatory agencies prepare for the probable launch of mass pandemic H1N1 2009 influenza vaccination programs in the fall of 2009.

The results of the trials could determine whether people with egg allergies can be offered pandemic (and seasonal) flu vaccine, whether pandemic and seasonal flu shots could be given at the same time and whether one company's vaccine can be given with another's adjuvant, a compound that boosts its potency. Vaccine manufacturers are either unable or unlikely to undertake the complicated studies required to answer these questions. Governments will fund the work instead.

Infectious diseases expert Dr. Anthony Fauci says the goal for organizations like the US National Institute of Allergy and Infectious Diseases--which he heads--is to fill key knowledge gaps for vaccine regulators.

Some of those priorities will be aired on 23 Jul 2009 when the U.S. Food and Drug Administration's vaccine and related biological products advisory committee meets in a session on clinical trials for pandemic vaccines. Vaccine manufacturers will do the basic testing, work designed to assure regulators and would-be recipients that their vaccine is safe and likely to protect against the pandemic strain, an H1N1 virus of undetermined origin.

But there are many other key questions. In fact, the list is too long to tackle in its entirety in the limited time available. So discussions between planners and regulators over the past few weeks have led to a paring down of priorities. In the case of the US, it is not yet clear which studies have survived the cut. However, Fauci says his institute will green-light one looking at whether the pandemic vaccine -- to protect against the new H1N1 virus -- could be given at the same time as seasonal flu vaccine, which protects against three types of flu viruses including a different H1N1.

Co-administration, as it is called, would make the logistics of pandemic vaccine delivery much easier, if the pandemic vaccine is ready in time. But would giving people vaccines that protect against two different H1N1 viruses at once actually undermine the effort by weakening the response to one or both? "As an immunologist, I don't think you're going to have any trouble with that. But you don't know," Fauci explains. "Would presenting two different H1N1 antigens to the body at the same time result in antigenic competition? On the other hand, we could be surprised, and giving them together might enhance the response to both."

In Canada, plans are underway to try to test whether people with egg allergies could be given flu shots containing vaccine produced in eggs. Currently, that is considered unsafe and is not done. With some manufacturers moving to grow their vaccine viruses in cell culture, that may be less of a problem in the future. But for now, egg-based production still generates most of the global flu vaccine output. Canada's entire supply will be egg-based vaccine. Dr. Scott Halperin, a vaccinologist from Dalhousie University in Halifax, says a newly formed, federally funded research network hopes to get ethics approval to test the assumption it is unsafe to give people with egg allergies flu shots. The goal will be "to basically look at what is the real risk and to immunize individuals under very carefully controlled (circumstances)," says Halperin, principal investigator of the Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network. "That is a real concern," he says of the current position on people with egg allergies. "You can't leave a whole segment of the population without access to protection."

Meanwhile, two Australian pharmaceutical companies said they began human trials of their pandemic H1N1 vaccines. CSL, based in Melbourne, said it hoped that results will allow release of the government-contracted vaccine in October 2009, and Vaxine said it hoped to have results in 6 to 8 weeks. In addition, reportedly two Chinese companies said they launched clinical trials of novel H1N1 vaccines. They are Hualan Biological Engineering and Sinovac.
(ProMED 7/20/09)

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Global: VACCINE UPDATE—WHO recommends use of adjuvants to maximize global pandemic H1N1 influenza vaccine resources
Imminent decisions on a strategy for H1N1 pandemic flu vaccination in the United States (US) could leave other countries short of vital doses if it elects not to follow World Health Organization (WHO) advice on vaccine formulation. The US is the biggest buyer among a group of rich countries whose combined orders for vaccine against the H1N1 2009 virus could potentially tie up most of the world's pandemic vaccine production capacity for six months or longer, depriving other countries of vaccine.

To counter this prospect, the WHO recommended on 13 Jul 2009 that countries use shots that contain adjuvants, chemicals that boost the immune system's response to a vaccine. This allows smaller amounts of antigen -- the molecule that stimulates the immune response -- be used in each dose, boosting the overall amount of vaccine available from existing production capacity and allowing orders to be filled more quickly.

