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

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** China: Four Possible SARS Cases Reported**
On April 23, 2004, the Chinese Ministry of Health reported four patients with possible severe acute respiratory syndrome (SARS) to the World Health Organization (WHO). Two of the cases are from Beijing and two are from Anhui Province, located in east-central China. One of the patients in Anhui Province died. The first patient is a 26-year-old female graduate student from Anhui Province who worked at the National Institute of Virology Laboratory of China 's Center for Disease Control in Beijing during March 7-22. The laboratory is known to conduct research on SARS coronavirus. She developed fever and other SARS-like symptoms March 25 while in Anhui Province; she traveled by train to Beijing and was admitted to a local hospital March 29 with pneumonia. She returned to Anhui Province April 2 and is currently under medical observation. Laboratory test results reported on April 23 showed evidence of antibodies to SARS coronavirus.

The second patient is the mother of the 26-year-old graduate student who had provided bedside care for her daughter during her recent illness. The mother became ill April 8 and was admitted to a hospital in Anhui Province with pneumonia. She died April 19; Chinese health authorities have identified her illness as a possible SARS case.

The third patient is a 20-year-old female nurse who provided care to the 26-year-old graduate student in a Beijing hospital from March 29 to April 2. The nurse became ill April 5, was admitted to a hospital in Beijing April 7, and was transferred to another Beijing hospital April 14, where she remains in intensive care. On April 22, her illness was identified as possible SARS on the basis of positive test results for antibodies to SARS-CoV in serum.

The fourth patient is a 31-year-old male graduate student who worked at the same research laboratory as the 26-year-old graduate student. He reported fever April 17 and was admitted to a hospital in Beijing April 22. Chinese authorities have identified the illness as possible SARS.

An epidemiologic investigation by Chinese public health authorities is under way. The Chinese MOH has requested local health authorities in China to enhance surveillance for SARS, influenza-like illness, and pneumonia of unknown etiology, and has initiated measures to prevent the spread of SARS among travelers, including screening of travelers at ports of entry. Chinese health authorities are also actively identifying contacts of these four patients and have identified 188 close contacts of the third patient (the nurse). Five of these 188 contacts have developed fever, and all the febrile contacts have been hospitalized and isolated. The National Institute of Virology Laboratory in Beijing has been closed, potentially exposed personnel are being screened, and possible sources of infection for the two laboratory workers are being investigated.
(WHO/CDC 4/23/04)

China — Fox and cat join civet cat as confirmed carriers of the SARS coronavirus
Chinese scientists have found that the coronavirus that causes severe acute respiratory syndrome (SARS) is also carried by foxes and cats, not just civets. Lin Jinyan, the leader of a SARS control and prevention research team in Guangdong Province, reported that other wild animals were also found to carry the virus. The team had tested thousands of people for SARS antibodies in 16 cities in Guangdong and found that among 994 people working in animal markets, 10.6 percent carried antibodies, and among 123 civet cat husbandry staff, only 3.25 percent tested positive. Experts also tested foxes, hedge-shrews and cats collected in the province and discovered that some carried the SARS coronavirus. On 16 Jan 2004, WHO experts said that the SARS coronavirus or a SARS-like coronavirus appeared to be linked to civet cats. WHO epidemiologist Robert Breiman said it's possible that other animals were also involved in the spread of SARS. These observations extend the range of species known to harbor the SARS coronavirus (or a closely related coronavirus). However, these data do not establish the direction of transmission—from animal to man, or the reverse. The origin of the SARS coronavirus remains obscure.
(Promed 4/17/04)

