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EINet Alert ~ Aug 28, 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 situation update on pandemic influenza H1N1
- Global: WHO advises saving antiviral treatment for high-risk pandemic H1N1 influenza cases
- Global: WHO announced influenza anti-viral can be stored for 2 more years
- Australia: Liability and insurance coverage threaten pandemic H1N1 vaccine program
- Australia: Suspected pandemic influenza H1N1 detected in Queensland piggery
- Malaysia: WHO experts to study country’s pandemic influenza H1N1 mortality rate
- Brazil: Reports highest pandemic H1N1 influenza death toll at 557
- Chile: Pandemic H1N1 influenza virus detected in turkeys
- US: Health official announce expectations for pandemic H1N1 vaccine trials, supply
- US: Committee advises health officials to prepare for pandemic H1N1 vaccine safety concerns
- US: Health officials address concerns about pandemic H1N1 vaccines for pregnant women
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- Epidemiology of fatal cases associated with pandemic H1N1 influenza 2009
- The public's acceptance of novel vaccines during a pandemic: A focus group study and its application to influenza H1N1
- Use of Influenza A (H1N1) 2009 Monovalent Vaccine--Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009
- 2009 Pandemic Influenza A (H1N1) Virus Infections--Chicago, Illinois, April--July 2009
- Surveillance for the 2009 Pandemic Influenza A (H1N1) Virus and Seasonal Influenza Viruses--New Zealand, 2009
- H1N1 Influenza, Public Health Preparedness, and Health Care Reform
- Weekly Epidemiological Record Bulletin
- PLoS launches preliminary flu research findings site
- Report to the President on US Preparations for 2009 H1N1 Influenza
- Influenza A (H1N1) 2009 Monovalent Vaccine Safety Monitoring: CDC Planning Recommendations for State, Local, Tribal, and Territorial Health Officials
1. Influenza News
Weekly APEC update of pandemic influenza H1N1
Because of the rapid spread of H1N1 flu, some South Korean schools are delaying their semester start, scheduled for 24 Aug 2009, to slow the spread of the virus. The number of South Korean cases reached 3,113 on the same day with 188 new cases in that day alone. The US Centers for Disease Control and Prevention (CDC) recorded 7,963 hospitalizations and 522 deaths attributed to novel H1N1 flu as of the end of the week 14 Aug 2009, up from 7,511 hospital cases and 477 deaths a week earlier, Dr. Jay Butler of the CDC. Butler said the overall level of flu activity was low, but two states, Alaska and Maine, still had widespread activity. Australia's H1N1 flu epidemic has not yet passed its peak. While there have been signs of a decline in cases in some areas, cases are still increasing in others. The country has had 138 deaths from the virus, and about 80% of people tested for flu-like illness have had it.
Two more oseltamivir (Tamiflu)-resistant cases of novel H1N1 flu have been identified in the United States, bringing the US total to four.
***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: 438 (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 situation update on pandemic influenza H1N1
WHO’s flu chief urged wealthy nations and drug makers to donate more novel H1N1 vaccines to the world's poorest countries, according to an Aug 22 Associated Press story. Dr. Keiji Fukuda said, "It is clear that the poorest countries in general are just the most vulnerable to any number of diseases." Two drug companies have already agreed to donate 150 million doses to developing countries, while a third is looking at reduced pricing.
Global: WHO advises saving antiviral treatment for high-risk pandemic H1N1 influenza cases
The WHO said the new guidelines were developed by an international expert panel that reviewed all available safety and efficacy studies. They focused on the neuraminidase inhibitors, oseltamivir and zanamivir, because the pandemic H1N1 virus is susceptible to both drugs (and is resistant to the older adamantane drugs). The panel concluded that both drugs can significantly reduce the risk of pneumonia and the need for hospitalization.
Healthy patients with uncomplicated infections should not be treated with antivirals, the group wrote. Some countries, such as the United Kingdom, have been prescribing oseltamivir for any patient with a suspected or confirmed novel flu infection.
