International Influenza Book

The Infuenza Division
International
Activities
Fiscal Year 2009 Annual Report
National Center for Immunization and Respiratory Diseases
Influenza Division
Suggested Citation
CentersforDiseaseControlandPrevention.InternationinuenzareportFY2009.Atlanta:U.S.Departmentof
HealthandHumanServices;2010.
Acknowledgement
TeU.S.CDCInuenzaDivisionwouldliketoacknowledgetheWHORegionalOces,theNationalInuenza
Centers,andallofourinuenzasurveillancecooperativeagreementpartnersfortheirdedicationanddetermination
toestablish,expand,andmaintainseasonalandpossiblepandemicinuenzasurveillancelocallyandglobally.Teir
notableeortsandcontributionshavesignicantlyincreasedlaboratoryandepidemiologiccapacityfortheworldto
respondbettertopandemicandotheremerginginfectiousdiseasethreats.Teircollectiveeorthascontributedto
greaterglobalhealthsecurity.
Cover Photo Credit
JoelM.Montgomery,PhD
Animalsinanopen-airmarketinPeru.
TheInfuenza
Division
International
Activities
FiscalYear2009AnnualReport
U.S.DepartmentofHealthandHumanServices
CentersforDiseaseControlandPrevention

Contents
InuenzaDivisionMission.......................................................................................................1
Background................................................................................................................2
U.S.CDCandWHOCollaborationsInuenza......................................................7
GlobalDiseaseDetectionandtheInuenzaDivision.................................................9
AfricaRegionalOce(AFRO)..............................................................................................17
Angola......................................................................................................................19
DemocraticRepublicofCongo................................................................................23
Ethiopia....................................................................................................................27
Ghana.......................................................................................................................31
Kenya.......................................................................................................................35
GDD-Kenya.............................................................................................................39
Madagascar...............................................................................................................41
Nigeria.....................................................................................................................43
RepublicofCtedIvoire..........................................................................................47
Rwanda....................................................................................................................51
SouthAfrica.............................................................................................................55
Tanzania...................................................................................................................61
Uganda.....................................................................................................................65
Zambia.....................................................................................................................69
EasternMediterraneanRegionalOce(EMRO)...................................................................73
Afghanistan..............................................................................................................79
ArabRepublicofEgypt............................................................................................83
GDD-Egypt.............................................................................................................85
Morocco...................................................................................................................87
Pakistan....................................................................................................................89
EuropeanRegionalOce(EURO)........................................................................................97
Armenia..................................................................................................................101
RepublicofGeorgia................................................................................................107
Kazakhstan.............................................................................................................111
GDD-Kazakhstan...................................................................................................115
KyrgyzRepublic.....................................................................................................117
RepublicofMoldova..............................................................................................121
Romania.................................................................................................................125
Ukraine..................................................................................................................127
iii
PanAmericanHealthOrganization(PAHO).......................................................................135
Argentina................................................................................................................139
Brazil ......................................................................................................................143
InuenzaProgramofGDDResponseCenterfor
CentralAmericaandPanama(GDD-RC/CAP)...............................................147
GDD-Guatemala....................................................................................................153
Mexico...................................................................................................................155
Paraguay.................................................................................................................159
Peru........................................................................................................................161
South-EastAsiaRegionalOce(SEARO)...........................................................................167
Bangladesh.............................................................................................................171
India.......................................................................................................................175
Indonesia................................................................................................................183
Nepal......................................................................................................................187
SriLanka................................................................................................................189
Tailand.................................................................................................................193
GDD-Tailand.......................................................................................................199
WesternPacicRegionalOce(WPRO).............................................................................203
Cambodia...............................................................................................................209
China.....................................................................................................................215
GDD-China...........................................................................................................219
LaoPeoplesDemocraticRepublic(LaoPDR) ........................................................221
Mongolia................................................................................................................225
TePhilippines.......................................................................................................229
SecretariatofthePacicCommunity,
PacicPublicHealthSurveillanceNetwork...................................................233
Vietnam.................................................................................................................239
ResearchandTraining..........................................................................................................247
BurdenofDiseaseandRiskFactors........................................................................251
DevelopmentandValidationofEnhancedSurveillanceandDiagnostics.................259
InuenzaPreventionProjects..................................................................................261
Animal-HumanInterfaceActivities........................................................................265
InuenzaCooperativeResearchattheAnimal-HumanInterface............................271
MolecularEpidemiology.........................................................................................273
U.S.CDCsTreatReductionCollaboration..........................................................275
LaboratoryTrainingandResearch...........................................................................277
InuenzaDivisionSta........................................................................................................283
iv
InfuenzaDivisionMission
TeInuenzaDivisionprovidesthescienticandprogrammaticfoundationandleadershipfor
thediagnosis,prevention,andcontrolofinuenzadomesticallyandinternationally.
Inaddition,theInuenzaDivision
Conductsglobalanddomesticsurveillancetoguidevaccineformulationandunderstand
theeectofinuenza.
Developspolicyforthepreventionandcontrolofinuenza.
Conductsstate-of-the-artresearchtobetterunderstandtheevolution,antigenicity,
geneticproperties,antiviralsusceptibility,transmissibility,pathogenicity,immune
response,andothercharacteristicsofinuenzavirusesinordertodevelopbettertools
forpreventingandcontrollinginuenza.
Providesinternationaltechnicalassistanceforoutbreakinvestigations,theexpansionof
laboratoryandepidemiologiccapacity,andinternationalanddomestictraining.
1
Background
TeInuenzaDivision(formerlytheInuenzaBranch)hasalonghistoryofproviding
internationaltechnicalassistanceandsupporttotheWorldHealthOrganization(WHO)and
WHONationalInuenzaCenters(NICs)toenhancelaboratorycapacity.Becauseoflimited
resources,mostsupportprovidedinternationallywastechnicalinnatureandincollaboration
withtheWHO.Foryears,mostofthetechnicalassistanceprovidedwasthroughhands-on
laboratorytrainingofstainothercountries,theannualprovisionofWHOreagentskits
producedanddistributedbytheU.S.CentersforDiseaseControlandPrevention(CDC),
andtechnicalconsultationsforvaccinestrainselections.Inaddition,theInuenzaBranch
conductedepidemiologicresearch,includingvaccinestudiesandserologicassays,andprovided
internationaloutbreakinvestigationassistance.
In1997,thersthumancasesofavianinuenzaA(H5N1)inhumanswerereportedinHong
Kong,andthebranchplayedakeyroleinassistingwiththeoutbreakinvestigations.Te
reemergenceoffatalhumancasesofavianinuenzaA(H5N1)inChinain2003following
severeaccuterespiratorysyndrome(SARS)ledtoagrowingconcernthatapandemicof
inuenzamightsoonoccur.
In2004,ongoingoutbreaksofavianinuenzaandhumancasesofavianinuenzainVietnam
andTailandheightenedtheconcernthatapandemicmightemerge.Teseeventsfostered
thebeginningofalargerinternationalprogramtoimproveglobalpandemicpreparednessand
enhancecapacityforlaboratoryandepidemiologicsurveillanceofseasonalandavianinuenza.
TehumanoutbreakscausedbyhighlypathogenicavianinuenzaA(H5N1)virusesin2003
and2004highlightedseveralimportantgapsthatneededtobeclosedtoimprovetheabilityto
rapidlyidentifyavianinuenzaviruseswithpandemicpotential.
Tesegapsincluded
Conspicuousgeographicgapsinhuman
inuenzasurveillance.
Criticalgapsininformation,laboratoryand
epidemiologictraining,andtechnologytrans-
ferforrapididenticationandanalysisofavian
inuenzavirusesinmanyaectedcountries.
Long-standingobstaclesandgapsinsharing
information,resources,andspecimensbetween
agricultureandhumanhealthauthorities.
Fundingwasmadeavailablein2004tobeginto
addressglobaldecienciesinpandemicprepared-
ness.TeU.S.government(HHS/CDC)committed
resourcesanddevelopedamultifacetedapproachto
enhancetheexistingWHOGlobalInuenzaProgram
(GIP),aswellasestablishinuenzasurveillancein
countriesthatdidnotparticipateinWHOsGIPby
providingtraining,stang,directassistance,suppliesandreagents,andtechnicalassistance.Te
programaccomplishedkeygoalsbybuildingonexistingprogramsandinfrastructure,includ-
ingtheWHOanditsregionaloces,U.S.CDCsGlobalDiseaseDetection(GDD)sites,
2
InternationalEmergingInfectionsProgram
(IEIP)sites,theDepartmentofDefenses
internationalprogramsites,andbyusing
theassistanceofU.S.embassies.
Overthepast5years,theprogram
hasundergoneremarkablegrowth(see
maps)andexpandedtoprovidesupport
tomorethan40countries,allWHO
regionalocesandheadquarters,and
hasdevelopedpartnershipswiththe
DepartmentofDefense,theUnitedStates
AgencyforInternationalDevelopment
(USAID),BureauofEngavingand
Printing(BEP,)CooperativeforAssistance
andReliefEverywhere(CARE),andother
entitiestoenhanceglobalsurveillanceand
preparedness.Wehaveplacedmorethan
20permanentsta(seemap)intheeldtoprovideon-the-groundassistanceandsupportto
countriesandWHO,andtoaugmenttheGDDprogram.
Becausedierentcountrieshavevaryingneeds,theprogramhasbeendesignedasacontinuum
toincludeimprovingsurveillance,implementingburdenofdiseasestudiestomeasurethe
impactofinuenza,andenhancingpandemicpreparedness.Byusingdatageneratedby
surveillance,eachcountrywillbeabletodeterminewhichpopulationsaremostvulnerableto
inuenza-relatedmorbidityandmortalityand,therefore,shouldreceiveinuenzavaccine.On
thebasisofsurveillanceandotheranalyses,inuenzavaccinationpolicycanbeformulated,and
issuesrelatedtovaccineproductioncanbeexaminedineachcountryandthrougharegional
perspective.BycollaboratingwithWHO,theUnitedStatesandothercountrieswithinuenza
vaccinationprogramscanshareinformationondevelopingvaccinationpoliciesandtechnologies
fordevelopinginuenzavaccineproduction.Tus,theresourcesandeortstoimprove
inuenzasurveillancewillpayfuturedividendsbyaidingindevelopingvaccinepolicy,vaccine
production,pandemicplanning,andpreparednessoverall.
OnApril13,2009,therstcaseof2009pandemicH1N1inuenzavirusinfectioninthe
UnitedStateswasidentied.SubsequentcaseswerequicklyidentiedinMexicoandother
countries.Teinuenzavirusidentiedintheseearlycaseswasuniqueandcontaineda
combinationofgenesegmentsthathadnotbeenpreviouslyreportedinanimalsorhumans.
AsofMarch2010,laboratory-conrmedinfectionswith2009pandemicH1N1inuenzahad
beenidentiedin212countriesandoverseasterritoriesandhavebeenassociatedwithmore
than15,000deathsreportedworldwidetoWHO.TeH1N1pandemicallowedmanyofthe
countriesthatweworkwithtoshowcasetheprogresstheyhavemade.First-timeinvestigations
ofinuenzawereconductedinresponsetothepandemic,andlaboratoriesthatpreviouslycould
notidentifyinuenzawereabletodiagnosepandemicH1N1byusingmoleculartechniques.
Manycountriesthathadnotreportedinuenzaroutinelybeforewereablethentoreport
consistentlyandcontributetotheglobalpictureofinuenzaduringthepandemic.
AlthoughtheresponsetotheH1N1pandemicwasanopportunitytoshowrecentprogress,
avianinuenzaH5N1outbreaksstillposeasignicantandongoingglobalhealththreat.
Tosustainthegainsmadeduring2009,abroad-basedcommitmenttobuildandmaintain
3
sustainable(andeventuallyself-sustainable)inuenzasurveillancegloballyrequiresdedicated
annualizedresourcesandstang.ItisourhopethattheseU.S.HHS/CDCresourcesand
technicalassistancewillactasacatalystforaectedcountries,neighboringcountries,and
donorcountriestocommitresourcestoestablishlong-terminuenzasurveillance,prevention
andcontrol,andpandemicpreparednessactivitiesashighpriorities.Inaddition,weenvision
thateachaectedcountrywillusethetechnicalassistanceandresourcesavailabletoimprove
surveillance,developinuenzavaccinationpolicy,planfortheuseofinuenzavaccineboth
annuallyandduringapandemic,andworkcloselywithregionalandinternationalpartnersto
furtherpreparedness.
Tisprogramhasimplications
beyondinuenza.Tecapacitythat
isbeingdevelopedforlaboratory
andepidemiologicsurveillancehas
servedasthebasisforthediagnosis
andinvestigationofotherinfectious
diseases.Laboratoryequipmentand
traininghasenabledthediagnosis
andinvestigationofotherdiseases.
Likewise,byimplementingaglobal
rapidresponsetrainingprogram,
U.S.CDChastrainedorprovided
materialstotrainthousandsof
peopleglobally.Tesecourses
haveenabledtheteamstrainedto
participateinoutbreaksforthe
recentpandemicandformanyother
pathogens,includingRiftValley
fever,Ebola,andotherrespiratory
diseases.Evidenceshowsthatthe
technicalassistanceprovidedbythe
InuenzaDivisionassistscountries
inincreasingtheircapacitynecessary
forcompliancewiththenew
InternationalHealthRegulations
(IHR).
Ourgenericapproachandafocus
onseasonalandavianinuenza
contributegreatlytotheglobal
capacityforlaboratory,epidemiology,andoverallpreparednessforemergingandreemerging
infectiousdiseases.TeInuenzaDivisionsinternationalprogramhascontributedgreatly
toglobalcapacityandreadiness,butthereisstillmuchworktodo.Tisreportisthesecond
annualupdateontheInuenzaDivisionsinternationalactivities.
4
U.S. CDC International Activities and Support, FY 2004
Cooperative Agreement WHO Cooperative Agreement DoD Collaborations
U.S. CDC International Activities and Support
FY 2004
FY 2007
Cooperative Agreement WHO Cooperative Agreement U.S. CDC Infuenza International Assignees
Direct Funding GDD Sites DoD Collaborations
5
Cooperative Agreement Indirect Fundi ng
Epidemiologist Veterinary Epidemiologist (recruiting)
Sustainability Cooperative
Agreement
Direct Funding
Lab oratorian Veterinary Epidemiologist
Laboratorian (Proposed) Pub lic Health Adviso r GDD Sit es Laboratory Systems (recruiting) DoD Collaborations
U.S. CDC Field Assignee, FY 2009
FY 2009
U.S. CDC International Field Assignee
FY 2009
Epidemiologist (Proposed) WHOCooperative Ag reement
Epidemiologist (Proposed) Veterinary E pidemiolog ist (Recruiting) Indirect Funding Cooperative Agreement
Epidemiologist
Public Health Advisor Sustainability Cooperative Agreement Direct Funding
GDD Sites
WHOCooperative Agreement DoD Collaborations Laboratorian (Proposed) Laboratorian
6
U.S.CDCandWHO
CollaborationsInfuenza
March2009
TeU.S.HHS/CDCInuenzaDivisionhasmaintainedcooperativeagreementswithWHO
headquartersandthePAHOandWPROregionalocesformanyyearstoaddressseasonal
andpandemicinuenza.In2006,newcooperativeagreementswereputinplacewithSEARO,
AFRO,EMRO,andEURO.Temainpurposeofthecooperativeagreementshasbeento
addressglobalandregionalpreparednessneedsforinuenzaseasonal,pandemic,and
avianandtosupportenhancementoftheWHOGlobalInuenzaSurveillanceNetwork.
Troughthesecollaborations,standardguidelinesforsurveillancehavebeendeveloped
andusedinmanycountriesandthenationaldiseaseburdenhasbeenestimated.Tiseort
eectivelyincreasedthenumberofcountriesparticipatinginglobalinuenzasurveillanceand
hasenhancedtheglobalandlocalcapacityforearlypandemicwarning,eectiveresponse,and
communication.Tisworkhelpedcountriesrespondtothe2009H1N1inuenzapandemic.
TeU.S.CDCInuenzaDivisionhasprovidedfundingandtechnicalsupporttoWHO
headquartersin2009formultipleprojectsrelatedtoinuenza:
Inuenza Pandemic Preparedness
WHOconductedaninventoryof180nationsanddistributedatoolkittosupport
countriesindesigningandconductingpandemicexercises.WHOpandemicinuenza
guidanceisunderrevision.
Animal-Human Interface Inuenza Surveillance
Aworkgrouphasbeenexpandedandmeetsthecriticallyimportantmandateof
improvingsurveillanceandcollaborationattheanimal-humaninterface.Environmental
surveillanceforbirdswasconductedinIndonesia,Kazakhstan,andEgypt,andpilot
toolsweredevelopedforriskassessmentofhumaninfection.Workhasbeencarried
outinmultiplecountries,andrelationshipswiththeOceofInternationalEducation
(OIE)andtheFoodandAgricultureOrganization(FAO)havebeenstrengthened.
Strengthening Inuenza Surveillance Nationally and Globally
Developinginternationalstandardsforsurveillanceisplanned.Teinternational
standardswillintegrateseasonalandavianinuenzagoals,developeducationalmaterials
formedicalcareworkers,andintegrateepidemiologicandlaboratorysurveillance.Work
todeveloppandemicsurveillanceguidelineshasbeenconductedincollaborationwith
otherinternationalexperts.
Inuenza Surveillance Laboratories
AprocesstolookatimprovingtheoverallfunctioningoftheGlobalInuenza
SurveillanceNetworkisunderway.Teprocessinvolvesanassessmentoftheevolving
needsofthesystem,whichisparticularlyimportantgiventhespreadofavianinuenza
andtheemergenceof2009H1N1inuenzavirus.On-siteconsultationstargeted
countriesinneedofsupport.Criticalworktodevelopanewplatformforsharing
informationisongoing.Lastly,globalcasedenitionshavebeendevelopedand
published.
7

External Quality Assessment Program (EQAP)
EQAPiscriticaltoimplementingqualityassurance/qualitycontrol(QA/QC)for
RT-PCR,themethodofchoiceforidenticationofH5viruses,becauseofthe
laboratorybiosafetyconditionsavailableinmostcountries(biosafetylevel2[BSL-2]).
Teobjectivesaretoestablishexternalqualitycontrolforthedetectionofinuenza
viruses,tomonitorqualityandstandardsofperformanceforNICs,andtopromote
goodlaboratorypractices.TeworkwiththeEQAPhasbeenongoinganddiagnostic
QAassessmentpanelsforPCRhavebeenshippedoutevery6monthsforthepast3
years.Anincreasingnumberofcountriesareparticipating.
Facilitating Early Response and Laboratory Conrmation
Tisprojectaddressesissueswiththespecimendeliverysystem.Ourgrantsupportsafull-
timestamemberdedicatedtofacilitatingshipments,keepingrecords,andenhancingthe
systemsetup.Preplacementofmaterialsinsomeregionalocesisplannedtoenhancethe
timelinessofdistributingmaterialstolaboratoriesworldwide.Virussharingissueshave
beenongoing,andmuchtimehasbeendedicatedtoplatformsforsharinginformation.
Pandemic Inuenza Rapid Response and Early Containment
Workhasbeenongoingtoupdateandpublishnewguidelinesforcontainment.Tese
activitiesstrengthentheglobalpandemicpreparednessbyoutliningstandardoperating
proceduresforglobalpartnersintheareasoflogistics,managementandrapiddeployment
ofantiviraldrugs,clearances,waiversandlicensureofantiviraldrugsandnonpharmaceuti-
calinterventionsincountries,deploymentofteams,andotherimportantprocedures.
Pandemic Risk Communication
WHOconductedtrainingforrepresentativesfrom150memberstatesinoutbreak
communication,providedtrainingtojournaliststoimprovequalityofoutbreak
coverage,developedtheOutbreakCommunicationPlanningGuidelines,initiatedthe
WHOGlobalHealthSecurityNetwork,andsupporteddevelopmentofanemergency
communicationsimulation(exercise)toolkit.
WHO Biosafety and Laboratory Capacity and Strengthening Programs
Teseprogramshavedevelopedapilottrainingtooltouse(Train-the-TrainersManual)as
ameansforlaboratorypersonnelandtheirmanagerstoimprovebiosafetypracticesaround
theworld.Biosafetytrainingseminarswereconducted.Teworkshopshaveprovideda
forumfornationalhealthauthoritiesanddirectorsofnational,centralhumanandanimal
laboratoriestomeetsubjectmatterexpertsinbiosafetyandbiosecurity,aswellasother
nationalauthoritiesfromthesameregionwithongoingexperienceintheseissues.
South-East Asia and Western Pacic Pandemic Inuenza Stockpile Development
WehaveprovidedcontinuedsupportfortheregionalWHOstockpile.Te3
componentsofthisprojectare
Establishinganavianandpandemicinuenzacountermeasurestockpilemodeled
oncommercialpharmaceuticaldistributionsystems.
Planningtherelease,shipment,receipt,anddistributionofstockpiledmaterialsto
countriesofSEAROandWPRO.
TrainingandexercisedrillsformemberstatesofSEAROandWPROforthereceipt
anddistributionofstockpiledmaterials(distaldistributionwithinnational
boundaries).
8
GlobalDiseaseDetectionandthe
InfuenzaDivision
TeU.S.CDCsInuenzaDivisionandGDDhaveworkedtogethersince2004todecrease
thethreatoffuturepandemics.Togetherwithpartners,theyhaveconnectedtheirtechnical
expertise,internationalpresence,andresourcestodevelopanintegratedglobalnetworkto
meetGDDscongressionalmandatetomitigatetheconsequencesofacatastrophicpublic
healthevent,whetherbyanintentionalactofterrorism,orthenaturalemergenceofadeadly
infectiousvirus.Congress,2004.
GDDandtheInuenzaDivisionprotectthehealthofAmericansandtheglobalcommunity
fromthespreadofinfectiousdiseasethreatsbycontributingtoaglobalsystemofdisease
protectioninsupportofWHOandthenewlyrevisedInternationalHealthRegulations(IHR).
Tegoalsofthispartnershipareto
EstablishconnectedglobalsystemsandcentersthroughouteveryWHOregioninorder
todetectandrespondtonewdiseasethreats,includinginuenza.
SupportaU.S.governmentresponsetoinfectiousdiseaseandinuenzapandemics.
Supportothercountriesresponsesbydecreasingthetimeittakestodetect,report,and
containormitigatethespreadofinfectiousdisease.
U.S.CDCsGlobalResponsetoPandemic2009
H1N1Infuenza
BeginninginearlyApril2009,U.S.CDCanalystsreceivedtherstreportsofunusual
outbreaksofpneumoniainpartsofMexico.Withindays,theInuenzaDivisionandGDD
recruitedepidemiology,laboratory,quarantine,communication,logistics,andpolicyexperts
fromaroundtheagencytojointheinternationalteamthathasbecometheepicenterofCDCs
globalresponseto2009H1N1inuenza.
TeU.S.CDCsInuenzaDivisionledtheagencysresponsetothepandemicboth
domesticallyandgloballywithsupportfromexpertsatU.S.CDCheadquartersandin
40countriesinwhichU.S.CDCsupportsinuenzapreparedness.
TeGDDoperationscentermonitoredreportsof2009H1N1infectionsandassociated
deaths,includingcountriesthathadnotyetociallyreportedcasestoWHO.
U.S.CDCstawhowereassignedtomorethan50countries,including6GDD
regionalcenters(oneineachWHOregion),providedreal-timereportsoninuenza
trendsintheirhostcountries.
GDDRegionalCenters
AcentralfocusofGDDisestablishingandexpandingGDDregionalcenters.Asanetwork,
GDDregionalcenterscoordinatewithlocal,regional,andglobalpublichealthentitiesto
rapidlydetect,accuratelyidentify,andpromptlycontainemerginginfectiousdiseasesand
bioterroristthreatsthatoccurinternationally.
9
CDCs Global Disease Detection (GDD) Program
GDD Regional Centers
During20042009,U.S.CDClaunchedanddeveloped6GDDregionalcenters,1ineach
oftheWHOregions.RegionalcentersarelocatedinChina,Egypt,Kazakhstan,Kenya,
Guatemala,andTailand.In2009,Indiawasidentiedasthelocationforthe7thGDD
regionalcenter,andinitialactivitiesareunderway.
U.S.CDC-FundedGlobalDiseaseDetectionRegional
Centers
Kazakhstan
2008
Egypt
2006
China
2006
Guatemala
2006
Thailand
2004
Kenya
2004
Location of GDD Center
Approximate Operational Reach of GDD Center
(Note: dependent upon establishment of agreements with neighboring countries)
GDDregionalcentersareselectedinconsultationwithnationalandinternationalpartners.
Centersassimilatetheon-siteexpertiseoffull-timeU.S.CDCassignees,MinistryofHealth
(MOH)staandpartners,andotherresourcestohelpthehostcountryandsurrounding
regionincreasetheirownabilitiestodetect,conrm,andcontainpublichealththreatsand
emergenciesofinternationalconcern.
TeInuenzaDivisionprovidessupportto
GDDsoutbreak,laboratory,surveillance,
training,andriskcommunicationactivities,
andthedivisionisavestedleaderindening
regionalcenterprioritiesincoordination
withMOHs,includingpolicydevelopment.
Forexample,byusingdatagenerated
fromthevarietyofsurveillancesystems
developedthroughtheNationalCenterfor
ImmunizationandRespiratoryDiseases
(NCIRD)andGDDscollectiveresources
andscienticscope,inuenzavaccination
wasrstrecommendedtoTailandin
2008.Questionsaboutvaccinepolicycan
beapproachedonacountry-by-countryandregionalbasistodeterminethepopulationsthat
aremostvulnerabletoinuenza-relatedmorbidityandmortalityandestablishevidence-based
decisionsonwhoshouldreceiveinuenzavaccine.
10

GDDOperationsCenter
TeGDDoperationscenterislocatedatU.S.CDCsheadquartersinAtlantaandisan
innovativeunitthatusesnontraditionalsurveillancemethodstoprovideearlywarningabout
internationaldiseasethreats.Tisevent-basedsurveillancesystemisparticularlyeectiveat
detectingdiseaseoccurrencesincountriesthathaveweaksurveillanceandreporting.Since
2006,theGDDoperationscenterhasprovidedsupporttomorethan30outbreakresponsesin
15countries.
TeoperationscenterisoftenthersttoalertCDCU.S.-basedprogramsorCDCinternational
staaboutapotentialdiseaseabnormalitywithpotentialtobecomeathreattothepublics
health.InformationiscollectedandanalyzedfromInternet-basedmediareportsbyusing
sophisticatedtext-miningandmultilingualtranslationsystemsandthenenteredintoacustom
designedsoftwareapplicationthatalsodistributesdailyreportstoU.S.CDCprograms.
TeoperationscenterisU.S.CDCsliaisonwiththeGlobalOutbreakAlertandResponse
Network(GOARN)toreceiveandrespondtorequestsforinternationalassistancetocontrol
diseaseoutbreaks.Inaddition,theoperationscenterprovidestechnicalsupportandfundsforout-
breakresponsetoU.S.CDCprogramswhenhostcountriesandWHOrequestU.S.assistance.
Development of Public Health Capacity
GDD Centers Core Capacities U.S. CDC Program Leads
Emerginginfectiousdiseasedetectionresponse. IEIP
Trainingineldepidemiologyandlaboratory
methods.
FieldEpidemiologyTrainingProgram(FETP)
Pandemicinuenzapreparednessandresponse. InuenzaDivision
Zoonoticdiseaseresearchandcontainmentat
thehuman-animalinterface.
NationalCenterforEmergingandZoonotic
InfectiousDiseases
Healthcommunicationandinformation
technology.
Twoprograms:
OceofCommunication
InformationTechnologyServicesOce
Laboratorysystemsandbiosafety. Twoprograms:
DivisionofLaboratorySystems
OceofHealthandSafety
ExtendingScientifcExpertise
GDDregionalcentersintegrateandextendtheabilitiesofdiversescienticdisciplinesand
publichealthprogramsthroughoutU.S.CDCthatareneededtocreatesystemsandsolutions
tobetteridentifyandcontrolpublichealththreatsatthesourceoftheproblem.GDDis
connectedtomorethan2,500U.S.CDCexpertsinmorethan50countries.Inaddition,GDD
providestacticalassistancethroughitsTechnicalSupportCorps,acadreoftechnicalexpertsthat
provide24-hour,7-daysupporttoGDDregionalcentersandcanfacilitateaidtotheeldin
thecaseofprolongedorcomplexemergencies.
Currently,14subjectmatterexpertsthroughoutU.S.CDCarefundedbyGDD.Manyare
ndingnewprotocolsandecienciesthatarebeginningtobesharedbetweenU.S.CDCpro-
gramsandGDDcenters.
11

GDDprogressrepresentsthecollectiveachievementsoftheGDDregionalcentersandotherU.S.
CDCprogramsandpartnersandisreportedcumulativelyfromJanuary2006throughOctober
2009.
GDDInfuenzaActivities
OutbreakResponse
GDDregionalcentersprovidedrapidresponsetomorethan436diseasesin2009.
Inuenza-relatedinfectionsaccountedfor45%oftotaloutbreaks.
Surveillance
Morethan4millionpersonsareundersurveillanceforpneumoniaandotherrespiratory
diseases,diarrhea,jaundice,febrileillness,andothersyndromes.
In2009,GDDcenterstrackedandanalyzedallavailablesurveillancedatarangingfrom
U.S.CDCsevent-basedsystems,sentinelsites,andpopulation-basedcohortstodetect
outbreaksforpandemic2009H1N1inuenzatoevaluateinterventionsandmake
policyrecommendations.
Networking
SinceApril2009,aspartoftheinternationalresponsetothepandemic2009H1N1inuenza
outbreak,U.S.CDChasdeployed67expertsto12countriestoassistwitheldinvestigations,
laboratorysetupandtraining,riskcommunication,mitigationstrategies,casedenitions,data
management,logistics,clinicalcare,surveillance,andtransmissionstudies.
GDDHeadquartersLeadership,Atlanta
ScottDowell,MD,MPH
DivisionDirector,DiseaseDetectionandEmergencyResponse
RayArthur,PhD
Director,GDDOperationsCenter
StephanieGriswold,MPH
GDDProgramManager
GDDRegionalCenterLeadership
GDD-Kenya: Established 2004
RobBreiman,MD,MPH
GDDCountryCoordinator
MarkKatz,MD
InuenzaLead
GDD-Thailand: Established 2004
SusanMaloney,MD,MPH
12
MarkSimmerman,MD,MPH
InuenzaLead
GDD-China: Established 2006
JeMcFarland,MD
GDDCountryCoordinatorandInuenzaLead
GDD-Central America and Panama (CAP): Established 2006
IsabellaDanel,MD,MPH
NivaldoLinaresPrez,MD,MSc,PhD
InuenzaLead
GDD-Egypt: Established 2006
EricaDueger,PhD,DVM
MichaelDemming,MD,MPH
InuenzaLead
GDD-Kazakhstan: Established 2008
JohnMoran,MD,MPH
InuenzaLead
GDD-India: Selected in 2009
RenuLal,PhD
ActingGDDCountryCoordinatorandInuenzaLead
Formoreinformation,pleasevisittheGDDWebsite:www.cdc.gov/globalhealth/GDD.
13
14
AfricaRegional
Offce(AFRO)
AfricaRegionalOffce(AFRO)
HumanInfuenzaSurveillance:AFRO2010
U.S. CDCAssignee
WHOAFROHeadquarters
WHORegionalLab
GDDSite
ProposedWHONationalInfuenzaCenter
WHONationalInfuenzaCenter
PasteurInstitute
AFROMemberStates
ProposedInfuenzaCooperativeAgreement
HHS/IPNCoAG
InfuenzaCooperativeAgreement 0 250 500 1,000 1,500
Miles
TeWHOAFROcoordinatesandoverseesactivitiesamong46memberstatesintheAFRO
region.In2006,WHOlisted9AfricancountrieswithNICsthatcoulddetectinuenzaviruses
andreportepidemiologicndingstoWHO.Laboratoryassessmentsconductedin2006and
2007byWHOandU.S.CDCdeterminedthatonly5of9NICswereactive.
TeU.S.CDCsigneda5-yearcooperativeagreementin2006tohelpstrengthenavianinu-
enzapreparednessandresponseintheAFROregion.TisinvolvesexpandingtheNICnetwork
toimprovebothdiagnosticandepidemiologiccapacitiesbyworkingtowardthefollowinggoals:
Enhancingepidemiologicandvirologicsurveillanceforinuenza,includinghighly
pathogenicavianinuenza.
Reinforcingresponseandcontainmentofavianandpandemicinuenza.
Strengtheningpreparednessandcommunicationforavianandpandemicinuenza.
TeU.S.CDCworkswithAFROtoexpandtheGlobalInuenzaSurveillanceNetwork
(GISN)intheAfricanregion.In2008,AFROdevelopedguidelinesforsentinelsitesurveillance
forinuenzaandsevereacuterespiratoryinfection(SARI)andincludedsurveillancefor
SARIwithintheIntegratedDiseaseandSurveillanceResponse(IDSR)system.AFROhas
recommendedthatallmemberstatesreportSARIintheirweeklyreportingactivitiesfromthe
17
districtlevel.TestatesareaskedtoimmediatelyreportunusualSARIcasesorclustersand
suspectedcasesofinuenzaAvirus(H5N1)orpandemic2009H1N1inuenza.
Allcountriesintheregionhavebeenreporting2009H1N1inuenzasinceMay2009.
CountriesinthewesternepidemiologicblockofAFROhavebeenreportinghumanavian
inuenzacasesweekly.AspartoftheWHOglobalresponseto2009H1N1inuenza,AFRO
disseminatedsurveillanceguidelinesfornovelinuenzatoallmemberstates.Tesecountries
useU.S.CDCpandemicinuenzafundstoimplementIDSRtraining,promotereporting
ofSARIandothernotiablediseasesbyclinicians,andenhancediseasesurveillanceat
internationalpointsofentry.
Tencountriesintheregion(i.e.,Angola,Benin,BurkinaFaso,RepublicofCongo,Gabon,
Malawi,Mali,Mozambique,SierraLeone,andTogo)havebegunorareplanningtobegin
inuenzatesting.CDCpandemicinuenzafundshavesupportedtheongoingtrainingof
laboratorysta.Inaddition,workshopshavebeenheldonbiosafetyandlaboratorysecurity.
U.S.CDCStaff
RichardDavis,MSFS
ProjectOcer
1600CliftonRoad,MSA20
Atlanta,GA30333
E-mail:rbdavis@cdc.gov
InzuneHwang,MD
Epidemiologist
1600CliftonRd.,MSA32
Atlanta,GA30333
E-mail:Ihwange@cdc.gov
CDC-KenyaFieldStaff
MarkKatz,MD
GlobalDiseaseDetectionDivision
CDC-Kenya
KEMRIHeadquarters
MbagathiRd.,oMbagathiWay
P.O.Box606
VillageMarket00621
Nairobi,Kenya
E-mail:MKatz@ke.cdc.gov
WHO/AFRO
CeliaWoodll,PhD
AvianInuenzaFocalPoint
CSR/AFRO/WHO
Brazzaville,RepublicofCongo
E-mail:woodll@afro.who.int
18
AfricanRegion
Angola
Capital:Luanda InfantMortalityRate:Total:182.31deaths/1,000
Area: 1,246,700sqkm
livebirths;male:194.38deaths/1,000livebirths;
Population:
female:169.64deaths/1,000livebirths(2008est.)
13,068,161(July2010est.)

LiteracyRate:
AgeStructure:
Totalpopulation:67.4%;male:
014years:43.6%(male2,760,264/
82.9%;female:54.2%(2001est.)
female2,707,665);1564years:53.6%(male
3,416,914/female3,302,552);65yearsorolder:2.7%
GDP: $114.6billion(2008est.)
(male151,609/female192,353)(2008est.) GDPperCapita: $9,100(2008est.)
LifeExpectancyatBirth:Totalpopulation:37.92
years;male:36.99years;female:38.9years(2008est.)
U.S.CDCDirectCountrySupport
PreparednessandResponsetoAvianandPandemicInuenzaCooperativeAgreement
BeganFY2006.
FY2009wasthe3rdyearofthecooperativeagreement.
TeNationalInstituteofPublicHealth(INSP)isthecentralreferencelaboratoryoftheMOH.
TeINSPledtheemergencyresponserolefor2009H1N1inuenza.TerstAngolacasewas
conrmedinSeptember2009atthelaboratoryoftheNationalInstituteofCommunicable
Disease(NICD)inSouthAfrica.U.S.CDCandNICDsupportedINSPtobuildthecapacity
ofthelaboratoryandtoprovideon-the-jobtrainingonmolecularbiologytechniquesto
diagnose2009H1N1inuenzaon-siteinAngola.
LaboratoryconsultantsfromNICDSouthAfricaprovidedadditionalsupportinAngolafrom
October2005toOctober2009totestforpandemicandseasonalinuenzaattheAngolaINSP.
Duringthisperiod,theconsultantsworkedwith3INSPlaboratorytechnicianstotest159
samples;20sampleswerepositivefor2009H1N1inuenzaviruses,and5sampleswerepositive
forseasonalinuenzaH3N2.Todate,196sampleshavebeentested,and36areconrmed
2009H1N1inuenzacases.Since2006,U.S.CDChassupportedtheINSPlaboratorywith
capacitybuilding,laboratorysupplies,andinfrastructureupgrades.
19
Surveillance
Angolahas3functioningsentinelsurveillancesitessupportedbytheavianandpandemic
inuenzacooperativeagreement.TeINSPmolecularbiologylaboratoryhasthecapacityto
diagnosetheinuenzavirusesbyusingreal-timeRT-PCR.
TenationalinuenzasurveillanceeortinAngolastartedinOctober2008throughintensive
on-sitetrainingactivitieswithnurses,medicaldoctors,andlaboratorytechnicians.Tehealth
workersweretrainedatthe3selectedsentinelsites:DavidBernardinoPediatricHospital,Josina
MachelCentralHospital,andUigeProvincialHospital.
InMay2009,activesurveillancestartedinthesesentinelsitesthroughSARIcaseidentication
andinuenza-likeillness(ILI)casesinoutpatients.Adatacollectiontoolwasdevelopedby
CDCSouthAfrica;itwasusedbydedicatednurseswhoworkedinthesentinelsitefacilities.
TeycollectedoralandnasalpharyngealsamplesandtransportedthemtotheINSP,wherethey
werepackagedandsenttotheSouthAfricaNICDforconrmationduringtheearlyphases
ofsurveillanceactivities.Tesurveillancesystemcollectsbothepidemiologicinformationand
laboratoryspecimensatthesentinelsitesinLuandaandUigeprovinces.
Laboratory
CDCAngolasupportsthemolecularbiologylaboratoryofINSPwithtraining,laboratory
equipmentprocurement,installation,andmaintenance.Reagentsandlaboratoryconsumables
arefurnishedtohelpwithinuenzasurveillanceactivities.ConsistenttrainingofINSP
laboratorytechniciansincludedhands-onworkwithmoleculartechniques,suchasreal-time
RT-PCRforH5N1,2009H1N1inuenza,andseasonalinuenza.Inaddition,laboratory
standardoperatingproceduresweredevelopedtoenhancequalitymeasures.
Laboratorydatabases,reportingsystems,andmechanismsforshippingsamplestoreference
laboratorieswereestablished.TenINSPlaboratorytechniciansreceivedcerticationtrainingon
theshipmentofdangerousgoods(IATAapproved).
Preparedness
Angolahasanationalpreparednessplanthatwascollaborativelydevelopedandupdatedwithall
stakeholdersinvolvedinthe2009H1N1inuenzaresponse.
20
Training
U.S.CDCfundinghassponsoredthefollowingtrainings:
Laboratorytrainingof2techniciansatNICDSouthAfricaon2009H1N1inuenza
diagnosisinMay2009.
SpecializedtrainingtostrengthenthecapacityofthepandemicinuenzaRapid
ResponseTeams(RRTs).TeRRTswereestablishedandtrainedinLuandain
September2008;theyhad36participantsfromtheMinistriesofHealthand
AgricultureandtheAngolaArmedForce.Te36participantsrepresented15ofthe18
provinces.
Twentyparticipantsweretrainedininuenzasentinelsurveillance;2hospitalsin
LuandawereselectedassentinelsitesforSARIandILIcases(Luanda,October2008).
Fortyparticipantsparticipatedinon-the-jobtrainingatJosinaMachelHospitaland
DavidBernardinoPediatricHospital(October2008May2009).
OnehundredsixtyparticipantsfromUigeandHuilaprovinces,whereanadditional2
sentinelsiteswereidentied(October2009),receivedtrainingataworkshop.
Twenty-twoprovincialministryofhealthandagricultureocersweretrainedinUige
Provinceininuenzasentinelsurveillance(April2009).
Sevenhealthworkershadon-the-jobtrainingatUigehospitalandprovinciallaboratory
toimplementSARIandILIsurveillance(August2009).
H1N1 Activities,FY2009
CDCAngolaandINSPplayedactiverolesinpreparedness,communicationstrategies,
andresponseeortsforoutbreaksofpublichealthconcerns,suchasthe2009H1N1
inuenzaepidemic.
CDCAngolaparticipatedintheMOHmultidisciplinarytechnicalteamthatwasassist-
ingwiththe2009H1N1inuenzaoutbreakandoeredaworkshopfornationaland
internationalstakeholders,includingCDCinuenzaexpertsfromSouthAfrica.
INSPlaboratorytechnicianstravelledtotheSouthAfricaNationalInstituteof
CommunicableDiseaseRespiratoryVirusUnittoreceivetrainingin2009H1N1
inuenzadiagnostictechniques.TiscollaborativeeortsupportedINSPsexpansionof
SARIillnessandILIsurveillanceactivitiesat3sentinelsites.
SeveraltrainingswereconductedbytheINSPandCDCAngolaandSouthAfrica:
Trained207healthworkersinLuandaprovinceonsamplecollection,preservation,and
transportation.
Supportedtheinterministerialcommissionsworkgroupofpandemic2009H1N1
inuenza.
Providedsurveillancematerialstoselectedsitesandprovinces(e.g.,questionnaires,per-
sonalprotectiveequipment[PPE]forthesurveillanceocers,samplecollections,swabs,
andviraltransportmedia,includingstandardoperatingproceduresandguidelines).
Provided2009H1N1inuenzaworkshops.
Providedinformation,education,andcommunicationmaterials.
Shippedsuspectspecimenstotheregionalreferencelaboratoryforconrmation(NICD
inJohannesburg).
21
NotableAchievements,2009
Established3functionalsentinelsitesinLuandaandUigeprovinces.
Supplied(U.S.CDC)reagentsandneededequipmentattheINSPlaboratorytohelp
with2009H1N1inuenzadiagnoses.
Contributedtoamorerobustpandemicinuenzaresponsethroughsuccessfulcapacity-
buildingactivitiesthatinvolvedhealthworkersatINSPlaboratoryandsentinelsites.
TeNationalInstituteofPublicHealthbecamethe4thlaboratoryintheSouthern
Africaregiontodiagnoseandconrm2009H1N1inuenzacaseson-site.
SpecialInfuenzaProjects
Discussionswereinitiatedtoestablishpartnershipsandresearchprojectsinvolvingthefaculty,
medical,andnursingstudentsofthepublicuniversity.
PrincipalCollaborators
FilomenaGomesDaSilva,Director
InstitutoNacionaldeSadePblica
RuaAmilcarCabral,Maianga,Luanda
RepublicadeAngola
E-mail:lomenasilva5@yahoo.com.br
YolandaCardoso,MSc,Virologist
RepblicadeAngola
E-mail:yolanda.insp@gmail.com
U.S.CDCStaff
FrancineBuranga
AvianInuenzaCoordinator
RepblicadeAngola
E-mail:francineb@ao.cdc.gov
MargaridaRodrigues,PhD
LaboratoryAdvisorCDC
RepblicadeAngola
E-mail:rodriguesm@ao.cdc.gov
XiomaraBrown,MD,MPH
Epidemiologist,GAPChiefofParty
RepblicadeAngola
E-mail:brownxluanda@ao.cdc.gov
22
AfricanRegion
DemocraticRepublicofCongo
Capital: Kinshasa LifeExpectancyatBirth:Totalpopulation:53.98
Area: 2,345,410sqkm
Population: 70,916,439
InfantMortalityRate:Total:83.11deaths/1,000
AgeStructure:
014years:47.1%(male
15,711,817/female15,594,449);1564years:
50.4%(male16,672,399/female16,875,468);65
LiteracyRate:Totalpopulation:67.2%;male:
yearsorolder:2.5%(male674,766/female985,607)
80.9%;female:54.1%(2001est.)
(2008est.) GDP: $21.08billion(2008est.)
GDPperCapita: $300(2008est.)
DevelopingInuenzaSurveillanceNetworksCooperativeAgreement
BeganSeptember2006.
FY2009isthe3rdyearoftheagreement.
DemocraticRepublicofCongo(DRC)hasbeencollaboratingwiththeU.S.CDCon
inuenzacontrolsince2006.TecollaborationisthroughacooperativeagreementSupport
SurveillanceandResponsetoAvianandPandemicInuenza.Acoreofprofessionals(technical
andadministrative)andexpertsfromthe4thdirectorate,InstitutNationaldeRecherche
Biomdicale(INRB),andtheKinshasaSchoolofPublicHealthworkontheinuenza
surveillancenetworkproject.TeteamcontinuesitsclosecollaborationwiththeU.S.CDC
avianinuenzafocalpointandWHOandthenationalcommitteeforavianinuenza.
Internationalsupporthascontributedtostrengtheninuenzasurveillanceandprioritydiseases
inthecountry,notably,supportfromU.S.CDCtoimproveinuenzalaboratorydiagnostic
capacity.Teagreementimprovesinuenzalaboratorytestingcapabilityandenhances
preparednessandresponsecapacitytoinuenzapandemicandotherdiseaseemergencies.
Sinceitsestablishmentin1984,INRBcontinuedtofunctiondespitemanysocialandeconomic
challengeswithinDRC.Asof1998,thankstobilateralandmultilateralcollaborationswith
internationaldonors,INRBenhanceditsresearchinfrastructureandimprovedthework
capacityofitstechniciansandscientists.Currently,INRBisinvolvedinthesurveillanceof
poliomyelitis,measles,andyellowfeverundertheauspicesofWHO.
23
Surveillance
TeDRChasnotdetectedhumanoranimalcasesofH5N1,butremainsathighriskbecause
ofcertainfactors,suchasitslargegeographicarea,locationinthedirectpathwayofwildbird
migratorymovementsthatoriginatefromAsiaandEurope,andtheimportationofpoultry
andproductsfromothercountrieswithH5N1.Anotherimportantfactorispublicknowledge
ofH5N1inuenzaprevention.Inaddition,therecentemergenceof2009H1N1inuenza
worldwidecausesfear,worry,andconfusionamongpeopleinDRC.
TencountrywidesentinelsitesweresupportedinFY2009tostrengtheneciencyin
detecting,reporting,sampling,testing,andshippinglaboratoryspecimenstothenational
inuenzalaboratory.Supportprovidedincludedtoolsandformsfordatacollection,laboratory
consumablesandsupplies,phonecredits,paymentofshippingcosts,andlocaltransport.
Overthepast3years,theKinshasaSchoolofPublicHealth(KSPH),theINRB,andtheMOH
4thdirectorateinchargeofdiseasecontrolcarriedoutsurveillanceactivities,suchashelpingto
Writenationalplansforsurveillanceandresponsetoavianandpandemicinuenza.
Integratehumaninfectionfromavianinuenzavirusonthenationallistofsurveillance
diseases.
Adaptanddisseminatedocumentsaboutinuenzacasedenitionandnotication,
samplescollectionandshipment,andreporting.
TrainmedicalbiologistsinPCR.
Trainnationalandprovincialsentinelsitesta.
Implementsentinelsitesthroughoutthecountryandsupplysamplesandavian
inuenzarapidtests.
Analyzesamplesandreportingresults.
Laboratory
INRB,DRCsnationalreferencelaboratory,performsseasonalandpandemicinuenza
laboratorydiagnostics.INRBhassetupadatabase,purchasedreagentsandoceequipment,
andhired2statoperformprojectfunctions.InFY2009,INRBreceivedanRT-PCRmachine
andreagentsfromCDC-Atlanta.TeRT-PCRmachinewassetup,andstaweretrainedbya
consultantcontractedbyCDC-Atlanta.Acoreofprofessionals(technicalandadministrative)
andexpertsfromthedirectorate,INRB,andtheKSPHworkedontheinuenzasurveillance
networkproject.TeteamcontinuestoworkcloselywiththeU.S.CDCavianinuenzafocal
point,WHO,andthenationalcommitteeforavianinuenza.Temaincomponentsofthe
INRBinclude
Clinicallaboratory.
Appliedresearch.
Laboratory-baseddiseasesurveillance.
Referencelaboratory.
24
Despitechallengestosettingupandmaintainingtheinuenzalaboratory,inuenzatestingwas
conductedduringFY2009withthefollowingresults:
Atotalof1,016sampleswerecollectedduringFY2009.
Atotalof360sampleswerecollectedfrompatientswithSARI.
Atotalof547sampleswerecollectedfrompatientswithILI.
Atotalof109sampleswerecollectedfrompatientswhowerenotclassied.
Ofthe1,016samples
Atotalof78(8%)testedpositiveforinuenzaA.
Atotalof20(2%)testedpositiveforinuenzaB,and908(90%)testednegative
forinuenzaAorB.
ResultsshowthatA(H3N2)wasthepredominantstraincirculatingin2008and2009.
Ofthe78patientswithinuenzaA
Atotalof32(41%)hadSARI,26(33%)hadILI,and20(26%)werenot
classied.
Seventy-eightsampleswithinuenzaAweresubtyped:
Forty-fourcasesofA/H3N2(56%).
TwelvecasesofseasonalA/H1N1(15%).
TwelvecasesofnewH1N1(15%).
Sixcasesunclassiedbyreal-timeRT-PCR(8%).
Fourcasesnotanalyzed(6%).
Preparedness
TeAvianInuenzaNationalPlanwasgeneratedin1996andrevisedinJune2008andMarch
2009.Telatestversioniswaitingtobeadoptedbythegovernment.Teplansgoalisto
Preventintroductionofavianandpandemicinuenzaintothecountry.
Controloutbreaksbykeyinterventions,surveillance,stockimportationcontrols,mass
communications,trainings,diseasecontainmentactivities,andcompensationforlost
poultrystock.
Tenewrevisionaimedtoadaptthenationalplanaccordingtothecurrentepidemiologic
contextandavailableresources.TeplanwasrevisedbytheAvianInuenzaNationalTechnical
Committeewithallthecommissionsintegratingthehumanandanimalaspectsofthesurveil-
lanceandresponse.TeDRCgovernmentisconsideringtheproductionofadistinctplanthat
willintegrateinuenzaH5N1and2009H1N1inuenza.Teintegratedplanisinprocess.
SupporttotheMOHisbeingprovidedtoconducteldassessmentsofweeklysurveillance
systemsandtoimprovethepreparednessplanningandrapidresponseteams.Aweeklydatabase
ismanagedbytheMOHoceinchargeofsurveillancediseases,andthisdataissharedglobal-
ly.Inaddition,thenationaltechnicalcommitteeorganized10monthlymeetingsfromOctober
2008throughSeptember2009.
25
Training
TrainingisprovidedbytheKSPHto
UpdatetheknowledgeandskillsofCongolesehealthprofessionals,asneeded,toaddress
healthmanagementpriorities.
Enhancediseasesurveillance,healthresearch,andoperationsresearchtogatherand
evaluatedataandprogramsintheDRC.
Provideleadershipandtrainingontheuseofinformationtechnologytothehealth
programmanagersandpolicymakersintheDRC.
Trainhealthcareprofessionalsfromtheinuenzasentinelsitestoensureadequate
performanceindetecting,reporting,sampling,usingrapidtests,managingcases,
andreducingtransmissionriskatthesites.Tisactivitywasconductedbytrained
supervisors,includingclinicians,medicalbiologists,andalaboratorytechnician.
Teoutbreakof2009H1N1inuenzawasagoodopportunitytostrengthenthenational
diseasesurveillancesystem.WHOhelpedtomanagetheoutbreakbydelivering100,000doses
ofantiviralmedicine(Tamiu)forthenationalH1N1response.
Duringtheoutbreak,messageswerecreatedandsentonasmallscaleaccordingtodeveloped
communicationstrategies.TesemessageshelpedpeopledistinguishbetweeninuenzaA
(H1N1)andavianinuenza(AI).Moreofthesemessageswillbedesignedandsenttotherest
ofDRC.
SpecialProjects
TereisagreatneedtoimprovecommunicationaboutinuenzasurveillancefromKinshasato
otherareasthroughouttheDRC.Aninuenzahotlinewassetupin2006byINRBtoprovide
awarenessofinuenzatothepopulation,anditcontinuestoprovidetheaccurateinformation.
TenumberofcallerstothehotlinedeclinedbeforetheHIN1pandemic,but84,200callers
receivedanswersandinformationabouttheirinuenzaquestionsduringFY2009.
PatrickKayembe
Director
KinshasaSchoolofPublicHealth
P.O.Box11850
Kinshasa1,DRC
E-mail:patkayembe@yahoo.fr
EmileokitolondaWemako
PrincipalInvestigator
KinshasaSchoolofPublicHealth
P.O.Box11850
Kinshasa1,DRC
E-mail:okitow@yahoo.com
26
AfricanRegion
Ethiopia
Capital:AddisAbaba InfantMortalityRate:Total:82.64deaths/1,000
Area: 1,127,127sqkm
Population:
88,013,491

LiteracyRate:
AgeStructure:
014years:46%(male18,922,334/

50.3%;female:35.1%(2003est.)
20,749,002/female21,656,509);65yearsorolder:
2.7%(male947,323/female1,252,077)(2008est.) GDPperCapita: $800(2008est.)
years;male:52.54years;female:57.51years
(2008est.)
BeganAugust2007.
FY2009wasthe3rdyearoftheinuenzacooperativeagreement.
Surveillance
Established3sentinelsitesinAddisAbabathatfeedintothenationalinuenza
laboratoryforILIinclinicpatientsandSARIinhospitalpatients.
Adaptedandnalizedsentinelsurveillanceimplementationguidelinesandprotocol;
ILIandSARIcasedenitions;andcase-based,weeklyaggregated,reportingformatsfor
inuenzasentinelsurveillanceinEthiopia.
Laboratory
CollectedspecimensinNovember2008fromILIsitesandinJanuary2009fromSARI
sites.Todate,thenumberofspecimenscollectedfromILIsitesis89andfromSARI
sitesis132.
Analyzed,laboratorysamplesbyusingreal-timePCRfromILIsites(60)andfromSARI
sites(47).
CDC-Kenyascientistsgaveanorientationonreal-timePCRandtroubleshooting,
August31,2009toSeptember10,2009.
27
ObtainedcerticationofbiologicsafetycabinetsinNationalInuenzaLaboratory,
September2009.
ParticipatedinWHOExternalQualityAssuranceProgram(EQAP)inJuly2009forthe
rsttime.
PresentedEthiopianNationalInuenzaLabatrstNICmeetingintheAFROregion,
Dakar,Senegal,November2008.
Preparedness
Reactivatedthenationaltaskforceforzoonoticdiseasesatthehighestgovernment
levelandreviewedthenationalpandemicpreparednessandresponseplaninvolvingall
stakeholders.
Developedpublicawarenessexercises.
Distributedstandardcasedenitions.
Developedaninuenzacommunicationstrategy.
Training
Provided2roundsoftrainingonspecimencollection,storage,transportation,infection
preventionandcontrol,andepidemiologyofavianinuenzafor58healthcareworkers
fromselectedinuenzasentinelsites,September2008andJanuary2009.
Laboratorystamemberparticipatedintrainingworkshop,SafeShipmentof
InfectiousSubstances,Johannesburg,SouthAfrica,March911,2009,organizedby
WHO.
TwolaboratorystamembersparticipatedintrainingorganizedbyCDC-Kenya,
KenyaMedicalResearchInstituteonreal-timePCRdiagnosisof2009H1N1inuenza,
Nairobi,Kenya,June24,2009.
28
Gaveorientationonnewinuenzato138federalandregionalhealthprofessionals,May
2009,andtostaofSt.PetersHospitalinAddisAbaba,thesiteidentiedforscreening
suspectcasesof2009H1N1inuenza.
Identied31federalandregionalhospitalsforthemanagementofcases.
Distributedspecimencollectionmaterialstohealthfacilitiesselectedforscreeningcases
of2009H1N1inuenza.
Distributedantiviraldrugs(i.e.,Tamiu)andN95maskstoselectedhospitals.
Identiedisolationandtreatmentwards,primarilyatSt.PaulsHospitalandlateratSt.
PetersTuberculosisSpecializedHospital,bothlocatedinAddisAbaba.
Initiatedlaboratorytestingofsuspectcasesimmediatelyafterreceiving2009H1N1
inuenzakitsandconsumablelaboratoryitemsfromU.S.CDC,June2009.
Screenedmorethan80suspectcases;10caseswerepositivefor2009H1N1inuenza.
Establishedanemergencyoperatingcenterundertheemergencypublichealth
managementdirectorate.
PreparedandsubmittedanabstractfortheAfricaInuenzaScienticSymposiumon
2009H1N1inuenzainEthiopia.
Participatedinbriengstothepubliconthethreatof2009H1N1inuenzaand
laboratorystatusregardingtestingforsuspectcases.
Initiatedtestingoflaboratoryspecimenscollectedthroughroutineinuenza
surveillance.
LaboratoryparticipatedinWHOEQAPforthersttime.
Builtcapacityforreal-timePCRtestingofinuenzavirusesattheEthiopianHealthand
NutritionResearchInstitute(EHNRI).
DaddiJima,MD,MPH
DeputyDirectorGeneral
EHNRI
P.O.Box1242
E-mail:daddij@ehnri.gov.et
WorkeneshAyele,PhD
NationalInuenzaLaboratoryHead
EHNRI
E-mail:wayele@gmail.com
29
U.S.CDCStaff
BerhanuAmare,MD,MPH
TechnicalOcer-AI
U.S.Embassy
EntotoStreet
P.OBox1014
AddisAbaba
Attention:CDC-Ethiopia
E-mail:amareb@et.cdc.gov
30
AfricanRegion
Ghana
Capital:Accra InfantMortalityRate:Total:49.89deaths/1,000
Area: 238,533sqkm
Population:
24,339,838

