Vol. XII, No. 20 ~ EINet News Briefs ~ Oct 02, 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
- 2009 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO situation update on pandemic influenza H1N1
- Global: Support for developing countries' response to the H1N1 influenza pandemic
- Global: WHO alert regarding antiviral use and the risk of drug resistance
- Europe: Approval of two pandemic H1N1 vaccines
- Netherlands: influenza pandemic A(H1N1) 2009 virus found with PB2 mutation
- Hungary: Adult Swine Flu Vaccine Receives Permit
- Australia: Pandemic H1N1 vaccinations begin
- Australia and New Zealand: "Flu A-associated acute respiratory syndrome"
- Chinese Taipei: Review of the first 100 confirmed pandemic H1N1 cases
- Viet Nam: Field hospital effective against flu; more requested
- Hong Kong: High antiviral dosage may have saved H1N1 patients
- Canada: Provinces suspend seasonal flu shots
- Mexico: Measures to address renewed pandemic H1N1 outbreaks
- USA: Military pandemic H1N1 vaccination campaign to provide data
- USA: Protection after early influenza vaccines likely to last all season
- USA: CDC cites bacterial infections in some H1N1 deaths

2. Infectious Disease News
- China: Animal attacks give rise to rabies concerns
- Indonesia (Bali): Supplies of rabies vaccine reach critical levels
- Thai-Cambodia Border: Resistant malaria a concern, WHO says
- Viet Nam: Ho Chi Minh City sees sudden increase of hand-foot-mouth disease
- Australia: Record number of Ross River virus infections

3. Updates

4. Articles
- Comparative Efficacy of Inactivated and Live Attenuated Influenza Vaccines
- Fatal co-infection with swine origin influenza virus A/H1N1 and community-acquired methicillin-resistant Staphylococcus aureus
- Expansion of seasonal influenza vaccination in the Americas
- Aerosol transmission of influenza A virus: a review of new studies
- Update on Vaccine-Derived Polioviruses--Worldwide, January 2008--June 2009
- Seasonal transmission potential and activity peaks of the new influenza A(H1N1): a Monte Carlo likelihood analysis based on human mobility
- Recent Human Influenza A/H3N2 Virus Evolution Driven by Novel Selection Factors in Addition to Antigenic Drift
- Modelling the progression of pandemic influenza A (H1N1) in Vietnam and the opportunities for reassortment with other influenza viruses

5. Notifications
- APEC EINet "Hot Topics" Video Conference: Lessons Learned from the First Wave
- World Response Conference on Global Outbreak 2009: H1N1 Flu + H5N1 Flu
- ISHEID Symposium on HIV and Emerging Infectious Diseases
- HealthMap: Global Disease Alert Map
- Updated influenza guidance and information from the US CDC
- Updated Arabic, French, & Russian translations of influenza information from the US CDC

1. Influenza News

Weekly APEC update of pandemic influenza (H1N1) 2009

The Chinese mainland had reported 18,285 confirmed cases of A (H1N1) influenza by 28 Sep 2009, about 73.3 percent of which had recovered, according to a notice on the website of the Ministry of Health (MOH). No deaths have been reported. In addition, hundreds of thousands of people have been inoculated with the China-made A (H1N1) flu vaccine and no serious adverse reactions have been reported, Health Minister Chen Zhu said 28 Sep 2009.

The Public Health Ministry on 30 Sep 2009 reported 5 more deaths from influenza A (H1N1) in the past week, bringing the total death toll from the flu in Thailand to 165. The health ministry also confirmed 297 new swine flu [influenza A (H1N1)] infections in the past 7 days.

Viet Nam
The Health Ministry on 29 Sep 2009 reported 248 new A (H1N1) flu cases, of which 213 are in the south, 20 in the north, 9 in the central provinces, and 6 in the Central Highlands. As of 29 Sep 2009, there have been 8,853 A (H1N1) flu cases reported in Viet Nam.
(ProMED 9/29/2009)


2009 Cumulative number of human cases of avian influenza A/H5N1

Economy / Cases (Deaths)
China/ 7 (4)
Egypt/ 36 (4)
Viet Nam/ 4 (4)
Total/ 47 (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: 442 (262) (WHO 9/24/09 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 (last updated 9/10/09)

WHO's map 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 7/27/09): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html


Global: WHO situation update on pandemic influenza H1N1

As of 20 September 2009, there have been more than 300,000 laboratory confirmed cases of pandemic influenza H1N1, 3,917 deaths, in 191 countries and territories reported to WHO. As more and more countries have stopped counting individual cases, particularly of milder illness, the case count is significantly lower than the actually number of cases that have occurred.

In the temperate regions of the northern hemisphere, influenza-like-illness (ILI) activity continues to increase in many areas. In North America, the United States has reported continued increases in activity above the seasonal baseline for the last 2 to 3 weeks, primarily in the southeast but now also appearing in the upper midwest and the northeast. In Europe and Central and Western Asia, the United Kingdom is reporting regional increases in ILI activity in Northern Ireland and Scotland and the Netherlands, France, Ireland, and Israel are reporting rates above the seasonal baseline. In Japan, influenza activity continues to be slightly above the seasonal epidemic threshold. The increases in ILI activity have been accompanied by increases in laboratory isolations of pandemic influenza H1N1 2009 in most of these areas.

