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Vol. XII, No. 21 ~ EINet News Briefs ~ Oct 16, 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: Children under 10 need two Sanofi pandemic H1N1 influenza vaccine doses
- Global: WHO sees November pandemic H1N1 vaccine delivery to developing nations
- Spain (Castile-La Mancha): Highly pathogenic avian influenza kills 30,000 chickens
- Australia (Queensland): Novel H1N1 detected at a pig farm
- China: Mecca pilgrims to be vaccinated against flu
- Japan: Tamiflu-resistant H1N1 teen had no Tamiflu record
- Viet Nam: Study of pandemic H1N1 viral clearance
- Cuba: Pregnant women are Cuba's first H1N1 deaths
- Mexico: Purchase of 10 million additional doses of pandemic H1N1 vaccine
- USA: FDA faces decision about emergency use of peramivir for H1N1
- USA: Pandemic H1N1 vaccine trials in HIV-infected groups
- USA: Pediatric H1N1 deaths already rival seasonal flu total
- USA: Preliminary data suggests seasonal and pandemic influenza vaccines may be given together

2. Infectious Disease News
- China (Shaanxi): Fatal Hand, Foot and Mouth Disease
- Indonesia (North Sumatra): Suspected Chikungunya Outbreak
- Malaysia (Sarawak): Chikungunya on the rise
- New Zealand (North Island): Meningococcal Meningitis
- Russia (Voronezh): Brucellosis infects 10 farm workers
- Russia (Tatarstan): 20 new cases of HFRS Hemorrhagic Fever with Renal Syndrome (HFRS)
- Viet Nam: Severe Hand, Foot and Mouth Disease in 2009

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

4. Articles
- Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome
- Critically Ill Patients With 2009 Influenza A(H1N1) in Mexico
- Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada
- Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome
- Chest Radiographic and CT Findings in Novel Swine-Origin Influenza A (H1N1) Virus (S-OIV) Infection
- Imaging Findings in a Fatal Case of Pandemic Swine-Origin Influenza A (H1N1)

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
- EPIDEMICS²: Second International Conference on Infectious Diseases Dynamics
- Updated influenza guidance and information from the US CDC


1. Influenza News

Global
Weekly APEC update of pandemic influenza (H1N1) 2009

Viet Nam
Vietnam confirmed 76 more cases of A/H1N1 influenza, bringing the total number of flu patients in the country to 10,124, said a daily report on the website of the Ministry of Health on 15 October 2009. Of the total, 9,437 patients have been discharged from hospitals due to their recovery, said the ministry. The rest are being quarantined and treated. So far, Vietnam has reported 23 deaths of A/H1N1 influenza since the first case was confirmed in the country, according to the report.
(healthmap.org 10/15/2009)

South Korea
South Korea on 13 October 2009 reported its fifteenth death related to A/H1N1 flu. The country reported its first new flu outbreak in early May, and so far the new virus has claimed the lives of 15 people, including a two-month-old infant. The other 14 victims were all categorized as high-risk, according to local media.
(healthmap.org 10/12/2009)

Chinese Taipei
Two new cases of influenza A(H1N1), were confirmed 11 October 2009, bringing the total number of such cases to 349 since the outbreak began, the Central Epidemic Command Center (CECC) reported. Some 24 of the 349 are still in hospital, although the A(H1N1) outbreak in the country has been showing signs of abating over the past few weeks. Meanwhile, as of 4:00 p.m. on Oct. 9, 419 classes in 265 schools around the country remained closed because of A(H1N1) infections among students.
(healthmap.org 10/12/2009)

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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 (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

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Global: WHO situation update on pandemic influenza H1N1

As of 4 October 2009, worldwide there have been more than 375,000 laboratory confirmed cases of pandemic influenza H1N1 2009 and over 4500 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. WHO is actively monitoring the progress of the pandemic through frequent consultations with the WHO Regional Offices and member states and through monitoring of multiple sources of data.

