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EINet Alert ~ Oct 23, 2009


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

1. Influenza News
- Weekly APEC update of pandemic influenza H1N1
- 2009 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO situation update on pandemic influenza H1N1
- Global: WHO underscores H1N1 risk to young and healthy
- Global: Novavax launches trial of virus-like-particle H1N1 vaccine
- Spain (Castile-La Mancha): Disinfection begun at site of H7N7 avian influenza outbreak
- Norway: Eight more swine herds infected with H1N1
- Chinese Taipei: First oseltamivir-resistant influenza (H1N1) virus discovered in Chinese Taipei
- Japan: H1N1 found in Japanese swine herd
- Japan: Launch of pandemic vaccine campaign
- Nepal: Novel H1N1 influenza appears among masses
- Argentina: Report cites high rate of lung disease in H1N1 cases
- Bolivia: Flu control measures seem to reduce other diseases in Bolivia
- Canada: Pandemic vaccine campaign will have an unadjuvanted option
- Canada (Ontario): Third case of oseltamivir resistant H1N1
- Canada (Ontario): Turkeys catch H1N1 infection
- USA: Flu cases increase on US campuses
- USA: CDC cites more evidence of H1N1 targeting the young
- USA: USDA confirms 1st case of H1N1 flu in US hog
- USA: CDC urges early antiviral use for some suspected flu patients
- Ivory Coast: H5N1-infected birds reported

2. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA

3. Articles
- A Novel Influenza A (H1N1) Vaccine in Various Age Groups
- Melting Muscles: Novel H1N1 Influenza A Associated Rhabdomyolysis
- Disparities in influenza vaccination coverage rates by target group in five European countries: Trends over seven consecutive seasons
- Novel Influenza A (H1N1) Outbreak at the U.S. Air Force Academy: Epidemiology and Viral Shedding Duration
- An influenza A H1N1 virus revival--pandemic H1N1/09 virus
- Screening for influenza infection in international airline travelers

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
- EPIDEMICS²: Second International Conference on Infectious Diseases Dynamics
- 14th International Congress on Infectious Diseases (ICID)
- ISHEID Symposium on HIV and Emerging Infectious Diseases
- Updated influenza guidance and information from the US CDC


1. Influenza News

Global
Weekly APEC update of pandemic influenza H1N1

China
China appears to be entering its second wave of the novel H1N1 pandemic, said an epidemiologist at the country's Center for Disease Control and Prevention who was quoted yesterday in China Daily. Cases are increasing rapidly, and the virus is spreading to small and medium-sized cities. China has had 26,300 known cases but just two deaths, the story said. The World Health Organization reported last week that the seasonal H3N2 flu virus was co-circulating in China with the pandemic H1N1 strain.
(CIDRAP 10/21/2009)

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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 11 October 2009, worldwide there have been more than 399,232 laboratory confirmed cases of pandemic influenza H1N1 2009 and over 4,735 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.

Influenza activity continues to increase in the northern temperate zones across the world. In North America, the United States is now experiencing nationwide rates of Influenza-Like Illness (ILI) well above seasonal baseline rates with high rates of pandemic H1N1 2009 virus detections in clinical laboratory specimens. Canada is reporting increases in ILI rates for the third straight week with some provinces now crossing the baseline. Mexico also reports high intensity and active transmission in some areas of the country. Western Europe and northern Asia are experiencing increased rates of ILI, well above baseline in some countries but activity is generally not as widespread as in North America. Of note, nearly half of the influenza viruses detected in China are seasonal influenza A (H3N2) viruses, which appeared prior to and is co-circulating with pandemic H1N1 2009 virus.

The tropical zones continue to have transmission that is mixed as some countries have now peaked and are declining, while others are experiencing increases. In the tropical region of the Americas, several Caribbean Island nations are now reporting increased rates of illness while Brazil, Costa Rica and other countries on the continent are declining. In South Asia, most countries now report a decline in rates of illness.

