Thursday, October 7, 2010

Expert pair airs lessons learned from global flu response

Lisa Schnirring Staff Writer

Oct 6, 2010 (CIDRAP News) – Two internationally known health officials yesterday gave their assessment of the global response to the 2009 H1N1 pandemic, saying good decisions were made based on what was known early in the outbreak but adding that the experience yielded several important lessons, such as the need for more flexible pandemic plans and the need to communicate more clearly about risks.

The experts are Dr Gabriel Leung, of Hong Kong's Food and Health Bureau, and Dr Angus Nicoll, of the European Center for Disease Prevention and Control in Stockholm. An essay they wrote on their pandemic observations appeared yesterday in the Public Library of Science (PLoS) Medicine. Their review covers the first 12 months of the pandemic response.

Their reflections on the world's pandemic response comes in the midst of an independent review of the World Health Organization's (WHO's) response and how the International Health Regulations (IHRs) functioned in their first major test during a public health crisis.

Though the 2009 H1N1 virus seemed to cause mild-to-moderate infections in most people, experts are still sorting out the mortality impact, Leung and Nicoll wrote. Young people were among the hardest-hit groups, and their deaths amount to more years of life lost than the deaths involving older people and those with chronic medical conditions.

Some countries turned quickly to containment strategies when the new virus emerged, using nonpharmaceutical interventions such as isolation and quarantine of people with suspected and confirmed disease, which in some ways was understandable for countries that had already grappled with the H5N1 avian influenza virus and the 2003 SARS epidemic, the authors wrote.

Though some of the measures may have delayed community transmission, it's unclear if the benefits were worth the costs, according to the authors.

Until the pandemic virus emerged, hardly any countries except Japan had used antiviral medications widely. Some struggled with whether to use the drugs for the treatment of sick patients or to prescribe them for prophylaxis. A few countries, such as England, developed innovative distribution methods.

Early evidence suggests that neuraminidase inhibitors reduced severe disease without causing adverse events, Leung and Nicoll wrote. However, they added that delayed antiviral treatment was linked to more severe complications worldwide, which points to gaps in indentifying and treating patients early.

The authors gave mixed reviews to the pandemic vaccine. Though they said it was a scientific success, it arrived too late with not enough supply to blunt the Northern Hemisphere's second pandemic wave. They noted that public health officials struggled with a difficult message when urging people to get the vaccine—that although the virus usually caused mild disease, it could sometimes be lethal, even in young and previously healthy people.

Though some critics have questioned their countries' expenditures for what may have later appeared to be excessive amounts of vaccine, the authors noted that when health officials placed their orders they didn't expect the later finding that a single dose rather than multiple doses was immunogenic in all but the youngest children.

"Hindsight always gives perfect vision and using post-hoc information to evaluate prior decisions at best confuses and often produces unfair conclusions," Leung and Nicoll wrote.

In addressing critics' charges that vaccine makers may have improperly influenced the expert advice WHO relied on in determining their recommendations and response actions, Leung and Nicoll emphasized that receiving advice is different than making decisions. Advisors' declarations of interest should be fully transparent and comprehensive and follow strict rules that can hold up to intense scrutiny, they said, and "The decision makers should also be prepared to justify their actions."

They predicted that communication about risk will remain a challenge in the months ahead because the 2009 H1N1 virus could undergo antigenic drift, given the greater number of people who are now immune through infection or vaccination.

As the lessons emerge about the pandemic response, countries will likely be retooling their pandemic plans, the authors wrote, urging the WHO to take a leadership role to coordinate the efforts. "A strong argument exists for making future plans more flexible and having extra descriptions including the many aspects of severity when a pandemic is emerging that then determine the consequential public health actions," they stated.

Their other recommendations include:

Establishing a clinical research infrastructure to help speed the collection and sharing of clinical data during the next flu pandemic or other disease outbreak
Improving surveillance systems to help gauge the true burden of flu
Developing new tools for treating severe flu infections.
Easing developing countries' access to antiviral medications and vaccines still represents a big gap, the authors wrote. "It is an indefensible fact that these vaccines started to flow to the poorer countries well after they began going to the countries with advance purchase agreements."

However, they noted that the long-term solution isn't simple and includes improving surveillance, monitoring disease burden, expanding flu prevention and control efforts, and establishing seasonal flu vaccine production and use in all parts of the world.

Study explores Southern Hemisphere pandemic patterns

Lisa Schnirring Staff Writer

Oct 5, 2010 (CIDRAP News) – A review of how the first wave of the 2009 H1N1 pandemic affected Southern Hemisphere countries found many similarities with Northern Hemisphere countries, though many patients had no underlying risk factors for flu complications and pregnant women didn't seem to have severe outcomes.

The authors from Greece and from Tufts University School of Medicine in Boston based their findings on 15 studies in the medical literature that described the epidemiologic findings in the Southern Hemisphere. They published their findings today in an early online posting by Epidemiology and Infection.

Seven of the studies detailed the experience of South American countries, six covered Australia and New Zealand, and two focused on Africa.

The Southern Hemisphere experienced its first pandemic wave during the region's 2009 winter influenza season (northern summer). Some countries, such as New Zealand and Australia, recently saw or are in the midst of a second pandemic wave. Australia's health ministry said in its most recent report that flu activity is increasing, with nearly 70% of cases caused by the 2009 H1N1 virus. The rise in cases there is unusual, coming at the end of the flu season.

All but one of the studies included in the literature review contained data on the characteristics of patients with lab-confirmed 2009 H1N1 infections.

In patients whose respiratory samples were evaluated with reverse -transcript polymerase chain reaction (RT-PCR) testing, the rate of positives ranged from 31.5% to 54% in four studies from Brazil, Argentina, and Australia, though a reference laboratory in Bolivia reported a lower rate of 12.7%. The positive rate was even lower, about 8.3%, in two Brazilian studies, and a general hospital in Argentina has a 3.3% positive rate.

Hospitalization rates in confirmed cases were about 45% in Brazil and Argentina and varied from about 17% to 31% in Australia and New Zealand.

Among five studies that included data on fatality levels, rates ranged from 0.5% to 0.9%.

The majority of lab-confirmed 2009 H1N1 cases were in young and middle-aged adults, with the second highest levels of infections in older children and adolescents. Though fewer seniors were affected, the ones who were sickened were more likely to be hospitalized, to be admitted to an intensive care unit, or to die. .

Nearly 67% of patients with severe infections did not have underlying medical conditions. Common conditions in patients that did have risk factors for flu complications included, for example, chronic respiratory disease such as asthma, cardiovascular disease, renal insufficiency, and diabetes.

Studies that included information on pregnant women reported that this group accounted for between 5.4% and 8.1% of severe infections. However, they didn't find that pregnant women were substantially more likely to be hospitalized or admitted to the ICU. "In other words, pregnancy might be mostly a risk factor for acquisition of infection with pandemic A (H1N1) 2009 influenza virus, rather than for an adverse outcome, " the researchers wrote.

They noted that pregnant women were more likely to be in the age-group most affected by the virus and may often have close contact with young children, who could expose them to the virus.

The researchers found that a substantial number of obese people were sickened during the pandemic wave, a pattern that also emerged in the United States and other Northern Hemisphere countries. However, the group emphasized that their findings concerning pregnant and obese patients were just observations.

They also pointed out that most cases of pandemic flu were mild and uncomplicated and went undiagnosed. Because their review focused on lab-confirmed cases, they said, it doesn't capture the true impact and characteristics of the 2009 flu pandemic in the Southern Hemisphere.

WHO pandemic review group concludes third session

Lisa Schnirring Staff Writer

Sep 29, 2010 (CIDRAP News) – The external committee tasked with reviewing the World Health Organization's (WHO's) response to the H1N1 pandemic wrapped up its third round of live meetings in Geneva today, hearing from an array of country and organization health representatives, as well as WHO Director-General Margaret Chan, who strongly defended the organization's response.

Chan, who spoke to the group yesterday during a public plenary session on the second day of its meeting, also said the WHO learned some important lessons that will position it to, for example, ease the flow of pandemic vaccine to developing countries. Her address to the group appeared yesterday on the WHO's Web site. The pandemic review committee is simultaneously reviewing how the International Health Regulations (IHRs) functioned during their first use in an international health emergency.

Dr Harvey Fineberg, the group's chairman, briefed reporters today at the conclusion of the group's 3-day meeting. He said the committee is still in an information-gathering mode and that the agenda consisted of public plenary sessions and deliberation meetings during which members met by themselves. He is president of the Institute of Medicine of the US National Academy of Sciences.

The review committee's last meeting in Geneva was in early July, and Fineberg told reporters the committee will meet again in November for deliberation sessions. He projected that the group would have a draft of a report for its own members to review by early January in time for its final plenary meeting. The members will submit a final report that includes a response from Chan in advance of the World Health Assembly next May.

Fineberg said the group heard testimony from a wide range of health and industry experts and confirmed, based on a journalist's question, that Michael T. Osterholm, PhD, MPH, addressed the group during the plenary sessions. Osterholm is director of the University of Minnesota's Center for Infectious Disease Research and Policy, publisher of CIDRAP News.

One of the largest blocks of testimony came from key people who led the WHO's response and were involved in administering the IHRs, including Chan, Fineberg said. At the committee's last meeting in July they heard from some of sharpest critics of the WHO's response, including a Council of Europe representative and the editor of the British Medical Journal.

