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Vol. VIII, No. 24 ~ EINet News Briefs ~ Nov 18, 2005


*****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:
- Global: Conference boosts global will to fight pandemic threat
- Global: Updates on Pandemic preparedness activities
- Pan-Asia: Lack of funds complicates fight against avian flu
- England/Taiwan: Query into quarantined bird deaths implicates Taiwan
- Kuwait: Avian influenza H5N1 confirmed case in flamingo
- Romania (Caraorman): Bird flu virus found in dead chickens
- Italy (Modena): H5N1 Low Pathogenic Avian Influenza confirmed in mallard
- South East Asia: Cumulative number of human cases of avian influenza A/(H5N1)
- China (Hunan, Anhui): Confirms first 2 human cases of avian influenza
- China: Additional bird flu outbreaks; enhanced control efforts
- China: Aims to vaccinate all poultry
- Indonesia: 2 more confirmed fatal human avian influenza cases
- Indonesia: Need for improved commitment against avian influenza
- Viet Nam: Confirmed human death from H5N1; 2 new suspected human cases of bird flu
- Viet Nam: New strains of bird flu viruses reported; Variation of H5N1 isolates reported
- Thailand: Additional human case of avian influenza infection
- Taiwan: Highly pathogenic H7N3 avian influenza detected in wild bird
- Singapore: Use of sentinel chickens for early detection of avian influenza
- Japan (Ibaraki): H5 virus detected in poultry farm
- Russia (Orenburg and Primorskiy krai): Outbreaks of hemorrhagic fever with renal syndrome
- Russia (Moscow): 4 cases of Psittacosis
- USA: CDC: No plans now to send 1918 virus to other labs
- Canada/Haiti: Malaria infections confirmed

1. Updates
- Influenza
- Cholera, diarrhea & dysentery
- Dengue
- Viral gastroenteritis
- West Nile Virus

2. Articles
- Lab study supports idea of 'cytokine storm' in H5N1 flu
- A Systematic Analytic Approach to Pandemic Influenza Preparedness Planning
- Trends in HIV/AIDS Diagnoses--33 States, 2001-2004
- Cruise-Ship-Associated Legionnaires Disease, November 2003--May 2004
- Immunization Information System Progress--United States, 2004
- A newly identified type of scrapie agent can naturally infect sheep with resistant PrP genotypes
- Interspecies transmission of chronic wasting disease prions to squirrel monkeys (Saimiri sciureus)

3. Notifications
- Fifth International Conference on Emerging Infectious Diseases

4. APEC EINet activities
- APEC e-Health seminar; Pandemic influenza videoconference

5. To Receive EINet Newsbriefs
- APEC EINet email list
- APEC EINet email list


Global
Global: Conference boosts global will to fight pandemic threat
Concluding a major conference on avian and pandemic influenza, officials reported a new level of international agreement on the need to confront the threat and released a list of key steps to do that. "There's consensus. There's clarity. There's cash," said David Nabarro, the UN’s special coordinator on avian and pandemic flu. WHO chief Lee Jong-Wook said the strategy aimed to boost early warning systems, strengthen veterinary services, make it easier for rich and poor nations alike to get antiviral drugs and step up research into pandemic vaccines. More than 600 delegates from over 100 countries agreed on the "urgent need" to assist countries affected by or at high risk for avian flu and "to identify and respond to a human pandemic the moment it emerges". The preparedness steps outlined by WHO include conducting a global pandemic response exercise, among others. The World Bank estimated it may take $1 billion over the next 3 years to combat poultry outbreaks in Asian countries already affected or at high risk. A WHO statement outlined the preparedness measures as follows:

• Improving veterinary services, emergency preparedness plans, and control campaigns, including culling, vaccination and compensation
• Assisting countries to control avian influenza in animal populations
• Strengthening early detection and rapid response systems for animal and human influenza
• Building and strengthening laboratory capacity
• Support and training for the investigation of animal and human cases and clusters, and planning and testing rapid containment activities
• Building and testing national pandemic preparedness plans, conducting a global pandemic response exercise, strengthening the capacity of health systems, training clinicians and health managers
• Developing integrated national plans across all sectors to provide the basis for coordinated technical and financial support
• To support all of the above, factual and transparent communications, in particular risk communication, is vital.

Nabarro said the conference has already improved international coordination and will increase the energy that countries devote to the pandemic threat. The World Bank estimated that the needs of affected countries may amount to $1 billion over the next 3 years, but this doesn't count the cost of human or animal vaccine development, antiviral drugs, or compensation for farmers whose flocks are culled. WHO estimated it would cost another $500 million over 3 years to develop and produce a pandemic vaccine and to research new antiviral drugs. The meeting supported an urgent request for $35 million to fund high-priority actions by the WHO, the UN FAO, and the World Organization for Animal Health (OIE) over the next 6 months. Dr. Bernard Vallat, head of the OIE, said the top priorities are to assess and strengthen veterinary services and laboratory and surveillance capacity in affected and at-risk countries. A financial conference for donor countries is scheduled for Jan 17-18, 2006 in Beijing. The Asian Development Bank said it could provide $300 million for poorer Asian countries, on top of $170 million already earmarked. (CIDRAP 11/9/05 http://www.cidrap.umn.edu/ ; Promed 11/10/05)

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Global: Updates on Pandemic preparedness activities
WHO released updates on avian flu and pandemic preparedness. WHO suggested that 2 older antiviral drugs, amantadine and rimantadine, could still be of some use in combating a pandemic. Researchers reported last year that H5N1 viruses in Vietnam and Thailand were resistant to amantadine, leading to a belief that M2 inhibitors would be of little use if H5N1 leads to a pandemic. WHO said that the M2 inhibitors "could potentially be used against pandemic influenza, but resistance to these drugs may develop rapidly and this could significantly limit their effectiveness. Some currently circulating avian H5N1 strains are fully resistant to the M2 inhibitors, while others remain fully susceptible." Meanwhile, Roche announced it had stopped selling Tamiflu in China and said supplies of the drug are "being transferred to China's Ministry of Health for centralized allocation and distribution". Concerns about possible hoarding of the drug recently prompted Roche to restrict sales in the US, Germany, Canada, and Switzerland. Roche recently announced it would increase production of oseltamivir to 300 million treatment courses annually by 2007. That would be a tenfold increase in production since 2004. Roche said it had received requests from more than 150 governments and companies to produce generic versions of oseltamivir or to get involved in outsourced production. Roche reported it had begun negotiations with 8 companies and several governments, including Taiwan and Vietnam.

Also, in an update on vaccine research and development, WHO said one of the several companies developing H5N1 vaccines plans to present the results of its clinical trials to the WHO by early December. "However, if a pandemic were to begin within the next few months, no company would be ready to move immediately into commercial production," the agency said. Current trends indicate that most developing countries "will have no access to a vaccine during the first wave of a pandemic and perhaps throughout its duration." On food safety issues, WHO emphasized that the H5N1 virus does not spread to humans through properly cooked food. However, the agency also said that H5N1 and other highly pathogenic viruses spread to nearly all parts of an infected bird, making proper handling and cooking imperative. In addition, WHO said H5N1 can survive for "at least one month at low temperatures," which means that freezing and refrigeration will not kill the virus or reduce its concentration in contaminated meat. Also, in countries with outbreaks, eggs may have the virus on both the outside and inside, so eggs should not be eaten raw or partially cooked. (CIDRAP 11/4/05, 11/8/05 http://www.cidrap.umn.edu/)

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Pan-Asia: Lack of funds complicates fight against avian flu
In China, Indonesia, and Vietnam, countries seen as ground zero in the global fight against avian influenza, efforts to quash the virus are hampered by the lack of money. Organizations such as the UN Food and Agriculture Organization (FAO), WHO, and the World Bank have made urgent calls for a quick infusion of aid to Southeast Asia. Yet little of the promised funding has materialized. The World Bank earlier this month offered up to $500 million to fight avian flu and hoped to have money flowing to needy nations by December. It estimated the potential cost of a human flu pandemic at $800 billion in 1 year. In addition, the World Bank is seeking contributions from developing countries as well as other donors to create an ongoing funding mechanism to bolster the $500 million, starting next year, said Jim Adams, World Bank vice president for operations policy and country services. Compensating farmers for culled poultry is one key to stemming H5N1, Adams said. Lack of money also endangers surveillance and vaccination efforts, Bernard Vallatt, director general of the World Organization for Animal Health (OIE), said. A senior government official in Vietnam said that the country needs about $150 million in aid, but has received only $10 million to date.

