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Vol. XII, No. 18 ~ EINet News Briefs ~ Sep 04, 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) 2009
- Cumulative number of human cases of avian influenza A/(H5N1)
- Global: WHO cites severe pandemic H1N1 cases as southern outbreaks wane
- Global: Expert warns of 2010 pandemic H1N1 influenza wave
- Global: WHO expert maintains effectiveness of vaccine even if virus mutates
- Britain and France: Receive first pandemic H1N1 influenza vaccine shipments
- China: Update on avian influenza H5N1 in poultry and wilds birds
- Indonesia: Surveillance update on highly pathogenic avian influenzaH5N1 in poultry
- Canada (Manitoba): Pandemic H1N1 influenza virus continues to be detected in swine herds
- Colombia: President diagnosed with pandemic H1N1 influenza
- Mexico: Health officials tout openness as most effective tactic in fighting pandemic H1N1
- US: CDC surveillance indicates flu activity stable
- US: Neurologists to help with pandemic H1N1vaccine safety surveillance
- Egypt: Two more cases of H5N1 avian influenza confirmed in children

2. Infectious Disease News
- Russia (Chelyabinsk Oblast): 200 children ill with serous meningitis in 2009
- Russia (Udmurt): Regional tick-borne encephalitis update
- Canada (British Columbia): Two suspected cases of West Nile virus would be first in province
- Mexico (Baja California): Hospital notification network reveals 52 cases hospitalized with rickettsial infection

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

4. Articles
- Lack of Airborne Transmission during Outbreak of Pandemic (H1N1) 2009 among Tour Group Members, China, June 2009
- The H1N1 vaccine race: Can we beat the pandemic?
- Rapid Antigen Tests for Diagnosis of Pandemic (Swine) Influenza A/H1N1
- Fitness of Pandemic H1N1 and Seasonal influenza A viruses during Co-infection: Evidence of competitive advantage of pandemic H1N1 influenza versus seasonal influenza
- Surveillance for Pediatric Deaths Associated with 2009 Pandemic Influenza A (H1N1) Virus Infection--United States, April--August 2009

5. Notifications
- Preparing for the second wave: lessons from current outbreaks
- Updated guidance and information from the US CDC
- Weekly Epidemiological Record Bulletin
- Assessment of the 2009 Influenza A (H1N1) Outbreak on Selected Countries in the Southern Hemisphere
- Conference: Keeping the World Working During the H1N1 Pandemic--Protecting Employee Health, Critical Operations, and Customer Relations
- Free software tools to aid in estimating the potential impacts of pandemic influenza H1N1


1. Influenza News

Global
Weekly APEC update of pandemic influenza (H1N1) 2009
Mexican officials project that 1 million of its citizens will become ill in winter 2009-10 with the novel H1N1 virus, although the number of infections is stable for now at 80-100 per day. Canada is concerned about the burden pandemic H1N1 may place on hospital intensive care units (ICUs). ICUs in some of the hospitals hit hardest by virus nearly ran out of specialized equipment and skilled staff. China approves country’s first pandemic H1N1 vaccine, which is claimed to be effective after only one dose.
(CIDRAP 8/31/09, 9/3/09)

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Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
2009
China/ 7 (4)
Egypt/ 34 (4)
Viet Nam/ 4 (4)
Total/ 45 (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: 440 (262).
(WHO 8/31/09 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 cites severe pandemic H1N1 cases as southern outbreaks wane
Novel H1N1 influenza outbreaks are starting to wane in the southern hemisphere, and while most cases are still mild, clinicians are reporting some severe cases of viral pneumonia in young, previously healthy people, the World Health Organization (WHO) said on 28 Aug 2009.

The WHO said the novel H1N1 virus has become the dominant flu strain in most of the world. In a weekly update, the agency said most southern hemisphere countries, including Chile, Argentina, New Zealand, and Australia, have passed their peak of flu activity, but South Africa and Bolivia are still seeing high levels of flu.

