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Vol. XIV No. 4 ~ EINet News Briefs ~ Feb 18, 2011


*****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
- 2011 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO reports increased 2009 H1N1 influenza activity in more countries
- Global: Influenza activity high in several European nations
- Global: WHO sticks with current strains for next influenza vaccine
- Cambodia: Girl dies of H5N1 avian influenza infection
- China: H1N1 takes over as dominant influenza strain

2. Infectious Disease News
- Australia (Victoria): Measles outbreak sparks vaccination warning from health authorities
- Chinese Taipei: CDC reports first case of measles in 2011
- Indonesia: Government allocates Rp 158.6 billion to treat rabies
- Indonesia: Bantul launches rat hunt to curb leptospirosis
- New Zealand: More measles cases confirmed in Auckland
- USA (Washington): Clark County child tests positive for measles

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

4. Articles
- Influenza, hepatitis B, and tetanus vaccination coverage among health care personnel in the United States
- Pandemics and Health Equity: Lessons Learned From the H1N1 Response in Los Angeles County
- Diagnosis and Antiviral Intervention Strategies for Mitigating an Influenza Epidemic
- We should not be complacent about our population-based public health response to the first influenza pandemic of the 21st century
- Swine-Origin Influenza A Outbreak 2009 at Shinshu University, Japan
- Compliant, complacent or panicked? Investigating the problematisation of the Australian general public in pandemic influenza control
- Drug-Resistant Pandemic (H1N1) 2009, South Korea
- The second wave of 2009 pandemic influenza A(H1N1) in New Zealand, January–October 2010
- Resource Burden at Children’s Hospitals Experiencing Surge Volumes during the Spring 2009 H1N1 Influenza Pandemic
- Strategies for antiviral stockpiling for future influenza pandemics: a global epidemic-economic perspective

5. Notifications
- APEC Senior Officials Meeting I and Related Meetings
- Communicable Disease Control Conference


1. Influenza News

Global
2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Cambodia / 1 (1)
Egypt / 3 (0)
Total / 4 (1)

***For data on human cases of avian influenza prior to 2011, go to:
http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 520 (307) (WHO 2/9/2011)
http://www.who.int/csr/disease/avian_influenza/country/cases_table_2011_02_09/en/index.html

Avian influenza age distribution data from WHO/WPRO (last updated 11/19/10):
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 12/9/10):
http://www.who.int/csr/disease/avian_influenza/2010_12_09_h5n1_avian_influenza_timeline_updates.pdf

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Global: WHO reports increased 2009 H1N1 influenza activity in more countries
Flu activity in the Northern Hemisphere is widespread, with some countries such as the United States and China reporting increased detection of the 2009 H1N1 virus, the World Health Organization (WHO) stated on 11 February 2011. Influenza B circulation remained strong in many countries, with H3N2 keeping a foothold in North American countries. In Europe, flu activity is declining in western countries and increasing in the other regions. Some countries, such as the United Kingdom and France, are reporting severe 2009 H1N1 infections in people aged 15 to 64. The UK's Health Protection Agency (HPA) stated on 10 February 2011 that doctor visits for flu have dipped below baseline levels, with influenza B edging out the 2009 H1N1 virus as the dominant strain. Most of the viruses circulating in North America and Europe are closely related to the strains in seasonal flu vaccines. In North Africa and the Middle East, flu activity seems to have peaked, except in Pakistan, Iran, and Oman, which are still reporting high percentages of respiratory samples testing positive for 2009 H1N1 and influenza B. In the tropical zone, the most active flu area is Asia in jurisdictions such as Singapore, China, and Hong Kong, and Madagascar is reporting increasing flu levels, mainly H3N2 and B strains. On 10 February 2011, Hong Kong's Center for Health Protection (CHP) said that the 2011 flu season is more serious than in 2010, comparable to other years with high flu activity. Dr. Thomas Tsang, the CHP's controller, said officials are seeing more flu hospitalizations in younger people. The WHO said Southern Hemisphere countries are reporting very little flu activity, except Australia, which is still reporting low-level summer H3N2 circulation.
(CIDRAP 2/11/2011)

