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Vol. VI, No. 22~ EINet News Briefs ~ November 21, 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
    – Japan: BSE accusations
    – China: Begins giving free HIV/AIDS drugs to the poor
    – China: Reports 840,000 HIV and 80,000 AIDS cases
    – China (Guangxi): Rabies kills 312 people, January to September 2003
    – China (Hunan, Hubei): Food poisoning in children
    – China (Guangzhou): Staphylococcal outbreak
    – China (Beijing): Hand, foot and mouth disease on increase
    – Thailand: AIDS vaccine shown to be ineffective
    – Thailand (Prachuap Khiri Khan): Foot and mouth disease epidemic
    – Russia (Moscow): Rise in meningitis, meningococcal, type A
    – USA (District of Columbia): Anthrax scare
    – USA (Pennsylvania): Restaurant–related hepatitis A outbreak toll reaches 500
    – USA (Virginia): First human death associated with raccoon rabies
    – USA (Washington): Death of student from Hantavirus pulmonary syndrome
    – USA (Idaho): First probable human case of West Nile virus infection
    – USA (Alaska): Salmonella confirmed at Kodiak school
  2. Updates
    – SARS: Nations prepare for return of SARS
    – USA: West Nile virus surveillance
    – Canada: West Nile virus surveillance
  3. Articles
    – Hepatitis A Outbreak Associated with Green Onions at a Restaurant—Monaca, Pennsylvania, 2003
  4. Notifications
    – WHO steps up action against substandard and counterfeit medicines
  5. How to join the EINet email list

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


Japan—BSE accusations
Japan is trying to blame its latest case of mad cow disease on Italy. In October, researchers in Italy reported finding two BSE–infected cows, whose test results revealed a slightly unusual balance of the different forms of the prion protein that causes the disease. Japan's eighth and latest case also gave an unusual test result. The finding prompted Takashi Onodera of the University of Tokyo, head of the Japanese government's BSE panel, to tell journalists that meat and bonemeal imported from Italy might have caused the Japanese case. However, the published results show the tests were abnormal in different ways, and the possibility that both results might just be accidental artifacts rather than representing real differences in the prions remains.

It has been almost 6 months since live cattle from Canada were banned from international markets, including Japan. Ann Veneman, U.S. Secretary of Agriculture, recently announced that the United States was seeking feedback on a proposal that would lift the ban on animals under 30 months, as a review of scientific evidence has shown the public health risk of Canadian beef to be extremely low.

In the last six weeks, Japanese bulls aged 23 and 21 months have tested positive for BSE. Japan is the only country where tests are not limited to bovines older than 24 (or 30) months, but include all animals arriving at slaughterhouses.
(Promed 11/10/03)

China—Begins Giving Free HIV/AIDS Drugs to the Poor
The Chinese government has started providing free treatment for poor people with HIV and AIDS and plans to expand the program next year. The speech by Gao Qiang, the executive deputy health minister, said health workers began handing out free anti–retroviral drugs several months ago in Henan Province, a region ravaged by AIDS. By the end of the year, Gao said 5,000 people should be getting the free medical treatment. He said the central and local governments are planning to improve and expand prevention and control programs and to upgrade blood–testing stations in central and western China. Chinese officials and AIDS experts estimate that 150,000 to 200,000 people have already died of AIDS in China.

Henk Bekedam, the World Health Organization (WHO) representative in Beijing, said the free drug program was the latest example of what appears to be a new, more proactive attitude toward AIDS taken by China's leaders. This week Beijing hosted a major international AIDS conference, and an AIDS meeting led by former President Bill Clinton will be held here on Monday. China recently received a $98 million grant, largely to fight AIDS, from the Global Fund.

