Thursday 21 December 2006
Contents
Epidemiological updates
Scientific advances
Public health developments
Meetings and workshops
Epidemiological updates
SEASONAL INFLUENZA– WEEKLY EISS UPDATE
The next EISS update for week 51 will be published on December 29th
Europe will probably experience low levels of influenza activity over Christmas and New Year
Summary: Clinical influenza activity in countries across Europe remained at baseline levels in week 50/2006. The number of laboratory confirmed cases of influenza continued to increase for Europe as a whole, but the percentage of respiratory specimens testing positive is still low at about 2%. Since the start of the 2006-2007 season a total of 194 cases of influenza A and 16 cases of influenza B have been detected across Europe, of which 71% were from France, Sweden, Switzerland and the United Kingdom.
Epidemiological situation - week 50/2006: National network levels of influenza-like illness (ILI) and/or acute respiratory infection (ARI) were at a low level in 25 countries. Northern Ireland reported a medium intensity of influenza activity, but this was not confirmed by influenza virus detections. Regional data indicated sporadic activity in ten countries, meaning that isolated cases of laboratory confirmed influenza were detected, whilst 17 countries reported no activity. Definitions of epidemiological indicators can be found here.
Cumulative epidemiological situation - 2006-2007 season (week 40-50/2006): So far this season, the consultation rates for ILI and/or ARI have been below baseline levels across Europe.
Virological situation - week 50/2006: The total number of respiratory specimens
collected by sentinel physicians was 515, of which 20 (3.9%) were positive for influenza virus. Of these, 18 (90%) specimens tested positive for influenza A virus and 2 (10%) tested positive for influenza B virus. In addition, 38 specimens from non-sentinel sources (e.g. specimens collected for diagnostic purposes in hospitals) tested positive for influenza virus, of which 35 (92%) were influenza A and 3 (8%) influenza B. Of the 58 sentinel and non-sentinel specimens positive for influenza A virus, 4 had the H1 and 5 the H3 subtype and 44 were not subtyped.
Cumulative virological situation - 2006-2007 season (week 40-50/2006): Based on (sub)typing data of all influenza virus detections (N=210; sentinel and non-sentinel data), 136 (65%) were type A not subtyped, 14 (7%) were type A subtype H1 of which three were subtype H1N1, 44 (21%) were type A subtype H3 of which 19 were subtype H3N2, and 16 (8%) were type B.
Based on the characterisation data of all influenza virus detections up to week 50/2006, 43 have been antigenically and/or genetically characterized. Thirty five were
A/Wisconsin/67/2005 (H3N2)-like, five were A/California/7/2004 (H3)-like [a strain of the A(H3N2) virus that emerged during the 2004-2005 season, circulated during the 2005-2006 season, and is closely related to the A/Wisconsin/67/2005 (H3N2) reference virus], two were A/New Caledonia/20/99 (H1N1)-like and one was B/Malaysia/2506/2004-like.
Comment: Influenza activity in Europe remains at baseline levels. For Europe as a whole and in a number of countries (England, France, Norway, Sweden and Switzerland) the number of laboratory confirmed cases reported per week continued to increase. However, this is not reflected in clearly increased consultation rates for ILI or ARI in these countries. In contrast, although clinical influenza activity in Northern Ireland is at a same level as in the peak of the two previous seasons, there has been only one influenza A virus detection reported (in week 50/2006) in this country.
So far this season, 92% of the virus detections were influenza A. Most of the virus detections, 71% of all virus reports, have been reported from France (20%), Sweden (29%), Switzerland (12%) and the United Kingdom (10%).
A number of countries also report detections of respiratory syncytial virus (RSV) to EISS. An infection with RSV shows clinical symptoms that are similar to influenza. For Europe as a whole, the number of RSV detections is low compared to week 50 of the 2005-2006 season. In a number of countries, RSV detections are still sporadic or are just starting to increase. In others it is similar (e.g. France and the Netherlands) or at moderate (e.g. England) levels compared to the same week of the previous season. In Ireland RSV reports are now declining.
The closing of schools and occurrence of public holidays over Christmas and New Year will probably reduce the rate of spread of influenza in the coming two weeks. This probably means that the current low levels of influenza activity will continue during the Christmas and New Year period.
Background: The Weekly Electronic Bulletin presents and comments influenza activity in 29 European countries that are members of EISS. In week 50/2006, 27 countries reported clinical data and 26 countries reported virological data. The spread of influenza virus strains and their epidemiological impact in Europe are being monitored by EISS in collaboration with the WHO Collaborating Centre in London (United Kingdom) and the European Centre for Disease Prevention and Control in Stockholm (Sweden).
