As the cold and flu season approaches and as concerns about avian flu rise, workplace preparedness is lagging behind, according to a survey from Kimberly-Clark Professional.
Seventy percent of respondents said they believed avian flu was likely
to hit North America, but only 25 percent responded "yes" when asked, "Has
your company engaged in building a plan in the event of an actual outbreak
of the avian flu?" Forty percent expressed concern about an avian flu
outbreak in their workplace.
Respondents were given a list of possible actions employers could take
to minimize workplace risk associated with avian flu outbreak and were
asked to give their opinion as either in "favor" or "opposed." Posting
respiratory etiquette and hand-washing posters or stickers garnered the
most positive responses, with 93 percent of respondents saying they favored
posting these in common areas. This was followed by:
-- Maintaining lists of health-related websites, telephone numbers and
other resources for senior leadership or building management personnel
(89 percent).
-- Training workers in the proper use of protective equipment (87
percent).
-- Establishing an emergency plan or kit to identify and treat avian flu
symptoms (86 percent).
-- Establishing a workplace continuity plan (85 percent).
-- Storing protective masks, gloves, hand sanitizer and other materials
in bulk (79 percent).
-- Installing a verbal reminder system to encourage hand washing (75
percent).
-- Encouraging people to work from home when possible (49 percent).
The national, online survey was conducted in May and polled employees
in health care, science, manufacturing, office buildings, lodging and other
industries. Kimberly-Clark Professional issued the voluntary, nonrandom
survey using its own industry e-newsletter and received 379 responses.
Avian Flu Resources Available Online
To help its customers maintain business continuity in the event of an
avian flu pandemic, Kimberly-Clark Professional has developed a wealth of
resources and information, including Frequently Asked Questions (FAQs) and
answers, downloadable posters, business continuity and preparedness
information, pamphlets and other materials. The Kimberly-Clark Professional
web site also contains links to avian flu information, safety
recommendations and checklists from the Centers for Disease Control (CDC),
the World Health Organization (WHO), the National Institute of Health
(NIH), the International Food Safety Authorities Network (INFOSAN), and
other health and safety organizations. Information is also available on
personal protection items for healthcare providers, laboratory workers,
farm workers and food handlers. More information is available at
kc-safety/avianflu.
About Kimberly-Clark Professional
Kimberly-Clark Professional offers a range of well-known brands and
product solutions for workplace settings, Do-It-Yourselfers (DIY) and away-
from-home washrooms. Kimberly-Clark Professional workplace products include
safety apparel, gloves and related accessories as well as task-engineered
wipers for both "clean" and "dirty" manufacturing environments. DIY and
professional contractor products include solutions for home improvement and
automotive projects that make fixing up and cleaning up fast, easy and
efficient. Known for innovative, quality solutions, Kimberly-Clark
Professional's pioneering products include Coreless Bath Tissue, JRT(R)
Bath Tissue, the KIMCARE(R) ALL-N-1 Skin Care System and KIMTECH(R) Wipers.
Kimberly-Clark Professional's well-known brands include KLEENEX(R),
SCOTT(R), WYPALL(R), KIMTECH(R), KLEENGUARD(R) and KIMCARE(R).
Kimberly-Clark Professional, located in Roswell, Ga., is one of
Kimberly-Clark Corporation's (NYSE: KMB) four business segments and can be
visited on the web at kcprofessional.
About Kimberly-Clark
Kimberly-Clark and its well-known global brands are an indispensable
part of life for people in more than 150 countries. Every day, 1.3 billion
people - almost a quarter of the world's population - trust K-C brands and
the solutions they provide to enhance their health, hygiene and well being.
With brands such as KLEENEX(R), SCOTT(R), HUGGIES(R), PULL-UPS(R), KOTEX(R)
and DEPEND(R), Kimberly-Clark holds the No. 1 or No. 2 share position in
more than 80 countries. To keep up with the latest K-C news and to learn
more about the company's 134-year history of innovation, visit
kimberly-clark.
Kimberly-Clark Professional
kcprofessional
пятница, 27 мая 2011 г.
четверг, 26 мая 2011 г.
Deadline For Joining GB Poultry Register (UK)
Defra's 'focus' pages aim to introduce and summarise a topical issue and provide links to more in-depth material elsewhere on this site.
Keepers with 50 or more poultry on commercial poultry premises have until 28 February to register their flocks on the GB Poultry Register. Those with fewer than 50 birds are strongly encouraged to register on a voluntary basis, and the Register will remain open after February to allow this.
The register was set up by Defra in December 2005, with the support of many organisations supporting the interests of poultry keepers. Its aim is to more accurately establish the locations of poultry flocks on a central database to help quick and effective control of an Avian Influenza outbreak.
The information will be used for:
-- Modelling disease spread scenarios to assess impact of disease spread. This will help enhance our contingency planning
-- Communicating with poultry keepers to provide them with guidance, for example biosecurity and housing, if the threat of disease increases
Who has to register?
By law you must register if you own or are responsible for a commercial poultry premises with 50 or more birds. This requirement also applies even if the premises is only stocked with 50 or more birds for part of the year.
Failure to register your commercial poultry is an offence, and will not help protect your birds. Premises with fewer than 50 birds are not legally required to register but are strongly encouraged to do so now, on a voluntary basis.
To register call the freephone 0800 634 1112 (Lines will be open 8am to 8pm, Monday to Friday, and 9am to 1pm, on Saturday and Sunday), or download a registration form (pdf) from the Poultry Register website.
All Poultry keepers should implement strict biosecurity and common sense hygiene practices at all times to protect their birds and themselves from a number of everyday infections, as well as a possible outbreak of avian influenza. All poultry keepers are responsible for the health and welfare of their own birds, and should look out for signs of disease in their birds. If you suspect that your birds are ill, contact your vet immediately.
Further information
-- the Poultry Register pages on Defra web site
-- the Avian Influenza pages on Defra web site
Department for Environment, Food and Rural Affairs (Defra)
Keepers with 50 or more poultry on commercial poultry premises have until 28 February to register their flocks on the GB Poultry Register. Those with fewer than 50 birds are strongly encouraged to register on a voluntary basis, and the Register will remain open after February to allow this.
The register was set up by Defra in December 2005, with the support of many organisations supporting the interests of poultry keepers. Its aim is to more accurately establish the locations of poultry flocks on a central database to help quick and effective control of an Avian Influenza outbreak.
