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EINet Alert ~ Oct 09, 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: No need to change vaccine policy based on Canadian vaccination data
- Global: UN officials call for more donated vaccine
- Europe: EU approves Baxter's pandemic H1N1 cell-based vaccine
- Japan: Excreted oseltamivir found in rivers
- Mexico: High Level North American Meeting in Response to 2009 Influenza A (H1N1)
- Canada: H1N1 vaccination campaign to begin in November
- Cuba: Government requests international assistance in acquiring H1N1 vaccine
- USA: CDC unveils system to gather data on flu-like illness
- USA (New York City): First wave of 2009 pandemic H1N1 may have given some protection
- USA: Guidance targets pandemic-related business concerns regarding disability law
- USA: Health workers get first pandemic flu vaccine doses

2. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA

3. Articles
- Evidenced-based tool for triggering school closures during influenza outbreaks, Japan.
- Hospitalized Patients with 2009 H1N1 Influenza in the United States, April-June 2009
- Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand
- Partial protection of seasonal trivalent inactivated vaccine against novel pandemic influenza A/H1N1 2009: case-control study in Mexico City
- Initial psychological responses to Influenza A, H1N1 ("Swine flu")
- Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers: A Randomized Trial
- Oseltamivir Carboxylate--the Active Metabolite of Oseltamivir Phosphate (Tamiflu), Detected in Sewage Discharge and River Water in Japan
- Potential Risks Associated with the Proposed Widespread Use of Tamiflu

4. 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
- Updated guidance on pandemic influenza H1N1 from the US CDC


1. Influenza News

Global
Weekly APEC update of pandemic influenza H1N1

China
China reported its first death due to A (H1N1) influenza on 6 Oct 2009. An 18-year-old woman in the Tibet Autonomous Region died of the virus 4 Oct 2009 at the county hospital. The Health Ministry sent 200,000 doses of vaccine to Lhasa by air on 6 Oct 2009 to help contain the virus from spreading in the region. Through 6 October 2009, there have been a total of 21,453 confirmed cases of H1N1 pandemic influenza.

Thailand
The Public Health Ministry on 7 Oct 2009 announced an end to the weekly report on the number of A (H1N1) flu victims after there were no more deaths from the virus during the past week. The total number of deaths from the A (H1N1) flu stands at 165. He attributed the drop in the number of deaths to the work of village health volunteers, saying they have been able to effectively introduce protective measures against the flu.

Viet Nam
There have now been 9,562 confirmed cases of influenza A (H1N1) infection, with 59 of the 63 provinces and cities reporting cases. The ministry also reported that 8,352 of these patients have been discharged from their hospitals, while remaining cases are undergoing treatment but are in stable condition. The Health Ministry has not yet officially confirmed the 19th and 20th deaths even though they tested positive for the virus.
(ProMED 10/07/2009)

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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 (WHO/WPRO 9/10/09)

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.htm

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Global: WHO situation update on pandemic influenza H1N1

As of 27 September 2009, worldwide there have been more than 340,000 laboratory confirmed cases of pandemic influenza H1N1 2009 and over 4100 deaths reported to WHO. As many 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.

Transmission of influenza virus and rates of influenza-like-illness (ILI) continue to increase in the temperate regions of the northern hemisphere. In North America, influenza transmission is geographically widespread and continues to increase. Levels of ILI have continued to increase and remain above the seasonal baseline for the past 4 weeks in most regions of the United States. In Mexico, a high intensity of respiratory diseases has been reported for two consecutive weeks (week 37 - 38), with large increases in cases being reported in the north and northwest of the country. In Europe and Central and Western Asia, although overall influenza activity remains low an increase in transmission has been noted in a number of countries and continues to intensify in others. Rates of influenza-like-illness continue to be above baseline levels in Ireland, parts of the United Kingdom (Northern Ireland), Israel, and France; in addition, more than 10 other countries in the region have reported geographically localized spread of influenza. In Japan, influenza activity has continued to increase above the seasonal epidemic threshold since week 33. These 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 transmission remains active but the trends in respiratory diseases activity are mixed. Although respiratory disease activity is geographically regional to widespread throughout the tropical region of the Americas, many countries have been recently reporting a declining trend (Bolivia, Brazil, Costa Rica, El Salvador, Panama, Paraguay, Venezuela), while others recently reported an increasing trend (Columbia and Cuba). In tropical regions of Asia, there continues to be an increasing trend in respiratory diseases in parts of India and in Cambodia, while other countries in the Southeast Asia have been recently reporting declining transmission.

