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EINet Alert ~ Feb 17, 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:
- Eurasia: Cumulative number of confirmed human cases of avian influenza A/(H5N1)
- Nigeria: Avian influenza update; panic among poultry farmers
- Nigeria: Implications from genetic sequencing
- Nigeria: Government and farmers move to curb avian influenza
- Europe: Economic impacts due to avian influenza; preparedness
- Italy: Sixth swan tests positive for H5N1 avian influenza
- Germany (Ruegen island): Avian influenza H5N1 found in dead swans
- Denmark (Falter and Bornholm islands): Avian influenza suspected in 9 swans
- Slovenia: Avian influenza H5 found in dead swan near Austrian border
- Austria (Styria): Tests indicate birds likely killed by avian influenza H5N1
- Hungary: Avian influenza H5 confirmed in swans
- Croatia: Excerpts from OIE report on avian influenza H5 detected in ducks
- Bulgaria: Confirmation of H5N1 avian influenza infection in swan
- Greece: Confirmation of H5N1 infection in birds; suspect human cases test negative
- Iraq: Suspected human cases of avian influenza under investigation
- Iran: Reportedly confirms H5N1 strain in wild swans
- Azerbaijan: Reports H5N1 strain found in wild birds
- Russia (Krasnodar, Dagestan): New cases of H5N1 avian influenza in wild fowl
- Ukraine: H5 avian influenza outbreak suspected
- Romania: Finds new suspect avian influenza cases in fowl
- Hong Kong: Additional suspected avian influenza cases in birds
- Indonesia: 26th human case of avian influenza; number of human cases rising
- China: 35 persons under quarantine; Twelfth confirmed human case of avian flu
- USA: CDC wants more healthcare workers to get flu shots
- USA: Summaries from the CIDRAP business preparedness conference

1. Updates
- Influenza

2. Articles
- Comparative Activities of Oseltamivir and A-322278 in Immunocompetent and Immunocompromised Murine Models of Influenza Virus Infection
- Recovery of drug-resistant influenza virus from immunocompromised patients: a case series
- Global macroeconomic consequences of pandemic influenza


Global
Eurasia: Cumulative number of confirmed human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

2003
Viet Nam / 3 (3)
Total / 3 (3)

2004
Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)

2006
China / 4 (3)
Indonesia / 8 (7)
Iraq / 1 (1)
Turkey / 12 (4)
Total / 25 (15)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 169 (91)
(WHO 2/13/06 http://www.who.int/csr/disease/avian_influenza/en/ )

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Nigeria: Avian influenza update; panic among poultry farmers
The virulent H5N1 strain was found in poultry in 3 states last week (Kano and Plateau States, either side of Kaduna). Health Minister Eyitayo Lambo said another 5 states had suspected cases: Abuja, where the capital is located, Katsina, Nassarawa, Yobe and Jigawa states. Reportedly, some officials believe more than 20 farms have been hit in Kano state. Experts with protective equipment are being flown in from abroad to help local officials contain the spread of the disease. Dr Mohammed Bala Abubakar, from Kaduna State’s health ministry, said tests were being carried out on some 120 workers from Sambawa farm in Kaduna State (the first poultry farm to be confirmed with the H5N1 virus in Africa) 13 Feb 2006 and would continue throughout the week. None of the workers on the farm where the outbreak was first identified have shown any signs of illness, he said. 2 children (age 4 years and 4 months), who live near the farm in Kaduna State and who fell ill last week, have since recovered and been released. However, their blood samples have been sent to several laboratories for analysis, he said.

A veterinary expert warned 14 Feb 2006 that panic selling of chickens was fueling a growing epidemic of bird flu. Dr. Lami Lombin, director of the National Veterinary Research Institute, said distress sales by poultry farmers were exacerbating the situation. She said that her message to them was to “keep it on your farm.” Lombin stressed that the government would compensate farmers for chickens that die and help them restock after the crisis abates. Lombin said avian flu had been detected in 2 more farms in Plateau State 14 Feb 2006, bringing the total there to 5, and that samples would be sent to the UN FAO for testing, as with previous outbreaks. “We are hoping that we will soon have the reagents to test for H5N1 ourselves; that is our most urgent need,” she said. Officials in Jigawa and Borno states in the north of the country, where there have been as yet no confirmed cases, said farmers were dumping chicken quickly on the market at low prices. Tens of thousands of chickens, geese and ostriches have been culled and the government has vowed measures to prevent the virus spreading to the densely-populated southwest and the economic capital Lagos. WHO has called for a massive public education campaign.

Elsewhere, Niger, the world’s least-developed nation, has said it was investigating 2 birds found dead in a market in Zinder, near the Nigerian border. Juan Lubroth, a senior animal health officer at the UN’s Food and Agriculture Organisation, said experts still do not know if it was avian flu, but “it’s likely that it’s H5N1. It’s highly suspected cases of H5N1.”
(Promed 2/12/06, 2/14/06, 2/15/06)

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Nigeria: Implications from genetic sequencing
Genetic sequencing on the H5N1 avian flu virus from birds in Nigeria show it is virtually the same as that found in fowl in Qinghai Lake, China and Turkey. Qinghai Lake is where there was an unprecedented die-off of 6000 migratory birds Apr 2005. A scientist said a limited number of migratory birds appear to be spreading a single sub-strain of the H5N1 virus. In theory, this could lower opportunities for the H5N1 virus to mutate into an easily transmissible form which could spark a human influenza pandemic, according to Michael Perdue, an epidemiologist in WHO’s global influenza programme. 4 family groups of the H5N1 virus have been identified, with multiple substrains within each, but it appeared that only 1 was “moving westward,” he said. “We are looking at what I think is probably limited (migratory bird) species that are infected with what appears to be a single sub-strain of the Asian viruses,” he said. “That is better news than thinking all the birds are spreading the virus all over the world -- that’s not happening. . .It could reduce the mutation level. . .You are less likely to have widespread mutation than if you had 20 strains hop-scotching across Asia. It also appears that this virus is relatively stable.” For programs addressing the epidemiology of avian influenza in wild birds, particularly related to Europe, see the following 4 presentations from the Standing Committee on the Food Chain and Animal Health (SCFCAH) working group meeting 6 Sep 2005:

1) David Stroud, Wetlands International. NEW-FLUBIRD Network for early warning of influenza viruses in migratory birds in Europe. Key Activity 1: Ornithological studies and sampling activities. http://europa.eu.int/comm/food/animal/diseases/controlmeasures/avian/birds.pdf

2) Department of Virology, Erasmus MC, Rotterdam. Proposal for a EU collaboration: http://europa.eu.int/comm/food/animal/diseases/controlmeasures/avian/early_warning.pdf NEW-FLUBIRD - Network for early warning of influenza viruses in migratory birds in Europe. http://europa.eu.int/comm/food/animal/diseases/controlmeasures/avian/early_warning.pdf.