For patients who have severe illness or are in a deteriorating condition, the WHO recommends oseltamivir treatment as soon as possible, preferably within 48 hours, though the drug should still be given even if started later. Pregnant women and those with underlying medical conditions such as asthma, obesity, or diabetes should be treated with oseltamivir or zanamivir as soon as possible after the onset of flulike symptoms, the WHO experts advise.
Because about 40% of severe case are occurring in otherwise healthy children and adults, WHO urges healthcare providers to be alert for sudden deterioration in clinical condition, which would warrant higher doses and longer duration of oseltamivir treatment than normally prescribed. Danger signs include shortness of breath, difficulty breathing, changes in mental status, and a high fever that persists.
The WHO noted that two recent reports in medical journals raised questions about the usefulness and side effects of antivirals in children. The expert panel considered those reports in making its recommendation that children who have severe or deteriorating illness, plus those who have underlying medical conditions, receive antiviral treatment, the agency said. However, the group said healthy children older than 5 years should not be given antivirals unless their illness persists or worsens.
Global: WHO announced influenza anti-viral can be stored for 2 more years
Antivirals such as Tamiflu can shorten influenza pandemic (H1N1) 2009 virus infection by about a day if started within two days of the onset of the disease. GlaxoSmithKline's Relenza is believed to be similarly effective. European Union members also have approved the extension of the shelf-life of Relenza, or zanamivir, from five years to seven years.
Tamiflu packages state that the drug should be used within five years of manufacture. Health authorities in Europe, the United States, Canada, Hong Kong and Australia have approved extending that to seven years for use against the pandemic strain of H1N1 flu, said Schmitt. The extension does not apply to Tamiflu's use against seasonal flu.
The decision may be in time to help some Asian countries that stockpiled the drug against the earlier outbreak of bird flu to avoid the expense of replacing it during the pandemic declared in June 2009. The World Health Organization accepts the decisions to approve the extension of the shelf life, and it is acceptable to apply the extension retroactively in this case, said WHO spokesman Gregory Hartl. "It is WHO's view that shelf-life extensions are a matter for national regulatory authorities," Hartl said.
WHO estimates that up to 2 billion people could become infected with pandemic influenza over the
next two years, so it would be impossible at the current rate to provide doses of the drug to everyone infected. To help bridge the gap, Roche has licensed several other producers to make a generic version of the drug oseltamivir, which Roche markets as Tamiflu. In addition, Schmitt said, "we are scaling up production of Tamiflu so we will be able, if required, beginning next year to produce about 400 million treatments per year." She said Roche was still fulfilling the promise it announced in May 2009 to donate 5.65 million treatments of Tamiflu to WHO to help developing countries cope with the pandemic. That comes on top of an earlier donation of 5 million treatments.
Australia: Liability and insurance coverage threaten pandemic H1N1 vaccine program
Australia's pandemic H1N1 vaccine campaign is in peril because the government has refused to indemnify physicians who administer the vaccine and insurance companies seem unwilling to pay doctors to deliver the vaccines. Insurance companies have also raised concerns about multidose vial safety and a lack of vaccine safety data. The country's vaccine campaign is slated to start in mid September, with enough vaccine to cover half of the population.
Australia: Suspected pandemic influenza H1N1 detected in Queensland piggery
Results of the flu tests are expected in the next couple of days, but Dr Glanville suspects the animals will test positive to the same strain affecting humans. "The infection should be self-limiting within the piggery and the response is designed to allow the disease to burn out as quickly as possible," he said.
Australian Pork Limited chief executive Andrew Spencer said it was important for people to remember there is no chance of the virus infecting meat. "We have a situation where there are hundreds of thousands of Australians walking around spreading these flu viruses around, so the expectation that we are not going to suffer in the pig industry is a little over-optimistic," Mr Spencer said. "A number of piggeries are starting to become affected by this virus and that's an issue we need to deal with on those piggeries and to again clean up the health status of those piggeries and get rid of the disease."
