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Vol. IX, No. 6 ~ EINet News Briefs ~ Mar 24, 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)
- WHO pandemic influenza draft protocol for rapid response and containment
- Two clades of avian influenza H5N1 virus
- Mad cow disease on the wane worldwide
- Improved formula for oral rehydration salts to save children’s lives
- Cameroon: Avian influenza H5N1 infection in poultry; contact with wild birds
- Egypt: Fourth suspected human case of avian influenza infection
- Nigeria: Excerpts from the OIE report on avian influenza H5N1
- Afghanistan: Tests confirm avian influenza H5N1 infection in dead chickens
- Albania: Avian influenza H5N1 infection confirmed in poultry
- Azerbaijan: Avian influenza H5N1 infection confirmed in 7 humans
- Croatia: Seagulls carrying avian influenza H5N1
- Denmark: More avian influenza cases found in birds; sequence information
- Greece: 4 more swans have avian influenza H5N1 infection
- Israel: Seventh outbreak of avian influenza in poultry
- Jordan (Jordan valley): Avian influenza H5N1 infection confirmed in turkeys
- Kazakhstan (west): Avian influenza H5N1 infection in wild birds
- Netherlands: Voluntary avian influenza vaccination; Japan bans Dutch poultry
- Pakistan: Avian influenza H5N1 infection confirmed in poultry
- Palestine (Gaza strip): Avian influenza H5N1 infection confirmed in poultry
- Poland: Second nucleus of H5 avian influenza found
- Romania (Ilfov): Avian influenza H5N1 infection in poultry outbreak
- Serbia and Montenegro: Excerpts from the OIE report on avian influenza H5N1
- Sweden: H5N1 strain in dead owl; excerpts from the OIE report on avian influenza H5N1
- Turkey: Excerpts from the OIE report on avian influenza H5N1
- Cambodia: Study suggests mild avian influenza cases are not going undetected
- Cambodia: Fifth case of human infection with avian influenza H5N1
- China: OIE says some Chinese avian influenza vaccines ineffective
- China: 16th human case confirmed
- India (Maharashtra): Avian influenza H5 in poultry
- Indonesia: Additional human case of avian influenza H5N1 infection
- Malaysia: Avian influenza H5N1 in poultry and wild birds
- Myanmar: Avian influenza H5N1 infection confirmed in poultry
- Russia: Avian influenza outbreaks in poultry; vaccinations
- Thailand (Nan): Botulism outbreak associated with bamboo shoots
- Malaysia (Sarawak): 8 killed in outbreak of Hand, foot, and mouth disease
- USA: Latest updates from Pandemicflu.gov
- USA: FDA Prohibits Use of Antiviral Drugs in Poultry
- USA (Alabama): BSE confirmed in cow
- USA (Iowa): Outbreak of 60 mumps cases
- USA (New Mexico): Third case of Hantavirus pulmonary syndrome in 2006
- Peru (Ayacucho): 4 people die from yellow fever

1. Updates
- Influenza
- Dengue

2. Articles
- CDC EID Journal, Volume 12, Number 4—April 2006
- Avian Influenza's Human-attack Pathway Revealed
- Study Identifies Mutations Needed For Human Bird Flu Pandemic
- Influenza in Tropical Regions
- Severe acute respiratory syndrome diagnostics using a coronavirus protein microarray
- Studies Propose Targeted Screening of Blood for West Nile Virus
- Concept of operations for triage of mechanical ventilation in an epidemic
- Emergence of Mycobacterium tuberculosis with Extensive Resistance to Second-Line Drugs--Worldwide, 2000-2004
- Trends in Tuberculosis ---United States, 2005
- Primary and Secondary Syphilis --- United States, 2003--2004
- Increased Antiviral Medication Sales Before the 2005-06 Influenza Season--New York City
- Inhalation Anthrax Associated with Dried Animal Hides--Pennsylvania and New York City, 2006

3. Notifications
- APEC Symposium on Emerging Infectious Diseases
- Advancing Global Health: Facing Disease
- Fiji to host global meeting in the fight against lymphatic filariasis
- World TB Day 2006

4. To Receive EINet Newsbriefs
- APEC EINet email list


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
Azerbaijan / 7 (5)
Cambodia / 1 (1)
China / 8 (6)
Indonesia / 12 (11)
Iraq / 2 (2)
Turkey / 12 (4)
Total / 42 (29)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 186 (105)

A collection of general and regional avian influenza maps from various websites, including interactive maps and maps which are updated daily, is available at http://www.lib.utexas.edu/maps/avian_influenza.html. To see the updated list of animal species known to be susceptible to infection by the HPAI H5N1 virus, go to: http://www.nwhc.usgs.gov/disease_information/avian_influenza/affected_species_chart.jsp
(WHO 3/24/06 http://www.who.int/csr/disease/avian_influenza/en/ ; Promed 3/12/06)

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WHO pandemic influenza draft protocol for rapid response and containment
"The WHO pandemic influenza draft protocol for rapid response and containment" posits the possibility of identifying an emerging pandemic in time to stop it by using antivirals, isolation, quarantine, and social distancing. The new document is a revision of a first draft that was released Jan 2006 and can be found at: http://www.who.int/csr/disease/avian_influenza/guidelines/pandemicfluprotocol_17.03a.pdf. The concept is based on mathematical models suggesting that early, efficient human-to-human transmission of a potential pandemic virus could be identified and contained if authorities had appropriate surveillance in place and moved quickly to quell the outbreak. The models relied on mass dispensing of antiviral drugs in an outbreak zone, along with social distancing and quarantine measures. "No attempt has ever been made to alter the natural course of a pandemic near its start," WHO says. "Moreover, given the unpredictable behavior of influenza viruses, no one can know in advance whether the start of a pandemic will begin gradually, following the emergence of a virus not yet fully adapted to humans, or be announced by a sudden explosion of cases, thereby precluding any attempt at containment."

To further that effort, an international stockpile of antivirals has been created with industry donations. 3 million treatment courses will be ready by May 2006 for use only in an intervention to contain the virus at it source, the WHO said. Success would depend on prompt response to suspicious clusters of human influenza cases. The mass dispensing of antivirals would need to start within 21 days after detection of the first case of efficient human-to-human transmission. Accomplishing that implies succeeding at a number of earlier steps, including detecting the clusters, communicating quickly and accurately from the local to the international level, and quickly obtaining outside assistance in investigation and response. WHO recommends investigating clusters of 3 or more people with unexplained moderate-to-severe respiratory illness and with illness onsets within 7 to 10 days of one another. In addition, the patients in the cluster must have a history "strongly suggesting potential exposure to the H5N1 virus". The WHO identified 4 trigger points for attempting rapid containment of a virus. The document also identifies situations in which rapid containment should not be tried. The initial protocol is still being refined, with a meeting scheduled 28 Mar 2006 with Roche officials to refine procedures for delivering the company's oseltamivir supplies to WHO. Currently the plan indicates that Roche stands ready to ship 1.5 million doses stored in the US and another 1.5 million doses stored in Switzerland. The WHO document further describes the roles and responsibilities of countries in helping to contain a pandemic, as well as the roles and responsibilities of WHO. One of the agency's roles will be to train rapid reaction teams over the next few months. (Promed 3/23/06)

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Two clades of avian influenza H5N1 virus
The H5N1 avian influenza virus in humans has evolved into 2 separate strains, a development that will complicate the search for a vaccine, U.S. researchers reported 20 Mar 2006. The genetic diversification of the pool of H5N1 avian influenza viruses with the potential to cause a human influenza pandemic heightens the need for careful surveillance, researchers said at the International Conference on Emerging Infectious Diseases. "Back in 2003 we only had 1 genetically distinct population of H5N1 with the potential to cause a human pandemic. Now we have 2," said Rebecca Garten of the U.S. CDC, who helped conduct the study. 1 of the 2 strains, or clades, made people sick in Vietnam, Cambodia and Thailand in 2003 and 2004 and the second caused the disease in people in Indonesia in 2005. 2 clades may share the same ancestor but are genetically distinct, the team found. "This does complicate vaccine development. But we are moving very swiftly to develop vaccines against this new group of viruses," said Dr. Nancy Cox, chief of the CDC's influenza branch. Cox said the evolution of a second clade does not move the virus closer to human-to-human transmission. "Like the group one or clade one viruses, the group 2 or clade 2 viruses are not easily transmitted from person to person," she said. "It really doesn't take us closer to a pandemic. It simply makes preparing for the pandemic a bit more difficult." The U.S. Health and Human Services Department has already recognized the 2 strains and approved the development of a second H5N1 vaccine based on the second clade. Several companies are working on H5N1 vaccines experimentally, although current formulations are not expected to protect very well, if at all, against any pandemic strain. A vaccine against a pandemic flu strain would have to be formulated using the actual virus passing from person to person. Researchers said while vaccines were needed against different strains of the virus, a vaccination against 1 clade could provide partial protection against another. For their study, Garten et al. analyzed more than 300 H5N1 virus samples taken from both infected birds and people from 2003 through the summer of 2005. (Promed 3/21/06)

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Mad cow disease on the wane worldwide
Cases of Bovine Spongiform Encepalopathy (BSE) worldwide are declining, according to the UN Food and Agriculture Organization (FAO). They have been dropping at the rate of some 50 percent a year over the past three years, the Organization said. In 2005, just 474 animals died of BSE around the world, compared with 878 in 2004 and 1646 in 2003, and against a peak of several tens of thousands in 1992, according to figures collected by the World Animal Health Organization (OIE). Only 5 human deaths resulting from variant Creutzfeldt-Jakob Disease (vCJD), believed to be the human form of BSE, were reported worldwide in 2005. All of them were in the UK – the country most affected by the disease – where 9 deaths were registered in 2004 and 18 in 2003. Andrew Speedy, an FAO animal production expert, commented: “It is quite clear that BSE is declining and that the measures introduced to stop the disease are effective. But further success depends on our continuing to apply those measures worldwide.” Vigilance is still needed.
(FAO 3/23/06 http://www.fao.org/newsroom/en/news/2006/1000258/index.html )

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Improved formula for oral rehydration salts to save children’s lives
WHO and UNICEF announced a new formula for the manufacture of Oral Rehydration Salts (ORS). The new formula will better combat acute diarrhoeal disease and advance the Millennium Development Goal of reducing child mortality by two-thirds before 2015. Diarrhoea is currently the second leading cause of child deaths and kills 1.9 million young children every year, mostly from dehydration. The latest improved ORS formula contains less glucose and sodium (245 mOsm/l compared with the previous 311 mOsm/l). The lower concentration of the new formula allows for quicker absorption of fluids, reducing the need for intravenous fluids and making it easier to treat children with acute non-cholera diarrhoea without hospitalization. ORS use is the simplest, most effective and cheapest way to keep children alive during severe episodes of diarrhoea. WHO provides the only updated international quality specifications for this formula and UNICEF is a leading supplier of ORS to poor countries. WHO and UNICEF recommend that countries manufacture and use the new ORS. WHO and UNICEF will help national authorities develop manufacturing guidelines and procedures for the new formula. Oral rehydration therapy should be combined with guidance on appropriate feeding practices. Provision of zinc supplements and continued breastfeeding during acute episodes of diarrhoea protect against dehydration and reduces protein and calorie consumption to have the greatest impact on reducing diarrhoea and malnutrition in children. (WHO 3/23/06 http://www.who.int/en/ )

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Cameroon: Avian influenza H5N1 infection in poultry; contact with wild birds
There was no contact between sick ducks in Cameroon and poultry in neighboring Nigeria, where bird flu has been discovered, said Livestock Minister Sarki Aboubakary 13 Mar 2006. Cameroon became Africa's fourth country to confirm an outbreak of the disease, when H5N1 was found in 1 of a number of ducks that died in Far North province. ". . .there was no contact between the farm in Maroua and birds from Nigeria. We suspect there may have been some contact between the farm and wild birds," Aboubakary said. Cameroon has dispatched experts to kill and burn the ducks remaining on the infected farm at Maroua, Far North province. The team would also disinfect all poultry and pig farms in the vicinity, he said. Farmers will receive 2000 CFA francs (USD 3.63) per bird culled. The Yaounde government has earmarked 8 billion CFA francs (USD 14.53 million) to tackle bird flu, and foreign donors have pledged contributions. Authorities have closed poultry markets in Maroua and banned birds, pigs and related products from coming in or out. Authorities are advising citizens they are safe to continue eating poultry products so long as they are cooked properly to least 70 C. But in the capital Yaounde and commercial port center of Douala, poultry farmers and traders say sales have slumped, forcing breeders to destroy large numbers of chicks.