Culling and vaccination efforts in Vietnam have been plagued by financial concerns, among other problems. Officials have told farmers in Hanoi and Ho Chi Minh City to kill or sell their poultry by 21 Nov 2005. They will be paid only half the current market value for poultry destroyed by the deadline. Live birds found after 21 Nov 2005 will be culled with no compensation. China will ship 45 tons of avian flu vaccine for poultry, worth $780,000, to Vietnam, but vaccine alone doesn't address all of the financial problems associated with the campaign. Low wages for people giving the vaccinations in Vietnam are hampering the aggressive campaign. About 109 million birds have been vaccinated in Vietnam, but the country still reported outbreaks in 61 communes between Oct 1 and Nov 14, 2005. In Indonesia, soldiers and volunteers will go door-to-door starting in the Jakarta area to find H5N1-infected poultry, the government announced. FAO is assisting Indonesia with surveillance efforts, and the World Bank president has offered help to Indonesia to fund a mass cull. The Indonesian government's avian flu plan includes searching door-to-door for infected poultry, designating people to constantly monitor the outbreaks, increasing vaccine and antiviral supplies, ordering state pharmaceutical maker PT Bio Farma to make vaccines, increasing the amount of money allocated to fight avian flu by about US $35 million next year, and seeking grants from international donors.

The Asian Development Bank estimated that an influenza pandemic in Asia could kill 3 million people and possibly trigger a world recession. A report by the Asian bank envisions 2 potential scenarios. Both scenarios assume that 20% of the region's population would get sick in a pandemic lasting about a year and that 0.5%, or 3 million, would die. In one scenario, a pandemic would seriously affect economic demand for 6 months, reducing consumer spending, trade, services, and investment by $99 billion. In the other scenario, a pandemic would restrict economic activity for a year, leading to $282 billion in losses. The second scenario would nearly stop Asia's economic growth and could also mean a 14%, or $2.5 trillion, reduction in global economic activity. (CIDRAP 11/4/05, 11/15/05 http://www.cidrap.umn.edu/ )

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England/Taiwan: Query into quarantined bird deaths implicates Taiwan
Investigation of an avian influenza outbreak points to a shipment of finches from Taiwan as the carriers of the H5N1 virus found in a quarantine facility in Sussex, England. The H5N1 virus infected finches known as mesias that were imported Sep 28, 2005 from Taiwan to England. While the virus spread among those finches, it did not spread to other species of birds held in the same quarantine station, according to the report by the UK’s Department for Environment, Food and Rural Affairs (DEFRA). Initial identification of the infected bird as a parrot from Surinam occurred because the parrot tissue sample was mixed with a finch's. "It has not been possible to say whether the virus isolated came from the parrot tissue or the mesia tissue or both," DEFRA notes. "However, in light of the other evidence the balance of probabilities is that the source was the Mesia sample." Subsequent tests of pooled finch samples showed the presence of the H5N1 virus. There was no evidence of transmission to other bird species in the facility. Taiwanese officials dismissed the report, saying the birds were healthy when they left Taiwan Sep 27, 2005 and no signs of the virus have been found in tests at the bird farm since then.

A full (9 page) copy of the report can be found at <http://www.defra.gov.uk/news/2005//animalh/diseases/notifiable/disease/ai/index.htm>. The consignment from Taiwan arrived at Heathrow airport 27 Sep 2005. 4 birds, dead on arrival, were not forwarded for examination. Details on a veterinary inspection upon arrival are not provided, nor the flight route, possible stopovers and/or contacts with other bird consignments under way. Such scenarios, even if remote, should be excluded. The current UK (import) strain is, reportedly, similarly closely associated with a virus isolated from ducks in China early in 2005. (CIDRAP 11/16/05 http://www.cidrap.umn.edu/ ; Promed 11/15/05)

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Kuwait: Avian influenza H5N1 confirmed case in flamingo
One of 2 birds found infected with bird flu in Kuwait has the H5N1 strain of the virus, authorities said. The infected bird was a migrating flamingo found on a Kuwait beach. The other was an imported falcon found to have the milder H5N2 variant. The infected birds are the first known cases of the virus in the Persian Gulf region. A senior official said the government didn't plan to cull any birds following the confirmation. Last month, Kuwait said it had earmarked USD 17 million to buy drugs to combat bird flu. The Middle East has been worried about possible outbreaks because the region sits on important migratory bird waterways south. Jordan and Israel have been among the other countries trying to impose precautions to prevent outbreaks. (Promed 11/12/05)

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Romania (Caraorman): Bird flu virus found in dead chickens
On 14 Nov 2005, the veterinary lab in Tulcea, Romania confirmed the presence of the bird flu virus in birds that died several days ago in a village called Caraorman. Caraorman, the village where last week many domestic birds died during the second week of Nov 2005, is in the Danube Delta. In the villages Partizani, Caraorman and Crisan, in the past days, hundreds of birds have died. Near Sulina, 100 swans have been found dead. Marian Avram, head of the Sanitary-Veterinary authority in Tulcea, said that, at this moment, lab analysis confirmed the presence of the bird flu virus only for chickens dead in Caraorman, but they have another 200 samples to analyze. Meanwhile, Lefter Chirica, a Tulcea county official, declared that troops are ready for quarantine procedures. The villagers will receive a total of about USD 20 000 for the eventual killing of their birds. Details on the 2 affected holdings in Caraorman are included in the official Romanian report sent 16 Nov 2005 to the OIE: http://oie.int/downld/AVIAN%20INFLUENZA/Romania%20Follow%20up%20No7.pdf. (Promed 11/17/05)

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Italy (Modena): H5N1 Low Pathogenic Avian Influenza confirmed in mallard
On 8 Nov 2005, a type A influenza virus isolate was submitted to the National Reference Laboratory for Avian Influenza in Legnaro for characterization. The virus was isolated from a wild mallard hunted in an area located in the municipality of Mirandola, province of Modena, in Emilia-Romagna Region. The virus was found in a young male of mallard aged around 1 year, which was killed by a hunter in Modena province. It was probably born in Italy, due to its young age. The virus could be also of local origin. On 9 Nov 2005, the isolate was typed as a Low Pathogenic H5N1. The Italian H5N1 represents a different virus, not related genetically to the Asiatic H5N1. The preliminary results indicate that the Italian virus is genetically related to other LPAI viruses commonly isolated in wild birds in Europe. Meanwhile, Italy has banned imports of live poultry, game birds and poultry products from Croatia, Romania and other Balkan states. It has also begun inspecting poultry farms and testing captured migratory birds as well as temporarily banning street poultry markets. Meanwhile, farmers have been staging protests over the fall in poultry sales, due to the bird flu scare. (Promed 11/10/05, 11/12/05)

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Asia
South East Asia: Cumulative number of human cases of avian influenza A/(H5N1)
***As CIDRAP has terminated reporting of unofficial cases, EINet will from hereon report only official (WHO-confirmed) cases.

Cumulative number of confirmed human cases of avian influenza A/(H5N1), 16 Dec 2004 to present:
Economy / Cases (Deaths)
Indonesia / 11 (7)
Cambodia / 4 (4)
Thailand / 4 (1)
Viet Nam / 65 (22)
Total / 86 (35)

Total number of confirmed human cases of avian influenza A/(H5N1), 26 Dec 2003 to present: 130 (67) (WHO 11/17/05 http://www.who.int/csr/disease/avian_influenza/country/en/index.html)

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China (Hunan, Anhui): Confirms first 2 human cases of avian influenza
WHO stated 17 Nov 2005 that it sees no sign that avian influenza is being passed from person to person after China reported its first cases of human infection. Henk Bekedam, the WHO representative in China, said, "If there would be something like that, we would expect more people would be unexpectedly dying of very severe pneumonia." The Ministry of Health confirmed the country's first 2 human cases of infection with the H5N1 avian influenza virus. The first case is a 9-year-old boy from the southern province of Hunan. He was hospitalized with respiratory symptoms 17 Oct 2005 and has since returned home, fully recovered. The second case is a 24-year old woman who worked as a poultry farmer in the south-eastern province of Anhui. She developed symptoms 1 Nov 2005 and died 10 Nov 2005. "We need to closely monitor the virus," Bekedam said. That means strong surveillance systems and quick responses, he said. "That's also a challenge not only for China, but a challenge for the whole world," he said. Hunan and Anhui are among the recently bird flu-hit provinces. Surveillance for human cases in China intensified over the past month following a recurrence of highly pathogenic H5N1 avian influenza in poultry. A WHO team has collaborated with national experts in the investigation of the Hunan cases.