Influenza rates in the temperate zones of the Southern Hemisphere have all returned to below baseline levels and very few detections of pandemic H1N1 2009 virus are being reported.

Three articles of interest published this week in the peer reviewed literature reported three different series of seriously ill pandemic influenza patients in Canada, Mexico, Australia, and New Zealand. Several important observations were made including:

  • A significant portion of patients with severe disease requiring intensive care had no predisposing conditions. The numbers are not directly comparable as the studies categorized conditions differently but nearly 1/3 of ICU patients in Australia and New Zealand had no predisposing conditions. 98% of ICU cases in Canada had a comorbid condition, which in this report included hypertension, smoking, and substance abuse, but only 30% had comorbid conditions that were considered "major". In Mexico, 84% of critical patients had an underlying condition, which in the report included hypertension, ever having smoked, and hyperlipidemia, conditions that are not considered risk factors for severe influenza outcomes. All three groups were impressed by the number of severe cases occurring in previously healthy individuals.
  • The researchers in Australia and New Zealand reaffirmed that infants under the age of 1 year have the highest risk of developing severe illness. The average age of ICU patients was 32, 40, and 44 years in Canada, Australia/New Zealand, and Mexico respectively.
  • The study from Australia and New Zealand estimated that the demand for ICU beds due to viral pneumonia during the pandemic was much higher than in previous influenza seasons. The Canadian study reported that intensive care capacity in Winnipeg, Manitoba, was "seriously challenged" at the peak of the outbreak with full occupancy of all regional ICU beds.
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.
(WHO 10/16/2009)

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Global: WHO underscores H1N1 risk to young and healthy

The susceptibility of some young, healthy people to severe illness with pandemic H1N1 influenza marks a striking difference from the pattern of disease seen in seasonal flu epidemics, the World Health Organization (WHO) said. The factors that increase the risk of severe illness in previously healthy people remain unknown, the WHO said in reporting on the results of a 3-day conference on the features of severe H1N1 cases. The meeting involved about 100 clinicians, virologists, and other experts at the Pan American Health Organization headquarters in Washington, DC, USA. The ability of the virus to make young, healthy people dangerously sick has been noted for months, but the WHO put new emphasis on the phenomenon. At the same time, the agency said pregnant women, children younger than 2 years, and people with chronic lung disease face the greatest risk of severe illness. The experts also confirmed that the vast majority of patients around the world experience an uncomplicated flu-like illness and recover within a week, even without treatment.
(CIDRAP 10/16/2009)

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Global: Novavax launches trial of virus-like-particle H1N1 vaccine

Novavax announced today the launch of clinical trials in Mexico to test the safety and efficacy of its virus-like particle pandemic H1N1 vaccine. Amivex, a company that will distribute the cell-based vaccine in Mexico in 2010 pending approval, is supporting the trial. If initial findings in 1,000 volunteers are favorable, the second stage of the trial will be conducted in 3,000 adults starting in January.
(CIDRAP 10/20/2009)

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Europe/Near East
Spain (Castile-La Mancha): Disinfection begun at site of H7N7 avian influenza outbreak

The Agricultural delegate in Guadalajara, Sergio Cabellos, announced the commencement of disinfection and cleaning of the poultry farm in Castile-La Mancha where a recent outbreak of H7N7 avian influenza lead to the culling of more than 320,00 chickens. Speaking to reporters, Cabellos has also reported that they have returned to the affected area and performed analyses that demonstrated "there have been no new cases" identified within a radius of 10 km. The avian flu virus detected on this farm, the H7N7 type, is rarely transmitted to humans.
(ProMED 10/22/2009)

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Norway: Eight more swine herds infected with H1N1

Eight more swine herds in one county in Norway have been found infected with the H1N1 virus, the pork industry Web site PigProgress.net reported on Oct 16, 2009. Because of concern about farmers spreading the virus to pigs, Agriculture Minister Lars Peder Brekk has asked that pig farmers get priority for H1N1 vaccination, the report said. Norway's first outbreak in pigs was reported in Nord Trondelag county a week ago.
(CIDRAP 10/19/2009)

