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1. OVERVIEW OF INFECTIOUS-DISEASE INFORMATION
Below is a semi-monthly summary of Asia-Pacific emerging infectious diseases.

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China (Guangdong)—New case of laboratory-confirmed SARS, 31 Jan 2004
A new case of laboratory-confirmed infection with the SARS coronavirus was reported 31 Jan 2004 by the Ministry of Health in China. This is the fourth case (three confirmed and one probable) detected in China since 16 Dec 2003. The new case is a 40-year-old director of a hospital and practicing physician from Guangzhou, Guangdong who developed symptoms of SARS on 7 Jan 2004. He was admitted to a hospital in Guangdong with pneumonia on 16 Jan and placed in respiratory isolation on the suspicion of SARS. He has made a full recovery and was discharged home 30 Jan 2004.
In accordance with WHO recommendations for SARS-CoV testing in the inter-epidemic period, the results of SARS-CoV testing performed at the national reference laboratory in Beijing were verified by a WHO SARS International Reference and Verification Network laboratory in Hong Kong.

At present, the source of infection in this most recent SARS case is unknown, and the Ministry of Health is conducting an epidemiological investigation into possible sources. To date, none of the contacts so far identified has developed symptoms of SARS. The Ministry is also collaborating with WHO to further investigate this and the other recent SARS cases in Guangdong. All four of the reported cases to date have been associated with a mild illness and full recovery. Of note, this case is in a healthcare worker, which may suggest that this individual was infected in the healthcare environment. In the outbreak in Guangdong reported in February 2003, the proportion of SARS cases in healthcare workers was approximately 30 percent. In the final analysis of the global outbreak, approximately 21 percent of SARS cases reported in 2003 were in health care workers, with a high of 43 percent reported in Canada — see The Consensus Document on the Epidemiology of SARS <http://www.who.int/csr/sars/en/WHOconsensus.pdf>.
(Promed 1/31/04)

China—New SARS study stresses need to act fast against epidemics
Chinese scientists analyzing the genome of the SARS virus have documented the immense rapidity with which it evolved from an animal pathogen into one capable of infecting human cells. Their analysis, reported in Science, shows that as the virus perfected its human attack mechanism, its potency soared from being able to infect only three percent of the people who came in contact with a patient to an infectivity rate of 70 percent a few months later. The speed of the SARS virus's transformation suggests that to prevent new viral epidemics, like the one that experts fear could emerge from the current cases of bird flu, it would help to identify and isolate patients at the earliest possible stages before a virus can attain
its peak infectivity.

The alacrity with which the virus adapted to humans underlines the importance of having a public health surveillance system to recognize and isolate patients at an early stage before a new virus has honed its attack skills. Even in the absence of the molecular epidemiology of the responsible agent, the earlier an outbreak is recognized, the sooner control measures can be implemented and transmission interrupted. Once the epidemiology of an outbreak has been defined, control measures directed at interrupting transmission can be implemented. With respect to SARS, transmission was interrupted by the use of strict infection control measures that required high levels of both material and human resources
per case.

To read this article, please see:
Science: Molecular Evolution of the SARS Coronavirus During the Course of the SARS Epidemic in China. The Chinese SARS Molecular Epidemiology Consortium. Published online 30 January 2004, 10.1126/science.1092002
(Promed 1/30/04)

East Asia—WHO recommends Asian countries stockpile antiviral drugs
Countries should consider stockpiling antiviral drugs in case avian influenza striking Asia's poultry becomes contagious among people, the WHO said. So far there have been no reports of human-to-human transmission, with all cases traced to direct contact with sick birds. Health experts fear that if avian influenza strikes someone suffering from human influenza, the viruses could create a hybrid, potentially causing a global pandemic. Because a vaccine for humans is many months away, and might not be widely available at first, countries need to consider stocking antiviral drugs, Klaus Stohr, WHO's chief flu expert, said. The virus appears to be resistant to two older influenza drugs, amantadine and rimantadine, but the newer drugs Tamiflu and Relenza are expected to work.

Indonesia, which for days insisted that large-scale slaughter of chickens was not necessary, reversed that decision and ordered a mandatory mass cull of poultry in infected areas; however, the outbreak could leave 1.25 million people jobless and cost the country $916 million. Japan, a big chicken customer, has banned Indonesian imports. Vietnam said it might be
necessary to destroy all the chickens in the country. Thailand said that bird flu has been found in poultry in a province bordering the popular tourist resort of Phuket. China confirmed cases of bird flu in poultry in two provinces and is investigating suspected cases in other regions. Their State Council set up a national command center to battle avian influenza and named a vice-premier to run it.
(Promed 1/31/04)

Pan-Asia—FAO/OIE/WHO call for targeted strategy to help curb avian flu
A targeted vaccination campaign for poultry at risk of being infected by the highly pathogenic avian influenza virus may be required in heavily affected countries to control the further spread of the epidemic, according to experts gathered for emergency talks at the UN Food and Agriculture Organization (FAO). Issuing a series of recommendations after two days of discussions, the group of experts, including representatives from the World Animal Health Organisation (OIE) and the WHO said vaccinating animals could be one method—along with culling and other priority measures—to contain the spread of the virus. The mass culling of flocks outside of infected sites in reaction to outbreaks might therefore be largely avoided and major damage to the livelihoods of rural households and national economies averted. Culling infected flocks remains the recommended response when the disease is detected, but vaccination, when used together with other control measures, such as market and movement management, and good agricultural practices, offers a suitable means to
support the suppression of the further spread of the virus.