"One of the things that was not surprising, but very revealing, was that the principals at the WHO secretariat were very eager to tell their story," he said. "They are as eager to tell their story as the critics are to tell theirs."

Chan spoke candidly about the challenges and successes she observed during the WHO's pandemic response and said the group welcomes the review and is mindful of the praise and criticisms it has received. She said the WHO is grateful for the moderate impact the pandemic had, and she said in retrospect some response measure may look excessive.

"Had the virus turned more lethal, we would be under scrutiny for having failed to protect large numbers of people," Chan said. "Vaccine supplies would have been too little, too late, with large parts of the developing world left almost entirely unprotected."

She said experts assumed that H5N1, with its more lethal severity, would cause the next pandemic, which guided preparations for a more severe pandemic than what emerged with the 2009 H1N1 virus. The phased pandemic alert approach was developed as cues to help countries increase their preparedness levels without causing public alarm. "In reality, it had the opposite effect. It dramatized the steps leading to the declaration of the pandemic and increased the build up of anxiety," Chan said.

Chan rejected charges that the WHO exaggerated the pandemic threat and said when she announced the move to alert phase 6 she reminded the world that the number of deaths were small, that she didn't expect to see them increase suddenly, and that most patients were recovering without medical care.

During a time when health officials had to make decisions in an environment of scientific uncertainty, most health officials erred on the side of caution, she said. "In this regard, the phased approach to the declaration of a pandemic was rigid and confining. In communicating the level of alarm, authorities need to be able to move down as well as up," Chan said, adding that limited vaccine capacity and long production times also hampered the flexibility of countries' pandemic responses.

She strongly rejected charges that commercial interests tainted the WHO's pandemic alert level decisions. "I can assure you: never for one moment did I see a single shred of evidence that pharmaceutical interests, as opposed to public health concerns, influenced any decisions or advice provided to WHO by its scientific advisors," Chan said in her statement.

On a positive note, Chan said some elements of the world's pandemic response worked well, including the IHRs, which she said provided a useful set of checks and balances, and the early distribution of oseltamivir stockpiles to developing countries.

"In my view, the Emergency Committee, with both experts and affected states represented, functioned well as a balanced and inclusive advisory body," she said. The emergency committee met at least nine times to advise Chan during pandemic phase and response discussions, and some critics charged that the process lacked transparency, because member names were confidential. The WHO has said the names were kept secret during the pandemic to protect members from undue influence. It revealed the member names on Aug 10 when the WHO declared that the pandemic was over.

In response to journalists' questions, Fineberg said several times that the role of the committee isn't to assign blame, but to identify ways that the WHO can improve its pandemic response.

He said the review committee is hearing a lot about the challenge of decision making under conditions of great uncertainty and that some response measures, such as the vaccine donation process, are very complex.

"Everyone came at this from their own perspective, but few had a vision of the whole. Each told an important side of the story," Fineberg said. "Our job is making a coherent whole out of these perspectives."

Tuesday, June 15, 2010

Pandemic (H1N1) 2009 - update 104

WHO's Weekly update

11 June 2010 -- As of 6 June, worldwide more than 214 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 18156 deaths.

WHO is actively monitoring the progress of the pandemic through frequent consultations with the WHO Regional Offices and Member States and through monitoring of multiple sources of information.

Situation update:
Active but declining transmission of pandemic influenza virus persists in limited areas of the tropics, particularly in Southeast Asia and the Caribbean. As countries of the temperate southern hemisphere enter winter, only sporadic influenza activity has been detected so far, except in Chile and Uruguay, both of which have recently reported small numbers of pandemic influenza virus detections. Although seasonal influenza B viruses have been the predominant type of influenza virus circulating worldwide since the end of February 2010, there have been increasing but low level detections of seasonal influenza H3N2 viruses, particularly in South America and in East Africa.

In the tropics of the Americas, overall pandemic influenza activity is low, however, both seasonal influenza H3N2 and type B viruses are actively circulating in parts of tropical South America. Active but declining transmission of pandemic influenza virus continues to be detected primarily in Cuba. Since early 2010, pandemic influenza virus has circulated at low levels in Costa Rica. Sporadic detections of pandemic influenza virus continue to be reported in Brazil. During the most recent reporting week (last week of May 2010), both Brazil and Venezuela reported regional spread of influenza activity associated with an increasing trend of respiratory diseases. In Venezuela, recent influenza activity (which began during early May 2010) has been predominantly due to circulating seasonal influenza A viruses. In Bolivia, circulation of seasonal influenza viruses, predominantly type B, was observed between March and May 2010 and now appears to be subsiding.

In Asia overall pandemic influenza virus transmission remains low, except in parts of tropical South and Southeast Asia, particularly Singapore, Malaysia, and Bangladesh. In Singapore, overall levels of ARI remained slightly below the epidemic threshold and the proportion of respiratory samples testing positive for pandemic influenza virus increased slightly to 34%. In Malaysia, limited data suggests that pandemic influenza virus transmission has begun to decline since plateauing during May 2010. In Bangladesh, there has been stable persistent low level co-circulation of pandemic and seasonal influenza B viruses since March 2010. Sporadic detections of pandemic influenza virus continued to be reported across other parts of Asia. In East Asia, overall influenza activity remains low, however, seasonal influenza B viruses continue to circulate at low and declining levels.

In Sub-Saharan Africa, pandemic influenza virus continued to circulate at low levels in parts of West Africa, most notably in Ghana. During the most recent reporting week, 13% of all respiratory samples tested positive for pandemic influenza virus in Ghana. Small but significant numbers of seasonal H3N2 viruses have been detected in Kenya and Tanzania since late May 2010.

Overall, in the temperate regions of the northern hemisphere, pandemic influenza viruses have been detected only sporadically during the past month. In the temperate southern hemisphere, only two countries, Chile and Uruguay, have recently reported small numbers of pandemic influenza virus detections. In Chile, there was low level geographically limited circulation of pandemic influenza virus during May 2010; 3.4% of respiratory samples tested positive for pandemic influenza virus during the last week of May 2010. Of note, in Uruguay, 11 (44%) of 25 samples tested positive for pandemic influenza during the most recent reporting week (the last week of May 2010); however, the corresponding intensity of respiratory diseases in the population is not yet known. Other respiratory viruses, most notably RSV, are known to be circulating in Chile and Argentina. There have been no recent detections of pandemic influenza virus in South Africa. In New Zealand and Australia, overall levels of ILI remain low; only sporadic detections of seasonal and pandemic influenza viruses have been recently reported in Australia.


WHO defends pandemic actions, says rules need tightening

Jun 10, 2010 (CIDRAP News) – The World Health Organization (WHO) replied at greater length today to recent criticism of the way it used science advisors in pandemic planning, defending its response to the H1N1 flu pandemic but allowing that its policies concerning transparency and relations with the pharmaceutical industry need strengthening.

Today's WHO statement largely reiterates points made by WHO Director-General Margaret Chan in a Jun 8 letter, but it offers more details and goes a step further by expressing regret that the agency did not list the industry connections of WHO advisors who helped develop pandemic guidance published in 2004 on the use of vaccines and antivirals.

The new statement was issued in response to an article and editorial published Jun 3 in BMJ (formerly the British Medical Journal) and a report by a committee of the Parliamentary Assembly of the Council of Europe (PACE), a human rights organization. The reports and editorial raised questions about possible conflicts of interest among the WHO's pandemic advisors because they had done paid work for pharmaceutical companies. The PACE committee report went further, branding the WHO's pandemic response an "unjustified scare" that led to wasteful spending.

Concerning potential conflicts of interest, the WHO notes that many leading experts who advise the agency have ties with industry, such as research funding, consulting work, and participation in industry-sponsored conferences. To guard against biased advice, the WHO requires expert advisors to declare their interests, and it assesses those interests to decide if any action is required, the statement says.

It adds, "The publication of summaries of relevant interests following meetings is inconsistent and needs to be made routine. WHO further acknowledges that safeguards surrounding engagement with industry need to be tightened, and is doing so."

The BMJ critique focused heavily on the 2004 pandemic guidance, stating that the industry connections of three scientists who helped write the guidance were not listed in the document. The guidance was based on a meeting held in 2002.

"In line with WHO policy, all experts who participated in this meeting were required to submit a declaration of interest form and all such forms were duly reviewed by WHO," today's statement says. "However, a summary of relevant interests was not issued together with the publication. WHO regrets this oversight.

"Since that time, a number of administrative and legal changes have been implemented to strengthen procedures for addressing potential conflicts of interest that might influence the advice provided to WHO. WHO is committed to tightening these procedures further and ensuring their more consistent application."

The BMJ critique also dwelt on the WHO's withholding of the names of members of the Emergency Committee it established last year to advise on its response to the pandemic. The article implied that the panel members may have conflicts of interest that slant their advice.

The WHO has said it has withheld the names to protect the members from commercial or political pressures. Today's statement provides more background on this rationale.

Whether to release the names was debated when the committee was set up under the International Health Regulations, the WHO said. The names of members of other advisory groups are released after their meetings. However, the SARS (severe acute respiratory syndrome) epidemic in 2003 showed that public health emergencies can cause considerable economic and social disruption, suggesting that "experts could well be lobbied or pressured for commercial or political reasons."