Cases of pandemic influenza H1N1 were detected at a piggery in northern Victoria during the week of 19 Aug 2009 and in New South Wales in July 2009.
Malaysia: WHO experts to study country’s pandemic influenza H1N1 mortality rate
"They would study the classification of the death due to H1N1. Some died due to co-morbid [presence of more than one disease or health condition in an individual at a given time] causes, and some die from direct infection. We want them to look into the classification of death for H1N1 so that we will not over report or under report. This is to ensure that we can set a fair comparison, as we have already adopted the WHO's guideline on this matter. The WHO will look into our death cases and observe the situation. The epidemiologists arrived here yesterday [19 Aug 2009] and have already started their work today," he said.
Health Ministry statistics showed that of the 68 deaths, 70 percent were due to co-morbid causes, 20 percent due to late treatment and 10 percent, mostly involving children, are direct infections. Liow said the WHO experts would also study the spread of the H1N1 at the community level to determine why the virus spread so fast in Malaysia compared with other countries.
According to health experts, the age group most likely to contract pandemic A (H1N1) flu is between 5 and 24 years. However, some experts said the number of pandemic influenza A(H1N1) deaths in
Malaysia may be higher than that of its neighbours, but the fatality rate of people with confirmed H1N1 is not remarkably high. Dr Christopher Lee, consultant physician and head of infectious diseases at the Sungai Buloh Hospital, said this was especially pertinent when one considered the WHO estimation that 15-20 cases went unreported for every case of confirmed A(H1N1).
Brazil: Reports highest pandemic H1N1 influenza death toll at 557
Brazil has displaced the United States as the country with the most 2009 H1N1 flu deaths, at 557. The latest official death toll for the United States was 522 as reported by the CDC on 21 Aug 2009. Brazil's health ministry said the country's H1N1 epidemic appears to be declining. The ministry has allocated $1 billion to buy 73 million doses of H1N1 vaccine, along with oseltamivir, hospital equipment, and diagnostic tests.
Chile: Pandemic H1N1 influenza virus detected in turkeys
Analysis by the Institute of Public Health confirmed the findings, proving that transmission of the new virus from humans to birds has occurred. The United Nations Food and Agriculture Organization (FAO) stated that the novel H1N1 strain is highly contagious but "no more deadly than common seasonal flu viruses. However, it could theoretically become more dangerous if it adds virulence by combining with H5N1, commonly known as bird flu, which is far more deadly but harder to pass along among humans."
"Chile does not have H5N1 flu. In southeast Asia where there is a lot of the virus circulating in poultry, the introduction of H1N1 in these populations would be of a greater concern," said Juan Lubroth, the FAO's interim chief veterinary officer.
Animal health expert, Dr. Les Sims of Asia Pacific Veterinary Information Services in Australia, said recently that he regarded the chance of an H1N1-H5N1 reassortment event as low. Sims, who is a consultant to the FAO, said he wasn't surprised by the news of the turkey outbreak. He added, "It was always a possibility that turkeys would be susceptible, albeit one that I had not considered as a threat in Asia given the limited number of turkeys reared in this part of the world.
The FAO statement said the risk of reassortment is one of the reasons FAO encourages improved monitoring of animal health and good farming practices, including protecting farm workers if animals are sick and not allowing sick workers near animals. The agency noted that Chile is the fourth country investigating the spillover of the 2009 H1N1 virus from farm workers into animals. Swine have been infected in Canada, Argentina, and, most recently, Australia.
US: Health official announce expectations for pandemic H1N1 vaccine trials, supply
The trials will help determine the dose size—15 versus 30 micrograms (mcg)—and whether each person will need one or two doses to get a good immune response. Federal officials have been saying two doses will probably be necessary, because most people lack any immunity to the novel virus. But no decision has been made yet, and officials said it will depend on the early results of the trials. A recommendation for two doses will slash the effective vaccine supply and complicate vaccination planning for the fall, as millions of people will need a dose of seasonal flu vaccine plus two doses of the novel H1N1 vaccine.
