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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, 34 confirmed cases, 23 deaths

Viet Nam — Declares avian influenza over; new regulations in Ho Chi Minh
Viet Nam declared an end to its bird flu crisis — over the objections of the World Health Organization (WHO) and the Food and Agriculture Organization (FAO) — after one month of no new recorded outbreaks. Agriculture Minister Le Huy Ngo made the announcement at a meeting on Tuesday last week, three months after the first cases hit Viet Nam. Ngo said the country would lift the bans on the transport, processing, and consumption of poultry across the country. The meeting heard reports that about 40 million poultry, or 15 per cent of the country's stocks, were killed or culled across the country, with almost half coming from the Cuu Long (Mekong) Delta provinces. The poultry industry's losses are estimated at USD 190 million. Ngo said the State would give affected farmers VND 5000 (USD 0.32) per culled bird, VND 2000 (USD 0.13) per breeding stock, with total state assistance coming to USD 13.73 million.

Ho Chi Minh City banned 6 Apr 2004 the sale of live poultry in urban markets to prevent a recurrence of the epidemic. City authorities also issued regulations requiring that slaughter take place only at government-approved facilities, which must be located away from the densest part of the city. Ho Chi Minh is also reportedly planning to build two or three large slaughterhouses to meet demand. The country's new rules stipulate that all birds be certified by veterinary inspectors prior to being sold, but the FAO questioned Viet Nam's ability to enforce the order. WHO, meanwhile, voiced fears that Viet Nam was putting its poultry industry ahead of public health. Bird flu killed 16 people in Viet Nam in this outbreak, more than in any other country.
(Promed 4/7/04)

Thailand — New bird-flu measures announced
In order to prevent the spread of avian influenza after chicken farming resumes on a mass scale, the Livestock Department announced measures to continue controlling the movement of chickens. Livestock Department director-general Yukol Limlaemthong said that the department recently issued an announcement designating Thailand as a suspected bird-flu epidemic zone — all provincial governors are being advised to limit the movement of chickens in their jurisdiction. After four months of the epidemic, farmers have sought permission to resume raising chickens. Yukol said it would not be possible to raise large numbers of chickens at many farms at the same time as some areas are still under surveillance, even though they have met the 21-day period required by the International Office of Epizootics (OIE). The department said it needed to further monitor the areas for three months, at the request of chicken importers.
(Promed 3/30/04)

Thailand —Poultry industry to restock
The Thai poultry industry could be about to restock on a massive scale after the devastation of the avian flu epidemic earlier this year. The country's feed industry is set to import cargoes of Argentine soybeans as the country prepares to declare itself free of the virus. Thailand is also looking to soymeal cargoes from India. The decimation of the poultry sector in Thailand, which accounts for more than half of commercial feed consumption, has resulted in a steep decline in feed demand, but this looks set to change. The Thai government is expected to declare by the end of the week that the outbreak is over. The country, whose poultry export business annually tops USD 1 billion, has been forced to cull over 25 million chickens, and like other counties stricken by the deadly virus, the country is desperate to restore its poultry industry.

The UN's FAO has warned that countries affected by the deadly avian influenza virus H5N1 should not restock their flocks too quickly to avoid the disease flaring up again. The FAO says that before restocking, countries must prove the absence of virus circulation by virus research, serological surveys and the use of non-vaccinated susceptible chickens (sentinels) on infected sites to test whether they become infected.
(Promed 4/7/04)

Britain: NIBSC Wins Race to Genetically Engineer H5N1 Vaccine Strain
A British government laboratory has genetically engineered a safe version of the avian influenza A (H5N1) virus to use as the basis of a vaccine, beating out the CDC and St. Jude Children's Research Hospital, who were pursuing the same goal. The achievement by the National Institute for Biological Standards and Controls (NIBSC) in London will be announced next week by the WHO. WHO is overseeing the research, which aims to create a vaccine against avian influenza A (H5N1) virus as insurance in case the disease begins to spread rapidly among people.

All three labs were trying to create a new virus using reverse genetics. The first step was to insert two genetic components, the H5 and N1 encoding subunits, from the H5N1 avian flu virus into a benign flu virus commonly used in labs. The second step was to grow the new virus in pure cell lines that would be acceptable to regulatory authorities, including the U.S. Food and Drug Administration. That was to be followed by safety-testing the reproduced virus on chickens and ferrets to prove that its virulent qualities were removed, the final hurdle before the new viral strain could be released to manufacturers. The new strain will be given to manufacturers next week when the official announcement is made.
(Promed 4/3/04)