Experts say China has begun manufacturing some anti–retroviral drugs, but only ones no longer under patent. China is negotiating with pharmaceutical companies to lower the price of newer, patented drugs. The difficult job of building the necessary health care infrastructure to treat such a major AIDS problem is the immediate challenge for China, but many experts believe that SARS, and the lessons the government learned, is one reason that senior leaders are no longer trying to ignore the country's AIDS problem. Still, many activists believe that China's top leaders, including President Hu Jintao and Prime Minister Wen Jiabao, must make high–profile gestures, as they did during the SARS crisis.
(SEA–AIDS 11/12/03)

China—Reports 840,000 HIV and 80,000 AIDS Cases
Gao Qiang, China's executive deputy minister of health, said China currently has 840,000 HIV carriers and 80,000 AIDS patients. He made the remark at an international economic forum on 6 Nov 2003, adding that the statistics were from a joint epidemiological survey conducted by China, the WHO and UNAIDS. He also said China is planning to offer free treatment to HIV carriers and AIDS patients in the country's rural areas and urban AIDS–infected population who are in financial difficulties.

About 5,000 HIV carriers and AIDS patients in poverty would receive free treatment this year and the free treatment would be available for all poor HIV carriers and AIDS patients next year, Gao announced. In all 124 counties where comprehensive prevention and treatment demonstration zones were established, integrated measures including antiviral treatment, care and life assistance will be adopted.

Gao said that HIV/AIDS is a common enemy of humankind and the Chinese government has attached great importance to prevention and treatment and treated it as a strategic issue for social stability, economic development, national prosperity and security. HIV/AIDS in China has not been controlled and prevention and treatment in China is still faced with arduous tasks, he said. China would protect the legitimate rights of HIV/AIDS patients and oppose social discrimination, he added.
(SEA–AIDS 11/19/03)

China (Guangxi)—Rabies Kills 312 People, January to September 2003
Rabies has killed 312 people in the Guangxi Zhuang Autonomous Region from January to September 2003, a 152.9 percent rise over the total rabies cases in 2002, according to the Regional Department of Health. The figures show the impact of the growing number of pets in the country, which has long been ravaged by infectious diseases. Local medical experts blamed the public's weak awareness of the need for vigilance and the low canine vaccination rate as the major causes of the high number of cases of rabies. There are currently some 6.2 million dogs in Guangxi, of which less than 20 percent have been immunized against the rabies virus.

A serious, fatal disease that can be transmitted by dogs, cats, livestock and certain wild animals, rabies infects and kills thousands of people every year in China. Rabies, called "mad dog disease," has become the most dangerous infectious killer in the country, easily surpassing diseases like SARS, pulmonary tuberculosis, AIDS, and anthrax. The ministry's statistics show that 854 deaths from rabies were reported in 2001, and the figure rose to 1003 in 2002. Some feared the toll might continue to rise this year, since rabies outbreaks had ravaged provinces like Guangdong, Hainan, Hunan, and Jiangsu this summer.
(Promed 11/12/03)

China (Hunan, Hubei)—Food poisoning in children
A total of three school children have died and 46 others have fallen ill in two separate food poisoning cases in Central China recently. In Hunan Province, a farmer deliberately poisoned food, leaving two pupils dead and 25 others hospitalized. In Hubei Province, one primary school student died and 21 others fell ill after having supper at their elementary school.

In the first case, a farmer from Nanjiang town in Pingjiang county of Hunan allegedly went to Daxing and Simei primary schools in the county and gave poisoned popcorn and citrus to a fifth–grade student and to a second–grade student and allegedly told them to share the treats with fellow pupils. After they ate the poisonous food, 27 schoolchildren immediately fell sick and were sent to the hospital. Two students died on the way to hospital. The suspect allegedly tried to escape by bus but was stopped by the police; the motives for the poisoning are unknown.