After considering the issues, the WHO decided to follow its usual practice of disclosing the names of experts after completion of the advisory group's work. But the committee has held a number of meetings over more than a year, rather than a single meeting like most advisory groups, so the release of names has been delayed.

The names of members and summaries of their declarations of interest will be issued after the pandemic is declared over, the WHO said. Meanwhile, "Procedures for revealing names of member of future Emergency Committees are under review."

Other points in today's statement, which is presented in a question-and-answer format, deal more with the substance of the WHO's pandemic guidance and decisions.

For example, the statement summarizes how the H1N1 virus differed from seasonal flu and met the criteria for a pandemic: it was genetically unique, it circulated in summer, it hit younger people, it crowded out other flu viruses, and antibodies to seasonal H1N1 flu did not protect people.

The WHO rejects the critics' assertion that it removed severity from its definition of a pandemic. In particular, it addresses a 2003 WHO document—often cited by critics—stating that a flu pandemic causes "enormous numbers of deaths and illnesses."

"At the time, this was considered a likely scenario should the highly lethal H5N1 avian influenza virus develop an ability to spread readily among humans, but it was never a formal definition," the statement says.

The WHO also repeated Chan's flat rejection of the allegation that it declared a pandemic to boost the earnings of drug companies, saying no evidence for this has been found.

The statement also defends the agency's guidance on use of antivirals during the pandemic.


Study raises questions about age-group impact of H1N1

Jun 14, 2010 (CIDRAP News) – A study by French researchers suggests that the H1N1 influenza pandemic may not have differed from seasonal influenza epidemics in its effects on different age-groups quite so much as has been supposed.

The general understanding is that H1N1 has disproportionately affected children and young adults, leaving elderly people relatively unscathed. The new study agrees that the younger groups have borne a much larger share of pandemic deaths than they do in seasonal flu, but it suggests that the age distribution of total cases is much the same as in past seasonal flu epidemics.

"The age distribution of influenza-like illness was similar between the 2009 H1N1 pandemic and seasonal epidemics whereas the proportion of under-60s among influenza deaths was markedly higher during the 2009 pandemic (peak<20 years) than during the seasonal epidemics," says the report by Magall Lamaitre and Fabrice Carrat. It was published online last week by BMC Infectious Diseases.

The US Centers for Disease Control and Prevention (CDC) has estimated that about 90% of all pandemic H1N1 cases were in people younger than 65 and that 32% were in children (under 18). The BMC study implies that this disproportionate burden of illness in young people is not much different from what happens in seasonal flu.

The French researchers compared the age distribution of cases and deaths during two different seasonal flu epidemics in the United States and France with the age distribution of pandemic H1N1 cases and deaths in the two countries.

For the seasonal epidemics, the researchers chose the H1N1 epidemics of 1978-79 in the United States and 1998-89 in France and the H3N2 epidemics of 1989-90 in both countries.

They used influenza-like illness (ILI) as the indicator of cases (morbidity), gathering data from published studies, the CDC, and France's Sentinel flu surveillance system. The age distributions of flu-related deaths were obtained from national death registries.

To assess the relative burden of illness and deaths on different age-groups, the investigators calculated a relative illness ratio (RIR) and a relative mortality ratio (RMR). The RIR is the percentage of sick people in a given age-group divided by the percentage of the total population belonging to that age-group. Similarly, the RMR is the percentage of total flu deaths in a given age-group divided by the percentage of total all-cause deaths in that age-group. Any ratio greater than 1 signals a disproportionate burden.

Overall, the age profile of the 2009 pandemic resembled that of the seasonal epidemics, the researchers found. The highest illness burdens (RIR values) in the pandemic were in 5- to 9-year-olds in France (RIR, 2.97) and in 0- to 4-year-olds in the United States (RIR, 3.49).

The 5- to 9-year-old group had the highest illness burdens in both seasonal epidemics in France (H1N1, 2.15; H3N2, 1.77). In the US seasonal epidemics, the highest illness ratio in the 1978-79 H1N1 outbreak fell on 10- to 14-year-olds (2.99) and, in the 1989-90 H3N2 epidemic, on 5- to 24-year-olds (1.84). All the RIRs for those 35 and older were lower than 1.

In contrast to the morbidity pattern, the age pattern for deaths differed sharply between the pandemic and the seasonal epidemics, the researchers found. In the pandemic, RMRs for those under 60 were all higher than 1, with peak ratios in those under age 20. In the United States the hardest hit age-group was 5- to 24-year-olds (RMR, 38.66), while 5- to 9-year-olds were hardest hit in France (RMR, 37.39).

In three of the four seasonal epidemics, the highest RMRs were in those 65 and older, the report says. The exception was the 1978-79 H1N1 epidemic in the United States, in which the 5- to-24-year-old age-group had the highest relative mortality (RMR, 3.91). As the authors note, the H1N1 virus re-emerged in 1977 after a 20-year absence, leaving young people at the time relatively unprotected.

The researchers say their morbidity findings suggest that "the age distribution of risk of infection did not differ" between the pandemic and the seasonal epidemics. They add that previous studies have shown that school-age children are most susceptible to contracting seasonal flu and that studies of the 1918, 1957, and 1968 pandemics showed an age distribution of cases similar to that of seasonal flu epidemics.

As for mortality findings, the authors write that while mortality was highest in children and younger adults, it decreased with age between 20 and 60. "Prior exposure to seasonal influenza viruses thus seems to protect against the 2009 H1N1 virus," they add. They further comment, as have others, that the relatively low mortality in elderly people suggests they have immunity related to their exposure to H1N1 viruses that circulated before 1957.

Cecile Viboud, PhD, a staff scientist in the division of international epidemiology and population studies at the National Institutes of Health's Fogarty International Center, observed that the finding of a shift in the mortality burden to younger people in the H1N1 pandemic has been detected in several other studies and also has been described in the previous three pandemics.

However, "the authors do not find evidence of an age shift in the distribution of influenza cases" in the 2009 pandemic, "which is perhaps a little surprising," Viboud told CIDRAP News by e-mail.

She said the study may lack the statistical power to detect changes in the age distribution of cases in pandemics. This is "mostly because they only have two seasonal epidemics to compare with, and also because the morbidity data come from several different studies with likely large variations in sampling and testing practices."

Viboud added that at least two previous studies "have noted a change in the age distribution of cases in [past] pandemics, with proportionally more children being sick than expected. Also, we know that seasonal A/H1N1 epidemics tend to cause illness in younger individuals than H3N2 epidemics, which is not obvious from their [Lamaitre and Carrat's] data, and suggests that the study may be underpowered."

She said another possible problem with the study is its use of data on deaths specifically coded as influenza, which underestimate the true flu burden and may introduce age-related biases in coding. She added that she looks forward to further studies on the age distribution of cases and deaths as more data on the 2009 pandemic become available.


Tuesday, June 8, 2010

Studies Needed to Address Public Health Challenges of the 2009 H1N1 Influenza Pandemic: Insights from Modeling

In light of the 2009 influenza pandemic and potential future pandemics, Maria Van Kerkhove and colleagues anticipate six public health challenges and the data needed to support sound public health decision making in the June edition of PLoS Medicine. Summary points from the group’s paper include the following:
  • As the global epidemiology of the pandemic (H1N1) 2009 influenza (H1N1pdm) virus strain unfolds into 2010, substantial policy challenges will continue to present themselves for the next 12 to 18 months.
  • Here, we anticipate six public health challenges and identify data that are required for public health decision making: Measuring age-specific immunity to infection; accurately quantifying severity; improving treatment outcomes for severe cases; quantifying the effectiveness of interventions; capturing the full impact of the pandemic on mortality; and rapidly identifying and responding to antigenic variants.
  • Representative serological surveys stand out as a critical source of data with which to reduce uncertainty around policy choices for both pharmaceutical and nonpharmaceutical interventions after the initial wave has passed.
  • Continuing to monitor the time course of incidence of severe H1N1pdm cases will give a clear picture of variability in underlying transmissibility of the virus during population-wide changes in behavior such as school vacations and other nonpharmaceutical interventions.

    The entire article is worth reading, and can be viewed by clicking on the hyperlink below.

    Article: Van Kerkhove MD, Asikainen T, Becker NG, Bjorge S, Desenclos J-C, et al. (2010) Studies Needed to Address Public Health Challenges of the 2009 H1N1 Influenza Pandemic: Insights from Modeling. PLoS Med 7(6): e1000275. doi:10.1371/journal.pmed.1000275

Wednesday, June 2, 2010

Scientists advising WHO could recommend ending the pandemic alert

(AFP) – 1 day ago

"GENEVA — Scientists advising the World Health Organisation on Tuesday held a meeting to give their latest assessment of swine flu, in a move that could end the pandemic alert, a WHO spokesman said.

The UN health agency said the result of the confidential meeting would be announced on Wednesday.

Speaking shortly before the teleconference began, WHO spokesman Gregory Haertl said the scientists would be 'reviewing the epidemiological situation around the world' and that a 'recommendation or announcement one way or the other' would be made. Asked if the emergency committee of scientists could recommend an end to the pandemic declared by the UN health agency nearly a year ago, Haertl said: 'They could.' 'The two most likely outcomes are either the status quo or post-pandemic,' he told journalists.

