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Vol. VI, No. 11~ EINet News Briefs ~ June 20 , 2003

****A free service of the APEC Emerging Infections Network*****

The EINet list serve was created to foster discussion, networking, and collaboration in the area of emerging infectious diseases (EID's) among academicians, scientists, and policy makers in the Asia–Pacific region. We strongly encourage you to share your perspectives and experiences, as your participation directly contributes to the richness of the "electronic discussions" that occur. To respond to the list serve, use the reply function.

In this edition:
  1. Infectious disease information
    –Australia (multistate): Hepatitis A
    –USA: Listeriosis, new prevention regulations
    –USA: Monkeypox Infections
    –International animal movement: veterinary control
    –Canada (Quebec): West Nile virus–infected Crow
  2. Updates
    –Multi Country Outbreak: Severe Acute Respiratory Syndrome (SARS)
    –Canada: Bovine spongiform encephalopathy
  3. Notices
    – WHO first Global Conference on Severe Acute Respiratory Syndrome (SARS)
  4. Article
    – Rocky Mountain spotted fever: a clinician's dilemma.
  5. How to join the EINet email list

Below is a semi–monthly summary of Asia–Pacific emerging infectious diseases.


Australia (multistate) — Hepatitis A
According to the Communicable Diseases Network Australia (CDNA), 6 cases from Tasmania, 2 from Victoria, and 2 from Queensland were believed to have been exposed to the liver virus (hepatitis A) while on tour in the Northern Territory from Apr. 24 to Apr. 27, 2003. Hundreds more may have been exposed to the disease, which is spread through person–to–person contact or from water or food that has been inadvertently contaminated by an infected person.

"Tasmania has the largest proportion of cases so far following a visit to the Northern Territory by a large group of people that included 106 from Tasmania," CDNA deputy chair Dr. Vicki Krause said in a statement. "It tends to be a more significant problem if the victim is older, or has an underlying immunity problem or a pre–existing liver Condition," Tasmanian public health director Dr. Roscoe Taylor. "The incubation period is usually about a month, but it can range from 15 to 50 days," Dr. Taylor said.

Dr. Taylor had been working with the Northern Territory health authorities to track the source as well as with authorities in Victoria and Queensland on identifying other possible cases.
(ProMed 6/04/03)


USA — Listeriosis, new prevention regulations
The USA Agriculture Department says it will require 2500 companies that make hot dogs and deli meats to come up with plans for preventing the harmful bacteria listeria from contaminating their products. Companies also must test areas such as walls, equipment, and countertops and share the results with inspectors, said Elsa Murano, head of the department's food safety division.

"The rule is tough, it's fair, it's based on science," she said on Jun 4, 2003. Plants that don't comply could be shut down by inspectors, Murano said.

Murano said it took months to finish the rule because the agency was completing studies that would determine the best way to prevent listeria. Advocates complained that the new regulations don't specify how often companies should test surfaces and products. They also said the rule should require companies to warn pregnant women and people with weak immune systems to reheat products before eating them.

"We hope that this regulatory approach, coupled with the scientific strategies employed by meat and poultry companies, will help us achieve our mutual goal: producing ready–to–eat meat and poultry products that consumers can enjoy with confidence," said J. Patrick Boyle, president of the American Meat Institute.

Because it's an interim rule, the industry and public can comment on the rule and the government can make changes over the next 18 months. However, it is scheduled to go into effect in September 2003.
(ProMed 6/05/03)

USA — Monkeypox Infections
As of June 18, a total of 87 persons with suspected monkeypox had been reported in Wisconsin (38), Illinois (19), Indiana (24), Ohio (4), Kansas (1), and Missouri (1). Monkeypox had been confirmed by laboratory tests in 20 persons. At least 20 of the people with suspected monkeypox had been hospitalized for their illness; there have been no deaths related to the outbreak.