In the other food poisoning case in Hubei, a total of 22 students fell ill on Tuesday night after they had their supper in the dining hall of the Nigou Central Elementary School in Jingyang.
The school immediately sent the poisoned students to a local hospital. A fifth–grade student died the next morning of respiratory failure. The local government said the cause of the poisoning was likely moldy corn in the food. By yesterday, 19 students had recovered, and two in critical condition had been transferred to the Yunxi County Hospital.
(Promed 11/14/03)

China (Guangzhou)—Staphylococcal outbreak
Recently, the media reported the occurrence of a viral gastroenteritis outbreak of unknown identity in Guangzhou. The Guangzhou Municipal Health Bureau has conducted investigations and now believes the cause of this illness was Staphylococcus aureus. After the outbreak, disease control departments immediately conducted thorough cleaning and disinfection of the school cafeteria and conducted physical exams on cafeteria employees. After adopting these measures, the outbreak was quickly brought under control, and there have been no further cases since 29 Oct 2003.
(Promed 11/16/03)

China (Beijing)—Hand, foot and mouth disease on increase
Hand foot and mouth disease is currently spreading rapidly among Beijing children. Director Zhao of the Beijing City Haidian Hospital Pediatric Department said that since the start of winter this year, the number of hand, foot and mouth disease patients treated at Haidian Hospital's Pediatric Department has shown a clear increase over previous years. During the peak period of this disease in the past, there would be one case every two or three days, but this year there are three or four children diagnosed each day.

Although the mortality rate for patients with hand, foot and mouth disease is less than one percent, if it leads to meningitis, there is still no effective medical treatment, China's CDC’s Jin Qi, said. Hand, foot and mouth disease is a commonly occurring infectious disease caused by an intestinal virus. Most patients are children under five years of age. It can lead to fever and rashes and ulcers on the hand, foot, mouth, and other spots. In exceptional cases it can lead to life–threatening complications like myocarditis, acute lung edema, and aseptic meningitis.
(Promed 11/18/03)

Thailand—AIDS vaccine tested in Thailand shown to be ineffective
The results of a large–scale test of an AIDS vaccine in Thailand showed the inoculation method to be ineffective, confirming the results of an earlier test conducted by the US pharmaceutical firm Vaxgen, which created the AIDS vaccine. AIDSVAX, the vaccine, was shown to be ineffective both in preventing infection by the human immunodeficiency virus that causes AIDS and in slowing the progression of the illness in people who were vaccinated and then became infected with the virus, according to Vaxgen.

The test was carried out in 17 medical centers in the Bangkok area. The first test on the vaccine, conducted in North America, Puerto Rico and the Netherlands, also delivered disappointing results. The vaccine was developed to encourage the immune system to create antibodies which, in principle, would cling to proteins on the virus and prevent it from latching onto the cell it wants to invade.
(SEA–AIDSs 11/17/03)

Thailand (Prachuap Khiri Khan)—Foot and mouth disease epidemic
All districts except two in the Thai province of Prachuap Khiri Khan have been declared as animal epidemic areas, as a large number of cattle in the area are suffering from foot and mouth disease (FMD). Pongsak Chaisit, acting provincial livestock officer, said on Saturday that a large number of cattle in all districts in the western Thai province, except Bang Saphan and Bang Saphan Noi, were found infected with FMD. "The districts are therefore now declared animal epidemic areas, as Prachuap Khiri Khan is a major transit point of cattle transport down to other provinces in the South, and even to neighboring countries," he said. To prevent the infectious disease, animals were being vaccinated, he stated. Local consumers were also advised to wash and fully boil all pieces of meat before they were served.
(Promed 11/16/03)

Russia (Moscow)—Rise in meningitis, meningococcal, type A
There has been a rise in the number of cases of meningococcal meningitis in Moscow. By the end of October 2003, there had been 268 cases (including 22 deaths), mostly in children, approximately twice the average number of cases reported. Unusually, many of the cases have been reported at the end of the summer and in early autumn; the usual seasonal increase occurs in February and March. Meningococcal serogroup A has been identified in 90 percent of the strains isolated. The city health authorities in Moscow have initiated a mass vaccination campaign in order to prevent further cases occurring during the coming peak transmission season.
(Promed 11/18/03)


