Vol. VII, No. 07~ EINet News Briefs ~ March 12, 2004
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In this edition:
1. OVERVIEW OF INFECTIOUS-DISEASE INFORMATION
Below is a semi-monthly summary of Asia-Pacific emerging infectious diseases.
East Asia: Avian influenza, latest updates ( 33 confirmed cases, 22 deaths)
Japan 's first case of bird flu in 79 years was detected at a poultry farm in Yamaguchi Prefecture in January. The second outbreak occurred in February among bantams kept as pets in Oita Prefecture. Both cases have been found to involve the H5N1 strain. No human infections have yet been confirmed in Japan.
In a move aimed at calming fears before they can take flight, the government's top spokesman issued a bulletin 9 Mar 2004 advising the public on the possible dangers of avian flu and what can be done to prevent its spread. The bulletin comes in the wake of the nation's most recent reports of avian flu since January 2004. The announcement, made by Chief Cabinet Secretary Yasuo Fukuda, advises bird owners to contact a veterinarian or public health official if their fowl start dying off suddenly and successively for no apparent reason. Owners are also warned not to handle dead birds with their bare hands or to bury them. Furthermore, bird owners are advised to keep pens clean and to keep out wild birds that may carry the avian flu virus.
On a more assuring note, the bulletin points out that humans are not in danger of contracting the disease through eating chickens or eggs. There have been no reports of infection through consuming raw eggs, but people worried about infection are advised to heat the eggs to at least 70 C. The bulletin also advises cooking chicken meat thoroughly, but to avoid food poisoning rather than the avian flu. Chicken meat and eggs that have been shipped to retailers will not be recalled. However, government officials are considering rounding up and destroying chickens in certain areas to prevent the disease from spreading among birds.
Only in rare cases, the bulletin notes, have humans come down with avian flu. Those who were infected inhaled feathers or powdered waste from infected chickens. With little chance of coming into close contact with sick birds, the bulletin concludes there is only the remotest possibility that an average citizen will contract the disease.
Thailand (Bangkok)—Avian influenza Emergency Meeting
Up to the end of 2003, highly pathogenic avian influenza (HPAI) has been considered a rare disease. Since 1959, only 21 outbreaks had been reported worldwide. The majority occurred in Europe and the Americas. Of the total, only five resulted in significant spread to numerous farms, and only one was associated with spread to other countries. Since mid-December 2003, eight Asian countries have confirmed outbreaks of highly pathogenic avian influenza caused by the H5N1 strain. Most of these countries are experiencing outbreaks of this disease for the first time in their histories. Over the past two months, more than 100 million birds have either died of the disease or been culled in Asia . Worldwide experience since 1959 supports official statements about the unprecedented nature of the present situation and the unique challenges for control. Unique features of the present situation include:
1. Concentration of poultry in backyard farms. In several countries experiencing outbreaks, up to 80 percent of poultry are produced on small farms and backyard holdings in rural areas, where poultry range freely. This situation makes implementation of strict control measures, essential to the control of previous outbreaks, extremely difficult. These control measures — including bird-proof, ecologically controlled housing, disinfection of all incoming persons, equipment, and vehicles, prevention of contact with insects, rodents, and other mechanical vectors — cannot be applied on small rural farms and backyard holdings.
2. Economic significance of poultry. The agricultural sector faces the challenge of minimizing losses to industry and subsistence farmers in ways that also reduce human health risks. Because the region is highly dependent on poultry, appropriate culling may be difficult to implement.
3. Lack of control experience. Since the disease is new to most countries in the region, very little experience exists at national and international levels to guide the best country-specific control measures. In some countries, announcements of successful culling in certain areas are being followed by subsequent eruptions of disease in the same areas.
4. Lack of resources. Several countries with very widespread outbreaks lack adequate infrastructure and resources, including resources to compensate farmers. In some countries that have announced outbreaks, neither surveillance to detect the extent of spread nor culling of animals known to be infected is taking place.
5. The scale of international spread. A region-wide strategy will be needed to ensure that gains in one country are not compromised by inadequate control in another.
