WHO: Pandemic (H1N1) 2009 – update 73

The WHO continues to issue weekly “updates” and briefing notes as below:
Pandemic (H1N1) 2009 – update 73
Weekly update

As of 1 November 2009, worldwide more than 199 countries and overseas territories/communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 6000 deaths.

As many countries have stopped counting individual cases, particularly of milder illness, the case count is likely to be significantly lower than the actual number of cases that have occurred. WHO is actively monitoring the progress of the pandemic through frequent consultations with the WHO Regional Offices and member states and through monitoring of multiple sources of data.

Situation update:

Intense and persistent influenza transmission continues to be reported in North America without evidence of a peak in activity. The proportion of sentinel physician visits due to influenza-like-illness (ILI)(8%) has exceeded levels seen over the past 6 influenza seasons; 42% of respiratory samples tested were positive for influenza and 100% of subtyped influenza A viruses were pandemic H1N1 2009. Rates of ILI, proportions of respiratory samples testing positive for influenza, and numbers of outbreaks in educational settings continues to increase sharply in Canada as activity spreads eastward. Significantly more cases of pandemic H1N1 have been recorded in Mexico since September than were observed during the initial springtime epidemic.

In Europe and Central and Western Asia, pandemic influenza activity continues to increase across many countries, signalling an unusually early start to the winter influenza season. Active circulation of virus marked by high proportions of sentinel respiratory samples testing positive for influenza has been reported in Belgium (69%), Ireland (55%), Netherlands (51%), Norway (66%), Spain (46%), Sweden (33%), the United Kingdom (Northern Ireland:81%), and Germany (27%). In addition, there is evidence of increasing and active transmission of pandemic influenza virus across Northern and Eastern Europe (including Ukraine and Belarus), and eastern Russia. For details on the situation in Ukraine please refer to the Disease Outbreak News update below. In Western Asia and the Eastern Mediterranean Region, increasing activity has been reported in Oman and Afghanistan.

Pandemic (H1N1) 2009, Ukraine – update 1

In East Asia, intense and increasing influenza activity continues to be reported in Mongolia. In China, after an earlier wave of mixed influenza activity (seasonal H3N2 and pandemic H1N1), pandemic H1N1 influenza activity now predominates and is increasing. Sharp increases in pandemic influenza activity continue to be reported throughout Japan with highest rates of illness being reported on the northern island.

Active influenza transmission and increasing levels of respiratory diseases continues to be reported in parts of the Caribbean, including in Cuba, Haiti, and other Caribbean Epidemiology Centre (CAREC) countries. Most other countries in the tropical region of Central and South America continue to report declining influenza activity. With the exception of Nepal, Sri Lanka, and Cambodia, overall transmission continues to decline in most but not all parts of tropical South and Southeast Asia. Influenza virus isolates from sub-Saharan Africa are predominantly pandemic H1N1 virus but some seasonal H3N2 has been detected even in recent weeks. Unconfirmed media reports from the area indicate that disease activity has increased in recent weeks.

Since the new pandemic H1N1 2009 virus emerged, infections in different species of susceptible animals (pig, turkey, ferret, and cat) have been reported. Limited evidence suggests that these infections occurred following direct transmission of the virus from infected humans. These isolated events have had no impact on the dynamics of the pandemic, which is spreading readily via human-to-human transmission. As human infections become increasingly widespread, transmission of the virus from humans to other animals is likely to occur with greater frequency. Unless the epidemiology of the pandemic changes, these will continue to pose no special risks to human health.

http://www.who.int/csr/don/2009_11_06/en/index.html

H1N1 Vaccine Allocation: CDC letter to state and local health officials

[Editor’s Note: The following letter to state and local health officials followed media reports last week about potential diversion of H1N1 vaccine stocks to non-priority groups]

November 5, 2009

Dear State/Local Health Officer:

Today we have 35.6 million doses of 2009 H1N1 vaccine allocated for ordering, with more coming every day. As you know all too well, at present, demand for the vaccine in your communities still exceeds the supply we have received from manufacturers. That means it is more important than ever to focus on ensuring equitable access to the vaccine for the priority groups identified by the Advisory Committee on Immunization Practices: pregnant women, caretakers of infants less than 6 months of age, health care workers, children and adults with health conditions such as asthma or diabetes, and people under the age of 25. These are the people who are most vulnerable to 2009 H1N1 influenza, and it’s our job to do everything we can to keep them safe this flu season.