The NIAID also announced the start of two H1N1 vaccine trials in children aged 6 months to 17 years, after the early experience in the adult trials showed no immediate safety problems. In addition, there are plans to conduct three trials involving pregnant women, testing one or two doses of 15 or 30 mcg, with about 120 women in each trial. Finally, trials in which different adjuvants will be matched with multiple vaccines will start in late September 2009, Fauci reported.
Meanwhile, Dr. Jay Butler of the Centers for Disease Control and Prevention (CDC) slightly revised the recently reduced forecast for the early supply of H1N1 vaccine. At a recent meeting, a Department of Health and Human Services official downsized the forecast of what will be available in mid October 2009 from the previous 120 million doses to 45 million doses. Butler said 21 Aug 2009, "We're expecting somewhere between 45 million and 52 million doses to be available by mid October . This will be followed by weekly availability of vaccine up to about 195 million doses by the end of the year."
US: Committee advises health officials to prepare for pandemic H1N1 vaccine safety concerns
The National Vaccine Advisory Committee (NVAC) unanimously passed a recommendation that HHS "develop, and where possible test in advance, a strong and organized response to scientific and public concerns about vaccine safety that may emerge during the 2009 H1N1 vaccination campaign."
"The challenge will be to communicate effectively and to differentiate rapidly between adverse events that may be causally related to the vaccine and those which would be expected by chance alone," states the recommendation.
The committee said HHS could prepare in two specific ways:
Planners are mindful of the 1976 swine flu vaccination campaign, which reached more than 40 million people but was associated with an increase in cases of Guillian-Barre syndrome. Officials say vaccine safety and purifications steps are much more advanced today than at that time.
The NVAC also approved a separate recommendation that HHS develop a detailed overall plan for communicating about the H1N1 vaccination program. The group urged HHS to develop a comprehensive plan for achieving at least the following aims:
Jenny Backus, HHS assistant secretary for public affairs, outlined steps the agency is currently taking to communicate with the public about preparing for both seasonal flu and the novel H1N1 virus. Backus said HHS pushed hygiene steps such as hand-washing and cough etiquette during the spring and renewed that emphasis starting in July 2009. From now into mid September 2009, the agency will be spreading the word about the importance of getting a seasonal flu shot. The third phase will be to urge target groups to get their H1N1 immunization.
US: Health officials address concerns about pandemic H1N1 vaccines for pregnant women
Pregnant women in the United States and other countries have had high rates of severe infections and deaths from the novel flu virus, which prompted a federal vaccine advisory group in July to recommend that pregnant women be placed high on the priority list to receive the vaccine. Experts say immune suppression during pregnancy puts women at greater risk for flu complications, and that respiratory compromise as women advance into the later trimesters may also play a role.
Judge turns back vaccine ban
Several advocacy groups have claimed that thimerosal, which contains ethyl mercury, is linked to autism and other birth defects. Thimerosal has been used in vaccines since the 1930s, but since 1999 it has been removed from most childhood vaccines. However, it is still used in injectable flu vaccines to guard against cross-contamination in multiuse vials, though some thimerosal-free flu vaccines are available in single-use vials and prefilled syringes.
Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said novel flu vaccine in single-use vials and preloaded syringes will not contain thimerosal and will be directed toward children and pregnant women. He said though scientific data do not show problems with thimerosal, the preservative has been eliminated from some vaccines because people are still concerned about it.
Officials make case for vaccination
Laura Riley, MD, medical director for labor and delivery at Massachusetts General Hospital in Boston, said pregnant women are understandably concerned about taking any medical intervention that might affect their babies, but she said the seasonal flu vaccine has had a strong safety record in pregnant women over the past several years. "There's no reason to suspect that this [the novel flu vaccine] is going to be different," she said, adding that maternal vaccination can help protect babies up to age 6 months, a group that can't be vaccinated. Riley is also a member of the National Vaccine Advisory Committee.