The US's global responsibility to consider dose-sparing strategies is briefly alluded to in the minutes of a mid-June 2009 US National Bio defense Science Board meeting, released on 17 Jul 2009: "Federal decision-making will affect not only the 300 million Americans who depend on the government to support the public health system but also people all around the world."

The US has certainly kept open the option of using adjuvants. It has already allocated almost USD 2 billion for antigen and adjuvant to provide every American with up to two doses of vaccine. That sum includes orders of USD 483 million for Novartis's MF59 adjuvant, and USD 215 million for GlaxoSmithKline's AS03 adjuvant.

But although Canada and many European countries are set to use adjuvanted pandemic flu vaccines, the US may do so only as a last resort. "All things being equal, an unadjuvanted vaccine is often just fine in terms of giving protection against influenza virus," Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, stated on 17 Jul 2009.

"Adjuvant use would be contingent upon showing that it was needed or clearly beneficial," added Jesse Goodman, acting chief scientist and deputy commissioner of the US Food and Drug Administration (FDA). "But we want them on the table in case there are issues where they might be needed to protect people in this country." If there is significant genetic drift in the virus, for example, adjuvanted vaccines are better able to handle such strain variations. And early attempts at pandemic vaccine manufacture are so far producing 2 to 4 times less antigen than seasonal flu strains, raising the threat that the world's production capacity is actually much less than was hoped.

If each shot of pandemic flu vaccine contains 15 micrograms of antigen -- the dose used in seasonal flu -- and no adjuvant, annual global capacity stands at about 876 million doses, according to the WHO. But as virtually no one is immune to the virus, most experts say that each person will need two doses, immediately halving that capacity. Moreover, higher doses of antigen may be needed to get an adequate response, further reducing capacity. Using adjuvants would boost annual capacity to more than 2 billion doses in some WHO projections.

Europe is well placed to quickly authorize adjuvanted pandemic vaccines. Since 2003, the European Medicines Agency (EMEA) has had a fast-track approval system in which manufacturers can prepare "mock-up dossiers," vaccine registration applications that use non-pandemic viral strains but for which pandemic strains can subsequently be substituted. GlaxoSmithKline and Novartis already have mock-up dossiers in place for the H5N1 avian flu virus and plan to file H1N1 substitutions by the end of July 2009.

Although the EMEA requires the companies to provide new clinical testing and data as they roll out their products, the product itself can be approved in five days if the agency is satisfied that the extrapolation to the new strain is valid, says Martin Harvey- Allchurch, a spokesman for the EMEA. In contrast, the US has never licensed an adjuvanted flu vaccine and has no fast-track system in place, although the FDA can give emergency authorization for new vaccines. The regulators are also mindful of political and public concerns about mass vaccination of the population, given that a vaccination program in 1976 against a new strain of swine flu caused neurological side effects in about one in 100,000 people and killed 25. Modern flu vaccines, however, have a very good safety record.

The WHO's Global Advisory Committee on Vaccine Safety says "no significant safety concern or barriers" exist to using adjuvanted pandemic H1N1 vaccines. But regulatory agencies may have to approve pandemic vaccines -- both adjuvanted and non-adjuvanted -- without all the data they would normally require, warns Marie-Paule Kieny, the WHO's vaccine research director. Some preliminary clinical and safety data may be available by September 2009, when flu cases could surge in the Northern Hemisphere, but complete data for adults are unlikely to be available until the end of December 2009, and not until February 2010 for children. Regulators would accompany pandemic vaccine rollouts with parallel clinical trials, and, as in any mass-vaccination campaign, extensive surveillance would monitor for any adverse side effects.
(ProMED 7/22/09; CIDRAP 7/22/09)

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Global: VACCINE UPDATE—Predictions that it may take much longer to produce adequate amounts of pandemic influenza H1N1 vaccine
It may take substantially longer to make the full amounts of pandemic H1N1 influenza H1N1 vaccine countries have contracted to buy because efforts to improve the yield of the vaccine seed strains are not working, experts say. Three of the laboratories involved in the work are sounding increasingly pessimistic that the yield problem can be fixed in the short term. Vaccine manufacturers have reported they are getting between 50 percent and 75 percent less vaccine with the new H1N1 virus as they do when they make seasonal flu vaccine. "It's not looking very bright at the moment," John Wood, principal scientist at Britain's National Institute for Biological Standards and Control, said on 21 Jul 2009.