In the tropical regions of the Americas and Asia, influenza activity remains variable. In parts of India, Bangladesh and Cambodia, influenza transmission continues to be active, while other countries in Southeast Asia have been recently reporting declining transmission (Indonesia, Singapore and Thailand). Although most countries in the tropical regions of the Americas are still reporting regional to widespread geographic spread of influenza activity, there is no consistent pattern in the trend of respiratory diseases. Peru and Mexico have reported an increasing trend in some areas, while most others are reporting an unchanged or decreasing trend (most notably Bolivia, Venezuela and Brazil).

In the temperate regions of the southern hemisphere, influenza transmission has largely returned to baseline (Chile, Argentina, and New Zealand) or is continuing to decline (Australia and South Africa).

All pandemic H1N1 2009 influenza viruses analyzed to date have been antigenically and genetically similar to A/California/7/2009-like pandemic H1N1 2009 virus.

Systematic surveillance conducted by the Global Influenza Surveillance Network (GISN) continues to detect sporadic incidents of H1N1 pandemic viruses that show resistance to the antiviral oseltamivir. To date, 28 resistant viruses have been detected and characterized worldwide. All of these viruses show the same H275Y mutation that confers resistance to the antiviral oseltamivir, but not to the antiviral zanamivir.
(WHO 9/25/2009)


Global: Support for developing countries' response to the H1N1 influenza pandemic

"Developing countries are likely to be at most risk from the pandemic. They face the dual problem of highly vulnerable populations and limited resources to respond to the pandemic. … Around US$ 1.1 billion are needed to ensure that least developed countries have the essential medicines needed to treat severe cases and sufficient vaccine to protect health care workers and other essential service personnel. This will help maintain critical services. An additional US$ 262 million is needed to provide urgent assistance to these countries so they can rapidly build further health system capacity to cope with the current influenza pandemic and future disease outbreaks, and ensure that essential medicines and vaccines can be distributed and used effectively."
(Joint Statement by the UN Secretary-General and the WHO Director-General, 9/24/2009)


Global: WHO alert regarding antiviral use and the risk of drug resistance

WHO encourages clinicians to be alert to two situations that carry a high risk for the emergence of viruses resistant to oseltamivir:

  1. patients with severely compromised or suppressed immune systems who have prolonged illness, have received oseltamivir treatment (especially for an extended duration), but still have evidence of persistent viral replication, and
  2. people who receive oseltamivir for so-called "post-exposure prophylaxis" following exposure to another person with influenza, and who then develop illness despite taking oseltamivir.
In both of these clinical situations, health care staff should respond with a high level of suspicion that oseltamivir resistance has developed. Laboratory investigation should be undertaken to determine whether resistant virus is present and appropriate infection control measures should be implemented or re-enforced to prevent spread of the resistant virus. When a drug-resistant virus is detected, WHO further recommends that an epidemiological investigation be undertaken to determine whether onward transmission of the resistant virus has occurred. In addition, community surveillance for oseltamivir-resistant pandemic H1N1 virus strains should be enhanced.

In general, WHO does not recommend the use of antiviral drugs for prophylactic purposes. For people who have had exposure to an infected person and are at a higher risk of developing severe or complicated illness, an alternative option is close monitoring for symptoms, followed by prompt early antiviral treatment should symptoms develop. WHO has also recommended against the use of a particular antiviral where the virus is known or highly likely to be resistant to it. For this reason, zanamivir is the treatment of choice for patients who become ill while on oseltamivir prophylaxis.
(WHO 9/25/2009)


Europe/Near East
Europe: Approval of two pandemic H1N1 vaccines

Europe's drug regulatory agency today approved two pandemic H1N1 vaccines, one made by GlaxoSmithKline and the other by Novartis. The two vaccines were developed through a "mock up" process that moved forward during preparation for the H5N1 avian influenza virus. Both vaccines contain adjuvants, with Novartis's having been in use since 1997. The agency is recommending a two-dose schedule but said it expects further data that may confirm one-dose efficacy.
(CIDRAP 9/25/2009)


Netherlands: influenza pandemic A(H1N1) 2009 virus found with PB2 mutation

Dutch medical researchers have reported 2 patients diagnosed with influenza pandemic A(H1N1) 2009 virus infection with a mutation (E627K) in the basic polymerase 2 (PB2) protein. This mutation has previously been associated with increased efficiency of replication and possible virulence changes in other influenza A viruses. The E627K mutation may result in enhanced virus replication efficiency in humans, possibly by adjustment to host body temperature or cellular cofactors, and has previously been shown to be associated with fatal cases of HPAI H5N1 and H7N7 virus infection in humans. Until now, A(H1N1)v viruses with Influenza pandemic (H1N1) 2009 (57): in PB2 have not been reported, and the clinical and epidemiological relevance of these findings remains unclear.