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Asia
Chinese Taipei: First oseltamivir-resistant influenza (H1N1) virus discovered in Chinese Taipei

On Tue 20 Oct 20, 2009, the Central Epidemic Command Center (CECC) announced the discovery of the first oseltamivir-resistant influenza (H1N1) virus strain in Taiwan. According to the epidemiological investigation conducted by the Taiwan Centers for Disease Control (Taiwan CDC), the first oseltamivir-resistant influenza A (H1N1) virus strain in Taiwan was discovered in an individual case and no signs of cluster outbreak or further transmission have been detected. According to statistics announced by the World Health Organization (WHO), a total of 10 countries have discovered a total of 35 strains of antiviral-resistant influenza A (H1N1) virus.
(ProMED 10/21/2009)

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Japan: H1N1 found in Japanese swine herd

Pooled samples from 10 pigs on a 1,000-head swine farm near Osaka, Japan, were positive for H1N1 flu during routine surveillance, according to the World Organization for Animal Health (OIE). None of the pigs died or showed signs of illness. The farm, which raises pigs from birth to slaughter age, is under limited movement control. The finding marks the first identification of H1N1 flu in swine in Japan.
(CIDRAP 10/21/2009)

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Japan: Launch of pandemic vaccine campaign

Japan started administering its first pandemic H1N1 doses today, starting with healthcare workers, Agence France-Presse (AFP) reported. So far Japan has a limited supply of a domestically produced vaccine, enough for 1.18 million people. The health ministry said in early November that the vaccination priority will shift to pregnant women and those with underlying medical conditions and that by late December the campaign will include babies and small children.
(CIDRAP 10/19/2009)

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Nepal: Novel H1N1 influenza appears among masses

Influenza pandemic (H1N1) 2009 virus infection has now appeared among the masses, the Health Ministry said at a press conference on 15 Oct 2009. "While the previous confirmed 36 cases had travel or contact history, we have now found the virus in persons who have no history of travel and have not come into contact with a confirmed patient," deputy coordinator of the Avian Influenza Control Project Dr Jitendra Man Shrestha said. Dr Shrestha said that random tests done on 46 common flu patients showed that 3 of them had the pandemic 2009 virus. The trio had no travel or contact history with H1N1 influenza patients. Similarly 2 additional people, including a foreigner, have been confirmed infected by the virus. Likewise, 3 out of 6 patients currently being treated for viral fever in Chitwan have also tested positive.
(ProMED 10/16/2009)

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Americas
Argentina: Report cites high rate of lung disease in H1N1 cases

An unexpectedly high rate of lower respiratory disease (8%, 166 of 2,135 patients) was found in adults with flu-like illness who were treated at a tertiary hospital in Buenos Aires, Argentina, during the H1N1 outbreak in June and July, says a report in Emerging Infectious Diseases. Although other pathogens were not ruled out, the authors say the finding suggests that "a unique pattern of virulence, pulmonary tropism, or both" may characterize 2009 H1N1 cases.
(CIDRAP 10/21/2009)

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Bolivia: Flu control measures seem to reduce other diseases in Bolivia

Health officials in Bolivia say a massive campaign to promote handwashing to prevent H1N1 flu seems to have reduced the spread of other common diseases, according to a Time magazine report. Dr. Rene Lenis, Bolivia's director of epidemiology, reported a 10% to 15% drop in incidence of acute diarrheal diseases in all age-groups this year compared with last year. Public health agencies began promoting handwashing when the virus emerged in April.
(CIDRAP 10/22/2009)

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Canada: Pandemic vaccine campaign will have an unadjuvanted option

Canada has purchased 1.8 million doses of unadjuvanted pandemic H1N1 vaccine to use in the youngest children as well as pregnant women and others who might want an alternative to the adjuvanted version, the Canadian Press reported yesterday. Canada's adjuvanted vaccine was approved Oct 16. Officials predict the unadjuvanted vaccine will be cleared in early November, but they do not want people to wait for it even though experts say it may produce a more robust response in children under age 3.
(CIDRAP 10/22/2009)