The information will be used for:
-- Modelling disease spread scenarios to assess impact of disease spread. This will help enhance our contingency planning
-- Communicating with poultry keepers to provide them with guidance, for example biosecurity and housing, if the threat of disease increases
Who has to register?
By law you must register if you own or are responsible for a commercial poultry premises with 50 or more birds. This requirement also applies even if the premises is only stocked with 50 or more birds for part of the year.
Failure to register your commercial poultry is an offence, and will not help protect your birds. Premises with fewer than 50 birds are not legally required to register but are strongly encouraged to do so now, on a voluntary basis.
To register call the freephone 0800 634 1112 (Lines will be open 8am to 8pm, Monday to Friday, and 9am to 1pm, on Saturday and Sunday), or download a registration form (pdf) from the Poultry Register website.
All Poultry keepers should implement strict biosecurity and common sense hygiene practices at all times to protect their birds and themselves from a number of everyday infections, as well as a possible outbreak of avian influenza. All poultry keepers are responsible for the health and welfare of their own birds, and should look out for signs of disease in their birds. If you suspect that your birds are ill, contact your vet immediately.
Further information
-- the Poultry Register pages on Defra web site
-- the Avian Influenza pages on Defra web site
Department for Environment, Food and Rural Affairs (Defra)
среда, 25 мая 2011 г.
Quarantined parrot dies of avian influenza in Great Britain
A parrot that was imported from Surinam, South America, died in the UK of avian influenza (bird flu) while in quarantine. All pets in the UK have to spend some time in quarantine before entering the country. A Dept of the Environment Food and Rural Affairs confirmed that the bird died of bird flu while in quarantine.
The parrot had arrived in September, 2005. It is not yet known whether the parrot had the lethal H5N1 strain of the virus.
As the bird was in quarantine, the general population of farmed birds are still free of bird flu in the UK.
148 parrots and soft bills from Surinam were in quarantine alongside some birds from Taiwan. During their whole time in quarantine they were held in a biosecure quarantine unit. All the birds have been culled.
The UK has the strictest quarantine laws in the world for imported animals and pets. An official said this incident demonstrated the importance and effectiveness of the UK's quarantine laws.
All staff who had come into contact with the birds have been given antiviral treatment and are free of bird flu.
Written by:
Editor:
The parrot had arrived in September, 2005. It is not yet known whether the parrot had the lethal H5N1 strain of the virus.
As the bird was in quarantine, the general population of farmed birds are still free of bird flu in the UK.
148 parrots and soft bills from Surinam were in quarantine alongside some birds from Taiwan. During their whole time in quarantine they were held in a biosecure quarantine unit. All the birds have been culled.
The UK has the strictest quarantine laws in the world for imported animals and pets. An official said this incident demonstrated the importance and effectiveness of the UK's quarantine laws.
All staff who had come into contact with the birds have been given antiviral treatment and are free of bird flu.
Written by:
Editor:
вторник, 24 мая 2011 г.
Bird Flu Outbreak In Quail Farm In South Korea
An outbreak of H5N1 bird flu was confirmed at a quail farm in Kimje, South Korea, say officials from the Ministry of Agriculture.
The farm has 270,000 quail. Authorities are currently removing the quail from the farm and have set up a quarantine zone around the area to stem the spread of the disease. All poultry within 500 meters of the farm will be destroyed, say officials.
This is be the country's third outbreak in one month. On November 18th and November 26th there were two outbreaks in two separate chicken farms - both farms are within a 22 km radius of the infected quail farm.
So far, no humans have become ill, say ministry officials.
Approximately 3,000 quail died of bird flu during the weekend.
Since 2003 over 5 million poultry have been destroyed in South Korea, in measures to prevent the spread of bird flu.
Ministry of Agriculture and Forestry, Republic of Korea (English version)
Written by:
The farm has 270,000 quail. Authorities are currently removing the quail from the farm and have set up a quarantine zone around the area to stem the spread of the disease. All poultry within 500 meters of the farm will be destroyed, say officials.
This is be the country's third outbreak in one month. On November 18th and November 26th there were two outbreaks in two separate chicken farms - both farms are within a 22 km radius of the infected quail farm.
So far, no humans have become ill, say ministry officials.
Approximately 3,000 quail died of bird flu during the weekend.
Since 2003 over 5 million poultry have been destroyed in South Korea, in measures to prevent the spread of bird flu.
Ministry of Agriculture and Forestry, Republic of Korea (English version)
Written by:
понедельник, 23 мая 2011 г.
Defra's Chief Vet Makes Statement On Avian Influenza (bird Flu) And The New Poultry Register, UK
1. Defra is closely monitoring global developments on avian influenza. Taking account of the latest incidents in Eastern Europe, our current risk assessment remains that the overall risk of an imminent outbreak in the UK of avian flu (H5N1) is increased, but still low. However, there is a high risk of further global dispersal and future events may lead us to change our risk assessment. That is why we constantly keep alert to developing factors and are ready to act if necessary.
2. Defra is working in close partnership with the UK poultry industry, independent experts and others to ensure that the UK is thoroughly prepared to prevent an outbreak of avian flu and has robust plans in place to contain and eradicate it if it does occur. With these partners we have issued leaflets and posters to poultry keepers on how they can protect their flocks. We have used specialist journals and representative bodies to get these messages to hobby groups and small and non-commercial keepers and have provided information materials to intermediaries, such as posters for veterinary surgeries.
3. In December we launched the Poultry Register. Its purpose is to provide a central database of information on poultry premises. This information will only be used for preventing and controlling avian flu, more specifically: to improve our risk assessment and contingency planning; and to enable effective up to date communication with poultry keepers.
4. Keepers with 50 or more birds have a statutory obligation to register. Priority has been given to these flocks because, if infected, they could act as significant sources of disease spread as they are large enough for virus to circulate and multiply sufficiently to spread infection through movement to or other contacts with another premises.
5. Small flocks have a low likelihood of contracting avian flu if good biosecurity practices are followed. Even if disease were to occur in small flocks the risk of further spread would likewise be very small. Backyard flocks in the UK are kept in different ways to the village flocks of SE Asia and Eastern Europe where some poultry keepers have been infected through intimate contact with infected birds. However, we are encouraging all owners of flocks of fewer than 50 birds to register voluntarily to enhance the value of the register to all concerned, both in terms of improving contingency planning and improving our ability to communicate with poultry keepers.
