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EINet Alert ~ Aug 14, 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 pandemic influenza 2009 H1N1 situation update
- Global: Possible fix found for problem of low yield in pandemic influenza H1N1 vaccine production
- Global: 3 separate doses may be necessary to vaccinate against seasonal and pandemic influenza
- United Kingdom: Research raises questions about antiviral treatment in children
- Indonesia: Suspected avian influenza H5N1 patient treated in hospital
- Mongolia: H5 avian influenza confirmed in wild birds
- Americas: Disease expert notes fever-free pandemic influenza H1N1 cases
- Peru: 7 cases of pandemic influenza H1N1 confirmed in indigenous tribe
- USA: CDC advises against closing schools during H1N1 outbreaks
- USA: Task force to make recommendations on protecting health workers from pandemic H1N1
- USA: Rapid tests miss many cases of pandemic influenza H1N1
- USA (Iowa): Study shows humans can catch H11N9 avian influenza from wild birds
- USA (Kansas): Child contracts H3N2 swine influenza virus
- USA (Minnesota): H7N9 avian influenza confirmed in commercial turkey flock
- Egypt: WHO confirms 2 new human cases of avian influenza H5N1

2. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA

3. Articles
- Interim analysis of pandemic influenza (H1N1) 2009 in Australia: surveillance trends, age of infection and effectiveness of seasonal vaccination
- Understanding Influenza Backward
- Poverty, Wealth, and Access to Pandemic Influenza Vaccines
- Highly pathogenic H5N1 influenza virus can enter the central nervous system and induce neuroinflammation and neurodegeneration

4. Notifications
- US CDC Novel H1N1 Vaccination Planning Q&A
- North American Leaders’ Declaration on H1N1
- ECDC guidance: Use of specific pandemic influenza vaccines during the H1N1 2009 pandemic


1. Influenza News

Global
Weekly APEC update of pandemic influenza H1N1
Novel H1N1 influenza is spreading in Thailand and Vietnam with the onset of Asia's monsoon season, the World Health Organization (WHO) said 11 Aug 2009. The regular flu season has started in those countries, and both H1N1 and seasonal flu are being detected, said WHO spokeswoman Aphaluck Bhatiasevi. Hanoi closed all of its schools on 7 Aug 2009 until further notice in an effort to contain the novel H1N1 outbreak. But the spread of pandemic H1N1 appears to have peaked in parts of the southern hemisphere, including Argentina, Chile, Australia, and New Zealand. WHO said on 12 Aug 2009 that China and Singapore have found osteltamivir (Tamiflu)-resistant novel H1N1 viruses.

The death toll from pandemic influenza 2009 H1N1 reached 436 as of 1 Aug 2009 in the United States, up from 353 the previous week. Flu activity in general continued to decline, however. Canada ordered over 50 million doses of vaccine. The federal government will cover 60% of the vaccine cost, with provinces and territories paying the rest.
(CIDRAP 8/7/09, 8/11/09, 8/13/09)

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

2009
China/ 7 (4)
Egypt/ 32 (4)
Viet Nam/ 4 (4)
Total/ 43 (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: 438 (262)
(WHO 8/11/09 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 7/1/09)

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 7/29/09):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: WHO pandemic influenza 2009 H1N1 situation update
In an update on the novel flu pandemic on 12 Aug 2009, the World Health Organization (WHO) said the virus has now been confirmed in 170 countries and territories. Newly confirming first cases are Timor-Leste, Pakistan, Kirabati, Maldives, French Guiana, Falkland Islands, and Wallis and Futuna. Global deaths, as of 6 Aug 2009, rose to 1,462. Flu activity is waning in many southern hemisphere countries and is picking up in tropical regions.

