Avian influenza
Scientific Developments
Meetings and workshops
Epidemiological updates
Seasonal Influenza – European Status
Issue 231, Week 31 (30/07/2007-05/08/2007)
No laboratory confirmed cases of influenza in Europe in the last two weeks
Summary: In week 30/2007 and 31/2007 seventeen countries reported virological data to the European Influenza Surveillance Scheme (EISS). No positive specimens were reported in weeks 30/2007 or 31/2007. Twelve countries reported an assessment of the geographical spread in week 31/2007 and all reported no influenza activity.
Since week 21/2007, a total of 12 positive specimens - 10 influenza A viruses and 2 influenza B viruses - have been reported to EISS (see graph and table for further details). Additionally, Finland reported one positive specimen (influenza B) in week 21/2007.
There have been no reports of unusual influenza activity in Europe at a community level (i.e. in a region or local area (such as a city, county or district)) since week 22/2007, when an outbreak of avian influenza A(H7N2) was reported in the United Kingdom.
Background: The Inter-season Electronic Bulletin presents and comments influenza activity based on virological data reported to EISS. The Inter-season Electronic Bulletin will be published between week 21/2007 and week 39/2007.
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 interactive EISS bulletin including maps and graphs by country and informative links in the text
National/regional bulletins in Europe and other bulletins from around the world
Links to general information from EISS:
General information on EISS, including background, membership and information on citing the EISS bulletin
Definitions of epidemiological indicators used by EISS
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HUMAN SEASONAL INFLUENZA – SOUTHERN HEMISPHERE WINTER 2007
SEVERE INFLUENZA IN PARTS OF AUSTRALIA
There are official reports from Australia that they are experiencing more severe epidemics of seasonal influenza this year than in recent years. The WHO Collaborating Centre has reported (August 13th) that some Australian States were reporting unusually high numbers of influenza cases and that there had been six deaths in children under age 5 with influenza. In much of Australia there has been predominately Type A/H3 influenza viruses detected (which was much the pattern in Europe as reported by EISS for the winter 2006-7). However in the more badly affected Australian States H1 viruses have been more important though the Australian Centre is cautious not to conclude that these H1 viruses are driving the intense local epidemics. The Australian experience is not being repeated in New Zealand where they are reported to be having another mild influenza winter. More information will be sought from the South looking both at Australasia and the Southern Cone of South America.
ECDC Comment (16-08-07) Whether they are based in the Northern or Southern hemisphere those responsible for influenza control watch developments in the other half of the world carefully as they can give a preview as to what will happen in the next winter. However the experience can also differ between and within hemisphere. Hence while these developments in Australia are concerning they will not necessarily be repeated in Europe in the coming winter (2007-8). Rather they are a reminder that while seasonal influenza epidemics have been mild in Europe in recent years that should not be seen as the norm. Europe has to be prepared for the occasional severe seasonal influenza winters (as well as for pandemics) notably by raising immunisation rates in the groups for whom immunisation is recommended.
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AVIAN INFLUENZA –HUMAN HEALTH – UPDATE
INDONESIA
14 August 2007
WHO has reported that The Ministry of Health has announced a new fatality in a person with H5N1 avian influenza. A 29-year-old female from Bali Province became unwell on 3 August and was hospitalized on 7 August and died on 12 August. Reportedly she had been exposed to sick and dead poultry. There may be a second case as the woman’s daughter (age 5) was sick and died with a respiratory illness (onset July 26th and died August 3rd) before the confirmed case became unwell. Human H5N1 infection was not suspected in the child’s case though the child also had contact with sick and dead poultry before becoming ill. There are no other reports of ill persons associated with either patient. I.e. no other indication of a cluster or possible person to person transmission. Of the 103 cases confirmed to date in Indonesia, 82 have been fatal. There have been 28 cases in 2007, 24 of those have died.
Currently Indonesia is not sharing influenza isolates from cases like these with other countries. However the laboratory in Indonesia invited a WHO team in and had a thorough inspection which suggested that its local results were reliable.
ECDC Travel Advice
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AVIAN INFLUENZA –HUMAN HEALTH – VIET NAM
August 2007
There are persistent media and government reports of a few sporadic human cases of influenza A(H5N1) virus infection recently in Viet Nam. These follow earlier cases in June which were reported and commented upon by ECDC. There were a considerable number of new poultry outbreaks of highly pathogenic avian influenza (H5N1) reported in Viet Nam during May and June this year.