I know you have been working hard to distribute vaccine to the people who need it most. You are on the front lines of the fight, and no one knows better than you how to reach people in your communities. I especially appreciate the many innovative ways you’ve found to reach them, including school-located vaccine clinics, special clinics for pregnant women, outreach to children with special needs, and making vaccine available to community- and faith-based organizations serving these high-risk populations.

The goal of the H1N1 vaccination program is to protect our population – focusing first on these high-risk groups and ensuring equitable access to the vaccine. While vaccine supplies are still limited, any vaccine distribution decisions that appear to direct vaccine to people outside the identified priority groups have the potential to undermine the credibility of the program.

It is important to make it clear to the public that we are all committed to the science-based vaccination recommendations established by the Advisory Committee on Immunization Practices. This may include making clear to the public as well as health care providers how the vaccine available to you is being targeted, and the basis for targeting. CDC expects all grantees to ensure that all vaccinators chosen by state and local health departments adhere to those recommendations. Toward that end, and in light of changing projections of vaccine availability, I ask each of you to review your plans immediately and work to ensure that the maximum number of doses is delivered to those at greatest risk as rapidly as possible.

I know how difficult your jobs are; we are ready and willing to help you any way we can.

Sincerely,

Thomas R. Frieden, M.D., M.P.H.
Director, Centers for Disease Control and
Prevention, and
Administrator, Agency for Toxic Substances
and Disease Registry

http://www.cdc.gov/media/pdf/Final-H1N1-Letter-to-State-Officials–CDC-Director.pdf

NIAID funds infectious disease research, including bioterrorism-induced events

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, said it awarded approximately US$208 million to two programs that support research “to better understand the human immune response to emerging and re-emerging infectious diseases, including those that may be introduced into a community through acts of bioterrorism.” The grants were awarded to the Cooperative Centers for Translational Research on Human Immunology and Biodefense (CCHI) and the Immune Mechanisms of Virus Control (IMVC). NIAID said it also received approximately US$21 million under the American Recovery and Reinvestment Act to supplement these two programs and fund some additional researchers. This funding is part of the US$5 billion awarded by NIH in FY 2009 for research projects under the Recovery Act. The long-term goal of the CCHI and IMVC programs is to identify new vaccines and drug targets.

Daniel Rotrosen, M.D., director of the NIAID Division of Allergy, Immunology and Transplantation, said, “Developing vaccines and treatments for emerging pathogens continues to be a priority for NIAID. The CCHI and IMVC programs will foster collaboration among many talented investigators working toward the common goal of understanding the human immune response to infectious diseases and developing more effective measures to prevent and treat infection.”

http://www.nih.gov/news/health/nov2009/niaid-04a.htm

PATH and PharmaJet to evaluate new generation of needle-free injection technologies

PATH and PharmaJet, a privately held company, said they are collaborating “to bring developing countries safe, effective, and affordable injections without using needles.” The new partnership “will evaluate a new generation of needle-free injection technologies, including PharmaJet’s needle-free, disposable-syringe jet injectors. These vaccine delivery technologies could reduce health risks and costs associated with traditional needle injections.” Starting in Brazil, where clinical studies are scheduled to begin in early 2010, PATH will evaluate needle-free delivery of a variety of vaccines compared to delivery by needle and syringe. Vaccines to be tested include those to prevent measles-mumps-rubella and yellow fever. PATH and its Brazilian partners also plan to conduct pilot introduction studies and other activities to facilitate adoption of needle-free technologies like the PharmaJet system. Darin Zehrung, team leader for vaccine delivery technologies at PATH, said, “Disposable-syringe jet injector technology has the potential to provide safer and more affordable vaccines to millions of people around the world. This collaboration is an important step in our work to explore the regulatory pathway, commercial viability, and sustainability of this class of jet injectors in the developing world and share that knowledge with the entire global health community.”

