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August 11, 2008 14:45 GMT
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Article Summaries ... Quid Novi
Indonesia: Poultry die-off reported in Rantauprapat district Regional Reporting and Surveillance
Knowledge, attitudes, and practices regarding avian influenza (H5N1), Afghanistan
8/11/08 CDC/EID --From February through April 2007, avian influenza (H5N1) was confirmed in poultry in 4 of 34 Afghan provinces. A survey conducted in 2 affected and 3 unaffected provinces found that greater knowledge about reducing exposure was associated with higher socioeconomic status, residence in affected provinces, and not owning backyard poultry.
Regional Reporting and Surveillance
Rwanda: Over 60 Health Experts to Discuss Avian Flu
8/11/08 All Africa --Over 60 health experts from at least 15 African countries, regional and international organizations are expected to attend a symposium on public health codes of ethics for pandemic influenza detection and control in Africa.
Regional Reporting and Surveillance
Thailand: Pitsanulok arranges meeting to prepare for bird flu threat during rainy season
8/11/08 ICT --This morning at the Ratchapruek Hotel in Pitsanulok province, provincial Governor Somboon Sripattanawat opened a pro-active meeting to rehearse measures safeguarding against Avian Influenza. The event took place as the province is now moving into the monsoon season and also as a review of past activity.
Regional Reporting and Surveillance
13 Indonesians Test Negative for Bird Flu
8/11/08 VOA News --Indonesian health officials say 13 people suspected of having bird flu have tested negative for the deadly disease.
Regional Reporting and Surveillance
FAO: New bird flu strain detected in Nigeria
8/11/08 FAO -- FAO calls for increased surveillance A strain of Highly Pathogenic Avian Influenza previously not recorded in sub-Saharan Africa has been detected in Nigeria for the first time, FAO said today. Nigeria has recently reported two new Highly Pathogenic Avian Influenza outbreaks in the states of Katsina and Kano.
Regional Reporting and Surveillance
FAO GLEWS: Vietnam Update
FAO field officer (08/08/08): The Department of Animal Health (DAH) reported HPAI in Thoi Quan commune, Go Quao district, Kien Giang province. The disease has been detected in a 50-day-old chicken flock at a raiser where 300 died among 612....
Regional Reporting and Surveillance
FAO GLEWS: India Update
FAO field officer (06/08/08): Regarding the die off poultry in West Bengal, the matter was investigated and the Director of Animal Health, West Bengal has informed that there has been no report of any unusual mortality in and around Gitaldaha...
Regional Reporting and Surveillance
Indonesia: Birds slaughtered as suspected flu breaks out
8/8/08 Daily Telegraph/Australia -- of chickens and ducks have been slaughtered to contain a suspected bird flu outbreak in Indonesia as 13 people with flu-like symptoms await laboratory results. Thirteen people were hospitalised earlier this week with fevers and respiratory problems after a large number of chickens died suddenly in their village in North Sumatra province.
Regional Reporting and Surveillance Science and Technology
Inverness Medical gets USDA approval for flu test
8/11/08 AP --Inverness Medical Innovations Inc. said Monday the U.S. Department of Agriculture issued the medical diagnostics company a license to make and sell its avian flu test kit for veterinary use.
Science and Technology
Contact With Birds Not Required to Contract Bird Flu Infection
8/11/08 Natural News --The World Health Organization (WHO) has warned that it may be possible to contract the avian flu without coming into direct contact with infected poultry.
AI Research
The 1918 ?Spanish Flu? in Spain
8/8/08 Clinical Infectious Diseases --Abstract--The 1918?1919 influenza pandemic was the most devastating epidemic in modern history. Here, we review epidemiological and historical data about the 1918?1919 influenza epidemic in Spain. On 22 May 1918, the epidemic was a headline in Madrid's ABC newspaper. The infectious disease most likely reached Spain from France, perhaps as the result of the heavy railroad traffic of Spanish and Portuguese migrant workers to and from France.