These unique features will make rapid control and long-term prevention of recurrence extremely difficult to achieve. Culling remains the first line of action, as recommended by FAO, OIE, and WHO, for bringing the current outbreaks under control. Unlike other economically important domestic animals, poultry raising takes place in a very short production system. Provided sufficient resources are available to replace culled poultry stock, countries should not postpone aggressive culling because of fears of long-term consequences on poultry production. Wild birds can play a role in introducing a virus of low pathogenicity into domestic flocks where, if allowed to circulate for several months, it can mutate into a highly pathogenic form. No evidence to date indicates that wild birds are the source of the present outbreaks of HPAI H5N1. Infected poultry are the species of greatest concern. Wild birds should not be culled.
Nepal — Influenza Outbreak Claims 16 Lives
Japan (Kanagawa) —Tenth case of mad cow confirmed
This will be the second case of mad cow found in that prefecture. The meat from the cow is stored at the slaughterhouse and will not be put on the market, according to the officials. Japan reported the first mad cow case in September 2001. According to the final report produced in September 2003 by a study team of the agricultural ministry, the source of infection for the six cows was meat-and-bone meal (MBM) manufactured from carcasses of cows infected with the disease before Japan imposed the ban on MBM production in November 2001. The team said it was made from carcasses of cows that came in the 1980s from Britain or MBM from Italy imported before 1990.
The team estimated there are about 30 potentially infected cattle in Japan. The latest case was found in the process of a government initiative, undertaken since the first mad cow case was reported in Japan, to test all cows for human consumption for the disease. At an international symposium on BSE held in Tokyo on Saturday, a Japanese researcher stressed the need for such comprehensive testing and criticized the U.S. argument that testing only so-called downer cows with walking difficulty for the disease should suffice. Noting that only two of the nine infected cows in Japan had downer symptoms, Yoshio Yamakawa from the NIID said, "The United States says it can find BSE only by checking downer cows, but that is utterly groundless." The Japanese government is calling on the U.S. to conduct blanket cattle testing for the disease if it wants Japan to lift the beef import ban, but the U.S. has rejected the suggestion as unscientific.
Bangladesh — Nipah-like virus, update
Pakistan (Sindh)—Cerebral malaria claims 19 lives in Mirpur Khas
The media has also reported massive casualties in the areas of Taulqa, Kot Ghulam Muhammad, Omar Kot, Degree, Misma, and other localities. The Sindh Province has historically had the highest incidence of malaria in Pakistan. Epidemics have occurred at 6- to 10-year intervals, the last one in 1972-73, and the present outbreak could be the start of a new epidemic.
There is also massive importation of malaria from Afghanistan. According to the recent Malaria Review Mission Report, 1998, malaria is on the increase in Pakistan. Pakistan's malaria control programme is also facing organisational problems due to insufficient rapport between central headquarters and malaria control programs in provinces, rapid turnover of staff, and relocation of recently trained specialists.
Indonesia — Incidence of Chikungunya Fever during 2003
The minister has issued an instruction to regency/city administrations to take prompt action to eradicate the disease by destroying the breeding places of the mosquito vector especially during the rainy season, thereby preventing outbreaks of chikungunya fever, dengue fever, and malaria. "The nine provinces which were the first to be attacked by chikungunya fever in 2003 include Central Java, Yogyakarta, Banten, West Java, East Java, Bali, West Nusas Tenggara, East Nusa Tenggara, and Lampung," he said. The most effective measures to prevent a chikungunya fever outbreak include a thorough cleaning, and often change of the water of one's bathroom pool in which the insecticide Abate should be poured, proper covers for water storage containers, burying objects or goods which are no longer in use, and filling in pools of water after the rain.
Australia ( North Queensland ) — Melioidosis claims woman's life
Melioidosis is an infection caused by bacteria living in the soil, particularly in the tropical north of Australia. The disease usually presents as either severe pneumonia or septicaemia, and it is usually acquired through scrapes or wounds on the skin having contact with contaminated soil or water. Dr Hanna said the disease mainly affected people with severe underlying medical conditions. Late in 2003, James Cook University microbiology lecturer Dr Natkunam Ketheesan said melioidosis had killed 28 of 125 people admitted to Townsville Hospital with the condition since 1996. Melioidosis was emerging as a most concerning infectious disease, Dr Ketheesan said. Townsville Hospital averages between 10-25 cases of melioidosis each year.