In the temperate regions of the Northern Hemisphere, transmission of influenza virus and rates of influenza-like-illness (ILI) continue to increase marking an unusually early start to fall and winter influenza season in many countries. Geographically widespread influenza is being reported throughout North America, with the United States reporting ILI levels elevated above the seasonal baseline for the past month and Mexico reporting a high intensity of respiratory diseases for the past three weeks. In Canada, although overall ILI activity remains low, focal increases have been reported in the western part of Canada. In Europe and Central and Western Asia, early transmission of influenza virus continues to increase in many countries, with more intense focal activity being reported in a few. National or regional ILI levels remained elevated above the baseline in parts of the United Kingdom (Northern Ireland and Scotland), Ireland, and Israel. In Ireland, a high intensity of respiratory diseases has been reported for the past two weeks, with the highest rates of ILI reported among children aged 5-14 years old. In addition to Ireland and Israel, widespread geographic spread of influenza virus is also now being reported in Belgium, the Netherlands, and Cyprus. At least 10 countries in the region are also reporting an increasing trend in respiratory diseases activity. In Japan, influenza activity continues to be elevated above the seasonal epidemic threshold since week 33, most recently in the large population centers.

In the tropical regions of the Americas and Asia, influenza virus transmission persists, however influenza activity remained variable. Geographically widespread to regional influenza activity continues to be reported throughout the tropical region of the Americas without a consistent overall trend (and increasing trend in parts of the Caribbean, and decreasing in much of tropical Central and South America). High intensity respiratory diseases activity was reported in Columbia, Cuba, and El Salvador, and moderate healthcare impact was experienced in many countries; two countries, Barbados and St. Lucia, reported severe healthcare impact. As influenza transmission slowly declines in many parts of South and Southeast Asia, several countries are reporting geographically regional spread (India, Bangladesh, and Thailand) or localized spread (Sri Lanka and Myanmar) of influenza activity; and most countries in the region have reported experiencing a low health care impact since late September.

In the temperate regions of the southern hemisphere, influenza transmission has largely subsided (Chile, Argentina, and New Zealand) or continues to decline substantially (South Africa and Australia).

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. To date, 31 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. 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 10/9/2009)

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Global: Children under 10 need two Sanofi pandemic H1N1 influenza vaccine doses

Reporting the first data in children younger than 10 years old, Sanofi Pasteur announced today that this age-group will need two doses of its injectable pandemic H1N1 influenza vaccine, while older kids will require only one shot, consistent with seasonal flu vaccine. In the ongoing clinical trial, after one shot, 50% of kids under 3 had an adequate immune response, compared with 76% of those 3 to 9. No serious side effects were reported.
(CIDRAP 10/14/2009)

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Global: WHO sees November pandemic H1N1 vaccine delivery to developing nations

An official from the World Health Organization said today that the group hopes to start shipping 60 million H1N1 vaccine doses to poor countries in November, the Associated Press (AP) reported. Marie-Paule Kieny, director of the WHO Initiative for Vaccine Research, said the first doses of the donated vaccine from drug companies and other countries will go to doctors and nurses and possibly high-risk patients in about 100 nations. She added that more donations are needed.
(CIDRAP 10/12/2009)

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Europe/Near East
Spain (Castile-La Mancha): Highly pathogenic avian influenza kills 30,000 chickens

An outbreak of highly pathogenic avian influenza (HPAI, serotype H7) on a Spanish farm has lead to the infection and death of 30,000 chickens among a susceptible population of 308,640. The apparent morbidity rate was 9.72% with an apparent case fatality rate of 100%. To control the outbreak, a 3km protection zone and a 10 km surveillance zone were implemented and the remaining 278,640 birds were destroyed. Diagnosis was made by nucleotide sequencing and RRT-PCR. The source of the outbreak remains unknown.
(ProMED 10/14/2009)

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Asia
Australia (Queensland): Novel H1N1 detected at a pig farm

Veterinary officials in Queensland, Australia, have detected the pandemic H1N1 virus at a pig farm near Toowoomba, the Australian Associated Press (AAP) reported today. The animals have been quarantined, and biosecurity authorities are working with the farm's owners to establish measures to control the virus. The latest outbreak is Queensland's second; in August the virus struck a farm near Dalby.
(CIDRAP 10/14/2009)

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China: Mecca pilgrims to be vaccinated against flu

China is to give pandemic H1N1 influenza vaccinations to 12,700 Muslims making the annual pilgrimage to Mecca, state media reported 15 October 2009, amid health concerns ahead of the three-million-strong hajj. The China Islamic Association said the pilgrims would also be given free medicine and disposable masks, and a medical team will accompany them to hand out advice on A(H1N1) flu prevention, the official Xinhua news agency reported.
(CIDRAP 10/15/2009)