AI Research
FDA approvals clear way for flu vaccine marketing
8/7/08 CIDRAP --The six companies that make influenza vaccine for the US market have won federal approval for their version of this year's vaccine, in which all three flu strains used in last year's product have been replaced, the Food and Drug Administration (FDA) announced yesterday.
Vaccines
Full Text of Articles follow ...
Regional Reporting and Surveillance
Knowledge, attitudes, and practices regarding avian influenza (H5N1), Afghanistan
8/11/08 CDC/EID --From February through April 2007, avian influenza (H5N1) was confirmed in poultry in 4 of 34 Afghan
provinces. A survey conducted in 2 affected and 3 unaffected provinces found that greater knowledge
about reducing exposure was associated with higher socioeconomic status, residence in affected
provinces, and not owning backyard poultry.
Avian influenza (H5N1) has been reported in southern Asia (1). In Afghanistan, avian
cases were confirmed from February through April 2007 in 4 of 34 provinces (1). No human
cases have been detected, although limited human-to-human transmission has been reported from
Pakistan (2). Backyard poultry (chickens) were affected in 20 of 22 outbreak sites in 4 eastern
provinces. No outbreaks have been reported from commercial facilities. The response in
Afghanistan was to cull all poultry within a 3-km radius, restrict poultry movement and
importation, and conduct intensive influenza-like illness surveillance and information, education,
and communication (IEC) campaigns within affected provinces. IEC campaigns included leaflets
distributed in affected areas and broadcast media coverage on local television and radio. The
campaign was designed to inform the public through messages aimed at reducing exposure to
disease, preventing spread in poultry, and encouraging reporting. Additional IEC messages were
aired nationally and outbreaks were widely reported by local news media. We conducted a
survey of knowledge, attitudes, and practices (KAPs) regarding avian influenza in Afghanistan.
The aim was to assess factors associated with KAPs.
The Study
Five provinces in Afghanistan were selected as a convenience sample (accessibility) that
included both affected and unaffected areas. Two accessible districts in each province were
randomly selected by using a random number generator. Random transects were used to select
10 households per village. To give an approximately equal male:female ratio, either the head of
household, spouse (woman), or the oldest person available at the time was selected. Participants
provided informed consent. Ethical approval was provided by the Institutional Review Board,
Ministry of Public Health, Afghanistan.
A standardized, structured questionnaire collected information on demographic and
socioeconomic measures, avian influenza information sources and knowledge of appropriate
preventive measures, poultry and animal handling, food and generic hygiene, and human
influenza knowledge and treatment seeking. Questions related to KAPs were scored by a panel
of experts in related disciplines. The questions were ranked for importance in preventing avian
influenza transmission in poultry or reducing human exposure and awarded 5 points, 3 points, or
1 point for correct answers. For each respondent, the sum of scores for correct answers divided
by the sum of available points generated a percentage score. Blank responses to questions were
counted as such and not included in individual denominators. The questionnaire was backtranslated
and pilot-tested. The survey was conducted in May 2007, by trained Afghan surveyors.
Data were double-entered by using Microsoft Access (Microsoft, Redmond, WA, USA) and
analyzed by using Stata 8 software (Stata Corporation, College Station, TX, USA).
KAP scores provided a weighted measure of KAPs related to prevention of avian
influenza. Percentage scores for each respondent were ranked and classified as above or below
the median. The primary analysis was conducted to compare factors (age, sex, socioeconomic
status, provincial exposure to avian influenza IEC campaigns, and poultry ownership) associated
with knowledge above the median. Socioeconomic quintiles (SEQs) were defined by principle
components analysis using employment, education, and household assets as indicators (3).
Factors independently associated by univariate regression at the 95% confidence level were
included in a stepwise multivariate logistic regression model. To numerically evaluate KAP
levels, a secondary analysis assessed differences between mean percentage scores, stratified by
factors identified by logistic regression analysis.
Data for 304 respondents were included in the analysis. Of the 5 provinces, Kabul and
Nangahar had had influenza outbreaks in poultry in 2007. Enrollment characteristics are shown
in the Table. Median age of respondents (38 years) was high, but it reflected the age of heads of
households and spouses. Poultry ownership was reported by 65.2% of households (>95%
backyard ownership) and differed significantly between SEQs (poorest 53/62 [85.5%] vs. least
poor 20/55 [36.4%]; ?2 30.0, p<0.001).