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Global: Influenza activity high in several European nations
Georgia and Luxembourg are reporting very high levels of influenza, while eight other European nations are reporting high levels, according to the World Health Organization (WHO). Georgia reported a severe impact on its healthcare system. For the week ending 30 January 2011, the flu is increasing in most countries in the WHO's European Region, which includes parts of Asia, with 23 nations reporting widespread activity. 46% of patients with flu-like illness or acute respiratory infections tested positive for influenza. The circulating flu strains continue to match well with the three strains in the vaccine: pandemic 2009 H1N1, H3N2, and B. Pandemic H1N1 viruses account for 65% of flu specimens typed, with influenza B making up 35%. Novel H1N1 is dominant in 19 countries, influenza B in four nations, and the two strains were co-dominant in 13 countries. The countries reporting high flu activity are Albania, Bulgaria, Greece, Italy, Lithuania, Norway, Russia, and Turkey.
(CIDRAP 2/7/2011)

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Global: WHO sticks with current strains for next influenza vaccine
Signaling that the current flu strains are likely to persist over the next several months, the World Health Organization (WHO) on 17 February 2011 recommended sticking with the current trio of vaccine strains for the Northern Hemisphere's next influenza season.

The WHO's vaccine strain advisory committee met on 15 and 16 February 2011 and released its recommendation. The group recommends the following for next season's vaccine:
- For the H1N1 component, a strain similar to A/California/7/2009
- For the H3N2 component, a strain similar to A/Perth/16/2009
- For the B component, a strain similar to B/Brisbane/60/2008-like virus

Each February, WHO experts assess the flu strains circulating throughout the globe before recommending the strains for the Northern Hemisphere's next seasonal flu vaccine. It takes about six months for vaccine manufacturers to grow the viruses in chicken eggs and formulate them into trivalent vaccines.

The full WHO report on strain selection can be accessed at
http://www.who.int/csr/disease/influenza/2011_02_recommendation.pdf
(CIDRAP 2/17/2011)

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Asia
Cambodia: Girl dies of H5N1 avian influenza infection
Cambodia's health ministry has confirmed that a five-year-old girl from Phnom Penh recently died from H5N1 avian influenza, the World Health Organization (WHO) said on 9 February 2011. She got sick on 29 January 2011 and was hospitalized on 3 February 2011, where she died 12 hours after admission, according to the WHO. An investigation revealed she had been exposed to sick poultry approximately on 22 January 2011. The girl's infection raises Cambodia's number of H5N1 cases to 11 and pushes fatalities to nine.

Cambodia reported its last human H5N1 case on 4 May 2010. The presence of the H5N1 virus in the girl's nasopharyngeal sample was confirmed by the Pasteur Institute at Cambodia's National Influenza Center. The WHO's confirmation of Cambodia's latest case raises the global H5N1 count to 520, of which 307 were fatal.
(CIDRAP 2/9/2011)

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China: H1N1 takes over as dominant influenza strain
As China enters the peak of its flu season, the 2009 H1N1 virus has edged out H3N2 as the dominant strain, the country's health ministry reported on 10 February 2011. Shu Yuelong, head of China's National Influenza Center, said 2009 H1N1 evolved as the dominant strain over December 2010 and January 2011, and though officials expect more severe cases to occur, the virus is not likely to have the same impact it did in 2009. The country has reported 129 severe 2009 H1N1 cases since late 2010, including 20 deaths since the start of 2011. Yuelong confirmed flu infections and outpatient and emergency department visits for flu-like illness are all below 2010’s high levels. Vaccination against the 2009 H1N1 virus also appears to be effective, Yuelong added.
(CIDRAP 2/10/2011)

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2. Infectious Disease News
Australia (Victoria): Measles outbreak sparks vaccination warning from health authorities
A resurgence of measles in Victoria has prompted health authorities to warn the public to ensure they are vaccinated against the highly infectious disease. There have been 15 cases of measles reported in the first six weeks of 2011. More than half of these cases have caught the disease overseas.

Victoria's Chief Health Officer Dr. John Carnie said eight people were diagnosed with the disease when they returned to Australia. Most of the additional seven cases are people who may have had contact with the returned travelers, Dr. Carnie said. There are fears more people have been infected. Six people, aged between eight months and 66 years, had to be hospitalized after contracting measles.

