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EINet Alert ~ Sep 25, 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 situation update on pandemic influenza H1N1
- Global: WHO Director-General states not to close borders or restrict trade
- Global: Pandemic influenza H1N1 vaccine donations for developing nations
- Global: WHO lowers H1N1 vaccine projection, targets some for developing nations
- Global: Trial suggests 2 H1N1 vaccinations needed for younger children
- Global: WHO picks novel H1N1 for 2010 southern hemisphere flu vaccine
- UK: Pandemic influenza H1N1 outbreak on farm
- Australia: Australia approves CSL's pandemic influenza H1N1 vaccine
- USA: H1N1 vaccine to ship in early October
- USA: Businesses share lessons from spring H1N1 outbreak
- USA: Additional funding for development of intravenous influenza drug
- USA: Government orders 29 million more doses of H1N1 spray vaccine
- Egypt: Eighty-seventh case of avian influenza A/(H5N1) confirmed
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review
- Influenza as a trigger for acute myocardial infarction or death from cardiovascular disease: a systematic review
- Q&A: What have we found out about the influenza A (H1N1) 2009 pandemic virus?
- APEC EINet “Hot Topics” Video Conference: Lessons Learned from the First Wave
- Conference: World Response Conference on Global Outbreak 2009: H1N1 Flu + H5N1 Flu
- ISHEID Symposium on HIV and Emerging Infectious Diseases
- US CDC Mobile Resources
- Updated guidance and information from the US CDC
1. Influenza News
Weekly APEC update of pandemic influenza H1N1
Economy / Cases (Deaths)
In the temperate regions of the northern hemisphere, influenza activity remains widely variable. In North America, the United States is reporting increases in influenza-like-illness activity above the seasonal baseline, most notably in the southern, southeastern, and parts of the northeastern United States.
In Canada, influenza activity remains low. In Europe and Central Asia influenza activity remains low overall, except in France, which is reporting increases in influenza-like-illness activity (for week 37) above the seasonal epidemic threshold. Geographically localized influenza activity is being reported in several countries (Austria, Georgia, Ireland, Luxembourg, Norway, Portugal, the Czech Republic, Cyprus, and Israel). In Japan, influenza activity remains stably increased above the seasonal epidemic threshold with the most notable increases being reported on the southern island of Okinawa.
In the tropical regions of the Americas and Asia, influenza transmission remains active. Geographically regional to widespread influenza activity continues to be reported throughout much of South and Southeast Asia, with increasing trends in respiratory diseases being reported in India and Bangladesh. Geographically regional to widespread influenza activity continues to be reported for the tropical regions of Central and South America without a consistent pattern in the trend of respiratory diseases (continued increases are being reported in Bolivia and Venezuela).
In the temperate regions of the southern hemisphere, influenza activity continues to decrease or has returned to the seasonal baseline in most countries. In Australia, later affected areas are also now reporting declining levels of influenza-like-illness. In South Africa, influenza activity appears to have recently passed over the second peak (the first peak was due to seasonal influenza A (H3N2) and second peak was due to pandemic (H1N1) 2009).
WHO Collaborating Centers and other laboratories continue to report sporadic isolates of oseltamivir resistant influenza virus. Twenty six such virus isolates have now been described from around the world, all of which carry the same H275Y mutation that confers resistance to the antiviral oseltamivir but not to the antiviral zanamivir. Of these, 12 have been associated with post-exposure prophylaxis, five with long term oseltamivir treatment in patients with immunosuppression. Worldwide, over 10,000 clinical samples and isolates of the pandemic (H1N1) 2009 virus have been tested and found to be sensitive to oseltamivir. WHO will continue to monitor the situation closely in collaboration with its partners.
Pandemic (H1N1) influenza virus continues to be the predominant circulating influenza virus, both in the northern and southern hemisphere.(WHO 9/18/2009)
Having considered the views of the Emergency Committee, and the ongoing pandemic situation, the WHO Director-General determined it was appropriate to continue the following temporary recommendations:
WHO applauds and welcomes the announcement of donations of pandemic vaccine made today by the United States of America, in concert with Australia, Brazil, France, Italy, New Zealand, Norway, Switzerland, and the United Kingdom. Given that current demand outstrips supply, these donations, together with the doses pledged by manufacturers, will help increase supplies of pandemic vaccines to populations that would otherwise not have access.(WHO 9/18/2009)
The World Health Organization scaled back its estimate of how many doses of pandemic vaccine that producers will likely make over the next year and said it hopes to gather enough vaccine donations to cover about 10% of developing countries' populations. These details about the WHO's efforts to collect vaccine donations for developing countries came the same day that the United Nations (UN) released a report detailing the urgent support needed to help developing countries respond to the pandemic.