An additional 2 possible human cases have been investigated in Hunan. The first is the boy's 12-year-old sister. She was hospitalized 16 Oct 2005 and died the following day. The additional case under investigation in Hunan is a 36-year-old schoolteacher. He was hospitalized with pneumonia 24 Oct 2005. Test results are pending. Chinese investigators were confident the girl died of avian influenza, but she couldn't be confirmed because her body was cremated. Reportedly, the teacher, who cut his hand while handling a chicken that may have been sick, was recovering in hospital. Officials were also monitoring a poultry worker in Liaoning province, which has recently seen 4 outbreaks. This woman had tested negative for the virus and was reportedly leaving the hospital soon. All farm birds in the province were ordered vaccinated early this month, said Fu Jingwu, deputy director of the provincial Animal Health Supervision and Management Bureau. He said the effort covered 320 million birds. Liaoning province also has destroyed more than 15 million chickens, ducks, and other birds. (Promed 11/16/05, 11/17/05)

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China: Additional bird flu outbreaks; enhanced control efforts
China has strengthened supervision and monitoring on bird flu, as new cases of the outbreak were reported in 2 counties of northwestern Xinjiang Uygur Autonomous Region 15 Nov 2005. Since 19 Oct 2005, China has reported 11 fresh outbreaks of the disease in 6 provinces. China's National Avian Flu Reference Laboratory confirmed the H5N1 strain virus, which was found in dead fowl sent from family farms in Zepu Economy and Urumqi County, both in Xinjiang. In the 2 bird-flu-hit counties, a total of 322 500 family birds within a radius of 3 km have been culled, and poultry and products markets within 10 km have been closed, the Ministry of Agriculture (MOA) said. "The epidemic is basically put under control," said Qian Zhi, Vice chairman of Xinjiang, adding the 2 counties have bought a large quantity of vaccine, protective suits and disinfectors to prevent the spread of the disease. The government in Xinjiang launched its quick-response mechanism, blockading the epidemic zone and disinfecting people, vehicles and relevant goods going in and out. All the poultry in the epidemic zone have been killed and disposed of. Just one day ago, MOA announced another highly pathogenic bird flu outbreak at a village in Anhui Province, which involved nearly 130 000 fowl killed. The ministry has sent expert panels and supervision teams to Anhui and Xinjiang to assist epidemic control.

Other provinces, autonomous regions and municipalities have strengthened monitoring on poultry farms and migrant birds, which are said to be carriers of the virus. Guangxi Zhuang Autonomous Region has set up special monitoring stations at its 8 counties bordering Viet Nam. In addition, Guangxi's health departments have resumed the monitoring on fever cases in hospitals and started to vaccinate the elderly, children, medical workers and poultry farmers, traders and butchers. In Fujian, the provincial forestry department has set up 24 monitoring stations for migrant birds in their major habitats. The stations are required to make a daily report on whether there are abnormal deaths of migrant birds. In Changchun, provincial capital of Jilin Province, the government has reportedly started to vaccinate pigeons in the city. The quarantine related to the epidemic was lifted in Tianchang City of Anhui and Xiangtan County of Hunan Province 15 Nov 2005; bird flu outbreaks were reported in Wantang Village, Xiangtan County 18 Oct 2005 and in Tianchang 20 Oct 2005, respectively.

Chinese Premier Wen Jiabao presided over an executive meeting of the State Council 2 Nov 2005 to analyze and step up bird flu prevention and control. According to 12 measures adopted at the meeting, China will allocate 2 billion yuan (25 million USD) to set up the bird flu prevention and control fund and initiate a national headquarters to oversee the prevention and control work. China's Health Minister Gao Qiang ordered 7 Nov 2005 health departments to strengthen work in 3 key areas, namely monitoring, control, and treatment, stressing that early action is crucial in all of them. "The health departments should work synchronously with the agricultural departments once they learn about the outbreak of an epidemic among animals," said Gao. He ordered the health departments to maintain an efficient information-sharing mechanism with relevant departments, including civil aviation and transportation departments. China has also reportedly ordered all ports to require passengers to fill out health forms.

Elsewhere, health departments in Guangdong Province and Hong Kong agreed to reinforce co-operation in monitoring and reporting any outbreak of public health events including flu, bird flu and other new diseases. In Guangdong province, the cities of Shenzhen and Zhuhai will check the temperatures of departing passengers. People feeding pigeons or ducks face a hefty fine in Hong Kong, where authorities are trying to reduce human contact with wild birds. A HKD 1500 (USD 260) fine will be slapped on anyone caught throwing food to the city's flocks of birds. In Shanghai, the authorities are planning to build an advanced animal disease prevention and control centre, equipped with a bio-safety level 3 laboratory, to strengthen tracking and research of the sources of animal diseases and enhance warning capacity. It is believed the centre will improve Shanghai's early-warning capacity against animal diseases. Shanghai has also banned sales of live ducks, quail and other birds. Reportedly, under new regulations that came into effect in Beijing 6 Nov 2005, anyone who fails to immunize their birds faces up to 15 days in prison and a 200 yuan (USD 34) fine.

The General Administration of Quality Supervision, Inspection and Quarantine said 13 Nov 2005 it would check processed poultry to ensure that no birds come from regions affected by bird flu. The inspections will cover 16 provinces, municipalities and autonomous regions. It will also check the quality of disinfectants used for combating bird flu. Quality supervisors will check the food production permits of poultry product makers and impose tough penalties on firms which do not have them. In particular, inspectors will look for proof of the makers, especially those in the vicinity of an outbreak site, to ensure that the birds have been certified by quarantine authorities. Violators will be dealt with severely. (Promed 11/4/05, 11/5/05, 11/6/05, 11/8/05, 11/10/05, 11/13/05, 11/17/05)

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China: Aims to vaccinate all poultry
China announced an ambitious effort to vaccinate all the country's farm birds. Over the course of a year, the nation produces 14 billion poultry. That campaign would be the largest single vaccination effort ever for any species, according to the UN Food and Agriculture Organization. It promises to be logistically complicated, not least as it entails chasing and catching billions of free-range birds. The Agriculture Ministry did not provide a timetable. The ministry said the country is producing more than 100 million doses of avian flu vaccine daily, but some areas are reporting shortages. At any one time, China has about 4 billion chickens and 1.2 billion ducks and geese, but even those numbers understate the size of the vaccination task. Dr Qi Xiaoqiu, director-general of the department for disease prevention and control at China's Health Ministry, said that three fifths of the poultry in China were kept by families, who let the birds and other domesticated animals wander around the neighborhood and the yard and often through the house. Constant close contact between animals and people is worrisome because birds and pigs can carry the H5N1 virus and may transmit it to people.

Reportedly, a fake flu vaccine, possibly including active virus, may have actually spread the disease among poultry instead of preventing it, although there has been no suggestion that this occurred elsewhere (virus can persist and spread even in properly vaccinated birds unless stringent precautions are taken). China has also reportedly developed its own version of Tamiflu, an antiviral drug, and is preparing to produce it in large quantities if a human pandemic occurs. Veterinary experts at the FAO said that more information was needed to assess the wisdom of China's decision to vaccinate all poultry. FAO normally recommends such large-scale programs only in areas where the H5N1 bird flu virus has become endemic - where culls and quarantines have proved ineffective. Parts of Viet Nam and Indonesia fall into this category, and widespread vaccination programs have controlled influenza among poultry in some areas. Bird vaccine has been widely available for several years. Costing merely 10 cents a dose and produced by a dozen manufacturers, it is nearly 100 per cent effective.