AgeStructure:
LiteracyRate:Totalpopulation:57.9%;male:
014years:36.8%(male4,529,594/
66.4%;female:49.8%(2000census)
3.6%(male395,007/female470,433)(2010est.) GDPperCapita: $1,500(2009est.)
U.S.CDCIndirectCountrySupport
Developing Infuenza Surveillance Networks in Collaboration with U.S. NAMRU-3 in Ghana
Continuousglobalscrutinyofinuenzavirusesthatcauseillnessinhumansisrequiredtodetect
changesinthevirusesanddistinguishoutbreaksthatcouldleadtopandemics.Terefore,inuenza
surveillancehasbeeninitiatedbyroutinelymonitoringacuterespiratoryillnessinselectedhealth
institutionsinGhana.Tissurveillanceispartofnationalpreparednesseortsforthethreatof
pandemicinuenzawiththeU.S.NavalMedicalResearchUnit-3(NAMRU-3)andU.S.CDC.
Surveillance
SeasonalinuenzasurveillancewasstartedatsentinelsitesinGhanainSeptember2007.Since
then,morethan1,700sampleshavebeenprocessed,and100isolateshavebeencultured.Before
FY2009,289sampleshadbeenprocessedand28isolatescultured.InFY2009,thisnumber
roseto1,380samplesprocessedand65isolatescultured.Morethan100sampleseachmonth
havebeenprocessedconsistentlysinceApril2009.
Laboratory
Tefollowinglistsquantitiesandtypesofsamplesprocessed:
ILI
Processed1,380samplesfrom10sentinelsites.
Cultured65isolates.
31
Detected4antigenicallydistinctH3N2viruses;thesamplesweresenttotheWHO
inLondonforfurtheranalysis.SeveralunusualH3N2viruseswereidentiedand
sequenced.
2009 H1N1 infuenza
Processed200samples.
FourteensampleswerepositiveforpandemicH1N1.
SARI
Processed32samplesbyDFA.
Twosampleswere2positivebyDFA(i.e.,RSVandinuenzaAH3).
Avian infuenza (AI)
Collectedandprocessed1,000birdsamples.
Preparedness
SensitizationofMuslimpilgrimsatHajjvillage.Drugsfortreatinginuenzahavebeen
leftwiththemedicalteamtotreatthosewhomaycontractinuenzawhileinMecca
duringthepilgrimage.
Undertooktechnicalsupportvisitsandtrainingforregionalanddistrictteamsin
surveillanceandmanagementofdiseasesbynationalteamsinall10regions.
Continuedsurveillanceandmanagedcasesbyregionalanddistrictteams.
Meetingsoftechnicalcoordinatingcommitteesatnational,regional,anddistrictlevels
areongoing.
Intensiedpubliceducationthroughmassmedia(i.e.,electronic,print).
CollectedandtransportedsamplesfromsuspectedcasestoNoguchifordiagnosisis
ongoing.
Distributedantiviraldrugsfor2009H1N1inuenzaandmaterialsforcollecting
specimensfromsuspectedpatientstoalltheregions.
Activatedthecommunicationstrategyanddistributedposterson2009H1N1inuenza
toalltheregions.
Directedallregionalhealthdirectoratestoworkwithmediahousestosecurefreeairtime
inordertoeducatethepubliconthedisease.
TeSchoolHealthEducationProgramcoordinatorsaretakingstepstosensitizeschool
childrenandtofacilitatethedetectionofanycaseoffeverwithcoughorsorethroatfor
immediatenotication.
Training
SARI (i.e., Global Emerging Infections Surveillance [GEIS], CDC)
Trained144hospitalstainresearchethics.
Provideddirectuorescentantibody(DFA)testtrainingfor10hospitallaboratorysta,
including2fromthe37thmilitaryhospital.
32
Providedsurveillanceprotocolandepidemiologictrainingformorethan80hospital
sta,including11fromthe37thmilitaryhospital.
Trained25healthcareworkersinsamplecollectiontechniquesfornasopharyngealand
oropharyngeal(NP/OP)swabs.
Infuenza (CDC-Atlanta)
Trained30participantsfromWestAfricancountries(i.e.,BurkinaFaso,CotedIvoire,
Ghana,Nigeria,Togo,Liberia,SierraLeone)insurveillanceepidemiologyand
laboratorytechniquesataregionaltrainingworkshopfundedbyCDC-Atlanta.
ILI
Trained36workersfrom12sentinelsitesinGhanainILIcasedenitionand
surveillancereviewtraining.
H1N1
Providedtrainingfor15peoplefrom5countries(i.e.,Ghana,BurkinaFaso,Nigeria,
Senegal,CtedIvoire)inGhanaattheNoguchiMemorialInstituteforMedical
Research(NMIMR).
Trained76healthcareworkersfrompublicandprivatefacilitiesdesignatedaspandemic
clinicsbytheMOHinH1N1casedenitionsandsamplecollection.
Tepandemicstrainof2009H1N1inuenzawasidentiedinGhanainAugust2009.To
date,345sampleshavebeencollectedfromsuspectedcases,andcontactshavebeentestedatthe
NMIMRlaboratory;38positivecasesofpandemic2009H1N1inuenzahavebeenconrmed
bythelaboratory.Fromthese38conrmedcases,33arefromtheGreaterAccraregion,3are
fromtheWesternregion,and2arefromtheAshantiregion.Nodeathshavebeenrecorded.
InAugust2009,aSARIprotocolwasimplementedatthelargesthospitalinGhana(i.e.,Korle
BuTeachingHospital),the37thmilitaryhospital,andtheTemaGeneralHospitalthrougha
collaborationamongtheU.S.CDC,theU.S.NAMRU-3,theGhanaHealthService(MOH),
andtheNMIMRinGhana.
JosephAmankwa,MD
DirectorofPublicHealthDivision
GhanaHealthService
E-mail:jaamankwa@yahoo.com
LawsonAhadzie,MD
DiseaseSurveillanceDepartment
GhanaHealthService
E-mail:lahadzie@yahoo.com
WilliamAmpofo,MD
InuenzaLaboratoryCoordinator
NoguchiMemorialInstituteforMedicalResearch
E-mail:wampofo@noguchi.mimcom.org
33
U.S.NAMRU-3andU.S.CDCStaff
LCDRKarlKronmann
Ocer-in-Charge
U.S.NavalMedicalResearchUnitNo.3,GhanaDetachment
E-mail:kckronmann@yahoo.comorkronmannkc@state.gov
Talla-NzussouoNdahwouh,MD
RegionalAvianandPandemicInuenzaAdvisor
U.S.NavalMedicalResearchUnitNo.3
E-mail:tallus5@yahoo.fr
34
AfricanRegion
Kenya
Capital:Nairobi InfantMortalityRate:Total:56.01deaths/1,000
Area: 582,650sqkm
Population:
40,046,566

LiteracyRate:
AgeStructure:
014years:42.2%(male8,065,789/
90.6%;female:79.7%(2003est.)
SurveillanceandResponsetoAvianandPandemicInuenzaCooperativeAgreement
BeganSeptember2004.
FY2009wasthe5thyearoftheagreement.
TeKenyaMinistryofPublicHealthandSanitation(MOPHS)hasalongstanding
collaborationwithU.S.CDCforinuenzapandemicpreparedness.Tebilateralagreement
betweentheKenyaMOPHSandU.S.CDCstartedin2004;ithasprovidedresourcestocreate
anationalsentinelsurveillancesystemforinuenza,including10sentinelsitesandaNIC.Te
collaborationhasalsosupportedworkininfectioncontrolandriskcommunicationrelatingto
inuenzapandemicpreparedness.
Surveillance
TeKenyaMOPHSandCDC-Kenyahasmaintainedanationalinuenzasentinelsurveillance
systemat10sites.SpecimensarecollectedfrompatientswithILIandSARIat7provincial
hospitals,2refugeecamphospitals,andthenationalreferralhospitalinNairobi.Samples
aretestedattheNIC,partoftheKenyaMedicalResearchInstitute,andtheCDC-Kenya
InternationalEmergingInfectionsProgramlaboratory.Everymonth,approximately500
samplesarecollectedandtested.
InearlyMay2009,followingtherstcasesof2009H1N1inuenzainNorthAmerica,the
KenyaMOPHSundertookacampaignwithCDC-Kenya,WHO-Kenya,andtheU.S.Army
35

MedicalResearchUnitinKenyatotraincliniciansatadditionalhospitalsandclinicsaround
thecountryinordertoidentifyandcollectsamplesfromsuspectedH1N1patients.Samples
aretestedattheNICandCDC-Kenyalaboratoriesdaily.Additionalsurveillanceanddetection
workundertakenincluded
RegionallaboratorytrainingsforlaboratoryscientistsinAfrica.
National,provincial,anddistrict-leveltrainingstosupportimplementingthenational
IntegratedDiseaseSurveillanceandResponse(IDSR)system.
PeriodicsupervisoryvisitstosentinelsurveillanceandIDSRsitestomonitorinuenza
surveillance.
SupportfortrainingofnationalMOPHSlaboratoriansininuenzalaboratorytesting,
includinghands-onrotationsthroughtheNICinNairobi.
Preparedness
WithsupportfrompartnersinKenya,theKenyaMOPHShasdevotedconsiderableeortto
preparingthecountryforaninuenzapandemic.Teresultsoftheworkthattookplaceover
thepast3to4yearswereclearwhenthepandemicemergedinKenyainJune2009.Kenyawas
abletoidentifyits1
st
caseof2009H1N1inuenzabytestingattheNIC,andcontacttracing
wasconductedwiththehelpofstafrominuenzasentinelsurveillancesitesthroughoutthe
country.Tepandemicinuenzataskforcemet,andmaterialsforriskcommunicationto
thepublicweredeveloped.Anenhancedtrainingprogramwasundertakentotrainclinicians
aroundthecountryabout2009H1N1inuenza.
Training
TeKenyaMOPHS,theKenyaMinistryofMedicalServices,theWHO,andCDC-Kenyahave
implementedtrainingatprovincialanddistricthospitalsthroughoutKenyatoestablishreporting
throughtheIDSRsystem.Additionally,theMOPHShassupportedtrainingoninuenza
laboratorytesting,inuenzasurveillance,andinfectioncontrolissuesrelatedtoinuenza.
H1N1Activities,FY2009
EnhancedH1N1surveillanceinhospitalsandclinicsthroughoutKenya.
ExtensivecontacttracingofinitialcasesofH1N1inKenya.
Developmentofcommunicationmaterialsforthepublicandguidelinesfornational
cliniciansabout2009H1N1inuenza.
36
Surveillanceanddetectionforseasonaland2009H1N1inuenzaatsitesthroughout
Kenya.
Nationalinfectioncontroltrainingfocusingonthedevelopmentofnationalinfection
controlguidelines.
Establishmentofsurveillanceforhospital-acquiredinfectionsin3Kenyanhospitals.
PrincipalCollaborator
CharlesNzioka,MD
DiseaseSurveillanceandResponseDeptartment
MinistryofPublicHealthandSanitation
P.O.Box2078100202
Nairobi,Kenya
E-mail:nziokacm2003@yahoo.com
37
38
AfricanRegion
GDD-Kenya
GDD-Kenyacenterwasestablishedin2004;itcollaborateswithKenyasMOHandis
recognizedasastrongresourcefordiseasedetectionandresponsethroughoutEastAfrica.
GDD-Kenyahelpsthecountryandtheregiondetectandrespondtoseriouspublichealth
threats,includingcholera,Ebola,extensivelydrug-resistanttuberculosis,inuenza,RiftValley
fever,andtyphoid.
GDD-Kenyahasextendeditscoveragetomorethan10countriesintheregionbydeveloping
regionalpublichealthleaderstrainedthroughtheFieldEpidemiologyandLaboratoryTraining
(FELTP).Mostofthesegraduatesholdleadershippositionsincountriesthroughouttheregion,
includingGhana,SouthSudan,Tanzania,andUganda.Oneofthe1
st
FELTPgraduatesis
leadingtheprograminNigeria.
Activities
Outbreakresponse.
Pathogendiscovery.
Training.
Surveillance.
Networking.
In2009,GDD-Kenyaearnedrecognitionforitsoutstandingworkinresearch,pathogen
discovery,andtraining.GDD-Kenyadiscovered3pathogensthatwerenewtotheregionand
1thatwasnewtotheworld.Inaddition,theyincreasedtheirlaboratorytestingcapacityby
81%.GDD-Kenyatrained13FELTPgraduatesandmorethan3,700participantsinshort-
termregionalandnationaltrainings.GDD-Kenyarespondedto31outbreaks,ofwhich94%
achievedameasurablepublichealthimpact.
In-CountryFieldStaff
RobBreiman,MD,MPH
GDD-KenyaCoordinator
MarkKatz,MD,MPH
InuenzaLead
PrincipalU.S.CDCProgramCollaborationsIn-Country
InuenzaPreparedness,Detection,andResponseProgram.
IEIP.
FELTP.
LaboratorySystemsandBiosafety.
Immigrant,Refugee,andMigrantHealth.
39
40
AfricanRegion
Madagascar
Capital:Antananarivo InfantMortalityRate:Total:52.84deaths/1,000
Area:Total:587,041sqkm
Population:
21,281,844(July2010est.)

LiteracyRate:
AgeStructure:
014years:43.3%(male4,641,212/
75.5%;female:62.5%(2003est.)
5,672,321/female5,745,901);65yearsorolder:3%
(male287,402/female359,879)(2010est.) GDPperCapita:$1,000(2009est.)
DevelopingSeasonal,Pandemic,andInuenzaSurveillanceNetworksCooperativeAgreement
InFY2009,Madagascarwasawardedanewcooperativeagreement.
AnewcooperativeagreementisnowinplacewiththeNICinAntananarivoonbehalfofthe
MOHoftheRepublicofMadagascar.Teagreementisdesignedtosupportexecutionofthe
existingSupportProgramforIntegratedNationalActionPlansAgainstAvianandHuman
Inuenza(SPINAP-AHI)andtocomplementandsupportongoingAIactivities.Teproject
aimstosupportnationaleortstoaddressapossiblepandemicofAIoremergingnovel
inuenzavirusesfromadiseasepreventionandcontrolperspective.Inaddition,theprojectwill
addresspreparednessforpossibleotheremerginginfectionsandSARIto
Monitortheemergenceofpandemicviruses(includingHPAIinhumans).
Reducemorbidityandmortalityfrompossibleemergingrespiratoryinfectiousdiseases
byrapiddetectionandcontainment.
Reduceeconomiceectsandsocialupheavalorunrestfromapandemic.
41
Teprojectsgoalsare
PreparednessandCommunication
Supportandendorseastrategicplanforcommunication.
SupportaKnowledge,Attitudes,andPracticesstudy.
Supporttheformulationofappropriatecommunicationmessagesandmaterial
neededtoaddressapotentialpandemic.
Endorsethecommunicationmessage.
Produceanddisseminatecommunicationmaterials.
SurveillanceandDetection
ContinuesupportingtheNICinMadagascar.
ExpandILIandSARIsurveillancesystems.
Establishacommunicationnetworkamongsentinelsites,theMOH,andIPM.
Recruitalocalepidemiologisttomonitorsentinelsites.
Recruitalocalstapersonfordatabasemanagement.
ImplementSARIsurveillancebydedicatingastapersonforthesurveillanceand
collectionofspecimens.
ResponseandContainment
RevisecomponentofNationalRapidResponseTraining.
TrainRegionalRapidResponseTeams(RRTs).
Developanationalcoursefortheeldinvestigationpracticeofepidemiology.
ProjectInvestigator
Jean-MichelHeraud,PhD
DirectorofVirology
InstitutPasteurdeMadagascar
BP1274
Antananarivo101
Madagascar
42
AfricanRegion
Nigeria
Capital:Abuja InfantMortalityRate:Total:95.74deaths/1,000
Area: 923,768sqkm
Population:
152,217,341

LiteracyRate:
AgeStructure:
otalpopulation:68%;male:75.7%;
014years:41.7%(male31,171,949/
T
female:60.6%(2003est.)
(male2,152,318/female2,270,267)(2008est.) GDPperCapita: $2,200(2008est.)
BeganSeptember2006.
FY2009isthe3rdyearoftheagreement.
TeNigerianFederalMinistryofHealth(FMOH)hasbeencollaboratingwiththeU.S.CDC
oninuenzacontrolsince2006.Tecollaborationisthroughacooperativeagreement
SupporttoSurveillanceandResponsetoAvianandPandemicInuenza.
Tesupporthascontributedtostrengtheninginuenzasurveillanceandsurveillanceforother
prioritydiseasesinthecountry.Notably,inuenzalaboratorydiagnosticcapacityhasimproved
remarkablysincethebeginningofthecollaboration.Teagreementhasalsoenhancedthe
generallevelofpreparednessandresponsecapacityofthecountrytoinuenzapandemicand
otherdiseaseemergencies.
Surveillance
Beforebeginningthecooperativeagreement,Nigeriahadapopulation-basedsurveillance
systemtheIDSRsystem.Tesurveillancesystemmonitorstheoccurrenceof21priority
diseasesinthecountry.Withthethreatofinuenzapandemic,inuenzaA(H5N1)hasbeen
addedtothelistofthecountrysprioritydiseases,bringingthetotalto22prioritydiseases.
43
TecooperativeagreementhasprovidedsupporttostrengthentheIDSRsystembytrainingand
providingsupplies.In2008,inuenzasentinelsurveillancewasintroducedinthecountrywith
thesupportoffundsfromthecooperativeagreement.
DuringFY2009(MarchApril),3sentinelsurveillancesiteswereaddedtotheinitialpilotsite
establishedin2008.EachofthesentinelsitesmonitorsoccurrencesofILIintheiroutpatient
clinicsandSARIamongtheirhospitalizedclients.Tesitesalsosupportsurveillancefor
inuenzaA(H5N1)and2009H1N1inuenzainthecountry.Samplescollectedfromthe
sentinelsitesaretransportedbyacouriersystemtoacentrallylocatedNationalInuenza
ReferenceLaboratory(NIRL)foranalysis.
InFY2009,nancialandtechnicalsupportwasprovidedtotheNigerianMOHforevaluating
thepossibleimplementationoftheIDSRsystemacrossthecountry.Findingsfromthe
evaluationweresharedwithstakeholders,andrecommendationsweremadetoimprovethe
surveillancesysteminthecountry.
Laboratory
Troughthecooperativeagreement,anNIRLwasestablishedin2007,whichbecamefully
functionalin2008.InFY2009,anadditionalPCRmachinewasdonatedbyU.S.CDCtothe
NIRL.U.S.CDCalsoprovidestechnicalsupport,supplies,andreagentstothelaboratory.Te
performanceofthe2ndNICinNigeriawasfurtherboostedinFY2009bythedonationofa
PCRmachine,trainingoflaboratorypersonnel,andtheprovisionofreagents.
Preparedness
PreparednessandresponsetoinuenzapandemicinNigeriaisguidedbyapolicydocument,
Te National Integrated Avian and Pandemic Inuenza Plan,whichwasdevelopedin2007.In
FY2009,U.S.CDCprovidedtechnicalandnancialsupportfortherevisionofthedocument
throughthecooperativeagreement.U.S.CDCalsofacilitatedtherequestandsubsequent
donationof7,000setsofPPEbyUSAIDtotheFMOH.
44
Training
SeveraltrainingswereconductedduringFY2009:
Trained120healthworkers(doctors,nurses,andpharmacists)perzoneonclinical
managementofavianinuenza.
Trained20laboratoriesscientistsonPCRtechnique(didacticsessionandhands-on
practice).
Trained50trainers(doctors,nurses,andpharmacists)forcliniciansonidentifyingand
managingcasesof2009H1N1inuenza.
Trained80stateepidemiologistsandavianinuenzadeskocersoncasedenitionand
surveillancefor2009H1N1inuenza.
Trained3laboratoryscientistsfromNigeriaonPCRdiagnosisof2009H1N1inuenza
inAccra,Ghana.
Aftertheemergenceof2009H1N1inuenzaandthesubsequentdeclarationofaninuenza
pandemicbyWHOsDirectorGeneral,severalresponseactivitieswereinstitutedbythe
cooperativeagreement.
Adaptedcasedenition,surveillanceguidelines,andcasetools.
Adapted2009H1N1inuenzacasedenitionandsurveillanceguideline.
Developed2009H1N1inuenzacasemanagementprotocol.
Adaptedrecommendationsforantiviraluse.
Trainedcliniciansonidentifyingandmanagingclinicalcasesof2009H1N1inuenza.
Trainedstateepidemiologistsandavianinuenzadeskocersfromallthestatesoncase
denitionandsurveillancefor2009H1N1inuenza.
Trained3laboratoryscientistsfromNigeriaonPCRdiagnosisof2009H1N1inuenza
inAccra,Ghana.
AcquiredkitsforRT-PCRtestingof2009H1N1inuenzafromU.S.CDC.
Receivedandtestedsamplesfromsuspectedcasesof2009H1N1inuenzaacrossthe
country.
RevisedtheNationalInuenzaPandemicResponsePlantoincorporate2009H1N1
inuenzaconcerns.
CommissionedandhandedoverafullyfunctionalNIRLtothegovernmentofNigeria
bytheU.S.AmbassadortoNigeria.
Activated3functionalinuenzasentinelsurveillancesites.
45
Participatedingrantmanagementtraining.
ParticipatedinMultinational Inuenza Seasonal Mortality Study(MISMS)research
workshoporganizedbyNIHatDakar,Senegal.
Facilitatedregionaltrainingofinuenzasentinelsurveillance,Accra,Ghana.
FacilitatedtheNigerianFieldEpidemiologyandLaboratorytrainingprogram.
FacilitatedtheNationalMDR-TBSurvey.
AbdulsalamiNasidi,MD
FederalMininstryofHealthofNigeria
AhmaduBelloWay,Abuja,
FCT,Nigeria
U.S.CDCStaff
EkanemE.EkanemMPH,PHD
1stCityPlaza,3rdFloor,HerbertMacaulayWay,Abuja,Nigeria
E-mail:Ekaneme@ngcdc.gov
IbrahimT.DalhatuMD,MPA,FMCPH
1stCityPlaza,3rdFloor,HerbertMacaulayWay,Abuja,Nigeria
E-mail:dalhatui@ng.cdc.gov
46
AfricanRegion
RepublicofCtedIvoire
Capital:Yamoussoukro InfantMortalityRate:Total:69.76deaths/1,000
Area: 322,460sqkm
Population:
21,058,798

LiteracyRate:
AgeStructure:
otalpopulation:48.7%;male:
ears:40.9%(male4,161,238/
T
014y
60.8%;female:38.6%(2000est.)
BeganSeptember2006.
FY2009isthe3rdyearofthecooperativeagreement.
TeMinistryofHealthandPublicHygiene(MSHP)ofCtedIvoirehasobtainednancial
andtechnicalsupportfromU.S.CDCforpandemicpreparednessandreinforcementof
inuenzasurveillance.TeNationalInstituteforPublicHygiene(INHP)isthetechnical
beneciaryofthiscooperativeagreementattheMSHP.
Duringthe20082009budgetperiod,allplannedoperationalactivitieswereimplemented.
Implementationoftheseactivitiesproducedanumberofresults,namelyreinforcinglaboratory
diagnosticcapacities.Quickaccesstoinformationandresultshasbeenimprovedbyproviding
sentinelsiteswithsurveillanceandcommunicationsoftware.
Surveillance
Distributionofreportingtoolsandinuenzasurveillancepoliciestosentinelsiteshasbecome
routine,andsamplecollectionandtransporttolaboratoriesareoperational.
Toensuretimelyinformationandavailabilityoflaboratoryresults,the4sentinelsiteswere
providedwithaconnectiontotheInternet.InadditiontoWebaccess,thelaboratoryreceived
computerequipment(i.e.,workstation,printer,UPS).Twodoctorsparticipatedinthe
47

conferenceoftheFrenchSocietyforPublicHealth(SocitFranaisedeSantPublique)in
NantesfromSeptember29,2008toOctober3,2008tosharetheirexperiencewithsurveillance
ofpotentiallyepidemicdiseases.
DuringNovember28December24,2008,anumberofavianinuenzariskcaseswere
investigated.InthehealthdistrictsofPort-Bouet,Treichville,Cocody-Bingerville,San-Pdro,
Sgula,Bouak,andAgnibilkrou,476caseswereinvestigated.
Laboratory
TeNIClocatedatthePasteurInstituteofCtedIvoire(IPCI)hasbeengivenreagentsand
laboratorymaterialsthroughthecooperativeagreementinordertofulllitsroleasinuenza
referencelaboratory,therebyreinforcingitsoperationalcapacity.Telaboratorywasable
toanalyze889inuenzasamplesin2008andapproximately1,000samplesin2009.Asof
September27,2009,thefollowingresultswereachieved:
TwentyspecimenspositiveforA(H1N1).
Onehundredthirty-twospecimenspositiveforA(H3N2).
Eighty-twospecimenspositiveforinuenzaB.
Preparedness
InJune2009,aseriesofsensitizationsessions,whichincluded20townsinNorthand
SouthCtedIvoire,impartedinformationtopoultrybusinessowners,community
leaders,andthelocalauthorities.Duringthesesessions,leaetsandbrochures
explainingtheinuenzamechanismandpreventivemeasuresweredevelopedand
distributedtothepopulation.
Ajournalisttrainingworkshoptookplace,anddiscussionswithneighboringcountries
andpartnerorganizationsareoccurringtodeterminetheidealdatesfortheplanned
cross-bordermeeting.
Training
Healthcareworkerswhoareinvolvedinepidemiologicandbiologicsurveillance
ofinuenzaweretrainedatnationalandinternationalworkshops.Teircapacities
andskillsfordetection,careandtreatment,datacollection,andmanagementwere
reinforced.
August26,2009September2,2009,40healthcareworkersweretrainedin
epidemiologicsurveillance.Tistrainingsessionwasaresponsetotheneedtoupgrade
theskillsofdistricthealthcareworkersforoperationsinthenewsentinelsurveillance
sitesofBouak,Korhogo,Soubr,andDaloa.
September2225,2009,28healthcareworkersfromthesentinelsitesofAgnibilkrou,
Abengourou,Adzop,andAkoupweretrainedinH1N1detectionandcareand
treatment.
DuringOctober1223,2009,24sentinelsitelaboratorytechniciansweretrainedin
IPCIonsamplingtechniques,sampleanalysis(i.e.,PCR),andcellculture.
Toimprovethequalityofdatarecordingandfacilitatedataanalysisduringepidemiologic
surveillanceatINHP,12healthcareworkersweretrainedontheuseofEpi-Infosoftware
duringMay47,2009andJuly69,2009(i.e.,2sessionswith6participantseach).
48
DuringasupervisoryvisittosentinelsitesinJuly2009,thedailyconstraintsandneedsof
healthcareworkerswereanalyzed.TevisitallowedINHPMOHtoanswerhealthcareworker
questionsandsuggestedsolutionstoenablethemtooperatemoreecientlytoimprovetheir
workingskills.Duringthesamemonth,anepidemiologistinchargeofthesurveillanceof
diseaseswithepidemicpotentialattendeda2-weekepidemiologictrainingcourseatParisXI
University,France.Topicscoveredincluded
Supervisinghealthcareworkers.
Buildingthecapacityatthesentinelsites.
Traininghealthdistrictmanagementon2009H1N1inuenzasurveillance,care,and
treatment.
Recruitinglaboratorytechnicians.
Recruitingamedicalepidemiologist.
Providinginformationtothepubliconpreventionandtransmissionof2009H1N1
inuenza.
H1N1ResponseActivities,FY2009
Reinforcementofsurveillancehasalloweddetection,isolation,andcareandtreatment
ofconrmed2009H1N1inuenzacases.
Duringthepastyear,3H1N1casesweredetectedandsuccessfullytreated.
AhotlinehasbeensetupbytheINHPMOHtoprovideanswerstoquestionsand
guidancetothepublicaboutthethreatofpandemic2009H1N1inuenza.
ImplementingSARIsurveillancewithasiteateachofthemedicalteachinghospitalsof
Abidjan(i.e.,Treichville,Cocody,Yopougon).
Real-timePCRtechniquemadeavailableattheNIC(IPCI).
TraininglaboratorystaonthenewH1N1primersandprobesdevelopedbyU.S.CDC.
Odehouri-KoudouPaul,MD
ProjectInvestigator
DirectorofInstitutNationaldHygienePublique
MinistryofHealth,CtedIvoire
E-mail:odehourik@yahoo.fr
CoulibalyDaouda,MD
InuenzaCoordinatorINHPMOH
DiseaseSurveillanceChief
InstitutNationaldHygienePublique
MinistryofHealth,CtedIvoire
BPV4
Abidjan,CtedIvoire
E-mail:daocoul@yahoo.fr
49
Kadjo-AdjeHerve,MD
NICCoordinator
LaboratoryofRespiratoryViruses
InstitutPasteurCtedIvoire
E-mail:rvkdjo@yahoo.fr
U.S.CDCStaff
Talla-NzussouoNdahwouh,MD
E-mail:tallus5@yahoo.fr63
50
AfricanRegion
Rwanda
Capital: Kigali InfantMortalityRate:Total:83.42deaths/1,000
Area: 26,338sqkm
Population:
11,055,976

LiteracyRate:
AgeStructure:
014years:41.9%(male2,143,479/
76.3%;female:64.7%(2003est.)
(male99,721/female149,698)(2008est.) GDPperCapita: $900(2008est.)
years;male:48.56years;female:51years(2008est.)
BeganFY2006.
Surveillance
SentinelsurveillanceofseasonalinuenzahasbeeninitiatedinRwanda.Accordingtothe
nationalstrategy,6activesentinelsiteshavebeenestablishedinordertohave1sentinelsitefor
eachprovince:2aretheuniversityhospitalsinKigaliCityandButarecity,and4aredistrict
hospitals(i.e.,Kibagabaga,Gihundwe,Kibungo,andRuhengeri).TesiteinKigaliCitywas
establishedinJuly2008,KibungoinAugust2008,GihundweinSeptember2008,Kibagabaga
inDecember2008,andButareandRuhengeriinMay2009.
Surveillanceisbasedon5casedenitions:ILI,SARI,personunderinvestigationofavian
inuenza,suspectedavianinuenza,andsuspectednovelinuenzaA(H1N1)2009.Intotal,
537specimensforseasonalinuenzasurveillancewerecollectedandtested.Fifteenpercentof
thespecimenswerepositiveforinuenza.Tepredominantcirculatingstrainwas2009H1N1
inuenza,followedbyinuenzaBandseasonalinuenzaA(H3N2).
Laboratory
TemolecularbiologyunitoftheNationalReferenceLaboratory(NRL)isequippedwithareal
timeRT-PCR7500ABI(AppliedBiosystemIncorporation)totestinuenzasamplesbytyping
51
andsubtypingseasonalinuenza,avianinuenza,and2009H1N1inuenzavirusstrains.
EquipmentthatincludedaBSL-3hood,CO2incubator,refrigeratedultracentrifuge,anddeep
freezers(i.e.,80C)wasreceivedinApril2009.
UndertheMaterialTransferAgreement(MTA)signedwithU.S.CDC,theNRLregularly
receivesprimers,probes,andcontrolsforinuenzavirusfordetectionandcharacterization.
TepanelincludesinuenzaA,inuenzaB,humanH1,humanH3,AsianavianH5(a),Asian
avianH5(b),RNaseprotein(RNP),humanseasonalinuenzaviruspositivecontrol,inuenza
A(H5N1)virusreal-timePCRpositivecontrol,andcompletekitstotest2009H1N1inuenza
virus.TeNRLisnowfullyequipped,andinuenzasampleshavebeentestedsinceSeptember
2008.TeNRLparticipatedinthe5thWHOEQAP.Inaddition,aliquotsareregularlysent
toCDC-Kenyaslaboratoryforqualitycontrol.Tehoodcabinetltersweremaintainedand
certiedinJuly2009bytheSouthAfricancompany,AirFilterMaintenanceServices(AFMS).
Preparedness
InAugust2009,CDC-Rwanda;theCenterforTreatmentandResearchonAIDS,Malaria,
Tuberculosis,andOtherEpidemics(TRACPlus);theRwandaAnimalResourcesDevelopment
Authority(RARDA);andNRLorganizedapandemicinuenzatabletopexerciseatKigali.
Teexercisebroughttogether52representativesfromvariousagenciesinRwanda.Tekey
institutionspresentattheexerciseincludedtheMOH,CDC,TRACPlus,theRwanda
DevelopmentBoard,RARDA,theRwandaBureauofStandards,NRL,WHO,theRwanda
InformationAgency,andtheCentralProcurementOceofEssentialMedicinesinRwanda.
Tediscussion-basedexercisetestedtheNationalPandemicInuenzaA(H1N1)Operational
PlanofRwanda.Itencompassed6sessionsonthefollowingselectedtopicspertainingtothe
pandemicinuenza:diseasesurveillance,laboratorycapacitytodiagnosepandemicinuenza
strains,communication,healthcareplanningandinfectioncontrol,communitydiseasecontrol
andprevention,andantiviralandvaccinedispensinganddistribution.Overall,participantssaid
themostvaluablecomponentsoftheexercisewerediscussingpandemicplan;identifyinggaps,
limitations,andconcerns;andnetworkingwithotherstakeholdersinRwandaonpandemic
inuenza.
Participantsindicatedthatthefollowingareasneededimprovement:
Communitydiseasecontrolandprivateclinicinvolvementinthenationalsurveillance
system.
Laboratorycapacitytodiagnosepandemicinuenzastrains.
Trainingandcommunicationatthecommunitylevel.
ElaboratingSOPsandlegalframeworkforpatientisolation.
Training
TeinuenzasurveillanceocerworkingforMOHTRACPlusattendedtherst
internationalFrancophonetrain-the-trainerworkshoponsentinelsurveillanceof
inuenzaorganizedbyU.S.CDC,InstitutePasteurMadagascar,andWHOAFRO
RegioninAntananarivo(Madagascar),August2008.
52
TwolaboratoryscientistsattheNationalVeterinaryLaboratoryandtheNRLhad
in-houserefreshercoursesontestingseasonalinuenzaanduseof2009H1N1inuenza
kitsbyCDC-KenyaMedicalResearchInstitute(KEMRI)laboratorytechnicians,
September2008.
TeU.S.CDCavianinuenzafocalpointpersonhada2-weektrainingcourseto
prepareforacerticateintheepidemiologyofemerginginfectiousdiseaseswiththe
UniversityofIowasCollegeofPublicHealth.Teonlinecourseisongoing.
Severalhealthcareworkershavebeentrainedininuenzasurveillanceatsentinelsites.
Overall,15medicaldoctors,72nurses,and11laboratorytechniciansweretrained.
CDC-RwandaandRARDAtrained62veterinaryandlaboratorytechnicianson
surveillanceofavianinuenzainpoultry.
Updatedthenationaloperationalplanfor2009H1N1inuenza.
Heldrefreshertrainingforrapidresponseteams.
Stockpiledsupplies(i.e.,14,000Tamiuunits,masks).
NRLtestedandfoundseasonalinuenzacirculatingstrains.
Increasedsentinelsitesfrom4to6.
CompletedisolationfacilityatKigaliUniversityTeachingHospital.
Completedthetabletopexercisetotesttheoperationalplan.
Trained62veterinaryandlaboratorytechniciansonsurveillanceofavianinuenzain
poultry.
DevelopedanabstractoninuenzasentinelsurveillanceinRwanda,July2008June
2009.
TeNRLwouldliketobecomeaNIC.Staneedtrainingandanappropriatefacilityto
performseasonalinuenzaviruscultureandisolationinordertobeableshareisolateswith
WHOcollaborativecenters.Further,theNRLwantstopurchaseareal-timeRT-PCRmachine
toimprovethetimelyreportingofinuenzatestingresults.Atpresent,noearlywarningsystem
exists,butNRLplanstousetheWHOGlobalOutbreakAlertandResponseNetwork.
JacksonSebeza,MD
ProjectInvestigator
DirectorofEIDUnit
TRACPlus
BoulevarddelaRevolution
BP2717Kigali,Rwanda
E-mail:sebeza@yahoo.com
53
OdetteMukabayire
DirectorGeneral,NationalReferenceLaboratory
BoulevarddelaRevolution
BPKigali,Rwanda
E-mail:oxm3@aol.com
TeogeneRutagwenda,DVM,PhD
DirectorGeneral,RARDA
POBox621Kigali
E-mail:rutagwendat2006@yahoo.com
U.S.CDCStaff
PratimaRaghunathan,PhD,MPH
CountryDirector
CDCGlobalAIDSProgram,Rwanda
c/oU.S.Embassy,Kigali
2657AvenuedelaGendarmerie
P.O.Box28,Kigali,Rwanda
E-mail:raghunathanp@rw.cdc.gov
DavidMcAlister,PhD
LaboratoryProgramsManager
CDC-Rwanda
E-mail:mcalisterd@rw.cdc.gov
DavidLowrance,MD,MPH
MedicalEpidemiologist
GlobalAIDSProgram,CDCRwanda
E-mail:lowranced@rw.cdc.gov
JeanBaptisteKoama,MD,MPH
HMISCoordinator
CDCGlobalAIDSProgram,Rwanda
E-mail:koamajb@rw.cdc.gov
JosephRukelibuga,DVM,MSc
CDC-Rwanda
AvianInuenzaFocalPoint
E-mail:rukelibugaj@rw.cdc.gov
54
AfricanRegion
SouthAfrica
Capital:Pretoria(administrativecapital) InfantMortalityRate:Total:45.11deaths/1,000
Area: 1,219,912sqkm
Population:
49,109,107

LiteracyRate:
AgeStructure:
otalpopulation:86.4%;male:87%;
014y
T
ears:29.2%(male7,147,151/
5.3%(male1,050,287/female1,518,044)(2008est.) GDPperCapita: $10,400(2008est.)
BeganAugust2007.
FY2008wasthe2ndyearoftheagreement.
Surveillance
Viral Watch Surveillance Program
SouthAfricahasalongstandingILIsurveillanceprogramwith256outpatientsentinelsites
inall9provincesthatincludesbothgeneralmedicalpractitionersandhospitals.In2009,in
responseto2009H1N1inuenza,theprogramexpandedtoincludeadditionalhospitalsitesin
all9provinceswherepatientswithSARIareenrolled.
55
SARI Surveillance Program

SARIsurveillancewasintroducedin2009with4publicsectorhospital-basedsitesasfollows:
ChrisHaniBaragwanathHospitalTisurbanhospitalislocatedinGautengProvince
withawell-denedpopulation(Soweto).
EdendaleHospitalTissemi-urbanhospitalislocatedinKwaZulu-NatalProvince.
MapulanengandMatikwanaHospitalsTeseruralhospitalsareadjacenttothe
AgincourtdemographicsurveillancesiteinMpumalangaProvince,whereannual
populationsurveysondemographicfactors(e.g.,births,deaths,migrations)are
captured.TesesurveyswillallowformoreaccurateestimationofratesofSARI
hospitalizations.
Detailedclinicalandepidemiologicdata,sitelaboratoryresults,patientoutcomes,and
specimensfordetectionofrespiratoryviruses(i.e.,inuenza,respiratorysyncytialvirus,
adenovirus,humanmetapneumovirus,enterovirus,rhinovirus,andparainuenza1,2,
and3),Streptococcus pneumoniae,andHIVinfectionarecollected.Tisprogramenabled
monitoringtheeectof2009H1N1inuenzainhospitalizedpatients.
56
)
)
)
d
e

SARI Surveillance in South Africa, 2009
Number of Infuenza Types and Subtypes and Detection Rate by Week
0
5
10
15
20
25
30
35
40
45
50
0
5
10
15
20
25
30
35
40
45
50
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53
D
e
t
e
c
t
i
o
n

R
a
t
e

(
%
)

N
u
m
b
e
r

o
f

P
o
s
i
t
i
v
e

S
a
m
p
l
e
s

Epidemiologic Week
Seasonal A (H1N1
Pandemic A (H1N1
A (H3N2
A Unsubtype
B
Detection Rat
Respiratory Consultations Surveillance System
Tisprogramobtainsdatafromnationalprivatesectorhealthcareprovidersonpatientsseen
withILIandpneumoniaandaimstotracktheprogressionoftheinuenzaseason.
Enhanced Surveillance Activities in Response to 2009 H1N1 Infuenza
Enhancedsurveillancewasinitiatedat9publicsectorhospitalsaroundthecountrytocollect
specimensforvirologicsurveillancefrompatientswithSARIs.Teseverityoftheepidemic
wasmonitoredandassessedbyestablishingaregistryforall2009H1N1inuenzalaboratory-
conrmedcases,severecases,anddeaths.Terst100conrmedcaseswerealsoinvestigated.
Teseinterventionsallowedriskfactorsforsevereillnessanddeathtobedetectedandthe
secondaryattackrate,serialinterval,andbasicreproductivenumber(R0)tobeestimated.
Reporting Surveillance Data
Allsurveillanceprogramsmanagedatainrealtime,andweeklysurveillancereportsare
disseminatedtoallstakeholdersandpublishedontheNationalInstituteforCommunicable
Diseases(NICD)Webpage(www.nicd.ac.za)duringtheinuenzaseasonorinuenzaoutbreak
periods.Inuenzadataarealsomadeavailabletotheinternationalcommunitythroughthe
WHOGISN.
57
Laboratory
TeRespiratoryVirusUnit(RVU)attheNICDisearmarkedasaWHOregionalreference
laboratoryforinuenzaandplaysakeyroleinsupportingtheestablishmentofinuenzalabora-
toryandsurveillancecapacityintheSouthernAfricanDevelopmentCommunity(SADC).Te
RVUandVirusIsolationUnit(VIU)haveregularlybeentestingandtypinginuenzasamples
collectedundertheViral-Watch,SARI,andthePandemicH1N1EnhancedSurveillancesys-
tems.TeRVUperformslaboratorysurveillance,moleculardiagnosis,andtypingofinuenza
virusesandistaskedwithinvestigatingtheannualinuenzamolecularepidemiology,genetic
drift,andresistancetestingaspartoftheannualWHOvaccinerecommendations.TeVIU
performsisolationandantigenictypingofvariousviralpathogens,includinginuenza.Specic
activitiesimplementedbytheRVUinclude
DevelopingstandardmethodsfordetectingH5byreal-timeandconventionalPCR.
DevelopingPCRcapacityfordetectionofH7andH9subtypes.
OptimizingPCR-baseddetectionmethodfordetectionofH275Yresistancethatcauses
mutationintheH1N1viruses.
DevelopinganewmultiplexPCR(usedforthescreeningallSARIsamples)thatcan
detect9dierentviruses,includinginuenza.
Developingguidanceforestablishingdiagnosticcapabilitiesforthe2009H1N1inu-
enzavirusforconrmedseverecasesanddeaths.
Implementingmoleculardiagnostictrainingsforavian,seasonal,and2009H1N1inu-
enzaoereduponrequestfromseveralcountriesfromtheSADCregion.
Technicalsupportandconrmatorytestingtootherinuenzalaboratoriesintheregion.
Testingforoseltamivirresistancein2009H1N1inuenzaandfewseasonalH1N1
specimensforthe2009season.
Inadditiontotheestablishingenhancedsurveillanceprogramsfor2009H1N1inuenza,the
followingactivitieswereimplemented:
FormulatingnationalguidelinesforhealthworkersincollaborationwiththeNational
DepartmentofHealthandotherpartners.
Implementingprovincialworkshopsin7ofthe9provincestoreinforceadherenceto
thepandemicresponseplansandhealthworkerguidelines.
Providingadviceonclinicalcasemanagementandcontrolmeasures,infectioncontrol
guidance,andguidelinesonappropriatespecimencollection,includingsupportwith
eldworkduringoutbreakinvestigations.
Supportingthedevelopmentofanetworkoflaboratoriesinpublicandprivatesectors.
Developingmonthlyandspecialcommuniqustoraiseawarenessandupdateclinicians
aboutmanagementofcommunicablediseases,including2009H1N1inuenza,which
aredistributedtoapproximately18,000healthprofessionalsandpostedontheNICD
Webpage.
Compilingweekly2009H1N1inuenzasituationreportsandpostingthereportson
theNICDWebpageanddistributingthemtohealthprofessionals.
58
MarietjieVenter,MSC,PhD
Head,RespiratoryVirusUnit(NationalInuenzaCentre)
NationalInstituteforCommunicableDiseases
PrivateBagX42131-Sandringam,
Johannesburg,SouthAfrica
E-mail:marietjiev@nicd.ac.za
LucilleBlumberg,MBBCH,MMed,FFTM,DCH,DTM&HDOH
Head,EpidemiologyDivision
NationalInstituteforCommunicableDiseases
PrivateBagX42131-Sandringam,
E-mail:lucilleb@nicd.ac.za
U.S.CDCStaff
MarinaMangerCats,MD,MPH
E-mail:mangercatsm@sa.cdc.gov
StefanoTempia,DVM,MSc,PhD
InuenzaTechnicalAdvisorCDC
AttachetotheNationalInstituteforCommunicableDiseases
PrivateBagX42131_Sandringam
E-mail:tempias@sa.cdc.govorstefanot@nicd.ac.za
59
60
AfricanRegion
Tanzania
Capital:DaresSalaam InfantMortalityRate:Total:70.46deaths/1,000
Area: 945,087sqkm
Population:
41,892,895

LiteracyRate:
AgeStructure:
014years:43.5%(male8,763,471/

BeganFY2006.
Tanzaniabeganavianandpandemicinuenzapreparednessandresponseactivitiesin2006by
constitutingtheNationalMultisectoralTaskforceanddevelopingthenationalavianand
pandemicinuenzapreparednessandresponseplan.In2008,theMinistryofHealthand
SocialWelfare(MOHSW)andU.S.CDCestablishedtheNationalInuenzaLaboratoryin
DaresSalaamandinitiatedthevirologicandepidemiologicinuenzasentinelsurveillancein
5hospitalsaroundthecountrytoenhancethenationalabilityforearlydetectionofhighly
pathogenicinuenzaviruses.Tissurveillanceenhancementcontributedtothecountrystimely
responsetoRiftValleyfeverin2007and2009H1N1inuenza.
Surveillance
TeinuenzasurveillancesysteminTanzaniausesboththeIDSRsystem,whichisbasedon
reportingsuspectedcasesofSARI,andsentinelsurveillance,whichisbasedonthelaboratory
conrmationofsampledpatientsmeetingILIstandardcasedenitionsandallSARIcases.
Established5inuenzasentinelhospitalsin5ofthe21regionsinTanzania.
61
Heldorientationfor78multisectoral
stakeholders,includingpolicymakersand100
sentinelsitemanagersoninuenzasurveillance.
All133districtsareimplementingIDSRweekly
reporting.
NoconrmedinuenzaA(H5N1)outbreaksin
birdsorcasesinhumanshavebeenreportedin
Tanzania.
Withtheemergenceof2009H1N1inuenzaglobally,
Tanzaniacontingencyplansincluded
Screeningtravelersatinternationalairports.
Identifyingandequippingdesignatedreferral
hospitals.
Providingstandardcasedenitionsand
collectingsamples.
Storingandtransportingmaterials.
Laboratory
Teinuenzalaboratorynetworkincludesthe5inuenzasentinellaboratories,whichare
mainlyspecimencollection,storage,andtransportationpoints,andtheNIC,whichistheonly
laboratoryinTanzaniahandlinginuenzaactivities.
Tested350samplesfromsentinelsitesattheNIC;sent80PCR-positivespecimensto
theWHOcollaboratingcenteraspartofWHOsglobalinuenzasurveillance.
HiredanadditionallaboratoryexpertfortheNICtostrengthenthecapacityofthe
laboratorytosupportthenationalinuenzasurveillanceactivities.
TeNICparticipatedintheWHOinuenzaExternalQualityAssessmentProgram
(EQA)andprovidedsupportivesupervisiontoallinuenzasentinelsurveillancesites.
Preparedness
TanzaniacontinuedtoworkwithU.S.CDC,theUnitedNations,andother
stakeholderstoimplementapreparednessandresponseplanforavianandpandemic
inuenza.
Conducted5sessionsofpublicawarenessseminarsinhigh-riskareas.
Developedanddistributed4,000avianandpandemicinuenzaleaetstothepublic.
DevelopedanddistributedIECinuenzamaterialstopoultrytradersanddisaster
managementcommittees.
Trained80of132districtrapidresponseteams.
Participatedinthersttabletopsimulationexercisethattestedtheeectivenessof
nationalpreparednessandresponseplan.
62
Training
TeNICconductedtrainingonspecimencollection,storage,andtransportationtoall
laboratoriesintheinuenzasurveillancenetwork.
Eighty-vehealthcareworkersreceivedon-sitetrainingoninuenzasurveillance.
OnelaboratoryexpertattheNICreceivedtrainingontheInternationalAirTransport
Association(IATA)-accreditedcourseonpackagingandshippingdangerousgoods.
TeNICreceivedtrainingin2009H1N1inuenzatestingusingreal-timePCRand
inuenzaculturetechniquesattheCDC-KEMRIlaboratoryinNairobi,Kenya.
Tanzaniadevelopedanddistributednationalguidelinesandproceduresforsurveillance
andmanagementofsuspectedandconrmedcasesof2009H1N1inuenza.
Setupscreeningoftravelersatinternationalairportsandprovidedhealthcarestawith
training,supplies,andcommunicationequipment.
ProvidedtrainingtoNIClaboratorystaon2009H1N1inuenzatestingbyusing
real-timeRT-PCR.
Providedtrainingtoregionalrapidresponseteamsandhospitalteamson2009H1N1
inuenzasurveillanceandsamplecollection,storage,andtransportation.
EnhancedthesurveillanceofILIandSARIinallpublicandprivatehealthfacilities.
Teestablishedinuenzascreeningprogramidentiedtherst2009H1N1inuenza
suspectcaseattheportofentryandconrmedthecasewithin24hours.
Tanzaniahadadequatedrugs(i.e.,Tamiu)totreatalllaboratory-conrmed2009
H1N1inuenza.
Establishedcapacitytotestinuenzasamplesbyusingreal-timeRT-PCRattheNIC.
ContributedpositivesamplestoWHOsGISN.
Providednationalinuenzasurveillancedatashowinginuenzatrendsandcirculating
virustypes.
InvolvedTanzaniaFieldEpidemiologyandLaboratoryTrainingProgram(T-FELTP)in
thesurveillanceandresponsetoavianandpandemicinuenza.
ParticipatedintheEastAfricancountries(i.e.,Tanzania,Kenya,Uganda)cross-border
avianinuenzasimulationexercise.
Enhancedcommunicationandsharingofdatawithlaboratoriesinthenetworkand
otherregionallaboratories.
63
PeterMmbuji,MD,MMed
ProjectInvestigator
AssistantDirector,Epidemiology
MinistryofHealthandSocialWelfare
P.O.Box9083
DaresSalaam,Tanzania.
E-mail:mmbuji@yahoo.co.uk
VidaMmbaga,MD,MPH
AvianInuenzaFocalPerson
MinistryofHealthandSocialWelfare
P.O.Box9083
E-mail:makundiv@yahoo.com
MiriamMatonya,ADMLS
LaboratoryTechnologist
TanzaniaNationalInuenzaCenter
NIMRHQBuilding,4thFloor
2448LithuliRoad,P.O.Box9083
E-mail:miriammatonya@yahoo.com
U.S.CDCStaff
JohnF.Vertefeuille,PhD,MHS
CountryDirector,CDCTanzania
E-mail:vertefeuillej@tz.cdc.gov
MichaelMwasekaga,HND
ProgramOcer,CDCTanzania
DaresSalaam,Tanzania
E-mail:mwasekagam@tz.cdc.gov
64
AfricanRegion
Uganda
Capital: Kampala InfantMortalityRate:Total:65.99deaths/1,000
Area: 236,040sqkm
Population:
33,398,682

LiteracyRate:
AgeStructure:
014years:50%(male7,903,935/

BeganAugust2007.
FY2009wasthe3rdyearoftheagreement.
UgandaVirusResearchInstitute(UVRI)wasdesignatedaNICinthe1980s.However,NIC
activitieshadslowedconsiderablyuntilrecently,whenproposalstocarryoutsurveillancefor
seasonalinuenzawerereinitiated.TeadventofHighlyPathogenicAvianInuenza(HPAI)
contributedtothereestablishmentoftheUVRINIC.
InresponsetotheriskofHPAIworldwide,inOctober2005,thegovernmentofUganda
establishedamultisectoralNationalTaskForce(NTF)forinuenzatoundertakearisk
assessmentandtoprepareandimplementanAvianandHumanPandemicInuenza
PreparednessPlan.Underthepreparednessplan,theMOHisresponsibleforestablishingand
implementingsystemsforthepreventionandcontainmentofhumaninuenza.UVRIwas
redesignatedastheNIC.
InAugust2006,supplementalfundingwasobtainedthroughtheU.S.CDCGlobalAIDS
ProgramtosupporttheNIC;thisfundingprovidesin-countryreferencelaboratoryfacilities
andsurveillanceforseasonalinuenzaandarapidresponsetopandemicoravianinuenza
outbreaks,llinginsomegapsinthenationalplan.
65
In2007,aproposalwaswrittenthatrequestedfundstosupporttheNIC.Tepurposewas
tohelpsupportthenationalavianinuenzapreparednessplanandtoestablishasustainable
inuenzasurveillancenetworkinUganda.Tiswastobeachievedby
SupportingtheNTFinawarenessandtrainingactivities.
SupportingtheNICatUVRIbycarryingoutbothPCRdetectionandvirusisolation
forinuenzaandotherrespiratoryviruses.
SupportingtheNICincarryingoutinuenzasurveillanceinareasofUgandathatare
notcovered.
Supportingepidemiologicsurveillanceandestablishingearlywarningsystems.
Establishingrapidresponseandtrainingteams.
Coordinatingin-countryinuenzaeorts.
A4-yearU.S.CDCcooperativeagreementfundsawardwasgiventotheinstituteforthese
activities.FY2009wasthe3rdyearoftheagreement.
Surveillance
In2007,surveillanceactivitieswereinitiatedatsentinelsitesinthecentralregionofKampala
andEntebbe,andthiswaslaterextendedtonorthwesternUganda,intheWestNileregionof
AruaandKobokodistricts.Terewere3sentinelsitesinKampalaandasiteinEntebbe,plusa
sentinelsiteeachintheAruaandKobokodistricts.
In2008,surveillancewasextendedtoanothersiteinKampala,and1wasclosed.Withthe
adventof2009H1N1inuenza,moresentinelsitesopenedinKampala.Tenewsiteswere
targetedtocollectsamplesfromthelocalcommunities(e.g.,KitebiHealthCenterIV)andfrom
expatriatestaandauentsocieties(e.g.,UNClinicandtheSurgeryClinic),whoweremore
likelytotraveloutofthecountryandbringbackdierenttypesofinuenza.Asatellitesentinel
site(Labole)openedinKoboko;itworkscloselywiththemainsiteinKobokoTown.
SurveillancewasstartedinMay2009insouthwesternUgandasMbararadistrictattheMbarara
RegionalReferralHospital.Tensitesareactive.Plansareunderwaytostartsurveillancein
Western(Kabaloredistrict)andEasternUganda(Tororodistrict).TeMOHandWHO
countryoceshaverequestedthattheNICopenmoresitestocoverthecountry.TeNIC
workswiththeMakerereUniversityWalterReedProgram(MUWRP),whichalsohassentinel
sitesinJinja,Bugiri,andKayungadistrictsinCentralandEasternUgandaandasentinelsiteat
MulagoHospital,theNationalReferralHospitalinKampala.MUWRPisalsogoingtoexpand
itssentinelsitestoWesternandNorthernUganda.
Laboratory
TeNICatUVRIistheonlylaboratorycapableofinuenzadiagnostictestinginthecountry.
Telaboratorycanusehemagglutination(HA)andhemagglutinationinhibition(HI)and
RT-PCRtestingtoconrmdiagnoses.Telaboratoryhasalsobeenevaluatingsensitivityand
specicitytovirusescirculatinginUgandabyusingcommerciallyavailablerapiddiagnosiskits
forseasonalinuenza.Telaboratorieshavebeennewlyrenovated,andmorespaceisduefor
refurbishment.Moreequipmenthasbeenacquiredtoassistthelaboratoryactivities.
66
TeNIChasworkedcloselywithU.S.CDCtoestablishastate-of-the-artlaboratory,and
technologistshavetrainedextensivelywithCDC-Atlantascientists,KEMRI,andscientistsat
theNationalInstitutesofCommunicableDiseases,SouthAfrica,ontyping,subtyping,and
real-timePCR.
TeNIClaboratoryparticipatesintheWHOEQAforinuenzaAviruses.Allviruseswere
successfullyidentiedinthelast6panelsinwhichthelaboratoryparticipated.Isolatesand
aliquotsofsomeofinuenzavirusstrainsthatcouldnotbetypedwereperiodicallysenttothe
WHOcollaboratingcenterinAtlanta.
Preparedness
TeNICparticipatedinthepreparationandimplementationoftheUgandapreparednessplan
andwaspartofthenationaltaskforceforinuenza.StafromtheNICparticipatedinnational
andregionaltabletopexercisestotestimplementationofthepreparednessplan.TeNICalso
providedfundingforsomeoftheactivitiesofthetabletopexercises.
Training
TeNICwasinvolvedintraininghealth,veterinary,andagriculturepersonnelineachdistrict,
andstaatWHO,USAID,theMinistryofAgricultureAnimalIndustriesandFisheries,and
theMOH.
TeNICtrainedhealthpersonnelinKampaladistrict,adenselypopulatedareawhere
2009H1N1inuenzahascirculatedinthepopulation.
TrainingofhealthpersonnelwascarriedoutinBushenyidistrict,whereclustered
episodesof2009H1N1inuenzaoccurredinschools.
ArefreshertrainingwasgivenbytheNICforstaofallsentinelsurveillancesites.
TelaboratoryconductedtrainingfortechnologistsfromtheMUWRPbeforethey
startedworkingintheNIC.
TeMUWRPheldanAfricanregionalinuenzadiagnosticstraininginwhich
participantshadhands-onexperienceattheNIC,andNICstamemberswerepartof
thetrainingteam.
NIClaboratoryscientistsandthetechnologiststaattendedtrainingatKenyaMedical
ResearchInstitute,Nairobi,Kenya.
TeNIChasbeeninvolvedinoutbreakinvestigation,collectionofsamples,and
conrmatorytesting.
AliquotsandisolatesfromtheoutbreakhavebeensenttotheAtlantaWHOforfurther
characterizationandtestingforresistancetoinuenzaantiviraldrugs.
NICstahavebeenperformingcontrolactivitiestolimitthespreadofpandemic
inuenza.
NICstahaveparticipatedintelevisionandradiotalkshowsonpandemicinuenza.
67
TeNIChasprovidedspecimencollectionsuppliestoseveraldistrictstoassistinthe
collectionofsamplesfortesting.
TeUgandaNICprovideddiagnosticcapacityforBurundiwhensamplesweresentfor
testing.Weconrmedpandemicinuenzafromsomeofthesamplessent.
AwingforinuenzalaboratoriesandNICoceswasrefurbishedandopened.
TeWorldBankapprovedaloantoUgandatoimplementthepreparednessplan,with
activeinvolvementfromtheNICinthepreparationandnegotiations.
AstudentpursuingaMasterofSciencedegreeperformedresearchintheNICbyusingsamples
collectedfrom2ofthesentinelsites.Testudy,IdenticationofRespiratoryVirusesand
EpidemiologicalFactorsAssociatedwithAcuteRespiratoryIllness(ARI)inKampalaand
Entebbe,Uganda,2008,aimedtoidentifyanddescribetheepidemiologyofrespiratoryviruses
associatedwithARIatKiswa,Kampala,andEntebbehospitals,specicallytherespiratory
virusescirculatingamongARIpatientsatKiswaandEntebbehospitalstodeterminethe
epidemiologicfactorsassociatedwithrespiratoryvirusinfections.Itwasacross-sectionalstudy.
SampleswerecollectedfromasubsetofclinicallydiagnosedARIpatientsofallages.A2-test
multiplexPCRfor12viruseswasperformedonthesamples.Tevirusesthatwerestudied
includedthefollowing:inuenzaA;inuenzaB;coronavirus229E;coronavirusOC43;
parainuenzas1,2,and3;rhinovirusA;respiratorysyncytialvirusA;respiratorysyncytialvirus
B;adenoviruses;andmetapneumovirus.
StudyresultsshowedthatthemainviralcausesofARIinthestudyareawereinuenzaA
(19.2%),adenoviruses(8.7%),andrhinovirusesA(7.9%).RiskfactorsassociatedwithARI
infectionincludedanageoflessthan10years,overcrowding,useofsomecookingfuels(e.g.,
charcoal),andcontactwithcertainbirds(e.g.,ducks).Inresponsetothesendings,further
studiesneedtobecarriedout,suchasprospectivestudiestodeterminethepublichealth
importanceofeachviralpathogenandtoidentifythecausativeagentsfortheremaining
undeterminedpathogens(53.4%).
JuliusJ.Lutwama,PhD
ProjectInvestigator
SROTeamLeader,ProgramCoordinator
UVRICDCInuenzaProgram
NationalInuenzaCenter
UgandaVirusResearchInstitute
P.O.Box49
Entebbe,Uganda
E-mail:jjlutwama03@yahoo.com
68
AfricanRegion
Zambia
Capital:Lusaka InfantMortalityRate:Total:99.92deaths/1,000
Population:
12,056,923