SEQ was positively associated with KAP score above the median (lowest vs. highest:
adjusted odds ratio [AOR] 14.3, 95% confidence interval [CI] 5.2?39.9), as was provincial
exposure to avian influenza IEC campaigns (AOR 9.5, 95% CI 4.9?18.6). Backyard poultry
ownership (nonowners vs. owners: AOR 0.3, 95% CI 0.2?0.7) and older age group (15?20 years
vs. >40 years: AOR 0.3, 95% CI 0.1?0.8) were both negatively associated.
For secondary analysis, overall mean KAP score was 44.4%. Mean KAP score differed
between SEQ (p<0.001, by analysis of variance) and was higher in provinces previously exposed
to IEC campaigns (50.2% vs. 40.1%; p<0.001, by t test).
Specific, self-reported practices also differed by SEQ. Reporting of sick or dead poultry
to authorities was less frequent among lowest SEQ (8/47 [13%]) than highest SEQ (20/49 [37%];
?2 6.6, p = 0.02) where selling poultry in the event of a local outbreak was more commonly
reported (21/66 [66%] vs. 10/51 [18%]; ?2 27.2, p<0.001). Presence of coops was less frequent in
lowest SEQ (9/49 [18.4%]) than in highest SEQ (21/46 [45.6%]; ?2 8.2, p = 0.004).
Conclusions
Human cases of avian influenza (H5N1) have resulted from contact between humans and
infected backyard poultry (4). Risk to humans is also related to frequency of disease occurrence
in the avian population (5). Recently, human-to-human transmission has been reported in the
neighboring Northwest Frontier Province of Pakistan (2). Knowledge of disease is therefore a
key factor in reducing exposure and enhancing reporting.
Overall knowledge was low, although in provinces exposed to intensive IEC campaigns,
KAP scores of the population were higher. This finding indicated that campaigns had some
success in increasing awareness. The level of concern generated by the campaign, government
response, media reports, and proximity to the outbreak are all likely to contribute to this
association. Despite this encouraging evidence, level of knowledge was far higher among
persons with higher socioeconomic status. This finding contrasts with frequency of poultry
ownership. Exposure risk is therefore likely to be considerably higher among lower
socioeconomic groups.
Our results can be broadly generalized to the population, although we did not have access
to unsafe districts (most of the districts in southern and eastern Afghanistan). This limitation may
introduce selection bias, which would underestimate the effect of socioeconomic status because
those living in inaccessible areas likely have a lower status than persons in accessible areas.
Preintervention and postintervention surveys would provide a more robust measure of
effectiveness. In the immediacy of an outbreak, this was unfeasible and would have been
unethical. Although there are limitations to the study design in concluding intervention
effectiveness, the results provide evidence to support further intensive campaigns as a response
to influenza outbreaks in poultry.
Several reports have examined KAPs and behavior related to avian influenza (H5N1) (6?
9). Similar to the finding in the Lao People?s Democratic Republic (6), our study suggests that
conventional education and behavior change messages have a limited effect in populations with
highest exposure. Efforts to ensure that IEC messages are suitable for lower socioeconomic
groups should be adopted, specifically by improving the knowledge of community leaders,
designing messages in a suitable format for the poor and illiterate, and ensuring that the most
accessible channels are used. Messages should carefully balance the risk for human disease
against potential nutritional and economic consequences of high population concern (e.g., food
scares).
Successfully promoting behavior change is a lengthy process and requires frequent
reinforcement. The acuteness of avian influenza (H5N1) outbreaks requires a concerted effort to
enhance knowledge and change behavior among those most at risk in low-income countries.
Page 5 of 6
Acknowledgments
We thank the participants and surveyors in this study for their cooperation; Katy Todd for advice on data
analysis; Annick Lenglet and Richard Reithinger for comments on the manuscript; Sayara Media Communication
for field management; and the Ministry of Public Health, Afghanistan, for support.