Preliminary experiments in ferrets using reverse genetics-derived new influenza A(H1N1)v viruses with the E267K mutation in PB2 did not indicate increased shedding, virulence or transmissibility. Further experiments as well as increased molecular surveillance to monitor the situation are ongoing.
(ProMed 9/28/2009)


Hungary: Adult Swine Flu Vaccine Receives Permit

Hungary's drug regulatory agency has approved the country's pandemic H1N1 vaccine, Dow Jones Newswires reported yesterday. Officials cleared the vaccine after clinical trials showed promising efficacy and safety results. The vaccine is made by Omninvest Kft, Hungary's only vaccine manufacturer. Based on the company's H5N1 avian flu vaccine, the pandemic H1N1 shot will be available within 2 weeks. The Hungarian government has ordered 4 million doses.
(CIDRAP 9/29/2009)


Australia: Pandemic H1N1 vaccinations begin

Australia began nationwide vaccinations against H1N1 influenza today, administering the first shots in what is intended to be a 21-million-dose campaign. The initial allotment of 5.5 million doses from Australian manufacturer CSL Ltd. will be given to pregnant women, healthcare workers, and the chronically ill. Authorities are concerned the vaccine will face low uptake because the flu season is waning after 35,000 confirmed cases and 178 deaths.
(CIDRAP 9/30/2009)


Australia and New Zealand: "Flu A-associated acute respiratory syndrome"

H1N1 pandemic influenza infection is most dangerous when it causes the lungs to become inflamed, flood with fluid, and fail to function, doctors in Australia and New Zealand have found. Steven Webb and Ian Seppelt, intensive care specialists, described the most common of 3 main complications from the pandemic 2009 strain as "flu A-associated acute respiratory disease syndrome", or "FLAARDS." They said the other predominant disease patterns associated with the pandemic influenza virus are community-acquired bacterial pneumonia and an exacerbation by the virus of airflow limitation. They observed that "many patients with FLAARDS are young and previously well." In Australia, the median age of people dying from seasonal flu is 83 whereas it is 51 for the novel H1N1 virus.
(ProMED 10/1/2009)


Chinese Taipei: Review of the first 100 confirmed pandemic H1N1 cases

A retrospective review was undertaken of the medical records of the first 100 laboratory-confirmed cases (by date of onset) of 2009 pandemic influenza A (H1N1) in Taiwan. The review found most of the severe complicated influenza patients to be children and young to middle-aged adults, with being overweight and pregnant contributing to higher risk. The preventive and control measures conducted by the public health sector have effectively accelerated diagnosis and treatment. However, quality of medical care remains to be improved to further reduce the number of severe complicated influenza cases and mortality.

[The full article is presently only available in Chinese and can be found at http://teb.cdc.gov.tw/upload/doc/23452_25-10-%E7%B6%B2%E8%B7%AF%E9%A0%90%E5%A0%B1-%E4%B8%AD.pdf. An English translation of the full article should be available by about 25 Oct 2009.]
(ProMED 10/1/2009)


Viet Nam: Field hospital effective against flu; more requested

Ho Chi Minh City's health department said an H1N1 field hospital that was set up in August has proved "immensely effective," according to the Vietnamese newspaper Thanh Nien. The 11-room hospital has treated 200 patients, some in critical condition. The health department is seeking permission to set up similar field hospitals in other parts of the city to relieve hospital overcrowding.
(CIDRAP 9/29/2009)


Hong Kong: High antiviral dosage may have saved H1N1 patients

Doubling the dosage of oseltamivir (Tamiflu) in patients with severe H1N1 flu cases has helped Prince of Wales Hospital in Hong Kong avoid any deaths from the disease so far, according to the Hong Kong newspaper The Standard. The hospital has treated at least 60 severely ill patients without loss of life, said Dr. David Hui Sui-cheong, a respiratory disease specialist. The hospital has focused on early treatment along with doubling the dose.
(CIDRAP 9/28/2009)


Canada: Provinces suspend seasonal flu shots

British Columbia said today it would delay promoting seasonal flu shots until early in 2010, except for those in high-risk groups such as older people, the Vancouver Sun reported. Quebec, Alberta, Saskatchewan, Ontario, and Nova Scotia announced similar steps in the past few days. The moves follow reports of an unpublished Canadian study that suggests seasonal flu vaccination may double the risk of pandemic H1N1 infection, a finding not confirmed by WHO and [US] CDC data.
(CIDRAP 9/28/09)


Mexico: Measures to address renewed pandemic H1N1 outbreaks

Mexico's health minister announced measures yesterday to address renewed novel H1N1 outbreaks in the country, Xinhua, China's state news agency, reported. Public hospitals will delay nonessential surgeries and reserve 12% of their beds for flu patients. The new measures also establish special areas in hospitals to isolate patients who have the virus. Officials expect 8,000 to 10,000 hospitalizations over the coming flu season.
(CIDRAP 9/25/2009)


USA: Military pandemic H1N1 vaccination campaign to provide data

Active-duty members of the US armed forces will begin receiving 1.4 million doses of H1N1 flu vaccine in the next 10 days, part of a 2.7-million-dose vaccine purchase by the Pentagon. The shots, which are mandatory, will go first to troops preparing to deploy, followed by troops on hold for domestic disasters. Planners hope the early shot campaign will provide needed data on efficacy and side effects.
(CIDRAP 9/30/09)


USA: Protection after early influenza vaccines likely to last all season

The current public health advice that Americans should get their seasonal flu shots early this year has prompted some to voice concern that their protection will fade later in the season-which typically peaks in February or ever later. But medical literature and disease experts indicate there is no good evidence that immunity conferred by the shots wanes so quickly.

