EINet Alert ~ May 26, 2006

*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Czech Republic: 2 new cases of avian influenza H5 in swans
- Denmark: Excerpts from the OIE report on avian influenza H5N1
- Iran: Health minister denies human avian influenza cases
- Romania: Avian influenza H5N1 spreads, poultry culled
- Russia: Reports recent poultry deaths were caused by avian influenza H5N1
- China (Qinghai, Tibet): 2 new outbreaks of avian influenza among wilds birds
- Indonesia (North Sumatra): Additional human case of avian influenza H5N1; cluster update
- Indonesia: New suspected human cases of avian influenza H5N1 infection
- USA: Sends supply of Tamiflu to Asia
- USA: How avian influenza H5N1 virus might reach US
- Burkina Faso: Government to cull more poultry

1. Updates
- Influenza

2. Articles
- WHO rapid advice guidelines on pharmacological management of humans infected with avian influenza A (H5N1) virus
- Safety of High Doses of Influenza Vaccine and Effect on Antibody Responses in Elderly Persons

3. Notifications
- FAO/OIE Conference to focus on wild birds
- WHO invokes influenza rules a year early
- World health community mourns WHO's Dr. Lee Jong-wook

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

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

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

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

Azerbaijan / 8 (5)
Cambodia / 2 (2)
China / 10 (7)
Djibouti / 1 (0)
Egypt / 14 (6)
Indonesia / 25 (22)
Iraq / 2 (2)
Turkey / 12 (4)
Total / 74 (48)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 218 (124).

The world situation of avian influenza will be one of the topics to be discussed in the 74th General annual session of the OIE (21 - 26 May 2006), where member countries will be represented by their respective Chief Veterinary Officers. International organizations and animal-health experts will participate as well.
(Promed 5/22/06; WHO 5/23/06 http://www.who.int/csr/disease/avian_influenza/en/ )


Europe/Near East
Czech Republic: 2 new cases of avian influenza H5 in swans
Vets have discovered 2 new cases of bird flu in dead swans found in southern Moravia, State Veterinary Authority spokesman Josef Duben said. Tests have confirmed the H5 virus in both birds, and a highly contagious form in 1 case. In all, 14 cases of bird flu have occurred in the Czech Republic. The previous 12 dead swans were found in South Bohemia and all of them were infected with H5N1. Special measures will now be introduced in the critical area. The towns and villages situated in the zones of strict protection and supervision must make a count of all household poultry breeds and secure containers for the dead birds. Local breeders must not keep poultry in open-air enclosures. A ban will be imposed on the transfer of poultry, eggs and further material, and access to poultry farms will be limited. Steps will be taken to secure disinfection of the people and cars in contact with the farms. The measures are to last at least 21 days.
(Promed 5/20/06)


Denmark: Excerpts from the OIE report on avian influenza H5N1
Information received (and dated) 18 May 2006 from Dr Preben Willeberg, chief veterinary officer, Danish Veterinary and Food Administration: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of first confirmation of event: 18 May 2006. Date of start of event: 16 May 2006. An outbreak of highly pathogenic avian influenza virus subtype H5N1 has been reported at Kerteminde in Funen county. The animals affected are backyard poultry (47 cases and 102 susceptible). The remaining 55 animals were slaughtered and a quarantine zone set up. The diagnosis has been established 18 May 2006 by the Danish Institute for Food and Veterinary Research using RT-PCR method and sequence analysis. The latest news about avian influenza in Denmark can be accessed at: http://www.uk.foedevarestyrelsen.dk/AnimalHealth/Avian_influenza/Latest_news/forside/htm.

Until now, all the avian influenza cases in Denmark have been in wild birds, but here a backyard flock of 51 chickens, 41 ducks, 5 geese, 3 guinea fowls and 2 peacocks became infected. Several "protection and surveillance" zones have been lifted since the 21 Apr 2006.
(Promed 5/20/06)