PATH noted WHO estimates that at least 16 billion injections are given in developing and transitional countries each year. Prior to the introduction of autodisable syringes and a worldwide emphasis on injection safety, “health officials estimated that at least 50 percent of injections in developing countries were considered to be unsafe.” Unsafe injections can expose individuals to the risk of infections such as HIV, hepatitis B, or hepatitis C. Infection can occur when health workers or patients reuse syringes, contaminate medications with used syringes, or accidentally injure the patient or themselves with a used needle. While developing countries have begun extensive efforts to improve injection safety, the costs and difficulty of managing ever-growing volumes of vaccine and sharps waste remain an obstacle to safety, PATH noted.

http://www.path.org/news/pr091105-pharmajet.php

World Epidemiological Record (WER): 6 November 2009

The World Epidemiological Record (WER) for 6 November 2009, vol. 84, 45 (pp 469–476) includes Outbreak news – Dengue fever, Cape Verde; Validation of neonatal tetanus elimination in the Congo by a lot quality-assurance

http://www.who.int/wer/2009/wer8445.pdf

Editorials: Influenza

JAMA
Vol. 302 No. 17, pp. 1839-1926, November 4, 2009
http://jama.ama-assn.org/current.dtl

Editorials

Respiratory Protection Against Influenza
Arjun Srinivasan; Trish M. Perl
JAMA. 2009;302(17):1903-1904. Published online October 1, 2009

Preparing for the Sickest Patients With 2009 Influenza A(H1N1)
Douglas B. White; Derek C. Angus

Influenza in 2009: New Solutions, Same Old Problems
Julie Louise Gerberding

Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers

JAMA
Vol. 302 No. 17, pp. 1839-1926, November 4, 2009
http://jama.ama-assn.org/current.dtl

Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers: A Randomized Trial
Mark Loeb, MD, MSc; Nancy Dafoe, RN; James Mahony, PhD; Michael John, MD; Alicia Sarabia, MD; Verne Glavin, MD; Richard Webby, PhD; Marek Smieja, MD; David J. D. Earn, PhD; Sylvia Chong, BSc; Ashley Webb, BS; Stephen D. Walter, PhD

Context  Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse. Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance.

Objective  To compare the surgical mask with the N95 respirator in protecting health care workers against influenza.

Design, Setting, and Participants  Noninferiority randomized controlled trial of 446 nurses in emergency departments, medical units, and pediatric units in 8 tertiary care Ontario hospitals.

Intervention  Assignment to either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season.

Main Outcome Measures  The primary outcome was laboratory-confirmed influenza measured by polymerase chain reaction or a 4-fold rise in hemagglutinin titers. Effectiveness of the surgical mask was assessed as noninferiority of the surgical mask compared with the N95 respirator. The criterion for noninferiority was met if the lower limit of the 95% confidence interval (CI) for the reduction in incidence (N95 respirator minus surgical group) was greater than –9%.

Results  Between September 23, 2008, and December 8, 2008, 478 nurses were assessed for eligibility and 446 nurses were enrolled and randomly assigned the intervention; 225 were allocated to receive surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group (absolute risk difference, –0.73%; 95% CI, –8.8% to 7.3%; P = .86), the lower confidence limit being inside the noninferiority limit of –9%.

Conclusion  Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza.

Trial Registration  clinicaltrials.gov Identifier: NCT00756574

Author Affiliations: Departments of Pathology and Molecular Medicine (Drs Loeb, Mahony, and Smieja and Ms Dafoe), Medicine (Dr Loeb), Clinical Epidemiology and Biostatistics (Drs Loeb, Smieja, Earn, and Walter), and Mathematics and Statistics (Dr Earn), Michael G. DeGroote Institute for Infectious Disease Research (Drs Loeb, Mahony, Smieja, and Earn), McMaster University, Hamilton, Ontario, Canada; St Joseph’s Hospital Regional Virology Laboratory, Hamilton (Dr Mahony and Ms Chong); Departments of Pathology and Microbiology and Immunology, University of Western Ontario, London (Dr John); Department of Microbiology, Credit Valley Hospital, Mississauga, Ontario (Dr Sarabia); Joseph Brant Memorial Hospital, Burlington, Ontario (Dr Glavin); and World Health Organization Collaborating Center for Studies on the Ecology of Influenza in Animals and Birds, St Judes Children’s Hospital, Memphis, Tennessee (Dr Webby and Ms Webb).