South Korea — Lapses in screening of donated blood (hepatitis C)
South Korea 's Red Cross mishandled donor information and circulated blood donated by hepatitis virus carriers, infecting nine people, government auditors said 29 Mar 2004 . The Board of Audit and Inspection (BAI) called on the Korea National Red Cross to punish officials responsible for shipping blood donated by hepatitis virus carriers to hospitals and pharmaceutical companies for five years up until Jan 2004. A BAI audit conducted at the end of 2003 found that 76,677 units of blood received from donors who had been infected with hepatitis C virus had been distributed for transfusions or research by the Red Cross. South Korea ’s Red Cross also put into circulation 228 units of blood donated by 99 people who had been suspected of carrying human immunodeficiency virus (HIV), but who later tested negative for the virus, an official said. Nine people were found to have been infected with hepatitis C virus during February 2004 after receiving blood transfusions from the Red Cross.

South Korean Red Cross spokesman Lee Jae-sung said the problems stemmed from a change in laws in Apr 2000 that banned donations from people who had been infected with hepatitis. The previous law had allowed donations from people who were hepatitis-free at the time they gave blood. It was not immediately clear whether there were also cases of hepatitis infections through blood donations made before Apr 2000 under the earlier rules. "We changed the rules for donation, but we only acquired a system to investigate donors' disease history in May 2003," Lee said. "The 9 people infected with hepatitis C virus received blood during the period between 1 Apr 2000 and May 2003," he said.
(Promed 3/30/04)

China (Hong Kong) — Ciguatera fish poisoning
The number of people falling ill from a marine toxin rose by eight cases. In the past three days, 53 people have been sickened by ciguatoxin — a poison that occurs naturally in some tropical fish. All patients have been released from hospital. The toxins are known to originate from several dinoflagellate (algae) species that are common to ciguatera endemic regions. The Food and Environmental Hygiene Department said it is considering amending the law to increase the number of tests for the toxin on imported fish. Department director Gregory Leung said suppliers currently provide small quantities of reef fish for testing by the government; he did not say whether the planned changes would mean that testing would be made compulsory.

One fish supplier in Kwun Tong voluntarily destroyed 2,000 fish and recalled six tons of the fish from retailers after suspicions were raised that stocks were contaminated. Leung urged the public to avoid eating big reef fish altogether — larger fish are thought to carry higher amounts of the toxin. Previously they were merely warned to avoid eating the internal organs of fish — the toxin usually accumulates in the liver and gonads. People were also told to avoid drinking alcohol or eating nuts together with the fish, because the combination can exacerbate the effects of the poisoning. The toxin cannot be destroyed by cooking

Clinical testing procedures are not presently available for the diagnosis of ciguatera in humans. Diagnosis is based on symptomatology and recent dietary history. The main symptoms are numbness of the mouth and limbs, vomiting, diarrhoea, hot and cold flushes, and aching joints and muscles. While symptoms usually subside after a few days, in severe cases the neurological symptoms can persist for months or even years. In some cases, patients can suffer relapses years after their recovery. There is a low incidence of death from ciguatera fish poisoning.
(Promed 4/1/04)

Russia (Omsk and Amur)—Measles outbreaks in Saratovo (Omsk) and Blagoveshensk (Amur)
After an interval of three years, there has been a resurgence of measles in the city of Saratovo. Thirteen cases of measles were recorded during 2003, but 40 cases of measles have been recorded during the first three months of 2004. Of those infected, 88 percent are adults between the ages of 20 and 40. None had suffered measles previously or had been vaccinated. In 2004, mass immunization of adults up to 35 years of age is planned. Immunization will be restricted to those who have never had measles or to those who have not been vaccinated previously.

Nineteen cases of measles had been recorded in Blagoveshensk by the end of March 2004. As of 5 Apr 2004, 29 cases of measles had been admitted to hospital in Blagoveshensk. Most of the cases are either students at the Amurskaya State Medical Academy or at a local high school, but one case is a child under the age of one. Preventive measures are being carried out in the outbreak area. A quarantine regime has been established at the Amurskaya State Medical Academy. (Promed 4/6/04) 

Russia (Tulskaya Oblast) — Hemorrhagic fever cases increase in frequency
Public health physicians in the Tulskaya Oblast are warning the public that hemorrhagic fever cases are becoming more frequent — 26 cases of hemorrhagic fever have been reported in Tula (capital of Tulskaya Oblast) since the beginning of 2004. The vectors of hemorrhagic fever with renal syndrome are rodents, which begin to increase in the spring. This year rodent numbers have increased 5- to 10-fold, possibly due to the gap of two years in the allocation of funds for rodent control. The main carrier of the infection is the gray rat, but cats, dogs, foxes,wolves, and other animals can become infected by killing and consuming virus-carrying rodents, which do not themselves exhibit signs of illness.The virus is transmitted to humans through contact with rodent excreta and detritus; little or no person-to-person transmission occurs. (Promed 3/26/04)