[ProMED note: Victoria joins the list of Australian states that are experiencing or recently have experienced outbreaks of measles imported from abroad. These outbreaks reveal that the uptake of the MMR triple vaccine in childhood in Australia is less than complete. In the interim, Australians traveling to countries where measles is prevalent should ensure that they have been vaccinated to protect both themselves and others on their return to Australia.]
(ProMED 2/17/2011)

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Chinese Taipei: CDC reports first case of measles in 2011
Although the measles, mumps and rubella (MMR) vaccine has been widely administered in Taiwan since 1978, there are still parts of the population that are not vaccinated. The Centers for Disease Control (CDC) on 9 February 2011 reported the first case of measles in 2011 and has so far put 467 people on a watch list for further follow-ups to prevent widespread infection.

The measles patient is a 28-year-old Swiss man who is currently a student at a college in the north of the country. He is suspected of having contracted measles overseas. He admitted himself for emergency treatment at a hospital on 3 February 2011, CDC deputy director-general Lin Ting said. Because the emergency ward at the time was filled with hundreds of patients and their family members, as well as nurses, doctors and other emergency medical staff, the number of people that the measles patient potentially came in contact with and could have infected was as many as 467 people, the CDC said.

Among the people who are in danger of contracting measles from the student are eight infants who were at the hospital at the time and are at higher risk of developing a serious illness. All 467 people have been put on a watch list for health officials to follow up for treatment, if necessary, to stop the case developing into a widespread infection.
(ProMED 2/12/2011)

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Indonesia: Government allocates Rp 158.6 billion to treat rabies
The government has allocated a total of Rp 158.6 billion (approximately USD 17.6 million) to curb the spread of rabies. Agriculture Ministry Director General for Livestock and Health, Prabowo R. Caturuso, said the largest portion of the funds would go to Bali, North Sumatra's Nias Island, and Maluku's West Maluku Tenggara, given their emergency rabies status. These areas recorded the highest numbers of people being bitten by dogs, Prabowo said on 4 February 2011. The funds are expected to be used to purchase rabies vaccines and to monitor and evaluate the implementation of prevention programs.

The island of Bali recorded the highest number cases, with more than 57,800 people bitten by dogs and 119 dead from rabies in 2010. Nias reported more than 1,100 people bitten by dogs and 26 deaths. West Maluku Tenggara reported 359 dog bites and 20 deaths. Nationwide, the figures stood at more than 74,800 people being bitten and 195 deaths from the disease.
(ProMED 2/14/2011)

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Indonesia: Bantul launches rat hunt to curb leptospirosis
According to the Bantul Health Office, 19 people have been killed by leptospirosis since the disease was initially found in Sedayu district in 2009, when ten cases and one death were reported. Leptospirosis surged by more than 1,000% in 2010, when 110 cases were reported. More than 15 cases, including four deaths were recorded in January 2011.

The Bantul administration says it will pay residents a bounty of Rp 500 for every rat killed as part of a campaign to halt the spread of leptospirosis in the regency. A main thrust of the campaign, which was officially launched on 7 February 2011, would be to fill rat nests with water and kill rats as they emerged, according to the administration. The administration would also spray areas where the disease was likely to linger. Based on its transmission history, leptospirosis bacteria are found in livestock pens and rice warehouses. Theoretically, we could kill the bacteria with disinfectants, Bantul Health Office surveillance division head Bintarto said. The surveillance division would also provide free rat poison to residents, he added.

Bintarto said that the most effective method to curb the disease was for people to lead healthy lifestyles, especially farmers, who were more frequently exposed to rat urine, which carries leptospirosis. Residents, especially farmers, must lead a clean and healthy lifestyle. This is the most effective method to prevent the disease, Bintarto said. The administration has instructed residents in areas where leptospirosis is prevalent on how to eradicate and prevent the disease.
(The Jakarta Post 2/8/2011)

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New Zealand: More measles cases confirmed in Auckland
A spate of measles in Auckland is growing. The Regional Public Health Service has now been notified of 12 people who have or possibly have the disease. Nine of them were passengers on Emirates Flight EK434 from Brisbane which arrived on 11 January 2011. Three more may have been in contact with the passengers or could have got it from another source.