Malaria: Is Eradication Possible without Modifying the Mosquito?

Journal of Infectious Diseases
Dec 2009  Volume 200, Number 11
http://www.journals.uchicago.edu/toc/jid/current

Editorial Commentaries
Perspective on Malaria Eradication: Is Eradication Possible without Modifying the Mosquito?
Louis H. Miller and Susan K. Pierce

Novel H1N1 Influenza and Respiratory Protection for Health Care Workers

New England Journal of Medicine
Volume 361 — November 5, 2009 — Number 19
http://content.nejm.org/current.shtml

Novel H1N1 Influenza and Respiratory Protection for Health Care Workers
Kenneth I. Shine, M.D., Bonnie Rogers, Dr.P.H., R.N., and Lewis R. Goldfrank, M.D.

[Initial language]
Your hospital has been seeing a large number of patients with influenza-like symptoms, many of whom turn out to be infected with the novel H1N1 influenza A virus. You have been asked to consult on the case of a 28-year-old woman who is in an isolation room because of an influenza-like presentation and shortness of breath. You put on a gown, carefully clean your hands with hand soap or an alcoholic gel, pull on gloves, and reach for a mask. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend the use of an N95 filtering facepiece respirator. Some states and many professional groups have suggested that a standard surgical mask is satisfactory in this situation, except when a clinician is performing high-risk procedures, such as airway suctioning, in which case the N95 is still recommended. What should the hospital and its infection-control officer provide when you reach into the box for a respiratory protective device? What should be available to others who will enter this room, including nurses, respiratory technicians, cleaners, and food servers?….

Human Papillomavirus Vaccine for Cancer Prevention

New England Journal of Medicine
Volume 361 — November 5, 2009 — Number 19
http://content.nejm.org/current.shtml

Human Papillomavirus Vaccine for Cancer Prevention
O. J. Finn and R. P. Edwards

[First 100 words per NEJM convention]
Cancer immunoprevention has become synonymous with the vaccines that have been approved for the prevention of infection with highly transmissible strains of human papillomavirus (HPV) that establish chronic infection and cause cervical and other cancers.1 Although many cancers may have a viral origin,2 only a small number of viruses have been implicated as causes of human cancer. Cancer having a viral origin provides an opportunity to develop virus-specific vaccines that lower infection rates and consequently lower the incidence of cancer; this is what the HPV vaccine is expected to do for cervical cancer and what the hepatitis B vaccine has . . .

Developing Countries to Get Some H1N1 Vaccine—But When?

Science
6 November 2009  Vol 326, Issue 5954, Pages 757-904
http://www.sciencemag.org/current.dtl

Swine Flu Pandemic:
Developing Countries to Get Some H1N1 Vaccine—But When?
Martin Enserink

The World Health Organization has said that about a month from now, it will begin supplying developing countries with H1N1 vaccine donated by manufacturers and rich countries. But it has secured only about 200 million doses for 95 countries that together are home to a third of the world’s population, compared with the 250 million doses that the United States has purchased, Germany’s 50 million, and France’s 94 million. Moreover, much of that vaccine won’t arrive for several months, and the pandemic marches on…

WHO: Pandemic (H1N1) 2009 briefing note 14; 30 October 2009

The WHO continues to issue weekly “updates” and briefing notes as below:

Pandemic (H1N1) 2009 briefing note 14

Experts advise WHO on pandemic vaccine policies and strategies

30 OCTOBER 2009 | GENEVA

The Strategic Advisory Group of Experts (SAGE) on Immunization, which advises WHO on policies and strategies for vaccines and immunization, devoted a session of its 27–29 October meeting to pandemic influenza vaccines. The experts reviewed the current epidemiological situation of the pandemic worldwide and considered issues and options from a public health perspective.

Items on the agenda included the status of vaccine availability, results from clinical trials on vaccine immunogenicity, and early results from safety monitoring in countries where administration of the H1N1 pandemic vaccine is currently under way.