3) Bjorn Olsen, Ottenby Bird Observatory. European Collaboration on AIV monitoring in wild birds. http://europa.eu.int/comm/food/animal/diseases/controlmeasures/avian/wild_birds.pdf.

4) Ian Brown, Community Reference Laboratory, Veterinary Laboratories Agency, UK. Surveys for avian influenza in poultry and wild birds in member states 2004. http://europa.eu.int/comm/food/animal/diseases/controlmeasures/avian/eu_ai_survey2004_en.pdf .
(Promed 2/11/06)

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Nigeria: Government and farmers move to curb avian influenza
The Federal Government has announced stringent measures to check the spread of avian flu. Nigerians, the government advised, must cook their chicken very well before consumption. Under the policy of cordoning, culling, destroying and disinfecting farms that may be affected, the Minister of Information and National Orientation, Frank Nweke Jr., said that the steps would be executed through immediate quarantine and closure of farms identified or under suspicion for a period of 1 year and a ban on movement of poultry from 1 state or local council to the other. Poultry farmers in the country converged 13 Feb 2006 to develop a solution to the problem. For affected farms to be disinfected effectively, all carcasses of affected birds must be either burnt or buried properly. The government has warned poultry farmers against restocking. Large poultry farmers are encouraged to reduce the frequency of their visits to their farms. When they do need to visit, they are encouraged to wear protective clothing (reports indicate a high level of non-protection; FAO and the US government are shipping over 1000 sets of protective gear to Nigeria). They have also been encouraged to monitor the mortality of poultry and to report such mortality to the appropriate authorities. The government has offered to pay N250 [approximately USD 2] as compensation for every bird killed. Poultry farmers have asked for a sum of NGN 1000 [USD 8] per bird. The government has approved 2 billion NGN [USD 15.5 million] to compensate affected farmers.

Meanwhile, experts from the Food and Agriculture Organization and WHO have arrived in the country to step up measures to prevent further spread of the virus. FAO and WHO urged neighboring Benin Republic, Cameroun, Chad, Ghana and Niger to tighten border inspections. According to FAO and OIE, priority measures include: appropriate culling respecting OIE standards in and around outbreak spots, ring vaccination around infected areas, the control of people and livestock moving to and from outbreak zones, thorough disinfection, hygiene and good farming practices. Only vaccines that fulfill OIE international quality standards should be used. The Director-General of WHO made an official statement regarding the implications of avian influenza in Africa, saying, “African health systems are already struggling to cope with children and adults suffering from HIV/AIDS, tuberculosis. . .and other infectious conditions. Human cases of H5N1 may be difficult to distinguish from other illnesses. We simply do not know what the impact of exposure to avian influenza will be on the many people who may be already immunocompromised and in a fragile state of health.”

As in most of sub-Saharan Africa, poultry are everywhere in Nigeria. Most poultry is bought live and slaughtered at home. It is speculated that Nigeria may lose 90 percent of its chicken population to bird flu in a few months if it relied absolutely on the policy of stamping out and depopulation. The General Manager of Zartech Limited, an agro allied industry, Mr. Roger Aboujaoude, advised the government to change its policy and embark on aggressive vaccination of birds in the industry and also allow importation of H5-type vaccines into the country. Neighbouring countries (e.g. Angola, Mali and Guinea) have banned chicken imports from Nigeria. Nigeria is a major trade partner of China. However, rumors about possible imports of breeding material from China or other East Asian countries could not be confirmed.
(Promed 2/11/06, 2/12/06, 2/13/06, 2/14/06)

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Europe: Economic impacts due to avian influenza; preparedness
Street markets selling live fowl have been shut down and surveillance of wild birds stepped up. Mounting public concern about the threat has hurt sales at poultry processors. Reportedly, sales of poultry in Italy dropped 13% in 2005 as people opted for alternatives to avoid contracting bird flu. The EU has tried to avoid avian influenza outbreaks by banning imports of poultry from infected areas and halting trade in pet birds. Greece now requires that poultry be kept indoors. In autumn 2005, several European nations, including Switzerland, Austria and the Netherlands, mandated that all commercial poultry be kept indoors to prevent any contact with migrating birds. Dead swans have become an important flu sentinel, because they are very susceptible to the virus and are so large that people notice when they die. The EU’s health commissioner said: “We should not be unduly surprised or alarmed if such cases are found in the European Union. What is important is that we have the framework in place to take the appropriate measures as soon as possible to contain it and prevent its spread to poultry, and that is what we are doing.”
(Promed 2/10/06, 2/11/06, 2/12/06, 2/14/06)

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Italy: Sixth swan tests positive for H5N1 avian influenza
A sixth wild swan that died in Italy has tested positive for the highly pathogenic H5N1 form of bird flu. A specialist lab in Padua 12 Feb 2006 confirmed the presence in the bird of the strain. On 11 Feb 2006, Italian Health Minister Francesco Storace said that more than 20 migratory swans (other sources mentioned 17 swans) found dead in the south of the country were infected by bird flu. An official in Sicily said the swans were believed to have migrated from Russia. Tests have been under way in Padua to determine whether they carried the H5N1 strain. Their corpses were found in the Puglia and Calabria regions and in Sicily. Authorities have put emergency health measures into place, including setting up protective zones around outbreak areas to control the movement of poultry and increasing agricultural and veterinary checks. Meanwhile, authorities urged people to remain calm and stressed that only migratory birds, and no domestic poultry, had been affected so far. Greece and Bulgaria, where H5N1 was detected in other wild swans, have also put similar emergency measures into place. “In Greece and Italy it is very clear wildlife introduced the virus,” says Lubroth, a senior officer with the FAO. Without better understanding of which species carry it, and where, it is hard to be certain in other cases, he says. The FAO hopes to radio-track birds and test water from bird habitats for the virus.

