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CONTENTS:
1) Bird Flu Spreads Widely Among Birds
2) Case of Oseltamivir-Resistant HPAI H5N1 Is Reported
3) Human Influenza Control - Another Complex Season
4) WHO Discussion Paper on Social Determinants of Health
5) Member Update
6) Acknowledgements
1) Bird Flu Spreads Widely Among Birds:
1) Bird Flu Spreads Widely Among Birds
Agricultural Authorities have confirmed spread of highly pathogenic avian influenza H5N1 (HPAI H5N1) to Turkey and Romania; preliminary investigations are under way in Serbia. It isn't clear how the virus has traveled, but the rapid jump to new areas suggests that at least some HPAI-infected birds may be healthy enough to migrate long distances. Migratory routes from affected areas go all over the Eastern Hemisphere. Investigation is continuing.
News reports of U.S. DHHS Secretary Mike Leavitt's visit to Southeast Asia weren't widely circulated. Available reports suggest that he saw examples of good poultry practices that discourage HPAI transmission, as well as those that facilitate spread. The cash difference between these practices isn't large -- at least in the developing countries -- but farmers and others must confidence about money and about the regulatory environment.
Without such confidence everywhere, it is nearly impossible to implement effective global veterinary public health measures.
There are no reports of epidemiologically significant human-to-human spread.
As reported in the 2005-10-10 E-News, human HPAI H5N1 transmission appears to require very close contact and it may be mediated more by ingestion pathways than respiratory pathways.
(Editor's Note: There is still no scientific consensus on the likelihood of a human H5N1 pandemic. The media consensus appears to have swung from near-indifference to near-panic. One veteran public health physician reminded me this week of U.S. authorities' overreaction to the spring 1976 reports of a swine influenza strain at Fort Dix, NJ. Those reports didn't involve many more human cases than have been reported so far with HPAI
H5N1.)
2) Case of Oseltamivir-Resistant HPAI H5N1 Is Reported:
Vietnamese and Japanese scientists published a report on "Isolation of Drug-Resistant H5N1 Virus", available without subscription at http://www.nature.com/nature/journal/vaop/ncurrent/pdf/4371108a.pdf.
The bad news: HPAI H5N1 appears to have significant potential to evolve resistance to prophylactic doses of oseltamivir (Tamiflu). This resistance can develop rapidly.
The good news: Oseltamivir-resistant strains appear to be less pathogenic, and less likely to kill their human hosts, than the oseltamivir-sensitive strains from which they arose.
The authors recommend routine monitoring of resistance patterns among HPAI
H5N1 patients who have been treated with neuraminidase inhibitors such as oseltamivir and zanamivir. They recommend stockpiling zanamivir as well as oseltamivir, in order to maintain response capability "in the event of an
H5N1 influenza pandemic".
*** Editor's Notes below: ***
Oseltamivir-resistant variants of HPAI H5N1 were reported in the 2005-09-29 New England Journal of Medicine article. The operative paragraph, without references (check http://content.nejm.org/cgi/content/full/353/13/1374 for full text with references), reads:
"High-level antiviral resistance to oseltamivir results from the substitution of a single amino acid in N1 neuraminidase (His274Tyr). Such variants have been detected in up to 16 percent of children with human influenza A (H1N1) who have received oseltamivir. Not surprisingly, this resistant variant has been detected recently in several patients with influenza A (H5N1) who were treated with oseltamivir. Although less infectious in cell culture and in animals than susceptible parental virus, oseltamivir-resistant H1N1 variants are transmissible in ferrets. Such variants retain full susceptibility to zanamivir and partial susceptibility to the investigational neuraminidase inhibitor peramivir in vitro."
Rereading the NEJM article in this context, it is clear it reported a variant of neuraminidase N1, NOT coinfection with HPAI H5N1 and a variant of H1N1. The new report suggests that the variant N1 is likely to make any strain of influenza -- not just H1N1 -- less pathogenic than its parent.
Even if the virus doesn't become resistant to zanamivir by this mechanism, could we afford enough zanamivir to slow a pandemic significantly? It would seem more productive and cost-effective to prepare first for non-pharmacologic controls including vaccines, masks, and limitations on gatherings; to support vigorous, global, and adequately-funded veterinary control measures, designed to avoid risks of drug resistance; and to assure, as much as possible, that neuraminidase inhibitors are used for human prophylaxis only under public health supervision.