The experts also advised WHO on the number of doses of vaccine needed to confer protection, also in different age groups, the co-administration of seasonal and pandemic vaccines, and vaccines for use in pregnant women. Recommendations on the formulation of seasonal influenza vaccines for the southern hemisphere in 2010 were also provided.

Current situation

Globally, teenagers and young adults continue to account for the majority of cases, with rates of hospitalization highest in very young children. Between 1% to 10% of patients with clinical illness require hospitalization. Of hospitalized patients, from 10% to 25% require admission to an intensive care unit, and from 2% to 9% have a fatal outcome.

Overall, from 7% to 10% of all hospitalized patients are pregnant women in their second or third trimester of pregnancy. Pregnant women are ten times more likely to need care in an intensive care unit when compared with the general population.

Based on these and other current findings, the experts made a number of recommendations.

Single dose recommended

The experts noted that a variety of pandemic vaccines, including live attenuated and both adjuvanted and non-adjuvanted inactivated vaccines, have now been licensed for use by regulatory authorities. SAGE recommended the use of a single dose of vaccine in adults and adolescents, beginning at the age of 10 years, provided such use is consistent with indications from regulatory authorities.

Data on immunogenicity in children older than 6 months and younger than 10 years are limited and more studies are needed. Where national authorities have made children a priority for early vaccination, SAGE recommended that priority be given to the administration of one dose of vaccine to as many children as possible. SAGE further stressed the need for studies to determine dosage regimens effective in immunocompromised persons.

Co-administration of vaccines

Clinical trials investigating the co-administration of seasonal and pandemic vaccines are ongoing, but SAGE acknowledged the recommendation, from the US Centers for Disease Control and Prevention, that live attenuated seasonal and live attenuated pandemic vaccines should not be co-administered.

The experts recommended that seasonal and pandemic vaccines can be administered simultaneously, provided both vaccines are inactivated, or one is inactivated and the other is live attenuated. The experts found no evidence that co-administration of vaccines, as recommended, would increase the risk of adverse events.

Vaccine safety

The experts reviewed early results from the monitoring of people who have received pandemic vaccines and found no indication of unusual adverse reactions. Some adverse events following vaccination have been notified, but these are well within the range of those seen with seasonal vaccines, which have an excellent safety profile. Although early results are reassuring, monitoring for adverse events should continue.

Vaccines for pregnant women

Concerning vaccines for pregnant women, SAGE noted that studies in experimental animals using live attenuated vaccines and non-adjuvanted or adjuvanted inactivated vaccines found no evidence of direct or indirect harmful effects on fertility, pregnancy, development of the embryo or fetus, birthing, or post-natal development.

Based on these data and the substantially elevated risk for a severe outcome in pregnant women infected with the pandemic virus, SAGE recommended that any licensed vaccine can be used in pregnant women, provided no specific contraindication has been identified by the regulatory authority.

Vaccines for the southern hemisphere in 2010

SAGE also considered vaccines for use in the southern hemisphere during the 2010 winter season. Two options were assessed: a trivalent vaccine, effective against the H1N1 pandemic virus, the seasonal H3N2 virus, and influenza B viruses, and a bivalent seasonal vaccine, effective against H3N2 and influenza B viruses, which might need to be supplemented with a separate monovalent H1N1 pandemic vaccine.

The experts concluded that both options should remain available for vaccine formulations in the southern hemisphere, subject to national needs.

http://www.who.int/csr/disease/swineflu/notes/briefing_20091030/en/index.html

WHO Briefing Note: Pandemic (H1N1) 2009, Ukraine

Pandemic (H1N1) 2009, Ukraine

On 28 October 2009, the Ministry of Health of the Ukraine informed WHO, through its Country Office in Ukraine, about an unusually high level of activity of acute respiratory illness in the western part of the country, associated with an increased number of hospital admissions and fatalities.

On 30 October 2009, the Ministry of Health of the Ukraine announced the confirmation of pandemic (H1N1) 2009 virus infection by RT-PCR in eleven out of 30 samples obtained from patients presenting with acute respiratory illness in two of the most affected regions. Tests were performed in two laboratories in Kyiv, including the National Influenza Centre. Confirmatory tests will be performed at one of the WHO Collaborating Centres for Influenza.