The Italian outbreak seems to have been a model of early detection, underlining how bird flu can be controlled in countries that have the money and the resources to do it. Recent outbreaks in poor countries have percolated for months before they were discovered, allowing the virus to spread widely to commercial chicken flocks and to humans. A spokesman for the Rome-based FAO said it was confident Italy was ready to deal with the outbreak. Finance ministers of the Group of Eight (G8), meeting in Moscow discussed the risk of a worldwide pandemic and issued a new call for wealthy countries to help poor ones fight bird flu.
(Promed 2/11/06, 2/12/06, 2/13/06)

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Germany (Ruegen island): Avian influenza H5N1 found in dead swans
2 dead swans in Germany have tested positive for the H5N1 strain, the Agriculture and Consumer Protection Ministry said. A ministry spokeswoman said 2 of 4 dead swans found on the Baltic Sea island of Ruegen had registered positive in an initial test--the first such positive result in Germany. She said samples were on the way to the UK lab for further testing. Elsewhere, France extended its poultry confinement measures Jan 2006 to 58 departments of the 96, from an original 26. The Netherlands said it would order poultry producers to keep animals indoors from around Mar 2006 to protect them from the threat of avian flu from migrating birds.
(Promed 2/12/06, 2/14/06)

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Denmark (Falter and Bornholm islands): Avian influenza suspected in 9 swans
Authorities say 9 dead swans have been found on Falter Island and Bornholm island in the Baltic Sea. Falter Island is just 30 miles from the German island of Ruegen, where bird flu-infected swans were found. The Danish Institute for Food and Veterinary Research are carrying out tests. Danish poultry farmers have been told to keep all their poultry indoors by the Veterinary and Food Administration. Poultry farmers are experiencing 2 serious problems: 1) The threat of losing their poultry to infection 2) crashing poultry sales. In Italy, supermarkets have reported a 90 percent drop in the sale of chicken. Ornithologists say that the spread of bird flu could be accelerated when birds start migrating from Africa to Europe. Suspected mortality was also reported 15 Feb 2006 from Poland (Gdansk), where 3 dead swans were found on a Baltic beach in Krynica Morska and forwarded to the laboratory. Preliminary tests showed no signs of bird flu. Infected swans have been identified, so far, in the following European countries: Russia, Ukraine, Turkey, Romania, Greece, Italy, Austria, Slovenia, Hungary, and Germany. For interactive maps of HPAI in Russia, Romania, Turkey and Ukraine: http://poultrymed.com/files/index.html.
(Promed 2/15/06)

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Slovenia: Avian influenza H5 found in dead swan near Austrian border
An infected swan was found dead near the Austrian border (less than 10 km from border), marking Slovenia’s first case of bird flu, authorities said 12 Feb 2006. A European Commission spokesman said the virus belonged to the H5 group. An exact diagnosis will be performed at the UK laboratory. According to the Austrian Health Ministry, preliminary tests had revealed that the virus was H5N1. Initially, there had been confusion over the exact location of the find. A farmer had discovered the animal in Maribor, but had taken it to his farm in St. Primoz and informed the authorities there. In Slovenia, a 10km surveillance zone extended into the Austrian province of Styria. First official statements in Austria had said that the province of Carinthia, which also borders on Slovenia, would be affected by the measures. Deputy Carinthian Governor Martin Strutz accused the Slovenian authorities of a “chaotic information policy.” In Styria, an emergency plan was set up for the villages in question. Among other measures, there would be a ban on keeping poultry in the open air, and the animals would be examined by veterinarians.
(Promed 2/12/06, 2/13/06)

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Austria (Styria): Tests indicate birds likely killed by avian influenza H5N1
2 of 21 birds found dead in Austria appear to have been killed by the H5N1 bird flu strain, a official said 14 Feb 2006. Hans Seitinger, a health official for Styria province, said there was a 70 percent chance that the H5N1 virus had reached Austria, according to the preliminary results of samples from the 21 birds examined at an Austrian veterinary laboratory. No previous cases of bird flu in fowl have been reported in Austria.
(Promed 2/14/06)

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Hungary: Avian influenza H5 confirmed in swans
3 dead wild swans found in southern Hungary have tested positive for the H5 avian influenza virus, the European Commission said 15 Feb 2006. The European Union’s executive arm said samples from the birds were being sent to the UK laboratory for confirmation. “The Hungarian authorities are applying the same precautionary measures as other member states in which the H5N1 virus has been confirmed or in which it is suspected in wild birds,” the Commission said. “The Commission will adopt a decision. . .today on the precautionary measures to be applied in Hungary, just as it did for the other affected member states,” the Commission said. Precautionary measures include setting up a 3 km protection zone around the area where the swans were found, and a surrounding surveillance zone of 10 km. Within the protection zone, poultry must be kept indoors, movement of poultry is banned except directly to the slaughterhouse, and the dispatch of meat outside the zone is forbidden except under very limited conditions.
(Promed 2/15/06)

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Croatia: Excerpts from OIE report on avian influenza H5 detected in ducks
Information received 8 Feb 2006 from Dr. Mate Brstilo, Director of the Veterinary Administration, Ministry of Agriculture and Forestry, Zagreb: Identification of agent: avian influenza virus serotype H5. Date of first confirmation of event: 21 Oct 2005. Date of start of event: 19 Oct 2005. During regular monitoring activities conducted at Ribnjak 1905 fish pond, samples were taken from 26 wild ducks (Anas platyrhyncos) and sent to the Poultry Centre of the Croatian Veterinary Institute for analysis. Laboratory testing (after 3 passages in chicken embryos) revealed 2 samples were positive for avian influenza virus subtype H5, but the genetic tests revealed negative results for N1. The amino-acid chain (PQRTRGL) does not point to a virus of high pathogenicity. The nucleotide sequence (500 base pairs that encode for hemagglutinin) resembles that of influenza virus type A (Anas platyrhyncos/Chany Lake/9/03 [H5N3]) isolated in Western Siberia. *** Previously, in Dec 2005, investigators found an H5N1 in swans from the same pond. December’s H5N1 was fingerprinted and found to be highly similar to virus subtypes previously identified in Qinghai lake (China), Turkey and Romania.
(Promed 2/13/06)