Iran: Health minister denies human avian influenza cases
Iran's Health Minister denied 23 May 2006 that tests on 2 dead patients had shown they had the H5N1 bird flu virus and insisted the results were negative. On 22 May 2006, an Iranian medical official said tests on the bodies of a brother and sister who died after falling ill with pneumonia-like symptoms in the northwestern city of Kermanshah showed they had contracted the H5N1 strain. But in Cairo, the WHO's regional adviser for emerging diseases, Hassan al-Bushra, said the agency had also been told that the results in Iran were negative for bird flu. He said so far WHO's regional office had not received any samples from Iran for testing. The Iranian siblings, a brother aged 41 and sister, 26, were among 5 family members who fell ill. The Iranian Health Minister said Iran had tightened its surveillance since cases were detected in neighboring states. The virus has killed people in neighboring Turkey, Iraq and Azerbaijan in recent months, while Afghanistan has had outbreaks in poultry. Iran found the virus in wild swans Feb 2006.
(Promed 5/23/06)


Romania: Avian influenza H5N1 spreads, poultry culled
A series of preliminary tests revealed 19 May 2006 that some domestic poultry in Bucharest might be carrying the H5 bird flu virus, prompting authorities to quarantine a street in the Andronache neighborhood of Sector 4 and restrict access to other areas in Sector 2. This is the first time in Romania that an industrial farm has been affected. "The president asked the ministers to take immediate measures to prevent the spreading of the disease and demanded disinfecting filters be established in the counties neighboring those areas affected by the bird flu," presidential aide Adriana Saftoiu said 20 May 2006. Final tests confirmed the H5 virus in samples from dead poultry 21 May 2006. Romanian authorities placed 60 households in the capital city's fourth district under first-degree quarantine 23 May 2006. Some 200 people from Bucharest District 2 were already quarantined from 21 May 2006. Bucharest's chief veterinarian, Constantin Savu, had said that authorities are considering ordering a ban on poultry husbandry in the city. 1 million domestic birds could be culled. Authorities have finished culling birds at the Dakrom poultry farm in Codlea, which is considered to be the source of the bird flu outbreak. Romania has reported more than 20 bird flu outbreaks over the past week, mostly in the central county of Brasov, just a month after the strain was said to have been eradicated in the Black Sea state. The H5N1 strain was confirmed 21 May 2006 by the UK reference laboratory in the samples from Brasov County.

The European Commission expressed its worry about the situation of the avian flu in Romania and the spread of the virus in the poultry farms, according to the Commission's spokesman Phillip Tod. "The EC limited the chicken imports from 5 more counties from Romania, apart from the previous 26," said Tod. He added that the EC holds no information which should suggest that Hungary and Slovakia were involved in any way in the new epidemic in Romania (as earlier news had first reported). In the latest outbreaks, the virus spread from 1 chicken farm in the county of Brasov, 170 km north of Bucharest, after it sold live chickens to peasants without health or veterinary certificates. The sanitary-veterinary authority and the farm ministry had launched an investigation to determine the cause of recent outbreaks.

Romanian authorities have now asked for assistance and a multidisciplinary team is being assembled to travel to Romania to assist on both the animal and human sides. Remarkably, in spite of the described difficulties and the presence of the H5N1 virus in commercial and backyard farms since Oct 2005, Romania has been able -- so far -- to prevent human infections. The European Union candidate has culled nearly half a million birds since discovering the first bird flu case in the Danube delta, Europe's largest wetlands, Oct 2005. Romania's last report, concerning 5 outbreaks in Brasov county, was sent to the OIE 16 May 2006. The situation in Romania is a reminder of the long-known fact that avian influenza spreads by 2 main routes: on the one hand by free-roaming birds; but certainly not less important, by uncontrolled trade and transportation of infected domestic or captive birds, poultry products, fomites, people, vehicles etc.
(Promed 5/22/06, 5/23/06, 5/25/06)


Russia: Reports recent poultry deaths were caused by avian influenza H5N1
Tests have confirmed that 86 dead chickens found in the village of Maksimovka in the Omsk region between 29 Apr and 13 May were infected with the H5N1 bird flu strain. "Examinations have confirmed the bird flu virus. A total of 3893 domestic birds have already been inoculated against the disease in the village," press service of the Emergency Situations Ministry's Siberian branch said 16 May 2006. The village has been quarantined. The avian flu virus which killed birds in the Novosibirsk and Omsk regions April-May 2006 does not significantly differ from the virus exposed in Siberia during 2005. "The H5N1 virus most likely had the same source as the spring outbreak at Lake Qinghai in China," Alexander Shestopalov, head of the laboratory monitoring and studying zoonotic infections, said. "This year's virus is almost the same by its pathological characteristics and methods of transmission. It still has a fecal-oral way of transmission. . ." the expert said. 2 villages in Novosibirsk and 3 in Omsk have registered cases of bird flu in 2006. However, specimens have not been shared with external laboratories for confirmation.
(Promed 5/20/06, 5/25/06)


