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EINet Alert ~ Mar 31, 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)
- Afghanistan: Suspected human cases of H5N1 infection; OIE update
- Bosnia and Herzegovina: Excerpts from the OIE report on avian influenza H5N1
- Czech Republic: Confirmation of avian influenza H5N1 infection in a swan
- Denmark: Avian influenza H5N1 infection confirmed in wild birds
- Israel: Eighth outbreak of avian influenza H5N1 in poultry
- Jordan: New avian influenza outbreak in poultry; OIE update
- Kazakhstan: Excerpts from the OIE report on avian influenza H5N1
- Palestinian Authority: UN calls for urgent avian influenza aid for Palestinians
- Poland: Excerpts from the OIE report on avian influenza H5N1
- Serbia and Montenegro: Confirms first case of avian influenza H5N1 infection in rooster
- Sweden: Mink found infected with H5 virus; H5N1 infection in wild birds
- Cambodia: Update on fifth human case of avian influenza H5N1 infection
- Cambodia: New avian influenza H5N1 outbreaks in poultry
- Hong Kong: Excerpts from the OIE report on avian influenza H5N1
- India: Detection of avian influenza in chickens in Madhya Pradesh
- Indonesia: Additional suspected human cases of avian influenza H5N1 infection
- Myanmar: Excerpts from the OIE report on avian influenza H5N1
- Pakistan (Bamyan): Suspected cases of avian influenza infection in birds
- USA: FDA approves Relenza for the prevention of influenza A and B in adults and children
- Cameroon: Confirmation of second case of avian influenza H5N1 infection in duck
- Egypt: 5 suspected human cases; preliminarily positive for H5N1 infection

1. Updates
- Influenza

2. Articles
- Safety and Immunogenicity of an Inactivated Subvirion Influenza A (H5N1) Vaccine
- Vaccines against avian influenza--a race against time.

3. APEC EINet activities
- APEC EID Symposium; HIT Workgroup Meeting


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)

The current USGS list of species affected by avian influenza H5N1, based on referenced reports, can be found at: http://www.nwhc.usgs.gov/disease_information/avian_influenza/affected_species_chart.jsp. A European map on avian influenza in wild birds is available at the EU website, which is updated on a daily basis: http://europa.eu.int/comm/food/animal/diseases/adns/index_en.htm#.
(WHO 3/24/06 http://www.who.int/csr/disease/avian_influenza/en/ ; Promed 3/28/06, 3/31/06)

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Europe/Near East
Afghanistan: Suspected human cases of H5N1 infection; OIE update
Afghan health authorities are investigating the deaths of 3 children on suspicion they might have had died of bird flu, the Public Health Ministry said. The H5N1 virus was confirmed in chickens in the Afghan capital and an eastern province this month and is assumed to have spread to 5 other provinces. The 3 children died in the central province of Ghor, which has not reported any suspected cases of avian flu in chickens. Ministry adviser Abdullah Fahim said 3 children from the same place had recently died in the province, and there had also been reports of dead wild birds in the vicinity. The children had been buried and no samples were taken. Health and agriculture officials were going to investigate the case in remote Dahor village, to determine if the children had been in close contact with birds, and to check on the reports of dead birds in the area. Poultry production is small in Afghanistan but many families have a few chickens in the yard.

Excerpts from the OIE report on avian influenza H5N1
Information received (and dated) 20 Mar 2006 from Dr Azizullah Osmani, general president of Animal Husbandry and Veterinary Services, Ministry of Agriculture, Animal Husbandry and Food: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 2 Mar 2006. Details of outbreaks: Between 2-19 Mar 2006, outbreaks have occurred in the following locations: Jalalabad - 5 outbreaks, Kabul - 6 outbreaks, and 1 outbreak each in Laghman, Vardak, and Kunar provinces. Description of affected population: chicken, turkeys and a crow. Diagnostic tests results: ELISA, positive. PCR (genes M, H5 and N1), positive for H5N1. Sequence analysis, amino acid sequence at cleavage site indicates a highly pathogenic avian influenza profile. (Promed 3/28/06, 3/31/06)

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Bosnia and Herzegovina: Excerpts from the OIE report on avian influenza H5N1
Information received (and dated) 22 Mar 2006 from Dr Jozo Bagaric, head of the State Veterinary Administration of Bosnia and Herzegovina, Sarajevo: Precise identification of agent: avian influenza virus subtype H5N1. Date of start of event: 16 Feb 2006. Details of outbreak (reminder): 2 swans out of about 150 swans at Plivsko lake, Srednjobosanski were found to be positive for avian influenza. 15 swans were destroyed. By 22 Feb 2006, all 2872 domestic poultry present within a 3 km radius around Plivsko Lake, where the positive swans were found, were killed and disposed of in a safe manner. From 2 to 5 Mar 2006, intensive sampling was carried out in the surveillance zone (10 km radius around Plivsko lake), during which 1214 samples were obtained from the domestic poultry population (blood samples and cloacal swabs); all the samples gave negative results. There have been no new cases, and all animals tested in the surveillance zone have given negative results. From 22 Mar 2006, all the protection measures applied in the area of the outbreak will be lifted. Diagnostic tests results: Virus isolation; positive for H5N1; sequence analysis; amino acid sequence at cleavage site indicates a highly pathogenic avian influenza profile. (Promed 3/28/06)

