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Vol. XIII No 19 ~ EINet News Briefs ~ Sep 17, 2010


*****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
- 2010 Cumulative number of human cases of avian influenza A/H5N1
- WHO situation update on pandemic influenza H1N1
- H1N1 pandemic influenza still active in some countries
- WHO reports that Tamiflu reduces death rates in H5N1 avian influenza
- Avian H5N1 influenza update
- GSK says no clear link between narcolepsy, pandemic H1N1 influenza vaccine
- Australia: National H1N1 pandemic vaccine uptake statistics

2. Infectious Disease News
- New gene in bacteria reported to be extremely antibiotic-resistant
- Australia: Measles outbreak feared
- India (Baba Raghav): Japanese encephalitis cases continue
- Indonesia (Bali): Rabies infections continue
- California: Pertussis diagnosis missed in infants who died
- Pennsylvania: Imported Lassa case sixth in USA

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- VECTOR-BORNE DISEASE
- CHOLERA, DIARRHEA, and DYSENTERY

4. Articles
- Practice and Child Characteristics Associated With Influenza Vaccine Uptake in Young Children
- Clinical Characteristics and 30-Day Outcomes for Influenza A 2009 (H1N1), 2008-2009 (H1N1), and 2007-2008 (H3N2) Infections
- Reassortant between Human-Like H3N2 and Avian H5 Subtype Influenza A Viruses in Pigs: A Potential Public Health Risk
- Effect of influenza vaccination on hospitalizations in persons aged 50 years and older
- Pandemic (H1N1) 2009 influenza vaccination coverage in Western Australia
- Pandemic (H1N1) 2009 influenza vaccine uptake in pregnant women entering the 2010 influenza season in Western Australia
- Expanding Practitioner Scopes of Practice During Public Health Emergencies: Experiences from the 2009 H1N1 Pandemic Vaccination Efforts
- Stigma, Health Disparities, and the 2009 H1N1 Influenza Pandemic: How to Protect Latino Farmworkers in Future Health Emergencies
- Response to H1N1 in a U.S.-Mexico Border Community
- Characteristics of paediatric patients with 2009 pandemic influenza A(H1N1) and severe, oxygen-requiring pneumonia in the Tokyo region, 1 September–31 October 2009
- Adverse reaction of influenza A (H1N1) 2009 virus vaccination in pregnant women and its effect on newborns
- Signs of the 2009 Influenza Pandemic in the New York-Presbyterian Hospital Electronic Health Records
- Potential spread of highly pathogenic avian influenza H5N1 by wildfowl: dispersal ranges and rates determined from large-scale satellite telemetry
- Effectiveness of Antiviral Treatment in Human Influenza A(H5N1) Infections: Analysis of a Global Patient Registry

5. Notifications
- Influenza 2010: Zoonotic Influenza and Human Health
- 4th Vaccine and ISV Annual Global Congress
- Cell Symposia – Influenza: Translating Basic Insights
- International TB Symposium (ITBS-2010): TB Diagnostics – Innovating to Make an Impact


1. Influenza News

Global
2010 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Cambodia / 1 (1)
China / 1 (1)
Egypt / 22 (9)
Indonesia / 6 (5)
Viet Nam 7 (2)
Total / 37 (18)

***For data on human cases of avian influenza prior to 2010, go to:
http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 505 (300)
(WHO 08/31/10
http://www.who.int/csr/disease/avian_influenza/country/cases_table_2010_08_31/en/index.html

Avian influenza age distribution data from WHO/WPRO (last updated 2/8/10):
http://www.wpro.who.int/sites/csr/data/data_Graphs.htm

WHO's map showing world's areas affected by H5N1 avian influenza (status as of 2/12/10):
http://gamapserver.who.int/mapLibrary/Files/Maps/Global_H5N1Human_2010_FIMS_20100212.png.

WHO’s timeline of important H5N1-related events (last updated 1/4/10):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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WHO situation update on pandemic influenza H1N1
Influenza activity is currently most intense in the temperate areas of the Southern Hemisphere and southern Asia.

India is still experiencing a country-wide outbreak of H1N1 (2009) with active transmission and a substantial number of fatal cases in several states across the country.

Chile reported on a sharp increase in respiratory disease activity since 30 August 2010. All age groups are affected but the age groups below 65 years appear to be more affected than the older population. The level of activity in Chile in September is very unusual for this time of the year, as the country usually experiences a peak of respiratory disease in June and July. H1N1 (2009) virus has been the most commonly detected influenza virus so far this season but in the recent weeks there has been a shift towards influenza virus type B and influenza A (H3N2), with a decreasing proportion of H1N1 (2009) viruses. Respiratory Syncitial Virus transmission has also been widespread and intense, primarily affecting young children.

Australia has reported increasing influenza activity throughout August and September 2010, though recently, the numbers of patients seen in emergency departments for influenza-like illness seem to have leveled off in parts of the country. Overall, influenza activity is well below the activity observed in the winter of 2009. The most commonly identified influenza virus in Australia is H1N1 (2009), though influenza type B is also being detected.

In New Zealand, influenza activity has decreased in the last week of August 2010, although activity is still well above baseline levels and with significant regional differences. The majority of influenza detections have been characterized as H1N1 (2009). Levels of influenza transmission in 2010 are below 2009 levels nationally but have exceeded 2009 in some localized areas of the country.

In Africa, the Central African Republic reported on their first ever detection of H1N1 (2009). South Africa observed a decrease in detection rate of influenza viruses in outpatients seen for respiratory disease for the second week in a row. Influenza type B has been the most commonly detected influenza virus throughout the 2010 winter season in South Africa though in recent weeks the proportion of H1N1 (2009) viruses has increased and a small, decreasing number of influenza A (H3N2) continues to be detected.
(WHO 09/10/2010)

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H1N1 pandemic influenza still active in some countries
Flu activity is continuing at various intensity levels, with India reporting more deaths, Australia reporting increasing numbers of cases late in its flu season, and transmission declining in New Zealand.

Though the World Health Organization (WHO) on 10 August 2010 moved to a post-peak pandemic phase, on 6 September 2010 WHO Director-General Margaret Chan repeated warnings that countries should stay alert for the 2009 H1N1 virus to limit the impact of outbreaks.

Chan, who spoke at the start of a four-day WHO meeting in Bangkok with health officials from the agency's South-East Asia region, said the 2009 H1N1 virus remains a serious health risk. She added that the WHO is seeing localized outbreaks and some continuing "hot spots," which were expected in the post-peak phase.

Let me remind you the pandemic virus has not gone away, Chan said. She said the virus is especially a threat to young people and pregnant women.

India's health ministry said that in the week ending 5 September 2010 it had received at least 128 reports of 2009 H1N1 deaths. The deaths were reported across 12 Indian states, but most were from Maharashtra (45), Gujarat (13), Madhya Pradesh (12), and Karnataka (9). India is in the midst of its second wave of infections, which was triggered by monsoon rains earlier in the summer of 2010.

Australia's health ministry, in its update for the week ending 27 August 2010, said flu activity is increasing, with the highest number of lab confirmations in South Australia and Queensland states. Of 335 confirmed cases reported that week, 221 involved the 2009 H1N1 virus.

The country reported 12 flu hospitalizations during the surveillance week, of which 11 were for 2009 H1N1 infections. Surveillance systems reported three intensive care unit (ICU) hospitalizations during the same time period.

Meanwhile, New Zealand, which has been reporting intense flu activity, said 6 September 2010 that the number of new cases was declining to levels seen at this time in 2008.