In the temperate regions of the southern hemisphere, influenza transmission has largely returned to baseline (Chile, Argentina, and New Zealand) or has declined substantially (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), supported by WHO Collaborating Centres and other laboratories, continues to detect sporadic incidents of H1N1 pandemic viruses that show resistance to the antiviral oseltamivir. To date, 28 resistant pandemic H1N1 influenza 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. No new resistant pandemic H1N1 influenza viruses have been officially reported to WHO during the past week. Worldwide, more than 10,000 clinical specimens (samples and isolates) of the pandemic H1N1 virus have been tested and found to be sensitive to oseltamivir.
(WHO 10/02/2009)

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Global: No need to change vaccine policy based on Canadian vaccination data

WHO has stated that there is no need for changing vaccination policies in light of a Canadian study which claimed heightened susceptibility to pandemic H1N1 infection following seasonal influenza vaccination. The consensus that emerged from a WHO teleconference 2 October 2009 on the controversial data seemed to be that the Canadian findings are likely due to confounding rather than a true increased risk of infection. According to David Wood, of WHO's department of immunization, vaccines and biologicals, none of the participants on the 4.5 hour conference call were able to definitively identify the confounding factor(s). He postulated that new prospective studies would be needed to get a definitive answer.

In the meantime, a summary of the situation will be presented to the WHO's Strategic Advisory Group of Experts on immunization, also known as the SAGE. The group, which meets later this month, makes recommendations for the WHO on vaccination policy. Though he cannot predict SAGE's eventual decision, Wood believes it is unlikely that the WHO will ask countries to change their vaccination programs this fall based on evidence from a single country.
(The Canadian Press 10/04/2009)

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Global: UN officials call for more donated vaccine

Though some vaccine companies and affluent nations have already donated supplies of pandemic flu vaccine to developing nations, more is needed, officials from the World Health Organization (WHO) and the United Nations said 03 October 2009. Julie Hall, an infectious disease expert at the WHO, said more readiness is needed in developing countries, especially if a different pattern is seen when big outbreaks hit poorer countries.
(CIDRAP 10/04/2009)

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Europe/Near East
Europe: EU approves Baxter's pandemic H1N1 cell-based vaccine

The European Commission approved Baxter International's pandemic H1N1 vaccine, Celvapan, for use in the European Union, the company announced. It is the first cell culture-based H1N1 vaccine as well as the first non-adjuvanted product to win European approval. The EU authorization calls for using two doses of the vaccine in adults and children; the company is awaiting trial results to determine if one dose will be sufficient in adults.
(CIDRAP 10/07/2009)

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Asia
Japan: Excreted oseltamivir found in rivers

Oseltamivir [Tamilflu] has been found to contaminate rivers downstream from sewage-treatment facilities in Japan. Concerns are now building that waterfowl, which are natural influenza carriers, are being exposed to waterborne residues of Tamiflu's active form and might develop and spread drug-resistant strains of seasonal and avian influenza. There is little chance of resistant pandemic H1N1 developing in exposed birds because the virus seems to bypass birds as it spreads among people.
(ProMED 10/03/2009)

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Americas
Mexico: High Level North American Meeting in Response to 2009 Influenza A (H1N1)

The Government of Mexico 5 October 2009 hosted a meeting with senior officials from Canada and the United States as part of ongoing North American efforts to address the challenges posed by the 2009 Influenza A(H1N1). The objectives of the meeting were for the three countries to take stock of efforts to date, and to continue sharing lessons learned and strategies to further prepare for and respond to the 2009 Influenza A(H1N1) virus.