The difficulty with the bird vaccine, particularly in Asia, is organizational: Veterinary workers must go village to village and door to door, since most poultry in this part of the world is kept on small farms and in backyards. In most parts of Asia, the vaccine is administered in endemic areas and in areas surrounding outbreaks that have been controlled by culls. The vaccine is also given to poultry in areas where wild birds are known to be infected. The vaccine is not recommended for use in birds in Europe or North America, as avian influenza is still rare in Europe and has not been seen in the US. In such places, the preferred method for stamping out the disease is culling birds for a radius of up to a few miles around the outbreak and quarantining poultry in a wider area for several weeks. (Promed 11/15/05, 11/16/05)

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Indonesia: 2 more confirmed fatal human avian influenza cases
Indonesia has had 2 more deaths from H5N1 avian influenza confirmed by a WHO laboratory, bringing the total number of deaths to 7 in the country, the Health Ministry said 17 Nov 2005. Hariadi Wibisono, a senior official from the Ministry, said that the tests were from a 20 year old woman who died 12 Nov 2005 and a 16 year old girl who died 8 Nov 2005. Both victims, who died in Jakarta, had contact with dead chickens. The newly confirmed cases bring the total in Indonesia to 11. Of these, 7 have been fatal. On 17 Nov 2005, the Health Ministry said it would more than double to 100 the number of hospitals designated to treat bird flu patients. President Susilo Bambang Yudhoyono has made fighting bird flu one of the government's top priorities. He has outlined measures to tackle the virus that included seeking licenses to make antiviral drugs as well as reviewing the budget to see if more funds could be allocated.

Earlier, the Ministry of Health also confirmed 2 additional cases of human infection with H5N1 avian influenza (confirmed by WHO laboratory). The first confirmed case was a 19-year-old woman from Tangerang, who died 28 Oct 2005 and the second case was her 8-year-old brother, who remains hospitalized in good condition. Investigation has found evidence of sick and dying chickens in the residential area of the 8-year-old. His 19-year-old sister is known to have visited this area. In the latest news, Indonesian tests on a 16 year old youth show he is suffering from the H5N1 bird flu virus, but the results have to be confirmed by the WHO lab. The youth was admitted to the Sulianti Saroso Hospital 11 Nov 2005. He was reportedly in intensive care. (Promed 11/7/05, 11/13/05, 11/15/05, 11/17/05)

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Indonesia: Need for improved commitment against avian influenza
Indonesia has to intensify its fight against bird flu, the European Union's top health official said 15 Nov 2005, warning that promises of action must be followed up on. EU Health Commissioner Markos Kyprianou said the government appears to have the political will to contain the disease that has recently spread from Asia to Europe. Now, it has to come up with detailed plans, from ways to monitor hundreds of millions of backyard chickens to guidelines for culling and vaccinations, and take steps to implement them. Indonesia was criticized for moving too slowly when bird flu first appeared in poultry stocks in 2003, but has promised recently to step up the fight. Even the military was getting involved, with President Susilo Bambang Yudhoyono saying troops would join students and volunteers in going door-to-door in search of sick birds. Still, the government has refused to slaughter all poultry in bird-flu infected areas, which experts claim is the best way to contain the spread of the virus, opting instead for mass vaccinations of chickens. Indonesia says it cannot afford to compensate farmers for culled livestock. Kyprianou cautioned vaccination alone "is not a long term solution." A combination of culling and vaccinations is recommended. FAO is setting up 4 local disease control centres across Java island (most of the known human infection has occurred in the western part of Java) and establishing disease surveillance teams at the village level where many "backyard" chickens are found.

The disease is widespread among Indonesia's chicken population, which the Agriculture Ministry puts at 1.4 billion. Bird flu first emerged among the country's fowl in late 2003 and has been found in poultry in 23 of Indonesia's 33 provinces, killing more than 10 million domesticated birds. Compounding the problem are what officials estimate at 30 million "backyard chicken" households, accounting for about 200 million birds. These are homes with just a handful of birds, many in urban areas. Officials say new infections in poultry in 2005 are so far around 800 000, compared with 5.3 million for all of 2004. (Promed 11/8/05, 11/9/05, 11/17/05)

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Viet Nam: Confirmed human death from H5N1; 2 new suspected human cases of bird flu
WHO confirmed that a 35-year-old Hanoi man who died Oct 29, 2005 was Vietnam's 42nd victim of avian flu. The man was admitted to a Hanoi hospital 4 days after his family bought a prepared chicken from a market near his house in Hanoi. Other family members did not show any symptoms of bird flu. Vietnamese officials said it was the first confirmed case in Vietnam since late July 2005. Authorities also said the case occurred earlier than the first case of the winter flu season in Vietnam last year, which came in mid-December. The newly confirmed case coincides with a recurrence of outbreaks in poultry. The case brings Vietnam's total reported cases to 92, for a 45.7% case-fatality rate among known H5N1 cases in humans. This is the lowest case-fatality rate among the 4 countries that have had human infections; Indonesia's rate is 55.6%, Thailand's is 65%, and Cambodia's is 100%. The total combined case-fatality rate from the 125 known cases and 64 deaths is 51.2%.

Avian influenza may have infected 2 more people in Viet Nam. State newspapers said 14 Nov 2005 that a student was being tested in hospital after eating chicken eggs along with samples from a 78 year old woman who died from serious pneumonia in Quang Binh province 11 Nov 2005. H5N1 virus had now hit 10 of Viet Nam's 64 provinces since returning in early Oct 2005. "There is much possibility that the disease spreading is due to improper quarantine of infected poultry and poultry products," Bui Quang Anh, head of the Ministry's animal health department, said. Search-and-destroy task force groups must be set up to deal with sick poultry, he said. Viet Nam is gearing up its battle against bird flu, with Hanoi and Ho Chi Minh City officials spreading the word about a 15 Nov 2005 deadline from when poultry raising will be banned in those cities. Agriculture Minister Cao Duc Phat said police and soldiers would be used to quarantine farms, destroy sick poultry and man checkpoints to control poultry transportation better. Additionally, the National Steering Board for Bird Flu Control is to set up another 9 delegations to inspect preventive and control measures in those areas where the epidemic has broken out again. (CIDRAP 11/8/05, 11/9/05 http://www.cidrap.umn.edu/ ; Promed 11/15/05, 11/17/05)

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Viet Nam: New strains of bird flu viruses reported; Variation of H5N1 isolates reported
Vietnamese scientists have reportedly found more variations of bird flu viruses in poultry, adding to the health risk to people if these strains are allowed to keep circulating, an official said 16 Nov 2005. Dong Manh Ha, director of the Ho Chi Minh City Regional Animal Health Centre, said a study conducted by the center found new avian influenza strains of the H3 and H4 subtypes in poultry. Scientists say strains of the H3 and H4 subtypes are capable of causing death in birds but are generally less virulent and spread more slowly than the H5 subtype. Ha said that samples had been sent to a World Organisation for Animal Health (OIE) reference laboratory for further investigation. Although H3 and H4 are not generally thought of as being highly pathogenic, there is a risk of these subtypes mixing and exchanging genetic material with the H5N1 virus. There would then be the possibility of the H3N4 and H4N5 strains becoming more pathogenic. Human influenza viruses are usually strains of H1N1, H2N2, and H3N2, but avian flu subtypes H5 and H7 can also infect people.

In addition, Viet Nam's Ho Chi Minh City Pasteur Institute reportedly discovered that the avian H5N1 influenza in the country has mutated into a more dangerous version. Results of the Institute's research on 24 virus samples from infected poultry and people in the southern region between Dec 2003 and Mar 2005 show there are some changes in gene segments coding for the surface antigens HA and NA and some other gene segments of the H5N1 virus in Viet Nam in early 2005. Reportedly, the changes indicate that the virus has been mutating to reproduce effectively in cells of mammals and increase its attacking capability. All the viruses researched by the institute in southern Ho Chi Minh City are resistant to Amantadine and Rimantadine. The Institute has decoded completely or partly genes of 24 virus samples. 5 samples from humans and 16 from fowl have been decoded completely. However, the institute has been unable to define which kinds of mutations allow human-to-human transmission, and which conditions lead to the mutations. ***Similar findings have been reported previously. It is not clear from this report whether experiments were conducted using experimental animals to substantiate the statement that all the viruses sequenced had enhanced ability to multiply effectively in the cells of mammals. This does not necessarily equate with increased ability to transmit from person-to-person.