Hong Kong — Export of live chickens resumes from mainland
The first batch of 6,000 live chickens passed the quarantine checkpoint in Shenzhen City 20 Apr 2004, marking the resumption of live chicken export to Hong Kong after a 2.5-month suspension. The first batch of live chickens came from chicken farms in Huadu district of Guangzhou city and Shenzhen city. The interior area's poultry exports to Hong Kong and Macao were suspended after cases of avian influenza were spotted in January 2004. Live chicken exports to Macao were restored 5 Mar 2004. After being checked by the Hong Kong side, these chickens will go on the market in Hong Kong. In the Jiangfeng Chicken Farm in Huadu, where 2000 of the chickens came from, the Guangdong administration of quality supervision, inspection and quarantine quarantined the chickens five days ago. They also took samples to test for H5 antibodies. Just before leaving for Hong Kong, the chickens also received another quarantine check. In the next three days, Jiangfeng Chicken Farm will also export 2000 live chickens to Hong Kong every day.
(Promed 4/21/04)

Thailand — Avian Influenza cuts exports
Thailand 's chicken exports will slide 21.9 per cent in 2004 because as a result of the outbreak of highly pathogenic avian influenza that swept Asia earlier in the year, according to a Dow Jones Newswire report. The value of the lost chicken exports was USD 965 million. Thailand is the fourth largest chicken exporter in the world behind the United States, Brazil, and China. Many countries banned imports of Thai chickens after the avian flu outbreak in Thailand was confirmed 23 Jan 2004. However, cooked chicken products are being imported by some major buyers such as Japan and countries belonging to the European Union, which consume 39 and 54 per cent, respectively, of Thai cooked chicken exports.

The Ministry expects exports of cooked chicken to surpass exports of raw chicken in 2004. Cooked chicken exports will rise to 220,000 to 230,000 tons from 128 000 tons in 2003, while frozen chicken exports will fall to 170,000 tons from 380,000 tons, the statement said. Chicken production in Thailand is still only about 40–50 per cent of the normal rate. Several farm areas are still being monitored for the avian flu virus before they can resume operations.
(Promed 4/23/04)

Taipei — Avian influenza (Low pathogenicity), final report
Unlike the recent outbreaks in eight other Eastern Asian countries, which were affected by a highly pathogenic avian influenza (HPAI) virus strain of subtype H5N1, the outbreak in Taipei was caused by a low pathogenic (LPAI) strain, of subtype H5N2. Though this was not a list A disease, severe and swift eradication programme was performed. The following final report, signed by Dr Jye Chang, dean, Department of Veterinary Medicine, National Chung Hsing University, was published by the OIE 21 Apr 2004:

“The strain of avian influenza (H5N2) detected in routine surveillance from 24 premises of 8 prefectures has been completely eradicated. The birds totaled 383 852 were stamped out and the affected premises have been cleaned and disinfected. Based on the results of genetic sequencing (PQREKR*GLF) and intravenous pathogenicity index (IVPI=0.0), the virus was identified as a low pathogenic avian influenza virus. Extensive surveillance has been conducted in the buffer zone (3 km radius) around the index flock. Serological as well as cloacal and tracheal samples (for virus isolation) were collected from all flocks (both non-commercial and commercial) within the buffer zone. This targeted surveillance has not detected any further evidence of the virus since 9 Mar, 2004.”
(Promed 4/23/04)

China — AIDS Prevention Targets High-Risk Activities
China 's Minister of Health recently announced intervention measures to stem the spread of HIV/AIDS via prostitution and intravenous drug use, the nation's two main routes of HIV transmission. The measures include free condom distribution at entertainment venues and provision of clean syringes or methadone treatment for IV drug users, according to Hao Yang, director of the ministry's HIV/AIDS Division. The strategies have already been undertaken in pilot trials in some regions over the past few years. The central government vowed to support the measures. With the assistance of international and nongovernmental groups, the Health Ministry has supplied drug users in 17 regions with new syringes since 2001. The ministry hopes the pilot initiatives will be more widely followed, in addition to the further dissemination of HIV prevention and control awareness. For example, Hubei province has promised to have condom-dispensing machines in all entertainment venues and hotels by 2006. In a recently released document, the State Council urged health, public security and other department officials to work more closely to prevent the spread of AIDS. The document stressed that HIV/AIDS prevention and control would be key indices for evaluating the achievements of local officials.
(SEA-AIDS 4/14/04)