USA (District of Columbia)—Anthrax scare
Final Test Results for Anthrax at Anacostia Naval Postal Sorting Facility Negative
PCR assays and final culture results from testing conducted by the Naval Medical Research Institute on environmental samples collected from at the Anacostia Naval Postal Facility have been completed and did not suggest the presence of Bacillus anthracis. A single screening assay on a routine air filter sample done on Nov. 5 at this facility using commercial technology was read as positive, prompting closure of the facility and 11 other postal facilities in metropolitan Washington that fed mail to this location. All postal facilities have been cleared for reopening. No one has been hospitalized in the incident, and workers from the Anacostia facility have been instructed that they can stop taking antibiotic prophylaxis.

In October 2001, at least five people died–including two Washington postal workers–and 17 became seriously ill within weeks of the anthrax attacks. Letters containing anthrax spores were sent to news media in New York and Florida, and anthrax–laced letters were sent to the Washington offices of two senators. Those responsible have not yet been caught. Since the attacks, the Postal Service has spent millions of dollars to test and install equipment to sterilize the post.
(Promed 11/08/03)

USA (Pennsylvania)—Restaurant–related hepatitis A outbreak toll reaches 500
The number of people infected in a hepatitis A outbreak linked to a western Pennsylvania restaurant has exceeded 500 and is likely to continue rising for another week, state Health Department officials said on 15 Nov 2003. Three people infected with the virus have died, and thousands have lined up for inoculations since the outbreak was reported in early November among people who ate at a Chi–Chi's Mexican restaurant. A Chi–Chi's executive said the company had adopted "extraordinary measures" company–wide, including sickness logs for employees and asking workers to sign "wellness statements" asserting they are not ill, in an effort to prevent similar outbreaks elsewhere.

As of 15 Nov 2003, 510 cases of hepatitis A have been confirmed in the outbreak, said Richard McGarvey, a spokesman for the Pennsylvania Health Department. He said more infections were expected because people who contract hepatitis A typically do not exhibit its early flu–like symptoms for 30 days. The state started offering antibody inoculations on 5 Nov 2003 to anyone who ate at the restaurant after 22 Oct 2003. The antibody reduces the risk of hepatitis A developing, but it must be given within two weeks of exposure. In severe cases, the virus can lead to liver failure. About 8500 people have received the shots because of the outbreak linked to a Chi–Chi's at the Beaver Valley Mall, about 25 miles northwest of Pittsburgh. The Beaver Valley branch is closed until 2 Jan 2004.

Health investigators said they still did not know the source of the virus. They are looking at foods, including green onions, which are difficult to clean and have been linked to smaller outbreaks in other states. Chi–Chi's has removed green onions from all of its restaurants as a precaution.
(Promed 11/16/03)

Please see Hepatitis A Outbreak Associated with Green Onions at a Restaurant––Monaca, Pennsylvania, 2003 in the Articles Section below.

USA (Virginia)—First human death associated with raccoon rabies
Rabies is an acute, progressive, incurable viral encephalitis, caused by the bite of an infected animal. In March 2003, a previously healthy man aged 25 years from northern Virginia died from a diagnosed illness of meningoencephalitis of unknown etiology after a 3–week illness. Histopathologic review of central nervous system tissues at CDC revealed viral inclusions suggestive of Negri bodies, and subsequent tests confirmed a diagnosis of rabies. Genetic sequencing identified a rabies virus variant associated with raccoons, but how the patient became infected remains unknown. After detailed investigation, five family members and three hospital employees received post–exposure prophylaxis for potential exposure to patient secretions. This is the first documented case of human rabies associated with a raccoon rabies virus variant in the United States and highlights the importance of continued education in the prevention and diagnosis of rabies.