Excerpts from the OIE report on avian influenza H5N1
Information received 12 Mar 2006 from Dr. Hamadou Saidou, Director of Veterinary Services, Ministry of Livestock, Fisheries and Animal Industries: Report date: 12 Mar 2006. Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of first confirmation of event: 11 Mar 2006. Date of start of event: 21 Feb 2006. An outbreak of avian influenza due to highly pathogenic virus subtype H5N1 was reported in 3 domestic duck farms in the Doualar area in Maroua, Diamare department, northernmost province. Number of animals in the outbreak: susceptible: 58; deaths: 50; destroyed: 8. Samples were sent to the OIE Reference Laboratory in Italy; results pending. Control measures: stamping out and destruction of birds by incineration; epidemiological survey to determine the origin of infection; formal ban on the movement of birds and poultry products in Maroua city; closure of all live bird markets and products in Maroua city; active surveillance of all poultry farms in Maroua city and nearby areas; screening; disinfection of infected premises and material. (Promed 3/13/06, 3/15/06)

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Egypt: Fourth suspected human case of avian influenza infection
Egypt reported a fourth suspected case of bird flu in humans 21 Mar 2006, in a 17-year-old boy whose father had an outbreak of the disease on his chicken farm in the Nile Delta 18 -19 Mar 2006. Health Minister Hatem el-Gabali said the boy was taken to hospital 19 Mar 2006 and was being treated with Tamiflu. His condition was "good and stable," he added. Of the first 3 other suspected cases, 1 died, 1 recovered and the other is receiving treatment. In preliminary tests, the first 3 were positive for the H5N1 avian influenza virus. Gabali said that 2825 of the chickens at the family's farm in Gharbia province died, and the rest of the 4000 flock had been culled. The boy had been working on the farm and on 18 Mar 2006 showed symptoms including an inflamed throat and muscle pain. Health authorities were testing samples from the boy for the virus and examining members of his family and other people who had handled the chickens. Hassan el-Bushra, WHO’s regional adviser for emerging diseases, said 21 Mar 2006 that a sample from the third Egyptian had tested positive for H5N1. "Specimens have been sent abroad for a third test. If this tests positive, then it is officially confirmed. . .Since the first 2 tests were positive, it is most likely that all 3 cases will be positive," Bushra added. The highly pathogenic H5N1 virus was first found in birds in Egypt Feb 2006. So far, 17 of Egypt's 26 governorates and the city of Luxor have reported cases, and millions of birds have been culled. In Egypt, poultry are often kept in close proximity to households. (Promed 3/20/06, 3/22/06)

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Nigeria: Excerpts from the OIE report on avian influenza H5N1
Information received 15 Mar 2006 from Dr. Junaidu A. Maina, Acting Director, Department of Livestock and Pest Control Services, Federal Ministry of Agriculture and Rural Development: Precise identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of the event: 10 Jan 2006. Details of new outbreaks: 12 new outbreaks are reported in Bauchi (1), Jigwa (1), Kaduna (2), Kano (2), Katsina (2), Lagos (2), Ogun (1) and Plateau (1) states. The largest outbreak is in Ogun state, where there were 94 000 deaths from a 135 000 bird flock. The outbreaks in Lagos are at Agege. Description of affected populations: At Gayawa Mallam village in Jigawa State and at Dargage village in Katsina State, the affected animals were free-range local birds. At Vom (Jos South, Plateau State), the case was in a wild vulture. The rest of the affected farms are commercial and backyard poultry layer production units in towns. Diagnosis: hemagglutination test; agar gel immunodiffusion test; virus isolation; RT-PCR: positive. Vaccination has been prohibited, the national emergency plan has been activated, and modified stamping out is being carried out at all affected locations. Payment of compensation by the government to farmers for birds destroyed has commenced. (Promed 3/15/06, 3/20/06)

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Afghanistan: Tests confirm avian influenza H5N1 infection in dead chickens
The bird flu found in dead chickens in Afghanistan has been confirmed as the H5N1 strain, the government and the UN said 16 Mar 2006. The samples came from dead birds found in the capital, Kabul, and in Nangarhar province, and were tested at FAO laboratories in Italy. Another 6 samples from Kandahar province and Kunduz province had tested negative. No human cases have been reported. Culling would begin immediately in affected areas and markets selling poultry and poultry products in these areas would be closed and disinfected. Farmers would be compensated for their culled chickens and efforts to increase public awareness of the disease were underway, they said. There is concern that Afghanistan, with weak veterinary and health sectors after decades of war, will struggle to contain an outbreak. Agriculture officials say they don't even have protective suits necessary to cull poultry. Adding to concerns, most Afghan farmers and chicken traders are illiterate and know little about bird flu. Afghanistan lies at a crossroads for migratory birds that are potential carriers of the virus, which has already been detected in countries in the region. (Promed 3/13/06, 3/16/06)

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Albania: Avian influenza H5N1 infection confirmed in poultry
Albania found its second case of H5N1 bird flu in poultry near the capital, but there was no evidence the virus had made people ill, despite the fact that some farmers had eaten infected birds. The Agriculture Ministry said tests at the UK laboratory confirmed H5N1 in 4 dead chickens in the Peze Helmes area, 10 km west of the capital. Ministry spokesman Rexhep Shahu said teams were working to cull some 600 chickens and disinfect the coops in the area. Albania confirmed its first case of H5N1 3 weeks ago in a chicken in the southern Sarande region, close to the Butrint lagoon, a known resting ground for migratory birds. The villagers in Peze Helmes said they had eaten some of their chickens recently. A vet said many households slaughtered the birds and ate them despite official advice to bury them and disinfect the area. All residents of the village had blood samples taken. Reportedly, villagers were to get 700 leks (6.80 USD) for a grown chicken and 400 leks (3.90 USD) for a chick for compensation. The bird flu scare has caused Albanian sales of chicken meat to fall by 80 percent.

Excerpts from the OIE report on avian influenza H5N1
Information received 11 Mar 2006 from Dr. Lefter Klimi, Director of Veterinary Services, Ministry of Agriculture, Food and Consumer Protection: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Details of new outbreak: Backyard chickens and turkeys are involved. Diagnostic test result: OIE Reference Laboratory in Weybridge, UK: RT-PCR: positive for H5N1. Source of outbreak or origin of infection: contact with wild animals. (Promed 3/10/06, 3/20/06, 3/23/06)

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Azerbaijan: Avian influenza H5N1 infection confirmed in 7 humans
As of 11 Mar 2006, samples from 11 patients under investigation in Azerbaijan for possible H5N1 infection have now been tested at the UK laboratory. Positive H5N1 results were obtained for 7 of these patients. 5 cases were fatal. 6 of the cases occurred in Salyan Rayon. All 6 cases resided in the small Daikyand settlement. A 17-year-old girl died 23 Feb 2006. Her first cousin, a 20-year-old woman, died 3 Mar. The 16-year-old brother of this woman died 10 Mar. A 17-year-old girl, a close friend of the family, died 8 Mar. All 4 of these cases lived together or near each other. The source of their infection is presently under investigation. The additional 2 cases in Salyan involve a 10-year-old boy, who has recovered, and a 15-year-old girl, who is hospitalized in critical condition. The seventh case occurred in a 21-year-old woman from the western rayon of Tarter. She died 9 Mar 2006. 2 additional patients, from Salyan and the adjacent rayon of Neftchela, have been hospitalized with symptoms of bilateral pneumonia. Testing of these patients is presently under way. Highly pathogenic H5N1 avian influenza was first reported in the country, in wild birds, 9 Feb 2006. Outbreaks in poultry were reported 24 Feb, but not in the Salyan or Tarter rayons.

Last week, WHO strengthened its field team in Azerbaijan to include experts in clinical management and infection control and additional senior epidemiologists. A field investigation in Salyan, jointly conducted by WHO and the Azeri Ministry of Health, found some evidence that carcasses of numerous swans, dead for some weeks but not buried, may have been collected by residents as a source of feathers. In this community, the defeathering of birds is a task usually undertaken by adolescent girls and young women. The WHO team is investigating whether this practice may have been the source of infection in Daikyand, where the majority of cases have occurred in females between the ages of 15 and 20 years. Interviews with surviving family members have failed to uncover a history of direct exposure to dead or diseased poultry for several of the cases. WHO is confident that ongoing house-to-house surveillance for cases of influenza-like illness will detect patients requiring further investigation. On-site diagnostic capacity continues to be provided by the US Naval Medical Research Unit 3. Reportedly, no new poultry outbreaks of avian influenza have been discovered. A better understanding of the situation in animals is, however, urgently needed. (WHO 3/14/06; Promed 3/21/06)

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Croatia: Seagulls carrying avian influenza H5N1
The H5N1 strain of bird flu has been detected in several seagulls in the south of Croatia, where several swans have already died of the disease. "We have carried out tests on 30 or more seagulls and several samples have come back positive for the H5N1 strain," agriculture ministry spokesman Mladen Pavic said 14 Mar 2006. Pavic said the samples had been taken randomly between 28 Feb and 3 Mar 2006 in the town of Pantana, in the country's southern coast. Health officials have been watching the area since mid-Feb 2006 when 2 swans were confirmed dead from the H5N1 infection. 1200 birds within a 3-km radius from where the swans were found have since been slaughtered. The ministry of agriculture stepped up safety measures to keep the disease from spreading. Such measures include the confinement of poultry throughout the country, a ban on the sale of poultry from affected areas and outlawing hunting of wild birds. (Promed 3/15/06)

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Denmark: More avian influenza cases found in birds; sequence information
9 more cases of the H5 bird flu virus have been found in Denmark. Peter Bagge of the Danish Food and Veterinary Research Institute said the 9 tufted ducks had been found in the town of Aeroeskoebing, on the small island of Aeroe. Bagge said authorities had set up a protection zone around the area. The institute said the first case of H5N1 had been found in Denmark in a wild buzzard. On 14 Mar 2006, an H5 avian influenza virus was detected in respiratory tissues from the dead buzzard (Buteo buteo) found in the southern part of the island of Zealand. The identification of the virus is A/Buzzard/Denmark/6370/06 (H5N1). Sequencing of the cleavage site of the HA gene revealed that the virus is highly pathogenic for fowl. On 15 Mar 2006, a virus isolate was obtained. The entire viral genome has been sequenced now in a collaborative work between the Danish Institute for Food and Veterinary Research (DFVF) and Statens Seruminstitut (SSI). Preliminary analysis of the sequences indicates that the HA gene has high homology with A/Cygnus olor/Astrakhan/Ast05-2-4/2005 (H5N1) and the NA gene with A/Cygnus olor/Astrakhan/Ast05-2-7/2005 (H5N1). Cygnus olor is the common mute swan.