Following the Summit of Health Ministers in Cancun in July and the declaration issued at the North American Leaders Summit in Guadalajara in August and building on the North American Plan for Avian and Pandemic Influenza, officials emphasized the importance of ongoing and enhanced collaboration among the three countries in responding to the spread of 2009 Influenza A(H1N1).
(Health Canada 10/05/2009)

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Canada: H1N1 vaccination campaign to begin in November

Canada's national campaign to vaccinate residents against the H1N1 flu is likely to begin in early November because attempts to move up the shots' delivery have not been successful, according to the Canadian Press. The US campaign uses multiple suppliers and began with a roll-out of aerosol vaccine; Canada uses only one manufacturer, and aerosol vaccine is not approved for sale there.
(CIDRAP 10/06/2009)

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Cuba: Government requests international assistance in acquiring H1N1 vaccine

The Cuban government has asked the World Health Organization (WHO) and the Pan American Health Organization to help the country acquire H1N1 vaccine, saying the formula is too expensive for it to afford on its own. The island nation has officially recorded 468 cases of H1N1 flu but no deaths since the pandemic began.
(CIDRAP 10/06/2009)

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USA: CDC unveils system to gather data on flu-like illness

The CDC announced the launch of a system to gather data about influenza-like illness (ILI) from syndromic surveillance systems run by health departments in cooperation with hospital emergency departments. The system, called Distribute, enhances existing flu surveillance by providing more details on geographic- and age-specific trends. The system involves a partnership of the CDC with the International Society for Disease Surveillance and the Public Health Informatics Institute.
(CIDRAP 10/08/2009)

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USA (New York City): First wave of 2009 pandemic H1N1 may have given some protection

New York City and a few other cities that had significant H1N1 outbreaks in the spring are seeing little activity now, leading to suggestions that the spring wave spawned a significant level of population immunity, the New York Times reported. City health officials believe that perhaps 20% to 40% of the population were exposed to the virus in the spring and gained immunity. But city officials and other experts agreed it would be unwise to assume that New Yorkers don't need the H1N1 vaccine.
(CIDRAP 10/08/2009)

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USA: Guidance targets pandemic-related business concerns regarding disability law

Businesses that take steps to protect workers during a pandemic have worried about staying in compliance with the Americans with Disabilities Act (ADA), and federal officials have responded by issuing new guidance that addresses many of the issues.

One of the top business worries is protecting workers who have underlying health conditions, but according to the new 14-page guidance document from the US Equal Employment Opportunity Commission (EEOC), issued on Oct 5, employers are barred from asking about chronic conditions unless the pandemic becomes severe. The guidance helps steer employers away from asking "disability related" questions, such as asking an employee if he or she has immune system compromise, which might suggest cancer or HIV. It also clarifies if pandemic flu is a "direct threat" according to ADA rules. A direct threat might trigger disability medical questions or medical examinations. The EEOC guidance says the flu isn't considered a direct threat if health authorities say the illness is like seasonal influenza or patterns that were seen in the spring and summer wave. However, the pandemic would be considered a direct threat if public officials determine it has become more severe.
(CIDRAP 10/07/2009)

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USA: Health workers get first pandemic flu vaccine doses

The nation's first doses of the pandemic H1N1 vaccine were administered today, mainly to a limited group of healthcare workers and emergency medical service workers. Federal, state, and local officials were on hand to witness the events at medical facilities in Memphis and Indianapolis. The very first doses were given to healthcare workers at Le Bonheur Children's Medical Center in Memphis, according to a press release from the hospital. Doctors, nurses, and respiratory therapists who work in the hospital's emergency department and intensive care units were in the first group to receive the live attenuated nasal mist form of the H1N1 flu vaccine, made by MedImmune. Pediatric physicians, residents, and infectious disease specialists were also among Le Bonheur's first recipients. About 150 workers lined up to receive the vaccine.
(CIDRAP 10/05/2009)

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2. Updates
INFLUENZA A/H1N1

The following websites provide the most current information and advice.