Public health clinical director Julia Peters says most of the cases are in West Auckland, but there is also one in Wellington. She says they are trying to trace people who have been in contact with those who have a confirmed case of measles.
(ProMED 2/7/2011)

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Americas
USA (Washington): Clark County child tests positive for measles
A Clark County infant who recently traveled overseas has tested positive for measles, health officials reported 15 February 2011. Anyone who might have come into contact with the child is urged to seek a vaccination for this uncommon but highly contagious disease before 17 February 2011, said Dr. Alan Melnick with Clark County Public Health.

On Monday 14 February 2011, the child visited the Evergreen Pediatric Clinic and Southwest Washington Medical Center in Vancouver. Anyone who visited those locations on 14 February 2011 -- particularly between 1:30 pm and 6:00 pm at the clinic and between 4:30 pm and 8:30 pm near the pharmacy or outpatient lab at the hospital -- could be at risk of exposure.

Measles is a potentially serious disease characterized by a rash, fever, and one or more of the following symptoms: cough, conjunctivitis, sneezing, nasal congestion, and nasal discharge, Melnick said. Outbreaks are uncommon in the United States – where vaccinations have effectively eliminated the disease -- but they do occur.
(The Oregonian 2/15/2011)

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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 update 115:
http://www.who.int/csr/don/2010_08_27/en/index.html
CDC Teleconference results: Healthcare groups need to share emergency plans:
http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/sep0210standards.html
American Academy of Pediatrics Policy Statement: Recommendations for Prevention and Control of Influenza in Children, 2010-2011:

>http://pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2216v1

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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.

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VECTOR-BORNE DISEASE
Peru (Cusco)
Julio Bejar, executive director of the Health Services Network of La Convencion (province in Cusco region) reported that nine cases of autochthonous malaria were registered in the city of Quillabamba. Those affected by this disease are among people who invaded a vacant lot located in the Urpipata sector, which lacks basic sanitation services. There are 400 families currently living there. Health authorities indicated that the problem was a result of work done by the Cosapi engineering company on the Cusco-Quillabamba road, which left puddles of stagnant water that favored the reproduction of the mosquitoes that transmit malaria. The affected people are receiving appropriate care to control the disease.
(ProMED 2/9/2011)


Peru (Amazon)
Health authorities have declared a red alert in Peru's northern Amazon jungle region following the outbreak of a very aggressive dengue strain that has killed 14 people and sickened thousands. Dengue is endemic to the jungle region, but until now, Peru has largely dealt with the American strain of the disease. Authorities are facing a new variety that we did not know in Peru and that probably entered from Brazil via the Amazon, health minister Oscar Ugarte said. About 13,000 people have been infected, and at least 1,600 people have been hospitalized for treatment, a health official in Loreto, in north-eastern Peru, said.

A senior Loreto health official, Hugo Rodriguez, says this dengue strain is known as the Asian-American variety and, unlike the American variety, produces severe shock among victims. It is a combination of both varieties, Mr. Rodriguez said. The virus can result in deadly fevers, especially among children: Half of those killed were minors.

Health officials in Iquitos, Peru's main city on the Amazon River, located 1,000 km north of Lima, have launched a fumigation program in an attempt to diminish the number of mosquitoes.
(ProMED 2/9/2011)


Peru (Madre de Dios)
The Regional President of Madre de Dios, Luis Aguirre Pastor, indicated that in the last six months 30,000 dengue cases, including himself, have been registered in his jurisdiction. There are two confirmed dengue deaths and five to be confirmed. He said that since two weeks ago, in dealing with the large numbers of infected people, service in the Santa Rosa Hospital, the largest in the area, and the medical posts collapsed.
(ProMED 2/14/2011)


Australia (Northern Queensland)
There were ten dengue virus type-2 cases and five dengue virus type-4 cases at Innisfail. Eight of these are in hospital.
(ProMED 2/14/2011)


The Philippines
The latest Philippines Department of Health numbers show that there were 1,340 dengue cases in the country from 1-15 January 2011; three of these resulted in deaths.
(ProMED 2/14/2011)

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CHOLERA, DIARRHEA, and DYSENTERY
USA (New York)
City officials confirmed on 5 February 2011, the first known cases of cholera in New York since the outbreak of the disease in Haiti in 2010. A commercial laboratory notified health officials on 4 February 2011, that three New Yorkers had cholera after developing diarrhea and dehydration, classic symptoms of the disease, after returning from a wedding on 22 and 23 January 2011 in the Dominican Republic, where the government has been trying to prevent the disease from spreading from neighboring Haiti. The three who contracted cholera were adults who returned to the city within days of the wedding. None were hospitalized. Dr. Sharon Balter, a medical epidemiologist for the city Department of Health and Mental Hygiene, said that the victims had all recovered.

