Vol. IX, No. 2 ~ EINet News Briefs ~ Jan 27, 2006

*****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: WHO updated factsheet on avian influenza
- Turkey: Update on human cases of avian influenza infection
- Near East: Regional avian influenza updates
- North Cyprus: Suspected avian cases of avian influenza
- Ukraine (Crimea): Sevastopol declared potential danger zone due to avian influenza
- Croatia: Official OIE update report on avian influenza
- Global: WHO calls for an immediate halt to provision of single-drug artemisinin malaria pills
- Eurasia: Cumulative number of human cases of avian influenza A/(H5N1)
- Indonesia: 2 additional fatal cases of avian influenza; additional suspected case
- China: Tenth confirmed human case of avian influenza
- North Korea, Japan: Group says North Korean infected with avian influenza
- China: New HIV data show growing AIDS epidemic
- New Zealand (Christchurch): Source of hepatitis A outbreak linked to childcare center
- Australia (New South Wales, South Australia): Increase in cases of Ross River virus
- Viet Nam (Ho Chi Minh): Nearly 260 children suffer from food poisoning
- Canada (Alberta): BSE Detected
- USA/Japan: Japan reimposes US beef ban
- USA/Taiwan: Taiwan reopens market to US beef
- USA: Limits on US distribution of Tamiflu lifted
- USA (Arizona, North Dakota): Human cases of Hantavirus pulmonary syndrome
- USA (Washington, Oregon): E. coli O157:H7 infections from unpasteurized milk
- USA: Recall of Vapotherm 2000i and 2000h respiratory gas humidifier

1. Updates
- Influenza
- Cholera, diarrhea & dysentery
- Dengue

2. Articles
- CDC EID Journal, Volume 12, Number 2-February 2006
- Orf virus infection in humans--New York, Illinois, California, and Tennessee, 2004--2005
- Surveillance for early detection of disease outbreaks at an outdoor mass gathering--Virginia, 2005
- Antivirals for influenza in healthy adults: systematic review
- Management of potential human cases of influenza A/H5N1: lessons from Belgium
- Large-Scale Sequence Analysis of Avian Influenza Isolates

3. Notifications
- Third International Conference on Current Research in Avian Zoonoses
- 2006 Annual conference on antimicrobial resistance, June 26--28, 2006

4. APEC EINet activities
- APEC EINet pandemic influenza videoconference

5. To Receive EINet Newsbriefs
- APEC EINet email list

Global: WHO updated factsheet on avian influenza
The updated WHO factsheet on avian influenza incorporates the most recent findings on the H5N1 avian influenza virus, which WHO says is causing by far the worst outbreak among both birds and people ever recorded. Bird droppings may be a significant source of its spread to both people and birds, WHO said. For example, the highly pathogenic H5N1 virus can survive in bird feces for at least 35 days at low temperature (4C). At 37C, H5N1 viruses have been shown to survive, in fecal samples, for 6 days. Poultry, especially those kept in small backyard flocks, are the main source of the virus. These birds usually roam freely as they scavenge for food and often mingle with wild birds or share water sources with them. Such situations create abundant opportunities for human exposure to the virus, especially when birds enter households or are brought into households during adverse weather, or when they share areas where children play or sleep, WHO states.

H5N1 has different qualities from seasonal flu. The incubation period for H5N1 avian influenza may be longer than that for normal seasonal influenza, which is around 2 to 3 days. Current data for H5N1 infection indicate an incubation period ranging from 2 to 8 days and possibly as long as 17 days. Initial symptoms include a high fever, usually with a temperature higher than 38C, and influenza-like symptoms. Diarrhea, vomiting, abdominal pain, chest pain, and bleeding from the nose and gums have also been reported as early symptoms in some patients. And with H5N1 infection, all patients have developed pneumonia, and usually very early on the illness, WHO states. On present evidence, difficulty in breathing develops around 5 days following the first symptoms. Respiratory distress, a hoarse voice, and a crackling sound when inhaling are commonly seen. There is bloody sputum. Another common feature is multiorgan dysfunction, notably involving the kidney and heart. WHO recommends using Tamiflu (oseltamivir), as soon as possible to treat bird flu. WHO stresses that H5N1 remains mostly a disease of birds, with tens of millions infected in 2 years. For unknown reasons, most cases have occurred in rural and periurban households where small flocks of poultry are kept. Very few cases have been detected in presumed high-risk groups, such as commercial poultry workers, workers at live poultry markets, cullers, veterinarians, and health staff caring for patients without adequate protective equipment. Also lacking is an explanation for the puzzling concentration of cases in previously healthy children and young adults.

The full factsheet as of 20 Jan 2006 is available at: http://www.who.int/csr/disease/avian_influenza/avianinfluenza_factsheetJan2006/en/index.html. Sections include: “The disease in birds: impact and control measures”, “A constantly mutating virus: 2 consequences”, “Human infection with avian influenza viruses: a timeline”, “Why H5N1 is of particular concern”, “Influenza pandemics: can they be averted”, “Clinical course and treatment of human cases of H5N1 avian influenza”. (Promed 1/21/06)


Turkey: Update on human cases of avian influenza infection
2 more children have been discharged from hospital after recovering from avian influenza in eastern Turkey doctors said, as they stressed that early treatment after infection was proving crucial for survival. A 9-year-old girl and her 3-year-old brother, 2 of 21 people who have been infected with avian influenza in Turkey, were discharged 22 Jan 2006 from the University Hospital in Van, their doctor, Ahmet Faik Oner, said. These siblings were cousins of a 16-year-old girl, 1 of 4 victims who have died of the disease in the country since 1 Jan 2006. 7 other carriers of H5N1 avian influenza virus remain under treatment in hospitals. Turkish officials say the outbreak in their country appears to be fading, with no new cases reported in nearly a week and infected people staging recoveries. In the Van hospital, where all 4 deaths occurred, physicians said they were hopeful of saving the remaining 2 patients there, including the 5-year-old brother of the deceased 16-year-old. Turkish doctors say the mortality rate they are observing (19%) is encouraging when compared with the 58% in eastern Asia. "We see that the sooner the patients are brought to hospital after infection, the more successful the treatment is," Oner said. "If we compare the 4 dead children to those who survived, we see that they came to the hospital 10 days on average after they began showing symptoms, while the others were hospitalized after 5 days on average," he said.

As of 25 Jan 2006, there is a continuing discrepancy between the number of confirmed human cases of H5N1 infection in Turkey cited by WHO and those reported by the Turkish authorities. According to WHO, the cumulative number of human cases of H5N1 virus infection in Turkey remains at 4 with 2 deaths, figures very different from the 21 cases with 4 deaths reported by the Turkish Ministry of Health. A map of the H5N1 situation in Turkey is available at http://disasters.jrc.it/AvianFlu/Turkey/. (Promed 1/23/06, 1/25/06)


Near East: Regional avian influenza updates
On 16 Jan 2006, the UN Food and Agriculture Organization (FAO) stated that "there are no reasons for not believing the avian influenza virus has not crossed the eastern limits of Turkey." Organization specialist Dr. Juan Lubroth confirmed the FAO statement that it has not been ruled out that the bird flu virus has penetrated into countries adjacent to Turkey -- Armenia, Iran, Syria -- Lubroth stated that “FAO has to get reliable and transparent information from countries neighboring Turkey, which will ensure [the] absence of avian influenza in those countries. Within [the] past few months, we [have] received reports [of a] high level of bird death[s] in countries neighboring with Turkey, owing to poisoning or other diseases. However, the diagnoses are to be confirmed by FAO laboratories and the World Organization for Animal Health," Lubroth said.