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Canada (Ontario): Third case of oseltamivir resistant H1N1

On 9 Aug 2009, influenza A virus was detected in a young adult in his 20s with an underlying hematological malignancy. The sample was forwarded to the Ontario Public Health Laboratory (OPHL) and identified as pH1N1 by rRT-PCR. On 7 Sep 2009, after 24 days of intermittent therapy, he was tested again by the OPHL and found to be infected with pH1N1. In early October, as part of Ontario's surveillance project for antiviral resistance, the sample was tested by pyrosequencing and was found to contain the H275Y mutation conferring oseltamivir resistance. This mutation was confirmed with Sanger sequencing at OPHL and at Canada's National Microbiology Laboratory (NML). The original sample collected on 9 Aug 2009 was also tested for oseltamivir resistance with no evidence of the H275Y mutation.

This appears to represent Canada's third case of oseltamivir resistant pH1N1, with Quebec and Alberta documenting one case each. As has been previously documented, immunocompromised patients are at risk of prolonged viral shedding with pH1N1, and prolonged therapy with oseltamivir predisposes them to develop infection due to neuraminidase resistant virus during the course of therapy. Resistance should also be considered in patients who develop pH1N1 infection while on oseltamivir prophylaxis, as has been recently documented.
(ProMED 9/22/2009)

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Canada (Ontario): Turkeys catch H1N1 infection

A press release from Hybrid Turkeys, a primary breeder of turkeys based in Ontario, has confirmed the presence of H1N1 in a single barn. The Canadian Food Inspection Agency (CFIA) has confirmed that the cause of an egg production drop in a flock in of Hybrid Grand Parent Breeding turkeys was due to the novel H1N1 influenza virus. The only sign in the affected Ontario flock was a decrease in egg production with no associated illness or mortality. The flock is showing normal feed and water consumption and is expected to fully recover, consistent with other flus that are more common in turkeys. Novel H1N1 was also recently reported as the cause of an egg production drop in turkey breeding hens in Chile.
(ProMED 9/22/2009)

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USA: Flu cases increase on US campuses

Flu-like illnesses on college campuses rose modestly last week, with schools in the mid Atlantic region reporting increases, while those in the Midwest, Rocky Mountains, and Southwest still cited robust activity, the American College Health Association (ACHA) said today. The report for the week ending Oct 16 says infections may have already peaked in the Southeast and Northeast. The incidence of flu-like illnesses on member campuses was 20.9 per 10,000 students, 9% higher than a week earlier.
(CIDRAP 10/21/2009)

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USA: CDC cites more evidence of H1N1 targeting the young

Federal health officials presented more evidence today that pandemic H1N1 influenza primarily targets young people, reporting that more than half of recently hospitalized patients and close to a quarter of those who died were younger than 25. In 4,958 hospital cases of H1N1 reported from 27 states, 53% of patients were younger than 25, while 39% were between 25 and 65, and another 7% were elderly, said Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC). The data cover the period from Sep 1 to Oct 10. The age distribution for deaths reported in that same period was slightly older. Of 292 deaths reported from 28 states, 23.6% were in people younger than 25, while 65% involved those between 25 and 64 years of age and 11.6% involved those 65 and older, she reported.
(CIDRAP 10/20/2009)

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USA: USDA confirms 1st case of H1N1 flu in US hog

The pandemic H1N1 flu virus was confirmed for the 1st time on 19 Oct 2009 in a US hog, which was exhibited at the Minnesota State Fair where 4 teenagers became sick, the Agriculture Department said on 19 Oct 2009. USDA said the discovery does not suggest infection of commercial pig herds raised for slaughter.
(ProMED 10/20/2009)

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USA: CDC urges early antiviral use for some suspected flu patients