Australia: Ross River fever alert for southeastern Queensland
An alarming outbreak of Ross River fever across southeastern Queensland prompted a health authority warning for holiday-makers to protect themselves this Easter. The 953 cases of the mosquito-borne virus already reported to Queensland Health in 2004 were well up on the same period of 2004. In 2002, just 886 cases were reported, attributed to drought conditions. However, 2003 was significantly worse, with 2,516 cases reported statewide. Authorities blamed heavy rainfall in the past 4-6 weeks for the increase, although they also said that increased awareness and testing may have pushed figures up recently. The southeast corner has been hardest hit, with north and southwest Queensland also reporting a sharp increase in cases in recent weeks.

Ross River virus is endemic in most coastal regions of Australia and since the 1980's appears to have extended its geographical range to include most of the island communities of the South Pacific. No cure is available, only prevention through measures such as mosquito repellent, fly screens, and covering up exposed skin. Residents have been urged to control mosquito breeding around homes. Only 25 to 45 percent of Ross River fever victims suffer symptoms, though for those who do, they can be debilitating. Symptoms include fever, pain, swelling of the joints, and a red rash affecting the trunk and limbs. Joint pain can last up to six weeks, though victims usually take 4-7 months to fully recover. Fortunately illness is not fatal and recovery is complete.
(Promed 4/3/04)

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Canada (British Columbia) — Avian influenza A (H7) virus human infections
The first human case of avian influenza A (H7) virus infection in British Columbia arose in a person who was involved in the culling of infected birds on 13-14 Mar 2004. On 16 Mar, he reported conjunctivitis and nasal discharge. Treatment with oseltamivir, an antiviral drug active against influenza A viruses, began on 18 Mar. On 30 Mar, Health Canada concluded that this case was caused by avian influenza A (H7) virus and informed WHO on 31 Mar. The patient has recovered fully. On 2 Apr 2004, WHO was informed by Health Canada of a second poultry worker in British Columbia infected with avian influenza A (H7) virus infection. This worker developed conjunctivitis on 25 Mar after close contact with infected birds. He was treated with oseltamivir on 25 Mar, and his symptoms resolved.

Based on this epidemiological information, WHO raised the global pandemic preparedness level from 0.1 to 0.2 for the Canadian outbreak. Global pandemic preparedness levels are dictated by the epidemiological situation for each local event. Level 0.2 means that more than one human case caused by a new subtype of influenza virus has been identified in the local event. The existing global preparedness level of 0.2 for the avian influenza in Asia remains unchanged. When a preparedness level is raised to 0.2, affected countries are advised to step up their surveillance in people exposed to affected poultry, to organize special investigations to better understand the new virus, to advise people at risk to wear protected clothing, and to consider the use of antivirals and normal human influenza vaccine. The new preparedness level for avian influenza A (H7) also means that WHO will begin a series of activities to obtain the virus, characterize it, and assess the needs for diagnostics and vaccine development. In addition, the Canadian Food Inspection Agency (CFIA) ordered the culling of 19 million domesticated fowl. The order will have an impact on 80 percent of British Columbia 's chicken and turkey producers.
(Promed 4/6/04, 4/7/04)

Canada (British Columbia) — WHO starts developing human vaccine to BC avian flu strain
The WHO is starting the process of producing a human vaccine for the H7 avian flu virus ravaging poultry stocks in British Columbia, and Canada's National Microbiology Laboratory will be one of the centers working on the project. Dr Frank Plummer, the lab's scientific director, confirmed that the lab will try to develop a viral seed — a genetically modified version of the H7 virus that could be used by commercial vaccine makers should the H7 strain emerge as a pandemic strain. That possibility appears unlikely at this point, but nevertheless health authorities have to prepare for the possibility. It's also good practice for when the next pandemic — believed by influenza experts to be inevitable — comes, Plummer said. Producing a seed vaccine for an H7 virus requires the capacity to use reverse genetics, a procedure in which the part of the virus, which is deadly to chickens, is plucked out. Vaccines are grown in fertilized eggs; unless an H7 virus is modified, it would kill the embryos and arrest the process. If all goes well the process should take between four and six weeks, Plummer said.