Syria has asked the UN to help it guard against bird flu and plans to tighten surveillance along its border with Turkey, Lubroth said 21 Jan 2006. Lubroth said FAO had received unconfirmed reports within the past week of poultry deaths in Syria. Syria has culled birds near its 483 km border with Turkey as a precaution, but said the birds had showed no sign of illness. Damascus, which has launched domestic awareness campaigns on bird flu and has prepared medical teams to monitor and deal with the eventuality that it spills over from Turkey, rarely asks foreign organizations for help. "They are going to increase their surveillance and maybe do some depopulation, some culling along the northern border with Turkey. That's what I have heard," he said. Beyond technical assistance from the FAO, Syria has also requested diagnostic technology, laboratory equipment and protective gear.

Cases of bird deaths are registered in a number of Armenian villages. Local authorities and high ranking officials assure the public that the dead birds were examined in labs and bird flu was not found. "We would like to closely cooperate with Armenian authorities [and] help them make sure the virus is absent," Lubroth remarked. FAO will send its specialists to Armenia, Georgia and Ukraine to check on whether their laboratories are able to provide accurate diagnostics, he said.

An Iranian animal health department official, Dr Kamyar Dahim, said 30 000 birds along a 10 km border and in Western Azerbaijan have been killed so far and their goal is to raise the number to 150 000 in 1 week. The Bird Flu Control committee has been receiving phone calls from villagers having fowls with the disease, and a significant drop in chicken and egg sales has been reported in Iran.

Noting that Azerbaijan has the shortest border with Turkey, the Deputy Chairman of the State Veterinary Service at the Azerbaijani Agriculture Ministry, Emin Shahbazov, stressed that 7 searches for bird flu have been held in the country so far, and no virus has been found: "The poultry farms and private farms are monitored now." Shahbazov added that US experts will arrive in Azerbaijan 23 Jan 2006 to study the bird flu situation in the country. According to him, WHO suggested that Azerbaijan would benefit from the assistance of Turkish experts to implement better precautions. Azerbaijan has accepted the offer.

Georgian and Russian scientists will cooperate in the fight against avian flu. The resolution was passed at a meeting between Vladimder Chipashvili, Health Care Minister of Georgia, and Oleg Kiselev, director of the Scientific-Research Flu Institute of the Russian Academy of Medical Sciences. "We are sure that Georgia will find a way out independently, but scientific cooperation is better," Kiselev declared.

WHO has installed a team in Van, Turkey, and a team of US experts arrived 21 Jan 2006 as part of a tour to Turkey's flu-stricken areas and 3 neighboring countries. "The cooperation among the ministries involved, and with international agencies on the ground here, and the 24-hour nature of the operations that allow rapid response are very important," Anne Derse, a State Department communications expert with the US team, said 22 Jan 2006. No cases of bird flu have been reported in the countries that the team will visit -- Azerbaijan, Armenia and Georgia -- but they all border the worst-hit regions of eastern Turkey. (Promed 1/21/06, 1/23/06)


North Cyprus: Suspected avian cases of avian influenza
Ferdi Sabit Soyer, the prime minister of the Turkish Republic of Northern Cyprus (TRNC) – a breakaway state recognized only by Turkey -- said 23 Jan 2006 that a routine veterinary inspection had revealed 2 suspected cases in a village near Famagusta. Samples from 2 birds were taken from close to Incircli, a village on the eastern part of the island. "There were 2 birds, 1 a turkey and 1 a chicken, and 2 suspicious deaths. Preliminary tests proved positive (for a form of bird flu)," said Turkish Cypriot health minister Esref Vaiz. "We have announced it to the public, and we are hiding nothing," he said. Poultry in the village was being slaughtered, and all traffic going into the community was being disinfected, a Turkish Cypriot official said. Samples have been sent to Turkey and Britain for analysis, and results are expected 26 Jan 2006. If the disease is confirmed, they would be the first bird flu cases in Cyprus. The internationally-recognized Greek Cypriot government in the south of the island said in early Jan 2006 that it was looking for cooperation from Turkey and the TRNC to prevent the spread of bird flu. Cyprus was partitioned in 1974; each side has separately taken identical measures to ward off avian influenza. The infected and suspected provinces in Turkey and Cyprus can be seen at: http://www.ecdc.eu.int/images/maps/turkey_poultry_17jan06.BMP. (Promed 1/23/06, 1/25/06)


Ukraine (Crimea): Sevastopol declared potential danger zone due to avian influenza
Sevastopol's State Emergency Anti-Epidemic Commission has decided to declare the Sevastopol area a potentially dangerous zone because of detection of bird flu in wild birds found in the area, said a spokeswoman for Sevastopol's City State Administration, Alla Shcherbakova. She said the decision was made after 5 dead birds were found in the city: 3 crows and a gull in 1 of the city's kindergartens and a jay in Kamyshovaya Bay. Laboratory tests have proven that all the birds died of bird flu. Nevertheless, Ms. Shcherbakova said that no bird flu cases were registered in the area among poultry. It is recommended that local inhabitants who own poultry keep it indoors to prevent contact with wild birds. Ukrainian officials have detected bird flu in 23 Crimean districts so far. Ukraine's last follow-up report, No. 6, was sent to the OIE 19 Jan 2006: http://oie.int/eng/info/hebdo/AIS_35.HTM#Sec12. (Promed 1/23/06, 1/25/06)


Croatia: Official OIE update report on avian influenza
Information received 19 Jan 2006 from Dr. Mate Brstilo, Director of the Veterinary Administration, Ministry of Agriculture and Forestry, Zagreb: Identification of agent: highly pathogenic avian influenza virus serotype H5N1. Date of first confirmation of the event: 21 Oct 2005. Date of start of the event: 19 Oct 2005. Clinical disease: yes. Nature of diagnosis: laboratory. During regular monitoring activities conducted at Ribnjak 1905 fish pond, 4 swans in a flock of around 265 swans were shot for diagnostic purposes; samples were taken and sent to the Poultry Center of the Croatian Veterinary Institute in Zagreb. Laboratory testing revealed that 2 samples were positive for avian influenza virus. All samples were found to be negative on virus isolation in chicken embryos. In the same location, 26 other birds (wild ducks) were shot for diagnostic purposes. Samples from these 26 birds were tested at the Poultry Center of the Croatian Veterinary Institute in Zagreb and were all found to be negative for avian influenza. Source of outbreak or origin of infection: seasonal migration of wild birds: swans. To view Croatia's OIE reports: http://oie.int/downld/AVIAN percent20INFLUENZA/A_AI-Asia.htm. (Promed 1/25/06)


Global: WHO calls for an immediate halt to provision of single-drug artemisinin malaria pills
WHO requested pharmaceutical companies to end the marketing and sale of “single-drug” artemisinin malaria medicines, in order to prevent malaria parasites from developing resistance to this drug. The use of single-drug artemisinin treatment (monotherapy) hastens development of resistance by weakening but not killing the parasite. When used correctly in combination with other anti-malarial drugs in Artemisinin Combination Therapies (ACTs), artemisinin is nearly 95% effective in curing malaria and the parasite is highly unlikely to become drug resistant. ACTs are currently the most effective medicine available to treat malaria. Dr LEE Jong-wook, WHO's Director-General, said, "We request pharmaceutical companies to immediately stop marketing single-drug artemisinin tablets and instead market artemisinin combination therapies only. The new treatment guidelines. . .provide countries with clear and evidence-based direction on the best treatment options for malaria." According to the new WHO guidelines, uncomplicated falciparum malaria must be treated with ACTs and not by artemisinin alone or any other monotherapy.

