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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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East Asia: Avian influenza, latest updates ( 33 confirmed cases, 22 deaths)

Thailand:
The Ministry of Public Health in Thailand has today confirmed an additional case of avian influenza A (H5N1) virus infection. The case is a 29-year-old man from Nakhon Ratchasima Province. He developed symptoms on 13 Feb 2004, was admitted to hospital on 20 Feb 2004, and was discharged on 7 Mar 2004. He gave a history of exposure to diseased and dead chickens. To date, Thailand has reported 11 laboratory-confirmed cases of avian influenza A (H5N1) virus infection in humans, of which seven have been fatal. This additional confirmed case in Thailand, together with the 22 cases and 15 deaths in Viet Nam, brings the total number of human cases in East Asia to 33, of whom 22 have died.

China:
To date, there have been a total of 49 outbreaks in 16 provinces, autonomous regions or municipalities. All of them have been confirmed by the National Avian Influenza Reference Laboratory as subtype H5N1-caused highly pathogenic avian influenza. Up to 27 Feb 2004 , quarantine restrictions had been lifted in a total of 18 areas where at least 21 days had elapsed since the last poultry had been culled.

Japan:
The bird flu virus detected at a second bird flu-hit poultry farm in Tanba, Kyoto Prefecture, is of the highly contagious H5N1 strain, the National Institute of Animal Health said. Self-Defense Forces personnel prepared a ditch to bury dead chickens at a poultry farm. Preliminary tests on the dead chickens at the family-run Takada farm, about 5 km from the Funai farm, were positive for bird flu. At the Funai Farm, thousands of chickens had died before authorities were alerted to the disease. Meanwhile, crows found dead at the poultry farm and in a nearby town last week were confirmed to be infected with H5 avian influenza. The strain was detected in a test by the animal health institute on samples taken from two crows. The virus is the same general strain found in chickens at the farm. It is the first case in Japan of the virus having been detected in wild birds. The birds were among four crows found dead. Two were found at the Funail farm. The others were found some 8 km to 9 km away, in the nearby township of Sonobe.

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.

Japan/Thailand:
On 8 Mar 2004, Japan announced it will resume imports of processed chicken items from 22 factories in Thailand. The plants had passed inspections by Japanese health officials. Products made in Thailand represent about 30 percent of Japan's imported processed chicken. Stocks of Charon Pokphand Foods and GFPT were higher on 8 Mar 2004 following Japan's resumption of cooked chicken imports from Thailand. Thailand declared the country free of avian influenza on 8 Mar 2004 and announced that farmers will resume breeding chickens in April. Thailand said no areas of the country have had an active case of avian influenza since 25 Feb 2004. OIE, the World Organization of Animal Health, allows the breeding of new chicken stocks three weeks after no new cases have been found.

Taiwan:
Taiwan has reported a new outbreak of a less virulent form of bird flu and plans to slaughter 12,000 chickens to curb its spread. The Bureau of Animal and Plant Health Inspection and Quarantine told the agency the virus was discovered from samples sent in by the farm in the southern Pingtung county on 1 Mar 2004. Taiwanese authorities have slaughtered 467,000 birds since H5N2, a less virulent strain of the bird flu which has hit the Asian region, was first detected at a chicken farm in the central county of Changhua on 15 Jan 2004. Authorities insist the outbreaks do not pose a threat to humans. The origin of the infection remains unknown.
(Promed 3/09/04 , 3/10/04 )

Thailand (Bangkok)—Avian influenza Emergency Meeting
During last week's emergency meeting in Bangkok, Thailand, officials from FAO, OIE, and WHO drew attention to several unique features of the current outbreaks of H5N1 in poultry in Asia; in particular its geographic distribution, rate of spread, and severity, which are unprecedented. Prospects for rapid control are inconsistent with worldwide experience, over more than more decades, with previous outbreaks, which have all been much smaller in scope and inherently less challenging. Even in countries with good surveillance, adequate resources, and geographically limited outbreaks, control has often taken up to two years.