Dr. Hanna said melioidosis was a wet-season disease and cases commonly increased after heavy rain and flooding. He encouraged North Queensland residents to wear gloves and footwear while working outdoors. They should also cover wounds with waterproof dressings to prevent exposure to contaminated soil or water, and wash their skin thoroughly after any exposure.
USA (Delaware/Maryland) — Eastern Shore Farmers Grapple with Avian Flu Outbreak
More than 27 nations have placed varying restrictions on imports of U.S. poultry in response to the appearance of avian flu in Delaware and Texas. Unlike the avian flu in Asia , the strain found in Delaware and Maryland has no history of harming humans, officials said. However, it can be deadly to birds. An airborne respiratory illness, avian flu spreads easily among chickens through nasal and eye secretions as well as manure. It can be transmitted from one farm to another by equipment, vehicles, and people whose clothing or shoes have come in contact with the virus.
Officials say that despite the slaughter of more than 400 000 chickens infected with the flu in the past month in five states, and bans on U.S. poultry exports by 37 countries and the European Union, the industry remains healthy, and the consumer impact invisible, because the total number of sick birds is relatively small. But they warn that financial pressure could increase if more cases are found or the bans continue. Five of the largest customers of domestic chicken farms — Hong Kong, South Korea, China, Japan, and Mexico — have totally banned U.S. chicken — a loss of USD nine million a week. But Russia, the biggest U.S. customer, has banned only Delaware and Texas chicken thus far, so processors can substitute chickens from other states. In all, the U.S. poultry industry exports USD 1.5 billion a year worth of meat.
Avian flu, as well as other animal ailments such as bovine spongiform encephalopathy could affect a total of 1/3 of global meat exports from all countries — or about USD 10 billion of the estimated USD 33 billion in animal trade — if trade bans remain in effect through the end of 2004, according to a recent report from the United Nations Food and Agricultural Organization. The trade losses are accruing in 12 countries, including the United States, with reported animal diseases. The biggest impacts are likely on small poultry producers in Asia , where more than 100 million birds have died or been destroyed. The report also said that a prolonged ban could force down prices for U.S. chicken, which accounts for about one third of the world's poultry exports. The U.S. Department of Agriculture has been negotiating with foreign countries to lift the bans.
USA (Kentucky)—US beef producer aims to test all its cattle for BSE
USA (Texas)—Outbreak of Cyclosporiasis Among Conference Participants
The outbreak may not be limited to persons who attended this conference. Although no food item has been implicated to date, a contaminated vehicle might have been distributed to other locations. Previous foodborne outbreaks of cyclosporiasis have been linked to various types of fresh produce (e.g., basil, mesclun lettuce, raspberries). Cyclospora is spread by people ingesting something that was contaminated with infected stool. The incubation period between acquisition of infection and onset of symptoms averages one week. Cyclospora infects the small intestine and typically causes watery diarrhea, with frequent bowel movements. Other symptoms can include loss of appetite, substantial loss of weight, bloating, increased flatus, stomach cramps, nausea, vomiting, muscle aches, low-grade fever, and fatigue. If untreated, illness may last for a few days to a month or longer, and may follow a remitting-relapsing course.
Australia (Cairns, Torres Strait)
On Thursday Island in the Torres Strait, Queensland Health staff this week joined local council officers to carry out an intensive dengue mosquito control program. Since the dengue outbreak began in the Torres Strait last November 2003, 254 cases of the disease have been reported. Dr. Ritchie said outbreaks on Yam and Murray Islands had been stopped by mosquito control and public education measures, but it was proving more difficult to stop on Thursday Island. He said this was due to the larger population, a large amount of discarded items collecting rainwater, and other hidden breeding sites such as underground wells. Early last month, a 40-year-old woman from Thursday Island died of dengue shock syndrome en route to Cairns Base Hospital. She is believed to be the first Queenslander to die of the infection with the virus in almost 100 years.
Study Shows High Level of Avian to Human Transmission of Influenza A (H7N7) Virus during Outbreak in the Netherlands 2003
Active case finding was implemented among poultry workers, poultry farmers and their families following an increase in anecdotal reports of health complaints from people involved in the control of the animal epidemic. Health complaints were reported among 453 people, with conjunctivitis the most commonly report symptom (349 cases). Influenza A (H7N7) was detected in 89 (19.6%) cases. There was one human fatality during the outbreak, a 57 year old veterinarian who had visited several farms with HPAI infected poultry flocks (2). In addition, three contacts of confirmed influenza A (H7N7) cases tested positive for influenza A/H7infection.