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Czech Republic: Confirmation of avian influenza H5N1 infection in a swan
Tests at the UK reference laboratory have confirmed a dead swan found in the Czech Republic had the highly pathogenic H5N1 bird flu virus, the Czech State Veterinary Authority said 28 Mar 2006. It is the first confirmed H5N1 case in the Czech Republic. The swan was found last week in Hluboka nad Vltavou in the south of the Czech Republic. Special measures will be taken, including the creation of 3 and 10 km security zones around the place where the dead swan was found. All of the central European country's neighbors -- Germany, Austria, Poland, and Slovakia -- have reported H5N1 cases in dead birds. (Promed 3/28/06, 3/30/06)

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Denmark: Avian influenza H5N1 infection confirmed in wild birds
On 30 Mar 2006 the Danish Veterinary and Food Research Institute detected highly pathogenic avian influenza (H5) in a tufted duck (Aythya fuligula) found dead on Kegnaes in the southern part of Jutland. The Danish Veterinary and Food Administration is implementing measures, including establishing a protection and surveillance zone. Kegnaes is located near Sonderborg, and surveillance zone already established 29 Mar 2006 is therefore not changed, but a new protection zone has been established. On 29 Mar 2006 the Danish Veterinary and Food Research Institute detected highlypathogenic avian influenza (H5) in a common buzzard (Buteo buteo) found dead near the town of Sonderborg in the southern part of Jutland. Denmark has reported 12 cases of H5N1 bird flu so far, and the UK reference laboratory has confirmed the first of 12 cases of the H5N1 strain of bird flu in Denmark. The UK laboratory said it trusted Denmark's testing facilities, and therefore the country did not need to send samples of the other infected birds for confirmation. (Promed 3/30/06, 3/31/06)

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Israel: Eighth outbreak of avian influenza H5N1 in poultry
Authorities are to oversee culling 29 Mar 2006 of 30 000 chickens at Kibbutz Ma'aleh Hahamisha near Jerusalem, 1 day after the H5N1 strain of the bird flu virus was confirmed there. On 28 Mar 2006, an abnormal death rate of poultry was noted, and samples sent to laboratories confirmed with near certainty the presence of the H5N1 strain. The Agriculture Ministry's veterinary services made preparations to cull the poultry. The chiefs of the veterinary services and agriculture ministry have met to discuss the complete destruction of all poultry within a 3-km radius from the affected site. It is unclear whether culling in surrounding areas will take place. The Jerusalem corridor is home to many moshavim in which poultry growing is a primary source of income. After the virus had spread to Gaza and Jordan, the agriculture ministry issued a warning of a potential recurrence in Israel. Poultry farmers have been compensated for 50 per cent of the direct economic damage done to them by the culling. The ministry estimates that the direct damage done to the poultry growers is NIS 24 million [USD 5.11 million]. The growers estimate a damage of NIS 30-40 million. According to <http://poultrymed.com/files/index.html>, this outbreak occurred in a broiler breeder farm (40 weeks of age). The (initial) mortality rate was very low (40 out of 30 000 birds in 6 buildings). The preliminary initial H5 diagnosis and its confirmation as H5N1 were obtained by PCR. (Promed 3/30/06)

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Jordan: New avian influenza outbreak in poultry; OIE update
No new cases of the avian flu were reported in the Kingdom until 25 Mar 2006, after the virus was detected in 4 turkeys in Ajloun Governorate 24 Mar 2006. The government decided 25 Mar 2006 to include the entire Kingdom in the deadline issued to Jordan Valley residents. On 23 Mar 2006, the government gave families in the Jordan Valley who raise poultry in their backyards 1 week to get rid of them, after which the authorities will start collecting these birds and culling them, Khalid Abu Rumman, head of the technical committee said. The infected turkeys were found in a house in the Kufranjeh area of Ajloun. Health and agriculture workers are destroying birds within a 6 km radius of Kufranjeh. In addition, they are vaccinating birds within a 10 km radius of the village. So far, more than 2500 birds in the area have been culled. Stressing that there were no cases of human infection, Abu Rumman said 22 people who lived in the farm and had direct contact with the birds tested negatively for the H5N1 virus.