The flu laboratories at the U.S. Centers for Disease Control (CDC) have made three new seed strains and are in the process of completing the paperwork needed to ship them to the manufacturers. The head of the CDC's influenza division said while the new vaccine candidate viruses are growing well in the hands of her scientists, there's no guarantee they will produce a better yield when manufacturers start to work with them. Dr. Nancy Cox said the issue isn't simply about growth, but also about how well the vaccine viruses hold up during the various steps of the manufacturing process. "I think it is possible we won't have a better yielding virus," she admitted. "(But) I think that it's still too early to say how this will impact the amount of vaccine that's available."

Each flu virus has its own characteristics, and vaccine makers are accustomed to working with new strains, fine-tuning processes to try to coax maximum yield from a virus. A spokesperson for Sanofi Pasteur said the company feels it hasn't yet exhausted efforts to improve the yield of the seed strain for the pandemic vaccine. Still, Len Lavenda suggested Sanofi doesn't expect those efforts to fully correct the problem. "Although we think it's too soon to project what the final yield will be, we anticipate it will remain lower than seasonal vaccine yield," Lavenda said. "Certainly if the yield doesn't increase, it means it will take longer to produce the vaccine. (But) I think at this point in time we remain hopeful that we'll be able to increase the yield."

The various companies making pandemic vaccine have been working with a seed strain produced at New York Medical College in NY. Its laboratory pioneered the process of engineering vaccine viruses to maximize growth decades ago, and scientists there have produced many of the vaccine seed strains used since. Its first pandemic H1N1 flu seed strain was overwhelmingly viewed as the best yielder by vaccine manufacturers. But even at that, manufacturers said they got about half of the yield generated with seasonal flu production. Doris Bucher, who heads the lab, says her team is trying other options, but they haven't seen anything promising yet.
(ProMED 7/22/09)

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Europe/Near East
UK: Commercial pig farm worker in Britain contracts pandemic H1N1 influenza
The first case of a pig farm worker contracting the influenza pandemic (H1N1) 2009 virus was reported. The stockman from the South West worked on a commercial pig farm. Other staff and pigs on the farm are free of the H1N1 virus.

Veterinary experts are working with the pig industry to agree a code of practice should pig herds become infected with the flu strain. There is no threat to human health if people eat pork, bacon and ham from a pig that has recovered from the novel flu, provided that the meat is cooked properly.

Any pig contracting flu is to be quarantined and cannot be slaughtered for the food chain unless the animal has been free of flu symptoms for seven days. Veterinary checks will also take place at the abattoir where any sick animals will be rejected. There are no plans to cull pigs with pandemic H1N1, but it is known that flu strains can easily pass between pigs and human beings as well as from pig to pig.
(ProMED 7/18/09)

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UK: Pandemic advice sows confusion among pregnant women
Messages from two health groups in Britain on 19 Jul 2009 caused confusion about the dangers posed by the novel H1N1virus to women who are pregnant or may become pregnant, according to a TimesOnline report. The Royal College of Midwives said pregnant women should not use public transport, while the National Childbirth Trust suggested that women delay pregnancy until the pandemic ends. Government health officials described the groups' advice as extreme and said their advice to women had not changed.
(CIDRAP 7/20/09)

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Asia
China (Hunan): CORRECTION—27th human avian influenza H5N1 infection reported on 15 Jul 2009 was in error
Referenced report from 17 July 2009 flu alert refers to cases confirmed by the WHO in February 2008. EINet regrets the error.

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Americas
Argentina: Government declares health emergency, pandemic H1N1 influenza found in pigs
The government declared a nationwide animal health emergency following the discovery of the new H1N1 flu virus in at least one pig herd. The flu strain has killed 137 people in the South American country during the Southern Hemisphere 2009 winter and the government has closed schools and urged Argentines to avoid crowded places to halt its spread.