Human monkeypox is a rare zoonotic viral disease that occurs primarily in the rain forest countries of central and west Africa. In humans, the illness produces a vesicular and pustular rash similar to that produced by smallpox.

Interim case definition is available at the following site:

The incubation period from exposure to fever onset is about 12 days. In humans, case–fatality ratios in Africa have ranged from 1 to 10 percent. For additional information about monkeypox, visit the following site: www.cdc.gov/ncidod/eid/vol7no3/hutin.htm

Currently, there is no proven, safe treatment for monkeypox. Smallpox vaccine has been reported to reduce the risk of monkeypox among previously vaccinated persons in Africa. CDC is recommending that persons investigating monkeypox outbreaks and involved in caring for infected individuals or animals should receive a smallpox vaccination to protect against monkeypox. Persons who have had close or intimate contact with individuals or animals confirmed to have monkeypox should also be vaccinated. These persons can be vaccinated up to 14 days after exposure. CDC is not recommending pre–exposure vaccination for unexposed veterinarians, veterinary staff, or animal control officers, unless such persons are involved in field investigations. Interim guidance for use of small pox vaccination is available at the following site:

In the current outbreak, illness in animals has been reported to include fever, cough, blepharoconjunctivitis, lymphadenopathy, followed by a nodular rash. Some animals have died while others reportedly recovered. The types of animals that may become ill with monkeypox are currently unknown; as a precaution, all mammals should be considered susceptible at this time.

Pet owners who suspect their animal may have an illness compatible with monkeypox should immediately isolate the animal from humans and other animals and contact their state or local health department. In most cases, evaluation by a veterinarian will be recommended. Owners should notify the veterinarian before transporting the animal to the clinic so that appropriate infection control precautions can be implemented prior to arrival.

Further information and the interim guidance for veterinarians and pet owners are available at the following site:

In Europe, the Standing Committee on the Food Chain and Animal Health (SCFCAH) agreed unanimously to ban the import of prairie dogs (Cynomys sp.) from the USA and rodents of non domestic species and squirrels from sub–Saharan Africa because of the risks of monkeypox disease. The decision will soon be adopted by the European Commission.
(CDC website 6/16/03, MMWR 06/20/03, ProMed 6/10,11,12/03)

International Animal Movement: Veterinary Control
The monkeypox outbreak illustrates a growing problem: Exotic animals give exotic diseases to people who get too close, a trend that some medical specialists call a serious public health threat. Such diseases can become a threat not just to the people who buy and sell exotic pets, but to the general public if the diseases spread to native animals and become established in the United States. Federal health officials are working frantically to ensure that doesn't happen with monkeypox.

"This is a harbinger of things to come," warns Michael Osterholm of the University of Minnesota, who advises the government on infectious diseases, and has long warned that there's too little oversight of the health threats of imported animals.

"There are some of us who feel like lone voices in the night" in calling for better scrutiny, adds Peter Jahrling, a scientist at the U.S. Army Medical Research Institute of Infectious Diseases (USAMRID). "Perhaps incidents like this might bring some much–needed re–examinations."

SARS, the respiratory epidemic, is thought to have come from civet cats bred as an exotic meat in Chinese markets where bats, snakes, badgers, and other animals live in side–by–side cages until they become someone's dinner.

Japan recently banned the importation of prairie dogs because they can carry plague. The rodents had been wildly popular as pets in that country.

Just last summer, a group of prairie dogs caught in South Dakota was discovered to have tularemia, a dangerous infection typically spread by the bites of infected ticks, deerflies, and such or through ingesting contaminated material. The disease was detected only after the animals were shipped to 10 other states and 5 other countries.

Then there's salmonella, which iguanas and other reptiles, as well as birds, routinely shed in their feces. The CDC counts a stunning 90,000 people a year believed to have caught salmonella from some form of contact with a reptile, either touching it or touching a surface where the reptile had tracked the bacteria.