Viet Nam: ECDC summary situation
ECDC Travel Advice
WHO latest avian influenza updates
WHO timeline of major events
Cumulative number of confirmed human cases of avian influenza A/(H5N1) reported to WHO (up to 14th August 2007)
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AVIAN INFLUENZA –ANIMAL HEALTH – GERMANY and OTHER EU COUNTIES
20th July 07
There continue to be reports by the German authorities of cases of HPAI A/H5N1 in wild birds. Details of these and a recent risk assessment are available (in German) through the web-site of the Fredrich Loffler Institute which is frequently updated. Over 200 outbreaks in wild bird and non-poultry species (many of these are single birds) have been reported since the beginning of July. These are focused in the regions of Thuringia and Saxony-Anhalt, with some isolated cases in Bavaria and Saxony. There was an outbreak involving poultry in a hobby farm in Thuringia in early July. Conventional control methods were applied and the outbreak was controlled. There were no reports of human cases.
OIE Report of wild birds cases from Germany reported between 5th-12th July (210 cases) (submitted to OIE on 20th July), including large scale map of locations.
OIE Report of wild birds cases from Germany reported on 13th July (20 outbreaks) (submitted to OIE on 20th July), including large scale map of locations.
EU’s Animal disease notification system (ADNS) recording information on wild bird cases of HPAI A/H5N1 in Germany (revised on 19th July)
(http://ec.europa.eu/food/animal/diseases/adns/adns_wildbirds2007.pdf.)
See also:
ECDC influenza team. Highly pathogenic avian influenza A/H5N1 in birds within the EU - Implications for Public Health. Euro Surveillance 2007;12(7):E070705.2. Available from: http://www.eurosurveillance.org/ew/2007/070705.asp#2
Relevant technical advice on the human aspects of highly pathogenic avian influenza A/H5N1 in humans (risk groups, risk assessments, advice to the public etc) is available through http://www.ecdc.europa.eu/Health_topics/Avian_Influenza/Guidance.aspx
Ongoing poultry outbreaks of HPAI/H5N1 have recently been reported by OIE in Ghana, Myanmar and Pakistan.
OIE official report – Ghana (August 13th)
OIE official report - Myanmar
OIE official report – Pakistan (August 6th)
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Scientific Developments
NONPHARMACEUTICAL MEASURES IN A PANDEMIC
Non-pharmaceutical interventions implemented by US cities during the 1918-19 influenza pandemic Markel, et al and Cetron – JAMA
Markel H, Lipman B B, Alexander Navarro J, et al
JAMA 2007 298(6):644-54
Description: During the 1918-19 pandemic of ‘Spanish Influenza’ a number of cities in the United States implemented so called non-pharmaceutical public health measures - PHMs (school closure, banning public gatherings, isolation, quarantine etc). They did so to varying degrees and for different durations. Some early in local epidemics and others later. The aim of this detailed and careful study, which examined massive amount of historical data and information, was to ascertain the likely impacts of these local measures on delaying the impact of that most severe pandemic, reducing its peak impacts and the reduction on excess mortality. It did so by observational methods comparing the impact overall of cities that intervened early versus those that intervened late and the seeming impact of different duration of applying the measures (in some cities when the relaxed the measures the influenza mortality rebounded). Other recent studies have similarly addressed this issue (and were described and commented on by ECDC), and came up with comparable findings, but this work covered the most cities.1,2 Data available was weekly reported mortality in 43 United States cities. The excess mortality was estimated by subtracting the median baseline mortality during 1910 – 1916. The dates for implementation of measures as school closure, banning public gatherings, isolation, quarantine and ancillary non pharmaceutical interventions were recorded, from a vast number of sources.
Analysis of a few cities that implemented the PHMs before they experienced a rise in mortality, found that excess mortality did not seem to depend on how early the measure was taken. Although there were only three cities that did this. This raises the difficult question about when to optimally start the interventions when cities do not exactly know when the pandemic will reach them. However in summary the study found that intervening early with the PHMs was associated with prolonging the time to the peak of the outbreak, magnitude of first mortality peak and the total excess mortality. All these results were statistically significant.