The country reported one more death linked to the virus, raising the total to 17. The health ministry said 11 people were currently receiving ICU treatment for their infections.
(CIDRAP 09/07/2010)

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WHO reports that Tamiflu reduces death rates in H5N1 avian influenza
A multinational team of researchers has determined that oseltamivir (Tamiflu) significantly reduces death rates in people infected with the deadly H5N1 avian flu virus when started up to eight days after symptoms begin. In studying records of 308 H5N1 patients from 12 countries (Azerbaijan, Bangladesh, Cambodia, China, Egypt, Hong Kong, Indonesia, Nigeria, Pakistan, Thailand, Turkey, and Vietnam), the researchers found an overall survival rate of 43.5%. However, survival rates varied from 24% in those who had no antiviral treatment to 60% in those receiving oseltamivir, a mortality reduction of 49%. The authors concluded that Oseltamivir significantly reduces mortality when started up to six to eight days after symptom onset and appears to benefit all age groups. An accompanying commentary states that the findings reinforce similar data in other studies, but it also cites some methodological weaknesses of the current study. They said the findings can be considered to be reasonable, based on other evidence and plausibility, but not definitive.
(CIDRAP 09/10/2010)

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Avian H5N1 influenza update
Since late 2003, 62 countries around the world have reported cases of highly pathogenic avian influenza H5N1 (H5N1 HPAI) in poultry and wild birds. Up to September 2010, the cumulative number of confirmed human cases of H5N1 HPAI reported to the World Health Organization is 504, of which 299 have resulted in death.

The H5N1 HPAI global disease situation is now relatively stable, but still alarming in some countries where the disease is considered entrenched. In these locations, pockets of infections are closely associated to well-known risk factors, such as high human and chicken densities, large free-grazing duck populations, poor biosecurity in smallholder units and culturally-determined food market habits linked to poor poultry hygiene.

In 2007, the use of spatial cluster analysis revealed the presence of more specific risk factors supporting the spread of infections in selected geographical clusters, such as the higher percentage of surface water which would support higher densities of domestic and wild water birds compared with other adjacent regions.

For instance, in Southeast Asia the presence of agro-livestock farming systems involving the combination of paddy rice production, domestic water birds and poultry in the river deltas is ubiquitous. These specific mixtures of factors are likely to be important for maintenance of infection given that H5N1 HPAI thrives in the presence of water, bird feces, ducks and chickens. More recently, a study published in the International Journal of Infectious Diseases found that two risk factors -- poultry density and road density -- had a statistically significant correlation with the number of H5N1 HPAI outbreaks in poultry at district levels in West Java Province, Indonesia.

Both the medical and veterinary professions recognize the vital roles played by identifying and understanding disease risk determinants. Such knowledge underpins a multilayered approach to proactive disease risk management; one that combines the interlocking elements of foresight, prevention, impact mitigation, early detection, and swift and effective reaction.

To accomplish its mandate of achieving food security for all, the Food and Agriculture Organization of the United Nations (FAO) is undertaking various studies to better understand the root causes that underpin pathogen evolution, establishment and persistence. These studies could potentially reveal viable options to address high-impact transboundary diseases that are emerging and re-emerging globally, thereby affecting animal and human health.
(PROMED 09/12/2010)

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Europe/Near East
GSK says no clear link between narcolepsy, pandemic H1N1 influenza vaccine
GlaxoSmithKline (GSK) said current data are insufficient to confirm that Pandemrix, its adjuvanted H1N1 pandemic vaccine, has caused the small number of cases of narcolepsy reported. The company has begun its own investigation of the cases. GSK said that the investigation has been primarily, but not exclusively, in Finland and Sweden, with a small number of additional cases reported in France. Citing adverse-event reports submitted to health officials, GSK released a statement saying the company has concluded that the currently available information is insufficient to assess the likelihood of a causal relationship between Pandemrix and narcolepsy after reviewing the currently available data and information regarding the reported cases of narcolepsy, which continues to remain limited, as well as GSK's own safety database. GSK said more than 30 million doses of the vaccine have been administered throughout Europe.
(CIDRAP 09/02/2010)

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Asia
Australia: National H1N1 pandemic vaccine uptake statistics
Australian health officials, on 10 September 2010 released the results of a survey on the nation's uptake of the 2009 H1N1 vaccine, which shows that about 18% of the population had been vaccinated by the end of February 2010. The rate is slightly lower than the 20.3% estimate of pandemic vaccine uptake in the United States. Compared with the general uptake, rates were higher in Australians with underlying health conditions (34%) and in health and community care workers (29.5%). Dr Penny Allbon, director of the Australian Institute for Health and Welfare, said rates varied by state, with Tasmania showing the highest uptake at 23.5% and Western Australia the lowest at 15%. The survey also explored reasons people did and didn't receive the vaccine. The most common reasons for forgoing immunization were the beliefs that the 2009 H1N1 virus wasn't a serious health threat, that the vaccine had flaws, and that vaccination wasn't a priority. The pandemic vaccine was free, available for all groups except babies under six months, and available starting in September 2009, which was near the end of Australia's flu season.
(CIDRAP 09/10/2010)

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2. Infectious Disease News

Global
New gene in bacteria reported to be extremely antibiotic-resistant
An infectious-disease nightmare is unfolding: a new gene that can turn many types of bacteria into superbugs resistant to nearly all antibiotics has sickened people in three states and is popping up all over the world, health officials reported 13 September 2010.

The USA cases and two others in Canada all involve people who had recently received medical care in India, where the problem is widespread. A British medical journal revealed the risk in August 2010 in an article describing dozens of cases in Britain in people who had gone to India for medical procedures.

How many deaths the gene may have caused is unknown; there is no central tracking of such cases. So far, the gene has mostly been found in bacteria that cause gut or urinary infections.

Scientists have long feared this, a very adaptable gene that hitches onto many types of common germs and confers broad drug resistance. It's a great concern, because drug resistance has been rising and few new antibiotics are in development, said Dr M Lindsay Grayson, director of infectious diseases at the University of Melbourne in Australia. It's just a matter of time until the gene spreads more widely person-to-person, he said.

The American cases occurred in 2010 in people from California, Massachusetts, and Illinois, said Brandi Limbago, a lab chief at the CDC. Three different bacteria were involved, and different mechanisms let the gene become part of them. We want physicians to look for it, especially in patients who have traveled recently to India or Pakistan, she said.

The gene can spread hand-to-mouth, which makes good hygiene very important. It's also why health officials are so concerned about where the threat is coming from, said Dr Patrice Nordmann, a microbiology professor at South-Paris Medical School. India is an overpopulated country that overuses antibiotics and has widespread diarrheal disease and many people without clean water. The ingredients are there for widespread transmission, he said. It's going to spread by plane all over the world.

The American patients were not related. The California woman needed hospital care after being in a car accident in India. The Illinois man had pre-existing medical problems and a urinary catheter, and is thought to have contracted an infection with the gene while traveling in India. The case from Massachusetts involved a woman from India who had surgery and chemotherapy for cancer there and then traveled to the USA.

Lab tests showed their germs were not killed by the types of drugs normally used to treat drug-resistant infections, including the last-resort class of antibiotics that physicians go to, Limbago said. She did not know how the three patients were treated, but all survived.

Doctors have tried treating some of these cases with combinations of antibiotics, hoping that will be more effective than individual ones are. Some have resorted to using polymyxins, antibiotics used in the 1950s and '60s that were unpopular because they can harm the kidneys.

The two Canadian cases were treated with a combination of antibiotics, said Dr Johann Pitout of the University of Calgary in Alberta, Canada. One case was in Alberta, the other in British Columbia. Both patients had medical emergencies while traveling in India. They developed urinary infections that were discovered to have the resistance gene once they returned home to Canada, Pitout said.

The CDC advises any hospitals that find such cases to put the patient in medical isolation, check the patient's close contacts for possible infection, and look for more infections in the hospital. Any case should raise an alarm, Limbago said.