Elsewhere, tropical countries are seeing increasing or sustained high levels of H1N1, while temperate areas of the northern hemisphere have low activity overall, punctuated by localized outbreaks. But in Japan, "the level of influenza activity has passed the seasonal epidemic threshold, signaling a very early beginning to the annual influenza season," the WHO said.

The novel virus continues to distinguish itself from seasonal flu by causing severe cases and deaths mainly in people younger than 50, the agency noted. "Perhaps most significantly, clinicians from around the world are reporting a very severe form of disease, also in young and otherwise healthy people, which is rarely seen during seasonal influenza infections," the WHO said. "In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays."

The agency listed an overall H1N1 death toll of 2,185 today, but it offered no estimate of how many severe cases or deaths involved viral pneumonia in young people. The WHO said several countries in the southern hemisphere have viewed the need for intensive care as the greatest burden on the healthcare system during the current flu season. Some cities reported that close to 15% of hospitalized patients needed intensive care.

In other observations in today's reports, the WHO said:
- Early studies show a higher risk of hospitalization and death among minority groups and indigenous populations—four to five times higher than the general population in some studies.
- Early data from two countries suggest that people infected with both HIV and novel H1N1 are not at increased risk for severe illness, provided they are on antiretroviral therapy.
- H1N1 viruses from all outbreaks are virtually identical, showing no signs of dangerous mutations.
(CIDRAP 8/28/09)

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Global: Expert warns of 2010 pandemic H1N1 influenza wave
The fall 2009 wave of pandemic H1N1 flu in the northern hemisphere will likely resemble the spring 2009 spread of the virus, but a more deadly outbreak could strike in 2010 because of natural selection pressure, virologist John Oxford said 27 Aug 2009. Once the virus infects a third of the population, it will find fewer susceptible individuals, which may give mutant viruses a selective advantage, he said. He urged governments not to let down their guard after the next wave.
(CIDRAP 8/28/09)

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Global: WHO expert maintains effectiveness of vaccine even if virus mutates
H1N1 vaccines should offer broad protection even if the pandemic flu virus mutates as it spreads, a top World Health Organization expert said on 2 Sep 2009. Marie-Paule Kieny, director of the WHO's vaccine research program, said that health workers should get immunized first when the shots begin to be distributed, as early as September 2009.

"The consensus is that the first doses will be available to governments for use in September [2009]," she said. The U.S. Centers for Disease Control and Prevention said recently that it was unlikely the vaccines would be available before October 2009. About 30 candidate vaccines are being worked on in the rush to combat the flu strain that first emerged in Mexico and the US and then moved around the world.

The pharmaceutical industry will used tiered pricing for the governments buying H1N1 vaccines, charging rich countries $10 to $20 per dose, middle-income countries half that amount and low-income countries half that again, according to Kieny.

Companies making H1N1 flu vaccines include AstraZeneca's MedImmune, CSL, GlaxoSmithKline, Novartis and Sanofi-Aventis. Other flu vaccine makers include Baxter and Solvay.

Kieny said "a complete clinical evaluation" of H1N1 vaccines was not necessary, but trials were needed to know whether one or two doses are necessary, whether some people may be at risk from the shot, and whether it can be delivered in a mixture with other vaccines.

Research on shots developed in response to H5N1 bird flu, which is more fatal than the pandemic variety but spreads much less easily between humans, has helped vaccine manufacturers develop safe H1N1 shots quickly, according to Kieny.

U.S. researchers said that H1N1 appeared unlikely to mix with other circulating flu viruses into a "superbug." Kieny said the new strain would have to mutate in a significant way for the vaccines in the works to be rendered ineffective. "Although the virus can mutate, we hope that there will be enough cross-protection through recognition of the new virus. But if the virus changes too much, we will need new vaccines," she said.

