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EINet Alert ~ Dec 09, 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:
- Romania (Tulcea): New suspect cases of avian influenza in birds
- Ukraine (Crimea): Birds culled after confirmation of H5 virus
- Ukraine (Crimea): State of Emergency to avian influenza endorsed
- Zimbabwe: Outbreak of avian influenza H5N2 in ostrich farms
- East Asia: Cumulative number of human cases of avian influenza A/(H5N1)
- Indonesia: Plans for an early avian influenza warning system
- Indonesia: Reports additional confirmed and suspected human cases of avian influenza
- Viet Nam (Cao Bang): Bird flu outbreaks in area near China
- Thailand: Additional human case of avian influenza confirmed
- Thailand: Discussion on human-to-human transmission of avian influenza
- China: Fifth human case of avian influenza confirmed
- Russia: Avian influenza quarantine lifted in provinces
- USA: States support HHS plan for flu preparedness summits
- USA: HHS hopes pandemic preparations will ease flu vaccine supply kinks
- USA: HHS urges business to plan for pandemic as economic impacts assessed
- USA (North Carolina): Low pathogenic avian influenza reported

1. Updates
- Influenza

2. Articles
- Adverse Events Reported Following Live, Cold-Adapted, Intranasal Influenza Vaccine
- Quantification of the effect of vaccination on transmission of avian influenza (H7N7) in chickens

3. Notifications
- FAO/WHO: No bird flu risk for consumers from properly cooked poultry and eggs


Global
Romania (Tulcea): New suspect cases of avian influenza in birds
Romania has discovered new suspect cases of avian flu in birds in 2 villages in the Danube delta, the area where the H5N1 strain of the virus was first detected, the Agriculture Ministry said 5 Dec 2005. All the outbreaks occurred in villages close to lakes where migratory birds often rest. Avian flu has been found in about a dozen villages in Romania since Oct 2005, including several places outside the delta. 3 outbreaks have been confirmed as the highly pathogenic H5N1 strain avian influenza. Samples from other outbreaks are being sent to Britain for testing. "A few samples from the villages Agighiol and Crisan from Tulcea County came out positive in the quick diagnosis test," the ministry said. "The actual virus hasn't been isolated yet." Agriculture Minister Gheorghe Flutur said the 2 villages had been quarantined and domestic birds would be culled. Also, samples from a virus detected in 4 outbreaks in Braila County outside the delta will be subject to further tests in Britain. However, officials said 4 Dec 2005 the birds had likely contracted the H5N1 strain. Disinfection checkpoints were installed on all roads leading out of Braila. Around 5000 birds in Ciocile, where bird flu was discovered 3 Dec 2005, have already been culled. Officials have told people to keep domestic birds isolated so they do not come into contact with wild birds. The Danube delta, near the Black Sea, is Europe's largest wetlands and lies on the migratory route of millions of wild birds towards warmer winter climes in North Africa. Romania has not reported any cases of bird flu in humans so far. (Promed 12/4/05, 12/5/05)

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Ukraine (Crimea): Birds culled after confirmation of H5 virus
More than 1600 domesticated birds have reportedly died due to avian influenza. Ukrainian troops were destroying domestic fowl in 5 villages near Lake Sivash in Crimea, a major stopping point on migratory flight routes, after experts detected a bird flu strain identified so far as H5. Reportedly, the strain was unlikely to harm humans, but samples have been sent to Britain and Italy for further tests. Yushchenko ordered the imposition of 3-km exclusion zones around the villages, patrolled by troops, while the birds were incinerated and dumped in hastily dug pits. Further 10-km monitoring zones were imposed around affected areas. The sale of privately-raised poultry was banned in Crimea, tough checks were ordered on farms and restrictions placed on the movement of livestock. Residents received cash compensation for handing over birds. Doctors were vaccinating villagers against seasonal flu. All hunting of birds has been halted, and residents have been told to keep their stocks indoors to prevent contact with wild birds. Russia banned poultry imports from Ukraine 5 Dec 2005. The European Union said it was likely to impose a temporary ban on feather imports, its only poultry-related import from Ukraine.