LiteracyRate:
AgeStructure:
014years:44.8%(male2,710,947/
86.8%;female:74.8%(2003est.)
TeMOHoftheRepublicofZambiaisworkingtosupporttheexecutionoftheexisting
NationalResponsePlan(NRP)forAvianInuenzaandtocomplementongoingandplanned
AIactivitiesfundedbyotherdonorsandtechnicalagencies.
TeinuenzasurveillancecooperativeagreementwiththeInuenzaDivisionwillcomplement
ongoinginitiativesbystrengtheningpublichealthlaboratoryandsurveillancecapacityforILI
andSARIinthecountry.Moreover,theprojectwillcontributetostrengthenrapidresponseand
infectioncontrolcapacityofthecountrythroughpotentialoutbreaksofAIandotheremerging
andreemerginginfectiousdiseases.TeprojectwillbeimplementedbytheUniversityTeaching
Hospital(UTH)andtheLusakaDistrictHealthOce(LDHO)onbehalfoftheMOH
andinclosecollaborationwithCDC-Zambia,CDC-SouthAfrica,theNationalInstitutefor
CommunicableDiseases(NICD-SouthAfrica),andtheWHO.
Teprojectunderthecooperativeagreementaimstosupportnationaleortstoaddressa
possiblepandemicofAIfromadiseasepreventionandcontrolstandpoint.Inaddition,the
projectintendstoaddresspreparednessforpossibleotheremergingSARIto
Monitortheemergenceofpandemicviruses,includingAIinhumans.
Reducemorbidityandmortalityfrompossibleemergingrespiratoryinfectiousdiseases
byrapiddetectionandcontainment.
Reduceeconomiceectsandsocialupheavalorunrestfromapandemic.
69
CurrentActivities
SurveillanceandDetectionGoal
TosubstantiallyincreasethecapacityoftheMOHforsurveillanceanddiagnosis
ofILIandSARIcases,includingseasonalinuenzaandHPAIinhumans.
Objectives
UTHVirologyLaboratorywillmeetrequirementstoperformmolecularbiology
diagnosisandviralisolationofinuenzasamplesandobtainWHOaccreditation
asaNIC.
Pediatricandadultmedicineadmissionwardsatthecentralreferralhospital
(UTH)andoneoutpatientpublicclinicinLusakawilleectivelyimplementSARI
andILIsurveillance,respectively.
ResponseandContainmentGoal
TosubstantiallyincreasethecapacityoftheMOHtoadequatelyrespondto
potentialAIandemergingorepidemicpronediseases.
Objectives
Reviewallrecentinuenzaoutbreaksforlessonslearnedandoutbreakresponse
plans.
UpdatepandemicinuenzapreparednessplansconsistentwithNRPandnational
disasterplans.
Train3districtsin4provincesinAIRRTaspartofrefreshertrainingonemerging
andreemerginginfectiousdiseases.
Provideinfectioncontroltraining,andprovidewrittenstandardoperating
procedurestoUTH.
Stapediatricandadultinternalmedicineadmissionwardsupportanddesignate
stafortheselectedisolationunit.
ProjectInvestigators
AndrosTeo,PhD
VirologyLaboratory
UniversityTeachingHospital
NationalistRoad
Lusaka,Zambia
MwakaMonze,MBChB,PhD
UnitHead
Virology/ImmunologyDepartment
UniversityTeachingHospital
PrivateBagRW1X
Lusaka,Zambia
70
Eastern
Mediterranean
RegionalOffce
(EMRO)
73
EasternMediterraneanRegional
Offce(EMRO)
NAMRU-3
CDC Assignee - Cairo
WHO EMRO Headquarters
WHO National Infuenza Center
GDD Site
Pasteur Institute
EMRO
Infuenza Cooperative Agreement
0 500 1,000 1,500 250
Miles
Human Infuenza Surveillance: EMRO 2010
Sustainability Cooperative Agreement
U.S.CDCDirectRegionalSupport
StrengtheningSurveillanceandResponsetoAvianandPandemicInuenzaintheEastern
MediterraneanRegionCooperativeAgreement
BeganOctober2006.
TecooperativeagreementbetweenEMROandtheU.S.CDCbeganinOctober2006and
isa5-yearprojectdesignedtoimproveinuenzasurveillanceandresponseinEMRO.Te
overarchinggoalistostrengthenthepublichealthcapacityofmemberstatesintheregionto
rapidlydetect,assess,respondto,andcontainpublichealthrisksthatresultfromthethreats
ofHPAIandhumanpandemicinuenza.Teprojectisbuiltontheexistingpartnershipsand
collaborativearrangementsinEMRObetweenWHO,FAO,theUnitedNationsChildrens
Fund(UNICEF),andtheWorldFoodProgram(WFP)onregionalpreparednessandresponse
forhumanpandemicinuenza.
TiscrosscuttingprojectinvolvesmultiplefocalpointsinEMRO.Aregionaltaskforce
representing12dierenttechnicalunitsintheregionaloceissupportingtheCommunicable
DiseasesSurveillance,Forecasting,andResponseUnittoimplementthis5-yearproject.
Teoverallobjectivesoftheprojectaretostrengthentheemergencypreparednessandrisk
communicationcapacityofEMROmemberstatestorespondtoHPAIandpandemichuman
inuenza.
EnhancethesurveillancecapacityofmemberstatestodetectHPAI,aswellasseasonal
humaninuenzaandILI.
AcceleratememberstatesabilitytoresponserapidlyandcontainHPAIoutbreaksin
EMROareas.
SinceOctober2006,theoperationalplansforyear1(2007),year2(2008),andyear3(2009)
havebeenimplementedincollaborationwithU.S.CDC,otherUnitedNations(UN)agencies,
andtheNAMRU-3,aWHOcollaboratingcenterforemergingdiseases.Aspartofthisongoing
project,EMROdevelopedaregionalstrategicplanforimplementingaglobalstrategyforavian
inuenzaandhumanpandemicinuenzatocomplementnationaleortsandenhancethe
capacityofthememberstatestorespondrapidlyandeectivelytopandemicinuenza.Te
regionalplanencouragesmemberstatesto
Ensureadequatestockpilingofantiviraldrugs.
Promotetheuseofappropriatenonpharmaceuticalinterventions(e.g.,avoidanceof
crowding,promotionofpersonalhygiene).
Promoteandsupportactivitiesinoperationalandepidemiologicresearchtoimprove
knowledgeofriskfactorsforspreadofinuenza.
Examinetheethicaldimensionsofenforcedquarantineorcompliancewithother
recommendedmeasures.
Tespecicobjectivesofthisprojectandgrantareasfollows:
Supportdevelopmentofintersectoralcollaborationandcooperationamong
organizations(e.g.,FAOandtheWorldOrganizationforAnimalHealth[OIE],
UNICEF,WFP,andotherUNagencies)andotherpartners,suchasNAMRU-3,and
maintainastandingcommitteetodealwithzoonoticdiseases,ingeneral,andavian
inuenza,inparticular,andstrengthentheregionalocecapacityinveterinaryhealth.
Increasethelevelofawarenessandcommitmentofpolicyanddecisionmakersand
identifyclearnationallinesofleadershipwithcleartermsofreference(TOR)for
implementationofnationalpandemicpreparednessplans.
Ensurethatpublichealthauthoritiesworkcloselywithanimalhealthandotherrelated
sectors,bothprivateandpublic.
Promoteintersectoralandintrasectoralplanningactivitiesbetweendierentministries
andrelatedstakeholderstodevelopandimplementnationalpreparednessplansforavian
inuenzaandhumanpandemicinuenza.
Ensurefulltransparencyandtimelyexchangeofinformationrelatedtoconrmedcases
ofavianinuenzaandhumanpandemicinuenza.
Supportcountriesinrevising,updating,andactivatingtheirnationalpandemic
inuenzapreparednessplanssotheyarereadywhenneeded.
74
Supportcountriestobuildtheirpublichealthcapacitiestoconductepidemicor
pandemicriskassessmentsforanynovelinuenzavirusonthebasisofepidemiologic,
virologic,andclinicalevidence.
Helpcountriesbuildtheirepidemiologicandlaboratorysurveillancecapacitiesforearly
detection,rapidresponse,andcontainmentofanycasesorclusterofcasesresultingfrom
HPAIvirusoranynovelstrainofinuenzavirushavingpandemicpotential.
Surveillance
Technicalassistancewasprovidedto8memberstatestosetupsentinelsurveillance
systemforILIandSARI.
AnIATAlicensingworkshopontheshipmentofinfectioussubstances,including
inuenzaspecimensandvirusisolates,wasorganizedtosupportallmemberstatesto
improvebiosafetyandbiosecuritypracticesfortheshipmentofinfectioussubstances
anddangerouspathogensbyusingstandardizedIATAguidelinesandotherinternational
procedures.
Aweeklyepidemiologicreportforinuenzasurveillancewaspublishedregularlyto
informallmemberstatesofthecurrentandongoinginfectiousdiseaseoutbreaksinthe
region,particularlythosecausedbyHPAIandnovelinuenzavirus.
Logisticsupportwasprovidedtoallmemberstatesforpropercollection,transport,and
shipmentofbiologicspecimens,includinginuenzavirusisolatesandpatientspecimens
ofsuspectedH5N1virus.
Technicalmissionswereconductedin8memberstatestoassessandreviewtheongoing
seasonalinuenzasurveillanceprogramsinthesecountries.
Technicalassistancewasprovidedto4memberstatestosetNICs.
Preparedness
Aguidancedocumentfordevelopingtabletopsimulationexerciseonpandemic
inuenzawasdevelopedforthememberstatesbyEMROthroughaconsultative
process.Technicalsupportalsowasprovidedto8memberstatestoconducttabletop
simulationexerciseonpandemicinuenza.
Technicalmissionswereconductedin6memberstatestoassessnationalpandemic
preparednessplans.
Anintercountryworkshoponriskcommunicationforpandemicinuenzawas
organizedtohelpallmemberstatesdeveloptheirownpandemicriskcommunication
strategiesforinuenza.
Multilingual(i.e.,Arabic,French,English)illustrativeposters,videoclips,andradio
messagesweredevelopedforinfectioncontrolinpublicplaces,communitymitigation
measuresinacademicsettings,andpatientcareinhealthcaresettings.
Aconsultativemeetingwasorganizedonhealthsystemspreparednessforpandemic
inuenzatohelpallmemberstatesimprovethesurgecapacityoftheirhealthsystems.
75
Training
Anationaltrainingcourseonavianinuenzaoutbreakandcontainmentofhuman
pandemicinuenzawasorganizedin4memberstates.
Twosubregionaltrainingworkshopswereorganizedoninfectioncontrolpracticesin
healthcaresettingsforepidemicandacuterespiratoryinfectionswithpandemicpotential.
AnintercountrytrainingworkshopontheuseofPCRtechniquesforthediagnosisof
H5N1inuenzaviruswasorganized.Teworkshopsupportedallmemberstatesto
buildandstrengthentheircapacitytousePCRtechniquestodetectsubtypeinuenza
Aviruses,includinginuenzaA(H5N1),andtopromotegoodlaboratorypracticesand
laboratorysafety.
Anintercountrytrainingworkshoponmanagementofpublichealthriskfollowing
disastersandpublichealthemergencies,includingpandemicinuenza,wasorganized
forall22memberstates.
Aninterimguidanceonclinicalmanagementofpandemic2009H1N1inuenza
infectionwasdevelopedforEMROthroughaconsultativeprocess.
AnintercountrytrainingworkshopontheuseofPCRtechniquestodiagnoseand
detect2009H1N1inuenzawasorganizedtosupportallmemberstatestobuildtheir
capacitytodiagnose2009H1N1inuenza.
Orientationsessionswereorganizedforthemediaonthedynamicsandtransmissionof
pandemic2009H1N1inuenzavirusinfection.
Aninterimguidanceoncommunitymitigationmeasuresforschoolsandotheracademic
settingsforpandemic2009H1N1inuenzavirusinfectionwasdevelopedforEMRO
throughaconsultativeprocess.
Aconsultativemeetingwasorganizedonhealthsystemspreparednessforpandemic
inuenzatosupportallmemberstatestoimprovethesurgecapacityofhealthsystems
forpandemic2009H1N1inuenzavirusinfection.
HassanE.ElBushra,MBBS,MCM,MPH,PhD,MFPHM
RegionalAdviser,EmergingDiseases
CommunicableDiseaseSurveillance,Forecasting,andResponseUnit
DivisionofCommunicableDiseases
EMRO-WHO
AbdulRazzakAlSanhouriStreet
P.O.Box7608,NasrCity11371
Cairo,EGYPT
E-mail:elbushrah@emro.who.int
76
KeyStaff
JohnJabbour,MD
MedicalOcer(Epidemiologist)
InternationalHealthRegulationsOcer
EMRO-WHO
Cairo,Egypt
E-mail:jabbourj@emro.who.int
L.MartinOpoka
TechnicalOcer
EMRO-WHO
Cairo,Egypt
E-mail:opokal@emro.who.int
MamunurRahmanMalik,MBBS,Dip(HealthEconomics),MSc,MPhil
Epidemiologist
EMRO-WHO
Cairo,Egypt
E-mail:malikm@emro.who.int
AliR.Ma,MD,MPH
TechnicalOcer
EMRO-WHO
Cairo,Egypt
E-mail:maa@emro.who.int
77
DaliaSamhouri(Salha)
TechnicalOcer
EMRO-WHO
Cairo,Egypt
E-mail:samhourid@emro.who.int
AminSharif
TechnicalOcer
MedicalMicrobiology
EMRO-WHO
Cairo,Egypt
E-mail:sharifa@emro.who.int
U.S.CDCContactforEMRO
MichaelDeming,MD,MPH
InuenzaProgramCoordinator
NAMRU-3
3AImtidadRamsesStreet
AdjacenttoAbbassiaFeverHospital
PostalCode11517
Cairo,Egypt
E-mail:msd1@cdc.gov
U.S.CDCStaff
CharleneSanders,MPH,RD
ProjectOcer
InuenzaDivision
Atlanta,GA30333
E-mail:zen3@cdc.gov
78
EasternMediterraneanRegion
Afghanistan
Capital:Kabul InfantMortalityRate:Total:154.67deaths/1,000
Area:647,500sqkm
Population:
29,121,286

LiteracyRate:
AgeStructure:

014years:44.6%(male7,474,394/
43.1%;female:12.6%(2000est.)
female7,121,145);1564years:53%(male8,901,880/
female8,447,983);65yearsorolder:2.4%(male
383,830/female409,144)(2008est.) GDPperCapita: $800(2008est.)
Began2006.
FY2009wasthe4thyearofthecooperativeagreement.
TeIslamicRepublicofAfghanistanisanationrecoveringfromdecadesofconictandan
economiccollapsethathasleftthecountryextremelypoorandlackingessentialsystemsand
infrastructure.TeAfghanPublicHealthInstitute(APHI)oftheAfghanistanMOHwas
dormantduringtheyearsofconict.Fundingfromthiscooperativeagreementsupports
APHItoplanandconductpandemicpreparednessandresponse,ILIsurveillance,andhealth
educationandtrainingactivities,aswellastobuildlaboratorycapacity.
Surveillance
TeDiseaseEarlyWarningSystem(DEWS)collectsinformationon15reportable
diseases,includingILI.
DEWSincludes154sentinelsurveillancesitescoveringall34provincesinthecountry.
Tereisadailyreportingsystemforallprovincialandregionalhospitals.
Sentinelsurveillancesiteswereestablishedatmilitaryandpolicehospitals.
79
Duringtherst6monthsof2009,DEWSdetected6suspectedoutbreaksofavian
inuenza;alloutbreakswereinvestigated,andnonewerefoundtobeH5N1.
Terewere12suspectedhumancasesofH5N1;however,uponfurthertesting,none
werefoundtobepositive.
Teinuenzaandpoliosurveillancesystemsineachcountrywerefunctionally
integratedtodetectandrespondtoclusters.
Laboratory
TevirologylaboratoryattheCentralPublicHealthLaboratorywasrecognizedbyWHOas
theNICinApril2009.
Atotalof559specimensofinuenza(ILI,avianinuenza[AI],andpandemic2009
H1N1inuenza)werecollectedfromdierentpartsofthecountryfortesting,with
isolationofvirusfrom2specimens.
Preparedness
NewguidelinesforH1N1surveillanceandcasemanagementweredeveloped,andthese
guidelinesweretranslated,printed,anddistributedtohealthcareworkers.
Fivethousandcapsulesofoseltamivirweredistributedtoeachregion,enoughfor
treatmentof500severecasesofinuenza.
FivehundredPPEkitsweredistributedineachregion.Tesekitsincludeasurgical
maskandgown,gloves,bootcovers,andaheadcover.
Preparednessworkshopswereconductedforreligiousleaders,teachers,themedia,and
800healthcareworkers.
Acommandandcontrolcenterwasestablished,and3hotlinenumbersareavailableto
thepublic.
Training
Refreshertrainingwasconductedforrapidresponseteamsfrom13provinces.
Intherst6monthsof2009,13workshopsandtrainingprogramswereconductedon
AI,pandemic2009H1N1inuenza,epidemiology,surveillance,pandemicplanning,
advocacyforpandemicresponse,anddatamanagement.
Laboratorycapacityforthediagnosisofpandemic2009H1N1inuenzawasstrength-
enedthroughmonitoringandadditionaltraining.
Terstcaseofpandemic2009H1N1inuenzawasdetectedintheNICbyusingthe
H1N1miniatureRNAkitprovidedbyU.S.CDC.
80
Apandemicactionplanforthehealthsectorwasdevelopedandpreparedwiththecoop
erationofallhealthsectorstakeholders;theplanwasnalizedinFebruary2009and
endorsedbytheMOH.
TeAfghanCentralPublicHealthLaboratoryreceivedWHOrecognitionasaNICin
April2009.
NewguidelinesforH1N1surveillanceandcasemanagementhavebeendevelopedand
theguidelinesweretranslated,printed,anddistributedtohealthcareworkers.
JawadMoeh,MD,MBA
Ultrasonologist,AvianInuenzaCoordinator,DEWSDirector
MinistryofPublicHealth,APHI
G.MassoudSquare,WazirAkbarkhanMena
MainBuilding,3
rd
oor
Kabul,Afghanistan
E-mail:jmoeh@yahoo.comorjmoeh@moph.gov.af
BashirNoormal,MD
AssociateProfessor
DirectorGeneral
MainBuilding,3
rd
oor
Kabul,Afghanistan
E-mail:noormalb@yahoo.comornoormalb@moph.gov.af
FaizullahKakar,MD,PhD
DeputyMinisterforTechnicalAairs
MainBuilding,3
rd
oor
Kabul,Afghanistan
E-mail:moph_aphi@yahoo.com
U.S.CDCStaff
ProjectOcer
InuenzaDivision
Atlanta,GA30333
E-mail:zen3@cdc.gov
-
81
82
ArabRepublicofEgypt
Capital:Cairo InfantMortalityRate:Total:26.2deaths/1,000live
Area:Total:1,001,450sqkm
births;male:27.84deaths/1,000livebirths;female:
Population:
24.48deaths/1,000livebirths(2010est.)
80,471,869(July2010est.)

LiteracyRate:
AgeStructure:
Totalpopulation:71.4%;male:83%;
014years:32.8%(male
13,495,577/female12,890,378);1564years:
62.8%(male25,689,588/female24,871,255);
65yearsorolder:4.4%(male1,602,219/female GDPperCapita: $6,000(2009est.)
1,922,852)(2010est.)
BeganAugust2009.
InEgyptsMOH,ocialsinthePreventiveSectorhaveoutlinedthefollowing3goalstoguide
eortstobuildcapacitytodetect,prepare,andrespondtoapotentialinuenzapandemic:
Preventtheemergenceandspreadofapandemicinuenzavirus.
Reducemorbidityandmortalitycausedbyapandemicinuenzavirus.
Improvethestateofpreparednessandthequalityofresponsetoaninuenzapandemic.
TeMOHproposesthefollowingactivitiesundereachofthemajorcomponents:
Surveillance
Improvelaboratorycapacityandinfrastructureforinuenzasurveillance.
Enhanceepidemiologycapacityandinfrastructurefordiseasesurveillance.
Developorenhancetheintegratedepidemiologicsurveillancenetworkforinuenza.
Developorexpandcomprehensive,territory-widesurveillanceforcasesandclustersof
respiratoryandfebrileillnessesthatcouldrepresentnewpandemics.
83
Laboratory
Developorexpandsentinel,laboratory-basedsurveillanceforSARI.
Developorenhancetheintegratedlaboratorysurveillancenetworkforinuenza.
Preparedness
Updatenationalpublichealthpreparednessplans.
Developcommunicationplans,riskmessages,andproducts.
Training
Developandimplementpandemicpreparednesstrainingcoursesasapilotin
2governates.
Trainrapidresponseteamsatthegovernateanddistrictlevels.
Trainhospitalworkersoninfectioncontrolpractices.
AmrKandeel
UndersecretaryofPreventiveAairs
EgyptMinistryofHealth
3,MaglesElShaabStreet
Cairo,Egypt
E-mail:kandeelamr@yahoo.com
SamirReay
DirectorofEpidemiologyandSurveillanceUnit
EgyptMinistryofHealth
Cairo,Egypt
ShermineSamir
OcerofInuenzaSurveillance
Cairo,Egypt
E-mail:shermineab@gmail.com
84
GDD-Egypt
Establishedin2006,theGlobalDiseaseDetectionRegionalCenterinEgypt(GDD-Egypt)
beganasanextensionofanestablishedagreementbetweentheU.S.CDC,WHO-EMRO,and
NAMRU-3todevelopnationalandregionalresourcestocontrolandcombatinfectiousdiseases
thataretheleadingcausesofdeath,disability,andillnessintheregion.Tecenterislocatedon
theNAMRU-3campus.
Coverage
GDD-Egypthasprovidedsupporttomorethan20countriesinAFRO,EMROandEURO
fromitsbaseatNAMRU-3.ItisalsotheplatformformuchofU.S.CDCspublichealth
supporttoIraqandAfghanistan.GDD-Egyptbenetsfromaccesstostate-of-the-art
laboratoryfacilities,includingBSL-3spacefromNAMRU-3.EgyptandtheUnitedStatesalso
worktogethertoconductjointsurveillanceactivities,suchasperformingtimelylaboratory
conrmationandpathogendiscoveryandtrainingpublichealthleadersineldepidemiology.
Activities
Outbreakresponse.
Pathogendiscovery.
Training.
Surveillance.
Networking.
Effect
In2009,GDD-Egyptrespondedtoandprovidedlaboratorysupportfor17outbreaks.GDD-
Egyptocialsalsodiscoveredapathogennewtotheregionandincreasedtheirlaboratory
testingcapacityfourfold.Inaddition,thecenterexpandedtheskillsofmorethan800
participantsthroughshort-termregionalandnationaltrainingcourses.
EricaDueger,PhD,DVM
GDD-EgyptCoordinatorandActingInuenzaLead
IEIP.
FETP.
85
86

Morocco
Capital: Rabat InfantMortalityRate:Total:38.22deaths/1,000
Area: 446,550sqkm
Population:
31,627,428

LiteracyRate:
AgeStructure:
014years:30.5%(male5,337,322/
5.2%(male765,882/female1,019,412)(2008est.) GDPperCapita: $4,000(2008est.)
StrengtheningInuenzaSurveillanceNetworksinMoroccoCooperativeAgreement
Began2006.
TeKingdomofMoroccosNationalInstituteofHygiene(NIH)istheNICandtherecipient
oftheU.S.CDCscooperativeagreementforinuenzasurveillance.U.S.CDCprovidesthe
onlyforeignfundsforinuenzasurveillanceinMorocco.
Surveillance
SARIsurveillanceisfunctionalin15regionsaroundthecountry.
ILIsurveillanceisfunctionalin15regionalhealthunitsandincludes110privatephysicians.
SARIsurveillanceisconductedin15regionalhospitals.
TeNICreceivedsamplesfrom1,299SARIandILIcasesin2009.Tirty-twospecimens
weresenttothereferencelaboratoryinLondon.
Anevaluationofthesurveillancesystemhasbeenconductedandcorrectiveactionsare
ongoing.
Faxmachineswerepurchasedforprivatephysicianstofacilitatethedatatransmission.
87

AWeb-baseddatabaseisoperationalfordataentry,analysis,retrieval,andcommunication
betweenpartners.
SupervisoryvisitsweremadebyrepresentativesfromtheNICandEpidemiologySurveillance
Unittoidentityregionsthatneededassistancetoimprovesurveillanceactivities.
Laboratory
Sixreal-timePCRmachinesforregionallaboratories,anextractionmachine,anda
sequencingmachinewerepurchased.
TeprojectregularlyorderslaboratoryconsumablesfortheNICandregionallaboratories.
TeprojectcoordinatorattendedaU.S.CDC-sponsoredserologycourseandaWHO-
sponsoredNICmeeting.
Preparedness
TeNationalPublicHealthPreparednessPlanwasupdated.
Training
Laboratoryandhealthprofessionalshaveattendeddataanalysistraining.
A2-dayevaluationworkshopwasheldforlaboratorydirectors,regionalhospital
directors,andrepresentativesfromregionalhealthobservatories.
Laboratoryprofessionalsreceivedtraininginmicroneutralization.
Amajorevaluationofthecountrysinuenzasurveillancesystemwasundertaken,and
recommendationsforcorrectiveactionsweremade.
Tenationalpreparednessplanwasupdatedanddistributed.
RajaeElAouad,MD
ProfessorofMedicine
Director
NationalInstituteofHygiene
27,AvIbnBattouta,BP769
Rabat,Morocco
E-mail:relaouad@sante.gov.maorrajaeelaouad@yahoo.fr
AmalBarakat,PhD
Virologist
NationalInstituteofHygiene,VirologyLaboratory
Rabat,Morocco
E-mail:amal.barakat@yahoo.fr
MohammedYoubi,MD
Epidemiologist
NationalInstituteofHygiene
Rabat,Morocco11
E-mail:moyoubi2006@yahoo.fr
88
Pakistan
Capital:Islamabad InfantMortalityRate:Total:66.94deaths/1,000
Area:803,940sqkm
Population:
177,276,594(July2010est.)

LiteracyRate:
AgeStructure:
014years:37.8%(male
female:36%(2005est.)
33,617,953/female31,741,258);1564years:58%
(male51,292,535/female48,921,023);65yearsor
older:4.2%(male3,408,749/female3,818,533) GDPperCapita: $2,600(2008est.)
(2008est.)
DevelopmentofInuenzaSurveillanceNetworksCooperativeAgreement
Began2004.
FY2009isthe5thyearofthecooperativeagreement.
Tiscooperativeagreementsupportsthedevelopmentandmaintenanceoflaboratorycapacities
atvarioussentinelsitesinPakistantoprovidemeansforrapidconrmationofcasesofhuman
andpandemicinuenza.Tefundingalsosupportspandemicinuenzapreparednessthrough
theimprovementofthenationalinuenzasurveillanceprogram,planningforpreventionand
controlprograms,anddevelopmentalofanationalvaccinepolicy.
PakistansMOHandNIHhaveimplementeda5-year,laboratory-basedinuenzasurveillance
programwithtechnicalassistancefromtheU.S.CDC.TecapacityoftheNIHcentral
laboratoryhasbeenenhanced,and1regionallaboratoryineachprovinceisbeingprovidedthe
requisiteequipmentandsuppliestoprocessspecimensfromsuspected2009H1N1inuenza
cases.Despiteadelayedstartandthecountryscurrentsociopoliticalsituation,signicant
progresshasbeenmade.
89
Surveillance
Designatedthefollowing5sentinelsitesattheoutpatientdepartmentsofmajortertiarycare
hospitalsinPakistans4provincesandthefederalcapital:
KingEdwardMedicalUniversity(KEMU),LahoreinPunjabProvince.
CivilHospital,KarachiinSindhProvince.
HayatabadMedicalComplex(HMC),PeshawarintheNorth-WestFrontierProvince
(NWFP).
BolanMedicalComplex(BMC),QuettainBalochistan.
FederalGovernmentServicesHospital(FGSH),IslamabadCapitalTerritory.
Tesesiteswerechoseninordertoensuredatafromallgeographicareasofthecountry.Tey
alsorepresentareasofhighpopulationdensityandfacilitieswithhighpatientturnover.Tese
sitescollectedmorethan1,018ILIand31SARIsamplesduringFY2009.
Othersurveillanceactivitiesincludedthefollowing:
JointMOH-WHOrapidresponseteamsweredispatchedtoaectedareasanddistricts.
Tecountrysexistingsurveillancesystemwasactivatedtoperformcasending,collect
samples,andsendinformationtothevirologylaboratoryattheNIH.
Provincialandregionalhealthdepartmentswereaskedtostrengthensurveillance
systemsanddesignatedistrictsurveillanceocers.
Laboratory
FiveBSL-2laboratorieswillbesetuptoconductinuenzasurveillance,diagnosticactivities,
viralisolation,andinformation-sharingwithstakeholders.TeNIHlaboratoryconductsPCR
testing,tissuecultures,andHA/HI.Te4labsinPeshawar,Lahore,Karachi,andQuetta
performreal-timePCR.
90

Viraltransportmediaandswabsweresuppliedtoprovincialhealthdepartmentsandall
internationalairportsforthecollectionandtransportationofsamplesfromanysuspectedpatients.
TelaboratoryfacilitiesinLahoreandPeshawarareundergoingbiosafetyenhancementstoensure
thattheyfollowtherequiredstandardsformoleculartestingforinuenza.Telaboratoriesalso
havereceivedtheequipmentandsuppliesneededtoconductreal-timePCR.
Sinceitsestablishment,thebiosafety-enhanced(BSL-2plus)inuenzalaboratoryatNIH
hasdeveloped,standardized,andimplementedstandardoperatingprocedures(accordingto
U.S.CDCprotocols)forseverallaboratorytechniques.Asthecountrysnationalinuenza
center,theNIHlaboratoryparticipatesininternalandexternalqualityassurancesurveys
conductedbyWHO.TelaboratorysPublicHealthLaboratoryDivisionoersafully
functional,standardizedfacilitythatcanperformtissuecultures,real-timePCRtesting,and
immunouorescentassays.
Preparedness
OcialsinPakistansMOHhavetakenseveralstepstopreventandcontrolpandemicinuenza
inthecountry,includingcreationoftheNationalPreparednessPlanforPreventionandControl
ofAvianandPandemicInuenza.TisplanwasdevelopedbythemultisectoralNational
ExpertCommitteein2005andledtoimplementationofaNationalProgramforPrevention
andControlofAvianandPandemicInuenza.Componentsofthisplanincludeemergency
response,clinicalhealthservices,antiviralmedicines,vaccine,containmentandquarantine,
communication,andstangissues.
Troughitslaboratorysurveillanceactivities,ocialsinPakistansNIHmonitortheglobal
inuenzapandemicsituationdaily.TeNIHalsoisreceivingtechnicalsupportfromWHO,
NAMRU-3,andtheU.S.CDC.
Specicstepstakenforsurveillanceofhumancaseswere
ImmediatedispatchingofjointMOH-WHOrapidresponseteamstoaectedareasand
districts.
StrengtheningofNIHlaboratorycapacitytoconductviralculture,subtyping,and
molecular(PCR)testing.
Activatingthecountrysexistingsurveillancesystemforcasending,samplecollection,
andtransportationtothevirologylaboratoryattheNIH.
Activatingdistrict-level
monitoringandresponse
committeesoverseenby
districtcoordinationocers
foravianinuenza.
Distributingviraltransport
mediatoprovincialhealth
departmentsandall
internationalairportsforthe
collectionandtransportation
ofsamplesfromany
suspectedpatients.
91

Generalstepstakenforsurveillanceofhumancaseswereasfollows:
Jointsteeringcommitteeswereestablishedatthefederallevel,withthefederalministers
forhealthandfood,agriculture,andlivestockservingascochairmen.
Jointcommitteeswereestablishedatdistrictlevelsundertheepidemiologydistrict
ocer,themedicalsuperintendentatDistrictHeadquartersHospital,theagricultureand
livestockdistrictocers,anocerfromthewildlifedepartment,thedeputydirectorof
theinformationdepartment,andarepresentativefromthedistrictnancedepartment.
TenationalreferenceBSL-3laboratoryatNIHisinitsnalphasesofconstruction.
TeMOHhasregisteredtheantiviralmedicinesthatareknowntobeeectiveagainst
inuenza,and13localpharmaceuticalcompanieshaveshowninterestinmanufacturing
genericversionsofoseltamivir(Tamiu).
Publichealthspecialistsfromprovincialhealthdepartmentshavebeenaddedtothe
rapidresponseteamsoftheministriesoffood,agriculture,andlivestock.
NationalandinternationalcollaborativelinkshavebeenestablishedamongtheMOH
andinternationalstakeholderssuchasWHOandtheU.S.CDC.
Standardoperatingproceduresforsurveillanceandrapidresponseforcasesofpandemic
inuenzahavebeencirculatedtotheprovincialhealthdepartmentsofPunjab,Sindh,
NWFP,andBalochistanandtotheregionalhealthdepartmentsoftheAzadStateof
JammuandKashmir(AJK).
Standardoperatingproceduresforcollection,storage,andtransportationofspecimen
fromsuspectedcasesofinuenzahavebeendeveloped.
TenationalinuenzaprojectsentinformationaboutPPEstandardstotheprovincial
healthdepartments,IslamabadCapitalTerritory,AJK,FederallyAdministeredNorthern
Areas,andFederallyAdministeredTribalAreas.
Antiviralmedicinessuchasoseltamivir(Tamiu)weresentfromthenationallevelto
high-riskdistrictsthroughoutPakistan.Oseltamivir(Tamiu),otherantiviralmedicines,
andseasonalinuenzavaccinewereprocuredforstaengagedinseasonal,swine,and
avianinuenzasurveillance.
92
Training
Severalphysicians,publichealthprofessionals,andlaboratorypersonnelweretrainedthrough
aprogramdesignedspecicallyforthisproject.Activitiesfocusedonprovidingrapidresponse
trainingforocialsinvolvedinoutbreakresponseactivities.In2009,
Fiveexerciseswereconducted,with46peopletrained.
Fivetrainingsforsentinelsitephysicianswereconducted,with42participants.
TenlaboratorystafromallsitesandprovincesattendedPCRtraining.
Anationalseminaroninuenzaandaworkshoponqualitycontrolareplannedforthe
nextquarter.
Publichealthandhealthcareprofessionalsweretrainedhowtoconductsurveillanceof
humancasesandhowtousePPEthroughtheFELTPinPakistan.
Healtheducationmaterialsandformswereproduced.
TebiosafetyenhancedlaboratoryatNIHisfullyfunctionaltopickuppandemic2009
H1N1inuenzacases.TefederalmonitoringcellatNIHismonitoringthesituation
constantly.
Consistentinformation-sharingwithGISNand100%evaluationresultsorscoresin
(EQAP)fromWHOforseasonal,avian,andswineinuenza.
Pressandmediacommunicationonregularbasis.
AllsentinelsitesatFGSH,KEMU,HMC,BMCandCHKareoperationalafterbasic
orientationtrainingofphysiciansandmedicalpersonnelforcollectionofepidemiologic
dataandsamplesfromILIandSARIcases.
SentinelsitevirologicspecimensandepidemiologicdataareshippedtoNIHbycourier.
Rapidresponseteamshavebeenreorganizedandactivatedfortimelyresponse.
BirjeesMazherKazi,MBBS,DCP,MPhil
ExecutiveDirectorNIH,ProjectDirectorNILSP
ParkRoad,ChakShahzad,Islamabad-54000,Pakistan
E-mail:bmkazi@gmail.com
SyedSohailZahoorZaidi,MPhil,MPhil
HeadVirology,TechnicalOcerNILSP
VirologyDepartment,PHLD
ParkRoad,ChakShahzad,Islamabad-54000,Pakistan
E-mail:zaidis@pak.emro.who.intorsohailz@live.com
93
94
European
RegionalOffce
(EURO)
EuropeanRegionalOffce(EURO)
HumanInfuenzaSurveillance:EURO2010
U.S. CDCAssignees
WHORegionalLaboratory
GDDSi te
WHOEUROHeadquarters
WHOHeadquarters
ECDCHeadquarters
European UnionMemberStates
WHOEURO
CDCIndirect Funding
Infuenza CooperativeAgreement 0 337.5 675 1, 350 2,025
Mi les
SurveillanceandResponsetoAvianandPandemicInuenzabyRegionalOcesofWHO
CooperativeAgreement
Armenia.
Georgia.
Kazakhstan.
Moldova.
Romania(throughWHO-EURO).
Ukraine(throughProgramAppropriateTechnologyinHealth[PATH]).
WHO-EUROworksincoordinationwiththeEuropeanCentersforDiseaseControl(ECDC)
tosupporttheimplementationofpublichealthprogramsintheregions53memberstates.
TesememberstatesarelocatedinEasternandWesternEurope,theCaucasusregion,and
CentralAsia.
TeU.S.CDCcurrentlyhasaninuenzaadvisorassignedtotheECDC,whichislocatedin
Stockholm,Sweden.During2009,U.S.CDCplacedanepidemiologistinWHO-EUROin
Copenhagen,Denmark.Placementoftheepidemiologistintheregionwillprovidecritical
97

supporttotheWHO-CDCmissiontosupportinuenzasurveillanceandresponseactivitiesin
theregion.
WHO-EUROandU.S.CDCarecollaboratingontheimplementationofacoordinated
plantoimprovelaboratorycapacityinmemberstateNICs.Tiscapacityisneededtodetect
andrespondtooutbreaksofnovelinuenzaandotherpathogenswithpandemicpotentialin
humansandtosupportpandemicplanningandcontainmenteortsintheregion.WHO-
EUROandU.S.CDCcoordinatecloselytoimplementinuenzasurveillanceandpandemic
activitiesinArmenia,Georgia,Kazakhstan,Moldova,Romania,andUkraine.
Surveillance
Peer-reviewedseasonalinuenzasurveillanceguidelinesweredevelopedandpublished
jointlybyWHO-EUROandU.S.CDC.(Seewww.euro.who.int/document/e92738.pdf.)
Tirteencountriesreceivedtechnicalassistanceandsupporttosubmitepidemiologic
andvirologicdataintotheWHO-EUROregionalsurveillanceplatform.
Aregionalplatformforinuenzasurveillancethatincludesdatabaseswithinformation
onthecapacitiesofEUcountrieswasestablishedandexpandedfrom29to53
countries.
ALabNetmeetingforNICsinCommonwealthofIndependentStates(CIS)andSouth
EasternEurope(SEE)countrieswasconductedjointlywithepidemiologistsresponsible
forinuenzaatthenationallevel.
TerestructuringoftheWHO-EUROCommunicableDiseaseSectionsinuenza
Websitewascompletedandexpandedtoincludeasectiononpandemic2009H1N1
inuenza.
Laboratory
Anintercountryworkshoponstrategiesforimprovinglaboratoryqualityaspartofthe
implementationofIHRcorecapacitieswasconducted.
Preparedness
Twopandemicpreparednessworkshopswereconducted;12CIScountriesattended1
workshop,and9SEEcountriesattendedtheother.
PandemicworkinggroupswereestablishedforCISandSEEcountries.
Treeeldmissionsweredeployedforoutbreakcontainment.
Training
Hands-ontraininginbiosafetywasconductedforseniorlaboratorystafromnational
inuenzalaboratoriesin12CIScountries.
IHR-relatedlaboratorymanagementtrainingwasconductedfor3countries.
TwosubregionalalertandresponsetrainingsessionswereconductedfortheBalticStates
andSEEcountries.
98
AregionalmeetingwasheldinAugust2009todiscusscurrentknowledgeof2009
H1N1inuenzaandreviewandreinforcestrategiesforsurveillance.
WHO-EUROcoordinatedpandemiccommunicationswithWHOcountryoces,the
EuropeanCommission,theECDC,andotherEUagenciesandpartners.
Nonpharmaceuticalsocialdistancingcontrolmeasureswerereviewed.
2009H1N1inuenzakitsandotherreagentsandsuppliesdevelopedbyU.S.CDC
weredistributedtocountriesinsupportofpandemicresponseeorts.
Launchoftheinuenzasurveillanceplatformforall53WHOmemberstates.
PublicationofWHO-EUROguidanceforinuenzasurveillanceinhumans.
Distributionoflaboratorykitstomemberstatesafteremergenceofthepandemic2009
H1N1inuenza.
Regionalmeetingfor25memberstatesontheresponsetothepandemic2009H1N1
inuenzainCopenhagen.
CarolineS.Brown,PhD
TechnicalOcer
CommunicableDiseasesUnit
WHORegionalOceforEurope
8,Schergsvej8
2100Copenhagen,Denmark
E-mail:cbr@euro.who.int
JoshuaMott,MA,EMT-P,PhD
Epidemiologist
8,Schergsvej8
E-mail:jmo@euro.who.int
U.S.CDCStaff
ProjectOcer
InuenzaDivision
Atlanta,GA30333
E-mail:zen3@cdc.gov
99
100
EuropeanRegion
Armenia
Capital:Yerevan InfantMortalityRate:Total:20.94deaths/1,000
Area:29,743sqkm
Population:
2,966,802(July2010est.)

LiteracyRate:
AgeStructure:
014years:18.7%(male296,401/
female259,594);1564years:70.3%(male
975,438/female1,111,989);65yearsorolder:11%
SurveillanceandResponsetoAvianandPandemicInuenzabyNationalHealthAuthorities
OutsidetheU.S.CooperativeAgreement
Began2006.
Since2006,Armeniahasbeenfundedtoenhanceinuenzasurveillanceandlaboratory
capacitytoimprovecapabilitiestorespondtoavianandpandemicinuenzaoutbreaks.Te
StateHygieneandAnti-EpidemicInspectorate(SHAEI)oftheMOHinArmeniahasproject
goalsthatfocusondevelopingappropriatelaboratoryanddiagnosticcapacitytorapidlydetect
suspectcasesofavian,seasonal,andpandemicinuenza.Inaddition,projectgoalsinclude
strengtheningepidemiologicsurveillancecapacityatalllevelsofgovernment,includinglocal
andbordersanitaryquarantineposts.
Surveillance
During20082009,thefollowingactivitieswereimplementedundertheepidemiologycapacity
andinfrastructurecomponentofthesurveillanceandresponsetoavianandpandemicinuenza
grantproject:
Withthesupportoflocalexperts(i.e.,epidemiologists,infectiousdiseasespecialists,and
virologists),guidanceoninuenzalaboratorydiagnostictestingwasdeveloped.
101
Rolesandresponsibilitiesweredenedfornotication,recording,andreportingof
inuenzalaboratorytestresults,aswellasfortheregimenandschemerequiredfor
packaging,shipping,andtransportinginuenzaspecimensfromsentinelsitesfromthe
PCRlaboratoryinLoriMarz(i.e.,theNorthernregionofArmenia)totheAIreference
laboratoryattheCDCMOH(Yerevan).
Rolesandresponsibilitiesofmedicaldoctors,epidemiologists,andnursesworkingat
sentinelsitesweredenedaccordingtotheinuenzaepidemiologicsurveillancescheme
andsurveillancestandard,includingthoserelatedtonotication,recording,reporting,
andsampling.Tesestandardsarebasedonthesurveillancestandardandprotocolfor
investigatingcasesandclusters.
Medicaldoctors,epidemiologists,andnurseswereidentiedandenrolledatsentinel
sitesinLoriMarzandYerevan.
Allsentinelmedicaldoctors,epidemiologists,andnursesfromLoriMarzandYerevan
weretrainedoninuenzaepidemiologicsurveillanceschemeandsurveillancestandards,
includingcasedenitions,rolesandresponsibilities,notication,recording,reporting,
andsampling.Sentinelsurveillanceisbeingpilotedat2sites.
GuidanceonhowtoconductasentinelsurveillancesystemwasadoptedbytheRepublic
ofArmeniasMOH.
Regulationsontheexchangeofinformationaboutcasesofanimalandhumandiseases
amongtheMOH,theMinistryofAgriculture,andtheMinistryofEcology(including
reportingforms)wasadoptedbytheArmeniangovernment.
Asmalllibraryofscienticperiodicalswasestablished,withapproximately100volumes
onpublichealth,epidemiology,andvirologyinEnglishandRussian.
Laboratory
Tesentinelsurveillancenetworkconsistsofthefollowing3laboratories:
CDC-MOH(Yerevan).
ExpertcenteroftheStateHygieneandAnti-EpidemicInspectorate(SHAEI)ofLori
Marz(Vanadzor,Armenia),whichwasrenovatedandequippedunderthisproject.
ExpertcenteroftheSHAEIofSyunikMarz(Kapan,Armenia),whichisnotfully
equippedyet.ItisbeingequippedthroughdonationsfromAustriaandshouldbe
operationalin2010.
TePCRLaboratoryofNorkInfectionHospitaloftheMOH(Yerevan,Armenia)hasno
real-timePCRequipment,onlyanopensystem,anditisnotyetpartoftheinuenzasentinel
network.
DuringFY20082009,thefollowingactivitywasimplementedunderthelaboratorycapacity
andinfrastructurecomponentoftheSurveillanceandResponsetoAvianandPandemic
InuenzaGrantProject:
TePCRopensystemoftheLoriMarzSHAEIlaboratorywasreequippedwitha
newreal-timePCRandnecessaryaccessoriestoimproveandenhancethesentinel
surveillancesystem.
102
Preparedness
TepreparednessplanforpandemicinuenzawasadoptedbytheArmeniangovernment.
Training
TrainingonhowtoconductinuenzaPCRdiagnosiswiththeLightCycler480
InstrumentII(RocheDiagnostics)wasprovidedfor2virologistsfromLoriMarz
inAugust2009.TistrainingwasperformedatthePCRLaboratoryoftheexpert
centeroftheSHAEIofLoriMarzandconsistedoftheoreticalandpractical
applications.
TrainingonPCRdiagnosisofavianandseasonalinuenzaandotherviraldiseases
wasconductedfor8PCRlaboratoryspecialistsfromCDCMOH(Yerevan),
LoriMarz,SyunikMarz,andNorkInfectiousClinicalHospitalPCRlaboratories
(eachfacilitysent2people).Tistrainingconsistedoftheoreticalandpractical
applicationsandwasperformedattheCDC-MOH(Yerevan).
Fourdaysoftrainingontheintroductionofaninuenzasentinelpilotsystemin
Yerevan,Vanadzor,andLoriMarzwasconductedfor47doctorsfrom6hospitals(4
hospitalsfromYerevan,1hospitalfromVanadzor,and1hospitalfromLoriMarz).
SinceAugust2009,projectteammembershaveparticipatedinregularweeklymeetings
ofthemultilateraltaskforceon2009H1N1inuenzaattheMOH.
Sanitaryquarantinecontrolwasstrengthenedonthefrontier,particularlyinthe
followinglocations:ZvartnotsInternationalAirport(Yerevan),ShirakAirport(Gyumri,
ShirakMarz),Bavra(ShirakMarz,borderwithGeorgia),Gogavan-Privolnoe(Lori
Marz,borderwithGeorgia),Ajrum-Jiliza(TavushMarz,borderwithGeorgia),
Bagratashen(TavushMarz,borderwithGeorgia),andMeghri(SyunikMarz,border
withIslamicRepublicofIran).
StaoftheSanitaryQuarantinePost(SQP)inZvartnotsInternationalAirport
(Yerevan)implementedthethermoscreeningofallpassengersarrivingfromother
countries.AllpassengerslledoutthePublicHealthPassengerLocatorCardand
providedittotheSQPsta.
Publicawarenessactivitieswereundertaken,includingdistributionofpracticalguidance
andadviceforthepublic.TesematerialswerepostedontheMOHWebsite.
103
TePCRlaboratoriesatCDC-MOH(Yerevan)andLoriMarzareoperational.
Tesentinelsurveillanceschemewasadopted,staweretrained,andpilotprograms
werelaunchedat2sentinelsites.
Regulationsontheexchangeofinformationaboutcasesofanimalandhumandiseases
amongtheMOH,theMinistryofAgriculture,andtheMinistryofEcology(including
reportingforms)wasadoptedbytheArmeniangovernment.
SpecialInfuenzaProject
WorldBankAvianInuenzaPreparedness
Procured16,000dosesofvaccineagainstseasonalinuenzaforthe200809inuenza
season.
Implementedvaccinationprotocolamongpopulationsathighrisk,suchasmembers
ofrapidresponseteams,physicians,pediatricians,familydoctors,nurses,workers
implementingbordercontrol,workersonbatteryfarms,zooworkers,ornithologists,
andchildrenaged67yearslivinginaterritorywherewildbirdssettle.
Constructed,renovated,andequippedthefollowingsanitaryquarantineborderpostson
northernandsouthernpartsofthefrontierofArmenia(AIPProjectbyWorldBank):
ZvartnotsInternationalAirport(Yerevan).
ShirakAirport(Gyumri,ShirakMarz).
Bavra(ShirakMarz).
Gogavan-Privolnoe(LoriMarz).
Ajrum-Jiliza(TavushMarz).
Bagratashen(TavushMarz).
Meghri(SyunikMarz).
104
ProvidedInternetconnectionstothefollowingSHAEIcenterstoallowthesesitesto
interactwiththeinuenzasurveillancenetwork:
CentraloceoftheSHAEIoftheMOH.
RegionalcenteroftheSHAEIofAragtsotnMarz(Ashtarak).
RegionalcenteroftheSHAEIofArmavirMarz(Armavir).
RegionalcenteroftheSHAEIofAraratMarz(Artashat).
RegionalandintraregionalcentersoftheSHAEIofSyunikMarz(Megri,Goris,
Kapan).
RegionalandintraregionalcentersoftheSHAEIofKotaykMarz(Abovyan,
Hrazdan).
IntraregionalcentersoftheSHAEIofGegharkunikMarz(Chambarak,Vardenis).
RegionalcenteroftheSHAEIofShirakMarz(Gjumri).
RegionalcenteroftheSHAEIofVajotsDzor(Vayq).
RegionalcenteroftheSHAEIofLoriMarz(Vanadzor,Tashir,Alaverdi).Nork
InfectionHospital.
PrincipalCollaboratorsfortheArmeniaNIC
SergeyKhachatryan
17ShirvanzadeStreet
Yerevan0014,Armenia
E-mail:hpiu@arminco.comorsrg@arminco.com
ArtavazdVanyan
10G.HovsepyanStreet
Yerevan0047,Armenia
E-mail:ph@ph.am
ArmenHayrapetyan
ExecutiveCoordinator
17ShirvanzadeStreet
Yerevan0014,Armenia
E-mail:hpiu@arminco.comorhayrarmen@armenia.com
NuneBakunts
ProjectTeamLeader
10G.HovsepyanStreet
Yerevan0047,Armenia
E-mail:ph@ph.amorn.bakunts@gmail.com
105
106
EuropeanRegion
RepublicofGeorgia
Capital:Tbilisi InfantMortalityRate:Total:16.78deaths/1,000
Area:69,700sqkm
Population:
4,600,825(July2010est.)