China (Qinghai, Tibet): 2 new outbreaks of avian influenza among wilds birds
China reported 2 new outbreaks of avian flu among migratory birds, bringing to 4 the number of such cases recorded in the northwest over the past month. A total of 399 bar-headed geese and ruddy shelducks had died from the virus in outbreaks in Tibet's Naqu prefecture and the Guoluo Tibetan Autonomous Prefecture in neighboring Qinghai province, the agriculture ministry said 24 May 2006. The ministry reported that the outbreaks were confirmed as the H5N1 virus. Local governments have disinfected the areas where the dead birds were found, and no domestic poultry have been affected. Although the 2 outbreaks had occurred in separate locations, they were linked by the same migratory route. The route also linked the outbreaks to 2 other recent incidents in the area, the ministry said. According to earlier reports, 123 birds had died in the previous outbreaks. The ministry said the currently affected area was thinly populated and had no farms where poultry was being raised, suggesting the risk to domesticated birds was small. Qinghai is along one of Asia's main bird migratory routes and a series of avian flu outbreaks were recorded there May 2005. An interactive H5N1 map, showing outbreaks in China, is accessible at http://www.flu.org.cn/map/MapBrowser.aspx?reportId=46.
(Promed 5/25/06)


Indonesia (North Sumatra): Additional human case of avian influenza H5N1; cluster update
The Ministry of Health has confirmed an additional case of human infection with the H5N1 avian influenza virus. The case occurred in a 32-year-old man who grew limes, chilies and tomatoes in a village. He developed symptoms 15 May 2006 and died 22 May. A WHO expert recommended 18 May that he be isolated and treated in hospital with Tamiflu. Instead the man fled local health authorities and sought care from a witch doctor. Disease trackers located the man late 21 May and took blood samples and swabs of his nose and throat. He died the following day after tests confirmed he had H5N1. Health officials' difficulty tracking down the ill man for the 3 days leading to his death suggests that Indonesia may have trouble containing a human outbreak that might jump from affected villages to the rest of Southeast Asia.

The case is part of a family cluster in the Kubu Sembelang village, Karo District, of North Sumatra. The man is the seventh member of an extended family to become infected with the H5N1 virus and the sixth to die. An additional person, who was the first member of the family to fall ill (developed symptoms 27 Apr 2006), died of respiratory disease 4 May. No specimens were taken prior to her burial and the cause of her death cannot be determined. However, as her clinical course was compatible with H5N1 infection, she is considered to be the initial case in the cluster. The 37-year-old woman worked selling limes at a market 5 km from her home. "We believe she may have had some contact either with dead or dying chickens in her household or through her activities as a vegetable grower and a seller in a market," said Steven Bjorge, a WHO epidemiologist in Jakarta, 25 May 2006.

The newly confirmed case is a brother of this initial case. His 10-year-old son died of H5N1 infection 13 May. The father was closely involved in caring for his son, and this contact is considered a possible source of infection. Preliminary findings indicate that 3 of the confirmed cases spent the night of 29 Apr in a small room together with the initial case at a time when she was symptomatic. These cases include the woman's 2 sons and a second brother, aged 25 years, who is the sole surviving case among infected members of this family. Other infected family members lived in adjacent homes. All confirmed cases in the cluster can be directly linked to close and prolonged exposure to a patient during a phase of severe illness. Although human-to-human transmission is possible, the search for a possible alternative source of exposure is continuing. Reportedly, tests on birds in the village where the family lives all came back negative.

Both the Ministry of Health and WHO are concerned about the situation and have intensified investigation and response activities. Priority is now being given to the search for additional cases of influenza-like illness in other family members, close contacts, and the general community. To date, the investigation has found no evidence of spread within the general community and no evidence that efficient human-to-human transmission has occurred. WHO officials have asked 54 people in the village to quarantine themselves at home. None of these, the officials said, have exhibited avian flu symptoms. 39 of the 54 are taking oseltamivir (Tamiflu) as a precaution. The others are not taking it because they are either pregnant, lactating mothers, or children.