“So far, no treatment failures due to artemisinin drug resistance have been documented, but we are watching the situation very attentively,” said Dr Arata Kochi, the newly appointed director of WHO's malaria department. “We are concerned about decreased sensitivity to the drug in South-East Asia which is the region that has traditionally been the birthplace of anti-malarial drug resistance.” In Thailand, sulfadoxine-pyrimethanime (SP) was initially almost 100% effective in curing malaria when introduced in 1977, but within 5 years was curing only 10% of cases due to drug resistance. The once-popular chloroquine has lost its effectiveness in almost every part of the world. Resistance to atovaquone developed within 1 year of introduction in 1997. In order to contain the circulation and use of counterfeit antimalarial medicines, WHO plans to strengthen its collaboration with international and national health and regulatory authorities. It is estimated that up to 25% of medicines consumed in developing countries are counterfeit or sub-standard. Additionally, to anticipate and prevent the onset and spread of drug resistance in the long term, WHO urges the global malaria research community and the pharmaceutical industry to rapidly invest in the design of the next generation of antimalarial drugs. By creating ACTs with multiple-drug combinations and transmission blocking components, resistance can be prevented. “Our biggest concern right now is to treat patients with safe and effective medication and to avoid the emergence of drug resistance. If we lose ACTs, we’ll no longer have a cure for malaria,” said Dr Arata Kochi, “and it will probably be at least 10 years before a new one can be discovered.” (WHO 1/19/06 http://www.who.int/mediacentre/news/releases/2006/pr02/en/index.html )


Eurasia: Cumulative number of human cases of avian influenza A/(H5N1)
Cumulative number of confirmed human cases of avian influenza A/(H5N1), 2005:
Economy / Cases (Deaths)
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 16 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 94 (41)

Cumulative number of confirmed human cases of avian influenza A/(H5N1), 2006:
Economy / Cases (Deaths)
China / 2 (2)
Indonesia / 3 (3)
Turkey / 4 (2)
Total / 9 (7)

Total number of confirmed human cases of avian influenza A/(H5N1), 26 Dec 2003 to present: 152 (83)
(WHO 1/25/06 http://www.who.int/csr/disease/avian_influenza/country/en/index.html )


Indonesia: 2 additional fatal cases of avian influenza; additional suspected case
The Ministry of Health has confirmed an additional 2 cases of human infection with the H5N1 avian influenza virus. The first patient was a 13-year-old girl. She developed symptoms 6 Jan 2006, was hospitalized 12 Jan, and died 14 Jan. The second patient was her 4-year-old brother. He developed symptoms 8 Jan, was hospitalized 14 Jan, and died 17 Jan. Health ministry official Hariyadi Wibisono said the pair were residents of Indramayu in West Java -- site of the fifth cluster case to date in Indonesia. 2 other family members, a 14-year-old sister and the 43-year-old father, remain hospitalized with respiratory symptoms. The sister was hospitalized 14 Jan and the father 17 Jan. Samples from these cases are being tested to determine whether they were also infected with H5N1. Investigations conducted by the Ministry of Health and WHO found evidence of a large poultry outbreak in the family's neighbourhood. Chickens kept by the family began to die 3 days before the first patient developed symptoms. All family members had close contact with the diseased chickens and assisted in the removal of dead birds. Contacts have been traced, blood samples have been taken, and monitoring for signs of influenza-like illness continues. Authorities have begun culling operations in the area.

Also, an Indonesian chicken seller whom local tests showed had been infected with H5N1 avian influenza virus has died, a hospital official said 26 Jan 2006. The victim’s blood samples had been sent to a Hong Kong laboratory recognized by the WHO for confirmation. If confirmed, the case would take total known deaths in Indonesia from avian flu to 15. "The 22-year-old man died. . .26 Jan 2006. He was the vendor from a traditional market and the only positive case that we were treating today," said Ilham Patu, a spokesman of the Jakarta hospital designated to deal with bird flu patients. This latest death comes as WHO drew attention to the threat posed by Indonesia's traditional markets and urged that hygiene and sanitation standards be improved. WHO has called for preventive measures included limiting contact between humans and poultry in markets, as well as better access to water and improved waste management. Indonesia is also still awaiting official confirmation of local tests that showed a 39 year old man died of bird flu earlier this month. The highly pathogenic strain of bird flu has affected birds in 2/3 of the provinces in Indonesia. The country has millions of poultry, many in the yards of rural or urban homes, raising the risk of more humans becoming infected with the virus. (Promed 1/21/06, 1/23/06, 1/25/06, 1/26/06)


China: Tenth confirmed human case of avian influenza
The Ministry of Health has confirmed the country's tenth case of human infection with the H5N1 avian influenza virus. The case occurred in a 29-year-old woman from Chengdu City in Sichuan province. She developed fever 12 Jan 2006 and was hospitalized with symptoms of pneumonia. Authorities say her condition deteriorated rapidly, and she died 23 Jan. Information provided to WHO indicates that she was self-employed in a shop selling dry goods. No information on possible exposure to diseased birds as the source of her infection is presently available, but an investigation is under way. Close contacts have been placed under medical observation. This is the second human case reported this year in China, both from Sichuan. The 2 Sichuan cases occurred in different prefectures located around 150 km apart. A confirmed outbreak of H5N1 in poultry began in late Dec 2005 in another part of the province. No outbreaks have been confirmed in the areas where the 2 human cases resided. During 2005, Chinese agricultural authorities reported 32 outbreaks in poultry in 12 provinces, resulting in the culling of more than 24 million birds. The appearance of human cases in areas without reported poultry outbreaks is a cause for concern. WHO recommends that, in China, testing for possible H5N1 infection should be undertaken in all cases of severe respiratory disease having no alternative diagnosis, even when no poultry outbreak has been reported in the patient's area of residence. Of the 10 cases confirmed in China, 7 have been fatal. The cases have occurred in 7 provinces and regions: Anhui, Guangxi, Liaoning, Jiangxi, Fujian, Hunan, and Sichuan. No poultry outbreaks have been officially reported in 2 of these provinces. (Promed 1/25/06)


North Korea, Japan: Group says North Korean infected with avian influenza
North Korean leader Kim Jong-Il has alerted his regime to fight bird flu after at least 1 person was infected with the virus in Pyongyang Dec 2005, a human rights activist said. Avian influenza also struck poultry at 3 different places in Pyongyang Dec 2005, said Lee Young-Hwa, who heads RENK, a Japanese group monitoring human rights in the communist state. (RENK [Rescue The North Korean People's Urgent Action Network], is known to have contacts within the secretive nation and has supplied media with confidential information) If confirmed, it would be the first known human case of bird flu reported in the country. "According to our information, Kim Jong-Il issued an internal order to party and government organs at the beginning of 2006 to work out measures for controlling and preventing bird flu," Lee said. The woman infected with the virus was admitted to the Red Cross hospital in the North Korean capital said Lee, an ethnic Korean economics professor at Osaka's Kansai University. The strain of bird flu was not identified and there was no other information on her condition or how she contracted the virus, he said. Lee said an ethnic Korean scientist in Japan was known to have travelled to North Korea during 2005 with 10 packs of Tamiflu for hospital use. A Japanese public security service source confirmed that the Association of Chosun People in Japan delivered a quantity of Tamiflu to Pyongyang Sep 2005.