Emergency medicine physicians, infectious–disease consultants, and state and national public health officials can provide advice on rabies prophylaxis for complicated or unusual exposure scenarios to prevent this fatal disease and aid in its diagnosis.
(Promed 11/14/03)

In order to see the article by CDC, please visit the following site:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5245a4.htm
(MMWR November 14, 2003 / 52(45);1102�)

USA (Washington)—Death of Student from Hantavirus pulmonary syndrome
The death of a community college soccer player marks the first known case of hantavirus infection in Skagit County. A 21–year–old student at Skagit Valley College died a week ago, just days after he was taken to a hospital for vomiting and diarrhea. State Health Department tests confirmed the presence of hantavirus, said Peter Browning, director of the Skagit County Health Department.

County health department investigators hope to identify where the individual may have been exposed to the virus. Because the disease cannot be spread through human contact, local residents should not become alarmed, Browning said. Migrant workers and people who work around barns where deer mice could be present are among those most at risk for contracting the virus.Hantavirus pulmonary syndrome is characterized by fever, chills, and severe muscle aches, followed by difficulty in breathing and shortness of breath. Deer mice are the main carriers of the deadly virus, which kills 40 percent of people infected. To prevent the disease, wear gloves and a dust mask when cleaning a rodent–infested area or a shed or cabin that has been closed up. Soak mouse nests and droppings with a solution that is one cup bleach to 10 cups water. Don't stir up any dust; use mops or rags soaked in the bleach solution.
(Promed 11/14/03)

USA (Idaho)—First probable human case of West Nile virus infection
State laboratory results have identified Idaho's first probable human case of West Nile virus infection acquired within Idaho's borders. The man works with a Twin Falls County farm; his only known exposure to the virus came when he worked with sick alligators later determined to be carrying the virus. The alligators were being raised at a local exotic animal farm. The juvenile alligators he handled were part of a legal shipment of 1000 alligators imported from Florida in September. They became ill almost immediately on arrival.

The man, in his 40s, has completely recovered from the infection and poses no health threat to other Idaho residents. Lab tests conducted at the Idaho Department of Health and Welfare's Bureau of Laboratories were positive for West Nile virus.

About 20 per cent of people who are infected with West Nile virus have symptoms of the infection, which can include headaches, body aches, and mild fever. Less than one per cent of people infected develop a serious illness from the viral infection. "We have known for some time that West Nile was coming," said Dr. Christine Hahn, state epidemiologist with the Idaho Department of Health and Welfare. "Counting Idaho, the virus has been found in 46 states now, including our neighboring states of Montana, Wyoming, Utah, and Nevada. And, we can expect that it will reappear in Idaho next year."
(Promed 11/07/03)

USA (Alaska)—Salmonella confirmed at Kodiak school
Four cases of salmonella connected to a lunch served at a private school have been confirmed by the Alaska Division of Public Health. The four were among 48 people sickened after eating at Kodiak Christian School on 31 Oct 2003.

Although health and school officials believe they have pinpointed the event at which the salmonella spread (an International Day potluck lunch) they do not know the direct source of the bacteria. The bacteria could already have been in a food or contaminated by handling, and there were few items at the lunch that are typically associated with salmonella. There was no dish with eggs, except sugar cookies, which appeared properly baked.

Salmonella bacteria cause an infection of the intestines. Infections can be caused by eating raw or undercooked foods such as meat, poultry, or eggs or by eating food or drinks contaminated by an infected person.
(Promed 11/14/03)


Nations prepare for return of SARS
Scientists believe SARS emerged from the animal markets of southern China a year ago this month, and with fall coming, fears that the virus will make a comeback are brewing. At its peak, more than 8,000 people in more than 25 countries were infected by SARS and more than 700 died, according to the WHO. The WHO declared the epidemic over in July, but health experts have said the disease is likely to return, much like seasonal outbreaks of the flu. Unlike the flu, however, SARS has no known treatment; governments around the globe are working on a vaccine, but WHO said this month that it will take at least two years to produce. SARS is caused by a coronavirus never before seen in humans and is a member of one of the viral families that cause the common cold.