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Bulgaria: Confirmation of H5N1 avian influenza infection in swan
On 13 Feb 2006 it was confirmed that samples sent to a reference laboratory after a first analysis by local institutes confirmed the H5N1 strain of bird flu in Slovenia, Bulgaria and Greece (see below for official OIE details). Bulgaria announced 11 Feb 2006 that the highly pathogenic H5N1 strain had been found in Bulgaria for the first time. The latest bird found with H5 was a swan near the Black Sea port Bourgas, 3.5 km from a farm with 120 000 egg-laying hens (the other dead birds were from Lake Shabla, near the northern border with Romania). Authorities are also awaiting results from 2 other H5-infected swans found dead near the Black Sea coast and have started preliminary tests on at least 9 more swans, 2 ducks and a cormorant found dead.

The Commission said that imports of poultry and poultry products from non-EU member Bulgaria were already banned and that the restrictions would be further extended to cover live poultry and birds as well as eggs and unprocessed feathers from the affected areas. The EU’s top veterinary experts are set to meet in Brussels 16 Feb 2006 to analyse the situation. Chicken consumption has already fallen in Bulgaria since reports on the imminent bird flu started circulating in the country. Bulgarian poultry producers said they were concerned that the spread could cause serious damage to a business worth millions of euros and which employs more than 20 000 people. Police have blocked access to wetland areas and begun to shoot wild predators to prevent them from spreading the remains of potentially contaminated birds. They also plan to post signs in high-risk areas warning. Elsewhere, authorities in Bosnia-Herzegovina announced a ban on the import of live poultry, poultry meat and poultry products from Bulgaria, Greece, Italy and Slovenia. Macedonia also suspended the import of live poultry and poultry meat from Bulgaria, Greece and Italy.

Official notification on the case was sent 12 Feb 2006 to OIE:
http://oie.int/downld/AVIAN%20INFLUENZA/Bulgaria_AI_10_02_2006.pdf. The report included the following: Swan (Cygnus olor) found dead in Vidin (Danube river). Start of event: 31 Jan 2006. First confirmation, by the National Diagnostic Research Veterinary Medical Institute - Sofia: 3 Feb 2006. Diagnosis details: Virus Isolation In Embryonated Chicken Eggs. Result: H5 positive. Final confirmation, by the Reference Laboratory of EU in England/Veterinary Laboratories Agency: 11 Feb 2006. Real time PCR result: H5N1 positive.
(Promed 2/10/06, 2/12/06, 2/13/06, 2/14/06)

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Greece: Confirmation of H5N1 infection in birds; suspect human cases test negative
Authorities confirmed the presence of the highly pathogenic H5N1 virus in 3 swans in northern Greece, reporting the first cases of infected migratory birds on European Union soil. Preventive measures include isolating poultry and keeping flocks indoors, banning hunting, disinfecting farms and a ban on meat or eggs from the areas. Greece also confirmed H5N1 infection in a dead wild goose from the Island of Skyros, after tests returned positive from the UK laboratory. On Skyros, an island of about 2900 inhabitants, the necessary precautions have already been taken, Mayor Miltiadis Hadjiyannakis said. “A veterinary squad from the local prefecture is already here, we have vaccinated a number of municipal staff for house calls, and our citizens have been briefed on the issue,” he said. Bird hunting has been banned there and the prefecture of Salonika, while owners of poultry in both areas have been ordered to shut their flocks indoors. Protection zones have been created around the airport of Skyros, and 3 beaches near Salonika. Skyros has no major poultry farms, but a 3-km zone around the area of the dead bird’s discovery has been imposed regardless, Hadjiyannakis noted. A Greek airman who found the goose at the island’s airport 2 Feb 2006 has already been tested, and has displayed no worrying signs, he added.

From OIE, 15 Feb 2006, the following are given pertaining to a case on Skyros island confirmed as H5N1 by the UK lab: On 3 Feb 2006 in the area of Skyros Island, people informed authorities about the presence of 1 wild goose (Branta ruficollis) found dead. Authorities observed no anatomopathological signs. According to an epizootic survey, there are no findings of avian influenza in the area, while strict biosecurity measures have been applied to all backyard flocks kept in villages over the whole island. There are no commercial poultry farms on the island.

Greek authorities stated 14 Feb 2006 that 2 suspected human cases of avian influenza infection had tested negative. A 15-year-old boy was released 13 Feb 2006 after twice testing negative. The 29-year-old hunter was released from quarantine 14 Feb 2006, after he also tested negative. They had both come into contact with suspect bird cases and had developed flu-like symptoms. Both were in quarantine in separate hospitals in Thessaloniki, close to where the initial cases of H5N1 bird flu were found. Officials have resorted to the Greek Orthodox church to step up the fight against bird flu. The Health Ministry asked priests to spread the word on precautions farmers should take to prevent infection by reading an advice bulletin to worshippers. It includes measures such as regular handwashing, a warning against approaching wild or free range birds, and a request that any dead poultry be reported immediately to the authorities.
(Promed 2/13/06, 2/14/06, 2/15/06)

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Iraq: Suspected human cases of avian influenza under investigation
Iraqi doctors are investigating 6 suspected human cases of avian influenza in southern Iraq, including 1 in which a 25-year-old fisherman died after contact with birds he was keeping in his yard, officials said 12 Feb 2006. Tests are now being performed to determine whether the fisherman, who died recently in a hospital after exhibiting symptoms of bird flu for more than 2 weeks, was infected with the A(H5N1) strain, said Dr. Ibitsam Aziz, a spokeswoman for an Iraqi government committee. The fisherman entered the hospital a week after developing a fever. 2 weeks after the fever began, the man had difficulty breathing. 5 of the fisherman’s cousins, who had all been living with him in Amara and had also come in contact with the same birds, are also being tested. A positive result would show that the H5N1 virus had spread to southern Iraq, where the quality of communications and health care is much lower than elsewhere in the country. The only confirmed human case of avian influenza in Iraq was reported Jan 2006 in Iraqi Kurdistan, after tests showed that a girl had died from bird flu. 2 other suspected cases in the same area are being investigated. Dr. Sam Yingst, an American veterinarian and virologist who led an international investigation team to Kurdistan, estimated that in the effort to halt bird flu there, at least 200 000 chickens had been slaughtered in Sulaimaniya Province, and tens of thousands in neighboring Erbil Province. Many Iraqis are now shunning chicken dishes, and chicken restaurants have shut their doors across the affected region, Dr. Yingst said, warning of unnecessary damage to a crucial part of Iraq’s agriculture industry. He said chickens could still be eaten if killed and cooked using basic sanitation methods.

