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EINet Alert ~ Jul 31, 2009
*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
1. Influenza News
- Weekly APEC update of pandemic influenza H1N1
- Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO update on pandemic influenza H1N1
- Global: WHO announces examination of anti-viral use
- Mexico: First known case of pandemic 2009 H1N1 influenza is baby in northern Mexico
- USA: ACIP targets up to 159 million Americans for pandemic H1N1 influenza vaccine
- UK: Guidance requests soft toys be removed to curb spread of pandemic influenza H1N1
- China: Defending decision to continue policy of quarantine to combat pandemic influenza H1N1
- Viet Nam: Ministry cautions pandemic influenza H1N1 spread on public transport
- Viet Nam: Report of avian influenza death
- Canada: PHAC launches trial to determine if vitamin D protects against pandemic influenza H1N1
- Canada (Quebec): Pandemic influenza H1N1 detected in hog herd
- Central America: Region is hardest hit by pandemic influenza H1N1 deaths
- Peru: 33 percent of pandemic influenza H1N1 cases are asymptomatic
- South America: Trade group asks WTO to ease influenza drug patent rules
- USA: Pandemic H1N1 influenza activity decreases; CDC announces end of national case counts
- USA (New York): Nurses object to mandatory influenza vaccination
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- H1N1 2009 influenza virus infection during pregnancy in the USA
- 2009 Swine-Origin Influenza A (H1N1) Resembles Previous Influenza Isolates
- Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009
- Gaps in Pandemic Planning and Preparedness Need to Be Addressed
- US CDC updated guidance and resources for pandemic influenza H1N1
- Novel H1N1 Vaccination Guidance for State, Local, Tribal and Territorial Health Officials
- Influenza in the Asia-Pacific
1. Influenza News
Weekly APEC update of pandemic influenza H1N1
The number of novel H1N1 cases in the Mexican state of Chiapas is soaring, with up to 130 new infections reported each day. The state has the country's highest case count and has reported 8 of the last 10 deaths. Thailand announced 21 deaths related to pandemic H1N1 during the week 22-29 Jul 2009, bringing its total death count to 65. Indonesia confirmed its first pandemic H1N1 related death. Japan reports two more cases of oseltamivir-resistant pandemic H1N1 infection. Meanwhile, Canada approves oseltamivir use for infants. Canada to use adjuvants in pandemic H1N1 influenza vaccine, but will wait until at least September to determine priority recipients.
(CIDRAP 7/24/09, 7/29/09, 7/30/09; Canadian Press 7//29/09; ABC News 7/26/09)
***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 7/29/09):
Global: WHO update on pandemic influenza H1N1
Global: WHO announces examination of anti-viral use
“They will be looking at specifics related to antiviral resistance and use of oseltamivir. WHO’s recommendation for use of oseltamivir is for treatment,” she underlined. Oseltamivir is the active ingredient of Tamiflu, one of two drugs the WHO recommends to treat influenza A(H1N1).
Different countries have evolved different approaches on the use of Tamiflu--normally a prescription drug--and some have been distributing it more widely to fearful populations than others. But some have expressed fears that excessive use, especially for preventive purposes or to tackle mild symptoms, could lead to the development of wider drug resistance and reduce the effectiveness of Tamiflu. Roche, the manufacturers of Tamiflu, has said it expects a 0.5 percent rate of case resistance based on clinical trials.
Mexico: First known case of pandemic 2009 H1N1 influenza is baby in northern Mexico
International attention has focused on two possible ‘patient zeros,’ including a 5-year-old boy who lived near a pig farm in eastern Mexico and a woman from Oaxaca, in the southeast, after the government first raised the A(H1N1) alert three months ago. Both had contracted the virus, which has now killed more than 700 people worldwide, in April 2009.
But studies carried out on a backlog of samples show that a first handful of recorded cases appeared in March 2009, in central and northern Mexico, before any showed up further south, said Ms Alpuche. "We have other positive samples in March  from Baja California [northwest], San Luis Potosi and Mexico City [center]," Ms Alpuche said, referring to results discovered around early July 2009. "It's complicated to say where it originated but the earlier samples are not from rural areas, that's to say areas with farms or pigs," she added.
Mexico's pandemic H1N1 death toll now stands at 138, with almost 14,800 recorded cases, and the country has recently seen an upsurge of cases in the impoverished southeast.
USA: ACIP targets up to 159 million Americans for pandemic H1N1 influenza vaccine
The Advisory Committee on Immunization Practices (ACIP) picked five target groups for initial immunization because of their increased risk of H1N1 infection or complications or their contact with vulnerable people:
But if the demand for vaccine outstrips supplies, said Dr. Anne Schuchat of the Centers for Disease Control and Prevention (CDC), the five groups would be as follows:
Healthy people between the ages of 25 and 64 can be immunized after the demand from the target groups has been met, said the committee, which advises the CDC. Because people 65 and older seem to have a lower risk of H1N1 infection than younger people, they can be vaccinated as supplies permit and other groups are served, the panel advised.