Officials at the CDC have noted a few cases of cholera in the past three or four months from travelers who arrived in the USA from Haiti or the Dominican Republic. While cholera can spread swiftly where sanitation is poor and clean drinking water is unavailable, the possibility of transmitting the disease in New York is considered low. The likelihood of person-to-person transmission is also low, as one would have to drink large amounts of water contaminated with Vibrio choleraev, the cholera-causing bacterium, to get sick. In New York, the occasional cholera case is not unusual. Officials see an average of one case per year, particularly among those traveling to regions where the disease is common, Dr. Balter said. But, until now, no cases have emerged since the outbreak in Haiti, she said.
(ProMED 2/8/2011)

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4. Articles
Influenza, hepatitis B, and tetanus vaccination coverage among health care personnel in the United States
Lu P-J, Euler GL. American J of Infection Control. 3 February 2011. doi:10.1016/j.ajic.2010.10.009.
Available at http://www.ajicjournal.org/article/S0196-6553(10)00944-2/abstract

Background. Health care personnel (HCP) are at risk for exposure to and possible transmission of vaccine-preventable diseases. Maintenance of immunity is an essential prevention practice for HCP. We assessed the recent influenza, hepatitis B, and tetanus vaccination coverage among HCP in the United States.

Methods. We analyzed data from the 2007 National Immunization Survey-Adult restricted to survey respondents aged 18 to 64 years. Influenza, hepatitis B, and tetanus vaccination coverage levels among HCP were assessed. Multivariable logistic regression was conducted to assess factors independently associated with receipt of vaccination among HCP.

Results. Among HCP aged 18 to 64 years, 46.7% (95% confidence interval [CI]: 39.6%-53.8%) had received influenza vaccination for the 2006-2007 season, and 70.4% (95% CI: 63.9%-76.1%) received tetanus vaccination in the past 10 years; 61.7% (95% CI: 52.5%-70.2%) had received 3 or more doses of hepatitis B vaccination among HCP aged 18 to 49 years. Multiple logistic regression analysis showed that being married was associated with influenza vaccination coverage, higher education level was associated with hepatitis B vaccination coverage, and younger age was significantly associated with tetanus vaccination among HCP. Among those HCP who did not receive influenza vaccination, the most common reason reported was respondent concerns about vaccine safety and adverse effects.

Conclusion. By 2007, influenza and hepatitis B vaccination coverage among HCP remained well below the Healthy People 2010 objectives. Tetanus vaccination level was 70%, and this study provided a baseline data for tetanus vaccination among HCP. Innovative strategies are needed to further increase vaccination coverage among HCP.

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Pandemics and Health Equity: Lessons Learned From the H1N1 Response in Los Angeles County
Plough A, Bristow B, Fielding J, et al. J of Public Health Management & Practice. February 2011; 17(1): 20-21. doi: 10.1097/PHH.0b013e3181ff2ad7.
Available at http://journals.lww.com/jphmp/Abstract/2011/01000/Pandemics_and_Health_Equity___Lessons_Learned_From.4.aspx

Background. Pandemic preparedness and response (as with all public health actions) occur within a social, cultural, and historical context of preexisting health disparities and, in some populations, underlying mistrust in government. Almost 200 000 people received H1N1 vaccine at 109 free, public mass vaccination clinics operated by the Los Angeles County Department of Public Health between October 23, 2009, and December 8, 2009. Wide racial/ethnic disparities in vaccination rates were observed with African Americans having the lowest rate followed by whites.

Methodology/Principal Findings. Demographic information, including race/ethnicity, was obtained for 163 087 of the Los Angeles County residents who received vaccine. This information was compared with estimates of the Los Angeles County population distribution by race/ethnicity. Rate ratios of vaccination were as follows: white, reference; African American, 0.5; Asian, 3.2; Hispanic, 1.5; Native American, 1.9; and Pacific Islander, 4.3.