Full EISS bulletin including maps and graphs by country
National/regional bulletins in Europe and other bulletins from around the world
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AVIAN INFLUENZA – HUMAN HEALTH - GLOBAL SITUATION
December 20 2006
No new human cases have been reported to WHO during the last week. The last reported human case of H5N1 was reported to the WHO on 29th November 2006. There remains 258 laboratory-confirmed cases and 154 deaths reported by WHO between 2003 and 29 November 2006.
For more information see: Global situation update
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AVIAN INFLUENZA – ANIMAL HEALTH – POULTRY OUTBREAKS
Outbreaks of H5NI in Poultry in Vietnam – December 19th
Government authorities in Vietnam have confirmed outbreaks of highly pathogenic avian
influenza infection in domestic poultry. The H5N1 virus was found in more than 6,000 dead
chickens and ducklings in the provinces of Ca Mau and Bac Lieu in the Mekong Delta. The infection is in provinces that have been practising immunisation of poultry, and it appears to confirm statements from Health officials earlier in December that a small density of the H5N1 virus existed in some birds despite the comprehensive poultry vaccination campaign. The Vietnamese authorities have been showing rapid reporting and good transparency. Any delay was due to reluctance to report the deaths by the farmers to the authorities. No human cases are reported. Further investigations are being undertaken and this may lead to other outbreaks coming to light in the area. Vietnam has been free of human bird flu cases since late 2005. In August, it found the H5N1 virus on a small duck farm in the southern province of Ben Tre in the Mekong Delta.
Link to official report to OIE by Vietnamese Authorities
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AVIAN INFLUENZA – COUNTRY UPDATE – HUMAN DISEASE AND RELATED POULTRY OUTBREAKS - EGYPT
December 20 2006
ECDC’s country situation report for Egypt has been updated to reflect the situation following cases of H5N1 in humans reported during Autumn 2006. ECDC maintains and updates country situation reports on a number of countries where H5N1 is thought to be present or there is on-going risk of infection among birds.
Country situation update: Human disease and related poultry outbreaks
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Scientific Advances
SCIENTIFIC ADVANCES – AVIAN INFLUENZA – EPIDEMIOLOGY
Highly Pathogenic Avian Influenza A/H5N1 – update and overview of 2006
ECDC Influenza team
Eurosurveillance 2006;1(10):E051027.6
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SCIENTIFIC ADVANCES - PANDEMIC INFLUENZA - PREPAREDNESS
Modeling Community Containment for Pandemic Influenza - a letter report
Committee on Modeling Community Containment for Pandemic Influenza
Institute of Medicine of the National Academy of Science (US) 2006
Description: The ‘letter report’ paper was published on December 11th and reports on the rapid conclusions from the Institute of Medicine (a highly regarded national academic body in the USA) advised by a committee of scientists and public health specialists. The context was that the United States has relatively low stocks of antivirals (compared to some European countries) and there are few prospects that a pandemic vaccine would be widely available in any country until after the initial impact of a pandemic. Consequently a number of community public health measures (PHMs school closures, banning mass meeting, travel restrictions and antivirals for public health purposes) had been suggested in the USA whereby transmission could be reduced or even contained. These proposals had mostly been investigated in
modelling exercises sometimes with very differing outcomes (notably PHMs on schoo
l closures and restricting the movement of young people sometimes called Targeted Layered Containment).1-3 Some authorities have expressed concern over whether the more simpler solutions would work, whether they were sustainable, whether they would be suitable for urban settings and not have averse effects that outweighed the benefits.4 Consequently this Report was Commissioned by the United States government to quickly review: 1) the quality of current models on pandemic influenza and their usefulness in predicting the effects of containment policies on disease mitigation; (2) the available science and previous analyses of the efficacy of community mitigation approaches; and (3) the historical record of community interventions utilized during previous influenza pandemics and other relevant outbreaks. Following a workshop in November the letter report was prepared with a tight time-table. It attempts to discuss and summarise the effectiveness of intervention strategies in six key categories: infection control and prevention; antiviral use; patient management; contact management; community restrictions and risk communication. The Report comes to
conclusions for each of the six categories and identified eleven key recommendations where further work is necessary to inform policy making in the area of pandemic preparedness planning and specifically how to respond to a pandemic so as to minimize the damage.