An bird flu outbreak that infected humans could be devastating in North Korea, where poultry is an important source of meat for its people. North Korea's official media reported outbreaks among poultry last year and in 2004. Pyongyang informed South Korea last year that it had culled thousands of chickens infected with the H7 strain of the virus. South Korea's unification ministry said it was unaware of any human cases in the North. Pyongyang's Korean Central News Agency reported 21 Dec 2005 that North Korean scientists had "found out the basis to rapidly and correctly identify any types of bird flu viruses." It said scientists had confirmed bird flu within 10 days when it broke out in spring 2005. (Promed 1/25/06, 1/26/06)


China: New HIV data show growing AIDS epidemic
China’s AIDS epidemic shows no signs of abating with an estimated 70,000 new HIV infections occurring in 2005, according to a report released by the Chinese Ministry of Health, the Joint UN Programme on HIV/AIDS (UNAIDS) and WHO. The latest data indicate that 650,000 (range 540,000 to 760,000) people are now living with HIV in China and that overall HIV prevalence is now estimated at approximately 0.05 percent. UNAIDS and WHO stress that the prevalence of HIV is not falling in China. The difference between the 2003 estimate of 840,000 (range 650,000 to 1,020,000) and the 2005 estimate of 650,000 (range 540,000 to 760,000) is due to improved HIV data collection and a better estimate of the most ‘at-risk populations’ in the country – including injecting drug users and sex workers. UNAIDS and WHO consider that the methods used in the 2005 revision of the national estimates are appropriate. China has greatly expanded and improved its surveillance system in recent years from 194 sites in 2003 to 329 in 2005, and increased the population groups covered. More data sources are now considered, including population size estimation data, special studies and behavioural surveillance. The new numbers should not mask the fact that HIV infections are on the rise. New infections are increasing by 70,000 (range 60,000- 80,000) per year. An upward trend can be seen if the figures for 2003 are recalculated using more complete data and better estimates of the size of groups at risk of being infected. Intensified prevention efforts are needed to stop the further spread of HIV in China and to keep the overall HIV prevalence low.

The majority of all estimated HIV infections (approximately 80 percent) are related to injecting drug use and commercial sex. The epidemic is equally or more serious than previously thought in all parts of China, except in central China where HIV transmission in connection with the sale of blood and blood plasma may have been overestimated in the past. The report released presents the new estimates of people living with HIV and AIDS in China. It also provides background and context to the new estimates, including a brief update on the response to the epidemic as well as the challenges for the future. (WHO 1/25/06 http://www.who.int/mediacentre/news/releases/2006/china_hiv_aids/en/index.html )


New Zealand (Christchurch): Source of hepatitis A outbreak linked to childcare center
A Ferrymead Child-care Centre is the source of the hepatitis A outbreak that has infected 21 people in Christchurch since Dec 2005. Public health officials said that all notified cases of the viral liver disease involved families with children at the ABC Learning Centre or people who had been to parties with the Centre's children. Canterbury medical officer of health Mel Brieseman said the Centre would not be closed. "Most of the exposure has already occurred, so closure would not achieve anything." He said it was likely the disease was introduced from outside, probably from a child returning from overseas during the incubation period. It was then spread by contact with faeces to other children at the Centre and to others at parties. Most sufferers were adults, including 2 who had been admitted to hospital and since discharged. Brieseman said several people remained "quite unwell" with the disease. Immunisation would be offered, although its value was uncertain at this late stage. "It is nonetheless worth considering because of the possibility of others incubating the disease," he said. He warned that further cases were likely because the disease was "extremely contagious", particularly in the 2 weeks before jaundice developed.

Hepatitis A is an enterically transmitted viral disease of the liver. Following exposure, an incubation period of 15 to 45 days precedes the development of clinical symptoms. Symptoms include general malaise, fever, nausea and jaundice. It is usually transmitted through contact with the faeces of infected people, or by environmental contamination. Unlike hepatitis B and C, it does not cause chronic liver disease. Most patients recover completely within 6-10 weeks. Close contacts of sufferers may be offered an injection of antibodies for temporary protection. Immunisation may also be offered for long-term protection. Day care centers have been identified as significant "players" in the epidemiology of hepatitis A outbreaks. The pre-school age children often have non-icteric (no jaundice) non-specific viral syndrome symptoms so that hepatitis A is not considered as an etiology until their parents and/or caretakers present with jaundice and other more typical symptoms associated with hepatitis A. (Promed 1/13/06)


Australia (New South Wales, South Australia): Increase in cases of Ross River virus
The Greater Western Area Health Service says there has been an increase in cases of Ross River fever across the region in the past 2 months. Another 18 cases of Ross River Virus have been reported in a week. Authorities reported last Friday that 42 new cases of Ross River Virus had been recorded in the previous 6 weeks compared with just 7 for the same time in 2005. Dr Ann Koehler, of the communicable diseases branch, said the total number of cases is now 60 in a little over 7 weeks. Authorities are urging people to cover up and use insect repellents on exposed skin to avoid infection.

Also, more than 20 Meningie residents have been infected with Ross River Virus in just 6 weeks, including children. Meningie now accounts for nearly half of all cases reported across South Australia since the start of Dec 2005, prompting Health Department calls for people to cover up against mosquitoes. For the same period last year, just 7 cases were reported in South Australia. Warm and wet weather conditions in 2005 provided a perfect breeding ground for virus-carrying mosquitoes, and in some areas, including Meningie, they have reached uncontrollable proportions. Because of this, Meningie general practitioner Dr Michael Kerrigan said the number of cases was not unexpected. However he said it was a wake-up call for local residents who had become complacent about the threat of infection from mosquitoes. While locals were likely to have the disease diagnosed quickly, Dr Kerrigan said he was concerned tourists from Adelaide would contract the disease and go undiagnosed by metropolitan doctors.

