Monday, November 30, 2009
Field Studies Inform Efforts to Prevent Avian Flu
By Tula Michaelides
Headlines such as “The Bird Flu: The Race to Prevent a Global Epidemic” and “The Next Killer Flu. Can we stop it?” abounded in late 2005. That’s when AED started reaching out to rural backyard poultry farmers in Southeast Asia—then the epicenter of bird flu outbreaks—with messages about how to protect themselves and their flocks from the destructive disease and‚ ultimately‚ improve their practices and behaviors.
As AED began its work on the Avian Influenza Behavior Change Communication project, funded by USAID, one thing became clear: little was known about this target audience in general‚ or about its perceptions of avian influenza in particular.
“AED quickly fielded a Knowledge‚ Attitudes‚ and Practices survey in Cambodia‚ Indonesia‚ Lao PDR‚ and Indonesia‚” said Robert Kelly‚ the project’s research director. “The initial research findings provided an understanding of what these farmers do that could put them at risk‚ and gave insight into their core values that would allow or prevent them from accepting change.”
The surveys were a form of riskmapping‚ which helped to identify not only the dangers‚ but also what actions could mitigate those threats‚ Kelly added. The findings showed that the farmers were reluctant to pen their birds because doing so would be expensive, and they did not believe that caging the birds would prevent avian influenza.
Using this information‚ AED designed interventions the farmers would use, such as constructing small cages from local materials. Once one farmer adopted a certain practice‚ others in the community usually would follow suit.
‘Too Much Information’
In addition‚ the avian influenza messages that were created early in the epidemic included a lot of information‚ which tended to overwhelm people.
Long lists of H5N1 virus symptoms were disseminated in calendars‚ posters‚ lectures‚ and news coverage. But people still did not know the difference between H5N1 and the common poultry diseases they had been dealing with for years.
“This ‘too much information syndrome’ led to confusion among these farmers and no reporting of sick poultry since they couldn’t distinguish one disease from the other‚” said Anton Schneider‚ a senior communication specialist for the project. ‘So AED stressed the one critical message—that avian influenza causes sudden death in large numbers—and subsequently started to see an increase in reporting.”
AED’s research found that the media‚ friends‚ and family members were the primary sources of information for farmers. However‚ when researchers asked the families what they actually did in the event of an emergency‚ they discovered that the people looked to their local authorities for guidance.
As a result‚ AED provided village leaders and health workers with comprehensive training packages to inform them about avian influenza and better equip them to respond to their communities’ concerns.
Supply Chain Intervention
To use resources effectively in combating infectious diseases, it is important to conduct riskmapping and identify hot spots‚ according to Kelly. AED analyzed the supply chain to determine potential opportunities for the virus to enter the system.
The research identified the key players—such as farmers‚ transporters‚ vendors‚ and consumers—what they knew‚ and what was important to them. The results showed much room for improvement.
“We discovered that biosecurity practices were lacking at all levels of poultry operations‚” said Schneider. “Hand hygiene and cleaning practices were abysmal‚ and community veterinary officials to help farmers improve practices were scarce.”
To address the problems and help control the spread of avian influenza in the supply chain‚ AED created awareness campaigns using effective teaching materials‚ knowledgeable trainers‚ and local media.
In the end‚ AED’s avian influenza projects conducted more than 50 qualitative and quantitative studies in more than 25 countries‚ and researchers have made their methodologies and instruments available to other organizations to assist in their studies.
For more information and to access the research studies visit http://www.avianflu.aed.org/.
Monday, November 23, 2009
The researchers aim to find out whether a higher-than-usual dose of vaccine will trigger a protective immune response in these individuals. Currently, adults have been shown to respond to only one dose of the vaccine, and this study is investigating whether HIV positive patients will have an immune response to one dose as well, or whether they will need two. The researchers will also be looking at how strong the immune response is in these individuals as well as how long the response lasts.
For more information on the trial, visit http://www.gainesville.com/article/20091123/ARTICLES/911231006/1002
Friday, November 20, 2009
The Norwegian Institute of Public Health reported on these detections, as did WHO (also see links to reports below). The Norwegian public health agency subsequently analyzed isolates from more than 70 patients infected with influenza A (H1N1) 2009 who manifested clinical illness, and no further instances of mutation were detected. These findings suggest that the mutation is not widespread in the country.