The Centers for Disease Control and Prevention (CDC) today urged clinicians to start flu patients on antivirals early, without waiting for test results, particularly if they are hospitalized or have underlying conditions. In an e-mail alert the CDC said that though most people recover without treatment, clinical judgment should guide antiviral use, recommended for anyone who has lower respiratory symptoms or worsening symptoms. A negative rapid test does not exclude flu, the agency said.
(ProMED 10/19/2009)

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Africa
Ivory Coast: H5N1-infected birds reported

Agricultural authorities in the Ivory Coast report that 30 wild white-necked ravens have been found dead and 9 tested positive on the highly pathogenic avian influenza virus H5N1. The birds died suddenly while they were flying over the secondary school located at Cocody in Abidjan. The site and its surroundings have been completely disinfected using Virkon. A surveillance zone was established within a 2 km radius around the point where the birds fell.
(ProMED 10/21/2009)

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2. 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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3. Articles
A Novel Influenza A (H1N1) Vaccine in Various Age Groups

Zhi FC, Wang H, Fang HH, et al. NEJM. 21 October 2009; doi:10.1056/NEJMoa0908535. Available at http://content.nejm.org/cgi/content/full/NEJMoa0908535?query=TOC.

Background. There is an urgent need for a vaccine that is effective against the 2009 pandemic influenza A (H1N1) virus.

Methods. A split-virus, inactivated candidate vaccine against the 2009 H1N1 virus was manufactured, and we evaluated its safety and immunogenicity in a randomized clinical trial. Subjects were between 3 and 77 years of age, stratified into four age groups. The immunization schedule consisted of two vaccinations, 21 days apart. Subjects were injected with placebo or with vaccine, with or without alum adjuvant, at doses of 7.5 µg, 15 µg, or 30 µg. Serologic analysis was performed at baseline and on days 21 and 35.

Results. A total of 2200 subjects received one dose, and 2103 (95.6%) received the second dose, of vaccine or placebo. No severe adverse side effects associated with the vaccine were noted. In the nonadjuvanted-vaccine groups, injection-site or systemic reactions, most mild in nature, were noted in 5.5 to 15.9% of subjects. Among the subjects receiving 15 µg of nonadjuvanted vaccine, a hemagglutination-inhibition titer of 1:40 or more was achieved by day 21 in 74.5% of subjects between 3 and 11 years of age, 97.1% of subjects between 12 and 17 years, 97.1% of subjects between 18 and 60 years, and 79.1% of subjects 61 years of age or older; by day 35, the titer had been achieved in 98.1%, 100%, 97.1%, and 93.3% of subjects, respectively. The proportion with a titer of 1:40 or more was generally highest among the subjects receiving 30 µg of vaccine, with or without adjuvant. Vaccine without adjuvant was associated with fewer local reactions and greater immune responses than was vaccine with adjuvant.

Conclusions. These data suggest that a single dose of 15 µg of hemagglutinin antigen without alum adjuvant induces a typically protective immune response in the majority of subjects between 12 and 60 years of age. Lesser immune responses were seen after a single dose of vaccine in younger and older subjects. (ClinicalTrials.gov number, NCT00975572 [ClinicalTrials.gov].)

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Melting Muscles: Novel H1N1 Influenza A Associated Rhabdomyolysis

D'Silva D, Hewagama S, Doherty R. PIDJ. 16 October 2009; doi: 10.1097/INF.0b013e3181c03cf2. Available at http://journals.lww.com/pidj/Abstract/publishahead/Melting_Muscles__Novel_H1N1_Influenza_A_Associated.99512.aspx.

Abstract. We report the first case of myositis and rhabdomyolysis after infection with novel influenza A (H1N1/09) virus. The case demonstrates the novel virus' capacity for causing significant disease. Myositis and the possibility of rhabdomyolysis should be considered in any individual presenting with influenza-like symptoms in which severe myalgia or muscle weakness is apparent. It is likely that we will see severe clinical manifestations of infection with this novel influenza virus in the coming respiratory virus season.