- WHO
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions: http://www.who.int/csr/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/

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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/
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm. Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library's Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds and poultry.

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3. Articles
Evidenced-based tool for triggering school closures during influenza outbreaks, Japan.

Sasaki A, Gatewood A, Ozonoff A, Suzuki H, Tanabe N, Seki N, et al. Emerg Infect Dis. 2009 Nov; [Epub ahead of print]. Available at http://www.cdc.gov/eid/content/15/11/pdfs/09-0798.pdf.

Summary. For optimal social distancing in a flu outbreak, schools should consider closing when they reach 5% absenteeism on a single day, 4% on 2 consecutive days or 3% on each of 3 days, researchers in Boston and Niigata, Japan, say. The group based its recommendation on absentee data gathered over four flu seasons from one 54-school district in Japan. [Summary provided by CIDRAP 10/05/2009]

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Hospitalized Patients with 2009 H1N1 Influenza in the United States, April-June 2009

Jain S, Kamimoto Laurie, Bramley AM, et al. N Engl J Med. 08 October 2009; 10.1056/NEJMoa0906695. Available at http://content.nejm.org/cgi/content/full/NEJMoa0906695?query=TOC.

Background. During the spring of 2009, a pandemic influenza A (H1N1) virus emerged and spread globally. We describe the clinical characteristics of the patients who were hospitalized with 2009 H1N1 influenza in the United States from April 2009 to mid-June 2009.

Methods. Using medical charts, we collected data on 272 patients who were hospitalized for at least 24 hours for influenza-like illness and who tested positive for the 2009 H1N1 virus with the use of a real-time reverse-transcriptase-polymerase-chain-reaction assay.

Results. Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. Forty-five percent of the patients were children under the age of 18 years, and 5% were 65 years of age or older. Seventy-three percent of the patients had at least one underlying medical condition; these conditions included asthma; diabetes; heart, lung, and neurologic diseases; and pregnancy. Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings consistent with pneumonia. Of the 268 patients for whom data were available regarding the use of antiviral drugs, such therapy was initiated in 200 patients (75%) at a median of 3 days after the onset of illness. Data suggest that the use of antiviral drugs was beneficial in hospitalized patients, especially when such therapy was initiated early.

Conclusions. During the evaluation period, 2009 H1N1 influenza caused severe illness requiring hospitalization, including pneumonia and death. Nearly three quarters of the patients had one or more underlying medical conditions. Few severe illnesses were reported among persons 65 years of age or older. Patients seemed to benefit from antiviral therapy.

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Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand

The ANZIC Influenza Investigators. N Engl J Med. 08 October 2009; 10.1056/NEJMoa0908481. Available at http://content.nejm.org/cgi/content/full/NEJMoa0908481?query=TOC.

Background. Planning for the treatment of infection with the 2009 pandemic influenza A (H1N1) virus through health care systems in developed countries during winter in the Northern Hemisphere is hampered by a lack of information from similar health care systems.

Methods. We conducted an inception-cohort study in all Australian and New Zealand intensive care units (ICUs) during the winter of 2009 in the Southern Hemisphere. We calculated, per million inhabitants, the numbers of ICU admissions, bed-days, and days of mechanical ventilation due to infection with the 2009 H1N1 virus. We collected data on demographic and clinical characteristics of the patients and on treatments and outcomes.

Results. From June 1 through August 31, 2009, a total of 722 patients with confirmed infection with the 2009 H1N1 virus (28.7 cases per million inhabitants; 95% confidence interval [CI], 26.5 to 30.8) were admitted to an ICU in Australia or New Zealand. Of the 722 patients, 669 (92.7%) were under 65 years of age and 66 (9.1%) were pregnant women; of the 601 adults for whom data were available, 172 (28.6%) had a body-mass index (the weight in kilograms divided by the square of the height in meters) greater than 35. Patients infected with the 2009 H1N1 virus were in the ICU for a total of 8815 bed-days (350 per million inhabitants). The median duration of treatment in the ICU was 7.0 days (interquartile range, 2.7 to 13.4); 456 of 706 patients (64.6%) with available data underwent mechanical ventilation for a median of 8 days (interquartile range, 4 to 16). The maximum daily occupancy of the ICU was 7.4 beds (95% CI, 6.3 to 8.5) per million inhabitants. As of September 7, 2009, a total of 103 of the 722 patients (14.3%; 95% CI, 11.7 to 16.9) had died, and 114 (15.8%) remained in the hospital.