WHO reports that worldwide, laboratory monitoring of influenza viruses has detected a similar mutation in viruses from several other countries (with the earliest detection occurring in April), including Brazil, China, Japan, Mexico, Ukraine, and the US. No evidence currently suggests these mutations are leading to an unusual increase in the number of H1N1 2009 infections or a greater number of severe or fatal cases.
Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention mentioned in a media briefing today that while this mutated virus is unusual, it sporadically has been detected in the US, though typically associated with more mild disease.
What are the implications of viral mutation?
- Viral mutations are normal; this specific mutation detected by the Norwegian Institute of Public Health probably will be of little or no importance (per Norwegian Institute of Public Health).
- This specific viral mutation is associated with the virus's virulence and ability to live deeper in respiratory tissue.
- Current data suggest this viral mutation has no implications for pandemic influenza A (H1N1) vaccine match or antiviral efficacy.
- The public health implications of this mutation are unclear, and may be difficult to assess (per WHO and Dr. Schuchat). It is important to note, however, that WHO reports there is no current evidence suggesting this mutation is leading to an unusual increase in the number of H1N1 2009 infections or a greater number of severe or fatal cases.
- To date, no links between the small number of patients infected with the mutated virus have been found, and the mutation doesn't appear to be spreading.
Norwegian Institute of Public Health: http://www.fhi.no/eway/default.aspx?pid=233&trg=MainLeft_5669&MainLeft_5669=5544:81363::0:5667:1:::0:0
CDC media briefing: http://www.cdc.gov/media/transcripts/2009/t091112.htm
The Ministry of Health of Saudi Arabia has recently issued a set of health requirements and recommendations for entry visas for Saudi Arabia for the Hajj and Umra season, with special focus on reducing the transmission of pandemic (H1N1) 2009 influenza among pilgrims.
These health requirements and recommendations call for those population groups who are considered to be at high risk for complications from influenza to refrain voluntarily from this year’s Hajj. The requirements issued by the Kingdom also request the health authorities in pilgrims’ countries of origin to educate and advise pilgrims on basic public health measures (personal hygiene measures, cough etiquette, use of antiseptic hand gel, etc.) to be followed during Hajj and Umra to prevent the spread of pandemic (H1N1) 2009 during the upcoming Hajj season.
There are some concerns about transmission in the Middle Eastern region because despite the preferred WHO/CDC nomenclature of 'influenza pandemic (H1N1) 2009 virus', the misleading name 'swine flu' is used more often than not. Joining the Arabic word for swine (transliterated 'alkhanaazeer') leaves an impression in a subset of the population that, there being no local swine population, the risk of transmission to animals is nil.
By some estimates, the Hajj is the single largest, annual gathering in the world; the pilgrimage of Muslims to Mecca attracts between 2 and 3 million visitors from all over the globe. In Saudi Arabia, health officers have been stationed at all points of entry, and some airports have even been equipped with heat sensors to detect people with high fevers. Officials have also recommended that travelers get vaccinated, but not all countries are going to be able to inoculate all pilgrims before they leave for Mecca. With low vaccine supplies globally, it's a problem that is likely to be repeated at other world events.
"To date, WHO has received vaccination information from 16 of around 40 countries conducting national H1N1 pandemic vaccine campaigns. Based on information in these 16 countries, WHO estimates that around 80 million doses of pandemic vaccine have been distributed and around 65 million people have been vaccinated. National immunization campaigns began in Australia and the People’s Republic of China in late September.
Vaccination campaigns currently under way to protect populations from pandemic influenza are among the largest in the history of several countries, and numbers are growing daily. Given this scale of vaccine administration, at least some rare adverse reactions, not detectable during even large clinical trials, could occur, underscoring the need for rigorous monitoring of safety. Results to date are encouraging.
Common side effects
As anticipated, side effects commonly reported include swelling, redness, or pain at the injection site, which usually resolves spontaneously a short time after vaccination.
Fever, headache, fatigue, and muscle aches, occurring shortly after vaccine administration, have also been reported, though with less frequency. These symptoms also resolve spontaneously, usually within 48 hours. In addition, a variety of allergic reactions has been observed. The frequency of these reactions is well within the expected range.
To date, fewer than ten suspected cases of Guillain-Barre syndrome have been reported in people who have received vaccine. These numbers are in line with normal background rates of this illness, as reported in a recent study. Nonetheless, all such cases are being investigated to determine whether these are randomly occurring events or if they might be associated with vaccination.