Kieny stressed that it was neither possible nor necessary to vaccinate every person against the H1N1 flu. "There are other measures, such as social distancing, school closure, avoidance of large gatherings, antibiotics and personal hygiene," she said. "This is not like rabies, which is 100 percent fatal. We are talking about a disease from which most people recover very well." The WHO predicts that a third of the world's population will eventually be infected with H1N1, commonly known as swine flu. So far, at least 2,185 people have died from it and millions of people have been infected.
(Reuters 9/2/09)

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Europe/Near East
Britain and France: Receive first pandemic H1N1 influenza vaccine shipments
Britain and France have received their first novel flu vaccine shipments, but they await regulatory approval and the vaccines likely won't be administered to patients until October 2009. British officials said they received 100,000 doses of a vaccine made by US-based Baxter, but French officials didn't specify the number of doses they received or the manufacturer.
(CIDRAP 8/28/09)

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Asia
China: Update on avian influenza H5N1 in poultry and wilds birds
Since 2004, over 100 H5N1 high pathogenic avian influenza (HPAI) outbreaks have been reported in poultry and wild birds in 23 provinces with over 35 million poultry culled to control the spread of the disease. No outbreaks were reported in June 2009. During the winter 2008-2009, surveillance activities found 45 H5N1 HPAI positive samples of chickens, ducks, and geese at markets in the provinces of Fujian, Chongqing, Guangdong, Guangxi, Guizhou, Henan, Hubei, Shandong and Sichuan. Vaccination has been an important component to control the infection since 2004. On mainland China, vaccination coverage officially reported is still very high in all provinces. Mean vaccination coverage through September 2008 is reported to be higher for most provinces than for the same period in 2007. Additionally, all but one province, Xinjiang, reported 80 percent vaccination coverage or higher.

Current challenges are:
1) the commercially used H5N1 inactivated vaccines do not allow for serological distinction between vaccination and field infection;
2) it is difficult to access poultry raised on backyard and small-scale farms;
3) vaccination coverage in domestic waterfowl is relatively low;
4) layer and breeder ducks in particular, since they do not display clinical signs, are often only vaccinated when they are young, but no booster vaccination is administered on most farms; and
5) waterfowl raised for meat consumption are usually not vaccinated because of the age at the time of marketing (4-6 weeks).
(ProMED 9/2/09)

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Indonesia: Surveillance update on highly pathogenic avian influenzaH5N1 in poultry
Indonesia continues to report a high number of H5N1 highly pathogenic avian influenza (HPAI) outbreaks in poultry, as it has for the past three years. HPAI is endemic on Java, Sumatra, Sulawesi and probably Bali islands, with sporadic outbreaks reported elsewhere. Village prevalence varies widely. Only two of its 33 provinces have not reported the occurrence of H5N1 HPAI. The high number of reported outbreaks each month is partially explained by the implementation of a participatory disease surveillance and response (PDSR) program that targets village-type poultry production systems (mainly backyard) and reports evidence of virus circulation in the village environment. Larger and less densely-populated provinces report HPAI outbreaks less often than more densely populated provinces.

During June 2009, PDSR officers visited 2112 villages, of which 193 (7 percent) were infected (187 were newly found, while the remaining six carried over the infection status from the previous month). This was lower than the May 2009 infection rate of 9 percent.
(ProMED 9/2/09)

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Americas
Canada (Manitoba): Pandemic H1N1 influenza virus continues to be detected in swine herds
Ongoing surveillance for respiratory diseases in Manitoba swine herds has detected the novel pandemic H1N1 influenza virus in several herds, including sow barns, nursery barns, and feeder barns in various locations in the province.

The pandemic virus was first suspected in a sow barn when sows that had been vaccinated against common strains of influenza, began to exhibit influenza-like symptoms. Samples from the herds in question were tested as positive for the novel H1N1 virus in Manitoba Agriculture's Veterinary Diagnostic Laboratory, and confirmed by the National Centre for Foreign Animal Disease in Winnipeg.

Further surveillance confirmed novel H1N1 diagnoses in several additional barns housing weanling and feeder pigs. Movement of pigs from these locations was immediately limited to prevent transmission of the virus to other swine herds. Biosecurity protocols, including the reminder to staff to wear their personal protective equipment properly, were enhanced to further protect both pigs and the workers in the barns.