In an alert message to the OIE on 5 Dec 2005, the Ukrainian authorities reported the confirmation of H5 infection in chickens and geese in 5 villages, situated in 3 separate districts (Dzhankoyskiy, Nizhnegorskiy and Sovetskiy districts) within the Autonomous Republic of Crimea. According to the message, the outbreaks started 25 Nov 2005 and were confirmed 2 Dec 2005. The Crimean peninsula and Azov Sea are situated on a main flyway of migratory birds on their route to the Balkans and the Near East. The urgent need for intensification of the epidemiological surveillance in wild birds was among the recommendations of the global avian influenza meeting, 8-10 Nov 2005. (Promed 12/2/05, 12/4/05, 12/5/05)

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Ukraine (Crimea): State of Emergency to avian influenza endorsed
Ukraine's parliament endorsed 6 Dec 2005 President Viktor Yushchenko's decision to declare a state of emergency to combat a bird flu outbreak, despite some lawmakers' claims that the move was excessive. Yushchenko put 3 regions in the Crimean peninsula under an indefinite state of emergency 3 Dec 2005, after the country recorded its first case of H5 bird flu. "Today it is better to do much more than necessary than tomorrow to have this problem throughout the whole of Ukrainian territory," Emergency Situations Minister Viktor Baloga said. It was the first time since the 1991 Soviet collapse that a state of emergency was enacted in Ukraine, Baloga said. Baloga defended the government's response as "justified," even as lawmakers grumbled that when bird flu appeared in neighboring Russia, a state of emergency was not declared. They also complained that Yushchenko did not specify when the emergency state would end. Mykhailo Pozhivanov, a lawmaker in Yushchenko's party, warned the measure could hurt Ukraine's image and scare away tourists from the Black Sea resort area.

On 6 Dec 2005, Petro Verbytsky, the Head Veterinary Surgeon of Ukraine, announced his resignation. The bird flu outbreak in Ukraine was reportedly provoked by a lack of preventive measures. Reportedly, the first cases of bird deaths were registered 2 months ago, but the government and the local authorities did not respond. Yushchenko reportedly said, "What happened in these villages is clearly a professional error of the veterinary service, and it must accept responsibility." (Promed 12/5/05, 12/7/05)

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Zimbabwe: Outbreak of avian influenza H5N2 in ostrich farms
Zimbabwe has imposed a quarantine on ostrich farms after detecting an outbreak of the H5N2 strain of avian flu, which can be lethal to birds but poses little risk to humans, a state newspaper reported. "Until the full extent of the disease can be established by completion of a national survey, all ostrich farms in the country have been placed under quarantine," Dr Stuart Hargreaves, the principal director for Veterinary Services, was reported as saying. The virus had been detected on 2 ostrich farms in Matabeleland North in the country's west from samples that had been sent to South Africa. A source at South Africa's Onderstepoort Veterinary Institute, where most testing of this nature is done in the country, could not confirm that it had received samples from Zimbabwe.

H5N2 is not as virulent as the H5N1 strain. According to the reports by the WHO, the OIE, and the South African Institute for Communicable Diseases, the H5N2-virus poses almost no risk to humans, who have no receptors for the virus in their respiratory tract. South Africa in 2004 had an outbreak of H5N2 among ostriches that led to around 26 000 of the birds being culled. It declared itself bird flu-free Sep 2005, and the EU in Nov 2005 lifted a ban on the import of South African ostriches and their meat. H5N1 has not yet been detected in Africa, but experts say uncovering it in the region's rural areas will be difficult because of poor surveillance and already high mortality rates among the continent's backyard chickens.

OIE avian influenza report
Information received 30 Nov 2005 from Dr Stuart K. Hargreaves, Director of Veterinary Services, Ministry of Agriculture, Harare: Report date: 28 Nov 2005. Identification of agent: avian influenza virus serotype H5. First administrative division (Province): Matebeleland North. Description of affected population: slaughter ostriches. Origin of infection: unknown or inconclusive. Control measures undertaken: quarantine; movement control inside the country; screening. No treatment of affected animals; vaccination prohibited. Highly pathogenic avian influenza has never been reported in Zimbabwe. (Promed 12/3/05, 12/8/05)

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Asia
East Asia: Cumulative number of human cases of avian influenza A/(H5N1)
Cumulative number of confirmed human cases of avian influenza A/(H5N1), 16 Dec 2004 to present:
Economy / Cases (Deaths)
Indonesia / 13 (8)
Cambodia / 4 (4)
Thailand / 5 (2)
Viet Nam / 61 (19)
China / 5 (2)
Total / 88 (35)

Total number of confirmed human cases of avian influenza A/(H5N1), 26 Dec 2003 to present: 137 (70)
(WHO 12/9/05 http://www.who.int/csr/disease/avian_influenza/country/en/index.html )

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Indonesia: Plans for an early avian influenza warning system
Indonesia is preparing an early bird flu warning system that will reach even the most remote areas to speed up reporting of any outbreaks, but U.N.’s FAO said the scheme needs more than goodwill. The "village preparedness policy" involves local governments setting up health posts in all villages, where personnel including doctors would be alert to flu cases in birds and humans, particularly in infected areas. "It is like an early warning system to achieve integrated communication in order to speed up action," said Syamsul Bahri, director of animal health at the agriculture ministry. Indonesia, with 220 million people, has many millions of chickens and ducks, the majority in the backyards of rural or urban homes. Such a close relationship between people and livestock has helped spread the disease in humans. The virus is endemic in poultry in Indonesia and has now been reported in 2/3 of the nation's 33 provinces. Health officials say better surveillance is crucial to stop the virus infecting any more people.