There is little federal scrutiny of most imported animals for potential human health risk, and rules on owning and selling exotic animals vary by state and city.
(ProMed 6/11/03)

Canada (Quebec) — West Nile Virus–infected Crow
West Nile Virus–infected North American crow was found dead in the area of Roxboro, near Montreal. Another dead crow carrying the potentially fatal virus was located in Huntingdon, southwest of Montreal, at the end of May 2003. It was the first confirmed case in Quebec this year.

John Carsley, head of the infectious diseases unit of the Montreal regional public health department, said the convergence of such factors as the presence of some contaminated birds and pools of contaminated mosquitoes in the same sector could lead to intervention through corrective measures, such as mosquito larvicide treatments.

There were 16 cases of humans infected with West Nile across the province last year, 2 of which resulted in deaths.
(ProMed 6/08/03)


Multicountry Outbreak — Severe Acute Respiratory Syndrome (SARS)
– Experts expand criteria for diagnosing SARS
According to the findings researchers in Hong Kong presented at a conference organized jointly by the World Health Organization and the Hong Kong government on June 13, about one in 4 elderly people suffering from SARS show no signs of fever during their illness and the incubation period for typical patients can range well beyond the standard of 10 days to as much as 16 days. Dr. S.Y. Au of Tuen Mun Hospital suggested that the absence of high temperature readings could be due to certain medications being taken by elderly patients that mask fevers, and said doctors should search carefully for atypical symptoms and whether the person had recently been hospitalized. Another researcher, Professor Joseph Sung from the University of Hong Kong, added that about 50 percent of the cases seen in Hong Kong were not typical. These patients often had diarrhea and liver problems. Researchers quickly agreed that the original WHO guidelines for diagnosing SARS were outdated and said they'd had to incorporate the latest findings early on in Hong Kong's outbreak last March, 2003.

– Situation in China
China's Executive Vice Minister of Health, Mr. Gao Qiang, and Dr. David Heymann, WHO's Executive Director for Communicable Diseases, briefed the press on the situation of SARS control in China on June 12. Dr. Heymann praised the openness with which the WHO team was welcomed by the Ministry of Health, and described the measures now in place to control and prevent SARS as "excellent". He cited the high level of commitment and determination at all levels of the health system as largely responsible for the dramatic recent decline in the number of cases seen throughout mainland China. Dr. Bekedam, Dr. Henk Bekedam, WHO Representative to China, said "With SARS seemingly on the decline for now, there is a great need to strengthen the SARS control and surveillance system in China," and "The system now in place grew out of an emergency response and has to be strengthened for the long run." He expressed doubt that the present system would be strong enough "to hold back the tide" when confronted with a resurgence of the disease. Dr. Heymann also stressed the need for systematic studies of the origins of SARS. "We still don't know exactly where SARS came from, or how it was transferred to the human population. We don't know if this disease is seasonal and will decrease this year but come back next year."

Chinese officials expressed deep concern about the country's capacity to deal with the next influenza season against a background of possible SARS cases. The presence of influenza could greatly complicate the detection and accurate diagnosis of SARS cases, while also considerably increasing the caseload of suspect cases.

In an earlier report, a WHO assessment team reached the following conclusion: "If SARS is not brought under control in China, there will be no chance of controlling the global threat of SARS. Achieving control of SARS is a major challenge especially in a country as large and diverse as China. Effective disease control and reporting are the cornerstones of any strategy to do this."

– Cumulative cases
As of June 19, 2003, a cumulative total of 8,462 SARS cases, 804 deaths, and 7,178 recovered cases since November 1, 2002, are reported from the following countries (number of cases): Australia (5), Brazil (3), Canada (245), China (5326), Hong Kong Special Administrative Region of China (1755), Macao Special Administrative Region of China (1), Taiwan (695), Colombia (1), Finland (1), France (7), Germany (10), India (3), Indonesia (3), Italy (9), Kuwait (1), Malaysia (5), Mongolia (9), New Zealand (1), Philippines (14), Republic of Ireland (1), Republic of Korea (3), Romania (1), Singapore (206), South Africa (1), Spain (1), Sweden (3), Switzerland (1), Thailand (9), United Kingdom (4), United States (75), Viet Nam (63).