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.
(Promed 3/03/04 )

Nepal — Influenza Outbreak Claims 16 Lives
An influenza epidemic has claimed the lives of at least 16 people in Western Nepal's Mugu district. Official sources here were quoted as saying that the deaths had occurred over the past week in the midwestern development region. The Nepalese government has reportedly sent a team of doctors and necessary medicine to the affected areas.
(Promed 3/10/04 )

Japan (Kanagawa) —Tenth case of mad cow confirmed
A dairy cow from Kanagawa Prefecture was confirmed Sunday as being infected with mad cow disease, Japan 's 10th case, the health ministry said. The Holstein, which is thought to have been approximately 12 years old when slaughtered, almost certainly had the usual form of the illness. The cow born in Kanagawa Prefecture had recently been purchased by a farm in Hiratsuka in that prefecture, according to the Health, Labor and Welfare Ministry. It was slaughtered Friday at a meat center in Atsugi, Kanagawa Prefecture. A primary test at a prefectural institute found the cow was possibly infected, and a secondary test at the National Institute of Infectious Diseases confirmed the infection. The cow started showing symptoms of joint dislocation and difficulty in standing about a week ago.

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.
(Promed 2/28/04 )

Bangladesh — Nipah-like virus, update
As of 26 Feb 2004, WHO has received reports of 22 cases, including 17 deaths, attributed to Nipah-like virus infections. Of the total cases, 11 are laboratory-confirmed. An additional 51 cases are under investigation. The changes in the number of cases is a result of a review of the case definition and the surveillance data currently being undertaken by the team of experts from WHO, partners in the Global Outbreak Alert and Response Network and the Ministry of Health. The infections have occurred in five districts: Rajbari, Manikganj, Jaipurhat, Naogang, and Faridpur. Guidelines for clinical management and hospital-based surveillance for encephalitis are being developed. Ecological, sero-prevalence, and case control studies are nearing completion.
(Promed 2/26/04 )

Pakistan (Sindh)—Cerebral malaria claims 19 lives in Mirpur Khas
Nineteen people including 18 children died of cerebral malaria in a civil hospital, and the district Nazim has ordered an investigation. About 255 patients were admitted to civil hospital with cerebral malaria from October to December 2003. The majority of the patients were children.

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.
(Promed 3/08/04 )

Indonesia — Incidence of Chikungunya Fever during 2003
Chikungunya fever with symptoms like pain in muscles and feet, causing difficulty in rising for a week, attacked 8068 people in 29 regencies/cities in nine provinces of Indonesia during 2003. "While this type of fever is actually not fatal, it affects the productivity of the sufferer," Minister of Health Achmad Sujudi said. He said chikungunya fever, which was first found in Yogyakarta in 1973, has symptoms similar to those of dengue fever, which is spread by Aedes aegypti and Aedes albopictus mosquitoes. "The only difference is that if a dengue fever sufferer is not immediately treated, by the administration of certain drugs and lowering of his or her body temperature substantially, the person may die, whereas a chikungunya fever patient will automatically recover and be cured after a week of the attack," he said.

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.
(Promed 2/26/04 )

Australia ( North Queensland ) — Melioidosis claims woman's life
A Townsville woman has died from melioidosis, sparking warnings that precautions should be taken against the soil-borne disease. The elderly woman died at Townsville Hospital 27 Feb 2004. The Tropical Public Health Unit revealed that a Townsville man had also died from melioidosis in recent weeks. Public health physician Dr. Jeffrey Hanna said there also had been two other cases in the city recently, as well as others across the region.

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.
(Promed 3/08/04 )

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USA (Delaware/Maryland) — Eastern Shore Farmers Grapple with Avian Flu Outbreak
Over the weekend, state authorities confirmed that the outbreak at the commercial poultry farm in Worcester County was the same strain identified at two Eastern Shore farms in Delaware in early February 2004. By yesterday afternoon, Maryland officials had strengthened already strict measures to contain the disease and announced that tests on all eight farms within two miles of the infected site had come back negative. Still, news of those results — as well as negative tests at two other farms in the region — did little to ease renewed fears among farmers that avian flu could spread through the region's USD 1.5 billion poultry industry with devastating effect.