Conclusions. The 2009 H1N1 virus had a substantial effect on ICUs during the winter in Australia and New Zealand. Our data can assist planning for the treatment of patients during the winter in the Northern Hemisphere.

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Partial protection of seasonal trivalent inactivated vaccine against novel pandemic influenza A/H1N1 2009: case-control study in Mexico City

Garcia-Garcia L, Valdespino-Gómez JL, et al. BMJ. 6 October 2009; 339:b3928. Available at http://www.bmj.com/cgi/content/full/339/oct06_2/b3928/.

Objective. To evaluate the association of 2008-9 seasonal trivalent inactivated vaccine with cases of influenza A/H1N1 during the epidemic in Mexico.

Design. Frequency matched case-control study.

Setting. Specialty hospital in Mexico City, March to May 2009.

Participants. 60 patients with laboratory confirmed influenza A/H1N1 and 180 controls with other diseases (not influenza-like illness or pneumonia) living in Mexico City or the State of Mexico and matched for age and socioeconomic status.

Main outcome measures. Odds ratio and effectiveness of trivalent inactivated vaccine against influenza A/H1N1.

Results. Cases were more likely than controls to be admitted to hospital, undergo invasive mechanical ventilation, and die. Controls were more likely than cases to have chronic conditions that conferred a higher risk of influenza related complications. In the multivariate model, influenza A/H1N1 was independently associated with trivalent inactivated vaccine (odds ratio 0.27, 95% confidence interval 0.11 to 0.66) and underlying conditions (0.15, 0.08 to 0.30). Vaccine effectiveness was 73% (95% confidence interval 34% to 89%). None of the eight vaccinated cases died.

Conclusions. Preliminary evidence suggests some protection from the 2008-9 trivalent inactivated vaccine against pandemic influenza A/H1N1 2009, particularly severe forms of the disease, diagnosed in a specialty hospital during the influenza epidemic in Mexico City.

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Initial psychological responses to Influenza A, H1N1 ("Swine flu")

Goodwin R, Haque S, et al. BMC Infectious Diseases. 06 October 2009; 9:166. Available at http://www.biomedcentral.com/1471-2334/9/166/abstract/.

Background. The outbreak of the pandemic flu, Influenza A H1N1 (Swine Flu) in early 2009, provided a major challenge to health services around the world. Previous pandemics have led to stockpiling of goods, the victimisation of particular population groups, and the cancellation of travel and the boycotting of certain foods (e.g. pork). We examined initial behavioural and attitudinal responses towards Influenza A, H1N1 ("Swine flu") in the six days following the WHO pandemic alert level 5, and regional differences in these responses.

Methods. 328 respondents completed a cross-sectional internet or paper-based questionnaire study in Malaysia (N = 180) or Europe (N = 148). Measures assessed changes in transport usage, purchase of preparatory goods for a pandemic, perceived risk groups, indicators of anxiety, assessed estimated mortality rates for seasonal flu, effectiveness of seasonal flu vaccination, and changes in pork consumption

Results. 26% respondents were 'very concerned' about being a flu victim (42% Malaysians, 5% Europeans, p<.001). 36% reported reduced public transport use (48% Malaysia, 22% Europe, pp<.001), 39% flight cancellations (56 % Malaysia, 17% Europe, pp<.001). 8% had purchased preparatory materials (e.g. face masks: 8% Malaysia, 7% Europe), 41% Malaysia (15% Europe) intended to do so (pp<.001). 63% of Europeans, 19% of Malaysians had discussed the pandemic with friends (pp<.001). Groups seen as at 'high risk' of infection included the immune compromised (mentioned by 87% respondents), pig farmers (70%), elderly (57%), prostitutes/ highly sexually active (53%), and the homeless (53%). In data collected only in Europe, 64% greatly underestimated the mortality rates of seasonal flu, 26% believed seasonal flu vaccination gave protection against swine flu. 7% had reduced / stopped eating pork. 3% had purchased anti-viral drugs for use at home, while 32% intended to do so if the pandemic worsened.