Anthony Fiore, MD, MPH, a medical epidemiologist in the CDC's Influenza Division, stated that there are no long-term data on how long protection lasts in younger populations. Though antibodies decline in the months following seasonal vaccination, it's not clear if the drop has any link to vaccine efficacy. For example, he said some people who received the 1976 swine flu vaccine still show some evidence of immune system priming. He added that flu experts also believe cell-mediated immunity, which is difficult to measure, may also play a role in long-term protection.
(CIDRAP 9/29/2009)


USA: CDC cites bacterial infections in some H1N1 deaths

Almost one third of a group of patients who died in the past 4 months from H1N1 influenza had bacterial infections that complicated their illnesses, the Centers for Disease Control and Prevention (CDC) said today in a conference call with healthcare providers. But the agency cautioned against applying that ratio to all cases of H1N1, saying the death records it reviewed were submitted by hospitals and medical examiners and did not represent a statistically valid sample. [Details available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58e0929a1.htm.]
(CIDRAP 9/28/2009)


2. Infectious Disease News

China: Animal attacks give rise to rabies concerns

More than 40 million people in the Chinese mainland are attacked by animals annually, a recently released Ministry of Health report said. The number was calculated from the amount of rabies vaccines consumed every year. The Ministry of Health also said China is one of the countries most threatened by rabies. In recent years, an average of more than 2,400 people in China have died from rabies infections annually. Only India has a higher number of rabies-related fatalities. Most rabies deaths in the past five years occurred in Guangxi Zhuang Autonomous Region and Guizhou, Guangdong, Hunan and Sichuan provinces, accounting for 60.85 percent of the total, the Ministry of Health report said. It also noted that rabies infections mostly occurred in rural areas among males, children under the age of 15, and elderly people over the age of 50.
(ProMED 9/27/2009)


Indonesia (Bali): Supplies of rabies vaccine reach critical levels

The stock of rabies vaccine (VAR) at the island's largest hospital RSUP Sanglah reached critical levels on Thursday [24 Sep 2009], reported a hospital official. "As of Thursday morning, the remaining stock is only 100 dosages of VAR," said Ken Wirasandhi, the head of the hospital's rabies mitigation team.

The hospital is the island's primary medical referral facility for people affected by rabies. In the last 30 days, it has experienced a surge in the number of people requesting VAR injections. The surge was triggered by the deaths of suspected rabies patients in Tabanan, a regency that was previously free from the rabies epidemic. "Prior to the suspected rabies related deaths in Tabanaan, the demand for VAR was around 50 dosages per day. After the deaths, the demand rose to 150 dosages per day, he said.
(ProMED 9/26/2009)


Thai-Cambodia Border: Resistant malaria a concern, WHO says

A drug-resistant strain of malaria observed on the Cambodian-Thai border threatens to overturn decades of progress in the worldwide fight against the disease, doctors from the World Health Organization (WHO) warned at a regional conference in Hong Kong on 23 Sep 2009.

"Artemisinin-based combination therapy, the most effective antimalaria treatment to date, and among the last resources in our arsenal of drugs against the disease, is seriously threatened by evidence of resistance to the treatment in the Cambodian-Thai border," said Shin Young-soo, WHO regional director for the Western Pacific. He continued, "Artemisinin-resistance needs urgent containment to prevent further spread of drug resistance."
(ProMED 9/27/2009)


Viet Nam: Ho Chi Minh City sees sudden increase of hand-foot-mouth disease

The number of children infected with hand-foot-mouth disease (HFMD) rose suddenly last week [14-20 Sep 2009], children hospitals No. 1 and 2 and Tropical Hospital in Ho Chi Minh City recently announced. Dr Truong Huu Khanh, head of the Infection and Neurology Department at Children's Hospital No. 1, said that his department had daily received more than 20 children with HFMD. Among them were 5 cases with serious nerve complications and needed respirators to breathe, he added. Although an HFMD epidemic has not broken out, the city has recorded 5 deaths due to the disease since the beginning of the year [2009], said the city's Preventive Health Center.
(ProMED 9/22/2009)


Australia: Record number of Ross River virus infections

Data from the Australian Centre of Disease Control shows up to 203 confirmed cases of Ross River virus from January to March [2009] -- the highest number since 1990. At the same time last year [2008] 94 cases were reported. Senior medical entomologist Peter Whelan said the numbers were "very high" compared to other states. The statistics showed the Darwin region accounted for most of the cases.
(ProMED 9/23/2009)


3. Updates


The following websites provide the most current information, surveillance, and guidance.

Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions: http://www.who.int/csr/disease/swineflu/frequently_asked_questions/en/index.html
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: http://www.pandemicflu.gov/
MOH Mexico: http://portal.salud.gob.mx/index_eng.html
PHA of Canada: 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.promedmail.org/



- 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/
- 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.