In a recent policy statement, Canadian Food Inspection Agency, and the Council of Chief Veterinary Officers agreed that farms where pigs have been diagnosed with novel H1N1 do not require quarantine or eradication of the pigs. The novel virus does not behave any differently in pigs than other influenza viruses commonly detected in swine herds, and there is no evidence to indicate that animals play a significant role in the spread of the virus in the general human population.
(ProMED 8/28/09)

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Colombia: President diagnosed with pandemic H1N1 influenza
President Alvaro Uribe of Colombia has been diagnosed with pandemic influenza H1N1, prompting urgent checks into the health of other South American leaders he recently met with at a summit. The Colombian leader has been kept partly secluded in an office at the presidential palace in Bogota. Officials said Uribe was expected to make a full recovery.

The 57-year-old conservative leader showed symptoms soon after addressing a summit at the Argentine ski resort of Bariloche on 28 Aug 2009. The presidents of Argentina, Bolivia, Brazil, Chile, Ecuador, Paraguay, Peru, Uruguay and Venezuela all attended the regional meeting. Uribe then returned to Colombia. During a public event on 29 Aug 2009, he was sneezing and had a fever and aching muscles. The following day, doctors confirmed the cause was pandemic (H1N1) 2009 virus infection. Checks were being carried out on the 55 people who flew with him to the summit, including cabinet ministers, and Colombian authorities were using diplomatic channels to urge other South American governments "to adopt the necessary measures," said Uribe's spokesman, Cesar Mauricio Velasquez.

It was not immediately clear whether President Uribe was infected with the virus in Colombia, which has 621 confirmed cases, or picked it up in Argentina, which is in the depths of the southern hemisphere winter and has tens of thousands of suspected cases. Alberto Cortez, an infectious disease specialist at Colombia's National University, said Uribe could have infected other leaders. The presidents shook hands, spent hours around a table and mingled during the joint photo session.
(ProMED 8/31/09)

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Mexico: Health officials tout openness as most effective tactic in fighting pandemic H1N1
Mexican health officials who are examining what worked and what didn't in fighting the first wave of H1N1 flu say that rapid notification of the public about the virus was the most effective step, though it cost the economy billions of tourist dollars, the Associated Press reported 1 Sep 2009. Rapid diagnosis, treatment, and quarantine, along with hand-washing, also were helpful. Ineffective steps included travel bans, school closures, and widespread use of surgical masks, the story said.
(CIDRAP 9/1/09)

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US: CDC surveillance indicates flu activity stable
The US Centers for Disease Control and Prevention (CDC) said on 28 Aug 2009 that US flu activity remains low overall but appears to be increasing in the Southeast. The agency also reported five more deaths linked to the novel virus in children.

The CDC reported today that the nation has had 8,843 hospitalizations and 556 deaths linked to the novel virus, up from 7,983 hospital cases and 522 deaths reported a week ago. In its flu surveillance report for the week that ended 22 Aug 2009, the CDC said flu activity remained stable or declined in most parts of the country, but it appeared to increase in the Southeast. The jurisdictions reporting widespread activity were Alaska, Georgia, and Puerto Rico.

Five pediatric deaths linked to H1N1 illness were reported, bringing the total to 42, CDC said. The deaths occurred between 7 Jun and 15 Aug 2009 in California, Georgia, Illinois, and Texas. CDC also said the number of cases of oseltamivir (Tamiflu)-resistant H1N1 infection has reached seven, up from four a week earlier. Six of the seven patients had received oseltamivir for either treatment or prophylaxis.
(CIDRAP 8/28/09)

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US: Neurologists to help with pandemic H1N1vaccine safety surveillance
The American Academy of Neurology has joined with the CDC to ask neurologists to report any potential new cases of Guillain-Barre syndrome (GBS) after the pandemic H1N1 vaccine campaign begins. The organizations are asking neurologists to report through the federal Vaccine Adverse Event Reporting System. The groups don't anticipate that the vaccine will pose a GBS risk, but they are acting with caution because some GBS cases were linked to the 1976 swine flu vaccine.
(CIDRAP 9/1/09)

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Africa
Egypt: Two more cases of H5N1 avian influenza confirmed in children
Egyptian authorities have reported two more H5N1 avian influenza cases, both in children, raising the country's total for 2009 to 34, the World Health Organization (WHO) reported 31 Aug 2009.