Full WHO situation update available at http://www.who.int/csr/don/2009_08_12/en/index.html.
(CIDRAP 8/13/09)

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Global: Possible fix found for problem of low yield in pandemic influenza H1N1 vaccine production
A British laboratory may have found a fix for the low yield problem that has been plaguing companies making pandemic influenza H1N1 vaccine, a scientist from the lab revealed 5 Aug 2009. John Wood of the U.K.'s National Institute for Biological Standards and Control (NIBSC) said an improved version of the seed strain his lab produced in May 2009 seems to generate a virus yield that is on a par with what manufacturers get when they make seasonal flu vaccine. While Wood cautioned the increased yield has to be confirmed by manufacturers, any improvement would be welcome news. Manufacturers have been clamouring for the new seed strain, which the lab started shipping out that same day.

Marie-Christine Beauchemin, a spokesperson for Canada's pandemic vaccine contractor, GlaxoSmithKline, confirmed it will obtain the new seed strain. And Sanofi Pasteur, the world's largest producer of flu vaccine, said it too is eager to give the new seed strain a try. "That would be a nice improvement," spokesperson Donna Cary said from Sanofi's U.S. headquarters in Swiftwater, Pennsylvania, when told NIBSC estimates the new seed strain increases yield 2.5-fold over the best producing vaccine virus currently available to manufacturers.

The first batch of seed strains available to manufacturers produced disappointingly low virus yields. Manufacturers reported getting somewhere between one-quarter and one-half of the yield with the pandemic virus seed strains as compared to seasonal flu vaccine production. If left unfixed, the yield problem would have considerably slowed the rate at which vaccine to protect against the pandemic H1N1 virus will roll off production lines in coming weeks and months. And as recently as two weeks ago, heads of labs that make seed strains -- including Wood -- were pessimistic they'd be able to find a way to increase the virus yield. "If it's confirmed, that would be good news," Dr. Marie-Paule Kieny, head of the World Health Organization's (WHO) vaccine research initiative, said of the better yield associated with the improved seed strain.
(ProMED 8/7/09)

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Global: 3 separate doses may be necessary to vaccinate against seasonal and pandemic influenza
People in groups targeted for both seasonal flu and H1N1 flu immunizations will likely need three separate vaccine doses in the 2009 fall, according to the Associated Press. Experts believe that two doses will be necessary for the pandemic H1N1 virus. Because giving seasonal and H1N1 vaccinations at the same time would complicate safety monitoring, US government experts prefer the idea of giving the three shots in three separate visits. But that's expecting a lot from the public, said one vaccine expert.
(CIDRAP 8/7/09)

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Europe/Near East
United Kingdom: Research raises questions about antiviral treatment in children
Children should not be given the antiviral drug Tamiflu (oseltamivir) for influenza pandemic (H1N1) 2009 virus infection because its harms outweigh any benefits, and the government should review its policy on dealing with the pandemic, researchers have said.

The antiviral drugs Tamiflu and Relenza (zanamivir) reduce the length of time children are ill with flu by about one day and can cause vomiting as a common side effect, Oxford researchers found. Vomiting is more dangerous in children than in adults, as it can rapidly lead to dehydration and admission to hospital, they said. Also, the drugs had little or no effect on asthma flare-ups, ear infections or the likelihood of a child needing antibiotics, meaning on balance the medicine does more harm than good in otherwise healthy children, the authors said. It comes after research in early August 2009 showed that Tamiflu reduced the length of flu in adults by just half a day.

Together, these findings question if the government's policy of stockpiling enough antiviral drugs for 80 percent of the population was a waste of money. The exact cost of the stockpile has been kept secret for "commercial reasons" but is expected to run to tens of millions of pounds. Countries around the world have stockpiled around 50 million doses of Tamiflu, made by Roche, for use during a flu pandemic.

Tamiflu has also been linked to side effects such as insomnia and nightmares in children. Dr Matthew Thompson, a general practitioner and senior clinical scientist at Oxford University and Dr Carl Heneghan, a clinical lecturer at Oxford University, said the findings review of seven research studies should prompt the Department of Health to reconsider its policy. The study, published online in the British Medical Journal, reviewed trials where children aged between one and 12 were either given Relenza or Tamiflu to treat seasonal flu or where one of their family had flu and they were given medicine to stop them becoming ill. The researchers said although the studies were carried out on seasonal flu, the findings are relevant to the current influenza H1N1 pandemic.