Plummer confirmed that the national lab would provide WHO with samples of the viruses taken from the two people who were infected with the H7 virus in British Columbia. WHO pandemic planning guidelines require the organization to commence production on a human vaccine for an avian influenza strain once there is evidence two people have been infected in an outbreak. The H7 strain hasn't proved to be as serious a threat to human health as the H5N1 strain, though one person died in a large H7 outbreak in the Netherlands in the spring of 2003 during which at least 89 people were infected. The Dutch outbreak was caused by an H7N7 strain. The two Canadian cases are believed to be an H7N3 strain.
(Promed 4/7/04)

USA (Oklahoma/Texas) — 66 tested positive for Legionnaires' bacterium
A bacterium that is connected to Legionnaires' disease has been confirmed in Oklahoma, and state health officials said 22 Mar 2004 that an Oklahoma hotel was the likely source. Approximately 70 players, parents, and others stayed at the Oklahoma City hotel last week during a basketball conference. The state Health Department and the Oklahoma City-County Health Department said that the bacterium Legionella pneumophila caused several upper respiratory illnesses among people who stayed in the hotel. Officials said that 66 people from Texas tested positive for the bacterium; 13 people from Houston developed upper respiratory illnesses. The city-county health department shut down the pool and spa where the outbreak is thought to have started, and the department is trying to reach everyone who stayed in the hotel recently.

The bacterium can lead to Legionnaires' disease, a severe infection that includes pneumonia. Most who succumb have other weakening conditions such as cancer, heart or lung illness, or extreme diabetes. The bacterium can also cause a milder illness called Pontiac fever, which usually passes after a few days and does not involve pneumonia. Officials said two Houston residents were in the hospital with Pontiac fever 22 Mar 2004. Both illnesses are treatable with antibiotics and neither is contagious. The bacteria are spread through such means as heated water and moisture in air conditioning ducts.
(Promed 3/23/04)

USA (Montana) — Sixth death in the state caused by hantavirus infection
Hantavirus has claimed another victim in northern Montana. The Glacier National Park's Deputy Superintendent, 61, became ill with flu-like symptoms in mid-March and died 25 Mar 2004. Blood tests confirmed hantavirus infection, said Elaine Sedlack, a nurse with the Flathead City-County Health Department. This is the 23rd case of hantavirus pulmonary syndrome reported in Montana since 1993 and the sixth death the state has reported. Officials are still investigating how the deputy superintendent contracted the disease.

Hantavirus infection is contracted by inhaling airborne particles from dried droppings, urine and saliva of infected deer mice. Rick Douglass, a hantavirus researcher said, "You absolutely have to mouse-proof your house. That includes filling any holes on the outside of your home's foundation that you can place your finger into. If you encounter any mouse droppings or urine, clean it up using one part chlorine bleach to 10 parts water; wear latex gloves and a paper mask. Don't vacuum or sweep up the droppings; they become dangerous when airborne." Hantavirus infection is not contagious, and cats and dogs have not been known to contract it. Symptoms include high fever, body aches, chills, nausea, vomiting, and diarrhea.
(Promed 4/1/04)

USA (California) — Local dogs diagnosed with leptospirosis
Five dogs in Marin County have recently been diagnosed with leptospirosis, a potentially serious bacterial disease that can be transmitted to humans, according to Marin County health officer Dr Fred Schwartz. He said it is endemic to many areas in California, but it is unusual that five dogs were diagnosed with it in a two-week period. Leptospirosis in humans can cause symptoms such as vomiting, chills, headache, and fever. If left untreated, it can cause kidney damage, meningitis, liver failure, respiratory distress, and in rare instances, death. Leptospirosis is transmitted through water contaminated with infected urine. According to a CDC report, "This may happen by swallowing the contaminated food or water or through skin contact, especially with mucosal surfaces, such as the eyes or nose, or with broken skin."

A CDC report labels leptospirosis a "re-emerging infectious disease in California." The report indicates that there were 61 human cases of the disease between 1981 and 2001. Twelve of those cases occurred within the last five years of that period. It also said that most of those who contracted leptospirosis did not get it from their pets but from recreational activities in contaminated fresh water. Schwartz said that anyone whose pet is showing signs of the disease should contact a veterinarian. He said that the best ways to avoid catching it from a pet are frequent hand washing, avoiding direct contact with animal secretions, and wearing gloves.
(Promed 4/6/04)

Panama (Veraguas) — Three cases of hantavirus infection
The Gorgas Commemorative Institute confirmed a third case of hantavirus infection in the Province of Veraguas, informed Ricardo Chong, Chief of Epidemiology of the Ministry of Health (MINSA) in the Region. Chong mentioned that the case is a 36-year-old male resident of Rio de Jesus District. This is the first case detected in 2004 in this region. The confirmation of a fourth case of hantavirus infection was in process in a female from El Cascajilloso in Arenas de Mariato. Several species of hantavirus may be present in Panama; previously, two hantaviruses have been isolated in Southwestern Panama: Choclo virus and Calabazo virus. Only the former has been associated with hantavirus pulmonary syndrome. (Promed 3/26/04)