WHO has received no reports of fatal outcomes among suspected or confirmed cases of Guillain-Barre syndrome detected since vaccination campaigns began. All cases have recovered. WHO recommends continued active monitoring for Guillain-Barre syndrome.
Investigations of deaths
A small number of deaths have occurred in people who have been vaccinated. All such deaths, reported to WHO, have been promptly investigated. Although some investigations are ongoing, results of completed investigations reported to WHO have ruled out a direct link to pandemic vaccine as the cause of death.
In China, for example, where more than 11 million doses of pandemic vaccine have been administered, health authorities have informed WHO of 15 cases of severe side effects and two deaths that occurred following vaccination. Thorough investigation of these deaths, including a review of autopsy results, determined that underlying medical conditions were the cause of death, and not the vaccine.
Safety profile of different vaccines
Campaigns are using nonadjuvanted inactivated vaccines, adjuvanted inactivated vaccines, and live attenuated vaccines. No differences in the safety profile of severe adverse events among different vaccines have been detected to date.
Although intense monitoring of vaccine safety continues, all data compiled to date indicate that pandemic vaccines match the excellent safety profile of seasonal influenza vaccines, which have been used for more than 60 years. "
Friday, November 13, 2009
In the document, entitled Interim planning considerations for mass gatherings in the context of pandemic (H1N1) 2009 influenza, authors recommend that event planners conduct a thorough risk assessment, in partnership with local and national public health authorities, prior to the event.
Highlighted considerations include:
- Level of influenza activity
- Period of time over which the gathering will take place - this has implications for when event-based cases would begin experiencing signs and symptoms of the flu (e.g., during the event if the event lasts longer than 2-3 days [the typical incubation period for flu] vs. afterward for events with shorter durations), and the type of resources (e.g., health care professionals, essential medical supplies/equipment, etc.) planners should have on hand during the event
- Age of participants
- Occurrence of severe disease and health care capacity
The guidance document can be downloaded free of charge at: http://www.who.int/csr/resources/publications/swineflu/h1n1_mass_gatherings/en/index.html
For additional information related to geographic spread of influenza activity, qualitative indicators, and virological surveillance data, view the weekly report in its entirety at: http://www.who.int/csr/don/2009_11_13/en/index.html
“Emergency supplies of antiviral drugs are being sent to Ukraine, Afghanistan and other countries in Eastern Europe and Central Asia, where hospitals report that they are being overwhelmed by patients with swine flu, the World Health Organization said Thursday….
The new guidelines say that anyone with flu-like symptoms for three days, along with people in several high-risk groups — pregnant women, children under 2 and people with underlying respiratory problems — should not wait for laboratory tests to confirm the diagnosis but should be treated right away with drugs like Tamiflu.
‘The pandemic virus can cause severe pneumonia even in healthy young people,’ Dr. [Nikki] Shindo [a medical officer with the organization’s global influenza program] said, adding that “the virus can take life within a week….’ ‘The window of opportunity is very narrow to reverse the progression of the disease,’ she said. ‘The medicine needs to be administered before the virus destroys the lungs.’
Although antiviral medications are most effective when used within 48 hours after symptoms start, Dr. Shindo said the drugs should be given even after that if a person is very sick.
Dr. Shindo said the guidelines, similar to those in use in the United States, had not been adopted sooner because the agency was not yet confident, as it is now, about the safety and efficacy of the antivirals, Tamiflu and Relenza. Doctors there were also worried about shortages.
The agency said the countries most affected were Afghanistan, Mongolia, Belarus, Ukraine, Azerbaijan and Kyrgyzstan. The first four have already been sent supplies; the other two are to receive them soon.
‘Doctors involved in caring for very sick patients in intensive care units regretted that the patients arrived too late and even the most sophisticated medical procedures could not save their lives,’ she said. ‘We asked what could have been done differently to avoid the tragic outcomes. All of them answered, without exception, that things may have been very different if they had been treated with an antiviral drug earlier.’
Although Tamiflu had been stockpiled, protocol required doctors to prove a patient had H1N1 with laboratory testing before prescribing the medicine, said Nadezhda Rudnitskaya, the chief of pulmonology at Lviv Medical University.”