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.
(Promed 3/09/04 )

USA (Kentucky)—US beef producer aims to test all its cattle for BSE
US beef producer Creekstone Farms has volunteered to start testing every animal it slaughters for mad cow disease, in a bid to relaunch exports to foreign customers. John Stewart, chief executive of Creekstone Farms, said the company has received assurances from its Asian customers that they would accept its beef products if every carcass is tested for BSE. "We believe it is the right thing to do: to test every animal to give the American public and consumers a comfort level that every animal coming from our facility, all the meat coming from our facility, has been BSE-tested and is BSE-safe," Stewart said. The company has submitted a request to the US Department of Agriculture for the voluntary testing. If the USDA does not approve the testing within the next two months, the company said it will be forced to lay off workers due to lower demand. The USDA's Animal and Plant Health Inspection Service is the only agency authorised to test for BSE in the US. Several countries have banned imports of US beef following the discovery of BSE in Washington state in December 2003. Japan, one of the largest buyers of US beef, has said it will not resume imports unless the US commences 100 percent testing for BSE.
(Promed 2/28/04 )

USA (Texas)—Outbreak of Cyclosporiasis Among Conference Participants
An outbreak of gastroenteritis caused by the parasite Cyclospora cayetanensis was associated with a conference held February 6-8 at a hotel in Irving , Texas. The conference was attended by approximately 40 persons from about 16 states. The meals eaten by the group were catered by the hotel, with the exception of one meal eaten at a local restaurant. On February 27th, a State health department reported a laboratory-confirmed case of Cyclospora cayetanensis infection in a conference attendee. This patient developed gastroenteritis approximately one week after the conference. Initial investigations suggest that at least 16-19 persons became ill; one person is known to have been hospitalized. Active case-finding is ongoing.

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.
(CDC Health Advisory 3/08/04 )

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2. UPDATES

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Dengue/DHF Update:

Indonesia
The death toll from dengue fever across Indonesia since January 2004 has reached 389 and the sufferers increased to 226 013, announced the Health Ministry. Jakarta is still the area with the most infections. Three ministries — ministries of health, the people's welfare and poverty alleviation, and home affairs — coordinated with all provincial governments to step up efforts to stop the spread of the outbreak. Syafei Achmad, secretary general of the prevention of the infectious disease under the Health Ministry, said that some 89 percent of the sufferers are in good condition. The toll of death and suffering in some provinces, such as Eastern Nusa Tenggara, Jambi, and Yogyakarta, has declined. The recent attack was different from the normal 5-year cycle because of the change of rainy season from October, November, and December to January and February, he said. Twenty-six of Indonesia 's 32 provinces have been affected.

Singapore
Singapore plans to step up dengue fever checks because of an outbreak in neighbouring Indonesia that has killed over 340 people and hospitlized around 20,000. Singapore 's own cases of the disease have declined, with the city-state reporting 560 cases in the first two months of 2004, down from 688 in the same period of 2003, the National Environment Agency said. Despite the decline, the agency, responsible for monitoring public health in the city-state, said it would step up enforcement and surveillance to prevent the mosquito-borne illness from spreading. Singapore issues fines for people who leave watering cans, buckets, and other containers with stagnant water in the open. During February 2004, the High Court fined a man 6000 Singapore dollars (US$3530) for leaving a water-filled plastic pail lid outside his residence.

Northern Fiji
Health authorities in Fiji have declared an alert following two confirmed cases of dengue fever in the Northern Division. A Health Ministry spokesperson has confirmed that two patients suffering from dengue were admitted to Labasa hospital. The spokesman says the red alert has been issued for the Northern Division and other parts of the country because of the dengue outbreak in Indonesia, which seems to have spread to Fiji. He says there is a high risk of dengue because of a high mosquito population during the current rainy season. Previous outbreaks of dengue in Fiji have resulted in tens of thousands becoming sick and scores of deaths.

Australia (Cairns, Torres Strait)
More cases of dengue fever have been reported in Cairns , bringing the year's total to ten, Queensland 's Tropical Public Health Unit said today. Medical entomologist Dr Scott Ritchie urged residents to regularly check their yards for mosquito breeding sites and use insect sprays, repellants, mozzie zappers, and coils. "Now that we are having a real wet season again, mosquito numbers have gone through the roof," Dr Ritchie said. Last year there were seven outbreaks of dengue fever in north Queensland affecting more than 600 people, 459 of them in Cairns.

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.