Meanwhile, Viet Nam has ordered 25 million tablets of the antiviral drug Tamiflu from Roche. Talks with Roche on a possible license for Vietnam to produce a generic version of the drug were still inconclusive. (CIDRAP 11/8/05, 11/9/05 http://www.cidrap.umn.edu/ ; Promed 11/13/05, 11/15/05, 11/17/05)

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Thailand: Additional human case of avian influenza infection
The Ministry of Public Health has confirmed a further case of human infection with H5N1 avian influenza. The case is an 18 month old boy from Bangkok. He developed symptoms 1 Nov 2005 and was admitted to hospital 5 Nov 2005. He remains in good condition. He will have to remain in hospital for 3 weeks to meet international health requirements. His grandmother, who was tested for the H5N1 virus, turned out to have ordinary human flu. The boy might have contracted the H5N1 virus from the droppings of chickens that died around his home Minburi. This is the fourth laboratory confirmed case in Thailand in 2005. Since January 2004, Thailand has reported 21 cases, of which 13 were fatal. The virus has re-emerged in 10 of Thailand's 76 provinces, mainly in central areas, since Oct 2005. 5 provinces were later declared free of the disease after a 21 day surveillance period. Despite the spread of the virus to the outskirts of Bangkok, outbreaks remain far fewer than at the same time in 2004. (Promed 11/12/05, 11/15/05)

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Taiwan: Highly pathogenic H7N3 avian influenza detected in wild bird
Taiwan found a highly pathogenic strain of avian flu, H7N3, in droppings left by a migratory bird and is carrying out tests to see whether the virus has spread to nearby poultry farms, the agriculture department said 14 Nov 2005. "We are most concerned about the H5 and H7, as these 2 can infect people and fowl," said Huang Kwo-ching, director of the animal health inspection division at the Council of Agriculture. "We are now carrying out testing at poultry farms within a 3 km radius of the area." The single sample of H7N3 was found in marsh land in Tainan; no dead birds were found in the area. It was the second time the strain has been detected in Taiwan. The first case of H7N3 was discovered in Taipei, April 2005. According to WHO, H5 and H7 viruses are the only avian influenza subtypes that are implicated in outbreaks of highly pathogenic disease. WHO recommends aggressive control measures for these 2 subtypes even when the virus initially shows low pathogenicity. Taiwan has not experienced a major outbreak of H5N1. In October 2005, the island found only its second case of H5N1 since 2003 in birds smuggled in a ship from China. An outbreak of the low pathogenic H5N2 strain of bird flu in Taiwan in 2004 led to the culling of hundreds of thousands of fowl. (Promed 11/15/05)

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Singapore: Use of sentinel chickens for early detection of avian influenza
Singapore's Jurong Bird Park has put 19 chickens, known as "sentinel chickens", in all its aviaries to help detect the presence of any infectious disease. Wong Hon Mun, executive director of Jurong Bird Park, said the chickens are bred from birds that have never been vaccinated against any disease and so act as a first line of defense against bird flu or any other illness brought in by wild birds. Since 2004 the park has started vaccinating all other birds and giving flu jabs to its staff. It has also introduced foot baths and disinfecting floor mats to reduce the risk of spreading the virus. Wong said the park has done scenario planning with the Agri-Food and Veterinary Authority, and added that if any of its captive birds were found to have contracted bird flu, the park would have to cull all the birds in that particular aviary. The park, the world's largest in terms of number of birds, would temporarily shut down if there were an outbreak. Despite growing fears about bird flu, Wong said visitor arrivals had not dipped. Although Singapore is currently free of bird flu, there are increasing concerns that imported birds could carry the virus onto its shores. Singapore's decision to use sentinels is a creative solution to a specific situation when direct or indirect contacts between the avian population of local parks and wild or migratory birds cannot be prevented. In contrast, commercial poultry are isolated from wild birds by their housing, while indirect contacts can be prevented by adequate biosecurity measures. (Promed 11/5/05)

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Japan (Ibaraki): H5 virus detected in poultry farm
Authorities have detected bird flu at a poultry farm but don't suspect it to be the H5N1 strain. Officials have identified an H5 virus in chickens at a poultry farm in Ibaraki prefecture. Officials have yet to determine what strain of the H5 family the virus is, but authorities believe it to be the H5N2 strain, which is less virulent than the H5N1 variety, according to wildlife official Nobuhito Kuriyama. About 80 000 birds from one of the 9 poultry houses at the farm will be culled and the movement of their eggs banned as a precautionary measure. The remainder of the farm's 710 000 birds will not be culled. Earlier tests in August 2005 showed that chickens at the farm had antibodies for a virus from the H5 family, meaning that they were infected in the past but had survived, Kuriyama said. In late October 2005, Japan set up a task force to plan against a possible outbreak of bird flu among humans. Agricultural authorities found H5 antibodies at several other farms in Ibaraki last week, prompting them to cull 180 000 free-range chickens. But this was the first time the bird flu virus, rather than antibodies, were detected in Japan since August 2005. Ibaraki prefecture has prohibited the movement of eggs or chickens within a 3.1-mile radius around the farm. The quarantine affects some 1.23 million chickens. According to those reports, a low-pathogenic-avian-influenza H5N2 strain has been lingering in Ibaraki since April 2005, identified in 31 farms throughout the period until mid-September 2005. The illegal use of a deficient vaccine, which might have included a live virus, was suspected but not (officially) proven.

Official OIE report:
Information received up to 4 Nov 2005 from Ministry of Agriculture, Forestry and Fisheries, Tokyo: Precise identification of agent: low pathogenic avian influenza virus subtype H5N2. Date of start of the outbreak: 4 Nov 2005. The affected birds showed few or no clinical signs. Source of outbreaks or origin of infection: unknown or inconclusive. Control measures undertaken: quarantine; movement control on farms within a radius of 5 km of the infected farms; screening; zoning; disinfection of infected premises/establishments. Control measures to be undertaken: all chickens in farms where the infection has been confirmed, except for those kept in premises with strict biosecurity equipment, are to be destroyed. (Promed 11/8/05, 11/15/05; CIDRAP 11/9/05 http://www.cidrap.umn.edu/ )

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Russia (Orenburg and Primorskiy krai): Outbreaks of hemorrhagic fever with renal syndrome
The hemorrhagic fever with renal syndrome disease situation in the Orenburg region is approaching a crisis point. Sergey Kajkov, the Head Physician of the City Infectious Diseases Hospital, stated that the situation is 10 times worse than in 2004. There has been a marked increase in the number of patients admitted to the hospital with a diagnosis of HFRS, and 2 fatalities have been recorded already. There have been no unusual features in the progression of disease, but in the majority of cases, illness takes a severe course. As of 9 Nov 2005, 4 patients have been moved to the resuscitation unit. Since Sep 2005, 200 persons with HFRS have received treatment in the infectious diseases department of the hospital.

Also, 73 cases of hemorrhagic fever with renal syndrome (HFRS) have been recorded in the Primorskiy region [krai] during the first 9 months of 2005. This is 1.8 times higher than for the same period in 2004. The greatest number of cases has been recorded in the city of Vladivostok (20 cases), in the Ternejskiy district (12 cases), the Dalnegorsk district (9 cases), and the Kavalerovskiy district (8 cases). There has been a marked increase in urban cases of HFRS in recent years. Epidemiologists consider that there has been a decline in urban rodent control, and financial support for public health initiatives have been insufficient. Rodent control is probably the most effective means of control of HFRS. The virus responsible for HFRS is transmitted from rodent detritus, not directly from the animals themselves. (Promed 11/7/05, 11/9/05)

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Russia (Moscow): 4 cases of Psittacosis
4 inhabitants of Moscow have fallen ill with a rare illness, psittacosis. 3 of the 4 cases of psittacosis have been linked to parrots. 2 persons were infected from their own birds. In both cases, parrots had been obtained locally. One more inhabitant of Moscow was infected with psittacosis in Mexico during an excursion to a local reserve. In the fourth case, the source of the infection was a pigeon. Psittacosis, also known as ornithosis or parrot fever, is a human disease caused by the bacterium Chlamydophila psittaci. Classically associated with psittacine birds such as parakeets, parrots, and cockatiels, it may affect other avian species such as turkeys, ducks, pigeons, and pheasants. Human infection in general is caused by inhalation of dust containing the bacterium, which is shed in large amounts in the feces and secretions of the infected birds. The respiratory infection, usually diagnosed serologically, can be fatal if untreated. Protective equipment may be recommended for individuals in areas frequently visited by free-ranging birds if contact with birds and their droppings is likely when performing outdoor activities. (Promed 11/4/05)