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Japan: Tamiflu-resistant H1N1 teen had no Tamiflu record

A genetic mutation of influenza pandemic (H1N1) 2009 virus that is resistant to the antiviral drug Tamiflu has been detected in a Japanese teenager who had not previously been treated with the drug. This case could mark Japan's first instance of person-to-person transmission of a Tamiflu-resistant strain of the pandemic (H1N1) 2009 virus, but Health Ministry official Takeshi Enami said there was still insufficient evidence to confirm that. The WHO said in late September [2009] that drug-resistant pandemic flu viruses had appeared infrequently and there was no evidence that they were spreading, but that further cases were likely.
(ProMED 10/9/2009)

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Viet Nam: Study of pandemic H1N1 viral clearance

Vietnamese researchers have found that most patients infected with the pandemic H1N1 2009 virus become RT-PCR negative within 5 days of starting 75 mg twice per day of oseltamivir. RT-PCR can remain positive for longer, but viral culture was negative in all samples from patients still RT-PCR positive after 5 days of treatment. This study in viral dynamics was made possible by Viet Nam's policy of screening at airports and quarantining individuals found positive for pandemic H1N1 2009 virus infection.

A series of 292 travelers were quarantined and treated with oseltamivir 75 mg twice per day for at least 5 days and were sampled frequently (initially daily, later after 0-3-5 days of treatment) by nose/throat swabs. Patients were discharged when the RT-PCR was negative. After 5 days of treatment, 7 percent (12/179) still had a positive RT-PCR. One patient remained RT-PCR positive on day 8 and one patient on day 14. A virus could not be isolated after days 5 of treatment in any patient, including those who were RT-PCR positive (n=12). Among these 292 cases, the H274Y neuraminidase mutation, associated with oseltamivir resistance, was not detected.

Reported by the Hospital for Tropical Diseases, Ho Chi Minh City South East Asia Infectious Diseases Clinical Research Network.
(ProMED 10/11/2009)

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Americas
Cuba: Pregnant women are Cuba's first H1N1 deaths

The Cuban government says that 2,100 pregnant women on the island have been treated for symptoms of H1N1 flu, 110 are seriously ill, and 3 have died, according to a report by state-sponsored media that was carried by the AP. While the first wave of illness was among tourists, Cuban residents are now contracting the flu, with 621 cases confirmed, including 177 children, the deputy health minister said.
(CIDRAP 10/12/2009)

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Mexico: Purchase of 10 million additional doses of pandemic H1N1 vaccine

Mexico's health secretary, Jose Angel Cordova, said that the government has agreed to obtain 10 million more doses of pandemic H1N1 vaccine from two unnamed European companies, the Canadian Press reported. He said the agreement will raise the country's pandemic vaccine supply to 30 million doses.
(CIDRAP 10/14/2009)

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USA: FDA faces decision about emergency use of peramivir for H1N1

In response to questions from citizens at a meeting on 14 October 2009, a Food and Drug Administration (FDA) official said the agency would make a decision "fairly soon" about permitting emergency use of the experimental antiviral drug peramivir to help patients severely ill with pandemic H1N1 influenza. The FDA has been reviewing a possible emergency use authorization (EUA) for peramivir, which, like the licensed drugs oseltamivir (Tamiflu) and zanamivir (Relenza), is a neuraminidase inhibitor. Peramivir can be given intravenously or intramuscularly, whereas oseltamivir is taken orally and zanamivir is inhaled as a powder.
(CIDRAP 10/15/2009)

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USA: Pandemic H1N1 vaccine trials in HIV-infected groups

The National Institute of Allergy and Infectious Diseases (NIAID) recently announced the launch of H1N1 vaccine trials in HIV-infected pregnant women and HIV-infected children and young adults. The trials are important because HIV infection and pregnancy increase the risk of a poor immune response to vaccines and because these groups have an increased risk of severe H1N1 illness, the NIAID said. Plans call for enrolling 130 pregnant women and 140 people aged 4 to 24 years in the two studies.
(CIDRAP 10/13/2009)

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USA: Pediatric H1N1 deaths already rival seasonal flu total