But putting in place an extensive, test-responding, monitoring system has been a huge challenge for the cash-strapped government as well as U.N. agencies, which have been calling for more foreign aid. The FAO welcomed the plan but said it required a national strategy and called on local officials not to cover up bird flu outbreaks. Peter Roeder, an animal health officer heading an emergency team from the FAO, said it was important that district leaders be aware of their responsibility and obligations and used their resources to make sure they [were] part of the reporting system. The FAO says it has launched its own grass-roots scheme covering Java island since Nov 2005. "[They are] very similar activities, and I hope we could build that into one unified system. I'm sure we can, but we haven't discussed this before with the minister," said Roeder referring to Agriculture Minister Anton Apriyantono. Indonesia, a country experiencing human cases, has not reported cases in avians to the OIE since 27 Jun 2005. (Promed 12/2/05)

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Indonesia: Reports additional confirmed and suspected human cases of avian influenza
The Ministry of Health has confirmed a further case of human infection with the H5N1 avian influenza virus. The case occurred in a 25-year-old woman from Tangerang (west of Jakarta). She developed symptoms of fever and stomach discomfort 17 Nov 2005, followed by cough and breathing difficulty. She was admitted to hospital 23 Nov 2005 and died 25 Nov 2005. The field investigation found a history of exposure to sick poultry around her house. Testing of poultry and environmental samples has been undertaken by the Ministry of Agriculture. Close contacts of the woman are being monitored.

Also, an 8-month-old baby is the latest patient to test positive for avian influenza in Indonesia. Reportedly, doctors believe the baby may have caught the disease from an infected pigeon. A spokesman at the Sulianti Soroso hospital says preliminary tests, yet to be confirmed by the WHO lab, show that the child is suffering from the H5N1 strain. The infant was reportedly put into an isolation ward at the designated avian influenza centre 4 Dec 2005, 5 days after contracting a high fever at his home in North Jakarta. 6 other patients are undergoing tests at the hospital. (Promed 12/6/05)

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Viet Nam (Cao Bang): Bird flu outbreaks in area near China
Viet Nam said 5 Dec 2005 that 4 bird flu outbreaks have killed more than 900 ducks and chickens in a province on the border with China. Health workers slaughtered another 3717 birds in Cao Bang province, after the outbreaks were reported in 4 communes 2 Dec 2005, the Agriculture Ministry's Animal Health Department said. "The test results showed the birds were positive with the H5 virus," it said. The poultry infections in Cao Bang, 270 km north of Hanoi, followed 6 outbreaks last week in Viet Nam's north. Bird flu has killed or resulted in the slaughter of 2.39 million poultry since the virus returned in early Oct 2005 and has now spread to 17 of Viet Nam's 64 provinces, most in the north, as winter arrives. (Promed 12/5/05)

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Thailand: Additional human case of avian influenza confirmed
The Ministry of Public Health has confirmed a further case of human infection with the H5N1 avian influenza virus. The case occurred in a 5-year-old boy, who developed symptoms 25 Nov 2005, was hospitalized 5 Dec 2005, and died 7 Dec 2005. The child resided in the central province of Nakhonnayok. A thorough investigation of this case is currently under way. Early results suggest that the child may have acquired his infection from dead chickens in the neighbourhood. His family members and neighbours have been placed under medical observation. All remain healthy to date. The child is the fifth laboratory-confirmed case in Thailand this year and the second death. Since Jan 2004, Thailand has reported 22 cases, of which 14 were fatal. (WHO 12/9/05)