View the entire article at: http://www.nytimes.com/2009/11/13/world/13flu.html?_r=2
Wednesday, November 11, 2009
WHO released revised guidance for clinical management of persons infected with 2009 H1N1. The 15-page document provides information on an array of topics; including guidance for clinical management in resource-poor settings, and examples of clinical triage algorithms for ILI and pneumonia.
The document provides information/guidance on the following:
- Risk factors for severe disease
- Case descriptions (uncomplicated influenza, complicated influenza, signs and symptoms of progressive disease)
- Infection control
- General treatment considerations
- Antiviral therapy
- Care of severely ill patients (initial evaluation, antiviral therapy, supportive care, adjunctive pharmacologic therapy, secondary bacterial pneumonia)
- Resource poor settings
- Examples of clinical triage algorithms for ILI and pneumonia
The guide can be viewed in its entirety at: http://www.who.int/csr/resources/publications/swineflu/clinical_management/en/index.html
Tuesday, November 10, 2009
"A guide for human resource (HR) managers looking for ways to quickly plan for and respond to the H1N1 pandemic has been issued by the University of Minnesota Center for Infectious Disease Research and Policy, publisher of CIDRAP News, and the Society for Human Resource Management. The free 42-page guide was prepared with support from the Centers for Disease Control and Prevention. It includes lessons learned by HR professionals whose response skills were tested in the early days of the pandemic."
The guide is available free of charge at: http://www.cidrap.umn.edu/cidrap/files/33/cidrap-shrm-hr-pandemic-toolkit.pdf
"We welcome this very generous donation by GlaxoSmithKline, which will go to protect the health of the world's poorest people. This is a real gesture of global solidarity towards those who would not be otherwise able to have access to the vaccine," said Dr. Margaret Chan. "WHO will now work to see that these vaccines are distributed to those who need them."
GSK expects to prepare the first shipments of vaccine to the WHO by the end of November. The WHO has a list of 95 developing countries that are eligible to receive donated vaccines, and aims to secure enough vaccines to cover 10 percent of the population of these countries.
Monday, November 9, 2009
CDC has updated its H1N1 Flu & You Q&A webpage to include questions and answers about 2009 H1N1 transmission from ill humans to their pets, including information on preventive measures. Information can be viewed at the bottom of the H1N1 Flu & You webpage (scroll down or click on the hyperlink on the right-hand side of the screen): http://www.cdc.gov/h1n1flu/qa.htm#f
Since the new H1N1 pandemic virus emerged, a small number of infections in swine herds have been reported. Limited evidence suggests that these infections occurred following direct transmission of the virus from infected humans to swine. As we mentioned in last week's Pandemic Influenza Update #11, WHO has characterized these infections as isolated events, which have not yet had any significant impacts on the dynamics of the 2009 H1N1 pandemic among humans. As human infections become more widespread, we can expect more frequent reports of transmission of the virus from humans to animals with greater frequency.
When influenza infections are detected in farmed animals, WHO recommends monitoring of farm workers for signs of respiratory illness, and testing for H1N1 infection should such signs appear. FAO and OIE recommend that animals that are showing signs of illness be examined and properly managed, and allowed to fully recover before being transported or marketed.
"This situation reinforces the need for close monitoring and close collaboration between public health and veterinary authorities."
For more information on WHO guidance on this topic, and results from testing by laboratories in the WHO influenza surveillance network, visit: http://www.who.int/csr/disease/swineflu/notes/briefing_20091105/en/index.html
The blog submission provides perspective on the way some people in southeast Asia may view 2009 H1N1 - in the context of other emerging infectious diseases such as SARS and Nipah virus, diseases with relatively high mortality rates.
More importantly, however, Dr. Bernstein takes this opportunity to call for prevention of epidemics such as H1N1 from a much broader level, by highlighting the linkage between ecological changes and global health, as he touches on factors affecting intermediate hosts (e.g., expansion of pig farming, changing dietary diversity) and viral reservoirs (e.g., deforestation).
Dr. Bernstein admits, "This comparison is by no means made to belittle H1N1 and its ill effects."
Dr. Bernstein's entire blog submission is worth a read and can be viewed at: http://childrenshospitalblog.org/a-new-perspective-on-preventing-an-epidemic-how-h1n1-compares-to-sars-and-the-nipah-virus/
'“Saudi Arabia does not ban anyone because the Haj is a religious event,” Al-Rabeeah told reporters. “Saudi Arabia has put in place strong recommendations that we hope individual countries will abide by.”