Full genetic sequencing of 2 viruses isolated from cases in this cluster has been completed by WHO reference laboratories. Sequencing of all 8 gene segments found no evidence of genetic reassortment with human or pig influenza viruses and no evidence of significant mutations. The viruses showed no mutations associated with resistance to the neuraminidase inhibitors, including oseltamivir (Tamiflu). The isolates are all virtually identical, implying a single source. However, the deceased man's actions and the local reaction to the deaths have officials worried about how to contain outbreaks should the virus become contagious among people. Reportedly, local authorities have resisted working with outside experts and many villagers blame black magic for the deaths. Some residents said they resented the rapid assessment by some government officials that there was avian flu in the village. Dozens of poultry farmers and sellers from the deceased man's district slaughtered chickens and drank the blood 22 May in a demonstration of their frustration at being branded as having been infected with avian flu.

WHO said it will leave its pandemic alert level unchanged at 3. The WHO Global Influenza Preparedness Plan defines phase 3 as "human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact." Phase 4 is characterized by "small cluster(s) with limited human-to-human transmission, but spread is highly localized, suggesting that the virus is not well adapted to humans." The WHO plan further states, "The distinction between phase 3, phase 4, and phase 5 is based on an assessment of the risk of a pandemic. Factors may include rate of transmission, geographical location and spread, severity of illness, presence of genes from human strains (if derived from an animal strain), and/or other scientific parameters."
(Promed 5/23/06, 5/25/06; CIDRAP 5/26/06 http://www.cidrap.umn.edu )


Indonesia: New suspected human cases of avian influenza H5N1 infection
Local tests have found 2 siblings admitted to hospital earlier this week in Bandung positive for H5N1 infection. The sibling, a 10-year-old girl and her 18-year-old brother, both died. Local results on bird flu cases are not considered definitive and need confirmation from WHO. Earlier, an 18-year-old East Java shuttlecock maker was diagnosed with bird flu, according to local test results announced 21 May 2006. Kandun said the victim was undergoing treatment in hospital and that a sample of his blood will be sent to a WHO laboratory for further testing. ". . .We are still tracing where (the factory) got the feathers," Kandun said. This is only the second avian influenza case to be reported from East Java. Also, Kandun said a 38-year-old man from Jakarta who died last week had also been declared positive for bird flu by local tests.
(Promed 5/22/06, 5/25/06; CIDRAP 5/26/06 http://www.cidrap.umn.edu )


USA: Sends supply of Tamiflu to Asia
The US is sending a load of oseltamivir (Tamiflu) to an undisclosed site in Asia for use in fighting a possible avian influenza pandemic, Health and Human Services Secretary Mike Leavitt said. He said President Bush is committed to "forward-positioning a portion of U.S. antiviral stocks for use in a human pandemic." Oseltamivir is considered the drug most likely to be helpful if the H5N1 avian flu virus evolves into a pandemic strain. Many countries, including the US, have been stockpiling it. Leavitt was quoted as saying that the oseltamivir supply sent to Asia "would belong to the United States and we would control its deployment." He declined to say how many treatment courses had been sent. The supply would be used in efforts to contain an emerging pandemic, but the government could recall the drug for domestic use if it became clear that containment overseas was not possible. The US government has a goal of stockpiling enough Tamiflu to treat 25% of the US population. Leavitt said the nation will have 26 million treatment courses by Dec 2006 and 75 million by the end of next year.
(CIDRAP 5/23/06 http://www.cidrap.umn.edu/ )


USA: How avian influenza H5N1 virus might reach US
US wildlife officials are predicting that when H5N1 avian flu comes to the US, it will most likely arrive aboard wild swans flying across the Bering Strait or exotic birds brought in by smugglers. H. Dale Hall, director of the US Fish and Wildlife Service, said swans are a good bet because they were the first birds found with the virus in many European countries. But he also said there's a good chance the virus could ride in on smuggled birds or other wildlife. State and federal agencies in Alaska recently began testing wild birds for the H5N1 virus. The first 1,300 tissue samples from migratory birds in Alaska are due to arrive at a US Geological Survey laboratory for testing later this week. The testing duties will be shared by the USGS lab, which will check the hemagglutinin (H) type, and the US Department of Agriculture lab, which will determine the neuraminidase (N) type.
(CIDRAP 5/25/06 http://www.cidrap.umn.edu/ )