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Disparities in influenza vaccination coverage rates by target group in five European countries: Trends over seven consecutive seasons

Blank PR, Schwenkglenks M, Szucs TD. Infection. October 2009; 37(5): (doi: 10.1007/s15010-009-8467-y). Available at http://www.springerlink.com/content/m485t0r44522m715/.

Background. The primary objective of this study was to measure influenza vaccination coverage rates in the general population, including children, and in high-risk groups of five European countries during the season 2007/2008. An additional aim was to analyze coverage trends over seven consecutive seasons and to gain an understanding of the primary drivers and barriers to immunization.

Methods. Community-based telephone and mail surveys have been conducted in the UK, Germany, Italy, France, and Spain, yearly, since 2001/2002. Approximately 2,000 individuals per country and season were interviewed who were considered to be representative of the adult population aged 14 years and older. Data on the vaccination status of children were obtained by proxy interviews. The questionnaire used was essentially the same for all seven seasons. Five target groups were identified for the study: (1) persons aged ? 65 years; (2) elderly suffering from a chronic illness; (3) patients suffering from a chronic illness; (4) persons working in the health care sector; (5) children.

Results. In the season 2007/2008, vaccination coverage rates in the general population remained stable in Germany. Compared to the coverage rates of the previous season, increases of 3.7%, 2.0%, and 1.8% were observed for the UK, Spain, and France, respectively, while a decrease of -1.5% was observed for Italy. Across all five countries, vaccination rates in the predefined target groups decreased to some extent (elderly) or increased slightly (chronically ill and health care workers). Vaccination rates among children varied strongly between countries and ranged from 6.1% in UK to 19.3% in Germany. The most powerful motivation for getting vaccinated in all countries was advice from a family doctor (58.6%) and the perception of influenza as a serious illness (51.9%). The major reasons why individuals did not become vaccinated were (1) the feeling of not being likely to catch influenza (39.5%) and (2) never having considered the option of being vaccinated (35.8%).

Conclusions. The change in general influenza vaccination coverage in the 2007/2008 season compared to the previous season was small, but decreases were seen in some target groups. The underlying motivations for and against vaccination did not substantially change. An effort to activate those driving forces that would encourage vaccination as well as dealing with barriers that tend to prevent it may help enhance coverage rates in Europe in the future.

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Novel Influenza A (H1N1) Outbreak at the U.S. Air Force Academy: Epidemiology and Viral Shedding Duration

Wiktop CT, Duffy MR, Macia EA, et al. Am J Prev Med. 20 October 2009. Available at http://www.ajpm-online.net/webfiles/images/journals/amepre/AJPM_Witkop.pdf.

Background. The U.S. Air Force Academy is an undergraduate institution that educates and trains cadets for military service. Following the arrival of 1376 basic cadet trainees in June 2009, surveillance revealed an increase in cadets presenting with respiratory illness. Specimens from ill cadets tested positive for novel influenza A (H1N1 [nH1N1])-specific ribonucleic acid (RNA) by real-time reverse transcriptase-polymerase chain reaction.

Purpose. The outbreak epidemiology, control measures, and nH1N1 shedding duration are described.

Methods. Case patients were identified through retrospective and prospective surveillance. Symptoms, signs, and illness duration were documented. Nasal-wash specimens were tested for nH1N1-specific RNA. Serial samples from a subset of 53 patients were assessed for presence of viable virus by viral culture.

Results. A total of 134 confirmed and 33 suspected cases of nH1N1 infection were identified with onset date June 25-July 24, 2009. Median age of case patients was 18 years (range, 17-24 years). Fever, cough, and sore throat were the most commonly reported symptoms. The incidence rate among basic cadet trainees during the outbreak period was 11%. Twenty-nine percent (31/106) of samples from patients with temperature _100°F and 19% (11/58) of samples from patients reporting no symptoms for _24 hours contained viable nH1N1 virus. Of 29 samples obtained 7 days from illness onset, seven (24%) contained viable nH1N1 virus.