Ross River virus (RRV) fever, or epidemic benign polyarthritis, is a viral infection. Ross River virus infection can be transmitted to humans by the bite of an infected mosquito. It generally results in a self-limiting flu-like non-fatal illness, but it can cause long-term joint pain and fatigue. Symptoms disappear eventually and leave few or no after-effects. Most people who have been exposed to RRV are immune for life. There is no vaccine and no specific treatment for Ross River virus infection, but treatment of symptoms can reduce discomfort. Medical treatment is aimed at easing joint pains and swelling, and minimizing fatigue and lethargy. A variety of mosquito species can transmit RRV, biting day and/or night. RRV fever is found in all States and Territories of Australia, but occurs more often in the northern States and in coastal areas. Infection can occur year-round, but is more common from late Nov to the end of Apr, during the wet season when mosquito activity increases. RRV is also found in Papua, New Guinea, areas of Indonesia and the Western Pacific islands. (Promed 1/14/06)


Viet Nam (Ho Chi Minh): Nearly 260 children suffer from food poisoning
Kitchens from the 3 Ho Chi Minh City schools where hundreds of pupils fell victim to food poisoning did not conform to basic hygienic requirements. Inspectors from the HCMC Health Department found out that the kitchens fell short of basic hygienic standards -- food storage systems were dirty, and 'chefs' did not distinguish cooking phases, mixing cooked and uncooked food. The manufacturing facility which supplied yogurt to the 3 schools was earlier found to be hygienically inadequate. Accordingly, the inspectors have sealed the remaining yogurt. Towards 17 Jan 2006, all the hospitalized pupils were discharged. The day before, nearly 260 children from 3 primary schools in HCMC's Binh Thanh district were rushed to hospitals in the most severe case of food poisoning so far in the city. (Promed 1/24/06)


Canada (Alberta): BSE Detected
The Canadian Food Inspection Agency (CFIA) confirmed 23 Jan 2006 that bovine spongiform encephalopathy (BSE) in an approximately 6-year-old cross-bred cow born and raised in Alberta. No part of the animal entered the human food or animal feed systems. This finding is not unexpected and was identified through Canada's national surveillance program, which targets cattle at highest risk of being infected with BSE. The program has tested more than 87 000 animals since Canada's first BSE case in 2003. The geographic location and age of this animal are consistent with the 3 domestic cases previously detected through the national BSE surveillance program and the current understanding of BSE in Canada. The clustering of these cases is examined in the epidemiological report "Canada's Assessment of the North American BSE Cases Diagnosed from 2003 to 2005 (Part II)," which is available at: http://www.inspection.gc.ca/english/anima/heasan/disemala/bseesb/eval2005/evale.shtml. Food safety remains protected through the removal of specified risk material (SRM) from all cattle slaughtered for human food in Canada. SRM are tissues that, in infected cattle, contain the BSE agent.

CFIA, working with the producer and the Province of Alberta, has launched an investigation into the feeding regime and storage practices employed on the farm as well as the production and source of feeds delivered to the farm. CFIA will identify cattle born on the farm within 12 months before and after the affected animal as well as offspring of the affected animal born during the last 2 years. Any live animals found from these groups will be segregated and tested. Definitive conclusions regarding the source of infectivity cannot be made until the investigation is complete; however, it is probable that the source is contaminated feed. This detection is consistent with a low level of disease and does not indicate an increased risk of BSE in Canada. This finding should not affect Canada's ability to export live animals, beef and beef products. Canada has notified its key trading partners. Since May 2003, Canada has clearly stated the possibility of finding a small number of additional BSE cases. This international dialogue will continue as Canadian officials work closely with their international counterparts to ensure the facts and supporting science of this case are shared in an open and timely manner. (Promed 1/23/06)


USA/Japan: Japan reimposes US beef ban
Japan has decided to reimpose a ban on US beef imports after finding risk materials that could cause mad cow disease in a US shipment. The decision comes just 1 month after Japan lifted a 2 year ban on imports of US beef that was put in place after the US found a case of mad cow disease in Dec 2003. A total of 390 kg of beef imported from a meatpacker in New York was found to contain the risk materials when it was inspected upon arrival at Narita International Airport, a Farm Ministry official said. "Under the agreement between the United States and Japan, we decided to stop imports from the facility," the official said. Japanese prime minister Junichiro Koizumi said the country's agriculture minister had recommended reimposing the ban on all US beef imports. Koizumi directed Agriculture Minister Shoichi Nakagawa to consult with the health minister on the appropriate response. Japan resumed some imports of beef from the US and Canada Dec 2005. Before the ban, Japan was the top importer of US beef, buying USD1.4 billion worth in 2003. Tokyo agreed Dec 2005 to the importation of cattle aged 20 months or younger. It also said all risk material that could cause the brain-wasting disease had to be totally removed. These materials include the spinal cord, which was found in the cargo of US meat from New York.

The US agriculture secretary Mike Johanns stated: “The processing plant that exported this product has been de-listed and therefore can no longer export beef to Japan. . .I am dispatching a team of USDA inspectors to Japan to work with Japanese inspectors to reexamine every shipment currently awaiting approval, to confirm compliance with the requirements of our export agreement with Japan. I have directed that additional USDA inspectors be sent to every plant that is approved to export beef to review procedures and ensure compliance with our export agreements, and I am requiring that 2 USDA inspectors review every shipment of US beef for export to confirm that compliance. I have also ordered unannounced inspections at every plant approved for beef export. These additional inspection requirements in the US will be applied to all processing plants approved for beef export and all beef shipments designated for export from the U.S. I am also requiring that all USDA beef inspectors undergo additional training to make certain they are fully aware of all export agreement requirements. And, I have directed my staff to coordinate a meeting of representatives from all US processing plants that export beef to review those requirements. While this is not a food safety issue, this is an unacceptable failure on our part to meet the requirements of our agreement with Japan. We take this matter seriously, recognizing the importance of our beef export market, and we are acting swiftly and firmly."

To view the transcript of remarks by the Agriculture Secretary, see: http://www.usda.gov/wps/portal/usdahome. (Promed 1/22/06; USDA 1/24/06)


USA/Taiwan: Taiwan reopens market to US beef
U.S. Agriculture Secretary Mike Johanns announced that Taiwan will resume trade in U.S. boneless beef from animals under 30 months of age. Taiwan's announcement closely follows the recent reopening of several other major Asian markets to U.S. beef. In 2003, the US exported more than $76 million worth of beef to Taiwan, with boneless beef products accounting for $56 million. Taiwan's market is now open to more than 90 percent of total U.S. ruminant and ruminant products whose value reached $325 million in 2003. After the discovery of a BSE-infected cow in the US, $4.8 billion worth of U.S. beef and beef product exports were banned. Markets accounting for $3.8 billion have since been recovered. Taiwan reopened its market to U.S. beef in April 2005, but closed it again in June following the confirmation of a second U.S. case of Bovine Spongiform Encephalopathy (BSE). (USDA 1/25/06 http://www.usda.gov/wps/portal/usdahome )