 Macao — Fatal Case of Enterovirus 71-associated Encephalitis
A 17-year-old schoolgirl was confirmed to have died of encephalitis after contracting enterovirus type 71 (EV71), the Macao Health Service announced 14 Apr 2004. Encephalitis is an inflammatory disease of the membranes that surround the brain and spinal cord. This is the first locally confirmed case of encephalitis caused by EV71 in Macao. The girl died 3 Mar 2004 in the Government Hospital after nearly a month of treatment. The Macao Center for Disease Prevention and Control confirmed the patient's infection with EV71. EV71 is one of the etiologic agents of epidemic hand, foot and mouth disease (HFMD), and outbreaks of EV71 have been reported since 1969. It is highly infectious among small children below the age of five, and spreads through fecal-oral contact and multiplies in the intestine before it is released into the bloodstream and spreads to other tissues. In order to prevent the spread of EV71, students suffering from HFMD have since 2000 been required by the Macao Health Service to be temporarily suspended from school. Macao recorded 330 HFMD cases during 2003. Residents are advised to ensure personal hygiene, especially before taking meals and after using the toilet.

HFMD is generally a benign disease with severe neurological sequelae in a small proportion of cases and is relatively rare in Europe, North America, and Australasia. Since 1997 there has been a significant increase in EV71 epidemic activity throughout the Asia-Pacific region. Recent HFMD epidemics in this region have been associated with a severe form of brainstem encephalitis associated with high case-fatality rates. The emergence of large-scale epidemic activity in the Asia-Pacific region has been associated with the circulation of 3 genetic lineages that appear to be undergoing rapid evolutionary change. A vaccine is currently not available.
(Promed 4/15/04)

Singapore — Meliodosis kills 16 of 32 cases so far in 2004
Meliodosis, a tropical disease linked to heavy rainfall, has killed 16 of 32 victims, including a foreigner, in Singapore this year. The number of fatalities is unusually high, and ministry spokeswoman Bey Mui Leng said that a directive had been issued to doctors and hospitals across Singapore to report all cases. The ministry has also put information on its website to inform the public about the disease. Out of 32 cases of meliodosis this year, 16 people had died, for a fatality rate of 50 percent. This compares with a fatality rate of 27.4 per cent out of an average 59 cases annually between 1990 and 2003, according to the ministry's website. Singapore has an average of 59 new cases every year. The highest number of cases was 114, in 1998. In 2003, there were 42 cases with five deaths.

Meliodosis is caused by a bacteria, Burkholderia pseudomallei, that emerges from the soil surface during wet weather. The bacteria exists as an environmental saprophyte living in soil and surface water in endemic areas (South East Asia and northern tropical Australia), particularly in rice paddies (sporadic cases have also been reported to have been acquired in Africa and the Americas). The most common form of transmission is through direct contact with water and mud, but it could also be acquired by inhaling contaminated dust particles or drinking infected water. Human-to-human transmission is possible, but rare. People with underlying predisposing condition such as diabetes, renal disease, cirrhosis, thalassemia, alcohol dependence, immunosuppressive therapy, chronic obstructive lung disease, cystic fibrosis, and excess kava consumption are most at risk of contracting the disease. Melioidosis may present at any age, but peaks in the fourth and fifth decades of life, affecting men more than women. Severe disease and fatalities are more common in those with risk factors.