Both patients have been treated with oseltamivir (Tamiflu) and are in stable condition, the WHO said. One is a 14-year-old girl from Damitta governorate who fell ill on 21 Aug 2009 and was hospitalized two days later. The other patient is 2-year-old girl from Menofyia governorate. She became ill 23 Aug 2009 and was admitted to a fever hospital 26 Aug 2009, the agency said. The WHO said investigations indicated that both girls had contact with dead and/or sick poultry.

Meanwhile, the Egypt-based Web site Strengthening Avian Influenza Detection and Response (SAIDR) reported that sampling triggered by the human case in Menofyia detected the virus on 30 Aug 2009 in some household chickens. SAIDR said two other poultry outbreaks were also found in Fayoum and Beheira governorates.

Of the 34 human H5N1 cases in Egypt this year, 4 have been fatal. The country has had a total of 85 cases and 27 deaths since the avian flu virus arrived in 2006, according to the WHO.
(CIDRAP 8/31/09)

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2. Infectious Disease News

Asia
Russia (Chelyabinsk Oblast): 200 children ill with serous meningitis in 2009
An outbreak of serous meningitis (acute meningitis with secondary external hydrocephalus/viral meningitis) has been reported in the Chelyabinsk Oblast. This disease is most dangerous for small children. Since the beginning of 2009, 200 preschool children have fallen ill with the disease. Currently 80 children are being treated in local hospitals. Forty-four local kindergartens have been closed as a quarantine measure.

Doctors say that the main reason for the spread of infection is lack of adherence to elementary rules of hygiene. However, Rospotrepnadzor (public health) officials suggested that the spread of infection is a consequence of lowered immunity. In most cases the disease is mild and presumed to be a consequence of enteroviral infection.
(ProMED 8/29/09)

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Russia (Udmurt): Regional tick-borne encephalitis update
According to the Administration of Rospotrebnadzor, in the Republic of Udmurtia there were 142 visits to healthcare facilities as a consequence of tick bites during 14-20 Aug 2009. This number is 1.4 times lower if compared with the same indicator for the previous year [2008].

In total, 19,878 people, including 3520 children (18 percent), reported tick bites since the beginning of the tick season in 2009, which is 7 percent more than in 2008. Over 17,000 ticks have been tested in the virology laboratory of Udmurtia. Nearly 13 percent of samples tested positive for tick-borne encephalitis virus infection, and 39.5 percent tested positive for tick-borne borelliosis (or Lyme disease, which is the other major tick transmitted disease in the Republic). Currently, there are 46 confirmed cases of tick-borne encephalitis, a 4 percent increase from 2008.
(ProMED 8/26/09)

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Americas
Canada (British Columbia): Two suspected cases of West Nile virus would be first in province
Two people in British Columbia are being tested for West Nile virus, which has been detected in the province for the first time, the BC Centre for Disease Control said on 22 Aug 2009. Epidemiologist Dr. Bonnie Henry said the two adults are from the same family in the Okanagan, near where a group of mosquitoes were found to have the virus.

"If these people are confirmed to be true cases of West Nile virus, they will be the first ones in Canada this year [2009]," she said. "We have expected this migration of the virus into BC, likely from the south rather than the east, as this (virus) moved across the continent." In Washington State, 207 groups of mosquitoes have tested positive for West Nile in 2009, and 7 birds and 12 horses have been infected, Henry said.

She said all previously recorded cases of West Nile virus in BC had been acquired outside the province, but the two people being tested had travelled only within the Okanagan. They showed various symptoms that have included fever, headache, eye pain, muscle weakness and a rash, Henry said.