Experts emphasized the importance of protecting people in contact with infected or suspected birds. They agreed that such targeted vaccination would help prevent animals falling ill and reduce the amount of virus in the environment. Experts agreed that the vaccination plan, using a vaccine that meets OIE's standards, should be accompanied by strict control
measures such as surveillance, elimination of infected birds, animal movement control, and observation of basic hygiene in animal production. They agreed that vaccine manufacturers would need a few months to gear up to produce sufficient amounts of the required vaccines. The recommendations issued included the need for substantial international
financial support to fund the intensified control measures required, and the creation of country-specific guidelines and regional coordination programmes. "These measures will not only help deal with the immediate crisis but will also lay the ground for capacity building programmes for national veterinary administrations. Priorities will be on surveillance
and monitoring of animal diseases; these measures will also help to rebuild the damaged export markets in the region," said Bernard Vallat, Director-General of OIE.
(Promed 2/5/04)

Pan-Asia—Avian influenza global surveillance guidelines and WHO update
WHO has today issued on its website guidelines for global surveillance aimed at monitoring the spread of avian influenza A (H5N1) virus infection in human and animal populations <http://www.who.int/en/>. The guidelines include the definition of a laboratory-confirmed case of avian influenza A (H5N1) virus human infection, and describe procedures for reporting cases to WHO. The guidelines also provide recommended procedures to monitor changes in transmission patterns and to detect potential human-to-human transmission. The guidelines are intended to improve global vigilance for the further spread of avian influenza A (H5N1) virus infections in humans and animals, and for the first signs that human-to-human transmission may be occurring. Use of standardized procedures and reporting forms will improve the quality of information needed by WHO to advise on the most appropriate control measures.

Chinese authorities have announced a suspected outbreak of avian influenza A (H5N1) virus infection at a chicken farm in Tianjin. Spread to additional farms within several provinces has also been reported. Altogether, outbreaks of H5N1 in poultry are suspected or confirmed at 39 farms in 14 of the country's provinces, autonomous regions, and municipalities. To date, no human cases have been reported in China.

WHO has today received the results from a study of virus isolated from a 23-year-old woman who is part of a family cluster in Viet Nam under investigation as the first possible instance of human-to-human transmission. Virus genetic material from this woman, as for the other case in this cluster, is of avian origin and contains no human influenza
genes. It has been reported previously that all affected members of this family cluster had handled diseased poultry.

The number of confirmed human cases in Thailand and Viet Nam remains unchanged at 23, and the number of deaths at 19 (or 18 according to WHO as of 11 Feb 2004). No confirmed human cases have been reported from elsewhere in the East Asian region. Earlier this week, the WHO warned the bird flu outbreak in Asia could take from six months to two years to get under control.
(Promed 2/11/04, CNN.com 2/12/04)\

Southeast Asia—Major flaws in avian flu detection
The bird flu ravaging Asia has prompted international calls to improve early warning systems for animal-borne diseases that threaten public health. But livestock surveillance practices in Asia are so shoddy that fixing them will be complex and costly. Many of the region's governments lack the trained manpower and financial resources, and the international agencies charged with monitoring global health risks—notably the World Organization for Animal Health and the FAO and the UN's WHO—also have weaknesses. Aside from having little tradition of cooperation, they have very few veterinary specialists on the ground in Asia and have no legal power to force individual governments to comply with recommended measures for detecting and dealing with outbreaks.

Moreover, poor communication and lack of coordination among government bureaucrats, international agencies and other foreign health experts may also allow prevent early detection. The failure to quickly detect and contain the spread of avian influenza highlights some fundamental flaws in the global disease-surveillance system, the focus of criticism when SARS
erupted in Asia. While news of Asia's bird flu outbreaks surfaced in January, there is growing evidence that H5N1 had infected poultry in Vietnam, Thailand, Indonesia and China last year but went undetected or unreported. The experience of Vietnam illustrates some of the key flaws in the surveillance system, and raises questions about the monitoring role of international agencies. For example, FAO runs a global program aimed at helping it detect and minimize the risk of disease outbreaks, but there are no formal guidelines on what governments should report to FAO, leaving holes in the disease defense. Problems are compounded by a historic lack of coordination among the main international agencies that track animal health and those that track human health; of the 55 people working full time for the FAO in Vietnam, none specializes in animal health. No one in the FAO's Hanoi office regularly consults the World Organization for Animal Health (OIE), which requests monthly reports from its 166 member-countries and posts disease alerts. And no Hanoi-based FAO staffer checks on whether Vietnam is filing its reports to the OIE.

The delayed international reporting of outbreaks in Vietnam, Thailand and Indonesia has prompted allegations of bird flu cover-ups by government officials and powerful industry groups in Asia. The system is vulnerable to cover-ups because international agencies have little power to police errant nations that fail to report outbreaks quickly and thoroughly. "Countries fear that by notifying the OIE, that may have a negative impact on trade," says Alex Thiermann, a senior OIE official. "Unfortunately, the lack of transparency and delay in reporting may have a greater negative impact, in the longer term, because their credibility will be affected." Furthermore, Vietnamese farmers have little incentive to report livestock
diseases to local authorities, given the absence of insurance or other routine compensation schemes.

