Affiliated Physicians October 07 Newsletter

The Centers for Disease Control and Prevention (CDC) has announced the designation of the week after Thanksgiving as National Influenza Vaccination Week. This year, National Influenza Vaccination Week will run from November 27 to December 2. This event is designed to raise awareness of the importance of continuing influenza (flu) vaccination, as well as foster greater use of flu vaccine through the months of November, December and beyond, during which time influenza is still a threat to good health.

According to the CDC, annual epidemics of influenza occur in the United States typically during the late fall and winter seasons. Average annual deaths totaled approximately 36,000 during 1990-1999 and an additional 226,000 hospitalizations during 1979-2001 have been associated with annual influenza epidemics. Says CDC: "Receiving an influenza vaccination is the most effective method for preventing influenza virus infection and its potentially severe complications."

UPDATED WHO BIRD FLU (H5N1) MANAGEMENT GUIDANCE REINFORCES TAMIFLU AS FIRST LINE TREATMENT

The World Health Organization (WHO) has reinforced that Tamiflu (oseltamivir) is the primary recommended antiviral of choice in managing patients infected with H5N1 in updated guidance published on the WHO website. Experts believe that a human influenza pandemic is imminent and could be triggered by the highly pathogenic H5N1 strain, which to date has infected 329 humans causing 201 deaths worldwide (as of Oct. 2, 2007).

Professor John Oxford, Professor of Virology at St Bartholomew's and the Royal London Hospital states,

The latest advice is based on evidence presented to the WHO by experts in countries that have reported human cases of bird flu. Tamiflu is the only neuraminidase inhibitor to have been used in the management of human cases of H5N1 and is the only antiviral strongly recommended for treatment of H5N1 infected patients by the WHO.

· Standardising care and promptly sharing clinical and treatment information to improve understanding of the disease and identify appropriate therapy
· Tamiflu remaining the primary antiviral treatment both early and late in the infection as there is evidence of prolonged replication with H5N1
· Modified Tamiflu treatment regimens - higher and longer dosing may be necessary given the virulence of some forms of H5N1 seen recently
· Possible combination therapy with adamantanes (case by case basis), particularly in patients with pneumonia or progressive disease

Tamiflu is an oral neuraminidase inhibitor that is active against all strains of influenza A and B tested. More than 80 governments worldwide are now stockpiling Tamiflu in preparation for a pandemic and many global businesses are in discussions with Roche and are now stockpiling for their employees and their families in line with local laws and regulations. Read the original WHO recommendation.

A mathematical analysis has confirmed that H5N1 avian influenza spread from person to person in Indonesia in April, U.S. researchers reported on Tuesday., stating that they had developed a tool to run quick tests on disease outbreaks to see if dangerous epidemics or pandemics may be developing. Health officials around the world agree that a pandemic of influenza is overdue, and they are most worried by the H5N1 strain of avian influenza that has been spreading through flocks from Asia to Africa.

It rarely passes to humans, but since 2003 it has infected 329 people and killed 201 of them. Most have been infected directly by birds. But a few clusters of cases have been seen and officials worry most about the possibility that the virus has acquired the ability to pass easily and directly from one person to another. That would spark a pandemic.

Ira Longini and colleagues at the Fred Hutchinson Cancer Research Center in Seattle looked at two clusters -- one in which eight family members died in Sumatra in 2006, and another in Turkey in which eight people were infected and four died.

Experts were almost certain the Sumatra case was human-to-human transmission, but were eager to see more proof.

"We find statistical evidence of human-to-human transmission in Sumatra, but not in Turkey," they wrote in a report published in the journal Emerging Infectious Diseases. "This does not mean that no low-level human-to-human spread occurred in this outbreak, only that we lack statistical evidence of such spread."

In Sumatra, one of Indonesia's islands, a 37-year-old woman appears to have infected her 10-year-old nephew, who infected his father. DNA tests confirmed that the strain the father died of was very similar to the virus found in the boy's body.

"It went two generations and then just stopped, but it could have gotten out of control," Longini said in a statement. "The world really may have dodged a bullet with that one, and the next time, we might not be so lucky," he added. The researchers estimated the secondary-attack rate, which is the risk that one person will infect another, was 20 percent. This is similar to what is seen for regular, seasonal influenza A in the United States.