A protection zone (minimum 3 km) and a surveillance zone (minimum 10 km) have been established around the location where the infected buzzard was found. All poultry within the zones must be kept inside, and all poultry holdings -- including hobby holdings -- must be registered. The Danish Veterinary and Food Administration will in the near future inspect all poultry holdings in the protection zone in order to look for possible further spread of avian influenza. Restrictions on movement of eggs and poultry have been imposed within the zones. All hunting within the zones is also prohibited. Danish poultry farmers produce about 3 billion crowns (USD 484 million) worth of mostly chickens per year, with two thirds going to export. (Promed 3/15/06, 3/19/06, 3/20/06)

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Greece: 4 more swans have avian influenza H5N1 infection
Greece confirmed 11 Mar 2006 4 more cases of the H5N1 strain of bird flu in swans found dead near its northern borders, bringing to 30 its total number of wild fowl known to have been infected. "(They) were confirmed today [11 Mar 2006] by the EU lab in London," the Agriculture Ministry said, adding that protective measures had already been in place. There have been no cases of bird flu identified in Greek farm poultry, but sales have plummeted, and the government has announced measures, including state-guaranteed loans, to help farmers. Wildlife experts say Greece had a high number of migratory birds this winter. (Promed 3/11/06)

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Israel: Seventh outbreak of avian influenza in poultry
The Agriculture Ministry said that dead birds found in a poultry coop in the Jordan Valley tested positive for the deadly strain of avian flu, confirming the virus was continuing to spread across the country. Initial PCR tests reportedly indicated H5, but in view of the low mortality observed, tests are being repeated. Earlier, the veterinary service confirmed 19 Mar 2006 that the bird flu virus that has hit turkeys in southern Israel is the H5N1 strain. Moshav Beqaot was quarantined after dozens of turkeys were found dead, and the Veterinary Services began culling the flocks in the 4 poultry coops in the community. These are the only coops in a 3-km radius from the moshav, therefore culling will not take place in nearby communities. The Veterinary Service imposed a 10-km-radius quarantine in the area. Israel has culled some 400 000 infected turkeys and chickens since discovering the bird flu virus in southern Israel last week. The bird carcasses are being deposited in 6-meter deep holes insulated with plastic and lime. Infected farms have been isolated and Israel is planning to compensate farmers economically hurt by the virus. Earlier, veterinarians and livestock farmers criticized the delayed and improper manner of bird culling in southern Israel. The Agriculture Ministry's deputy director general, Itzik Ben David, said 19 Mar 2006 that the culling process could affect a total of 900 000 birds. He estimated that the financial compensation to farmers will total between NIS 15 and 20 million [USD 3.2-4.3 million], assuming no additional communities are affected.

Israel halted all exports of unprocessed chicken and turkey meat. In view of Israel's situation as a main flyway of migratory birds, the Israeli Veterinary Services have undertaken (passive) surveillance in dead wild birds since fall 2005. Agriculture Minister Ze'ev Boim said that a shipment of 4 million doses of vaccine will be arriving from the Netherlands. This vaccine will be used only if the quarantine imposed on infected areas proves ineffective. The Health Ministry is continuing to administer Tamiflu pills to several dozen workers who handled turkeys in the moshavim and kibbutzim that had the virus, as well as to Agriculture Ministry employees involved in the culling operation there. The Health Ministry has sent blood samples from several dozen workers to the laboratory to check whether they have been infected.

Excerpts from the OIE report on avian influenza H5N1
Information received 16 and 17 Mar 2006 from Dr. Moshe Chaimovitz, Director of Veterinary and Animal Health Services, Ministry of Agriculture and Rural Development: Report date: 17 Mar 2006. Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Location of outbreaks: En Hashelosha: susceptible: 12 000 deaths: 1800. Holit: susceptible: 30 000 deaths: 9000. Sede Moshe: susceptible: 6500 deaths: 500. Nahshon: susceptible: 20 000 deaths: 500. Description of affected population: fattening turkeys 16 weeks old. Diagnostic tests used: PCR (H5N1): positive; in progress for Sede Moshe and Nahshon; virus isolation: pending. (Promed 3/16/06, 3/18/06, 3/19/06, 3/20/06, 3/22/06, 3/23/06)

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Jordan (Jordan valley): Avian influenza H5N1 infection confirmed in turkeys
Jordan confirmed cases of the H5N1 strain of bird flu but said no humans had been infected and the outbreak was under control. Jordanian Health Minister Said Darwazeh said at least 3 dead turkeys at a domestic farm in Ajloun had tested positive for the disease. 20 people were given the antiviral Tamiflu and the area has been cordoned off to prevent the disease from spreading further, he said. Darwazeh said Jordan had been on high alert since bird flu was detected in Israel and that its own outbreak was isolated. Darwazeh said that Jordan had notified WHO of the cases and would ask it for technical assistance if there was a serious outbreak. Israel and Jordan were coordinating efforts to combat the spread of the virus. Jordan began culling birds within a 6-km radius of the outbreak. Birds further away will be vaccinated. Officials have ordered people in the Jordan Valley to eat poultry from their farms within a week or risk of having their birds culled. Officials have also increased monitoring of birds on poultry farms in the valley. Jordan had already imposed a ban on imports of poultry products and pet birds before the discovery this week. Jordan has reportedly imported 60 000 doses of Tamiflu, and it has set aside significant funds to handle a possible outbreak. It has said it would use the money to vaccinate poultry and to compensate farmers for the loss of their flocks. (Promed 3/24/06)

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Kazakhstan (west): Avian influenza H5N1 infection in wild birds
The H5N1 strain of bird flu has been discovered in western Kazakhstan, officials said 22 Mar 2006. "Cases of highly pathological bird flu [H5N1] have been confirmed by laboratory tests in a dead wild bird from the Caspian shore [Mangistau province]," the agriculture ministry said. An earlier report stated that the H5N1 bird flu strain was found among dead swans. No cases of humans contracting bird flu have been reported in Kazakhstan, which saw an outbreak of the disease in animals Aug 2005. In an effort to stave off outbreaks in domestic birds, preventive measures are already under way in western Kazakhstan, including vaccination of domestic birds, particularly backyard poultry. "As of Wednesday, 32 800 domestic fowl have been vaccinated against the highly pathogenic avian influenza in the area," the agriculture ministry stated. Asylbek Kozhimuratov, head of the Kazakh agriculture ministry, said that all domestic poultry had been vaccinated in Mangistau province. Vaccination is under way in another western province, Atyrau, which is believed to be vulnerable to the virus. Some 40 000 doses of vaccine have been provided for that purpose, according to the ministry. "There has not been any culling of domestic birds because avian flu has been registered only in wild birds so far," officials said. But officials have called for people to take care to prevent transmission of the virus. "People should follow hygiene norms and avoid contact with wild birds; especially they should prevent their children from such contact," Kozhimuratov added. Kazakhstan's population exceeds 16 million; according to FAO, in 2005 the egg-production industry exceeded 13 million laying hens. (Promed 3/21/06, 3/23/06)

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Netherlands: Voluntary avian influenza vaccination; Japan bans Dutch poultry
Dutch authorities will launch a postponed voluntary vaccination campaign against bird flu 16 Mar 2006, the farm ministry said 14 Mar 2006. The Netherlands initially planned to launch voluntary vaccination of its 1-to-3 million backyard poultry and about 5 million free range poultry against the H5N1 avian flu virus last week after receiving EU permission 22 Feb 2006. The ministry said that owners would have to bear the costs of the vaccination, which is an alternative to the requirement to keep birds indoors to avoid contact with any wild [birds] infected with H5N1. The Dutch government fears a repeat of the devastating 2003 outbreak of a different type of bird flu that led to the culling of 30 million chickens, and says vaccination could limit the spread of the disease. But Dutch farmers fear more countries will follow Japan's decision to ban Dutch poultry imports when the vaccination begins as consumers shun meat from vaccinated animals because of possible health risks. The Netherlands is a top world poultry exporter with annual sales of 1.5 billion euros (USD 1.79 billion) and Europe's second biggest producer after France. The Netherlands' main poultry markets are Germany, Britain, Belgium, France, Ukraine, Japan, Poland and Russia. (Promed 3/15/06)

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Pakistan: Avian influenza H5N1 infection confirmed in poultry
Pakistan's first 2 cases of the H5N1 strain of bird flu in chickens in the country's North West Frontier Province have been confirmed by lab tests. Reportedly the samples containing H5N1 bird flu virus were taken from chickens at 2 farms late Feb 2006. Tests conducted in Britain confirmed H5N1 infection. "They (the British lab) have also endorsed the finding of our laboratory that infection was avian influenza H5N1," the Agriculture Ministry said. The flocks have since been culled, and officials say they have not found any other incidents of bird flu. No human cases were detected. Pakistan early this month culled 25 000 chickens on farms in the towns of Charsadda and Abbottabad after confirming the presence of the H5-type virus.

Excerpts from the OIE report on avian influenza H5N1
Information received 3 Mar 2006 from Mr. Rafaqat Hussain Raja, Animal Husbandry Commissioner, Ministry of Food, Agriculture and Livestock: Identification of agent: avian influenza virus subtype H5. Date of first confirmation of event: 27 Feb 2006. Date of start of event: 23 Feb 2006. Nature of diagnosis: clinical and laboratory. Details of outbreaks: First administrative division: North West Frontier. Date of start of outbreak: 23 Feb 2006. Number of animals in outbreaks: susceptible (10 450); cases (2420); deaths (2000); destroyed (8450); slaughtered (0). First administrative division: North West Frontier. Date of start of outbreak: 23 Feb 2006. Number of animals in outbreaks: susceptible (16 000); cases (1045); deaths (875); destroyed (15 125); slaughtered (0). Description of affected population: poultry at a layer farm and a breeder farm. Diagnostic tests used: virus isolation; agar-gel immunodiffusion; hemagglutination; hemagglutination inhibition; PCR. Positive for H5. Source of outbreaks or origin of infection: unknown. Control measures: all birds at the farms have been quarantined. Layer and breeder flocks have been destroyed under the supervision of state veterinarians; strict biosecurity and zoosanitary measures have been instituted; farm workers have been examined by the health authorities; disinfection of the premises and farm equipment has been carried out; serosurveillance within a 15-km radius around the infected area is in progress; an avian influenza emergency cell has been established. There have not been any other reports of disease from the surrounding areas. No cases have been reported at any broiler farms. (Promed 3/15/06, 3/21/06)

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Palestine (Gaza strip): Avian influenza H5N1 infection confirmed in poultry
Palestinian officials confirmed an outbreak of the H5N1 strain of bird flu at a second farm in the Gaza Strip 24 Mar 2006, and Israel's foreign minister appealed to UN for international assistance to the Palestinians to contain the disease. The first outbreak in the Palestinian territories was announced by the Agriculture Ministry 22 Mar 2006. The virus was found in coops built on the ruins of the former settlement of Netzarim, in the central Strip. In all, bird flu has been detected at 2 farms in the Gaza Strip, 1 near Gaza City and 1 near the southern town of Rafah (where 200 chickens were found dead in a coop), said Deputy Agriculture Minister Azzam Tubaili. Gaza chicken farmers planned a protest, after officials told them they would not be compensated for culled birds. The 2 affected farms have a total of 80 000 chickens. "They (the farmers) are preventing the culling because they want compensation before they let us do this," Tubaili said. "This is causing confusion. Any second of delay will really make a difference." Israel conducts all tests on behalf of the Palestinians, who do not have the technology. The sides have been cooperating for months. (Promed 3/22/06, 3/24/06)