Significance. Significant political challenges and media coverage focused on equity in vaccination access specifically in the African American population. An important challenge was community-level informal messaging that ran counter to the “official” messages. Finally, we present a partnership strategy, developed in response to the challenges, to improve outreach and build trust and engagement with African Americans in Los Angeles County.

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Diagnosis and Antiviral Intervention Strategies for Mitigating an Influenza Epidemic
Moss R, McCaw JM, McVernon J. PLoS ONE. 4 February 2011; 6(2):e14505. doi:10.1371/journal.pone.0014505.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0014505

Background. Many countries have amassed antiviral stockpiles for pandemic preparedness. Despite extensive trial data and modelling studies, it remains unclear how to make optimal use of antiviral stockpiles within the constraints of healthcare infrastructure. Modelling studies informed recommendations for liberal antiviral distribution in the pandemic phase, primarily to prevent infection, but failed to account for logistical constraints clearly evident during the 2009 H1N1 outbreaks. Here we identify optimal delivery strategies for antiviral interventions accounting for logistical constraints, and so determine how to improve a strategy's impact.

Methods and Findings. We extend an existing SEIR model to incorporate finite diagnostic and antiviral distribution capacities. We evaluate the impact of using different diagnostic strategies to decide to whom antivirals are delivered. We then determine what additional capacity is required to achieve optimal impact. We identify the importance of sensitive and specific case ascertainment in the early phase of a pandemic response, when the proportion of false-positive presentations may be high. Once a substantial percentage of ILI presentations are caused by the pandemic strain, identification of cases for treatment on syndromic grounds alone results in a greater potential impact than a laboratory-dependent strategy. Our findings reinforce the need for a decentralised system capable of providing timely prophylaxis.

Conclusions. We address specific real-world issues that must be considered in order to improve pandemic preparedness policy in a practical and methodologically sound way. Provision of antivirals on the scale proposed for an effective response is infeasible using traditional public health outbreak management and contact tracing approaches. The results indicate to change the transmission dynamics of an influenza epidemic with an antiviral intervention, a decentralised system is required for contact identification and prophylaxis delivery, utilising a range of existing services and infrastructure in a “whole of society” response.

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We should not be complacent about our population-based public health response to the first influenza pandemic of the 21st century
Kelly HA, Priest PC, Mercer GN, et al. BMC Public Health. 3 February 2011; 11:78. doi:10.1186/1471-2458-11-78.
Available at http://www.biomedcentral.com/1471-2458/11/78

Background. More than a year after an influenza pandemic was declared in June 2009, the World Health Organization declared the pandemic to be over. Evaluations of the pandemic response are beginning to appear in the public domain.

Discussion. We argue that, despite the enormous effort made to control the pandemic, it is now time to acknowledge that many of the population-based public health interventions may not have been well considered. Prior to the pandemic, there was limited scientific evidence to support border control measures. In particular no border screening measures would have detected prodromal or asymptomatic infections, and asymptomatic infections with pandemic influenza were common. School closures, when they were partial or of short duration, would not have interrupted spread of the virus in school-aged children, the group with the highest rate of infection worldwide. In most countries where they were available, neuraminidase inhibitors were not distributed quickly enough to have had an effect at the population level, although they will have benefited individuals, and prophylaxis within closed communities will have been effective. A pandemic specific vaccine will have protected the people who received it, although in most countries only a small minority was vaccinated, and often a small minority of those most at risk. The pandemic vaccine was generally not available early enough to have influenced the shape of the first pandemic wave and it is likely that any future pandemic vaccine manufactured using current technology will also be available too late, at least in one hemisphere.

Summary. Border screening, school closure, widespread anti-viral prophylaxis and a pandemic-specific vaccine were unlikely to have been effective during a pandemic which was less severe than anticipated in the pandemic plans of many countries. These were cornerstones of the population-based public health response. Similar responses would be even less likely to be effective in a more severe pandemic. We agree with the recommendation from the World Health Organisation that pandemic preparedness plans need review.

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Swine-Origin Influenza A Outbreak 2009 at Shinshu University, Japan
Uchida M, Tsukahara T, Kanako M, et al. BMC Public Health. 4 February 2011; 11:79. doi:10.1186/1471-2458-11-79.
Available at http://www.biomedcentral.com/1471-2458/11/79

Background. A worldwide outbreak of swine flu H1N1 pandemic influenza occurred in April 2009. To determine the mechanism underlying the spread of infection, we prospectively evaluated a survey implemented at a local university.