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Americas
USA: CDC: No plans now to send 1918 virus to other labs
CDC has no current plans to release the reconstructed version of the virus that caused the 1918 influenza pandemic to other laboratories. A report in Nature quoted CDC spokesman Von Roebuck as saying that labs that are registered to work with select agents could request the virus. No labs had made such a request yet, Roebuck said. The CDC classified the virus as a select agent Oct 20, 2005. CDC Director Dr. Julie Gerberding said the virus currently exists nowhere else than the CDC, which is studying it in the hope of learning more about influenza and pandemics and helping to develop better vaccines and drugs. "We have to balance that with our overarching moral and scientific imperatives to make sure that virus is handled with the absolute best possible biocontainment and biosafety procedures," she said. CDC handles the virus under enhanced biosafety level 3 conditions and has said that other labs with the same level of security can work with it. The Nature report says that scientists at Canada's National Microbiology Laboratory in Winnipeg plan to work with the 1918 virus but will not request it from CDC. Frank Plummer, the lab's scientific director, said the lab would obtain constructs containing the virus's DNA from the University of Wisconsin in Madison. An unsigned editorial in Nature this week endorses research on the virus but says that sharing it with other labs would increase the risk of an accidental release. The editorial suggests working toward an international agreement governing the distribution and handling of potentially dangerous reconstructed viruses. (CIDRAP 11/11/05 http://www.cidrap.umn.edu/ )

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Canada/Haiti: Malaria infections confirmed
2 patients suspected of having Plasmodium falciparum malaria infection have been confirmed, as proven by blood smears examined in Canada and in Haiti and the US. Potential contribution by other pathologies (such as dengue and leptospirosis) is currently being investigated in laboratories in Haiti, Canada, and the US. The Ministry of Public Health and Population of Haiti is currently conducting epidemiologic investigations in Port-au-Prince and in Cotes des Arcadins, the beach area visited by these 2 patients approximately 2 weeks before their first symptoms. Malaria remains a major problem in Haiti, though fortunately chloroquine resistance has not yet been a significant issue. (Promed 11/11/05, 11/15/05)

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1. Updates
Influenza
Seasonal influenza activity for the Asia Pacific and APEC Economies

Canada. Localized influenza A activity continued in Manitoba and was reported in British Columbia in week 44. Activity remained low in the rest of the country.

Other reports. During week 44, low influenza activity was detected in Australia (B), Hong Kong (H1, A and B), and the USA (A and B). (WHO 11/16/05 http://www.who.int/csr/disease/influenza/update/en/ )

USA
During week 45 (6 Nov – 12 Nov 2005), influenza activity occurred at a low level in the US. 9 (0.7%) specimens tested by U.S. WHO and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories were positive for influenza. The proportion of patient visits to sentinel providers for influenza-like illness (ILI) and the proportion of deaths attributed to pneumonia and influenza were below baseline levels. 21 states, New York City, the District of Columbia, and Puerto Rico reported sporadic influenza activity, and 29 states reported no influenza activity. (CDC http://www.cdc.gov/flu/weekly/ )

Avian/Pandemic influenza websites

- Latest CDC updates on pandemic influenza: http://www.cdc.gov/flu/pandemic.htm; for avian influenza: http://www.cdc.gov/flu/avian/ (updated 17 Nov 2005). The “Questions & Answers: Vaccine Supply and Prioritization Recommendations for the U.S. 2005-06 Influenza Season” has been updated 14 Nov 2005: http://www.cdc.gov/flu/about/qa/0506supply.htm.
- The US government’s official Web site for pandemic flu: http://www.pandemicflu.gov/.
- Latest FAO updates on avian influenza: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html.
- Latest OIE updates on avian influenza: http://www.oie.int/eng/en_index.htm. Includes documents from the Geneva 7-9 Nov 2005 meeting.
- WHO “Influenza pandemic threat: current situation”: http://www.who.int/csr/disease/avian_influenza/pandemic/en/index.html. WHO recommendations relating to travelers coming from and going to countries experiencing outbreaks of highly pathogenic H5N1 avian influenza: http://www.who.int/csr/disease/avian_influenza/travel2005_11_3/en/index.html. ***WHO does not recommend any restrictions on travel to any areas affected by H5N1 avian influenza; WHO does not recommend screening of travelers coming from H5N1 affected areas; WHO advises travelers to avoid contact with high-risk environments in affected countries
- PAHO’s latest updates on avian influenza: http://www.paho.org/
- American Public Health Association (APHA) information on Influenza (http://www.apha.org/preparedness/influenza.htm) and Avian Influenza (http://www.apha.org/preparedness/avian.htm).
- The American Veterinary Medical Association information on avian influenza: http://www.avma.org/public_health/influenza/default.asp
(Washington Dept of Health 11/2/05; CDC; WHO; APHA)

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Cholera, diarrhea & dysentery
China (Zhejiang)
The cholera outbreak in Jiaxing and Huzhou in Zhejiang Province has been basically brought under control, authorities said 29 Oct 2005. From 25 to 28 Oct 2005, no new cholera case was spotted in the 2 cities for 4 consecutive days, and the last cholera-bacteria carrier left hospital 28 Oct 2005. Jiangxi reported its first cholera case 2 Sep 2005 and its last case 17 Oct 2005. During this period, the city recorded a total of 184 cholera cases and 60 cholera bacterial carriers, with no deaths reported. Since 18 Oct 2005, Jiangxi has had no new cholera cases for 10 days, and its last cholera patient left hospital 23 Oct 2005. On 13 Oct 2005, sporadic cholera outbreaks were reported among migrant workers at a brick mill in Huzhou. The city has since recorded 19 cases of cholera, and another 34 cholera bacterial carriers. The city provided free medical care for the patients. No more cholera cases have been reported in the city for the past 4 consecutive days, and the last bacterial carrier left hospital 28 Oct 2005. Authorities attributed the outbreak of the waterborne disease this year largely to drinking unsanitary water, eating unclean food, and paying little attention to personal hygiene. (Promed 11/4/05)

New Zealand (North Island) The region's Medical Officer of Health, Jonathan Jarman, says 25 people suffering cramps and diarrhea have been diagnosed with shigellosis. He says there would normally only be 2 or 3 cases a year. Dr Jarman says it seems the bacteria came from shellfish that was harvested from beds contaminated with human waste. He says all of the people they have spoken to ate raw oysters in the Bay of Islands. (Promed 11/11/05)

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Dengue
Malaysia (Kuala Lumpur)
2 more deaths took the dengue death toll to 83 [case fatality rate (CFR) of 252 per 100 000] this year. The Health Ministry's Disease Control Division for the period Oct 23-29, 2005 said an 18-year-old girl died in Segamat, Johor. The second death was that of a 4-year-old girl from Jempol, Negeri Sembilan Oct 29, 2005 due to dengue haemorrhagic fever (DHF). 75 deaths [CFR of 304 per 100 000] from dengue fever were reported at the same time in 2004. The accumulated dengue fever cases so far in 2005 stood at 32 950 cases, including 1635 cases of DHF, an increase of 33 per cent compared to 24 699 cases during the same period in 2004. Up to Oct 22, a total of 9381 cases were confirmed positive--8897 dengue fever and 484 DHF. Selangor recorded the highest total accumulated cases with 11 049 cases and 24 deaths; Kuala Lumpur, 4875 cases and 14 deaths; Penang, 2976 cases and 6 deaths, and Perak, 2559 cases and 6 deaths. (Promed 11/5/05)

Hong Kong/Bangladesh
The Centre for Health Protection urges people to guard against Dengue fever after it confirmed an imported case involving a 50-year-old woman. The woman was visiting Bangladesh when she developed a fever, chills, headache, muscle pain and sore eyes 15 Oct 2005. She returned to Hong Kong on October 21 and was admitted to Princess Margaret Hospital. She recovered and was discharged 3 days later. None of her home contacts had any symptoms. This brings the total number of Dengue fever cases in 2005 to 23, all imported. People are reminded to stay alert and to help fight against mosquito breeding. (Promed 11/5/05)