Schuchat said the broader target groups total roughly 159 million people, adding, "But there's a lot of overlap in some of the groups, so it's probably lower than that." She said the smaller set of target groups, or what she called the "just-in-case prioritization group," numbers about 41 million people.
The committee issued its recommendations as five vaccine manufacturers race to make H1N1 vaccines ordered by the Department of Health and Human Services (HHS). Federal officials have been saying they hope to have the first doses ready to use by mid-October 2009, but some doubt about that date was expressed at the meeting.
Guidance assumes no adjuvants
Dr. Robin Robinson, director of HHS's Biological Advanced Research and Development Authority (BARDA), predicted that about 120 million doses of vaccine could become available in October 2009 and another 80 million per month after that. He said the manufacturers so far have made the bulk equivalent of about 20 million doses of injectable vaccine and 12.8 million doses of nasal spray vaccine. However, he said that one manufacturer is having trouble finishing its production of this year's seasonal flu vaccine. "We'll see what impact that has on H1N1. We're working with them," he said.
On the other hand, Robinson said the manufacturers are seeing some improvements in the production yields of the vaccines, which are grown in eggs. Yields have been reported to be only 25% to 50% as high as typical yields for seasonal flu vaccines.
One or two doses?
In that regard, the ACIP recommended that if supplies are short, providers not turn vaccine seekers away in order to save supplies for second doses. Even if supplies initially run short, "supply and availability will continue, so the committee stressed that programs and providers continue to vaccinate unimmunized patients and not keep vaccine in reserve for later administration of the second dose," the CDC said.
Schuchat said the demand for the vaccine is likely to be well below the number of people in the targeted groups. "We think it's important to differentiate the size of the populations from the number of doses we have and the number we need," she said. Seasonal flu vaccination is recommended for 83% of the population, but actual uptake is less than 40%, she observed, adding, "If we use this as our expectation, we may have plenty of vaccine right away."
Obesity as a potential risk factor
Concerning the vaccination target groups, the new ACIP recommendations call for using the same list of risk factors as are used for seasonal flu. Those include things like chronic respiratory, heart, liver, or kidney disease; diabetes; suppressed immunity, and pregnancy, but not obesity by itself, she said.
Schuchat was asked what she would tell an elderly person about the H1N1 vaccine, given the potential for confusion with different recommendations for seasonal and H1N1 flu vaccination. "As a provider with the elderly, I'd strongly recommend seasonal flu vaccine, and say that from what we've seen so far with this [H1N1] virus, you're probably going to be spared," she replied.
ACIP recommendations are routinely approved and issued by the CDC. "These recommendations will be reviewed quickly by CDC and we expect them to be rapidly disseminated to state and local health departments," which are actively planning their vaccination programs, Schuchat said.
UK: Guidance requests soft toys be removed to curb spread of pandemic influenza H1N1
Britain's Department of Children, Schools and Families has come under fire for issuing recommendations that nurseries and "childminders" remove communal soft toys from care settings to help contain the spread of pandemic H1N1 flu, saying the toys cannot be cleaned adequately. The agency also recommended that crayons and pencils not be shared and large assemblies be suspended. Defenders of the guidance say it is sensible but should be administered sensitively so as not to upset children.
The guidance follows a surge in pandemic H1N1 cases during the week ending 24 Jul 2009. The official estimate of 100, 000 cases is up from 55,000 cases the previous week.
China: Defending decision to continue policy of quarantine to combat pandemic influenza H1N1
Since May 2009, more than 1,800 Americans and unknown hundreds of other nationalities visiting China have been quarantined in response to the pandemic H1N1 influenza. Most have said they were treated well, and those confined early said they were even presented with flowers by apologetic tourism officials. Some of the hundreds of American and British students confined recently said they were fed pizza, though it was left outside their doors so they did not come face-to-face with hotel workers.
Ignoring the advice of the World Health Organization, China is aggressively using quarantine in an effort to stop an infectious but thus far not very serious virus. It is virtually alone in doing so. In the pandemic’s early days, some countries, including South Korea, Japan and Egypt, confined whole dormitories if one student returned from North America with the flu, but they have since stopped doing so.
The WHO advised against quarantines at the very beginning of the pandemic. Dr. Keiji Fukuda, the agency’s deputy director general, said on 27 Apr 2009 that the new flu was already so widespread that “containment is not a feasible option.” China is also resisting public opposition from the United States (US), which along with Britain has the most citizens quarantined there.