Problems such as insufficient funding and lack of political clout need to be overcome. "As for countries that fail to report outbreaks to the OIE", Thiermann says, "we don't have any legal teeth to go after them." The main challenge lies in training a fresh generation of vets in the field, while improving the knowledge of locally based animal-health workers and
devising compensation plans that will motivate farmers to notify authorities about their sick livestock. Such improvements take money and time, but are necessary to plug the gaps in the early warning net.
(Far Eastern Economic Review, 2/12/04)

Cambodia, Laos, Pakistan, and Viet Nam—FAO aid to help battle bird flu outbreak
The United Nations food arm has announced it is giving four Asian countries—Cambodia, Laos, Pakistan, and Viet Nam—USD 1.6 million to help them battle the recent outbreak of avian influenza. The Food and Agriculture Organization (FAO) created the emergency aid package after a request from the four nations to improve their emergency disease control and surveillance systems. At least 13 people have died in Viet Nam and Thailand as a result of contracting the H5N1 virus strain in the current outbreak. Millions of domestic birds have died or been slaughtered in the Republic of Korea, Viet Nam, Japan, Thailand, Cambodia, China, Laos, Pakistan, Taiwan, and Indonesia since December 2003. The aid package will be used to prepare a zoning plan for culling birds, to train farmers and government workers on safe disposal and disinfection, to provide protective gear, equipment and laboratory supplies for making rapid diagnoses, and to begin national epidemiological studies of the disease.
(Promed 2/5/04)

China (Tianjin)—Another region hit by bird flu
China reported four new suspected bird flu outbreaks on Monday, including one in the northern municipality of Tianjin, which had previously been unaffected. Tianjin municipality is located close to the capital Beijing, which has yet to report any outbreaks. Hubei, Yunnan, and Shaanxi provinces had reported other outbreaks earlier. Meanwhile, WHO experts
have discussed with Chinese health officials the possibility that humans may be infected by bird flu, despite government insistence that it has found no cases of human infection. China has reported more than 30 suspected or confirmed bird flu outbreaks in 13 of its 31 provinces. "We believe that what is known by the central government is being shared with
WHO and FAO (the United Nations' Food and Agriculture Organisation), to better allow us to support China at this crucial time," Henk Bekedam, WHO representative in China, said. "However, that may not be the same as knowing all that is happening across the country." With the additional outbreak in Tianjin, 14 of the total 31 main administrative regions in China seem to have been found affected to date; the H5N1 HPAI virus strain has, so far, been definitely confirmed in six of them.
(Promed 2/10/04)

China—All provinces instructed to crack down on fake poultry vaccines
The central government is to crackdown on fake vaccines for poultry after the WHO warned yesterday that using poor-quality products would make the bird flu outbreak worse. As part of the move, all provinces are being told to deal with the problem. The bird flu outbreak continues to spread on the mainland. The South China Morning Post reported that chicken farmers in Guangdong had been using vaccines secretly produced in underground factories to try to protect their flocks against the disease. WHO has been pressing the Ministry of Agriculture for more information about the quality and type of vaccines being used. The unofficially produced vaccine is only half the price of the government-approved variety. Using a
poor-quality vaccine could have adverse effects, and may end up masking an infection in birds.

The Guangdong government said it would allocate a further 5 million yuan to produce proper vaccines against bird flu. Thirteen provinces and regions are now either confirmed as having bird flu or have suspected cases. Officials from the ministries of health and agriculture have held meetings with WHO and FAO specialists to plan joint action. Henk Bekedam, the WHO representative in China, said that while WHO had not been presented with any evidence of human infection on the mainland, it did not rule out the possibility of such cases existing.

HPAI vaccination is currently officially applied in China and Indonesia. Though no official data are available, news items that included pictures indicate that animals of several species are being vaccinated, including chickens, ducks, geese, and doves. Although only killed vaccines are allowed, in one press picture, allegedly photographed at a chicken farm in Banten, West Java, Indonesia on 30 Jan 2004, the use of an eye-drop vaccine is shown; if authentic, this might indicate the application of a live-attenuated vaccine. More information on the vaccines applied in China and Indonesia, with special reference to the measures taken by the responsible authorities to control vaccine production and testing and to certify their release, is urgently needed.
(Promed 2/11/04)

Bangladesh—Nipah-like virus outbreaks in Manikganj and Rajbari
From 4 Jan 2004 to 8 Feb 2004, WHO received reports of a total of 42 cases and 14 deaths attributed to Nipah-like virus infections in Bangladesh. The infections have occurred in Manikganj (7 cases, 4 deaths) and Rajbari provinces (35 cases, 10 deaths). An additional 45 cases are under investigation. Laboratory testing performed by CDC has confirmed
Nipah-like virus in nine of the cases to date. A team comprising experts from WHO, partners in the Global Outbreak Alert and Response Network, and the Institute of Epidemiology Disease Control and Research, Bangladesh is assisting the Ministry with epidemiological investigations. Further activities include case control studies, serosurveys of humans, and
serosurveys of animals in the region to identify the viral reservoir. Manikganj lies 50 km to the south west of Rajbari, and at a distance from the site of the first recorded outbreak of Nipah-like virus infection in Bangladesh in 2001. It can be inferred, therefore, that this Nipah-like paramyxovirus is prevalent throughout central Bangladesh. Previous reports
suggested that children were most affected.
(Promed 2/12/04)