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Poland: Second nucleus of H5 avian influenza found
Poland's second nucleus of H5 bird flu has been uncovered in a western town, the country's chief veterinary officer said 11 Mar 2006. "The H5 bird flu virus has been diagnosed in a dead swan found near a water-pumping station in the town of Kostrzyn on the Odra river," Krzysztof Jazdzewski said. Emergency procedures have been put into effect, with a restricted 3-km area under special surveillance as well as a 10-km endangered zone, which overlaps into Germany. Special patrols have begun counting poultry and policing compliance with a ban on free-ranging birds in the surrounding countryside, and disinfectant mats have been laid out on roads leading out of town. Jazdzewski said the UK Reference Laboratory had confirmed that the swans found a week earlier in Torun had been infected with the H5N1 virus. The Kostrzyn pumping station lies at the edge of the Mouth of the Warta National Park, one of Europe's largest wetland nesting areas of migratory waterfowl. (Promed 3/11/06)

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Romania (Ilfov): Avian influenza H5N1 infection in poultry outbreak
Reportedly, veterinary officials confirmed a bird-flu outbreak in poultry near Romania's capital. The officials said dead poultry found in a village were infected with the H5N1 strain and ordered quarantine in the area. Disinfection checkpoints were set up around Magurele in Ilfov County and the officials began testing for bird-flu virus in other poultry. In the meantime, quarantine was lifted in 3 areas of Constanta County, on the Black Sea coast. The total number of bird flu outbreaks in Romania was about 50. Apart from thousands of birds already destroyed, the officials said more than 100 000 birds would be killed.

Excerpts from the OIE report on avian influenza H5N1
Information received 13 and 14 Mar 2006 from Dr. Gabriel Predoi, Director General, National Sanitary Veterinary and Food Safety Authority: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of the event: Oct 2005. New outbreaks: 2-11 Mar 2006. 4 new outbreaks are reported in Constanta in poultry and wild birds. One new outbreak is reported in Ialomita in poultry. One new outbreak is reported in Olt in wild birds. Diagnostic tests: rapid detection test; RT-PCR; virus isolation; positive for H5 in hens. Diagnostic tests: RT-PCR; virus isolation; positive for H5 in hens. Source of outbreaks: contact with infected animal(s) at grazing/watering; contact with wild animals. (Promed 3/20/06, 3/23/06)

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Serbia and Montenegro: Excerpts from the OIE report on avian influenza H5N1
Information received 15 Mar 2006 from Dr. Dejan Krnjaic, Chief Veterinary Officer, Ministry of Agriculture, Forestry and Water Management: Report date: 15 Mar 2006. Identification of agent: avian influenza virus subtype H5. Details of outbreak: An outbreak in a rooster in Zlatiborski is reported. The chicken flock had 23 birds, total. Description of affected population: chicken; the case was a rooster. On 4 Mar 2006, a dead swan (Cygnus olor) was found in the river Drina near Bacevci village at the border with Bosnia and Herzegovina; and the presence of avian influenza was confirmed. Diagnostic tests: hemagglutination; hemagglutination inhibition; virus isolation: positive for H5. Source of outbreak or origin of infection: contact with wild animals. (Promed 3/20/06)

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Sweden: H5N1 strain in dead owl; excerpts from the OIE report on avian influenza H5N1
Swedish authorities confirmed the owl found dead near Oxelosund had the bird flu strain H5N1, according to the Swedish Veterinary Medicine Institute. 27 cases of bird flu in wild birds have been registered in Sweden since 28 Feb 2006, but this is the first time the strain has been found in an owl.

Excerpts from the OIE report on avian influenza H5
Information received 20 Mar 2006 from Dr. Leif Denneberg, Chief Veterinary Officer, Swedish Board of Agriculture: Identification of agent: highly pathogenic avian influenza virus subtype H5. Date of start of event: 24 Feb 2006. Details and Location of outbreak: Gasshult, Oskarshamn municipality, Kalmar County. There was 1 case, and 692 susceptible birds were destroyed. There is no commercial poultry in the area. All birds were clinically healthy at the time of sampling, and there is no high mortality among wild birds noted in the area either. Description of affected population: in a holding which included game birds (500 farmed mallards [Anas platyrhynchos]), 150 pheasants, 30 pigeons, 10 backyard hens and 2 peafowl; 50 samples were taken from mallards and pheasants. HPAI virus subtype H5 found in 1 mallard.

Earlier, the chapter "Description of affected population(s)" in Sweden's official "immediate notification" sent to the OIE 16 Mar 2006, describe the surveillance carried out in Sweden subsequent to the detection of the first cases in wild birds 24 Feb 2006. Total of 243 dead birds analyzed between 10 Feb 2006 and 15 Mar 2006 - 36 positive for HPAI subtype H5. No high mortality among wild birds noted. It is late in the season and freezing, so some dead birds are to be expected this time of the year. (Promed 3/15/06, 3/17/06, 3/22/06)

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Turkey: Excerpts from the OIE report on avian influenza H5N1
Information received 7 Mar 2006 from Dr. Huseyin Sungur, Director General, General Directorate of Protection and Control, Ministry of Agriculture and Rural Affairs: Precise identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of first confirmation of event: 26 Dec 2006. Date of start of event: 15 Dec 2006. New outbreaks: First administrative division: Istanbul. Date of start of outbreak: 24 Feb 2006. Number of animals in the outbreak: cases (2); deaths (2). First administrative division: Sinop. Date of start of outbreak: 24 Feb 2006. First administrative division: Diyarbakir. Date of start of outbreak: 12 Jan 2006. Number of animals in the outbreak: susceptible (1541); cases (15); deaths (15); destroyed (1526); slaughtered (0). First administrative division: Istanbul. Date of start of the outbreak: 27 Feb 2006. Number of animals in the outbreak: cases (2); deaths (2). First administrative division: Izmir. Date of start of the outbreak: 16 Feb 2006. Number of animals in the outbreak: cases (6); deaths (6). Description of affected population: until now, only 1 outbreak has occurred in a commercial poultry unit in a small-scale commercial (broiler) poultry flock. All the other outbreaks have occurred in backyard (village) poultry flocks. Source of outbreaks or origin of infection: contact with infected animal(s) at grazing/watering and contact with wild animals. Control measures undertaken: stamping out; quarantine; movement control inside the country; screening; zoning; disinfection of infected premises/establishment(s). No treatment of affected animals. Vaccination prohibited. (Promed 3/15/06)

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Asia
Cambodia: Study suggests mild avian influenza cases are not going undetected
New data from Cambodia presented at a conference 20 Mar 2006 suggest mild or symptomless human cases of H5N1 avian flu may not be occurring. Many have hoped that the world is overestimating the virulence of the H5N1 virus, based on an assumption the disease surveillance systems in affected countries might not be sensitive enough to pick up mild infections. But if the work presented at the International Conference on Emerging Infectious Diseases is borne out by additional larger studies, it would suggest the current case fatality rate of roughly 54 percent might indeed be close to reality. Lead researcher Dr. Philippe Buchy of the Institut Pasteur in Phnom Penh put a positive spin on his findings. The head of the influenza branch at the U.S. CDC said the findings have both positive and negative implications. "You can look at it in the way that it's encouraging, because it means that the virus is not jumping to humans very readily. And that of course is very important, and that's a positive thing," said Dr. Nancy Cox. "But on the other side of the coin, it means that the case fatality rate is still very high. And that is a negative thing." Cox said it will be important to do this type of work on a larger scale, to get a more definitive picture of whether mild or asymptomatic H5N1 human cases are occurring. The situation in Cambodia may not be typical--only 4 cases of human infection (all fatal) were recorded in Cambodia during early 2005, and unlike the situation in neighboring countries, the outbreak did not run out of control.

Buchy and his colleagues reported on work they conducted last spring in a Cambodian village that had H5N1 outbreaks in poultry and where one of that country's 4 recorded cases lived. The researchers tested blood samples from 351 of the villagers looking for the antibodies to the virus that would be proof of mild or asymptomatic infections. They found no signs of additional infections, this despite the fact that many of the villagers had significant exposure to infected poultry. Even a doctor who was involved in a difficult process to insert a ventilator tube into the windpipe of an H5N1 patient did not became infected, said Buchy, who noted the doctor wore no protective gear. Buchy said blood samples taken from 2 veterinarians who had autopsied birds that had died from H5N1 showed no sign of antibodies to the virus either. Like the doctor, the veterinarians hadn't taken any precautions. (Promed 3/22/06)

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Cambodia: Fifth case of human infection with avian influenza H5N1
As of 24 Mar 2006, the Ministry of health in Cambodia has confirmed the country's fifth case of human infection with the H5N1 avian influenza virus. The case, which was fatal, occurred in a 3-year-old girl from Kampong Speu Province, west of Phnom Penh. The child developed fever 14 Mar 2006. Her condition deteriorated rapidly and she was hospitalized in Phnom Penh 20 Mar 2006. She died 21 Mar. Samples from the girl tested positive for H5N1 infection at the Pasteur Institute in Cambodia. Backyard poultry began dying in the village Feb 2006, and chicken deaths have continued. The child is known to have played with chickens, including some showing signs of illness. The child's mother said she still had no idea what had killed her daughter, an indication that bird flu public education campaigns in one of Asia's poorest nations still have a long way to go. The investigation found 7 residents with fever but no respiratory symptoms. All had a history of recent contact with diseased birds or had been involved in caring for the child. Although none of these people presently shows symptoms compatible with H5N1 infection, all have been placed under medical observation. Samples have been taken from these people and other close contacts of the child. The Ministry of Agriculture has taken samples from chickens in the area. Testing is under way. This is the fifth confirmed case in Cambodia and the first in almost a year. The 4 previous cases, all from the adjacent Kampot Province which borders Viet Nam, and all fatal, occurred between Jan 2005 and Apr 2005. (Promed 3/24/06)

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China: OIE says some Chinese avian influenza vaccines ineffective
China may be using some substandard poultry vaccines to fight bird flu that could allow birds to keep spreading the virus despite not showing symptoms, a top animal health expert said 21 Mar 2006. Christianne Bruschke, a member of the bird flu task force at the World Animal Health Organisation (OIE), said the vaccines made in China at the Harbin Veterinary Institute conformed to international standards and were fully effective. "But there are local companies in China that produce vaccines, and it's possible these don't have the efficacy of those made at Harbin," she said. Chinese officials have said their vaccines are effective and that no healthy-looking bird has yet been found carrying H5N1. But there have been outbreaks in areas where poultry were supposedly already vaccinated, and this has raised the possibility that birds are continuing to spread the virus. "There are 2 possibilities," Bruschke said. "Either the vaccine is not strong enough, or that it is a good vaccine but not administered properly. Vaccines have to be given twice to be fully effective, maybe that is not happening. When a vaccine is not effective enough, it could prevent clinical signs from showing, but the bird could still spread the virus. That's certainly a possibility," she said. And she said poultry that had not been properly vaccinated may also pose a health risk to humans, although it was difficult to quantify the danger. "The vaccines are, when administered properly according to manufacturers' instructions, effective in preventing the spread in chickens and ducks," she said.