Al-Rabeeah made the comments at the launch of a national swine flu vaccine campaign in which he rolled up his sleeve and took the first shot. He then administered the vaccine to one of his twin daughters, Hana, 8. Her sister Haifa did not get the vaccine because she contracted swine flu recently.'
View the entire story from its original source at: http://www.arabnews.com/?page=1§ion=0&article=128181&d=8&m=11&y=2009
Wednesday, November 4, 2009
Regions in western Ukraine continue to show the highest rates of acute respiratory illness/influenza-like illness. The level of activity in the Kyiv area is also increasing rapidly.
Laboratory testing in Ukraine has confirmed pandemic H1N1 influenza virus in samples taken from patients in two of the most affected regions. As the pandemic virus has rapidly become the dominant influenza strain worldwide, it can be assumed that most cases of influenza in Ukraine are caused by the H1N1 virus.
As elsewhere, WHO strongly recommends early treatment with the antiviral drugs, oseltamivir or zanamivir, for patients who meet treatment criteria, even in the absence of a positive laboratory test confirming H1N1 infection.
At the request of the government, a multi-disciplinary team of nine experts has been deployed by WHO and arrived in Kyiv yesterday evening. Discussions with the Minister of Health were held this morning to brief the team.
Team members will now begin field investigations to characterize the clinical and epidemiological features of the outbreak. Work will initially begin in Lviv region, where reported numbers of cases showing severe manifestations of acute respiratory illness have been especially high. Two virologists on the team have started working at the National Influenza Centre and the laboratories of the Central Sanitary and Epidemiological Station in Kyiv to provide diagnostic support.
Many questions remain to be answered. The outbreak in Ukraine may be indicative of how the virus can behave in the northern hemisphere during the winter season, particularly in health care settings typically found in Eastern Europe.
Given the potential significance of this outbreak as an early warning signal, WHO commends the government of Ukraine for its transparent reporting and open sharing of samples.
WHO continues to recommend no closing of borders and no restrictions on international travel, including to Ukraine. Experience shows that such measures will not stop further spread of the virus.
The CDC has issued interim guidance for commercial pig farm workers on preventing the spread of influenza A viruses, including the 2009 H1N1 virus.
In October 2009, the first case of 2009 H1N1 influenza virus in a pig in the
The interim guidance is issued with the goal of preventing the spread of this novel virus or any other influenza (flu) virus from people to pigs and from pigs to people. The recommendations are based on what are deemed optimal precautions for protecting workers exposed to pigs with known or suspected flu infection on production premises AND for protecting pigs from people with flu.
Items addressed in the recommendations include among others:
- Recognizing the signs of flu in pigs
- Preventing transmission of influenza viruses from pigs to people
- Preventing spread of flu virus from workers to pigs
- Surveillance and monitoring of workers' health
View the guidance in its entirety at http://www.cdc.gov/h1n1flu/guidelines_commerical_settings_with_pigs.htm
Tuesday, November 3, 2009
The U.S. Department of Agriculture has confirmed that at least one pig in Minnesota has contracted the 2009 Novel H1N1 influenza virus. Researchers had begun collecting samples from an undisclosed number of pigs at the fair between Aug. 26 and Sept. 1 in St. Paul in a project to document influenza infections in humans and pigs.
The USDA did not release results of the other confirmatory tests, and the agency could not immediately be reached for further comment.
The Centers for Disease Control and Prevention is funding the study by the University of Iowa and University of Minnesota.
"The infection of the fair pig does not suggest infection of commercial herds because show pigs and commercially raised pigs are in separate segments of the swine industry that do not typically interchange personnel or animal stock," the USDA announcement states. "USDA continues to remind U.S. swine producers about the need for good hygiene, biosecurity, and other practices that will prevent the introduction and spread of influenza viruses in their herd and encourage them to participate in USDA's swine influenza virus surveillance program."
People involved with the swine industry have expected some pigs would become infected with the H1N1 influenza strain, Dr. Burkgren, executive director of the American Association of Swine Veterinarians, said. He stressed that people cannot contract the disease from handling or eating pork, and personal hygiene is most effective at preventing infection, and he is hopeful that the confirmed infections will not have an impact on consumer demand.