6. In the event of an outbreak there would be movement restrictions that would apply to all birds in the area. SVS patrols will identify any flocks that should have registered but did not, including any small poultry flocks.
7. As with all our communications on avian influenza poultry keeping organisations have played an important role in promoting the register to their members. They have circulated thousands of leaflets and held events to raise awareness of the need to register and implement strict biosecurity. This activity will continue over the coming weeks, including advertisements in local press and specialist magazines, several of which have also published editorials urging readers to register. The deadline for registering flocks with 50 or more birds is 28 February 2006. However, we are keeping the register open after this date to allow voluntary registrations to continue.
8. Everyone keeping poultry should follow the biosecurity advice that has been made available and take commonsense hygiene precautions as a barrier to disease. It is important to remember that the UK is free from avian influenza and we want to keep it that way. Meanwhile, if there are any suspicions of avian flu, poultry keepers should report them to local Animal Health Divisional Office immediately.
To register your poultry: CLICK HERE.
Department for Environment, Food and Rural Affairs, UK
2. Defra is working in close partnership with the UK poultry industry, independent experts and others to ensure that the UK is thoroughly prepared to prevent an outbreak of avian flu and has robust plans in place to contain and eradicate it if it does occur. With these partners we have issued leaflets and posters to poultry keepers on how they can protect their flocks. We have used specialist journals and representative bodies to get these messages to hobby groups and small and non-commercial keepers and have provided information materials to intermediaries, such as posters for veterinary surgeries.
3. In December we launched the Poultry Register. Its purpose is to provide a central database of information on poultry premises. This information will only be used for preventing and controlling avian flu, more specifically: to improve our risk assessment and contingency planning; and to enable effective up to date communication with poultry keepers.
4. Keepers with 50 or more birds have a statutory obligation to register. Priority has been given to these flocks because, if infected, they could act as significant sources of disease spread as they are large enough for virus to circulate and multiply sufficiently to spread infection through movement to or other contacts with another premises.
5. Small flocks have a low likelihood of contracting avian flu if good biosecurity practices are followed. Even if disease were to occur in small flocks the risk of further spread would likewise be very small. Backyard flocks in the UK are kept in different ways to the village flocks of SE Asia and Eastern Europe where some poultry keepers have been infected through intimate contact with infected birds. However, we are encouraging all owners of flocks of fewer than 50 birds to register voluntarily to enhance the value of the register to all concerned, both in terms of improving contingency planning and improving our ability to communicate with poultry keepers.
6. In the event of an outbreak there would be movement restrictions that would apply to all birds in the area. SVS patrols will identify any flocks that should have registered but did not, including any small poultry flocks.
7. As with all our communications on avian influenza poultry keeping organisations have played an important role in promoting the register to their members. They have circulated thousands of leaflets and held events to raise awareness of the need to register and implement strict biosecurity. This activity will continue over the coming weeks, including advertisements in local press and specialist magazines, several of which have also published editorials urging readers to register. The deadline for registering flocks with 50 or more birds is 28 February 2006. However, we are keeping the register open after this date to allow voluntary registrations to continue.
8. Everyone keeping poultry should follow the biosecurity advice that has been made available and take commonsense hygiene precautions as a barrier to disease. It is important to remember that the UK is free from avian influenza and we want to keep it that way. Meanwhile, if there are any suspicions of avian flu, poultry keepers should report them to local Animal Health Divisional Office immediately.
To register your poultry: CLICK HERE.
Department for Environment, Food and Rural Affairs, UK
воскресенье, 22 мая 2011 г.
Antibiotic-resistance, Avian Flu And Other Viral Epidemics At ECCMID In Nice
16th European Congress of Clinical Microbiology and Infectious Diseases
Nice, France - Globalisation is a phenomenon involving ever wider spheres: economic, social, cultural, and religious. But these are not the only areas to be affected. Fading national boundaries caused by intensification of commercial trading and increased migration, as well as the tendency for more "exotic" tourism, has caused a globalisation of infectious diseases that is involving all European countries.
This is the background to the importance of a European organisation such as ESCMID (European Society of Clinical Microbiology and Infectious Diseases), which pursues as its major goal the improvement of the diagnosis, prevention and clinical management of infections, including those with a high public health impact.
Indeed, there is currently a paradoxical situation: despite the enormous progress made in medical science, there are new diseases emerging, either as adaptations of existing diseases which lose their responsiveness to traditional treatments, or as new diseases based on previously unknown pathogens for which a mode of transmission and control still have to be established and treatment regiments still to be developed.
The ECCMID (European Congress of Clinical Microbiology and Infectious Diseases), organized by ESCMID in Nice from 1 - 4 April 2006, is the most important annual event of its kind in Europe. Now in its 16th edition, the Congress unites a large number of European and other international experts and over 6000 delegates with the aim of increasing knowledge and discussing future research, treatment and public health strategies needed to tackle infectious diseases.
Resistance to antibiotics
The first problem, the loss of efficacy in treating some common infectious diseases, is predominantly due to antibiotic resistance. The alarm raised by infection experts is serious: the dramatic increase of bacteria resistant to antibiotics paralleled by a lack of new antibiotics has already led to infections being no longer curable.
In fact, it has been seen that some pathogens, particularly those occurring in hospitals (e.g. Staphylococcus aureus and Pseudomonas aeruginosa), are now extensively resistant to widely used antibiotics. Furthermore, recent studies have demonstrated that genes conveying antibiotic resistance can spread between different strains even across species barriers. Combined, all of the above leads to an ever increasing number of difficult-to-treat bacterial infections. In the case of Pseudomonas, but now even in the case of common and "easy-to-treat" bacteria such as Escherichia coli, the most recent and dangerous mechanisms of resistance are the so-called "carbapenemase" enzymes, which attack and destroy the most frequently used antibiotics and make bacteria, which produce these enzymes, resistant to all drugs.
The problem of antibiotic-resistance is further worsened by the disinvestment of several pharmaceutical companies in the field of antibiotic research and development and the resulting shortage of new drugs.
The experts at ECCMID therefore consider measures to contain antibiotic resistance by optimally using the currently available drugs absolutely essential.
"The key to controlling the development of antibiotic resistance", explains Prof. Hermann Goossens of the Department of Medical Microbiology at Antwerp University Hospital, Edegem, Belgium, "is the ability to choose antibiotics selectively." Making a precise diagnosis and understanding the probable aetiology should enable the correct treatment of the main community-acquired infections. "However, in order to do this," continues Goossens, "it is very important that fast, new diagnostic tools are developed for the identification of diseases of bacterial origin. This would permit the prescription of antibiotics only in the case of real need."