Viet Nam (Ho Chi Minh City)
Viet Nam has had more than 35 700 dengue cases so far this year, up 4 per cent compared to the same period in 2004. Most of the dengue cases had been in the southern and central provinces, with only 600-700 cases occurring in northern provinces. Khanh Hoa Province had the largest number of people infected with dengue fever, nearly 4000 cases. The province was currently seeing an average of more than 50 dengue victims a day. This year's drought led local people to store water in tanks near or in their homes, but many have not covered the tanks properly, creating ideal conditions for the larvae of the Aedes aegypti. Khanh Hoa's Preventive Health Centre has attempted to prevent the transmission of dengue by using chemicals to kill Aedes aegypti. Dengue fever has already infected 24 545 people in the Mekong Delta in 2005. Of the delta's provinces, Dong Thap and An Giang have the largest number of victims, with a total of 7350 people affected. 36 deaths [CFR of 490 per 100 000] from the disease have so far been reported in 2005 in Viet Nam. (Promed 11/5/05)

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Viral gastroenteritis
Canada (British Columbia)
An outbreak suspected to be caused by a Norwalk-type virus spread to about 30 percent of the pupils at a grade school, and classes have been canceled until 7 Nov 2005. 143 students and employees at Mill Plain Elementary School were out sick 3 Nov 2005. The school would be closed 4 Nov 2005 for extensive disinfecting. Norwalk-type virus outbreaks have occurred in hotels, on cruise ships and in other contained environments. The infectious agent, norovirus, is spread through food, water and close contact with infected people or items they have touched and causes vomiting and diarrhea. Officials were trying to determine what strain was involved in the outbreak. Food service is not believed to be involved, because no kitchen workers have fallen ill, and health inspection reports have indicated no problems. (Promed 11/6/05)

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West Nile Virus
Canada
During week 43 (23 Oct - 29 Oct 2005), 1 new West Nile virus clinical case was reported in Ontario, and 1 old case was removed from Ontario. A previously reported case in Quebec was also removed. As of 29 Oct 2005, 226 WNV clinical cases and 13 asymptomatic infections have been reported to the Public Health Agency of Canada. Of the 226 clinical cases, 51 (23 percent) were reported as West Nile Neurological Syndrome, 168 (74 percent) were reported as West Nile Non-Neurological Syndrome, and 7 (3 percent) were Unclassified/Unspecified. To date, there have been 12 deaths [Saskatchewan (2), Manitoba (1), Ontario (8) and Quebec (1)] reported in patients with WNV infection. (Promed 11/13/05)

USA
As of 8 Nov 2005, 42 states have reported 2,653 cases of human WNV illness in 2005. By comparison, a total of 2,282 WNV cases had been reported as of 8 Nov 2004. A total of 1,405 (56%) of the 2,490 cases for which such data were available in 2005 occurred in males; the median age of patients was 51 years (range: 3 months--98 years). Dates of illness onset ranged from January 2 to October 21, 2005; a total of 86 cases were fatal. A total of 381 presumptive West Nile viremic blood donors (PVDs) have been reported during 2005. Of these, 3 persons aged 53, 56, and 72 years subsequently had neuroinvasive illness; 7 persons (median age: 41 years [range: 17--64 years]) subsequently had other illnesses; and 84 persons (median age: 46 years [range: 17--78 years]) subsequently had West Nile fever. For additional information: http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and http://westnilemaps.usgs.gov. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5444a6.htm (MMWR November 11, 2005 / 54(44);1133-1134)

Russia (Rostov)
15 cases of West Nile fever have been laboratory confirmed since the beginning of 2005 in the Rostov region. Reportedly, the antigen for West Nile fever has been detected in the Myasnikovskiy and Peschanokopskiy districts of Rostov. 150 persons fell ill with West Nile fever in summer 2005 in the Volgograd, Rostov and Astrakhan regions, 35 of whom died. http://www.rian.ru/analytics/20051031/41945669.html. Presently, biologists, virologists and entomologists are actively working in these territories. (Promed 11/6/05)

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2. Articles
Lab study supports idea of 'cytokine storm' in H5N1 flu
Chan MCW, Cheung CY, Chui WH, et al. Proinflamatory cytokine responses induced by influenza A(H5N1) viruses in primary human alveolar and bronchial epithelial cells. Respir Res 2005 (published online Nov 11, 2005):
A recent study has produced more evidence that infection of human lung cells with the H5N1 avian influenza virus leads to intense inflammation similar to what was seen in victims of the 1918 pandemic. Researchers from Hong Kong report that lung cells growing in a lab responded much more intensely to the H5N1 virus than to an ordinary flu virus, even though the viruses reproduced at about the same rate. The H5N1 viruses were "more potent inducers" of cytokines and chemokines—chemical messengers that trigger inflammation—than H1N1 viruses were, says the report by a team led by J.S.M. Peiris of the University of Hong Kong. Autopsies of H5N1 avian flu victims in Vietnam and elsewhere have revealed lungs choked with debris from the excessive inflammation triggered by the virus. Similar severe lung damage was frequently reported in victims of the 1918 pandemic, which disproportionately killed people with the strongest immune systems—young, healthy adults. The researchers sought to test their hypothesis that the H5N1 virus's ability to trigger a flood of cytokines may contribute to the unusually severe disease it causes in humans. They used H5N1 viruses isolated from a patient who died of the infection in Hong Kong in 1997 and from 2 Vietnamese patients who were infected in 2004, plus an ordinary H1N1 virus isolated in Hong Kong in 1998. "We have found that infection with H5N1 viruses led to the production of 10 times higher levels of cytokines from human cells than normal human flu viruses," said Peiris. The different cytokine responses are not explained by different viral growth rates, because all 3 virus subtypes replicated with similar efficiency, they say. (CIDRAP 11/16/05 http://www.cidrap.umn.edu/ )

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A Systematic Analytic Approach to Pandemic Influenza Preparedness Planning
Daniel J. Barnett, Ran D. Balicer, Daniel R. Lucey, George S. Everly, Saad B. Omer, Mark C. Steinhoff, Itamar Grotto.
Excerpted from paper: “. . . Although the Haddon matrix may seem unfamiliar to some infectious disease scientists, it incorporates familiar analytic elements in a systematic way. The four columns represent the classical epidemiologic triad of host, agent, and environment (physical and sociocultural). The three rows are equivalent to primary, secondary, and tertiary prevention of disease outbreaks. Indeed, Haddon himself used his analytic matrix to describe an outbreak of polio, and this matrix has been recently applied to other public-health emergency preparedness challenges such as SARS. Comprehensive public health emergency preparedness and response efforts require effective pre-event (preventive), event (mitigation), and post-event (consequence management) strategies. By identifying the factors that may modify the outcome in each of these phases, one can prescribe the appropriate measures necessary to tackle each factor. To this end, we specifically applied the Haddon matrix to pandemic influenza planning and response, systematically identifying relevant factors in each phase (pre-event, event, post-event) and on each axis (human, agent/vector, physical environment, sociocultural environment). We then identified factors that may be associated with opportunities for public health intervention, and marked these factors in bold within the matrix (consistent with an approach described by Runyan). . .” (CIDRAP http://www.cidrap.umn.edu/ ; PLoS Med. 2005 Nov 1;2(12):e359)

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Trends in HIV/AIDS Diagnoses--33 States, 2001-2004
“In 2003, more than 1 million persons in the United States were estimated to be living with human immunodeficiency virus (HIV) infection. As a result of advances in treatment with highly active antiretroviral therapy (HAART) since 1996, persons infected with HIV are living longer than before and progression to acquired immunodeficiency syndrome (AIDS) has decreased. Consequently, AIDS surveillance no longer provides accurate population-based monitoring of the current HIV epidemic. Therefore, CDC recommends that all states and territories adopt confidential, name-based surveillance systems to report HIV infection. This report describes the characteristics of persons for whom HIV infection was diagnosed during 2001-2004 and reported to 33 state and local health departments with name-based HIV reporting. The findings indicate that the rate of HIV diagnosis in these states decreased among non-Hispanic blacks from 2001 to 2004; however, the rate of HIV diagnosis among blacks remained disproportionately high. . .Improved knowledge of HIV status and access to care and prevention services is important to decrease the number of new HIV infections. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5445a1.htm (MMWR November 18, 2005 / 54(45);1149-1153)