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Thailand: Discussion on human-to-human transmission of avian influenza
The 2 recent confirmed cases of human bird flu in Thailand might be [the result of] human-to-human transmission, a senior health official has said. Dr Charoen Chuchottaworn, an avian influenza expert at the Public Health Ministry's Department of Medical Services, said doctors concluded after reviewing the history of the past 2 cases that both victims presented very mild symptoms of avian influenza and neither had any physical contact with birds. Reportedly, one of the victims was a boy in Bangkok and the other was an 18-year-old man from Nonthaburi province. This left doctors no clues as to where the patients became infected with the H5N1 virus and showed that avian influenza had moved from causing severe human infection to milder cases. Dr Kamnuan Ungchusak, Director of the Epidemiology Bureau, challenged Charoen's assertion about human-to-human transmissions. He said that while neither of the patients had direct contact with chickens, they lived in an environment where the virus was prevalent. "Chickens were dying near their homes and chicken droppings were everywhere around their neighborhood," he said. Dr Charoen said the milder the symptoms, the harder it is for doctors to diagnose infection. This means that a lot more advanced laboratory are needed to confirm cases and decide if patients should be treated with Tamiflu. At present, Thailand has about one million capsules for 100 000 treatments of Tamiflu, but it is estimated that about 120 million capsules of the drug will be needed.

Only severe cases of human bird flu have previously been detected in Thailand simply because patients went to hospital for treatment. But doctors believe that there have been many cases with mild symptoms of the disease. Signs of possible human-to-human transmission were closely observed in Vietnam, where 10 clusters of probable human transmissions were detected in which the victims had no contact with infected poultry, Charoen said. Thailand and Indonesia had one official cluster, he said, but the Indonesian cluster showed clear-cut evidence because a child contracted H5N1 without going to an infected area, as her father had. From an analysis of a cluster of 3 cases in the same family in 2004, it was concluded previously that person-to-person transmission may have occurred in Thailand at an earlier phase of the outbreak. 2 family members appeared to have contracted infection from a critically ill index patient, but onward transmission was not observed.

The situation emphasizes the need for comprehensive serological surveys of the general population in East Asian countries. (Promed 12/2/05)

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China: Fifth human case of avian influenza confirmed
The Ministry of Health in China has confirmed a further case of human infection with the H5N1 avian influenza virus. The case is a 10-year-old girl from Ziyuan County, Guangxi Zhuang Autonomous Region. She developed symptoms of fever and cough 23 Nov 2005, followed by pneumonia. She remains in the hospital, where she is receiving care. Local health authorities have launched investigations to determine the source of exposure and search for further cases in the patient's village of residence and surrounding areas. To date, monitoring of health status has revealed no additional cases of influenza-like illness. The Chinese Ministry of Health is supporting this investigation with an expert team. Experts are making further investigation into the source of the avian influenza virus, since no avian influenza cases had been reported in the county before. This is the fourth human case reported in China. Of these, 2 were fatal. The 4 confirmed cases of human influenza appear to be sporadic cases unconnected to each other and located in 3 separate provinces.

The Ministry of Health in China has confirmed a further case of human infection with the H5N1 avian influenza virus. The case is a 31-year-old female farmer from the Heishan county, Liaoning province. She developed symptoms 30 Oct 2005 and subsequently underwent extensive hospital care for severe pneumonia and acute respiratory distress. She recovered and was discharged from hospital 29 Nov 2005. Initial tests on this case produced negative results for infection with the H5 virus subtype. Diagnostic confirmation was made following antibody testing using a microneutralization test. Using this test, a positive diagnosis is made when antibody levels in a blood sample taken late in illness are at least four times higher than those found in a sample taken early in illness. Diagnostic confirmation using antibody tests, though reliable, is thus slower than that achieved using direct tests for virus RNA.

The "China Daily" reported that there have been at least 30 avian outbreaks of bird flu in 11 provinces and regions so far in 2005. Beginning in late October, Chinese authorities have reported several outbreaks of highly pathogenic H5N1 avian influenza in poultry in Liaoning Province. Investigation of this case has linked the woman’s infection to direct exposure to diseased poultry. Agricultural authorities have detected the H5N1 virus in samples taken from poultry in the province. As a precaution, local authorities placed contacts of the woman under medical observation pending definitive laboratory results. No signs of influenza-like illness were detected, and all contacts have now been released from observation. This is China’s fifth laboratory-confirmed case. Of these cases, two were fatal. The cases have been reported from Anhui, Hunan, Guangxi, and Liaoning provinces. OIE avian influenza report
Information received 25, 28 and 30 Nov 2005 from Mr. Jia Youling, Director General, Veterinary Bureau, Ministry of Agriculture, Beijing: Precise identification of agent: highly pathogenic avian influenza virus serotype H5N1. Provinces affected: Hunan, Inner Mongolia autonomous region, Xinjiang autonomous region, and Xinjiang autonomous region. Description of affected population in the new outbreaks: chickens. Source of new outbreaks: unknown or inconclusive. Control measures undertaken: stamping out applied to 189 237 birds around the outbreaks; quarantine; movement control inside the country; screening; zoning; vaccination; disinfection of infected premises/establishments; dipping/spraying. (Promed 12/3/05, 12/6/05, 12/7/05, 12/8/05; WHO 12/9/05)