LiteracyRate:
AgeStructure:
Totalpopulation:100%;male:
014years:16.3%(male402,961/
100%;female:100%(2004est.)
female352,735;1564years:67.1%(male
SurveillanceandResponsetoAvianandPandemicInuenzabyNationalHealthAuthorities
OutsidetheUnitedStatesCooperativeAgreement
Began2006.
Surveillance
Atotalof1,382sampleswerereceivedattheNationalInuenzaLaboratory(NIL)from
1,371casesofILI.Ofthesesamples,688weretestedbyrapid-test,78werepositivefor
inuenzaA,and74werepositiveforinuenzaB.
Atotalof1,190samplesweretestedbyreal-timeRT-PCR.Ofthesesamples,28were
positiveforpandemic2009H1N1inuenza,5werepositiveforseasonalA/H1
inuenza,34werepositiveforA/H3inuenza,and31werepositiveforinuenzaB.
Twenty-veinuenzaisolatescultivatedonMadin-Darbycaninekidney(MDCK)cells
weretestedbyHI/HA.OnewasseasonalA/H1inuenza,8wereA/H3inuenza,and
16wereinuenzaB.
InMay2009,ocialsintheRepublicofGeorgiaconductedtherstroundofmonitoringof
theinuenzasurveillancesystem.Oneobjectiveofthismonitoringwastoevaluateawareness
aboutinuenzaandpandemic2009H1N1inuenzaamonghealthcareproviders.Tedata
obtainedwillallowprojectstatopreparetrainingmaterialsthatincludeallinformation
107
relevanttotheseissues.AsecondroundofmonitoringwasconductedinSeptember2009and
showedthathealthcareprovidershadsatisfactoryknowledgeabout2009H1N1inuenza.
Duringthe2roundsofmonitoring,50healthcarefacilitieswerevisited.Tequalityof
registrationandnoticationhasincreasedsignicantlysince2007,whenmonitoringwasrst
establishedtomaintainthenationalsurveillancenetwork.
Datareceivedfromanevaluationsurveyofissuesrelatedtothediagnostic,registration,and
reportingsystemforinuenzaandacuteinfectionsoftheupperrespiratorytractinGeorgia
wereanalyzedinFY2009.Asaresultofthisanalysis,negotiationsaboutwhatchangesshould
bemadetothecountrysinuenzasurveillancesystemareongoing.Tedataalsowereusedto
developrecommendationsandguidelinestoaddressexistinggapsinthesystem.New
recommendationsandguidelineswillbepublishedinFY2010.
OthersurveillanceactivitiesduringFY2009includedthefollowing:
TerapidresponseteaminGeorgiaconductedseveralcaseinvestigationsinvolving
SARI.
Necessaryequipmentandsupplieswerepurchasedanddistributedto8sentinelsites.
SinceMay2009,anadditionalsentinelsitewasestablishedatalargeoutpatientclinicin
Tbilisi.NILreceivesabout60samplesweeklyfromthissite.
Laboratory
ByApril2009,theNRLatGeorgiasNationalCenterforDiseaseControlandPublic
Health(NCDC)wasprovidedwithallnecessaryreagentsandsuppliesforlaboratory
functionsduringroutinesurveillanceandpandemiccircumstances.
Reagentswereprocuredtoconductdierentialdiagnosticsforinuenzaviruses.
108
Additionalprimersforotherrespiratoryinfectionswereacquired,andtheNCDCsNIL
cannowconductdierentialdiagnosticsforotherrespiratoryinfections.
During2009,theNRLsent2additionallaboratorytechniciansforinternational
trainingoninuenzatestingtechniques.Tetechniciansareworkingundercontractfor
theproject,andtheircontractswereextendedtothe3rdbudgetyear.
BecauseofmilitaryoperationsinGeorgiainAugust2008,theProjectManagement
Unit(PMU)couldnottakepartinameetinginCairo.Instead,stamembersfrom
thePMUvisitedtheU.S.CDCtofamiliarizethemselveswithmaterialsfromtheCairo
meetingandtoconsiderprojectplans.
Inaddition,PMUstamemberswereabletolearnaboutU.S.CDCsorganization
andstructure,discussexistingproblemswithGeorgiassurveillancesystem,learnmore
abouttheU.S.surveillancesystem,visitU.S.CDCsinuenzalaboratory,andreceive
recommendationsaboutlaboratoryequipment.
DiagnosticswereconductedinBSL-2laboratoriesequippedbytheTreatAgent
DetectionandResponseProject,withvirologyandPCRdiagnosticsperformedonlyfor
specialcases.TenumberofsamplestestedbyPCRwasincreasedbecausetheecacy
ofvirologytestingissignicantlylowandtime-consuming.
BecausethePCRmachineattheNRLisinusealmostcontinuously,ocialsfound
spacetoaccommodateasecondmachine.Othernecessaryequipmentalsowaspur-
chasedaspartoftheU.S.CDCproject.
Becauseoftheoccurrenceofpandemic2009H1N1inuenza,fundswereredirectedto
payfordevelopingandprintingtrainingmaterialsabouttheemergencyofthenewpan-
demic.Materialsweredevelopedtoincreaseawarenessofhealthcareprovidersthrough-
outthecountry.
TrainingsonhowtocontrolpandemicinuenzaandusePPEwereconductedfor1,000
healthcareprovidersinall63districtsofGeorgia.
Ocialsconductedacaseinvestigationoftherstclusteroutbreakofpandemic2009H1N1
inuenza,withthefollowingresults:
OnJuly30,2009,amemberofaGeorgiandancegroupreturningfromWesternEurope
wasconrmedtohave2009H1N1inuenza.
Projectstainvestigatedtransmissionofinuenzawithinthedancegroupandwith
theirclosecontactsuponreturntoGeorgia.Astandardizedquestionnairewasusedto
collectinformationonage,symptoms,andhealthpractices.
Fivecaseswereconrmed,and8probablecase-patientsweresuspectedtohave2009
H1N1inuenzavirus(13of35groupmembers,attackrate(AR)=37%;1of37
in-countrycontacts,AR=3%).Terstprobablecase-patientdevelopedsymptoms
onJuly20,2009,duringthetour.Teagedistributionofthecase-patientswas1018
years;noneof30adults(4groupmembersand26in-countrycontacts)wasaected.
109
Commonsymptomsofcase-patientswerefevermorethan38
C(70%),cough(35%),
sorethroat(35%),runnynose(35%),andheadache(29%).
Surveillancealsorevealedthat93%ofallcase-patientshadpracticedlimited
handwashingduringthetour,andallhadbeeninclosecontactwitheachotherfor
5dayswhiletravelingbyferryandbus.Nogroupmembersorcontactswereever
vaccinatedagainstseasonalinuenza.
Noonereceivedantiviraltreatment.Nocomplicationsordeathshaveoccurred.
Beforethisclusterwasidentied,only7sporadicimportedcasesofpandemic2009
H1N1inuenzahadbeenconrmed.
Oneadditionalsentinelsurveillancesitewasestablishedatalargeoutpatientclinicin
TbilisiinMay2009bringingthetotalofsentinelsitesinGeorgiato9.TeNILreceives
approximately60samplesweeklyfromthisnewsite.
SpacewithintheNRLwasupgradedtoaccommodateanadditionalPCRmachineand
otherequipmenttomeetthegrowingneedsoftheproject.
KhatunaZakhashvili,MD
ProjectCoordinator
HeadofSurveillanceDepartment
NationalCenterforDiseaseControlandPublicHealth(NCDC)
0177,9M.AsatianiStreet
Tbilisi,Georgia
E-mail:episurv@ncdc.ge
OlgaTarkhan-Mouravi,MD
ProjectAssistant
HeadofVaccinePreventableDiseaseUnit,NCDC
Tbilisi,Georgia
E-mail:vpd@ncdc.ge
AnnaMachablishvili
LaboratoryOcer
HeadofInuenzaLaboratory,NCDC
Tbilisi,Georgia
E-mail:lrc@ncdc.ge
PaataImnadze,MD,DPH
MainExpert
DirectorGeneralofNCDC
Tbilisi,Georgia
110
EuropeanRegion
Kazakhstan
Capital: Astana InfantMortalityRate:Total:26.56deaths/1,000
Area: 2,717,300sqkm
Population:
15,460,484(July2010est.)
ears:22.1%(male1,734,622/

LiteracyRate:
AgeStructure:
T
014y
99.8%;female:99.3%(1999est.)
DevelopmentofInuenzaSurveillanceNetworksCooperativeAgreement
Began2005.
Fundingthroughthecooperativeagreementhasbeencombinedwithothersupportfromthe
U.S.CDCandcontributionsfromUSAIDandNAMRU-3toestablishaninuenzasentinel
surveillancenetworkof7sitesthatprovideinuenza-positivespecimenstotheGISNthrough
theKazakhstanNIC.
Surveillance
SurveillanceactivitiesinKazakhstanincludethefollowing:
FourteenoblastSanitaryEpidemiologicalService(SES)laboratoriesand2citySES
ocesreportallcasesofacuteviralrespiratorydiseaseandinuenzatotheRepublican
SanitaryEpidemiologicalService(RSES).
TeU.S.CDChelpedtheKazakhstanMOHestablish3geographicallydispersed
sentinelsitestocollectinformationonacuterespiratorydisease.
111
Ateachsite,trainedepidemiologistsandclinicianscollectedepidemiologicandclinical
information,aswellasupperrespiratorytractspecimens,fromasampleofpersonswho
mettheWHOILIorSARIcasedenitions.
Laboratory
FourteenoblastSESlaboratories,2citySESlaboratories,andtheNICcandetectinu-
enzavirusbycultureandimmunouorescencemicroscopy.
Te14oblastSESlaboratoriescandiagnoseinuenzabytestingacuteandconvalescent
serumspecimens.
Eachsiteobtains2nasaland1pharyngealswabsfromasampleofpersonswhomeet
theWHOILIorSARIcasedenitionsandwhohavesymptomsformorethan72
hours.Teswabsareplacedinviraltransportmedium,whichisdividedinto2aliquots
andfrozenatlessthan70C.
Duringthe200809inuenzaseason,sentinelsitessubmitted669specimensfrompatients.Of
these,270(40%)werepositivebyPCRforinuenzavirus.Ofthese270specimens,97(36%)
wereinuenzaBand173(64%)wereinuenzaA.AmongtheinuenzaAviruses,79%were
2009H1N1inuenzaand21%wereseasonalH3N2inuenza.
Tefollowingarelaboratorymilestones:
In2009,Kazakhstangainedthecapabilitytoreliablydiagnoseinuenzavirusinfections.
In2009,theRSESvirologylaboratorybecameafullyfunctioningNICandwaso-
ciallyrecognizedbyWHO.
Duringthe200809inuenzaseason,morethan100inuenzavirusesweretypedand
subtypedinKazakhstanforthersttimeinadecade.
Duringsummer2009,asadirectresultofU.S.CDC-ledeorttoestablishreal-time
PCRcapabilityintheRSESlaboratory,theKazakhstanMOHdiagnosed17imported
casesof2009H1N1inuenzaandruledoutotherviruses.Tesendingslesseneda
publichealthchallengepresentedbytheinitialintroductionof2009H1N1inuenzain
KazakhstanandallowedtheMOHtomakeprudentresponses.
TesentinelsurveillancenetworkinKazakhstanwillexpandto7sites,coveringthe
entirecountryduringthe200910inuenzaseason.
Inuenzavirusidenticationandtypingbyreal-timePCRthatusesAmplisenseprim-
erswillbeperformedattheoblastlevelforallpositivesandasampleofnegativesand
forwardedtotheNICforconrmationwithU.S.CDCprimers.
Preparedness
PreparednessactivitiesforFY2009includedthefollowing:
U.S.CDCstadraftedaNationalPandemicPreparednessPlanandsubmittedittothe
MOH.
U.S.CDCsupportedandledtheMOHworkgroupcreatedtorenetheplan.
112
U.S.CDCsponsoredtwo1-dayinterministerialmeetingstodiscussandpublicizethe
planandtwo2-daytabletopsimulationexerciseswithrepresentativesofallrelevant
ministriesandNGOstofurtherrenetheplan.
TeplanwasapprovedbytheprimeministerofKazakhstaninAugust2009.
ImplementationguidelineswereapprovedbythechiefstatesanitarydoctorinOctober
2009.
Training
TrainingactivitiesinKazakhstanincludedthefollowing:
Aweek-longcourseonlaboratorybiosafetyandbiosecurityforlaboratorydirectorsand
workersfromCentralAsiaandtheCaucasus.
Five-and2-daysentinelsurveillancetrainings(i.e.,clinical,epidemiologic,laboratory)
wereconductedtwiceinUralsk,Petropavlovsk,andTaldykorganandonceinAktau,
Astana,Taraz,andUst-Kamenogorsk.
Two-daytabletopexercisesonpandemicinuenzawereheldnearAstana.Onewasfor
national-levelocialsrepresentingallrelevantministriesandNGOs,andtheotherwas
foroblast-levelrepresentativesofthesameorganizations.
Aweek-longworkshoponthecleaningandanalysisofinuenzasentinelsurveillance
datawasheldforsentinelsiteandRSESepidemiologistsinAlmaty.
A2-dayregionaltrainingonhowtousereal-timePCRtodetect2009H1N1inuenza
washeldinAlmaty.
Ahalf-daytrainingontheproperuseofbiosafetycabinetswasprovidedto400usersof
biosafetycabinetsintheRSESlaboratories.
113
Acquired2009H1N1inuenzatestkitsfromU.S.CDC.
Providedregionaltrainingontheuseofthe2009H1N1inuenzatestkitswithhelp
fromNAMRU-3.
ProvidedconsultativeservicestotheMOHduringsummer2009when17H1N1cases
wereconrmedandagaininOctoberwhenadditionalcasesweresuspected.
Supportedanurgent1-dayconvocationofseniorhealthocialsfromthroughoutthe
nationtoensurediscussionof2009H1N1inuenzaandthenationalpandemicplan.
AnassessmentofthesensitivityandspecicityofinuenzaAandBtypingtestkitsfrom
Amplisense(Moscow)willbeperformedbyusingU.S.CDCprimersasareferencestandard.
AinagulKuatbayeva
ChiefEpidemiologist,RSES
84AuezovStreet
Almaty,Kazakhstan480008
E-mail:kainagul@yahoo.com
ElmiraUtegenova
ChiefofVirologyLaboratory,RSES
84AuezovStreet
Almaty,Kazakhstan480008
E-mail:elmira_utegenova@mail.ru
U.S.CDCStaff
GulzhanMuratbayeva,MD
AvianandPandemicInuenzaProjectManagementSpecialistforCentralAsia
JohnS.Moran,MD,MPH
InuenzaAdvisorandGDDCoordinatorforCentralAsia
EuropeanRegion
114
EuropeanRegion
GDD-Kazakhstan
Establishedin2008,theGlobalDiseaseDetectionRegionalCenter,Kazakhstan(GDD-
Kazakhstan)beganasanextensionoftheU.S.CDCspresenceandsuccessfromitsFETP,
whichbeganin2003.Inaddition,integratedeortswitheldstafromU.S.CDCsInuenza
Divisionin2007helpedformthefoundationofthecentersactivities.
Coverage
GDD-Kazakhstancovers5countriesinCentralAsiaandhasreliedheavilyontheexpertiseof
theU.S.CDCsInuenzaDivisiontolinksurveillanceandlaboratoryconrmationofnewand
emergingpathogens.TwooutbreaksofhighlypathogenicavianinuenzaA(H5N1)havebeen
reportedinCentralAsia:anoutbreakamongpoultryinnorthernKazakhstanin2005andan
outbreakamongwildswansinwesternKazakhstanin2006.
Activities
Outbreakresponse.
Pathogendiscovery.
Training.
Surveillance.
Networking.
Effect
In2009,GDD-Kazakhstanrespondedto14outbreaks,93%ofwhichresultedinaconrmed
causethroughlaboratoryanalysis.Inaddition,theydetected1pathogennewtotheregionand
developednewlaboratorytestingcapacityforinuenzaAandB.GDD-Kazakhstantrained
6FETPgraduatesandmorethan200participantsthroughshort-termregionalandnational
trainings.
Staff
In-CountryFieldSta
JohnMoran,MD,MPH
GDD-KazakhstanCoordinatorandInuenzaLead
IEIP.
FETP.
All-HazardsPreparednessandResponse.
115
116
EuropeanRegion
KyrgyzRepublic
Capital:Bishkek InfantMortalityRate:Total:30.25deaths/1,000
Population:
5,508,626(July2010est.)

LiteracyRate:
AgeStructure:

014years:29.4%(male827,346/
female794,746);1564years:65%(male
AlthoughthereisnocooperativeagreementintheKyrgyzRepublic(i.e.,Kyrgyzstan),theU.S.
CDChasreceivedWorldBankfundingthroughtheU.S.CDCFoundation.Tesefundswere
usedtosupplementsupportfromtheUSAID,U.S.CDCsInuenzaDivision,andtheGDD.
Surveillance
TereisuniversalreportingofacuteviralrespiratorydiseaseandinuenzatotheRSES.
Duringthe200708inuenzaseason,U.S.CDChelpedtheMOHinKyrgyzstan
establish2geographicallydispersedsentinelsitestocollectinformationonacute
respiratorydisease.Ateachsite,trainedepidemiologistsandclinicianscollect
epidemiologicandclinicalinformation,aswellasupperrespiratorytractspecimens,
fromasampleofpersonswhomeettheWHOSARIcasedenition.
Duringthe200910inuenzaseason,thesentinelsiteswillattempttoobtain
specimensfromILIandSARIpatients.
Laboratory
GovernmentlaboratoriesinKyrgyzstangenerallylacktrainedstaandsupplies.U.S.CDC
worksmainlywiththeRSESvirologylaboratoryinBishkekandthelaboratoryinOsh.
DuringMarch2006February2008,theRSESvirologylaboratorysubmitted12
inuenzavirusisolatestotheGISNthroughNAMRU-3.Tenofthe12testedpositive
forinuenzaB.
117
ImprovingthesensitivityofviralcultureintheNICinKyrgyzstancontinuestobea
projectgoal,andU.S.CDChassupportedviralisolationintheRSESvirologylaboratory
withequipment,supplies,andtraining.Atthesametime,U.S.CDCanditspartnersalso
haveestablishedreal-timePCRcapabilityintheRSESlaboratoryand2geographically
dispersedsurveillancesitesforacuterespiratorydisease.Ateachsite,2nasaland1
pharyngealswabsareobtainedfromasampleofpersonswhomeettheWHOSARIcase
denitionsandwhohavehadsymptomsforlessthan72hours.Teswabsareplacedin
viraltransportmedium,whichisdividedinto2aliquotsandfrozenatlessthan70C.
Duringthe200809inuenzaseason,thesitessubmitted390specimensfrompatients
whomettheSARIcasedenition.Ofthese,33%werepositivebyPCRforinuenza
virus.Ofthissubgroup,5%wereinuenzaBand95%wereinuenzaA.Amongthe
inuenzaAviruses,21%were2009H1N1inuenzaand79%wereseasonalH3N2
inuenza.
Preparedness
U.S.CDCstahelpedwriteaNationalPandemicPreparednessPlan,whichwas
submittedtotheMOH.U.S.CDCsupportedtheMOHworkgroupcreatedtorene
theplan.Aspartofthiswork,U.S.CDCsponsoredtwo1-dayinterministerialmeetings
todiscussandpublicizetheplanandtwo2-daytabletopsimulationexerciseswith
representativesofallrelevantministriesandNGOstofurtherrenetheplan.
Training
Two-daysentinelsurveillancetraining(i.e.,clinical,epidemiologic,laboratory)was
conductedinBishkekandOsh.
Two-daytabletopexercisesonpandemicinuenzawereheldatIssky-Kul.Onewasfor
national-levelocialsrepresentingallrelevantministriesandNGOs,andtheotherwas
foroblast-levelrepresentativesofthesameorganizations.
Aweek-longworkshoponthecleaningandanalysisofinuenzasentinelsurveillance
datawasheldforsentinelsiteandRSESepidemiologistsinBishkek.
A2-dayregionaltrainingonhowtousereal-timePCRtodetect2009H1N1inuenza
washeldinAlmaty.U.S.CDCsponsored2laboratoryworkersfromBishkektoattend.
Ahalf-daytrainingintheproperuseofbiosafetycabinetswasprovidedto125usersof
biosafetycabinetsintheRSESlaboratories.
Acquired2009H1N1inuenzatestkitsfromU.S.CDC.
Providedregionaltrainingontheuseofthe2009H1N1inuenzatestkitswithhelp
fromNAMRU-3.
ProvidedconsultativeservicestotheMOHduringsummer2009when4H1N1cases
wereconrmedandagaininOctoberwhenadditionalcasesweresuspected.
In2009,Kyrgyzstangainedthecapabilitytoreliablydiagnoseinuenzavirusinfection.
In2009,theRSESvirologylaboratorybecameafullyfunctioningNICandwas
ociallyrecognizedbytheWHO.
118
Duringthe200809inuenzaseason,morethan100inuenzavirusesweretypedand
subtypedinKyrgyzstanforthersttimeinadecade.
Insummer2009,solelyasaresultoftheU.S.CDC-ledeorttoestablishreal-time
PCRcapabilityintheRSESlaboratory,theKyrgyzstanMOHwasabletodiagnose4
casesof2009H1N1inuenzaandruleoutothers.Tesendingslessenedthepublic
healthchallengepresentedbytheinitialintroductionof2009H1N1inuenzato
KyrgyzstanandallowedtheMOHtomakeprudentresponses.
ZuridinNurmatov,MD
ChiefEpidemiologist,RSES
535FrunzeStreet
Bishkek,KyrgyzRepublic,720033
E-mail:zuridin@mail.ru
KaliyaKasimbekova,MD
ChiefofVirologyLaboratory,RSES
535FrunzeStreet
Bishkek,KyrgyzRepublic,720033
E-mail:kasymbekova@list.ru
119
120
EuropeanRegion
RepublicofMoldova
Capital: Chisinau(Kishinev) InfantMortalityRate:Total:12.77deaths/1,000
Population:
4,317,483(July2010est.)

LiteracyRate:
AgeStructure:
014years:15.7%(male347,808/

99.7%;female:98.6%(2005est.)
EnhancingPandemicPreparednessandResponseCapacityintheRepublicofMoldova
CooperativeAgreement
BeganAugust2009.
TeRepublicofMoldovasMOHisnewlyfundedtosupportthedevelopmentof
epidemiologic,laboratory,andrelatedcapacitytodetect,respond,andmonitorshiftsin
inuenzaviruses.Temainobjectivesoftheprojectareto
Strengthenpandemicinuenzapreparednesscapacitytoreducetheeconomicandsocial
impactofapandemic.
Improvedetectionandresponsecapacitiesbyenhancingthesurveillancesystemand
laboratorynetwork.
Strengthenresponseandcontainmentcapacitythroughrapidresponseandinfection
control.
ActivitieswillbeimplementedinclosecollaborationwithWHOregionalandcountryoces
andotherinternationalpartners.
121
Surveillance
TeMOHproposestoenhancedetectionandresponsecapacityto
Improveinformationanddatamanagementcapacitythroughintegrationofthe
technologysystemforthesurveillanceofinfectiousdiseases.
Improvetheprocessofspecimencollectionatfacilitiesinthesentinelsystem.
ImprovetheprocessofinformationcollectionforSARIateachsiteinthesentinel
systembyusingstandardcasedenitions.
Strengthenearlywarningsystemsforreportinghumancasesofinuenza.
Strengtheninfectioncontrolcapacity.
Laboratory
TeMOHproposestostrengthenthecurrentsentinellaboratorynetwork,whichconsistsof
theNationalViralRespiratoryLaboratory(NVRL)and9additionallaboratoriesaroundthe
country,tosupportsurveillanceanddetectionofinuenzathroughthefollowingactivities:
Strengtheningandimprovingthe
laboratorycapacityoftheNVRL
forperformingtheisolationand
typingofinuenzavirusesby
usingmoleculartechnology.
Maintainingthediagnostic
capacitiesneededtocarryoutthe
functionsoftheNVRLandthe
sentinel-basedlaboratorynetwork
throughtheprocurementof
essentialequipment,supplies,and
consumables.
Maintainingandensuringthebiosafetyandbiosecurityoftargetedlaboratories
accordingtonationalandinternationalstandardsthroughtheuseofguidelines,
standardoperatingprocedures,andtraining.
Preparedness
TegovernmentoftheRepublicofMoldovaapprovedtheNationalPreparednessPandemic
PlanforHumanPandemicInuenzain2005.Duringthecourseofthecurrentcooperative
agreement,projectstaproposedto
UpgradetheNationalPandemicPlan.
Establishaninterdepartmentalworkingtaskforcewithmultisectoralinvolvementfrom
governmentalministries.
Strengthenandadjustthelegalframeworkforanationalresponsetopotential
outbreaks.
Improvethecoordinationcapacitybetweenhumanandanimalsectors,government
ministries,businesses,andNGOs.
122
Establishacommunicationcomponenttothepandemicpreparednessplan.
Developandadoptrapidresponseandcontainmentprotocolstostrengthenlocalrapid
responsecapacity.
Training
TeMOHproposestotrain
Epidemiologiststoincreasetheirknowledgeandskillstosupportsurveillance,outbreak
investigationandresponse,anddiseasecontrolactivities.
Rapidresponseandcontainmentteams.
Laboratoryscientistsandtechniciansinthesentinelnetworkinsamplecollection,and
theproperlaboratorytechniquesfordetection,typing,andsubtypingoftheinuenza
virus.
TeWorldBankinitiatedtheAvianInuenzaControlandHumanPandemicPreparednessand
Response(AIHP)projectinMoldovain2006.TeprojectisapartoftheGlobalProgramfor
AvianInuenzaControlandHumanPandemicPreparednessandResponse(GPAI).Moldova
mettheeligibilitycriteriasetintheGPAIdocumentforacountryatrisk.Teoverallobjective
oftheprojectistominimizethethreatposedtohumansbyHPAIandenhancenational
pandemicpreparedness.Tehumanhealthcomponentoftheprojectisdesignedto
Enhancethenationalresponsecapacitythroughreviewoftheregulatorysystem.
Improvetheinformationaltechnologysystemforsurveillanceofinfectious
diseasesandtrainpersonnel.
Strengthenthenationallaboratory
capacitytodetectavianinuenzavirusbybuildinganewmoduleforinuenzaA
(H5N1)diagnosisandrenovationoftheNVRL.
Strengthenthehealthsystemresponsecapacitythroughrenovationoftheintensivecare
unitofthecountrysreferralhospitalforsuspectedcasesofavianinuenza.
PrincipleCollaborators
RaduCojocaru,MD,PhD
ExecutiveCoordinator
DirectoroftheLaboratory
67AGheorgheAsachiStreet
Chisinau,2068,NCPM
RepublicofMoldova
E-mail:radu_cojocaru@hotmail.comorrcojocaru@sanepid.md
123
AngelinaUrsu,MD
ProgramManager
HumanHealthComponentCoordinator
AvianInuenzaControlandHumanPandemicPreparednessandResponse
Chisinau,2068,NCPM
RepublicofMoldova
E-mail:cphm_md@yahoo.com
OlegBenes
GeneralDirector
Chisinau,2068,NCPM
RepublicofMoldova
E-mail:obenes@sanepid.md
124
EuropeanRegion
Romania
Capital:Bucharest InfantMortalityRate:Total:22.09deaths/1,000
Population:
22,181,287(July2010est.)

LiteracyRate:
AgeStructure:
014years:15.5%(male1,768,207/

Romaniaissupportedinitseortstoenhancelaboratoryandsurveillancecapacitytodetectand
respondtoavian,seasonal,andpandemicinuenzathroughaU.S.CDCcooperative
agreementwithWHO-EURO.ARomanian-basedNationalProfessionalOcerhasbeen
recruitedtofacilitatetheimplementationofactivitiesintheareasofpandemicpreparedness,
surveillance,andresponsetoavianinuenzaoutbreaks,laboratorycapacity,anddesktop
simulationactivities.TeNICislocatedintheCantacuzinoInstituteinBucharest.
Surveillance
SurveillanceactivitiesforRomaniaincludethefollowing:
AnassessmentoftheRomaniansurveillancenetworkwascompleted.
SentinelsurveillancesitesforILIandSARIhavebeenestablishedin20countiesand
Bucharest.
SARIsurveillanceisbeingimplementedinIasi,Cluj,Constanta,Timisoara,and
Bucharestonthebasisofrecommendationsfromthesurveillanceassessment.
GuidelinesandtrainingmaterialsforSARIsurveillanceandproceduresforquality
assuranceweredeveloped.
125
Duringthe200809inuenzaseason,1,064samplesweretestedbyRT-PCR,
resultingin384positiveresultsforinuenzaAH3,77positiveresultsforinuenzaB,
and4positiveresultsforinuenzaH1.
Laboratory
LaboratoryactivitiesinFY2009includethefollowing:
DevelopmentoftheCantacuzinoInstituteasaregionalinuenzacenterforlaboratory
diagnosticsandasamodelforimplementationandsupportofinuenzasurveillance.
TeCantacuzinoInstitutehasperformedinuenzaspecimentestingandqualitycontrol
forothercountriesintheregion.
RT-PCRlaboratorieswereupgradedandinstalledat4sentinelsites.
AlaboratoryexpertfromRomania(AlinaBaetel)traveledtoMacedoniaandAlbaniato
supportlocallaboratoriesintestingpandemicsamples.
Training
RomaniaconductedthefollowingtrainingactivitiesinFY2009:
LaboratorystamembersweretrainedontheSARIsurveillanceguidelinesanduseof
RT-PCRmachines.
PhysiciansweretrainedontheSARIsurveillanceguidelinesandstandards.
RecruitmentandplacementoftheNationalProfessionalOcerforRomaniawas
successfullycompleted.
SARIsurveillanceisbeingimplementedaspartofthesentinelsurveillancescheme.
TeCantacuzinoInstitutewasestablishedasaregionalinuenzacenter.
CarolineS.Brown,PhD
TechnicalOcer
8,Schergsvej8
E-mail:cbr@euro.who.int
LaurentiuZolotusca
SeniorEpidemiologist
MinistryofHealth,Romania
Intr.CristianPopisteanu
Nr.1-3,sector1
Code010024
Bucharest,Romania
E-mail:laurentiu_zolotusca@hotmail.com
126
EuropeanRegion
Ukraine
Capital:Kyiv(Kiev) InfantMortalityRate:Total:9.23deaths/1,000live
Area:603,700sqkm
Population:
45,415,596(July2010est.)

LiteracyRate:
AgeStructure:
014years:13.9%(male3,277,905/
female3,106,012;);1564years:70%(male
InuenzaSurveillanceandPandemicPreparednessinUkraineCooperativeAgreement
Began2006.
SinceOctober2006,theU.S.CDChasprovidedfundstotheProgramforAppropriate
TechnologyinHealth(PATH)tohelptheUkraineMOHinitseortstostrengtheninuenza
surveillanceandpandemicpreparedness.Activitieshavebeenfocusedinthefollowingareas:
StrengtheningtheNICinKiev.
EstablishingsentinelsitevirologicandepidemiologicsurveillanceforILIandSARI
frominuenza.
DevelopingnationalguidelinesforhealthservicesinUkrainetoplanandorganize
measurestocombatpandemicinuenza.
Enhancingthenationwideearlywarningsystemandepidemiologiccapacitytodetect
andrespondtohumanillnesscausedbynovelinuenzaAinfectionsorinfectionsfrom
otherrespiratorypathogenwithpandemicpotential.
PATHfacilitatedtheUkraineNICseortstodevelopnationalguidelinesforhealthservicesin
Ukrainetoplanandorganizemeasurestocombatpandemicinuenza.In2009,theseguidelines
127
wereapprovedbytheacademiccounciloftheNationalInstituteofEpidemiologyandInfectious
DiseasesandusedforpandemicpreparednesstrainingsandtoguidetheMOHs2009H1N1
inuenzaresponseactivitiesduringtheOctoberNovembersurge.
Surveillance
PATHhashelpedestablishafullyfunctioningsentinelinuenzasurveillancesysteminKiev,
Donetsk,andOdessaanddevelopedaWebsite(www.gripnaglyad.com)tosupportelectronic
reporting,dataanalysis,presentation,andotheraspectsofthesystem.Tesentinelsurveillance
networkincludes19hospitalsandpolyclinics.Datandingssuggestthat11%ofSARIand
21%ofILIcasesreportedtothesentinelsiteswerecausedbyinuenza.Twocasesofpandemic
2009H1N1inuenzawerecapturedbythesystemduringsummer2009,demonstratingthe
strengthofthesystemevenduringthesummerperiod.Informationonseasonalinuenzais
routinelysubmittedtoFluNetandtheEuropeaninuenzasurveillancescheme.
Laboratory
FundingfromthepartnershipbetweenU.S.CDCandPATHandtheUkraineMOHwasused
topurchaseRT-PCRequipment,biologicsafetyinstruments,autoclaves,reagents,consumables,
andothersupportingitemstostrengthenthecapabilitiesoftheNICinKiev,theMechnikov
Anti-PlagueResearchInstituteinOdessa,and2regionalvirologiclaboratoriesinthesentinel
regions.TeselaboratoriesarenowabletoperformPCRandvirusisolationoncellcultures.
Duringthe200809inuenzaseason,theNICreceivedandtested119seasonalinuenza
samplesfromthecountrylaboratories;95weretypeA(primarilyH3N2),and24weretypeB.
U.S.CDCsAssociationofPublicHealthLaboratories(APHL)reviewtoolwasusedtoconduct
anNILcapacityassessmentin2009.TereviewdemonstratedthattheUkraineNIChas
anadvancedsyndromicandlaboratory-basedsurveillancesystemandwell-trainedstawho
arecapableofservingasapotentialmodelforothercountriesintheregion.Inaddition,the
assessmentrevealedthatthereiscapacitytoadvanceintomoleculardiagnosticsforinuenza.
SamplesfromUkraineareroutinelysubmittedtotheWHOcollaboratingcenterforthe
surveillance,epidemiology,andcontrolofinuenzaatU.S.CDC,andtheWHOcollaborating
centerforreferenceandresearchoninuenzaattheNationalInstituteforMedicalResearchin
London,England.
Preparedness
In2006,theUkraineCabinetofMinistersapprovedthegeneralframeworkofanationalplan
ofactiontocombatinuenzaandtoprepareforapotentialpandemic.TeUkraineMOH
wastaskedwithdevelopingspecicoperationaldetailsandimplementingkeyprovisionsof
theplan.Asaresult,thepartnershiponpandemicpreparednessbetweentheMOH,PATH,
U.S.CDC,andWHOhasresultedinthedevelopmentoftheNationalGuidelinesforHealth
ServicesofUkraineRegardingPlanningandOrganizationofMeasurestoCombatPandemic
Inuenza(i.e.,theGuidelines).In2009,theGuidelineswereapprovedbytheacademiccouncil
oftheUkrainianInstituteofEpidemiologyandInfectiousDiseasesandendorsedbyWHO-
EURO.TeGuidelineswereusedtodeveloppandemicpreparednesssimulationexercisesin
Ukraine,Kazakhstan,andtheKyrgyzRepublictoplannationalandlocalpreparednessactivities
andtoguideMOHpandemic2009H1N1inuenzaresponseactivitiesduringtheOctober
November2009surge.
InJune2009,PATHorganizedandfacilitatedapandemicpreparednesssimulationexercisefor
membersoftheinteragencycoordinationcounciloninuenzapandemicpreparedness,withthe
128
participationofaWHOUkraineexpert.Temeetinghighlightedseveralgapsinpreparedness
andhelpedidentifythemostpressingneedsandpotentialsolutions.Recommendationsfor
internationalassistancealsowerediscussed.Afterthemeeting,severalmeasuresweretakento
increasepreparednessinthecityofKiev,includingthefollowing:
Updatingthecityplan.
Reningcommunicationchannels.
Creatingasmallstockpileofantivirals.
Increasingthereserveofantibiotics.
Purchasingadditionalinuenzapreventionsupplies.
Updatinginformationforthecityinuenzahotline.
Trainingthecitysphysicians.
Developingalistofspecialistsresponsiblefor
communicationwiththemedia.
MakingarrangementswiththeNationalMedicalUniversityandnursingschoolsinthe
cityforrapidmobilizationofstudentsincaseofemergency.
Ensuringadditionalnancing,asnecessary,throughthecitysfundforepidemiologic
emergencies.
LobbyingtheMOHocialstoupdatethelegaldocumentationneededtosupport
pandemicresponseactivities.
ConductingsimilarexercisesinKazakhstanandtheKyrgyzRepublicattherequestof
theU.S.CDCoceinKazakhstan.
Participatinginajointavianpandemicinuenzapreparednessexercisefor
representativesofseveralministries(includingtheMOH)thatwasorganizedbythe
MinistryofEducationandScienceandtheCaliforniaNationalGuard.Teaimof
theexercisewastohelptheministriesdeneagencyrolesinaresponsetoapotential
pandemicandtoimproveinteragencycoordinationatvariouslevels.
Training
PATHcontinuestoprovidetechnicalassistanceandtrainingtoensurethefunctioningof
thesentinelsurveillancesystem,qualityofthesurveillancedata,promptdataanalysis,and
integrationofthepandemicworkplanwithpreparednessactivities.
EightvirologistsfromtheNICregionalSESsweretrainedoninuenzavirusisolation
andidenticationattheNIC.
RepresentativesfromtheNICandplaguelaboratoriesparticipatedinbiosafety,
biosecurity,andadvancedRT-PCRdiagnosticsinternationaltrainingworkshops
conductedbyU.S.CDCexpertsinAlmaty,Kazakhstan,andSt.Petersburg,Russia.
TeNICstaalsoweretrainedinreal-timePCRdiagnosticsduringU.S.CDCsAPHL
laboratorycapacityreview.
129
PersonnelofallsentinelinuenzastationsandregionalSESsinKiev,Odessa,andDonetskwere
trainedbythecooperativeagreementprojectstainallaspectsofsentinelsurveillance.Training
includedthefollowing:
SARIandILIcasedenitions.
Flowoflaboratoryspecimens.
Epidemiologicdatacollectionandreportingprocedure.
Scopefordataanalysis.
Datainterpretationguidelines.
Arangeofrecommendedcontroleortsandmonitoringandevaluationindicatorsto
assessthequalityofthefunctioningofthesystem.
Approximately2,000epidemiologistsandhealthcareworkers(i.e.,directorsofhealth
settings,infectiousdiseasespecialists,therapists,familyphysicians,andambulancephysicians)
representingseveralregionsofthecountryweretrainedbyexpertsfromPATH,theUkraine
MOH,theNIC,andregionalSESs.Keytopicsincludedthefollowing:
Novelinuenzaandrespiratorysurveillance(i.e.,newlydevelopedtechnicalguidelines)
focusingoncasedetectionandtriggersforreporting,investigation,andimmediate
responsefromthediagnosingphysicianinthebroadercontextofinternationalhealth
regulations.
Instructionsoninvestigationofcasesandoutbreaks,organizationofresponseatthe
rayonlevel,recommendedcontrolresponsemeasures(includingguidelinesforuseof
PPEandantivirals),seasonalinuenza
vaccinationrecommendations,and
infectioncontrolrecommendationsfor
healthcarefacilities.
RepresentativesoftheMOH,theNIC,and
PATHalsoparticipatedinU.S.CDCand
WHOinuenzapandemicpreparedness
workshopsandmeetingsinGeneva,
Copenhagen,St.Petersburg,Ashgabat,and
Bangkok.
MOH,NIC,SES,andPATHsta
weretrainedthroughthepartnership
toprovidetechnicalguidancetohealth
careworkersnationwide.
Inuenzapandemicpreparednessand
inuenzaoutbreakresponseguidelines
developedinpartnershipwithPATH
andU.S.CDCwereusedtoguide
responseactivitiesinthecountry.
130
Laboratoryequipmentandconsumablespurchasedthroughthepartnershipwereused
todetectpandemic2009H1N1inuenzacases.
Tesentinelsurveillancesystemcurrentlyoperatingat2sitescomplementsroutineARI
surveillancedesignedtomonitorthe2009pandemic.
TesentinelSARIandILIsurveillancesystemwasfullyoperationalattheKievand
Odessasites.
SentinellaboratoriesandtheNICidentied14casesofpandemic2009H1N1
inuenza.
TeGuidelinesweredevelopedandusedforpandemicpreparednesstoguideH1N1
responseactivities.
TabletoppandemicpreparednesssimulationexerciseswereconductedinKievand
helpedthecityimproveitsresponsecapacity.
PATH.
MOH.
WHO.
NIC.
RegionalSESinsentinelsites,sentinelhospitals,andpolyclinics.
KaterynaGamazina,MD
UkraineCountryDirector,PATH
25bShotaRustaveliStreet
Kiev,01033Ukraine
E-mail:kgamazina@path.org
AllaMironenko,MD,PhD
LaboratoryOcer
Head,InuenzaLaboratory
UkrainianCenterofInuenzaandAcuteRespiratoryInfectionsoftheMOH
5MykolyAmosovaStreet
Kiev,03038Ukraine
E-mail:miralla@ukr.net
GalinaRomanyuk,MD
EpidemiologyProgramOcer,PATH
25bShotaRustaveliStreet
Kiev,01033
Ukraine
E-mail:hromanyuk@path.org
131
AntonLuchitsky,MD
EpidemiologyProgramOcer,PATH
1800KStreet,NW,Suite800
Washington,DC20006
E-mail:aluchitsky@path.org
132
PanAmerican
Health
Organization
(PAHO)
PanAmericanHealth
Organization(PAHO)
Human Infuenza Surveillance: PAHO 2010
WHO NIC
NMRCD
GDD Site
PAHO Headquarters
PAHO
Cooperative Agreement
0 270 540 1,080 1,620
Miles
Began2006.
TePanAmericanHealthOrganization(PAHO)promotesthedevelopmentofNational
InuenzaPandemicPreparednessPlans(NIPPPs)andsupportsallassociatedmemberstatesin
thiseort.Asof2007,memberstateswereactivelyengagedininuenzapreparednessactivities
andhaddevelopednationalplans.PAHOsupporteditsmemberstatestoenhanceinternal
communication,riskcommunication,andmediatrainingandtoworkwithjournalists.
135
TeGenericProtocolforInuenzaSurveillance(GPIS)developedbytheU.S.CDCand
PAHOisdesignedtostandardizeinuenzasurveillancethroughouttheregionandhasbeena
modelforotherWHOregions.EverycountryinLatinAmericaandtheCaribbeanhasbeen
trainedtousetheGPIS,andimplementationisunderway.Todate,163nationalocialshave
beentrainedtousetheGPIS.Inaddition,morethan500professionalshavebeentrainedon
hospital-basedacuterespiratoryeventsurveillance.
PAHOhasanetworkofinuenzalaboratorieswheremoreadvancedlaboratoriesroutinelytrain
otherlaboratoriesthatneedtoenhancetheirtechnicalskills.PAHOhasfacilitatedthetraining
oflaboratoriesintheregioninclassicalandmoleculardiagnosticmethods.Incollaboration
withU.S.CDC,PAHOconvenedaPCRworkgroupthatworkedtostandardizelaboratory
protocolsformoleculardiagnosisofinuenza.Inaddition,PAHOpurchasedlaboratory
materials,supplies,andequipmenttosupportvirologicsurveillanceintheregion.
Surveillance
PAHOdevelopedoperationalguidelinesandtrainingpackagestohelpMOHstrain
localpersonnelinordertosupportimplementationofinuenzasurveillance.
PAHOprovidedIATAtrainingandcerticationonhowtouseinfectioussubstances
senttoeveryNICand16countriesintheEnglish-speakingCaribbean.
PAHOpurchasedreal-timeRT-PCRmachinesforChile,Paraguay,Uruguay,andthe
CaribbeantoserveallCaribbeanEnglish-speakingcountries.
PAHOsupportedpersonneltoprovidetechnicalcollaborationforpandemic2009
H1N1inuenzaintheDominicanRepublic,Paraguay,Uruguay,Argentina,Mexico,
andBrazil.
Laboratory
NicaraguahasbeenapprovedasaNIC,andGuatemalahasrequestedNICdesignation.
PAHOpurchasedreagents,materials,andequipmentforreal-timeRT-PCRdiagnosisof
inuenza.
PAHOslaboratorysupportresultedineverycountryinLatinAmericahavingcapability
toperformreal-timeRT-PCRforseasonalandpandemicinuenza.
Preparedness
PAHOsupportedriskcommunicationworkshopsinPeru,Bolivia,Uruguay,Paraguay,
Colombia,Ecuador,andChilethatincludedsimulationexercisestotestnational-
levelcommunicationpreparednessplansandplansunderdevelopmentforlocal-level
implementation.
PAHOhelpedtoimplementriskandsocialcommunicationmodulesatthelocallevel,
whichwereupdatedandadaptedtofocusonpandemicinuenzaandallpublichealth
emergencies.
136
Training
PAHOconductedtrainingonacuterespiratoryeventsurveillance(Nationwide
EnhancedSurveillance)inDominica,TrinidadandTobago,andJamaica,andsentinel
surveillancetraininginBarbados,Dominica,Guyana,Jamaica,SaintLucia,Saint
Vincent,Suriname,andTrinidadandTobago.
PAHOslaboratorytrainingnetworkhastrainedinuenzalaboratoriesinUruguay,
Paraguay,andinCentralAmerica.Afterthestartofthe2009pandemic,alaboratory
teamwasdeployedtotrainmembercountriesinreal-timeRT-PCRtechniques.
PAHOsupportedCentralAmericancountriesandtheDominicanRepublicinathird
assessmentoftheirNIPPPs.
PAHOhostedworkshopsinCentralAmericatohelpimplementhospital-based
nationwideenhancedsurveillance.
ResponseandContainment
PAHOdeployedanoutbreakinvestigationteamtoMexicoinMay2009tosupportthat
countrysresponsetothepandemic.
PAHOhiredaninuenzaconsultanttohelpimplementtheGPISintheCaribbean.
Teconsultantalsohasbeenintegralinrespondingtothepandemic.Mostrecently,
heprovidedsupporttotheinvestigationoftheoutbreakofpandemic2009H1N1
inuenzaonacruiseshipinAruba.
OtavioP.deOliva,MD,MPH
PanAmericanHealthOrganization
52523rdStreetNW
Washington,DC20037
E-mail:olivaota@paho.org
KeyStaff
TaisDoSantos,MS
TechnicalOcer
PanAmericanHealthOrganization
52523rdStreetNW
Washington,DC20037
E-mail:dossantt@paho.org
U.S.CDCStaff
TomasRodriguez,MA
ProjectOcer
InuenzaDivision
1600CliftonRd,MSA20
Atlanta,GA30333
E-mail:trr0@cdc.gov
137
138
PanAmericanRegion
Argentina
Capital:BuenosAires InfantMortalityRate:Total:11.78deaths/1,000
Area:2,766,890sqkm
Population:
41,343,201(July2010est.)

LiteracyRate:
AgeStructure:
014years:25.8%(male
5,341,642/female5,095,325);1564years:63.5%
(male12,807,458/female12,884,745);65yearsor
GDP: $585billion(2008est.)
older:10.8%(male1,784,652/female2,568,176) GDPperCapita: $14,500(2008est.)
(2008est.)
years;male:73.11years;female:79.77years(2008
est.)
BeganSeptember2006.
Argentinahas3regionalNICsanditsvirologicsurveillancenetworkconsistsoflaboratoriesin
bothpublicandprivatehealthcaresettings.EachNICworkswithsentinelunitslocatedwith
localprovincialhealthauthoritiestoconductvirologicandepidemiologicsurveillance.Te
centersalsoperformvirusisolationandtypingandsubtypingofviralisolatesandsendvirus
isolatestotheWHOcollaboratingcenterinAtlanta.TeNICsreportweeklyinformation
oninuenzaviruscirculationthroughFluNetandprovidetechnicalexpertiseandtrainingto
surveillancesitesandlaboratoriesthroughoutthecountry.
TeMOHofArgentinaanditsIntegratedPandemicInuenzaResponsePlanand3NICshave
along-standingandmeaningfulcollaborationwiththeU.S.CDCthatisfocusedoninuenza
surveillance(seasonal,pandemic,avian,and2009H1N1inuenza).Tisbilateralagreement
hasresultedinthepreparation,planning,programming,andimplementationofanational
pandemicinuenzaresponseplan,whichculminatedinthecreationofDirective644/07.
ArgentinasILIsurveillancesystemhasbeenaugmentedconsiderablythroughthisagreement.
Technicalcapacityinlaboratoriesthatparticipatedinthevirologicsurveillancesystemhasbeen
improvedconsiderablyduringthepastyear.
139
Surveillance
EpidemiologicsurveillancehasbeenimprovedbytheimplementationoftheNational
HealthSurveillanceSystem(SNVS).
ArgentinahasdevelopedanInternetdatabasethatprovidesinstantnoticationof
inuenzaactivity.Teinuenzadataenteredbysentinelsurveillancesitesandrecorded
inthissystemaresummarizedonaweeklybasis.
Tesoftwareallowsgraphicstodisplayandupdateepidemiologic,virologic,andclinical
information.
TeArgentinaMOHusedtheGPIScreatedbyPAHOandU.S.CDCtoimplement
thesystemthroughouttheprovinces.
TeArgentinaMOHcreatedaspecicpandemicinuenzasituationroomandan
inuenzapandemicemergencyoperationcenter(EOC),whichisequippedwith
desktopandnotebookcomputersandanLCD-TVtodisplayalargeamountofdata.
Teseroomsfacilitatetherapidanalysisandtransformationofdataintoactionable
informationandallowtheMOHtoquicklyprovidetechnicalandepidemiologicadvice
toallepidemiologicunitsinthecountry.
Tesituationroomactsasthecentralplacetostoreanddistributesuppliesforpandemic
response(i.e.,PPE,medicine,laboratoryequipment)forbothseasonalandnovel
inuenza.
TeEOCalsoservedasacontingency
centertoprovideinputintohowto
supplydisposablePPE,medicine,
andlaboratorysuppliestonetwork
laboratories.TeEOCdevelopedan
epidemiologyexpertadvisorycommittee
thatprovidesinputintoanypandemic
emergency.
Tenewintegratedgeographic
informationsystem(GIS)allowsfor
thedevelopmentofahealthcrisis
managementsystem.Healthfacilitydata
necessarytoanalyzetheepidemiology,
transmissibility,trends,eectsonhealth
facilities,andseverityofseasonalor
pandemicinuenzahasbeenincorporated
intotheoverallsystem.Tesystem
isbeingenhancedwithinformation
aboutILIandclimatic,geographic,and
demographicdata.Tenewsystemwill
helpdeterminetrendsininuenzaactivity.
140
Laboratory
Argentinahas3regionalNICsthatsubmitisolatestotheWHOcollaboratingcenterat
U.S.CDCforcharacterization.
Te3NICsinArgentinahaveworkedcloselywithU.S.CDCtoevaluatethe
capabilityoflocallaboratoriesandprovidequalitycontrol.Teyalsohaveundertaken
extensivetrainingofscientistsintyping,subtyping,andcharacterizingofviruses,aswell
asinRT-PCR,real-timeRT-PCR,andreversegeneticstechniques.Tistrainingwas
enhancedduringthersthalfof2009,whenmanylabsreceivedU.S.CDCprimersfor
thediagnosisof2009H1N1inuenzathroughRT-PCRtechniques.
TeRespiratoryVirusLaboratoryNetworkhasincreaseditscapacityfrom26to29
laboratoriesin16of24provincesoverthepast3years.PCRactivityhasbeenincreased
from1laboratoryto22publicandprivatelaboratorieswiththiscapacity.
TeILIsentinelsurveillancesystemcontains20sentinelunits.Datafromthesystemare
incorporatedinweeklyreports.Collaboratinglaboratoriesinthesentinelsurveillance
networksendpositivesamplesand10%ofnegativesamplestotheNICsfortyping,
subtyping,characterizing,andensuringqualitycontrol.
ArgentinasNICshavebeencollaboratingwithU.S.CDConseveralprojectsthat
includethefollowingactivities:
Sequencinginuenzavirus,RT-PCR,andHItechniquestoanalyzeantigenicand
geneticdierencestodeterminethecirculationofinuenzavirusesamong
dierentareasandtimes.
ProvidingrecommendationsfortheselectionofvaccinestrainsfortheSouthern
Hemisphere.
Monitoringantiviraldrugsensitivitytoguideclinicaltreatmentandprophylaxisof
inuenza.
ImprovinglaboratorytechniquestodetectseasonalinuenzainArgentina.Tese
activitiesincludestrengtheningthequalitycontrolsystemoflaboratoriesinthe
inuenzanetworkandaserologicsurveyfor2009H1N1inuenzaintheMardel
Plataregion.
Preparedness
TeArgentinaMOHcontinuestopursueitsnationalpandemicpreparednessplan
(i.e.,IntegratedResponsePlanforPandemicInuenzaDirective644/07)andplansto
consultwithexpertsfromPAHOandU.S.CDConpandemicplanning.
Tenewpandemicinuenzasituationroomisthefocalpointforallsurveillanceand
responseactivitiesforpandemicinuenza.Tesituationroomalsoworkscloselywith
theIHRfocalpointandcoordinatingcenter.
141
Training
Inthepast3years,approximately43professionalstafrom29networklaboratories
becamecapableofdoingHAandHIassaysandconventionalPCR,and22laboratories
weretrainedinreal-timeRT-PCR.
In24provinces,80professionalsweretrainedonhowtousetheinuenzasurveillance
system.
In24provinces,124peopleweretrainedonhowtousetheinuenzasurveillancesystem.
Inthepast3years,6pandemicexercisesandseveraltabletopexerciseswereconducted.
Forthersttime,rapidresponseteamswitheldepidemiologistsandinuenzaexperts
wereemployedtoworkthroughtherstwaveofpandemic2009H1N1inuenzain
Argentina.
ArgentinacreatedacrisismanagementsystemthatusesGIStointegrateall
healthfacilitiesinthecountryandthedataneededtoanalyzetheepidemiology,
transmissibility,andtrendsofinuenzainfection,aswellastheeectonhealth
institutionsandtheseverityofseasonalorpandemicinuenzathroughoutthecountry.
TecrisismanagementsystemcombinesILI,climate,geographic,anddemographic
datatoexploretrendsininuenzaactivitiesandtounderstandtheeectofthesefactors
onthedisease.
HoracioEnchenique,MD
ProjectManager
MdicoNeumonlogo,Epidemilgo
9deJulio1925
BuenosAires,Argentina
142
PanAmericanRegion
Brazil
Capital:Brasilia InfantMortalityRate:Total:23.33deaths/1,000
Area: 8,511,965sqkm
Population:
201,103,330(July2010est.)