Burkina Faso: Government to cull more poultry
Burkina Faso is preparing to cull more poultry, after the highly pathogenic H5N1 bird flu first detected near the capital last month spread to 2 more towns, the government said 19 May 2006. The disease had been confirmed in Bobo-Dioulasso, the second city, 360 km west of the capital Ouagadougou, and in Sabou, 100 km west of the capital. A new outbreak had also been found in Ouagadougou itself. The impoverished nation first confirmed Apr 2006 that it had found the virus in poultry at a motel on the outskirts of Ouagadougou. It has since isolated the area and culled birds within a 3 km radius. Animal resources minister Tiemoko Konate said the new cases -- found in traditional artisanal rather than modern farms -- had been confirmed 19 May 2006 by the World Organisation for Animal Health (OIE). WHO officials fear human cases have gone undetected in West Africa due to poor health services. So far, the region has no confirmed human infections, though in another part of the continent, [6] Egyptians have died from the virus. Konate said tests had been carried out on the staff working at the motel in Burkina Faso where the virus was first found but said that no human cases had been discovered. Burkina Faso sent to the OIE a report 4 Apr 2006, notifying a single outbreak of HPAI H5N1 in the province of Kadiogo.

Elsewhere in Africa, a total of 8 African countries (Burkina Faso, Cameroon, Egypt, Niger, Nigeria, Sudan, Cote d'Ivoire and Djibouti) have been reporting infections in poultry to OIE. For Cote d'Ivoire, confirmation of the OIE reference laboratory is still awaited. Nigeria's agriculture ministry reported a new H5N1 outbreak in its northern state of Kano. The Nigerian Veterinary Research Institute said that samples of dead chickens from a farm near Kano tested positive for avian flu. Avian flu control teams reportedly destroyed more than 16,000 chickens on the farm to try to prevent spread of the virus.
(Promed 5/21/06, 5/25/06; CIDRAP 5/26/06 http://www.cidrap.umn.edu )


1. Updates
Seasonal influenza activity in the APEC Economies
During weeks 17–19, overall influenza activity declined further and was low in most parts of the world.
Canada. Influenza activity continued to decline during weeks 17–19 and low activity was reported in week 19. The overall consultation rate of influenza-like illness (ILI) remained within the expected range, with influenza A and B viruses co-circulating.
Hong Kong. Overall influenza activity was moderate, with A(H1N1) virus predominating during weeks 17–19.
Republic of Korea. Localized influenza B activity has been reported since week 14.
Russia. Localized influenza activity continued to be reported during weeks 17–19, with A(H1), A(H3N2) and B viruses co-circulating. Overall activity declined.
USA. Influenza activity in the US peaked in early March and continued to decrease during week 20 (May 14 -20, 2006). 51 specimens (6.3%) tested by U.S. WHO and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories were positive for influenza. The proportion of patient visits to sentinel providers for influenza-like illness (ILI) was below the national baseline. The proportion of deaths attributed to pneumonia and influenza was below the threshold level. 25 states, the District of Columbia, New York City, and Puerto Rico reported sporadic influenza activity; and 25 states reported no activity. ***This is the final CDC report of the 2005-2006 influenza season.
Other reports. During weeks 17–19, low influenza activity was reported in Chile (H3 and A) and Japan (H1 and B). Mexico and the Philippines reported no influenza activity.
(CDC 5/25/06 http://www.cdc.gov/flu/weekly/ ; WHO 5/26/06 http://www.who.int/csr/disease/influenza/update/en/ )

Avian/Pandemic influenza updates
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html. Includes Global/country maps. WHO Rapid Advice Guidelines on pharmacological management of humans infected with avian influenza A (H5N1) virus: http://www.who.int/csr/disease/avian_influenza/guidelines/pharmamanagement/en/index.html
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Read the new articles: “Avian flu: FAO in action”; “Protect poultry, protect people”; “A manual for countries at risk”.
- OIE: http://www.oie.int/eng/en_index.htm. Read the highlights from the 74th Annual General Session of the International Committee of the OIE.
- US CDC: http://www.cdc.gov/flu/avian/index.htm.
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/. Latest updates on U.S. State Summits are available. Read the following articles: “Indonesia situation update—May 25” and “Congressional Budget Office Updates Report on Possible Macroeconomic Effects and Policy Issues”.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and scholarly articles. Read “Pandemic planning puts ethics in spotlight”—the article raises important ethical issues for preparedness.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm. Read the article, “Americas Make Progress on Pandemic Preparedness”, regarding the PAHO conference “Responding to an Influenza Pandemic in the Americas”.
- American Veterinary Medical Association: http://www.avma.org/public_health/influenza/default.asp.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Very frequent news updates.