Referring to the collection and culling of birds, Zu'bi said pet birds kept indoors would not be included. Only chickens, doves and turkeys will be affected because they live in open places and are not well-protected; therefore they are the most likely to come into direct contact with migratory birds and contract the virus, Zu'bi said. Ajloun Governor Ahmad Shayyab said more than 20 000 chickens in 4 poultry farms in Kufranjeh would be culled 26 Mar 2006. In central Jordan Valley, the Public Works and Housing Department, in cooperation with local municipalities in the area, have started digging trenches close to poultry farms in the area, which contain more than 100 000 chickens. "We are making advance preparations so if the deadly virus is detected in the area, we will cull the poultry and bury them in these trenches," Central Jordan Valley district governor Hakam Faouri said. In the capital, the Greater Amman Municipality decided to close its 3 bird gardens in Amman. Amman governor Saed Wadi Manasir took a decision 25 Mar 2006 to prohibit the breeding of poultry and doves in houses and on rooftops.

Excerpts from the OIE report on avian influenza H5N1
Highly pathogenic avian influenza has never been reported before in Jordan. Information received 24 Mar 2006 from Dr Fares Bakhit Naser, director of Veterinary Department, Ministry of Agriculture: Identification of agent: highly pathogenic avian influenza (HPAI) virus subtype H5N1. Date of first confirmation of event: 23 Mar 2006. Location of outbreak: Kofranja, Ajloun governorate. Number of animals in outbreak: 21 cases -- including the 20th death from a flock of 8000 -- are reported. The animal health officials destroyed another 1500 birds. The affected population was backyard poultry (turkeys and chickens). Diagnostic tests used: Rapid test; Capture ELISA; Real time PCR for genes A, H5 and N1. Samples will be sent to an OIE reference laboratory for confirmation. (Promed 3/27/06, 3/28/06)

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Kazakhstan: Excerpts from the OIE report on avian influenza H5N1
Information received 21 Mar 2006 from Dr Asilbek A Kozhumratov, director, Veterinary Control Department, Ministry of Agriculture: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 10 Mar 2006. Details of outbreak: 3 cases of avian influenza in wild swans occurred at Cape Peschannyi, Mangghystau. Diagnostic tests: PCR; hemagglutination test; positive for H5. Rapid test; positive for H5N1. Virus isolation; PCR; sequence analysis; positive for H5N1. Amino acid sequence at cleavage site indicates a highly pathogenic avian influenza profile. (Promed 3/28/06)

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Palestinian Authority: UN calls for urgent avian influenza aid for Palestinians
WHO urged international donors to provide urgent aid to the Palestinian Authority to contain an outbreak of bird flu in the Gaza Strip. It called on the "international community and Israel to promptly support the PA with financial resources in order to immediately begin the culling of birds, assist in the provision of compensation for affected farmers and the procurement of anti-viral drugs as well as to facilitate the import of alternative sources of protein." WHO said that in addition to 2 confirmed cases in Juhr al-Deik in the center of the territory and Rafah in the south, there were a further 2 suspected cases in El-Bureij and Beit Lahia. "According to the international guidelines, the local authorities should start containment measures, which include culling birds within a radius of 3 km around the location of the outbreak," it said. There also needed to be "health monitoring of cullers and individuals with known exposure to infected poultry farms and administration of antiviral drugs. . .” Although the Palestinian Authority has been working on a national preparedness emergency plan to implement in the event of an avian influenza outbreak, culling did not start 3 days after the outbreak was confirmed. The Agriculture Ministry of the PA is preparing to cull 80 000 fowl in the center and the south of the Gaza Strip.

The deputy agriculture minister in the outgoing Palestinian government, Azzam Tbeileh, laid the blame on Israel 23 Mar 2006. "It's the occupation's responsibility. . .We are going to maintain the highest degree of coordination and cooperation with the Israelis, but there are huge difficulties," he said. On 24 Mar 2006, Israeli acting prime minister Ehud Olmert said every assistance was being offered to the Palestinians in order to help them deal with the bird flu outbreak. "I have instructed the foreign and defense ministries to be in touch with the Palestinians and offer them assistance, including medicine and equipment. . ." he said.

Palestinian agriculture officials began poisoning 15 000 chickens in the Gaza Strip following an outbreak of the H5N1 bird flu virus. The culling began after the World Bank offered to donate USD 2 million to compensate the farmers, who had been reluctant to put down their chickens without recompense. Israel has put down more than 1 million turkeys and chickens in the past 2 weeks after an outbreak of the virus at 6 farms, most of them near the Gaza Strip. There have been no confirmed cases of the virus infecting humans in Gaza or the occupied West Bank. An outbreak in the West Bank has so far been limited to a Jewish settlement under Israeli control. (Promed 3/27/06)