This study was supported by the Animal Population Health Institute and the US Naval Medical Research
Unit 3, Cairo, Egypt, with funding from the Centers for Disease Control and Prevention, Atlanta, Georgia, USA, and
the United Nations Children?s Fund, Kabul, Afghanistan.
Mr Leslie is an infectious disease epidemiologist working as a technical advisor to the Afghan Public
Health Institute in Kabul and a doctoral student at the London School of Hygiene and Tropical Medicine doing
research on malaria in Afghanistan and Pakistan. His research interests include infectious disease epidemiology
(primarily vector-borne and zoonotic disease), outbreak investigation, and socioeconomic factors related to disease.
References
1. World Organisation for Animal Health. Update on avian influenza in animals (type H5) [cited 2008
Apr 15]. Available from http://www.oie.int/downld/AVIAN%20INFLUENZA/A_AI-Asia.htm
2. World Health Organization. Avian influenza ? situation in Pakistan ? update 2. April 3, 2008 [cited
2008 Apr 15]. Available from http://www.who.int/csr/don/2008_04_03/en/index.html
3. Filmer D, Pritchett LH. Estimating wealth effects without expenditure data ? or tears: an application to
educational enrollments in states of India. Demography. 2001;38:115?32. PubMed
4. Dinh PN, Long HT, Tien NT, Hien NT, Mai le TQ, Phong le H, et al. Risk factors for human infection
with avian influenza A H5N1, Vietnam, 2004. Emerg Infect Dis. 2006;12:1841?7. PubMed
5. Mills CE, Robins J, Bergstrom CT, Lipstich M. Pandemic influenza: risk of multiple introductions and
the need to prepare for them. PLoS Med. 2006;3:e135. PubMed DOI:
10.1371/journal.pmed.0030135
6. Barennes H, Martinez-Aussel B, Vongphrachanh P, Strobel M. Avian influenza risk perceptions, Laos.
Emerg Infect Dis. 2007;13:1126?8. PubMed
7. Olsen SJ, Laosiritaworn Y, Pattanasin S, Prapasiri P, Dowell SF. Poultry-handling practices during
avian influenza outbreak, Thailand. Emerg Infect Dis. 2005;11:1601?3. PubMed
8. Abbate R, Di Giuseppe G, Marinelli P, Angelillo IF. Knowledge, attitudes, and practice of avian
influenza, poultry workers, Italy. Emerg Infect Dis. 2006;12:1762?5. PubMed
Page 6 of 6
9. Al-Shehri A-S, Abdel-Fatteh M, Hifnawy T. Knowledge and concern among avian influenza among
secondary school students in Taif, Saudi Arabia. East Mediterr Health J. 2006;12(suppl 2):S178?
88. PubMed
Address for correspondence: Toby Leslie, Research Department, Afghan Public Health Institute, Ministry of Public
Health, Great Massoud Square, Kabul, Afghanistan; email: toby.leslie@lshtm.ac.uk
Table. Enrollment data for avian influenza knowledge, attitudes,
and practices survey, Afghanistan, May 2007
Characteristic Value
No. respondents 304
% Male 46.8
Median age, y (interquartile range) 38 (27?50)
Age range, y, no. (%)*
15?20 30 (10.0)
21?30 85 (28.2)
31?40 64 (21.3)
>40 122 (40.5)
No. (%) in each province
Herat? 32 (10.5)
Kabul? 64 (21.0)
Kandahar 79 (26.0)
Nangahar? 64 (21.0)
Samangan 65 (21.0)
No. (%) with no formal education
Male 36 (26.1)
Female 117 (75.0)
*Age data missing for 3 respondents.
?Only 1 district reported results because of security concerns.
?Provinces exposed to avian influenza and intensive information,
education, and communication campaigns (Kabul, March 2007, and
Nangahar, February 2007).
Science and Technology
Inverness Medical gets USDA approval for flu test
8/11/08 AP --Inverness Medical Innovations Inc. said Monday the U.S. Department of Agriculture issued the medical diagnostics company a license to make and sell its avian flu test kit for veterinary use.