WHO Director General Margaret Chan has closely followed the advice of the 15-member emergency committee headed by Australian infectious diseases expert John Mackenzie since swine flu was first uncovered in April 2009. It played a crucial role in recommending an international emergency over the new virus and scaling up different stages of alert, including the declaration of a pandemic on June 11, 2009. The committee declined to wind down the pandemic alert at its last meeting in February after the disease appeared to wane in North America and Europe.

Mackenzie said in April that he was waiting to see how A(H1N1) influenza progressed in the southern hemisphere's traditional autumn and winter flu seasons, amid predictions of a second wave. Last Friday, the WHO's weekly pandemic assessment noted that there was 'little evidence of pandemic influenza activity in the temperate zone of the southern hemisphere,' except for parts of Chile.

Haertl told journalists: 'Examining what's happening, or has not yet happened, in the southern hemisphere yet will probably be key to their discussions this afternoon (Tuesday).' "


Wednesday, May 26, 2010

FAO: Early and Rapid Diagnosis of Avian Influenza

20 May 2010 - Influenza A, including avian influenza, is a major public health threat in developed and developing countries. Early, rapid and accurate detection is a key component of strategies to contain, halt or mitigate disease transmission. In the context of highly pathogenic avian influenza (HPAI), the efficient diagnosis of this and other emerging and transboundary diseases is essential to protect animal and human health in the event of a major outbreak.

In a recent scientific consultation on influenza and other emerging infectious diseases at the human-animal interface held in Verona, Italy, it was concluded that there is an urgent need to gain a deeper understanding of host and susceptible population dynamics, along with a firmer grasp of the active and multifaceted interplay between domestic animals and wildlife in diverse agro-ecological systems.

In recent years, experts, scholars and practitioners have highlighted the benefits of using science-based laboratory applications to further elucidate the environmental characteristics used by actual and potential animal hosts in their natural settings. This can be done, for instance, by using stable isotope analysis (SIA), which is a technique that aids in identification of isotopic signatures, the distribution of certain light stable isotopes (for example, Hydrogen-2, Carbon-13, Nitrogen-15, Oxygen-18 and Sulfur-34), and specific chemical elements within complex chemical compounds. This technique, or variations thereof, such as isotope ratio mass spectrometry (IRMS), are utilised to trace food webs and track the origins of target animal species. Some of the substrates for these applications are feather, blood, faecal, hair and aqueous samples collected from animals and the environment.

These techniques are now used - and hopefully can be broadly adopted - to produce the tangible evidence needed to support anecdotal reports that resident animal species are picking up viral diseases from visiting species after they move out (for example, asymptomatic mallard ducks during their sojourn in Siberia shed HPAI in the environment) and also to generate data on the ecology of avian influenzas in key bird species worldwide. In fact, several research institutes around the world have been trying to gather evidence and generate data through careful and systematic tracking of migratory birds along their flyways by collecting and analysing samples from wintering and nesting sites to build up reliable isotopic profiles and comparing them to local profiles from where viral disease outbreaks are reported.

In addition to isotope tracing, classical molecular techniques such as Polymerase Chain Reaction (PCR) are being further refined to enhance detection of influenza viruses. In particular, given that HPAI is oftentimes reported in fairly inaccessible rural settings, field PCR tests are now being designed and tested to assess its applicability and usefulness. The advent of new applications and the differing diagnostic capacities of infected locations call for cross-validation of PCR technique between countries experiencing recurrent disease flare-ups.

Given that early and rapid pathogen detection has been posited as a pillar of comprehensive animal disease risk management programmes, the Joint International Atomic Energy Agency (IAEA)/Food and Agriculture Organization of the United Nations (FAO) Division, held the Final Research Coordination Meeting of the Coordinated Research Project (CRP) on "Early and Rapid Diagnosis of Emerging and Transboundary Animal Diseases" on 10-14 May 2010, in Rome, Italy, in which seasoned veterinary laboratory practitioners and diagnostic experts share their knowledge and expertise as the scientific and technical basis for developing or modifying the early and rapid diagnosis of avian influenzas.

The rapid molecular technology platforms developed and fine-tuned by the CRP has allowed improved turnaround time: early, rapid, and confirmed diagnosis has moved from weeks to a day or two, which has in turn improved field cooperation with surveillance programs. This has been critical to rapid and effective avian influenza control in a country with a confirmed incursion of avian influenza H5N1 (e.g. Nigeria). The infrastructure developed with the avian influenza CRP has allowed future development and growth of other laboratory services (the capability is generic in nature and can be utilized laterally). The avian influenza technology has been shared with public health laboratories where possible, and this has allowed new cooperation and collaboration between the public health and veterinary diagnostic community.

The associated molecular diagnostic training has also allowed improvements to laboratory capability and capacity-building. The sharing of information between the CRP members has assisted in the development of a better understanding of avian influenza diagnosis through molecular techniques including an increased knowledge about the disease's epidemiology, transmission and risks. The project has improved the profile of surveillance programs, including wildlife surveillance, and the capability of the laboratory to carry out the diagnostic components of surveillance efforts.

Additionally, as a complement to ongoing research initiatives and capacity-building efforts, the FAO/IAEA Agriculture and Biotechnology Laboratory, located in Vienna, specializes in research, development and transfer of nuclear methods in animal production and health, among other areas. The laboratory provides a broad range of specialized services and training of scientists, as well as guidance on the introduction of analytical quality control and assurance into counterpart laboratories, and training in the maintenance of laboratory equipment and instruments.


S. Korea to share bird flu quarantine knowhow with ASEAN countries

SEOUL, May 24 (Yonhap) -- South Korea will share its knowhow on bird flu quarantine with Southeast Asian countries as part of its effort to help contain future outbreaks of the disease, the government said Monday.

The National Veterinary Research and Quarantine Service said 30 quarantine experts from eight Association of Southeast Asian Nations (ASEAN) countries have been invited to the country next week.

The training program, which begins next Monday and runs through June 15, was arranged in cooperation with the Korea International Cooperation Agency -- an organization that offers free programs for developing countries.

Outbreaks of bird flu have posed a health problem for many parts of Asia with many deaths attributed to the potentially fatal disease, which can be passed from birds to humans.

In addition, the agency will also give lectures on various animal test kits and drugs manufactured in South Korea.

The local animal quarantine service, under the farm ministry, said ASEAN officials will also be briefed on Seoul's countermeasures to deal with other livestock diseases, such as foot-and-mouth disease and brucella.

South Korea is currently trying to contain an outbreak of foot-and-mouth disease that has caused authorities to cull around 50,000 animals.


FDA Clears H1N1 Test for General Use

WASHINGTON -- A test for the pandemic H1N1 influenza has been formally approved for use outside a public health emergency situation, the FDA announced.

Until the clearance of Simplexa Influenza A H1N1 (2009), which is used to test for the pandemic virus in patients with signs and symptoms of respiratory infection, tests for the new virus were available only through an Emergency Use Authorization (EUA).

Such use was allowed after the Department of Health and Human Services declared a public health emergency related to the new H1N1 virus on April 26, 2009. All EUAs expire when the emergency for which they are issued is considered over.

"With this clearance, the availability of the Simplexa H1N1 test will not be affected when the public health emergency expires," said Jeffrey Shuren, MD, JD, director of the FDA's Center for Devices and Radiological Health, in the agency's announcement.

Although a positive result on the test, which uses specimens from nasal swabs or nasal aspirates, indicates infection with H1N1 flu, a negative result does not rule out infection.

The Simplexa test is made by Focus Diagnostics.


No Pandemic but Endemic - Managing Avian Influenza Outbreaks in Nepal

Nepal has faced seven avian influenza outbreaks in animals since early-February this year. In the Central, Southern and Eastern Regions, these outbreaks were quickly spotted by field monitors and successfully contained by Rapid Response Teams, thanks to the Avian Influenza Control Project (AICP).

The project is helping the Government of Nepal to prepare, prevent and control avian influenza outbreaks together with our partner organizations, including USAID, FAO, OiE, WHO and UNICEF. Implemented jointly by the Departments of Livestock Services and Health Services, the project is strengthening surveillance, diagnostic capacity, and prevention and containment activities, improving bio-security in poultry production and trade, and raising awareness through communication activities.

With support from the partners, the AICP has trained field monitors and health workers in 26 High-Risk Zones, set up Rapid Response Teams in all 75 districts, and trained the Teams in stamping out operations, including culling, safe disposal, cleaning and disinfection. It has also established a compensation scheme for poultry farmers, and provided pre-positioned Personal Protective Equipment, antiviral and vaccines for 40-50% of high risk occupations groups.

AICP was initially set up to respond to a potential global avian flu pandemic, which fortunately never happened. However, the avian flu is “here to stay” in Nepal as this is the second series of outbreaks after those in 2009. With no pandemic, the Bank has recently streamlined the project, to strengthen activities which would help Nepal prepare and prevent the outbreaks in animals and humans.

Surveillance has been intensified at commercial farms and at district level through engaging farmer groups, which helped the rapid detections of outbreaks in February in 2010. The project is strengthening existing diagnostic facilities, including upgrading central and five regional laboratories equivalent to the Bio-Security Laboratories 2 (BSL2) standard and operationalizing the National Public Health Laboratory.