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Poland: Excerpts from the OIE report on avian influenza H5N1
Information received and dated 20 Mar 2006 from Dr Krzysztof Jazdzewski, chief veterinary officer, General Veterinary Inspectorate: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of first confirmation of event: 6 Mar 2006. Date of start of event: 2 Mar 2006. New outbreaks: Clinical disease Description of affected population: wild swans in Bydgoszcz, Bydgoski. Diagnostic tests: RT-PCR (H5); RT-PCR (N1); virus isolation; positive. (Promed 3/28/06)

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Serbia and Montenegro: Confirms first case of avian influenza H5N1 infection in rooster
Serbia confirmed 25 Mar 2006 its first case of the H5N1 strain of bird flu in poultry, in an area close to the Bosnian border. The rooster was found 10 days ago in the Bajina Basta area, south west of Belgrade. The results were confirmed by the European Union reference laboratory in the UK, the Serbian Agriculture Ministry said. The affected area has already been declared a risk zone within a 10 km radius, and veterinarians are monitoring all wild fowl and domestic poultry within it. Over 30 people in the area were under medical supervision as a precautionary measure. (Promed 3/27/06)

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Sweden: Mink found infected with H5 virus; H5N1 infection in wild birds
Swedish veterinarians have found a mink with an aggressive form of the H5 bird flu virus and had the mammal put down, the National Veterinary Institute said 27 Mar 2006. The animal was found in the Blekinge region of south Sweden, an area where several bird flu cases have been found. What is initially described as an aggressive form of H5 bird flu is often later confirmed as the highly pathogenic H5N1 virus. The mink probably got the disease from eating wild birds which were already infected, the Institute said. The H5N1 virus has also recently been detected in a marten, a weasel-like mammal, cats in Germany, and reportedly a dog in Azerbaijan. WHO says that so far only domestic poultry are known to have played a role in transmitting the virus from animals to humans, but it has called for further investigation into the significance of infection in other mammals.

Excerpts from the OIE report on avian influenza H5N1
Information received (and dated) 16 Mar 2006 from Dr Leif Denneberg, chief veterinary officer, Swedish Board of Agriculture: Date of start of event: 24 Feb 2006. Identification of agent: avian influenza virus subtype H5N1. Details of outbreaks: Oskarshamn: 2 tufted ducks (Aythya fuligula), 24 Feb 2006; Oxelosund: 3 tufted ducks (Aythya fuligula), 3 Mar 2006; Karlskrona: 1 greater scaup (Aythya marila), 6 Mar 2006; Gotland: 2 tufted ducks (Aythya fuligula), 7 Mar 2006; Faro Gotland: 5 tufted ducks (Aythya fuligula) and 1 greater scaup (Aythya marila), 15 Mar 2006. A total of 243 dead wild birds from the aforementioned areas were analyzed between 10 Feb and 15 Mar 2006. 36 were positive for HPAI subtype H5. No high mortality among wild birds has been noted. It is late in the season, and temperatures are below freezing, so some dead birds are to be expected at this time of the year. Diagnostic tests had been performed at the OIE Reference Laboratory in the UK: virus isolation and N-typing, 15 Mar 2006, positive for HPAI H5N1 virus. (Promed 3/28/06)

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Asia
Cambodia: Update on fifth human case of avian influenza H5N1 infection
Reportedly Cambodian authorities have found no sign of H5N1 virus infection in birds in the village where a 3 year old girl died of avian flu 21 Mar 20006, the fifth fatal case in Cambodia. Although about 200 poultry reportedly died in the village before the girl got sick, initial tests of poultry samples are negative for H5N1, said Kao Phal, director of the Cambodian agriculture ministry's Animal Health Department. Investigators were expanding their search for sick birds outside her village, Phum Tuol Prich. Dr Michael O'Leary of WHO said that the fact that H5N1 has not been found in poultry was troubling because it meant that people were encountering sick birds of which the authorities were unaware. Phal suggested that wild birds or their infected droppings could have caused the girl's infection. Meanwhile, the number of possible human cases in Cambodia seems smaller than authorities feared. So far 7 other people from the victim's village who were suspected of having H5N1 virus infection have tested negative, the head of Cambodia's infectious disease department, Ly Sovann, said. Another 42 people who came into contact with the dead girl or the suspected cases have also tested negative for H5N1. Reportedly 2 adults and 1 child who live in a neighboring village were being treated for fever and respiratory problems at a Phnom Penh hospital. They also tested negative for H5N1. An additional 5 people who had contact with people suspected of having H5N1 are being tested. (Promed 3/29/06)