Seventy-six children and teenagers have died of H1N1 flu since the novel strain emerged in April, the Centers for Disease Control and Prevention (CDC) said today, representing both an increase of 19 in a week and a total that rivals the child deaths for entire past flu seasons. According to Dr. Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases, up to 30% of the children who died from H1N1 flu had no underlying conditions that would make them vulnerable. She also said bacterial co-infections were "a very important problem" in that group, adding that the CDC is alerting clinicians to use antibiotics when bacterial infections are suspected and encouraging use of pneumococcal vaccines to reduce the chance of illness.
(CIDRAP 10/9/2009)

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USA: Preliminary data suggests seasonal and pandemic influenza vaccines may be given together

New data from U.S. studies seems to confirm that only one dose of pandemic H1N1 influenza 2009 vaccine will be needed to protect adults and seniors, the head of the National Institute of Allergy and Infectious Diseases said on 9 Oct 2009. Testing showed that adults and seniors who received a second dose of the pandemic vaccine didn't gain much additional benefit from the second shot, Dr. Anthony Fauci said in a media teleconference.

He also revealed preliminary data from another study examining whether it was safe to give both seasonal and pandemic flu shots at the same. "The vaccine when given simultaneously does not impair the immune response to either of those (shots)," Fauci said. "That I believe is going to be important as we roll out the vaccination program. And individuals will go to their offices and would like at the same time to get both vaccinations [i.e. seasonal influenza and pandemic influenza]." There were theoretical concerns that giving 2 flu vaccines at once might interfere with the immune system's ability to generate a good response to all the viruses covered in the shots.
(Promed 10/11/2009)

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2. Infectious Disease News

Asia
China (Shaanxi): Fatal Hand, Foot and Mouth Disease

Fatal cases of hand, foot and mouth disease (HFMD) have recently occurred in some areas of Shaanxi. To aggressively bring down the incidence rate and reduce fatalities among serious cases, the provincial health bureau announced 29 Sep 2009 that it is requiring confirmed cases of HFMD to be treated at health care facilities ranked as county level and above.
(ProMED 10/6/2009)

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Indonesia (North Sumatra): Suspected Chikungunya Outbreak

Hundreds of residents from 18 villages and subdistricts in the Southeast District Padang Sidempuan [North Sumatra] have been afflicted by suspected chikungunya disease. Analysis of information gathered on 7 October 2009 showed the disease was spreading weekly in densely populated areas.
(ProMED 10/8/2009)

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Malaysia (Sarawak): Chikungunya on the rise

Thus far this year, there have been 397 reported cases of chikungunya in Sarawak state, according to a statement by deputy chief minister Tan Sri Dr George Chan on 1 October 2009. There were no reported cases before 2008. He said people who contracted the chikungunya virus in infected areas brought the disease into the state. State Health Department deputy director Dr Faizul Mansor said they were investigating the source of the spread of the disease in Sibu.
(ProMED 10/2/2009)

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New Zealand (North Island): Meningococcal Meningitis

A total of 6 cases of meningococcal disease in as many weeks around the MidCentral health district of the North Island have prompted a warning from medical officer of health Jill McKenzie to take symptoms seriously. While the MenzB vaccination campaign that reached more than 1 million children and young people in 2005 helped stop New Zealand's epidemic of the disease, the cases presenting now have been caused by other strains of the bacteria. All of those affected were under age twenty and were recovering due to rapid diagnosis and receipt of antibiotics.
(ProMED 10/13/2009)

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Russia (Voronezh): Brucellosis infects 10 farm workers

Ten farm workers in the Liskinsky district of the Voronezh region have been infected with brucellosis. It is thought that the infections arose from the importation of young animals without veterinary clearance on 52 different occasions.
(ProMED 10/12/2009)

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Russia (Tatarstan): 20 new cases of HFRS Hemorrhagic Fever with Renal Syndrome (HFRS)

The regional office of Rospotrebnadzor, the Federal Public Health Service, has stated that 20 confirmed or suspected cases of hemorrhagic fever with renal syndrome (HFRS) have been recorded in Tatarstan between 25 Sep 2009 and 1 Oct 2009. The largest number, five cases, were recorded in Kazan.
(ProMED 10/9/2009)

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Viet Nam: Severe Hand, Foot and Mouth Disease in 2009