“Quarantine measures don’t work,” said Dr. Anthony S. Fauci, head of the National Institute of Allergy and Infectious Diseases, noting that China already had more than 2,000 flu cases when the WHO stopped counting them in early July 2009.
The US State Department has “strongly expressed our concern,” said a spokesman, Andrew J. Laine. In an advisory, it warned travelers that many healthy visitors to China had been held, sometimes without “suitable drinking water and food,” telephones or interpreters. In a few cases, it said, children had been kept apart from their parents, raising the possibility that medications were given without parental consent.
But Chinese health authorities--who underwent criticism for failing to react promptly and openly in the 2003 outbreak of the respiratory disease SARS--say they learned the importance of stringent monitoring during that epidemic. Furthermore, China says its pandemic influenza strategy is working, that the number of cases so far, many in tourists, is insignificant in a country of one billion people. And it notes proudly that it has had no confirmed deaths. Worldwide there have been more than 700 deaths recorded since April 2009.
China also began clinical trials on a pandemic influenza H1N1 vaccine in July 2009, starting even earlier than the US. If all goes well, Chinese state news media said, it will begin producing 600,000 doses a day by October 2009. If it can vaccinate vulnerable elements of its population before flu season, China could argue that quarantine slowed its epidemic enough to save lives.
Viet Nam: Ministry cautions pandemic influenza H1N1 spread on public transport
Meanwhile, the disease continues to spread in Viet Nam, with 45 more new cases reported on 26 Jul 2009, taking the total number so far to 612, health officials said. The Department of Preventive Medicine in the southern province of Binh Duong said an expatriate working for THP Company tested positive for the virus and he is also suspected of transmitting it to a colleague. Health authorities have quarantined them as well as a third person with flu symptoms who had been in contact with them.
Viet Nam: Report of avian influenza death
Canada: PHAC launches trial to determine if vitamin D protects against pandemic influenza H1N1
To see if high vitamin D levels help protect against novel H1N1 flu, the Public Health Agency of Canada is launching a trial to compare blood levels of the vitamin in those with mild and severe cases, the Toronto-based Globe and Mail reported on 27 Jul 2009. Scientists speculate that the winter spike in flu infections is related to lower vitamin D levels associated with reduced exposure to sunlight. Higher vitamin D levels in mildly infected people might suggest a low-cost flu prevention measure.
Canada (Quebec): Pandemic influenza H1N1 detected in hog herd
The provincial agriculture, food and fisheries ministry (MAPAQ) said 28 Jul 2009 that the strain had been identified 24 Jul 2009 at the labs of the National Centre for Foreign Animal Disease in Winnipeg. MAPAQ emphasized on 28 Jul 2009 that no other case has been reported on any other hog farm in Quebec and no people have caught the virus from the herd, saying "there is no human case related to this situation." A MAPAQ spokesman said that it's not known how the hogs caught the virus.
MAPAQ pathologist Dr Alain Laperle said that no one in the hog farmer's family, nor any of the hog farm's workers or visitors, has been sickened by the virus. Laperle added that the first clinical signs of the flu were detected in the herd at the end of June 2009. Laperle also said that while the vector by which the disease came to the farm may never be known, the "most probable hypothesis" is that it came through a human carrier. The ministry also emphasized that Quebec's pork supply is safe to consume and poses no human health risk.
The announcement follows a statement on 24 Jul 2009 from the Canadian Food Inspection Agency (CFIA) that it will not quarantine hog herds found to carry (H1N1). The agency hasn't yet made any official statement on the Quebec case.
CFIA said that affected animals from now on "will be managed using the same veterinary management and biosecurity practices employed for other swine influenza viruses." That means "limiting opportunities for (H1N1) to spread to susceptible animals," the agency said, noting pork slaughter plants have "multiple inspection points to ensure that only healthy animals enter the food supply." All herds in which (H1N1) is detected will be monitored to verify that infected animals recover. As well, CFIA added, surveillance for the presence of (H1N1) in swine will continue, so as "to detect any changes in how the virus affects swine and to identify any changes in the structure of the virus."
CFIA's decision follows the quarantine it slapped on a hog herd in Alberta in the spring of 2009. The herd was believed to have caught the virus from a person, although the visitor previously suspected of bringing the virus to the farm from Mexico has since been ruled out as the carrier. None of the animals that came down with (H1N1) died from it, but the federal quarantine dragged on as positive tests continued to turn up within the herd. Faced with an indefinite quarantine and overcrowded facilities, the hogs' owner eventually culled all of his 2000-plus animals in June 2009 for animal welfare reasons.