2. Articles
WHO rapid advice guidelines on pharmacological management of humans infected with avian influenza A (H5N1) virus
Human cases of avian influenza A(H5N1) infection have remained rare and sporadic, but the disease is very severe and the case fatality is high. With the H5N1 virus now confirmed in birds in more than 50 countries, additional sporadic human cases should be anticipated. Using innovative guideline development methods based on the best available evidence, WHO assembled an international panel of experts Mar 2006 to develop rapid advice for the pharmacological management of patients with H5N1 infection. The recommendations are classified as strong or weak and cover several specific patient and exposure groups for the treatment and chemoprophylaxis of H5N1 virus infection. All recommendations are specific to the current pre-pandemic situation and are based on careful consideration of the current evidence about benefits, harms, burdens and cost of interventions. As there are currently no clinical trials in patients with avian influenza H5N1 disease, the overall quality of evidence on which to base judgments is very low.

Visit http://www.who.int/csr/disease/avian_influenza/guidelines/pharmamanagement/en/index.html for the full document. The guidelines include the following sections: 1) Recommendations for treatment of patients with confirmed or strongly suspected human infection with the H5N1 virus [Where neuraminidase inhibitors are available vs. Where neuraminidase inhibitors are NOT available]; 2) Recommendations for chemoprophylaxis [Where neuraminidase inhibitors are available vs. Where neuraminidase inhibitors are NOT available]; 3) Recommendations for other treatments; 3) Recommendations for use of antibiotics and; 4) Risk categories.
(WHO May 2006)


Safety of High Doses of Influenza Vaccine and Effect on Antibody Responses in Elderly Persons
Wendy A. Keitel et al. Arch Intern Med. 2006;166:1121-1127.
“Background: Immune responses after influenza immunization are reduced in elderly individuals, the group at greatest risk for complications and death after influenza. Improved vaccines are needed to address this problem. Methods: Ambulatory individuals 65 years and older (N = 202) were assigned randomly to receive a single intramuscular injection of the 2001-2002 formulation of trivalent inactivated influenza vaccine containing 15, 30, or 60 µg of hemagglutinin per strain (up to 180 µg total per dose) or placebo. Clinical and serologic responses were assessed during the month after immunization. Results: Increasing dosages of vaccine elicited significantly higher serum antibody levels, frequencies of antibody responses, and putative protective titers after vaccination. Mean serum hemagglutination inhibition antibody titers 1 month after immunization in groups given 0-, 15-, 30-, and 60-µg dosages were 23, 37, 50, and 61 against influenza A/H1N1; 43, 86, 91, and 125 against influenza A/H3N2; and 10, 14, 18, and 24 against influenza B, respectively. Mean serum hemagglutination inhibition and neutralizing antibody levels against the 3 vaccine antigens in participants given the 60-µg dosage were 44% to 71% and 54% to 79%, respectively, higher than those in participants given the standard 15-µg dosage, and the 60-µg dosage level nearly doubled the frequency of antibody responses in those whose preimmunization antibody titers were in the lower half of the antibody range. Dose-related increases in the occurrence of injection site reactions were observed (P<.001), but all dosages were well tolerated. Conclusion: The improved immunogenicity of high-dose influenza vaccine among elderly persons should lead to enhanced protection against naturally occurring influenza.”
(CIDRAP http://www.cidrap.umn.edu/ )