Dr. Paul Hasselback, the Interior Health Authority's medical health officer for the central and south Okanagan, said several sites in the south Okanagan are being looked at for West Nile virus but that surveillance will be increased starting next week.
(ProMED 8/24/09)

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Mexico (Baja California): Hospital notification network reveals 52 cases hospitalized with rickettsial infection
In the five months since the State Health Secretariat implemented the hospital notification network because of the outbreak of rickettsial infection, 52 persons have been admitted to hospitals, 50 individuals recovered and were released, and two people died.

Rickettsial infection has been one of the biggest health problems in Baja California, said the secretary of health Jose Guadalupe Bustamante Moreno. In February 2009, after an outbreak of rickettsial infection that resulted in four deaths, the health secretariat began an active surveillance system for cases in the localities of Los Santorales and Mexicali. Extensive surveillance for ticks on domestic dogs and fumigation campaigns are being carried out in the area.
(ProMED 8/21/09)

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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

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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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DENGUE
Viet Nam
At the end of August 2009, the Hanoi Health Department reported that nearly 2500 cases of dengue fever had been recorded citywide since the beginning of 2009, 10 times more than over the same period in 2008. The department said the figures were the worst in years. "The number of dengue cases has gone up critically," said National Institute of Infectious and Tropical Diseases deputy director Nguyen Hong Ha, adding that the institute had admitted up to 45 dengue patients a day recently. "Around 100 patients are receiving treatment at the institute right now' we're on overload," he said. "Patients have to share beds, and we've even had to set up beds in the corridors. But that's still not enough;. . .we're buying more beds."

According to the doctor, most of the patients had come from inner-city districts like Hoang Mai, Thanh Xuan, and Dong Da. He said that fact refuted the popular theory that the number of Hanoi dengue patients had gone up because the capital had absorbed parts of Hoa Binh and Vinh Phuc in 2008.

Although the number of dengue cases recorded in Ho Chi Minh City (HCMC) has not increased sharply in 2009, more patients have reached critical condition, and there have been more deaths related to dengue, said Dr. Phan Van Nghiem from the city's health department. Over 7100 cases have been recorded citywide since the beginning of 2009, an increase of 5 percent compared with the same period in 2008. The city has already seen seven deaths due to dengue, according to the department.

Doctor Le Bich Lien, head of the Dengue Fever Department at Children Hospital No. 1, said her facilities were treating around 80 kids for dengue, one quarter of whom were in stages 3 and 4 with symptoms like circulatory failure, neurological problems and hemorrhaging. "Around 20-25 children are admitted to the hospital with dengue fever every day," said Dr. Lien. "HCMC kids account for 70 percent of our child patients."

Between 50 and 60 kids, mainly 3-10 years old, are receiving treatment for dengue at HCMC Children Hospital No. 2, said Dr. Tran Thi Thuy, deputy head of the hospital's Infection Department. "Around 10 percent of them are in phase 4, the most critical phrase, and experiencing physical shock," Dr. Thuy said.
(ProMED 8/31/09)

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4. Articles
Lack of Airborne Transmission during Outbreak of Pandemic (H1N1) 2009 among Tour Group Members, China, June 2009
Han K et al. Emerg Infect Dis. Oct 2009. Available at http://www.cdc.gov/eid/content/15/10/pdfs/09-1013.pdf.

During June 2–8, 2009, an outbreak of influenza A pandemic (H1N1) 2009 occurred among 30 members of a tour group in China. To identify the mode of transmission and risk factors, we conducted a retrospective cohort investigation. The index case-patient was a female tourist from the United States. Secondary cases developed in 9 (30%) tour group members who had talked with the index case-patient and in 1 airline passenger (not a tour group member) who had sat within 2 rows of her. None of the 14 tour group members who had not talked with the index case-patient became ill. This outbreak was apparently caused by droplet transmission during coughing or talking. That airborne transmission was not a factor is supported by lack of secondary cases among fellow bus and air travelers. Our findings highlight the need to prevent transmission by droplets and fomites during a pandemic.