Although the main cause of antibiotic resistance in community-acquired infections is inappropriate prescribing of antibiotics, another important factor is patients' non-compliance.
It has, in fact, been demonstrated that the therapeutic efficacy of antibiotics also depends heavily on patients respecting the prescriptions and instructions received from their doctors about the correct dose, the dosing interval and the duration of treatment.
Prevention is another aspect that should not be forgotten when discussing antibiotic resistance. It was found that the introduction of the pneumococcal conjugate vaccine in Europe often coincided with a decrease in the resistance to macrolides and to penicillin. Streptococcus pneumoniae, also called pneumococcus, is one of the most important pathogens of the respiratory tract, with a high frequency of resistance to commonly used antibiotics.
Another important factor for treating infectious diseases and surveillance of resistance is the definition of "susceptible" or "resistant" pathogens; paradoxically, these definitions are not the same in all European countries.
In this regard, ESCMID has convened a strategically important committee, called EUCAST (European Committee on Antimicrobial Susceptibility Testing), with the goal to produce uniform guidelines for susceptibility testing of antibacterial drugs and to define "breakpoints" (that is, the values differentiating susceptible form resistant bacteria) in Europe.
The importance of tackling resistance through co-ordinated action of all European countries is further confirmed by the support that ESCMID gave to the creation of GRACE (Genomics to combat Resistance against Antibiotics in Community-acquired LRTI in Europe), a network of excellence financed by the European Union which brings together major European experts to increase knowledge, guarantee the practical application of research, develop new diagnostic tests and improve the prescribing habits and training of health care workers.
Avian flu
Another issue discussed in particular detail by the experts at ECCMID was avian flu. "Also in this case," said Albert Osterhaus, Head of the Department of Virology and Director of the National Influenza Centre, Erasmus Medical Centre, Rotterdam, "a better co-ordination is needed in Europe among all the stakeholders, researchers, public health care workers and veterinarians in order to prevent a possible pandemic. This can be achieved by creating a European task force to share knowledge and to tackle the possible risks."
Osterhaus continued, "So far, the crisis in Europe has predominantly affected the avicultural sector. Community regulations to safeguard this production chain and those working in the sector are needed. The most important message to convey to the population is that of not confusing the problems related to the avicultural sector with the possibility of a pandemic developing."
Scientific societies, such as ESCMID, which have access to a network of experts throughout the continent, can contribute to this co-operation by acting as interlocutor with academia, health authorities of individual states, the European Commission and the EDCD (European Centre for Disease Prevention and Control).
Ragnar Norrby, Director of the Swedish Institute for Infectious Diseases Control in Stockholm and current President of the ESCMID, re-addressed the "basic" information to be conveyed to the population, confirming that "avian flu is a disease of birds and that the risk of humans catching the infection, although theoretically possible, is very low and limited to those people who have direct contact with infected birds. However, as of today, there is no convincing evidence of man-to-man transmission."
Turkey, the only large reservoir so far observed in Europe, is a paradigmatic example: the cases of transmission of the virus to humans was limited mainly to the rural areas, where direct contact with animals is frequent, and did particularly involve children who have deliberately touched dead or sick birds. Also in these cases, the danger can be limited by applying ordinary rules of hygiene such as frequent hand-washing, not eating meat that is of suspicious provenance or poorly cooked and prohibiting hunting within a 10 km radius of where an animal infected by H5N1 has been found.
Although the H5N1 virus (responsible for avian flu) can cross the barriers between species and infect other animals, such as cats, so far the virus has not spread from cats to different species.
Concerning the possibility of a pandemic to occur, Norrby emphasized that "the worldwide spread of influenza among humans occurs when a new influenza virus develops, usually as a result of recombination of genetic material from a human influenza virus with genetic material from an animal influenza virus. A pandemic virus can, therefore, arise anywhere in the world, but the probability is higher in countries with a high population density and many domestic birds and pigs such as in Asia or Africa."
"So far," continued Norrby, "pandemics have developed at irregular intervals (Spanish 'flu in 1918, the Asiatic pandemic of 1957 and the one arising in Hong Kong in 1968). Therefore, although it can be presumed that another will occur, no-one is able to predict when and with what variant of the influenza virus".
Norrby concluded, "it is important to emphasize two aspects: although the high density of H5N1 virus in birds from all over the world (and particularly in Asian and African countries) facilitates the development of a pandemic infection caused by the virus, the fact that millions of Asians have probably been in contact with infected, dead birds since 1997 (the year in which the first severe spread of avian flu occurred in Hong Kong) without the virus having mutated into a pandemic variant, speaks against a variant of H5N1 virus becoming a pandemic virus."
As far as regards the availability of a human vaccine against avian flu, it was repeated during the ECCMID Congress that large-scale production of such a vaccine requires from four to six months. Considering that avian influenza has had a seasonal trend so far, affecting the population during the winter in countries with a temperate climate, it is probable that if a vaccine is needed it will be scarce during the first wave of infections, but fully available for the second season.
The most important antiviral drug on the market is oseltamivir (Tamiflu), since it has few side effects and is easy to administer. It is important to highlight that oseltamivir can be used for prophylaxis, but considering that the influenza season lasts four to six months it is not feasible to store the supplies necessary to administer the drug to a large number of people. Although studies have not been carried out in patients infected by H5N1, it has been documented that in order to reduce the duration and the severity of symptoms, oseltamivir-based treatment must be administered within 48 hours of the onset of the symptoms. It is also important to remember that treatment with antiviral agents can lead to the development of resistance.
Finally, it should be appreciated that - even in the absence of a vaccine against avian influenza - primary prevention, in particular vaccination against "common" influenza and pneumococcal respiratory infections, plays an essential role in the defence against a possible pandemic.
In fact, immunization could increase resistance to strains never previously encountered, such as a potentially pandemic virus. For example, in the case of the H5N1 strain, it is known that N1 (neuroaminidase 1) is contained in other viruses and vaccines. It is, therefore, possible that a previous infection or vaccination with virus containing N1 can provoke a certain response that then remains in the immunological "memory" of the individual.
Antipneumococcal vaccination should also play a strategic role in prevention, since it has been demonstrated that a considerable proportion of the pulmonary complications in previous pandemics was linked to superimposed bacterial infections, including those caused by pneumococci.