LiteracyRate:
AgeStructure:
014years:27%(male26,986,909/
88.4%;female:88.8%(2004est.)
GDP: $2.03trillion(2008est.)
BeganSeptember2006.
Brazil,thelargestcountryinSouthAmerica,launcheditsnationalinuenzasurveillancesystem
in2000.Brazilsinuenzasystemcomprisesanetworkofsentinelsurveillanceproviderunits
thatcollectclinicalsamplesfromsuspectcasesforlaboratorydiagnosisandconsolidatesdata
fromoutpatientswithILI.Teinuenzasurveillanceinformationsystem(i.e.,SIVEPGripe)is
onlineanddataaresimultaneouslyavailableatalllevelsofthesurveillancenetwork.
TreeNICsareabletoisolateviruses,sharesampleswithU.S.CDC,androutinelyprovide
informationtoWHOsFluNet.TeNICshaveregularcommunicationwithlocalandregional
laboratories.Te3rdversionoftheBrazilianinuenzaplanisontheirWebsite;itsummarizes
thecurrentepidemiologicsituationinBrazil,explainsandadaptsWHOguidelines,and
describestheavailableinfrastructureformanagingthe2009Surveillance.
InuenzasurveillanceinformationiscollectedthroughBrazilsnationalsurveillance
informationsystemofnotiablediseases(SINAN).
SeasonalinuenzacasenoticationisnotmandatoryinBrazilunlessanovelstrainis
detectedorasevereseasonaloutbreakoccurs.
143
Onlineformswereusedtogatherclinicalanddemographicinformation.
Brazilhasasurveillancenetworkcomprising22centersandaStrategicInformation
andResponseHealthSurveillanceNetwork(CIEVS),whichaimstodevelopactivities
forcrisismanagementinfections,includingthemonitoringofsentinelcasesand
managementofepidemicemergencies.
Laboratory
Brazilhas3regionalNICswithBSL-3capabilities.
TeNICsroutinelyisolateviruses,sharesampleswithotherinternationalagencies,and
provideinformationtoFluNet.
NICshaveregularcommunicationwithlocalandregionallaboratoriestoprovide
technicalassistanceandmonitorinuenzatestingactivities.
Advancedmoleculartesting,suchasreal-timePCRandviralsequencing,areusedfor
surveillanceofcirculatinginuenzaviruses.
BrazilsNICshaveconductedtrainingandprovidedadditionalequipmenttoenhance
thediagnosticcapacityoftheirreferencelaboratories.
NICsprovidetechnicalassistancetolocalprovinciallaboratoriestoimprovethe
virologicanddisease-basedsurveillancecapabilities.
Preparedness
Te4theditionofthenationalpreparednessplanisbeingdraftedtoincorporatelessons
learnedfromtheH1N1pandemic.
Brazilhasengagedneighboringcountriesinjointpandemicpreparednessplanningand
bordercontrolactivities.
Brazilhasweekly,national-level,rapidresponse,preparednessvideoconferenceswiththe
26statesandthefederaldistrict.Tesevideoconferencesdiscussadjustinglocalrapid
responseteamactivitiestoimproveandevaluatelocalpreparednessissues.
144
Training
TeNICsperformthediagnosiscapacitytrainingforallthestatepublichealth
laboratories.
TepublichealthlaboratoriesprovideRT-PCRassaytrainingforthe2009H1N1
inuenzadiagnosisforthestatelaboratorynetwork.
Brazilcontinuestoprovidetrainingtohaverapidresponseteamsinallstates,including
remotestates.
Atotalof52referenceunitswerecreatedtomonitorcasesofpossible2009H1N1
inuenza.
AnextensiveH1N1communicationcampaignwasdevelopedthatincludedtelevision,
radio,newspapers,airportpublicserviceannouncements,andsocialnetworking(i.e.,
Twitter,Orkut,Facebook,YouTube).
Ariskcommunicationteamwastrainedtoworkwithcliniciansandcommunities.
Te63referencehospitalswereprovidedadditionalresourcestoenablethemtotreat
possiblecasesof2009H1N1inuenza.
Guidelinesfornotifying,investigating,andtreatingpossiblecasesofH1N1were
developed.
AdditionalantiviralsandPPEwerepurchasedforhospitalsandotherhealthcare
settings.
Allthepreparednessstateplanswereevaluatedandupdatedonthebasisofthelessons
learnedfromthe2009H1N1inuenzapandemic.
TeRT-PCRdiagnosisforthe2009H1N1inuenzapandemicwasdecentralizedto
stateandlocalhealthagencies.
Terapidresponseunitswithinallstateswereexpandedwithemphasisonremotestates.
MarciaLopesdeCarvalho
NationalHealthSurveillanceSecretariat
MinistryofHealth,Brazil
SCSQuadra4,BlocoA,2andar-EdifcioPrincipal
70.304-000-BrasliaDF
E-mail:marcia.lcarvalho@saude.gov.br
RicardoMalaguti
Epidemiologist
E-mail:ricardo.malaguti@saude.gov.br
145
LigiaMariaCantarinodaCosta
HeadofNationalNetworkofDiagnosticInuenzaLaboratories,Brazil
GeneralCoordinationofPublicHealthLaboratories
EpidemiologicalSurveillanceDepartment
SecretariatofHealth
E-mail:ligia.cantarino@saude.gov.br
146
PanAmericanRegion
InfuenzaProgramofGDDResponse
CenterforCentralAmericaandPanama
(GDD-RC/CAP)
U.S.CDCDirectRegionSupport
InuenzaisacorecomponentofU.S.CDCsGDDinGuatemala,whichcovers8countriesin
CAP.Temissionoftheprogramistoprovideleadershipandprogrammaticguidanceto
preventandcontrolinuenzaandtocontributetopreparednessandresponsetopandemic
inuenzainthePAHOarea.CoverageextendstoGuatemala,Honduras,ElSalvador,
Nicaragua,CostaRica,Panama,Belize,andtheDominicanRepublic.
Surveillance
TeCDC-CAPhassupportedtheimplementationofnationalinuenzaprotocolsonthebasis
ofthePAHO-CDCGenericProtocolforInuenzaSurveillance.TeyprovidetheMOHswith
technicalassistance,training,andsuppliestoreinforcesentinelsitesandlaboratories.Te
inuenzasurveillanceiscoordinatedtoestablisharegionalinuenzasurveillancenetwork.
Regionalinuenzasurveillancecoursesintegrateeachcountrysepidemiologyandlaboratory
nationalteams.
Laboratory
TeCDC-CAPsupportsthenationallaboratoryofGuatemalaandtheDominicanRepublicby
providingRT-PCRequipmenttoallnationallaboratorieswithIFandPCRreagentsand
laboratorysupplies.Teysupportlaboratorycomponentsininuenzasentinelunitsin
Guatemala,ElSalvador,andNicaragua.IntheGorgasInstituteLaboratoryinPanamaCity,
theydeveloped2trainingcoursesaboutrespiratoryvirusinmunouorescencyandbiosafety
aspectstoreinforcediagnosiscapacityinsentinelunitsofinuenzaintheregion,andtheyhave
supportedregionalmeetingstoharmonizelaboratorydiagnosisproceduresamongcountriesfor
the2009H1N1inuenzapandemic.
Preparedness
TeinventoryofcorecapabilitiesdevelopedbyU.S.CDCandtheWHOchecklistwere
implementedinthe8countriesoftheregion.Tisprovidedrelevantinformationabout
preparednessandresponsecomponentsofeachcountry,andthisinformationwasusedto
updatethetechnicalassistanceneedsineachcountry.
RapidresponseactivitiesarefocusedontheconformationanddevelopmentofRapidResponse
Teams(RRTs)atthesubnationallevel.Standardoperatingproceduresandguidelineswere
developedtocontributetothedevelopmentofaregionalnetworkofRRTsonthebasisofthe
nationalteams.
GDD-CAPconductedregionaldrillstotestthepandemicresponseplanleadingtoregional
updatesandimprovements.Teysupportedandguided7tabletopexercisesand26drills.
CountrieshavebeenencouragedtoconductmorefunctionalexercisesthatwillallowRRT
memberstodevelopbetterskillsandbecomemoreknowledgeableaboutrapidoperations.Te
147
supportalsoincludeddevelopingandimplementingnational-andsubnational-leveldrillsand
simulationsthatfocusoninuenzapandemiccaseinvestigation,casemanagement,andhealth
careservicesresponse.
During2009,inuenzastaaswellasotherGDDprogramsta(e.g.,FETP,IEIP)were
requestedtoparticipateinsuspectedinuenzapandemiccaseoroutbreakinvestigationsin
severalcountriesintheregionandwerepartoftheteamthatconductedtheevaluationprocess
throughWHOGOARN.
Training
Onehundredandfourteentrainingactivitieswereconductedduring2009.Topicsincluded
preparednessandresponse,diagnostictestingforinuenza,inuenzaandotherrespiratoryvirus
surveillance,riskcommunication,infectioncontrol,andcasemanagement.Inaddition,12,275
personsfrom8countriesweretrained(33.5%inrapidresponse,29.5%inpreparednessin
general,and15.8%inhealthcareservicespreparedness,amongothers).Teinuenzaprogram
incollaborationwiththeFETPsponsors15healthprofessionalsfromtheregiontobetrained
oneldepidemiologyfocusingoninuenzaandacuterespiratoryinfections.
Workshopsweredesignedandconductedin
Inuenzasurveillancestrategies
(Guatemala).
Analysisstrategiesabout
inuenzasurveillance
(Nicaragua).
Writingskills(Guatemala).
AninformationsystemWebplatform
wasdesignedforinuenzasurveillance
bysentinelunitanddevelopedand
implementedatoolthatfacilitates
theanalysisofsurveillancedata
(EpiVigila).
InfuenzaVaccine
CDC-CAPhasworkedwithselectcountriestosupportvaccinationagainstinuenza.InEl
Salvador,theydevelopedandevaluatedtheeectivenessofseasonalinuenzavaccine.Tey
conductedarapidassessmentexerciseofthecoverageofseasonalinuenzavaccinationand
trainedtechnicalteamsfrom12institutionsin4regions,includingepidemiologistsand
laboratoryandeldworkersonsurveillance,sampling,andmonitoring.
CDC-CAPassistedtheGuatemalannationallaboratoryatthestartofthepandemicand
ranallH1N1testsfor7weeksuntilthenationallaboratoryhadthecapacitytorunits
ownsamplesonequipmentpurchasedanddonatedbyCDC-CAP.
CDC-CAPdonatedseveralhundredkitsfromitsstocktoCostaRica,Honduras,and
Guatemalawhentheywererunningshort.U.S.CDCsentthousandsmore.
148
TwovisitsweremadetoCostaRicainMay.OnevisitwasforH1N1surveillanceand
informationrelatedtohospitalinfectioncontrol.
TechnicalassistancevisitswithPAHO(GOARN)toHonduras,Guatemala,Dominican
Republic,andNicaraguaweremadetoassistcountriesintheirresponsetothe
pandemic.
IntensiedsurveillancewasprovidedforSARI,vaccines,community-basedsurveillance
forU.S.CDC-fundedH1N1projectsinCostaRica,ElSalvador,Nicaragua,
DominicanRepublic,andGuatemala.
Intherst6weeksofthepandemic,7regionalalertsweresent.Te1stwasissuedthe
lastweekofAprilandprovidedanalertandinformationonthesituationinMexico;the
other6alertsprovidedtechnicalguidelinesandrecommendationsonthebasisofU.S.
CDCguidelines.
Duringtherst2monthsofthepandemic,thereweredailyteleconferenceswith
inuenzaepidemiologiststhatweresubsidizedbytheinuenzaprograminallthe
countriesoftheregion.
GDD-RCparticipatedasPAHOGOARNteammembersduringinuenzapandemic
countryassessmentsandresponses.FieldepidemiologistsweredeployedtoMexico,
Argentina,DominicanRepublic,Honduras,Guatemala,andNicaragua.
GDD-RCsupportedtheCouncilofMinistersofHealthofCentralAmerica,which
hadanemergencymeetingonApril28atthebeginningofthepandemicandagreedto
developaregionaleortrelatedtosurveillance,informationsharing,andrisk
communication.CDC-CAPassistedtheMeetingofCentralAmericanHealthMinisters
indevelopingaunied,regionalinformationsystemandcarriedoutseveralrisk
communicationworkshopstoassistindevelopmentofstrategiesandinterventionsto
communicatewiththepublic.
149
Inuenzasurveillancewascoordinatedintheregionandhelpedtoestablishtheregional
inuenzasurveillancenetworkonthebasisofthePAHO-CDCGenericProtocolfor
InuenzaSurveillance.
Allcountrieshaveidentiedthe2009H1N1inuenzaviruseitherattheirown
laboratoriesorbysendingsamplestoU.S.CDCortotheCAREClaboratoryinBelize.
Atthestartofthepandemic,only3nationallaboratorieshadRT-PCRcapacity(i.e.,
Panama,CostaRica,Nicaragua).CurrentlyallnationallaboratoriesexceptBelizehave
RT-PCRcapacity.
Laboratorycapacitywasincreasedtodetect
inuenzaandotherrespiratoryviruses.
TwonewNICsweresupported.
Tenumberofsentinelsiteswereincreased
therebyincreasingthenumberoflaboratory
samplesby20%.
Aprotocolwasdevelopedtoinstall
inuenzasentinelunitsinGuatemalaand
ElSalvador.Weareintheprocessofadding
sentinelsitesinCostaRica(Puntarenas),
Panama(ChiriquiandCocle),Dominican
Republic(Santiago),andBelize(BelizeCity).
Technicalassistancewasprovidedon
immunizationpoliciesandpracticestoght
inuenzainCentralAmerica,Panama,and
DominicanRepublic.
JorgeH.Jara,MD,FES
InuenzaProgram,UVG-CDCCooperativeAgreement
CentrodeEstudiosenSalud.UniversidaddelValledeGuatemala(CES-UVG)
16Avenida10-50,Zona15,VistaHermosaIII.AnexoCDC/CAP-UVG/CES
C.P.01015.CiudaddeGuatemala,Guatemala
E-mail:jjara@gt.cdc.gov
PercyMinaya,MD,MSc
InuenzaProgram,TEPHINET-CDCCooperativeAgreement
TrainingProgramsinEpidemiologyandPublicHealthInterventionsNETwork(TEPHINET).
16Avenida10-50,Zona15,VistaHermosaIII.AnexoCDC/CAP-UVG/CES
C.P.01015.CiudaddeGuatemala,Guatemala
E-mail:pminaya@gt.cdc.gov
150
RafaelChacn,MD,MSc
InuenzaProgram,CARE-CDCCooperativeAgreement
Av.LosAbetos#23,ColoniaSanFrancisco,SanSalvador,ElSalvador,C.A.
E-mail:rchacon@gt.cdc.gov
WilfridoA.Clar,MD,MSc,MPH
InuenzaProgramFieldOceinElSalvador(TEPHINET-CDCCooperativeAgreement)
Av.LosAbetos#23,ColoniaSanFrancisco,SanSalvador,ElSalvador,C.A.
E-mail:aclara@gt.cdc.gov
EthanGough,MPH
NationalEpidemiologist,Director,EpidemiologyUnit
FirstFloorEastBlockBuilding,BelmopanBelize
E-mail:egough@health.gov.bz
FransicoArdn,MD,MPH
NationalEpidemiologyCenter,Director,MinistryofPublicHealthofGuatemala
6aav.3-45Zone11,GuatemalaCity,Guatemala
E-mail:fardonp@yahoo.com
JulioArmero,MD,MSc
HealthSurveillanceDirector,MinistryofPublicHealthofElSalvador
CalleARCENo.827,SanSalvador,ElSalvador
E-mail:jarmero@mspas.gob.sv
MarcoPinel,MD,MPH
GeneralHealthSurveillanceDirector,HealthSecretariatofHonduras
Bo.ElCentro,EdicioSecretariadeSalud,Tegucigalpa,Honduras
E-mail:pinelval@yahoo.com
MariaEthelTrejos,MD
HealthSurveillanceDirector,MinistryofPublicHealthofCostaRica
EdicioNorte3erpisoSedeCentralMINSA,SanJos,CostaRica
E-mail:vigsalud@netsalud.sa.cr
EdmundoSnchez,MD,MSc
NationalHealthSurveillanceDirector,MinistryofPublicHealthofNicaragua
ComplejoNacionaldelaSalud.Dra.ConcepcinPalacios.EntradaColoniaPrimerodeMayo
Managua,Nicaragua
E-mail:dgvs@minsa.gob.ni
GladysGuerrero,MD
NationalEpidemiologyDepartmentDirector,MinistryofPublicHealthofPanama
AnconEdicio2611er.piso
E-mail:gguerrero@minsa.gov.pa
RaquelPimentel,MD,MSc
NationalEpidemiologyUnitDirector,MinistryofPublicHealthofDominicanRepublic
E-mail:raquelpimentel@sespasdigepi.gob.do
151
U.S.CDCStaffinCentralAmerica(GDD-RC/CAP)
NivaldoLinares-Prez,MD,MSc,PhD
TeamLeaderInuenzaProgram
RegionalOceforCentralAmericaandPanama
16Ave.10-50Zona15VistaHermosaIII.CP.01015
GuatemalaCity,Guatemala
E-mail:nlinares@gt.cdc.govorhht6@cdc.gov
152
PanAmericanRegion
GDD-Guatemala
Establishedin2006,theGDDcenterinGuatemala(GDD-Guatemala)buildsonU.S.CDCs
morethan30yearsofhistoryofprograms,activities,andpartnershipsinCentralAmerica,the
DominicanRepublic,andPanama.Togetherwithpartners,includingPAHO,U.S.CDChas
helpedtheregiondetectandrespondtoseriouspublichealththreats,includinginuenza,
diarrhealandneurologicdiseases,andfebrileillnesses,suchasrickettsiaanddengue.
Coverage
GDD-Guatemalacovers8countries:Guatemala,Belize,Honduras,DominicanRepublic,
Nicaragua,ElSalvador,CostaRica,andPanama.Teinuenzaprogramsubsidizesan
epidemiologistineachofthe8CAPcountries,providinglinkstotheMOHsandbetter
collaborationduringoutbreakinvestigations.GDD-Guatemalahasworkedacrosstheregionin
pandemicpreparednessandrapidresponseactivitiesinthesecountrieswithmeasurablesuccess
onthebasisofPAHOsevaluationmetrics.
Activities
Outbreakresponse.
Pathogendiscovery.
Training.
Surveillance.
Networking.
In2009,GDD-Guatemalarespondedto39outbreaks,mostofwhichachievedameasurable
publichealtheect,andlaboratorysupportwasprovided.Teydiscovered2pathogensnewto
theregionandincreasedtheirlaboratorytestingcapacityby35%.Laboratorysupporttotest
for2009H1N1inuenzawasfacilitatedinall8CAPcountries.Additionally,GDD-Guatemala
trainedmorethan5,000participantsinshort-termregionalandnationaltrainings.
IsabellaDanel,MD,MPH
GDD-GuatemalaCoordinator
NivaldoLinaresPrez,MD,MSc,PhD
InuenzaLead
IEIP.
FETP.
153
154
PanAmericaRegion
Mexico
Capital:Mxico(DistritoFederal) InfantMortalityRate:Total:19.01deaths/1,000
Area: 1,972,550sqkm
Population:
112,468,855(July2010est.)

LiteracyRate:
AgeStructure:
Totalpopulation:91%;male:92.4%;
014years:29.6%(male
16,619,995/female15,936,154);1564years:
64.3%(male34,179,440/female36,530,154);
3,666,472)(2008est.)
BeganSeptember2006.
TeMexicanNationalLaboratoryNetworkconsistsof31statelaboratoriesandtheNational
InstituteofDiagnosisandEpidemiologicReference(InDRE),inwhichthecountrysNIC
islocated.InMexico,theresponsetopandemicinuenzaisinitiatedatthelocallevelwith
guidancefromfederalandstateauthorities.
Surveillance
Temajordevelopmentsthattookplaceinthesurveillancesystemduring2009includethe
following:
InclusionofsurveillanceofSARIanddeaths;previously,sentinelsitesreportedonlyILI.
Increaseinthenumberofreportingsentinelsiteswiththeadditionofhospitals;
previously,mostsiteswereprimarycarefacilities.
DevelopedanewWeb-basedreportingsystemtoallowthecombiningoflaboratoryand
epidemiologicinformationonILIandSARIcasesanddeaths.
MexicosInuenzaSurveillanceSystemhasbeenenhancedsince2006toincludemore
than500sentinelsitesthroughoutthecountry.
155

Laboratory
In2006,MexicocreatedtheLaboratoryActivitiesCoordinationforPandemicInuenza
PreparednessatInDRE,whichdevelopedacomprehensivesurveytoevaluatethe
inuenzasurveillancecapacityforall31statelaboratoriesandonefederallaboratory.
Teresultswereusedtoimplementaplantoreinforcetheinuenzadiagnostictesting
instatelaboratories.
Atotalof31statelaboratoriesacrossMexicohavethecapacitytoperforminuenza
diagnostictests,suchasIFA,7laboratoriesperformRT-PCR,24laboratorieshave
incorporatedreal-timeRT-PCRtestingtoconrmdiagnosis,and4laboratoriesarein
theprocessofimplementingviralisolationfromcellculture.
InDREroutinelyreceivesinuenzasamplesfromstatelaboratoriesforconrmation
anddiagnosisofinuenzaviruses.InDREperformsreal-timeRT-PCRtesting,isolation
(embryonatedeggsandcellculture),HAI,anddierentialdiagnostics;participatesin
FluNet;andsendssamplestoWHOcollaboratingcentersforfurtheranalysis.
Inaddition,InDREisworkingtostrengthenseasonalandavianinuenzadetectioninthestate
laboratorynetworkbydoingthefollowing:
DevelopingandenhancingabioinformaticsplatformintheNationalNetworkofPublic
HealthLaboratories(RedNacionaldeLaboratoriosdeSaludPblica.
Providingstandardreagents,suchasprimers,toinuenzanetworklaboratoriesin
Mexico.
Evaluatingavailablecommercialrapid
diagnosiskitsforseasonalinuenzaparticular
tovirusescirculatinginMexico.
Strengtheningthequalitycontrolsystemof
inuenzanetworklaboratories.
InDREisintheprocessofbecomingpartof
theLaboratoryResponseNetwork(LRN),
whosemembersarechargedwithmaintaining
anintegratednetworkofstateandlocalpublic
health,federal,military,andinternational
laboratoriesthatcanrespondtobioterrorism,
chemicalterrorism,andotherpublichealth
emergencies.
Mexicoisintheprocessofrestructuringits
BSL-3laboratorybyusingfederalfunding.
Telaboratoryequipmentwasacquiredwith
U.S.CDCfunding.
156
Preparedness
TeMexicanMOHdevelopedamultisectorialoperationstrategyforpandemic
planningthatincludes7strategicgroupsconsistingofgovernmentandbusiness
representatives.
Eachgroupintegratesitsinstitutionalcontingencyplanwiththecountryssector-wide
preparednessstrategy.Rapidresponsetooutbreaksisintegraltothisstrategy.
EachstateinMexicohasarapidresponseteamthatincludesmedicaldoctors,
epidemiologists,laboratorysta,andequipment.
Eachstatehasidentiedaleast1hospitalasanisolationfacilityincaseofamajor
publichealthevent.
Training
MexicosMOHhasconductedtrainingofhealthcareprovidersatalllevelsondiverse
aspectsofinuenza,includingepidemiologicsurveillance.State,jurisdictional,and
hospitalepidemiologistsweretrainedinanewWeb-basedreportingsystemandother
surveillanceprocedures.Acurriculumondataanalysisiscurrentlybeingdeveloped.
Mexicohasprovidedupdatedtrainingtoits31statelaboratoriesondiagnostic
techniquesforinuenza,includingtheproperwaytocollect,ship,process,andhandles
specimens.
Duringthe1stpandemicwave,withsupportfromU.S.andCanadiancolleagues,
thousandsofspecimenswereprocessed,andpersonnelfrom6statelaboratorieswere
trainedonreal-timeRT-PCR.TetechniquehasbecomestandardizedatInDRE.
InDREparticipatedintheworkshoponguidelinesofIATAtransportationforinfectious
substances,whichwassupportedbyPAHO.
Aspartoftheresponsetothe2009H1N1inuenzaoutbreak,weeklysessionswereheldwith
strategicagentsatthefederalleveloftheMOHandwithstateepidemiologistsviatheInternet.
Duringthosemeetings,thecurrentsituationofinuenzawasreviewed,andmitigationand
preventioneortswerediscussed.
AweeklynationalinuenzabulletinthatreportscountsandtrendsofILI,SARI,deaths,and
conrmed2009H1N1inuenzacaseswasdeveloped.Tebulletinalsoincludesother
indicators,suchaspercentageofvisitsforILIinsentinelsites.
HugoLpez-Gatell,MD,PhD
ProgramInvestigator
DirectorGeneraldeEpidemiologa
FranciscodeP.Miranda177,4opiso
Col.UnidadPlateros,Del.lvaroObregn
Mxico,D.F.01480
E-mail:hlgatell@dgepi.salud.gob.mx
157
CeliaM.AlpucheAranda,MD,PhD
LaboratoryOcer
DirectoraGeneralAdjuntadelInstitutodeDiagnsticoyReferenciaEpidemiolgicos
Prol.deCarpioNo.470,3erpiso
Col.Sto.Toms,Del.MiguelHidalgo
Mxico,D.F.C.P.11340
E-mail:celiam@servidor.unam.mxorcalpuche@salud.gob.mx
IetzaBojrquezChapela,MD,PhD
Epidemiologist
DirectoradeInvestigacinOperativaEpidemiolgica
DireccinGeneraldeEpidemiologa
FranciscodeP.Miranda177,3erpiso
Mxico,D.F.01480
E-mail:ibojorquez@dgepi.salud.gob.mx
EthelPalaciosZavala,MD
InternationalProgramCoordinatorDGE/InDRE
Mxico,D.F.01480
E-mail:pethel@dgepi.salud.gob.mx
RitaFloresLen,MSc
InternationalLaboratoryProgramCoordinator
Mxico,D.F.01480
E-mail:rores@dgepi.salud.gob.mx
158
PanAmericanRegion
Paraguay
Capital: Asuncion InfantMortalityRate:Total:23.83deaths/1,000
Population:
6,375,830(July2010est.)

LiteracyRate:
AgeStructure:
014years:29.5%(male955,532/

female:93%(2003est.)
BeganSeptember2009.
FY2009isthe1styearofthecooperativeagreement.
In1997,Paraguaystartedvirologicsurveillanceofinuenzaandotherrespiratoryvirusesat
siteswiththecapacitytotakesamplesandshipthemtotheCentralPublicHealthLaboratory
(ElLaboratorioCentraldeSaludPblica)fordetectingrespiratoryvirusesbyIFA.In1998,the
LCSPbeganperformingcellculturetoisolateandcharacterizeviralstrains,andthelaboratory
wasdesignatedasaNIC.
In2004,inuenzawasincludedinthelistofnotiablediseasestotheNationalOceof
CommunicableDiseaseSurveillance.Paraguaypreparedits1stversionofaNationalInuenza
PandemicPreparednessPlanin2005.TisplanwasreviewedandinJune2007,a2ndversion
wasdeveloped.In2006,sentinelsurveillanceofinuenzaandotherrespiratoryviruseswas
implemented,andin2008,thenationwideenhancedsurveillanceofunusualorunexpected
SARIwasimplemented.
159
Objectivesforthecomingyearareto
ImplementParaguaysNIPPPandcommunicationstrategyinthesubnationallevels.
Strengthennationalsurveillancesystemstobeabletodetectemerginginfectious
diseases,suchaspandemicinuenza.
Developnationalandsubnationalcapacitytorespondtooutbreaks.
FernandoAllende,MD
DirectorGeneral
DireccionVigilanciadelaSalud
MinisteriodelaSalud
ManuelDominguez,EdicioSenepa
Asuncion,Paraguay
E-mail:iallende@mspbs.gov.py
MercedesCarrillo
LaboratoryOcer
DirectoraGeneraldelLCSP(NIC)
AvenidaVenezuelaYFlorida
Ascuncion,Paraguay
E-mail:direccion@lcsp.gov.py
160
PanAmericanRegion
Peru
Capital: Lima InfantMortalityRate:Total:29.53deaths/1,000

Area: 1,285,220sqkm
Population:
29,907,003(July2010est.)
ears:29.7%(male4,409,227/

LiteracyRate:
AgeStructure:
T
014y
93.5%;female:82.1%(2004est.)
BeganSeptember2006.
Peruisthe3rdlargestcountryinSouthAmericaandhasapopulationofapproximately28
millionpeople.Peruhas15regionallaboratoriesinvolvedinlaboratorysurveillancefor
inuenzaandotherrespiratoryvirusesbyusingIFA.IFA-positivesamplesaresentforvirus
isolationandidenticationtotheNIClocatedintheNationalInstituteofHealthinLima.
Peruhasconcentratedondevelopinglocalcapacityforrapidresponsetooutbreaksof
respiratorydisease,viralrespiratorydiseasecontrol,andriskcommunicationbyusing
workshopsandinformationsharingamongits34regionalhealthdirectors.Inaddition,
Peruhasdevelopedanationalpandemicplanandrecentlymodiedtheirnationalpandemic
responseplanonthebasisoflessonslearnedfromthe2009H1N1inuenzapandemic.
Surveillance
Sentinelsurveillancehasbeenimplementedin50healthcentersthroughoutthe
country,including30healthcenterssupportedbyU.S.CDCandU.S.Naval
MedicalResearchCenterDetachment(NMRCD).Ofthese50centers,6arenewly
implementedbytheMOH.NasalorpharyngealswabsareprocessedattheInstituto
NacionaldeSalud(INS,PeruvianNationalInstitutesofHealth)andNMRCD.
161
TeMOHhasrecentlyimplementedaWeb-baseddatabase,wherebyallgroups(i.e.,
DGE,INS,andNMRCD)aresubmittinglaboratoryandepidemiologicdata.Overall,
23sitesperformSARIsurveillanceinPeru.
Laboratory
AfterWHOdeclaredthepandemic,thereal-timeRT-PCRprotocolandmethodfor
detecting2009H1N1inuenzaviruswasimplementedatINSandNMRCDforall
samplescollectedatsentinelsurveillancesites.Additionalcellcultureinoculationand
nucleicacidsequencingwasperformedatNMRCD.
TeMOHiscurrentlyplanningtoimplementreal-timeRT-PCRatseveralofthe
regionallaboratoriesfortheupcominginuenzaseason.
Training
Technicalassistancehasbeenprovidedbyusingvideoandteleconferenceandcontinues
tobeprovidedtonationalandregionalalertresponseteams.
Peruhasoeredassistancetoallepidemiologynetworkstoprepareforpandemic
inuenza.
Onthebasisofthecasedenitionfor2009H1N1inuenzainMay2009,thePeruMOH
establishedaslightlymodiedsurveillancesystem.AftertheWHOdeclarationofthepandemic,
anactivesurveillancesystemwasestablishedtodenetheproceduresfordetecting,notifying,
investigating,following,andcontrolling2009H1N1inuenzainPeru.Tissystemwashalted
onJuly7andchangedtoamitigationphase.DuringtheH1N1pandemic,Peruintensied
inuenzasurveillancesystemsby
ReinforcingsentinelsurveillanceofSARIthroughanonlineplatformwithinformation
abouthospitalization,comorbidities,outcomes,treatment,andothervariables.
OptimizinganddeningthescopeofthepandemicinPerubyreportingARIcasesin
childrenlessthan5yearsofageandpneumoniacasesanddeathsforallagegroups.
162
ControlMeasures
Activesurveillancewasimplementedinallairports.Forexample,duringthemiddleof
the2009H1N1inuenzacrisis,travelrestrictionstoMexicowereimplemented.
Atelephonehotlinewasdevelopedtoreceivepublicreportsonrespiratorydiseases.
Tehealthdepartmentimplementedantiviraltreatmenttosymptomatichigh-risk
groups.
TeclinicalandepidemiologicformsofinuenzacaseswereenteredintotheNMRCD
databaseordirectlyintotheMOHWeb-basedplatform.
TeMOH-implementedand-supportedtelephonehotlinehelpedtoidentifyseveral
casesamonginternationaltravelers.
Peer-reviewedpublicationsbytheMOH(i.e.,DGE,INS)andNMRCDhavedescribed
theclinicalandepidemiologicfeaturesofpandemic2009H1N1inuenza.
LuisAntonioNicolasSuarezOgnio,MD
ProgramInvestigator
Director,DirectionGeneraldeEpidemiologia
MinisteriodeSaluddelPer
CamiloCarrillo402
Lima11,Peru
E-mail:lsuarez@dge.gob.pe
AnibalVelsquez,MD
Director,InstitutoNacionaldeSalud
CalleCapacYupanqui1400(JessMaria)
Lima,Peru
E-mail:anibal.velasquez@gmail.com
JoelM.Montgomery,PhD
CDR,U.S.PublicHealthService
Director,DepartmentofEpidemiologyandEmergingInfections
NavalMedicalResearchCenterDetachment-Peru
CDCLiaisonandInuenzaDivisionFieldAssignee
CentrodeInvestigacindeEnfermedadesTropicales
NMRCDCentroMedicoNavalAv.
Venezuelacuadra36Bellavista,Callao2,Lima,Peru
or
U.S.NavalMedicalResearchCenterDetachment
3230LimaPlace,Washington,DC20521-3230
E-mail:joel.montgomery@med.navy.milorztq9@cdc.gov
163
164
South-EastAsia
RegionalOffce
(SEARO)
166
South-EastAsiaRegionalOffce
(SEARO)
HumanInfuenzaSurveillance:SEARO2010
U.S.CDCAssignees
SEAROHeadquarters
SEARO
SingleCooperativeAgreement
MultipleCooperativeAgreements
SustainabilityCooperativeAgreement
0 262.5 525 1,050 1,575
Miles
SurveillanceandResponseforPandemicandAvianInuenzabyRegionalOcesofWHO
BeganSeptember2006.
WHO-SEAROislocatedinNewDelhi,India.Teoceserves11countrieswithmorethan
1.7billionpeople.MembercountriesareBangladesh,Bhutan,DPRKorea,India,Indonesia,
Maldives,Myanmar,Nepal,SriLanka,Tailand,andTimor-Leste.Sixofthe11countries
receiveU.S.CDCInuenzaDivisioncooperativeagreementfunds,includingNepalandSri
Lanka,whicharereceivingfundsforthe1sttimethisyear.In2009,SEAROstaprovided
training,support,andtechnicalassistancetomembercountries;developedstandardized
inuenzalaboratoryprocedures;andstrengthenedlaboratorynetworkingamongmember
countries.
167

In2010,SEAROwillfocusonthefollowing:
Enhancecountriescapacitiestomoreecientlycarryoutsurveillanceandresponsefor
inuenza.
Assistcountriesinrevisingtheirpandemicpreparednessplanstoensuretheyareinline
withnewWHOguidance.
SetuparegionaldatabasetotrackandmonitorresultsofspecimenssubmittedbyNICs
intheregion.
Strengthenlaboratoryinfrastructureandbuildlaboratoryandepidemiologycapacities
toaccuratelyandpromptlydiagnoseinuenzawithpandemicpotential.
Surveillance
SEAROhasassistedinstrengtheningpandemicinuenzasurveillanceandresponsein
WHO-SEAROmembercountries.
Laboratory
Standardoperatingproceduresforlaboratorieshavebeenrevisedandsharedwith
membercountries.
Preparedness
SEAROestablishedbilateralarrangementsamongmembercountriesforfastspecimen
shippingandprocessing.
Standardlaboratoryprocedureswerereviewed.
Training
Rapidresponseandcontainmenttrainingatthesub-nationallevelwasconductedin
Maldives,Bangladesh,India,Nepal,andBhutan.
Trainingoftrainersforoutbreakinvestigationandearlywarningalertandresponsetook
placeinNovember2008inIndonesia,Maldives,andSriLanka.
AregionalworkshopwasheldinJune2009inBangkokforNICSregardingH1N1U.S.
CDCtestkits.
Respiratoryinfectioncontrolandhospitalpreparednessandcontingencyplanning
workshopswereheldindierentcountries.
SEAROestablishedbilateralarrangementsamongmembercountriesforrapidspecimen
shippingandprocessing.
SEAROdevelopedaguideforenhancedsurveillanceandmonitoringofILI/SARIentitled,
A Practical Guide to Conducting ILI/SARI and Respiratory Event-based Surveillance.
SEAROestablishedarrangementsamongmembercountriesforinuenzadiagnosiswith
fastspecimenshippingandprocessing.
SEAROdevelopedatrainingpackageforhospitalpreparednessandinfectioncontrolfor
respiratoryillnesses.
168
U.S.CDCFieldStaff
WHOSouth-EastAsiaRegionalOce
SuzanneWestman,MD,MPH
I.P.EstateMahatmaGhandiMarg
NewDelhi110002,India
E-mail:westmans@searo.who.int
JaiP.Narain
I.P.Estate,MahathmaGandhiMarg
NewDelhi,11000,India
E-mail:NarainJ@searo.who.int
WHOSEARORegionalAdviser
KhanchitLimpakarnjanarat
I.P.Estate,MahatmaGhandiMarg
NewDelhi11000,India
E-mail:KhanchitL@searo.who.int
InfuenzaDivisionStaff
KarenSiener,MPH
ProjectOcer
EstramuralProgramOce,InuenzaDivision
1600CliftonRoad,MSA-20
Atlanta,GA30333
E-mail:ksiener@cdc.gov
169
170
SoutheastAsiaRegion
Bangladesh
Capital:Dhaka InfantMortalityRate:Total:57.45deaths/1,000
Area: 144,000sqkm
Population:
158,065,841(July2010est.)

LiteracyRate:
AgeStructure:
014years:33.4%(male
53.9%;female:31.8%(2003est.)
26,364,370/female24,859,792);1564years:
63.1%(male49,412,903/female47,468,013);
2,529,502)(2008est.)
Beganin2006.
TePeoplesRepublicofBangladeshisoneofthemostpopulouscountriesintheworldwith
anestimated165millionpeople.Bangladeshfacesseriouschallengesincontrollinghumanand
avianinuenza.Eachyear,duringAprilthroughOctober,seasonalinuenzacausesILIin10
Bangladeshisforeach100person-years.Ofpeopleillwithinuenza,3%havelaboratory-
conrmedco-infectionswithdierentinuenzatypes.
InJune2009,Bangladeshidentiedits1stcaseofpandemic2009H1N1inuenza.Te
pandemicspreadrapidlythroughoutthecountry,causingillnessamonganestimated8.6
millionpeopleandacasefatalityproportionamonglaboratory-conrmedcasesof0.9%.In
September2009,asthe1stwaveofthepandemicwassubsiding,animalhealthauthoritiesand
theInternationalCenterforDiarrhealDiseaseResearch,Bangladesh(ICDDR,B)identied
outbreaksofavianinuenzaamongdomesticpoultry.
Bangladesh,acountrywithapproximately183millionpoultry,hasreportedinuenzaA
(H5N1)outbreaksin287farmsthroughoutthecountrysinceFebruary2007.Tespread
ofpandemic2009H1N1inuenzaandtheseavianinuenzaoutbreaksareofgreatconcern
becauseofthehighpopulationdensityandfrequentinteractionbetweenhumansandpoultry.
171
Approximately50%ofBangladeshispoultryareraisedinbackyards.Althoughtransmissionof
avianinuenzatohumansoccursinfrequently,inMarch2008,the1sthumancaseofinuenza
A(H5N1)inBangladeshwasidentiedthroughapopulation-basedhumaninuenzastudy
inDhaka.Publichealthauthoritiesareveryconcernedthatthecirculationofpandemic2009
H1N1alongwiththesignicantrateofco-infectionsofinuenzaA(H5N1)andotheravian
inuenzaAviruses(H2,H7,H9)indomesticpoultrymaypredisposeBangladeshtothe
developmentoffurthernovelinuenzastrainswithpandemicpotential.
Topreventandcontrolhumanseasonalandpandemicinuenza,aswellasavianinuenza,
BangladeshsInstituteofEpidemiology,DiseaseControl,andResearch(IEDCR)hastakena
leadershiprole.TeIEDCRhaspartneredwithnationalandinternationalorganizationsto
understandtheburdenofdiseasecausedbyseasonalinuenzaandtoguidethecountrythrough
pandemicresponse.IEDCRistheorganizationwithintheMinistryofHealthandFamily
Welfarethatisresponsiblefordiseasesurveillanceandoutbreakinvestigation.
Surveillance
TeIEDCRpartneredwiththeICDDR,BtoconductILIandSARIsurveillancein12
hospitalsthroughoutBangladesh.TemainobjectivesweretoidentifyclustersofSARI
thatmayrepresentpublichealtheventsofinternationalconcernandtocharacterizethe
epidemiologyofseasonalinuenzacirculatinginBangladeshinformationnecessaryto
guideannualpreventionandcontroleorts.
Fourofthesentinelsurveillancehospitalshavecompletedthe1stphaseofastudy,
estimatingthenationalburdenofinuenzadiseaseinBangladeshas9hospitalizations
foreach1,000childrenagedlessthan5years.Teprimaryinvestigatorsoftheseeorts
havecirculatedmanuscriptsforpublicationinpeer-reviewedjournalsinaneortto
disseminatetheirndingsandbetterguideregionalinuenzacontroleorts.
TeIEDCRplanstostrengthenthesurveillancesystembyimplementingasoftware
systemwiththehelpoftheU.S.HHS,CDC,andIEIPtoallowpublichealthocers
throughoutthecountrytoreportinuenzacasesbyusingtheInternet.
TeIEDCRplanstoexpandinuenzasurveillanceto18newsitesthroughout
Bangladeshinthecomingyears.
172
Laboratory
TeIEDCRlaboratoryisdesignatedastheNICbyWHOandiscapableoftesting
humansamplesbyRT-PCRtoidentifyseasonal,pandemic2009H1N1,andH5N1
inuenzas.
TeIEDCRremodeleditsfacilitiesandin2009,installedaprefabricatedBSL-
3inuenzalaboratory.TeBSL-3laboratorywillhelpIEDCRphaseininuenza
surveillanceactivitiesthatarecurrentlybeingconductedwiththeassistanceof
ICDDR,Bslaboratoryfacility.
USAIDandU.S.CDCfundinghasbeenleveragedtoassistICDDR,B,animportant
IEDCRpartner,toconstructastate-of-the-artBSL-3+facilityandananimalBSL-2
facilitytounderstandbettertheriskofavianandhumaninuenzainBangladeshand
exploreopportunitiestocontrolthisrisk.
TeICDDR,Bfacilitieshaveinitiatedpoultrysampletestingduring2009,leadingto
theidenticationofseveraloutbreaksofavianinuenza.
Preparedness
ByrequestoftheMOH,theIEDCRiscurrentlyrevampingitspandemicresponseand
avianinuenzaplan.TeIEDCRiscollaboratingwiththeDepartmentofLivestock
Services,WHO,USAID,ICDDR,B,andDANIDA(i.e.,theDanishgovernment)to
revisethislivingdocument.
Standardoperatingprocedurestorolloutnonpharmaceuticalinterventions,triage,and
alternatecarefacilitiesduringapandemicarecurrentlybeingrevisedtoreectlessons
learnedduringthe1stwaveofpandemic2009H1N1inuenza.
Training
AlthoughtheIEDCRdoesnothaveaformaltrainingprogram,theIEDCRhas
partneredwithWHOandIDDCR,Btofacilitatethepreventionandcontrolof
inuenza,aswellastheinformalandformaltrainingofyounggovernmentscientists.
TeIEDCRhaspartneredwithICDDR,Bonanambitiousresearchagendato
characterizetheinuenzastrainscirculatinginBangladesh,estimatetheburden
ofinuenzadisease,explorelong-termsequelaoffrequentinuenzaillnesses(e.g.,
cognitivedevelopmentaldelays),andpilotandtestnonpharmaceuticalinterventionsto
controlinuenza(e.g.,handwashingandrespiratoryhygieneinterventions).
TeIEDCRhaspartneredwithICDDR,BandtheDepartmentofLivestockServices
toidentifytheriskfactorsassociatedwithpoultryandhumaninfectionwithavian
inuenza(e.g.,inuenzaA/H5N1).
AcomprehensivelistoftheseresearchprojectsisprovidedintheResearchSectionof
thisbook.Teseprojectsarebeginningtoyieldpublishabledatatoguidepolicyduring
2009.
173
TeIEDCRhasavarietyoffundingandtechnicalpartnerswithintheBangladeshigovernment
andwithinternationalorganizations.Eachpartnerprovidesadierentperspective,corecapac-
ity,andfundingsourcetoleveragethevariousinuenzapreventionandcontroleortsofthe
governmentofBangladesh.Tesepartnersinclude
DepartmentofLivestockServices(GovernmentofBangladesh).
WHO.
USAID.
ICDDR,B.
DANIDA(Danishgovernment).
CAREInternational.
U.S.CDCFieldStaff
StevenLuby,MD
U.S.GovernmentHealthAttach
DivisionDirectorofHealthSystemsandImmunizationDivision
ICDDR,B(CDC,CCID)
EduardoAzziz-Baumgartner,MD,MPH
HeadofInuenzaCluster,ICDDR,B
(CDC,InuenzaDivision)
MahmudurRahman,MD
Director,InstituteofEpidemiologyDiseaseControlandResearch
Mohakhali,Dhaka1212,Bangladesh
E-mail:mrahman@citechco.net
ProjectManager
A.S.MAlamgir,MD,PhD
InstituteofEpidemiologyDiseaseControlandResearch
Mohakhali,Dhaka1212,Bangladesh
E-mail:aalamgir@gmail.com
174
SoutheastAsiaRegion
India
Capital:NewDelhi InfantMortalityRate:Total:32.31deaths/1,000
Area: 3,287,590sqkm
Population:
1,173,108,018(July2010est.)

LiteracyRate:
AgeStructure:
014years:31.5%(male
female:47.8%(2001census)
189,238,487/female172,168,306);1564years:
63.3%(male374,157,581/female352,868,003);
31,277,725)(2008est.)
FirstinuenzacooperativeagreementbeganinSeptember2004andendedin
September2009.
FY2009isthe1styearofanew5-yearsustainabilitycooperativeagreement.
Indiaprovidesauniqueopportunitytostudyinuenzatransmissionandprevalenceamong
variouspopulationsbecauseofthesocioeconomic,ethnic,andgeographicdiversityofits
population.TeU.S.CDC,incoordinationwithotherU.S.governmentagencies,supports
internationalresponsemeasuresagainstavianandpandemicinuenzainIndiathroughmultiple
implementingpartners.
IndiasNICispartoftheIndianCouncilofMedicalResearch(ICMR),DepartmentofHealth
ResearchwithintheMinistryofHealthandFamilyAairs(MOHFW).TeIndiaNIC,which
islocatedattheNationalInstituteofVirology,Pune,hasalong-standingcollaborationwith
theU.S..CDCinseasonal,avian,andpandemicinuenzasurveillance.Tebilateralagreement
betweentheIndiaNICandtheU.S.CDChasbeenongoingsince2004andhasprovided
resourcesforagreatlyexpandedsurveillancesystem,includingsurveillancefornovelH1N1.
175
ICMRconductsepidemiologicandvirologicinuenzasurveillanceindierentgeographicareas
ofIndiabycollaboratingwith9regionalcenters.Collectively,morethan16,000specimens
havebeencollectedfromsurveillancesites,andapproximately800isolateshavebeenwell
characterizedsincethebeginningoftheCDC-ICMRinuenzanetwork,whichstartedin2004.
TeIndiaNIChasworkedcloselywithU.S.CDCtoestablishstate-of-the-artlaboratories
andhastrainedextensivelywithU.S.CDCscientistsontyping,subtyping,PCR,real-time
PCR,andreversegeneticstechniques.Notableprogressoflaboratorysurveillancecapacityhas
occurredoverthepast5years,andthesuccessofthispartnershiphasledtosignicant
enhancementsbenetingbothIndiaandtheglobalinuenzasurveillancenetwork.
In2010,ICMRplanstobuildontheseactivitiesandworkcloselywiththeinuenzanetwork
byenhancingregionalsurveillancesystems,developingstandardizedinuenzalaboratory
procedures,conductinglaboratorytrainingworkshops,enhancingpreparednessplans,
strengtheningthecapabilitiesof4oftheregionalcenters,conductingexpandedH1N1
surveillanceinhospitalizedcases,andsupportingahealthcarefacilitypreparednessinitiative.
Surveillance
AssistICMRwithconductingvirologicsurveillanceforseasonalinuenzathroughout
IndiatounderstandtheviralcharacteristicsandseasonalityofinuenzainIndia.
Advanceinuenzavirussequencing,realtimeRT-PCR,andHItechniquestoanalyze
antigenicandgeneticdierencesinordertoascertaininuenzaviruscirculationamong
dierentgeographicareaswithdierenttemperatezones.
Provideisolatesanddataforvaccinerepresentativestrains.
Providetechnicalguidanceforsurveillanceactivitytocreatediseaseburdenestimates.
Contributeseasonalinuenzaisolatesforannualvaccinestrainselectionforinuenza.
TeCDC-ICMRinuenzanetworkiscoordinatingwiththeNationalCenterofDisease
Control(NCDC)inDelhitocreatealargernetworkofinuenzasurveillanceunitsin
India.
Buildcapacityfordiseasesurveillanceandlaboratorynetworksforrapiddetectionof
avianinuenza.
Shareinuenza-relatededucationalandinformationalmaterialsandcreatepublichealth
messagingsystems.
Comparetheinuenzasurveillancedatawithclimate,geography,anddemographicdata
toexploretrendsofinuenzaseasonality.
Conductantiviraldrugsensitivitysurveillancetoguideclinicaltreatmentand
prophylaxisofinuenza.
176
Multicentric infuenza surveillance network in India
Current Infuenza Network Sites, India

Regional Centers 2004
RMRC,
Dibrugarh
NICED,
Kolkata
KIPM,
Chennai
NIV,
Pune
AIIMS
CMC,
Vellore
Haffkine
Inst.
Mumbai
IGGMC,
Nagpur
VP
Chest
Regional Centers 2006
Referral Center
177
Laboratory
Indiahas9inuenzalaboratoriesthatarecapableofinuenzadiagnostictests,suchasvirus
isolation,HAandHI,andRT-PCRandreal-timeRT-PCRtestingtoconrmdiagnosisfor
seasonalinuenza.MostoftheselaboratoriescanalsotestforH5N1andH1N1.Laboratory
techniquesandguidancethatfurtherstrengthenseasonal,avian,andpandemicinuenza
laboratorialdetectioninIndiaincludetheabilityto
Buildcapacitybydevelopinganetworkof9laboratoriesforinuenzasurveillance
throughoutIndia.
TrainstaatNIV,Pune,andextendingtrainingforadditionalnetworkmembersin
Indiaandtheregion.
TrainedstatodetectpandemicH1N1byusingreal-timePCRandcreatesurge
capacityatmanylaboratoriesinIndia.
ProvidetechnicalguidanceforcreatingBSL-3plusandBSL-4laboratoriesand
developingstandardoperatingprocedures(SOPs).
Providestandardreagents,suchasHA/HIandPCRreagents,toinuenzanetwork
laboratoriesinIndia.
Strengthenthequalitycontrolsystemofinuenzadiagnosticnetworklaboratories.
EnhancerapidsequencingandphylogeneticanalyticcapabilityatNIV,Pune.
Preparedness
AssistgovernmentofIndiaintrainingforearlydetection,rapidresponse,and
containmentofavianandpandemicinuenzaatitssource.
AssisttheMOHFWinincreasingawarenessandresponseinordertominimizetherisk
ofthespreadofhumaninfectionsanddisease.
Providetechnicalguidancefordevelopingandimplementingtrainingmodulesforrapid
responseandcontainment,physicianawareness,andinfectioncontrolinhealthcare
facilitiesjointlydevelopedbyIndiaMOH,U.S.CDC,andWHO.
Makeaself-assessmentmonitoringandevaluationtoolavailabletoenableIndiatotake
inventoryoftheircapacitytohandlepotentialpandemicsandtoidentifypossiblegaps
forfutureimplementationofpandemicplans.
Developtheskillsandlaboratorynetworkcapacitytodetectnovelinuenzaviruseswith
NIV,Pune,asthefocalpointforlaboratorydetectionofaninuenzapandemic.
Training
Extendedtrainingopportunitiesanddevelopedcapacityandhumanresourcesatthe
collaboratinginstitutionsinIndia.
Providedhands-ontrainingoflaboratorystainIndiatoidentifypotentialpandemic
inuenzabyPCR.
Conductedtechnicaltrainingworkshopsonseasonalinuenzalaboratorydetectionfor
allinuenzasurveillancenetworklaboratoriesinNIV,Pune.Tistrainingisongoing
yearly.
Providedtechnicalguidanceforthetrainingphysiciansatthetertiarycarelevelfor
earlywarningsigns,developedasurveillancenetwork,andidentiedpossibleH5N1
infections.
ProvidedtrainingforregionalRRTteamsmadeupofhealthandveterinary
practitionersinIndiaattheregionalanddistrictlevels.
178
TrainedWHO-supporteddistrict,state,andregionalsurveillancemedicalocersofthe
NationalPolioSurveillanceProgramandstate-levelconsultantsoftheRevisedNational
TuberculosisControlProgramonEpidemicandPandemicPreparednessandResponse.
Undertookstate-leveltabletopexerciserelatedtoimplementingthepandemicplanin
partnershipwiththeMOHandtheWHOcountryoce.
Providedtrainingonrespiratoryinfectioncontrolandpreventioninhealthcarefacilities
thatincludedcasemanagementguidelinesforavianandpandemicinuenzaandhowto
appropriatelyuseofPPEforhealthcareworkers.
ExtendedthefollowingtrainingtoinuenzanetworkmembersinIndiaandtheregion:
Real-timePCRassaytrainingforCo-PIfromtheregionalcenter:CMCVellore,
September1618,2008.
TeNICatNIV,Pune,participatedasanexpertcommitteememberand
deliveredalectureontheprinciplesofreal-timePCRforinuenzaoravian
inuenzaattheNICD-WHOhands-onlaboratorytrainingoninuenzaoravian
inuenzawithspecialreferencetomolecularcharacterization:NationalInstituteof
CommunicableDiseases,Delhi,December1820,2008.
TwostamembersfromVPCI,Delhi,trainedatNIVforinuenzaisolationand
antigenicanalysestechniques,February26,2009.
A1-dayorientationprogramfortheinuenzadiseaseburdenstudyfor29
physicians:Vadustudysite,February23,2009.
Developedbroadactivitiesthatencompassedtheepidemiologic,basic,andapplied
researchaspectsofavianandpandemicinuenzawithmultiplepartnersinIndia.
Facilitatedtechnologytransferforvariousresearchtools,includingcapacitytotestfor
humanexposuretoH5N1andcreationofreversegeneticsmodiedIndianH5N1as
potentialvaccinecandidateimmunogens.
Developedprogramstoassesshost-viralinteractingproteinsatthemolecularlevelthat
mayeventuallyhelpexplainthepathogenesisofinuenzaindierenthostspecies.
U.S.CDCsInuenzaDivisionprovidedthenovelH1N1detectionkitswithinweeksof
theH1N1outbreak.Further,NIVprovidedscienticandtechnicalsupportforreal-
timePCR,SOPs,reagents,andpositivecontroltoallregionallaboratories.
RefreshertrainingsfornetworklaboratoriesinvolvedinthediagnosisofH1N1and
laboratory-basedsurveillanceofILI,includingthegovernmentofIndiasNational
CentersforDiseaseControl(NCDC).
Tefollowingtrainingsfordetectionof2009H1N1inuenzabyreal-timePCRand
conventionalPCRwereundertakenbyNIV,Pune:
Real-timePCR-baseddiagnosisof2009H1N1inuenza,SoutheastAsia
(organizedbyWHO,SEARO);June812,2009,Bangkok,Tailand.Twosta
membersfromNIV,Pune,wereinvitedasadvisorymembersfortheworkshop.
179

Twelveparticipantsfrom9countries(i.e.,India,Nepal,Bangladesh,Bhutan,
Indonesia,Maldives,SriLanka,TimorListe,Tailand)weretrainedindetecting
2009H1N1inuenzabyreal-timeandconventionalPCR.
RegionalICMRnetworkmembers(14stafromAIIMS,VPChest,
NICED,CMCVellore,KIPMChennai,RMRCDibrugarh,andPGIMR
Chandigarh)weregivenrefreshercoursesindetectingH1N1bymoleculartests,
June1718,2009.
FourICMRnetworkmembers(11stafromBhubaneswar,Patna,Jabalpurand
Andamanand2fromJodhpur)weregivenrefreshercoursesforH1N1detection
bymoleculartests,August2425and2728,2009.
FourstamembersofKasturbaHospitalMumbai(Maharashtrastatehealth
system)and2stamemberofJodhpurweretrainedindetecting2009H1N1
inuenzabyreal-timePCRandconventionalPCR,September1112,2009.
DuringthepeakoftheH1N1outbreakinlateJulythroughAugust2009,NIV,
Pune,washandlingmorethan500specimenseachweekforinuenzatestingby
PCR.
TeNIC,Pune,recordedmorethan11,000casesofILIandSARIinAugust2009
(peakofH1N1outbreakinPune)withapproximately20%positivityforinuenzaA
byreal-timePCR.Approximately50%oftheinuenzacaseswerenovelH1N1,andthe
remainingwereinuenzaH3orseasonalH1.
Ofthe1,084SARIcases,mostpatientshadmilderillness,and25deathswererecorded.
Atotalof44isolatesofnovelH1N1havebeenisolated,and4full-lengthsequences
carriedout.
Surge of ILI Cases in Pune, India, August 2009 (approximately 50% novel H1N1
infections)
0
200
400
600
800
1,000
1,200
1,400
July August
Week
180
Seasonal Infuenza A
P (H1N1)
34 33 32 31 30 29 28 27
ILI Cases
Teinuenzanetworkcollected4,030respiratoryspecimensin2009andisolatedand
characterized307inuenzaviruses.Ofthese,107isolateshavebeensenttoU.S.CDCs
InuenzaDivisionforfurtherantigenicanalysis.DataindicatesthatinuenzaA(H1N1
andnovelH1N1),A(H3N2),andtypeBcocirculatedinIndia.
Anextensiveanalysisof4yearsofseasonalinuenzadatacollectedhasshownthat
seasonalityvariesaccordingtogeographiclocation:
NorthIndiademonstratespeakactivityinwinterandlimitedactivityduringrains.
EasternandWesternIndiademonstratehighestactivityduringrainsandlimited
activityinwinter.
SouthIndiademonstratespeakactivityincoolerseasonduringrains.
GeneticanalysisofHAsequencesfrominuenzatypeAH1(n=137),H3(n=142),
andtypeB(n=124)demonstratedthatallcirculatingstrainsinIndiaclusteredwith
correspondingvaccinestrainsduring20042009.
Inuenzaisthecausativeagentinatleast5%ofacuterespiratoryinfections(isolation).
In2009,severalisolateswereidentiedwiththeoseltamivirresistanceatH274Yinthe
NeuraminidasegeneamongH1isolatesandresistanttoadamantane(S31N)insome
H3isolates.
TeNICatNIV,Pune,servedasastrongpillarofsupportforthein-countryresponse
tothepandemicH1N1outbreak.Itquicklyhandledthesurgeintestingfornovel
H1N1byreal-timePCRandprovidedin-countrytrainingforothercentersforH1N1
testing.
TeNICatPuneidentiedtheoutbreakofnovelH1N1withindaysandprovided
necessarysupportforfurtherconrmationofinfectionelsewhere.
Phylogeneticanalysisofall8genesegmentsof4novelH1N1identiedthatIndian
isolatesweregeneticallyclosetoA/California-04/2009,withgreaterthan99%identity
ataminoacidlevel.
TenovelH1N1virusshowedresistanceforamantadinebutsensitivitytooseltamivir.
TeIndiaNICdevelopedaWebsite:http://www.idbi-india.orgto
Sharetechniquesandexperiencesandenhancecommunicationwithnetwork
laboratoriesandotherlaboratoriesaboutinuenzadiseaseburden.
Strengthencommunicationandcooperationwithothersandimprove
managementofnetworklaboratories.
Collectandpublishthelatestseasonal,avian,andpandemicinuenzanews.
Inaddition,2researchstudiesaddressingissuesrelatedtoinuenzadiseaseburdenand
vaccineeectivenessareunderwayinIndia.
181
U.S.CDCFieldStaff
RenuB.Lal,PhD
U.S.CDCInuenzaCoordinator
U.S.Embassy,Shantipath,Chanakyapuri
NewDelhi110021,India
E-mail:rbl3@cdc.govorLalR@state.gov
AkhileshC.Mishra,PhD
Director,NationalInstituteofVirology
IndianCouncilofMedicalResearch
MinistryofHealthandFamilyWelfare,
GovernmentofIndia
20-A,Dr.AmbedkarRoad,PostBoxNo.11
Pune-411001,India
E-mail:acm1750@redimail.com
HarpreetKaur,PhD
ProgramManager
AssistantDirectorGeneral/ScientistD
DivisionofEpidemiologyandCommunicableDiseases
IndianCouncilofMedicalResearch
DepartmentofHealthResearch
MinistryofHealthandFamilyWelfare
AnsariNagar,NewDelhi-110029,India
E-mail:harpreet_k99@yahoo.com
182
SoutheastAsiaRegion
Indonesia
Capital:Jakarta InfantMortalityRate:Total:31.04deaths/1,000
Area: 1,919,440sqkm
Population:
242,968,342(July2010est.)

LiteracyRate:
AgeStructure:
otalpopulation:90.4%;male:94%;
014y
T
ears:28.4%(male34,343,198/
Tereare2cooperativeagreementsbetweentheIndonesianMOHandU.S.CDC.Te1st
istheDevelopingInuenzaSurveillanceNetworksCooperativeAgreement(withCenterfor
BiomedicalandPharmaceuticalResearchandDevelopment(Cbp-Rd),NationalInstituteof
HealthResearchandDevelopment[NIHRD]).
Te1stinuenzacooperativeagreementwithNIHRDbeganinSeptember2004and
endedinSeptember2009.
FY2009isthe1styearofanew5-yearsustainabilitycooperativeagreementwith
NIHRD.
TecooperativeagreementwiththeDirectorateGeneralofDiseaseControland
EnvironmentalHealth[DDCEH])beganinSeptember2006.
FY2009isthe3rdyearofthecooperativeagreementwiththeDDCEH.
TeRepublicofIndonesiaistheworlds4thmostpopulouscountryandhasapproximately245
millionpeople.Tecountryspreadsover5,300kmandincludesmorethan17,000islands,
6,000ofwhichareinhabited.SurveillanceforinuenzaoccurswithintheMOH.TeNIHRD
isdesignatedasthecountrysNICandconductssurveillanceforpatientswithILIinanetwork
of20primarycarefacilitiesandforpatientswithSARIin15hospitals.NIHRDalsoprovides
laboratorytestingandsupporttotheDDCEHforavianinuenzasurveillanceactivities.
183
In2009,DDCEHimplementedanearlywarningsurveillancesystem(EWARS)for22priority
diseases,includingILI,pneumonia,andavianinuenzaintheprovincesofLampungandBali.
DDCEHplanstoexpandthesystemto2otherprovincesin2010:NorthSulawesiandWest
Kalimantan.Toraiseawarenessofinuenzaduringthepastyear,DDCEHconductedtraining
fordoctorsondetectingH1N1andavianinuenza,awarenesstrainingforindustrialsectors
oninuenza(bothavianandpandemic),andmultisectoraltrainingonpandemicpreparedness
acrossseveralprovincesinIndonesia.
ILIandSARISurveillance
In2009,datacollectioninstrumentswererevisedtobettercaptureILIdiseaseburden
data.Inaddition,specimenreferralsystemsweredevelopedtoestablishfrontlinetesting
forbothILIandSARIpatientsattheregionalreferencelaboratories.
TeSARIsurveillancesystemwasexpandedinTangerangdistricttocapture
population-baseddataontheeectofnovelH1N1(nH1N1)inIndonesia.Both
surveillancesystemswereusefulinmonitoringtheemergenceofnH1N1inIndonesia.
Tereareplanstoconductanationalworkshoponlong-termplansforinuenza
surveillanceinJanuary2010followedbyanin-depthreviewofsurveillanceactivities.
Objectivesofthismissionwillbetointegratevariouslogisticanddatamanagement
activitiesandensurelong-termsupportofinuenzasurveillanceinIndonesia.
DDCEHimplementedcommunity-basedsurveillancein2provinces:EastJava
(2districts)andLampung(2districts).Villagesurveillanceworkerswererecruitedto
collectmorbiditydatafromthecommunityandprivatepractitionersandriskfactor
data.
Duringtherstquarter2010,thesurveillancesubdirectoratewillconductanin-depth
reviewandonthebasisoftheresults,thesubdirectoratehopestoexpandthesystem
nationwidependingavailabilityofresources.
184
Laboratory
Overthepast5years,NIHRDusedcooperativeagreementfundstodevelopan
extensivenetworkof12regionallaboratoriesandseveralhospitalswithreal-timePCR
laboratorycapacity.
NIHRDengagedtheregionallaboratoriesinILIandSARIsurveillanceactivities.
Preparedness
GiventhewidescaleH5N1epizoonoticinIndonesiaandthecontinuedoccurrenceof
H5N1infectioninhumans,epicentercontainmentandpandemicpreparednessarea
highpriorityfortheMOH.
Totestprotocolsforepicentercontainment,theMOHconductedanoperational
simulationexerciseinSouthSulawesiprovinceinApril2009.
EWARSwassuccessfullyimplementedin2provincesthisyearbyusingacombination
ofU.S.CDCandWHOfunding.
TeMOHdevelopedaninuenzapandemicsurveillanceguidelineforeldhealth
ocersandasurveillanceguidelineforocersatthePortHealthOce.
DDCEHdevelopedanationalcontingencyplantorespondtoaninuenzapandemic.
TedraftsofthatplanwereusedtoinformdecisionmakersduringtheH1N1pandemic.
Training
ByusingU.S.CDCfunds,theMOHestablishedthefollowingtrainingactivitiesin2009:
EWARSsurveillance,epidemiology,laboratory,andinformationmanagement.
SimulationexercisesforepicentercontainmentinSouthSulawesiprovince.
SurveillanceforH1N1andH5N1fordoctorsofprimarycarefacilitiesandprivate
doctors.
Pandemicpreparednessandbusinesscontinuityforindustrialsectors.
Multisectoralpandemicpreparednessandresponsein10provincesand84districts.
Acommunity-basedKAPsurveywasconductedinNorthSumatrawhereclusteredcases
ofH5N1occurred.
Population-basedsurveillanceforpatientswithSARIhasbeenimplementedin
TangerangdistricttocharacterizetheburdenofdiseaseassociatedwithnovelH1N1
infectioninIndonesia.
U.S.CDCFieldStaff
FrankMahoney,MD
U.S.EmbassyJakarta
U.S.CDCOce,Inuenza
FPO,AP96520-8137
E-mail:fmahoney@cdc.gov
185
PhilipSmith,MPH
U.S.EmbassyJakarta
CDCOce,Inuenza
U.S.EmbassyJakartaKeyCollaborators
CatharinaPraptiningsih,MDDs,MEpid
E-mail:praptiningsihcy@state.gov
AmalyaMangiri,MScPH
DataManagementSpecialist
FebryNova
Logistician
AnggiHartajaya
AdministrativeAssistant
PrincipalInvestigators
Trihono,MD,MSc
CenterforBiomedicalandPharmaceuticalResearchandDevelopment
NationalInstituteofHealthResearchandDevelopment
Jl.PercetakanNegaraNo.29
JakartaPusat10560
Indonesia
DorshintaSimangunsong,SE
CenterforInfectiousDiseaseControlandEnvironmentalHealth
E-mail:dorakeupppl@yahoo.co.id
ProjectManagers
FaridaSoetiarto,DDS,DrPH
CenterforBiomedicalandPharmaceuticalResearchandDevelopment
NationalInstituteofHealthResearchandDevelopment
Jl.PercetakannegaraNo.29
JakartaPusat10560
Indonesia
E-mail:farito@centrin.net.id
HikmahSariLoebis,MScPH
CenterforInfectiousDiseaseControlandEnvironmentalHealth
E-mail:hikmah.sari@gmail.com
186
SoutheastAsiaRegion
Nepal
Capital: Kathmandu InfantMortalityRate:Total:46deaths/1,000live
Population:
28,951,852(July2010est.)