Doctors in Ho Chi Minh City have stated that 2009 has been an especially severe year for hand, foot and mouth disease (HFMD). Hospitals are seeing more children with the disease and with more critical conditions than in years past. On 9 October 2009, nearly half of inpatient children at Children's Hospital No.1's Infection Mental Health Department were hospitalized with HFMD. Three of these patients needed respirators. Truong Huu Khanh, head of the department, said the emergency room had received several HFMD children in severe condition for several days straight. HFMD patients also top the list at the Children's Hospital No.2, with 55 children admitted on 9 October 2009, including 7 in the emergency room.
(ProMED 10/9/2009)

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3. Updates
INFLUENZA A/H1N1

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

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

Indonesia
Health workers in Indonesia's quake-hit Sumatra are battling to contain local outbreaks of diarrhea and dengue fever, and require more specialist equipment, officials and a doctor said on 12 October 2009. "There has been no widespread outbreak of disease yet, but we are seeing more cases of diarrhea and dengue fever," said Gde Yogadhita, the World Health Organization's emergency field operations program manager.
(Reuters 10/12/2009)

Philippines (Metro Manila)
The Cavite Provincial Health Office denied a report that there is dengue epidemic in Dasmarinas town. Sanitary inspector Anabelle R Dilig made the clarification amid a report that there were 5 dengue deaths in the province's most populated town. "While it is true that there were 5 dengue deaths in Dasmarinas, the report that there is a dengue outbreak in the town is false. The epidemic threshold can attest to this," said Dilig. There were 80 cases of dengue, including the 5 deaths, in Dasmarinas during August and September 2009.
(ProMED 10/12/2009)

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4. Articles
Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome

The ANZ ECMO Influenza Investigators. JAMA. 12 October 2009; 302(17):(doi:10.1001/jama.2009.1535). Available at http://jama.ama-assn.org/cgi/content/full/2009.1535.

Context. The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO).

Objectives. To describe the characteristics of all patients with 2009 influenza A(H1N1)-associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes.

Design, Setting, and Patients. An observational study of all patients (n = 68) with 2009 influenza A(H1N1)-associated ARDS treated with ECMO in 15 intensive care units (ICUs) in Australia and New Zealand between June 1 and August 31, 2009.

Main Outcome Measures. Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival.

Results. Sixty-eight patients with severe influenza-associated ARDS were treated with ECMO, of whom 61 had either confirmed 2009 influenza A(H1N1) (n = 53) or influenza A not subtyped (n = 8), representing an incidence rate of 2.6 ECMO cases per million population. An additional 133 patients with influenza A received mechanical ventilation but no ECMO in the same ICUs. The 68 patients who received ECMO had a median (interquartile range [IQR]) age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a median (IQR) PaO2/fraction of inspired oxygen (FIO2) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H2O, and an acute lung injury score of 3.8 (3.5-4.0). The median (IQR) duration of ECMO support was 10 (7-15) days. At the time of reporting, 48 of the 68 patients (71%; 95% confidence interval [CI], 60%-82%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%; 95% CI, 11%-30%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO.

Conclusions. During June to August 2009 in Australia and New Zealand, the ICUs at regional referral centers provided mechanical ventilation for many patients with 2009 influenza A(H1N1)-associated respiratory failure, one third of whom received ECMO. These young adults with severe hypoxemia had a 21% mortality rate at the end of the study period.

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Critically Ill Patients With 2009 Influenza A(H1N1) in Mexico

Domínguez-Cherit G, Lapinsky SE, Macias AE, et al. JAMA. 12 October 2009; 302(17):(doi:10.1001/jama.2009.1536). Available at http://jama.ama-assn.org/cgi/content/full/2009.1536.

Context. In March 2009, novel 2009 influenza A(H1N1) was first reported in the southwestern United States and Mexico. The population and health care system in Mexico City experienced the first and greatest early burden of critical illness.

Objective. To describe baseline characteristics, treatment, and outcomes of consecutive critically ill patients in Mexico hospitals that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1).

Design, Setting, and Patients. Observational study of 58 critically ill patients with 2009 influenza A(H1N1) at 6 hospitals between March 24 and June 1, 2009. Demographic data, symptoms, comorbid conditions, illness progression, treatments, and clinical outcomes were collected using a piloted case report form.

Main Outcome Measures. The primary outcome measure was mortality. Secondary outcomes included rate of 2009 influenza (A)H1N1-related critical illness and mechanical ventilation as well as intensive care unit (ICU) and hospital length of stay.