In order to see further details, including cumulative number of cases and deaths, please visit the following URL:

As of June 19, 2003, WHO has listed the following areas with recent local transmission of SARS, where in the last 20 days, one or more reported cases of SARS have most likely acquired their infection locally regardless of the setting in which this may be occurred:
Canada (Toronto), China (Beijing, Hong Kong SAR, and Taiwan).

As of June 19, the areas to which travelers to consider postponing all but essential travel are as follows: China (Beijing)

For the full WHO travel advisory, together with additional information about this disease, please visit the following URL:

For information from CDC including guidelines and recommendations, please visit the following URL:

For information from Department of Health Hong Kong SAR, please visit the following URL:

For information from Singapore Ministry of Health, please visit the following URL:
(WHO–WER 6/12,13,18/03, ProMed 6/15/03)

Bovine Spongiform Encephalopathy in Canada
Since a cow from a northern Alberta farm was diagnosed as bovine spongiform encephalopathy (BSE), no other cattle have tested positive. A total of 18 farms were quarantined as part of the BSE investigation. Six farms remain quarantined, all of which are in Alberta.

About 2700 cattle in total have been destroyed. Rapid diagnostic testing has been completed and all results are negative. The traditional tests are partially completed and all are negative to date, meaning that the incidence of BSE in Canada remains confined to one cow.

Regarding the feed component of the investigation, quarantine has now been lifted on all three farms in this line of inquiry. All tests have come back negative. Any required feed clean–up has been completed.

As part of the extended trace–out investigation, it was found that 5 bulls had been exported to the United States of America (USA) in early 1997 from one of the herds that had been quarantined. Identification of these animals was provided to the importing country.
(ProMed 6/17/03)


WHO first Global Conference on Severe Acute Respiratory Syndrome (SARS), June 17 –18, 2003, Kuala Lampur, Malaysia.
Some of the issues discussed in the conference are highlighted at WHO website (http://www.who.int/csr/don/2003_06_19/en/ ).
– An adequate point–of–care diagnostic test is still not available for SARS and remains a top priority.
– Researchers at the conference confirmed that far too little is understood about the origins of the SARS virus and the possible role.
– WHO continues to stress the need to break the chain of human–to–human transmission through use of currently available control tools.
– The long–term response to SARS, which includes the prevention of importation or re–importation of cases into SARS–free areas, will clearly require different strategies for surveillance and response, as current measures cannot be sustained over time.
– Scientists cannot, on the basis of the very limited data available, rule out the possibility that SARS will resurface when environmental conditions or seasons again favor transmission among humans. Should this occur, countries will need to be ready with alert surveillance systems and good preparedness strategies.
Conference materials are also available at the following URL:


Rocky Mountain Spotted Fever: A Clinician's Dilemma
“Rocky Mountain spotted fever is still the most lethal tick–vectored illness in the United States. We examine the dilemmas facing the clinician who is evaluating the patient with possible Rocky Mountain spotted fever, with particular attention to the following 8 pitfalls in diagnosis and treatment:
(1) waiting for a petechial rash to develop before diagnosis;
(2) misdiagnosing as gastroenteritis;
(3) discounting a diagnosis when there is no history of a tick bite;
(4) using an inappropriate geographic exclusion;
(5) using an inappropriate seasonal exclusion;
(6) failing to treat on clinical suspicion;
(7) failing to elicit an appropriate history; and
(8) failing to treat with doxycycline.
Early diagnosis and proper treatment save lives.”
(Masters EJ, et al. Arch Intern Med. 2003 Apr 14;163(7):769㫢.)


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