LiteracyRate:
AgeStructure:
014years:35.6%(male5,253,150/
InFY2009,Nepalappliedforandwasawardedtheir1
st
U.S.CDCSurveillanceand
ResponsetoAvianandPandemicInuenzacooperativeagreement.
GrantawardedonAugust1,2009.
Nepalisamountainouscountrywithmostpeoplelivinginruralareas,andmanyaredependent
onpoultryandanimalfarming.WithsupportfromtheWorldBank,Nepalpreparedajoint
HealthandAgricultureNationalAvianInuenzaandInuenzaPandemicPreparednessand
ResponsePlanin2006,andlaterthatyear,anOperationalInuenzaPlan.In2008and2009,
easternNepalexperiencedanH5N1avianoutbreak;nohumancasesweredetected.TeU.S.
CDCgrantee,thePatanAcademyofHealthScienceswillcollaboratewithNepalsMinistryof
HealthandPopulation(MOHP)tobuildcapacityinthecountrytomonitoranddetect
circulatinginuenzaviruses.
Surveillance
Nepalproposestosetup3sentinelsurveillancesitesat3keyhospitals:Patanin
Katmandu,NepalgunjMedicalCollegeinwesternNepal,andBPKoiralaInstituteof
HealthSciencesineasternNepal.
WithU.S.CDCsupport,Nepalplanstoincreasecapacitytocreateandmaintaina
mechanismforregularvirologicandepidemiologicsurveillance.Currently,thereisno
routinevirologicsamplecollectionprotocolinplaceinNepal.Todate,hospitalsonly
takeswabsfrompatientswhoareseverelyill.
187
Laboratory
Currently,thegovernmentsNationalPublicHealthLaboratory,thenational
referencelaboratory,hasreal-timeRT-PCRandistestingfortheH1N1virus.TePatan
Academylaboratory,withthesupportoftheU.S.CDCgrant,planstopurchasea
real-timeRT-PCRandupgradetheirlaboratorytoconductroutinemoleculardiagnostic
testing.
NepalaspirestomovetowardfulllingthetermsofreferencetobecomeaWHONIC.
Tiswillincludecollectingandsharinginuenzavirusisolatesandmaintainingactive
communicationwiththeWHOGlobalInuenzaSurveillanceNetwork.
Preparedness
WithsupportfromtheWorldBank,NepalpreparedajointHealthandAgriculture
NationalAvianInuenzaandInuenzaPandemicPreparednessandResponsePlanin
2006andlaterthatyearanOperationalInuenzaPlan.Nepalwillpreparethe3sentinel
hospitalstomobilizetechnicalteamscapableofrespondingatthedistrictleveltoan
inuenzaoutbreak.
Training
TeMOHPoeredlabtechnicianstrainingoncorrecttechniquesfortakingand
handlingnasopharyngealswabsandspecimens.
Aswithotheroutbreaks,whenaclusterofcasesarereported,thegovernmentsendsa
medicalteamtoinvestigate.DuringthecurrentH1N1epidemic,caseswere1st
concentratedinthecountryside,butthenspreadtothemorepopulatedKatmandu
valley.
Anincreasingnumberofsamplesarebeingcollectedandsenttothelaboratory.Tamiu,
masks,gloves,andshippingicepacksarebeingprovidedtoallzoneandregional
hospitals.
Airportscreening(nativeorforeigners)isongoing.Passengerswithpossiblecasesof
H1N1aresenttoaninfectiousdiseaseshospitalforfurtherwork-upandtherapeutic
interventions.
ArjunKarki,MD
ViceChancellor
PatanAcademyofHealthSciences
P.O.BoxNo.26500
Kathmandu,Nepal
E-mail:drakarki@pahs.edu.np
KedarPrasadBaral,MD,MPH
DeputyProjectDirector
PatanAcademyofHealthSciences
P.O.BoxNo.26500
Kathmandu,Nepal
E-mail:kedarbaral@yahoo.co.uk
188
SoutheastAsiaRegion
SriLanka
Capital: Colombo InfantMortalityRate:Total:18.14deaths/1,000
Population:
21,513,990

LiteracyRate:
AgeStructure:
014y
T
ears:23.6%(male2,593,007/
InFY2009,SriLankaappliedforandwasawardedtheir1stU.S.CDCSurveillance
andResponsetoAvianandPandemicInuenzacooperativeagreement.
GrantawardedAugust1,2009.
SriLankaisahigh-riskcountryforavianinuenzabecauseitattractsmigratorybirdsandhas
alargepoultryindustryandalargenumberofpeoplekeepingpoultryintheirbackyards.Te
countryhasonlyonemajorportofentry.SriLankasPandemicInuenzaPreparednessand
Responseactivitiesbeganin2005withsupportfromtheWHOandtheWorldOrganization
forAnimalHealth(OIE).WithadditionalsupportfromtheWorldBankin2008,thecountry
initiatedtheNationalPandemicInuenzaPreparednessandResponseProgramheadedjointly
bytheMOHandLivestockDevelopmentandAgriculture.TeEpidemiologyUnitinthe
MOHwilloverseethenewU.S.CDC-fundedprogram,whichwillcomplementcurrentand
ongoinginuenza-relatedactivities.
Surveillance
SriLankacurrentlyhas20sentinelhospitalsselectedascentersofinuenzasurveillance.
U.S.CDCfundingwillbeusedtoincreasetheircapacitytoconductregularvirologicand
epidemiologicsurveillanceandtomonitoranddetectcirculatinginuenzastrains.Asmany
as30samplesofILIaretobecollectedeachmonthfromtheinpatientandoutpatient
departments.DataonILIpatientsareroutinelyincludedinthenationalinuenzasurveillance
database.WithU.S.CDCfunding,thisactivitywillbestrengthened.
189
Laboratory
SriLankasmaingovernmentlaboratory,theMedicalResearchInstitute(MRI),isaWHO
NIC.Telaboratoryisequippedwithreal-timeRT-PCRandcantestfortheH5N1andH1N1
viruses.SriLankacollectsandsharesinuenzavirusisolatesandmaintainscommunication
withtheWHOGlobalInuenzaSurveillanceNetwork.WithU.S.CDCsupport,the
MOHproposestostrengthentheirinuenzalaboratorysurveillancebyimprovinglaboratory
diagnosticfacilities.SriLankaproposestosetupaninformationmanagementcomputer
networkthatlinkstheNIC,theEpidemiologyUnit,andtheregionalinuenzasentinelsites.
Preparedness
SriLankahaspreparedaNationalPandemicInuenzaPreparednessPlanandhasaNational
SteeringCommitteeandaNationalTechnicalCommitteeonAvianandPandemicInuenza
Preparednessthatallmeetregularly.Preparednessplansforall26administrativedistrictshave
beendeveloped.TeNationalCommunicationStrategyonAvianandPandemicPreparedness
wasdevelopedandisperiodicallyupdated.TeMOHhasstockpiledTamiuthatcanbeused
duringtheH1N1pandemic.
Training
WithU.S.CDCfunds,theMOHEpidemiologyUnitandtheMRIisplanningtotrain
regionalepidemiologists,hospitalinfectioncontrolnursingocers,andlaboratorytechnicians
oninuenzalaboratoryandepidemiologicsurveillance.
Terehavebeen115conrmedH1N1
casesfromJune2009,whentherst
H1N1casewasidentiedtoOctober
15,2009.Morethan90%ofthesewere
visitorsfromotheraectedcountries.
Mostweredetectedbyusingairport
surveillanceandscreening.Sustained
communitytransmissionwasconrmed
onOctober16,2009.Asaresult,
strategiesincaseidenticationand
laboratorysurveillanceweremodied:
airportscreeningwassuspended,and
onlyepidemiologicallyimportant
patients,orthosewithsevereillness
fromtreatinghospitals,weretested.
Terehasbeenanother70conrmed
casessincethen.SriLankareports
weeklytoWHOandU.S.CDCon
conrmedH1N1casesbylocation,age,
andsex.
190
Partners
MedicalResearchInstituteNIC.
HealthEducationandPromotionBureau.
DepartmentofAnimalProductionandHealth(DAPH).
PabaPalihawadana,MD,MSc,MBBS
ChiefEpidemiologist
EpidemiologyUnit,MinistryofHealthcareandNutrition
231DeSaramPlace,Colombo010
SriLanka
E-mail:paba@health.gov.lk
WasuJayasinghe,MD,MSc,MBBS
MedicalOcer
AI/AFPTeam
EpidemiologyUnit,MinistryofHealthcareandNutrition
231DeSaramPlace,Colombo010
SriLanka
E-mail:wasujayasinghe@gmail.com
PatrickGlew,MPH
Epidemiologist
EpidemiologyandPreventionBranch
Atlanta,Georgia
JaclynKing,MPH
Epidemiologist
Atlanta,Georgia
PamelaKennedy
DataBaseDeveloper
ExtramuralProgramOce
Atlanta,Georgia
191
192
SoutheastAsiaRegion
Thailand
Capital:Bangkok InfantMortalityRate:Total:18.23deaths/1,000
Area: 514,000sqkm
Population:
66,404,688

eStructur
LiteracyRate:
Ag e:
014years:21.2%(male7,104,776/
22,763,274/female23,304,793);65yearsorolder
FirstinuenzacooperativeagreementbeganinSeptember2004andendedin
September2009.
FY2009isthe1styearofanew,5-yearsustainabilitycooperativeagreement.
TeTaiNationalInstituteofHealth(NIH)islocatedwithintheDepartmentofMedical
Sciences(DMSc),TailandMinistryofPublicHealth(MOPH)andemploys215permanent
and237project-basedsta.TeTaiNIHhasbeenrecognizedbyWHOasaNICsince1972.
TeTaiNIHcomprisesmanyscienticgroupswithinitspublichealthlaboratory
infrastructureandservesasthecountrysnationalreferencelaboratoryandtheresearchand
developmentarmoftheMOPHforinfectiousandnoninfectiousdiseases.TeTaiNIH
laboratoryiscompliantwithISOstandardsandaccreditedbytheBureauofLaboratoryQuality
Standard,Tailand,andotherinternationalorganizations,includingWHO.Teroleofthe
NICistoactasthenationalreferencelaboratoryforinuenzaandotherrespiratoryviruses,
includinginuenzasurveillanceandresearchinclosecollaborationwiththeU.S.CDC.
Surveillance
Tereare10establishedsentinelinuenzasurveillancehospitalsthroughoutthe5
regionsofTailandandtheBangkokmetropolitanarea.
193
TeTaiMOPHhasrecentlyintegratedan
additional8sitesaspartofitseortstoenhancethe
countrysinuenzasurveillanceprogram.
In2009,theNICprocessed3,428specimenswith
811(23.7%)positiveresultsforseasonalinuenza
fromthe10sentinelsites,andapproximately20
inuenzaspecimensfromneighboringregional
countriesweresentforconrmation.Tesurveillance
dataandinuenzaviralstrainsobtainedwereshared
withWHOandU.S.CDC.
SurveillancedatawasreportedtotheTaiMOPHto
beusedinpolicydecisionstoenhancethenational
inuenzapreventionandcontrolinTailand.
Duringthelast5years,theNICexpandedthe
virologicsurveillancesystem,whichisfullycapableofmonitoringcirculatinginuenza
strainsanddetectingnewvariantsanddrugresistantstrains.
Since2008,theNICandBureauofEpidemiology(BOE)integratedandharmonized
virologicandepidemiologicsurveillancetoestablishaneectiveandtimelyinuenza
surveillancesystemcapableofdetectingandreportinganincreaseininuenzaactivity
forthecountrysalertsystem.
PassivesurveillancedatafromBOEisusedtoestimateseasonal,specic,baselinerates
ofreportedinuenza.
Laboratory
TeNIChasthecapacityforthefollowing:viralRNAextraction;RT-PCRfordetectionof
inuenzaAandB;inuenzavirusisolationbycellculturemethodbyusingMDCK-cell;
inuenzaAsubtypingbyreal-timeRT-PCR;strainanalysisbyhemagglutinationinhibition
(HI);immunouorescencetesting;wholegenomesequencingofnovelviruses;andsequence
analysisofselectedspecimenstodescribeinuenzageneticdiversityforvaccinedevelopment
purposes.
Antiviraldrugresistancetestingwasimplementedin2008byusingneuraminidasegene
sequencinganduorescence-baseNAenzymeinhibitionassay.
TeDMSchas1NICand14regionalmedicalsciencecenters(RMSCs)thatconduct
PCRtestingforinuenzaspecimens.
DuringthenovelH1N1pandemic,thecapacityforinuenzatestingattheNIC
laboratorywasapproximately400500specimenseachdayandatotalforallthe
RMSCsof7001,400specimenseachday.
Preparedness
TeTaiNationalCommitteeonAvianInuenzaControlandPandemicInuenza
Preparedness,chairedbythedeputyPrimeMinister,developedtherstnational
strategicplanforavianinuenzacontrolin2005onapprovaloftheTaicabinet.
In2008,thisplanwasmodiedasthe2ndNationalStrategicPlanforAvianInuenza
andInuenzaPandemicPreparedness,20082010.
194
OnApril28,2009,theNational Action Plan for Preparedness Response to Pandemic

Outbreaks of Inuenza Virus wasapprovedbytheTaicabinetandpublished.
TeactionplanforLaboratoryDiagnosisofPandemicInuenzaandAvianInuenza
Virus(2006)wasupdatedtotheactionplanforlaboratorydiagnosisofthepandemic
2009H1N1inuenzavirus.
Training
InsupportoftheWHOinuenzaprogram,theNICprovidedtechnicalsupportto
organizehands-onworkshopsinPCRtechnologyspecictopandemic2009H1N1
inuenzavirusto14NIClaboratorystafrom7countries(i.e.,Bangladesh,Bhutan,
Indonesia,MaldivesNepal,SriLanka,Timorese),inadditiontotraining14DMSc
regionalnetworklaboratorystaand32Tairegionalhospitalsta.
TeNIChostedlaboratoryscientistsfromLaos,Myanmar,andNorthKoreainPCR
diagnosticstesting,virusisolations,laboratoryqualityassurance,andbiosafetysystems.
Networking
TeTaiNICprovidesamonthlyreporttotheWHOGlobalInuenzaSurveillance
Network(GISN)tosupportvaccinestrainselectiondecisions.
TeNICparticipatedintheWHOEQAPandpreformedcontinuousquality
improvementsinaccordanceofWHOcriteria.
TeNICprovidestechnicalsupportandconrmatorytestingforthenational
laboratoriesofneighboringcountries.
Attheonsetofthepandemic2009H1N1inuenzaoutbreak,Tailandhadthe
capacitytoprocessspecimensfortheH1N1virusbyusingreal-timePCRtechnology
andsupportednationaleortstocombattheinuenzapandemic.
Incollaborationwiththeuniversitylaboratories,theTaiNICconducteddrug
resistancemonitoringandfollow-upofgeneticvariationsbyviruscharacterization.
Approximately150viralisolatesweresharedwithWHO.
TecapacityoftheTaiDMSc(i.e.,TaiNIHandRMSCs)is22PCRunitsthat
weredeployedstrategicallyamongtheNICs,14regionalmedicalcenters,and7mobile
laboratoriestocoverthepandemic2009H1N1inuenzatestingduringMayOctober
2009.Atotalof67,769specimensweretestedwith26,231(38.7%)positiveresultsfor
theH1N1virus.Tefacilitiesoperate24hoursaday,7daysaweek,andprovideresults
within24hours.
IncollaborationwiththeMOPH,theNIChasintegratedthevirologicandepidemiologic
ILIsurveillanceforearlywarningsystemandeectivelydevelopedrapidresponsecapacity
fortestingpandemic2009H1N1inuenzavirusanddrugresistancestrains.TeBureauof
Epidemiology,DepartmentofDiseaseControl,planstoadaptandmodeltheirsurveillance
systemonthebasisofthesuccessoftheNICproject.
195
ThailandsFuturePlansforExpansionofLaboratoryFacilitieswithCapabilityof
PCRTesting
TeTaigovernmenthasinitiatedplanstoexpandthenumberoftestingsites.InphaseI,
approximately25laboratorieslocatedinprovincialhospitalsarebeingincludedthrough
trainingandupgradingofinfrastructure.Initialplansindicatethatthesewillbeusedfortesting
ofinuenzaonly;however,tohaveabetterreturnoninvestmentandtoprovidecomprehensive
supporttonationalsurveillanceactivities,ithasbeenconsideredprudenttousethesefacilities
fordiagnosisofotheremerginginfectiousdiseasestoo.
InphaseII,thecountrylikelywillhaveanetworkofapproximately100PCRfacilitiesthatwill
provideinvaluablesupporttoanyinfectiousdiseasesprogramatlocalandnationallevels.
ThailandsKeyPartners
TeMOPH.
TeBureauofEmergingInfectiousDiseases,TaiDepartmentofDiseaseControl
(DDC).
TeBOE,TaiDepartmentofDiseaseControl.
TeNationalInstituteofHealth,DepartmentofMedicalSciences(TaiNIH,DMSc).
TeRMSC.
TeSentinelInuenzaSurveillanceHospitals.
TeProvincialHealthOce.
TeInternationalHealthPolicyProgram.
TeMinistryofInterior.
NonproftOrganizations
TeVirologyAssociationofTailand.
TeInuenzaFoundationofTailand.
InternationalPartners
U.S.CDC,IEIP.
WHO.
PathomSawanpanyalertMD,DrPH
ProjectDirector,PrincipleInvestigator
Director,NationalInstituteofHealth,DepartmentofMedicalSciences
MinistryofPublicHealth,TiwanonRoad,Nonthaburi11000,Tailand
E-mail:pathom@health.moph.go.thorpathoms@loxinfo.co.th
196
ProjectCoordinator
KrongkaewSupawat,BSc,MSc
DeputyDirector,TaiNationalInstituteofHealth,DepartmentofMedicalSciences
E-mail:krongkaew.s@dmsc.mail.go.thorkrongkaewdaeng@yahoo.com
MalineeChittaganpitch,BSc,MSc
Chief,WHONationalInuenzaCenter,Tailand
TaiNationalInstituteofHealth,DepartmentofMedicalSciences
E-mail:malinee.c@dmsc.mail.go.th
U.S.CDCStaffinThailand
MarkSimmerman,PhD,RN
ChiefofInuenzaSection,InternationalEmergingInfectionsProgram
TailandMOPH,U.S.CDCCollaboration
E-mail:msimmerman@cdc.gov
SusanA.Maloney,MD,MHSc
Director
DDC7Building,3rdFloor
MinistryofPublicHealth,Soi4
Nonthaburi11000,Tailand
SonjaOlsen,MD
TailandMOPH,U.S.CDCCollaboration
197
198

SoutheastAsiaRegion
GDD-Thailand
Establishedin2004,GDD-Tailandandnationalandregionalpartnerssupportessentialpublic
healthfunctionstorapidlydetectandrespondtoSoutheastAsiasemergingandreemerging
infectiousdiseases.Tesehealththreatsrangefrompneumonia,includinginuenzaandpandemic
inuenzathreats,tohand,foot,andmouthdisease(HMFD),tuberculosis,andzoonoticdiseases.
Coverage
GDD-TailandisconnectedbyeldactivitiesthroughoutSoutheastAsiaandisfoundedon
U.S.CDCshistoryofcollaboration,whichdatesbacktotheestablishmentoftheworlds1st
FETPin1980.Tisfoundationhasprovidedsomeofthemostinnovativepublichealthwork
intheworld,includingthe1stsiteofU.S.CDCsIEIPin2001andsupportresponsestothe
post-September11thanthraxevents,SARS,andthesubsequentandcontinuedthreatofavian
inuenza.
Activities
Outbreakresponse.
Pathogendiscovery.
Training.
Surveillance.
Networking.
Effect
In2009,GDD-Tailandrespondedto9outbreakswithin24hours.Teydiscovered1
pathogennewtotheworldandincreasedtheirlaboratorytestingcapacityby107%.In
addition,GDD-Tailandtrained10FETPgraduatesandmorethan1,500participantsin
short-termregionalandnationaltrainings.
Staff
In-Country Field Staff
SueMaloney,MD,MPH
GDD-TailandCoordinator
MarkSimmerman,MD,MPH
InuenzaLead
Principal CDC Program Collaborations In-Country
IEIP.
FETP.
Immigrant,Refugee,andMigrantHealth.
199
200
WesternPacifc
RegionalOffce
(WPRO)
WesternPacifcRegionalOffce
(WPRO)
HumanInfuenzaSurveillance:WPRO2010
CDCVeterinaryAssignee
CDCAssignee
WPROHeadquarters
PasteurInstitute
WPRO
WPRODirectFunding
InfuenzaCooperativeAgreement
SustainabilityCooperativeAgreement 0 310 620 1,240 1,860
Miles
U.S.CDCDirectRegionSupport
SurveillanceandResponsetoPandemicandAvianInuenzabyRegionalOcesoftheWorld
HealthOrganization
BeganSeptember2006.
FY2009isthe4thyearoftheagreement.
TeWesternPacicRegionalOce(WPRO)islocatedinManila,Philippines.Teoceserves
37countriesandterritories,coveringapproximatelyone-thirdoftheworldspopulation
approximately1.6billionpeople.WPROisoneofthemostdiverseWHOregionsbecauseits
memberstatesrangefromthehighlydeveloped(e.g.,Australia,Japan,NewZealand,theRepublic
ofKorea,Singapore),totherapidlydeveloping(e.g.,China,Vietnam),andthosewithfewhealth
resources(e.g.,Laos).WPROstacontinuetoprovidetraining,support,andtechnicalassistance
tomembercountries.Duringthepast7-yearperiod,U.S.CDCassistanceandsupporthas
focusedonpandemicpreparedness,epidemiologicandvirologicsurveillance,infectioncontrol,
rapidresponseforcontainment,andoutbreakinvestigationthroughouttheregion.Inaddition,
severalcountriesgetfundingsupportdirectedtotheMOHthroughtheirWHOcountryoce.
TesecountriesareLaos,Cambodia,China,Vietnam,Fiji,andPapuaNewGuinea.
203

Surveillance
WPROpublisheditssurveillanceguidanceforcountriesinWPROinNovember2008.Te
documentisentitled,A Practical Guide to Harmonizing Virological and Epidemiological Inuenza
Surveillance; itcanbelocatedonlineatthefollowingWebsite:http://www.wpro.who.int/internet/
resources.ashx/CSR/Publications/GuideToHarmonizingInuenzaSurveillance-revised2302.pdf.
China
WPRO-Chinasupportedtheweeklydatacollectionandanalysisactivitiesatthe
ChinaNICthroughouttheyear.Teyalsosupportedvirusisolatesidenticationand
validationattheChinaNIC.
WPROfunded6ChineseocialstudytoursattheWHOcollaborationcenterfor
referenceandresearchoninuenzaattheOceofHealthProtectioninAustralia
fromFebruary23toFebruary26,2009tolearnaboutseasonalinuenzasurveillance
experiencesandpandemicpreparednessplansandtovisitinuenzalaboratoriesand
sentinelhospitalsinordertostudysurveillanceactivities.
Cambodia
Tenumberofsentinelsiteswasincreasedfrom5to7sitesasofMay2009.
TefollowingactivitieshavebeensupportedtoenableILIsurveillance:
RefreshertrainingforstafromILIsentinelsites.
SupervisionofILIsentinelsitesbyU.S.CDC-supportedWHOandMOHsta.
Trainingworkshopforthestainthenewlyadded6thand7thsentinelsites.
FinancialsupporttoInstitutePasteurCambodiatoprovidelaboratoryservicesfor
theILIsurveillanceprogram.
QuarterlyreportfromtheILIsurveillancesystem.
PublicationoftheannualILIreport.
TeCambodiaEarlyWarningandResponseNetwork(CAMEWARN)activities
include
OngoingupgradestotheU.S.CDCWebsite.
Productionofmonthlysurveillancebulletins.
InstallationofremoteSMSsystemsinalloperationalhealthandprovincialhealth
departmentshasbeencompleted.TeCAMEWARNsurveillancedataformfor
thesesitesisnowautomaticallyupdatedtotheservers.
LaoPeoplesDemocraticRepublic(PDR)
WPROparticipatedwiththeMekongBasinDiseaseSurveillanceProjectandKenan
Institutescross-bordersurveillanceexercisesanddraftedacasescenarioonahumanAI
casetoassistwiththesecross-borderneeds.
SupportwasprovidedtotheLaoNationalCenterforLaboratoryandEpidemiology
(NCLE)withinterpretation,investigation,andresponsetosuspectedhumanAIatthe
nationallevelandbyprovidinghumanresourcesupportintheeldinborderareas.
204
WPROworkedwithnationalsurveillancestatoimproveanddisseminateinuenza
outbreaksurveillanceandcontroltrainingtoprovincial-anddistrict-levelsta.Te
traininghasoccurredduringpoultryAIoutbreaksandfeverorrespiratorydisease
outbreaksinnumerousprovinces.WHOstahavetravelledwithcentral-levelsta
totheoutbreakstosupportsurveillanceandcontroleortsandprovidedon-the-spot
trainingaboutPPE,appropriateTamiuuse,isolationandquarantine,andlinelisting
eorts.
WPROhasinstalledanelectronicindicator-basedsurveillancetool,theLaoEarly
WarningandResponseNetwork(LaoEWARN).WHOtrainedprovincialstafrom
allprovincesinLaoPDRandnationalstaontheuseofthiselectronicformatto
facilitaterapidreportingof19reportableconditions,includingacuterespiratoryillness
tothecentrallevelandrapidlocalresponseattheprovinciallevel.Tisnewdatabasehas
signicantlyenhancednationalweeklysurveillanceeorts.
AspartofInternationalHealthRegulations,communityevent-basedsurveillance
(CEBS)pilot,projectswereestablishedin4provincesofLaoPDR.Onesuchpilot
hasbeensupportedbyWHOandtheVientianeCapitalPublicHealthDepartment.
Tesepilotshavebeendevelopedtoincreasethecapacityatthecommunityanddistrict
levelstodetectdiseaseclustersthatincludehumanandanimalAIoutbreaks.Aformal
evaluationofall4pilotsisunderway,whichwillbeusedtoinformthepotentialrollout
ofCEBStotherestofthecountry.
Laboratory
PatrickReadingwasrecruitedastemporaryadvisortoMataikaHouse,Fiji,from
February22-28,2009,forinuenzalaboratorytrainingandtechnicalassistanceon
real-timePCRdiagnosisofinuenza,goodlaboratorypractice,anddevelopmentof
recommendationsonthemanagementofthelaboratoryandfuturedevelopment.
Alaboratoryfreezerandrefrigeratorwereprocuredforthenationalinuenzalaboratory
inMataikaHouse,Fiji.
205
Laos
WHOsupportedNCLEtorolloutalaboratory-basedILIsurveillanceprojecttoreceive
laboratoryspecimensfrompatientsexperiencingILIsymptomsatlargehospitalsin3
newsentinelsitesin2provincesinJune2009.Teprogramwillbuildonthesuccess
andexperienceofthecurrentILIprogramwithinVientianecapital.
Preparedness
TeConsultationfortheEstablishmentoftheRegionalClinicalAdvisoryNetworkon
EmergingInfectiousDiseases(EID)inWPROwasheldinManila,Philippines,December
1718,2008.
Temeetingwasattendedby11TemporaryAdvisorsfrom10countries.TeWHO
secretariatconsistedof7representativesfromGenevaHeadquarters,WPRO,andthe
CountryOceinthePhilippines.
Teobjectivesoftheconsultationwereto
Developdrafttermsofreferenceandoperationalproceduresfortheregional
clinicaladvisorynetwork.
Discussthemembershipofthenetwork.
Tetermsofreference,operationalprocedures,andmembershipoftheregional,clinical
advisorynetworkwerediscussedanddraftedduringtheconsultation.Temeeting
concludedwithrecommendednextstepsforthemembersoftheconsultationandWHO.
LaoPDR
Te1stprovincialpandemicplanwasdraftedinVientianeProvincewithsupportbyU.S.
CDCandWHO.Tisrstprovincialplanisanoperationalplanforrespondingtoa
pandemicinuenzaandusesthenationalplandraftedinearly2008asaguideline.Ithas
beenusedsinceasamodelfordraftingprovincialoperationalplansinallLaoprovinces.
Training
Ahands-ontrainingworkshoponlaboratorydatabasesoftwarewasconductedto
addressthedatamanagementneedsoftheNICsinWPRO,November1921,2008.
Atleast1personfromeachofthefollowingNICsintheregionparticipated:Cambodia,
China,LaoPDR,Fiji,SouthKorea,Malaysia(2),Mongolia,Philippines,PNG,
Singapore,andVietnam.
Fourmajoractivitieswereconductedduringtheworkshop:
Introductionofthedatabasesoftware.
Optionsfortransferringdatafromtheexistingdatabasetothenewdatabase
software.
Hands-onpracticeoneachmoduleofthesoftware.
Feedbackfromtheparticipantsonhowtoimprovethedatabasesoftware.
Attheendofthetraining,theparticipantswereabletoproperlysetupthedatabase
softwaresystem,managedatafordailyactivitiesintheNICseciently,andperform
analysisandgeneralreportsbyusingthedatabasesoftware.
206
A5-daytrainingworkshoponinuenzavirusisolationandcharacterizationofseasonal
inuenzaviruseswascompletedfromMarch30,2009toApril3,2009,inSingapore.
Tisworkshopwasco-sponsoredbytheRegionalEmergingDiseasesIntervention
CenterandWHOWPRO.Tisworkshopaimedtoteachbasiclaboratorytechniques
essentialfortheisolationandsubsequentcharacterizationofseasonalinuenzaviruses
forthepurposeofinuenzasurveillance.TetrainingwasheldattheSingapore
Polytechnic.
FourteentraineesfromtheWPROandSEAROregionsattendedtheworkshop,and
thecountriesrepresentedwereCambodia,Laos,Fiji,PapuaNewGuinea,Bangladesh,
Indonesia,Nepal,andSriLanka.
WPROpublisheddiseaseburdenguidanceforcountriesinWPROinNovember2008.Te
documentisentitled,A Practical Guide for Designing and Conducting Inuenza Disease Burden
Studies,andcanbefoundonlinehere:http://www.wpro.who.int/internet/resources.ashx/CSR/
Publications/GuideforDesigningandConductingInuenzaStudies.pdf.
U.S.CDCFieldStaffthroughJune2009
WeigongZhou,MD,PhD
WHO,WPRO
UnitedNationsAvenue1000
Manila,Philippines
E-mail:waz6@cdc.gov
InfuenzaDivisionStaffProjectOffcers
VashoniaSmith,MPA
ProjectOcer
WPRO,Vietnam,Cambodia,Laos
Atlanta,GA30333
E-mail:vdw8@cdc.gov
TeresaTurksi,MPH
ProjectOcer
China,Mongolia,Philippines,SPC/PPHSN
Atlanta,GA30333
E-mail:tnt7@cdc.gov
207
MargaretMcCarron,MPH
EpidemiologyandSurveillanceOcer
Atlanta,GA30333
E-mail:dme8@cdc.gov
208
WesternPacifcRegion
Cambodia
Capital:PhnomPenh InfantMortalityRate:Total:56.59deaths/1,000
Area: 181,040sqkm
Population:
14,753,320

LiteracyRate:
AgeStructure:
ears:33.2%(male2,389,668/
014y
84.7%;female:64.1%(2004est.)
BeganJune2006.
Cambodia1streportedacaseof2009H1N1inuenzavirusinfectioninJune2009.Asof
October2,2009,120casesofH1N1havebeenreportedfrom8provinces.Treeofthecases
havebeenfatal.
UndertheMOH,theCambodiaCommunicableDiseaseControlDepartment(CCDC)
conductsinfectiousdiseasesurveillance,monitoring12diseasesandsyndromes.Dataonthese
conditionsarecollectedandrecordedineachprovincialhealthdepartmentandcompiled
nationally.InthecaseofasuspectedoutbreakoftheH5N1subtype,rapidresponseteamshave
beentrainedtoverifytheoutbreaks,conductearlymitigationandcontainmentinterventions,
andimmediatelyimplementinfectioncontrolmeasures,ifnecessary.Onefunctioning,
nongovernmentalNationalNIC,thePasteurInstitute,whichperformsdiagnostictestingfor
inuenza,includingtheH5N1andH1N1subtypes,iscurrentlyinthecountry.
TeUnitedStatesNavalMedicalResearchUnitNo.2(NAMRU-2)upgradeditsdetachment
inPhnomPenhbeginninginJuly2006.Inthatyear,anInuenzaDivisionepidemiologist
wasassignedtothedetachmentasdirectorandreceivedpartialfundingfromtheU.S.CDC
InuenzaDivisiontoconductinuenzastudies.SinceDecember2006,theNavyhasconducted
209
clinic-basedsurveillanceforthecausesofacutefeverandbyusingthatdata,providedthe
governmentwithinformationontheepidemiology,symptomology,andviralcharacteristicsof
inuenza.TeseresultscomplementtheMOHsILIsurveillance.
Surveillance
SARIsurveillancehasbeen
implementedforthe1sttimeat
3hospitalsinPhnomPenhand
KandalProvince.Allspecimens
aretestedforinuenzavirusesat
theNationalInstituteofPublic
Health(NIPH).Trainingon
reportingrequirements,suchas
completionofcasereportforms
andproperspecimencollection
andtransport,wasconducted
beforecommencementof
surveillanceateachsite.
NationalILIsurveillancewasexpandedto2newsitesinSiemReapandSvayRieng
Provinces.Initialtrainingwasconductedforstafromthesenewsites.
WeeklyILIsurveillancereportingfromsentinelsiteshasbeenupgradedfrompaper
submissionstoelectronictransferdirectlytotheMOHILIdatabasebyusingSMS
mobiledevices.
InresponsetotheH1N1pandemic,theMOHsetupanewtoll-freehotlineaspartof
event-basedsurveillancetodisseminateinformationanddetectandcoordinateresponse
tosuspectedH1N1casesincommunitiesorhospitals.
Newguidelinesandoperationalplansforemergingdiseaseoutbreaks,includingAI,are
underreviewbytheDivisionofCommunicableDiseaseControl,MOH.
Laboratory
TechniciansinthemolecularlaboratoryofNIPHcompletedtrainingconductedbysta
fromtheU.S.CDCInuenzaLaboratoryonreal-timeRT-PCRtestingforinuenza
viruses.Inaddition,themolecularlaboratorycompletedacquisitionofequipment,
reagents,andconsumablesforRT-PCRtesting.
RT-PCRtestingatNIPHforinuenzavirusesbeganApril2009withsamplesfrom
1nationalILIsurveillancesite.Sincethen,NIPHhasexpandedinuenzatesting
responsibilitiestoincludetestingofallsamplesfromSARIsurveillanceandoutbreak
investigationsofrespiratorydisease.
NIPHacquiredtestingcapabilityforH1N1virusinJune2009andhasconrmed
H1N1infectionincasesdetectedthroughILIsurveillance,SARIsurveillance,and
contactinvestigationsofconrmedcases.
NIPHpurchaseda2ndreal-timeRT-PCRmachine(BioRadPCRIQ5Detection
System).
210
Preparedness
A17-monthprovincialmultisectorpandemicplanningpilotprojectinSiemReap
Provincewascompleted.Teaimofthepilotwastoinformnational-leveldecision
makersonpolicyrequirementstosupportimplementationoflocal-levelplansandto
provideamodelplanningprocessforuseinotherprovinces.
Afunctionalpandemicsimulationexercisewasconductedinvolvingapproximately60
players,30observers,6facilitators,andanexercisemanagementandlogisticssupport
teamof25.
TeNationalHealthSectorPandemicResponsePlaniscurrentlybeingrevisedand
adaptedtoaccommodatetheH1N1virologicandepidemiologiccharacteristics.
Training
FourrefresherMOH-WHOtrainingcoursesonILIsurveillancewereconductedfor
stafromparticipatingsentinelsitesinCambodia.Teobjectivesofthesecourseswere
togooversurveillanceprocedures,shareILIdata,anddiscussgeneralorsite-specic
problemsorconcerns.CourseswereheldinPreyVengProvince,November2008,and
inSihanoukville,March,June,andSeptember2009.Eachcourselasted2daysandwas
attendedby4050participants.
DuringOctober2008andJune2009,theMOHsDepartmentofHospitalServices,
withsupportfromWHO,conducteda2-daytrainingcourseaboutinfectioncontrolfor
AIinhumansat18referralhospitalsthroughoutCambodia.Courseparticipants
includedphysicians,medicalassistants,nurses,midwives,andotherhospitalpersonnel.
Eachcoursewasattendedbyapproximately3035hospitalstamembers.Te
objectivesofeachcourseweretoprovidebasicinformationoninfectioncontrolofAIin
hospitalsettingsandinformationaboutthediseaseandcasemanagement.WHOand
CalmetteHospital(adesignatedAIreferralhospitalinCambodia)staalsohelpedto
conductpartsofthetraining.
ANationalHospitalEmergencyPreparednessWorkshoporganizedbytheMOHs
DepartmentofHospitalServicesandsupportedbyWHOwasheldinKampongCham
Province,September78,2009.Atotalof78seniorhospitalandprovincialhealth
departmentmanagementstawhoareresponsibleforhospitalemergencyresponse
plansattended.NGOsinvolvedinhospitalsupportalsoattended.Teobjectivesof
theworkshopweretodeterminepriorityactivitiesforhospitalmanagementduring
epidemics,particularly
low-resourcesettings,and
identifygapsinhospital
preparednesstomanage
majorepidemicsand
makerecommendations
toaddressthesegaps.
Duringtheworkshop,
participantsreceived
trainingonH1N1
infectioncontrol,surge
capacityissues,and
clinicalmanagementof
severeH1N1cases.
211

RapidcontainmenttrainingandcommunityawarenessforH1N1wasconductedin10
provincesbyMOHsRapidResponseTeams.ParticipatingprovinceswereBathambang,
SiemReap,KampongChhnang,Pursat,Pailin,BanteayMeanChey,KampongTom,
PreahVihear,OudarMeanChey,andKampongSpeu.Trainingsessionswereconducted
MaySeptember2009.Atotalof1,240individualsparticipatedfromRapidResponse
Teammembersandphysiciansattheprovincial,operationaldistrict,andhealth
communitylevels.
SpecialProjects
TeCooperativeforAssistanceandReliefEverywhere,Inc.(CARE)completedits
pilotprojectonvillage-basedsurveillanceinKohKongProvince,alongwithexternal
evaluationsconductedbyhumanandanimalhealthpartners.Inaddition,CARE
completedfocusedgroupdiscussionswithVillageSurveillanceTeams,anendline
survey,andqualitativeandquantitativedataanalysesfortheproject.
AdraftoftheNationalGuidelinesonInfectionControlwascompletedbyaworking
groupledbytheDepartmentofHospitalServices,CambodianMOH.Teguidelines
wereinitiallywrittenintheKhmerlanguage,subsequentlytranslatedintoEnglish,and
forwardedtoexpertsininfectioncontrolforexternalreviewandcomments.Oncenal-
ized,theseguidelineswillbeusedtodeveloptrainingmaterialsforhospitalsnationwide.
Anationalinfectioncontrolpolicyandstrategicoperationalplanarecurrentlyunder
development.
WHOsupportedprintingofinformation,education,andcommunicationmaterialsfor
infectioncontrolamonghealthcareworkersandinthecommunityduringapandemic.
FieldStaff
PaulKitsutani,MD,MPH
Director
CDCInuenzaProgram,Cambodia
U.S.Embassy,Cambodia
Unit8166,BoxP
APAO,AP96546
E-mail:kitsutanip@kh.cdc.gov
BorannSar,MD,PhD
MolecularBiologyLabSpecialist
Unit8166,BoxP
APAO,AP96546
E-mail:SarB@kh.cdc.gov
KunthyChan
BudgetAnalyst
Unit8166,BoxP
APAO,AP96546
E-mail:KunthyC@kh.cdc.gov
212
TomWierzba,PhD,MPH
Director
Unit8166,BoxP
APAO,AP96546
E-mail:wierzba@namru2.org.kh
PrincipleInvestigator
UngSamAn,MD,MPH
Director
NationalInstituteofPublicHealth
#2,KimYiSungBlvd.,KhanTuolKork
P.O.Box1300,PhnomPenh
Cambodia
E-mail:usa@camnet.com.kh
AdditionalCollaborators
SokTouch,MD,MPH
Director
CommunicableDiseaseControlDepartment
MinistryofHealth,Cambodia
No.151-153KampucheaKromAve
PhnomPenh
Cambodia
E-mail:touch358@moh.gov.kh
SovannLy,MD,DTMH,MCTM
DeputyDirector
CommunicableDiseaseControlDepartment
MinistryofHealth
No.151-153KampucheaKromAve.
PhnomPenh
Cambodia
E-mail:sovann_ly@online.com.kh
ButhSokhal,Pharmacist
DeputyDirector
NationalInstituteofPublicHealth
#2,KimYiSungBlvd.,KhanTuolKork
Cambodia
E-mail:buthsokhal@yahoo.com
213
MichaelOLeary,MD,MPH
WHORepresentative
WorldHealthOrganization
WHORepresentativeOce
No.177-179cornerPasteur(51)and254
Cambodia
E-mail:olearym@wpro.who.int
NimaAsgari-Jirhandeh
PublicHealthSpecialist
Cambodia
E-mail:asgarin@wpro.who.int
MaggsMacGuinnes
TechnicalOcer,EmergencyPreparedness
Cambodia
E-mail:macguinnessm@wpro.who.int
214
WesternPacifcRegion
China
Capital:Beijing InfantMortalityRate:Total:21.16deaths/1,000
Area: 9,596,960sqkm
Population:
1,330,141,295(July2010est.)

LiteracyRate:
AgeStructure:
014years:20.1%(male
142,085,665/female125,300,391);1564years:
71.9%(male491,513,378/female465,020,030);
65yearsorolder:8%(male50,652,480/female GDPperCapita: $6,100(2008est.)
55,472,661)(2008est.)
DevelopingSustainableInuenzaSurveillanceNetworksandResponsetoAvianandPandemic
Inuenza
BeganAugust2009.
Previousagreement(DevelopingInuenzaSurveillanceNetworksCooperative
Agreement)beganSeptember2004andendedAugust2009.
InuenzaisacorecomponentofU.S.CDCsGDDprograminChina,whichisidentied
in-countryasanimportantemerginginfectiousdiseasefordecades.TeUnitedStateshasbeen
abletoprovidedataderivedfromanalysisofChineseinuenzavirusestoassisttheWHOwith
thetwiceannualinuenzavaccinestrainconsultations.
Formorethan20years,theU.S.CDChassupportedChineseinuenzaworkthrough
assistancetotheWHO.Inaddition,forapproximately20years,theU.S.CDCinuenza
grouphasprovidedsupporttothenational-levelChineseinuenzalaboratory.Mostrecently,
thissupporthasbeenprovidedthroughtheDevelopingInuenzaSurveillanceNetworks
CooperativeAgreement,(September2004August2009).Sincelate2007,theInuenza
Divisionhashad1medicalepidemiologistassignedinChina.
Tepandemic2009H1N1inuenzaviruschallengedallaspectsoftheclinicalandpublic
healthsystemsinChina.Toavertseriouscomplicationsandexcessdeathsfromthispandemic,
Chinaactivelyrespondedbyusingvigorouscommunitymitigationactivities,publiceducation,
215
improvedclinicalguidelines,vaccinedevelopmentanddeployment,andrapidexpansionof
laboratorycapabilities.TeexistingChineseinuenzasurveillancenetwork,whichconsistedof
awidespreadhospital-basedsentinelsurveillancesystemandlaboratorynetwork,hadtoprocess
asignicantinuxofcasesandsamplesmorequicklyandconductsophisticatedtestsofthe
virusesgeneticcharacteristics,includingdrugresistances.
Surveillance
AtthebeginningofFY2009,therewere197sentinelsurveillancehospitalslocatedthroughout
Chinathatfedinto63networklaboratories.Asthepandemicprogressed,thesurveillance
systemexpandedto556sentinelhospitalsand411networklaboratoriescapableofperforming
PCRtestsoninuenzaspecimens.OthersurveillanceactivitiesinFY2009were
AnimprovedinuenzasurveillanceWebsitethatincludesanonlineforumfornetwork
laboratoriestodiscussissuesofmutualinterest,includingsurveillancetechniques,
troubleshooting,andexchangingresults.Inaddition,otherfunctionswereaddedto
collect,manage,andanalyzeinuenzasurveillanceresults(http://www.cnic.org.cn).
ContinuingtodevelopanddistributeinuenzaweeklyreportsinChineseandEnglish
toshareinformationwithnationalandinternationalpartners.
Laboratory
Afterseveralyearsofpeerreview,assessments,andtraining,theChineseNICappliedtobecome
the5thWHOCollaboratingCenterforSurveillance,EpidemiologyandControlofInuenzain
2007.Muchprogresshasbeenmadetowardachievingthisgoal.TeWHOconductedan
on-sitereviewofprogressinNovember2009withfavorableresults.TispositionsChinaasan
evenstrongerglobalpartnerininuenzalaboratorysurveillanceandprovidesanothermajor
sourceoftechnicalassistanceforothercountries.OtherlaboratoryaccomplishmentsinFY2009
includethefollowing:
SelectedandsentrepresentativeinuenzavirusstrainscirculatinginmainlandChina
totheWHOCollaboratingCentersforSurveillance,EpidemiologyandControlof
InuenzaattheU.S.CDC(110strains)andtoJapansNationalInstituteofInfectious
Diseases(70strains)duringthe200809inuenzaseason.
216
Draftedpandemicpreparednessguidelinesthatincludedstorageandadministration
guidelinesforvaccinesandantiviraldrugsduringthedierentpandemicphases.
Inresponsetothespreadofthepandemic2009H1N1inuenzavirus,supportedthe
expansionfrom63to411networksurveillancelaboratories.
DevelopedM2andneuraminidase(NA)genotypingmethodsforantiviraldrug
susceptibilitysurveillance.Inaddition,conductedantiviralsusceptibilitytests,
establishingbiologicmethodsforNAinhibitors(NAIs)andadamantinedrugs.
Preparedness
PreparednessplanningwaswidelytestedduringtheH1N1pandemicinChina.Likeother
countries,Chinadiscoveredwhichpreparednessactivitieswereworthkeepingandwhich
neededtobechanged.Beforethepandemic,guidelinesweredraftedonthestorageanduseof
vaccinesandantiviraldrugsduringdierentpandemicphases.
Training
Chinacontinuedtoprovideup-to-datetrainingoninuenzatesting,infectioncontrol,and
epidemiologytomedicalpractitionersthroughrelevanton-siteandclassroomdiscussion.Key
featuresoftrainingsinFY2009were
Trained306peoplefromtheinitial63networklaboratoriesonseasonalinuenza
laboratorydetection:HA/HIassay,PCR,rapiddiagnostickitsdetection,chicken
embryopassagetechnique,andsingleradialhemolysistechnique.
Trained40provincialstaoninfectioncontrolforrespiratorydiseases.Inturn,these
participantswilltakethecurriculumtotheirprovincesandtrainothersinthese
techniques.
Trained130laboratorytechniciansandmanagersfromtheinitial63network
laboratoriesoninuenzasurveillancequalitycontrolandGoodLaboratoryPractices.
Trained12peoplefrom6provincialU.S.CDCsonavianinuenzanucleicacid
detectiontechnology.
Providedhands-ontrainingfor27peoplefrom10provincialU.S.CDCsonlaboratory
techniques.
DevelopednucleicaciddetectionkitforinuenzaAH1N1.
UrgentlyprovidedinuenzaAH1N1nucleicaciddetectionkitstothenational
surveillancenetworkandothercountries.
Conductedtrainingonpandemic2009H1N1inuenzalaboratorydetection
techniquesfor34U.S.CDCstafrom11importantportcitiesand30membersof
ChinaCDCrapidresponseteams.
ConvenedChinaASEANTrainingCourseonInuenzaA(H1N1)Laboratory
DetectionTechniquesfor16laboratorytechniciansfrom8ASEANcountries.
Developedsurveillanceguidelinesforpandemic2009H1N1inuenza.
217
ShuYuelong,PhD
Director
ChinaNationalInuenzaCenter
ChinaCentersforDiseaseControlandPrevention
InstituteforViralDiseaseControlandPrevention
YingxinStreet,#100,XuanwuDistrict
Beijing,PeoplesRepublicofChina10005
E-mail:yshu@vip.sina.com
XinLi
ProgramOcer
ChinaNationalInuenzaCenter
ChinaCentersforDiseaseControlandPrevention
InstituteforViralDiseaseControlandPrevention
YingxinStreet,#100,XuanwuDistrict
Beijing,PeoplesRepublicofChina10005
E-mail:xinli0003@hotmail.com
U.S.CDCStaffinChina
JereyMcFarland,MD
CentersforDiseaseControland
Prevention
U.S.EmbassyChina
PSC461,Box50
FPOAP96521
E-mail:jwm5@cdc.gov
SongYingMD,MS,MHS
ProgramOcer
U.S.-ChinaCooperationProgramonEmergingandReemergingInfectiousDiseases
U.S.EmbassyChina
PSC461,Box50
FPOAP96521
E-mail:songying@cn.cdc.gov
ZhouSuizan,MPH
InuenzaProgramOcer
U.S.-ChinaCooperationProgramonEmergingandReemergingInfectiousDiseases
U.S.EmbassyChina
E-mail:zhousz@cn.cdc.gov
218
WesternPacifcRegion(WPRO)
GDD-China
EID
Establishedin2006,theChina-U.S.CollaborativeProgramonEIDintegratesessentialpublic
heathfunctionstorapidlydetectandrespondtoChinasinfectiousdiseaseandhealththreats.
Formorethan20years,U.S.CDChassupportedandcollaboratedwiththeChinesenational
inuenzalaboratory.In2001,theChinaFETPbeganits1stcohortandtodayhasgraduated
morethan100publichealthocerswhoworkinleadershippositionsthroughoutChinas
publichealthcommunity.TeEIDprogramintegratestheseestablishedactivitieswithnew
abilitiesinemerginginfectionsandhealthcommunicationforgreaterhealtheect.
ActivitiesinChinaaredirectedathelpingthecountryreachitspopulationof1.5billionpeople.
Teprogramstrengthensinfectiousdiseaseoutbreakinvestigationsandresponseatthenational
andprovinciallevels,enhancingavianinuenzaandpandemicpreparedness,andimproving
thestrategicdevelopmentofinfectiousdiseasesurveillancesystems.Responseshaveincluded
pandemic2009H1N1inuenza,multidrug-resistanttuberculosis,humanenterovirus71(i.e.,
adangerousformofhand,foot,andmouthdisease),Streptococcus suis,plague,andfoodborne
risks,suchassalmonella,brucellosis,cholera,andbotulism.
Activities
Outbreakresponse.
Pathogendiscovery.
Training.
Surveillance.
Networking.
In2009,EIDrespondedto13outbreaks,73%ofwhichachievedameasurablepublichealth
eect,andcommunicationsupportwasprovided.Teytrained13FETPgraduatesandmore
than1,000participantsinshort-termregionalandnationaltrainings.
Staff
JeMcFarland,MD,MPH
EIDCoordinatorandInuenzaLead
PrincipalCDCProgramCollaborationsIn-Country
IEIP.
FETP.
HealthCommunication.
219
220

WesternPacifcRegion
LaoPeoplesDemocraticRepublic(LaoPDR)
Capital:Vientiane(Viangchan) InfantMortalityRate:Total:79.61deaths/1,000
Area: 236,800sqkm
Population:
6,993,767(July2010est.)