The kit called BinaxNOW, gives test results within 15 minutes, compared with traditional methods which can take days. The company already has a kit for human use approved by the Food and Drug Administration.
Regional Reporting and Surveillance
Rwanda: Over 60 Health Experts to Discuss Avian Flu
8/11/08 All Africa --Over 60 health experts from at least 15 African countries, regional and international organizations are expected to attend a symposium on public health codes of ethics for pandemic influenza detection and control in Africa.
The convention will take place from 11-15 August at the Speke Resort Hotel Munyonyo in Kampala.
The symposium will identify key pandemic influenza ethical challenges and build consensus on African sensitive public health code of ethics for pandemic Influenza for various African regions and countries.
"The risk of Avian Influenza epizootic and pandemic in Africa has increased following detection of H5N 1 virus in a number of countries.
East Africa as a region is at risk because there is a lot migration of a variety of birds that are capable of transmitting the virus to humans.
There is also a lot of human migration and this puts everybody at risk,"said Dr. Patrick Nguku, an epidemiologist at the African Field Epidemiology Network in an interview with The New Times.
Pandemic influenza raises unique ethical challenges to governments such as quarantine and isolation, border control and vaccination and treatment.
"This makes it important to develop guidelines beforehand to be able to effectively respond when the attacks. It is difficult to make decisions on these issues on how to respond in the heat of a pandemic.
East Africa is on alert because cases of the pandemic have been reported in some of our boardering countries like Southern Sudan," Dr.Nguku explained.
Cases of the outbreak in Africa have been reported in Nigeria, Egypt, Ghana, Southern Sudan, Burkina Faso, Ivory Coast and Cameroon among others.
The symposium will also develop strategies to ensure that various countries in Africa adopt these codes of ethics for adequate pandemic influenza preparedness.
Under the theme "Identifying African Perspectives on Pandemic Influenza Ethics; Building Consensus on Ethical challenges" the meeting has been organized by African Field Epidemiology Network (AFENET ) in collaboration with the US Centers for Disease Control and Prevention (CDC ).
The World Health Organisation, African Union, Red Cross, World Bank and Southern African Development Community (SADC ) are expected at the symposium.
Regional Reporting and Surveillance
Thailand: Pitsanulok arranges meeting to prepare for bird flu threat during rainy season
8/11/08 ICT --This morning at the Ratchapruek Hotel in Pitsanulok province, provincial Governor Somboon Sripattanawat opened a pro-active meeting to rehearse measures safeguarding against Avian Influenza. The event took place as the province is now moving into the monsoon season and also as a review of past activity.
Officers of the provinces Livestock Authority reviewed work of relevant employees from all 9 districts of the province including animal detainment authorities.
Quid Novi
Indonesia: Poultry die-off reported in Rantauprapat district
8/11/08 ARGUS--According to a local media, approximately 800 chickens died suddenly in the past two weeks in Rantauprapat district, Labuhanbatu regency. These bird die-offs were spread among 3 sub-districts. Based on rapid testing, these chickens were infected with avian influenza. Nevertheless, a confirmation from laboratory testing is still pending. Standard control measures have been implemented.
Regional Reporting and Surveillance
13 Indonesians Test Negative for Bird Flu
8/11/08 VOA News --Indonesian health officials say 13 people suspected of having bird flu have tested negative for the deadly disease.
Officials in Asahan district in North Sumatra province said villagers began showing symptoms of avian flu after a large number of chickens died suddenly last week in Air Batu village.
Tests run on the chickens showed they died from the lethal H5N1 strain of avian flu.
More than 240 people around the world have died since an outbreak of the H5N1 strain was first detected in poultry stocks across Asia in 2003. Indonesia has recorded 111 deaths from the virus, the highest of any nation.
Humans can contract avian flu only from direct contact from infected poultry.
Experts fear the virus will mutate into a form easily passed between humans, which could lead to a pandemic that could kill millions of people.