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Cambodia: New avian influenza H5N1 outbreaks in poultry
Bird flu has been found in ducks on 2 family farms in south western Cambodia, a little more than a week after a toddler died from the H5N1 virus. Though no new human infections have been found, the latest outbreak marks the fourth time in 2 months the virus has struck in Cambodia after a year without any reported cases. Samples taken from 3 ducks in Kampot province's Angkor Chey district tested positive for the H5N1 strain of the virus, which has killed 5 people in Cambodia. A number of ducks have died on the 2 farms, and nearly 200 were slaughtered after the virus was detected. The discovery follows the death of a 3 year old girl from bird flu 21 Mar 2006. Prime minister Hun Sen has called for the government to step up its public awareness campaigns. People from the dead toddler's village said just after her death that they had been eating chickens that fell ill and died. Most poultry in Cambodia is raised on small farms or in backyards, making it difficult to prevent the spread of the virus. The virus has been found in ducks in the province of Kompong Cham twice since Feb 2006, triggering the slaughter of hundreds of birds. Thousands of birds smuggled in from Vietnam, next to Kampot province, have also been destroyed in recently. (Promed 3/31/06)

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Hong Kong: Excerpts from the OIE report on avian influenza H5N1
Information received (and dated) 20 Mar 2006 from the director of the Agriculture, Fisheries and Conservation Department. Identification of agent: avian influenza virus subtype H5N1. Date of start of event: 4-8 Jan 2006. Details of outbreaks: This report describes isolation of H5N1 in 16 cases. The following species were involved: Oriental magpie robin (Copsychus saularis), crested myna (Acridotheres cristatellus), chicken (Gallus domesticus) [these chickens were not found in a poultry farm or live poultry markets], common magpie (Pica pica sericea) little egret (Egretta garzetta), Japanese white-eye (Zosterops japonica simplex), munia (Lonchura spp.), white-rumped munia (Lonchura striata) large-billed crow (Corvus macrorhynchus), house crow (Corvus splendens).

The intensive avian influenza surveillance system in Hong Kong showed no outbreaks of H5N1 infection in local poultry farms and live poultry markets. From 2005 to the end of Feb 2006, over 11 400 fecal or cloacal/tracheal swabs from local poultry farms, 15 300 from wholesale or retail live poultry markets, 3200 from waterfowl and aviaries in recreational parks, 3500 from pet bird shops and markets, and 13 700 from wild birds were tested in Hong Kong as part of the avian influenza surveillance program. There have been no reports of unusual mortality in wild birds. All chicken farms are routinely vaccinated with inactivated H5N2 vaccine, and each batch of chickens has 60 unvaccinated individually identified sentinels, which are monitored over the production life of the batch.

Diagnostic tests performed: real time RT-PCR (H5 gene) positive; RT-PCR (N1 gene): positive; sequence analysis: amino acid sequence at cleavage site indicates a highly pathogenic avian influenza profile. The H5-HA genes of these viruses have the highest homology (99 per cent) to each other's HA1 gene and high homology (98 per cent) to that of A/Dk/Hunan/5806/03[H5N1]. Analysis showed that these viruses all belong to H5N1 genotype V, which has previously been recorded in southern China, Japan and South Korea. (Promed 3/28/06)

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India: Detection of avian influenza in chickens in Madhya Pradesh
From Jalgaon to Icchapur, the avian flu has crossed the state borders of Maharashtra and entered Madhya Pradesh 28 Mar 2006. A report from Mumbai said that for the third time in the last 2 months, the H5N1 virus has been detected in chickens in Maharashtra. On 28 Mar 2006, the Center told state and Jalgaon district officials that the virus had been detected in 6 new pockets of Jalgaon district. The new areas Erandol, Uttran, Bhadgaon, Parola, Varad and Paladhi are located close to the 4 villages of Jalgaon district where the bird flu virus was earlier detected. A sample from Icchapur village, Burhanpur district, bordering Maharashtra tested positive for bird flu, triggering a panic and forcing the administration to ban movement of birds and animals from Burhanpur district. Even movement of people was restricted. (Promed 3/30/06)

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Indonesia: Additional suspected human cases of avian influenza H5N1 infection
A 1-year-old girl from west Jakarta has died of avian influenza, a health official said 25 Mar 2006, citing the results of local tests. If confirmed, the child would be the country's 23rd death [and 30th case] from the H5N1 virus, which is now endemic in poultry in the world's fourth most populous nation. The girl died 24 Mar 2006, shortly after coming into a Jakarta hospital emergency room, Hariadi Wibisono, Director general of Control of Animal-borne Diseases at the national health ministry, said. A sample of the girl's blood has been sent to a laboratory in a Hong Kong laboratory for confirmation. It was not immediately clear whether the girl had been in contact with fowl. In addition, a child under 5 years old who was admitted to the Dr Soedono General Hospital in Madiun, East Java with symptoms compatible with bird flu died 28 Mar 2006 after treatment. Hospital spokesman Sugeng Haryanto said the patient was weak, in a coma, convulsive, and having breathing difficulty. The Magetan hospital suspected the child was suffering from avian influenza, and therefore needed further treatment. "We contacted the Dr Soetomo hospital in Surbaya, and a team from that hospital was expected to arrive Tuesday [28 Mar 2006] morning to take blood samples from the child, but the patient died before the team arrived. . ." he said. The Dr Soedono hospital has so far treated 3 suspected avian influenza patients, and 2 of them were eventually declared H5N1 virus-negative and recovered. The hospital has formed a special team to deal with avian influenza cases. "The team was the one that treated the child last night. The team is always ready any time it is needed," he said.