LiteracyRate:
AgeStructure:
014years:41%(male1,374,966/
LaosreceivessupportthroughtheWHOWPROcooperativeagreementandCARE
International.
BeganFebruary2006.
FY2009wasthe4thyearofsupporttoLaos.
U.S.CDCoperationsinLaoPDRwererecognizedandlegitimizedthroughbilateralarrangements
betweenthegovernmentsofLaoPDRandtheUnitedStates(representedbytheU.S.Embassy)
inMay2006withbothMinistriesofHealthandAgriculture.Tisagreementhasopenedthedoor
forU.S.CDCassistanceinaddressingemergingdiseaseconcernsprincipallythroughcapacity-
buildingmeasuresincounteringtheAIthreatthroughpandemicpreparedness.
Surveillance
TeU.S.CDC-WHOcollaborationorganizedaNationalWorkshoponSurveillance
andResponseofNotiableSelectedDiseases,July810,2009.Atotalof95
participantsfrom17provincesandvariousconcernedsectorsfromtheMOH(e.g.,
secretariatsoce,6centralhospitals,DeptartmentofHygieneandPrevention,Curative
Dept.)attended.Tepurposeworkshopwastoreviewthesituationofthesurveillance
systemandmakerecommendationsforfurtherprogressandimprovement.
AU.S.CDC-CAREhotlinewasusedtoidentifythePhongsalyHPAIoutbreakofJanuary
2009andthefowlcholeraoutbreakofMarch2009.Tehotlinefunctionedduringthe
221

pandemic2009H1N1inuenzaoutbreakandaveraged1,200callsdailysinceJune2009.
HotlineoperationsweresuccessfullytransitionedtotheNationalEmergingInfectious
DiseaseCoordinatingOce(NEIDCO)withsupportfromtheWorldBank.
WithsupportfromtheU.S.CDC-WHOLaoCollaboration,NCLEisnowregularly
contributingtotheWHOGlobalInuenzaSurveillanceNetwork.
TeU.S.CDC-WHOLaoCollaborationsupportedtransformationofroutinenational
surveillanceintotheLaoEWARNcontributingtosignicantlyimprovedaccuracyand
completenessofreporting.
ExpansionoftheInuenza-LikeIllness(ILI)VirologicSurveillanceNetworktothe
northandsouthofthecountry,providedrsttimevirologicevidenceofseasonal(H1,
H3,andFLUB)inuenzainLaos,aswellascapturingA/H1N1clustersthroughout
thecountry.
CompletionofauniformCEBSevaluationbyusingCARE-supportedactivities
targetingremoteethnicminorities.LessonslearnedarebeingusedtodeveloptheLao
NationalCEBSStrategy.
TeNationalCenterforLaboratoryandEpidemiologyisnowproducingthe1stdaily
andweeklyinuenzareportthattakesadvantageofthevarioussurveillancesystemsand
laboratoryndings.
Laboratory
Completionofbiosafetyenhancementsandequipmentprocurementandinstallation
forthenewlaboratoryextensionattheNCLEinDecember2008wasaccomplished
throughtheU.S.CDC-WHOcollaborationinpartnershipwithPasteurLaos.
U.S.CDCexpertsprovidedtrainingtoNCLEstainestablishingcellcultureand
improvedtestingreliabilityofreal-timePCR,enablingNCLEtosubmitits1stviral
inuenzaisolatestotheWHOGlobalInuenzaSurveillanceNetworkinthenear
future.
NCLEsincreasedlaboratorycapabilitiesallowedfordetectionof2009H1N1inuenza
byusingU.S.CDCprovidedprimersandreagentthatledtotheearlydetectionofthe
pandemicvirusinJune2009withmorethan270casessubsequentlyidentied.
NCLEreceivedits1stshipmentofessential
materialsandreagentstosupportlabora-
torydiagnosticfunctionsthrougha2-year
arrangementwithU.S.CDCIEIPTailand,
April2009.
Training
Te1stFieldEpidemiologytrainingclass
startedinFebruary2009throughtheU.S.
CDC-WHOLaoCollaboration.Eight
studentsfrom5provinces(andrepresentation
fromtheanimalhealthsector)beganayear-
longtrainingactivityconsistingofthree
4-monthmodules:eachconsistingof1month
classroomtrainingand3monthsofsupervised
Participantsaretrainedinestablishing
frst-timecellcultureandHIT
capabilitiesforinfuenzaviralisolationat
NationalLaboratory,February2009.
222

eldactivity.Tepurposeofthistrainingactivitywastodevelopand
decentralizeepidemiologycapabilitiesinsupportofprovincialanddistrictsurveillance
andoutbreakresponseactivities.
InfectionControl
U.S.CDC-WHOsupportedthetrainingoncasemanagementandinfectioncontrol
of2009H1N1inuenzafor6centralhospitals(63people),May2829,2009.Te
purposeofthistrainingworkshopwastoinformcentralhospitalstaaboutthe2009
H1N1pandemic,clinicalmanagementofpandemicH1N1cases,andappropriate
infectioncontrolmeasures.
Atrain-the-trainercourseonclinicalmanagementandinfectioncontrolof2009H1N1
inuenzain3regionsofLaoPDR(i.e.,LuangPrabang,Savannakhet,Champasakprov-
inces)washeldJune2330,2009.Tetrainingcoursewasattendedby256participants.
FieldStaff
AndrewLeeCorwin(CaptainRet.),PhD,MPH
InuenzaCoordinator
AmericanEmbassy
RueBartholonie,TatDam
P.O.Box114
Vientiane,LaoPDR
ViengphoneKhanthamaly,MD
U.S.CDCAssistant
AmericanEmbassy
P.O.Box114
VientianeCapital
LaoPDR
USDA/APHIS
BounheuangKounnavong,DVM
AgriculturalScientist
AmericanEmbassy
P.O.Box114
VientianeCapital
LaoPDR
U.S.CDC-WHOCollaboration
ReikoTsuyuoka,PhD
125SaphanthongRoad,Unit5,BanSaphanthongtai,SisattanakDistrict
P.O.Box343
VientianeCapital
LaoPDR
223
JustinDenny,MD
P.O.Box343
VientianeCapital
LaoPDR
IrwinLaw,MD
P.O.Box343
VientianeCapital
LaoPDR
HannahLewis,MPH
P.O.Box343
VientianeCapital
LaoPDR
U.S.CDCandCareInternationalLaosCollaboration
MelanieKempster
CareInternationalinLaoPDR
129LuangPrabangRoad
P.O.Box4328
VientianeCapital
LaoPDR
NationalEmergingInfectiousDiseasesCoordinationOffce
BounlayPhommasack,MD,PhD
Director
Simoung,SisatanakDistrict
VientianeCapital
LaoPDR
SomphanhChanphengsay,DVM,MSc
DeputyDirector
Simoung,SisatanakDistrict
VientianeCapital
LaoPDR
NationalAnimalHealthCenter
BounlomDouangNgeun,DVM
Director
SouphanouvongRoad
SithanNeua,Sikhottabong
Vientiane
LaoPDR
224
WesternPacifcRegion
Mongolia
Capital: Ulaanbaatar
Area: 1,564,116sqkm
Population: 3,086,918(July2010est.)
AgeStructure: 014years:28.4%(male433,835/
3.9%(male51,093/female66,168)(2008est.)
LifeExpectancyatBirth: Totalpopulation:67.32
InfantMortalityRate: Total:41.24deaths/1,000
LiteracyRate: Totalpopulation:97.8%;male:98%;
female:97.5%(2000census)
GDPperCapita: $3,300(2008est.)
Inuenza
BeganAugust2009.
LandlockedbetweenRussiaandChina,Mongoliaisanexpansivecountryofsparsepopulation
andharshgeographicandclimateextremes.Teinuenzasurveillancecooperativeagreement
betweenMongoliaandU.S.CDCstartedin2004andhasenabledadvancesinthedevelopment
andenhancementoflaboratorycapacityduringthepast5years.Withthesupportofthe
cooperativeagreement,sentinelsurveillancesitesforoutpatientandhospital-basedsurveillance
havebeenestablishedinthecapitalcityofUlaanbaatar(UB)andseveralprovinces(i.e.,
Darkhan-uul,Dornod,Dornogobi,Khovd,Orkhon,Uvurkhangai)inthedierentgeographic
regionsofthecountry.Nationalinuenzaworkshopshavebeenheldeachyearsince2005to
educateandupdaterepresentativesofallstakeholdersoftheinuenzapandemicpreparedness
plan.
Surveillance
Duringthe2009inuenzaseason,activitywaslow,andtherewasonlyasmallincreaseofILI
cases.Sentinelsitespecimencollectionremainedvigilantthroughouttheyear,subsequently
detectingthe1stcaseofH1N1inMongoliainfall2009.
225
Mongoliahas2tiersofinuenzasurveillance,epidemiologicandvirologic:
EpidemiologicsurveillanceisbasedonclinicaldiagnosisofILIoutpatientandinpatient
visits.
RoutineweeklyinformationaboutILIandalloutpatientvisitsfromall21provinces
and9citydistrictsofUBcity.
DailyactivereportingbyphoneaboutILIforalloutpatientvisitsat64sentinelsitesin
UBand7provinces.
Weeklyactivereportingbyphoneforpneumoniahospitalizationsandallpatientsfrom
15hospital-basedsentinelsurveillancesites.
Virologicsurveillanceisbasedondailycollectionsofsamplesinsentinelsitesfollowing
inuenzavirusdetectionbyreal-timeRT-PCRandvirusisolationsbyusingMDCKcell
cultureandembryonatedheneggs.
Laboratory
RoutineinuenzavirusdetectionandisolationisperformedattheVirology
Department,NIC,NationalCenterforCommunicableDiseaseinUB.Laboratorysta
isskilledinreal-timePCRandothercriticaltechniquesforthedetectionofinuenza
virusesandantiviralresistance.
MongoliajoinedtheWHOEQAPin2007,andthelast5panelssentweredeciphered
100%bytheNICMongolialaboratory.
Duringthe200809inuenzaseason,6,100samplesweretestedwith309(5.1%)
positiveresults,mostlyseasonalinuenzaA(H1N1)viruses.
TirteenrepresentativeinuenzavirusesweresenttoWHOcollaboratingcentersin
TokyoandtheUnitedStatesforfurthercharacterization.
DuringFY2009,522nasopharyngealsampleswerecollectedfromSARIsurveillance
sites(i.e.,SelengheprovinceandBaganuurdistrict,UB).Ofthese,522specimenswere
testedbyreal-timeRT-PCR,and132(25.2%)testedpositive.
226
Preparedness
TeFourthNationalInuenzaWorkshop(NIW4)wasorganizedOctober910,2008inUB.
Tismeetingwaswellattendedby220participantsfrommanyagenciesacrosstheMongolian
government:theMOH;theNationalEmergencyManagementCenter;theMinistryofFood
andAgriculture;theStateProfessionalInspectionAgency;WHOcountryoces;UNICEF;the
U.S.EmbassyinMongolia;theUBcityProfessionalInspectionAgency,VI;HealthSciencesof
UniversityofMongolia;NCHD;directorsofhealthdepartmentsfrom21provincesandUB
districts;headsofselectedfamilygeneralpractitioners;epidemiologists;ocersofemergency
departmentsfromallprovincesandUBdistricts;theNationalCenterforCommunicable
Disease(NCCD);andtheCenterforInfectiousDiseaseswithNaturalFocci.Inaddition,
representativesfromU.S.CDC,Japan,WPRO,andWHOattended.
AtNIW4,apandemicinuenzainventoryassessmenttookplacebyusingamodiedU.S.
CDCtooltoaddressMongoliasneeds.Preparednessplansbegantodevelopattheaimak
(county)districtlevels.PreparednessmaterialscanbeviewedattheNIC,MongoliaWebsite:
http://www.u.mn/eng/index.php?option=com.content&task=view&id=110&Itemid=52.
Otherpreparednessactivitiesinclude
A1-dayretrospectiveassessmentofnationwidepandemicpreparednessforthe200304
inuenzaseasons.
AnevaluationoftheInuenzaPandemicPreparednessPlan(IPPP)inKhan-Uuland
BayanzurkhdistrictsofUBtookplaceDecember2008attheNCCDwith30
participants,including2districtchancelleriesofgovernorsandtheheadsofthedistrict
healthdepartment,DistrictEmergencyManagementAgency,districthospitals,
epidemiologists,andphysicians.
AnewversionoftheIPPPassessmenttoolforprovincesandUBdistrictsisbasedon
theU.S.CDCassessmenttool.P.Nymadawawasappointedbytheprojectteamasa
consultantfordraftingthenewtoolandfororganizingtheentireexercise.
Fiveteams(25participants)fromtheMongoliangovernmentweretrainedand
conductedtheassessmentin21provincesand9districtsofUBcityMarch2009.
Ineachprovinceorcitydistricts,1525ocersfromallrelevantbranches
(approximately600ocers)participatedintheIPPPassessmentworkshops.Tenal
reporthasbeenproducedinEnglishandMongolian.PleaseseethereportattheNIC,
MongoliaWebsite:http://www.u.mn/eng/index.php?option=com.content&task=view
&id=110&Itemid=53.
Training
Troughout2009,stadevelopmentandtrainingcontinuedtobeapriorityforMongoliaas
severalscientistsattendedtraininginAsia,Europe,andtheUnitedStatesaboutmonitoringand
evaluation,emerginginfectiousdiseases,SARIsurveillance,andinuenzaburdenofdiseaseissues.
OnApril27,2009,whenWHOannouncedthatpandemicphasealertwouldberaisedfrom
3rdto4thbecauseoftheincreasingnumberof2009H1N1inuenzavirusinfectionsinUnited
StatesandMexico,theMongolianStateEmergencyCommitteeheldameetingandrequested
therelatedministriesandagenciestakeurgentactions.InMongolia,the1stsuspectedcase
227
of2009H1N1inuenzawasregisteredonMay6,2009,when7artistsfromMongolia,who
weretravellinginMexico,returnedhome.Teyweremonitoredbycameraattheairportin
Moscow,and2ofthemwereisolatedbecausetheywerefeverish.Whentheother5returnedto
Mongolia,theMOHtookrapidresponsemeasuresandisolatedall103passengersand7aircraft
staattheNCCD.TeyweregivenprophylacticdosesofTamiuandsamplesweretakenfrom
5suspectedcases.Noinuenzavirusesweredetected.SinceMay2009,theNICinMongolia
hasbeenaskedtoinvestigatemorethan50suspectedcasesandmorethan700contactcasesof
2009H1N1inuenzavirus.
GradualshifttotestallsamplescollectedbyrealtimeRT-PCR.
MongoliahasdevelopedaWebsiteinEnglishandMongolian(http://www.u.mn)for
rapidsharingofinformation.TeWebsitehasbeenfunctionalsinceApril2009.
P.Nymadawa,MD,PhD,DSc(Med)
ScienticAdvisorandProjectDirector
NIC,NationalCenterofCommunicableDiseases
MinistryofHealth,Mongolia
NamYanJuStreet1
BayanzurkhDistrict
CentralPostOce:POBox13
UlaanbataarCity,Mongolia210-648
E-mail:nymadawa@gmail.com
B.Darmaa,MD,PhD
Director,DepartmentofVirology
NIC,NationalCenterofCommunicableDiseases
MinistryofHealth,Mongolia
NamYanJuStreet1
BayanzurkhDistrict
CentralPostOce:POBox13
UlaanbataarCity,Mongolia210-648
E-mail:darmaa2001@yahoo.com
OtherPartners
WorldBank,especiallyonIPPPactivities.
NationalEmergencyManagementAgency(NEMA),especiallyonIPPPactivities.
USAID,especiallyonIPPPactivities.
WHO,technicalconsultation.
MinistryofFoodandAgricultureandIndustry(MOFALI),surveillanceofinuenza
virusesinwildanddomesticatedanimalsandsharingofBSL-3facilityincaseofneed.
228

WesternPacifcRegion
ThePhilippines
Capital:Manila InfantMortalityRate:Total:21.2deaths/1,000live
Area: 300,000sqkm
Population:
99,900,177(July2010est.)

LiteracyRate:
AgeStructure:

014years:35.5%(male
17,392,780/female16,708,255);1564years:
60.4%(male28,986,232/female29,076,329);
2,215,602)(2008est.)
Inuenza
BeganAugust2009.
TeResearchInstituteforTropicalMedicine(RITM)istheNICofthePhilippinesandcontinues
toreceivetheU.S.CDCgrantforits5thyearofoperationstocompletetheDISN.Inaddition
tocontinuingitssurveillanceactivitiesatestablishedsentinelsites,theNICinitiatedtheinuenza
burdenofdisease(BOD)activityin1oftheregionsofthecountry,increasingitspartnersand
stakeholders.Tefthyearalsomarkedtheoccurrenceofthe2009H1N1inuenzapandemic
internationallyandlocally,andhighlightedthesignicanceoftheroleoftheNIC.
Surveillance
ForFY2009,thenetworkmaintainedthenumberofsentinelsitesithadestablishedintherst
4yearsofthegrant.
Teinuenzasentinelsurveillancenetworkissetupin11ofthe17regionsofthe
Philippines.Tereare17InuenzaSurveillanceOcersworkingoninuenza
throughoutthecountry.
Atotalof23sentinelsiteswereaddedtotheexistingsystem,increasingthenumberof
sentinelsitesfrom35to54(33healthcenters,20hospitals,and1processingzone).
229
Atotalof16healthcentersand6hospitalswereaddedintheCordilleraAutonomous
Region,whereBODactivityisconductedforthePhilippines.
AninuenzasentinelsitewasopenedattheOneStopProcessingZone,animmigration
sitewheretestingwasconductedonFilipinodeporteesarrivinginboatsfromMalaysia
andIndonesia.TissitewasoperatedincollaborationwiththeDepartmentofSocial
WelfareandDevelopmentandtheRegionIXBureauofQuarantine.
Appropriatequalitycontrolandassuranceactivitieswereimplementedoninuenza
laboratoryanddatamanagementactivitiesthroughoutthecountry.
Monitoringofsentinelsiteswasconductedtoensureadherencetostandardoperating
proceduresandvalidatesomeinformationcollected.
TeprimaryactivityoftheNICinvolvesinitialidenticationofinuenzavirustypeand
subtype,aswellasisolationofotherviruses,suchasadenovirus,enterovirus,HSV-1,andRSV
throughviralculture.Inaddition,theNICperformsrapidviralidenticationforspecimens
fromsuspectedrespiratoryinfectionoutbreaksbyusingreal-timePCR.
TeNICcontinuedtoproviderepresentativeisolatesonaregularbasistotheWHO
CollaboratingCenterforInuenzaReferenceandResearch,Melbourne,Australia,for
conrmationandhigherantigeniccharacterization.
PerformanceintheWHOExternalQualityAssessmentProgram(EQAP)demonstrated
thecompetenceoftheNICtoidentifyseasonalinuenza,andsatisedtheWHOglobal
standards.
TeEQAPshoweditsprociencyinidentifyingavianinuenzavirusesbyusingPCR.
TeNICprovidedweeklyupdatesoninuenzaactivityinthecountrytotheWHO
FLUNET.
Preparedness
TeNICwasactivelyinvolvedinpandemicpreparednessplanningwiththeDepartment
ofHealth.DiscussiontopicsrelevanttotheNICincludedalgorithmsusedinspecimen
receipt,processing,testing,andcommunicationowofresultsanddata.Teeciencyofthe
algorithmswasputtothetestoncepandemic2009H1N1inuenzastartedinthePhilippines.
TesurveillancenetworkestablishedundertheU.S.CDCgrantwaspivotalinalertinghealth
ocialsoftheoutbreakofH1N1inthecountry.
Inuenzasurveillanceocers(ISOs)werecrucialinextendingassistancetohealthworkersin
thenonsentinelsitesonthebasisofcorrectspecimencollection,storage,andshipment.Te
NICwascommendedbytheWHO-WPROforitspromptandecientresponseduringthe
pandemic.AsaresultofworkingthroughtheH1N1pandemic,theNICcanbecanbefurther
strengthenedthroughthefollowinglessonslearned:
TeNICssurgecapacityplanshouldberevisedandupgradedonaregularbasis.
CommunicationowbetweentheNICandNationalEpidemiologyCenter(NEC)
shouldbeupgradedandstrengthenedtoencourageoptimalresponsetopandemicsand
otherpublichealthemergencies.
Datacommunicationsystemscurrentlyinplaceamongdierentdepartmentswithinthe
NICshouldbereviewedandstrengthenedtoenhanceawarenessandshareinformation.
FutureplansshouldincludeadoptingabarcodingsystembytheNICforspecimen
receipt,processing,andreportingofresults.
230

Training
TeNICandNECcollaboratedtoprovideallISOsinthesentinelsiteswithrefreshertrainingon
thecollectionofepidemiologic,clinical,andspecimencollection.Tistrainingwasconductedfor
boththeoldandnewISOstoensureoperationsacrossallthesiteswerestandardized.
Intensivetrainingwasconductedinthedataentryprocessing,cleaning,validation,and
reportingprocedurestotheregionaloces.
SimilartrainingwasperformedamongtheISOs
assignedintheBODsitesintheCordillera
AutonomousRegion.
Nursesandmedicaltechnologistsfromnonsentinel
sitesandothergovernmentandprivatehospitalswere
trainedondataandspecimencollection,storage,
andshipmentimmediatelyaftertheonsetofthe
pandemic2009H1N1inuenzaoutbreak.
Atleast10ofthesetrainingsessionswereconducted
duringMayJune2009,resultinginnoticeable
improvementinthereceiptofspecimensfor
pandemicH1N1processingatRITM.
TeNICsepidemiologistandbiostatisticianattendedthePracticalAspectsof
ConductingBurdenofDiseaseStudiesattheUniversityofQueenslandinBrisbane,
Australia,throughafellowshipprograminNovemberandDecember2008.Teir
exposuretothistrainingwillassistwithconductingtheBODstudy.
TeNICparticipatedintheChina-ASEANTrainingCourseonInuenzaA(H1N1)
LaboratoryDetectionTechniquesinBeijing,June2009.
Toincreaselaboratorycapacityinresponse,theDepartmentofHealth(DOH)upgradedand
procuredacompletelineofreal-timePCRequipmentfor5governmenthospitals,September
2009.TesehospitalsincludedtheBaguioGeneralHospitalandMedicalCenterinnorthern
Philippines;theSanLazaroHospital,LungCenterofthePhilippinesinMetroManila;the
VicenteSottoGeneralHospitalinCentralVisayas,andtheDavaoMedicalCenterinsouthern
Philippines.Laboratorystaweretrainedinthesenewtechniquesandgivenacerticateof
prociencyafterbeingtestedonthesetechniquesbytheNIC.
TeNICassumedtheleadroleindetectingcasesofthepandemic2009H1N1inuenzaoutbreak
inthePhilippines.TroughtheInuenzaSurveillanceProject,real-timePCRdetectionof
circulatinghumanandavianinuenzasubtypeswasestablishedatRITM.Tissametechnology
wasadoptedfordetectingthepandemic2009H1N1inuenzavirusbyusingprimersandprobes
developedbyCDCandmadeavailablethroughtheWHO.Todate,morethan11,500samples
weretestedbytheNICforthepandemicsubtype.TeNICalsoestablishedcloselinkswiththe
DOHandtheNECforrapidreportingofcasesdetectedinthecountry.
Tenetworkhasattainedbroadersurveillancecoverageinits5thyear,thus,iscondentinthe
representationofitsresults.TeinitiationoftheBODstudywillprovidetheDOHwithinforma-
tioncriticaltothedevelopmentofpoliciesrelativetoinuenzacontrol.Itsresponsetothepan-
demic2009H1N1inuenzaoutbreakwasappropriate,timely,andgainedrecognitionfromthe
dierentpartsofthecountryandfromWHO-WPRO.
231
RemigioOlveda,MD,CESOIII
DirectorIV,ResearchInstituteforTropicalMedicine
9002ResearchDrive,FilinvestCorporateCity
Alabang,MuntinlupaCity1781,
Philippines
E-mail:rolvedamd_ritm_doh@yahoo.com
MembersoftheProjectManagementTeam(PMT)
AgnesV.Barrientos,MD.
MarillaG.Lucero,MD,PhD.
VeronicaL.Tallo,PhD.
MariluO.Venturina,CPA.
RodolfoB.Villarico,CPA.
NormaDabu,CPA.
NICStaff
EdelwisaMercado-Segubre.
AnalisaBautista,RMT.
VinaLeaArguelles,RMT.
MarianetteInobaya,MSc.
AlvinTan,MSc.
NationalEpidemiologyCenter
EricTayag,MD,FETP,FPSMAD
DirectorIV,NationalEpidemiologyCenter
PhilippinesDepartmentofHealth
SanLazaroCompound,SantaCruz
Manila,Philippines1003
E-mail:eriqtayag4health@yahoo.com
OtherPartners
Regionalcentersforhealthdevelopment.
RegionalEpidemiologyandSurveillanceUnit.
Localgovernmentunits.
BureauofQuarantine,RegionIX.
DepartmentofSocialWelfareandDevelopment,RegionIX.
NationalChildrensHospital,Manila.
St.LouisUniversityHospital,BaguioCity.
NotreDameHospital,BaguioCity.
BaguioMedicalCenter,BaguioCity.
PinesCityHospital,BaguioCity.
232
WesternPacifcRegion
SecretariatofthePacifc
Community,PacifcPublicHealth
SurveillanceNetwork
DevelopingInuenzaSurveillanceNetworksCooperative
Agreement
Beganin2005.
FY2008wasthe4thyearoftheagreement.
TeSecretariatofthePacicCommunity(SPC)isaninternationalorganizationwitha
membershipof22PacicIslandCountriesandTerritories(PICTs).Establishedin1947,SPC
wascreatedtocarryoutactivitiesonsocial,economic,andhealthissuestodeveloptheregions
land,marine,andhumanresources.WithintheframeworkofSPCisthePacicPublicHealth
SurveillanceNetwork(PPHSN),whichisdedicatedtocommunicablecontrolandsurveillance
withaspecicfocusonoutbreak-pronediseases.
TecurrentInuenzaSurveillanceNetworksCooperativeAgreementbetweenSPCPPHSN
andtheU.S.CDCsupportsthedevelopmentofinuenzasurveillancenetworksacrossavast
geographicarea,includingboththenorthandsouthPacic,covering10timezonesandwide
geographic,sociopolitical,andculturaldiversity.InadditiontoH1N1inuenza,abroad
spectrumofoutbreak-pronediseasesinPICTssuchasdengue,cholera,anddysentery,and
naturaldisasters,includingoodsandtsunamisstretchedtheresourcesofSPCandPPHSNin
FY2009.
Surveillance
Terewasincreasedfocusduringimplementationandfollow-upvisitsontheintegrationof
laboratoryandILIsurveillanceduringFY2009.Limitedsurveillanceinfrastructureandhuman
resourcesinmanyPICTscontinuedtobeaconstrainttostrengtheninginuenzasurveillance,
yetSPCPPHSNwasabletoaccomplishseveralsurveillanceactivitiesinFY2009thatincluded
Increasingthenumberofsentinelsitesto45locatedin13PICTsfollowingnew
implementationsandfollow-upvisits.
Strengtheninglaboratory-basedandsyndromicsurveillanceforinuenzathrough
frequentfollow-upvisitstoPICTsbyprojectsta.
DevelopingastandardoperatingprocedureforILIsurveillanceandpromotingitsusein
PICTs.
ContinuingsupportforPICTsprovidedthroughscheduledfollow-upvisitsandregular
communication.
233
Trainingofsentinelsiteandlaboratorypersonnelonhowtocorrectlycollect
nasopharyngealsamplesoccurredduringallimplementationsandfollow-upvisits.
DevelopingajointSPC-WHOproposalforaregionalapproachtosyndromic
surveillance;thisincludesILIandSARIsyndromicsurveillance.TePPHSNmeetingin
MarchprovidesavenueforPICTstodiscussthisproposal.
Laboratory
FY2009sawthenumberoftestingsiteswithIFAmicroscopycapabilityincreasefrom10to
14in13PICTsas4newsiteswereestablishedin2009inthePacicRegion.Severalfollow-up
visitstoPICTlaboratoriesprovidedon-sitetrainingonIFAandinuenzasamplepackagingand
shipping.Testatusofinfrastructure,trainedsta,andresourcesinmanyPICTlaboratories
haschallengedtheimplementationandsustainabilityofalaboratory-basedsurveillanceproject.
TereisacompellingneedtoestablisharegionalreferencelaboratoryintheNorthPacicto
makesignicantenhancementswiththepublichealthlaboratoryservicesintheregion.With
thesechallengesinmind,activitiesleadingtowardstrongerinuenzalaboratorysurveillancein
thePacicincluded
Increasedthenumberofsamplessenttoreferencelaboratories;623of3,077samples
testedattheWHOinMelbournesinceJanuary1,2009,camefromPICTs.
Developedandimplementedstandardoperatingproceduresforlaboratoryinuenza
testingsites,revisingSOPsasneeded,duringallfollow-upvisits.
Establishedstreamlinedsampleshippingarrangementstoadditionalreference
laboratories(i.e.,InstituteofEnvironmentalSciencesandResearch,Wellington,NZ;
MataikaHouse,Suva,Fiji;andHawaiiStateLaboratory)thatallowedfasterandmore
reliablesampletransport.
WorkedcloselywiththePacic
IslandHealthOcersAssociation
(PIHOA)toshipinuenzasamples
forlaboratoriesintheU.S.-aliated
PacicIslands(USAPIs).PIHOA
alsoprovidessupportandtechnical
expertiseasakeypartnerinthe
projectinUSAPIs.
Supportedinuenzasampleshipping
arrangementsfromPICTstoreference
laboratoriesthroughfundingand
trainingworkshops.
Workedtowardsdevelopingastrategic
approachforfurtherenhancementof
testingcapabilitieswithstakeholders
withtheaimofimplementing
expandedPCRcapabilitiesand
strengtheninginuenzasample
shippingarrangementsinthePacic
Islandregion.
234
Preparedness
TePacicIslandsexperiencedseverediseaseoutbreaksandnaturaldisastersinFY2009,and
althoughtheeectsoftheseeventswereprofound,theregionrespondedtothesetrialsby
strengtheningitsnetworkofpreparednessactivities.TroughSPCsPublicHealthSurveillance
andCommunicableDiseaseControlSectionandthePacicRegionalInuenzaPandemic
PreparednessProject(PRIPPP)ofPPHSN,technicalassistanceandconsultationoninuenza
preparednesswasprovidedtoall22PICTS.Someofthepreparednessactivitiesfor2009
included
Implementedroutineinuenzasurveillancein4newsitesandsupportin10existing
sites.
Strengthenedsampleshippingarrangementstofacilitatethetransportationofsamples
foroutbreak-proneandemergingdiseases.
Providededucationalmaterialsonthepreventionoftransmissionofinuenza.
ProvidedtemplatesofeducationalmaterialstoPICTstoadaptforlocaluse,including
thetranslationintolocallanguagesofkeymessagesoncoughandsneezeetiquetteand
properuseofPPE.
AcloseworkingrelationshipwithPRIPPPcontinuedastheprogramhasbeeninvolvedin
developingprocurementandstockpilestrategies,pandemicplanning,andreviewingexisting
plans,emergencyexercises,andcommunicationplans.
Training
OneofthemajorchallengeswithinuenzasurveillanceinthePacicistheshippingofsamples.
ResolutionofthisissueisparamountaslaboratorystathroughoutthePICTsweretrained
topackageinuenzasamplesaccordingtoInternationalAirportTransportAssociation(IATA)
requirements.Eortscontinuetoaddresstechnicaltrainingtoincreaselaboratorycapability
throughoutthePacic.SomeofthesetrainingeortsinFY2009wereasfollows:
Clinicians,nurses,andlaboratorystaweretrainedonsamplecollection,storage,and
transportation.
Presentationsoninuenzasurveillancewereprovidedduringallimplementationand
follow-upvisits.
Atleast2laboratorytechnicianswerecertiedassampleshippersineachof10USAPI
laboratories;thePIHOARegionalLaboratoryCoordinatorprovidedtraining.
Overthecourseoftheproject,33laboratorytechniciansweretrainedinIFAmethods
atthe14sites,and10laboratorytechniciansweresentforfurthertrainingatWHO-
Melbourne.
235
TePacicIslandsfacedanenormous
challengepresentedbythepandemic
2009H1N1inuenzaduringspring
andsummer2009.Withenhanced
communicationthroughPacNet
andPacNetRestricted,thePPHSN
Website,andperson-to-person
communicationfromtechnical
expertsprovedtobetheprimary
communicationstoolsfortheregion.
Complicatedsolutionswereneededto
addressthevolumeofinformationandconictingdatafrommanyagencies.
TeSPCPPHSNandPICTsfacedchallengesinapplyingormodifyingrecommendationsto
suitthePacicIslandcontext.Limitedsurveillanceinfrastructureandhumanresourcesinsome
PICTsmeantthatfragilesurveillancesystemsforH1N1startedslowlyandweredicultto
sustain.TeSPCPPHSNusedavailableresourcestondsolutionsandmountawidespread
H1N1responsethatincludedthefollowing:
LeddiscussionswithWHOaboutoptionsavailabletoPICTsregardingborderclosure
andquarantine.TesediscussionsconsideredtheInternationalHealthRegulationsand
recognizedtheuniquesituationfacedbysmall,isolated,andvulnerablePacicIsland
communities.
Developedposters,advisories,andguidancepostersoncoughandsneezeetiquettethat
werewidelyusedthroughouttheregionandtranslatedintolocallanguages.
Providedantiviralmedication,PPE,andadditionalinuenzatestingreagentstoPICTs.
Providedongoingsupporttopandemictaskforcesandhealthpersonnel.Visitswere
madetoVanuatu,theSolomonIslands,theCookIslands,andKiribati.
EncouragedandsupportedPICTstodevelopsurveillancesystemsandshareinformation
collectedonPacNetduringtechnicaladvisoryvisits.
Evaluatedtheresponsetopandemic2009H1N1inuenzainthe22PICTs.
Improvedpandemicandriskcommunicationisunderwaythroughaanagency
collaborationapproachamongSPC,UNICEF,andWHOthatfocusedonproducing
educationalmaterials,mediatraining,anddevelopingnewcommunicationplansand
systems.
Duringthepandemic,samplesfromPICTsrepresentedthe2ndlargestgroupofsamplessentto
WHO-MelbourneafterAustralianspecimens.
SPCisworkingwithpartnerstofacilitatearegionalapproachtosurveillanceandlaboratory
testingofinuenzaandotherdiseases.SPCleddiscussionswithWHOaboutoptions
availabletoPICTsregardingborderclosureandquarantine.Tesediscussionsconsideredthe
InternationalHealthRegulationsandrecognizedtheuniquesituationfacedbysmall,isolated,
andvulnerablePacicIslandcommunities.
236
Atthe39thCommitteeofRepresentativesofGovernmentsandAdministrationsand
ConferenceofthePacicCommunity,ameetingheldinTonga,October2009,PICTs
acknowledgedtheworkoftheSPCPublicHealthDivisionduringaparticularlychallenging
period.
JustusBenzler,MD
CommunicableDiseaseSurveillanceSpecialist
PublicHealthSurveillanceandCommunicableDiseaseControlSection
SecretariatofthePacicCommunity
BPD5,98848NoumeaCedex,NewCaledonia
E-mail:justusb@spc.int
TomKiedrzynski,MD
Epidemiologist
E-mail:tomk@spc.int
SalaElbourne
LaboratorySpecialist
E-mail:salae@spc.int
AnthonyKolbe
InuenzaSurveillanceSpecialist
E-mail:anthonyk@spc.int
JennieFischer
ProjectCoordinator
PacicRegionalInuenzaPandemicPreparednessProject
E-mail:jennief@spc.int
237
Partners
U.S.CDC(fundingagencysince2005).
WHO.
PIHOA.
MinistriesofHealthinPacicIslandCountriesandTerritories.
AusAIDandNZAidthroughthePacicRegionalInuenzaPandemicPreparedness
ProjectimplementedbySPC.
ReferenceLaboratories
WHOCollaboratingCenter,Melbourne.
InstituteofEnvironmentalScienceandResearch(ESR)Wellington,NewZealand.
PasteurInstitute,Noumea,NewCaledonia.
MataikaHouse,Suva,Fiji.
HawaiiStateLaboratory,Honolulu,Hawaii.
238
WesternPacifcRegion
Vietnam
Capital:Hanoi InfantMortalityRate:Total:23.61deaths/1,000
Area: 329,560sqkm
livebirths;male:24.01deaths/1,000live;female:
Population:
89,571,130(July2010est.)

LiteracyRate:
AgeStructure:
014years:25.6%(male
93.9%;female:86.9%(2002est.)
11,418,642/female10,598,184);1564years:
68.6%(male29,341,216/female29,777,696);
3,055,212)(2008est.)
U.S.U.S.CDCDirectCountrySupport
DevelopmentofInuenzaSurveillanceNetworkinVietnam
BeganApril2005.
SurveillanceandResponsetoAvianandPandemicInuenzainVietnam,20062010
BeganSeptember2006.
CommunityMobilizationforEnhancedSurveillanceandPreventionofAvianInuenzain
Vietnam(DevelopmentofaModel)
BeganSeptember2006.
InuenzaandOtherEmergingInfectiousDiseasesinVietnam
BeganAugust2009.
FY2009isthe1styearofthecooperativeagreement.
239
Animal-HumanInterfaceStudies:PilotSurveillanceProjectforInuenzaVirusesInfecting
HumansandAnimalsinVietnam
BeganSeptember2009.
FY2009isthe1styearofthecooperativeagreementsupplement.
SinceJanuary2009,H5N1outbreakshave
resultedin4humancases,allofwhichwere
fatal.TelasthumancasewasreportedinApril
2009.Intotal(i.e.,January2003October
2009),therehavebeen111A(H5N1)human
casesand56deathsreportedfrom36provinces
andmunicipalitiesthroughoutVietnam,repre-
sentingthehighestratesperpopulationexperi-
encedbyanycountry.
InApril2009,NorthAmericaconrmedcasesofhumaninfectioncausedbyaquadruplereas-
sortmentvirusnotpreviouslydetectedinanimalsorhumans.Vietnamreportedits1stcaseof
pandemic2009H1N1inuenzaMay31,2009,andits1stdeathAugust3,2009.ByOctober
11,2009,morethan10,000caseshadbeenlaboratoryconrmed,andmorethan36deaths
werereported.
InAugust2009,theU.S.CDCInuenzaDivisionplacedaVeterinaryMedicalEpidemiologist
intheInuenzaProgramofCDC-Vietnam,attheU.S.EmbassyinHanoi.Alongwiththis
position,theInuenzaProgrambegantheAnimal-HumanInterface(AHI)initiativein
Vietnam.TeChiefoftheAHIinitiativeworksincollaborationwiththeChiefoftheInuenza
Program.
TeAHIinitiativeisacollaborativeeortbetweenCDC-VietnamandVietnamesecollabora-
torstoidentifyandstudygapsinknowledgerelatedtotheinuenzavirusandotherzoonotic
diseases,suchasanimal-to-humantransmissioncharacteristics,virusreassortment,geographic
cohabitation,riskoftransmission,andotherriskfactorsassociatedwithdiseasetransmission.
Surveillance
DatacollectedfromVietnams15sentinelsitessinceimplementationindicatethatmore
than2.4millionoutpatientswerescreened,ofwhom332,301(14%)mettheWHO
casedenitionforILI;ofthese,24,012patientsweretestedbyRT-PCR,and5,163
(22%)werefoundtobeinfectedwithinuenzaviruses.
Teoutpatientsentinelsurveillancewashelpfulindocumentingtheshiftininuenza
subtypesoverthe1stseveralmonthsofthepandemic.BySeptember2009,52%ofthe
inuenza-positivesampleswerepandemic2009H1N1inuenza,whereasbyOctober,
thatproportiondramaticallyincreasedto93%.In2009,50seasonalinuenzavirus
isolatesweresenttotheWHOCollaboratingCenter,Atlanta,forcharacterizationand
vaccinestrainselection,ofwhich2isolatescontainedthepandemic2009H1N1inu-
enzastrain.
TeSevereViralPneumonia(SVP)surveillancecomponentoftheNationalInuenza
SurveillanceSystemhasidentied719casesacrossthecountrytodate.Tenpercentof
thesewereconrmedtobecausedbyinuenza.Ofnote,seasonalinuenza(A/H1,
240
A/H3,andB)wasresponsibleformorethantwicethenumberthanthosecausedby
H5N1(40vs.17,respectively).Tiscomponenthasprovedtobesensitiveforhuman
H5N1infections,detecting17ofthe18infectionsreportedinVietnamsincethe
inceptionoftheSVPsurveillance.Intherst5monthsofthecurrentpandemic,this
systemcaptured7casesof2009H1N1,2ofwhichwerefatal.
Laboratory
TeNationalInstitutesofInfectiousandTropicalDiseases,Hanoi,andtheHospital
forTropicalDiseases,HoChiMinhCity,inpartnershipwithNationalInstituteof
Health(NIH)/HealthandHumanServices(HHS)andtheOxfordResearchGroup,
haveadvanceddiagnosticandresearchcapacitytostudyinuenzaviruses,including
pandemic2009H1N1inuenza.
Preparedness
SinceMarch2008,theU.S.CDCInuenzaDivisionhasassignedanepidemiologist
totheWHOcountryoceinVietnamtoprovidetechnicalsupporttotheMOH,
UnitedNations(UN)agencies,bilateraldevelopmentagencies,andnongovernmental
organizationsforcommunicablediseasesurveillanceandcontrolprograms,particularly
activitiesrelatedtoinuenzaA(H5N1)andpandemic2009H1N1inuenza.
Tetechnicalsupporthashelpedwithdeveloping,revising,andtestingofavian
inuenzaandpandemicinuenzapreparednessplansforthegovernmentagenciesand
organizations;coordinatingactivitiesandsharinginformationamongpartners;and
developinganddisseminatingcommunicationmessagesandmaterials.
Training
Aseriesof3trainingcourseswereheldfromMay120,2009,totrainpreventative
medicinestaonincreasingcapacityforavianinuenzasurveillanceandepidemiology.
Atotalof70participantsweretrainedfrom63provinces,4regionalinstitutes,andthe
GeneralDepartmentofPreventativeMedicineandEnvironmentalHealth.
TwotrainingcourseswereheldDecember2008forpreventativemedicinestaatstate
andprivatehealthunitsontheearlydetectionandreportingofA(H5N1)clustersand
methodsforepidemiccontrol.Tetrainingwasheldfor60preventativemedicinesta
traineesinNhaTrangandDakLakprovinces.
241
AnAHIpilotprojectwasinitiatedin2009aspartofasupplementtotheU.S.
CDCsurveillancecooperativeagreementwiththeNationalInstituteofHygieneand
Epidemiology(NIHE).TeAHIinitiative,whichispartoftheInuenzaProgram,
U.S.CDC-Vietnam,includingthein-countryplacementofaveterinarymedical
epidemiologistandamedicalepidemiologist,worksside-by-sidewithMOHand
MinistryofAgricultureandRuralDevelopmentprofessionalstondpeople,pigs,
andpoultrylivingincloseproximity,andseekstodeterminehowtheinuenzavirus
istransmittedfromanimalstohumansandviceversa.Duringthestudy,humanand
animalhealthworkersatthecommunelevelwillidentifypeopleconrmedtohavethe
current2009H1N1inuenzastrainofthepandemicinuenzavirusandwholivein
closeproximitytopigsandpoultry.Sampleswillbecollectedforlaboratoryanalysis,
whichwillallowNIHEandNationalCenterforVeterinaryDiagnosticsscientiststo
determinehumanandanimalpopulationspotentiallyatrisk.Withthisinformation,
scientistswillbeabletofollowexposedpopulationsofanimalsandstudywhichrisk
factorsleadtodangerousgeneticmutationoftheinuenzavirus.
AnewlydevelopedU.S.CDCcooperativeagreementforresearchoninuenzaand
otheremerginginfectionswasapproved2009.Tiscooperativeagreementwilladdress
molecularco-evolutionofhumanandavianinuenzavirusesinVietnam,burdenof
inuenzaillnessstudies,developmentofriskfactorstudies,andevaluationofnew
diagnosticmethodologies,aswellasothertopics.
242
U.S.CDCFieldStaff
DavidT.Dennis,MD,MPH
FormerU.S.CDCFieldSta,active20082009
InuenzaCoordinator
U.S.EmbassyAnnex
RoseGardenBldg.,170NgocKhanh
Hanoi,Vietnam
E-mail:dtd1@cdc.gov
B.K.Kapella,MD,MS
Chief,InuenzaProgram
U.S.EmbassyAnnex
Hanoi,Vietnam
E-mail:KapellaBK@vn.cdc.gov
JamesC.Kile,DVM,MPH
Chief,Animal-HumanInterfaceInitiative
U.S.EmbassyAnnex
Hanoi,Vietnam
E-mail:KileJC@vn.cdc.gov
NguyenPhuCuong,MD,MPH
FormerU.S.CDCFieldSta,active20082009
AvianInuenzaProgramOcer
U.S.EmbassyAnnex
Hanoi,Vietnam
E-mail:NguyenCP@vn.cdc.gov
NicoleM.Smith,PhD,MPH,MPP
Epidemiologist,CommunicableDiseaseSurveillanceandResponse
63TranHungDao
Hanoi,Vietnam
E-mail:smithn@wpro.who.int
NguyenTranHien,AssociateProfessor,MD,PhD
Director
NationalInstituteofHygieneandEpidemiology
1Yersin
Hanoi,Vietnam
E-mail:nthiennihe@vnn.vn
243
NguyenTiTuYen,PhD,MD
ProjectDirector
HeadofEpidemiologyDepartment
NationalInstituteofHygieneandEpidemiology
1Yersin
Hanoi,Vietnam
E-mail:yentc2004@gmail.com
NguyenHuyNga,AssociateProfessor,MD,PhD
PrincipalInvestigator,Director
GeneralDepartmentofPreventiveMedicineandEnvironmentalHealth
MinistryofHealth
135NuiTruc
Hanoi,Vietnam
E-mail:huynga@vaac.gov.vnorhuynga2000@yahoo.com
TranTanhDuong,MD,PhD
ProjectDirector
ViceDirector
GeneralDepartmentofPreventiveMedicineandEnvironmentalHealth
MinistryofHealth
135NuiTruc
Hanoi,Vietnam
E-mail:tranthanhduong@hotmail.com
244
Researchand
Training
ResearchandTraining
TeInuenzaDivisionsinternationalprogramsconductawiderangeoflaboratory,clinical,
andepidemiologicresearch.Tegeneralgoalsoftheresearchaddresscriticalgapsinknowledge
thatadvanceprogramstowardspreventionandtreatmentofinuenza.Areasofresearchinclude
thefollowing:clinicalstudiestoevaluatetheeectivenessofantiviralmedicationsandvaccines;
thedevelopmentofnewdiagnostictests;worktounderstandriskfactorsforsevereinuenza
infection;laboratorystudiestobetterdesignvaccinesandimprovevaccineproduction;work
tounderstandtheeectofinuenzaonvariouspopulations;studiesoftheinterfacebetween
animalsandhumans;andotherareas.Teresearchagendaisdesignedtocomplementand
extendthecoreprogrammaticworkoftheInuenzaDivisioninbuildingcapacityforinuenza
preventionandcontrolglobally.
247
248
MeetingonInfuenzaResearchandPreparednessat
theAnimal-HumanInterface
DuringApril13,2009,the2ndmeetingonInuenzaResearchandPreparednessatthe
Animal-HumanInterfacewasheldatU.S.CDC.Tepurposeofthemeetingwastoprovide
updatesontheresearchactivitiesoftheAvianInuenzaCooperativeResearchCentersand
toenhancecommunicationandcoordinationamonginvestigators,U.S.CDC,andhuman
andanimalhealthauthoritiesregardinginuenzaresearchattheanimal-humaninterface.A
secondgoalofthemeetingwastoimprovepreparednessattheanimal-humaninterfacethrough
discussionsoftheanimalandpublichealthagencyroles,responsibilities,noticationplans,
communicationstrategies,andplansofactionrelatedtothedetectionofpotentialorconrmed
humannovelinuenzaAinfectionsintheUnitedStates.
Tofacilitatethisplanning,3brieftabletopexercisesthatsimulatedthedetectionofnovel
zoonoticswine,avian,andhumaninuenzaAinfectionintheUnitedStateswereperformed.
Tismeetingwasattendedbyzoonoticinuenzaresearchers,animalandhealthocials
fromtheUnitedStatesandothercountriesthathadpreviousexperiencewiththedetection
andcontrolofH5N1andothernovelinuenzaAviruses,U.S.CDC,theU.S.Department
ofAgriculture,theU.S.DepartmentoftheInteriorsta,andotherguestsfromacademia,
professionalanimalandhealthorganizations,andthepoultryandporkindustries.
Go
Select a Reagent
Advanced Search
Forms
Suggest a Reagent
Upcoming items
Announcements
Contact Us
Quick Order
WHO Kit Forms
IRR website goes live!
Please register and login to view a complete list of available materials.
Influenza Reagent Resource (IRR) was established by the
Centers for Disease Control and Prevention(CDC)
Click here to join Mailing List
Kits
Proteins
Reagents
Viruses
Antisera
Plastics
Access your Web Portal Account: Login
Home
Call Us Toll-Free: (866) 951-2822 | E-mail: contact@influenzareagentresource.org
Home | Site Map | FAQs | Privacy Policy | Careers | Contact Us | Terms of Use
2009 ATCC. All Rights Reserved.
Home Catalog Deposits Register About
249
InuenzaReagentResources(IRRs)rolesinpandemicpreparednessandinuenzaresearchare
Tomanufactureanddistributeinuenzadiagnostickits,viruses,andreagentstopublic
health,commercial,domestic,andinternationalresearchlaboratories.
Toimprovepandemicpreparedness,enhancedetectionandcontrolofseasonal
inuenza,andprovidebetteraccesstoreagentsviaasecure,Web-basedsystem.
ToaugmentU.S.CDCsinternationalpandemicpreparednessplantoprovideasurge
option(~$10+Mperyear)whichcanbeexercisedtodistributereagentsanddiagnostic
kitstodomesticandinternationalpublichealthlaboratories.
DuringtheH1N1pandemic,U.S.CDCandIRRcoordinatedwithWHOtoprovideRT-PCR
H1N1andseasonalinuenzadiagnostickitsandothermaterialsto150countriessupporting
morethan300laboratoriesinternationally.Tesekitsandreagentswerealsoprovidedtomore
than120publichealthlaboratoriesdomesticallyin50statesandterritories.IRRalsofacilitated
themanufactureanddistributionofanH1N1supplementalWHOinuenzareagentkitto
approximately100laboratoriesgloballyandthe20092010WHOinuenzareagentkitto
morethan150laboratoriesglobally.
Product Total Kits
Int
# Countries
Distributed
# Int Labs
Distributed
Total Kits
Dom
# Domestic
Distributed
# State Labs
Distributed
Total Kits
Int & Dom
H1N1 RT-PCR 873 665
50 + DC+
PR
124
1,538
516
Seasonal
RT-PCR
118
150 306
398
WHO H1N1 HI
Supplemental
44 36 44 48 43 48 92
WHO H1N1
HI Kit
96 79 96 71 45 71 167
InadditiontoaugmentingtheH1N1pandemicresponse,IRRwillprovidebetteraccessto
qualityinuenza-relatedreagentsbymanufacturinganddistributinginuenzavirusesalacarte
andaspanels,recombinantproteins,antisera,monoclonalantibodies,RNAstandards,nonin-
uenzarespiratorypathogensandmore.Institutionsthathaveaccesstothesereagentsarequali-
eddomesticandinternationalWHOnationalinuenzacentersandpublichealthlaboratories,
commercialtestdevelopers,vaccinemanufacturers,andresearchinstitutions.
250
BurdenofDiseaseandRisk
Factors
Bangladesh
Population-basedSurveillanceinKamalapur
Kamalapurisadenselypopulated,urban,low-incomecommunityinDhaka,Bangladesh,where
inuenzasurveillancehasbeenongoingsince2004.Testudyinthiscommunitywillmeasure
theincidenceofinuenza,assesstheproportionofpersonsinfectedwithpandemicinuenza
(H1N1)whodevelopsevereillness,measuretherateofsecondaryhouseholdtransmissionof
inuenza,andcharacterizethefullspectrumofillnessamongpersonswhoareinfectedwith
pandemicinuenza.BecausethissitewasestablishedbeforetheemergenceofA(H1N1)
inuenza,ithasbeeninvaluableinunderstandingtheepidemiologyofpandemicinuenza.
ProgressandInitialConclusions
Severalmanuscriptshavebeensubmittedforpublicationduring2009,andmorearebeing
draftedtosharethissitesimportantndings.
MirpurPopulation-basedStudy
Tisstudyaimstoassesstherateofpandemic2009H1N1inuenzainrelationtoattributable
riskofsecondarytobaccoexposure,indoorairpollution,andinfrequenthandwashingtothe
frequency,duration,orseverityoflaboratory-conrmedinuenza.Testudyalsoexplores
genome-wideassociations(e.g.,potentialassociationsbetweensinglenucleotidepolymorphisms
ingenesinvolvedinthetoll-likereceptorsignalingimmuneresponsepathway)withduration
andseverityof2009H1N1inuenza.Inaddition,thestudyassessespotentialassociations
amongthedurationandseverityofinuenzadiseaseanddelayedcognitivedevelopmentina
birthcohortofMirpurchildrenparticipatinginanongoingamebiasisstudy.
InitialFindingsandProgress
Preliminarydataanalysesofthe1styearofincidenceofrespiratoryvirusesandhouseholddata
isongoing.
SurveillanceandEpidemiologyofInfuenza
Tepurposeofthisstudywastoestimatenationalinuenzaratesamongoutpatientpopulations
inBangladeshbyestablishingsurveillanceatsentinelhospitalsandclinicsthroughout
Bangladesh.
FindingsandConclusions
Tisstudyisenteringits3rdyearofdatacollectionandhasyieldedimportantestimatesof
nationalinuenzaratesamongoutpatientpopulations.Tendingsfromthe1stphaseofthis
studywereinstrumentalforguidingpandemicresponse(e.g.,allocatingmasksandoseltamivir
toruralhospitalsduringthe1stphaseofthepandemic).Amanuscriptpresentingthesedatahas
beenpreparedandiscurrentlyunderreview.Testudynowintendstoproviderobustburdenof
diseasedatafromhospitalizedcase-patients,estimatemortalityrates,andquantifythepandemic
2009H1N1inuenzaburdenofdiseaseinruralBangladesh.
251

AnalysesofPandemic2009(H1N1)Epidemiology
InvestigatorsatIEDCRandICDDR,Bhavecompileddatafromalllaboratory-conrmed
pandemic2009H1N1inuenzacase-patientstoquantifyandexploretheirepidemiologic
characteristics,includingcaseseverity,casefatalityrates,associationwithriskfactorsforsevere
disease,andsecondaryattackrates.
FindingsandConclusions
Tepreliminaryndingsofthisinvestigationhavebeenpublishedinanopen-sourcejournal
andarebeingupdatedforpublicationinapeer-reviewedjournaltoguideregionalresponseto
thepandemic.TedatawereusefultoWHOandotherinternationalpartnersinassessingthe
epidemiologyandseverityofthepandemic.
Cambodia
U.S.CDC-SupportedStudiesattheU.S.NavalMedicalResearchUnitNo.
2(NAMRU-2)Detachment,CambodiaSurveillanceInitiationat9Health
CentersOutsidePhnomPenh
Althoughgreatlyimproving,Cambodiastilllackssucientinformationontheepidemiology,
clinicalpresentation,andetiologyofinfectiousdiseases,includinginuenza.
Approach
ToimprovepublichealthinterventionsbeginninginDecember2006,NAMRU-2initiated
surveillanceat9healthcentersin2provincesoutsidePhnomPenh.Patients2yearsandolder
withacutefever(i.e.,temperaturegreaterthan38C)ofatleast24hoursindurationwere
enrolledfollowingwritteninformedconsent.
Timeline
Testudyisplannedtocontinueuntil2012.
Progress and Initial Conclusion
OurdatapublishedinEpidemiology and Infection in2009suggestedthat15.1%of2,257patients
wereRT-PCRpositiveforinuenza.Whencomparedtoinuenza-negativepatients,inuenza-
positivepatientsweremorelikelytohavecoughandsorethroat.Eachyear,inuenzapeaked
duringtherainyseason.In2008,thepredominantsubtypewasAH1N1andantigenciallyrelated
toA/SolomonIsland/O3/2006.Datasuggestedthatinuenzawasanimportantcontributorto
healthcareusewithnearly1in5feverpatientsinfectedwiththisvirus.
U.S.CDC-SupportedStudiesattheU.S.NAMRU-2Detachment,Cambodia
BurdenofDiseasein2CambodianCommunes
Purpose, Approach, and Timeline
Inmid-2009,tofurthercharacterizetheburdenofdiseasefrominuenza,weestablisheda
longitudinalstudyof15,500personsresidingin2Cambodiancommuneswiththehelpof
theMOH.Atbaseline,personswerepolledtoobtainhealthcareusepatternsandestimate
theincidenceofinuenzamorbidityandmortality.Passivesurveillancewillbeestablishedat5
governmentandprivatehealthclinicsforinuenzainfections.
252