The drugs may still be of some benefit for children who have underlying conditions such as cystic fibrosis or whose immune system is compromised because they are being treated for leukaemia, for example, but there was not enough evidence to be conclusive about this, the researchers said. Dr Thompson said the government's current policy of giving Tamiflu to all symptomatic people was "inappropriate."
(ProMED 8/11/09)

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Asia
Indonesia: Suspected avian influenza H5N1 patient treated in hospital
A 15-year-old female resident of Pulesari Kecamatan Tembuku, Bangli, was rushed to Sanglah hospital, on the evening of 5 Aug 2009 after several chickens belonging to her family were found suddenly to have died. Reports indicate the victim had contact with the dead chickens when burying them. She developed fever and flu symptoms after that.

On 6 Aug 2009, the Health Service and Livestock Service officers of Bangli investigated the victim's surroundings and found H5N1 influenza virus in the dead chickens using a rapid test. Subsequent to this finding, the Livestock Service culled all remaining chickens belonging to the family.
(ProMED 8/7/09)

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Mongolia: H5 avian influenza confirmed in wild birds
An official with Mongolia's Emergency Situations Ministry confirmed on 11 Aug 2009 that avian influenza recently occurred in Arkhangai Province. Mongolian disease control and prevention agencies found 56 dead swans, wild geese, and other kinds of birds in the area around Shelechagan Lake in Tsetserleg District of Arkhangai Province and after testing samples, confirmed that the birds had died of avian influenza virus. It has been confirmed that the virus is subtype H5.
(ProMED 8/11/09)

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Americas
Americas: Disease expert notes fever-free pandemic influenza H1N1 cases
In his clinical observation of novel flu cases in the United States and South America, Richard Wenzel, former president of the Infectious Diseases Society of America, has noted that some patients are afebrile, even some with serious infections, and lack of fever might underestimate case totals. He said diarrhea seen in a portion of patients suggests a need for stool testing to assess transmission and the role of better hand hygiene.

Full article available from The New York Times at http://www.nytimes.com/2009/08/11/health/11docs.html?_r=1.
(CIDRAP 8/11/09)

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Peru: 7 cases of pandemic influenza H1N1 confirmed in indigenous tribe
Seven members of the native Amazonian Matsigenka tribe tested positive for pandemic H1N1 and have recovered, Peruvian health officials said 12 Aug 2009. But because the tribe lives near a reserve set aside for tribes that have limited contact with modern society, human rights groups fear the virus could spread to the more isolated native people who lack immunity to the disease.
(CIDRAP 8/13/09)

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USA: CDC advises against closing schools during H1N1 outbreaks
US federal officials recommended 7 Aug 2009 that schools should not close down during novel H1N1 influenza outbreaks, though they emphasized that the advice is a guideline and that decisions should be made based on local conditions.

The guidelines, composed by the US Centers for Disease Control and Prevention (CDC) and released by the Department of Health and Human Services (HHS), build on revised guidance that the CDC issued in May 2009. Early in the pandemic's spring wave, schools were told to close for up to two weeks, but the CDC changed its advice shortly afterward to say that schools should focus on keeping sick students and staff out of school.

The new advice is being issued because "once you close a school, as we saw last spring, that creates a very significant ripple effect" on parents and businesses, Janet Napolitano, secretary of the Department of Homeland Security, said. However, the officials said, some schools will be justified in closing if they have a high rate of infection or large numbers of students with the underlying conditions that make the virus more dangerous. "We hope no schools will have to close, but realistically, some schools will close this fall [2009]," Department of Education Secretary Arne Duncan said.

The advice affects approximately 55 million students and 7 million staff who work in more than 130,000 public and private K-12 schools in the United States. Separate advisories for colleges and universities, and for pre-kindergarten and early-childhood programs, are expected to be issued in the next few weeks.

More than 700 schools closed when H1N1 flu first struck in April and May 2009. About 50 were in New York City, where the local outbreak was at least 800,000 cases. As New York City health commissioner, Dr. Thomas Frieden oversaw those closings. But, speaking as new director of the CDC, he said that additional information about the behavior of the novel virus has made school closings a choice rather than a necessity.