AI Research
Contact With Birds Not Required to Contract Bird Flu Infection
8/11/08 Natural News --The World Health Organization (WHO) has warned that it may be possible to contract the avian flu without coming into direct contact with infected poultry.
In a report published in the New England Journal of Medicine, WHO researchers examined all 350 known cases of infection with the H5N1 strain of influenza, known popularly as "bird flu." Approximately three-quarters of these cases could be attributed to close contact with infected birds, often by poultry workers. A very few cases of human-to-human transmission are suspected, always between family members who came into close contact with each other. But the rest of the cases were more ambiguous.
"In one quarter or more of patients with influenza A (H5N1) virus infection, the source of exposure is unclear, and environment-to-human transmission remains possible," the researchers wrote. Some of the unclear cases occurred in people whose only contact with birds was walking through live poultry markets.
The authors speculated that the virus may remain active in fertilizer made from bird feces, or in certain fluids that stick to surfaces eventually touched by humans. The question has also been raised as to whether the virus needs to enter the nose or can infect humans by merely being eaten.
"It is unknown whether influenza A (H5N1) virus infection can begin in the human gastrointestinal tract," the researchers wrote. "In several patients, diarrheal disease preceded respiratory symptoms, and virus has been detected in feces."
The report confirmed government reassurances that well-cooked food is not a source of the disease, but cautioned that non-potable water might be: "Drinking potable water and eating properly cooked foods are not considered to be risk factors, but ingestion of virus-contaminated products or swimming or bathing in virus-contaminated water might pose a risk."
Bird flu is a highly lethal strain of the influenza virus, killing 61 percent of the people that it has infected. Scientists fear that it might mutate into a variety that passes easily to and between humans, with catastrophic public health consequences.
Regional Reporting and Surveillance
FAO: New bird flu strain detected in Nigeria
8/11/08 FAO -- FAO calls for increased surveillance A strain of Highly Pathogenic Avian Influenza previously not recorded in sub-Saharan Africa has been detected in Nigeria for the first time, FAO said today. Nigeria has recently reported two new Highly Pathogenic Avian Influenza outbreaks in the states of Katsina and Kano.
Laboratory results from Nigeria and an FAO reference laboratory in Italy show that the newly discovered virus strain is genetically different from the strains that circulated in Nigeria during earlier outbreaks in 2006 and 2007. The new strain has never been reported before in Africa; it is more similar to strains previously identified in Europe (Italy), Asia (Afghanistan) and the Middle East (Iran) in 2007.
?The detection of a new avian influenza virus strain in Africa raises serious concerns as it remains unknown how this strain has been introduced to the continent,? warned Scott Newman, International Wildlife Coordinator of FAO?s Animal Health Service.
?It seems to be unlikely that wild birds have carried the strain to Africa, since the last migration of wild birds from Europe and Central Asia to Africa occurred in September 2007 and this year?s southerly migration into Africa has not really started yet,? Newman said. ?It could well be that there are other channels for virus introduction: international trade, for example, or illegal and unreported movement of poultry. This increases the risk of avian influenza spread to other countries in Western Africa.?
Swift reporting
?Uncertainty about virus spread and transmission is a major challenge for control campaigns. Increased surveillance is key to monitor the situation and keep track of virus spread,? said FAO Chief Veterinary Officer Joseph Domenech. ?FAO greatly appreciates Nigeria?s swift reporting and sharing of the relevant information about this new virus strain.?
Since the avian influenza epidemic caused by the H5N1 strain started five years ago in Asia, the disease has affected over 60 countries; the vast majority of countries have succeeded to eliminate the virus from poultry. In Nigeria, the virus was first confirmed in February 2006 and infected poultry in 25 states before being contained.
FAO supports affected countries and countries at risk to detect bird flu outbreaks at a very early stage. FAO has also contributed to an efficient global response to HPAI.
In Nigeria, FAO has a team of animal health experts and veterinary epidemiologists working with the government and its veterinary services. FAO has assisted the government with disease surveillance and outbreak investigations, as well as establishing a stockpile of veterinary drugs both at central and state levels. FAO and the Federal Government of Nigeria have identified priority areas where animal health and transboundary animal disease prevention measures need to be improved.