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The H1N1 vaccine race: Can we beat the pandemic?
Hebert PC and MacDonald N. CMAJ. 31Aug 2009. Available at http://www.cmaj.ca/earlyreleases/31aug09_editorial.shtml.

Editorial
Canada proudly claims to be the first nation with an influenza pandemic plan--a response, in part, to the lack of vaccine during the 1976 swine flu scare. We are told that there is a guaranteed supply of pandemic vaccine from a domestic source. But this is only the first step. The bigger issue is: Will we be able to immunize vulnerable populations in time? Under the current plan, the answer is “No.” (Excerpt.)

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Rapid Antigen Tests for Diagnosis of Pandemic (Swine) Influenza A/H1N1
Vasoo S et al. Clin Infect Dis. 2 September 2009. Available at http://www.journals.uchicago.edu/doi/abs/10.1086/644743.

We found that the sensitivities of 3 rapid influenza antigen tests for pandemic influenza A/H1N1 virus were low to moderate: BD Directigen EZ Flu A+B test (Becton Dickinson), 46.7%; BinaxNOW Influenza A&B (Inverness Medical), 38.3%; and QuickVue Influenza A+B Test (Quidel), 53.3%. A patient with influenza-like illness who has a negative rapid antigen test result should undergo further testing using reverse-transcription polymerase chain reaction.

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Fitness of Pandemic H1N1 and Seasonal influenza A viruses during Co-infection: Evidence of competitive advantage of pandemic H1N1 influenza versus seasonal influenza
Perez D et al. PLos Currents: Influenza 2009. Available at http://www.ncbi.nlm.nih.gov/rrn/RRN1011.

On June 11, 2009 the World Health Organization (WHO) declared a new H1N1 influenza pandemic. This pandemic strain is as transmissible as seasonal H1N1 and H3N2 influenza A viruses. Major concerns facing this pandemic are whether the new virus will replace, co-circulate and/or reassort with seasonal H1N1 and/or H3N2 human strains. Using the ferret model, we investigated which of these three possibilities were most likely favored. Our studies showed that the current pandemic virus is more transmissible than, and has a biological advantage over, prototypical seasonal H1 or H3 strains.

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Surveillance for Pediatric Deaths Associated with 2009 Pandemic Influenza A (H1N1) Virus Infection--United States, April--August 2009
US Centers for Disease Control and Prevention. MMWR. 4 Sep 2009; 58(34): 942-947. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5834a1.htm.

Children aged <5 years or with certain chronic medical conditions are at increased risk for complications and death from influenza. Because of this increased risk, the Advisory Committee on Immunization Practices (ACIP) has prioritized influenza prevention and treatment for children aged <5 years and for those with certain chronic medical and immunosuppressive conditions. CDC monitors child influenza deaths through its influenza-associated pediatric mortality reporting system. As of August 8, 2009, CDC had received reports of 477 deaths associated with 2009 pandemic influenza A (H1N1) in the United States, including 36 deaths among children aged <18 years. To characterize these cases, CDC analyzed data from April to August 2009. The results of that analysis indicated that, of 36 children who died, seven (19%) were aged <5 years, and 24 (67%) had one or more of the high-risk medical conditions. Twenty-two (92%) of the 24 children with high-risk medical conditions had neurodevelopmental conditions. Among 23 children with culture or pathology results reported, laboratory-confirmed bacterial coinfections were identified in 10 (43%), including all six children who 1) were aged ≥5 years, 2) had no recognized high-risk condition, and 3) had culture or pathology results reported. Early diagnosis of influenza can enable prompt initiation of antiviral therapy for children who are at greater risk or severely ill. Clinicians also should be aware of the potential for severe bacterial coinfections among children diagnosed with influenza and treat accordingly. All children aged ≥6 months and caregivers of children aged <6 months should receive influenza A (H1N1) 2009 monovalent vaccine when available. (Excerpt with references removed.)

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5. Notifications
Preparing for the second wave: lessons from current outbreaks
WHO briefing note released 28 Aug 2009.