Chickens usually die within 24 hours of being infected with H5N1, but without signs of disease the virus is harder to detect, control, and also much easier to pass on to unsuspecting humans. The risk of such asymptomatic poultry came to the fore earlier this month when a man died in Guangdong after visiting several live poultry markets and officials later said he probably caught the disease from live but H5N1- infected birds. "Places like Vietnam and Thailand are importing these Chinese vaccines. So what is happening in China (asymptomatic poultry) can happen in these places soon," said one expert. But Vietnam, which has had no new bird flu outbreaks in poultry or humans since Nov 2005, is not overly worried. It says the China-made vaccines must pass quality-control tests. Although Thailand bans H5N1 vaccination in chickens, there have been reports of police seizing vaccines being smuggled along the Mekong River from China. But nobody knows if they have been smuggled in successfully and used. Although China has been vaccinating its farmed poultry in the past few years, that has not stopped the virus from proliferating and mutating. After scientists first isolated H5N1 in a goose in Guangdong in 1996, the virus has continued brewing and there are now 5 dominant subtypes in southern China.

A study published in the Proceedings of the National Academy of Sciences in late Feb 2006 showed that up to 1 percent of apparently healthy chickens, ducks and geese in wet markets in southern China are infected with the H5N1 avian flu virus. The finding shows people may be far more exposed to the virus than previously thought. Led by microbiologist Guan Yi from the University of Hong Kong, researchers collected 51 121 faecal and other samples from healthy-looking birds in live-poultry markets across 7 provinces in southern China from Jan 2004 to Jun 2005. The H5N1 virus was found in 1.8 percent of ducks, 1.9 percent of geese, 0.46 percent of minor poultry like pheasants and quail, and 0.26 percent of chickens. (Promed 3/10/06, 3/18/06, 3/22/06)

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China: 16th human case confirmed
As of 24 Mar 2006, The Ministry of Health in China has confirmed the country's 16th case of human infection with the H5N1 avian influenza virus. The case, which was fatal, occurred in a 29-year-old female migrant worker. She was hospitalized in Shanghai 15 Mar 2006 with symptoms of pneumonia and died 21 Mar 2006. Doctors and nurses who tended the patient were under quarantine, said a source at the hospital. The government has also disinfected places where the deceased patient had visited. This is the first case reported in Shanghai. Her source of infection is under investigation. No poultry outbreaks have been reported in the Shanghai area since Feb 2004. According to Chinese authorities, the woman's close contacts have been placed under medical observation. (Promed 3/23/06, 3/24/06)

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India (Maharashtra): Avian influenza H5 in poultry
India said 14 Mar 2006 that it had detected a fresh outbreak of avian influenza in the state of Maharashtra, the scene of the country's first brush with the virus Feb 2006. "Several poultry samples were received ... towards the end of February [2006]. Some of these samples have tested positive for avian influenza (H5)," a government statement said. Officials said that they were checking whether the latest outbreak was of the H5N1 strain. They said 4 villages in Jalgaon district in Maharashtra were affected by the outbreak. Jalgaon is a district away from Nandurbar, where India reported an outbreak of the H5N1 strain. Hundreds of thousands of chicken were culled in the town of Navapur and neighbouring areas after that outbreak. In Jalgaon, the government said it would start the culling of chicken in the area. After the Navapur outbreak, India tested more than 100 people for bird flu but all the results proved negative. The government said it would step up surveillance of residents of the 4 villages in Jalgaon. According to India's official reports to the OIE, 2 States were initially affected, Maharashtra and Gujarat. (Promed 3/14/06)

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Indonesia: Additional human case of avian influenza H5N1 infection
The Ministry of Health has confirmed an additional case of human infection with the H5N1 avian influenza virus. The case, which was fatal, occurred in a 12-year-old girl from Boyolali, Central Java. She developed symptoms (fever) 19 Feb 2006, was hospitalized 23 Feb, and died 1 Mar 2006. Chickens in her household died in the days preceding symptom onset. The girl's 10-year-old brother also fell ill 19 Feb and died 28 Feb 2006. As his symptoms were compatible with a clinical diagnosis of dengue haemorrhagic fever, no testing for H5N1 was carried out. It will therefore never be known whether he may have died following co-infection with dengue and H5N1 avian influenza. A local investigation was conducted and no additional cases or symptomatic contacts were found. Rapid tests detected the H5 virus subtype in chickens from the children's household. The newly confirmed case brings the total in Indonesia to 29. Of these, 22 were fatal.

Also, laboratory tests on blood samples from 4 dead chickens and one ailing chicken in Batam have shown that they carried the bird-flu virus. Jusak, an official of the local marine resources, fisheries and agricultural service, said 11 Mar 2006 the discovery meant that the disease had already reached Batam, the country's oldest industrialized zone. He said that how the virus had come to Batam was still unknown but that it was believed the source of the infection was wild birds. The blood sample from a sick chicken in Kampung Tiban Koperasi in Sekupang had also tested positive for the H5N1 virus. In view of the discoveries, Jusak said his office had called on all parties, particularly poultry farmers, to increase cleanliness at their farms. (WHO 3/13/06 http://www.who.int/csr/don/2006_03_14/en/index.html )

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Malaysia: Avian influenza H5N1 in poultry and wild birds
All states have been ordered to conduct comprehensive sampling of birds nationwide following the discovery of 3 new bird flu cases in Perak. The latest bird flu cases were detected in Kampung Changkat Legong near Gopeng, at the Titi Gantung Agriculture Training Institute in Bota, and at Taman Lapangan Perdana in Ipoh. Agriculture and Agro-Based Industry Minister Tan Sri Muhyiddin Yassin said Malaysia was no longer exempt from the avian flu virus. Muhyiddin believed that migratory birds were the likely cause of avian flu infection in Malaysia, which compounded efforts to contain the spread. One preventive measure, he said, was banning the slaughter of poultry in wet markets and in the open. So far, no one has been infected in Malaysia. The minister said the Federal Territory and Perak governments had approved the ban on open slaughtering of poultry. In the meantime, the ministry will step up its education and awareness campaigns on bird flu among villagers, as the cases have been found in villages and not commercial farms. "We will also discuss with the state governments whether all birds in their villages should be culled," he added. Muhyiddin said there was a manpower shortage but other departments and agencies were helping out.

The 3 cases of bird flu detected in Perak were the latest in a series of outbreaks since the first was discovered in Setapak, Kuala Lumpur, Feb 2006. Samples taken from live birds in Kampung Changkat Legong near Gopeng tested positive for H5N1. "2 free-range chickens in the village were found infected following random testing within the 10-km radius of Kampung Changkat Tualang, where avian flu was first detected in the state," Perak Agriculture, Agro-based Industry and Tourism Committee chairman Datuk Mohd Radzi Manan said. The virus was also found in 6 samples of broiler chicken within the Titi Gantung Agriculture Training Institute in Bota, and in samples taken from dead cattle egrets in Taman Lapangan Perdana in Ipoh.

Recent Malaysia avian influenza timeline
Feb 20, 2006: The highly pathogenic H5N1 virus was first detected in the country in samples taken from dead ayam kampung (free-range chicken) in Setapak, Kuala Lumpur.

Mar 16, 2006: Cases were detected in Perak among birds at the Ecopark in Bukit Merah Laketown Resort in Taiping, and dead chickens at Kampung Changkat Tualang some 100 km from the Ecopark.

Mar 20, 2006: The avian flu virus was detected in samples taken from 6 dead free-range chickens in Kampung Permatang Bogak in Penaga, Penang.

Mar 21, 2006: Cases of bird flu detected in Perak -- the virus was found in samples taken from free-range chickens in Kampung Changkat Legong near Gopeng, among broiler chickens at the Titi Gantung Agriculture Training Institute in Bota, and dead cattle egrets in Taman Lapangan Perdana in Ipoh.
(Promed 3/20/06, 3/22/06, 3/23/06)

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Myanmar: Avian influenza H5N1 infection confirmed in poultry
Myanmar's state-run media reported 16 Mar 2006 the outbreak of suspected H5N1 bird flu. A total of 5628 chickens and 4482 quail died in farms in 3 townships in northwestern Sagaing division, and 4 townships in northern Mandalay division, as of 16 Mar 2006, since the outbreak of bird flu began Feb 2006. Reportedly, the 3 townships in Sagaing division are Shwebo, Kanbalu and Khin U, while the 4 in Mandalay division are Pyigyidagun, Chanmyathazi, Chanayethazan and Amarapura. Authorities have slaughtered a total of 13 970 chickens and 77 018 quail and quail eggs in these townships. No human infection was found in the infected areas. The authorities have placed the townships in the 2 divisions under restricted zones, banning movement of poultry and temporarily closing down fowl markets with other preventive measures being undertaken. Meanwhile, a Bangkok laboratory has confirmed that the current bird flu occurring in the country is H5N1 after samples of the dead chickens were tested, disclosed He Changchui, a resident representative of the Food and Agriculture Organization (FAO). An FAO expert group is currently in the bird flu-infected areas of Mandalay to coordinate and cooperate with the Myanmar authorities for measures in preventing H5N1 from spreading further. FAO has preliminarily provided USD 45 000 dollars worth of equipment to Myanmar for use in the measures which include 100 sets of protection equipment, 500 liters of disinfectant, 50 sets of sprayers and 2 containers for shipping samples, according to the FAO.

Excerpts from the Official OIE report on avian influenza
Information received 13 Mar 2006 from Dr. U Maung Maung Nyunt, Director General, Livestock Breeding and Veterinary Department, Ministry of Livestock and Fisheries, Yangon: Identification of the agent: highly pathogenic avian influenza virus subtype H5N1. Date of the start of the event: 8 Mar 2006. Date of first confirmation of the event: 9 Mar 2006. An outbreak of highly pathogenic avian influenza subtype H5N1 has been reported in poultry at Aung Myae Thar Zan Township, in Mandalay Division (780 susceptible animals, 113 cases, 112 deaths, 668 destroyed). The diagnosis has been made by the Central Veterinary Diagnostic Laboratory, Yangon and Regional Veterinary Diagnostic Laboratory in Mandalay. It was confirmed 12 Mar 2006. A high mortality has been reported. Control measures applied: Modified stamping out; quarantine; movement control inside the country; zoning. (Promed 3/15/06, 3/16/06, 3/18/06)

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Russia: Avian influenza outbreaks in poultry; vaccinations
Bird flu is posing a growing challenge in Russia, the chief veterinarian said. "Last year we lost 662 000 heads of poultry, which died or were slaughtered. This year (so far) the figure is 1.3 million poultry," Sergei Dankvert said. "This year, the situation is more difficult (and) will depend on steps taken in the regions," said Dankvert, who heads the Russian Federal Veterinary Control Service. He said poultry needed to be protected from contact with wild birds, which would reduce the risk of contamination by 50 percent, and he urged further vaccinations. "Last year, the virus affected 62 towns in 10 Russian regions, while since the start of 2006, already 56 towns in 9 regions have been affected," he said. In 16 of the towns, infected birds have been slaughtered, but the virus is still present in the other 40, he said. Farms were affected in the southern regions of Stavropol, Krasnodar and Dagestan. Reportedly, 30 000 birds died in a 24-hour period in southern Russia -- including almost 22 000 in the Krasnodar region with the rest in Daghestan. Officials say southern Russia is especially vulnerable to the disease because of the number of migrating birds that pass through the area. So far, more than 350 000 birds have died of the disease or been culled in Krasnodar and 760 000 in Daghestan. Earlier, tests at the laboratory of the Animal Protection Institute in Vladimir confirmed that birds in the Bogoslovskaya poultry farm in Stavropol were infected with the H5N1 virus. More than 70 000 chickens out of 120 000 in the Bogoslovskaya farm have died; the rest have been killed. Farm work has been halted. The area and its roads have been disinfected. The farm is the fifth bird flu outbreak site in Stavropol. The virus had also penetrated factory farming in Russia for the first time this year. Hitherto, it had been found only in private holdings.