Today [24 Sep 2009] at a press conference, Dr Marie-Paule Kieny, the WHO's director of vaccine research, said the latest assessments indicate vaccine makers will make 3 billion doses over the next year, which would cover less than half of the world's population of 6.8 billion people. Kieny said the WHO based its original estimate of global pandemic vaccine production on a survey it conducted in May of 26 manufacturers that indicated a willingness to make pandemic H1N1 vaccine. Some of the original assumptions weren't realistic, she said.
Despite decreased projections, there are several promising vaccine developments, Kieny said. For example, a handful of countries, including China and the United States, have already approved pandemic H1N1 vaccines, and China is already administering the vaccine, with other countries, such as Hungary, soon to follow. She also added that clinical trial findings showing that most people will need only one dose of the vaccine will help stretch the world's supply.
Developing countries will likely start receiving their first doses at the end of October or in November, Kieny told the media. The WHO said it will distribute about 300 million doses of vaccine to more than 90 countries. Two vaccine makers have already donated 150 million doses to developing countries, and on Sep 17 the United States and eight other nations announced they would share some of their vaccine supply as doses come available. Kieny projected that the donations from the countries would total 50 million doses, though she said she anticipates that more countries will sign on to the donation push. She added that the WHO could round out the supply by purchasing vaccine from manufacturers that have offered a discount for developing countries.(CIDRAP 9/24/2009)
The earliest results from testing of a pandemic H1N1 vaccine in children suggest that older children will get a good immune response with a single dose, but children younger than 10 are likely to need two doses a few weeks apart, US health officials said 21 Sep 200. The early findings, based on blood samples taken 8 to 10 days after vaccination, demonstrate a response "strikingly similar" to children's responses to seasonal flu shots, said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), which sponsored the trial.
Seventy-six percent of children between 10 and 17 years old had a strong immune response to a single injection of vaccine made by Sanofi Pasteur. But, according to Fauci, among 3- to 9-year olds, the proportion with a good immune response (hemagglutination inhibition titer of 1:40) dropped to 36%, and in children between 6 and 35 months old it was 25%. Fauci said the data suggest that one dose would be enough to generate a protective immune response in 10- to 17-year-olds but that younger children may need two doses, depending on their health history.
Although trial results for the nasal-spray (live attenuated) vaccine have not yet been announced, Dr Jesse Goodman of the Food and Drug Administration (FDA) said today [21 Sep 2009], "I think it is likely that younger children may need a second dose with that vaccine as well."
Another NIAID-sponsored trial is looking at children's responses to H1N1 and seasonal flu vaccines when given at the same time or sequentially. Fauci said it will probably take until November to get "meaningful" results from that trial.(CIDRAP 9/21/2009)
The World Health Organization (WHO) has recommended that seasonal influenza vaccines for use in the southern hemisphere next year contain the pandemic H1N1 virus instead of a current seasonal H1N1 strain, signaling that the pandemic strain is expected to push the older H1N1 strains aside. The WHO also picked a new strain of influenza A/H3N2 for the 2010 Southern Hemisphere vaccine, while keeping the influenza B strain the same. The recommendation means that manufacturers will likely be changing two of the three strains used in the vaccine.
The WHO annually recommends one H1N1, one H3N2, and one B strain for use in seasonal flu vaccines, trying to match the current circulating strains. The three recommended flu strains are normally combined in one vaccine, but the WHO said it was not ready to decide whether the three newly recommended strains should be combined or if separate seasonal and pandemic vaccines should be used next year in the southern hemisphere. "WHO will be in a position to provide guidance on this issue after the Strategic Advisory Group of Experts (SAGE) meets in late October and deliberates on this issue," the agency said.
The three strains recommended by the WHO are:
UK: Pandemic influenza H1N1 outbreak on farm
A large outbreak of pandemic H1N1 influenza has been reported on a farm in Northern Ireland. There were 4,500 cases among 5,000 susceptible pigs with 0.1% of susceptible animals lost through death, destruction and/or slaughter. Suspected cases were confirmed by real-time PCR [16 Sep 2009], gene sequencing [17 Sep 2009] and PCR [17 Sep 2009]. No known cases of human influenza are currently associated with this outbreak.
Information provided by Dr Nigel Gibbens, Chief Veterinary Officer, Department for Environment, Food and Rural Affairs, LONDON, United Kingdom(ProMED 9/18/2009)
Australia: Australia approves CSL's pandemic influenza H1N1 vaccine
A pandemic H1N1 influenza vaccine has been approved by the Therapeutic Goods Administration (TGA), federal Health Minister Nicola Roxon has confirmed. The vaccine, developed by pharmaceutical firm CSL, will be available later in September. Ms Roxon said there was enough vaccination available for all adults.