Excerpts from OIE report on avian influenza
Information received 7 Feb 2006 from Dr. Dawood M. Sharief, Director General, Iraqi Veterinary Services, Ministry of Agriculture: End of previous report period: 2 Feb 2006. End of this report period: 7 Feb 2006. Identification of agent: avian influenza virus subtype H5. Date of first confirmation of the event: 1 Feb 2006. Date of start of the event: 18 Jan 2006. First administrative division: Missan. Lower administrative division: Amarha. Number of animals in the outbreak: Susceptible (980); cases (2) deaths (2) destroyed (978) slaughtered (0). Description of affected population: pigeons. Source of outbreak or origin of infection: under investigation. Control measures: stamping out; quarantine; movement control inside the country; screening; zoning; disinfection of infected premises/establishment(s); dipping/spraying. Vaccination prohibited.
(Promed 2/13/06)

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Iran: Reportedly confirms H5N1 strain in wild swans
Iran’s veterinary organisation said the first cases of the H5N1 strain of bird flu had been detected in wild swans. “International laboratory results confirm that some wild swans died from bird flu,” the organisation said. An official from the organization confirmed the birds had died from the H5N1 strain. The dead swans came from wetlands near the Caspian Sea port of Bandar-e Anzali on Iran’s northern coast, a wintering spot for many wild fowl from Russia. On 7 Feb 2006, the Iranian veterinary Services officially reported to the OIE about suspected cases of avian influenza in swans. (see EINet Newsbrief 10 Feb 2006). Following the addition of Iran, Austria and Germany, there are, as of 14 Feb 2006, 12 countries where swans have been found affected by H5N1: Mongolia, Russia (Astrakhan region, Krasnodar region and Dagestan), Romania, Croatia, Bulgaria, Greece, Italy, Slovenia, Iran, Austria and Germany.
(Promed 2/14/06)

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Azerbaijan: Reports H5N1 strain found in wild birds
Azerbaijan said 10 Feb 2006 that the H5N1 strain of bird flu had been found in birds. Samples from wild birds in the Caspian Sea were sent for tests to London and showed the bird flu strain was present, a spokesman for the Health Ministry said. “In some analyses the H5N1 bird flu strain was found,” a spokesman for the ministry said. “Bird flu has not yet been found in the human population.” At the beginning of Jan 2006, the Azerbaijani veterinary services stated that mass mortality of birds in the Massaly region (near the Iranian border) was not caused by avian influenza. Deaths of birds were recorded in Azerbaijan also during Oct/Nov 2005 (see FAO review of 6 Nov 2005). They remain undiagnosed.
(Promed 2/10/06)

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Russia (Krasnodar, Dagestan): New cases of H5N1 avian influenza in wild fowl
Russia has found new cases of H5N1 in wild fowl in the south of the country, the Agriculture Ministry said 13 Feb 2006. The virus was found in wild swans and ducks in 2 regions bordering the Black Sea and the Caspian Sea. “Cold weather forces wild fowl to migrate over short distances, spreading the (bird) flu virus of group A, H5N1 strain,” the ministry said. “Recently, the virus has been found in wild swans and wild ducks in the littoral zone of the Krasnodar region and Dagestan.” Veterinary experts have been sent to the region to monitor the situation. Also, a total of 42 467 chickens have died at the Makhachkalinskaya poultry farm, a source at the Emergency Situations Ministry southern regional center said 13 Feb 2006. The farm housed 275 000 chickens before the outbreak. Samples have been sent to the Dagestani veterinarian laboratory, the central veterinarian laboratory, the Poultry Research Institute, and the Animal Health Institute. The Eldama poultry farm in the Karabudakhkent district of Dagestan, which suffered an outbreak of Newcastle Disease 3 Feb 2006 in which 300 000 chickens were lost, is situated 40 km away from Makhachkalinskaya, the source said. Russia has been battling bird flu in poultry since July 2005, culling more than 600 000 domestic fowl.
(Promed 2/14/06, 2/15/06)

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Ukraine: H5 avian influenza outbreak suspected
An H5 avian-flu subtype was found in 24 villages in Crimea and the village of Tsevetochnoe was quarantined, the Ukraine Health Ministry said. The country of 47 million people has reported at least 33 outbreaks of avian flu since Nov 2005, according to the World Organization for Animal Health. Further difficulties are expected when migratory birds pass through Ukraine on their way north in the spring. OIE said more than 40 000 poultry had been culled in the Shevchenkovskiy district of Ukraine’s Kharkiv region after Newcastle disease infected 13 346 fowl. Ukraine sent a report on Highly Pathogenic Avian Influenza to the OIE 9 Feb 2006: <http://www.oie.int/eng/info/hebdo/AIS_32.HTM#Sec11>. According to the said notification, “no further suspected cases have been reported” since 28 Jan 2006.
(Promed 2/12/06, 2/14/06)

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Romania: Finds new suspect avian influenza cases in fowl
Romania found cases of suspected bird flu in fowl close to the Black Sea port of Constanta, authorities said 13 Feb 2006. Avian flu has been discovered in 29 villages across the country since the virus was first detected Oct 2005. “Rapid tests on 2 dead hens found in a courtyard [backyard?] led to suspicion of the presence of the H5 type of the virus in the Topraisar village, in the county of Constanta,” the country’s chief veterinarian Ion Agafitei said. The village is 40 km north of the border with Bulgaria. Agafitei said all 20 hens from the courtyard were killed. The village will be quarantined, and birds will be culled there if further checks confirm the presence of the H5 type. Samples will be sent to the UK laboratory for more testing. Last week, Romania confirmed the presence of the H5 type in poultry in a village. The delta is Europe’s largest wetlands and lies on a major migratory route for wild birds.
(Promed 2/10/06, 2/13/06)