Argentina (Buenos Aires) — Shigellosis outbreak
Buenos Aires Health Minister Ismael Passaglia said 31 Mar 2004 that water contaminated with bacteria has infected some 900 people in the Buenos Aires province district of Rojas over the past week. Authorities explained that the outdated system which provides water for the 26,000 residents of Rojas and the lack of maintenance caused the outbreak. "Scientists found the bacteria, Shigella sp. and the protozoan Giardia lamblia, which is why the water is not safe for humans," said Passaglia. Rojas Mayor Norberto Aloe said: "It's been a long time since the tank has been cleaned, and a lot of the pipelines connected to the water pumps have leaks." The outbreak began 24 Mar 2004, when five children from a private school became ill. By 29 Mar, hundreds suffered from stomach cramps, vomiting, diarrhea, and fever. Over 80 percent of the 900 cases are children between the ages of 6 and 12. On 30 Mar 2004, the army sent a portable water-processing plant to distribute to residents. Any role that giardiasis plays in symptoms is unknown at this point, but it is likely not to be negligible.
(Promed 4/1/04)

Brazil (Para) — Rabies deaths following vampire bat attacks
Thirteen deaths, possibly due to rabies, have occurred in the Amazonian town of Portel in the state of Para (Northern Brazil). Two of these deaths have been confirmed and the others are being studied. The rabies transmission is thought to be from vampire bat attacks, which are reported as being not unusual in the area. The outbreak is apparently under control — more than 680 persons have been vaccinated in the last few days, and the last death occurred 1 Apr 2004.

Rabies has not been adequately controlled in some areas of Brazil. During the course of 2003, there were 17 reported and confirmed human cases, almost all in the north (Amazonian Region) and northeast. Rabies transmitted by dogs is rare in other areas of the country, whereas rabies associated with vampire bat attacks on humans is not infrequent in the Amazonian region. Such attacks usually occur when bats are deprived of their usual source of food, such as domestic pigs and cattle. Elsewhere (Australia, Chile, Europe, and North America), insectivorous bats are usually associated with transmission of rabies virus to humans.
(Promed 4/3/04)

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2. UPDATES

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Dengue/DHF update:

Taiwan (South)
Taiwan has so far reported 18 cases of imported dengue fever, but no local cases. The government has activated its dengue fever awareness mechanism, with central and local governments joining hands to check the outbreak. The Executive Yuan's service center in southern Taiwan urged heightened alert 6 Apr 2004 against dengue fever and asked passengers returning from Indonesia and Vietnam to keep tabs on their own health.
(Promed 4/8/04)

Indonesia
From 1 Jan to 4 Apr 2004 a total of 52,013 mainly hospitalized cases of dengue and 603 deaths have been registered with the Indonesian Ministry of Health. The overall case fatality rate this year, particularly in Jakarta, has been lower than in previous years. Dengue occurs every year in Indonesia, but this year the number of cases has been unusually high in at least 12 of 32 provinces of the country. Compared with the same period in 2003, the number of cases has doubled.

The Ministry of Health has set up rapid response and surveillance teams to update and analyze the data from all provinces to guide appropriate action. The national government is providing free hospital care to those patients presenting with symptoms of dengue and without adequate financial resources. The local health authorities are conducting intensive vector control activities and are mobilizing the communities to eliminate unwanted containers in which the mosquitoes breed. WHO is assisting the Ministry of Health with laboratory diagnosis.
(Promed 4/8/04)

Bangladesh
Dengue threatens to strike Dhaka off guard as the health ministry, health department, and Dhaka City Corporation (DCC) are in apparent inaction to fight a repeat of the deadly outbreak that killed 193 people on record since 2000. About 12,000 people have been infected and hospitalized since 2000, the year dengue struck Bangladesh for the first time; 136 people died of dengue in 2000, 36 in 2001, and 21 in 2002 in Dhaka. How many people died last year is not known. Dengue, which usually breaks out in May and rages full-blown for the next three months, is still a major threat to public health but has been ignored over the last two years. The DCC has no surveillance and runs short of adulticide and larvicide to spray in city wards.
(Promed 4/8/04)

Cholera, diarrhea Update:

India (New Delhi) — Cholera
The number of cholera cases reported in the city has risen to 21 since Jan 2004 according to Municipal Corporation of Delhi (MCD) records. This year, the number of cases in March 2004 was 15 as compared to five cases in March 2002. No cases were reported in March during 2003. The highest number of cases is in the central zone, which has reported 11 cases. The incidence of cholera rises during the monsoon when dirty water collects around shallow hand-pumps. (Promed 4/3/04)