Another background resource on pandemic influenza is "Tracking The Next Killer Flu" in the October issue of National Geographic. Despite its title, the article itself appears balanced. A summary of the article is available at http://www7.nationalgeographic.com/ngm/0510/feature1/index.html.
3) Human Influenza Control - Another Complex Season:
Today's report focuses on resources from CDC and from the National Association of County and City Health Officials (NACCHO).
***
Ray Strikas, MD, and Kari Sapsis, from the National Immunization Program, spoke on "The Upcoming Flu Season" on CDC's Clinician Outreach telephone call 2005-10-11. A replay of the call is available without charge, for a limited time, at (800) 839-1334.
***
These points were reiterated from the 2005-07-29 ACIP recommendations at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5408a1.htm:
The 2005 recommendations include five principal changes or updates:
ACIP recommends that persons with any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular
disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration be vaccinated against influenza (see Target Groups for Vaccination).
ACIP emphasizes that all health-care workers should be vaccinated against influenza annually, and that facilities that employ health-care workers be strongly encouraged to provide vaccine to workers by using approaches that maximize immunization rates.
Use of both available vaccines (inactivated and LAIV) is encouraged for eligible persons every influenza season, especially persons in recommended target groups. During periods when inactivated vaccine is in short supply, use of LAIV is especially encouraged when feasible for eligible persons (including health-care workers) because use of LAIV by these persons might considerably increase availability of inactivated vaccine for persons in groups at high risk.
The 2005--06 trivalent vaccine virus strains are A/California/7/2004 (H3N2)-like, A/New Caledonia/20/99 (H1N1)-like, and B/Shanghai/361/2002-like antigens. For the A/California/7/2004 (H3N2)-like antigen, manufacturers may use the antigenically equivalent A/New York/55/2004 virus, and for the B/Shanghai/361/2002-like antigen, manufacturers may use the antigenically equivalent B/Jilin/20/2003 virus or B/Jiangsu/10/2003 virus (see Influenza Vaccine Composition).
CDC and other agencies will assess the vaccine supply throughout the manufacturing period and will make recommendations preceding the 2005--06 influenza season regarding the need for tiered timing of vaccination of different risk groups. In addition, CDC will publish ACIP recommendations regarding inactivated vaccine subprioritization (tiering) on a later date in MMWR.
***
On 2005-08-05, CDC issued recommendations for the tiered use of vaccine in priority groups; these recommendations are at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a4.htm .
***
Dr. Strikas described national vaccine supplies, updating the projections and prioritization issued 2005-09-02 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a4.htm. The number of projected doses is still between 89 million and 97 million, but shipping from some manufacturers is delayed and there are reports of influenza vaccine shortages in various health departments around the country. Chiron hasn't shipped any vaccine yet. CDC is encouraging health departments to have smaller, focused clinics as vaccine is available. Vaccine production is a long and complex process; vaccine is not always available when people might like it.
With CDC blessing, Sanofi Pasteur has been making partial vaccine shipments as supplies have become available. CDC prefers partial shipments to an "all or none" shipment system.
The Federal government has limited influence over the vaccine distribution system, as it is private and only 20% of U.S. influenza vaccine supplies are purchased directly by the Federal government.
***
Kari Sapsis, from the Office of Communications at the National Immunization Program, spoke about this year's communication campaign.
Patient and clinician educational materials are available from http://www.cdc.gov/flu/gallery . These include black-and-white masters suitable for office copying, and color graphics suitable for large organizations with in-house printing. CDC is not budgeting for physical distribution of printed materials this year. Public and private partners are encouraged to print their own.
CDC is trying to increase the rate of influenza vaccination among health care workers, which is now about 45%. Their materials for health care workers state, "They count on you."
Ms. Sapsis' PowerPoint slides are at
http://www.bt.cdc.gov/coca/ppt/upcomingflu.ppt .
***
Dr. Strikas and Ms. Sapsis answered many questions on the 2005-10-11 conference call.
One vaccine company is shipping vaccine first to its previous customers -- regardless of other considerations. CDC staff believe that within this constraint, and other self-imposed constraints, the industry appears to be cooperating with the priority groups as outlined by the CDC.