Conclusions. Initial responses to Influenza A show large regional differences in anxiety, with Malaysians more anxious and more likely to reduce travel and to buy masks and food. Discussions with family and friends may reinforce existing anxiety levels. Particular groups (homosexuals, prostitutes, the homeless) are perceived at greater risk, potentially leading to increased prejudice during a pandemic. Europeans underestimated mortality of seasonal flu, and require more information about the protection given by seasonal flu inoculation.

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Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers: A Randomized Trial

Loeb M, Dafoe N et al. JAMA. 01 October 2009; 302(17):(doi:10.1001/jama.2009.1466). Available at http://jama.ama-assn.org/cgi/content/full/2009.1466.

Context. Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse. Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance.

Objective. To compare the surgical mask with the N95 respirator in protecting health care workers against influenza.

Design, Setting, and Participants. Noninferiority randomized controlled trial of 446 nurses in emergency departments, medical units, and pediatric units in 8 tertiary care Ontario hospitals.

Intervention. Assignment to either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season.

Main Outcome Measures. The primary outcome was laboratory-confirmed influenza measured by polymerase chain reaction or a 4-fold rise in hemagglutinin titers. Effectiveness of the surgical mask was assessed as noninferiority of the surgical mask compared with the N95 respirator. The criterion for noninferiority was met if the lower limit of the 95% confidence interval (CI) for the reduction in incidence (N95 respirator minus surgical group) was greater than -9%.

Results. Between September 23, 2008, and December 8, 2008, 478 nurses were assessed for eligibility and 446 nurses were enrolled and randomly assigned the intervention; 225 were allocated to receive surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group (absolute risk difference, -0.73%; 95% CI, -8.8% to 7.3%; P = .86), the lower confidence limit being inside the noninferiority limit of -9%.

Conclusion. Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza.

Trial Registration. clinicaltrials.gov Identifier: NCT00756574

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Oseltamivir Carboxylate--the Active Metabolite of Oseltamivir Phosphate (Tamiflu), Detected in Sewage Discharge and River Water in Japan

Ghosh, GC et al. EHP. 28 September 2009; doi: 10.1289/ehp.0900930. Available at http://www.ehponline.org/members/2009/0900930/0900930.pdf.

Background. Oseltamivir phosphate (OP; Tamiflu) is a prodrug of the anti-influenza neuraminidase inhibitor oseltamivir carboxylate (OC), and has been developed for the treatment and prevention of both A and B strains of influenza. The recent increase in OP resistance in influenza A virus (H1N1) has raised questions about the widespread use of Tamiflu in seasonal epidemics and the potential ecotoxicological risk associated with its use in the event of a pandemic.

Objectives. (1) To develop an analytical method for quantitative determination of OC in sewage treatment plant (STP) effluent and receiving river water. (2) To investigate the occurrence of OC in STP effluent and river water in Japan during a seasonal flu outbreak.

Methods. We developed a successful analytical method based on solid-phase extraction followed by liquid chromatography - tandem mass spectrometry. Three sampling campaigns were conducted during the 2008-09 flu season in Kyoto City, Japan.

Results. The highest concentration of OC detected in STP discharge was 293.3 ng/L from a conventional activated-sludge-based STP, but only 37.9 ng/L from an advanced STP with ozonation as a tertiary treatment. In the receiving river water samples, OC was detected in the range of 6.6 to190 ng/L.

Conclusion. OC is present in STP effluent and river water only during the flu season. Ozonation as tertiary treatment in STP will substantially reduce the OC load in STP effluent during an influenza epidemic or pandemic.