Mexico (Jalisco)
Jalisco state has emerged as the leader in new dengue infections. During epidemiological week 36 of 2009 (6-12 Sep 2009), 340 confirmed cases were reported, the greatest number of any Mexican state. With a total of 1,408 dengue cases recorded in 2009, Jalisco has failed to meet Secretariat of Health's goal of a 10 percent reduction in dengue cases as compared with the 1,441 cases in 2008. Jalisco has risen one spot, to 6th place, among the states with the most dengue cases in the country.
(ProMED 9/28/2009)

Philippines (Cordillera Administrative Region)
The Department of Health [DOH] has confirmed that dengue in the region is rising with 858 recorded cases compared with the 647 cases within the same period last year [2008]. According to DOH medical officer III and anti-dengue program coordinator, Dr Alexei Marrero, the DOH has already intensified its campaign against dengue in terms of advocacy and Information, Education and Communication (IEC) campaign. The office is providing logistics and technical assistance to different hospitals in the region. The DOH is also currently implementing dengue-free schools initiatives by providing mosquito insecticide treated curtains to selected areas throughout the region.
(ProMED 9/28/2009)

Philippines (Antique)
The Antique Provincial Health Office reported 210 dengue cases and 3 deaths for the period 1 Jan - 10 Sep 2009. Among the age groups that have the most number of cases are ages 1-10 years old, with 103 cases, followed by 11-20 years with 65 cases, while there are 9 cases that are below one-year-old. The Provincial Health Office and the Municipal Health Offices of the 18 towns continue to campaign for peoples' participation in the massive cleanliness and sanitation drives, particularly undertaking search and destroy operations for breeding places of mosquitoes in consonance with the order of President Gloria Macapagal-Arroyo to intensify the campaign against dengue through public health educational programs.
(ProMED 9/21/2009)

USA (Florida)
Keys health officials say they've confirmed 3 Key West cases of dengue fever. The Monroe County Health Department said one of the Key West cases, involving a New York tourist, was the 1st locally acquired case of dengue reported in the state in more than 40 years. The state Department of Health and the Centers for Disease Control and Prevention are sending a team to Key West this weekend to interview residents and take blood samples in an effort to identify the specific serotype of the virus and to determine its place of origin. In addition, the Florida Keys Mosquito Control District has increased aerial and ground spraying, and environmental surveys.
(ProMED 9/21/2009)

Viet Nam (National)
Viet Nam has recorded more than 58,000 cases of dengue fever, a 25 percent increase compared to the same period last year [2008], according to Dr. Nguyen Huy Nga, the head of the Health Ministry's Preventive Medicine and Environment Department. The numbers of dengue fever cases increased 8-fold in the North and doubled in the Central and Central Highland regions, Dr Nga said. More than 6,000 cases of dengue fever have been reported in Hanoi during the last 9 months, with half of them recorded in August alone. Dr. Nga postulates that the focus on preventing pandemic H1N1 influenza has lead to the neglect of dengue control measures.
(ProMED 9/29/2009)



Russia (Sverdlovsk)
The Center for Hygiene and Epidemiology of Sverdlovsk Oblast's report on cholera says: "The epidemic situation for quarantine infections worsened in several African and Asian countries, especially for cholera. Outbreaks are being registered, including with lethal outcomes. The situation in the Russian Federation for quarantine infections is tense because of economic and transport ties and the high level of immigration from countries which are endemic for cholera." 1,923 samples have been taken from open water bodies in Middle Ural for surveillance purposes. There were 44 positive cultures for V. cholerae O1/O139 negative (non-toxigenic). Positive cultures came from Yekaterinburg, Sukhoy Log, Bogdanvich and Kamenskoe administrative regions. Kamenskoe accounted for 82 percent of cultures. There were no positive cultures among 171 specimens from suspected cases.
(ProMED 9/30/09)

Singapore has seen a 50 percent increase in diarrhea cases at local polyclinics in the past week, local media reported 10 Sep 2009. The country's 18 polyclinics, which are government-owned clinics, treated 2990 patients for acute diarrhea last week [week of 1 Sep 2009], or about 50 percent more than the weekly average of 2072 cases, local newspaper the Straits Times reported. When polyclinics see more than 2668 cases a week, it is considered an epidemic. The last time such an outbreak happened was 2 years ago. Doctors who have seen many more cases than usual in the last 2 weeks, said it appears to be highly contagious.
(ProMED 9/21/2009)


4. Articles
Comparative Efficacy of Inactivated and Live Attenuated Influenza Vaccines

Monto AS, Ohmit SE, Petrie JG, et al. N Engl J Med. 24 September 2009; 36(13):1260-7. Available at http://content.nejm.org/cgi/reprint/361/13/1260.pdf.

Background. The efficacy of influenza vaccines may vary from year to year, depending on a variety of factors, and may differ for inactivated and live attenuated vaccines.

Methods. We carried out a randomized, double-blind, placebo-controlled trial of licensed inactivated and live attenuated influenza vaccines in healthy adults during the 2007-2008 influenza season and estimated the absolute and relative efficacies of the two vaccines.

Results. A total of 1952 subjects were enrolled and received study vaccines in the fall of 2007. Influenza activity occurred from January through April 2008, with the circulation of influenza types A (H3N2) (about 90%) and B (about 9%). Absolute efficacy against both types of influenza, as measured by isolating the virus in culture, identifying it on real-time polymerase-chain-reaction assay, or both, was 68% (95% confidence interval [CI], 46 to 81) for the inactivated vaccine and 36% (95% CI, 0 to 59) for the live attenuated vaccine. In terms of relative efficacy, there was a 50% (95% CI, 20 to 69) reduction in laboratory-confirmed influenza among subjects who received inactivated vaccine as compared with those given live attenuated vaccine. The absolute efficacy against the influenza A virus was 72% (95% CI, 49 to 84) for the inactivated vaccine and 29% (95% CI, ?14 to 55) for the live attenuated vaccine, with a relative efficacy of 60% (95% CI, 33 to 77) for the inactivated vaccine.