"The contingency plan . . . allows for an increase in testing in pig farms and in slaughter houses in order to guarantee early detection," the government's Official Gazette said. The emergency measure, which will also give officials extra funding to deal with the outbreak, was drawn up by the state-run SENASA agency, responsible for animal health and food safety.
(ProMED 7/18/09)

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Canada (Alberta): Inspectors caught pandemic H1N1 influenza while investigating pig farm outbreak
Two Canadian Food Inspection Agency (CFIA) inspectors appear to have contracted pandemic H1N1 influenza while investigating an outbreak of the new virus in pigs on an Alberta farm in late April 2009, the agency confirmed on 21 Jul 2009. The cases appear to be the first reports of people catching the novel H1N1 virus from pigs.

The agency said that it's impossible to say with 100 percent certainty that the inspectors were infected by the animals. But the infections took place in the early days of the new H1N1 outbreak, when few cases were being reported in Canada. It is known that the men did not use proper safety techniques while in the barn, apparently removing the N-95 respirators that covered their noses and mouths because they were hot. "We conducted a review of the situation and determined that CFIA protocols for personal protection were not fully observed in this case," the agency said.

The agency said it doesn't intend to change protocols for conducting this type of investigation because its existing protocols, if complied with, would have been adequate to protect the workers. "Supervisors are being asked to ensure inspection staff have received the appropriate training and understand the procedures before being assigned to the investigation."

The Alberta pig farm incident was the first report of this new virus being found in pigs. The source of the infection in the pigs remains a mystery. Officials at first identified a carpenter who worked briefly on the farm while ill with flu-like symptoms as being the source of the infection. But the man, who had recently returned from a trip to Mexico, was later told tests showed he was never infected with the new virus. There were reports that members of the farm family were also sick shortly before the pigs started showing symptoms. But samples taken from them were not adequate to confirm or dismiss them as possible sources of the infection. Officials now admit they will likely never know how the virus was introduced into the herd.

Influenza experts are not surprised the virus can infect pigs and pass back from them to people. But they worry that if this type of ping-ponging occurs, it will allow the viruses to mutate. It is impossible to predict what the outcome of that type of evolution would be, but it could undermine the effectiveness of the pandemic H1N1 flu vaccine currently being developed for people.

Earl Brown, an expert in influenza virus evolution, called the trend toward increasing interspecies transmission of flu viruses "disquieting." "When it was in Alberta, you had this virus of swine origin . . .and then you had the question: Well, is it now a human flu or is it a swine flu? And it's clear that it's both," said Brown, a virologist at the University of Ottawa. He said there has been rapid evolution of flu viruses in pigs in recent years, as well as cases of avian influenza viruses, including the dangerous H5N1 virus, jumping into people.

In the influenza world, pigs are described as the mixing vessel, because they can be infected with both bird viruses and human viruses -- giving rise to hybrids that they can pass back to people. "You just don't want the pig to be the conduit for all these adapted viruses they've got from birds," Brown said. "I think the general trend is not good but this particular virus, you know it's still an open book at to whether it's going to tone down, or it's going to become more like a seasonal flu fast, or if it's going to ramp up. We really can't predict and we're just watching and trying to read the numbers."
(ProMED 7/23/09)

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USA: Malicious software poses as pandemic influenza H1N1 update from CDC
A piece of malicious computer software that's disguised as H1N1 information from the US Centers for Disease Control and Prevention (CDC) is circulating, according to the Internet security firm F-Secure. The file, called Novel H1N1 Flu Situation Update.exe, has an icon that makes it look like a Microsoft Word document. When opened, the file creates several new files that contain "backdoor functionality" and a key logger, or program that records keystrokes.
(CIDRAP 7/21/09)

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USA (Washington): Seattle volunteers sought to test pandemic H1N1 influenza vaccine
Seattle will be one of eight U.S. cities to test a new vaccine for pandemic H1N1 influenza in August 2009, just ahead of the anticipated fall return of a novel virus that triggered a global pandemic alert in the spring 2009.

Group Health Cooperative will recruit hundreds of volunteers to test whether the vaccine will protect against H1N1 virus. The Seattle health co-op will join research centers in seven other cities in fast-track clinical trials directed by the National Institutes of Health.