Methods. Between August 2009 and March 2010, we surveyed 3 groups of subjects: 2318 children in six schools attached to the Faculty of Education, 11424 university students, and 3344 staff members. Subjects with influenza-like symptoms who were diagnosed with swine flu at hospitals or clinics were defined as swine flu patients and asked to make a report using a standardized form.

Results. After the start of the pandemic, a total of 2002 patients (11.7%) were registered in the survey. These patients included 928 schoolchildren (40.0%), 1016 university students (8.9%), and 58 staff members (1.7%). The incidence in schoolchildren was significantly higher than in the other 2 groups (P < 0.0001) but there were no within group differences in incidence rate between males and females. During the period of the survey, three peaks of patient numbers were observed, in November 2009, December 2009, and January 2010. The first peak consisted mainly of schoolchildren, whereas the second and third peaks included many university students. Staff members did not contribute to peak formation. Among the university students, the most common suspected route of transmission was club activity. Interventions, such as closing classes, schools, and clubs, are likely to affect the epidemic curves.

Conclusion. School children and university students are vulnerable to swine flu, suggesting that avoidance of close contact, especially among these young people, may be effective way in controlling future severe influenza pandemics, especially at educational institutions.

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Compliant, complacent or panicked? Investigating the problematisation of the Australian general public in pandemic influenza control
Monash MD, Stephenson N. Social Science & Medicine. 5 February 2011. doi:10.1016/j.socscimed.2011.01.016.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-523V3J2-1&_user=10&_coverDate=02%2F05%2F2011&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=73edc4480f78beb73be4973656a829e0&searchtype=a

Abstract. This article examines how pandemic influenza control policies interpellate the public. We analyse Australian pandemic control documents and key informant interviews, with reference to the H1N1 virus in 2009. Our analysis suggests that the episodic and uncertain features of pandemic influenza give control measures a pronounced tactical character. The general public is seen as passive and, in some cases, vulnerable to pandemic influenza. Communication focuses on promoting public compliance with prescribed guidelines, but without inspiring complacency, panic or other unruly responses. These assumptions depend, however, on a limited social imaginary of publics responding to pandemics. Drawing on Foucault, we consider how it is that these assumptions regarding the public responses to pandemics have taken their present form. We show that the virological modelling used in planning and health securitisation both separate pandemic control from its publics. Further, these approaches to planning rely on a restricted view of human agency and therefore preclude alternatives to compliance-complacency-panic and, as we suggest, compromise pandemic control. On this basis we argue that effective pandemic control requires a systematic dialogue with the publics it seeks to prepare in anticipation of the event of pandemic influenza.

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Drug-Resistant Pandemic (H1N1) 2009, South Korea
Shin SY, Kang C, Gwack J, et al. Emerg Infect Dis. 9 February 2011. doi: 10.3201/eid1704.101467.
Available at http://www.cdc.gov/eid/content/17/4/pdfs/10-1467.pdf

Introduction. The Korea Centers for Disease Control and Prevention asked clinicians to report all patients with suspected cases of drug-resistant pandemic (H1N1) 2009 when these patients showed treatment failure for oseltamivir or had unusually prolonged viral shedding (defined as >5 days after the onset of symptoms) (1). We report nationwide surveillance data on the epidemiologic and clinical characteristics of patients infected with pandemic (H1N1) 2009 in South Korea.

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The second wave of 2009 pandemic influenza A(H1N1) in New Zealand, January–October 2010
Bandaranayake D, Jacobs M, Baker M, et al. Eurosurveillance. 10 February 2011; 16(6): pii=19788.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19788

Background. This paper uses data from multiple surveillance systems to describe the experience in New Zealand with the second complete wave of pandemic influenza A(H1N1)2009 in 2010. Measures such as hospitalisation rates suggest the overall impact of influenza A(H1N1)2009 in 2010 was between half and two thirds that of the first wave in 2009. There was considerable regional and sub-regional variation with a tendency for higher activity in areas that experienced low rates in 2009. Demographic characteristics of the second wave were similar to those in 2009 with highest rates seen in children under the age of five years, and in indigenous Māori and Pacific peoples. Hospital services including intensive care units were not under as much pressure as in 2009. Immunisation appears to have contributed to the reduced impact of the pandemic in 2010, particularly for those aged 60 years and older.