Chikungunya
During the ECCMID another epidemic was discussed: chikungunya, a rare viral disease transmitted by mosquitoes (Aedes albopictus). This epidemic appeared one year ago in La Rйunion, where 186,000 cases, including 93 deaths, have been registered so far. The infection has spread to Mayotte (924 cases), to the Seychelles (4650 suspected cases), to Mauritius (2553 cases notified, of which 1173 confirmed) and to Madagascar (sporadic cases). In Europe "imported" cases have been reported in France (n=160), Switzerland (n=12) and Germany (n=4).
The current level of risk of chikungunya (a fever that causes violent joint pains) being introduced into Europe is low, given the unfavourable climatic conditions in this period of the year, although the risk cannot be excluded completely. There is lack of consensus on whether there will be a real risk of autoctonous spread of the virus in the warmer season, when the number of mosquitoes increases.
What is certain, as concluded by the experts meeting at the ECCMID, is the need to activate close monitoring of the epidemic at a European level and to identify efficient diagnostic tools.
escmid
View drug information on Tamiflu capsule.
Nice, France - Globalisation is a phenomenon involving ever wider spheres: economic, social, cultural, and religious. But these are not the only areas to be affected. Fading national boundaries caused by intensification of commercial trading and increased migration, as well as the tendency for more "exotic" tourism, has caused a globalisation of infectious diseases that is involving all European countries.
This is the background to the importance of a European organisation such as ESCMID (European Society of Clinical Microbiology and Infectious Diseases), which pursues as its major goal the improvement of the diagnosis, prevention and clinical management of infections, including those with a high public health impact.
Indeed, there is currently a paradoxical situation: despite the enormous progress made in medical science, there are new diseases emerging, either as adaptations of existing diseases which lose their responsiveness to traditional treatments, or as new diseases based on previously unknown pathogens for which a mode of transmission and control still have to be established and treatment regiments still to be developed.
The ECCMID (European Congress of Clinical Microbiology and Infectious Diseases), organized by ESCMID in Nice from 1 - 4 April 2006, is the most important annual event of its kind in Europe. Now in its 16th edition, the Congress unites a large number of European and other international experts and over 6000 delegates with the aim of increasing knowledge and discussing future research, treatment and public health strategies needed to tackle infectious diseases.
Resistance to antibiotics
The first problem, the loss of efficacy in treating some common infectious diseases, is predominantly due to antibiotic resistance. The alarm raised by infection experts is serious: the dramatic increase of bacteria resistant to antibiotics paralleled by a lack of new antibiotics has already led to infections being no longer curable.
In fact, it has been seen that some pathogens, particularly those occurring in hospitals (e.g. Staphylococcus aureus and Pseudomonas aeruginosa), are now extensively resistant to widely used antibiotics. Furthermore, recent studies have demonstrated that genes conveying antibiotic resistance can spread between different strains even across species barriers. Combined, all of the above leads to an ever increasing number of difficult-to-treat bacterial infections. In the case of Pseudomonas, but now even in the case of common and "easy-to-treat" bacteria such as Escherichia coli, the most recent and dangerous mechanisms of resistance are the so-called "carbapenemase" enzymes, which attack and destroy the most frequently used antibiotics and make bacteria, which produce these enzymes, resistant to all drugs.
The problem of antibiotic-resistance is further worsened by the disinvestment of several pharmaceutical companies in the field of antibiotic research and development and the resulting shortage of new drugs.
The experts at ECCMID therefore consider measures to contain antibiotic resistance by optimally using the currently available drugs absolutely essential.
"The key to controlling the development of antibiotic resistance", explains Prof. Hermann Goossens of the Department of Medical Microbiology at Antwerp University Hospital, Edegem, Belgium, "is the ability to choose antibiotics selectively." Making a precise diagnosis and understanding the probable aetiology should enable the correct treatment of the main community-acquired infections. "However, in order to do this," continues Goossens, "it is very important that fast, new diagnostic tools are developed for the identification of diseases of bacterial origin. This would permit the prescription of antibiotics only in the case of real need."
Although the main cause of antibiotic resistance in community-acquired infections is inappropriate prescribing of antibiotics, another important factor is patients' non-compliance.
It has, in fact, been demonstrated that the therapeutic efficacy of antibiotics also depends heavily on patients respecting the prescriptions and instructions received from their doctors about the correct dose, the dosing interval and the duration of treatment.
Prevention is another aspect that should not be forgotten when discussing antibiotic resistance. It was found that the introduction of the pneumococcal conjugate vaccine in Europe often coincided with a decrease in the resistance to macrolides and to penicillin. Streptococcus pneumoniae, also called pneumococcus, is one of the most important pathogens of the respiratory tract, with a high frequency of resistance to commonly used antibiotics.
Another important factor for treating infectious diseases and surveillance of resistance is the definition of "susceptible" or "resistant" pathogens; paradoxically, these definitions are not the same in all European countries.
In this regard, ESCMID has convened a strategically important committee, called EUCAST (European Committee on Antimicrobial Susceptibility Testing), with the goal to produce uniform guidelines for susceptibility testing of antibacterial drugs and to define "breakpoints" (that is, the values differentiating susceptible form resistant bacteria) in Europe.
The importance of tackling resistance through co-ordinated action of all European countries is further confirmed by the support that ESCMID gave to the creation of GRACE (Genomics to combat Resistance against Antibiotics in Community-acquired LRTI in Europe), a network of excellence financed by the European Union which brings together major European experts to increase knowledge, guarantee the practical application of research, develop new diagnostic tests and improve the prescribing habits and training of health care workers.
Avian flu
Another issue discussed in particular detail by the experts at ECCMID was avian flu. "Also in this case," said Albert Osterhaus, Head of the Department of Virology and Director of the National Influenza Centre, Erasmus Medical Centre, Rotterdam, "a better co-ordination is needed in Europe among all the stakeholders, researchers, public health care workers and veterinarians in order to prevent a possible pandemic. This can be achieved by creating a European task force to share knowledge and to tackle the possible risks."
Osterhaus continued, "So far, the crisis in Europe has predominantly affected the avicultural sector. Community regulations to safeguard this production chain and those working in the sector are needed. The most important message to convey to the population is that of not confusing the problems related to the avicultural sector with the possibility of a pandemic developing."