Conclusions. In the 2007-2008 season, the inactivated vaccine was efficacious in preventing laboratory-confirmed symptomatic influenza A (predominately H3N2) in healthy adults. The live attenuated vaccine also prevented influenza illnesses but was less efficacious. (ClinicalTrials.gov number, NCT00538512.)


Fatal co-infection with swine origin influenza virus A/H1N1 and community-acquired methicillin-resistant Staphylococcus aureus

Cheng VC, Lau Y-K, et al. Journal of Infection. 24 September 2009; 10.1016/j.jinf.2009.08.021. Available at http://www.journalofinfection.com/article/PIIS0163445309002461/.

Summary. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) co-infection has been described previously in association with respiratory tract infection caused by seasonal influenza A viruses, but not with swine origin influenza A (H1N1) virus (S-OIV). We report the clinical and pathological findings of the first death with fulminant co-infection by CA-MRSA. Since early empirical treatment with beta-lactam plus fluoroquinolone or macrolides is often initiated before specimen collections, bacterial co-infection in S-OIV may have been under-reported.


Expansion of seasonal influenza vaccination in the Americas

Ropero-Alvarez AM, Kurtis HJ, et al. BMC Public Health. 24 September 2009; 9(361); doi:10.1186/1471-2458-9-361. Available at http://www.biomedcentral.com/1471-2458/9/361/abstract.

Background. Seasonal influenza is a viral disease whose annual epidemics are estimated to cause three to five million cases of severe illness and 250,000 to 500,000 deaths worldwide. Vaccination is the main strategy for primary prevention.

Methods. To assess the status of influenza vaccination in the Americas, influenza vaccination data reported to the Pan American Health Organization (PAHO) through 2008 were analyzed.

Results. Thirty-five countries and territories administered influenza vaccine in their public health sector, compared to 13 countries in 2004. Targeted risk groups varied. Sixteen countries reported coverage among older adults, ranging from 21% to 100%; coverage data were not available for most countries and targeted populations. Some tropical countries used the Northern Hemisphere vaccine formulation and others used the Southern Hemisphere vaccine formulation. In 2008, approximately 166.3 million doses of seasonal influenza vaccine were purchased in the Americas; 30 of 35 countries procured their vaccine through PAHO's Revolving Fund.

Conclusions. Since 2004 there has been rapid uptake of seasonal influenza vaccine in the Americas. Challenges to fully implement influenza vaccination remain, including difficulties measuring coverage rates, variable vaccine uptake, and limited surveillance and effectiveness data to guide decisions regarding vaccine formulation and timing, especially in tropical countries.


Aerosol transmission of influenza A virus: a review of new studies

Tellier, R. J. R. Soc. Interface. 22 September 2009; doi:10.1098/rsif.2009.0302.focus. Available at http://rsif.royalsocietypublishing.org/content/early/2009/09/17/rsif.2009.0302.focus.full.

Abstract. Over the past few years, prompted by pandemic preparedness initiatives, the debate over the modes of transmission of influenza has been rekindled and several reviews have appeared. Arguments supporting an important role for aerosol transmission that were reviewed included prolonged survival of the virus in aerosol suspensions, demonstration of the low infectious dose required for aerosol transmission in human volunteers, and clinical and epidemiological observations were disentanglements of large droplets and aerosol transmission was possible. Since these reviews were published, several new studies have been done and generated new data. These include direct demonstration of the presence of influenza viruses in aerosolized droplets from the tidal breathing of infected persons and in the air of an emergency department; the establishment of the guinea pig model for influenza transmission, where it was shown that aerosol transmission is important and probably modulated by temperature and humidity; the demonstration of some genetic determinants of airborne transmission of influenza viruses as assessed using the ferret model; and mathematical modelling studies that strongly support the aerosol route. These recent results and their implication for infection control of influenza are discussed in this review.


Update on Vaccine-Derived Polioviruses--Worldwide, January 2008--June 2009

CDC. MMWR Morb Mortal Wkly Rep. 18 September 2009; 58(36):1002-6. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5836a3.htm?s_cid=mm5836a3_e. (references removed)

Introduction. In 1988, the World Health Assembly resolved to eradicate poliomyelitis worldwide. Subsequently, the Global Polio Eradication Initiative of the World Health Organization (WHO) reduced the global incidence of polio associated with wild polioviruses (WPVs) from an estimated 350,000 cases in 125 countries in 1988 to 1,651 reported cases in 2008 and reduced the number of countries that have never interrupted WPV transmission to four (Afghanistan, India, Nigeria, and Pakistan). Under current WHO plans, when the goal of eradicating all WPV transmission is attained, oral poliovirus vaccine (OPV) use worldwide eventually will be discontinued. However, because vaccine-derived polioviruses (VDPVs) can produce polio outbreaks in areas with low rates of Sabin OPV coverage and can replicate for years in immunodeficient persons, enhanced strategies are needed to limit emergence of VDPVs. This report updates previous summaries and describes VDPVs detected worldwide during January 2008--June 2009.