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Resource Burden at Children’s Hospitals Experiencing Surge Volumes during the Spring 2009 H1N1 Influenza Pandemic
Sills MR, Hall M. Academic Emergency Medicine. 11 February 2011; 18(2):158-166. doi: 10.1111/j.1553-2712.2010.00992.x.
Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2010.00992.x/abstract

Objectives. The objective was to describe the emergency department (ED) resource burden of the spring 2009 H1N1 influenza pandemic at U.S. children’s hospitals by quantifying observed-to-expected utilization.

Methods. The authors performed an ecologic analysis for April through July 2009 using data from 23 EDs in the Pediatric Health Information System (PHIS), an administrative database of widely distributed U.S. children’s hospitals. All ED visits during the study period were included, and data from the 5 prior years were used for establishing expected values. Primary outcome measures included observed-to-expected ratios for ED visits for all reasons and for influenza-related illness (IRI).

Results. Overall, 390,983 visits, and 88,885 visits for IRI, were included for Calendar Weeks 16 through 29, when 2009 H1N1 influenza was circulating. The subset of 106,330 visits and 31,703 IRI visits made to the 14 hospitals experiencing the authors’ definition of ED surge during Weeks 16 to 29 was also studied. During surge weeks, the 14 EDs experienced 29% more total visits and 51% more IRI visits than expected (p < 0.01 for both comparisons). Of ED IRI visits during surge weeks, only 4.8% were admitted to non–intensive care beds (70% of expected, p < 0.01), 0.19% were admitted to intensive care units (44% of expected, p < 0.01), and 0.01% received mechanical ventilation (5.0% of expected, p < 0.01). Factors associated with more-than-expected visits included ages 2–17 years, payer type, and asthma. No factors were associated with more-than-expected hospitalizations from the ED.

Conclusions. During the spring 2009 H1N1 influenza pandemic, pediatric EDs nationwide experienced a marked increase in visits, with far fewer than expected requiring nonintensive or intensive care hospitalization. The data in this study can be used for future pandemic planning.

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Strategies for antiviral stockpiling for future influenza pandemics: a global epidemic-economic perspective
Carrasco LR, Lee VJ, Chen MI, et al. J of the Royal Society Interface. 4 February 2011. doi: 10.1098/rsif.2010.0715.
Available at http://rsif.royalsocietypublishing.org/content/early/2011/02/03/rsif.2010.0715.abstract

Abstract. Influenza pandemics present a global threat owing to their potential mortality and substantial economic impacts. Stockpiling antiviral drugs to manage a pandemic is an effective strategy to offset their negative impacts; however, little is known about the long-term optimal size of the stockpile under uncertainty and the characteristics of different countries. Using an epidemic–economic model we studied the effect on total mortality and costs of antiviral stockpile sizes for Brazil, China, Guatemala, India, Indonesia, New Zealand, Singapore, the UK, the USA and Zimbabwe. In the model, antivirals stockpiling considerably reduced mortality. There was greater potential avoidance of expected costs in the higher resourced countries (e.g. from $55 billion to $27 billion over a 30 year time horizon for the USA) and large avoidance of fatalities in those less resourced (e.g. from 11.4 to 2.3 million in Indonesia). Under perfect allocation, higher resourced countries should aim to store antiviral stockpiles able to cover at least 15 per cent of their population, rising to 25 per cent with 30 per cent misallocation, to minimize fatalities and economic costs. Stockpiling is estimated not to be cost-effective for two-thirds of the world's population under current antivirals pricing. Lower prices and international cooperation are necessary to make the life-saving potential of antivirals cost-effective in resource-limited countries.

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5. Notifications
APEC Senior Officials Meeting I and Related Meetings
Washington DC, USA, 27 February to 12 March 2011

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Communicable Disease Control Conference
Canberra, ACT, Australia, 4-6 April 2011
The Communicable Disease Control Conference aims to promote evidence-based discussions on the theme: Science and Public Health meeting the challenges of a new decade.
Additional information at http://www.phaa.net.au/2011CommunicableDiseaseConference.php

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 apecein@u.washington.edu