The communication campaign through TV and radio spots and a travelling skit team has proven effective in increasing the level of awareness among Nepali. Surveys show that 76% of poultry farmers know and follow practices to prevent spread of avian flu to healthy chickens, such as separating sick chickens from a healthy flock, and reporting sick chickens to vet or local authorities. Moreover, 72% of health workers and almost 70% of general populations wash hands after handling birds, before cooking, etc., which would prevent avian flu to jump from animals to humans.

As the virus actively circulates in West Bengal, Sikkim and Bangladesh, AICP is also actively engaged in managing avian influenza in Nepal and at its borders. In addition to the already successful communication campaign, the project is organizing trans-border quarantine workshops, and successfully conducted one in the West with Indian and Nepali officers.

AICP is making a good progress in achieving its development objectives through effective containment and intensive surveillance and awareness raising activities. The capacity being built by AICP will be enhanced through the Regional Training Program in Epidemiology and Bio-security, which is implemented by Massey University, New Zealand.

The Program will provide 70 animal and human health practitioners in the Region with on-line training at Master’s level in epidemiology and establish centers of excellence in epidemiology or "One Health" hubs in Nepal and other six participating countries in the Region to control avian influenza and other zoonoses that emerge through the interface of animal, human and environment.

These activities will complement each other to help the Government of Nepal to further prevent and control outbreaks in avian influenza.


Thursday, May 20, 2010

The 2nd International Forum on Pandemic Influenza

24-25 July 2010, Qingdao, China

Cambodia: Survey finds low practice of prevention measures

May 2010 CBAIRRP Newsletter--To assess the needs of the newly selected areas in Prey Veng and Svay Rieng, CARE conducted six focus group discussions with villagers in four districts.

The FGD found that over 90 percent of the villagers raise chicken in small scale backyard system, mostly for household consumption, with around 10 to 20 percent of households raising ducks as small-scale business enterprise. There is high awareness of avian influenza but low practice of prevention measures.

Villagers believe that AI can be prevented through washing hands with soap after handling poultry and not eating sick or dead poultry, both actions are considered to be the most effective for AI prevention in humans. Direct contact with poultry without wearing protective clothing is believed to be the main route of AI transmission in humans, with eating sick or dead poultry as another key source of infection. Those who directly handle poultry are considered most vulnerable to AI.

Very few people wear masks or scarves and gloves when slaughtering poultry and those who do, do so only when handling sick or dead poultry suspected of AI. Around half of the villagers interviewed are frightened by AI while the rest don?t concern themselves with this disease.

Those who raise ducks practice more preventative measures but not because of
avian influenza but because it makes good business sense; any disease affecting their flock will impact on their ability to earn more income. Hand washing with soap topped the list of the prevention measures practiced by duck raisers as well as regular cleaning of poultry area , which is practiced by over 90 percent.

Most of the duck raisers are not willing to report sick or dead birds which are rather sold to the market to maximize earning potential. They are only concerned about AI infection when there is massive mortality. Even so, reporting is rarely done as duck raisers are concerned they will not get paid for the number of birds authorities will cull.

Villagers believe in the following prevention measures but some consider them costly: confining new incoming poultry around 2 weeks; raising poultry in fence; not allowing sick or dead poultry coming to the raising areas; cleaning areas regularly; keeping middleman away from poultry pen; Among the members of Village Surveillance Team, the village chief is the most trusted source of information on AI as he plays a prominent role in disseminating or promoting AI messages, followed by the Village Animal Health Worker. Chicken raisers interviewed would report suspect case of AI to the village chief or village animal health worker since they are considered to be easily accessible and their response was expected to be more effective than those of other authorities. However, reporting will only be resorted to in the event of massive deaths.

Newly selected VST members strongly feel responsible for AI prevention in their village. VST and district vet have good collaboration in responding to AI issues rather than health center and other relevant agencies. The messages they will disseminate to villagers are: 1) do not eat sick or dead poultry; 2) look out for these symptoms in poultry (black/swollen head and combs and massive death of poultry); 3) wash hands and clean house and yard. Other messages included fencing poultry, and reporting to the VST if they have sick or dead poultry; 4) wear masks when handling poultry.

However, VST members consider it difficult to identify AI cases since the clinical signs in poultry and symptoms in humans are similar to common poultry diseases such as Newcastle Disease, Fowl Pox, Fowl Cholera and seasonal flu in humans. It is also a challenge to carry out regular surveillance as VST members do not receive any monetary incentive and they have other other community development activities to tend to. Their limited knowledge of technical aspects and prevention measures is also considered a barrier.

Wednesday, May 12, 2010

Southeast Asia aims to eradicate H5N1 by 2020

Maryn McKenna Contributing Writer

Apr 28, 2010 (CIDRAP News) – A multi-national meeting aimed at freeing Southeast Asia from H5N1 avian flu within 10 years wrapped up deliberations yesterday with a call for cooperation to keep animal diseases from crossing national borders.

The First Technical Working Group Meeting on Highly Pathogenic Avian Influenza (HPAI) Roadmap, a project of the Association of Southeast Asian Nations (ASEAN), met for 2 days in Jakarta to work out mutually agreed plans—the "roadmap"—that will be submitted to the 10 member countries later this year.

In the meeting's opening remarks Apr 26, H.E. S. Pushpanathan, ASEAN's deputy secretary-general, recalled the deep damage done to the Southeast Asian economy by the first sustained outbreak of H5N1 starting in 2003, in which 200 million poultry were culled and nations recorded a collective $10 billion in losses.

"HPAI is a transboundary animal disease. Successful eradication would require effective regional collaborative mechanisms and actions," Pushpanathan said in remarks posted on the ASEAN Web site. "Animal health and the issues related to it are important concerns to ASEAN as it will have a serious impact on ASEAN's continued growth and development."

The draft produced by the end of the meeting points the member countries toward establishing a single regional economic market in livestock and animal products by 2015 and eradicating H5N1 from the region by 2020, according to an Apr 28 Xinhua report. It pays particular attention to instituting a "One World, One Health" approach (a concept backed by 38 national and international health organizations) of treating animal and human diseases as a continuum that requires consistent policy responses across government and development agencies.

The move to strengthen Southeast Asian responses to avian flu comes at a time when H5N1, which had slipped behind novel H1N1 in activity and in public health attention, appears to be rising again in both realms.

Vietnam's Department of Animal Health reported yesterday that the country's central province of Quang Tri has recorded an outbreak that killed 250 ducks out of 1,500 on one farm, according to an Apr 27 Xinhua story. Three other provinces have had recent outbreaks, including Quang Ngai (three provinces to the south of Quang Tri), and Bac Kan and coastal Quang Ninh in northern Vietnam.

Bangladesh announced plans to upgrade 19 live-bird markets in Dhaka (the capital) and 11 other cities, using a $575,000 grant from the UN Food and Agriculture Organization (FAO) that funds worker training and sanitation improvements, the Bangladesh Daily Star reported today. Five other markets in the capital have already been upgraded.

The need in Bangladesh is critical: According to the World Organization for Animal Health (OIE), there have been 12 new farm and village outbreaks in Bangladesh since the beginning of March.

And in Indonesia, the Metro Riau news site in Riau province on Sumatra is reporting illness among chickens, believed to be flu, that may have spread to children in a family.


WHO panel offers clinical profile of H1N1

Robert Roos News Editor

May 5, 2010 (CIDRAP News) – A panel of experts assembled by the World Health Organization (WHO) has published a clinical profile of pandemic H1N1 influenza, using data from scores of studies to fill in details of the broad picture that has emerged over the past year.

The report, released today by the New England Journal of Medicine, affirms that the disease has taken its heaviest toll on young adults and children but otherwise generally resembles seasonal flu.

The international team of 15 authors writes that the overall estimated case-fatality rate (CFR) has been less than 0.5%, with estimates ranging all the way from 0.0004% to 1.47%, reflecting uncertainty about the true number of cases. The US CFR has been estimated at 0.048%, a bit higher than the United Kingdom's estimate of 0.026%.

About 90% of those who have died of the virus were younger than 65, while hospitalization rates have been highest in children under 5 years old and lowest in the elderly, the report notes.

The virus seems to be about as contagious as seasonal flu or slightly more so, with estimates of the basic reproduction number (the number of secondary cases caused by the primary case in a susceptible population) ranging from 1.3 to 1.7. But in school outbreaks the number may be about twice as high: 3.0 to 3.6.

The report says that about 25% to 50% of H1N1 patients who were hospitalized or died had no coexisting medical condition. Risk factors for complications are generally the same as those for complications in seasonal flu, including age under 5 years, pregnancy, cardiovascular disease, asthma, diabetes, immunosuppression, and several other conditions. Obesity is "suggested but not yet proved to be an independent risk factor" for severe disease or death.

The virus's incubation period is about 1.5 to 3 days, similar to that of seasonal flu, the report says. But viral replication may persist longer in H1N1, as some studies have found that patients with uncomplicated cases still carried infectious virus 8 days after illness onset.

A mild illness with no fever has been reported in 8% to 32% of cases, the article says. It affirms that gastrointestinal symptoms have been more common in H1N1 than in seasonal flu, especially in adults.

The most common clinical syndrome leading to hospitalization and intensive care, the experts write, is "diffuse viral pneumonitis associated with severe hypoxemia, ARDS [acute respiratory distress syndrome], and sometimes shock and renal failure." This has been seen in about 49% to 72% of intensive care unit (ICU) cases.