Philippines
The Philippine government urged the public to observe cleanliness to prevent a dengue fever epidemic after 399 cases, including three deaths, were reported nationwide in the first two months of this year. "Despite the 33 percent decrease in the number of cases compared to the same period of 2003, we are alerting the public this early because 2004 might be an epidemic year due to the cycle of the disease," Health Secretary Manuel Dayrit was quoted by the Philippine News Agency as saying. He urged the public to practice preventive measures such as cleaning roof gutters, puncturing old tires, regularly replacing water at flower vases, and using mosquito nets.
(Promed 3/08/04 )

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4. ARTICLES

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Study Shows High Level of Avian to Human Transmission of Influenza A (H7N7) Virus during Outbreak in the Netherlands 2003
“A report on the highly pathogenic avian influenza (HPAI) (H7N7) outbreak that occurred in the Netherlands in 2003 has been published. Koopmans et al. describe the epidemiological and virological results of case finding during the outbreak period, and the preventative measures implemented. The outbreak began at the end of February 2003 and the Dutch Ministry of Agriculture announced a ban on the export of all poultry and poultry related products on 1 March. During the outbreak the infection spread to 225 farms, and led to the culling of approximately 30 million chickens.

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
(Eurosurveillance Weekly, Volume 8, Issue 9. 26 Feb 2004 )

Brief Report: Azithromycin Treatment Failures in Syphilis Infections — San Francisco, California, 2002—2003
“The San Francisco Department of Public Health (SFDPH) is investigating several clinical failures in syphilis patients treated with the macrolide antibiotic azithromycin. This report describes the use of azithromycin for syphilis treatment, recent treatment failures in San Francisco , and CDC recommendations for syphilis treatment. Clinicians should exercise caution in using azithromycin for treating incubating syphilis or syphilis infection until the risk and mechanism of failure are better understood.

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.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5309a4.htm
(MMWR March 12, 2004 / 53(09);197-198)

Updated Recommendations on the Use of Pneumococcal Conjugate Vaccine: Suspension of Recommendation for Third and Fourth Dose
“On February 13, 2004 , CDC recommended that health-care providers temporarily suspend routine use of the fourth dose of 7-valent pneumococcal conjugate vaccine (PCV7) when vaccinating healthy children. This action was taken to conserve vaccine and minimize the likelihood of shortages until Wyeth Vaccines, the only U.S. supplier of PCV7 (marketed as Prevnar ® ), restores sufficient production capacity to meet the national need. Since that recommendation, PCV7 production has been much less than expected because of continuing problems with the PCV7 vial-filling production line. Shipments have been delayed, resulting in spot shortages that might continue beyond summer 2004 and become widespread. Effective immediately, to further conserve vaccine, CDC recommends that all health-care providers temporarily suspend routine administration of both the third and fourth doses to healthy children.

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.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d302a1.htm
(MMWR March 2, 2004 / 53(Dispatch);1-2)

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4. NOTIFICATIONS

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“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
http://www.cdc.gov/flu/avian/prepchicken.htm
(CDC 3/2/04)

Notice to Readers: Satellite Broadcast on HIV Prevention
“CDC and the Public Health Training Network will present a satellite broadcast and webcast, 'Prevention with Positives: HIV Risk Reduction Strategies for Health Care Providers,' on Thursday, April 29, 2004, beginning at 1 p.m., EDT. The 2-hour forum will discuss evidence-based behavioral interventions and ongoing research about HIV prevention with persons living with HIV (PLWH), describe examples of behavior interventions for PLWH in community-based organizations and clinical settings, and identify opportunities and methods for health-care providers to link PLWH to local HIV-prevention resources. A panel of experts will address viewers' questions, which can be sent via fax before, during, and after the program.

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
(MMWR March 05, 2004 / 53(08);178)

CDC MMWR—Spain Mirror Site
CDC, in collaboration with the Toxic Oil Syndrome Research Centre (CISAT) of the Institute of Health Carlos III , Madrid, Spain, has established a MMWR mirror website in Spain. The website was developed to reduce the delay caused by transoceanic electronic transfers of large documents and to increase access to information published in MMWR for European public health practitioners. The mirror website is updated simultaneously with the posting of new reports on the MMWR website ( http://www.cdc.gov/mmwr ). The address for the CISAT MMWR mirror website is http://cisat.isciii.es/mmwr .

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