The situation is quickly changing with increasingly high levels of acute respiratory illness (ARI)/Influenza-like-illness (ILI) activity being observed in Ternopil, Lviv, Ivano-Frankivsk, and Chernivtsi regions. The higher levels of transmission in these regions corresponds to an increased number of hospital admissions and fatalities associated with severe manifestations of acute respiratory illness.

As of 30 October 2009, over 2,300 individuals have been admitted to hospital, including over 1,100 children. One hundred and thirty one (131) cases have required intensive care, including 32 children. As of 31 October 2009, a total of 38 fatalities associated with severe manifestations of ARI have been registered. Preliminary epidemiological data analysis indicates that severe cases and deaths primarily occur among previously healthy young adults aged 20 – 50 years. Fatal and severe cases are reported to have sought medical attention 5 to 7 days after onset of symptoms.

International experience of the (H1N1) 2009 pandemic to date, especially from the Southern Hemisphere, has shown that poor clinical outcomes are associated with delays in seeking health care and limited access to supportive care. In addition, this virus has also shown its ability to cause rapidly progressive overwhelming lung disease which is very difficult to treat.

Public health measures recommended by the Ministry of Health of the Ukraine across the entire country include: social distancing (school closures and cancellation of mass gatherings); enhancement of surveillance activities; increased respiratory hygiene; and continuation of the vaccination campaign against seasonal influenza targeting at risk groups.

The Government of the Ukraine has activated coordination mechanisms to respond to the rapidly evolving situation, including the harmonization of response plans across all administrative levels.

In response to the request from the Minister of Health of the Ukraine, WHO is deploying a multi-disciplinary team of experts to assist national authorities in mitigating the impact of the pandemic. The team comprises of the following expertise: health emergencies coordination, case management, epidemiology, laboratory diagnostics, logistics, and media/risk communications.

As per WHO’s communication in May 2009, there is no rationale for travel restrictions because such measures will not prevent the spread of the disease.

Travellers can protect themselves and others by following simple recommendations aimed at preventing the spread of infection such as attention to respiratory hygiene. Individuals who are ill should delay travel plans and returning travellers who fall ill should seek appropriate medical care. These recommendations are prudent measures which can limit the spread of many communicable diseases and not only the pandemic (H1N1) 2009 virus. http://www.who.int/csr/don/2009_11_01/en/index.html

WHO/UNICEF launch GAPP: avoiding 5.3 million pneumonia deaths by 2015

The WHO and UNICEF launched a “comprehensive action plan that can save up to 5.3 million children from dying of pneumonia by 2015.” The Global action plan for the prevention and control of pneumonia (GAPP) includes “recommendations on what needs to be done, specific goals and targets, and estimates of what it will cost and how many lives will be saved…its aim is to increase awareness of pneumonia as a major cause of child deaths, and it calls on global and national policy-makers, donor agencies and civil society to take immediate action to implement the plan.” The release of the GAPP strategy coincides with the first Global Pneumonia Summit being held in New York City on 2 November.

The GAPP has a three-pronged vision:

- Protecting every child by providing an environment where they are at low risk of pneumonia (with exclusive breastfeeding for six months, adequate nutrition, preventing low-birth-weight, reducing indoor air pollution, and increasing hand washing);

- Preventing children from becoming ill with pneumonia (with vaccination against its causes: measles, pertussis, Streptococcus pneumoniae and Haemophilus influenzae b, as well as preventing and treating HIV in children, and providing zinc for children with diarrhoea);

- Treating children who become ill with pneumonia with the right care and antibiotics (in communities, health centres and hospitals).

The cost of implementing the GAPP by scaling up the recommended measures in the 68 high burden countries is estimated at US$39 billion for 2010-2015. The costs are expected to double over the six-year period, rising from an annual need of US$ 3.8 billion in 2010 to US$ 8.0 billion by 2015.

Specific targets and goals to be reached by 2015 under the GAPP strategy are to expand coverage of all relevant vaccines and exclusive breastfeeding rates to 90%, and raise the level of access to appropriate pneumonia case management to 90%. This will lead to a reduction in child pneumonia deaths by 65% and cutting the number of severe pneumonia cases in children by 25%, compared to 2000 levels.