Monitoring of outbreaks from different parts of the world provides sufficient information to make some tentative conclusions about how the influenza pandemic might evolve in the coming months. WHO is advising countries in the northern hemisphere to prepare for a second wave of pandemic spread. Countries with tropical climates, where the pandemic virus arrived later than elsewhere, also need to prepare for an increasing number of cases. Countries in temperate parts of the southern hemisphere should remain vigilant. As experience has shown, localized “hot spots” of increasing transmission can continue to occur even when the pandemic has peaked at the national level.

Full note available at http://www.who.int/csr/disease/swineflu/notes/h1n1_second_wave_20090828/en/index.html.

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Updated guidance and information from the US CDC
Vaccine Distribution Q & A
Released 31 Aug 2009.
Available at http://www.cdc.gov/H1N1flu/vaccination/statelocal/centralized_distribution_qa.htm,

CDC 2009 H1N1 Vaccination Campaign Planning Checklist
Released 31 Aug 2009.
Available at http://www.cdc.gov/H1N1flu/vaccination/statelocal/planning_checklist.htm.

2009 H1N1 Influenza Vaccine and Pregnant Women Q & A
Released 1 Sep 2009.
Available at http://www.cdc.gov/H1N1flu/vaccination/pregnant_qa.htm.

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Weekly Epidemiological Record Bulletin
WHO. 4 September 2009; 84(36): 361-372. Available at http://www.who.int/wer.

Contents include:
Global influenza surveillance network: laboratory surveillance and response to pandemic H1N1 2009
Global detection of wild and vaccine-derived polioviruses, January 2008-June 2009

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Assessment of the 2009 Influenza A (H1N1) Outbreak on Selected Countries in the Southern Hemisphere
US Health & Human Services document.
Released 3 Sep 2009.
Available at http://www.pandemicflu.gov/professional/global/southhemisphere.html.

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Conference: Keeping the World Working During the H1N1 Pandemic--Protecting Employee Health, Critical Operations, and Customer Relations
Minneapolis, MN
22-23 Sep 2009

A convention of pandemic response experts in public and private sectors who know their business and are ready to act. We'll tackle with candor, urgency, and practicality how to brace our enterprises for the months ahead.

Additional information at registration available at http://attendesource.com/profile/web/index.cfm?PKwebID=0x65757d46

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Free software tools to aid in estimating the potential impacts of pandemic influenza H1N1
SurvCost - to aid public health officials to estimate the cost of Integrated Disease Surveillance and Response (IDSR) systems.
http://www.cdc.gov/idsr/survcost.htm

FluWorkLoss - to estimate the potential number of days lost from work due to an influenza pandemic.
http://www.pandemicflu.gov/plan/tools.html.

FluSurge 2.0 - to aid public health and hospital administrators plan for an influenza pandemic-related surge in demand for hospital resources.
http://www.pandemicflu.gov/plan/tools.html

FluAid 2.0 - To aid state and local public health officials plan, prepare and practice for the next influenza pandemic.
http://www.pandemicflu.gov/plan/tools.html

Instructions to estimate impact of next pandemic using 1968 and 1918 - type scenarios.
http://www.pandemicflu.gov/plan/tools.html

Maxi-Vac AND Maxi-Vac Alternative - to aid the planning of large-scale smallpox vaccination clinics.
http://www.bt.cdc.gov/agent/smallpox/vaccination/maxi-vac/index.asp

VacStockpile - to help planners and policy makers evaluate the potential health and cost impacts of decisions for the National Pediatric Vaccine Stockpile.
http://emergency.cdc.gov/stockpile/vacstockpile/ - to estimate the baseline medical care requirements of a displaced population following a disaster.
http://emergency.cdc.gov/planning/medcon/

HIVEcon - to evaluate both the potential number of HIV-positive immigrants to the United States and the health system cost over time, given a change in immigration regulations.
http://www.cdc.gov/ncidod/dq/laws_regs/part34/hivecon.html

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 apecein@u.washington.edu