Of Indonesia's internationally confirmed fatalities from the H5N1 virus, 11 have occurred in 2006, making it the country with the most bird flu deaths so far this year. Most of the cases in humans have been in or around Jakarta. But the virus has been detected among poultry in about 2/3 of the country's 33 provinces. (Promed 3/25/06, 3/30/06)

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Myanmar: Excerpts from the OIE report on avian influenza H5N1
Information received (and dated) 16 Mar 2006 from Dr U Maung Maung Nyunt, director general, Livestock Breeding and Veterinary Department, Ministry of Livestock and Fisheries: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 8 Mar 2006. New outbreaks: 7 new outbreaks were reported in Mandalay and 1 in Sagoing. In Mandalay, there were between 50 and 400 cases reported in the outbreaks and 155 cases in Sagoing. All the cases resulted in deaths in Mandalay, while only 5 deaths were reported in Sagoing division, Shewbo district. Affected populations: layers chickens and quail. Diagnostic tests performed: rapid test; positive for H5N1. 2. PCR; positive for H5N1. (Promed 3/28/06)

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Pakistan (Bamyan): Suspected cases of avian influenza infection in birds
Over 100 dead chickens [and other] birds in Bamyan district [Punjab] have raised residents' concerns about the possible outbreak of bird flu. Scores of wild migratory birds had been found dead in the Ghosak area, he said. Confirming the finding of the dead birds in Punjab district, Provincial Public Health director Dr Ihsanullah Shahir said: "It cannot be ascertained what is the reason behind the death of the chickens; if it is influenza, we don't have facilities for diagnosing bird flu." About 2 weeks earlier, many dead birds had been found in a pool in the outskirts of Bamyan city. (Promed 3/30/06)

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Americas
USA: FDA approves Relenza for the prevention of influenza A and B in adults and children
The Food and Drug Administration approved the use of Relenza (zanamivir for inhalation) for prevention of influenza in adults and children 5 years of age and older. Relenza, an antiviral medication, was previously approved for the treatment of influenza A and B virus infections in adults and children. Tamiflu (oseltamivir phosphate) previously was approved for both prevention and treatment of flu; the approval of Relenza for prevention provides Americans with another option for the prevention of influenza A and B infections. The effectiveness of Relenza in preventing seasonal influenza has been demonstrated in 4 large studies. In 2 of these trials, the use of the drug substantially reduced the spread of influenza in the participating households where participants were 5 years of age or greater. In both of these trials, the proportion of households that developed symptoms confirmed to be flu was 19.0% for the placebo group and 4.1% for the Relenza group. In the other 2 trials, which were conducted in communities experiencing an influenza outbreak, Relenza reduced the incidence of the disease in both young and older populations. In the first study, with participants 18 years of age or older, the proportion of people who developed symptoms confirmed to be flu was 6.1% for the placebo group and 2.0% for the Relenza group. The second community study enrolled people 12 to 94 years of age. In this trial, the percent of people who developed symptoms confirmed to be flu were reduced from 1.4% of the participants on placebo to 0.2% for those who used Relenza.

In all of these studies, the most common events during treatment with Relenza in adults and adolescents were headaches; diarrhea; nausea; vomiting; nasal irritation; bronchitis; cough; sinus infections; ear, nose, and throat infections; and dizziness. In children, the most common side effects were ear, nose, and throat infections; vomiting; and diarrhea. Less common reported events included rashes and allergic reactions, some severe. Breathing problems, including deaths, were reported in some patients after the initial approval of Relenza. Most of these patients had asthma or chronic obstructive pulmonary disease. Relenza therefore is not recommended for treatment or prophylaxis of seasonal influenza in individuals with underlying airways disease. Relenza has not been proven effective for treatment of influenza in people with underlying airways disease, or for prevention of influenza in nursing homes. The drug is also not a substitute for the flu vaccine. Consumers should continue receiving an annual flu vaccination according to guidelines on immunization practices. In preparation for a potential pandemic, FDA has assembled a Pandemic Influenza Preparedness Task Force. The Task Force is charged with developing a comprehensive plan to accelerate the development, production, and regulatory review of antivirals and other pandemic countermeasures. FDA also is working with the pharmaceutical industry to make available appropriate products and ensure that mechanisms are in place to collect the necessary efficacy and safety information. Both Relenza and Tamiflu have been identified for stockpiling. Relenza is manufactured and distributed by GlaxoSmithKline Inc. (FDA 3/29/06 http://www.fda.gov/bbs/topics/NEWS/2006/NEW01341.html )