South Korea—Brucellosis Outbreak Reported in cattle
Brucellosis, an infectious disease that can cause miscarriages in cows and chronic flu-like symptoms in humans, has re-emerged in South Korea, sending shudders through the domestic cattle industry. Humans can contract the sickness by consuming contaminated dairy products or coming into direct contact with infected cattle. Fifteen dairy cows on a farm in Chongup, North Cholla Province, have tested positive, while four others tested "quasi-positive". To prevent the spread of the disease, quarantine authorities have decided to slaughter all infected cows and decontaminate nearby areas. Brucellosis is endemic in Korea; 110 outbreaks have been reported during 2002, the last year for which Brucellosis data are available on the OIE web-site.
(Promed 2/4/04)

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USA (Delaware)—Avian influenza virus subtype H7 outbreak
An outbreak of avian influenza was reported 9 Feb 2004 in a flock of about 12,000 chickens (all in one house) in Kent County, State of Delaware. The outbreak was first detected 5 Feb 2004 and the estimated date of primary infection is 2 Feb 2004. Mortality rates were within the normal range. Preliminary testing results using rapid testing procedures and serology were positive for avian influenza; the avian influenza virus subtype is H7. Pathogenicity testing is being conducted at the National Veterinary Services Laboratories (NVSL). Source of agent/origin of infection is unknown at this time, but the virus isolate seems to be the same one as that known to circulate in live bird markets in the New York City area.
Birds raised on the premises were being sold specifically to supply the live bird markets in New York City. Poultry premises within a 3 km radius of the index farm are being sampled and tested. To date, all farms tested within this radius are negative for avian influenza. The flock has been completely depopulated, and USDA-APHIS is working closely with the State of Delaware by conducting epidemiological investigations and area surveillance testing. A quarantine zone has been implemented within a 3 km radius.
(Promed 2/11/04)

USA (Delaware): Avian influenza found on second farm
Delaware Department of Agriculture (DDA) found 10 Feb 2004 that avian influenza is present on a second farm in Delaware. The H7-type avian influenza was found in a commercial flock of roaster-type chickens in northern Sussex County, at least five miles away from the southern Kent County farm identified Friday as being infected. A flock of 72 000 birds in three chicken houses on the northern Sussex County farm is being destroyed this afternoon. The source of infection of the second farm is unknown at this time. While dangerous to poultry, the H7 strain of avian influenza is not generally considered to pose a danger to humans and is not the same strain that has caused illness and deaths in Asia. Avian influenza is most often transmitted from one bird to another through mud and manure that can be tracked via shoes or vehicles. It can also be transmitted from bird to bird through the air.

Test results show that all 20 farms within a two mile radius of the non-commercial southern Kent County farm with the first detected case of H7 avian influenza were found to be negative for avian influenza. The specific strain of avian influenza at the first farm has been confirmed as H7N2, which has never been known to cause harm to humans. The strain at the second infected farm is known to be H7, but the more specific N-type is not yet known. DDA is asking anyone with small numbers of backyard chickens or other poultry to report any disease or suspicions of disease immediately to the Department. DDA is canceling all scheduled farmer and grower related meetings in order to prevent spread of the disease, and asking that all sales or auctions of farm equipment be cancelled. DDA is also banning all sale of live poultry in Delaware. Individuals and the media are asked to stay away from poultry farms in Delaware in order to prevent spread of this disease.

Japan and South Korea quickly banned the importation of American poultry after the first outbreak. About 10 percent of all of Japan's poultry imports and about half of South Korea's come from the United States. China announced its ban on U.S. chickens late Tuesday, joining Singapore and Malaysia. Brazil said separately it had also banned U.S. poultry imports. U.S. trade officials say any ban is unnecessary as the Delaware virus is not a threat to humans.
(Promed 2/11/04, CNN.com 2/12/04)

USA (Northwest)—BSE investigation completed by USDA
On 9 Feb 2004, the USDA's Animal and Plant Health Inspection Service announced the completion of the field investigation of the case of BSE in a cow in the state of Washington. The epidemiological tracing and DNA
evidence proves that the BSE-positive cow slaughtered in Washington on 9 Dec 2003, was born on a dairy farm in Calmar, Alberta, Canada, on 9 Apr 1997. She was moved to the US in September 2001 along with 80 other cattle
from that dairy. A brain sample collected from the cow at slaughter tested positive for BSE. A total of 255 "Animals of Interest" were identified on 10 premises in Washington, Oregon, and Idaho. "Animals of Interest" are defined as animals that were — or could have been — from the source herd in Alberta, Canada. All 255 animals were depopulated and BSE testing was negative on all of them.

The USDA feels confident that the remaining animals represent very little risk. Any of these animals showing nervous system disorder — or any that are nonambulatory at the time of slaughte r— will not be allowed into the human food chain. Any animals slaughtered after 12 Jan 2004 would have the SRMs (Specified Risk Materials—those tissues or portions of the carcass likely to contain the infectious agent in an infected animal) removed and not allowed into the human food chain. And, the USDA has had an effective feed ban in place for over six years, thus preventing the transmission of
the disease to other animals.