Some health experts fear the virus may return to the Northern Hemisphere in a more virulent or more contagious form. And because most people have no natural immunity against it, an effective vaccine is considered the best defense. Even if the clinical trials show the H1N1 vaccine to be safe and effective, health experts don't know yet if it can be manufactured quickly enough to inoculate everyone in high-risk groups, including school-age children.

Group Health expects to get the test vaccines the first week of August 2009 and to begin giving shots to volunteers the next week, said Dr. Lisa Jackson, a senior scientist with Group Health Center for Health Studies. Would-be subjects must be 18 or older and in generally good health. They would need to make five visits to Group Health's research clinics in Seattle over six weeks. All would get pandemic two H1N1 flu shots three weeks apart, and have their blood drawn to measure their antibodies to the virus.

If the vaccine appears safe initially, the trials would expand to include children 6 months to 17 years old. The other test sites are Baltimore, Iowa City, St. Louis, Atlanta, Cincinnati and Houston and Nashville, Tenn. In all, thousands of volunteers will be enrolled nationwide. In return, they would be the first to "get a vaccine you can't otherwise get," said Jackson.

Jackson said the tight timeline for testing the pandemic H1N1 flu vaccine should not be a big safety concern because this vaccine is not wholly different from other flu vaccines. Researchers will track any unexpected side effects, including allergic reactions, fever or swelling.

With seasonal flu, developing effective vaccines can sometimes be hit or miss because the virus mutates from year to year. Jackson thinks the pandemic flu vaccine could be very well matched to the H1N1 virus now circulating, albeit in much weaker form, in the Southern Hemisphere. The bigger challenge, she said, is figuring out the exact vaccine strength needed to trigger sufficient immune response. Getting the minimum dosage right is important in order to distribute the vaccine to the greatest numbers of people around the world.

President Obama has warned Americans to brace for an aggressive return of the pandemic H1N1 flu virus. The administration is preparing for public vaccinations to begin in October 2009. Unlike seasonal flu, which is most dangerous to the elderly and infants, H1N1 has hit more students and young adults. Six people in Washington State died from complications of pandemic H1N1 influenza, but most who got it suffered only mild illnesses.

Public-health officials — who each fall try but fail to prod enough Americans to get vaccinated for seasonal flu — are waiting to see if people will clamor for pandemic influenza shots. Tim Church, a spokesman for the Washington State Department of Health, said the state usually has a surplus of seasonal-flu vaccine each year. One exception was in 2004, when the shutdown of a vaccine factory cut supplies to the United States by half. The shortage caused a panicked run on flu shots, with some desperate patients even traveling to Canada, Church said. "It was like a rock concert to get flu shots," Church said. "When they can't get something, there is more interest in getting it."
(The Seattle Times, 7/23/09)

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2. Infectious Disease News

Asia
China (Shandong): 2009 outbreak of hand, foot and mouth disease continues
Another child died of hand, foot and mouth disease (HFMD) in eastern China's Shandong Province, bringing the toll from the 2009 outbreak to 44 in the worst-affected province, provincial health authorities said on 7 Jul 2009.

The new death occurred in the week from 29 Jun to 5 Jul 2009, during which the province reported 6919 new HFMD cases. Of those cases, 2944 required hospitalization, and 245 were serious. The local health authorities said that from 1 Jan to 5 Jul 2009, Shandong reported 85,301 HFMD cases. So far, 78,831 patients have recovered. Hospitals in the province were ordered to reserve enough beds and other resources to prepare for a massive outbreak, and public awareness campaigns are in progress.

HFMD is a common illness that mainly affects children under the age of 10 years. It usually starts with a slight fever followed by blisters and ulcers in the mouth and rashes on the hands and feet. It is spread through contact with the saliva or feces of the infected. There is no vaccine or specific treatment, but most children affected by the disease recover quickly. May and July are peak periods for the disease.
(ProMED 7/10/09)

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New Zealand: Measles outbreak raises question of faulty vaccine
Health authorities in Christchurch are trying to trace a measles vaccine to find out whether it was faulty, after six people who had been immunized caught the disease. The Canterbury District Health Board has so far identified 16 confirmed and 10 probable cases of measles. Most occurred in youth aged between 11 to 16 years old who had not been vaccinated, although six of the cases had been.