Other syndromes seen in severe cases include severe exacerbation of chronic obstructive pulmonary disease (COPD) and asthma. About 24% to 50% of hospitalized patients have had a history of asthma, and COPD has been reported in about 36% of hospitalized adults.

Secondary bacterial pneumonia has been suspected or confirmed in 20% to 24% of ICU patients and found in 26% to 38% of patients who died. The most common pathogens are Staphylococucs aureus (often methicillin-resistant), Streptococcus pneumoniae, and S pyogenes.

The article affirms the established advice about early treatment with oseltamivir (Tamiflu) or zanamivir (Relenza) for high-risk patients and adds that doubling the dose and duration of oseltamivir therapy is reasonable in patients with pneumonia or evidence of disease progression.

The report notes that antiviral resistance has been seen sporadically, mainly in treated patients. The His275Tyr mutation confers resistance to oseltamivir (and to peramivir, a drug that is used intravenously under an emergency use authorization) but does not cause resistance to zanamivir.

Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic 2009 Influenza A (H1N1). Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection. N Engl J Med 2010 May 6;362(18):1708-19 [Full text]


WHO Update - Pandemic (H1N1) 2009 - update 99 (7 May 2010)

Weekly update
7 May 2010 -- As of 2nd May, worldwide more than 214 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 18001 deaths.

WHO is actively monitoring the progress of the pandemic through frequent consultations with the WHO Regional Offices and Member States and through monitoring of multiple sources of information.

Situation update:
The most active areas of pandemic influenza virus transmission currently are in parts of West Africa, the Caribbean, and Southeast Asia. In the temperate zone of the northern and southern hemisphere, overall pandemic influenza activity remains sporadic. Seasonal influenza virus type B continues to be detected sporadically across Asia, Africa, Europe, and the Americas, however, low levels of late season virus circulation have primarily detected in East and Central Asia, southern Europe, and central Africa.

In Sub-Saharan Africa, limited data from several countries suggest that active transmission of pandemic influenza virus persists in parts of West Africa while low levels of seasonal influenza type B viruses continue to circulate in parts of central Africa. In Ghana, pandemic influenza virus detections may be declining after peaking during early April 2010; during the most recent reporting week, 14% of respiratory specimens tested positive for pandemic influenza virus. In Cameroon, low levels of pandemic and seasonal influenza type B virus continue to co-circulate, though the latter have been predominant during April 2010. In the Democratic Republic of Congo, circulation of seasonal influenza H3N2 viruses during February and mid-March 2010 has been largely replaced by circulation of seasonal influenza type B viruses during April 2010. Localized, low level pandemic influenza virus circulation continues to be observed in parts of East Africa, particularly in Rwanda and Tanzania. Sporadic detections of seasonal influenza H3N2 viruses continue to be reported across eastern, central, and western Africa.

In tropical zone of the Americas, limited data suggest that pandemic influenza virus transmission remains active in several countries. In Central America, Guatemala reported three consecutive weeks of an increasing trend of respiratory diseases activity associated with regional spread of pandemic influenza virus and detection of severe cases. In Cuba, detections of pandemic virus and numbers of severe cases have increased since late March, however overall pandemic influenza activity may have recently peaked during the most recent reporting week. In Peru, the number of pneumonia cases in children under 5 years of age in the capital area has been increasing for the past seven weeks and remains above the epidemic threshold; however, the extent to which these pneumonia cases have been due to pandemic influenza H1N1 virus versus other respiratory viruses circulating in the region, is not known. Although the overall intensity of respiratory diseases across the region remained low to moderate during April 2010, for short periods of time, circulation of pandemic influenza virus was reported to widespread (in Cuba and Barbados) or regional (in Mexico, Honduras, Nicaragua, Columbia, Venezuela, Brazil, Ecuador and Bolivia).

In Southeast Asia, pandemic influenza virus continues to actively circulate in several countries of the region, however, respiratory disease trends in the region are variable. In Malaysia, limited data suggest that pandemic influenza virus transmission persists with ongoing reports of new cases (including severe cases) and media reports of several school outbreaks, particularly during late April and early May 2010. In Singapore, the national level of ARI has been steadily increasing since early April 2010 and now exceeds the epidemic threshold; 37% of sentinel respiratory specimens tested positive for influenza during the most recent reporting week. In Thailand, the proportion of sentinel outpatients with ILI and sentinel inpatients with pneumonia testing positive for pandemic influenza virus infection has declined significantly since peaking during late March 2010.

In South Asia, the most active area of pandemic influenza virus transmission continues to be in Bangladesh, which continues to report increasing respiratory diseases activity associated with co-circulation of pandemic and seasonal influenza type B viruses since mid April 2010. However, persistent low level co-circulation of both viruses has been detected since late February 2010. In India, localized low level circulation of pandemic influenza virus continues to be detected in parts of western and southern India.

In East Asia, very low levels of pandemic influenza virus continue to be detected. Although overall rates of respiratory illness remain low across the region, recent low levels of influenza activity in a number of countries in the region have been largely due to circulating seasonal influenza type B viruses. Three countries in region, Mongolia, China, and South Korea, each experienced a period of sustained seasonal influenza type B virus circulation following an earlier, generally more intense, wintertime period of pandemic influenza virus transmission. China and South Korea continue observe active but declining levels of seasonal influenza type B virus circulation.

In the temperate zone of the southern hemisphere, overall pandemic and seasonal influenza activity remains sporadic, except in Chile, where there is evidence of low level community circulation of pandemic influenza virus, including detection of small numbers of severe cases; however it too early to know if this signals an early start to wintertime influenza season. The national level of ILI in Chile remained near baseline; however, in at least two southern regions the region specific level of ILI was elevated above baseline, and in one region, Los Lagos, the region specific baseline has been elevated slightly above the epidemic threshold for the past four weeks. Of note, 6% of sentinel respiratory samples in Chile tested positive for a respiratory virus, of these 32% were positive for respiratory syncytial virus (RSV), and 27% were positive for influenza viruses (half of which were subtyped as pandemic H1N1 virus).

In Europe, overall influenza activity remained low with very low level co-circulation of pandemic and seasonal influenza type B viruses. The overall proportion of sentinel respiratory samples testing positive for influenza remained stable at about 5.3%; and the total number of sentinel influenza B virus detections continued to exceed that of influenza A viruses, primarily due to low level seasonal influenza type B virus circulation in the Russian Federation and Kazakhstan.


WHO panel to review H1N1 pandemic status in coming weeks

The Emergency Committee is waiting for the onset of winter in the southern hemisphere before making its recommendation, spokesman Gregory Hartl said.

That meant the 15-member independent panel would probably meet at the end of May or in early June, after the WHO's governing World Health Assembly next week, he told a briefing.

"They have to look at the information that exists at that time on the activity of the H1N1 virus," Hartl said.

The WHO's guidance on whether a disease constitutes a pandemic determines how its 193 member governments handle an outbreak, including stockpiling vaccines and antivirals.

The United Nations body has been accused of exaggerating the dangers of the H1N1 outbreak, which was declared a full pandemic in June 2009 after dominating last year's health assembly.

The current virus appears to have been less severe than the two previous influenza pandemics in 1957 and 1968, which killed about 2 million and 1 million people respectively, with most victims suffering only mild symptoms.

Confirmed deaths from H1N1 since the outbreak emerged in April last year number at least 18,000, but it will be a few years before the real -- much higher -- figure is known.

John Mackenzie, who chairs the emergency committee and is the only one of its 15 members to have been publicly identified, said last month that the current pandemic was as severe as the two previous ones and remained a threat.

Members' identities are kept secret to protect them from pressure from drugs companies or other interest groups.

Hartl said the committee was likely to have three options: conclude that the pandemic was still in force and retain the WHO's current phase 6 on its 6-level pandemic scale; state that the pandemic had moved into a transitional "post-peak" phase; or declare that the pandemic had passed.

(Reporting by Jonathan Lynn; Editing by Stephanie Nebehay and Reed Stevenson)


U.S. official says scientific cooperation with Indonesia to benefit both

5/11/10 Xinhua--A U.S. senior official promised Indonesian government here on Monday that the further possible science and technology cooperation between the United States and Indonesia would be benefiting to each other.

Speaking on the sidelines of his meeting with Indonesian President Susilo Bambang Yudhoyono, the visiting U.S. special envoy for science and technology affairs Bruce Alberts said there has been misunderstanding of such cooperation, particularly when it was established with developed countries.

"The reason of my appointment as the envoy was not to take something. I was tasked to encourage towards good cooperation," the U.S. envoy said.

Bruce said that Indonesia would eventually be a great and powerful nation only if it is using the science and knowledge.

"Indonesia can be a rich country should it use the correct science and knowledge. We can help Indonesia to attain that condition. Some fears (related to the scientific cooperation with the U.S.) had persisted in a number of cooperation with Indonesia in the past," Bruce was quoted by the Antara news agency as saying.

Due to the fear that results from bird flu research conducted in U.S-Indonesia 'Namru' joint laboratory would be misused by the U.S.military for its own interest, Indonesia closed down the laboratory last year.

Indonesian president is scheduled to sign documents on several cooperation wrapped in comprehensive agreements with the United States during the visit of U.S. President Barack Obama scheduled for June this year.

Indonesian presidential spokesperson Dino Pati Djalal said that President Yudhoyono preferred cooperation in science, knowledge and other non-political sectors would dominate the comprehensive agreements with U.S.