[ProMED note: There is every reason to assume that once introduced into a country these organisms will persist by hospital-associated spread to other patients. The only ways of preventing this spread are adequate barrier protection, manifest primarily by aggressive hand washing, and by rational use of antimicrobials to minimize the niche for these pathogens.]
(ProMED 09/14/2010)

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Asia
Australia: Measles outbreak feared
Health authorities across New South Wales and Queensland are urging residents to make sure they are immunized against measles. A spate of outbreaks across the eastern Australian seaboard has doctors worried that a pandemic that was raging in South Africa during the World Cup is quietly spilling across the Indian Ocean. GPs [General Practitioners] say the reluctance by some parents here to immunize their children has put the public in danger of a major outbreak.

Queensland Health officials believe the most recent case of measles was contracted by an adult from north Queensland, who was returning home on a flight from South Africa August 2010. Public medical officer Dr Steven Donohue says since then another two people have been infected in Townsville after they came into contact with the traveler.

Measles is not a trivial illness -- this thing is the worst of the childhood diseases and used to kill a lot of children, Dr Donohue said. In the last two weeks seven cases were confirmed at Tweed Heads on the New South Wales/Queensland border, and a local mine worker in Moranbah to the south-west of Mackay contracted the disease. Another two people in Townsville are still waiting on results. Dr Donohue says he is concerned the disease is spreading undetected, as the time between contracting the virus and showing symptoms can be up to two weeks.

You can walk past somebody with measles in a supermarket while they're infectious and if you're not immune, then it's quite possible for you to get this disease, he said. He says adults under the age of 45 are most at risk, as they may not have received a vaccination. Basically anyone born during or after 1966 should be checking if they received two doses of MMR [measles, mumps and rubella] vaccine and if not, then our advice is to go along to your GP and get a free additional dose of MMR just to make sure, Dr Donohue said.

Townsville GP network chairman Dr Kevin Arlett says there has been a reduction in vaccinations over the last decade, and that could be disastrous. Because a lot of people haven't seen these diseases, there's been a whole generation basically who hasn't seen a lot of these infectious diseases, he said. People are feeling a little bit blasé about it perhaps, but they're also being fed some information by some of the anti-vaccination lobby groups suggesting that vaccinations are more dangerous than the disease itself.

He says the Australian public may have forgotten what toll the measles disease can take on the human body. He said it can lead to all sorts of problems, but as with most viral infections it affects the whole body so you can end up with problems of the lungs, you can end up with problems with the brain and that's obviously where disasters occur.

[ProMED note: Current measles activity includes outbreaks in several countries in southern Africa. Over the past year, high numbers of measles cases have been reported in many countries, including Lesotho, Malawi, Namibia, Mozambique, South Africa, Zambia, and Zimbabwe. Several hundred deaths have also been reported. Travelers attending the FIFA World Cup in South Africa in June/July 2010 were warned of the risk of measles virus infection and advised to review their vaccination status. Despite this recent cases of measles in Australia appeared to have been introduced by this route.

Because of this risk of measles in both developed and developing countries, all international travelers should be up to date on immunizations, irrespective of their travel destination.]
(ProMED 09/14/2010)

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India (Baba Raghav): Japanese encephalitis cases continue
The deadly Japanese encephalitis (JE) toll 14 September 2010 mounted to 296 with the death of three more children in Gorakhpur. According to official sources, the inflow of JE patients continued unabated at the Baba Raghav Das Medical College here.

Since 1 January 2010, a total of 1899 people -- including 15 fresh cases -- suffering from JE have been admitted at the medical college in Gorakhpur, of whom 296 have succumbed, including 197 from Bihar and nine from Nepal. As many as 287 people were still under treatment. The fresh deaths included one each in Deoria and Kushinagar [districts, Uttar Pradesh], and one in Bihar.

In 2009, JE had claimed more than thousands of lives in UP alone.

[ProMED note: The ongoing outbreak now has the number of deaths increasing from 254 in the report of 8 September 2010, to 296 in this current report. Although previous reports indicated that most of these encephalitis cases are not caused by Japanese encephalitis virus (JEV) infections, the report above attributes all cases to JEV infections with no mention of non-JEV cases that may be due to enterovirus infections.]
(ProMED 09/15/2010)

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Indonesia (Bali): Rabies infections continue
Bali's rabies epidemic continues to plague the island. A total of 93 people have died from suspected rabies spread from dog bites, despite massive expenditures and efforts to inoculate pet dogs and eliminate stray animals.

Ketut Teneng, the spokesman for the Bali provincial government, said that 93 people have died after suffering dog bites. Of that total, he said, 41 of those deaths were clinically linked to rabies through laboratory tests on the victims. The remaining victims were buried without aid of laboratory test but after exhibiting symptoms consistent with a rabies infection.

The number of new dog bites reported in Bali remains very high. On an average day, 165 people are bitten by dogs in Bali, adding to widespread fear among visitors and locals of the danger of contamination with a potentially fatal disease. Teneng said the elimination of stray dogs must continue, adding that this does not have to done only by government officials who kill the dogs, but also by the public who undertake the elimination of stray animals. Saying the threat of infection is before our very eyes, Teneng pointed to the high number of stray dogs living in Bali, resulting in a greater risk of dog bites and possible infection with rabies. We have a clear choice; do you want to get rabies or not? If we allow the dog population to grow, it means the chance of getting rabies is also high, said Teneng.

Teneng said that for the year 2010 through 2 September 2010, a total of 37,901 dog bites have been inflicted on Bali residents. From that total, 34,485 victims have been treated with rabies anti-serum. These figures show a dramatic increase over 2009, when only 21,806 dog bites were reported, of which 18,825 victims received anti-rabies serum.

According to the chief health officer for Bali, Dr Nyoman Sutedja, the costs of fighting rabies in Bali is substantial. In 2009 the provincial government of Bali spent Rp. 6.5 billion [USD 723,000], Bali regencies Rp. 3.5 billion [USD 389,000] and the central government contributed Rp. 15 billion [USD 1.7 million] to Bali's anti-rabies campaign resulting in total expenditures of Rp. 25 billion [USD 2.7 million]. In 2010, the total spent in combating rabies is expected to rise.

[ProMED note: The numbers of dog bites and human rabies deaths continue to be alarming. Human fatalities during this two-year rabies outbreak have risen from 76 on 6 August 2010 to the current 93 just a month later. It would be of interest to know what proportion of the total population has been vaccinated. It would also be of interest to know if the Rp 25 billion (USD 2.7 million) has gone to dealing with the dog population, or if this includes post-exposure treatment of people bitten by dogs as well.]
(ProMED 09/06/2010)

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Americas
California: Pertussis diagnosis missed in infants who died
California health officials said the eight infants who have died of whooping cough (pertussis) in 2010 were not diagnosed as having the disease despite repeated visits to hospitals and clinics. As a result, the California Department of Public Health (CDPH) recently sent a letter to physicians advising that anyone younger than six months who has trouble breathing should be treated for pertussis until the disease is ruled out. By the time these infants developed severe respiratory distress, it was usually too late for any intervention to prevent their tragic deaths, John Talarico, the state's immunization branch chief, wrote in the letter. A similar letter was sent to hospitals. Meanwhile, the CDPH said 09/06/2010 that 3,834 confirmed, probable, and suspected cases of pertussis have been reported in the state in 2010, seven times as many as at this time in 2009 The number signals an incidence of 9.8 cases per 100,000 people, the highest since 1962. Of 1,549 cases with available information, 187 patients were hospitalized, 139 of whom were under six months of age. Seven of the eight infants who died were less than two months old and had not received any doses of pertussis vaccine.
(CIDRAP 09/08/2010)