Schools can reasonably consider closing if they have large numbers of students who are medically frail or pregnant, are in an area where the local outbreak is especially intense, or if the virus begins to cause more severe illness, he said. Otherwise, schools will need to rely on parents to keep children at home if they are feverish. But he cautioned that some of the spring closings in New York City were driven by children showing up to school with fever because their parents did not or could not keep them at home. Because closings may yet happen, school should prepare by getting temporary home-schooling plans ready, Duncan warned.

Along with the advice on closings, which were published on the CDC's H1N1 flu Web page, the guidelines include new advice on when to allow ill students and staff to return to school: when 24 hours have passed with no fever, whether or not the person is taking antiviral drugs. Previously, federal guidance required flu patients to stay home for 7 days.

The guidelines also advise:
- Sending ill students and staff home, and holding them in rooms separate from the main student body until they can leave
- Emphasizing hand-washing and covering coughs with tissues or shirt-sleeves
- Regularly cleaning surfaces in schools with regular cleansers (bleach is not advised)
- Making sure that students and staff with high-risk conditions see healthcare professionals as soon as possible after they show symptoms

If the fall flu wave involves more severe disease than what was seen in the spring, the guidelines also call for (among other steps):
- Conducting active screening for fever and other symptoms as students and staff enter school each morning
- Asking students and staff with underlying conditions to stay home when flu is circulating locally
- Asking students and staff with ill family members to stay home for 5 days after the first household member falls ill
(CIDRAP 8/7/09)

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USA: Task force to make recommendations on protecting health workers from pandemic H1N1
A task force of the Institute of Medicine (IOM), charged with making recommendations about how to protect healthcare workers against novel H1N1 influenza, on 12 Aug 2009 heard a variety of evidence that respirators and masks can shield health care workers (HCWs) and others from getting respiratory illnesses.

The IOM panel learned, for example, that N95 respirators—whether fit-tested or not—reduced respiratory illnesses in a recent multiple-hospital study in China, whereas surgical masks were not effective. But other studies, focusing on household transmission of flu, suggested that both surgical masks and N95-type respirators are valuable. Another study, involving students at the University of Michigan, suggested that the combination of surgical masks and hand sanitizers may reduce the risk of respiratory illness, but the results didn't achieve statistical significance.

The committee also heard about the problems that some HCWs have with face protection—including a concern among pregnant HCWs in Singapore that wearing an N95 may cause fetal hypoxia. Evidence on the clinical effectiveness of personal protective equipment (PPE) has been notoriously fuzzy. In the face of the murky science, the IOM has been asked to provide a recommendation to the US Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) by 1 Sep 2009. The CDC currently recommends that HCWs who enter the room of a patient in isolation for suspected or confirmed novel H1N1 flu should wear an N95 respirator or equivalent protection.
(CIDRAP 8/12/09)

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USA: Rapid tests miss many cases of pandemic influenza H1N1
Current quick tests for flu miss many cases of the new pandemic H1N1 strain, researchers at the US Centers for Disease Control and Prevention [CDC] reported on 6 Aug 2009. The accuracy of the tests ranged from just 40 percent to 69 percent in detecting pandemic flu, the CDC team reported.

The findings confirm the CDC's warnings that instant tests performed on the spot in doctor's offices and clinics are not highly worthwhile for diagnosing H1N1 infections. The three popular tests were better at detecting seasonal influenza, catching more than 80 percent of H3N2 infections, the CDC found. But in general for patients, the agency advises treating based on symptoms and the knowledge that the virus is circulating in a community.