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Africa
Cameroon: Confirmation of second case of avian influenza H5N1 infection in duck
Cameroon, the fourth African country affected by the H5N1 virus, has confirmed the presence of a second case of bird flu. In a statement 29 Mar 2006, minister for livestock, fisheries and animal industries Aboukary Sarki said an Italian lab detected the H5N1 virus on a wild duck found dead on Lake Malape, situated 40 km west of Garoua near the border with Nigeria. The minister urged people in the area "not to manipulate bodies of dead wild birds. . .not to consume flesh of any wild bird and to alert veterinary officials of dead birds found in their vicinities". The case in Cameroon’s North province comes 2 weeks after the announcement of a first case detected still farther north in Maroua. After the outbreak of bird flu in Nigeria Feb 2006, the first African country hit by the H5N1 strain, Cameroon banned poultry imports both from across the Nigerian border and from other countries where the disease has been detected. It also intensified controls along its 1600-km frontier with Nigeria though consumer groups said poultry products were still filtering across the border. Over 1000 chicks were found dead around Maroua in the same week as bird flu was first detected in Cameroon, and at least 400 birds have died since in and around the capital Yaounde, said the Inspector General at the Livestock, Fisheries and Animal Industries Ministry, Oumaoru Dawa. The virus has not been confirmed in the southern region, though some 240 chickens were recently reported dead in the southwest provincial town of Limbe. Samples of some of the dead birds are still being tested. Consumption of chicken and eggs has fallen, with prices slashed by 50 to 75 per cent. (Promed 3/31/06)

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Egypt: 5 suspected human cases; preliminarily positive for H5N1 infection
The Ministry of Health in Egypt has confirmed the country’s second fatal case of human infection with the H5N1 avian influenza virus. The death occurred in a 30-year-old woman from the Qaliubiya governorate near Cairo. She developed symptoms 12 Mar 2006 following the home slaughter of chickens. She was hospitalized 16 Mar and died 27 Mar. The country’s first case occurred in a 30-year-old woman, also from Qaliubiya, who died 17 Mar. Tests conducted by the US Naval Medical Research Unit 3 (NAMRU-3) have confirmed an additional 3 cases. A 32-year-old man, who worked on a farm where poultry were recently culled, developed symptoms 16 Mar and was hospitalized. He has since recovered. A 17-year-old boy, whose father runs a poultry farm in the Gharbiya governorate, developed symptoms 18 Mar and was hospitalized. He has since recovered. The fifth case is an 18-year-old girl from the Kafr El-Sheikh governorate. She developed symptoms following the slaughter of sick backyard poultry. She was hospitalized 25 Mar (and reportedly treated with Tamiflu). At present, the Ministry of Health has confirmed all five cases based on results from the NAMRU-3 laboratory. Samples from these cases have been sent to a WHO collaborating laboratory in the UK for diagnostic verification.

Health authorities have screened more than 350 people who were contacts of these patients or had a recent history of exposure to diseased birds. All test results have been negative for H5N1 infection. Egypt has a large population of poultry, many of which are kept on roof terraces in close proximity to humans. H5N1 outbreaks in poultry have now been reported in 19 of the country’s 26 governorates. Since the first outbreak was confirmed 17 Feb 2006, more than 25 million birds have died or been destroyed. Most of Egypt's cases so far have been among people who raise poultry in their backyards and many are not following instructions from the Health Ministry, WHO officials say. Farmers in Egypt say the poultry market -- worth about 17 billion Egyptian pounds (USD 3 billion) and supporting up to 3 million people -- has been devastated. (Promed 3/27/06, 3/29/06, 3/30/06)

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1. Updates
Influenza
Seasonal influenza activity in APEC Economies
Overall influenza activity remained moderate to low, though a gradual increase in activity continued to be observed during week 11 in some European and Asian countries in the northern hemisphere.
Canada. In week 11, overall influenza activity remained similar to previous weeks. The overall influenza-like illness (ILI) consultation rate was within the expected range. Influenza A and B viruses co-circulated.
Russia. A slight increase in influenza activity continued to be observed during week 11. Overall activity remained localized with influenza A(H1), A(H3N2) and B viruses co-circulating.
Japan. During week 11, low influenza activity was reported in Japan (H3 and A).
USA. During week 12 (Mar 19 – Mar 25, 2006), influenza activity continued approximately at the same level as recent weeks in the US. 681 specimens (21.6%) tested by US WHO and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories were positive for influenza. The proportion of patient visits to sentinel providers for influenza-like illness (ILI) was above the national baseline. The proportion of deaths attributed to pneumonia and influenza was below the baseline level. 16 states reported widespread influenza activity; 16 states reported regional influenza activity; 13 states, New York City, and the District of Columbia reported local influenza activity; and 5 states and Puerto Rico reported sporadic influenza activity.