3. Notifications
FAO/OIE Conference to focus on wild birds
The role of wild birds in spreading H5N1 will be the focus of a conference scheduled May 30-31 by the FAO and the World Organization for Animal Health (OIE). About 300 scientists from more than 100 countries will attend the meeting to deal with the controversy over the role of wild birds versus domestic birds. The problem at the heart of the controversy, said FAO Chief Veterinary Officer Joseph Domenech, is that no one knows whether wild birds can serve as long-term reservoirs of highly pathogenic avian flu viruses. "Where they are not reservoirs but only victims of contamination from poultry, then prevention has to remain at the domestic bird level," Domenech said. "But where they are, we have to find out which birds are involved and where they migrate to in order to prevent other wild birds and poultry being infected." Jan Slingenbergh, senior animal health officer at FAO, said he expects there will be no clear conclusion as to whether wild or domestic birds spread avian flu to new areas. In most European countries where the virus has appeared, it has been in wild birds, he said. In East Asia, the virus was probably spread by a combination of wild and domestic birds, while in Africa it appears that poultry trade has been mainly responsible, he said.
(CIDRAP 5/25/06 http://www.cidrap.umn.edu/ )


WHO invokes influenza rules a year early
Member states of WHO agreed to invoke a set of health regulations related to influenza a year early because of the threat that H5N1 avian flu will trigger a flu pandemic. The voluntary regulations are part of the International Health Regulations (IHR), which were approved by the World Health Assembly a year ago but are not scheduled to take effect until Jun 2007. "The provisions identified for early voluntary compliance include those relating to rapid and transparent notification, support to countries that request it in investigating and controlling [influenza] outbreaks, and providing essential information including recommendations for control measures," WHO said. The resolution passed by the WHA notes that rapid detection and reporting of human cases of avian flu "underpin WHO's ability to issue a reliable risk assessment and declare an appropriate phase of pandemic alert."

Among other things, the voluntary measures adopted under the resolution call on countries to: Promptly report to the WHO any probable or confirmed human illnesses caused by any new flu virus subtype; Designate an official IHR "focal point" to communicate information and collaborate with the WHO on risk assessment (the language doesn't specify whether this would be an individual or an agency); Designate IHR "contact points"; Provide WHO collaborating centers with information and biological materials related to highly pathogenic avian influenza and other novel flu strains in a timely manner. The resolution also covers regulations related to surveillance, information-sharing, consultation, verification, public health response, and public health measures for travelers.

The measure calls on WHO director-general to "further accelerate steps" to set up a roster of experts [on avian and pandemic flu] and to invite proposals for its membership." In addition, the WHO chief is asked to help mobilize international help for needy countries affected by avian flu and to search for solutions to the shortage of, and unequal access to, flu vaccines. Anders Nordstrom, acting WHO director-general, said the agency has increased its ability to provide on-the-ground help to avian-flu–affected countries in the past year. "The number of missions from WHO has gone up since the last year," said Nordstrom. "And now we expect with this decision, which is more of a political commitment, that we will be able to accelerate even more." Nordstrom said WHO and affected countries need more people and money to cope with avian flu. Nordstrom said that only $12 million of $89 million promised to the WHO has come in.
(CIDRAP 5/26/06 http://www.cidrap.umn.edu/ )


World health community mourns WHO's Dr. Lee Jong-wook
Dr. Lee Jong-wook, 61, director-general of WHO died following emergency surgery for subdural hematoma May 20, 2006. Lee, appointed director-general in 2003, had been spearheading the WHO's efforts against avian flu, HIV, and other significant infectious diseases. He stressed repeatedly that all heads of state should ensure that their countries develop a national pandemic preparedness plan. "The world has lost a great man today," the WHO quotes UN Secretary-General Kofi Annan. "Lee Jong-wook was a man of conviction and passion. He was a strong voice for the right of every man, woman, and child to health prevention and care, and advocated on behalf of the very poorest people. "He will be very gravely missed, but history will mark Lee Jong-wook's many contributions to public health." Lee, a native of the Republic of Korea who worked at the WHO for 23 years, led a healthy lifestyle, which for some only heightened the shock of his sudden death. Lee is survived by his wife and son, two brothers, a sister, and their families. Dr. Anders Norstrom of Sweden will serve as acting director-general until a replacement is named.

For the comprehensive memorial on Dr. Lee Jong-wook, visit the WHO webpage at: http://www.who.int/dg/lee/tributes/en/index.html.
(CIDRAP 5/22/06 http://www.cidrap.umn.edu/ ; WHO 5/24/06 http://who.int/en/ )