Dogs, cats, rabbits, badgers and other animals are sold to be eaten as delicacies in markets in southern China, where scientists think the SARS virus jumped from animals to humans, possibly from a wild civet cat. At the height of the SARS epidemic last spring, the Chinese government banned the sale of wild animals in the markets, but lifted the ban in August.

In China and Hong Kong–hardest–hit by SARS–authorities are already taking precautions in case of a re–emergence. Last month Beijing unveiled a new anti–SARS task force aimed at preventing any further outbreaks, and officials said hospitals and specialist clinics began intensive training for preventing and handling the disease. In Hong Kong, Dr. Tong Chak–kwan said they are ready at Princess Margaret Hospital, which handled more than a third of all Hong Kong's SARS cases.
(CNN 11/17/03)

USA—West Nile virus surveillance
As of 19 Nov 2003, a total of 8470 human cases of WNV infection and 189 deaths during 2003 have been reported. Only 4 states–Hawaii, Alaska, Nevada, and Oregon–have remained entirely free of West Nile virus infection of any animal species (apart from travel–related human cases) since the appearance of the virus in North America. The weekly counts of new human cases during the past 12 weeks have been 414, 1046, 1214, 690, 1034, 646, 450, 429, 332, 502, 176, and now 77. It appears that with the onset of colder weather the outbreak is past its peak. The three western/midwestern states of Colorado, Nebraska, and South Dakota, together with the state of Texas, have accounted for 67.5 percent (5719/8470) of the total number of confirmed human cases, and 56.1 percent (106/189) of fatalities during 2003.

Please visit the following URL for more details:
(Promed 11/20/03)

Canada—West Nile virus surveillance
As of 10 Nov 2003 there has been a total of 1306 probable or confirmed cases of human infection in Canada and 10 deaths (an increase of six cases and no deaths since 4 Nov 2003). Saskatchewan remains the most severely affected province with 767 probable or confirmed cases and six deaths followed by Alberta with 269 confirmed cases and no deaths. The outbreak of
West Nile virus infection in Canada continues to wane. During the past six days there have been only six new probable or confirmed cases of human infection, a single confirmed dead bird, and no new equine cases or positive mosquito pools.
(Promed 11/13/03)


Hepatitis A Outbreak Associated with Green Onions at a Restaurant—Monaca, Pennsylvania, 2003
“The Pennsylvania Department of Health and CDC are investigating an outbreak of hepatitis A outbreak among patrons of a restaurant (Restaurant A) in Monaca, Pennsylvania. As of November 20, approximately 555 persons with hepatitis A have been identified, including at least 13 Restaurant A food service workers and 75 residents of six other states who dined at Restaurant A. Three persons have died. Preliminary sequence analysis of a 340 nucleotide region of viral RNA obtained from three patrons who had hepatitis A indicated that all three virus sequences were identical. Preliminary analysis of a case–control study implicated green onions as the source of the outbreak.”

In order to see the entire article, please visit the following site:
(MMWR November 21, 2003 / 52(Dispatch);1ן


WHO steps up action against substandard and counterfeit medicines
Asian and African Countries Move to improve the quality of their medicines
“The World Health Organization (WHO) will launch an action plan against substandard and counterfeit medicines with six countries from the Greater Mekong sub–region this week. The plan follows similar initiatives begun in Africa and will continue to expand in response to countries’ increasing call for assistance to improve the quality of their medicines.

Counterfeit and substandard medicines are frequently detected in Cambodia, China, the Lao People’s Democratic Republic, Myanmar, Thailand and Viet Nam and the problem seems to be increasing. Products most commonly counterfeited in this region include antibiotics and those used in the treatment of tuberculosis, malaria and HIV/AIDS. The use of poor quality or counterfeit medicines has little or no therapeutic effect and in poor settings often leads to death.

“Combating low quality or illegal medicines is now more important than ever. Expanding access to safe, effective treatment for AIDS and other illnesses is no longer an option, it is an imperative,” says Dr Lee Jong–wook, WHO Director–General.”

In order to see the entire article, please visit the following site:
(WHO 11/11/03


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