Thursday, April 29, 2010

H1N1 Lessons Learned Resource

CIDRAP has issued the first of a series of articles reviewing the world's experience with pandemic H1N1 influenza and what lessons have been learned in the past year.

This first issue covers geographic expectations, wave pattern, impacts on populations, as well the stresses of H1N1 on health systems. The resource also talks about clinical components of illness related to H1N1, as well as about high risk populations.

Source: CIDRAP

International Group Renews Push to Fight Avian & Pandemic Influenza

Apr 22, 2010 – An international avian and pandemic flu meeting in Hanoi concluded yesterday, with health ministers and top officials from more than 70 countries agreeing on a set of strategies for responding to future disease threats.

The agreement, titled the Hanoi Declaration, includes national measures to identify new diseases that cross from animals to humans and quickly deploy public health responses, the United Nations (UN) said yesterday in a press release. Documents related to the meeting are available on the Web site of the Seventh International Ministerial Conference on Animal and Pandemic Influenza, where the Hanoi Declaration will be posted shortly, according to the group.

The ministerial conference was hosted by the Vietnamese government and organized by the United States, the European Union, UN groups, and other global health organizations. It was the latest in a series of high-level meetings over the past 4 years to tackle international avian and pandemic flu issues.

Clouds of volcanic ash hampered travel to the 3-day meeting over Europe, which blocked about a fifth of the delegates from attending the meeting, the UN said. China's earthquake limited that country's participation. "The severity of these natural occurrences, and the suddenness with which they struck, reminded delegates about the swift and unpredictable spread of new hazards that can emerge from the animal world," the UN release said.

The meeting also took place in the wake of warnings from several global organizations about the continued risk of H5N1 avian influenza. Countries where the disease is endemic, such as Egypt and Vietnam, have reported several outbreaks in poultry this year, along with a spate of human cases.

A few weeks in advance of the meeting, organizers released a draft report on how to sustain momentum in the fight against animal and pandemic flu. The report was slated to be finalized when the group met in Hanoi. Some of the topics include broad-based prevention and control, incentives, measuring progress, and building financial and technical assistance.

The health officials rejected an effort put forth by Poland to include in the declaration a statement on pharmaceutical company conflict of interest and their responsibility for vaccine side effects, Deutsche Presse-Agentur (DPA) reported yesterday. The Polish government did not purchase a stockpile of pandemic vaccine, in part because it objected to liability limits on companies' pandemic vaccines.

David Nabarro, the UN's system influenza coordinator, said in the press release that the global capacity to collaborate in response to disease threats has improved over the past 5 years, but the conference helped identify areas that can enhance the world's security during future emerging disease threats.

At the closing ceremony yesterday, Bui Ba Bong, Vietnam's vice-minister of agriculture and rural development, said the world needs to continue responding to H5N1 and pandemic H1N1 while preparing for other diseases that move from animals to humans. "In Vietnam's experience, this calls for good human and animal health services, excellent communications, and whole of society responses," he said.

Source: CIDRAP

Accelerated 2009 H1N1 Infection Rates in Bangladesh

According to recent reports, Bangladesh has directed health officials across the country to remain on alert after finding that the 2009 H1N1 influenza virus has spread rapidly this month.

They said the disease had been remaining at lower levels in Bangladesh from January-March of 2010, but this month it has spread hastily, infecting many across the country, posing a fresh threat of a massive outbreak.

"So, we've asked all officials concerned to remain on alert," Mahmudur Rahman, Head of the country's Institute of Epidemiology, Disease Control and Research (IEDCR) under the Health Ministry, told Xinhua Tuesday.

As to whether there is a possibility of major outbreak of the disease in the country in the coming months, Rahman said the possibility is very low, as they have adequate preparations to contain the spread of the disease.

"The virus sustained at a lower level in Bangladesh during January-March period but it showed rising trend since the beginning of this month," he said, adding this is not something unusual as April-September period is considered to be the peak season of the disease.

He did not cite the exact number of people infected by the disease so far this month but said that the April's figure is not something negligible compared to the first three months of 2010 and confirmed that no one died due to the flu this year.

According to the official record of the Bangladesh Health Ministry, the 2009 H1N1 death toll in the country in 2009 rose to 6.

A 35-year old female flu positive patient in Aug. 31, 2009 died in Dhaka which was first fatality the country has had since recording its first A(H1N1) case on June 18. Three people died until the first week of October, 2009 since June while three other died in the later October and early November period.

Rahman also said that Bangladesh will very shortly launch flu vaccination program as part of its efforts to protect people.

"As part of our strengthening measures we're now collecting flu samples from 28 points of the country instead of 14 earlier," he said, adding there is nothing to be much worried following the disease's rapid outbreak this month as there is also huge supply of medicines in the Health Ministry's stock.

The country's Health Ministry had already permitted the marketing of 2009 H1N1 flu vaccine in the country.

Currently, the Bangladeshi government has asked hospitals and clinics in the country to immediately treat anyone who displays symptoms of H1N1 rather than to spare time by having to test them first.



Balita News flu-infection-accelerates/?date=042110

Vaccine Shortage Threatens 2009 H1N1 Control in Nigeria

Despite the recent outbreak of the pandemic 2009 H1N1 virus in Ghana, Nigeria is yet to receive stocks of vaccine to prepare for a possible outbreak in the country.

Two Nigerians have so far died of the virus and 11 cases have been confirmed by the Federal Ministry of Health (FMOH). A nine-year-old American girl was the first case of HINI in Nigeria, which was reported in November 2009.

Experts are worried that the scenario may threaten efforts to control the virus, especially in developing countries. They said the demand for the vaccine worldwide has outstripped the supply, which coupled with the high cost of the vaccine, has made it difficult to obtain.

Former Health Minister, Prof. Babatunde Osotimehin, has been elected Vice Chair, International Health Regulations (IHR) Review Committee, which was set up by the World Health Organisation (WHO) to assess the global response to the pandemic H1N1.

Source: Nigerian Guardian Newspaper

US Global Funds for Avian & Pandemic Influenza Reach $1.5 Billion

From CIDRAP News - April 20, 2010

Lat week, the US delegation to the International Ministerial Conference on Animal and Pandemic Influenza (IMCAPI) meeting in Hanoi, Vietnam, noted the country has spent more than $1.5 billion to combat global avian and pandemic influenza. This figure represents $627 million invested since the previous 2008 IMCAPI conference held in Sharm el-Sheikh, Egypt, according to a Department of State press release.

The additional US funding will be allocated to multilateral organizations, such as the World Health Organization, as well as to bilateral and regional programs. This investment includes the donation of 10% of the US H1N1 vaccine supply to developing countries, as well as in-kind assistance such as personal protective equipment, laboratory and decontamination kits, technical and humanitarian assistance, and vaccine research. The 3-day conference, was hosted by Vietnam with support from the US Agency for International Development, the United Nations, and the European Commission.

Source: CIDRAP

Friday, April 16, 2010

Humanitarian Pandemic Preparedness (H2P): Red Cross Annual Report

The International Federation of Red Cross and Red Crescent Societies (IFRC) is supporting National Societies with financial and technical support, to prepare for, and respond to, an outbreak of pandemic influenza in their countries.

Essential to the program's success is ongoing collaboration and coordination with multiple implementing partners, including NGOs (including CARE), UN agencies, local governments and Movement partners. National Societies implementing H2P projects are developing pandemic preparedness and response plans, training staff and volunteers, providing consistent messages to their communities, in addition to the ongoing in-country coordination with all stakeholders. Health, Food Security, Livelihoods and Communications working groups consisting of IFRC and partner organizations have developed tools, materials, guidelines and a website for pandemic preparedness and response efforts

View the full annual report at$File/full_report.pdf, and visit the H2P website at for more information on pandemic preparedness.

Renal Complications Common with Pandemic Flu

According to an article published in Renal & Urology News, acute kidney injury (AKI), acute renal failure (ARF), and the need for dialysis are common complications in critically ill patients with 2009 H1N1, and are associated with an increased death risk, according to Canadian researchers.

Manish M. Sood, MD, and colleagues at the University of Manitoba in Winnepeg, prospectively studied 50 patients with 2009 H1N1 admitted to one of seven ICUs in Manitoba. Subjects had a mean age of 35.5 years and 72% were women.

AKI developed in 66.7% of the patients for whom this complication could be determined. Eleven patients (22%) required dialysis; of these, 10 recovered. Eight patients (16%) died. AKI and kidney failure were associated with a 5.7 and 11 times increased risk of death. The need for dialysis was associated with a 21% increased risk.

In addition, patients requiring dialysis had a significantly increased ICU stay compared with those not requiring dialysis (mean 33.3 vs. 19.3 days).

The researchers concluded that critically ill patients with H1N1 infection suffer a high rate of kidney injury, kidney failure, and the need for dialytic therapies. Kidney injury was also strongly associated with mortality.

The researchers also stress that longer ICU stay for patients needing dialysis could significantly stress hospital resources in the event of a future outbreak.

Source: Renal & Urology News

Egypt: Confirmed H5N1 Infection in Donkeys

A new study investigating H5N1 in mammalian hosts has confirmed that the virus was found in donkeys in Egypt.