USA: Limits on US distribution of Tamiflu lifted
Roche announced it was again shipping its antiviral drug oseltamivir (Tamiflu) to all US markets, lifting restrictions imposed last fall. The restrictions were lifted in response to reports of increasing flu outbreaks around the country and the recent revelation of a high rate of resistance to 2 older antiviral drugs used to treat flu, the company said. CDC recommended Jan 14, 2006 that clinicians not prescribe amantadine or rimantadine for the rest of this flu season because the dominant flu strains had become resistant to them. Roche announced Oct 26, 2005 the suspension of oseltamivir shipments to US pharmacies in order to prevent hoarding, which the company feared could lead to a shortage during the winter flu season. Officials said there had been a huge spike in demand. On Jan 4, 2006 the company said it was resuming distribution of the drug to wholesalers in US cities hit by flu outbreaks, mainly in California, Arizona, New Mexico, Utah, Texas, Oregon, Nevada, and Kansas. On 24 Jan 2006, the company said that flu activity had reached high levels in about half the country, according to data from its own flu surveillance network, called Flu STAR. Health officials believe that oseltamivir and zanamivir (Relenza) could be of some use if the H5N1 avian flu virus evolves into a pandemic virus. (CIDRAP 1/25/06 http://www.cidrap.umn.edu/index.html )


USA (Arizona, North Dakota): Human cases of Hantavirus pulmonary syndrome
An Arizona woman who lived on the Navajo Nation died of hantavirus pulmonary syndrome (HPS), which is caused by the hantavirus [Sin Nombre virus], an Indian health Services (IHS) official said. The Native American woman died Dec 2005, but the cause of her death wasn't confirmed until this month, said Jenny Notah, associate director for the office of program planning and evaluation for the Navajo Area Indian Health Service. "This (new case of HPS alerts the community that the potential for hantavirus infection is still out there. Be careful and avoid [rodent] droppings, because HPS can occur at any time of the year," said Notah. This was the first HPS-related death on the reservation since Apr 2005, Notah said. Elsewhere, North Dakota had its eighth-ever confirmed case of hantavirus infection, and the first in 6 years. The case was diagnosed in a woman, who is recovering. State Health Department disease specialist Kirby Kruger says the first cases of hantavirus in North Dakota were diagnosed in 1993. Officials later determined there had been cases dating back to the late 1970s. 2 cases were reported in 2000.

HPS is a disease transmitted by infected rodents through urine, droppings, or saliva. Humans can contract the disease when they breathe in aerosolized virus. Hantavirus infection causes flu-like symptoms as fever, shortness of breath, chills, nausea, headache, diarrhea, and abdominal pain. HPS was first recognized in 1993 and has since been identified throughout the US. Although rare, HPS is potentially deadly. Rodent control in and around the home remains the primary strategy for preventing Hantavirus infection. As of 6 Jul 2005 there had been a total of 396 cases of HPS in the US. As of 6 Jul 2005, New Mexico topped the list with 64 cases, and North Dakota now ranks as 11th in frequency of disease. For more information on HPS: http://www.cdc.gov/ncidod/diseases/hanta/hps/index.htm. (Promed 1/20/06, 1/21/06)


USA (Washington, Oregon): E. coli O157:H7 infections from unpasteurized milk
Lab analysis has conclusively linked 18 cases of Escherichia coli [O157:H7] illness to raw milk from the Dee Creek Farm in Cowlitz County, WA, officials said 18 Jan 2006. All of the victims, including 3 children once critically ill, are at home recovering, said Dr Justin Denny, Clark and Skamania county health officer. Jerry Beundel, a food safety officer with the Washington State Department of Agriculture, said 18 Jan 2006 that the DNA "fingerprint" of raw milk from dairy customers, the dairy, and samples swabbed from the cattle matched. Some patients had started antibiotics when tested because of a delay in identifying dairy customers involved in the outbreak, Denny said. Cultures from them were inconclusive, but those cases matched key symptoms from other dairy customers. 5 patients were hospitalized; the other 13 reported distinctive symptoms such as bloody diarrhea. Victims were from Washington and Oregon.

Raw milk can contain a variety of bacteria, including E. coli O157:H7, which are destroyed by the heat of pasteurization, Beundel said. Milk contains minor amounts of vitamin C and thiamine, which also are removed by pasteurization, but they can be replaced through supplements, he said. Among the improvements the state wants at Dee Creek are a concrete floor in the milking parlor, replacing a muddy rubber mat; running water in the milking area for hand washing; and an improved area for filtering and chilling the milk, now done in the family kitchen. Denny said E. coli can grow "even in a healthy cow, and can be intermittently shed" via milk or feces. (Promed 1/21/06)


USA: Recall of Vapotherm 2000i and 2000h respiratory gas humidifier
Vapotherm, Inc., is initiating a nationwide recall of all Vapotherm 2000i Respiratory Gas Humidification devices. Some of these devices have been found to contain the Ralstonia species of bacteria. Ralstonia, as with any Gram-negative organism, may cause infection, sepsis and in most severe cases be life-threatening. Health care practitioners should seek alternative respiratory gas humidification devices. Any health care facilities that have the Vapotherm 2000i device must return all devices to Vapotherm, Inc. Instructions for return are at <http://www.vtherm.com/recall> or by calling Vapotherm, Inc. at 1-866-827-6843. This device is used in both the home and in health care institutions for warming and humidifying breathing gases, such as oxygen, delivered by nasal cannula. The firm first learned that patients were colonized by the bacteria from a Pennsylvania hospital 17 Aug 2005, and subsequently issued a voluntary recall of the Vapotherm 2000i 13 Oct 2005. FDA has since been apprised of this action. At this time, the following is known: There are numerous reports of Ralstonia colonization, including 3 reports of infection; 1 hospital reported a death, but this has not been confirmed by Vapotherm; and 26 hospitals in 16 states have reported positive cultures of Ralstonia species from the Vapotherm 2000i device. Vapotherm's investigation is currently ongoing to identify the source of the Ralstonia contamination. In the meantime, Vapotherm's plans include recalling and performing a disinfection process on the units. For the official FDA recall, see: http://www.fda.gov/cdrh/recalls/recall-101305.html. (Promed 1/26/06)


1. Updates
Seasonal influenza activity for the Asia Pacific and APEC Economies
WHO’s surveillance information has not been updated since the 18 Jan 2006 report. Please see EINet’s 20 Jan 2006 Alert for further details.

USA.During week 3 (Jan 15 – Jan 21, 2006), influenza activity continued approximately at the same level as recent weeks in the US. 247 specimens (10.8%) 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) was above the national baseline. The proportion of deaths attributed to pneumonia and influenza was below the baseline level. 5 states reported widespread influenza activity; 23 states and New York City reported regional influenza activity; 9 states and the District of Columbia reported local influenza activity; and 13 states reported sporadic influenza activity. (CDC 1/27/06 http://www.cdc.gov/flu/weekly/ )

For the comprehensive update on recent influenza activity in the USA (“Update: Influenza Activity --- United States, January 8--14, 2006”): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5503a4.htm. (MMWR January 27, 2006 / 55(03);74-76)

Avian/Pandemic influenza updates
- WHO’s comprehensive information on avian influenza: http://www.who.int/csr/disease/avian_influenza/en/index.html. WHO pandemic influenza draft protocol for rapid response and containment, updated 27 Jan 2006: http://www.who.int/csr/disease/avian_influenza/guidelines/RapidResponse.pdf. 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 animation timeline of avian influenza outbreaks in Turkey.

- OIE updates and documents on avian influenza: http://www.oie.int/eng/en_index.htm. Includes the major veterinary proposals by OIE.