Russian authorities have commenced the mass vaccination of the whole country's poultry stock, a massive undertaking in the world's largest country (by geographical size). In southern Russia, where vaccination programs got off the ground early, tens of millions of poultry have already been vaccinated. Many experts say that vaccinating birds does not stop the spread of the H5N1 virus. All it does is protect the bird that received the shot, but that bird can still be a carrier of the virus and infect other birds and possibly humans. Another problem with vaccination is its high cost. Dankvert said he did not foresee problems over vaccines this year. 32 million vaccine [doses] would be produced in Russia by the end of Mar 2006, 42 million in Apr 2006 and 70 million in May 2006 with the aim of a production peak of 1.2 billion annually, he noted. Demand on the Russian poultry market dropped by 20-25 percent between Nov 2005 and Mar 2006 because of the bird flu scare, said Galina Bobyleva, head of the poultry producers' union. (Promed 3/11/06, 3/19/06, 3/22/06)

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Thailand (Nan): Botulism outbreak associated with bamboo shoots
On 17 Mar 2006, WHO received reports of a possible outbreak of botulism in northern Thailand (Nan Province) among guests at a festival who had eaten home-preserved bamboo shoots. WHO was able to ensure delivery of antitoxin to Thailand by 19 Mar 2006. As of 20 Mar 2006, the Ministry of Public Health (MOPH) established that 152 of the 170 people attending a local village Buddhist festival in Banluang District, Nan Province, had developed symptoms suggestive of botulism. All of the affected people had eaten pickled bamboo shoots prepared in a traditional manner, with symptoms developing and progressing over 24-48 hours following consumption. 100 of the 152 people were hospitalized, and 40 have since required intubation and respirator support. To date, no deaths have been reported. The local health office has traced and recalled the suspect cans of locally produced bamboo shoots and is providing public education on food safety. WHO is working with partners in support of case diagnosis, investigation, and foodborne disease investigation and surveillance. A case control and cohort study is under way. To date, 60 doses of antitoxin (20 from UK, 30 from CDC and 10 from Sanofi-Pasteur Canada) have been provided, and severely affected patients are being treated. The Japanese National Institute of Infectious Disease is planning to deliver another 23 doses of antitoxin to Thailand 22 Mar 2006.

Patients who contracted botulism from contaminated processed bamboo shoots were airlifted to hospitals in Bangkok 23 Mar 2006 from Thailand's northern province of Nan. A Thai cargo aircraft transported 17 patients to 7 hospitals in Bangkok. Most are in critical condition. Dr. Prat Boonyawongvirot, Deputy Permanent Secretary for Public Health, said the Department of Medical Services covered all expenses to transport the patients. It will take about 2 months for them to recover under medical treatment if the hospitalized patients don't have complications, he added. In Nan, there are 79 patients including 15 critically ill cases, in hospitals. 9 patients still on respirators were admitted to hospitals in other provinces nearby. Meanwhile, Public Health Minister Pinij Jarusombat said he had ordered health officials in Nan and nearby provinces to inspect tinned bamboo shoots in the market as the products of low quality can be contaminated with Clostridium botulinum spores. Botulism is a disease caused by toxins produced by several members of a group of bacteria known as Clostridium botulinum. The number of the patients intoxicated by botulinum is the largest reported incident of botulism ever in Thailand. (Promed 3/20/06, 3/23/06)

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Malaysia (Sarawak): 8 killed in outbreak of Hand, foot, and mouth disease
Malaysia's eastern state of Sarawak said it was stepping up efforts to control an epidemic of hand, foot and mouth disease (HFMD), with indications it was spreading to rural areas. The outbreak has escalated into an epidemic, with some 200 cases being reported daily. All kindergartens in the state have been shut down to prevent the spread of the disease, and hospitals are on alert to treat and isolate people. A public awareness campaign would soon be launched. The state's deputy chief minister, George Chan, said Sarawak would deploy its flying doctor service to monitor people for symptoms of the disease, which affects mainly infants and young children. The death toll from the disease has climbed to 8, while cases have been recorded in the state's interior as well as the smaller towns of Mukah, on the central coast, and Kapit in central Sarawak, Chan said. The majority of cases have so far been recorded in Sarawak's main towns. The minister said the state would also increase staff numbers in hospitals to cope with the situation. HFMD is endemic in Malaysia. Malaysia has outbreaks of hand, foot and mouth illness, about every 3 years. Sarawak has been hit periodically by the disease. In the worst outbreak in 1997, the state on Borneo island recorded 31 fatalities. HFMD is a common illness of infants and children. It is characterized by fever, sores in the mouth, and a rash with blisters. HFMD is caused by enteroviruses (EV). Among them, EV 71 and coxsackievirus A16 are the 2 major pathogens. HFMD is usually spread by person-to-person contact. For the HFMD fact sheet, see: http://www.cdc.gov/ncidod/diseases/submenus/sub_hfmd.htm. (Promed 3/13/06, 3/19/06)

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Americas
USA: Latest updates from Pandemicflu.gov
There have been a number of new updates from the U.S. government (Department of Health and Human Services) regarding avian and pandemic flu information:
- Medical offices and clinics pandemic influenza planning checklist
- USDA, DOI and HHS Expand Screening For H5N1 Avian Influenza in Migratory Birds
- Colleges and Universities Checklist
- Child Care and Preschool Checklist
- HHS Buys More Antiviral Medication for the Strategic National Stockpile New maps of nations with confirmed cases of H5N1 avian influenza and bird migration have been uploaded.
(Pandemicflu.gov http://www.pandemicflu.gov/ )

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USA: FDA Prohibits Use of Antiviral Drugs in Poultry
The Food and Drug Administration published a proposed final rule to prohibit the extralabel use in poultry of 2 classes of approved human antiviral drugs in treating influenza. FDA is taking this measure to help preserve the effectiveness of these drugs for treating or preventing influenza infections in humans. The order prohibits the extralabel use by veterinarians of anti-influenza adamantane (amantadine and rimantadine) and neuraminidase inhibitor (oseltamivir and zanamivir) drugs in chickens, turkeys, and ducks. Extralabel use is the actual use or intended use of a drug in an animal in a manner that is not in accordance with the approved labeling. Currently, no drugs are approved for the treatment or prevention of influenza A in animals. However, 2 classes of antiviral drugs are approved in the US for the treatment or prevention of influenza A in humans. Under the Animal Medicinal Drug Use Clarification Act veterinarians can legally prescribe these drugs to protect animals from influenza. However, FDA can issue an order prohibiting certain extralabel uses in animals if such extralabel use presents a risk to public health. Thus far, there have been no reported cases of avian influenza H5N1 in the U.S. Nor is FDA aware that there is ongoing extralabel use of these drugs in the U.S. by poultry producers. However, concerns have been raised by WHO, Food and Agriculture Organization, and the World Animal Health Organization, that the extralabel use of these drugs in poultry could lead to the emergence of resistant strains of type A influenza. This is of particular concern if the avian influenza H5N1 has been identified in other countries were to emerge in the U.S. Repeated and improper use of anti-influenza drugs could allow resistant influenza viruses to flourish. (FDA 3/20/06 http://www.fda.gov/bbs/topics/NEWS/2006/NEW01339.html )

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USA (Alabama): BSE confirmed in cow
The western blot analysis at the National Veterinary Services Laboratory (NVSL) is positive with regard to bovine spongiform encephalopathy [BSE]. The samples were taken from a cow on a farm in Alabama. The western blot is enough for the US Department of Agriculture (USDA) to call this a positive case of BSE. The cow was 10 years old or older; it was born prior to the feed ban being enacted in 1997. The animal was treated by a veterinarian as a non-ambulatory animal. On a subsequent visit, the animal was not improving and was euthanized and sampled by the veterinarian. The animal was buried, and it did not enter the animal or human food chains. 2 rapid tests at a satellite lab proved to be inconclusive, and the sample was sent to NVSL. It has tested positive by western blot at the NVSL. USDA is now working with Alabama animal health officials to conduct an investigation to gather further information on the herd of origin of this animal. The animal had only resided on the most recent farm in Alabama for less than a year. Dr. Clifford does not anticipate this animal affecting any trade with Japan or with Korea. USDA will be working to locate animals from this cow's birth cohort and any offspring. They will also work with Food and Drug Administration. All animals of interest will be tested for BSE. To date, including this animal, 2 animals have tested positive for the disease as part of the enhanced surveillance program. (Promed 3/13/06)

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USA (Iowa): Outbreak of 60 mumps cases
State health officials are concerned about a rare strain of mumps virus behind an outbreak of 60 mumps cases in Iowa. Mary Gilchrist, director of the State University's Hygienic Laboratory, said the genotype G strain is infrequently seen in the US. She predicted there could be more outbreaks in spring 2006. The patients with confirmed cases of mumps range in age from 11 to 41, but Gilchrist said half have been college students. She said the virus may have come from Europe, but a similar strain has been detected in New Jersey. CDC is investigating. Symptoms of mumps include fever, headache and swollen salivary glands at the jaw line, below and in front of the ears. Mumps is generally a mild illness for healthy people and is spread through coughing or sneezing. It can cause serious complications, including deafness in children and spontaneous abortion in pregnant women. A mumps vaccine was introduced in 1967. People born before 1957 are believed to have been exposed to mumps during childhood and therefore immune. Mumps infection occurs worldwide, and humans are the only natural host for the virus. The virus is essentially monotypic, although there may be some mismatch between individual strains and vaccines. Despite the monotypic nature of mumps virus, different genetic lineages of mumps virus exist and co-circulate globally. (Promed 3/15/06)

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USA (New Mexico): Third case of Hantavirus pulmonary syndrome in 2006
New Mexico's third case of hantavirus infection for 2006 has been confirmed in a Taos County woman. The woman was hospitalized 13 Mar 2006 at the University of New Mexico Hospital in Albuquerque. She has been diagnosed with hantavirus pulmonary syndrome (HPS). Health officials were investigating to determine where the woman may have been exposed to the virus. The disease is transmitted through particles of dried urine, droppings or saliva of infected rodents. Earlier cases in 2006 included a woman who has since recovered and a man who died from the virus. New Mexico had 1 case reported during 2005. There is no specific treatment, but the chances for recovery are better if medical attention is sought early. Early symptoms of HPS include fever and muscle aches, possibly with chills, headache, nausea, vomiting, diarrhea, abdominal pain and a cough. The symptoms develop within 1- 6 weeks after exposure. (Promed 3/16/06)

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Peru (Ayacucho): 4 people die from yellow fever
The death of 4 people from yellow fever in Santa Rosa, San Martín & Palmapampa, in the jungle part of Ayacucho Department, has caused the Regional Health Directorate to declare an epidemiological red alert. Silvia Saravia, Regional Director of Health, said the measure included permanent surveillance for new cases in ministry of health institutions, and the start of vaccination days. Vaccination will take 30 days and cover 500 000 people. "We will vaccinate in both the jungle and the mountainous part of Ayacucho. In this way, we hope to control the epidemic, which we haven't seen in 10 years," said the specialist. (Promed 3/18/06)

