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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 Global: Cumulative number of human cases of avian influenza A/(H5N1) Economy / Cases (Deaths)
2003
2004
2005
2006 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. 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
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. Iran: Health minister denies human avian influenza cases
Romania: Avian influenza H5N1 spreads, poultry culled
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. Russia: Reports recent poultry deaths were caused by avian influenza H5N1
Asia 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 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." Indonesia: New suspected human cases of avian influenza H5N1 infection
Americas 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
Africa 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. 1. Updates Influenza 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 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. 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 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
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. World health community mourns WHO's Dr. Lee Jong-wook
For the comprehensive memorial on Dr. Lee Jong-wook, visit the WHO webpage at: http://www.who.int/dg/lee/tributes/en/index.html.
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