The vaccination program would be the largest in the nation's history with the initial rollout to focus on protecting frontline health workers and those most at risk. "The priority groups for vaccination are frontline healthcare and community care workers who have direct contact with patients, people with underlying medical conditions such as asthma, cancers, HIV, heart disease, diabetes and chronic kidney failure." Ms Roxon said people who are obese, indigenous Australians, children in special schools aged over nine, pregnant women and parents and guardians of children aged up to six would also receive priority care.(Australian Associated Press 9/18/2009)
USA: H1N1 vaccine to ship in early October
The first wave of H1N1 vaccine will probably consist of 3.4 million doses of MedImmune's nasal-spray product and is likely to reach providers the first week in October, federal health officials said. Previously the general expectation was that the first doses wouldn't be available until mid October. The vaccine will be allocated to states in proportion to their population. The CDC expects about 90,000 sites to participate in the campaign, some of which may be retail chains that further redistribute vaccine to their outlets.
According to Dr. Jay Butler, head of the CDC H1N1 Vaccine Task Force, "In any given location the availability of the vaccine may actually vary. So oftentimes that decision of who is actually administered the vaccine may ultimately be decided by the provider and the patient."
The CDC has been predicting that about 45 million to 50 million doses of vaccine will become available in mid October, followed by about 20 million a week after that, reaching a total of 195 million in December. Butler reaffirmed that forecast today.(CIDRAP 9/18/2009)
On the final day of a business preparedness summit in Minneapolis, a panel of experts emphasized having clear, open communication with employees as well as having flexible plans—lessons they learned from being on the frontlines during the spring novel H1N1 outbreak. Other critical lessons shared by the panelists were the need to build strong relationships between corporations and national and local governments and recognizing the importance of promoting prevention measures both in and outside of the workplace.
The 2-day summit, "Keeping the World Working during the H1N1 Pandemic," was sponsored by the CIDRAP Business Source, part of the University of Minnesota Center for Infectious Disease Research and Policy.
Building strong relationships
One critical lesson Palensky learned from his company's experience is the importance for businesses to develop a strong relationship with national and local governments, particularly when there is a lot of conflicting information about what is occurring. It is important, he said, to try to have access to the highest levels of government to get a consensus of what is going on.
Other critical relationships to form are with people who have expertise in pandemic preparedness. Palensky said that, along with having a corporate medical director with pandemic planning expertise, the company also works with local medical experts.
Maintaining good communication
One important aspect of developing good communication with employees is to identify high-risk patients, according to Cabanilla. Highlighting that 99.5% of employees who get sick will only be mildly affected and return to work, he stressed the importance of "attending to and identifying as soon as possible high-risk people and provide interventions."
Taking care of families
BioCryst Pharmaceuticals said it received a request for proposal (RFP) from the U.S. Department of Health & Human Services for the supply of its experimental intravenous drug, peramivir, to treat critically ill influenza patients under emergency use authorization (EUA). The company also said it received an additional $77.2 million from the department to complete late-stage development of peramivir.(CIDRAP 9/22/2009)
MedImmune announced that the U.S. Department of Health and Human Services (HHS) has placed an order for an additional 29 million doses of its live attenuated influenza vaccine (LAIV) against the 2009 H1N1 influenza virus. This brings HHS orders to date to more than 40 million vaccine doses. Previous HHS orders for approximately 13 million doses of LAIV for the 2009 H1N1 strain were placed in May and July.(CIDRAP 9/23/2009)
Egypt: Eighty-seventh case of avian influenza A/(H5N1) confirmed
The Ministry of Health of Egypt has reported 2 new confirmed human cases of avian influenza A(H5N1). Both cases, a 13-year old male and a 14-month old female, received oseltamivir treatment and are in stable condition. Investigations into the source of infection indicated that both cases had close contact with dead and/or sick poultry. The cases were confirmed by the Egyptian Central Public Health Laboratories. Of the 87 cases confirmed to date in Egypt, 27 have been fatal.
The following websites provide the most current information and advice.
- 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.
Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review
Jefferson et al. BMJ. 22 September 2009; 2009;339:b3675. Available at http: http://www.bmj.com/cgi/content/abstract/339/sep21_1/b3675.
Objective. To review systematically the evidence of effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.
Data sources. Cochrane Library, Medline, OldMedline, Embase, and CINAHL, without restrictions on language or publication.
Data selection. Studies of any intervention to prevent the transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection, and hygiene). A search of study designs included randomised trials, cohort, case-control, crossover, before and after, and time series studies. After scanning of the titles, abstracts and full text articles as a first filter, a standardised form was used to assess the eligibility of the remainder. Risk of bias of randomised studies was assessed for generation of the allocation sequence, allocation concealment, blinding, and follow-up. Non-randomised studies were assessed for the presence of potential confounders and classified as being at low, medium, or high risk of bias.