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Russia: Avian influenza quarantine lifted in provinces
The quarantine imposed in relation to bird flu will be lifted in the last Russian communities 7 Dec 2005. "The quarantine period is expiring in all communities where the disease was registered in the public sector and homesteads. The last quarantine will be lifted on Wednesday [7 Dec 2005]," said Sergei Dankvert, head of the Federal Veterinary and Phytosanitary Control Service (Rosselkhoznadzor). Dankvert said monitoring and preventive efforts will continue, because bird flu remains in wildlife. Dankvert said that initial sampling did not confirm bird flu in Kalmykia. "In addition, Rosselkhoznadzor missions have inspected the entire coastal zone of the Volga. Birds have stopped dying," he said. Since the beginning of the epidemic, bird flu has been confirmed in over 60 communities in 8 constituent territories of Russia. In over 90, the bird flock was under suspicion. Reportedly, migrating birds, mainly from Southeast Asia, spread the disease. The Russian Poultry Union has estimated the related damage at over 100 million rubles [approximately USD 3.5 million]. (Promed 12/7/05)

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Americas
USA: States support HHS plan for flu preparedness summits
State and local health officials from around the nation voiced support for a federal government plan to hold a "summit" meeting on pandemic influenza preparedness in every state over the next few months. Health and Human Services Secretary Michael Leavitt described the plan for a "50-state summit" as part of his quest to achieve an unprecedented level of public health preparedness for the pandemic threat posed by the H5N1 avian flu virus. State and local health officials generally expressed support for the summit meetings and preparedness efforts, though they had some reservations about costs and about what will happen if the pandemic doesn't materialize. They spoke of "fatigue" from having to prepare for a succession of public health threats in recent years and said the smallpox vaccination program in 2003 damaged their credibility.

Leavitt said two things convince him that pandemic preparations are essential. One is that history shows that "ultimately this is going to happen." Second, a pandemic differs fundamentally from other disasters in that it happens everywhere at the same time. He said that states should follow up on their summit meetings by regularly assessing the progress of preparations. Leavitt said the meetings are part of his strategy to drive pandemic planning "deep" into state and local governments, business, and other sectors of society. Heads of state now understand the significance of the pandemic threat, but local politicians, business leaders, and school officials generally don't, he said. "We're looking to create a rallying event to help you engage, inform, and motivate people who are critical to your capacity to implement a local strategy," he explained. HHS officials envision the meetings as lasting about 4 to 6 hours and involving a simple tabletop exercise that could be customized to fit local conditions, Leavitt said.

HHS has a goal of obtaining 81 million courses of antiviral treatment, of which 6 million are to be reserved for emergency use to stop a budding pandemic. Leavitt explained that under the plan, HHS will pay for 50 million courses to be allocated to the states. The remaining 25 million treatment courses would also be available to the states, but the federal government would pay only 25% of the cost, with the states bearing the rest. Even if Congress "didn't appropriate a dime" for pandemic preparedness, "It would still be our constitutional and moral responsibility to do everything that is possible for us to be prepared," Leavitt said. He added that the federal plan to pay for 50 million doses fulfills the government's obligation to ensure that everyone has access to antivirals. (CIDRAP 12/5/05 http://www.cidrap.umn.edu/ )

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USA: HHS hopes pandemic preparations will ease flu vaccine supply kinks
At a Washington, D.C., meeting, state health officials expressed frustration over problems with supplies of seasonal flu vaccine, while federal officials promised that the government's pandemic influenza preparedness plan will help clear up those problems. The Bush administration's pandemic plan calls for reinvigorating the nation's depleted vaccine industry so that it can produce enough flu vaccine for all Americans within 6 months after the start of a pandemic. That would also help eliminate the annual flu vaccine supply problems that have frustrated the public and health agencies the past several years, the administration asserts. Health and Human Services Secretary Michael Leavitt said, "The president's plan calls for nothing short of revitalizing an entire industry. We must be able to create as much as 300 million courses of vaccine in a relatively short period. In a pandemic, vaccine must be produced here, not in another country, because it'll be hard to get it out of another country."