- CDC website on pandemic influenza: http://www.cdc.gov/flu/pandemic.htm. For avian influenza: http://www.cdc.gov/flu/avian/. “Questions and Answers” have been updated 18 Jan 2006.

- The US government’s web site for pandemic flu: http://www.pandemicflu.gov/. New State Summit summaries have been uploaded.

- Influenza information from the US Food and Drug Administration: http://www.fda.gov/oc/opacom/hottopics/flu.html.

- Latest CIDRAP updates on avian/pandemic influenza: http://www.cidrap.umn.edu/index.html.

- PAHO’s updates on avian influenza: http://www.paho.org/English/AD/DPC/CD/influenza.htm.

- 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 animal influenzas: http://www.avma.org/public_health/influenza/default.asp

- US Geological Survey, National Wildlife Health Center: http://www.nwhc.usgs.gov. NWHC Avian Influenza Information (with bulletins, maps, and news reports): http://www.nwhc.usgs.gov/research/avian_influenza/avian_influenza.html.


Cholera, diarrhea & dysentery
Philippines (Palawan)
In response to the reported outbreak of diarrhea in southern Palawan, the Department of Health and the Provincial Health Office dispatched health teams to provide medical assistance to remedy the outbreak (e.g. first aid supplies, antibacterials, IV fluids, etc.). The Rural Health Units in the affected areas are already in short supply of medicines. A total of 214 cases have been reported in the 22 barangays in the 3 southern towns of Palawan-Bataraza, Espanola, and Rizal. Bataraza, with 15 barangays affected, reported the highest number of patients at 168; 22 deaths. In Puerto Princesa City, the Ospital ng Palawan, a DOH-run hospital reported 99 cases but only 15 were admitted for hospitalization. Reportedly, 64 percent of the cases in Bataraza are amoeba-related and 30 percent were caused by bacteria. (Promed 1/14/06)


A total of 1099 people died of dengue fever in Indonesia in 2005, a health ministry official said 17 Jan 2006. "The number is higher than 2004's 957," said Rita Kusriastuti, head of the subdirectorate of arboviruses of the directorate general of disease control and environmental health. In percentage, the number of deaths in 2005 ranged from 1 to 1.4 per cent, compared with 2.5 per cent in 2004. She said cases of dengue fever were found across the provinces in the country with Jakarta claiming the highest number of lives (238), followed by East Java (200). "In some cases the deaths occurred because of the lack of health services," she said. Kusriastuti said the number of dengue fever cases in the country had increased during 2002-2005. In 2002 they were recorded at only 40 377, but in 2003 they increased to 52 000 and later to 79 462 in 2004 and 80 837 in 2005. Besides lack of funds for controlling the disease, implementation has yet to be maximized. She said, "the government has actually prepared a good program for disease control but as usual its implementation is not always as expected." (Promed 1/19/06)

Hong Kong/Indonesia
The Centre for Health Protection has confirmed the year's second imported case of dengue fever--a 22 year old man who recently travelled to Indonesia. The man came down with fever, muscle pain, chills, and headache 31 Dec 2005. He travelled to Indonesia between 18 and 24 Dec. He consulted a doctor and has recovered. His home contacts did not have any symptoms. (Promed 1/19/06)


2. Articles
CDC EID Journal, Volume 12, Number 2-February 2006
CDC Emerging Infectious Diseases Journal, Volume 12, Number 2-February 2006 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. The following expedited articles are available online: Clostridium difficile Infection in Patients Discharged from US Short-Stay Hospitals, 1996–2003, L.C. McDonald et al., and West Nile Virus Infections Projected from Blood Donor Screening Data, United States, 2003, M.P. Busch et al.


Orf virus infection in humans--New York, Illinois, California, and Tennessee, 2004--2005
“Orf virus is a zoonotic parapoxvirus endemic to most countries in the world and is principally associated with small ruminants (e.g., sheep and goats). Human orf infections appear as ulcerative skin lesions after contact with an infected animal or contaminated fomite. This report summarizes the epidemiologic and laboratory investigations of 4 sporadic cases of human orf infection, emphasizing the temporal association between human lesions and skin trauma or recent flock vaccination with live orf vaccine. This zoonotic infection shares clinical manifestations and exposure risks with other, potentially life-threatening zoonoses (e.g., cutaneous anthrax) and is likely under-recognized because of a lack of clinical suspicion and widely available diagnostics. Barrier precautions and proper hand hygiene are recommended for the prevention of orf virus infection in humans. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5503a1.htm (MMWR January 27, 2006 / 55(03);65-68)


Surveillance for early detection of disease outbreaks at an outdoor mass gathering--Virginia, 2005
“Implementing public health surveillance at mass gatherings might help detect outbreaks or possible acts of biologic terrorism and enable prompt public health intervention. In July 2005, a daily syndromic sentinel surveillance system was implemented to monitor disease and injury among approximately 43,000 youths and adults attending a 10-day camping event held every 4 years by a national youth organization. Camp activities began on July 25, 2005, and included events such as mountain boarding, rappelling, and whittling. This report describes public health surveillance and response activities during the 10-day event and presents recommendations for health surveillance at large outdoor events. Public health surveillance should be implemented at mass gatherings to facilitate rapid detection of outbreaks and other health-related events and enable public health teams to respond with timely control measures. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5503a3.htm (MMWR January 27, 2006 / 55(03);71-74)


Antivirals for influenza in healthy adults: systematic review
Jefferson T, et al. Lancet 2006 Jan 19. Abstract:
http://www.thelancet.com/journals/lancet/article/PIIS0140673606679701/abstract Researchers who analyzed numerous clinical trials concluded that the 2 newest antiviral drugs for influenza, oseltamivir (Tamiflu) and zanamivir (Relenza), should not routinely be used against seasonal flu. The researchers also raise doubts about using the 2 drugs, called neuraminidase inhibitors (NIs), in a potential flu pandemic. They say they found no "credible evidence" that the drugs are helpful in human cases of avian flu. The accumulated evidence "suggests that neuraminidase inhibitors should not be used routinely for seasonal influenza and only with associated public health measures in a pandemic situation," says the report by Tom Jefferson and 4 colleagues with the Cochrane Vaccines Field in Italy and the University of Queensland in Australia. They also said the 2 older antiviral flu drugs, amantadine and rimantadine, should not be used for flu, because they don't prevent infection or viral shedding and they have potential serious side effects.

Roche, the maker of oseltamivir, said, "Roche fundamentally disagrees with the conclusions reached by the authors that oseltamivir should not be used for the treatment or prevention of seasonal influenza. The conclusion is at odds with the opinion of experts and regulatory authorities around the world." WHO and many countries are stockpiling the NIs, mainly oseltamivir, in the hope that they will be useful if H5N1 avian flu leads to a pandemic. "After carefully reviewing this analysis, WHO will not be changing its stockpiling recommendations," WHO spokesman Dick Thompson said. Roche did not directly challenge the authors' conclusion about the effectiveness of oseltamivir against avian flu strains in humans, but the company reported that the drug performed well in a recent animal study, as well as previous ones.