Medical Officer of Health Dr Cheryl Brunton says the situation is a concern, and the district health board is working to identify what vaccine the sufferers were given. She says it is possible there was a problem with a particular batch, or that some vaccine was not handled properly. Dr Brunton is urging Canterbury parents with young babies to get themselves immunized against measles, as the illness is highly contagious. Young babies are a particular concern because they cannot have their first vaccination until they are 15 months old, and if they are exposed to measles, they are at risk of complications. Dr Brunton says the best protection is for people around them to be immunized.
(ProMED 7/12/09, 7/14/09)

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South Korea: Hundreds contract skin disease at mud festival
Hundreds of people were taken to hospital after contracting a skin disease during lead up events for the Boryeong Mud Festival in South Korea. Some 200 out of 1500 participants suffered skin inflammations after undergoing mud baths. In one case, 50 students of a grade school complained of dermatitis symptoms. A number foreign tourists, including American soldiers, also suffered from dermatitis.

The Boryeong Mud Festival, on the banks of Daecheon Stream, has become an international event, attracting visitors from throughout the world. Town officials discovered that the mud is more lucrative as a tourist attraction than using the muddy fields for agriculture. As a result they set up mud baths, mud slides and competitions including mud wrestling and escaping a mud prison. The economy generated from the festival supports hotels and restaurants along the waterway.
(ProMED 7/14/09)

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Americas
USA (Maine): Year on year increase in Lyme disease in both 2007 and 2008
Maine health officials report back-to-back increases in confirmed or probable cases of Lyme disease in 2007 and 2008. The Maine Center for Disease Control and Prevention said there were more than 900 cases of the tick-borne illness in humans in 2008, an increase of 72 percent from 2007. In 2007, there was a 57 percent increase over 2006, the Maine Center for Disease Control and Prevention said.

Lyme disease is caused by bacteria that are transmitted to humans through the bite of an infected deer tick. Most common in southern and coastal Maine, Lyme disease is gradually moving up the state. While the disease often causes symptoms such as joint pain and fatigue, it's much more serious for some people. For some, it brings fevers and meningitis-type symptoms. Sometimes, it's difficult to confirm a diagnosis. "When we're fortunate and people show up and tell us that they've had a tick [bite], and then they get the rash and the rash is an expanding red rash at the site of the bite, that's an easy diagnosis. The problem is, most people don't remember a tick attachment and not everyone gets a rash," said Dr Bea Szantyr, a Lincoln-based physician who specializes in educating people about Lyme disease. Gordon Smith, director of the Maine Medical Association, said it's not uncommon for patients to disagree with some of the treatment decisions their doctors make.
(ProMED 7/15/09)

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USA (Tennessee): 2009 sees spike of Rocky Mountain spotted fever
More cases of Rocky Mountain spotted fever are being found statewide during the 2009 summer over the same period in 2008. The Tennessee Department of Health reports 65 confirmed cases of the tick-borne disease in the first half of 2009, up from 46 in 2008. Dr. John Williams at Vanderbilt University's Monroe Carrell Children's Hospital said two patients there have died from the illness. Williams says while he has seen deaths in past years, having two in one year is unusual.

Williams also said the hospital is seeing not only more infections, but more serious infections in 2009.
(ProMED 7/20/09)

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

- 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
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
http://www.who.int/csr/disease/influenza/pipguidance2009/en/index.html
International Health Regulations (IHR) at http://www.who.int/ihr/en/index.html.