President Bush had proposed spending $2.8 billion to improve cell-culture technology for flu vaccine production. The administration also wants to expand existing egg-based vaccine production and develop adjuvant, or dose-sparing, technology. To clear the way, the administration wants Congress to pass laws protecting vaccine makers from lawsuits over vaccine-related injuries. But health officials also said that expanding US production capacity depends on having a dependable market for the vaccine, the demand for which has been unpredictable. "We've got to build the demand for the annual flu vaccine," said Leavitt. "So the annual flu vaccine is a very important part of the strategy to have pandemic preparedness." CDC Director Julie Gerberding said that having a "reliable large supply" of annual vaccine will help iron out kinks in distribution, but a steady demand is necessary to drive production.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said the government will have about 6.5 million doses of the experimental "prepandemic" vaccine for the H5N1 avian flu virus by January. Leavitt raised the question of what will happen if no flu pandemic erupts anytime soon. "My guess is that people will in fact say, 'They overreacted, they cried wolf,'" he said. "The truth is that a pandemic influenza of some sort will ultimately be our lot to handle. But what I believe to be an opportunity is that we can become the first society in history to do something about it." (CIDRAP 12/6/05 http://www.cidrap.umn.edu/ )

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USA: HHS urges business to plan for pandemic as economic impacts assessed
Large businesses should examine their sick-leave policies and figure out ways to limit face-to-face contact, among many other steps to prepare for an influenza pandemic, according to a planning checklist released by federal health agencies. The list provided by the US Department of Health and Human Services (HHS) also calls on businesses to try to predict and allow for employee absenteeism and to set policies on sick leave and restriction of travel to affected areas. "In the event of a pandemic, planning by business leaders will be critical to protecting employees' health, limiting the negative economic impact and ensuring the continued delivery of essential services like food, medicine and power," HHS Secretary Michael Leavitt said. Earlier, HHS officials said they estimate that at the peak of a pandemic, up to 40% of people might stay home from work or school. The HHS pandemic flu plan says that a severe pandemic, similar to that of 1918, could sicken up to 90 million people, or about 30% of the population. In a recent survey, 70% of 179 companies said they would need help in determining how to prepare for a pandemic, and almost 40% said there wasn't much a company could do to prepare.

HHS's "Business Pandemic Influenza Planning Checklist" is intended for large businesses, but it doesn't spell out how large. It was prepared by CDC. The list offers 35 suggestions grouped in 6 categories. Sample suggestions from a few of the categories:

- Plan for the impact of a pandemic on your business: Identify a pandemic coordinator and/or team with defined roles and responsibilities for preparedness and response planning; Identify essential employees and other critical inputs required to maintain business operations; Determine the potential impact of a pandemic on company financial results under multiple possible scenarios; Establish an emergency communications plan.
- Plan for the impact of a pandemic on your employees and customers: Forecast and allow for employee absences during a pandemic due to factors such as personal illness, family member illness, and quarantines; Implement guidelines to modify the frequency and type of face-to-face contact among employees and between employees and customers; Encourage and track annual influenza vaccination for employees.
- Establish policies to be implemented during a pandemic, including: Compensation and sick-leave absences unique to a pandemic, including policies on when a previously ill person can return to work; Flexible worksite (eg, telecommuting) and flexible work hours (eg, staggered shifts); Restricting travel to affected geographic areas, evacuating employees working in or near an affected area, and guidance for employees returning from affected areas.
- Coordinate with external organizations and your community: Collaborate with federal, state, and local public health agencies and/or emergency responders to participate in their planning processes; Share best practices with other businesses.

The Congressional Budget Office (CBO) estimated that a severe pandemic like that of 1918 would cut gross domestic product (GDP) in the ensuing year by about 5%. By comparison, the typical business recession in the US since World War II cut GDP by 4.7%, the report says. The estimate is based on a pandemic scenario involving 90 million illness cases and 2 million deaths. In a milder pandemic, like that of 1957 or 1968, GDP would be reduced by about 1.5%, according to the CBO. This second scenario assumes 75 million cases with about 100,000 deaths.

The CBO report was criticized by Dr. Michael Osterholm, a leading pandemic preparedness proponent and director of CIDRAP. He called the report "overly simplistic" because the CBO assessed only lost work days and reduced sales due to restricted social interaction. "The inability to transport products would result in a much greater impact" than the CBO estimated. He predicted that a severe pandemic would bring "an abrupt halt" to global, regional, and national economies. "Foreign trade and travel will be reduced or even ended in an attempt to stop the virus from entering new countries—even though such efforts will probably fail given the infectiousness of the virus and the volume of illegal crossings at most borders," he said. He predicted that curtailment of international trade will trigger shortages of critical products, such as those needed to maintain water, power, and communication systems and meet health needs unrelated to flu prevention and treatment. As an example of an area demanding "critical product continuity" planning, Osterholm said the US pharmaceutical industry obtains more than 80% of its raw materials from foreign sources. He added that the common business practice of maintaining very limited inventories of raw materials and products will likely exacerbate the problems. (CIDRAP 12/9/05 http://www.cidrap.umn.edu/ )