Scientific societies, such as ESCMID, which have access to a network of experts throughout the continent, can contribute to this co-operation by acting as interlocutor with academia, health authorities of individual states, the European Commission and the EDCD (European Centre for Disease Prevention and Control).
Ragnar Norrby, Director of the Swedish Institute for Infectious Diseases Control in Stockholm and current President of the ESCMID, re-addressed the "basic" information to be conveyed to the population, confirming that "avian flu is a disease of birds and that the risk of humans catching the infection, although theoretically possible, is very low and limited to those people who have direct contact with infected birds. However, as of today, there is no convincing evidence of man-to-man transmission."
Turkey, the only large reservoir so far observed in Europe, is a paradigmatic example: the cases of transmission of the virus to humans was limited mainly to the rural areas, where direct contact with animals is frequent, and did particularly involve children who have deliberately touched dead or sick birds. Also in these cases, the danger can be limited by applying ordinary rules of hygiene such as frequent hand-washing, not eating meat that is of suspicious provenance or poorly cooked and prohibiting hunting within a 10 km radius of where an animal infected by H5N1 has been found.
Although the H5N1 virus (responsible for avian flu) can cross the barriers between species and infect other animals, such as cats, so far the virus has not spread from cats to different species.
Concerning the possibility of a pandemic to occur, Norrby emphasized that "the worldwide spread of influenza among humans occurs when a new influenza virus develops, usually as a result of recombination of genetic material from a human influenza virus with genetic material from an animal influenza virus. A pandemic virus can, therefore, arise anywhere in the world, but the probability is higher in countries with a high population density and many domestic birds and pigs such as in Asia or Africa."
"So far," continued Norrby, "pandemics have developed at irregular intervals (Spanish 'flu in 1918, the Asiatic pandemic of 1957 and the one arising in Hong Kong in 1968). Therefore, although it can be presumed that another will occur, no-one is able to predict when and with what variant of the influenza virus".
Norrby concluded, "it is important to emphasize two aspects: although the high density of H5N1 virus in birds from all over the world (and particularly in Asian and African countries) facilitates the development of a pandemic infection caused by the virus, the fact that millions of Asians have probably been in contact with infected, dead birds since 1997 (the year in which the first severe spread of avian flu occurred in Hong Kong) without the virus having mutated into a pandemic variant, speaks against a variant of H5N1 virus becoming a pandemic virus."
As far as regards the availability of a human vaccine against avian flu, it was repeated during the ECCMID Congress that large-scale production of such a vaccine requires from four to six months. Considering that avian influenza has had a seasonal trend so far, affecting the population during the winter in countries with a temperate climate, it is probable that if a vaccine is needed it will be scarce during the first wave of infections, but fully available for the second season.
The most important antiviral drug on the market is oseltamivir (Tamiflu), since it has few side effects and is easy to administer. It is important to highlight that oseltamivir can be used for prophylaxis, but considering that the influenza season lasts four to six months it is not feasible to store the supplies necessary to administer the drug to a large number of people. Although studies have not been carried out in patients infected by H5N1, it has been documented that in order to reduce the duration and the severity of symptoms, oseltamivir-based treatment must be administered within 48 hours of the onset of the symptoms. It is also important to remember that treatment with antiviral agents can lead to the development of resistance.
Finally, it should be appreciated that - even in the absence of a vaccine against avian influenza - primary prevention, in particular vaccination against "common" influenza and pneumococcal respiratory infections, plays an essential role in the defence against a possible pandemic.
In fact, immunization could increase resistance to strains never previously encountered, such as a potentially pandemic virus. For example, in the case of the H5N1 strain, it is known that N1 (neuroaminidase 1) is contained in other viruses and vaccines. It is, therefore, possible that a previous infection or vaccination with virus containing N1 can provoke a certain response that then remains in the immunological "memory" of the individual.
Antipneumococcal vaccination should also play a strategic role in prevention, since it has been demonstrated that a considerable proportion of the pulmonary complications in previous pandemics was linked to superimposed bacterial infections, including those caused by pneumococci.
Chikungunya
During the ECCMID another epidemic was discussed: chikungunya, a rare viral disease transmitted by mosquitoes (Aedes albopictus). This epidemic appeared one year ago in La Rйunion, where 186,000 cases, including 93 deaths, have been registered so far. The infection has spread to Mayotte (924 cases), to the Seychelles (4650 suspected cases), to Mauritius (2553 cases notified, of which 1173 confirmed) and to Madagascar (sporadic cases). In Europe "imported" cases have been reported in France (n=160), Switzerland (n=12) and Germany (n=4).
The current level of risk of chikungunya (a fever that causes violent joint pains) being introduced into Europe is low, given the unfavourable climatic conditions in this period of the year, although the risk cannot be excluded completely. There is lack of consensus on whether there will be a real risk of autoctonous spread of the virus in the warmer season, when the number of mosquitoes increases.
What is certain, as concluded by the experts meeting at the ECCMID, is the need to activate close monitoring of the epidemic at a European level and to identify efficient diagnostic tools.
escmid
View drug information on Tamiflu capsule.
суббота, 21 мая 2011 г.
Excessive Use Of Antiviral Drugs Could Aid Deadly Flu According To Study
Influenza's ability to resist the effects of cheap and popular antiviral agents in Asia and Russia should serve as a cautionary tale about U.S. plans to use the antiviral Tamiflu in the event of widespread avian flu infection in humans, scientists say.
Researchers analyzed almost 700 genome sequences of avian influenza strains to document where and when the virus developed resistance to a class of antiviral drugs called adamantanes and how far resistant strains spread. The analysis suggests that widespread antiviral drug use can accelerate the evolution of drug resistance in viruses, and that resistant strains can emerge and spread rapidly.
The results should serve as a warning to those who consider Tamiflu the next great antiviral medication, the researchers say. Stockpiling Tamiflu has become a standard part of many government, business and health organization plans to prepare for a long-feared pandemic flu outbreak, especially in the event that avian flu mutates enough to infect and be easily transmitted among humans.
"We can't necessarily say what we've seen in adamantanes is predictive of what will happen with Tamiflu. But in the larger dynamic, perhaps it serves as a cautionary tale," said Daniel Janies, senior author of the study and an associate professor of biomedical informatics at Ohio State University.
"Fighting infection is an arms race, and if we're not smart about how we use our arms and understand the evolutionary implications, then we will have ongoing and accelerating problems with drug-resistant microorganisms."