"The recent appearance and worldwide spread of novel influenza pandemic (H1N1) 2009 virus has highlighted the need to evaluate commercially available, widely used, rapid influenza diagnostic tests," the researchers wrote in the CDC's weekly report on death and disease. The team at CDC's influenza division tested three popular diagnostics: BinaxNow, made by Inverness Medical Innovations, Becton Dickinson's Directigen EZ Flu A+B test and Quidel's QuickVue. They used 65 respiratory specimens collected during April and May 2009 that had previously tested positive either for influenza pandemic (H1N1) 2009 virus or one of the seasonal flu viruses. All had been evaluated using a slower but highly accurate test called real-time reverse transcription-polymerase chain reaction, or rRT-PCR, which checks for the genetic material of the virus.

"The results showed that, although the (rapid tests) were capable of detecting the pandemic (H1N1) 2009 virus from respiratory specimens containing high levels of virus, the overall sensitivity was low," the CDC team wrote. None of the three tests can distinguish among the different types of flu -- they just tell a patient and a doctor if one of the flu viruses is there. In its latest update, the World Health Organization reported 162,230 confirmed cases of the pandemic H1N1 virus and 1154 deaths, but the CDC says more than a million people in the United States alone have been infected. Most public health officials have given up on trying to get precise counts of how many people are infected. The CDC's study gives one reason why: even if patients go to the doctor to be tested, not all do, and the instant test does not do a good job of detecting pandemic flu.
(ProMED 8/7/09)

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USA (Iowa): Study shows humans can catch H11N9 avian influenza from wild birds
A study of duck hunters in Iowa is believed to be the first to show people can catch bird flu -- a non-threatening kind -- from wild birds. Previous cases of people being infected with any form of bird flu have involved domestic poultry, like chickens. The type of bird flu seen in this study is not H5N1, the deadly form that emerged in Asia and has sparked concerns of a potential worldwide flu epidemic. Rather, it is H11N9, another form seen in ducks and other waterfowl that has not been associated with human illness. In the Iowa study, one hunter and two state environmental workers tested positive for the virus, though none of the three men got sick, said Dr. James Gill, the University of Iowa researcher who led the study. Federal health officials say the finding is noteworthy. Domesticated birds like chickens are an established source of bird flu transmission to humans, but this is believed to be the first documented case of a person getting such a virus from a wild bird.
(ProMED 8/8/09)

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USA (Kansas): Child contracts H3N2 swine influenza virus
A Riley County child has been infected with a strain of swine influenza virus not commonly seen in humans, but has fully recovered following a mild illness. No other cases have been identified, but an investigation is underway. The influenza strain that infected the child was identified as an H3N2 virus that commonly circulates in pigs in North America. It is different from the pandemic H1N1 virus, also of swine origin, that was first detected in the United States in mid-April 2009. It presumably also differs from the current human seasonal H3N2 virus.

"It is critical for people to understand that this H3N2 virus is not related to the pandemic H1N1 virus," said Jason Eberhart-Phillips, Kansas State Health Officer and Director of Health at the Kansas Department of Health and Environment (KDHE). "This is not a mutation or a recombination of the pandemic strain, and it does not appear at this time to be a threat to human health." The child was likely exposed to the virus during the Riley County Fair in late July 2009, where the child had direct contact with pigs. The child later developed influenza-like symptoms and sought medical care. The child has fully recovered and no other family members have reported illness.

The KDHE and the local health department are working to determine if the Riley County Fair swine exhibitors, or their pigs, have been ill. Swine flu viruses do not normally infect humans, but human infections occur from time to time. Typically the CDC has received reports of approximately one human infection with a swine influenza virus each year. That number has risen slightly in the past few years. The increased number of reported cases this year is likely the result of increased influenza testing related to the H1N1 pandemic. So far this year, 14 cases of human infections with swine influenza viruses have been reported in the United States. That number does not include the number of H1N1 cases, as the H1N1 virus has not been detected in swine in the USA.

"Most instances of human infection with animal influenza viruses, like the swine H3N2 virus, do not result in human-to-human transmission," Dr. Eberhart-Phillips said. "However, each case needs to be fully investigated to be sure that the viruses are not spreading among humans." Most commonly, cases of human infection with swine influenza occur in people with direct exposure to pigs, he added.
(ProMED 8/8/09)

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USA (Minnesota): H7N9 avian influenza confirmed in commercial turkey flock
A turkey flock in south central Minnesota tested positive for the H7N9 strain of avian influenza. The birds in a commercial flock located in Meeker County, Minnesota, appear healthy and show no sign of infection. The poultry on the premises have been quarantined by the Minnesota Board of Animal Health. The State Board of Animal Health has also established a surveillance zone around the operation.