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Pennsylvania: Imported Lassa case sixth in USA
A man who lives in Pennsylvania returned from a trip to his native Liberia with Lassa fever, marking the sixth case of the tropical disease imported into the United States and the first since 2004. The Lassa fever virus is endemic in West Africa and causes an illness that is fatal in 1% to 2% of cases, the CDC noted in a report published in Emerging Infectious Diseases. The patient, 47, traveled to Liberia January of 2009 and stayed in his native village, sleeping in a hut infested with rats. He fell ill on the day of his departure from Liberia and sought treatment after returning to the United States, leading to 21 days in a hospital. The virus was identified on his fifth hospital day, but he was not given ribavirin, a recommended treatment, because he was improving by the time the virus was suspected. The man had 140 contacts who were given information about Lassa fever, but no secondary cases were found. The CDC says clinicians treating patients who have a fever after traveling to West Africa should obtain detailed histories to learn if they have been in rural areas where they risked exposure to rodents. Early treatment with ribavirin can greatly reduce death rates in patients with severe Lassa fever.
(CIDRAP 09/15/2010)

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3. Updates
INFLUENZA A/H1N1
- 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/en/what-we-do/health-topics/diseases-and-conditions/influenza/pandemic-influenza
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.flu.gov
MOH México: http://portal.salud.gob.mx/index_eng.html
PHA of Canada: http://fightflu.ca

- 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/

WHO H1N1 pandemic influenza status update:
On August 10 the WHO Director-General Dr Margaret Chan announced that the H1N1 influenza event has moved into the post-pandemic period. The influenza situation update will no longer be posted on the Disease Outbreak News website. The global influenza program will continue to monitor the influenza activity worldwide on a weekly basis and every two weeks a WHO influenza update will be published.
(WHO 09/10/2010)

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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. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/
- 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 H5N1.
- 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 health officials prepare for an influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.flu.gov/. “Flu Essentials” are available in multiple languages.
- CIDRAP: Avian Influenza page:
http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/.
- 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 avian influenza H5N1 in wild birds and poultry.

NYTimes story on FDA release of updated guidelines on animal antibiotics:
http://www.nytimes.com/2010/09/15/us/15farm.html?_r=1&scp=1&sq=antibiotics&st=cse

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VECTOR-BORNE DISEASE
Global
The World Health Organization (WHO) warned 16 September 2010 that the number of severe dengue infections and hospitalizations in the Asian Pacific region continues to grow, with some countries reporting significant increases over the same time in 2009. WHO said dengue is one of the fastest emerging infections in the world and that more than 70% of the at-risk population live in Asian Pacific countries, with Laos, Malaysia, the Philippines, and Vietnam among the hardest-hit areas. Though Singapore had a spike in dengue infections in recent months, its number of infections over the years continues to decrease, perhaps because of an effective response system, the WHO said. Increases noted in other countries could be due to a combination of factors, including higher temperatures and rainfall this year, growing population densities, and greater international travel. It said though there is no evidence that global warming is driving the increase in dengue cases in the area, climate changes play a spatial and temporal role in disease distribution. The mosquitoes that spread the virus are now found in areas where they were rare, including South Korea and the highlands of Papua New Guinea. Dr Shin Young-soo, who directs the WHO's Western Pacific region, said the agency is working closely with countries on surveillance activities.
(CIDRAP 09/16/2010)


Chinese Taipei
The Taiwan Centers for Disease Control (CDC) said 7 September 2010 that 25 cases of indigenous dengue fever were recorded the week of 30 August 2010, the highest weekly number in 2010. All 25 cases were in southern Taiwan. In the last six months of 2010, 80 cases of indigenous dengue fever have been recorded in Taiwan, it said. The number of imported cases also rose in the week of 30 August 2010, bringing the total to 182 so far in 2010, the CDC said. CDC statistics show that 23 cases of imported dengue fever were recorded the week of 30 August 2010 and the total number for August was 66, the highest in a single month since 1998. These numbers basically tell us that the dengue fever situation, in terms of both indigenous and imported cases, is quite serious, said Dr Kuo Tsung-wen of the CDC.

The Centers for Disease Control (CDC) warned 14 September 2010 that the number of domestic dengue fever cases could exceed 1,000 by the end of 2010, and urged the public to get rid of standing water, especially around residential areas.

Speaking at a weekly briefing, CDC Epidemic Intelligence Center Director Chuang Jen-hsiang also said there had been a record high number of imported cases of dengue fever in southern Taiwan in 2010 and predicted that the number will peak in November.

So far in 2010, there have been 169 cases of domestic dengue fever, including 18 new cases reported the week of 30 September 2010 and 49 confirmed in the week of 6 September 2010. In the same period, the CDC also recorded 202 cases of imported dengue fever, the highest number in Taiwan's history for the period.

Chuang pointed out the number of imported cases has never exceeded 200 in past years.

According to the CDC, the biggest epidemics of dengue fever were in 2002 with 5,000 domestic cases, followed by 2007 with 2,000 cases and 2009 with 848 cases.

The CDC urged the public to clear standing water from their neighborhoods and to avoid places that could be potential breeding sites for the disease-carrying mosquitoes.
(ProMED, China Post 09/07/2010, 09/15/2010)


India
The Cycling Federation of India (CFI) has decided to shift its Commonwealth Games camp from Delhi to Patiala following an outbreak of dengue fever among the cyclists. Delhi is reeling under dengue attacks since June 2010 and nearly 1,500 cases have already been reported in local hospitals. While 25 participating nations have sent letters to the Commonwealth Games Organising Committee (CGOC) enquiring about the disease, a host of countries including Australia and Malaysia have recently issued travel advisories for their citizens coming to Delhi for the Games.
(ProMED 09/09/2010)


India
A steep rise in malaria cases has been registered in the western part of Rajasthan. The districts of Jaisalmer and Barmer registered more than 1000 cases the week of 30 August 2010.

The disease has emerged strongly in the Pokran area of Jaisalmer, where two children reportedly died of malaria. There had been 432 cases of malaria reported from the district last week, among these, 410 were of PV malaria, while 20 were of PF malaria [Plasmodium falciparum], two were of mixed kind [P. falciparum and P. vivax], said chief medical and health officer (CMHO), Jaisalmer, M L Purniya.

Across the state, malaria has been registered at a comparatively low incidence in 2010 however, districts of Jaisalmer and Barmer have seen an uptrend in the disease.

The figures are being viewed with apprehension, as there have only been 769 cases of malaria reported from Jaisalmer since January 2010, including the patients reported last week.

The adjoining Barmer district has been facing a similar issue: There were 513 new cases of malaria reported last week, of these, four were of malaria PF, said CMHO Barmer Ganpat Singh. The district has so far reported 695 cases in 2010.

According to the health department officials, antilarval activities have been intensified in the affected areas, while arrangements have been made for handling the rising number of patients. As the malaria-causing mosquito usually breeds in shallow and clean water, household tanks, desert coolers, and shallow ponds often become breeding grounds.

[ProMED note: Malaria is endemic in Rajasthan, but the increase in the number of cases is substantial. Jaisalmer is about 150 km [93 miles] from the border of Pakistan, and the increase in malaria cases is most likely not related to the floods in Pakistan.]
(ProMED 09/09/2010)


India (Delhi)
With 71 fresh cases surfacing 4 September 2010, the total number of dengue cases in the city went up to 1226. According to official sources, out of the total cases so far, 1,061 have been reported from Municipal Corporation of Delhi (MCD) areas and 125 from New Delhi Municipal Committee (NDMC) areas. The remaining cases have emerged from other parts of the city while some are from some outstation. The total number of deaths due to dengue has been three in the 2010 season.

What is cause for concern is that in comparison to previous years, the number of infections in 2010 has crossed the 1000 mark within three months when even in years which were the worst for the disease the 1,000-mark was attained only at the very end of the season. According to statistics released by the MCD, the number of cases till August end in 2009 was only 12 while the infections were 136 and 24 in the same periods in 2008 and 2007 respectively. The total number of dengue cases and deaths were 1312 and two (2008), 548 and one (2007), and 3366 and 36 (2006).

What is baffling the civic authorities is that besides the unauthorized colonies and low-lying areas of the capital, affluent regions and establishments have been found to be conducive for mosquito breeding.