Indonesia (Maluku)—Diarrhea
At least five people have died of diarrhea, and more than 40 have been treated by central health office following an outbreak of the disease in Indonesia's Maluku province, a local health official told ASEAN-Disease-Surveillance.net 1 Apr 2004. The official said the outbreak hit the village of Amarlaut, Gorom Sub-district of Seram Bagian Timur Regency, Maluku beginning in early March 2004. The village has about 1000 residents, and most of them have difficulties finding clean water. This critical situation put them at risk for the disease; local health agencies have sent medicine and medical officers to support treatment in the area.
(Promed 4/3/04)

Update: Influenza Activity —- United States, 2003—04 Season
A summary of influenza activity in the United States during September 29, 2003 — March 27, 2004 is now available through CDC’s MMWR report. This report also summarizes human infections with avian influenza viruses related to poultry outbreaks in North America. Preliminary data collected through CDC influenza surveillance indicate that national influenza activity peaked during late November – December. The most frequently isolated viruses were influenza A (H3N2), and approximately 87% of these were similar to the drift variant A/Fujian/411/2002.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5313a2.htm
(MMWR April 9, 2004 / 53(13);284-287)

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4. ARTICLES

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Progress Toward Poliomyelitis Eradication —- India, 2003
“Since the World Health Assembly resolved in May 1988 to eradicate poliomyelitis, the estimated global incidence of polio has decreased >99%, and three World Health Organization (WHO) regions (Americas, Western Pacific, and European) have been certified as polio-free. Since 1994, when the countries of the WHO South-East Asia Region (SEAR) began accelerating polio-eradication activities, substantial progress toward that goal has been made. By 2001, poliovirus circulation in India had been limited primarily to the two northern states of Uttar Pradesh and Bihar, with 268 cases reported nationwide. However, a major resurgence of polio occurred during 2002, with 1,600 cases detected nationwide, of which 1,363 (85%) were in Uttar Pradesh and Bihar. This report summarizes the status of polio eradication activities in India during 2003 and describes the actions being taken to reduce poliovirus transmission.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5311a3.htm
(MMWR March 26, 2004 / 53(11);238-241)

Imported measles case associated with nonmedical vaccine exemption — Iowa, March 2004
“On March 13, 2004, the Iowa Department of Public Health (IDPH) reported to CDC that a male student aged 19 years with measles in the infectious stage had flown from New Delhi, India, to Cedar Rapids, Iowa, on March 12. Because of a nonmedical exemption, the student had not received measles-containing vaccine (MCV). This report describes the measles case, the public health response to prevent secondary cases, and the impact on the public health system. Health-care providers and state and local public health departments should be alert to possible cases of measles in persons who traveled with this student or their contacts. Parents considering nonmedical exemptions for their children should be aware of the potential risk for disease both for their children and the public.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5311a6.htm
(MMWR March 26, 2004 / 53(11);244-246)

Multistate investigation of measles among adoptees from China —- April 2004
“On April 6, 2004, Public Health — Seattle and King County, Washington, reported a laboratory-confirmed case of measles in a recently adopted child from China. Public health authorities in Washington state notified CDC, which collaborated with health officials in other states to locate other recently adopted children from China and contact their adoptive families. This report summarizes the preliminary results of an ongoing multistate investigation that has so far identified four confirmed and five suspected cases of measles among adoptees from China, underscoring the need for health-care providers to remain vigilant for measles and other vaccine-preventable communicable diseases in children adopted from international regions.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d409a1.htm
(MMWR April 9, 2004 / 53(Dispatch);1-2)

Update: West Nile Virus Screening of Blood Donations and Transfusion-Associated Transmission —- United States, 2003
“In 2002, transfusion-associated transmission (TAT) of West Nile virus (WNV) infection acquired through blood transfusion marked the emergence of a new threat to the U.S. blood supply. Although mosquito-borne transmission remains the predominant mode of WNV transmission, identification of TAT underscored the need for WNV screening of donated blood. In June 2003, blood-collection agencies (BCAs) implemented investigational WNV nucleic acid — amplification tests (NATs) to screen all blood donations and identify potentially infectious donations for quarantine and retrieval. This screening was performed on approximately 6 million units during June — December 2003, resulting in the removal of at least 818 viremic blood donations from the blood supply. This report summarizes the results of blood-donation screening tests conducted during 2003 and describes six cases of WNV TAT that occurred because of transfusion of components containing low levels of virus not detected by the testing algorithm. These data indicate that blood screening for WNV has improved blood safety. However, a small risk of WNV transfusion-associated transmission remains. To address this risk, changes to screening strategies are planned for 2004.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5313a1.htm
(MMWR April 9, 2004 / 53(13);281-284)