BAH Assistant Director and Minnesota Poultry Testing Laboratory Director Dr. Dale Lauer says this development should serve as a reminder to all involved with animal agriculture the need to be vigilant in observing the strictest possible biosecurity to protect our animals.

Officials say the H7N9 avian influenza virus is different from the H5N1 virus, in that the virus isn't a threat unless it mutates. Officials add that bird flu in domestic poultry is not unusual and it's still safe to eat Minnesota turkey.
(ProMED 8/8/09)

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Africa
Egypt: WHO confirms 2 new human cases of avian influenza H5N1
The World Health Organization (WHO) confirmed on 11 Aug 2009 two new human cases of H5N1 avian influenza in Egypt, bringing the number of Egyptian cases in 2009 to 32, far more than any other country. The first case is in an 8-year-old girl from Kafr El Sheikh governorate. Her symptoms started on 24 Jul 2009, and she was admitted to a hospital the following day, where she received oseltamivir (Tamiflu). She is reported in stable condition. The second case-patient is an 18-month-old boy from Menoufia governorate. His symptoms started on 28 Jul 2009, and he was admitted to hospital one day later, where he also received oseltamivir treatment and is listed in stable condition. The WHO said both patients had close contact with dead or sick poultry. Of the 32 Egyptian cases in 2009, 4 have been fatal, and, of the 83 cases confirmed in total in Egypt, 27 have been fatal.
(CIDRAP 8/11/09)

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2. Updates
INFLUENZA A/H1N1
The following websites provide the most current information and advice.

- WHO
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions: http://www.who.int/csr/swine_flu/swine_flu_faq_26april.pdf
Map of the spread of influenza A/H1N1: http://www.who.int/csr/don/GlobalSubnationalMaster_20090507_1800.png.

- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: www.pandemicflu.gov
MOH Mexico: http://portal.salud.gob.mx/index_eng.html
PHAC Canada: http://www.phac-aspc.gc.ca/media/nr-rp/index-eng.php
PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm

- Other useful sources
CIDRAP: Influenza A/H1N1 page: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promed.org

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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.

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3. Articles
Interim analysis of pandemic influenza (H1N1) 2009 in Australia: surveillance trends, age of infection and effectiveness of seasonal vaccination
Kelly H & Grant K. Eurosurveillance. 6 Aug 2009; 14(31). Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19288.

Between May and September each year, influenza sentinel surveillance is conducted in general practices in Melbourne and the state of Victoria in southern Australia. We describe the first 11 weeks of sentinel surveillance in 2009 (weeks 18-28), during which time pandemic influenza (H1N1) 2009 virus became established, and investigate the protective effect of seasonal influenza vaccine against laboratory-confirmed infection caused by the pandemic virus. At the time of reporting, the peak ILI activity in 2009 had been reached and was similar to the peak recorded in 2007 but below the peak of 2003. The proportion of cases positive for any influenza virus increased from 6% in the first week of surveillance (week 18) to 59% by week 28, during which time the proportion of influenza viruses detected as pandemic influenza increased from zero to 95%, with at least 91% of all influenza viruses confirmed as pandemic influenza by the eighth week of surveillance (week 25). The median age of all 223 patients with pandemic influenza for whom age was known was 21 years (range 2-63 years) compared with the median age of 53 patients with seasonal H1N1 influenza in 2007 or 2008 of 23 years (range 1-75 years). There was no evidence of significant protection from seasonal vaccine against pandemic influenza virus infection in any age group.

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Understanding Influenza Backward
Morens DM, Taubenberger JK. JAMA. 12 Aug 2009; 302(6): 679-680. Available at http://jama.ama-assn.org/cgi/content/extract/302/6/679.