Directorate of National Vector Borne Disease Control Programme (NVBDCP), the department that implements antilarval measures in Delhi, detected 40 per cent of the total breeding sites in posh south and central Delhi colonies. A massive cleaning up campaign to tackle the dengue menace will begin from 6 September 2010.

The MCD and the NDMC will start spraying operations for killing of larva in all stagnant pools of water in public places.

[ProMED note: This report is an example of how dengue virus vector mosquitoes can breed in more affluent neighborhoods as well as in poorer ones. Given the steady increase in dengue cases in Delhi for over a month, one wonders why the vector mosquito control effort is just now getting started.]
(ProMED 09/05/2010)


Russia
The number of people sickened with West Nile encephalitis [WNE] in the Volgograd region has increased to 365. In the period from 16 July-14 September 2010, 365 cases were registered, including 295 in Volgograd (81 percent), 25 in the town of Volzhsky (6.8 percent), and 45 in municipal districts (12.3 percent), the regional department of the Rospotrebnadzor [Federal Service for Consumer Affairs and Human Welfare] said.

Rospotrebnadzor said five WNE patients died. The lethal outcomes were reported for the group over 60 years of age (80 percent); they were confirmed in four people by the polymerase chain reaction (PCR) method in laboratories, it said.

All the WNE patients have been hospitalized; medical assistance is being provided to them.

Rospotrebnadzor said the number of patients grows by 10-20 people a day.

As of 1 September 2010, there were just 206 WNE patients in the province.

According to Rospotrebnadzor officials, the climate of the region and natural migration of birds of passage that make nests in the estuary of the Volga, create favorable conditions for the transmission of the virus. As a result, the region hosted stable WNE nidi, which have intensified since 1999, and remain active up to date. Mosquitoes are the main carriers.
(ProMED 09/15/2010)


Philippines
The mosquito-borne virus continues to wreak havoc in the province, claiming at least eight lives of children in September 2010 alone, the Regional Epidemiology Surveillance Unit (RESU) 7 revealed late in the week of 6 September 2010.

The latest fatalities expired midweek the week of 6 September 2010 inside the Vicente Sotto Memorial Medical Center (VSMMC), a RESU 7 personnel said. There were at least 270 patients brought to the VSMMC during a one-week period from 1 September 2010; five of them died. These patients, whose ages range from nine months old to 35 years old are from the different parts of Cebu, including Cebu City.

DoH 7 director Susana Madarieta said from January to September of 2010, the region has recorded 5571 dengue cases or 1229 cases more compared to the same period of 2009.

With the number of dengue cases in Cebu and the rest of Central Visayas rapidly increasing, local government officials and the DoH 7 are stepping up its measures against the mosquito-borne dengue disease here.

Cebu City Medical Center (CCMC) has been jam packed with dengue patients being brought in almost daily, prompting Cebu City mayor Michael Rama to ask those from outside the city to go to other hospitals so as not to drain the city's resources.
(ProMED 09/15/2010)


Thailand
More than 2,300 residents of Buri Ram province have caught dengue fever. The Ministry of Public Health is deploying village health volunteers to help combat the disease in local communities. Buri Ram Provincial Public Health Officer MD Sompong Jarungjittanuson stated that the outbreak of dengue fever in the province remained a cause for concern mainly due to ongoing rainfall and widespread inundation in the area during this period.

According to the record, the number of people infected with dengue fever within Buri Ram has reached 2,354 since the beginning of 2010 with one fatality. Children between five and 10 years of age are at the highest risk, followed by those between 10 and 14 years old. Areas with highest infection rates are Nang Rong, Phutthaisong, Na Pho, Ban Mai Chaiyaphot, and Lahan Sai districts.

MD Sompong hence suggested parents dwelling in the mentioned districts to closely monitor their children to keep them safe from mosquito bites. As for preventive measures against the spread of the disease, he said relevant authorities in the province as well as village health volunteers were being dispatched to remove all stagnant waters which could become mosquito breeding grounds. The teams are also educating local residents on how to eradicate mosquito larvae and prevent the disease outbreak.
(ProMED 09/11/2010)


Viet Nam
The Health Ministry's Preventive Medicine Department reports more than 4,300 dengue fever patients have been treated during the past eight months. Health experts warn that the dengue fever epidemic is caused by two viruses, D1 and D2. The disease has been diagnosed in Ha Noi and Ho Chi Minh City and Khanh Hoa, Phu Yen, Dac Nong, Gia Lai, and Kon Tum Provinces.
(ProMED 09/09/2010)

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CHOLERA, DIARRHEA, and DYSENTERY
China
Nearly 20 middle school students have been diagnosed with cholera in eastern China, the government has said, in the second outbreak of the potentially fatal disease in the nation in a month.

A total of 19 cases have been detected at a school in Huaian city in Jiangsu province, prompting health authorities to issue a warning for the region and urge increased disease monitoring, the Jiangsu government said 9 September 2010.

The students began falling ill on 2 September 2010, displaying common symptoms including fever, abdominal pain, and serious diarrhea and vomiting. The city is on the border with Anhui province, where authorities covered up a cholera outbreak for 12 days in August 2010 out of fears that publicizing it would shock the local population, state media said earlier the week of 6 September 2010.

The Anhui health department acknowledged 7 September 2010 that at least 38 people in the province had been sickened with cholera since 16 August 2010, with all patients already out of hospital and no new cases discovered in September 2010.

It was not immediately clear if the strain of cholera found in Anhui was the same as the one detected in Huaian. No fatalities have been reported in either outbreak.
(ProMED 09/10/2010)


China
China's Ministry of Health on 10 September 2010 reported nearly 1,600 deaths from infectious diseases on the mainland in August 2010. Some 590,000 infections were registered in August 2010, including 63 cholera infections, according to a statement released by the ministry. However, no deaths from cholera were reported in August 2010, the statement said.

Among the 63 cholera infections, 38 were in Mengcheng County in eastern Anhui Province. Local residents blamed poor hygiene awareness and street food stalls for the outbreak.
(ProMED 09/10/2010)


India
Cholera, and other water borne diseases, which have claimed 39 lives since the end of August 2010, have infected 124 more people in Orissa's Rayagada district in the last two days, and triggered panic among the residents, an official said 14 September 2010.

According to the latest data, the number of people and villages affected by the diseases has risen to 784 and 156 respectively. Over 100 more people have been infected and the diseases have been reported from 54 new villages, an official of the health control room told IANS.

However, local newspapers claimed that the government figure was far from the real figure. Dharitri, a vernacular Oriya daily, said in a report on 14 September 2010 that the number of deaths in Rayagada district has crossed the 100 mark and the number of people affected has crossed the 1000 figure. Another vernacular newspaper 'The Samaja' said the disease has also spread to the neighboring Gajapati and Nabrangpur districts. The paper also said that during the past two days, at least seven people have died of cholera and other water borne diseases in Rayagada, Gajapati, and Nabrangpur.
(ProMED 09/14/2010)

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4. Articles
Practice and Child Characteristics Associated With Influenza Vaccine Uptake in Young Children
Poeling KA, Faribrother G, Zhu Y, et al. Pediatrics. 6 September 2010. doi:10.1542/peds.2009-2620.
Available at http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-2620v1

Objectives. The objective of this study was to determine both practice and child characteristics and practice strategies associated with receipt of influenza vaccine in young children during the 2004–2005 influenza season, the first season for the universal influenza vaccination recommendation for all children who are aged 6 to 23 months.

Methods. Clinical and demographic data from randomly selected children who were aged 6 to 23 months were obtained by chart review from a community-based cohort study in 3 US counties. The proportion of children who were vaccinated by April 5, 2005, in each practice was obtained. For assessment of practice characteristics and strategies, sampled practices received a self-administered practice survey. Practice and child characteristics that predicted complete influenza vaccination were determined by using multinomial logistic regression.