Conclusions. In the nH1N1 outbreak under study, the number of cases peaked 48 hours after a social event and rapidly declined thereafter. Almost one quarter of samples obtained 7 days from illness onset contained viable nH1N1 virus. These data may be useful for future investigations and in scenario planning.

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An influenza A H1N1 virus revival--pandemic H1N1/09 virus

Michaelis M, Doerr HW, Cinatl J. Infection. October 2009; 37(5): (doi: 10.1007/s15010-009-9181-5). Available at http://www.springerlink.com/content/c3322417238138l2/.

Abstract. In April 2009, a novel H1N1 influenza A virus, the so-called pandemic H1N1/09 virus (former designations include swine influenza, novel influenza, swine-origin influenza A [H1N1] virus [S-OIV], Mexican flu, North American Flu) was identified in Mexico. The virus has since spread throughout the world and caused an influenza pandemic as defined by the criteria of the World Health Organization. This represents the first influenza A virus pandemic since the emergence of H3N2 ("Hong Kong" Flu) in 1968. Vaccine production has started, and vaccines are expected to become available during the course of 2009. Although the pandemic H1N1/09 virus originates from the triple-reassortant swine influenza (H1) virus circulating in North American pigs, it is not epidemic in pigs. Although the H1N1/09 virus pandemic is currently mild, concerns remain that it may become more aggressive during spreading. The distribution of proper information to the public on the status of the H1N1/09 virus pandemic will be important to achieve a broad awareness of the potential risks and the optimum code of behavior during the pandemic. Here, the features of pandemic H1N1/09 virus are discussed within the framework of knowledge gained from previous influenza A virus pandemics.

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Screening for influenza infection in international airline travelers

Duncan AR, Priest PC, Jennings LC, Brunton CR, Baker MG. Am J Public Health. October 2009; 99 Suppl 2:S360-2. Available at http://www.ajph.org/cgi/content/full/99/S2/S360.

Abstract. We sought the collaboration of an international airline and border control agencies to study the feasibility of entry screening to identify airline travelers at increased risk of influenza infection. Although extensive and lengthy negotiations were required, we successfully developed a multisector collaboration and demonstrated the logistical feasibility of our screening protocol. We also determined the staffing levels required for a larger study to estimate the prevalence of influenza in international airline travelers.

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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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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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14th International Congress on Infectious Diseases (ICID)
Miami, Florida, Mar 9-12, 2010

The November 1 deadline for abstract submissions is fast approaching. Take advantage of reduced registration fees by registering on or before January 15, 2010.
Additional information and registration available at http://www.isid.org/14th_icid/.

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ISHEID Symposium on HIV and Emerging Infectious Diseases
Marseille, France, 24-26 Mar 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 influenza guidance and information from the US CDC

Updated Interim Recommendations-HIV-Infected Adults and Adolescents: Considerations for Clinicians Regarding 2009 H1N1 Influenza
Released 21 October 2009
Available at http://www.cdc.gov/h1n1flu/guidance_HIV.htm.

Q&A: Opening and Mixing Tamiflu® Capsules with Liquids if Child Cannot Swallow Capsules
Released 20 October 2009
Available at http://www.cdc.gov/H1N1flu/antivirals/mixing_tamiflu_qa.htm.

Antiviral Safety Information
Released 19 October 2009
Available at http://www.cdc.gov/H1N1flu/antivirals/safety_info.htm.

Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season
Released 16 October 2009
Available at http://www.cdc.gov/h1n1flu/recommendations.htm.

Recommendations for Use of Antiviral Medications for the Management of Influenza in Children and Adolescent for the 2009-2010 Season -- Pediatric Supplement for Health Care Providers
Released 16 October 2009
Available at http://www.cdc.gov/h1n1flu/recommendations_pediatric_supplement.htm.

2009-2010 Influenza Season Triage Algorithm for Children (18 years or Younger) With Influenza-Like Illness
Released 16 October 2009
Available at >http://www.cdc.gov/h1n1flu/clinicians/pdf/childalgorithm.pdf.

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 apecein@u.washington.edu