Results. Critical illness occurred in 58 of 899 patients (6.5%) admitted to the hospital with confirmed, probable, or suspected 2009 influenza (A)H1N1. Patients were young (median, 44.0 [range, 10-83] years); all presented with fever and all but 1 with respiratory symptoms. Few patients had comorbid respiratory disorders, but 21 (36%) were obese. Time from hospital to ICU admission was short (median, 1 day [interquartile range {IQR}, 0-3 days]), and all patients but 2 received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia (median day 1 ratio of PaO2 to fraction of inspired oxygen, 83 [IQR, 59-145] mm Hg). By 60 days, 24 patients had died (41.4%; 95% confidence interval, 28.9%-55.0%). Patients who died had greater initial severity of illness, worse hypoxemia, higher creatine kinase levels, higher creatinine levels, and ongoing organ dysfunction. After adjusting for a reduced opportunity of patients dying early to receive neuraminidase inhibitors, neuraminidase inhibitor treatment (vs no treatment) was associated with improved survival (odds ratio, 7.4; 95% confidence interval, 1.8-31.0).

Conclusion. Critical illness from 2009 influenza A(H1N1) in Mexico occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, and had a high case-fatality rate.

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Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada

Kumar A, Zarychanski R, Pinto R, et al. JAMA. 12 October 2009; 302(17):(doi:10.1001/jama.2009.1496). Available at http://jama.ama-assn.org/cgi/content/full/2009.1496.

Context. Between March and July 2009, the largest number of confirmed cases of 2009 influenza A(H1N1) infection occurred in North America.

Objective. To describe characteristics, treatment, and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection.

Design, Setting, and Patients. A prospective observational study of 168 critically ill patients with 2009 influenza A(H1N1) infection in 38 adult and pediatric intensive care units (ICUs) in Canada between April 16 and August 12, 2009.

Main Outcome Measures. The primary outcome measures were 28-day and 90-day mortality. Secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU stay.

Results. Critical illness occurred in 215 patients with confirmed (n = 162), probable (n = 6), or suspected (n = 47) community-acquired 2009 influenza A(H1N1) infection. Among the 168 patients with confirmed or probable 2009 influenza A(H1N1), the mean (SD) age was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%). Overall mortality among critically ill patients at 28 days was 14.3% (95% confidence interval, 9.5%-20.7%). There were 43 patients who were aboriginal Canadians (25.6%). The median time from symptom onset to hospital admission was 4 days (interquartile range [IQR], 2-7 days) and from hospitalization to ICU admission was 1 day (IQR, 0-2 days). Shock and nonpulmonary acute organ dysfunction was common (Sequential Organ Failure Assessment mean [SD] score of 6.8 [3.6] on day 1). Neuraminidase inhibitors were administered to 152 patients (90.5%). All patients were severely hypoxemic (mean [SD] ratio of PaO2 to fraction of inspired oxygen [FIO2] of 147 [128] mm Hg) at ICU admission. Mechanical ventilation was received by 136 patients (81.0%). The median duration of ventilation was 12 days (IQR, 6-20 days) and ICU stay was 12 days (IQR, 5-20 days). Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%), high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3.0%). Overall mortality among critically ill patients at 90 days was 17.3% (95% confidence interval, 12.0%-24.0%; n = 29).

Conclusion. Critical illness due to 2009 influenza A(H1N1) in Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.

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Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome

Lombardi VC, Ruscetti FW, Das Gupta J, et al. Science. 08 October 2009. Available at http://www.sciencemag.org/cgi/content/abstract/sci;1179052v1.

Abstract. Chronic fatigue syndrome (CFS) is a debilitating disease of unknown etiology that is estimated to affect 17 million people worldwide. Studying peripheral blood mononuclear cells (PBMCs) from CFS patients, we identified DNA from a human gammaretrovirus, xenotropic murine leukemia virus-related virus (XMRV), in 68 of 101 patients (67%) compared to 8 of 218 (3.7%) healthy controls. Cell culture experiments revealed that patient-derived XMRV is infectious and that both cell-associated and cell-free transmission of the virus are possible. Secondary viral infections were established in uninfected primary lymphocytes and indicator cell lines following exposure to activated PBMCs, B cells, T cells, or plasma derived from CFS patients. These findings raise the possibility that XMRV may be a contributing factor in the pathogenesis of CFS.