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Asia
Hong Kong: Additional suspected avian influenza cases in birds
Hong Kong authorities 9 Feb 2006 said they won’t be surprised if more birds fall ill. The government announced 8 Feb 2006 that a dead egret found in an urban district has tested positive for H5N1. Final test results on a dead chicken and on a Japanese White-eye (Zosterops japonicus) weren’t available yet. Officials collected another dead bird 9 Feb 2006, a Red-whiskered Bulbul (Pycnonotus jocosus), in the same area. It will be tested but wasn’t yet considered a suspect case. Health Secretary York Chow said the government is searching for sites near chicken farms to set up slaughterhouses for centralized killing of chickens. The government has also tried to control the outbreak by banning people from raising poultry at home. The ban, under which offenders can be fined up to 100 000 Hong Kong dollars (USD 12 880), reportedly starts 13 Feb 2006. Hong Kong has been successfully implementing an AI prevention/control policy, combining effective, strict biosecurity measures in poultry farms and markets, intensive surveillance in domestic and wild birds, regulated controlled imports and preventive poultry vaccination.
(Promed 2/10/06)

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Indonesia: 26th human case of avian influenza; number of human cases rising
The Ministry of Health has confirmed an additional 2 cases of human infection with the H5N1 avian influenza virus. Both cases were fatal. The first case occurred in a 22-year-old woman who developed symptoms 25 Jan 2006 and died 10 Feb. Her neighbours kept chickens. Samples from these chickens and from pet birds in a market near the woman’s home are being tested by Indonesia’s authorities. The second case occurred in a 27-year-old woman who developed symptoms 31 Jan and died 10 Feb. Deaths of chickens in her neighbourhood were reported 4 days prior to symptom onset. The 2 women resided in different sub-districts of West Java Province (suburb area of Bekasi). The newly confirmed cases bring the total in Indonesia to 25. Of these, 18 were fatal. Additionally, Indonesia reported 13 Feb 2006 that WHO confirmed the country’s 26th human case of bird flu. Hariadi Wibisono, Director of Control of Animal-borne Diseases at the ministry, said a WHO-recognized laboratory had confirmed a Nov 2005 case in which the patient survived. “It was an old case, but we only recently received the confirmation. He was admitted on 25 Nov 2005 but became well again,” Wibisono said; the man was from Central Java province. Local tests also showed a 23-year-old man died of bird flu 10 Feb 2006, and samples have been sent to the WHO laboratory. Reportedly, he worked in a traditional market transporting chicken eggs. For financial, social and political reasons, Indonesia has been reluctant to undertake the mass culling of fowl, concentrating instead on selective culling, and on public education and hygiene measures aimed at prevention.

Indonesia’s human cases of avian influenza are occurring with increasing frequency, prompting the government to step up monitoring efforts aimed at slowing the spread of the virus among animals, the agriculture minister said. Humans are contracting H5N1 strain of the virus at a faster pace, causing more deaths, said Agriculture Minister Anton Apriantono. “We will step up preventive efforts, be more proactive. We will do checking even on areas that haven’t seen any cases of dead poultry. Information dissemination about bird flu will be stepped up.” Indonesia has the second-highest number of avian influenza cases among humans in the world (Indonesia has the most bird flu deaths so far this year). The H5N1 virus has affected birds in 2/3rds of the provinces in Indonesia. The country’s suspected sixth cluster of human infections, involving 2 adults and their 2-year-old daughter, has heightened concerns. WHO has said public awareness needs to be increased, particularly in urban areas where there is a greater density of both human and fowl populations. About 30 million households in villages live alongside more than 200 million fowl. Indonesia is aiming to raise the number of designated bird flu hospitals to 100 from 44 by the end 2006 and plans to boost stocks of the antiviral Tamiflu.
(Promed 2/12/06, 2/13/06, 2/15/06)

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China: 35 persons under quarantine; Twelfth confirmed human case of avian flu
Chinese authorities have placed 35 people under observation after 15 000 fowl died of avian influenza on the farm where they were working. The Xinhua news agency, citing government sources in Shanxi province, said the 35 workers had been confined to their homes in Yangquan city and were receiving twice-daily medical check-ups. Authorities have confirmed that the H5N1 strain killed 15 000 poultry on their farm and said 187 745 more had been culled in the affected area. The health ministry had just announced China’s 11th human case of bird flu. The 26-year-old woman from Fujian province tested positive for H5N1 after being hospitalised 10 Jan 2006, but was in a stable condition, it said. Like most of the other human cases in China, no outbreak among animals was detected in Zhangpu county where the woman lived. The Fujian provincial agricultural department has collected 319 poultry samples within a 3-km radius of the woman’s home, but all have reportedly tested negative. Julie Hall, a WHO expert, said “What we’ve seen in quite a number of other cases in China is that the Ministry of Agriculture has not been able to identify viruses in the animals in that area. But there certainly have been reports from the health authorities and patients themselves that animals in their areas have been dying and have been sick for some weeks prior to their onset of their illness. We believe the virus is endemic in parts of China and certainly endemic in wild birds.” China has reported 34 H5N1 outbreaks among poultry since 2005, with most appearing since Oct 2005.