Seasonal transmission potential and activity peaks of the new influenza A(H1N1): a Monte Carlo likelihood analysis based on human mobility

Balcan D, Hu H, et al. BMC Medicine. 10 September 2009; 7(45); doi:10.1186/1741-7015-7-45. Available at http://www.biomedcentral.com/1741-7015/7/45/.

Background. On 11 June the World Health Organization officially raised the phase of pandemic alert (with regard to the new H1N1 influenza strain) to level 6. As of 19 July, 137,232 cases of the H1N1 influenza strain have been officially confirmed in 142 different countries, and the pandemic unfolding in the Southern hemisphere is now under scrutiny to gain insights about the next winter wave in the Northern hemisphere. A major challenge is pre-empted by the need to estimate the transmission potential of the virus and to assess its dependence on seasonality aspects in order to be able to use numerical models capable of projecting the spatiotemporal pattern of the pandemic.

Methods. In the present work, we use a global structured metapopulation model integrating mobility and transportation data worldwide. The model considers data on 3,362 subpopulations in 220 different countries and individual mobility across them. The model generates stochastic realizations of the epidemic evolution worldwide considering 6 billion individuals, from which we can gather information such as prevalence, morbidity, number of secondary cases and number and date of imported cases for each subpopulation, all with a time resolution of 1 day. In order to estimate the transmission potential and the relevant model parameters we used the data on the chronology of the 2009 novel influenza A(H1N1). The method is based on the maximum likelihood analysis of the arrival time distribution generated by the model in 12 countries seeded by Mexico by using 1 million computationally simulated epidemics. An extended chronology including 93 countries worldwide seeded before 18 June was used to ascertain the seasonality effects.

Results. We found the best estimate R0 = 1.75 (95% confidence interval (CI) 1.64 to 1.88) for the basic reproductive number. Correlation analysis allows the selection of the most probable seasonal behavior based on the observed pattern, leading to the identification of plausible scenarios for the future unfolding of the pandemic and the estimate of pandemic activity peaks in the different hemispheres. We provide estimates for the number of hospitalizations and the attack rate for the next wave as well as an extensive sensitivity analysis on the disease parameter values. We also studied the effect of systematic therapeutic use of antiviral drugs on the epidemic timeline.

Conclusions. The analysis shows the potential for an early epidemic peak occurring in October/November in the Northern hemisphere, likely before large-scale vaccination campaigns could be carried out. The baseline results refer to a worst-case scenario in which additional mitigation policies are not considered. We suggest that the planning of additional mitigation policies such as systematic antiviral treatments might be the key to delay the activity peak in order to restore the effectiveness of the vaccination programs.


Recent Human Influenza A/H3N2 Virus Evolution Driven by Novel Selection Factors in Addition to Antigenic Drift

Memoli MJ, Jagger BW, Dugan VG, et al. J Infect Dis. 10 September 2009; 200(8): 1232-1241. Available at http://www.journals.uchicago.edu/doi/abs/10.1086/605893.

Background. Examination of the evolutionary dynamics of complete influenza viral genomes reveals that other processes, in conjunction with antigenic drift, play important roles in viral evolution and selection, but there is little biological evidence to support these genomic data. Previous work demonstrated that after the A/Fujian/411/2002-like H3N2 influenza A epidemic during 2003-2004, a preexisting nondominant Fujian-like viral clade gained a small number of changes in genes encoding the viral polymerase complex, along with several changes in the antigenic regions of hemagglutinin, and in a genome-wide selective sweep, it replaced other co-circulating H3N2 clades.

Methods. Representative strains of these virus clades were evaluated in vitro and in vivo.

Results. The newly dominant 2004-2005 A/California/7/2004-like H3N2 clade, which featured 2 key amino acid changes in the polymerase PA segment, grew to higher titers in MDCK cells and ferret tissues and caused more-severe disease in ferrets. The polymerase complex of this virus demonstrated enhanced activity in vitro, correlating directly to the enhanced replicative fitness and virulence in vivo.

Conclusion. These data suggest that influenza strains can be selected in humans through mutations that increase replicative fitness and virulence, in addition to the well-characterized antigenic changes in the surface glycoproteins.


Modelling the progression of pandemic influenza A (H1N1) in Vietnam and the opportunities for reassortment with other influenza viruses

Boni MF, Manh BH, et al. BMC Medicine. 3 September 2009; 7(43); doi:10.1186/1741-7015-7-43. Available at http://www.biomedcentral.com/1741-7015/7/43/.

Background. A novel variant of influenza A (H1N1) is causing a pandemic and, although the illness is usually mild, there are concerns that its virulence could change through reassortment with other influenza viruses. This is of greater concern in parts of Southeast Asia, where the population density is high, influenza is less seasonal, human-animal contact is common and avian influenza is still endemic.

Methods. We developed an age- and spatially-structured mathematical model in order to estimate the potential impact of pandemic H1N1 in Vietnam and the opportunities for reassortment with animal influenza viruses. The model tracks human infection among domestic animal owners and non-owners and also estimates the numbers of animals may be exposed to infected humans.