Osteomyelitis/Septic Arthritis Caused by Kingella kingae Among Day Care Attendees —- Minnesota, 2003
“Kingella kingae is a fastidious gram-negative coccobacillus that colonizes the respiratory and oropharyngeal tract in children. K. kingae occasionally causes invasive disease, primarily osteomyelitis/septic arthritis in young children, bacteremia in infants, and endocarditis in school-aged children and adults. Although diagnosis of this organism frequently is missed, invasive disease is uncommon. Only sporadic, non-epidemiologically linked cases have been reported previously. In October 2003, the Minnesota Department of Health (MDH) investigated a cluster of two confirmed cases and one probable case of osteomyelitis/septic arthritis caused by K. kingae among children aged 17–21 months attending the same toddler classroom in a daycare center. All reported within the same week with onset of fever, preceding or concurrent upper respiratory illness (URI), and refusal to bear weight on the affected limb. This report summarizes these cases and describes the epidemiologic investigation of the day care center. The findings underscore the need for clinicians and laboratorians to consider K. kingae infection in young children with Gram stain — negative or culture-negative skeletal infections.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5311a4.htm
(MMWR March 26, 2004 / 53(11);241-243)

WHO sees surge in progress against tuberculosis; health, finance ministers meet in New Delhi on challenge of treating an additional one million patients a year
The number of tuberculosis patients diagnosed and treated under DOTS, the internationally recommended strategy for TB control, is now rising much faster than at any time since DOTS expansion began in 1995, according to a new report by the WHO. The 2004 Global Tuberculosis Control report confirms that DOTS programmes are now treating three million TB patients every year, an increase of more than one million patients compared to just two years ago. That increase is nearly double the average annual increment of 270,000 patients during the previous six-year period, and the trajectory is still heading upward. India is leading the surge, followed by smaller but significant increases in five other key countries with high rates of TB: South Africa, Indonesia, Pakistan, Bangladesh and the Philippines.

"DOTS expansion is one of the major public health success stories of the past decade, one that is saving thousands more lives every day," Dr. Lee Jong-wook, WHO Director-General, said. "But to reach the 2005 targets for detection and treatment, the challenge now is to add another one million TB patients to DOTS programs each year. Many of these new cases will be recruited from the hospitals and private health sector in Asia, especially China, and from beyond the present limits of health systems in Africa."The global 2005 targets for TB control are to detect 70% of all infectious TB cases and cure 85% of those cases detected. According to the WHO report, the case detection rate has risen to 37% and cure rates to 82%. Meeting the 2005 targets will put the world's TB control programmes on the path to achieving the Millennium Development Goal (MDG) of halving the global TB burden by 2015. Expanding and strengthening DOTS is key to halting the spread of TB because it is cost-effective, ensures treatment compliance, and prevents the development of drug-resistant strains of TB. The World Bank, a key member of the Stop TB Partnership and a leading financier of TB-related programmes in developing countries, welcomed the WHO report as evidence that donor funding for expanding DOTS treatment had proven effective in improving the health and welfare of communities afflicted by the disease.

There are an estimated 8.8 million new cases of TB each year of which 3.9 million are infectious. The number of new cases is increasing rapidly in Eastern Europe, mainly countries of the former Soviet Unio, which only recently started to implement DOTS. TB incidence rates also continue to rise at an alarming rate in African countries with high HIV prevalence. "HIV/AIDS is driving the TB epidemic in southern and eastern Africa and will worsen the situation in Eastern Europe, India and China in the years ahead," said Dr Jack Chow, the WHO Assistant Director-General for HIV/AIDS, Tuberculosis and Malaria. "We cannot control one without controlling the other, and must begin rapidly scaling up TB/HIV collaborative activities to provide a synergy of prevention, treatment and care for co-infected patients."
(WHO 3/23/04)

WHO leads drive for international coordination of clinical research
The WHO and Current Controlled Trials (CCT) have announced that all randomized controlled trials approved by the WHO ethics review board will be assigned an International Standard Randomised Controlled Trial Number (ISRCTN). As a result, the scientific community should now find it easier to keep up-to-date with current research. Randomised controlled trials are considered the best way to compare — in an unbiased manner — the effects of particular interventions on people or populations either for health promotion, prevention, treatment or for rehabilitation. However, information about these trials is difficult to find, because several trials may have the same title, one trial may be reported in several places under different titles, and many trials are never reported at all.

Information is even more difficult to find about neglected diseases that disproportionately affect poor and marginalized populations. WHO supports and funds much of the research in this area. However; so far, there has been no mechanism to make the information generated from this research easily available to researchers, particularly those in developing countries whom it affects most. By providing free access on the internet, ISRCTNs offer a way to keep the international community informed about these clinical trials. Randomised trials in the other major research areas that the WHO supports — infectious diseases, childhood diseases, vaccines and others will be added shortly to the ISRCTN Register. The Register also tackles the problem of publication bias — trials that are not published either because of negative findings, or language barriers, or inaccessibility of the researcher to journals. By registering clinical trials at the start of the research, the ISRCTN Register will ensure that this information is now more easily available.