?Many countries have succeeded in getting the virus under control; but as long as avian influenza remains endemic in some countries, the international community needs to be on alert. Both, at risk and affected countries have to keep a high level of surveillance,? Domenech said.
Regional Reporting and Surveillance
FAO GLEWS: Vietnam Update
FAO field officer (08/08/08): The Department of
Animal Health (DAH) reported HPAI in Thoi Quan
commune, Go Quao district, Kien Giang province.
The disease has been detected in a 50-day-old
chicken flock at a raiser where 300 died among
612.
Regional Reporting and Surveillance
FAO GLEWS: India Update
FAO field officer (06/08/08): Regarding the die
off poultry in West Bengal, the matter was
investigated and the Director of Animal Health,
West Bengal has informed that there has been no
report of any unusual mortality in and around
Gitaldaha area of Coochbehar district or
elsewhere in state of West Bengal.
AI Research
The 1918 ?Spanish Flu? in Spain
8/8/08 Clinical Infectious Diseases --Abstract--
Antoni Trilla,
Guillem Trilla, and
Carolyn Daer
Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer, University of Barcelona and Centre de Recerca en Salut Internacional de Barcelona, Barcelona, Spain
The 1918?1919 influenza pandemic was the most devastating epidemic in modern history. Here, we review epidemiological and historical data about the 1918?1919 influenza epidemic in Spain. On 22 May 1918, the epidemic was a headline in Madrid's ABC newspaper. The infectious disease most likely reached Spain from France, perhaps as the result of the heavy railroad traffic of Spanish and Portuguese migrant workers to and from France. The total numbers of persons who died of influenza in Spain were officially estimated to be 147,114 in 1918, 21,235 in 1919, and 17,825 in 1920. However, it is likely that >260,000 Spaniards died of influenza; 75% of these persons died during the second period of the epidemic, and 45% died during October 1918 alone. The Spanish population growth index was negative for 1918 (net loss, 83,121 persons). Although a great deal of evidence indicates that the 1918 A(H1N1) influenza virus unlikely originated in and spread from Spain, the 1918?1919 influen za pandemic will always be known as the Spanish flu.
Received 24 February 2008; accepted 6 May 2008; electronically published 24 July 2008.
Reprints or correspondence: Dr. Antoni Trilla, UASP, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain (atrilla@ub.edu).
Vaccines
FDA approvals clear way for flu vaccine marketing
8/7/08 CIDRAP --The six companies that make influenza vaccine for the US market have won federal approval for their version of this year's vaccine, in which all three flu strains used in last year's product have been replaced, the Food and Drug Administration (FDA) announced yesterday.
The FDA announcement clears the way for marketing of the vaccines. At least three vaccine makers have begun shipping vaccine to distributors and providers, according to recent company announcements.
The six manufacturers and their vaccines are CSL Limited, Afluria; GlaoxSmithKline Biologicals, Fluarix; ID Biomedical Corp. of Quebec (a unit of GlaxoSmithKline), FluLaval; MedImmune, FluMist; Novartis Vaccines and Diagnostics, Fluvirin; and Sanofi Pasteur, Fluzone.
In the wake of a relatively poor match between the vaccine and circulating flu strains last season, experts at the World Health Organization and the FDA in February recommended changing all three strains of virus used in the vaccine. In most years only one or two of the three strains are changed.
"One of the biggest challenges in the fight against influenza is producing new vaccines every year," Jesse Goodman, MD, MPH, director of the FDA's Center for Biologics Evaluation and Research, said in a news release. "There is no other instance where new vaccines must be made every year."
Two of the three strains in the 2008-09 vaccine are included in vaccines now being used in the Southern Hemisphere, where the flu season is under way, the FDA noted.
The decision to change all three strains in the vaccine had generated some concern about possible production delays or low yields of the viruses, which are grown in eggs. But Curtis Allen, a spokesman for the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC) in Atlanta, said today he hasn't heard of any problems growing the strains.