Data synthesis. 58 papers of 59 studies were included. The quality of the studies was poor for all four randomised controlled trials and most cluster randomised controlled trials; the observational studies were of mixed quality. Meta-analysis of six case-control studies suggested that physical measures are highly effective in preventing the spread of severe acute respiratory syndrome: handwashing more than 10 times daily (odds ratio 0.45, 95% confidence interval 0.36 to 0.57; number needed to treat=4, 95% confidence interval 3.65 to 5.52), wearing masks (0.32, 0.25 to 0.40; NNT=6, 4.54 to 8.03), wearing N95 masks (0.09, 0.03 to 0.30; NNT=3, 2.37 to 4.06), wearing gloves (0.43, 0.29 to 0.65; NNT=5, 4.15 to 15.41), wearing gowns (0.23, 0.14 to 0.37; NNT=5, 3.37 to 7.12), and handwashing, masks, gloves, and gowns combined (0.09, 0.02 to 0.35; NNT=3, 2.66 to 4.97). The combination was also effective in interrupting the spread of influenza within households. The highest quality cluster randomised trials suggested that spread of respiratory viruses can be prevented by hygienic measures in younger children and within households. Evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks was limited, but they caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to reduce respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. Evidence was limited for social distancing being effective, especially if related to risk of exposure—that is, the higher the risk the longer the distancing period.
Conclusion. Routine long term implementation of some of the measures to interrupt or reduce the spread of respiratory viruses might be difficult. However, many simple and low cost interventions reduce the transmission of epidemic respiratory viruses. More resources should be invested into studying which physical interventions are the most effective, flexible, and cost effective means of minimising the impact of acute respiratory tract infections.
Warren-Gash et al. The Lancet Infectious Diseases. October 2009; 9(10); 601 – 610. Available at http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2809%2970233-6/abstract.
Summary. Cardiac complications of influenza infection, such as myocarditis, are well recognised, but the role of influenza as a trigger of acute myocardial infarction is less clear. We did a systematic review of the evidence that influenza (including influenza-like illness and acute respiratory infection) triggers acute myocardial infarction or cardiovascular death. We examined the effectiveness of influenza vaccines at protecting against cardiac events and did a meta-analysis of data from randomised controlled trials. 42 publications describing 39 studies were identified. Many observational studies in different settings with a range of methods reported consistent associations between influenza and acute myocardial infarction. There was weaker evidence of an association with cardiovascular death. Two small randomised trials assessed the protection provided by influenza vaccine against cardiac events in people with existing cardiovascular disease. Whereas one trial found that influenza vaccination gave significant protection against cardiovascular death, the other trial was inconclusive. A pooled estimate from a random-effects model suggests a protective, though non-significant, effect (relative risk 0.51, 95% CI 0.15–1.76). We believe influenza vaccination should be encouraged wherever indicated, especially in people with existing cardiovascular disease, among whom there is often suboptimum vaccine uptake. Further evidence is needed on the effectiveness of influenza vaccines to reduce the risk of cardiac events in people without established vascular disease.
Q&A: What have we found out about the influenza A (H1N1) 2009 pandemic virus?
Stephen Turner and colleagues follow up their earlier Q&A on influenza A (H1N1) 2009 and ask what we now know about its transmissibility, pathogenicity and variability, and the likelihood of more severe disease in the Northern hemisphere winter.
APEC EINet “Hot Topics” Video Conference: Lessons Learned from the First Wave
APEC EINet is currently actively organizing a videoconference on pandemic influenza: “Pandemic H1N1 preparedness: lessons learned & preparing for the second wave”. The videoconference is set for 4 Nov 2009 Americas time and 5 Nov 3009 Asia time. The session will feature case studies to discuss how preparedness plans affected the response to pandemic influenza, what worked, did not work, and what could be changed for a more effective response in the future. Participating economies are: Australia, Canada, Mexico, Philippines, Singapore, Chinese Taipei, and the USA.
The purpose is to create an Ad Hoc multi-sector Crisis Management Consortium during the event, to be studied as a model by communities worldwide. It is the first world event to invite leaders representing every sector of society to model a community process to help prepare, respond, and recover from a localized outbreak, as well as broader pandemic. Additional information and registration available at >http://wrcgo.eve-ex.com/.
The 16th ISHEID Symposium on HIV & Emerging Infectious Diseases will take place in Marseille, France, from 24 to 26 March, 2010. Tackling each topic from basic science to clinical applications, this meeting will deal with issues of HIV/AIDS, Viral Hepatitis, Emerging Infectious Diseases, and welcome many Key Opinion Leaders.
Submit an abstract before 9 Nov 2009:
Registration and hotel booking are open on-line, we recommend you to secure your participation.
The ISHEID 2010 congress organizing office...
H1N1 Flu Mobile Texting Pilot
H1N1 Flu (Swine Flu): Preparedness Tools for Professionals