Results. Forty-six (88%) of 52 sampled practices completed the survey and permitted chart reviews. Of 2384 children who were aged 6 to 23 months and were studied, 27% were completely vaccinated. The proportion of children who were completely vaccinated varied widely among practices (0%–71%). Most (87%) practices implemented 1 vaccination strategy. Complete influenza vaccination was associated with 3 practice characteristics: suburban location, lower patient volume, and vaccination strategies of evening/weekend vaccine clinics; with child characteristics of younger age, existing high-risk conditions, 6 well visits to the practice by 3 years of age, and any practice visit from October through January.

Conclusions. Modifiable factors that were associated with increased influenza vaccination coverage included October to January practice visits and evening/weekend vaccine clinics.

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Clinical Characteristics and 30-Day Outcomes for Influenza A 2009 (H1N1), 2008-2009 (H1N1), and 2007-2008 (H3N2) Infections
Belongia EA, Irving SA, Waring SC, et al. JAMA. 8 September 2010; 304(10):1091-1098. doi:10.1001/jama.2010.1277.
Available at http://jama.ama-assn.org/cgi/content/abstract/304/10/1091

Context. The clinical characteristics of pandemic 2009 influenza A(H1N1) infections have not been compared directly with illnesses caused by other influenza A strains.

Objective. To compare clinical features and outcomes for 2009 H1N1, seasonal H1N1, and H3N2 influenza in a population-based cohort.

Design, Setting, and Participants. Active surveillance with 30-day follow-up for influenza cases among children and adults living in a 14–zip code area in Wisconsin. Patients with subjective fever, chills, or cough of fewer than 8 days' duration were screened for eligibility during an outpatient or inpatient encounter. Consenting patients were interviewed and tested for influenza A during the 2007-2008 and 2008-2009 influenza seasons and from May to November 2009; 6874 patients (70%-86% of eligible patients) agreed to participate. Medical records were reviewed to assess outcomes.

Main Outcome Measures. Hospital admission, radiographically confirmed pneumonia, and clinical characteristics of influenza A by strain.

Results. We identified 545 2009 H1N1, 221 seasonal H1N1, and 632 H3N2 infections. The median ages of infected participants were 10, 11, and 25 years, respectively (P < .001). Hospital admission occurred within 30 days for 6 of 395 children with 2009 H1N1 (1.5%; 95% confidence interval [CI], 0.6%-3.1%), 5 of 135 with seasonal H1N1 (3.7%; 95% CI, 1.4%-8.0%), and 8 of 255 with H3N2 (3.1%; 95% CI, 1.5%-5.9%). Among adults, hospital admission occurred in 6 of 150 with 2009 H1N1 (4.0%; 95% CI, 1.6%-8.1%), 2 of 86 with seasonal H1N1 (2.3%; 95% CI, 0.3%-8.1%), and 17 of 377 with H3N2 (4.5%; 95% CI, 2.7%-7.0%). Pneumonia occurred in 10 children with 2009 H1N1 (2.5%; 95% CI, 1.3%-4.5%), 2 with seasonal H1N1 (1.5%; 95% CI, 0.2%-5.2%), and 5 with H3N2 (2.0%; 95% CI, 0.7%-4.3%). Among adults, pneumonia occurred in 6 with 2009 H1N1 (4.0%; 95% CI, 1.6%-8.1%), 2 with seasonal H1N1 (2.3%; 95% CI, 0.3%-8.1%), and 4 with H3N2 (1.1%; 95% CI, 0.3%-2.7%).

Conclusions. In this population, individuals with 2009 H1N1 infection were younger than those with H3N2. The risk of most serious complications was not elevated in adults or children with 2009 H1N1 compared with recent seasonal strains.

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Reassortant between Human-Like H3N2 and Avian H5 Subtype Influenza A Viruses in Pigs: A Potential Public Health Risk
Cong Y, Wang G, Guan Z, et al. PLos ONE. 7 September 2010. doi:10.1371/journal.pone.0012591.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0012591

Background. Human-like H3N2 influenza viruses have repeatedly been transmitted to domestic pigs in different regions of the world, but it is still uncertain whether any of these variants could become established in pig populations. The fact that different subtypes of influenza viruses have been detected in pigs makes them an ideal candidate for the genesis of a possible reassortant virus with both human and avian origins. However, the determination of whether pigs can act as a “mixing vessel” for a possible future pandemic virus is still pending an answer. This prompted us to gather the epidemiological information and investigate the genetic evolution of swine influenza viruses in Jilin, China.

Methods. Nasopharyngeal swabs were collected from pigs with respiratory illness in Jilin province, China from July 2007 to October 2008. All samples were screened for influenza A viruses. Three H3N2 swine influenza virus isolates were analyzed genetically and phylogenetically.

Results. Influenza surveillance of pigs in Jilin province, China revealed that H3N2 influenza viruses were regularly detected from domestic pigs during 2007 to 2008. Phylogenetic analysis revealed that two distinguishable groups of H3N2 influenza viruses were present in pigs: the wholly contemporary human-like H3N2 viruses (represented by the Moscow/10/99-like sublineage) and double-reassortant viruses containing genes from contemporary human H3N2 viruses and avian H5 viruses, both co-circulating in pig populations.

Conclusions. The present study reports for the first time the coexistence of wholly human-like H3N2 viruses and double-reassortant viruses that have emerged in pigs in Jilin, China. It provides updated information on the role of pigs in interspecies transmission and genetic reassortment of influenza viruses.

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Effect of influenza vaccination on hospitalizations in persons aged 50 years and older
Baxter R, Ray GT, Fireman BH. Vaccine. 9 September 2010. doi:10.1016/j.vaccine.2010.08.088.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-5101PF9-6&_user=10&_coverDate=09%2F09%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=9c1fd86e2dafe9f0b730df0ca4d4072d&searchtype=a

Objective. To estimate influenza vaccine effectiveness (VE) in preventing hospitalizations in persons over 50 years of age.

Design. We performed a retrospective, population based study, using a “difference-in-differences” approach to determine the association between hospitalization and prior vaccination. We examined this association when influenza was not circulating and compared it to the association found when influenza was circulating. VE was estimated from the difference in the association between hospitalization and prior vaccination, inside vs. outside influenza seasons.

Setting. Kaiser Permanente in Northern California.

Patients. Health plan members aged 50 years and older during the September 1997 to August 2008 study period, when there were about 68,000 pneumonia hospitalizations in 10 million person-years.

Results. Vaccination was associated with lower risk of hospitalization for pneumonia and influenza, even before flu season, presumably due to unmeasured confounders. When influenza arrived the hospitalization-vaccination association strengthened, yielding an adjusted VE estimate of 12.4% (95% CI: 1.6–22.0) in persons aged 50–64, and 8.5% (95% CI: 3.3–13.5) in those aged 65 years and older. There was no significant effect on hospitalizations for ischemic heart disease (IHD), congestive heart failure (CHF), cerebrovascular disease (CVD), or trauma.

Conclusions. Influenza vaccination has a modest but significant effect on prevention of hospitalization for pneumonia and influenza in persons 50 years of age and older.

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Pandemic (H1N1) 2009 influenza vaccination coverage in Western Australia
Mak DB, Daly AM, Armstrong PK, et al. Med J Aust. 6 September 2010; 193:1-4.
Available at http://www.mja.com.au/public/issues/193_07_041010/mak10281_fm.html

Objective. To assess pandemic (H1N1) 2009 influenza vaccination coverage in Western Australians, up to 31 January 2010.

Design, setting and participants. Vaccination data for Western Australians aged 10 years and older were obtained from two sources: the WA Pandemic Influenza Vaccination Database (PIVD; which collected reports of pandemic influenza vaccinations from vaccination providers statewide) for the period 30 September 2009 to 31 January 2010, and the WA Health and Wellbeing Surveillance System (HWSS; a continuous population-based telephone survey) for the period 1 December 2009 to 31 January 2010. Data from the PIVD was used to impute vaccination coverage estimates for at-risk subpopulations not assessed in the HWSS interviews.