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USA (North Carolina): Low pathogenic avian influenza reported
A low pathogenic strain of avian influenza has been found on a single turkey farm in Sampson County, North Carolina. Reportedly, the strain was H3N3, which presents no threat to humans, and was confirmed by the National Veterinary Services Laboratory 28 Nov 2005. No birds were reported as ill. Low pathogenic avian influenza is spread through direct contact of infected birds and healthy birds. The virus may also be transmitted by contact with contaminated materials and equipment. Infected birds excrete viral particles in the feces as well as nasal, oral, and ophthalmic secretions. Additional information on low pathogenic avian influenza is available from the Animal, Plant Health Inspection Service of the USDA: http://www.aphis.usda.gov/lpa/pubs/fsheet_faq_notice/fs_ahlpai.html (Promed 12/2/05)

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1. Updates
Influenza
Seasonal influenza activity for the Asia Pacific and APEC Economies
Influenza activity remained low during weeks 46-47.

Canada. Localized activity of influenza B virus was reported from Alberta during week 46. Activity remained low in the rest of the country.

Others. During weeks 46–47, low influenza activity was detected in Australia (B), Hong Kong (H1, H3, A and B), Japan (H1 and H3), Mexico (H1, H3 and A), Russia (H1, H3 and B), and USA (H3, A and B). Philippines reported no influenza activity. (WHO 12/8/05 http://www.who.int/csr/disease/influenza/update/en/ )

USA
During week 47 (Nov 20 – Nov 26, 2005), influenza activity occurred at a low level. 22 (1.8%) 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. 23 states, New York City, the District of Columbia, and Puerto Rico reported sporadic influenza activity, and 27 states reported no influenza activity. (CDC 12/2/05 http://www.cdc.gov/flu/weekly/ )

Avian/Pandemic influenza updates
- WHO “Influenza pandemic threat: current situation”: http://www.who.int/csr/disease/avian_influenza/pandemic/en/index.html. Comprehensive information on the avian influenza 7-9 Nov 2005 meeting are available at: http://www.who.int/mediacentre/events/2005/avian_influenza/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. WPRO website on avian influenza: http://www.wpro.who.int/health_topics/avian_influenza/overview.htm
- Latest FAO updates on avian influenza: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Includes maps documenting the latest avian flu outbreaks and an interactive map displaying the timeline of the outbreaks. Documents from the avian influenza meeting (7-9 Nov 2005) are available.
- OIE updates on avian influenza: http://www.oie.int/eng/en_index.htm. Includes documents from the 7-9 Nov 2005 meeting (including editorial by the OIE Director General) and the 15-18 Nov 2005 Conference of the OIE Regional Commission for Asia, the Far East and Oceania.
- CDC website on pandemic influenza: http://www.cdc.gov/flu/pandemic.htm (includes the new Business Pandemic Plan Checklist and the State and Local Pandemic Influenza Planning Checklist); for avian influenza (available in Chinese, Korea, Vietnamese, and Japanese): http://www.cdc.gov/flu/avian/ .
- The US government’s official Web site for pandemic flu: http://www.pandemicflu.gov/.
- Influenza information from the US Food and Drug Administration: http://www.fda.gov/oc/opacom/hottopics/flu.html. Q & A on Using PPE During Influenza Outbreaks, Including Bird Flu: http://www.fda.gov/cdrh/emergency/flu_qa.html.
- PAHO’s latest updates on avian influenza: http://www.paho.org/ Includes press release on the Summit of the Americas.
- 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
(WHO; FAO, OIE; CDC; US FDA; CIDRAP; PAHO; APHA; AVMA)