The GAPP strategy document is available at: http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_NCH_09.04_eng.pdf

http://www.who.int/mediacentre/news/releases/2009/child_pneumonia_gapp_20091102/en/index.html

WER: 30 October 2009

The World Epidemiological Record (WER) for 30 October 2009, vol. 84, 44 (pp 453–468) includes: Oseltamivir-resistant pandemic (H1N1) 2009 influenza virus, October 2009; Meeting of the International Task Force for Disease Eradication, June 2009; Monthly report on dracunculiasis cases, January–August 2009.

http://www.who.int/wer/2009/wer8444.pdf

IVI: new low-cost killed whole-cell (WC) oral cholera vaccine

The International Vaccine Institute (IVI) said its new low-cost killed whole-cell (WC) oral cholera vaccine was found to be protective against clinically significant cholera in an endemic setting in a large-scale field trial conducted in nearly 70,000 residents of Kolkata, India. The new vaccine was found to be safe, and was effective in young children as well as older persons. IVI developed the vaccine “by modifying an inexpensive vaccine produced in Vietnam and said the new vaccine was licensed early this year in India. This major study was conducted by the IVI in collaboration with the National Institute of Cholera and Enteric Diseases (NICED) in Kolkata, India. Based in Seoul, Korea, the IVI is a nonprofit international organization devoted exclusively to development and deployment of new vaccines primarily for people in developing countries.

IVI Director-General Dr. John Clemens said, “This interim analysis shows that the modified vaccine is safe and efficacious, providing nearly 70 percent protection against clinically significant cholera for at least two years after vaccination.” IVI noted that an internationally licensed, killed whole-cell vaccine containing the recombinant cholera toxin B subunit (rBS-WC) is currently available. IVI said that due to the high cost and requirement of buffer for administration of rBS-WC, it is not feasible for use in developing countries. In contrast, the new IVI vaccine does not require any buffer, making it easier to administer, and is cheaper to produce, making mass vaccination campaigns more feasible, IVI said. In order for the new vaccine to be purchased by United Nations organizations such as UNICEF, the IVI said it transferred its production technology to the vaccine manufacturer, Shantha Biotechnics, in India, where the national regulatory authority is approved by the WHO. Shantha obtained licensure for this vaccine (Shanchol) on February 24, 2009 from the Indian national regulatory authority, paving the way for the expanded use of the vaccine.

http://www.ivi.org/event_news/news_view.asp?enid=105

Long-Lasting Measles Outbreak Affecting Several Unrelated Networks of Unvaccinated Persons (Quebec)

Journal of Infectious Diseases
15 November 2009  Volume 200, Number 10
http://www.journals.uchicago.edu/toc/jid/current

Major Articles and Brief Reports
VIRUSES
Long-Lasting Measles Outbreak Affecting Several Unrelated Networks of Unvaccinated Persons

Frédéric Dallaire, Gaston De Serres, François-William Tremblay, France Markowski, and Graham Tipples

Abstract
Despite a population immunity level estimated at 95%, an outbreak of measles responsible for 94 cases occurred in Quebec, Canada. Unlike previous outbreaks in which most unvaccinated children belonged to a single community, this outbreak had cases coming from several unrelated networks of unvaccinated persons dispersed in the population. No epidemiological link was found for about one-third of laboratory-confirmed cases. This outbreak demonstrated that minimal changes in the level of aggregation of unvaccinated individuals can lead to sustained transmission in highly vaccinated populations. Mathematical work is needed regarding the level of aggregation of unvaccinated individuals that would jeopardize elimination.

Malaria: a research agenda for the eradication era

The Lancet
Oct 31, 2009  Volume 374  Number 9700  Pages 1473 – 1566
http://www.thelancet.com/journals/lancet/issue/current

Comment
Malaria: a research agenda for the eradication era

Wen Kilama, Francine Ntoumi
The world’s largest meeting on malaria, the 5th Multilateral Initiative on Malaria (MIM) Pan-African Malaria Conference, convenes in Nairobi, Kenya, on Nov 1–6.1 Since the last MIM meeting in 2005, the malaria landscape has transformed dramatically. Scientific progress and support from the highest levels of government galvanised the field, and the global community has begun to coalesce around the most ambitious goal possible—eradication.