Nasal swabs were collected from donkeys suffering from respiratory distress. Phylogenetic analysis showed that the virus clustered within the lineage of H5N1 from Egypt, closely related to 2009 isolates. It harbored few genetic changes compared to the closely related viruses from avian and humans. The neuraminidase lacks oseltamivir resistant mutations.

These findings extend the host range of the H5N1 influenza virus, possess implications for influenza virus epidemiology and highlight the need for the systematic surveillance of H5N1 in animals in the vicinity of backyard poultry units especially in endemic areas.

Source: Journal of Biomedical Science

Bangladesh: Confirmed H5N1 Outbreaks in Poultry, Narayangonj and Mymensingh

Following active surveillance, outbreaks of H5N1 were observed:
  1. On 7 April 2010 in Mymensingh District, Dhaka division,where 4 out of 123 backyard poultry died. The rest of the poultry were culled.
  2. On 11 April 2010, when three outbreaks occurred at threebackyard poultry in Araihazar Upazila. Narayangonj District, Dhaka division and 3,136 out of 10,700 died. The rest of the chickens were culled.
The farms are clustered in the same area (the distance from each other being 10-15 meters).

Narayangonj District last reported four outbreaks in March 2007.


Thursday, April 15, 2010

New UN study urges sustained momentum to tackle human, animal influenza threats

14 April 2010 While there has been substantial global progress towards pandemic preparedness in recent years, it is vital to maintain that momentum to respond effectively to existing and possible future threats, according to a new study by the United Nations and the World Bank.

“Continued global vigilance for infectious disease outbreaks and pandemics is of critical importance for health security and well-being,” says the report, entitled “Animal and pandemic influenza: a framework for sustaining momentum.”

The report notes that an estimated 75 per cent of new human diseases originate in animals and an average of two new animal diseases with cross-over capabilities emerge every year. We have to find ways to put the work on bird flu and on pandemics more into the routine business of ministries of health and ministries of agriculture
The emergence of three major epidemiological events into the first decade of the new century – SARS, H5N1 avian influenza and H1N1 pandemic influenza – is an indication of the rate at which threats may continue to arise, it adds.

“Sustaining momentum,” states the report, “will require a strategic use of resources and a move away from emergency response-driven projects and special, single-focus initiatives, to long-term capacity-building.”

The report will be taken up by delegates from over 80 countries when they meet at the International Ministerial Conference on Animal and Pandemic Influenza, which will be held in Hanoi, Viet Nam, from 20 to 21 April.

“This is a really significant conference,” David Nabarro, Senior UN System Influenza Coordinator, told reporters in New York, noting that the gathering will take stock of where the world is with regard to bird flu and the H1N1 virus, review preparedness and consider lessons learned from countries with successful control efforts.

The threats from bird flu and H1N1 are not over yet, he noted, stressing the need for further measures to ensure an effective global response.

“We have to find ways to put the work on bird flu and on pandemics more into the routine business of ministries of health and ministries of agriculture, into the routine work of disaster preparedness units in countries,” he stated. “And so an important element of the discussions in Hanoi will be the way forward.”

Part of the work in Hanoi, he added, will be to consider whether or not extra preparedness is necessary to ensure that those who look after animal health and those that look after human health are working together well enough to prepare for disease threats that come from animals.

A key question, he noted, is: “Are we well enough organized as a world to be prepared for diseases that can jump from the animal kingdom and lead to sickness and possibly quite widespread suffering among humans?”

Find this story at Scroll down to Topics: Health, Poverty, and Food Security

Wednesday, April 14, 2010

Outbreak Study: Satellite Tracking Reveals How Wild Birds May Spread Avian Flu

For the first time, migratory birds marked with satellite transmitters were tracked during an outbreak of highly pathogenic H5N1 avian influenza virus (H5N1) in Asia, providing evidence that wild birds may be partly responsible for the spread of the virus to new areas.
In the study, scientists from the USGS Alaska Science Center and the University of Tokyo attached satellite transmitters to 92 northern pintail ducks several months before the H5N1 virus was discovered in dead and dying whooper swans at wetlands in Japan.
They found that 12 percent of marked pintails used the same wetlands as infected swans and that pintails were present at those sites on dates the virus was discovered in swans. During the first week after they become infected with H5N1, ducks such as pintails can shed the virus orally or in their feces, potentially contributing to the virus’ spread.
Researchers found that some of the marked pintails migrated 700 miles within four days of leaving the outbreak sites; marked pintails ultimately migrated more than 2,000 miles to nesting areas in eastern Russia. The study’s discovery that northern pintails made long-distance migrations during the period when an infected duck would likely shed the virus offers insight on how H5N1 could be spread by wild birds across large areas.
The research, published in the journal Ibis, does not prove the marked pintails were actually infected with the H5N1 virus or that they definitively contributed to its spread. However, it does demonstrate that pintails satisfied two requirements necessary for migratory birds to spread the virus: they used outbreak sites at times when the virus was present and some birds migrated long distances within a week of using the sites.
Jerry Hupp, Ph.D., a U. S. Geological Survey scientist and one of the lead authors of the study, noted that the H5N1 virus has been found in wild birds, including northern pintails, which show no visible signs of illness. Also, laboratory studies have shown that pintails and some other wild birds remain healthy when infected with H5N1.
“Consequently,” said Hupp, “infected wild birds that do not become ill, or birds that shed the virus before they become ill, may contribute to the spread of H5N1.”
The extent to which the virus has been spread via the wild bird trade, wild bird migration, and shipping of infected poultry or poultry products has been the focus of debate. “Studies of the movements of wild birds during H5N1 outbreaks can help scientists evaluate the overlap between migratory pathways and the occurrence of the virus,” Hupp said.
The region in eastern Russia that pintails migrated to is also an important migration and nesting area for many North American birds. Mingling of Asian and North American migrants in Russia can result in exchange of influenza virus genes. Previous USGS studies have demonstrated that northern pintails in Alaska often carry low pathogenic influenza virus genes that can be linked to Asian sources.
“Because northern pintails in Alaska exchange influenza viruses with Asian birds, movement of the H5N1 virus into eastern Russia would increase the risk for its transmission to North America via wild birds -- such as the northern pintail -- that migrate between continents,” said Hupp.
The study also noted that Japanese wetlands where the H5N1 virus was found are important migration habitat for other waterfowl, including as many as 11,000 Eurasian wigeon and 8,000 greater scaup, demonstrating the potential for large numbers of wild birds to pass through sites where the H5N1 virus is present if outbreaks occur during migration.
Although the highly pathogenic H5N1 virus has not been discovered in North America, it continues to plague the poultry industry throughout Eastern Europe, Asia and Africa and is a serious health threat to humans.
Satellite-tracking of northern pintail during outbreaks of the H5N1 virus in Japan: implications for virus spread was published in Ibis (February 2010, Volume 152) and was authored by Noriyuki Yamaguchi (University of Tokyo), Jerry Hupp (USGS), Hiroyoshi Higuchi (University of Tokyo), Paul Flint (USGS), and John Pearce (USGS).
For more information on avian influenza research, visit the USGS Alaska Science Center.

Monday, April 12, 2010

WHO Global Influenza Update: Distribution, Spread and Resistance

Though pandemic flu activity stayed stable in most parts of the world, Chile is reporting new detections of the pandemic virus in at least three regions in advance of the start of its flu season, with other hot spots occurring in Bangladesh and parts of Africa, the World Health Organization (WHO) reported today.

Localized pandemic flu transmission is persisting in Tanzania and Rwanda. Several countries in the tropical zones of the Americas are reporting localized flu activity as well, including Cuba, Guatemala, Peru, and Bolivia. WHO said in its weekly flu report that the significance of the rise in pandemic flu in parts of Chile to the rest of its flu season is unknown.

Data from Mexico suggest that several states reported localized activity throughout March, particularly in Federal district, an area that has reported recent spikes in severe and fatal pandemic H1N1 infections, the WHO said. Brazil, which has reported increased levels of influenza-like illnesses over the past month, has reported that most of the severe and fatal pandemic H1N1 infections are occurring in the country's northern regions.

In some parts of the world, including China and European countries such as Italy, flu activity is occurring at expected levels, much of which is influenza B. Other countries reporting increased detections of influenza B strains include Hong Kong and Chinese Taipei. Some parts of Africa, such as Cameroon, are also reporting influenza B illnesses.

Small number of seasonal H3N2 viruses have been detected in West and East Africa, the WHO said. Indonesia is still the most active area for seasonal H3N2 transmission, though activity is leveling off there, the WHO said.

In addition, the seasonal H1N1 virus has been reported sporadically by the Russian Federation.

Most pandemic virus samples that countries have submitted to WHO collaborating center laboratories are closely related to the strain recommended for pandemic influenza vaccines.

Ten more cases of oseltamivir-resistant pandemic H1N1 were reported last week, most of which occurred in the last quarter of 2009, WHO said. All 278 samples so far have the H275Y substitution, and all remained sensitive to zanamivir. Most cases were linked to treatment or postexposure prophylaxis or occurred in severely immunocompromised patients. Only 7% had no known association to treatment.

In addition, WHO said it has received preliminary notification about a pandemic H1N1 isolate that has reduced sensitivity to neuraminidase inhibitors.

So far more than 213 countries and overseas territories or communities have reported lab-confirmed pandemic H1N1 cases, the WHO said. The agency has received reports of more than 17,700 deaths, a number it says greatly underestimates the true burden of the disease.

Source: CIDRAP