The Ministry of Health has also just reported the country’s 12th laboratory confirmed case of human infection with the H5N1 avian influenza virus. The case occurred in a 20-year-old female farmer from Hunan province. She developed symptoms 27 Jan 2006 and was subsequently hospitalized with severe pneumonia. Symptom onset followed the culling of poultry raised by her household. She died 4 Feb 2006. To date, China has reported 8 fatal human cases.
(Promed 2/11/06, 2/13/06)

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Americas
USA: CDC wants more healthcare workers to get flu shots
CDC issued new recommendations in an effort to push the percentage of healthcare workers who receive influenza shots above the 40% range. “The new recommendations provide strategies to make vaccine more accessible to healthcare workers and to help facilities better determine coverage rates and the reasons their staff have for not getting vaccinated,” CDC said. The new recommendations are intended to help healthcare workers boost immunization rates in their institutions. Flu immunization coverage among healthcare workers was only about 10% as recently as 1989. The rate improved to 40% in the ensuing few years, but it has remained relatively constant since 1997. The recommendations were prepared by the Healthcare Infection Control Practices Advisory Committee and the Advisory Committee on Immunization Practices. They recommend that healthcare facilities:

- Educate employees about the benefits of flu immunization and the risks of flu for themselves and their patients
- Offer vaccine each year to all eligible employees in order to protect them, their patients, and family members and to reduce absenteeism
- Provide free flu shots on site during all shifts and use strategies such as mobile carts and modeling and support by leaders
- Obtain a signed “declination form” from employees who refuse a flu shot for reasons other than medical contraindications
- Monitor flu vaccination coverage and refusals at regular intervals during the flu season and provide staff/administrators with information on rates by wards, units, and specialties
- Use flu immunization rates “as one measure of a patient safety quality program”

CDC states the effect of signed declination statements on immunization rates has not been studied. Using such forms can help facilities identify workers “who might require targeted education or other interventions to overcome barriers to vaccine acceptance.” The practice would also help facilities monitor how many employees are offered vaccine. How many healthcare facilities currently offer free flu shots or ask for signed refusal forms is unclear. Researchers have found that the leading reason healthcare workers refuse flu shots is fear of side effects, followed by inconvenience and perceived ineffectiveness of the vaccine. The CDC report says that as of Jan 2005, 13 states had passed laws concerning flu immunization for staff members in long-term-care facilities. But the effects of the laws are not yet clear. Last October the federal government began requiring nursing homes that serve Medicare and Medicaid recipients to offer flu shots to all residents. But the rule did not require vaccination of staff members.
(CIDRAP 2/13/06 http://www.cidrap.umn.edu/ )

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USA: Summaries from the CIDRAP business preparedness conference
The business preparedness conference sponsored by the Univ. of Minnesota Center for Infectious Disease Research and Policy, along with the US and Minnesota Chambers of Commerce, brought predictions that a major pandemic would put the world economy into reverse. The meeting drew representatives of more than 200 companies with a total of more than 7.5 million employees and $2.6 trillion in annual revenue. But speakers also said that 98% of people would survive, and preparation for “foreseeable risks” will help businesses weather the storm with less damage. US Health and Human Services Secretary Michael Leavitt warned that every business, government agency, community, school, organization, and household should develop and test a pandemic preparedness plan. Dr. Michael T. Osterholm, director of CIDRAP, presented background on pandemics; a major theme was that recent research has uncovered chilling similarities between the current H5N1 virus and the H1N1 virus responsible for the 1918 pandemic.

Economic strategist Dr. Sherry Cooper, executive vice president of BMO Financial Group, said the SARS outbreak in Toronto hinted at the possible impact of a pandemic. The virus infected only 252 people and caused 44 deaths in the city, but hospitals filled up and had to stop all nonessential services, while WHO warned against traveling to Toronto. She spoke of the “blurring” of national economic boundaries in a world of multinational corporations, global travel, and international supply chains. Travel now accounts for 10% of the world’s gross economic activity and 8% of jobs, she said. “It is our rough estimate that. . .the global economy would lose roughly 6 percentage points worth of growth in a 3-month period.” The US economy would take an estimated $670 billion hit. She advised businesses to expect absenteeism rates of about 30% at the peak. “Imagine no waste management, no clean water, no electricity—not just for a couple of days, but perhaps for weeks,” she said. Fuel shortages, consumer hoarding, shortages of medical supplies, etc. would make matters worse.

Attorney Cheryl Falvey advised business leaders to assess the risks a pandemic would pose and then take documented steps to limit them. Falvey is a partner with Akin Gump Strauss Hauer and Field LLP. Consequences of a pandemic include economic losses, supply-chain disruptions, employee absenteeism, quarantines and travel restrictions, an increase in health care, and in tourism decline. Most juries in liability suits understand that accidents happen and human errors occur, Falvey said. “What juries don’t forgive is a failure to assess, a failure to act, to commit money and resources to deal with a problem,” and to involve top management in that effort, she said. “Jurors want to know that there was an adequate planning process and that all possibilities were considered, and they were balanced,” she said.

Only 18% of the companies have completed a preparedness plan, according to the conference poll. 59% of respondents said their companies had started working on preparedness but did not yet have a plan in place. Another 21% said they hadn’t started planning, and 2% said they would rely on their existing crisis management plan. 23% said their company perceived the likely impact of a pandemic on its operations as a “crisis,” 40% viewed the impact as serious, and 25% called it important. 84% said they “definitely” believed that a pandemic would disrupt their supply chains, and 14% called this outcome probable. 53% said the federal government is definitely not doing enough to prepare the private sector for the threat. 73% thought government interventions would have a major impact on their business during a pandemic; 68% thought that impact would be unfavorable. 92% agreed that developing relationships now with local governments would help them respond to a pandemic. 75% agreed that information-technology preparedness, especially having secure remote access to their computer systems, would be a “key issue”. Close to 2/3 said they were already prepared or somewhat prepared to move employees to remote locations or let them work at home (29% said they were not prepared). 85% agreed strongly or somewhat that employees would be reluctant to come to work in a pandemic. Communication was listed as the most important planning area by 52%.

A major flu pandemic would make it very difficult for the US healthcare system to maintain routine services, a reality that few Americans are aware of, said Dorothy Teeter, interim director of public health for Seattle and King County, Washington. Teeter said her department has assembled a coalition of healthcare organizations “to work on what the healthcare system would look like” during a pandemic, when hospitals and clinics could be overwhelmed. “We have a whole team working on triage, self-care, and telephonic consultations,” among other approaches for maintaining services to special populations in that situation, she said. “People will have to understand there will be a very different [healthcare] system in place. If you don’t tell them the truth, I think we’ll have a huge social unrest problem.”