Symptoms such as swelling, lung infection, high fever, cough, chest pains, diarrhea, and skin lesions may surface within two days or only after several years. There is no vaccine for melioidosis, but the disease can be treated with some antimicrobials. The lung infection can be rapidly fatal or somewhat more indolent. Acute melioidosis septicemia is the most severe complication of the infection. It presents as a typical sepsis syndrome, and the syndrome, usually in patients with risk factor comorbidities, has a very high mortality rate of 80–95 percent. With prompt optimal therapy, the case fatality rate can be decreased to 40–50 percent.
(Promed 4/9/04, 4/14/04)

Viet Nam (Long An) — Report of unidentified disease
In mid-April, 70 people in the Vietnamese southern province of Long An were hospitalized due to an unidentified infectious disease. The disease, whose symptoms include rash on the face, neck, legs and arms, and mild fever, has quickly been transmitted from the sufferers to a number of their relatives, other patients, and healthcare staff in the Long An Hospital, local newspaper People's Police reported. The disease may have been caused by a virus which lives in insects, the hospital's Vice Director Phan Loi said, and the hospital has sprayed insecticides and closed the windows to prevent insects from entering. The cause of the disease is being investigated.
(Promed 4/20/04)

Bangladesh (Faridpur) — Nipah Virus Confirmed
As of 20 Apr 2004, WHO has received preliminary reports of one cluster of 30 cases, including 18 deaths, attributed to Nipah virus infection in Faridpur district. Laboratory testing performed by Centers for Disease Control and Prevention (CDC), Atlanta has confirmed Nipah virus infection in 16 of the cases. A team comprising experts from the Institute of Epidemiology Disease Control and Research, Bangladesh, the International Centre for Health and Population Research (ICDDRB), Bangladesh and the WHO country office is carrying out epidemiological investigations. The team has developed guidelines for case management. These will be used at workshops planned for this week on infection control and safe clinical management for local medical staff in different health care settings in Faridpur district.
(Promed 4/20/04)

India (West Bengal) — Human anthrax cases in Murshidabad
In the last three months more than 30 anthrax cases have been reported from Murshidabad District of West Bengal in India. The cases were found mainly in the Hariharpara and Domkal areas. In all cases there was a history of eating meat from a sick cow; the medical team has collected samples from the affected areas, and the villagers have been advised not to consume meat of any sick cattle. In West Bengal this a common practice in all tribal areas as well as in poor communities. Interestingly, we are not getting cases of intestinal anthrax; as also in this situation, the main manifestations are blisters and ulcers. It has been found that populations who regularly eat anthrax-infected carcasses have a moderate prevalence of antibodies, which is believed to suppress the incidence of clinical disease and thereby provides an excuse to those communities to continue to eat this high-risk meat.
(Promed 4/20/04)

Australia (Northern Territory) — Death of Child, Murray Valley Encephalitis Warning
A Northern Territory-wide warning has been issued after a young child was diagnosed with a potentially fatal Murray Valley encephalitis virus (MVEV) infection. The Department of Health and Community Services issued the warning after the child contracted the virus in Central Australia. The warning particularly applies to people living, visiting or camping within five km of swamp, creek and river systems overnight, as the virus is carried by mosquitoes.

Symptoms of MVEV infection include severe headache, high fever, drowsiness, tremors and seizures, especially in young children. In some cases the disease progresses to coma. The Department has warned people experiencing these symptoms to seek urgent medical attention. Above-average rainfall for many regions in February and March is thought to be responsible for increased mosquito numbers and an increased risk of virus transmission. February to May is the peak risk period for the virus in the Territory. The Department also issued a warning for Kunjin virus. Kunjin virus disease is not normally fatal; symptoms include fever, headaches and muscle and joint aches and pains. Both viruses are transmitted by the common banded mosquito. This mosquito bites only after sundown, with a peak in the first two hours of the night.

Murray Valley encephalitis virus is endemic in New Guinea and parts of Australia. Inapparent infection is common, and the elderly and the young are most at risk from this potentially fatal encephalitis. Kunjin virus is closely related to Murray Valley encephalitis virus and West Nile virus. It occurs predominantly in Australia and Sarawak, where it normally causes mostly asymptomatic infections, although occasional cases of encephalitis have been reported.
(Promed 4/21/04)

Papua New Guinea (Eastern Highlands Province) — Mystery disease near Yonki
More than 100 people have reportedly died in a month following the outbreak of a mystery disease in several villages near Yonki, Eastern Highlands Province. Kollen Upa, a community leader and chairman of the Eastern Highlands Blockholder coffee growers' association, raised the alarm; in his village of Omaura, three people had died "strangely" in just one day. Villages affected by what they claimed to be malaria and typhoid were Omaura, Onanika, Sasaura, Ikana and hamlets surrounding the Yonki dam, in the Obura-Wonenara electorate. These villages — from the last census — have a total population of more than 5,000 people.