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Chest Radiographic and CT Findings in Novel Swine-Origin Influenza A (H1N1) Virus (S-OIV) Infection

Prachi P. Agarwal PP, Cinti S, Kazerooni EA. AJR. December 2009; 193: (doi:10.2214/AJR.09.3599). Available at http://www.ajronline.org/aheadofprint/12_09_3599.pdf.

Objective. This article reviews the chest radiographic and CT findings in patients with presumed/laboratory-confirmed novel swine-origin influenza A (H1N1) virus (S-OIV) infection.

Materials and Methods. Of 222 patients with novel S-OIV (H1N1) infection seen from May 2009 to July 2009, 66 patients (30%) who underwent chest radiographs formed the study population. Group 1 patients (n = 14) required ICU admission and advanced mechanical ventilation, and group 2 (n = 52) did not. The initial radiographs were evaluated for the pattern (consolidation, ground-glass, nodules, and reticulation), distribution, and extent of abnormality. Chest CT scans (n = 15) were reviewed for the same findings and for pulmonary embolism (PE) when performed using IV contrast medium.

Results. Group 1 patients were predominantly male with a higher mean age (43.5 years versus 22.1 years in group 2; p < 0.001). The initial radiograph was abnormal in 28 of 66 (42%) subjects. The predominant radiographic finding was patchy consolidation (14/28; 50%) most commonly in the lower (20/28; 71%) and central lung zones (20/28; 71%). All group 1 patients had abnormal initial radiographs; extensive disease involving ? 3 lung zones was seen in 93% (13/14) versus 9.6% (5/52) in group 2 (p < 0.001). No group 2 patients had > 20% overall lung involvement on initial radiographs compared with 93% of group 1 patients (13/14). PEs were seen on CT in 5/14 (36%) of group 1 patients.

Conclusion. Chest radiographs are normal in more than half of patients with S-OIV (H1N1) and progress to bilateral extensive air-space disease in severely ill patients, who are at a high risk for PE.

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Imaging Findings in a Fatal Case of Pandemic Swine-Origin Influenza A (H1N1)

Mollura DJ, Asnis DS, Conetta R, et al. AJR. December 2009; 193: (doi:10.2214/AJR.09.3365). Available at http://www.ajronline.org/aheadofprint/12_09_3365.pdf.

Objective. Although most cases of swine-origin influenza A (H1N1) virus (S-OIV) have been self-limited, fatal cases raise questions about virulence and radiology's role in early detection. We describe the radiographic and CT findings in a fatal S-OIV infection.

Conclusion. Radiography showed peripheral lung opacities. CT revealed peripheral ground-glass opacities suggesting peribronchial injury. These imaging findings raised suspicion of S-OIV despite negative H1N1 influenza rapid antigen test results from two nasopharyngeal swabs; subsequently, those results were proven to be false-negatives by reverse transcriptase polymerase chain reaction. This case suggests a role for CT in the early recognition of severe S-OIV.

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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.

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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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EPIDEMICS²: Second International Conference on Infectious Diseases Dynamics
Athens, Greece, 2-4 Dec 2009

Following the highly successful inaugural Epidemics Conference in Asilomar, USA in 2008, the organizers are pleased to announce a second conference in the series to be held in Athens, Greece in December 2009.
H1N1 pdm abstract deadline: 13 November 2009
Additional information and registration available at http://www.epidemics.elsevier.com/.

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Updated influenza guidance and information from the US CDC

2009 H1N1 Flu (referred to as "swine flu" early on) and Seasonal Flu Information for Rheumatology Health Professionals
Released 15 October 2009
Available at http://www.cdc.gov/h1n1flu/arthritis_clinicians.htm.

Questions and Answers about CDC's Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel
Released 14 October 2009
Available at http://www.cdc.gov/H1N1flu/guidance/control_measures_qa.htm.

Questions and Answers Regarding Respiratory Protection For Preventing 2009 H1N1 Influenza Among Healthcare Personnel
Released 14 October 2009
Available at http://www.cdc.gov/h1n1flu/guidelines_infection_control_qa.htm.

Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel
Released 14 October 2009
Available at http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm.

Interim Guidance for Influenza Surveillance: Prioritizing RT-PCR Testing in Laboratories
Released 09 October 2009
Available at http://www.cdc.gov/h1n1flu/screening.htm.

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 apecein@u.washington.edu