The only other known case of the pandemic strain of (H1N1) crossing over from humans to hogs was reported in Argentina earlier in July 2009.
Central America: Region is hardest hit by pandemic influenza H1N1 deaths
Peru: 33 percent of pandemic influenza H1N1 cases are asymptomatic
"The patients do not necessarily consult a health center or seek medical attention because they recover in three or four days with conventional medicines, a healthy diet, and plenty of liquids," Bolarte said. He added that, according to statistics, another 30 percent of people infected with influenza (H1N1) can show all the symptoms of the disease. Therefore, prompt and adequate care by health services is required paying particular attention to the 'risk groups,' such as children younger than 5 years of age, the elderly, persons with depressed immune systems, persons with hypertension, diabetes, Down syndrome, bronchial asthma, and pregnant women, among others.
Bolarte noted that in Peru less than one percent of the patients with influenza (H1N1) die. Furthermore, the number of patients who respond well to treatment and are discharged exceeds 80 percent of the total cases. He explained that when people contract influenza (H1N1) and recover with medical treatment, they won't become re-infected because their body generates the specific defenses against this type (that is, the homologous strain) of virus and prevents the infection from recurring.
Bolarte emphasized that MINSA has an epidemiological and virological surveillance system in place, which tracks the behavior of diseases such as influenza in its seasonal and (H1N1) variants.
South America: Trade group asks WTO to ease influenza drug patent rules
USA: Pandemic H1N1 influenza activity decreases; CDC announces end of national case counts
The nation's number of lab-confirmed novel flu cases rose to 43,771, including 302 deaths, the CDC said. Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, said that this would be the last national case count update, though the CDC will still provide regular updates on hospitalizations and deaths. Many public health officials say keeping case counts in countries that have had ongoing widespread transmission isn't useful, because it dramatically underestimates the true burden of the disease and can be a waste of public health resources. This decision follows the World Health Organizations announcement that they would discontinue case counts on 16 Jul 2009.
Despite the dip in lab-confirmed cases in the United States, Schuchat said the level of flu circulation is still very unusual for the summer months. She added that the CDC has gotten reports of outbreaks at summer camps and military academies where people from different parts of the country come together. "Unfortunately, it's been a challenging summer," she said.
Seven states are reporting widespread activity, including California, Delaware, Georgia, Hawaii, Maine, Maryland, and New Jersey, the CDC said in its flu surveillance report for the week ending 17 Jul 2009. Thirteen states and Puerto Rico are experiencing regional activity. Many of the states reporting regional activity are on the East coast.
Five pediatric flu deaths were reported during the past flu surveillance week, though some occurred as far back as February 2009. Four of the deaths were from novel H1N1, and one was associated with an influenza B virus. Of the 95 pediatric deaths that have been reported during the current flu season, 27 were related to the new flu virus.
More than 99% of all subtyped influenza A viruses reported to the CDC were the novel flu strain. Pneumonia and influenza deaths, tracked through the 122-Cities Mortality Reporting System, were at 6.7%, which is slightly above the 6.5% baseline.
USA (New York): Nurses object to mandatory influenza vaccination
The following websites provide the most current information and advice.
- North America
- Other useful sources
H1N1 2009 influenza virus infection during pregnancy in the USA
Jamieson DJ et al. The Lancet. 29 Jul 2009. Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61304-0/abstract.
Methods After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confirmed case was defined as an acute respiratory illness with laboratory-confirmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defined as a person with an acute febrile respiratory illness who was positive for influenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness.
Findings From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0.32 per 100 000 pregnant women, 95% CI 0.13—0.52 vs 0.076 per 100 000 population at risk, 95% CI 0.07—0.09). Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation.
Interpretation Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs.
2009 Swine-Origin Influenza A (H1N1) Resembles Previous Influenza Isolates
Methodology We conducted a comprehensive computational search of all available sequences of the surface proteins of H1N1 swine influenza isolates and found that a similar strain to S-OIV appeared in Thailand in 2000. The earlier isolates caused infections in pigs but only one sequenced human case, A/Thailand/271/2005 (H1N1).
Significance Differences between the Thai cases and S-OIV may help shed light on the ability of the current outbreak strain to spread rapidly among humans.
Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009
Gaps in Pandemic Planning and Preparedness Need to Be Addressed
US GAO report of the US House of Representatives testimony released on 29 Jul 2009.
Available at http://www.gao.gov/new.items/d09909t.pdf.
US CDC updated guidance and resources for pandemic influenza H1N1
Novel H1N1 Influenza Vaccine Q & A released 28 Jul 2009.
H1N1 Monitoring Q & A releases 24 Jul 2009.
Novel H1N1 Vaccination Guidance for State, Local, Tribal and Territorial Health Officials
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.