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Potential Risks Associated with the Proposed Widespread Use of Tamiflu

Singer AC, Nunn MA, et al. EHP. January 2007; doi:10.1289/ehp.9574. Available at http://www.ehponline.org/docs/2006/9574/abstract.html.

Background. The threat of pandemic influenza has focused attention and resources on virus surveillance, prevention, and containment. The World Health Organization has strongly recommended the use of the antiviral drug Tamiflu both to treat and prevent pandemic influenza infection. A major concern for the long-term efficacy of this strategy is to limit the development of Tamiflu-resistant influenza strains. However, in the event of a pandemic, hundreds of millions of courses of Tamiflu, stockpiled globally, will be rapidly deployed. Given its apparent resistance to biodegradation and hydrophilicity, oseltamivir carboxylate (OC) , the active antiviral and metabolite of Tamiflu, is predicted to enter receiving riverwater from sewage treatment works in its active form.

Objective. Our objective in this study was to determine the likely concentrations of OC released into U.S. and U.K. river catchments using hydrologic modeling and current assumptions about the course and management of an influenza pandemic.

Discussion. We predict that high concentrations of OC (micrograms per liter) capable of inhibiting influenza virus replication would be sustained for periods of several weeks, presenting an increased risk for the generation of antiviral resistance and genetic exchange between influenza viruses in wildfowl. Owing to the apparent recalcitrance of OC in sewage treatment works, widespread use of Tamiflu during an influenza pandemic also poses a potentially significant, uncharacterized, ecotoxicologic risk in each affected nation's waterways.

Conclusion. To gauge the hazard presented by Tamiflu use during a pandemic, we recommend a) direct measurement of Tamiflu persistence, biodegradation, and transformation in the environment ; b) further modeling of likely drug concentrations in the catchments of countries where humans and waterfowl come into frequent close contact, and where significant Tamiflu deployment is envisaged ; and c) further characterization of the risks of generating Tamiflu-resistant viruses in OC-exposed wildfowl.

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4. 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.

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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/.

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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 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

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Updated guidance on pandemic influenza H1N1 from the US CDC

H1N1 Clinicians Questions and Answers
Released 08 Oct 2009.
Available at http://www.cdc.gov/h1n1flu/vaccination/clinicians_qa.htm.

Template Letter for Healthcare Providers about the Vaccine Adverse Event Reporting System (VAERS)
Released 06 Oct 2009.
Available at http://www.cdc.gov/H1N1flu/vaccination/statelocal/letter_template_HCP.htm.

Healthcare Providers and Facilities - Decision Tree for 2009 H1N1 Vaccination
Released 06 Oct 2009.
Available at http://www.cdc.gov/H1N1flu/vaccination/decisiontree.htm.

2009-2010 Influenza Season Triage Algorithm for Adults (>18 Years) With Influenza-Like Illness
Released 02 Oct 2009.
Available at http://www.cdc.gov/h1n1flu/clinicians/pdf/adultalgorithm.pdf.

Patients with Asthma: Considerations for Clinicians Regarding 2009 H1N1 Influenza Virus
Released 02 Oct 2009.
Available at http://www.cdc.gov/h1n1flu/asthma_clinicians.htm.

2009 H1N1 Influenza Vaccine and Pregnant Women: Information for Healthcare Providers
Released 02 Oct 2009.
Available at http://www.cdc.gov/h1n1flu/vaccination/providers_qa.htm.

Vaccine Information Statement (VIS) for Live, Intranasal 2009 H1N1 Influenza Vaccine
Released 02 Oct 2009.
Available in English (http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-laiv-h1n1.pdf), Spanish (http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-laiv-h1n1-sp.pdf), & Simplified Chinese (http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-laiv-h1n1-ch.pdf).

Vaccine Information Statement (VIS) for Inactivated 2009 H1N1 Influenza Vaccine
Released 02 Oct 2009.
Available in English (http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-inact-h1n1.pdf), Spanish (http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-inact-h1n1-sp.pdf), & Simplified Chinese (http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-inact-h1n1-ch.pdf).

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 apecein@u.washington.edu