There were several lessons learned from the Washington case. The North American cases demonstrate again that exporting countries feel significant national social and financial impacts when importing countries fail to comply with international rules regarding trade. Therefore, the US should demonstrate leadership in trade matters by adopting import/export policy in accordance with international standards, and thus encourage the discontinuation of irrational trade barriers when countries identify their first case of BSE. In addition, the US should continue to act responsibly
when considering export of potentially contaminated materials. Risk materials must be destroyed or safely utilized to protect human health, animal health, and the environment.

Specific trade information can be found at: <http://www.aphis.usda.gov/lpa/issues/bse/trade/bse_trade_ban_status.html>

Additional information on BSE can be obtained by visiting the USDA website: <http://www.usda.gov/>; past BSE updates can also be found at <http://www.aphis.usda.gov/>.
(Promed 2/5/04, 2/10/04)

USA (Northeast)—USDA issues beef warning after salmonella outbreak
The U.S. Agriculture Department has issued a public health warning about raw ground beef, after dozens of people in the Northeast became ill with salmonella infections. The CDC is investigating a salmonella outbreak of at least 37 cases in Connecticut, Maine, Massachusetts, New Hampshire, New York, and Vermont. Health officials said many of the people who became ill reported eating ground beef, and some ate the meat raw. No deaths have been reported. The USDA is investigating whether the tainted products originated from a common source. Salmonella, which sickens one million people annually, can cause vomiting, diarrhea, and fever in healthy adults and can be fatal for elderly people or those with weak immune systems. Symptoms usually occur 8-72 hours after eating infected meat. About 600 Americans die from salmonella infections annually. Salmonella are found widely in the animal kingdom and are frequent contaminants of animal parts used for food—especially chickens, but also cattle and other animal products. Adequately cooking meat will kill most if not all Salmonella in the meat.
(Promed 1/31/04)

USA (Pennsylvania)—suspected norovirus outbreak at Philadelphia hotel
Health officials are investigating an outbreak of illnesses at a Philadelphia hotel that recently played host to about 200 Republican leaders, including President George W Bush. At least 69 guests at the Loews Philadelphia Hotel—all attending a business conference—went to the hospital last week when an undiagnosed presumptive infectious agent caused
dizziness and vomiting. More fell ill, but did not seek medical attention. In addition, two people at a Republican retreat to discuss party policy on 29 – 31 Jan 2004 became ill the day after checking out, an aide to the Illinois Republican said. Neither was admitted to hospital. Philadelphia Health Department said investigators are looking at several possible causes for the outbreak, including food contamination and norovirus infection, an illness that has been known to afflict travelers on cruise ships. Most of the sicknesses did not occur until several days after the Republicans left, and there was nothing to indicate the outbreak was linked to the Republican gathering, and no foul play was suspected. City health officials were contacting hotel guests to ask what they ate, and some have been tested, which may help identify the illness. There have
been no new cases in several days.
(Promed 2/12/04)

USA (Texas)—West Nile virus infected bird found in Houston
Officials in Houston, Texas, have discovered West Nile virus in a bird, but its early detection may not indicate a severe season. The fact the dead blue jay (found in north west Houston on 22 Jan 2004) tested positive for West Nile virus indicates the virus survived through winter and that Texas can expect to grapple with the mosquito-borne virus again this
summer, according to Ray Parsons, head of Harris County's mosquito control division. In 2003, infected birds were not found until May 2003, but the early detection is probably not an indicator of the severity of the problem West Nile may pose this year, the Houston Chronicle reported. "There is really no need for alarm right now," Parsons said. "We wanted to put this information out because if we find something, we want to let the public know." The vast majority of people who become infected with West Nile virus show no symptoms, or only mild symptoms such as a low fever. Severe symptoms, such as high fever, stiff neck, and muscle weakness, usually occur between 5 and 15 days after a bite from a virus-carrying mosquito, usually after the month of June. This is the first report of West Nile virus infection of any species in the USA for the year 2004.
(Promed 2/11/04)

USA (Washington)—Breastfed baby exposed to smallpox vaccine virus
Breastfeeding women who live with someone who has been recently vaccinated against smallpox should take extra precautions to prevent their infants from being exposed to the virus used in the vaccine, according to a new report. Doctors at the Madigan Army Medical Center in Tacoma, Washington, have documented the case of a breastfed infant who was exposed to vaccinia virus, which is used as the smallpox vaccine. The baby's mother had not been vaccinated against smallpox but her husband was given the vaccine soon before the baby developed symptoms. The CDC already recommends that women who are breastfeeding should not receive the vaccine, but there are no guidelines against vaccination of other people living in the same household. Transfer of the vaccinia virus within a household remains "extremely rare," according to Dr Mary P Fairchok, but she said this case demonstrates the need for extra precautions in households where a child is breastfeeding. About 10 days after the husband was inoculated, his wife developed blisters on her nipples, and shortly after, a blister was seen on the baby's upper lip. Testing showed that vaccinia virus was the cause of the lesions for both the mother and the child. The infant in the report recovered well, but she could have ended up with scarring.