Resistance to adamantanes among strains of seasonal influenza spiked in Asia in 2002, and by 2006 the agents were considered virtually worthless worldwide as a treatment for the flu because more than 90 percent of the strains had developed a resistance to the drugs.
With that knowledge, Janies and colleagues analyzed hundreds of avian flu genomes isolated from avian, feline and human hosts between 1996 and 2007. They found that about one-third of those samples carried mutations enabling the virus strains to resist the effects of adamantane drugs.
The researchers also looked at resistance to oseltamivir-based agents (Tamiflu is the brand name for oseltamivir phosphate), but found that fewer than 1 percent of all of the samples were resistant to that class of drugs. Different classes of antivirals target influenza in different ways in the hosts' cells.
Janies and researchers from the University of Colorado and Kansas State University also designed a four-dimensional interactive map that traces the resistant avian flu lineages, showing over time where they originated and where they moved, mostly across Asia, but also to one European site in Belgium. The map is projected onto a virtual globe using Google Earth and can be downloaded at: supramap.osu/supramap/files/h5n1_677.kmz.
The study is published online in the journal Infection, Genetics and Evolution.
So far, avian flu, the H5N1 strain of the influenza A virus, has been restricted to fewer than 400 human cases worldwide, but the virus's presence in birds has led to culling of large populations of infected species. Experts believe that to date, the avian flu can be transmitted to humans only from diseased birds. But the 63-percent death rate among the humans who had the virus has led to global concerns that if H5N1 were to become highly transmissible among humans, it could start an influenza pandemic.
Janies and colleagues obtained 676 whole genomes of influenza A/H5N1 available in Genbank, a public database of sequences supported by the National Institutes of Health, as of June 2007. They then used powerful supercomputers to analyze these genomes and their various mutations.
Adamantanes fight influenza by inhibiting the function of a protein called the membrane ion channel, or the M2 protein. According to the computational comparison of the avian flu genomes, upwards of one-third of the strains contained a key mutation that changed the M2 protein in a way that allowed the virus to escape the inhibiting effects of adamantanes. To evade adamantanes, mutations can occur at several positions on the protein, suggesting that influenza can evolve in many ways to resist the drug.
The researchers also were able to demonstrate that the resistance developed as a result of natural selection, because the avian flu virus strains experienced mutations that changed the M2 protein to evade the drug more often than one would expect by chance. Sometimes, dramatic changes to the genetic code occur when diverse strains of viruses shuffle whole genes among themselves in a process called reassortment. The analysis determined that any reassortment that occurred in the H5N1 strains studied did not lead to drug resistance.
The study also showed that the mutation-mediated cases of drug resistance didn't start in just one strain of avian flu. One resistant strain originated in China and spread through Southeast Asia, while another strain that was originally susceptible to adamantanes spread to Indonesia and then independently developed resistance in that country. The Google Earth map offers a vivid visualization of exactly where in the world these resistant lineages originated and where they are spreading.
At the height of their popularity in China and Russia, adamantanes were added to over-the-counter cold medicines and were also given to animals in some agricultural settings.
"We don't have hard data on how it was used or whether it was appropriately or inappropriately used, but in general, people are putting a lot of antimicrobials into the environment now," Janies said. "When people do that, they change the selective landscape. The virus would rather remain in its wild type form, but that one gets killed by the drug. So according to the survival of the fittest, a slightly modified virus can spread by escaping the effects of the drug."
Researchers believe that Tamiflu has not been used widely anywhere in the world except Japan, and no pattern of resistance similar to that seen for adamantanes has emerged. However, recent reports have suggested a spike of resistance to oseltamivir in strains of seasonal influenza have occurred in Northern Europe and Canada. In analyzing the avian flu genomes, the researchers looked for mutations that would show the virus's ability to resist the oseltamivir class of drugs to which Tamiflu belongs. These drugs fight flu by inhibiting the neuraminidase protein in the virus.
"Resistance to Tamiflu was not nearly as widespread as is resistance to adamantanes," Janies said. "But based on our results, we know resistance to Tamiflu can occur spontaneously in nature, we know it can occur in patients, and we know Tamiflu is widely used in Japan. We should continue to watch for resistance, and use this adamantane history as a warning."
A critical part of any genome comparison is assembling supercomputers that allow researchers to put complex data into context.
"Genomes are represented as raw, partially annotated strings of letters. Each genome on its own doesn't tell you much because all you see is a single state. What we need to see is change over time to find the evolutionary history. That requires computational power to match like regions of the genome, put the data into context and see the trajectory of the change," Janies said.
The result is called a phylogenetic tree that documents the shared mutations. Phylogenetics is the study of the evolutionary relationships among various biological species believed to have a common ancestor. In this analysis, the phylogenetic tree is projected into Google Earth and animated to show when mutations emerged and where drug-resistant avian flu strains are traveling.
Key to any ongoing tracking of antiviral drug resistance will be the broad availability of genomic data, Janies said. The technology exists to do the job, but worldwide cooperation in data sharing is still a work in progress."Not all viruses that are isolated are sequenced, and not all viral genomes that have been sequenced are shared," he said.With this publication, Janies and colleagues have done some sharing of their own, establishing a service for other researchers at supramap.osu. "Anyone can go there, upload genomes, and our computers will calculate a tree for them and give them both the tree and that tree data mapped into the earth. We're rolling out our methods and making our supercomputer available for anyone in the world to do this kind of work," Janies said.
This research is supported by the U.S. Army Research Laboratory and the U.S. Army Research Office; the Hewlett Packard Corp.; the Ohio Supercomputer Center; and the Department of Biomedical Informatics and School of Biomedical Sciences within Ohio State's College of Medicine.
Janies' coauthors are Andrew Hill, Meredith Wilson and Robert Guralnick of the University of Colorado and Farhat Habib, a former Ohio State graduate student now at Kansas State University.
Source: Daniel Janies
Ohio State University
View drug information on Tamiflu capsule.
Researchers analyzed almost 700 genome sequences of avian influenza strains to document where and when the virus developed resistance to a class of antiviral drugs called adamantanes and how far resistant strains spread. The analysis suggests that widespread antiviral drug use can accelerate the evolution of drug resistance in viruses, and that resistant strains can emerge and spread rapidly.
The results should serve as a warning to those who consider Tamiflu the next great antiviral medication, the researchers say. Stockpiling Tamiflu has become a standard part of many government, business and health organization plans to prepare for a long-feared pandemic flu outbreak, especially in the event that avian flu mutates enough to infect and be easily transmitted among humans.