For the comprehensive update on recent influenza activity in the USA (“Update: Influenza Activity--United States, March 12--18, 2006”): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5512a5.htm
(WHO 3/30/06 http://www.who.int/csr/disease/influenza/update/en/ ; CDC 3/31/06 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. State Summits are available, along with “H5N1 Avian Flu Vaccine Clinical Trial Results”.
- 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: Animal, Human Surveillance Critical to Contain Avian Influenza”.
- The American Veterinary Medical Association information on animal influenzas: http://www.avma.org/public_health/influenza/default.asp
- US Geological Survey, National Wildlife Health Center: http://www.nwhc.usgs.gov. NWHC Avian Influenza Information (with bulletins, maps, and news reports): http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp.
(WHO; FAO, OIE; CDC; US FDA; CIDRAP; PAHO; APHA; AVMA; USGS)

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2. Articles
Safety and Immunogenicity of an Inactivated Subvirion Influenza A (H5N1) Vaccine
Treanor JJ, Campbell JD, Zangwill KM, Rowe T, Wolff M. N Engl J Med. 2006 Mar 30;354(13):1343-51. http://content.nejm.org/cgi/content/full/354/13/1343
Abstract: “Background: Influenza A (H5N1) viruses could cause a severe worldwide epidemic, with high attack rates, large numbers of deaths and hospitalizations, and wide disruption. Effective vaccines against these viruses in humans are urgently needed. Methods: We conducted a multicenter, double-blind two-stage study involving 451 healthy adults 18 to 64 years of age who were randomly assigned in a 2:2:2:2:1 ratio to receive two intramuscular doses of a subvirion influenza A (H5N1) vaccine of 90, 45, 15, or 7.5 µg of hemagglutinin antigen or placebo. The subjects were followed for the safety analysis for 56 days. Serum samples obtained before each vaccination and again 28 days after the second vaccination were tested for H5 antibody by microneutralization and hemagglutination inhibition. Results Mild pain at the injection site was the most common adverse event for all doses of vaccine. The frequency of a serum antibody response was highest among subjects receiving doses of 45 µg or 90 µg. Among those who received two doses of 90 µg, neutralization antibody titers reached 1:40 or greater in 54 percent, and hemagglutination-inhibition titers reached 1:40 or greater in 58 percent. Neutralization titers of 1:40 or greater were seen in 43 percent, 22 percent, and 9 percent of the subjects receiving two doses of 45, 15, and 7.5 µg, respectively. No responses were seen in placebo recipients. Conclusions A two-dose regimen of 90 µg of subvirion influenza A (H5N1) vaccine does not cause severe side effects and, in the majority of recipients, generates neutralizing antibody responses typically associated with protection against influenza. A conventional subvirion H5 influenza vaccine may be effective in preventing influenza A (H5N1) disease in humans.” (CIDRAP http://www.cidrap.umn.edu/ )

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Vaccines against avian influenza--a race against time.
Poland GA. N Engl J Med. 2006 Mar 30;354(13):1411-3.
http://content.nejm.org/cgi/content/full/354/13/1411
“Avian influenza A (H5N1) virus poses an important pandemic threat. A study by the Congressional Budget Office estimates that the consequences of a severe pandemic could, in the United States, include 200 million people infected, 90 million clinically ill, and 2 million dead. The study estimates that 30 percent of all workers would become ill and 2.5 percent would die, with 30 percent of workers missing a mean of three weeks of work — resulting in a decrease in the gross domestic product of 5 percent. Furthermore, 18 million to 45 million people would require outpatient care, and economic costs would total approximately $675 billion. As of March 10, 2006, the World Health Organization (WHO) had reported 176 confirmed human cases of influenza A (H5N1) across seven countries, with 97 deaths (a 55 percent mortality rate for identified cases). . .”
(CIDRAP http://www.cidrap.umn.edu/ )

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3. APEC EINet activities
APEC EID Symposium; HIT Workgroup Meeting
Dr. Ann Marie Kimball, Director of APEC EINet, will be speaking at the APEC Symposium on Emerging Infectious Diseases in Beijing, China, April 4-5, 2006 http://apec.org/apec/apec_groups/som_special_task_groups/health_task_force.html ; and at the Health Information Technology and Policy (HIT) workgroup meeting in Tokyo, Japan April 11-12, 2006. She will discuss pandemic influenza preparedness and recent EINet activities. Recent updates by the APEC Health Task Force (HTF) can be found at: http://apec.org/apec/news___media/media_releases/280206_vn_htf.html.

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 apecein@u.washington.edu