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Cruise-Ship-Associated Legionnaires Disease, November 2003--May 2004
“More than 9.4 million passengers traveled on pleasure cruises departing from North American ports in 2004, an increase of 13% since 2003 and 41% since 2001. . . Travelers are at risk for becoming ill while on board, most commonly from person-to-person spread of viral gastrointestinal illnesses. Certain environmental organisms, such as Legionella spp., pose a risk to vulnerable passengers. During November 2003-May 2004, 8 cases of Legionnaires disease (LD) among persons who had recently traveled on cruise ships were reported to CDC. This report describes these cases to raise clinician awareness of the potential for cruise-ship--associated LD and to emphasize the need for identification and reporting of cases to facilitate investigation. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5445a2.htm (MMWR November 18, 2005 / 54(45);1153-1155)

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Immunization Information System Progress--United States, 2004
“One of the national health objectives for 2010 is to increase to at least 95% the proportion of children aged <6 years who participate in fully operational, population-based immunization registries . . . Immunization registries are confidential, computerized information systems that collect and consolidate vaccination data from multiple health-care providers, generate reminder and recall notifications, and assess vaccination coverage within a defined geographic area. A registry with added capabilities, such as vaccine management, adverse event reporting, lifespan vaccination histories, and linkages with electronic data sources, is called an immunization information system (IIS). This report summarizes data from CDC's 2004 IIS Annual Report, a survey of 56 grantees in 50 states, five cities, and the District of Columbia (DC) . . . The findings indicate that approximately 48% of U.S. children aged <6 years participated in an IIS. Moreover, 76% of public vaccination provider sites and 39% of private vaccination provider sites submitted immunization data to an IIS during the last 6 months of 2004. Overcoming challenges and barriers to increasing the number of provider sites and the percentage of children aged <6 years participating in an IIS is critical to achieving the national health objective. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5445a3.htm (MMWR November 18, 2005 / 54(45);1156-1157)

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A newly identified type of scrapie agent can naturally infect sheep with resistant PrP genotypes
The paper by Annick Le Dur et al., published in PNAS online 20 Oct 2005, describes observations that support the view that a truly infectious TSE agent, unrecognized until recently, infects sheep and goat flocks. Abstract: "Scrapie in small ruminants belongs to transmissible spongiform encephalopathies (TSEs), or prion diseases, a family of fatal neurodegenerative disorders that affect humans and animals and can transmit within and between species by ingestion or inoculation. Conversion of the host-encoded prion protein (PrP), normal cellular PrP (PrPc), into a misfolded form, abnormal PrP (PrPSc), plays a key role in TSE transmission and pathogenesis. The intensified surveillance of scrapie in the European Union, together with the improvement of PrPSc detection techniques, has led to the discovery of a growing number of so-called atypical scrapie cases. These include clinical Nor98 cases first identified in Norwegian sheep on the basis of unusual pathological and PrPSc molecular features and "cases" that produced discordant responses in the rapid tests currently applied to the large-scale random screening of slaughtered or fallen animals. Worryingly, a substantial proportion of such cases involved sheep with PrP genotypes known until now to confer natural resistance to conventional scrapie. Here we report that both Nor98 and discordant cases, including 3 sheep homozygous for the resistant PrPARR allele (A136R154R171), efficiently transmitted the disease to transgenic mice expressing ovine PrP, and that they shared unique biological and biochemical features upon propagation in mice. These observations support the view that a truly infectious TSE agent, unrecognized until recently, infects sheep and goat flocks and may have important implications in terms of scrapie control and public health." (Promed 11/8/05 see: http://www.pnas.org/cgi/content/abstract/0502296102v1?etoc )

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Interspecies transmission of chronic wasting disease prions to squirrel monkeys (Saimiri sciureus)
The inflamed mammary glands of sheep have been found to contain protein particles that cause scrapie, a sickness similar to mad cow disease. This suggests that the suspect proteins, called prions, may also be present in the milk of infected animals. If prions exist in the milk of cows infected with both an inflammatory illness and bovine spongiform encephalopathy (BSE), this raises concerns for human health. Consumption of prion-contaminated meat from cows with BSE is believed to cause the fatal variant Creutzfeldt-Jakob disease (vCJD) in people; so might contaminated milk. Prions are mainly found in the brain, spinal cord and immune system. Until recently, other body parts were thought to be relatively safe. But in a series of studies, Adriano Aguzzi and his group has shown that prions can be present in other organs as well, provided that these organs are inflamed. Earlier in 2005, his group found prions in inflamed pancreases, livers and kidneys. A study in Oct 2005 showed that the urine produced by inflamed kidneys in mice also contains prions. All this has helped to solve the mystery of how wild elk and deer, which are vegetarian, might manage to contract prion diseases from each other. And it prompted Aguzzi to look at mammary glands to see if they could carry prions too. The researchers went to Sardinia and analysed 261 sheep that were genetically susceptible to scrapie. Of those, 7 had scrapie, and 4 also had an infection of their mammary glands. All these 4 had prions in their mammary glands; the others did not. The study appears in Nature Medicine [Ligios C., et al. Nature Medicine, 11. 1137 - 1138 (2005)]. Aguzzi says that if this prion-virus combination is common, it may be a clue to how to fight the transmission of scrapie. http://jvi.asm.org/cgi/content/abstract/79/21/13794?maxtoshow=3D&HITS=3D10&=hits (Promed 11/8/05)

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3. Notifications
Fifth International Conference on Emerging Infectious Diseases
CDC, the American Society for Microbiology, the Council of State and Territorial Epidemiologists, the Association of Public Health Laboratories, and WHO will cosponsor the Fifth International Conference on Emerging Infectious Diseases, 19-22 Mar 2006 in Atlanta, Georgia, USA. The conference will explore current research, surveillance, and prevention and control programs addressing all aspects of emerging infectious diseases. The conference will include general and plenary sessions, symposia, panels of speakers, oral and poster presentations, and exhibits. The deadline for submitting abstracts for presentations is 2 Dec 2005. The deadline for late-breaker abstracts is February 1, 2006. Information regarding abstract submission: http://www.iceid.org/abstractsubmission.htm; regarding registration: http://www.iceid.org. For more information, e-mail meetinginfo@asmusa.org or thj0@cdc.gov. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5444a7.htm (MMWR November 11, 2005 / 54(44);1135)

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4. APEC EINet activities
APEC e-Health seminar; Pandemic influenza videoconference
EINet presented an update of their work and next steps at the e-Health Seminar in Seoul, Korea, 14 Nov 2005, part of the APEC meetings in Korea. EINet is preparing for a major video conference on pandemic influenza preparedness 19 Jan 2006. The goal of this “virtual symposium” is to promote regional information sharing and collaboration to enhance biopreparedness against pandemic influenza. In order to improve preparedness regionally, it is vital to understand how each economy is undertaking preparedness and response planning. South Korea has generously offered EINet their video of their preparedness exercise drill. The video can be found in our “About EINet” section, under Library: http://depts.washington.edu/einet/about.html?a=about&sub=docs.

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5. To Receive EINet Newsbriefs
APEC EINet email list
The APEC EINet email list was established to enhance collaboration among health, commerce, and policy professionals concerned with emerging infections in APEC member economies. Subscribers are encouraged to share their material with colleagues in the Asia-Pacific Rim. To subscribe, go to: http://depts.washington.edu/einet/?a=subscribe or contact apecein@u.washington.edu. Further information about APEC EINet is available at http://depts.washington.edu/einet/.

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APEC EINet email list
The APEC EINet email list was established to enhance collaboration among health, commerce, and policy professionals concerned with emerging infections in APEC member economies. Subscribers are encouraged to share their material with colleagues in the Asia-Pacific Rim. To subscribe, go to: http://depts.washington.edu/einet/?a=subscribe or contact apecein@u.washington.edu. Further information about APEC EINet is available at http://depts.washington.edu/einet/.

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 apecein@u.washington.edu