"We can't necessarily say what we've seen in adamantanes is predictive of what will happen with Tamiflu. But in the larger dynamic, perhaps it serves as a cautionary tale," said Daniel Janies, senior author of the study and an associate professor of biomedical informatics at Ohio State University.
"Fighting infection is an arms race, and if we're not smart about how we use our arms and understand the evolutionary implications, then we will have ongoing and accelerating problems with drug-resistant microorganisms."
Resistance to adamantanes among strains of seasonal influenza spiked in Asia in 2002, and by 2006 the agents were considered virtually worthless worldwide as a treatment for the flu because more than 90 percent of the strains had developed a resistance to the drugs.
With that knowledge, Janies and colleagues analyzed hundreds of avian flu genomes isolated from avian, feline and human hosts between 1996 and 2007. They found that about one-third of those samples carried mutations enabling the virus strains to resist the effects of adamantane drugs.
The researchers also looked at resistance to oseltamivir-based agents (Tamiflu is the brand name for oseltamivir phosphate), but found that fewer than 1 percent of all of the samples were resistant to that class of drugs. Different classes of antivirals target influenza in different ways in the hosts' cells.
Janies and researchers from the University of Colorado and Kansas State University also designed a four-dimensional interactive map that traces the resistant avian flu lineages, showing over time where they originated and where they moved, mostly across Asia, but also to one European site in Belgium. The map is projected onto a virtual globe using Google Earth and can be downloaded at: supramap.osu/supramap/files/h5n1_677.kmz.
The study is published online in the journal Infection, Genetics and Evolution.
So far, avian flu, the H5N1 strain of the influenza A virus, has been restricted to fewer than 400 human cases worldwide, but the virus's presence in birds has led to culling of large populations of infected species. Experts believe that to date, the avian flu can be transmitted to humans only from diseased birds. But the 63-percent death rate among the humans who had the virus has led to global concerns that if H5N1 were to become highly transmissible among humans, it could start an influenza pandemic.
Janies and colleagues obtained 676 whole genomes of influenza A/H5N1 available in Genbank, a public database of sequences supported by the National Institutes of Health, as of June 2007. They then used powerful supercomputers to analyze these genomes and their various mutations.
Adamantanes fight influenza by inhibiting the function of a protein called the membrane ion channel, or the M2 protein. According to the computational comparison of the avian flu genomes, upwards of one-third of the strains contained a key mutation that changed the M2 protein in a way that allowed the virus to escape the inhibiting effects of adamantanes. To evade adamantanes, mutations can occur at several positions on the protein, suggesting that influenza can evolve in many ways to resist the drug.
The researchers also were able to demonstrate that the resistance developed as a result of natural selection, because the avian flu virus strains experienced mutations that changed the M2 protein to evade the drug more often than one would expect by chance. Sometimes, dramatic changes to the genetic code occur when diverse strains of viruses shuffle whole genes among themselves in a process called reassortment. The analysis determined that any reassortment that occurred in the H5N1 strains studied did not lead to drug resistance.
The study also showed that the mutation-mediated cases of drug resistance didn't start in just one strain of avian flu. One resistant strain originated in China and spread through Southeast Asia, while another strain that was originally susceptible to adamantanes spread to Indonesia and then independently developed resistance in that country. The Google Earth map offers a vivid visualization of exactly where in the world these resistant lineages originated and where they are spreading.
At the height of their popularity in China and Russia, adamantanes were added to over-the-counter cold medicines and were also given to animals in some agricultural settings.
"We don't have hard data on how it was used or whether it was appropriately or inappropriately used, but in general, people are putting a lot of antimicrobials into the environment now," Janies said. "When people do that, they change the selective landscape. The virus would rather remain in its wild type form, but that one gets killed by the drug. So according to the survival of the fittest, a slightly modified virus can spread by escaping the effects of the drug."
Researchers believe that Tamiflu has not been used widely anywhere in the world except Japan, and no pattern of resistance similar to that seen for adamantanes has emerged. However, recent reports have suggested a spike of resistance to oseltamivir in strains of seasonal influenza have occurred in Northern Europe and Canada. In analyzing the avian flu genomes, the researchers looked for mutations that would show the virus's ability to resist the oseltamivir class of drugs to which Tamiflu belongs. These drugs fight flu by inhibiting the neuraminidase protein in the virus.
"Resistance to Tamiflu was not nearly as widespread as is resistance to adamantanes," Janies said. "But based on our results, we know resistance to Tamiflu can occur spontaneously in nature, we know it can occur in patients, and we know Tamiflu is widely used in Japan. We should continue to watch for resistance, and use this adamantane history as a warning."
A critical part of any genome comparison is assembling supercomputers that allow researchers to put complex data into context.
"Genomes are represented as raw, partially annotated strings of letters. Each genome on its own doesn't tell you much because all you see is a single state. What we need to see is change over time to find the evolutionary history. That requires computational power to match like regions of the genome, put the data into context and see the trajectory of the change," Janies said.
The result is called a phylogenetic tree that documents the shared mutations. Phylogenetics is the study of the evolutionary relationships among various biological species believed to have a common ancestor. In this analysis, the phylogenetic tree is projected into Google Earth and animated to show when mutations emerged and where drug-resistant avian flu strains are traveling.
Key to any ongoing tracking of antiviral drug resistance will be the broad availability of genomic data, Janies said. The technology exists to do the job, but worldwide cooperation in data sharing is still a work in progress."Not all viruses that are isolated are sequenced, and not all viral genomes that have been sequenced are shared," he said.With this publication, Janies and colleagues have done some sharing of their own, establishing a service for other researchers at supramap.osu. "Anyone can go there, upload genomes, and our computers will calculate a tree for them and give them both the tree and that tree data mapped into the earth. We're rolling out our methods and making our supercomputer available for anyone in the world to do this kind of work," Janies said.
This research is supported by the U.S. Army Research Laboratory and the U.S. Army Research Office; the Hewlett Packard Corp.; the Ohio Supercomputer Center; and the Department of Biomedical Informatics and School of Biomedical Sciences within Ohio State's College of Medicine.
Janies' coauthors are Andrew Hill, Meredith Wilson and Robert Guralnick of the University of Colorado and Farhat Habib, a former Ohio State graduate student now at Kansas State University.
Source: Daniel Janies
Ohio State University
View drug information on Tamiflu capsule.
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