The novel 2009 influenza A(H1N1) pandemic virus has been an unexpected trigger for pandemic preparedness plans in the United States and elsewhere. It is appropriate to ask how the novel virus might behave epidemiologically in coming months, including the possibility of multiple recurrences or "waves." Spring circulation of the novel virus in the Northern Hemisphere at the end of the 2008-2009 influenza season inevitably has led to comparisons with events in 1918-1919, which in some settings were preceded and followed by outbreaks of respiratory illnesses. Some also believe that the 1918 pandemic began with a premonitory "herald wave," a term related to an old hypothesis, which influenza and dengue fever appeared to have supported, that as new viruses begin to circulate in human populations they inevitably acquire mutations that increase transmissibility and virulence. (Excerpt with references removed.)

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Poverty, Wealth, and Access to Pandemic Influenza Vaccines
Yamada, T. NEJM. 12 Aug 2009. Available at http://content.nejm.org/cgi/content/full/NEJMp0906972.

Perspective
On June 11, 2009, Margaret Chan, director general of the World Health Organization (WHO), declared that the status of the influenza A (H1N1) pandemic had reached phase 6 — active transmission on a global scale. Until now, the case fatality rate of this influenza has been quite low, but history teaches us that the situation could take a turn for the worse during the next wave of the pandemic. If a 1918-like pandemic were to occur today, tens of millions of people could die, the vast majority of them in the world's poorest countries.

Fortunately, the prospects for developing an effective vaccine to prevent infection with the current H1N1 virus are excellent, and the world's pharmaceutical companies are working diligently at this task. In contemplating equal access to such a vaccine, it is important to consider three key issues: manufacturing capacity, cost, and delivery. (Excerpt.)

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Highly pathogenic H5N1 influenza virus can enter the central nervous system and induce neuroinflammation and neurodegeneration
Jang H et al. Proc Natl Acad Sci. 10 Aug 2009. Available at http://www.pnas.org/content/early/2009/08/07/0900096106.abstract.

Abstract
One of the greatest influenza pandemic threats at this time is posed by the highly pathogenic H5N1 avian influenza viruses. To date, 61% of the 433 known human cases of H5N1 infection have proved fatal. Animals infected by H5N1 viruses have demonstrated acute neurological signs ranging from mild encephalitis to motor disturbances to coma. However, no studies have examined the longer-term neurologic consequences of H5N1 infection among surviving hosts. Using the C57BL/6J mouse, a mouse strain that can be infected by the A/Vietnam/1203/04 H5N1 virus without adaptation, we show that this virus travels from the peripheral nervous system into the CNS to higher levels of the neuroaxis. In regions infected by H5N1 virus, we observe activation of microglia and alpha-synuclein phosphorylation and aggregation that persists long after resolution of the infection. We also observe a significant loss of dopaminergic neurons in the substantia nigra pars compacta 60 days after infection. Our results suggest that a pandemic H5N1 pathogen, or other neurotropic influenza virus, could initiate CNS disorders of protein aggregation including Parkinson's and Alzheimer's diseases.

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4. Notifications
US CDC Novel H1N1 Vaccination Planning Q&A
Published on 10 Aug 2009.
Available at http://www.cdc.gov/h1n1flu/vaccination/statelocal/qa.htm.

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North American Leaders’ Declaration on H1N1
US President Barack Obama, Mexican President Felipe Calderon, and Canadian Prime Minister Stephen Harper included the flu pandemic on their agenda when they met 9-10 Aug 2009 in Guadalajara, Mexico. The leaders conferred about vaccine development for the H1N1 flu wave expected in the 2009 fall and discussed mitigation measures. The statement was released 10 Aug 2009.

Available at http://www.whitehouse.gov/the_press_office/North-American-Leaders-Declaration-on-H1N1/.

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ECDC guidance: Use of specific pandemic influenza vaccines during the H1N1 2009 pandemic
Released August 2009.
Available at http://www.ecdc.europa.eu/en/files/pdf/Publications/090813_Pandemic_vaccines_guidance.pdf.

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 apecein@u.washington.edu