The researchers analyzed 19 randomized controlled trials of oseltamivir and zanamivir along with 34 trials of amantadine and rimantadine. They examined the drugs' record in preventing and treating lab-confirmed influenza and influenza-like illness in patients aged 16 to 65. For treatment of symptomatic flu, oseltamivir had 61% to 73% efficacy, depending on the dosage, and zanamivir had 62% efficacy. The NIs were found to have no significant effect when used to prevent flu-like illness. But for preventing flu after exposure to the virus (postexposure prophylaxis), oseltamivir was 58.5% efficacious in households and 68% to 89% efficacious in contacts of index cases, the analysis showed. The researchers also found evidence that the NIs shortened the duration of symptoms and reduced the viral load in nasal secretions, but the drugs did not eliminate viral shedding. Oseltamivir, 150 mg daily, reduced the incidence of bronchitis and pneumonia in flu cases but not in flu-like illness cases. "We do not see a role for the use of neuraminidase inhibitors in seasonal inflenza, since the evidence shows that they are ineffective against influenza-like illness," they write. But they add that in the context of a known flu epidemic, flu-like illness is more likely to be actual influenza and the NIs are more likely to be helpful.

In responding to the article, Roche officials said, "The statement by the author that neuraminidase inhibitors should not be used in seasonal influenza control is inappropriate and inconsistent with data. Roche strongly disagrees with this article; surveillance activities and the appropriate use of antivirals are critical to combat influenza." Roche took issue with using oseltamivir's reported lack of effectiveness against flu-like illness as a reason not to use it for seasonal flu: "Once influenza is circulating and with clearly defined symptoms identified[,] influenza is easy to diagnose. Roche has never advocated the use of Tamiflu for control of influenza-like symptoms."

The researchers also examined reports on the effects of oseltamivir in human H5N1 flu patients in Southeast Asia. There, oseltamivir treatment had no clear effect on mortality, although this could have been a result of starting treatment late in patients who already had a high viral load, the report says. In H5N1 cases, the viral load can be 10 times greater than in seasonal flu, a WHO study showed. Resistance to oseltamivir was seen in 7 of 43 children and in 2 of 8 Vietnamese children and adults, the report says. The scientists also found no clear benefits from the use of oseltamivir in people exposed to H7N7 avian flu in the Netherlands in 2003 and H7N3 avian flu in Canada in 2004. "As viral load and virulence of pandemic viruses are considerably higher than those of seasonal influenza viruses, the use of neuraminidase inhibitors in a serious epidemic or pandemic should not be considered without concomitant measures, such as barriers, distance, and personal hygiene." They add that overestimating the ability of NIs to prevent illness could cause those treated to be less careful, leading to increased spread. (CIDRAP 1/20/06 http://www.cidrap.umn.edu/index.html )


Management of potential human cases of influenza A/H5N1: lessons from Belgium
S Quoilin et al. Jan 29, 2006 Eurosurveillance Weekly.
“Since the first human cases of influenza A/H5N1 were widely reported from Turkey in early January, many European patients with suspected influenza, who might have been exposed to influenza A/H5N1 in countries reporting human or avian cases, have been tested for the infection. The 28 countries participating in the European Influenza Surveillance Scheme (EISS, http://www.eiss.org) have been invited to report any laboratory tests for H5N1, and by 25 January, six countries had reported a total of 19 tests [personal communication, A Meijer, 25 January 2006]. This small number of tests – all of which were negative – probably represents only a small proportion of the suspect cases of influenza A/H5N1 that have been treated in Europe in recent weeks. We present here Belgium’s experience in managing its first suspected human case of influenza A/H5N1. . .” (CIDRAP http://www.cidrap.umn.edu/index.html )


Large-Scale Sequence Analysis of Avian Influenza Isolates
John C. Obenauer et al. Science, published online Jan 26, 2006.
Abstract: “The spread of H5N1 avian influenza viruses (AIV) from China to Europe has raised significant global concern about their potential to infect humans and cause a pandemic. In spite of their significant threat to human health, remarkably little AIV whole genome information is available. We report here a preliminary analysis of the first large-scale sequencing of AIV including 2,196 AIV genes and 169 complete genomes. We combine this new information with public AIV data to identify new gene alleles, persistent genotypes, compensatory mutations, and a potential virulence determinant.” (CIDRAP http://www.cidrap.umn.edu/index.html )


3. Notifications
Third International Conference on Current Research in Avian Zoonoses
Kalmar, Sweden; 3-5 May 2006. http://www.mikrobiologi.net/avian.
From Dr. Ingvar Eliasson (ingvar.eliasson@skane.se): “I would like to announce the third international conference on current research in zoonotic ecology and epidemiology, organized by the Society for Zoonotic Ecology and Epidemiology (SocZEE). The theme of the upcoming meeting is zoonotic diseases associated with birds: avian zoonoses. The purpose of the meeting is to bring together both basic and clinical scientists active in the field of zoonotic infections and zoonotic infectious agents in order to increase networking and interdisciplinary collaboration between human and veterinary medicine, microbiology, epidemiology, ecology, biology, and other related biosciences. This time, we have added interaction with authorities and journalists in a special seminar entitled Risk Communication. By doing this, we hope to assist the participants in their preparedness to meet the media and to inform the public about their research in a professional way. The conference will be followed by a 2 day optional tour to Ottenby Bird Observatory. The participants will be introduced to the different methods used to monitor migrating birds for viral and bacterial pathogens. . .” (Promed 1/22/06)


2006 Annual conference on antimicrobial resistance, June 26--28, 2006
CDC and 10 other agencies and organizations will collaborate with the National Foundation for Infectious Diseases in sponsoring the 2006 Annual Conference on Antimicrobial Resistance (including basic science, prevention, and control), Jun 26-28, 2006 in Bethesda, Maryland. 28 invited speakers will address such topics as rapid diagnostics, community-associated methicillin-resistant Staphylococcus aureus infections, the reemergence of Clostridium difficile, controversies in antimicrobial resistance, innovations and increasing efficiency in clinical trials for infectious disease, and vaccines as a strategy for preventing and controlling drug-resistant infections. Oral and poster presentations will be selected from submitted abstracts. Deadline for submission of abstracts is Mar 3, 2006. For more information: http://www.nfid.org/conferences/resistance06 ; e-mail (resistance@nfid.org); fax (301-907-0878); tel (301-656-0003, ext. 19); or mail (NFID, Suite 750, 4733 Bethesda Avenue, Bethesda, MD 20814).
(MMWR January 27, 2006 / 55(03);77)


4. APEC EINet activities
APEC EINet pandemic influenza videoconference
EINet celebrated its 10th anniversary of service to the Asia Pacific by hosting the APEC EINet Virtual Symposium on Pandemic Influenza Preparedness, Friday 20 Jan 2006, 02:00 – 07:00 UTC. Participants in the videoconference included the economies of: Australia, Canada, People’s Republic of China, Republic of Korea, Philippines, Singapore, Chinese Taipei, Thailand, USA, and Viet Nam. Each economy presented briefly their state of pandemic influenza preparedness, followed by moderated questions and answers. Overall, the collaborative event was very successful, and the economies were able to share a rich level of information and engage in productive discussions. Evaluation of the videoconference and a formal report are currently pending. For more information please visit: http://depts.washington.edu/einet/symposium.html.


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/.