Smallpox vaccination can cause severe side effects, including brain damage and even death, in a small percentage of people, particularly children and people with weakened immune systems. But even if individuals who are at
high risk of side effects are not given the vaccine, there are fears that they might be infected by vaccinia virus that is shed by others during the weeks after vaccination. After being vaccinated, the baby's father reported following all precautions to prevent the spread of vaccinia virus, including keeping the vaccination site covered. However, the wife did all of the family's laundry, so she could have been exposed through contact with infected laundry. Based on this case, Fairchok advises that CDC recommend that vaccine recipients not share a bed with a breastfeeding mother and that they do their own laundry. Also, women who are breastfeeding should always wash their hands before nursing, the report
recommends.

To read the article, please see: (Garde V, Harper D, Fairchok MP. Tertiary contact vaccinia in a
breastfeeding infant. JAMA 2004; 291: 725-7, 11 Feb 2004 http://jama.ama-assn.org/cgi/content/abstract/291/6/725).
(Promed 2/11/04)

Chile (Region VIII)—Five cases of hantavirus pulmonary syndrome registered
During the past few days, five cases, two of them fatal, have been registered in Region VIII of Chile. The victims are three males and two females, all of them from rural areas. According to the Public Health Institute of Santiago, the two fatal victims were an 11-year-old girl from Tome, and a 55-year-old adult from Biobio. Both presented with Hantavirus Pulmonary Syndrome (HPS) and died on 26 Jan 2004 in the hospitals of Talcahuano and Los Angeles, respectively. The minor was hospitalized on 20 Jan 2004 with flu-like symptoms. Her condition worsened and she died 6 days later as a consequence of multi-systemic failure. The health authorities of Talcahuano inspected the hygiene conditions in her house
and collected samples from her parents and three siblings, all of whom will remain under observation for six weeks, the period during which they could present symptoms. The second fatal victim was hospitalized with severe illness on 25 Jan 2004 after having suffered respiratory symptoms for several days. According to the health authorities of the locality of Biobio, the patient frequently camped in rural areas.

During 2003, 56 cases were registered in Chile; Region VIII was the most affected, with 21 cases. There were 19 deaths, representing a mortality rate of 29 percent, the lowest since 1997, when hantavirus infection was first recorded. More details on the epidemiology of hantavirus infection in Chile can be accessed at the following website, which is updated with
every new case: http://epi.minsal.cl/epi/html/bolets/reportes/Hantavirus/Hantavirus.htm
(Promed 1/31/04)

Guatemala—24 deaths in outbreak of rotavirus infection
The Ministry of Health reported that a one-year-old child died yesterday in San Juan Sacatepequez, a village located 18 miles west of Guatemala's capital. The death toll in an outbreak of rotavirus infection, over the past two weeks, has reached 24. According to statistics, 15 children have died in the state of Guatemala, six in Escuintla, one in Suchitepequez,
and two in Sacatepequez. In the period between 7 Feb 2004 and 9 Feb 2004, 230 new pediatric cases of "acute diarrheal disease" were registered. Due to the crisis last weekend, the Ministry has opened 11 health centers available 24 hours a day to handle the large number of cases. Rotavirus infection primarily affects young children under two years of age and is manifested as vomiting, diarrhea, and fever. Spread is mainly by the fecal-oral route. Dehydration is common and if not dealt with promptly has
serious consequences.
(Promed 2/12/04)

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2. UPDATES

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Office International des Epizooties—new update on avian influenza in animals in Asia
A new update on avian influenza in animals in Asia, issued by the Office International des Epizooties (OIE) on 11 Feb 2004, may be seen at <http://oie.int/downld/AVIAN%20INFLUENZA/A_AI-Asia.htmText>. It includes the official follow-up report No. 1 of the Chinese Veterinary Services, titled "Information of Highly Pathogenic Avian Influenza (HPAI) in Mainland, P. R. China". According to this report, up to 2 Feb 2004, there have been a total of 38 outbreaks of the disease in 14 provinces, 23 of which have been confirmed by the National Avian Influenza Reference
Laboratory as subtype H5N1-caused HPAI; the rest of 15 being suspected cases.
(Promed 2/11/04)

CDC: Precautions for Travel to Countries Reporting Avian Influenza A (H5N1)
The Centers for Disease Control and Prevention (CDC) has issued precautions for travel to countries that are reporting outbreaks of avian influenza A (H5N1) in humans and animals. Currently, CDC does not recommend that the general public avoid travel to any of the countries affected by avian influenza A (H5N1). Currently no definitive evidence has
been found of human-to-human transmission; no H5N1 infections have been documented among health-care workers. The source of exposure in human cases of H5N1 influenza is under investigation, although most human cases have been linked to direct contact with diseased birds. Outbreaks of H5N1 infection have been detected in the poultry populations of Cambodia, China, Indonesia, Japan, South Korea, Laos, Thailand, and Viet Nam. The virus was also confirmed in a single peregrine falcon in Hong Kong. For more information on these reports visit the World Organization for Animal
Health website: http://www.oie.int

CDC has issued the following recommendations for travel to countries reporting human or animal cases of avian influenza A (H5N1):

Before you leave:
Assemble a travel health kit containing basic first aid and medical supplies. Be sure to include a thermometer and alcohol-based hand rub for hand hygiene. Educate yourself and others who may be traveling with you about influenza. Information about influenza is provided on CDC's influenza website: http://www.cdc.gov/flu/ Be sure you are up to date with all your shots, and see your health-care provider at least four to six weeks before travel to get any additional shots or information you may need. CDC health recommendations for international travel are provided on CDC's Travelers Health website: http://www.cdc.gov/travel/ You may wish to check your health insurance plan or get additional insurance that covers
medical evacuation in the event of illness. Identify in-country health-care resources in advance of your trip.