Main outcome measures. Vaccination coverage of Western Australians aged 10 years and older and of subgroups targeted by the national pandemic (H1N1) 2009 influenza vaccination campaign.

Results. A total of 171 789 pandemic influenza vaccinations were reported to the PIVD by 31 January 2010 and 88% of these were administered by 1 December 2009. Based on HWSS data, vaccination coverage of persons aged 10 years and older was 14.5% (95% CI, 12.6%–16.6%) and of persons aged 18 years and older was 15.3% (95% CI, 13.3%–17.6%). Based on PIVD data, coverage in adults ranged from 10.3% in pregnant women to 52.8% in health care workers.

Conclusions. Our estimate of pandemic influenza vaccination coverage in the adult population of WA is comparable to the national estimate of 19%, but it did not reach levels considered sufficient to interrupt community transmission. Future influenza vaccination programs should target groups at increased risk of severe influenza, such as pregnant women.

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Pandemic (H1N1) 2009 influenza vaccine uptake in pregnant women entering the 2010 influenza season in Western Australia
White SW, Petersen RW, Quinlivan JA. Med J Aust. 6 September 2010; 193:1-3
Available at http://www.mja.com.au/public/issues/193_07_041010/whi10200_fm.html

Objective. To audit the uptake of pandemic (H1N1) 2009 influenza vaccine in pregnant women entering the 2010 influenza season in Western Australia, and to identify why some women did not receive the vaccine.

Design, setting and participants. Cross-sectional study of consecutive patients attending the Joondalup Health Campus public antenatal clinics in WA in January 2010.

Intervention. Audit of uptake of the H1N1-specific vaccine.

Main outcome measures. Rate of H1N1-specific vaccination, and reasons for not being the vaccinated.

Results. 479 of 541 women who attended the clinics (88.5%) were included in the audit. Three women had been infected with pandemic influenza in the preceding influenza season, leaving 476 women who were eligible for vaccination in pregnancy. Of these 476 women, only 33 (6.9%) had been vaccinated. Of the remaining 443 women who were eligible to receive the vaccine but had not been vaccinated, 63.9% had not been offered vaccination despite multiple visits to their general practitioners during pregnancy, 19.6% had been advised by their GPs against vaccination in pregnancy, and 61.6% stated that they would decline vaccination if offered because of safety concerns.

Conclusions. Uptake of H1N1-specific influenza vaccine in pregnant women was poor. Reasons for this relate both to vaccination not being offered to or actively sought by the women, as well as concerns — of both the women and their GPs — about vaccine safety in pregnancy. Uptake in this setting may improve if vaccination is offered through public antenatal clinics with concurrent safety education for obstetricians and vaccination providers

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Expanding Practitioner Scopes of Practice During Public Health Emergencies: Experiences from the 2009 H1N1 Pandemic Vaccination Efforts
Courteny B, Morhard R, Bouri N, et al. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 8 September 2010; 8(3):223-231. doi:10.1089/bsp.2010.0036.
Available at http://www.liebertonline.com/doi/abs/10.1089/bsp.2010.0036

Introduction. In a public health emergency involving significant surges in patients and shortages of medical staff, supplies, and space, temporarily expanding scopes of practice of certain healthcare practitioners may help to address heightened population health needs. Scopes of practice, which are defined by state practice acts, set forth the range of services that licensed practitioners are authorized to perform. The U.S. has had limited experience with temporarily expanding scopes of practice during emergencies. However, during the 2009 H1N1 pandemic response, many states took some form of action to expand the practice scopes of certain categories of practitioners in order to authorize them to administer the pandemic vaccine. No standard legal approach for expanding scopes of practice during emergencies exists across states, and scope of practice expansions during routine, nonemergency times have been the subject of professional society debate and legal action. These issues raise the question of how states could effectively implement expansions for health services beyond administering vaccine and ensure consistency in expansions across states during catastrophic events that require a shift to crisis standards of care. This article provides an overview of scopes of practice, a summary of the range of legal and regulatory approaches used in the U.S. to expand practice scopes for vaccination during the 2009 H1N1 response, and recommendations for future research.

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Stigma, Health Disparities, and the 2009 H1N1 Influenza Pandemic: How to Protect Latino Farmworkers in Future Health Emergencies
Schoch-Spana M, Nidhi B, Rambhia KJ, et al. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 8 September 2010, 8(3): 243-254. doi:10.1089/bsp.2010.0021.
Available at http://www.liebertonline.com/doi/abs/10.1089/bsp.2010.0021

Introduction. At the outset of the 2009 H1N1 influenza (“swine flu”) pandemic, Mexican nationals and Mexican commodities were shunned globally, and, in the United States, some media personalities characterized Mexican immigrants as disease vectors who were a danger to the country. We investigated instances in the U.S. of stigmatization of Latino migrant and seasonal farmworkers (MSFWs) and developed guidance for officials in curtailing its effects. At the same time, we explored social factors that make farmworkers more vulnerable to influenza infection and its complications, including high rates of underlying medical conditions, limited access to health care, and certain circumstances that interfere with the ability to implement community mitigation measures. This article reviews study findings and concludes with advice to policymakers and practitioners on the need to mitigate stigmatization in future outbreaks, to create public health preparedness systems that better protect migrant and seasonal farmworkers, and to undertake larger reforms to reduce institutional conditions that render farmworkers at greater risk for morbidity and mortality during health emergencies.

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Response to H1N1 in a U.S.-Mexico Border Community
McCormick JB, Yan C, Ballou J,et al. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 8 September 2010, 8(3): 233-242. doi:10.1089/bsp.2010.0014.
Available at http://www.liebertonline.com/doi/abs/10.1089/bsp.2010.0014

Introduction. Public health experts from a county health department and a school of public health collaborated to establish a simple, functional surveillance system to monitor swine-origin influenza virus as it crossed from Mexico into a Texas border community during the 2009 pandemic. The draft national and state preparedness plans were found to be cumbersome at the local level, so a simple, more practical real-time surveillance and response system was developed, in part by modifying these documents, and immediately implemented. Daily data analyses, including geographical information system mapping of cases and reports of school and daycare absences, were used for outbreak management. Aggregate reports of influenza-like illness and primary school absences were accurate in predicting influenza activity and were practical for use in local tracking, making decisions, and targeting interventions. These simple methods should be considered for local implementation and for integration into national recommendations for epidemic preparedness and response

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Characteristics of paediatric patients with 2009 pandemic influenza A(H1N1) and severe, oxygen-requiring pneumonia in the Tokyo region, 1 September–31 October 2009
Nishiyama M, Yoshida Y, Sato M, et al. Eurosurveillance. 9 September 2010;15(36):pii=19659.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19659

Abstract. Few reports describe the features of 2009 pandemic influenza A(H1N1) pneumonia in children. We retrospectively reviewed 21 consecutive children admitted to hospital from September to October 2009 in the Tokyo region. The diagnosis of 2009 pandemic influenza A(H1N1) virus infection was based on positive results of real-time RT-PCR or rapid influenza antigen test. All patients were hospitalised for pneumonia with respiratory failure and severe hypoxia. The median interval from onset of influenza symptoms to admission was 14 hours (range: 5–72 hours) and the median interval from the onset of fever (≥38ºC) to hospitalisation was 8.5 hours (range: 0–36 hours). All patients required oxygen inhalation. Four patients required mechanical ventilation. Chest radiography revealed patchy infiltration or atelectasis in all patients. Antiviral agents and antibiotics were administrated to all patients. Antiviral agents were administered to 20 patients within 48 hours of influenza symptom onset. No deaths occurred during the study period. Paediatric patients with this pneumonia showed rapid aggravation of dyspnoea and hypoxia after the onset of influenza symptoms.