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1. Updates
Influenza
Seasonal influenza activity for the Asia Pacific and APEC Economies
Similar to the previous 6 weeks, influenza activity continued to increase gradually during week 10 in many countries of the northern hemisphere, although overall activity remained moderate to low.
Canada. Influenza activity continued to increase during week 10 with widespread activity reported from 3 provinces. Overall ILI consultation rate remained within the expected range. A and B viruses co-circulated.
Hong Kong. A slight increase in influenza A(H1) and B activity continued to be observed since week 1, whereas overall activity remained moderate to low.
Japan. After a peak during weeks 3–4, influenza A activity continued to decline and was reported as localized during week 10.
Russia. A slight increase in influenza activity continued to be observed during week 10. Overall activity remained localized. Influenza A(H1), A(H3N2) and B viruses co-circulated.
USA. During week 11 (Mar 12 – 18, 2006), influenza activity decreased in the US. 655 specimens (21.2%) tested by U.S. WHO and National Respiratory and Enteric Virus Surveillance System 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. 23 states and New York City states reported widespread influenza activity; 14 states reported regional influenza activity; 8 states and the District of Columbia reported local influenza activity; and 5 states reported sporadic influenza activity.
(WHO 3/24/06 http://www.who.int/csr/disease/influenza/update/en/ ; CDC 3/24/06 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. Includes documents: “WHO pandemic influenza draft protocol for rapid response and containment” and “Advice on use of oseltamivir”.
- FAO updates on avian influenza: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Includes special report on avian influenza and cats.
- OIE updates and documents on avian influenza: http://www.oie.int/eng/en_index.htm. Includes information on the Asian European Conference on Avian Influenza 2006.
- CDC website on pandemic influenza: http://www.cdc.gov/flu/pandemic.htm. Now available: “Instructions to Estimate Impact of Next Pandemic”. For avian influenza: http://www.cdc.gov/flu/avian/.
- The US government’s web site for pandemic flu: http://www.pandemicflu.gov/. Latest update on U.S. government’s preparedness activities and State Summits 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. Read the articles: “PAHO Calls for North-South Cooperation to Prepare for Pandemic” and “International Agencies Plan Joint Action against Bird Flu in the Americas”.
- 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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Dengue
Malaysia (Penang)
Reported dengue cases are on the rise in Penang. There are now 22 suspected dengue cases in hospitals here, Health Ministry parliamentary secretary Datuk Lee Kah Choon said 10 Mar 2006. Lee said there were 88 reported dengue cases between 20 Feb and 5 Mar 2006. During 20 to 25 Feb 2006, there were 30 reported cases in the state. "But in the following week, from 26 Feb to 5 Mar 2006, there was a 93 percent increase to 58 cases," he said. "But there is no cause for alarm, as these numbers are quite normal," he said. He reminded people to take the usual precautions to rid their homes of mosquito breeding grounds. Reportedly, there were more than 3000 dengue cases last year. Of these, 875 were confirmed; 7 were fatal cases. (Promed 3/12/06)

Malaysia (Kedah)
13 housing estates and villages in 5 districts in Kedah have been declared dengue outbreak zones. State Health Committee chairman Datuk V. Saravanan said 304 confirmed dengue cases had been reported from 1 Jan to 12 Mar 2006. He said 5 of the 13 housing estates were in Baling, 4 in Kota Star, 2 in Kuala Muda, and 1 each in Pendang and Sik. From Jan 1 to Mar 12, 2006, Kota Star recorded 108 confirmed cases, followed by Baling (53), Kuala Muda (46), Kulim (24), Bandar Baharu (7), Kubang Pasu (20), Sik (16), Pendang (9), Padang Terap (9), Langkawi (7) and Yan (5). "We need public co-operation to keep dengue at bay,'' he said, adding that the victims were aged between 7 and 52 years. (Promed 3/18/06)

Malaysia (Malacca)
10 people from Taman Maju in Jasin are down with dengue in the last month. Malacca State committee chairman for human resource, health and consumer affairs Datuk Seah Kwi Tong said the Health department is monitoring the area after the victims were admitted to hospital. Earlier, Taman Malim Jaya and Parameswara residential areas in Melaka Tengah district were classified as dengue zones but no outbreak has been reported so far. Seah said 113 cases of dengue were reported to the department between Jan - 11 Mar 2006, compared to the same period last year, when 201 dengue cases were reported with 1 death, he said. He said the awareness campaigns on dengue, which started a few months ago, were not well accepted. (Promed 3/18/06)

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2. Articles
CDC EID Journal, Volume 12, Number 4—April 2006
CDC Emerging Infectious Diseases Journal, Volume 12, Number 4—April 2006 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. An expedited article is available online: Coronavirus HKU1 Infection in the United States, F. Esper et al.

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Avian Influenza's Human-attack Pathway Revealed
2 separate research groups have independently discovered why the H5N1 avian influenza virus causes lethal pneumonia in people, but is--so far--hard for people to catch. In the process, they have found a way to predict which mutations might make the virus more contagious and potentially become a pandemic strain. To date, confirmed human deaths from the disease stand at 103 worldwide. The H5N1 virus binds to sugars on the surface of cells deep in human lungs, but not to cells lining the human nose and throat, report the 2 research teams led by Thijs Kuiken at Erasmus University and Yoshihiro Kawaoka at the Universities of Tokyo and Wisconsin at Madison. This fits the few autopsies that have been performed on H5N1 victims. Both groups concluded that poor binding of the H5N1 high in the respiratory tract might be why the virus has so far not been able to spread easily between people, a major factor keeping it from becoming pandemic. "We will now try to look at what mutations in the virus improve binding in the upper respiratory tract," said Kuiken. That could show what mutations to watch for as H5N1 continues to spread. They will also study which other human tissues H5N1 can bind to. Cases so far suggest it might affect the gut and the brain.

The Nature paper (Nature. 2006 Mar 23;440(7083):435-6) is entitled "Avian flu: influenza virus receptors in the human airway. " by Kyoko Shinya, et al. The introductory paragraph reads: "Although more than 100 people have been infected by H5N1 influenza A viruses, human-to-human transmission is rare. What are the molecular barriers limiting human-to-human transmission? Here, we demonstrate an anatomical difference in the distribution in the human airway of the different binding molecules preferred by the avian and human influenza viruses. The respective molecules are sialic acid linked to galactose by an alpha-2,3 linkage (SAalpha2,3Gal) and by an alpha-2,6 linkage (SAalpha2,6Gal). Our findings may provide a rational explanation for why H5N1 viruses at present rarely infect and spread between humans, although they can replicate efficiently in the lungs." (Promed 3/22/06)

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Study Identifies Mutations Needed For Human Bird Flu Pandemic
Scientists said they had identified some of the mutations that the H5N1 virus needs to gain a permanent foothold in the human population. They said the glycan microarray test might be useful in monitoring the virus in birds and as it infects people, to see whether it is mutating into a form that would allow it to pass easily from person to person. Ian Wilson and a team at The Scripps Research Institute looked at a structure on the surface of all influenza viruses called hemagglutinin (H). Only 3 -- H1, H2 and H3 -- have been known to cause human disease, and they caused the last 3 great influenza pandemics. Wilson's team imaged a sample of influenza virus that killed a 10-year-old Vietnamese boy in 2004. They found its hemagglutinin looked very similar to the virus that caused the 1918 pandemic. It looked less similar to H5N1 taken from a duck in Singapore. "Of the H5N1 viral isolates studied to date, A/Vietnam/1203/2004 (Viet04) is among the most pathogenic in mammalian models. . ." the researchers wrote. Hemagglutinin allows the virus to attach to the cells it infects, and it has to be able to grapple a structure called sialic acid, which is slightly different in different animal species. So to pass from birds to humans, the virus must mutate enough to allow it to bind to, for instance, both a human lung cell and a chicken's intestinal cell. Wilson's team identified a structure that, in the human configuration, is called an alpha 2-6 receptor and in birds an alpha 2-3 receptor. It must change from the bird to human configuration to cause human epidemics. This "critical step. . .appears to be one of the reasons why most avian influenza viruses, including current avian H5 strains, are not easily transmitted from human-to-human following avian to human infection," they wrote. Earlier studies had shown it took only 2 changes to make the 1918 virus look just like a purely avian virus.

James Stevens et al. Structure and Receptor Specificity of the Hemagglutinin from an H5N1 Influenza Virus. Science. 2006 Mar 20: http://www.sciencexpress.org. Introduction: "The hemagglutinin (HA) structure at 2.9 angstrom resolution, from a highly pathogenic Vietnamese H5N1 influenza virus, is more related to the 1918 and other human H1 HAs than to a 1997 duck H5 HA. Glycan microarray analysis of this Viet04 HA reveals an avian a'2-3 sialic acid receptor binding preference. Introduction of mutations that can convert H1 serotype HAs to human a'2-6 receptor specificity only enhanced or reduced affinity for avian-type receptors. However, mutations that can convert avian H2 and H3 HAs to human receptor specificity, when inserted onto the Viet04 H5 HA framework, permitted binding to a natural human a'2-6 glycan, which suggests a path for this H5N1 virus to gain a foothold in the human population."

A perspectives article in the 17 Mar 2006 issue of Science (“Clues to the Virulence of H5N1 viruses in Humans”) discusses other evidence relating to determination of H5N1 virus virulence for mammals. (Promed 3/20/06)

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Influenza in Tropical Regions
Viboud C, Alonso WJ, Simonsen L. PLoS Med. 2006 Mar 7;3(4):e89.
“The global burden of influenza on morbidity and mortality is considerable, with an estimated 1 million annual deaths worldwide. In temperate regions, there are clear seasonal variations in the occurrence of influenza, with a marked peak in cold winter months. In contrast, seasonality is less defined in tropical regions—here, there is high background influenza activity throughout the year, on top of which epidemics occur at intermediate months between the influenza season in temperate countries of the Northern and Southern hemispheres. . .Very little is known about exactly how and why the seasonality of influenza varies with latitude. No link with environmental conditions has been convincingly shown, although influenza activity appears to coincide with the rainy season in some tropical countries. . .” (CIDRAP http://www.cidrap.umn.edu/ )

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Severe acute respiratory syndrome diagnostics using a coronavirus protein microarray
Heng Zhu et al. Proc Natl Acad Sci U S A. 2006 Mar 14;103(11):4011-6. Epub 2006 Mar 7.
Abstract: “To monitor severe acute respiratory syndrome (SARS) infection, a coronavirus protein microarray that harbors proteins from SARS coronavirus (SARS-CoV) and five additional coronaviruses was constructed. These microarrays were used to screen 400 Canadian sera from the SARS outbreak, including samples from confirmed SARS-CoV cases, respiratory illness patients, and healthcare professionals. A computer algorithm that uses multiple classifiers to predict samples from SARS patients was developed and used to predict 206 sera from Chinese fever patients. The test assigned patients into two distinct groups: those with antibodies to SARS-CoV and those without. The microarray also identified patients with sera reactive against other coronavirus proteins. Our results correlated well with an indirect immunofluorescence test and demonstrated that viral infection can be monitored for many months after infection. We show that protein microarrays can serve as a rapid, sensitive, and simple tool for large-scale identification of viral-specific antibodies in sera.” (CIDRAP http://www.cidrap.umn.edu/ )