Mr. Upa said men, women and children in the area have been falling sick and dying since mid-March 2004. Children have been worst hit by the outbreak. Health authorities in Kainantu confirmed receiving verbal reports of the diseases and deaths in the area. However, the chief executive officer of the Kainantu hospital, Thomas Koimbu said reports have been sketchy, as the villages were remote. "We will investigate, however, at this stage we are only getting verbal reports coming from the area," Mr Koimbu said. "At this stage we have yet to establish a firm diagnostic on whether the reported cases are of malaria or typhoid." Mr Koimbu said malaria was endemic in the area due to the rising water levels of the Yonki dam.
(Promed 4/19/04)

Russia (Novgorod) — Imported Malaria Case
The first case of imported 3-day malaria caused by Plasmodium vivax was registered in Novgorod oblast. According to the informational agency of the City of Novgorod and Marina Pribitkina, the press secretary of State Epidemiological surveillance center, a 63-year-old habitant of Borovichekiy region district had been ill for three days in the beginning of April 2004. The patient arrived in Novgorod from Tajikistan on October 2003 and was hospitalized in the infectious unit of Borovicheskaya central hospital 5 Apr 2004. The malaria parasites were also discovered during medical assessment of her grandchildren: two girls (4 and 8 years old) and a 5-year-old boy. The children are doing well after treatment. The suspected source of the infection is unknown. According to Marina Pribitkina, the last case of 3-day malaria caused by Plasmodium vivax was registered in August 2003 in an inhabitant of Novgorod city.
(Promed 4/20/04)

Russia (Udmurtia) — Increased Number of HFRS Cases Expected
In 2003 there were 299 cases of HFRS (Hemorrhagic fever with renal syndrome) in Udmurtia, while so far this year in 2004, 400 HFRS cases have already been registered. According to preliminary assessments, the number of rodents has increased significantly in comparison with 2003. Field voles, the carriers of HFRS, are particularly abundant. Relatively warm winter weather and a good harvest have created the best conditions for the early reproduction of rodents. According to epidemiologists, peaks in HFRS activity are observed every three to four years. The past two years have been relatively quiet, and the expectation is that the incidence of HFRS will increase in 2004. Most of the cases are in rural areas where many people are agricultural workers and sanitary conditions are poor. Urban residents can also become infected, especially if they have gardens located near forested areas. The most active foci of HFRS infection are forests.
(Promed 4/15/04)

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Canada — Avian flu found on Two more British Columbia farms (31 total)
The number of Fraser Valley commercial poultry operations infected with avian influenza has grown to 31, the Canadian Food Inspection Agency (CFIA) has announced. The two latest sites, located within a cluster of infected farms near this town a few miles north of Sumas, Wash, were confirmed as Canadian and British Columbia officials met at Abbotsford. Ten so-called backyard poultry operations in the valley also have been found to have the fast-spreading virus, which can kill entire flocks within days. Bob Bugslag, director of the Provincial Emergency Program, said dozens of extra staff ordered last week by British Columbia Premier Gordon Campbell have begun preparing to help with the destruction of more than a million infected birds. The Agriculture Ministry hopes to eliminate the entire Fraser Valley poultry population of 19 million by May 21. Carcasses of infected birds will be incinerated, composted or--as a last resort--stuffed into sealed bags and buried in landfills. The kill order extends to non-infected flocks within a kilometer, about six-tenths of a mile, from any infected farm. Disease-free poultry may be processed for retail sales to consumers.
(Promed 4/22/04)