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Adverse reaction of influenza A (H1N1) 2009 virus vaccination in pregnant women and its effect on newborns
Lim S-H, Lee J-H, Kim B-C, et al. Vaccine. 9 September 2010. doi:10.1016/j.vaccine.2010.08.087.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-5101PF9-5&_user=10&_coverDate=09%2F09%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=992d4d216bbf5f3e8b478e257c1a50db&searchtype=a

Abstract. Pregnant women are reluctant to be vaccinated during their pregnancy. Their main concern is the safety of influenza vaccine. We investigated the adverse reactions of pregnant women who received the influenza A (H1N1) 2009 virus vaccination and also conditions of neonates of the vaccinated women. Various adverse reactions developed after vaccination, but the symptoms were mild and resolved within several days without requiring any treatment or hospitalization.

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Signs of the 2009 Influenza Pandemic in the New York-Presbyterian Hospital Electronic Health Records
Khiabanian H, Holmes AB, Kelly BJ, et al. PLos ONE. 9 September 2010. 5(9): e12658. doi:10.1371/journal.pone.0012658.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0012658

Background. In June of 2009, the World Health Organization declared the first influenza pandemic of the 21st century, and by July, New York City's New York-Presbyterian Hospital (NYPH) experienced a heavy burden of cases, attributable to a novel strain of the virus (H1N1pdm).

Methods and Results. We present the signs in the NYPH electronic health records (EHR) that distinguished the 2009 pandemic from previous seasonal influenza outbreaks via various statistical analyses. These signs include (1) an increase in the number of patients diagnosed with influenza, (2) a preponderance of influenza diagnoses outside of the normal flu season, and (3) marked vaccine failure. The NYPH EHR also reveals distinct age distributions of patients affected by seasonal influenza and the pandemic strain, and via available longitudinal data, suggests that the two may be associated with distinct sets of comorbid conditions as well. In particular, we find significantly more pandemic flu patients with diagnoses associated with asthma and underlying lung disease. We further observe that the NYPH EHR is capable of tracking diseases at a resolution as high as particular zip codes in New York City.

Conclusion. The NYPH EHR permits early detection of pandemic influenza and hypothesis generation via identification of those significantly associated illnesses. As data standards develop and databases expand, EHRs will contribute more and more to disease detection and the discovery of novel disease associations.

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Potential spread of highly pathogenic avian influenza H5N1 by wildfowl: dispersal ranges and rates determined from large-scale satellite telemetry
Gaidet N, Cappelle J, Takekawa JY, et al. Journal of Applied Ecology. 4 August 2010. 47: 1147–1157. doi: 10.1111/j.1365-2664.2010.01845.x
Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2664.2010.01845.x/abstract

Summary. 1. Migratory birds are major candidates for long-distance dispersal of zoonotic pathogens. In recent years, wildfowl have been suspected of contributing to the rapid geographic spread of the highly pathogenic avian influenza (HPAI) H5N1 virus. Experimental infection studies reveal that some wild ducks, geese and swans shed this virus asymptomatically and hence have the potential to spread it as they move.
2. We evaluate the dispersive potential of HPAI H5N1 viruses by wildfowl through an analysis of the movement range and movement rate of birds monitored by satellite telemetry in relation to the apparent asymptomatic infection duration (AID) measured in experimental studies. We analysed the first large-scale data set of wildfowl movements, including 228 birds from 19 species monitored by satellite telemetry in 2006–2009, over HPAI H5N1 affected regions of Asia, Europe and Africa.
3. Our results indicate that individual migratory wildfowl have the potential to disperse HPAI H5N1 over extensive distances, being able to perform movements of up to 2900 km within timeframes compatible with the duration of asymptomatic infection.
4. However, the likelihood of such virus dispersal over long distances by individual wildfowl is low: we estimate that for an individual migratory bird there are, on average, only 5–15 days per year when infection could result in the dispersal of HPAI H5N1 virus over 500 km.
5. Staging at stopover sites during migration is typically longer than the period of infection and viral shedding, preventing birds from dispersing a virus over several consecutive but interrupted long-distance movements. Intercontinental virus dispersion would therefore probably require relay transmission between a series of successively infected migratory birds.
6. Synthesis and applications. Our results provide a detailed quantitative assessment of the dispersive potential of HPAI H5N1 virus by selected migratory birds. Such dispersive potential rests on the assumption that free-living wildfowl will respond analogously to captive, experimentally-infected birds, and that asymptomatic infection will not alter their movement abilities. Our approach of combining experimental exposure data and telemetry information provides an analytical framework for quantifying the risk of spread of avian-borne diseases.

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Effectiveness of Antiviral Treatment in Human Influenza A(H5N1) Infections: Analysis of a Global Patient Registry
Adisasmito W, Chan PKS, Lee N, et al. J Infect Dis. 10 September 2010. doi: 10.1086/656316.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/656316

Background. Influenza A(H5N1) continues to cause infections and possesses pandemic potential.

Methods. Data sources were primarily clinical records, published case series, and governmental agency reports. Cox proportional hazards regression was used to estimate the effect of treatment on survival, with adjustment using propensity scores (a composite measure of baseline variables predicting use of treatment).

Results. In total, 308 cases were identified from 12 countries: 41 from Azerbaijan, Hong Kong SAR, Nigeria, Pakistan, and Turkey (from clinical records); 175 from Egypt and Indonesia (from various sources); and 92 from Bangladesh, Cambodia, China, Thailand, and Vietnam (from various publications). Overall crude survival was 43.5%; 60% of patients who received 1 dose of oseltamivir alone (OS+) survived versus 24% of patients who had no evidence of anti‐influenza antiviral treatment (OS−) ( ). Survival rates of OS+ groups were significantly higher than those of OS− groups; benefit persisted with oseltamivir treatment initiation 6–8 days after symptom onset. Multivariate modeling showed 49% mortality reduction from oseltamivir treatment.

Conclusions. H5N1 causes high mortality, especially when untreated. Oseltamivir significantly reduces mortality when started up to 6–8 days after symptom onset and appears to benefit all age groups. Prompt diagnosis and early therapeutic intervention should be considered for H5N1 disease.

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5. Notifications
Influenza 2010: Zoonotic Influenza and Human Health
Oxford, United Kingdom 22 Sep 2010
The Oxford influenza conference, Influenza 2010, will address most aspects of basic and applied research on zoonotic influenza viruses (including avian and swine) and their medical and socio-economic impact.
Additional information available at http://www.libpubmedia.co.uk/Conferences/Influenza2010/Home.htm.

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4th Vaccine and ISV Annual Global Congress
Vienna, Austria 3-5 October 2010
Now in its fourth year, the annual Vaccine Congress has become the forum for the exchange of ideas to accelerate the rate at which vaccines can come to benefit the populations that need them.
Organized by: Vaccine – the pre-eminent journal for those interested in vaccines and vaccination – in collaboration with the International Society for Vaccines
Deadline for abstracts/proposals: 18 June 2010
Additional information available at http://www.vaccinecongress.com

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Cell Symposia – Influenza: Translating Basic Insights
Washington DC, USA: 2-4 December 2010
This meeting will foster interactions among scientists studying the influenza virus from the perspective of the virus itself, host response to viral infection, clinical manifestations, as well as vaccine and therapeutic approaches.
Organized by: Cell Press - Sponsor Journal - Cell Host and Microbe
Additional information available at http://www.cell-symposia-influenza.com/index.asp

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International TB Symposium (ITBS-2010): TB Diagnostics – Innovating to Make an Impact
New Delhi, India 16-17 December 2010
The Symposium will take stock of current status of TB diagnostics and unravel future directions for translating research results into reliable and efficient point-of-care methods of TB diagnosis.
Additional information available at http://www.icgeb.org/meetings-2010.html

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 apecein@u.washington.edu