While you are in an area where avian influenza cases have been reported: At this time, CDC recommends that travelers to countries experiencing outbreaks of this disease in poultry should avoid areas with live poultry, such as live animal markets and poultry farms. As with other infectious illnesses, one of the most important and appropriate preventive practices is careful and frequent hand hygiene. Cleaning your hands often, using either soap and water or waterless alcohol-based hand sanitizers, removes potentially infectious materials from your skin and helps prevent disease transmission. Influenza viruses are destroyed by heat; therefore, as a precaution, all foods from poultry, including eggs, should be thoroughly cooked. If you develop respiratory symptoms or any illness that requires prompt medical attention, a U.S. consular officer can assist in locating appropriate medical services and informing family or friends. See this website for more information about what to do if you become ill while abroad: http://www.cdc.gov/travel/other/illness-abroad.htm

After your return:
Monitor your health for 10 days. If you become ill with fever or respiratory symptoms during this 10-day period, consult a health-care provider. Before your visit to a health-care setting, tell the provider about your symptoms and recent travel so that he or she can be aware you have traveled to an area reporting avian influenza. Information for health care providers wishing to test for or report cases of influenza A (H5N1) and SARS can be found at this website: http://www.cdc.gov/flu/han020302.htm
(Promed 2/8/04)

CDC/WHO travel recommendations regarding SARS
The CDC has been working closely with the WHO and other international partners to track cases of SARS. Since 16 Dec 2003, the Chinese Ministry of Health has reported four cases of SARS (three confirmed and one probable). All four cases are from Guangdong, the same province where the first case of SARS in 2003 was confirmed and where the first cases of SARS were identified in November 2002. All four patients have recovered from their illness and have been discharged from the hospital. None of their contacts have developed SARS-like illness. For additional information,
see: <http://www.who.int/csr/sars/archive/en/>.

Currently CDC and WHO do not recommend that the general public avoid travel to any of the countries affected by SARS. Previous SARS research has shown that SARS can be controlled and contained through early detection, isolation of suspect cases, and tracing of their contacts. In addition, it would be prudent for travelers to China to avoid going to live food markets and having direct contact with wildlife from these markets. Although there is no evidence that direct contact with civets or other wild animals from live food markets has led to cases of SARS, viruses similar to the SARS-CoV have been found in these animals, and some humans working with these animals have evidence of infection with SARS-CoV, or a very similar virus.
(Promed 2/12/04)

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4. ARTICLES

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Outbreaks of Avian Influenza A (H5N1) in Asia and Interim Recommendations for Evaluation and Reporting of Suspected Cases — United States, 2004
"During December 2003 – February 2004, outbreaks of highly pathogenic avian influenza A (H5N1) among poultry were reported in Cambodia, China, Indonesia, Japan, Laos, South Korea, Thailand, and Vietnam. As of February 9, 2004, a total of 23 cases of laboratory-confirmed influenza A (H5N1) virus infections in humans, resulting in 18 deaths, had been reported in Thailand and Vietnam. In addition, approximately 100 suspected cases in humans are under investigation by national health authorities in Thailand and Vietnam. CDC, the World Health Organization (WHO), and national health authorities in Asian countries are working to assess and monitor the situation, provide epidemiologic and laboratory support, and assist with control efforts. This report summarizes information about the human infections and avian outbreaks in Asia and provides recommendations to guide influenza A (H5N1) surveillance, diagnosis, and testing in the
United States." http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5305a1.htm
(MMWR February 13, 2004 / 53(05);97-100)

Cases of Influenza A (H5N1) — Thailand, 2004
"Since mid-December 2003, eight Asian countries (Cambodia, China, Indonesia, Japan, Laos, South Korea, Thailand, and Vietnam) have reported an epizootic of highly pathogenic avian influenza in poultry and various other birds caused by influenza A (H5N1). As of February 9, 2004, a total of 23 laboratory-confirmed human cases of influenza A (H5N1) had been reported in Thailand and Vietnam. In 18 (78%) of these cases, the patients died. Clinical experience with avian H5N1 disease in humans is limited (1). The human H5N1 viruses identified in Asia in 2004 are antigenically and genetically distinguishable from the 1997 and February 2003 viruses. To aid surveillance and clinical activities, this report provides a preliminary clinical description of the initial five confirmed cases in Thailand." http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5305a2.htm
(MMWR February 13, 2004 / 53(05);100-103)

Update: Adverse Events Following Civilian Smallpox Vaccination — United States, 2003
"During January 24–December 31, 2003, smallpox vaccine was administered to 39,213 civilian health-care and public health workers in 55 jurisdictions to prepare the United States for a possible terrorist attack using smallpox virus. This report updates information on vaccine-associated adverse events among civilians vaccinated since the beginning of the program and among contacts of vaccinees, received by CDC from the Vaccine Adverse Event Reporting System (VAERS) during August 9–December 31." http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5305a4.htm
(MMWR February 13, 2004 / 53(05);106-107)