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2. Articles
Adverse Events Reported Following Live, Cold-Adapted, Intranasal Influenza Vaccine
Hector S. Izurieta, et al. JAMA. 2005;294:2720-2725.
Abstract: “Context: In June 2003, the US Food and Drug Administration licensed a trivalent live, attenuated influenza vaccine (LAIV-T) for intranasal administration to healthy persons 5 to 49 years of age. Although prelicensure testing involved 20 228 vaccinees, clinical trials were not of sufficient size to detect rare adverse events reliably. Objective: To identify adverse events reported following LAIV-T administration after licensure. Design, Setting, and Participants: All adverse events reported to the US Vaccine Adverse Event Reporting System (VAERS) during the 2003-2004 and the 2004-2005 influenza seasons. Main Outcome Measures: Numbers and proportions of reported adverse events and reporting rates of adverse events per 100 000 vaccinees. Results: Approximately 2 500 000 persons received LAIV-T during the first 2 postlicensure seasons. As of August 16, 2005, VAERS received 460 adverse event reports for vaccinations received from August 2003 through July 2005. No fatalities were reported. There were 7 reports of possible anaphylaxis, 2 reports of Guillain-Barré syndrome, 1 report of Bell palsy, and 8 reports of asthma exacerbation among individuals with a prior asthma history. Events in individuals for whom the vaccine was not indicated accounted for 73 reports (16%). Conclusions: Reports to VAERS in the first 2 seasons of LAIV-T use did not identify any unexpected serious risks with this vaccine when used according to approved indications. Like many vaccines and other medical products, LAIV-T may rarely cause anaphylaxis. Secondary transmission of the vaccine virus merits further investigation. Reports of asthma exacerbations in vaccinees with prior asthma history highlight the risks of vaccine use inconsistent with approved labeling.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Quantification of the effect of vaccination on transmission of avian influenza (H7N7) in chickens
J. A. van der Goot, G. Koch, M. C. M. de Jong, and M. van Boven
Proc. Natl. Acad. Sci. USA, 10.1073/pnas.0505098102
Abstract: “Recent outbreaks of highly pathogenic avian influenza (HPAI) viruses in poultry and their threatening zoonotic consequences emphasize the need for effective control measures. Although vaccination of poultry against avian influenza provides a potentially attractive control measure, little is known about the effect of vaccination on epidemiologically relevant parameters, such as transmissibility and the infectious period. We used transmission experiments to study the effect of vaccination on the transmission characteristics of HPAI A/Chicken/Netherlands/03 H7N7 in chickens. In the experiments, a number of infected and uninfected chickens is housed together and the infection chain is monitored by virus isolation and serology. Analysis is based on a stochastic susceptible, latently infected, infectious, recovered (SEIR) epidemic model. We found that vaccination is able to reduce the transmission level to such an extent that a major outbreak is prevented, important variables being the type of vaccine (H7N1 or H7N3) and the moment of challenge after vaccination. Two weeks after vaccination, both vaccines completely block transmission. One week after vaccination, the H7N1 vaccine is better than the H7N3 vaccine at reducing the spread of the H7N7 virus. We discuss the implications of these findings for the use of vaccination programs in poultry and the value of transmission experiments in the process of choosing vaccine.”
(CIDRAP http://www.cidrap.umn.edu/ )

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3. Notifications
FAO/WHO: No bird flu risk for consumers from properly cooked poultry and eggs
Chicken and other poultry are safe to eat if cooked properly, according to a joint statement by FAO and the WHO issued to national food safety authorities. However, no birds from flocks with disease should enter the food chain. FAO/WHO made the statement to clarify food safety issues in relation to the current bird flu crisis. The statement has been issued through the International Food Safety Authorities Network (INFOSAN) and is available in 6 languages. In areas where there is no bird flu outbreak in poultry, there is no risk that consumers will be exposed to the virus via the handling or consumption of poultry and poultry products. Cooking of poultry at or above 70C throughout the product, so that absolutely no meat remains raw and red, is a safe measure to kill the H5N1 virus in areas with outbreaks in poultry. Eggs from areas with outbreaks in poultry should not be consumed raw or partially cooked. To date, there is no epidemiological evidence that people have become infected after eating eggs, egg products, or contaminated poultry meat that has been properly cooked.

In the process of killing and preparing a live bird for food, slaughtering poses the greatest risk of passing the virus from infected or diseased birds to humans. When a diseased bird is slaughtered, defeathered and eviscerated, virus from that bird can transfer to humans through direct contact. Infected poultry excrete virus in their secretions and faeces. Exposure might also occur when the virus is inhaled through dust and possibly through contact with surfaces contaminated with the virus. In areas where marketing of live birds is common, the practices of home slaughtering, defeathering, and eviscerating increase the exposure to potentially contaminated parts of a chicken. These practices therefore result in a significant risk of infection in areas with outbreaks in poultry. It is not always possible to differentiate infected and non-infected birds in outbreak areas. Some avian species, such as domestic ducks, may harbour the virus without displaying symptoms. Therefore, people need to be fully informed about preventive measures, including the use of protective equipment. The practice of slaughtering and eating of infected birds, whether diseased or already dead, must be stopped. These birds should also not be used for animal feed. (FAO 12/5/05 http://www.fao.org/newsroom/en/news/2005/1000172/index.html )

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