ECDC comment (2006-12-21): This ‘letter report’ was eagerly awaited. However it had to be prepared at speed by what is essentially an academic rather than a public health body and perhaps for these two reasons it will disappoint some readers responsible for public health action. There are many good points made and the recommendations are hard to argue with. Most of the latter repeat the point that there are no simple answers and when considering community public health measures it is essential to consider their consequences and potential negative effects as well as their benefits. I.e. that making policy decisions is a complex process. The report acknowledges the arguments for early interventions but has concerns about the ability to sustain PHMs (intervention fatigue). It particularly considers school closures as an example and expressed concern that closures enforced without planning for their consequences could in some populations in the USA result in loss of childrens’ parents to the workforce, increase poverty (parents losing wages) and put at risk children in deprived circumstances where school provides social care, nutrition etc. Points are made that what might work in one type of community would not work in another. I.e. one size does not fit all. It was noted that modelling of school closures as a way of reducing influenza transmission came up with very differing outcomes in different models.1-3 These are not entirely new thoughts. They and many other points have already been well summarized in a peer review paper by Ingelsby et al published in the summer.4 The case for human H5N1 vaccines
(prepandemic vaccines) were not within the remit of the report though these are now
becoming more available.5 There is some focus on the application of antivirals making the usual points about the need to monitor resistance and especially the need to attend the logistics of delivering antivirals in a timely manner to those that need them. A point that applies also in Europe where countries have acquired stockpiles but some have yet to develop mechanisms for delivering them. Good points are made about lack of knowledge about how seasonal influenza transmits and the difficult of interpreting historical data but the concluding remarks come over as perhaps excessively negative. They state that it is almost impossible to conclude whether or not the proposed measures, singly or in combination would be effective in mitigating a pandemic. This is probably excessively strong a statement given influenza is a respiratory infectious disease and if taken literally could be a recipe for avoiding policy decisions. Certainly the measures would not contain pandemics such as the three seen in the 20th Century but most of them would mitigate transmission. The question is by how much and whether the secondary effects would outweigh the benefits. Finally a frustrating element is that many of the references in the report are to power-point presentations made at the workshop. This is a growing trend in rapid publications and no substitute to textual analysis especially if it can be made in well-prepared peer-reviewed articles. Hopefully many of the presentations will mature into such outputs.
Comments and responses to influenza@ecdc.europa.eu
1. Germann TC, Kadau K, Longini IM, Macken CA. Mitigation strategies for pandemic influenza in the United States PNAS 2006; 103: 5935-40
www.pnas.org/cgi/doi/10.1073/pnas.0601266103
2. Glass RJ, Glass LM, Beyeler WE, Min HJ. Targeted social distancing design for pandemic influenza. Emerg Infect Dis [serial on the Internet]. 2006 Nov [cited October 10th 2006]. Available from http://www.cdc.gov/ncidod/EID/vol12no11/06-0255.htm
3. Ferguson NM, Cummings DA, Fraser C, Cajka JC, Cooley PC, Burke DS.Strategies for
mitigating an influenza pandemic Nature 2006 Jul 27;442(7101):448-52. Epub 2006 Apr 26; doi:10.1038/nature04795
4. Inglesby TV, Nuzzo JB, O’Toole T, Henderson DA. Disease mitigation measures in the
control of pandemic influenza. Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science. 2006; 4 (4): 1-10.
5. ECDC, Human H5N1 vaccines – WHO produces guidance on virus composition
http://www.eurosurveillance.org/ew/2006/060921.asp#3
See also: Agenda and presentations from IoM ‘s November workshop on modelling
community containment
http://www.eurosurveillance.org/ew/2006/061221.asp#1
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SCIENTIFIC ADVANCES - SEASONAL INFLUENZA – VACCINATION
Influenza vaccination coverage among children aged 6-23 months - six
immunization information system sentinel sites, United States, 2005-06 influenza season.
Fredrickson K, et al.
Morbidity and Mortality Weekly Report. 2006; 55(49): 1329-30
Description: Beginning with the 2004-05 influenza season, the Advisory Committee on Immunization Practices (ACIP) in US recommended that all children aged 6-23 months - and, since 2006, all children aged 24-59 months - receive influenza vaccinations annually. This report assesses influenza vaccination coverage among children aged 6-23 months during the 2005-06 influenza season by using data from six immunization information system (IIS) sentinel sites. Less than 23% of children in five out of the six sites were fully vaccinated, underscoring the need for increased measures to improve the proportion of children who are fully vaccinated.
ECDC comment (2006-12-21): Routine influenza vaccination of children is a controversial issue in Europe. This report underscores once more the obstacles in reaching high coverage levels in children. Finding out effective measures to improve the proportion of fully vaccinated children against influenza can represent a good basis for those countries that are considering such vaccination option. Currently an independent scientific panel is preparing a report for ECDC on this topic and their opinion will be made public in January.