- WHO regional offices
Africa: http://www.afro.who.int/
Americas: http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=805&Itemid=569
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Europe: http://www.euro.who.int/influenza/ah1n1
South-East: http://www.searo.who.int/EN/Section10/Section2562.htm
Western Pacific: http://www.wpro.who.int/health_topics/h1n1/

- 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

- Other useful sources
CIDRAP: Influenza A/H1N1 page: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promed.org
(WHO; US CDC; MOH Mexico; PHAC; PAHO; CIDRAP; ProMED)

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AVIAN INFLUENZA
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services and includes the website of the Central Fund for Influenza Action. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The (interim) Influenza Virus Tracking System can be accessed at: www.who.int/fluvirus_tracker.
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help hospital administrators and state and local health officials prepare for the next influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.pandemicflu.gov/. View archived Webcasts on influenza pandemic planning.
- CIDRAP: http://www.cidrap.umn.edu/ Access their Swine Influenza website at http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/index.html.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds and poultry.
(UN; WHO; FAO, OIE; CDC; CIDRAP; PAHO; USGS)

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DENGUE
Mexico (Jalisco)
Tonala is facing a dengue outbreak. It is not known if the virus that is circulating in the municipality is dengue virus type 1 or 3. The Tonala municipality has recorded 17 cases of classical dengue (virus infection), and the other probable cases are under study, makes this the first municipality in the Guadalajara Metropolitan Zone with a dengue outbreak in 2009. All the cases have been recorded since the second week of June 2009, in neighboring areas of Altamira, in Tonala.

Salazar Montes reported that during the week 21 - 27 June 2009, 28 new dengue cases were recorded in the state, only one of which resulted in dengue hemorrhagic fever (DHF).
(ProMED 7/13/09)

Viet Nam
The Ministry of Health has warned that the coming rains could result in a resurgence of dengue fever; 26 people have already been killed by the mosquito-borne illness so far in 2009. Nguyen Huy Nga, head of the ministry's Bureau for Preventive Health and Environment, said many southern provinces had seen dramatic rises in infection rates recently. He warned the rainy season could bring more deaths. Approximately 25,700 people have contracted dengue fever in Viet Nam in 2009, 25 percent more than the same period in 2008, according to the ministry.

Nga said the fact that Mekong Delta residents often store their water in large open containers had contributed to the increase in mosquito populations that transmit the dengue virus. The health ministry warns about this problem every year. Nga also said that all four known strains of the virus had been detected in Viet Nam and that a patient could contract more than one type, making the sickness more difficult to diagnose.

Dr Le Bich Lien, head of the Ho Chi Minh (HCM) City Paediatrics Hospital No 1's Dengue Fever Ward, said the hospital had admitted 20-30 dengue fever cases a day since the end of June 2009. "Most patients live in HCM City and several have symptoms of a serious illness when being admitted to the hospital," Lien said. The hospital's dengue fever ward has only 80 beds, but last week it provided treatment for more than 100 patients.

HCM City had more than 4000 dengue fever cases in the first half of 2009, an increase of 50 percent against the same period in 2008, according to the Ministry of Health's Department of Preventive Medicine and Environment. Tran Van Ngoc, head of the HCM City Tropical Diseases Hospital's Pediatrics Ward A, said the number of children with dengue fever had increased rapidly in the past few weeks. The HCM City Tropical Diseases Hospital on Monday had 50 dengue fever child patients, and admitted 30 dengue fever adult patients last week.

The city leads the country's 15 cities and provinces hardest hit by dengue fever in 2009. The Department of Preventive Medicine and Environment has set up 4 teams to monitor the task of combating dengue fever in those localities since early this month. The inspection will last until 10 Jul 2009.
(ProMED 7/13/09, 7/20/09)

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4. Articles
Neurologic Complications Associated with Novel Influenza A (H1N1) Virus Infection in Children--Dallas, Texas, May 2009
US Centers for Disease Control and Prevention. MMWR. 24 Jul 2009; 58(28): 773-778. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5828a2.htm?s_cid=mm5828a2_e.