ACIP may recommend that health care facilities require employees to sign a declination form if they don't receive influenza vaccine. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is considering a performance measure that would require institutions to monitor employees' vaccine status.
Unvaccinated workers should be excluded from work during an outbreak.
Exclusion of unvaccinated workers without an outbreak is controversial, especially with unions, and no national organization seems to be pursuing an absolute requirement for health care worker vaccination. Participants were reminded that intranasal vaccine is appropriate for many health care workers.
In the past, vaccine that has arrived after the end of November has been very difficult to market. Some organizations may be ordering duplicate vaccine supplies with plans to cancel other orders when the first order arrives.
All influenza vaccines now available in the United States are egg-based.
People who can't receive these vaccines because of allergies should use meticulous preventive measures, including handwashing, and should discuss antiviral medications with their clinicians.
One caller noted that many individuals are trying to bypass the priority groups, and many are stockpiling oseltamivir. CDC discourages both of these practices, but neither of them is a violation of federal law.
CDC's influenza education materials, for professionals and the public, are indexed at the CDC influenza page at http://www.cdc.gov/flu/ .
***
Influenza prevention was also discussed in an informative press briefing sponsored by NACCHO on 2005-09-22.
Public Health professionals from New York and Missouri described preparedness issues in their communities, provided background that may be useful to reporters nationwide, and applicable NACCHO policies.
Public Health physician and NACCHO President Rex D. Archer, MD, MPH stated that NACCHO recommends a national policy recommending influenza vaccine for everyone. He gave four reasons:
First, universal flu vaccine recommendations would give additional protection to everyone.
Second, universal recommendations would help expand vaccine production capability, allowing a substantial amount of public protection even in years of vaccine production problems.
Third, universal recommendations would avoid the need for year-to-year changes, which confuse the public and disrupt everyone's vaccine-related routines.
Fourth, because the vaccine is not 100% effective for individuals, the highest risk people will be best protected if we do everything possible to reduce influenza circulation in communities, and if we repeat this protection annually so everyone builds up as much immunity as feasible.
A full transcript of the NACCHO press conference is at http://www.naccho.org/press/documents/FluVaccineAudioConferenceTranscript.pdf .
4) WHO Discussion Paper on Social Determinants of Health:
Earlier this year, the World Health Organization circulated a paper, "Towards a Conceptual Framework for Analysis and Action on the Social Determinants of Health". This synthesizes epidemiologic and social-science thinking on mechanisms by which social differences affect health in all social classes, reminding us that people in all income groups experience a health impact from policies that produce economic insecurity. The full paper is at http://ftp.who.int/eip/commision/Cairo/Meeting/CSDH%20Doc%202%20-%20Conceptu al%20framework.pdf .
5) Member Update:
Thanks to Dawn Allicock, MD, MPH and Dorothy S. Lane, MD, MPH, for joining and/or renewing AAPHP membership since the last E-News.
New memberships and renewals are being accepted for 2006. Members joining or renewing now can pay 2006 dues at the 2005 rates ($85 Active, $30 retired).
Go to the Web site at http://www.aaphp.org/Membership/membership.htm or call AAPHP's Membership Officer Rob Rader at (202) 207-0709.
6) Acknowledgements:
Thanks to the sponsors and moderators of ProMED-Mail (http://www.promedmail.org <http://www.promedmail.org/> ) at the International Society for Infectious Diseases and Elsevier Medical Publishers, for original distribution of much of the material summarized in this issue.
Thanks also to the Nature Publishing Group (http://www.nature.com/index.html); CDC's Clinician Outreach and Communication Activity (http://www.bt.cdc.gov/coca/); the National Association of City and County Health Officials (http://www.naccho.org); and the World Health Organization (http://www.who.int/en/), for making the above materials available to the public without charge.
AAPHP offers free E-News subscriptions on request to all public health physicians; please contact the editor. We are still offering free E-News subscriptions to anyone who is involved in public health emergency response.
Back issues of the E-News are available without charge at http://www.aaphp.org/bulletincnt1.HTM.
Dave Cundiff, MD, MPH (cundiff@reachone.com) AAPHP Secretary and E-News Editor
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