"Vaccine production is always fraught with risk and anywhere along the line things can go wrong, but so far they have not, and we're looking forward to a season with adequate supplies of vaccine," Allen told CIDRAP News.
At a meeting in May, manufacturers estimated they would produce a record total of 143 million to 146 million doses of flu vaccine for the US market this year. Allen said the estimates of vaccine production have not changed since then. Last year 140 million doses were produced.
Allen listed the manufacturers' production estimates as follows: Sanofi Pasteur, 50 million doses; GlaxoSmithKline (including ID Biomedical), 35 million to 38 million; MedImmune, 12 million; Novartis, 40 million; and CSL, 6 million.
Sanofi announced Aug 1 that it had begun shipping the first 1.3 million doses of Fluzone. "Vaccine shipments to healthcare providers and to the [CDC] for distribution through the Vaccines for Children Program will continue through the fall and are planned to be completed in October," the company said in a news release.
The statement indicated that replacing all three strains of virus has not caused any major production problems.
"Introduction of three new strains for the influenza vaccine was unprecedented and could have resulted in a low yield or delay given our tight production timeline. Despite these challenges, we are pleased that once again Sanofi Pasteur has demonstrated its reliability in supplying Fluzone vaccine to the US market," said Wayne Pisano, the company's president and chief executive officer, in the news release.
MedImmune announced yesterday that shipments of FluMist, a nasal-spray vaccine that uses a weakened form of live virus, had begun on Jul 31. In a news release, the company affirmed that it plans to produce about 12 million doses, a record number.
FluMist will be available at some retail pharmacies and supermarkets and in nearly 200 school-based vaccination programs and university health centers, the company said. In addition, the federal government, as in past years, is buying some doses for use in military personnel, officials said.
Novartis announced Aug 7 that it has begun shipping Fluvirin to US healthcare providers. The company said it expects to deliver 20 million doses by the end of September and aims to deliver the remaining 20 million by Oct 31. Officials said the company has added a second manufacturing facility, located in Rosia, Italy, to help supply flu vaccine earlier in the season. The firm's other facility is in Liverpool, England.
"Despite the new composition [of the vaccine], Novartis made sure we were able to deliver a timely and robust supply of influenza vaccine this year," said Rajiv De Silva, president of Novartis Vaccines in the US, in a news release.
This is the first year the CDC is formally recommending flu shots for school-age children, adding about 30 million people to the ranks of those targeted for vaccination. Allen said the total number of those targeted for vaccination?including people at risk for serious flu complications and their close contacts?is about 258 million, or roughly 84% of the population.
Regional Reporting and Surveillance
Indonesia: Birds slaughtered as suspected flu breaks out
8/8/08 Daily Telegraph/Australia -- of chickens and ducks have been slaughtered to contain a suspected bird flu outbreak in Indonesia as 13 people with flu-like symptoms await laboratory results.
Thirteen people were hospitalised earlier this week with fevers and respiratory problems after a large number of chickens died suddenly in their village in North Sumatra province.
Two of them, a baby boy and a seven-year-old girl, have been put in a bird flu isolation unit at a hospital in the provincial capital Medan.
"We have taken measures since Tuesday when we found strong indications of bird flu virus in some 100 chickens and ducks in several places in Air Batu village," said local husbandary office chief Oktoni Eryanto.
At least 400 birds have been slaughtered and burned, and officials were continuing to spray backyard coops with disinfectant, he said.
"We don't need to send samples from the poultry to a laboratory because it's pretty clear that the cause is the bird flu virus," he said.
"Preventive action is more important to control it."
A nurse at a local hospital said this week that three people had died in the village with flu-like symptoms, but health ministry officials have not been able to confirm any suspect deaths.
The ministry, which has not confirmed the latest suspected outbreak, has stopped providing regular public updates on human bird flu deaths even though Indonesia is the country most affected with 112 confirmed cases.
The deadly H5N1 strain of bird flu has killed more than 240 people worldwide since late 2003.
The virus typically spreads from bird to human through direct contact, but experts fear it could mutate into a form easily transmissible between humans, with the potential to kill millions in a pandemic.
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