Neurologic complications, including seizures, encephalitis, encephalopathy, Reye syndrome, and other neurologic disorders, have been described previously in association with respiratory tract infection with seasonal influenza A or B viruses, but not with novel influenza A (H1N1) virus. On May 28, 2009, the Dallas County Department of Health and Human Services (DCHHS) notified CDC of four children with neurologic complications associated with novel influenza A (H1N1) virus infection admitted to hospitals in Dallas County, Texas, during May 18--28. This report summarizes the clinical characteristics of those four cases. Patients were aged 7--17 years and were admitted with signs of influenza-like illness (ILI) and seizures or altered mental status. Three of the four patients had abnormal electroencephalograms (EEGs). In all four patients, novel influenza A (H1N1) viral RNA was detected in nasopharyngeal specimens but not in cerebrospinal fluid (CSF). Antiviral therapy included oseltamivir (four patients) and rimantadine (three patients). All four patients recovered fully and had no neurologic sequelae at discharge. These findings indicate that, as with seasonal influenza, neurologic complications can occur after respiratory tract infection with novel influenza A (H1N1) virus. For children who have ILI accompanied by unexplained seizures or mental status changes, clinicians should consider acute seasonal influenza or novel influenza A (H1N1) virus infection in the differential diagnosis, send respiratory specimens for appropriate diagnostic testing, and promptly initiate empirical antiviral treatment, especially in hospitalized patients. (Excerpt with references removed.)

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Investigation of the first cases of human-to-human infection with the new swine-origin influenza A (H1N1) virus in Canada
Cutler J et al. CMAJ. 20 Jul 2009. Available at http://www.cmaj.ca/cgi/rapidpdf/cmaj.090859.

Abstract
The outbreak of human infection due to the novel swine origin influenza A (H1N1) virus began in Mexico in March 2009. As of July 6, 2009, more than 94 000 laboratory confirmed cases were reported in over 100 countries, including 7983 cases in Canada. In this report, we describe the epidemiologic and clinical characteristics of the first cluster of reported cases of human-to-human transmission of the new influenza virus in Canada.

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Pandemic influenza preparedness in Latin America: analysis of national strategic plans
Mensua A et al. Health Policy and Planning Advance Access. 1 May 2009. Available at http://bit.ly/AsZJI.

Excerpt
The threat of a human pandemic of influenza has prompted the development of national influenza pandemic preparedness plans over the last four years. Analyses have been carried out to assess preparedness in Europe, Asia and Africa. We assessed plans to evaluate the national strategic pandemic influenza preparedness in the countries of Latin America.

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5. Notifications
WHO revises its reporting requirement for pandemic H1N1 virus infection
Changes in the case reporting requirements can be accessed at:
http://www.who.int/csr/disease/swineflu/notes/h1n1_surveillance_20090710/en/index.html

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US CDC’s Questions & Answers: Novel H1N1 Influenza Vaccine
Released 20 July 2009.
Available at http://www.cdc.gov/h1n1flu/vaccination/public/vaccination_qa_pub.htm.

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European CDC’s Interim Risk Assessment for pandemic H1N1 influenza
Released 20 July 2009.
Available at http://ecdc.europa.eu/en/files/pdf/Health_topics/090720_Influenza_A(HINI)_Risk_Assessment.pdf.

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Business continuity training exercise available online
A pandemic flu event has hit your area and the number of people absent from work continues to increase. How does business continue?

This FREE training exercise will allow you to simulate such an event and discover the strong and weak links in your business continuity plan. This exercise leads to the creation of stronger policies and better emergency response. The CD-ROM includes all necessary materials and customizable templates for your organization.

To order this exercise free of charge or for more information, please visit http://www.nwcphp.org/training/courses-exercises/courses/continuity-tabletop.

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Weekly Epidemiological Record Bulletin
WHO. 24 July 2009; 84(30): 301-308. Available at http://www.who.int/wer.

Contents include:
Strategic Advisory Group of Experts on Immunization - report of the extraordinary meeting on the influenza A (H1N1) 2009 pandemic, 7 July 2009
Human infection with pandemic A (H1N1) 2009 influenza virus: clinical observations in hospitalized patients, Americas, July 2009 – update

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International Swine Flu Conference
Dates: 19-20 August 2009; Location: Washington, DC

Learning objectives for the conference:
- Maintaining cash flow and work flow--keeping the business process alive.
- How to plan--making everyone a stakeholder and spelling out roles and responsibilities.
- Protecting your community--knowing your resources and testing them against your toughest scenarios.

Additional information available at http://new-fields.us/em/link.php?M=9950864&N=90&L=187&F=T.

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 apecein@u.washington.edu