The researchers developed a software product called TranStat and said they would provide it free of charge on the National Institutes of Health's Models of Infectious Disease Agent Study, or MIDAS, Web site.

"We know the key to preventing a pandemic is early detection, containment and mitigation with antiviral therapy and this tool will enable those on the front lines, such as physicians, epidemiologists and other public-health officials, to carry that out efficiently," said Elizabeth Halloran, who worked on the study.

The World Health Organisation warned Monday against complacency in the fight against bird flu, saying another human influenza pandemic is inevitable sooner or later.

"I am often asked if the effort invested in pandemic preparedness is a waste of resources," director general Margaret Chan told a regional meeting of the world organization. "Has public health cried wolf too often and too loudly?" she said in a speech. "Not at all, Pandemics are recurring events. We do not know whether the H5N1 (avian influenza) virus will cause the next pandemic. But we do know this: the world will experience another influenza pandemic sooner or later."

WHO Regional Director Shigeru Omi noted that bird flu deaths in the Western Pacific -- which excludes Indonesia -- had fallen from 19 two years ago to five in the past year. But he said the virus was still "entrenched" in several countries. "Because the virus continues to evolve and mutate, we must maintain constant vigilance," he said.

Speed would be the key in handling any human pandemic triggered by bird flu, he said. "If a human pandemic associated with avian influenza were to break out in the region, rapid containment would be our highest priority. Such an effort would require the massive deployment of antiviral drugs, personal protection equipment and other supplies."

Takeshi Kasai, WHO Regional Adviser for communicable disease surveillance and response, reiterated that the main fear is of H5N1 mutating into a forum easily transmissible between humans. He told AFP in an interview that past experience and data indicated it might be high time for a new human global influenza outbreak, following pandemics in 1968, 1953 and 1918. "Sadly, the H5 virus is mutating and changing very rapidly. Usually the bird flu virus changes slowly but this one changes very, very fast," he said. Kasai said it was unclear if this was an indication that it could mutate into a form easily transmissible between humans. "But these are the facts that make the WHO concerned. I'm sure if people are ready, its impact would be low, but if they are not, there would be big disasters."

After years of shortages and confusion, this fall promises plenty of flu vaccine to go around - up to 132 million doses, more than the nation has ever produced. The ample supplies have the government urging vaccinations not just for people at highest risk of dying from influenza, but for anyone who wants to avoid a week of aching misery.

"Flu is a formidable foe," Dr. Julie Gerberding, Head of the Centers for Disease Control (CDC) and Prevention, said Wednesday. "It is not an illness we should be complacent about."

But new CDC data show only a fraction of people who need flu shots the most get them, including just one in five babies and toddlers. And there's wide geographic variation, with Rhode Island reporting the most high-risk adults vaccinated and Nevada the fewest.

Indeed, there already are reports of sick schoolchildren in Hawaii, although the geographic distance makes it impossible to predict if that signals an unusually early flu season for the rest of the country.

Perhaps of more concern, CDC is closely monitoring whether a new strain that emerged near the end of Australia's flu season will cause illness here - a strain that this year's vaccine doesn't specifically target.

Each year's vaccine contains protection against three influenza strains - two Type A strains, an H1N1 and an H3N2 version, plus a milder Type B - that experts predict will cause the most illness. The vaccine isn't always a perfect match, and this year's contains a different H3N2 version than the newly emerging one, nicknamed H3N2/Brisbane-like.

"Get vaccinated anyway", Gerberding stressed. The other two strains in the vaccine are causing illness around the world, and even if the newer one travels here, too, the vaccine should provide some cross-protection.

Who's at highest risk? Anyone over 50 or under 5; people of any age who have asthma, heart disease, weakened immune systems or other chronic illnesses; and pregnant women. Vaccine also is particularly recommended for relatives and caregivers of those people, and health care workers _ people who may be robust enough to recover themselves, but could infect the more vulnerable before they realize they're ill.

"The day before you become sick, you're already excreting the virus," warned Dr. William Schaffner of Vanderbilt University, vice president of the National Foundation for Infectious Diseases.

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