Adoption of Rotavirus Vaccination by U.S. Pediatricians and Family Medicine Physicians

Pediatrics
November 2009 / VOLUME 124 / ISSUE 5
http://pediatrics.aappublications.org/current.shtml

Adoption of Rotavirus Vaccination by Pediatricians and Family Medicine Physicians in the United States
Allison Kempe, Manish M. Patel, Matthew F. Daley, Lori A. Crane, Brenda Beaty, Shannon Stokley, Jennifer Barrow, Christine Babbel, L. Miriam Dickinson, Jonathan L. Tempte, and Umesh D. Parashar

OBJECTIVES: The goals were to assess, among pediatricians and family medicine physicians, (1) rates of offering the vaccine in their office; (2) knowledge of Advisory Committee on Immunization Practices recommendations; (3) barriers to use; and (4) factors associated with offering the vaccine.

METHODS: Surveys of pediatricians and family medicine physicians were conducted in August to October 2007.

RESULTS: Response rates were 84% for pediatricians and 79% for family medicine physicians (N = 623). Proportions routinely offering the vaccine were 85% of pediatricians and 45% of family medicine physicians (P < .0001); 70% of pediatricians and 22% of family medicine strongly recommended the vaccine (P < .0001). Sixty-two percent of pediatricians and 32% of family medicine physicians (P < .0001) knew the age by which all 3 doses should be completed. Definite barriers to vaccine use included reported lack of coverage by insurance companies (family medicine physicians: 22%; pediatricians: 19%; not significant), costs of purchasing vaccine (family medicine physicians: 22%; pediatricians: 17%; not significant), lack of adequate reimbursement (family medicine physicians: 18%; pediatricians: 15%; not significant), concerns about safety (family medicine physicians: 25%; pediatricians: 9%; P < .0001), and concerns about adding another vaccine to the schedule (family medicine physicians: 22%; pediatricians: 5%; P < .0001).

CONCLUSIONS: Rates of offering the new rotavirus vaccine are high among pediatricians but <50% among family medicine physicians. Both specialties identified financial barriers to use of the vaccine, but family medicine physicians had significantly more concerns about safety and about adding another vaccine to the vaccination schedule.

Transmissibility and Control of Pandemic Influenza A (H1N1) Virus

Science
30 October 2009  Vol 326, Issue 5953, Pages 639-737
http://www.sciencemag.org/current.dtl

Reports
The Transmissibility and Control of Pandemic Influenza A (H1N1) Virus

Yang Yang,1 Jonathan D. Sugimoto,1,2 M. Elizabeth Halloran,1,3 Nicole E. Basta,1,2 Dennis L. Chao,1 Laura Matrajt,4 Gail Potter,5 Eben Kenah,1,3,6 Ira M. Longini, Jr.1,3,*

Pandemic influenza A (H1N1) 2009 (pandemic H1N1) is spreading throughout the planet. It has become the dominant strain in the Southern Hemisphere, where the influenza season has now ended. Here, on the basis of reported case clusters in the United States, we estimated the household secondary attack rate for pandemic H1N1 to be 27.3% [95% confidence interval (CI) from 12.2% to 50.5%]. From a school outbreak, we estimated that a typical schoolchild infects 2.4 (95% CI from 1.8 to 3.2) other children within the school. We estimated the basic reproductive number, R0, to range from 1.3 to 1.7 and the generation interval to range from 2.6 to 3.2 days. We used a simulation model to evaluate the effectiveness of vaccination strategies in the United States for fall 2009. If a vaccine were available soon enough, vaccination of children, followed by adults, reaching 70% overall coverage, in addition to high-risk and essential workforce groups, could mitigate a severe epidemic.

1 Center for Statistics and Quantitative Infectious Diseases, Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA 98109, USA.
2 Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA 98195, USA.
3 Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA 98195, USA.
4 Department of Applied Mathematics, University of Washington, Seattle, WA 98195, USA.
5 Department of Statistics, University of Washington, Seattle, WA 98195, USA.
6 Department of Global Health, University of Washington, Seattle, WA 98195, USA.

* To whom correspondence should be addressed. E-mail: longini@scharp.org