USA (New York) — Human Case of Avian Influenza A (H7N2) Virus Infection Confirmed
The case of a Westchester County man who survived an extremely rare case of avian influenza during the fall of 2003 is a mystery. Five months after the patient checked into Westchester Medical Center complaining of fever and cough, no one knows how he contracted avian influenza. The man recovered and went home after a few weeks, but it was not until March 2004 that CDC suspected an avian virus had caused his illness, and confirmed that diagnosis on 16 Apr 2004. Any new case of avian influenza is a threat, because it can spread rapidly among birds and it can be serious in humans on the rare occasions when they are infected. In recent years, cases of avian influenza in Asia, Europe and North America have prompted the slaughter of millions of poultry. Avian influenza killed 23 victims in Viet Nam and Thailand early in 2004. Invariably, the human victims have turned out to be people who had close contact with birds. In the only previous case in the US, in 2002, the patient was a poultry worker in Virginia.

Health officials say they have found no evidence that the Westchester County patient had direct contact with birds or had traveled to any region affected by avian flu. Officials said the man was infected with influenza A(H7N2) virus, the same virus that hit chicken farms in New Jersey, Maryland and Delaware in 2004. The H7-type avian viruses are thought to be less virulent in humans than the H5-type strain that recently appeared in Asia. Other H7-type strains were responsible for outbreaks in Canada (H7N3) in 2004 and in the Netherlands in 2003 (H7N7).

The Westchester patient, a Caribbean immigrant, lives with his wife and children. He entered the hospital November 2003 suffering from other serious ailments that weakened his immune system. One official said the patient had symptoms of a respiratory illness, including coughing and an abnormal chest X-ray. The county's laboratory tentatively identified the virus as a human influenza A (H1N1) virus, and sent samples to CDC. The specimen was set aside because few H1N1 cases were reported during winter 2003-2004, and the centers routinely concentrate on testing the most prevalent strains. In February 2004, CDC tested the sample, and found that it was an influenza A virus, but not H1, H3 nor H5 subtype. On 17 Mar 2004 scientists using other tests identified the virus as H7N2, and CDC soon notified health officials in New York that they had a suspect human case of avian influenza. Doctors asked the patient for another blood sample, to compare antibody levels in it with another sample kept from the initial phase of his illness. Last week, the tests confirmed a recent infection with H7N2, and CDC alerted state and local officials. Westchester officials and the state Department of Health have also tested the man's family, co-workers and close contacts — none of whom were sick — without finding evidence that any had also been infected. CDC does not believe that the case represented an imminent threat to public health.
(Promed 4/20/04)

USA — USDA Will Not Allow Independent Mad Cow Disease Tests
The U.S. Agriculture Department (USDA) will not allow American beef companies to independently test their cattle for mad cow disease, an agency official said 9 Apr 2004. The USDA said it rejected a request by Creekstone Farms Premium Beef to allow 100 percent testing for the brain-wasting disease, a step the privately owned company deemed necessary to resume trade with Japan. "The use of the test as proposed by Creekstone would have implied a consumer safety aspect that is not scientifically warranted," said USDA Undersecretary Bill Hawks in a statement. "The test is now licensed for animal health surveillance purposes." Creekstone offered to pay for its own testing to appease Japan, which shut its borders to U.S. beef after the discovery of the first and only U.S. case of mad cow disease in Dec 2004. Japan accounts for 40 percent of U.S. beef exports, buying more than USD 1 billion a year in beef, veal and variety meats. As a step to restoring trade, Japan wants the United States to test all slaughtered cattle for mad cow disease. The USDA repeated its stance that such testing was not scientifically justified. U.S. Vice President Richard Cheney was expected to raise the issue when he visits Japan next week.
(Promed 4/14/04)