Results. In the absence of effective interventions, the model predicts that the introduction of pandemic H1N1 will result in an epidemic that spreads to half of Vietnam's provinces within 57 days (interquartile range (IQR): 45-86.5) and peaks 81 days after introduction (IQR: 62.5-121 days). For the current published range of the 2009 H1N1 influenza's basic reproductive number (1.2-3.1), we estimate a median of 410,000 cases among swine owners (IQR: 220,000-670,000) with 460,000 exposed swine (IQR: 260,000-740,000), 350,000 cases among chicken owners (IQR: 170,000-630,000) with 3.7 million exposed chickens (IQR: 1.9 M-6.4 M), and 51,000 cases among duck owners (IQR: 24,000 - 96,000), with 1.2 million exposed ducks (IQR: 0.6 M-2.1 M). The median number of overall human infections in Vietnam for this range of the basic reproductive number is 6.4 million (IQR: 4.4 M-8.0 M).

Conclusion. It is likely that, in the absence of effective interventions, the introduction of a novel H1N1 into a densely populated country such as Vietnam will result in a widespread epidemic. A large epidemic in a country with intense human-animal interaction and continued co-circulation of other seasonal and avian viruses would provide substantial opportunities for H1N1 to acquire new genes.


5. Notifications
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 2009 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.


World Response Conference on Global Outbreak 2009: H1N1 Flu + H5N1 Flu
Las Vegas, Nevada, 12-13 Nov 2009

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/.


ISHEID Symposium on HIV and Emerging Infectious Diseases

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: http://ems6.net/r/?F=t52gxqgrsuxuaj8rzw4tzbgnse3bjbkvlppph78fc3wvvx2943s5v72-1224022

Preliminary program: http://ems6.net/r/?F=t52gxqgrsuxuaj8rzw4tzbgnstb7z348677srxae9269mghaltvxj72-1224022

Registration and hotel booking are open on-line, we recommend you to secure your participation.

The ISHEID 2010 congress organizing office...
E-mail: isheid@clq-group.com; Ph. : +33 1 44 64 15 15 - Fax : +33 1 44 64 15 16


HealthMap: Global Disease Alert Map

HealthMap brings together disparate data sources to achieve a unified and comprehensive view of the current global state of infectious diseases and their effect on human and animal health. This freely available Web site integrates outbreak data of varying reliability, ranging from news sources (such as Google News) to curated personal accounts (such as ProMED) to validated official alerts (such as World Health Organization).
Available at http://www.healthmap.org/.


Updated influenza guidance and information from the US CDC

2009 H1N1 Influenza Vaccine and Seniors
Released 30 Sep 2009
Available at http://www.cdc.gov/H1N1flu/vaccination/vaccine_seniors.htm.

Interim Recommendations for Clinical Use of Influenza Diagnostic Tests During the 2009-10 Influenza Season
Released 29 Sep 2009
Available at http://www.cdc.gov/h1n1flu/guidance/diagnostic_tests.htm.

Questions & Answers: Interim Recommendations for Clinical Use of Influenza Diagnostic Testing During the 2009-2010 Influenza Season - For Health Care Providers
Released 29 Sep 2009
Available at http://www.cdc.gov/h1n1flu/diagnostic_testing_clinicians_qa.htm.

Questions & Answers: Influenza Diagnostic Testing During the 2009-2010 Flu Season - For the Public
Released 29 Sep 2009
Available at http://www.cdc.gov/h1n1flu/diagnostic_testing_public_qa.htm.

CDC Says "Take 3" Steps To Fight The Flu
Released 25 Sep 2009
Available at http://www.cdc.gov/flu/freeresources/2009-10/pdf/h1n1_take3.pdf.

Use of Antiviral Medicines for the Treatment and Prevention of Flu among Pregnant Women for the 2009-2010 Season
Released 25 Sep 2009
Available at http://www.cdc.gov/H1N1flu/pregnancy/antiviral_pregnant_qa.htm.

Flyer: 2009 H1N1 and Seasonal Flu: What To Do If You Get Sick
Released 25 Sep 2009
Available at http://www.cdc.gov/flu/freeresources/2009-10/pdf/what_to_do_if_you_get_sick.pdf.

CDC Health Alert Network (HAN) Info Service Message: Updated Pediatric Antiviral Dosing Syringe and Compounding Information for 2009 H1N1 and Seasonal Flu
Released 25 Sep 2009
Available at >http://www.cdc.gov/h1n1flu/HAN/092509.htm.


Updated Arabic, French, & Russian translations of influenza information from the US CDC
Released 25 Sep 2009.

Action Steps for Parents of Children at High Risk for Flu Complications
Available at http://www.cdc.gov/h1n1flu/schools/toolkit/parentfactsheet3.htm.

Action Steps for Parents to Protect Your Child and Family from the Flu this School Year
Available at http://www.cdc.gov/h1n1flu/schools/toolkit/parentfactsheet2.htm.

Emergency Use Authorization of Tamiflu (oseltamivir)
Available at http://www.cdc.gov/h1n1flu/eua/tamiflu.htm.

Preparing for the Flu: A Communication Toolkit for Institutions of Higher Education
Available at http://www.cdc.gov/h1n1flu/institutions/toolkit/.

Action Steps for Parents if School is Dismissed or Children are Sick and Must Stay Home
Available at http://www.cdc.gov/h1n1flu/schools/toolkit/parentfactsheet.htm.