The following websites provide the most current information and advice.
- North America
- Other useful sources
Epidemiology of fatal cases associated with pandemic H1N1 influenza 2009
Vaillant L et al. Eurosurveillance. 20 Aug 2009; 14(33). Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19309.
This article describes the characteristics of 574 deaths associated with pandemic H1N1 influenza up to 16 July 2009. Data (except from Canada and Australia) suggest that the elderly may to some extent be protected from infection. There was underlying disease in at least half of the fatal cases. Two risk factors seem of particular importance: pregnancy and metabolic condition (including obesity which has not been considered as risk factor in previous pandemics or seasonal influenza).
The public's acceptance of novel vaccines during a pandemic: A focus group study and its application to influenza H1N1
Use of Influenza A (H1N1) 2009 Monovalent Vaccine--Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009
2009 Pandemic Influenza A (H1N1) Virus Infections--Chicago, Illinois, April--July 2009
On April 21, 2009, CDC reported the first cases of 2009 pandemic influenza A (H1N1) virus infection in the United States. On April 24, in response to those reports, the Chicago Department of Public Health (CDPH) established enhanced surveillance for 2009 pandemic influenza A (H1N1) virus infections. The first cases were identified on April 28. This report summarizes laboratory-confirmed cases identified during April 24--July 25 and provides clinical and epidemiologic data for a subset of those cases. By July 25, a total of 1,557 laboratory-confirmed cases had been reported to CDPH. The overall attack rate was highest among children aged 5--14 years (147 per 100,000 population), which was 14 times higher than for adults aged ≥60 years. A total of 205 (13%) patients were hospitalized, with the highest rate observed among children aged 0--4 years (25 per 100,000), followed by children aged 5--14 years (11 per 100,000). These findings affirm prevention strategies that target children and young adults, who are at a disproportionate risk for infection and hospitalization. The Advisory Committee on Immunization Practices (ACIP) recommends that these populations should be among the first groups targeted for vaccination with influenza A (H1N1) 2009 monovalent vaccine. (Excerpt with references removed.)
Surveillance for the 2009 Pandemic Influenza A (H1N1) Virus and Seasonal Influenza Viruses--New Zealand, 2009
The 2009 pandemic influenza A (H1N1) virus, which was first identified in the United States and Mexico, was imported into New Zealand by a high school group returning from Mexico in late April 2009. By June, sustained community transmission of the virus had been established in New Zealand. To track the incidence of influenza-like illness (ILI) and compare the number of viruses identified as 2009 pandemic influenza A (H1N1) with the number identified as seasonal influenza, New Zealand public health officials analyzed weekly data from the country's sentinel general practitioner (GP) surveillance system and nonsentinel laboratory surveillance network for the period extending from the week ending May 3 through the week ending August 2. This report describes the results of those analyses, which determined that the number of viruses identified as 2009 pandemic influenza A (H1N1) rapidly overtook the number identified as seasonal influenza, and the peak weekly consultation rate for ILI was three times the peak rate in New Zealand during the same period in 2008. These findings demonstrate the value of using integrated epidemiologic and virologic surveillance in New Zealand to monitor the scope of an influenza epidemic, identify circulating strains, assist public health control measures, and guide effective use of influenza vaccines and antivirals. (Excerpt with references removed.)
H1N1 Influenza, Public Health Preparedness, and Health Care Reform
Weekly Epidemiological Record Bulletin
WHO. 21 Aug 2009; 84(34): 341-348. Available at http://www.who.int/wer.
Contents of this issue:
PLoS launches preliminary flu research findings site
Access the site at http://knol.google.com/k/plos/plos-currents-influenza/28qm4w0q65e4w/1%23#.
Report to the President on US Preparations for 2009 H1N1 Influenza
Influenza A (H1N1) 2009 Monovalent Vaccine Safety Monitoring: CDC Planning Recommendations for State, Local, Tribal, and Territorial Health Officials