USA (Ohio) — First Probable Human Case of West Nile Virus Infection in 2004
The Ohio Department of Health (ODH) announced its first probable case of West Nile virus (WNV) infection in 2004. The patient is a 79-year-old male. "With warm weather in recent weeks, mosquitoes have become active," said ODH Director J. Nick Baird. In 2003, Ohio reported 108 probable and confirmed human cases of WNV and 8 WNV-related deaths; the first human case was reported 18 Jul 2003. In 2002, Ohio reported 441 human cases and 31 deaths. Human WNV cases typically do not appear until late summer in Ohio. ODH is working to determine where the patient may have been exposed. " West Nile virus and other vector-borne illnesses are preventable," Baird said. "By taking some simple steps, you can help ensure that you and your loved ones remain healthy and safe when outside this spring and summer."
(Promed 4/13/04)

USA (Hawaii) — Leptospirosis blamed in student's death
Laboratory tests concluded that the bacterial disease leptospirosis — and not dengue fever — caused the death on 26 Jan 2004 of a Big Island college student, state officials said. But the tests, performed by CDC, also revealed that the 22-year-old man had dengue antibodies. State chief epidemiologist Paul Effler said the tests showed that the student was indeed exposed to dengue before his death, a finding that has kept officials alert to the possibility that the virus is present on the island of Hawaii. Preliminary tests released earlier in 2004 said dengue likely killed the student, who died in Maryland, where he attended Washington College. In response, the Health Department asked Big Island doctors to look out for residents with symptoms of the virus and report any cases. No one has been diagnosed with dengue in the months before the death or since. The student is believed to have contracted leptospirosis while vacationing with his family. Family members say the student was in good health when he returned to school in Jan 2004 but went briefly to the hospital 18 Jan 2004 and was found seriously ill in his dormitory the next day. He was re-admitted to the hospital and died six days later.

This is the seventh reported leptospirosis death in the past decade, Effler said. Every year, between 30 and 70 people in the islands are diagnosed with the disease. Exposure to leptospirosis, which is usually transmitted through infected animal urine, can come from contact with animals, taro farming, swimming in freshwater streams, and using water catchment systems.
(Promed 4/11/04)

El Salvador (Intipuca) — Rabies kills boy
Sources from the Salvadoran Ministry of Health reported 6 Apr 2004 that a six year old boy died of rabies. Julio Castro, chief of epidemiology of the Ministry said that the boy was hospitalized in the intensive care unit of the Benjamin Bloom pediatric hospital, and died 4 Apr 2004. The victim, who lived in the municipality of Intipuca, 112 miles south east of San Salvador, contracted the infection when his pet dog, a boxer puppy, bit him. The symptoms of the disease — restlessness, fear of water, difficulty walking — appeared 1 Apr 2004 and caused his parents to consult a physician who subsequently referred the patient to the Bloom hospital. Castro commented that, as a preventive measure, about 200 dogs and 50 cats in the immediate vicinity of the boy's home "were vaccinated". The other fatal victim so far in 2004 was a 45-year-old man who died in January. In 2003, five people died in El Salvador as a consequence of rabies.
(Promed 4/9/04)

Brazil — Deaths associated with suspected hepatitis D virus infection
At least 20 Marubo Indians have died from suspected hepatitis delta virus infection in the Javari Valley, extreme west of Amazonas state. The disease also threatens other tribes. Two boatloads of health personnel, including four doctors, departed 11 Apr 2004 to take medical aid to the tribes. The boat is equipped with ultrasound and digital x-ray machines, and will send test results by satellite for analysis in Florianopolis, Santa Catarina state. They expect to examine 1,000 Amerindians in the Indian reserve of the Javali Valley.