The ISRCTN Register is the first online service that provides unique numbers to randomised controlled trials in all areas of health care and from all countries around the world. Access to the ISRCTN Register is free and open to the public. Since its launch in May 2003, the Register has assigned ISRCTNs to over 1800 trials, and is growing fast. The ISRCTN Register has been developed by Current Controlled Trials Ltd, part of the Current Science Group of companies.
(WHO 4/2/04)

Human and avian influenza viruses target different cell types in cultures of human airway epithelium
Mikhail N. Matrosovich, Tatyana Y. Matrosovich, Thomas Gray, Noel A. Roberts, and Hans-Dieter Klenk.
http://www.pnas.org/cgi/content/abstract/101/13/4620?etoc

"The recent human infections caused by H5N1, H9N2, and H7N7 avian influenza viruses highlighted the continuous threat of new pathogenic influenza viruses emerging from a natural reservoir in birds. It is generally believed that replication of avian influenza viruses in humans is restricted by a poor fit of these viruses to cellular receptors and extracellular inhibitors in the human respiratory tract. However, detailed mechanisms of this restriction remain obscure. Using cultures of differentiated human airway epithelial cells, we demonstrated that influenza viruses enter the airway epithelium through specific target cells and that there were striking differences in this respect between human and avian viruses. During the course of a single-cycle infection, human viruses preferentially infected non-ciliated cells, whereas avian viruses, as well as the egg-adapted human virus variant with an avian virus-like receptor specificity, mainly infected ciliated cells. This pattern correlated with the predominant localization of receptors for human viruses (2-6-linked sialic acids) on non-ciliated cells and of receptors for avian viruses (2-3-linked sialic acids) on ciliated cells. These findings suggest that although avian influenza viruses can infect human airway epithelium, their replication may be limited by a non-optimal cellular tropism. Our data throw light on the mechanisms of generation of pandemic viruses from their avian progenitors and open avenues for cell level-oriented studies on the replication and pathogenicity of influenza virus in humans."
(Promed 3/31/04)

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4. NOTIFICATIONS

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PAHO: Vaccination Week in the Americas
Coordinated by WHO's Regional Office for the Americas (PAHO), from April 24 to 30, countries from Canada to the tip of South America and throughout the Caribbean will be part of an unprecedented “Vaccination Week in the Americas”. Targeting 40 million people, the beneficiaries will be children, young women, and seniors, mostly in remote areas. Participating countries will vaccinate against diseases such as measles, polio and rubella.
http://www.paho.org/English/DD/PIN/sv_2004.htm
(WHO, PAHO)

53rd Annual Epidemic Intelligence Service (EIS) Conference
April 19-23, 2004; Atlanta, GA
EIS is the country's critical epidemiology training service, combating the causes of major epidemics. Over the past 50 years, EIS officers have played pivotal roles in combating the root causes of major epidemics. The primary purpose of the EIS Conference is to provide current EIS officers a training experience for making scientific presentations. Additional purposes include: 1) providing an opportunity for scientific exchange regarding current epidemiologic topics; 2) highlighting the breadth of epidemiologic activities at CDC; 3) providing a setting for strengthening the EIS professional network among new, current, and former EIS officers; and 4) providing a forum for CDC programs to recruit new EIS officers.
http://www.cdc.gov/eis/conference/conference.htm
(CDC)

Guidelines for preventing healthcare–associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee
This report updates, expands, and replaces the previously published CDC "Guideline for Prevention of Nosocomial Pneumonia". The new guidelines are designed to reduce the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health-care settings (e.g., ambulatory and long-term care institutions) and other facilities where health care is provided.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
(MMWR March 26, 2004 / 53(RR03);1-36)

GIDEON: Infectious Disease and Epidemiology database
The University of Washington library http://healthlinks.washington.edu/ is offering the GIDEON, Infectious Disease and Epidemiology database on a trial basis and looking for feedback. GIDEON diagnoses Infectious Disease (see Avian Flu diagnosis http://www.gideononline.com/avianflu.htm) and provides up-to-date Epidemiology data including emerging infections like Avian Influenza. GIDEON provides complete anti-infective drug and vaccine treatment and pathogen information. The University is deciding now whether to offer this resource. If you or your colleagues can benefit from access, please email Nanette Welton, nwelton@u.washington.edu. If you have any questions, please contact Adrienne Rutledge of GIDEON at: Tel: 1-888-644-3366 or 1-510-430-9594 or email: rutledge@GIDEONonline.com.

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