King County has also set up groups to work with the business community and with public officials on pandemic preparedness. The business group has discussed issues such as school closings. Business leaders said they would like a couple of days’ warning if the county decides to close schools, because many parents then would need to stay home to care for their children. Teeter said the county is stockpiling Tamiflu to help maintain the healthcare workforce. “We’re not thinking about prophylactic use, because there’s not enough Tamiflu,” she said. “But we are going to be prepositioning Tamiflu. . .We’ve been able to buy Tamiflu over and above normal use.” A Seattle medical examiner suggested that health officials develop instructions for residents on how to bury bodies in their backyards, in case the number of flu victims outstrips the area’s ability to handle the bodies. That situation occurred in some cities in the 1918 pandemic. Teeter cited an estimate that a pandemic could kill 11,000 people in Seattle in 6 weeks.
(CIDRAP 2/14/06, 2/15/06 http://www.cidrap.umn.edu/ )

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1. Updates
Influenza
Seasonal influenza activity for the Asia Pacific and APEC Economies During weeks 2–3 2006, widespread influenza activity was reported in a few states/provinces in Canada, Japan and the US, while in the rest of the world activity remained low.

Canada. The consultation rate of influenza-like illness (ILI) was below the epidemic threshold during weeks 2–3. Widespread influenza activity was reported in part of British Columbia during week 3, while activity was low in the rest of Canada.
Hong Kong. A slight increase in influenza A(H1) and B activity continued to be observed during weeks 2–3. Overall activity was low.
Japan. Widespread influenza A(H3N2) activity continued to be reported. Other reports. During weeks 2–3, low influenza activity was detected in Chile (A) and Mexico (A). Russian reported no influenza activity
(WHO 2/13/06 http://www.who.int/csr/disease/influenza/update/en/ )

USA. During week 6 (Feb 5 – Feb 11, 2006), influenza activity increased in the US, primarily in the eastern half of the country. 455 specimens (18.7%) 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 was above the national baseline. The proportion of deaths attributed to pneumonia and influenza was below the baseline. 13 states reported widespread influenza activity; 21 states and New York City reported regional activity; 11 states and the District of Columbia reported local activity; and 5 states and Puerto Rico reported sporadic activity.

For the comprehensive update on recent influenza activity in the USA (“Update: Influenza Activity--United States, January 29—February 4, 2006”): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5506a4.htm (CDC 2/17/06 http://www.cdc.gov/flu/weekly/ )

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 is available. WPRO website on avian influenza: http://www.wpro.who.int/health_topics/avian_influenza/overview.htm
- FAO updates on avian influenza: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Includes latest documents on Nigeria situation.
- OIE updates and documents on avian influenza: http://www.oie.int/eng/en_index.htm. Includes latest updates on Nigeria situation.
- CDC website on pandemic influenza: http://www.cdc.gov/flu/pandemic.htm. For avian influenza: http://www.cdc.gov/flu/avian/.
- The US government’s web site for pandemic flu: http://www.pandemicflu.gov/. The latest State Summit summaries are available.
- 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/.
- PAHO’s updates on avian influenza: http://www.paho.org/English/AD/DPC/CD/influenza.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/disease_information/avian_influenza/index.jsp.
(WHO; FAO, OIE; CDC; US FDA; CIDRAP; PAHO; APHA; AVMA; USGS)

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2. Articles
Comparative Activities of Oseltamivir and A-322278 in Immunocompetent and Immunocompromised Murine Models of Influenza Virus Infection
Ison MG, Mishin VP, Braciale TJ, Hayden FG, Gubareva LV.
Abstract: We developed an immunocompromised murine model of influenza virus infection and demonstrated comparable efficacy of oral oseltamivir and A-322278 (both given at dosages of 10 mg/kg/day) in reducing viral replication, decreasing weight loss, and prolonging survival. Once the treatment was discontinued, severe combined immunodeficient (SCID) mice had progressive viral replication and clinical decline. Drug-resistant variants were detected in 4 (29%) of 14 and 2 (13%) of 15 mice (both BALB/c and SCID) treated with oseltamivir or A-322278, respectively; no resistant variants were detected in placebo-treated mice. Amino acid substitutions in the hemagglutinin receptor-binding site at aa 137 or 225 were detected in cloned resistant isolates. A substitution in the neuraminidase (NA) active site (Arg292Lys) was detected in the cloned virus recovered from an oseltamivir-treated mouse. This model would be useful for elucidation of the molecular mechanisms of resistance to NA inhibitors and for testing of anti-influenza therapy options that might prevent the emergence of resistant variants.
J Infect Dis. 2006 Mar 15;193(6):765-772. Epub 2006 Feb 13.
(CIDRAP http://www.cidrap.umn.edu/ )

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Recovery of drug-resistant influenza virus from immunocompromised patients: a case series
Ison MG, Gubareva LV, Atmar RL, Treanor J, Hayden FG.
Abstract: Influenza virus with resistance to antiviral drugs emerges with increased frequency in immunocompromised patients and can limit the benefit of M2 and neuraminidase (NA) inhibitors. We document 3 cases of influenza in severely immunocompromised patients from whom virus variants with molecular markers of resistance to anti-influenza drugs were recovered. Virus variants recovered from 2 patients had mutations in the M2, NA (with a previously recognized Glu119Val NA substitution), and hemagglutinin genes. We describe a novel Asp198Asn NA mutation in an influenza B virus and its decreased susceptibility to both oseltamivir and zanamivir.
J Infect Dis. 2006 Mar 15;193(6):760-764. Epub 2006 Feb 13.
(CIDRAP http://www.cidrap.umn.edu/ )

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Global macroeconomic consequences of pandemic influenza
CIDRAP offers a new document in PDF from the Lowy Institute for International Policy: http://www.cidrap.umn.edu/. The article concludes that, while there are many unknowns in modeling pandemic influenza scenarios, the analysis was able to draw some economic insights and quantify potential economic consequences of 4 plausible epidemiological scenarios. Their analysis suggests that the economic consequences are potentially very large and disparate across countries. Developing countries are far more negatively affected than large economies. The extent of potential losses suggest that large investment of resources should be dedicated to preventing an outbreak of pandemic influenza.

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 apecein@u.washington.edu