Secondary and tertiary transfer of vaccinia virus Among U.S. military personnel — United States and Worldwide, 2002–2004
"In December 2002, the Department of Defense (DoD) began vaccinating military personnel as part of the pre-event vaccination program (1). Because vaccinia virus is present on the skin at the site of vaccination, it can spread to other parts of the body (i.e., autoinoculation) or to contacts of vaccinees (i.e., contact transfer). To prevent autoinoculation and contact transfer, DoD gave vaccinees printed information that focused on hand washing, covering the vaccination site, and limiting contact with infants (1,2). This report describes cases of contact transfer of vaccinia virus among vaccinated military personnel since December 2002; findings indicate that contact transfer of vaccinia virus is rare. Continued efforts are needed to educate vaccinees about the importance of proper vaccination-site care in preventing contact transmission, especially in household settings." http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5305a3.htm
(MMWR February 13, 2004 / 53(05);103-105)

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4. NOTIFICATIONS

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"Learning from SARS: Preparing for the Next Disease Outbreak", available free to public
Due to recent developments concerning both SARS and H5N1, The Institute of Medicine and the National Academy Press have broken with usual policy and made the full IOM workshop report, "Learning from SARS: Preparing for the
Next Disease Outbreak", available for free to the public. In response to the SARS epidemic and its lingering consequences, the IOM's Forum on Microbial Threats convened a two-day scientific workshop in fall 2003 to consider the lessons that might be drawn from a better understanding of the origin, spread, and eventual control of the first outbreak.

"Learning from SARS: Preparing for the Next Disease Outbreak" presents an overview of the workshop's proceedings, including presentations and an overall summary and assessment of the issues that were raised. Topics addressed include the response to SARS by public health systems within individual countries; the biology of the SARS coronavirus and related coronaviruses in animals; the economic and political fallout of the SARS epidemic; quarantine law and other public health measures that apply to combating infectious diseases; and the role of international organizations and scientific cooperation in halting the spread of SARS. These materials provide an illuminating survey of findings from 2003's epidemic, along with an assessment of what might be needed in order to contain any future outbreaks of SARS or other emerging infections.

You can read "Learning from SARS: Preparing for the Next Disease Outbreak" on the NAP website: http://www.nap.edu/catalog/10915.html For more information on this workshop summary, please contact Katherine
Oberholtzer, <koberhol@nas.edu>.
(Promed 2/8/04)

HIV Materials available in Asian languages from CDC NPIN
New materials on HIV/AIDS and STDs are now available in Asian languages (Tagalog, Khmer, Vietnamese, Chinese, and Korean, as well as in Spanish and English) from the CDC National Prevention Information Network (NPIN).
To order materials, go to: http://www.cdcnpin.org/scripts/pubs/matlpubsearch.asp and search by title
or SKU/inventory number.

"Living with HIV/AIDS" will help people with HIV/AIDS understand how to live with HIV and how to stay healthy. This pamphlet explains how HIV is transmitted, dispels myths about transmission, and explains prevention methods. It also discusses confidential and anonymous testing and lists sources providing referrals and general information, free materials, free treatment information, information on drugs, and Social Security benefits.

"HIV and Pregnancy: Ten Things You Should Know: For You and Your Baby Now available in Chinese and Vietnamese" is a brochure that explains the risk behaviors associated with HIV transmission and advises women who are pregnant or want to become pregnant to get tested for HIV and to discuss it with their health care providers. By taking the drug zidovudine (AZT) and having a cesarean birth, women can lower the risk of HIV transmission to their infants.

"Teens and HIV and other STDs: At Risk? Get Tested!" is a pamphlet that discusses testing for sexually transmitted diseases (STDs) and HIV. It describes STDs and the epidemiology of STDs among adolescents in the United States. It lists reasons to get tested for STDs and HIV, and describes HIV testing. The brochure identifies high risk behaviors that could warrant getting tested, and differentiates between anonymous and confidential testing for HIV and STDs.

"Learn About HIV Testing" is a pamphlet that describes HIV testing and who needs to be tested. It explains how HIV testing is structured, what the results mean, and what one should do if one tests positive. The brochure makes recommendations about how to avoid contracting HIV.
(SEA-AIDS eForum 2/5/04 )

WHO/UNICEF Workshop on the Expanded Programme on Immunization in the Pacific
During 8-12 Mar 2004, in Auckland, New Zealand, the WHO/UNICEF Workshop on the Expanded Programme on Immunization will evaluate progress made in controlling vaccine-preventable diseases and address the gaps in immunization coverage across the Pacific region.
(WHO)

World TB Day '04 and the Second Stop TB Partners Forum
On Mar 24, 2004 World TB Day and the second Stop TB Partners' Forum in New Delhi will coincide. This is a unique opportunity to launch an evocative world-wide Stop TB Campaign for 2004 - 2005. Catalysing greater public participation, strengthening political commitment, and intensifying action on the ground forms the core of the themes and strategies. For details on the themes/strategies for World TB Day '04 and, the second Stop TB Partners Forum in New Delhi, please visit the website: http://www.stoptb.org/
(WHO)

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