Comments and responses to influenza@ecdc.europa.eu
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SCIENTIFIC ADVANCES - SEASONAL INFLUENZA – VACCINATION
Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial.
Hayward A et al.
British Medical Journal, 2006; 333: 1241-44
Description: It is known that the immune response in elderly patients following influenza vaccination is not as high as in younger fit adults, and hence even when vaccine coverage is high, the elderly may still be vulnerable to influenza. The paradox is authors report work indicating that seasonal influenza vaccination of health care workers in care homes bolsters influenza protection in elderly residents, and reduces influenza like illness, health service use and death.
ECDC comment (2006-12-21): While many EU countries recommend that health care workers should receive seasonal influenza vaccination, uptake amongst health care workers remains poor- often less than 25%.The underlying conclusions in the article provides valuable evidence of the positive effects on elderly care home residents of applying seasonal influenza vaccination to health care workers, and indicates the value of extending vaccination programmes to staff in addition to elderly residents. The randomised control trial used to elucidate the findings in the study also demonstrates the value of such tools in the
development of public health vaccination policy. It is the hope that similar studies will be deployed in other areas to demonstrate seasonal vaccination efficacy.
See also: Influenza in elderly people in care homes (Editorial, British Medical Journal 2006;
333: 1229)
Comments and responses to influenza@ecdc.europa.eu
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Public Health Developments
PH DEVELOPMENTS – PANDEMIC INFLUENZA – PREPAREDNESS
European Medicines Agency adopts first positive opinion for mock-up pandemic
influenza vaccine
Description: On 15th December The European Medicines Agency (EMEA) announced the adoption of the first positive opinion recommending the granting of a Community
authorisation for a mock-up pandemic influenza vaccine. The objective behind a mock-up vaccine is to have a marketing authorisation in place that can be changed quickly in the event of a pandemic to include the virus strain responsible, once it has been identified. The EMEA positive opinion on the vaccine concerned, Daronrix from GlaxoSmithKline Biologicals S.A., will now be forwarded to the European Commission, which takes the final decision on the granting of a marketing authorisation.
ECDC comment (2006-12-21): This is positive step forward in improving the ability of the EU to counter emerging pandemic influenza strains, as it provides for an accelerated
procedure for vaccine authorisation during crisis, and potentially increases the speed at
which effective vaccines can be made available for disease intervention. However, EMEA estimate that once the flu strain causing a pandemic is known, it will take about 12 weeks to prepare a suitable vaccine as the viruses need to be grown in live cells. This manufacturing period must still be factored into all pandemic vaccination strategies. There are also other steps that need to take place (hopefully in parallel) such as preparation of reagents. Following this first authorisation, it is hoped that other putative vaccines will now also now be submitted for, and fulfil, EMEA authorisation for mock-up pandemic influenza vaccine to further expand the tools that could be quickly deployed to develop immuno-resistance in naive EU populations following the emergence of a pandemic strain.
For more information see:
http://www.emea.eu.int/pdfs/general/direct/pr/50287306en.pdf
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Meetings and workshops
International Conference on Avian and Pandemic Influenza, Bamako, Mali, West Africa. December 6-8th
The conference was a one year follow up to Beijing pledging conference. The Conference was supported by the European Union. Documents from the conference have now been posted at the conference and UNDP websites. Especially recommended by the ECDC
represenatatives is a talk by the United Nations Systems Influenza Coordinator Dr David Nabarro as well as the Bamako Declaration. There were EU presentations on the response to avian influenza by DG-Sanco and the process of improving European Pandemic Preparedness by ECDC and WHO-Europe.
Conference website
Post conference documentation
EU response to Avian Influenza
EU Pandemic Preparedness
Bamako Declaration
UNDP website
Speech by Dr Nabarro
UNDP web-site – UN System Influenza Coordination
For information on the EU support
See also 2006 update in Eurosurveillance
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Vaccines: a tool for the control of AI (animal health). March 20-22nd Verona. Italy
This scientific conference on vaccination, co-organised by the OIE, FAO and the Istituto Zooprofilattico Sperimentale delle Venezie (IZSVe), and supported by the European
Commission, aims to address the issue of global guidelines for vaccination in poultry with regard to international standards, regulations and the implementation of vaccination
programmes. Delgates will also review the current methods and recent experiences in the use of vaccination as one of the tools to control and prevent losses due to avian influenza in poultry, and discuss the appropriate decision-making process for the implementation of a vaccination strategy.
Conference website: http://www.avianfluvaccine2007.org/
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