Censusresultssuggestedthatduringthe2-weekreportingperiod,whichwasthepeakseasonfor
inuenza,18%ofpatientsreportedhavingsymptomsconsistentwithanILI.Ofthesepatients,
only5%soughtcareatagovernmentclinic,whereasmostsoughthelpatapharmacyorfroma
privatemedicalclinic.Inadditiontoresearch,thissitewillbeusedtotraingovernmentstaon
methodsforstudyinginuenzaepidemiologyandinterventions.Testudywillcontinuefor5
years.
CDC-PasteurCambodiaStudyEpidemiologyofHumanInfuenzainKampong
ChamProvince,Cambodia,20082009
Population-basedsurveillanceforinuenzahasneverbeenconductedinCambodiainthepast.
InformationondiseaseburdenofinuenzainCambodiaislacking,butiscriticaltocreatedata
tosupportpossibleintroductionofseasonalinuenzavaccinationinthiscountry.
Approach
Prospective,active,community-basedsurveillanceforestimatingtheincidenceof
inuenzain20semiruralvillagesin23districtsinKampongChamProvince(oneof
themostpopulatedprovincesinCambodia),aswellas5districtsinKampongCham
City.Personsofallageswithadocumentedfeverofgreaterthanorequalto38Care
eligibleforenrollment.
Case-controlstudytodetermineriskfactorsforsevereoutcomesofinuenzabyusing
patientsrecruitedunderacurrenthospital-basedstudy(KampongChamProvincial
Hospital)onetiologiesofacutelowerrespiratoryinfections(SISEA).
Population-based,active,deathsurveillanceinahigh-riskareabyusingverbalautopsies
forestimatingfrequencyofinuenza-relatedmortalityandriskfactors.
Timeline
Teprojectbeganinearly2009andisexpectedtoconcludeinthe2ndhalfof2010.
Progress and Initial Conclusions
Caseenrollmentatthecommunityandhospitallevelsisongoing.
Kenya
TransmissionofPandemicandSeasonalH1N1 inUrbanandRuralCommunities
inKenya
Tejusticationistounderstandbetterhouseholdandcommunitytransmissionofseasonaland
pandemicinuenza.
Approach
WeeklyvisitstoallhouseholdsinKiberaandLwakcatchmentareascombinedwithsurveillance
atafreeclinicwillallowustotracethespreadoflaboratory-conrmedinuenzaamong
householdmembersandwithincompoundsinKenya.
253
Timeline
WeeklysurveillancestartedSeptember2009inKiberaandwilllikelystartNovember2009in
Lwak.Biweeklysurveillancehasbeenongoingsince2006.
Analysesonseasonalinuenzatransmissionpatternsarecurrentlybeingconducted.
India
Population-based,LongitudinalBurdenofDiseaseStudyofInfuenzainIndia
TeburdenofdiseaserelatedtoinuenzavirusinfectioninIndiaisnotyetwelldenedbut
likelytobesubstantialgiventhatIndiaaccountsfor20%ofglobalchildhooddeathscaused
byacuterespiratoryinfections.Toaddressthisissue,apopulation-based,longitudinal,burden
ofdiseasestudyhasbeenimplementedat2sitesinruralIndia,bothofwhichhaveongoing
communityanddemographicsurveillancesystems.
Study Aims and Objectives
Estimatetheincidenceoflaboratory-conrmedinuenzaamongpersonshospitalized
foracuterespiratoryillnessesandacuteexacerbationsofchronicmedicalconditions.
Characterizetheclinicalspectrumofinpatientandoutpatientdiseaserelatedto
inuenza;evaluatedierentclinicalcasedenitionsandsyndromestopredictinuenza;
anddescribetheseasonalityofinuenza.
Determineriskfactorsforseverediseasecausedbyinuenza,includingunderlying
chronicconditions,demographics,smoking,andsocioeconomicstatus.
Describethehealthcareuseofthepopulationanddenetheburdenofrespiratory
diseaseforthosewhodidnotseekcareorrefusedhospitalizationforsevererespiratory
illness.Describeobstaclestocare.
Estimatetheannualmortalityratefromsevererespiratorydiseaseandinuenzainthe
population.
Approach
PersonslivingintheBallabhgarh(Delhisuburb)andVadu(Punesuburb)Demographic
SurveillanceStudyareasthatseekinpatientmedicalattentionandmeetthespecicstudy
enrollmentcasedenitionareenrolledinthestudy.Clinicalandepidemiologicinformationand
oropharyngealandnasalswabspecimensarecollectedfromallconsentingandenrolledpersons,
asperprotocols.AsofOctober2009,Ballabhgarhhasenrolledmorethan3,300households;
1,900patientshavebeenscreened;and77patientshavebeenenrolled,ofwhich7are
laboratory-conrmedtobepositiveforinuenza.Likewise,Vaduhasenrolled954households,
screened1,054patients,andenrolled423patients,ofwhich56arepositiveforinuenza.Te
studyisinprogresstodeterminetheincidenceofinuenza,especiallythepresenceofnovel
H1N1inthesecommunities.
Timeline
April2009May2011
254
Indonesia
EnhancedSARISurveillanceduringthe20092010Pandemic
TeepidemiologyofnovelH1N1infectionintropicalcountriesisnotwelldescribed.OnJune
24,2009,novelH1N1was1stidentiedinIndonesia.Tocharacterizetheepidemiologyof
novelH1N1inIndonesia,weimplementedenhancedsurveillanceforhospitalizedpatientswith
SARIinanetworkof12hospitalsinTangerangDistrict,Indonesia,inearlyJune2009.
Approach
WeidentiedallhospitalsthatmanagepatientswithrespiratoryillnessinTangerangDistrict
andtrainedclinicianstoidentifySARIpatients,collectedclinicalspecimens,andcompleted
astandardizedcaseinvestigationform.TroatandnasalswabsweretestedbyRT-PCRinthe
IndonesianNICbyusingprimersfromtheU.S.CDC.
Timeline
SurveillancewasimplementedinlateJune2009andwillcontinuethroughout2010.
Progress
DuringJune28September3,2009,weidentied216patientswithSARI,including19
patients(9%)withnovelH1N1infection.PatientswithnovelH1N1infectionwereidentied
in7hospitalsandrangedinagefrom11monthsto54years(medianage20years);59%were
male.Teagespecicrateforhospitalizationrangedfrom5.7per100,000populationin
persons04yearsofageto0amongpersonsmorethan60yearsofage.Tenumberofpatients
withnovelH1N1infectionpeakedinmid-July,whichisthelowseasonforseasonalinuenza
transmissioninBanten,Indonesia.Temediantimefromsymptomonsettohospitaladmission
was2days,ranging18days.SixpatientswithnovelH1N1infectionhadcomplicatedcourses
ofillness,including2patientswhodied.Amongthe19patientswithnovelH1N1,6had
underlyingmedicalconditions,includingasthmaandtuberculosis.Allpatientswithnovel
H1N1infectionweretreatedwithoseltamivir.
Conclusion
WeobservedarapidriseinthenumberofSARIpatientswithnovelH1N1infectionshortly
afterintroductionofthisvirusinIndonesia.Teagedistribution,clinicalfeatures,and
mortalityofhospitalizedpatientsaresimilartothatobservedinothercountries.Weanticipate
muchhigherratesofdiseaseduringpeakseasonforinuenzatransmissioninIndonesia.Tis
workwillcontinuetomonitorinuenzaafterthepandemic.
Kenya
Population-basedSurveillanceforInfuenzaandOtherRespiratoryDiseasesin
NairobiandKisumu,Kenya
Tepurposeofthisprojectistounderstandtheburdenofinuenzaandotherrespiratory
virusesinanurbanandruralsettinginanequatorialAfricancountry,andtounderstandthe
contributionofILIandSARItomorbidityandmortalityinthesesamecommunities.
255
Approach
Ineachcatchmentarea(approximately25,000peoplepercatchmentarea),weeklyhousehold
visitsareperformedtorecordepisodesofrespiratoryillness.Allresidentshaveaccesstoafree
clinicineachsitewheresamplesarecollected,ifpatientsmeetthecasedenitioncriteriafor
ILIorSARI.InKisumu,theclinicisattachedtoaninpatientfacility.InKibera,follow-upis
performedonpatientswhoarehospitalizedatthereferralhospital.
Timeline
StartedOctober2006;noscheduledenddate.
Burdenanalysisiscurrentlybeingdone;projecteddraftofresultsareexpectedDecember2009.
Case-ControlStudytoAssessRiskFactorsforSevereInfuenzaInfection,
Bondo,Kenya,20072009.
Tisprojectwasconductedtounderstandriskfactorsforsevereinuenzainfection.
Approach
Casesfromactivehospital-basedsurveillanceinBondoDistrict,WesternKenya,wereselected,
andage-matchedcommunitycontrolshavebeenidentied.Approximately60casesandtwice
asmanycontrolshavebeenidentied.
Timeline
Enrollmentiscomplete.Analysisisbeingcompleted.Adraftmanuscriptisprojectedfor
December2009.
Initialndingsidentiedpotentialriskfactorsforinfection.
SurveillanceforHospital-AcquiredInfections,Kenya
Tisprojectwasundertakentounderstandtheburdenofhospital-associatedrespiratory
infections(HAIs)inKenyaandtherelativecontributionofinuenzaandothervirusestoHAIs.
Approach
Surveillancehasbeenestablishedinmultiplewardsin3hospitalsinKenya.Testingformultiple
pathogensisconductedattheCDC-KenyaIEIPlaboratory.
Timeline
SurveillancestartedJuly2009andisscheduledtocontinuefor2yearswithaplanforthe
introductionofinterventions,suchasimprovedsafewateraccessafterthe1styear.
Preliminaryresultsareexpectedearly2010.
ProspectiveEvaluationofAdmittedPatientswithPandemicH1N1inKenya
Tepurposeofthisprospectiveevaluationistounderstandtheclinicalpresentation,course,and
riskfactorsassociatedwithseverepandemicH1N1infection.
256
Approach
SurveillanceisbeingperformedonallH1N1patientsadmittedtoareahospitals.Standarddata
arebeingcollectedonH1-positivepatients.
Timeline
Surveillanceisongoing.
Peru
NMRCD-CDCBurdenofIllnessandRiskFactorsforTransmissionofSeasonal
Infuenzain4DistinctRegionsofPeru
Teepidemiology,incidence,andeconomicburdenofinuenzadiseasearenotwell
characterizedinPeru.
Approach
Tisstudyincludesaprospectivecohorttoestimateincidenceanddiseaseburdenandassess
riskfactorsandseasonalitypatternsforinuenza(i.e.,seasonalandpandemicH1N1inuenza),
andtoevaluatealternativeroutesofviraltransmission.Toaccomplishthesegoals,aprospective
population-basedcohortstudywasimplementedin4locationsthatarerepresentativeofthe
geographicandclimaticdiversityofPeru(i.e.,coastal,highlands,jungle,tropicaldryforest)for
a3-yearperiod,June2009June2012).
Atotalof375households(i.e.,approximately1,500personspersite)areenrolledineach
location.ILIscreeningisconducted3timeseachweekamongeachofthehouseholds
occupants(activesitevisits).OnceILIcaseshavebeenidentied,theyaresampledbyusing
throatandnoseswabsforlaboratoryidenticationofetiologicagent.Inaddition,theyreceive
follow-upvisitsfor15daystoassesstheeconomicburdenofinuenzabyusingin-depth
questionnaires.
ProgressandInitialConclusions
Asaresultofthisactivesurveillance,wehaveidentied938ILIcases;540(44%)werepositive
forH1N1.Wehavealsoidentiedacumulativeattackrateof7.7%forH1N1and3.3%for
otheretiologiesinLima.Datageneratedthroughoutthisstudywillallowustodetermine
groupsathighriskforinuenzainfection.TisdatawillallowPeruvianpolicymakersand
programmanagerstomakemoreinformeddecisionsregardingdevelopmentofprevention
andcontrolmeasuresforthecountry.Furthermore,ourdatawilllikelybequiteusefulin
understandingthetransmissiondynamicsofinuenzainotherdevelopingtropicalcountries.
257
258
DevelopmentandValidation
ofEnhancedSurveillanceand
Diagnostics
EvaluationofCaseDefnitionsforSARIAssociatedwithInfuenza
Tounderstandtheburdenofinuenzaworldwide,appropriateandstandardmethodsto
identifycasesarerequired.U.S.CDCandothershaveadvancedSARIasasurveillance
andresearchcasedenitioninrecentyears.U.S.CDChasengagedpartnersinprojectsto
understandhowwellSARIcapturesthetrueburdenofinuenzaandotherrespiratoryviruses.
WorkinGuatemala,Egypt,andTailandIEIPsiteshavebeenundertakeninrecentyears,
andthisworkwillleadtoimprovedsurveillanceguidelinesandtheabilitytounderstandthe
inuenza-associateddiseaseburdenacrossregionsandsites.
Kazakhstan
ValidationofaReal-TimePCRTestCommerciallyAvailableinCentralAsiafor
theDetectionofInfuenzaAandBViruses
Forlogisticalreasons,itismoreconvenientandlessexpensivefortheregionallaboratoriesin
KazakhstantousecommercialinuenzaprimersfromRussia(Amplisense)thantousethe
primersprovidedbyU.S.CDCforreal-timePCRtestingofrespiratoryspecimens.Verylimited
comparisontestingsuggeststhattheAmplisensekitsworkwell,butalargersampleisneededto
conrmthisdata.
Approach
SevensentinelsitelaboratorieswilluseAmplisensetodetectinuenzaAandB.Allpositive
resultsandasubsetofnegativeresultswillbesenttotheRSESfortestingbyusingU.S.CDC
primersandprotocols.TesensitivityandspecicityoftheAmplisensetestswillbecalculated
byusingtheU.S.CDCtestresultsasareference(goldstandard).
Timeline
TetimelineforthisprojectisKazakhstansinuenzaseason,whichisweek39of2009toweek
16of2010.
Kenya
ComparativeStudyofRelativeYieldofNasopharyngeal(NP)SwabsVersus
Oropharyngeal(OP)SwabsinDetectingSeasonalandPandemicInfuenza,
Kenya
TisprojectwasconductedtoevaluateuseofsingleNPorOPswabsindetectinginuenzaby
RT-PCR.
259
Approach
Surveillancesamplesin2refugeecampsinKenya(i.e.,DadaabandKakuma)arebeingseparat-
edintoseparatecryovialsandtestedseparately.TestingforinuenzaisperformedattheCDC-
KenyaIEIPlaboratory.
Timeline
TeprojectstartedMay2009andisexpectedtocontinueforayear.Preliminaryanalysiswillbe
performedNovember2009.
260
InfuenzaPreventionProjects
Bangladesh
Prevalent,High-Risk,RespiratoryHygienePracticesinUrbanandRural
Bangladesh
Te1stphaseofthisproject,whichaimedtoexploreandpilotscalablenonpharmaceutical
interventionstoimproverespiratoryhygiene,documentedthatstudyparticipantsfrequently
coughedorsneezedintotheairanddidnotwashtheirhandsaftercoveringtheirmouthornose
whilecoughingorsneezing.Testudysuggeststhatculturallyappropriate,cost-eective,and
scalableinterventionsneedtobedevelopedinordertoimproverespiratoryhygienepractices
andassesstheireectivenessinreducingrespiratorypathogentransmission.
Amanuscriptthatdetailsstudyndingsisbeingcirculatedforreviewandpublicationina
peer-reviewedjournal.Investigatorsarepreparingtheconceptandfundingrequestsforthenext
phaseofthestudythatplanstoassessthehealtheectsofascalablepublichealthintervention
toimproverespiratoryhygiene.
PreventionofSecondaryTransmissionofNovelA(H1N1)Infuenzaby
PromotingHandwashingwithSoap(BISTISStudy)
Tisstudy,whichiscompletingits1stphase,measuresthesecondaryattackratioofinuenza
amonghouseholdcontactsofindexcaseswithinuenza,teststheecacyofanintervention
promotinghandwashingwithsoapforpreventionofintrahouseholdtransmissionofinuenza,
andidentiesriskfactors,otherthanhandwashingwithsoap,forintrahouseholdtransmission
ofinuenzainruralsetting.
Initial Findings and Progress
Tisstudywillbeenteringits2ndphaseduring2010,atwhichtimeaseriesofmanuscriptsto
sharendingsfromphaseonewillbedraftedandsharedwithstakeholders.
India
DirectandIndirectProtectionbyInfuenzaVaccineGiventoChildreninIndia
InuenzavaccinesareinroutineuseinchildrenintheUnitedStates,andalthoughlicensed
inIndia,theyareseldomgiven.Indeed,itisnotknownwhetherinuenzavaccineecacy
inatropical,developingcountrywillbethesameasindevelopedcountries.Tisstudywill
determinewhetherimmunizationofyoungchildrenwithinuenzavirusvaccinewillprotectthe
immunizedchildrenandolderchildrenandadultswhoarearoundthem.Byundertakingthese
studiesinIndia,the2ndmostpopulouscountryintheworld,informationcanbeobtainedthat
willbeusefulinIndiaandinothertropical,developingcountries.
Approach
Tisstudyisbeingconductedin3ruralvillagesoutsideofDelhi,India.Ithas2parts:weekly
householdsurveillanceforFARIforpersonsofagegroups,andvaccinationofchildrenaged6
monthsto10years(randomizedatthehouseholdlevel)witheitherTrivalentInuenzaVaccine
(TIV)orthecontrolvaccine,IPV.FARIsurveillancedatawillbeusedtoevaluatethedirect
eectsofvaccinationamongchildren,aswellastheeectofvaccinatingonlychildrenonthe
261
incidenceofinuenzaamongtheseolderpersons(herdimmunity).Tetotalpopulationunder
surveillanceforall3villagesisapproximately20,000,withanestimated3,500childreneligible
forvaccination.Inaddition,asmallsubsetofvaccinatedchildren(n=200)willbeenrolledinto
animmunogenicitystudy,whichwillmeasuretheirimmuneresponsetovaccinationandrisk
factorsaectingimmunogenicity.
Progress
Tesitepreparatorywork,sitesensitization,andtrainingofeldandlaboratorystahave
beencompleted.Successfuldevelopmentofahouseholdrandomizationstrategytoaddressthe
directeectsofinuenzavaccineprotectionhasbeencompleted.Allrequiredhumansubject
approvalsanddrugcontrollerclearanceshavebeenobtained.Proformasdeveloped,piloted,
anddatamanagementissuesarebeingaddressed.Avaccinecampaignwillstartbytheendof
November2009.
Timeline
July2008June2011
Senegal
DirectandIndirectProtectionbyInfuenzaVaccineGiventoChildrenin
Senegal
InuenzavaccinesareinroutinegiventochildrenintheUnitedStates,andalthoughlicensedin
Senegal,theyareseldomgiven.Itisnotknownwhetherinuenzavaccineecacyinatropical,
developingcountrywillbethesameasindevelopedcountries.Tisstudywilldetermine
whetherimmunizationofyoungchildrenwithinuenzavirusvaccinewillprotectthe
immunizedchildrenandtheolderchildrenandadultswhoarearoundthem.Byundertaking
thesestudiesinSenegal,informationcanbeobtainedthatwillbeusefulinSenegalandinother
tropical,developingcountries.
Approach
TisstudyisbeingconductedinaruralsiteinNiakhar,Senegal.Tetotalpopulationunder
surveillanceisapproximately18,000,withanestimated3,500childreneligibleforvaccination.
Twentycommunitieshavebeenrandomizedinto2armsof10.In1arm,allchildrenaged6
monthsto10yearsreceivethesouthernformulationoftrivalentinactivatedvaccine(TIV).In
theotherarm,childrenreceiveinactivatedpoliovaccine(IPV).Weeklyhouseholdsurveillance
forfebrileacuterespiratoryillnessforpersonsofallagegroupswillbeconducted.Boththe
total(directplusindirect)eectsofvaccinationamongchildren,aswellastheindirecteect
onunvaccinatedpersonsinthecommunity,willbemeasured.Inaddition,asmallsubsetof
vaccinatedchildrenhavebeenenrolledintoanimmunogenicitystudythatwillmeasuretheir
immuneresponsetovaccinationandriskfactorsaectingimmunogenicity.
Progress
TestudycompletedvaccinationinJune2009andisnearingtheendofacompleteyearof
follow-upamongcommunities.Te2ndroundofvaccinationwillbeunderwayinMayand
June2010.
Timeline
July2008June2011
262
Thailand
HouseholdInfuenzaTransmissioninBangkokandEffectivenessof
NonpharmaceuticalInterventionsToReduceTransmission
TeinuenzasectionoftheU.S.CDCIEIPinTailandcollaborateswiththeQueenSirikit
NationalInstituteofChildHealthandtheArmedForcesResearchInstituteofMedicalSciences
toconductastudyofhouseholdinuenzatransmission(HITS)inBangkok.
Approach
HITSenrollsthefamiliesofchildrenwithlaboratory-conrmedinuenzainfectiontostudy
theeectivenessofnonpharmaceuticalinterventionstoreduceinuenzatransmission.Index
casesareprospectivelyidentiedbyrapidinuenzatestingandthenconrmedbyRT-PCR
testing.Consentinghouseholdsarerandomizedto1of3studyarms:control,handwashing,
andhandwashingplussurgicalfacemaskuse.Toidentifysecondaryinfections,researchnurses
conducthomevisitsondays1,3,and7followingenrollment.Duringthesevisits,respiratory
swabspecimensarecollectedfromallhouseholdmembersandtestedforinuenza.Te
durationofviralsheddingisalsomeasuredinthepediatricindexcasesfromeachhousehold.
Finally,bloodisdrawnfromparticipantsforantibodytestingtodetectmildandasymptomatic
inuenzainfections.
Timeline
EnrollmentbeganinApril2008,andasofOctober2009,499householdshadbeenenrolled.
Secondarytransmissionofinuenzahasoccurredin37%ofallhouseholdsand18%ofall
familymembers.Morethan90%ofillchildrenintheHITSstudysleepinthesameroom
astheirparents,afactorthatmayexplainthehighsecondarytransmissionrates.Preliminary
analysishasnotdemonstratedaprotectiveeectoftheinterventionsagainstsecondaryinuenza
infections.Furtheranalysisisongoing.Tehumanandlaboratoryinfrastructureestablishedto
conducttheHITSstudyhasalsobeenusedtostudytheperformanceofinuenzarapidtests
andexploretheprevalenceofinuenzavirussurfacecontaminationoncommonhousehold
surfaces.
263
264
Animal-HumanInterface
Activities
AssessmentofHealth-SeekingBehaviorsandAnimal-to-HumanInterface
Approach
Involving1,200households(principalsamplingunit)fromparaurbanandruralcommunitiesin
Laos,thisworkwillbecarriedoutincollaborationwithCAREInternationalandtheNational
UniversityforHealthSciences,Laos.
Proposed Timeline
DesigncompletedJanuary2009.
TrainingcompletedMarch2009.
FieldactivitiesMarchApril2009.
AnalysisJuneJuly2009.
PresentationandpublicationMarchApril2010.
Bangladesh
AvianInfuenzaSurveillance,InfuenzaASurveillanceinBangladeshPoultry
DuringthePandemic
TissurveillanceaimstoidentifyanyinuenzaAstrainsthatarecocirculatingindomestic
poultryinBangladeshtoidentifypoultrydie-ocausedbyinuenzaandrelatedviraldisease
andtoconductpassivesurveillanceinordertoidentifyunusualpoultrydie-osuspectedof
novelinuenza.Findingsofthissurveillancesystemhavedemonstratedthatoutbreaksof
inuenzaA(H5N1)andothervirusesarecirculatingconcurrentlywithpandemic2009H1N1
inuenza.
SerosurveyAmongPoultryWorkersExposedtoInfuenzaA(H5N1)
Teinvestigativeteamhasrecentlycollectedepidemiologicdataandserumfrompeoplewho
workedinfarmswithinuenzaA(H5N1).Teteamhasalsocompleteddatacollection
amongpersonsinruralBangladeshwhoworkatpoultrywetmarkets.Attheendofthestudy,
during2010,investigatorsintendtoquantifyratesofseroconversionamongpoultryworkers
toinuenzaA(H5N1)andotheravianinuenzavirusesanimportantissueinacountryin
which69%ofthepopulationraisepoultryasanimportantproteinsource.
NationalInfuenzaSurveillanceandaCase-ControlStudyonAvianInfuenza
Tesecomplementaryprojectsarecollectingnationalrepresentativeinformationaboutpoultry-
rearingpracticesandexploringriskfactorsfortheinfectionofbackyardpoultryanddispersion
ofavianinuenzainthecommunity.Datacollectionisenteringitsnalquarterof2009but
isexpectedtocontinueduring2010.Preliminaryndingssuggestthatcurrentmultilateral
responseeortsmaybeineectivetocontrolavianinuenza.Tesepreliminaryndingsare
beingincorporatedintomanuscriptstohelpguideregionalresponsetoavianinuenza.
265
EvaluationofCAREInterventionToPromoteSaferAnimalHusbandry
Tisstudyintendstoassesscommunityawarenessbeforeandafterandadoptionofgovernment
recommendedavianinuenzapreventionstrategies.Baselinendingshavebeensenttolocal
healthauthorities.TesendingssuggestthattheruralpopulationofBangladeshisunaware
oftheriskposedbyinuenzacirculatingamongpoultry.Apeer-reviewedmanuscriptisbeing
preparedforthewiderdisseminationofstudyndingspendingthepostinterventionevaluation.
CAREBangladeshwillcompleteitsinterventiontopromotethesaferhusbandryofpoultry
duringearly2010whenthepostinterventionevaluationwilltakeplace.
AvianInfuenzaEthnographies
IEDCRandICDDRemploytheexpertiseofanthropologistswhoareexploringhowpeople
inruralBangladeshraisepoultryandperceiveavianinuenzaoutbreaks.Tendingsofthis
ethnographyhaveyieldedawealthofinformationthatchallengestraditionalconceptsof
communityeducationasamainstayofavianinuenzapreventionandcontrol.Findingshave
beensharedamongregionalstakeholders,anda2ndphaseoftheseprojectsintendstodevelop
scalable,culturallyappropriateinterventionsthatmayhavemoreeectthanthosecurrently
promulgatedbyinternationalbodies.
Cambodia
ActiveSurveillanceforAvianInfuenzaVirusesinRuralAdults,Cambodia
Approach
NAMRU-2andU.S.CDCinBangkokcompletedafullyearofactivesurveillanceforavian
inuenzavirusesamong1,600ruraladults.Eachweek,eldstafollowsupwithenrolled
adultsintheirhomesandasksaboutinuenzasymptoms.Ifsymptomatic,serumsamplesand
throatandnasalswabsareobtained.Serumsamplesarealsocollectedatbaselineandannually
thereafter.
Timeline
Testudywillcontinuefor2additionalyears.
Atbaseline,Cambodiaserologydatasuggestedthathighandlowpathogenicavianinuenza
virusinfectionswererareevents,despiteadultsbeingroutinelyexposedtopoultry.Preliminary
datafromTailandindicatedthatH5infectionswereslightlymorecommonbutnal
conrmationispending.
Kenya
SurveillanceinMigratoryBirdsinKenya
Surveillancehasbeenconductedtounderstandtheprevalenceanddistributionofcirculating
virusesinmigratorybirdsinKenya.
266
Approach
AnnualsurveillanceisperformedonbirdsatmultiplesitesaroundKenyabefore,during,and
afterthemigratorybirdseason.TisprojectisajointonewithWalterReedProject,Kenya
NationalMuseums,andtheDivisionofVeterinaryServices,Kenya.Testingwasperformedat
CDC-KenyalaboratorieswithadditionaltestingatU.S.CDCinAtlanta.Resultsarepending.
Timeline
Testudystarted2006andwillcontinuethrough2010.
Asummaryoftherst3yearsisbeingdrafted.
AnalysisofPoultryTradeNetworks,Kenya
TespreadofavianinuenzaA(H5N1)aroundtheworldhasbeenasourceofgreat
concernforseveralyears.H5N1hasbeenreportedinbirdsinmorethan60countries,and
understandinghowthevirusspreadsgloballywillhelppredicttransmissionpatternsanddesign
betterinterventionandcontrolmeasures.Somedebateexistsaboutwhetherthevirusisspread
primarilythroughthemovementsofmigratorybirdsorthroughtheinternationaltradeof
poultry.
Approach
TeInuenzaDivisionhascollaboratedwiththeKenyaMinistryofAgriculture,Divisionof
VeterinaryServicestoundertakeananalysisofpoultrytradeinKenya.Teprojectseekstouse
networkanalysistocharacterizethedensityofthetradenetworkandthenmodelthespread
ofvirusthroughthisnetworktogainabetterunderstandingoftherolethattrademightplay
inthespreadofavianinuenza.Abetterunderstandingofpoultrytradenetworkswillaidin
developinginterventionstostopthespreadofvirusinareaspronetosustainedtransmission
throughdomesticpoultrypopulations.
PoultryTradeNetworkAnalysis,Kenya
Tisstudyisbeingconductedtounderstandthenationalpoultrytradenetworksothattimely
andeectiveinterventionscanbeimplementedinthecaseofanavianinuenzaoutbreak.
Approach
JointprojectwithU.S.CDCandtheDepartmentofVeterinaryServices,Kenya.Extensive
interviewswithpoultryowners,sellers,andmarketworkersareconductedtounderstandtrade
network.
Timeline
Testudystartedin2008andwillconcludein2009.
Teanalysisisongoing.Areportisexpectedinlate2009.
LiveBirdMarketSurveillance,Kenya
Tepurposeofthisprojectistounderstandtheprevalenceanddistributionofcirculatingavian
inuenzavirusesinmarketsinNairobiandNakuru,Kenya.
267
Approach
IncollaborationwiththeDepartmentofVeterinaryServices,asamplingofmarketbirdsisdone
monthlyatthesame5markets.TestingwillbeperformedattheCDC-KenyaIEIPlaboratory,
DVSlaboratories.
Timeline
TestudystartedMarch2009andisplannedfor2years.
AwaitingtestingatnewavianBSL-3laboratoryinKisumu(expectedtobefunctional
November2009).
Nigeria
SurveyofKnowledge,Attitudes,andPracticesRelatedtoReportingofSuspect
HumanCasesofAvianInfuenzaandOtherNotifableInfectiousDiseasesin
Nigeria
AnoutbreakofhighlypathogenicavianinuenzaH5N1inpoultrywasdetectedinNigeriain
January2006withcontinuedsporadicreportsofoutbreaksinbirds.InJanuary2007,the1st
humancaseofavianinuenzaH5N1wasidentied.Abroadrangeofpublichealthresponse
andcontrolmeasureswereundertakeninresponsetothisthreat,includingstrengtheningthe
detectionandreportingofprioritydiseases,suchasavianinuenza.
Approach
Tounderstandthebarrierstocompleteandtimelyreportingofprioritydiseasesbyhealthcare
workers,asurveyofphysiciansworkingaturbanpublichospitalsisbeingconductedin6large
citiesinNigeria.Teknowledge,attitudes,andpracticesofthesephysiciansrelatedtotheir
reportingofhumanavianinuenzainfectionsandotherprioritynotiableinfectiousdiseaseswill
beevaluated.Tesourcesofinformationandtypesofinformationtechnologythatphysicians
routinelyusetoacquirenewmedicalandpublichealthknowledgewillalsobeassessedtoimprove
eortstoeectivelydisseminatepublichealthcommunicationsintendedforphysicians.
Peru
OccupationalExposuretoZoonoticInfuenzainPeru
Inaneorttobetterunderstandtransmissionofzoonoticinuenzatohumansafterintense
occupationalexposuretoswineandavianspecies(i.e.,backyardpoultry,backyardswine,formal
andformalpoultryandswinefarmers,slaughterhouses,livebirdmarkets,game-birdbreeders),
wewillconductaprospective,3-yearcohortstudyoftransmissionofzoonoticinuenzaamong
1,500adultsexposedtoswineandbirds.
Teobjectivesofthestudyaretodeterminetheprevalenceofantibodiestoavianandswine
inuenzaamonghumans,particularlyagainstthosestrainsthathavebeenshowntopossessthe
abilitytocrossthehuman-avian-swinespeciesbarrier;estimatetheincidenceofzoonoticinuenza
infection;determineriskfactorsforzoonoticinuenzainfection;studythepresenceofinuenza
infectionamongswine;anddeterminewhichinuenzastrainsarecirculatinginthesepopulations.
268
Approach
TestudywillbeconductedinareasofPeruwithlargeconcentrationsofpotentiallyexposed
humans.Questionnairesandserumcollectionsfromparticipantswillbeobtainedat0,12,24,
and36months.Activesurveillanceforinuenzavirusinfectionsamonghumanparticipants
andrelatedanimalpopulationswillbeperformed.Duringtheactivesurveillance,ifparticipants
developILI,theywillbeaskedtoseekmedicalattentionwithin48hoursofsymptom
developmentatspecicmedicaltreatmentfacilitieswhereamedicalworkerwillcollect2
pharyngealswabsforvirusdetectionandcollectepidemiologicinformationfromparticipants.
Serologicassays,RT-PCR,viralisolation,andnucleicacidsequencingwillbeusedtoidentify
circulatinginuenzastrains.Withabetterunderstandingoftransmissionofzoonoticinuenza
inthesespecicpopulations,pandemicplanningcanbestrengthenedbyincludingmeasures
thatwillpreventinuenzatransmissionwithinthispopulationandtoothergroupsatrisk.
MonitoringofAvianInfuenzainWildBirds,Peru
Migratorywaterfowlarecurrentlyconsideredtobetheprimaryreservoirsforavianinuenza
viruses.AlthoughinuenzasurveillanceinwildbirdshasbeenoccurringinEurope,North
America,Asia,andAfrica,fewactivitiesarepresenttodateinSouthAmerica.
Approach
TodeterminegenotypesofavianinuenzacirculatingamongwildbirdsinSouthAmerica,we
havebeencollectingenvironmentalfecalsamplesfrom5wetlandsalongthecentralcoastof
PerusinceJune2006.
Todate,wehavecollectedandtested6,587fecalsamplesandhaverecovered21AIisolates,
representing9dierentstrains(7dierenthemagglutininand6neuraminidases).
SurveillanceforAvianInfuenzainLiveBirdMarketsofPeru
AIandotheraviandiseasesinbirdsinPeruvianwetmarketsandthoseseizedduring
governmentconscationsarecurrentlybeingtested.Tiswillallowustoassessthepotential
directthreatofAIandotherzoonoticdiseasestohumans,aswellastolivestock,inthese
settings.Tisstudyincludeswild-caughtbirds(forexportationandsaletopetmarkets),exotic
cagedbirds,anddomesticavianspecies.PreviousstudieshaveshownthatwildbirdsinPeru
mayserveascompetentreservoirsforinuenzastrains.TeriskofAItransmissionmayincrease
ifthesewildbirdsarehousedalongwithdomesticpoultryorotherdomesticspecies,suchas
swine.
Approach
Allsamplesarecollectedwiththeconsentofthebirdseller.Trachealandcloacalswabsare
collectedforviralisolationineggculture.PositiveisolatesarefurtheranalyzedbyRT-PCR,
followedbysequencingforconrmationandmolecularcharacterization.
Todate,birdsfrom16livebirdmarkets(in7Peruviancities)arebeingmonitoredandsampled.
Morethan1,700samples(oral,cloacal,andfecalswabsandfeces)havebeenobtainedfrom630
birds.Nonehavebeenpositive(n=793)forAI;however,18havebeenpositiveforNewcastle
disease(Paramyxovirustype1).
269
Knowledge,Attitudes,andPracticesaboutAvianInfuenzainWildBirdsand
PoultryHoldersatPeruvianWetMarkets,Peru
Wetmarkets,alsoknownasliveanimalmarkets,provideoptimalconditionsforthe
amplicationandtransmissionofdiseaseagents,suchasavianinuenza.Suchmarketsare
quitecommonindevelopingcountriesofAsiaandSouthAmericaandarecharacterizedby
thepresenceofanimalsindenselypackedcageswithpoorhygienicconditions.Inaddition
towildbirds,localpopulationsoftenbringdomesticallyraisedpoultrytomarketplacesfor
saleorslaughter.Furthermore,illegaltradeofwildbirdsatwetmarketsintroducesnewand
poorlystudiedpotentialrisks.Teaimsofthisstudyaretoassesstheknowledge,attitudes,and
practicesofwildbirdhandlersandpoultryworkersregardingAI,andtoestablishbaselinedata
inordertodevelopeducationalandpreventiveinterventionmethodsinthispopulation.
Approach
Tepopulationunderstudyincludeswildbirdhandlersandpoultryworkersworkinginwet
marketsin7citiesincoastalandrainforestregionsofPeru(i.e.,Pucallpa,Piura,Ica,Tumbes,
Lima,Iquitos,Chiclayo).Aninformationsheetexplainingallthestudyproceduresisgiventoall
participantsbeforerecruitment.Allparticipantsareaskedaboutsociodemographicinformation,
generalknowledgeaboutavianinuenzatransmissionandprevention,aswellasattitudesand
practicesrelatedtoholding,slaughtering,andmanagementofhealthy,ill,anddeadbirds.
InfuenzaViralSurveillanceinSwinePopulationsofPeru
Pandemicinuenzaviruseshavebeentheproductofthereassortmentofcirculatinghuman,
avian,andswineinuenzastrains.Pigsareoftenblamedasmixingvesselsbecausetheseanimals
mayserveashostsforproductiveinfectionsofavian,swine,andhumanviruses.Tegoalofthis
studyistodeterminethedierentstrainsofinuenza(swine,avian,andhuman)circulatingin
Peruvianswinepopulations.
Approach and Timeline
Weareperformingaserologicandvirologicsurveillancetomonitorandstudyinformal
(backyard)andformal(mechanized)swinefarmsandslaughterhouses.Studiesarebeing
conductedinmultiplelocationsinPeru(i.e.,Tumbes,Cuzco,Lima,PuertoMaldonado).Tis
studyusesinfrastructureandworkforcethathavealreadybeenestablishedbyotherNMRCD
studies.Nasalandtrachealswabsandblood
samples(antibodydetection)willbecollected
frompigs3timesayearfromMarch2009to
December2010.RT-PCR,viralculture,and
nucleicacidsequencingwillbeusedtoidentify
circulatingstrainsofinuenza.
Todate,noinuenzaisolateshavebeen
recoveredfrom300slaughteredpigsfrom
Tumbes.Serologicresultsarepending.
270
InfuenzaCooperativeResearch
attheAnimal-HumanInterface
In2006,ve3-yearcooperativeagreementswereinitiatedtoestablishasetofresearchprojects
relatedtodetecting,preventing,andcontrollingzoonoticinuenza.Teagreementsprovidea
moreintegratedpublichealthresponsetoavianandswineinuenzaoutbreaksbyhumanand
veterinaryhealthservices.CollaboratorsincludedColoradoStateUniversity,theUniversity
ofMinnesota,theUniversityofGeorgia,theNationalInstituteofPublicHealthandthe
Environment(TeNetherlands),andMahidolUniversity(Tailand).
ColoradoStateUniversity
Tegoalsofthisstudyaretounderstandbetterthetransmissionofavianinuenzainsmallbird
ocksintheUnitedStatesandIndonesiaandtoassessthepotentialriskforinfectionofpeople
interactingwiththesebirds.AsurveyofbackyardocksinurbanColoradowasperformed
tounderstandthesizeofbackyardchickenandduckocksandthecharacteristicsofock
ownershipinurbanareas.Teresultsofthisresearchwillbecombinedwithdemographic
informationandusedtodevelopamodeltopredictthespreadofavianinuenzaintheseareas.
Anationwidesurveyofuplandgamebirdfacilitiesisbeingperformedtounderstandock
characteristics,husbandrypractices,diseasemanagement,movement,andbiosecuritypractices.
Characteristicsofhuman-to-birdinteractionswillalsobeexamined,andthisinformation
willbeusedtoevaluatethepotentialroleofthisbirdpopulationduringanoutbreakofavian
inuenzaintheUnitedStates.AdditionalresearchisbeingperformedinIndonesiatoexamine
theprevalenceofhighlypathogenicavianinuenzainducksraisedunderdieringmanagement
systemsandtoevaluatetheinteractionsoftheseduckswithotherpoultry,wildbirds,and
humans.
UniversityofMinnesota
Tegoalsofthisresearcharetoevaluateavian,swine,andhumaninuenzavirustransmission
atthehuman-animalinterface.Inordertoaccomplishthisgoal,studiesareongoingin
severalhumanandanimalpopulations.Surveillanceforavianinuenzaisbeingconducted
amongbackyardpoultryocksandtheirhandlersinMinnesotaandWisconsin.Surveillance
isalsoongoingamonganurbanwildgeesepopulationinMinnesotaandthehuman
recreationalusersoftheirhabitat.Swineinuenzavirussurveillanceisconductedtodetectand
characterizeinuenzaAvirusesfrompigsandpeoplewhoworkwiththemincommercialand
noncommercialoperationsintheMidwest.TissurveillanceisoccurringwhereinuenzaA
virushasbeendetectedinpigsandwherehumancasesofILIhavebeenreported.
InTailand,theprevalenceandviralsheddingofinuenzavirusisalsobeingassessedin4rural
villageswherehighlypathogenicavianinuenzahasbeenpreviouslydetected.Teinformation
fromthesestudieswillbeusedtoidentifyfactorsthatfacilitatevirustransmissionfromanimals
tohumans,tocharacterizehumanillnesscausedbyavianandswineinuenzaviruses,andto
assesstheuseandeectivenessofinterventionsthatinterrupttransmissionofinuenzaviruses
fromanimalstohumans.
271
UniversityofGeorgia
Teriskofhumaninfectionwithavianinuenzavirusfromanenvironmentalsourceisnot
wellunderstood.Tounderstandthatrisk,studiesareunderwaytoestimateavianinuenza
virusloadsassociatedwithenvironmentalsourcesofpotentialpublichealthsignicance
andtoidentifyfactorsthatmayenhanceorlimitpersistenceoftypeAinuenzavirusesin
theseenvironmentalsources(i.e.,surfacewater,environmentalsurfaces,feces,carcasses).A
quantitativeriskassessmentofthepublichealthriskassociatedwithenvironmentalsources
ofavianinuenzawillbeperformed,andriskforexposuretothehumanpopulationfrom
environmentalsourcesofavianinuenzawillbecharacterizedtodeterminetheexposure
pathways,likelyexposureamounts,andfrequencyanddurationofexposure.Transmission
studieswillalsobeperformedinferretsandcatstoexaminethepotentialriskofhuman
exposurefromthesespecies.
NationalInstituteofPublicHealthandthe
Environment(TheNetherlands)
AnepidemicofhighlypathogenicavianinuenzavirussubtypeH7N7occurredinthe
Netherlandsin2003atcommercialpoultryfarms.Duringthisoutbreak,89conrmedhuman
casesofavianinuenzawereidentiedamongpoultryworkersandtheirfamilies,including
1death.Tisstudywillfurtherevaluatethisoutbreakofavianinuenzavirusinhumans.
Researcherswillestimatethelevelofvirusexposurefrompoultrybystudyingthedynamicsof
avianinuenzaintheock.Additionalmethodswillbeusedtoevaluatetransmissionofavian
inuenzasubtypeH7N7tohumans,andthisinformationwillbeusedtoidentifyactivities
associatedwithincreasedriskforinfectionofavianinuenzavirusinfectioninhumans.
MahidolUniversity(Thailand)
Since2004,outbreaksofhighlypathogenicavianinuenzavirusH5N1haveoccurred
frequentlyinbirdsinTailand,andnumeroushumancaseshavebeenidentied.Tegoalsof
thisresearcharetounderstandtheincidenceandprevalenceofavianinuenzavirusinfectionin
birds,humans,andotheranimalsinTailand,andtoassessthetransmissionofavianinuenza
topeopleexposedtohumans,birds,orotheranimalsinfectedwithavianinuenzaviruses.To
determinetheroleofmigratorybirdsinthetransmissionofavianinuenzavirus,themigratory
routesofopen-billedstorksandlesserwhistlingducksandgullsinandoutofTailandare
beingevaluatedbytheuseofsatellitetelemetry.Teprevalenceofavianinuenzainthese
birdsandinnonmigratorybirds,otheranimals,andhumanswhoshareahabitatwithtracked
migratorybirdsisbeingmonitored.Inaddition,theprevalenceofavianinuenzainpoultryin
theareawhereavianinuenzahasbeenfoundinmigratorybirdsisunderstudy.Tediversity
andphylogenyofavianinuenzavirusesisolatedinTailandduringthestudyisalsobeing
evaluated.
272
MolecularEpidemiology
LaoPDR
ProflingTemporalandSpatialPhylogenicEvolutionofHPAI
InLaos,theU.S.CDCexpertswillassisttoestablishrst-timesequencingcapabilitiesinclade
molecularcharacterizationwhenprolingthetemporalandspatialphylogenicevolutionof
HPAI.TisactivityhasbeendelayedbecauseofU.S.CDCsfocusonpandemic2009H1N1
inuenza.Nevertheless,thisactivitywillbecarriedoutinFY2010.
Proposed Timeline
VisitbyU.S.CDCteamtoreviewsequencinginformation(July2010).
TrainingofstafromNationalCenterforAnimalHealth(NCAH)andNCLEin
AtlantatocarryoutsequencingwithisolatesfromLaos(November2010).
Installationofnew(unused)sequencingmachineatNCAH(February2011).
Publication(May2011).
273
274
U.S.CDCsThreatReduction
Collaboration
TeU.S.CDCsInuenzaDivisionandtheDepartmentofStatesOceofCooperativeTreat
Reduction(CTR)collaboratedin2007.TeCTRisanocelocatedintheU.S.Department
ofStateandworkstoenhanceglobalhealthsecurityandfostersafe,secure,andsustainable
biosciencecapacitydevelopment.TeCTRaccomplishesthisthroughjointscienticwork,
prevention,detection,andresponsetobiologicthreatsandcapacitybuildinginnationsand
regionswhereterrorism,highinfectiousdiseaseburden,proliferationofbiotechnology,andhigh
containmentbiologyfacilitiescoexist.TeultimategoaloftheCTRistofosterlong-termU.S.
engagementwithforeigngovernmentsandinternationalorganizationstoharmonizebiologic
safetyandsecuritybestpracticeguidelines.
Troughthecollaboration,whichwasdevelopedin2007,theCTRhasprovidedfundsforthe
InuenzaDivisiontosupplementcooperativeagreementsincountrieslocatedintheEMRO,
namelyAfghanistan,Morocco,andPakistan.TeCTRhasassistedtoimprovelaboratory
capacitybyprovidingfundsforlaboratoryequipmentandtraining.Tecollaborationprovided
nancialassistancetocountieswithcooperativeagreementsandtechnicalassistancetocountries
relatedtobiosecurityandbiosafety.TeCTRhasgraciouslyagreedtoassistcountriestoensure
qualitybiosafetyandbiosecurityinlaboratoriesintheMiddleEastandNorthAfrica.
TroughtheirworkwiththeseEMROcountries,theCTRidentiedaneedtohavethe
Biosafety in Microbiological and Biomedical Laboratories,5
th
Edition(BMBL)translatedintothe
predominantlanguagesusedinthesecountries.TroughaninteragencyagreementwithU.S.
CDCsInuenzaDivision,theBMBLdocumentwastranslatedintothefollowinglanguages:
Arabic,Bahasa,French,Mandarin,Spanish,Tai,andUrdu.Tesetranslationsrepresentthe
languagesspokeninmanyofthecountrieswithwhomtheCTRprovidesnancialortechnical
assistance.TeInuenzaDivisionandtheCTRarehopefulthesetranslationswillprovidethe
basistoimprovebiosafetypracticeandpolicyforlaboratoryworkers.
275
InfuenzaBurdenofDiseaseWorkshopandVaccine
EffectivenessMeeting,Bangkok,2009
DuringAugust2628,2009,theInuenzaDivisionsponsoreda3-dayworkshopinBangkok,
Tailand,withmorethan40participantsfrom15countries:Bangladesh,Cambodia,China,
India,Indonesia,Laos,Mongolia,Nepal,Philippines,Senegal,SouthAfrica,SriLanka,
Tailand,UnitedStates,andVietnam.U.S.CDCstafromtheInuenzaDivisionandthe
InternationalEmergingInfectionsProgramwerealsoinattendance.
Tegoalsofthemeetingweretoreviewtheneedforcountry-leveldiseaseburdenestimation,to
presentburdenofdiseaseestimatesfrompartnersinattendanceandtodiscusstheapplicationof
theseestimatesininformingvaccination,particularlyinthecontextofpandemic2009H1N1
inuenza.
Majortopicsaddressedincluded
Diseaseburdeninthecontextofpandemic
2009H1N1inuenza.
Lessonslearnedfromotherglobaldisease
programs.
Technicalconsiderationsinestimating
inuenzadiseaseburden.
Country-basedexamplesfordierent
methodsofdiseaseburdenestimation.
Presentationofsurveillancedataand
nationaldiseaseburdenestimates.
Currentandfuturevaccineeectiveness
studies.
Tenextburdenofdiseasemeetingwillbeheld
July2010inAtlanta,Georgia.
276

LaboratoryTrainingandResearch
Training
TeInuenzaDivisionandpartnershaveledthedevelopmentanduseoftrainingmodulesfor
improvedinfectioncontrolpracticesinhealthcaresettingsandfocusedonreducingrespiratory
diseasetransmissioninhospitals.TetrainingprogramwasdevelopedbyTailandIEIP/GDD
staincollaborationwiththeREDICenter,Singapore,andJhpiego.
ImmunologyandPathogenesisBranch
InternationalcollaborationwithHuanNguyenattheInternationalVaccineInstitute,Seoul,
Korea,andscientistsattheNationalCenterforVeterinaryDiagnostics,DepartmentofAnimal
Health,Hanoi,Vietnamtotesttheprophylacticandtherapeuticeectivenessofavian
antibodiesagainstpandemicinuenza.
Passiveimmunization(thetransferofantigen-specicantibodiestoapreviouslynonimmune
recipienthost)oersanalternativestrategytopreventandtreatinuenzavirusinfections.Even
aftertargetedvaccinesbecomeavailable,passiveimmunizationcouldstillhaveaprophylactic
eectandprovideanadditionalcountermeasureagainstinuenza.Chickensproduceaunique
immunoglobulinmoleculecalledIgYthatisfunctionallyequivalenttomammalianIgG.IgYis
foundintheseraofchickensandispassedfromhenstotheembryoviatheeggyolk.EggIgY
hasbeenusedtopreventbacterialandviralinfectionsofthegastrointestinaltractandrecentlyfor
protectionagainstPseudomonas aeruginosa infectionoftherespiratorytractofpatientswithcystic
brosis.However,theprophylacticandtherapeuticeectivenessofIgY(isolatedfromeggsofhens
immunizedwithH5N1virusvaccine)againstinuenzavirusinfectionhasnotbeentested.
TeepidemicofHPAIH5N1virushasresultedinseriouseconomiclossestothepoultry
industry,mostlyinSoutheastAsia.Terefore,manycountries,includingChina,Indonesia,
Tailand,andVietnamhaveintroducedmassvaccinationofpoultrywithH5N1virusvaccines
thatcontroltheH5N1epidemictosomeextent.Inthiscollaboration,theeectivenessof
chickenIgYantibodiesisbeingexaminedagainstH5N1virus.Wefoundthatmarketedchicken
eggsinVietnam,wheremasspoultryvaccinationagainstH5N1virusismandatory,contain
highlevelsofvirus-specicIgYthatprovideprotectionagainstandtherapyofH5N1virus
infectionsinmammals.Virus-specicIgYoerspotentiallyinexpensive,yethighlysafeand
eective,alternativesforpreventionandtreatmentagainstpotentialH5N1pandemicstrains.
LiboDongInternationalEIDFellowwiththe
PandemicPreparednessTeamintheImmunology
andPathogenesisBranch
LiboDong,anInternationalEIDfellow,beganherfellowshiponOctober16,2008with
thePandemicPreparednessTeam,ImmunologyandPathogenesisBranchoftheInuenza
DivisionatU.S.CDC.ShecomesfromtheNationalInuenzaCenter,VirusDiseaseControl
andPreventionInstituteatCDC-ChinainBeijingwheresheworkedwiththeavianinuenza
surveillancegroup.LibosmentoratCDC-ChinaisXiuhuaLu.TepurposeofLibosfellowship
istoprovidetrainingonserologicalassaysusedforinuenzaserodiagnosis,onferretandmouse
animalmodelsofinuenzainfection,andontechniquesforworkingwithhighlypathogenic
avianinuenzaviruses.TroughLibosfellowship,wewillbetransferringtechnologytoChinas
NationalInuenzaCenterandstrengtheningthetiesbetweenthe2institutions.
277
ByMarch,2009,Libowasanexpertinthemicroneutralizationandhemagglutinationassaysfor
inuenzaserodiagnosis.HerpartinthePandemicPreparednessTeamsresponsetotheemerging
H1N1pandemicinApril,May,andJunewascrucial.Teseearlystudiesofcross-reactive
neutralizingantibodiesresultedin2publications;1inMorbidityandMortalityWeeklyReport
andtheotherintheNewEnglandJournalofMedicine.Libocontinuestoplayakeyroleinour
evaluationoftheantibodyresponsetothepandemicvirus.
UnderLusguidance,LiboandFengLiuhavedevelopedmethodstodeterminethespecicityof
theantibodyresponsetothepandemicvirus.Atthesametime,LiboisworkingalongsideU.S.
CDCexpertsinanimalmodelsofinuenza,learningtechniquesandprocedures.Liboreturns
toCDC-ChinainMarch,2010.
Laboratory Training Table
Month/ Country Institute Location Infuenza TrainingType
Year Division
Laboratory
Oct2008 Nigeria HHS/CDCNigeria Atlanta,GA Immunology SerologyTraining:
andPathogenesis Microneutralizationandhorse
Branch RBCHIassayforthedetection
ofneutralizingantibodiesto
inuenzaviruses.
Oct2008 Ghana NoguchiMemorial Atlanta,GA Immunology SerologyTraining:
InstituteforMedical andPathogenesis Microneutralizationandhorse
Research,Universityof Branch RBCHIassayforthedetection
Ghana ofneutralizingantibodiesto
inuenzaviruses.
Oct2008 Uganda UgandaVirusResearch Atlanta,GA Immunology SerologyTraining:
Institute andPathogenesis Microneutralizationandhorse
inuenzaviruses.
Oct2008 Morocco NationalInstituteof Atlanta,GA Immunology SerologyTraining:
Health andPathogenesis Microneutralizationandhorse
inuenzaviruses.
FebMar NationalCenter Vietienne, VSDB Diagnosisofinuenza
2009 forLaboratoryand Laos infections
Epidemiology,Ministryof
Health
Mar2009 Cambodia NationalInstituteof Phnom VSDB Diagnosisofinuenza
PublicHealth,Ministryof Penh, infections
Health Cambodia
Mar2009 Tailand ArmedForcesResearch Bangkok, VSDB Diagnosisofinuenza
InstituteofMedical Tailand infections
Sciences(AFRIMS)
Apr2009 Egypt NAMRU-3 Cairo,Egypt MolecularVirology Geneticsequencingofinu-
andVaccines enzaviruses
Branch
JunJul Chile MinistryofHealthISP Chile MolecularVirology Diagnostics
2009 andVaccines
Branch
Aug2009 Kenya NationalInuenzaCenter Nairobi, VSDB Diagnosisofinuenza
Egypt infections
AugSep Mexico LaboratoriodeVirus MexicoCity VSDB Diagnosisofinuenza
2009 Respiratorios Infections
278
LaboratoryCapacityBuildingandTechnicalAssistancetoNAMRU-3,Cairo,Egypt
Twosta.
Ongoingcollaborationtoprovidetechnicalassistance(diagnostic/sequencing)to
internationalcounterpartsperformedatCDC-Atlanta.
Nodaysspentoverseasforgloballaboratorycapacitybuilding.
LaboratoryCapacityBuildingandTechnicalAssistancetotheNationalCenterforVeterinary
Diagnostics,DepartmentofAnimalHealth,Hanoi,Vietnam
Twosta.
Ongoingcollaborationtoprovidetechnicalassistance(diagnostic/sequencing)to
internationalcounterpartsperformedatCDC-Atlanta.
TechnicalAssistancetoCEMICUniversityHospital,BuenosAires,Argentina
Afull-timestamemberfor1week.
Fivedaysprovidingtechnicalassistance(diagnostic/sequencing)tointernational
counterpartsperformedatU.S.CDC.
LaboratoryCapacityBuildingandTechnicalAssistancetotheChileanMinistryofHealthfor
pandemic2009H1N1InuenzaResponse
Afull-timestamemberfor4weeks.
Atotalof20daysspenttraininginternationalcounterpartsinlaboratoryactivities
(in-country).
Atotalof28daysspentoverseasforgloballaboratorycapacitybuilding.
LaboratoryCapacityBuildingandTechnicalAssistancetoIstitutoZooprolatticoSperimentale
delleVenezie,Padua,Italy
Onestamember.
Atotalof10weeksoftrainingtoprepareprepandemicinuenzacandidateseedviruses
performedatCDC-Atlanta.
279
280
Infuenza
DivisionStaff
InfuenzaDivisionStaff
EduardoAzziz-Baumgartener,MD,MPH
MedicalOcerEpidemiologist
InuenzaDivision,EpidemiologyandPreventionBranch
InternationalEpidemiologyandResponseTeam(IERT)
Dhaka,Bangladesh
eha9@cdc.gov
JoeBresee,MD,FAAP
BranchChief
Atlanta,Georgia
jsb6@cdc.gov
AndrewCorwin,PhD,Captain(ret.)USN
InternationalEpidemiologyandResponseTeam
U.S.Embassy
Vientienne,Laos
corwin2e@yahoo.com
NancyCox,PhD
Director
InuenzaDivision
WHOCollaboratingCenterforSurveillance,EpidemiologyandControlofInuenza
Atlanta,Georgia
njc1@cdc.gov
RichardDavis,MSFS
ProjectOcer,AfricaRegion
InuenzaDivision,ExtramuralProgramsOce
Atlanta,Georgia
tzd6@cdc.gov
MichaelDeming,MD
Cairo,Egypt
Msd1@cdc.gov
DavidDennis,MD,MPH
MedicalOcer(retiredAugust2009)
Hanoi,Vietnam
283
RubenDonisDVM,PhD
Chief
MolecularBiologyandVaccinesBranch
Atlanta,Georgia
rvd6@cdc.gov
AliciaFry,MD,MPH
Atlanta,Georgia
agf1@cdc.gov
PatrickGlew,MPH
Epidemiologist
Atlanta,Georgia
ftm0@cdc.gov
DianeGross,DVM,PhD
Atlanta,Georgia
bwc3@cdc.gov
InzuneHwang,MD,MPH
Atlanta,Georgia
IHwang@cdc.gov
Brian(BK)Kapella,MD,MPH
Hanoi,Vietnam
bk.kapella@cdc.gov
MarkKatz,MD
GlobalDiseaseDetectionOce
Nairobi,Kenya
284
PamelaKennedy
DataBaseDeveloper
ExtramuralProgramOce
Atlanta,Georgia
lux5@cdc.gov
JamesC.Kile,DVM,MPH,DACVPM
Chief,Animal-HumanInterfaceInitiative
Hanoi,Vietnam
KileJC@vn.cdc.gov
JaclynKing,MPH
Epidemiologist
Atlanta,Georgia
hsn8@cdc.gov
AlexanderKlimov
Chief
VirusSurveillanceandDiagnosticBranch
DeputyDirector
WHOCollaboratingCenterforSurveillance,EpidemiologyandControlof
Inuenza
Atlanta,Georgia
axk0@cdc.gov
PaulKitsutani,MD,MPH
Cambodia
KitsutaniP@kh.cdc.gov
KathrynLaFond,MPH
Epidemiologist,ORISEFellow
Atlanta,Georgia
gmj3@cdc.gov
JacquelineKatz,PhD
BranchChief
ImmunologyandPathogenesisBranch
Atlanta,Georgia
jmk9@cdc.gov
285
NivaldoLinaresPerez,MD,MScPhD
CC/CAPGlobalDiseaseDetectionOce
Guatemala
nlinares@gt.cdc.gov
RenuLal,PhD,MSc
InuenzaDivision,ViralSurveillanceandDiagnosticsBranch
U.S.Embassy
NewDehli,India
rbl3@cdc.gov
StephenLindstrom,PhD
TeamLead
sql5@cdc.gov
FrankMahoney,MD
MedicalOcer
U.S.Embassy
Jakarta,Indonesia
fm2@cdc.gov
MarinaMangerCats,MD,MPH
HumanInuenzaCoordinator,CTSGlobal,Inc.
CDC-SouthAfrica
Margaret(Meg)McCarron,MPH
Epidemiologist
Atlanta,Georgia
dme8@cdc.gov
JereyMcFarland,MD
U.S.CentersforDiseaseControlandPrevention
Beijing,China
jwm5@cdc.gov
286
JenniferMichalove,MPH
Epidemiologist,ORISEFellow
Atlanta,Georgia
AnnMoen,MPA
AssociateDirectorforProgram
Atlanta,GA
alc3@cdc.gov
JoelMontgomery,PhD
NMRDU.S.Embassy
Lima,Peru
joel.montgomery@med.navy.mil
JohnS.Moran,MD,MPH
InuenzaAdvisor
CDCCentralAsiaRegionalOce
Almaty,Kazakhstan
jsm4@cdc.gov
JoshuaMott,MA,EMT-P,PhD
WHOEuropeanRegionalOce
Copenhagen,Denmark
zud9@cdc.gov
AnthonyMounts
WHOHeadquarters
Geneva,Switzerland
apm8@cdc.gov
TallaN.Nzussouo,MD
U.S.CentersforDiseaseControlandPrevention
Legon,Ghana
tallus5@yahoo.frornnzussouo@noguchi.mimcom.org
287
SarahOBrien,MFA
MeetingCoordinator
InuenzaDivision,ExtramuralProgramOce
Atlanta,Georgia
Iwr7@cdc.gov
SonjaJ.Olsen,PhD
U.S.Embassy
Bangkok,Tailand
SOlsen@cdc.gov
TammyOtober
SeniorProgramAnalyst,CarterConsulting,Inc
Atlanta,Georgia
tdo6@cdc.gov
TomasRodriguez,MA
ProjectOcer
Atlanta,Georgia
trr0@cdc.gov
ProjectOcer
InuenzaDivision,ExtramuralProgramOce
Atlanta,Georgia
zen3@cdc.gov
DavidShay,MD
Atlanta,Georgia
dks4@cdc.gov
KarenSiener,MPH
ProjectOcer
Atlanta,Georgia
khs3@cdc.gov
288
MarkSimmerman,PhD,RN
MedicalOcerEpidemiologist(retiredApril2010)
U.S.Embassy
Bangkok,Tailand
NicoleSmith,PhD,MPH,MPP
WHOVietnamCountryOce
Hanoi,Vietnam
nbs8@cdc.gov
VashoniaSmith,MPA
ProjectOcer
Atlanta,Georgia
vdw8@cdc.gov
StefanoTempia,MD
Epidemiologist
CDC-SouthAfrica
tempias@sa.cdc.gov
TeresaTurski,MPH
ProjectOcer
Atlanta,Georgia
tnt7@cdc.gov
TimUyeki
Atlanta,Georgia
tmu0@cdc.gov
J.ToddWebber
EuropeanCentersforDiseaseControlandPrevention
jtw5@cdc.gov
289
SuzanneWestman,MD,MPH
MedicalOcer
WHOSoutheastRegionalOce
India
suw4@cdc.gov
Marc-AlainWiddowson,DVM,MS
TeamLead,InternationalTeam
Atlanta,Georgia
zux5@cdc.gov
TomasWierzba,PhD,MPH
Epidemiologist
NAMRU-2
Cambodia
tqw@cdc.gov
XiyanXu,MD
TeamLead
Atlanta,Georgia
WilliamE.Brady,MPH,PA
Epidemiologist
Atlanta,Georgia
web0@cdc.gov
290
CS207000

International Influenza Book

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

International Influenza Book

Caricato da

Copyright:

Formati disponibili

The Infuenza Division

SARI Surveillance Program

Capital: Lima InfantMortalityRate:Total:29.53deaths/1,000

OnApril28,2009,theNational Action Plan for Preparedness Response to Pandemic

Progress and Initial Conclusion

Potrebbero piacerti anche