ECDC comment (07/08/07)
Non-pharmaceutical public health measures (which include the personal measures) are an important part of the countermeasures against pandemic influenza. In poorer countries they will be all that is available, while in developed countries like the EU they will complement medical interventions (antivirals, antibiotics, supportive care, human avian influenza vaccines etc) until a specific vaccine becomes available. Their impact has previously been studies both by modelling and historical analysis of available data.1-4,
For this study a very large number of cities have been gathered, more could have been added but the lack of available data made it not feasible. There might be some selection bias induced by this limitation. The researchers had to cope with the usual problems of historical data such as measures like school closures being defined differently and on different scales. However taken in combination the studies conclude that non-pharmaceutical interventions probably can have a mitigating impact for the next influenza pandemic. What is an insoluble problem is that due to the overlapping nature of the interventions (understandably city authorities did not conveniently try single interventions) not even the most sophisticated statistical method could isolate what was the specific effects of individuals interventions cannot be measured. Exactly the same problem came up when trying to work out what exactly caused respiratory infections (including seasonal influenza) to decline during the use of PHMs in Hong Kong during SARS.5
In some ways these finding should not be surprising. With an infection that spreads from person to person keep people apart by school closures, banning meetings etc and you get less infection. On the basis of these and other observations WHO and some European countries recommend adopting non-pharmaceutical measures when the next pandemic occurs. However at the national level more sophisticated planning has been undertaken by the United States which has a comprehensive interim plan.6 One of its components is to grade the severity of the pandemic on a five point scale easily understandable in the US because it conforms to the national hurricane severity scale. This is necessary because the major problem with the PHMs is their costs and secondary impacts.7 Even something that sounds simple like closing schools has significant social effects and so in a mild pandemic implementing the PHMs would probably ‘cost’ more than sticking to the personal measures supplemented by medical interventions. Also pandemics vary in other characteristics. Children were especially important amplifiers of the 1957 pandemic but less so in those of 1968 or 1918/9 so closing schools might be efficacious in one pandemic but not another. Finally cities and countries vary socially even within Europe so that a measure that could be feasible in one setting may not be acceptable elsewhere.
1. Bootsma MN, Ferguson NM, The effect of public health measures on the 1918 influenza pandemic in U.S. cities. PNAS 2007; 104(18):7588-93
Proc Natl Acad Sci USA published on line Apr 6 2007
2. Hatchett RJ, Mecher CE, Lipsitch M Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proc Natl Acad Sci U S A. published online Apr 6, 2007
3 Ferguson NM, Cummings D, Cauchemez, S et al. strategies for mitigating an influenza pandemic. Nature 2006;442:448-452
4. 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
5. Lo JYC, Tsang THF, Leung Y-H, Yeung EYH, Wu T, Lim WWL. Respiratory infections during SARS outbreak, Hong Kong, 2003. Emerg Infect Dis [serial on the Internet]. 2005 Nov Available from http://www.cdc.gov/ncidod/EID/vol11no11/05-0729.htm
6. United States Department of Health and Human Services and Centers for Disease Prevention and Control. Interim pre-pandemic planning guidance: Community strategy for pandemic influenza Mitigation in the United States. Dec 2006 http://www.pandemicflu.gov/plan/community/community_mitigation.pdf
7. 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.
Comment to influenza@ecdc.europa.eu.
UK PUBLISHES ITS SCIENTIFIC BASIS FOR COUNTERMEASURES AGAINST PANDEMIC INFLUENZA
The United Kingdom (UK) has a Scientific Advisory Group on Pandemic Influenza which has been meeting regularly to inform its national policy and planning. This week the Department of Health in London has made public five scientific papers developed in 2006 by the Group, dealing with the clinical countermeasures and the risk of a pandemic originating from an H5N1 virus. These consist of papers on the risk of a pandemic (and specifically an H5 based pandemic), antivirals, vaccines (specific pandemic vaccines and a pre-pandemic vaccine), antibiotics (including published clinical guidelines from a working group with input from the Department of Health, British Thoracic Society, British Infection Society and the Health Protection Agency) and the use of masks. These papers do not represent national policy and the web-site emphasises that the policy implications of these papers, all of which have significant costs are still under consideration.
The papers are available from the Department of Health web-site
Comment to influenza@ecdc.europa.eu.
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Meetings and workshops
4th European Pandemic Preparedness Workshop, Luxembourg Sept 25th-27th 2007.
The fourth Europe-wide workshop is being organised by the European Commission, ECDC and WHO European Region with for this workshop the Commission taking the lead. It will be open to a limited number of senior officials from countries of the WHO Europe region including the EU Member States. These will be those with expertise in influenza pandemic preparedness that are either invited by the organisers or identified by the national authorities.
The report on the Third Joint Meeting in Uppsala in May is available at Third joint EC/ECDC/WHO Workshop on Pandemic Influenza Preparedness
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Perspectives in Interpandemic Influenza, Madrid, 12-14 October 2007.
The inaugural Congress on Perspectives in Interpandemic Influenza will take place 12-14 October 2007 in Madrid, Spain. This Congress aim’s to provide an update on the latest treatment and management options available for seasonal influenza. The agenda is focused on therapeutic approaches to patient care, and is targeted at health care professionals in the primary care sector.
Conference website: Perspectives in Interpandemic Influenza
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3rd ESWI European Influenza Conference, Vilamoura, Portugal, 14-17 September 2008.
The European Scientific Working group on Influenza (EWSI) - an independent group of European scientists promoting the study of influenza – will hold its third European Influenza Conference in the Autumn of 2008.
Preliminary conference information can be found at: http://www.eswi.org/Events.cfm
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