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Studies Propose Targeted Screening of Blood for West Nile Virus
Kuehn BM. JAMA. 2006 Mar 15;295(11):1235-6.
“When evidence emerged in 2002 that the West Nile virus could be transmitted through blood, the US Food and Drug Administration (FDA) and blood-screening organizations reacted quickly to maintain the safety of the blood supply by screening for this infectious agent. By 2003, the FDA had recommended that blood banks screen blood for the West Nile virus using an investigational nucleic acid test. Since then, blood banks across the country have used various strategies, including individual or pooled blood sample testing, to prevent this infectious agent from contaminating the blood supply. But some scientists believe these strategies may not provide sufficient public health benefit to justify their expense, and they recommend using more targeted testing strategies that would reduce costs. Two recent cost-effectiveness analyses suggest two reasons for considering alternative screening strategies: the high cost of testing the blood supply and the low risk that infection with . . .” (CIDRAP http://www.cidrap.umn.edu/ )

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Concept of operations for triage of mechanical ventilation in an epidemic
Hick JL, O'Laughlin DT. Acad Emerg Med. 2006 Feb;13(2):223-9. Epub 2006 Jan 6.
Abstract: “The recent outbreak of severe acute respiratory syndrome and the growing potential of an influenza pandemic force us to consider the fact that despite great advances in critical care medicine, we lack the capacity to provide intensive care to the large number of patients that may be generated in an epidemic or multisite bioterrorism event. Because many epidemic and bioterrorist agent illnesses involve respiratory failure, mechanical ventilation is a frequently required intervention but one that is in limited supply. In advance of such an event, we must develop triage criteria that depend on clinical indicators of survivability and resource utilization to allocate scarce health care resources to those who are most likely to benefit. These criteria must be tiered, flexible, and implemented regionally, rather than institutionally, with the backing of public health agencies and relief of liability. This report provides a sample concept of operations for triage of mechanical ventilation in epidemic situations and discusses some of the ethical principles and pitfalls of such systems.” (CIDRAP http://www.cidrap.umn.edu/ )

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Emergence of Mycobacterium tuberculosis with Extensive Resistance to Second-Line Drugs--Worldwide, 2000-2004
“During the 1990s, multidrug-resistant (MDR) tuberculosis (TB), defined as resistance to at least isoniazid and rifampin, emerged as a threat to TB control, both in the United States and worldwide. MDR TB treatment requires the use of second-line drugs (SLDs) that are less effective, more toxic, and costlier than first-line isoniazid- and rifampin-based regimens. In 2000, the Stop TB Partnership's Green Light Committee was created to increase access to SLDs worldwide while ensuring their proper use to prevent increased drug resistance. While assisting MDR TB treatment programs worldwide, the committee encountered reports of multiple cases of TB with resistance to virtually all SLDs. To assess the frequency and distribution of extensively drug-resistant (XDR) TB cases, CDC and. . .WHO surveyed an international network of TB laboratories. This report summarizes the results of that survey, which determined that, during 2000--2004, of 17,690 TB isolates, 20% were MDR and 2% were XDR. . .New anti-TB drug regimens, better diagnostic tests, and international standards for SLD-susceptibility testing are needed for effective detection and treatment of drug-resistant TB. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5511a2.htm
(MMWR March 24, 2006 / 55(11);301-305)

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Trends in Tuberculosis ---United States, 2005
“For 2005, a total of 14,093 tuberculosis (TB) cases (4.8 cases per 100,000 population) were reported in the United States, representing a 3.8% decline in the rate from 2004. This report summarizes provisional 2005 data from the national TB surveillance system and describes trends since 1993. The findings indicate that although the 2005 TB rate was the lowest recorded since national reporting began in 1953, the decline has slowed from an average of 7.1% per year (1993--2000) to an average of 3.8% per year (2001--2005). . .Moreover, the number of multidrug-resistant (MDR) TB cases in the United States increased 13.3%, with 128 cases (up from 113 in 2003) of MDR TB in 2004, the most recent year for which complete drug-susceptibility data are available. . .Effective TB control and prevention in the United States require sufficient resources, continued collaborative measures with other countries to reduce TB globally, and interventions targeted to U.S. populations with the highest TB rates. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5511a3.htm
(MMWR March 24, 2006 / 55(11);305-308)

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Primary and Secondary Syphilis --- United States, 2003--2004
“In 2000, the rate of primary and secondary (P&S) syphilis in the United States was 2.1 cases per 100,000 population, the lowest since reporting began in 1941. From 2001 to 2004, the P&S syphilis rate increased to 2.7, primarily as a result of increases in cases among men who have sex with men (MSM). To characterize the recent epidemiology of syphilis in the United States, CDC analyzed national notifiable disease surveillance data for 2000--2004, focusing on 2003--2004. This report describes the results of that analysis, which indicated that the disparity between syphilis rates among blacks and whites in 2004 increased for the first time since 1993 and is associated with a substantial increase of syphilis among black men. Syphilis rates continue to increase among MSM. After declining for 13 years, the rate of P&S syphilis in 2004, compared with 2003, increased in the South and remained the same among women. The findings underscore the need for enhanced prevention measures among blacks and MSM. In addition, enhanced surveillance is needed to detect any early increases in P&S syphilis among women. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5510a1.htm
(MMWR March 17, 2006 / 55(10);269-273)

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Increased Antiviral Medication Sales Before the 2005-06 Influenza Season--New York City
“. . .As part of syndromic surveillance, the New York State Department of Health (NYSDOH) monitors sales of antiviral influenza medications paid for by the Medicaid system, and the New York City Department of Health and Mental Hygiene (NYCDOHMH) monitors sales of antiviral influenza medications by a retail pharmacy chain. Syndromic data are used in combination with data provided by laboratories, health-care facilities, and health-care providers to monitor influenza activity. In October 2005, a spike in antiviral medication sales was noted. The spike did not coincide with other markers of influenza activity but did coincide with the beginning of media coverage of avian influenza A (H5N1) and the potential for an influenza pandemic. Tracking prescription medication sales can detect spikes for which no immediate indication exists. Such syndromic data might be used to guide issuance of public health recommendations regarding the limited availability of certain medications and the inadvisability of personal stockpiling. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5510a3.htm
(MMWR March 17, 2006 / 55(10);277-279)

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Inhalation Anthrax Associated with Dried Animal Hides--Pennsylvania and New York City, 2006
“On February 21, 2006, the Pennsylvania Department of Health (PDOH) reported to CDC and the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) a case of inhalation anthrax in a man who resided in New York City. This report summarizes the joint epidemiologic and environmental investigation conducted by local, state, and federal public health, animal health, and law enforcement authorities in Pennsylvania and NYC to determine the source of exposure and identify other persons who were potentially at risk. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5510a4.htm
(MMWR March 17, 2006 / 55(10);280-282)

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3. Notifications
APEC Symposium on Emerging Infectious Diseases
In order to promote cooperation among members and establish a mutual technical assistance and information sharing mechanism, the APEC Symposium on Emerging Infectious Diseases will be held in China in April 4 -5, 2006. In 2005 and 2006 the APEC Health Task Force (HTF) has supported numerous activities directly relevant to planning and preparedness against infectious diseases, particular avian influenza and potential of pandemic influenza. Those activities include: Situation Assessment Project: Influenza Surveillance, and Pandemic Planning and Preparedness; Enhancing Influenza Surveillance, and Pandemic Planning and Preparedness; APEC Symposium on Response to Outbreaks of Avian Influenza and Preparedness for a Human Health Emergency; APEC Workshop on Avian Influenza Preparedness. Due to the importance of increasing coordination and improving collaboration for enhancing preparedness and response planning, timely communication for information sharing among member economies has been a main concern in addressing infectious diseases. The first APEC Virtual Symposium on Pandemic Preparedness was held 19 Jan 2006 by APEC Emerging Infections Network (EINet).

Also, the HTF has agreed on its 2006 Work Plan that includes a joint action plan to address health and economic impacts of infectious disease and in particular deal with pandemic influenza preparedness and response. The HTF will also provide significant support to the APEC Ministerial Meeting on Avian and Influenza Pandemics that will be held in Viet Nam, on May 4-5. HTF Chair, Mr Ian Shugart, said key issues in the Work Plan include implementing measures to help APEC Member Economies to prepare for the threat posed by potential pandemics. "As part of the plan a workshop, will be convened in Da Nang to strengthen the capacity of economies in the region to build communications networks that will be essential in the event of a pandemic outbreak. The workshop will take place on the sidelines of the APEC Ministerial Meeting on Avian and Influenza Pandemics,” he said. Mr Shugart said another priority of the HTF will be pursuing activities to strengthen the ability of APEC economies to respond to HIV/AIDS. (APEC http://www.apec.org/ )

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Advancing Global Health: Facing Disease
The 55th Annual Meeting of the Wildlife Disease Association in conjunction with the American Association of Wildlife Veterinarians will be held 6-10 Aug 2006 at the University of Connecticut in Storrs, Connecticut, USA. Diseases that cross the wildlife, human and livestock interface have enormous health, economic, and social ramifications. Consequently, there is a great need to improve collaboration and communication among wildlife, livestock and human health practitioners. The Wildlife Disease Association (WDA) and the American Association of Wildlife Veterinarians (AAWV) invite members from a variety of human and animal health disciplines to attend a conference entitled "Advancing Global Health: Facing Disease Issues at the Wildlife, Human, and Livestock Interface." This meeting will bring together animal and human health practitioners in one forum to discuss these increasingly challenging issues. Who should attend and/or submit abstracts? Ecologists, veterinarians, medical practitioners, researchers, biologists, and any professional with an interest in human and animal health. For more information: http://www.conferences.uconn.edu/wildlife or email Damien Joly at wda.2006@gmail.com.

Damien Joly, PhD, Wildlife Disease Specialist, Fish and Wildlife Division, Alberta Sustainable Resource Development; damien.joly@gov.ab.ca
(Promed 3/21/06)

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Fiji to host global meeting in the fight against lymphatic filariasis
The Global Alliance to Eliminate Lymphatic Filariasis will meet in Fiji from 29 – 31 March to review progress in the fight against the disease. Representatives from the health sector, including ministers of health, health workers, the Global Alliance donor pharmaceutical companies, donor agencies, academic institutions and other non-governmental organizations from over 40 countries, are attending the meeting. For more information, visit: http://www.wpro.who.int/media_centre/news/news_20060310.htm.
(WHO/WPRO 3/10/06 http://www.wpro.who.int/home.htm )

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World TB Day 2006
The aim of World TB Day 2006 (24 Mar 2006) is to mobilize support for the fight against tuberculosis. By mobilizing communities, raising awareness, encouraging governments and donors to invest in tuberculosis control, and calling for strengthened commitment, we can ensure that tuberculosis is placed prominently on the global agenda and is eliminated by 2050. The thematic focus for World TB Day is built on the Global Plan to Stop TB advocacy strategy, key messages and action points, and utilizes the report subtitle “Actions for Life: towards a world free of tuberculosis” as a basis for campaign development. TB control is cost-effective but still seriously under-funded in Africa. The Americas, South-East Asia and the Western Pacific should reach targets set by the World Health Assembly, to detect 70% of TB cases and to successfully treat 85% of these cases by the end of 2005. The report confirms 26 countries had already met the targets a year ahead of time, 2 of them being the high TB burden countries of the Philippines and Viet Nam. 5 other high-burden countries - Cambodia, China, India, Indonesia and Myanmar - should have reached the targets within the 2005 timeframe; final confirmation will come later. (WHO 3/22/06 http://www.who.int/en/ )

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

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 apecein@u.washington.edu