Control measures were implemented early during the outbreak. Following confirmation of influenza A (H7N7) as the cause of the avian influenza outbreak on 3 March, all workers in contact with poultry were advised to wear protective glasses and face masks. Shortly afterwards, and following the increase in cases of human infection, influenza vaccination was offered to, and accepted by, all poultry workers involved in handling, screening or culling potentially infected poultry. This policy was aimed at reducing possible genetic mixing or reassortment of avian and human influenza viruses in one infected person. The influenza vaccination recommendation was subsequently extended to all poultry workers and their families in a 3km radius of infected poultry farms, and those suspected of having the infection. Treatment with oseltamivir was recommended for all conjunctivitis cases, and a prophylactic regimen of oseltamivir was given to all people handling potentially infected poultry for two days after their last exposure.
Virological sequence data published elsewhere indicate that the virus strains were of entirely avian origin, with no human genes (3). The virus isolated from the fatal case had, however, accumulated significant mutations, which may have been associated with enhanced virulence in this case. Further cohort studies are also underway to compare infection rates between different categories of poultry workers, and examine the effects of various risk factors.
This study describes a large outbreak of avian influenza infection in humans, with possible person to person spread among household contacts. The authors highlight the difficulty of implementing control measures early in the outbreak, when few data were available on which to base their decisions. They note that by the time prophylactic measures were reinforced one week after confirmation of the first human infection, more than one thousand people within the Netherlands and from abroad had already been exposed to this avian influenza variant, thus demonstrating the need for pandemic preparedness. http://www.eurosurveillance.org/ew/2004/040226.asp#1
Brief Report: Azithromycin Treatment Failures in Syphilis Infections — San Francisco, California, 20022003
Syphilis has been increasing in the United States since 2000 and is of particular concern in San Francisco , which, in 2002, had one of the highest rates of primary and secondary syphilis in the United States . To facilitate treatment of early syphilis patients and their sexual contacts, certain disease-control programs have administered azithromycin as a single oral regimen. Several small studies have documented the efficacy of a single oral dose of azithromycin in the treatment of incubating and early syphilis infection in patients who were not infected with the human immunodeficiency virus (HIV) ( 1 ). In addition, the oral dose is more convenient to administer than intramuscular benzathine penicillin, CDC's recommended treatment for sexually transmitted diseases.
Updated Recommendations on the Use of Pneumococcal Conjugate Vaccine: Suspension of Recommendation for Third and Fourth Dose
Approximately 1.3 million doses of PCV7 are needed each month to provide every infant in the United States with the full, 4-dose vaccination series. For January—April 2004, total shipments are estimated to be < 55% of the amount needed. Limiting healthy children to 2 doses of PCV7 will conserve vaccine and permit more children to receive at least 2 doses. More vaccine is expected to become available for distribution in May and June, but availability cannot be guaranteed. CDC will continue to update health-care providers on the status of vaccine supplies while the shortage persists.
Influenza A H5N1 WHO interim infection control guidelines for health care facilities can be found at the following website (updated Mar 10, 2004) www.wpro.who.int/avian/docs/Guidelines_for_health_care_facilities_10Mar.pdf
Website for the Western Pacific Regional Office (WPRO) of the WHO offers general information about the status of avian influenza: www.wpro.who.int/avian
Avian Influenza: Interim Recommendations for Working with and Preparing Chicken
Notice to Readers: Satellite Broadcast on HIV Prevention
Additional information and instructions for continuing education are available at http://www.cdcnpin.org/broadcast and through the CDC Fax Information System, telephone 888-232-3299, by entering document number 130039 and a return fax number. Organizations are responsible for setting up their own viewing sites and are encouraged to register their sites as soon as possible so persons who want to view the broadcast can access information online. Directions for establishing and registering a viewing site are available on the website. The broadcast also can be viewed live or later on computers with Internet and RealPlayer ® capability through a link at http://www.phppo.cdc.gov/phtn . Videotapes and CD-ROMs of the broadcast can be ordered by telephone, 800-458-5231. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5308a6.htm
CDC MMWR—Spain Mirror Site
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