HDV infection can be acquired either as a co-infection with HBV or as a superinfection of persons with chronic HBV infection. Chronic HBV carriers who acquire HDV superinfection usually develop chronic HDV infection. Control of HBV infection using HBV vaccine would simultaneously eradicate any hepatitis D virus, since it is dependent on HBV for its replication. Studies performed on communities in Bolivia, Brazil, Colombia, Peru, and Venezuela have shown a high endemicity of HBV infection all over the region. Disease related to HDV infection in these outbreaks has been very severe, with rapid progression to fulminant hepatitis and case-fatality rates of 10-20 percent. The cause of the atypical course of HDV infection in these populations is unknown. The modes of HDV transmission are similar to those for HBV, with percutaneous exposures the most efficient. Sexual transmission of HDV is less efficient than for HBV. Perinatal HDV transmission is rare.
(Promed 4/13/04)

Panama — Tenth Case of Hantavirus Infection Reported
The Panamanian health authorities reported that, so far in 2004, 10 cases of human hantavirus infection have been detected. No deaths have been reported. Fernando Gracia, Minister of Health, told the media that the latest case was detected in the area of Sona, in the central province of Veraguas, approximately 248 miles west of the capital city. The patient is a 40-year-old male. Gracia reported that cases have been registered in different areas of the country and explained that, while there is no epidemic or outbreak of hantavirus in Panama, the disease has arrived in the country and will stay. The minister also urged the population to implement several measures to stop the propagation of the virus, such as avoiding deforestation, burning of trees, and inadequate disposal of garbage, and preserving gardens around houses. According to official data, as of December 2003, 39 cases of hantavirus infection had been confirmed, nine of them fatal, since the first case was reported in Panama in 1999.
(Promed 4/15/04)

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2. UPDATES

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Diarrhea and dysentery update:

Indonesia (Madura)
Following a dengue outbreak, a dysentery outbreak has hit Bangkalan district in Madura island. At least 17 people were treated at Bangkalan General Hospital 12 Apr 2004. The 17 people, 13 of them children, were suffering from dehydration and their condition was very weak. Director of Bangkalan General Hospital, Dr. Heru Ariyadi, confirmed that some areas in Bangkalan were affected, but it was too early to declare an emergency in the area. He explained that the increase in the cases of dysentery was largely attributed to the change in seasons, from wet to dry. The weather reduced the amount and quality of fresh water. He urged local residents to only drink boiled water and if they had diarrhea to immediately consume rehydration salts or drink warm lime juice, with a little salt added.

India (Gorakhpur)
At least five children have died in the last two days in Gorakhpur as hospitals reported an alarming rise in dysentery cases. Dozens more are seriously ill and hospitals are overflowing with more children being brought in everyday. The disease has taken on serious proportions as a severe heat wave has led to water shortage, forcing villagers to draw water from untreated sources. "The epidemic started three to four days back and we expect more patients. If primary aid is given to them then they can be saved. Five children have expired. Daily, 10 – 15 children are being admitted in the Out Patients Department," Dr. R.K Gupta, at the city's main medical college, said.

Bangladesh (Jhenidah)
Two persons died of diarrhea in Sailkupa upazila in Jhenidah district in the last two days. At least 5,000 people have been affected by the disease, Civil Surgeon Dr Nazrul Islam said. The dead were aged 4 and 85 years, and both died 12 Apr 2004. The disease has spread to 34 villages in five unions in the Upazila. The civil surgeon said the situation is under control now after nine medical teams started working in the area. Three camps have been opened. About 100 patients have been admitted to upazila health complexes at Sailkupa and Sripur (Magura). Abdul Bari, chairman of Dhalaharchandra Union Parishad in the affected area, said the disease is spreading and more people are being attacked. He said besides medicine, food should be supplied, as many people are starving because their bread-earning male members have been infected.
(Promed 4/19/04)

Viral gastroenteritis update:

Australia (New South Wales)
An outbreak of gastroenteritis has struck Woy Woy and Gosford Hospitals with 28 patients and nine staff members falling ill since 11 Apr 2004. While the cause of the outbreak is yet to be determined, the illness has been contained to two wards in Gosford Hospital and to the general ward at Woy Woy Hospital. A spokeswoman for Central Coast Health said access to the affected wards has been restricted to prevent further spread. Staff and visitors to the affected wards at Gosford and Woy Woy Hospitals are wearing additional protective clothing including gloves and masks to guard against infection. The most common symptoms of gastroenteritis include nausea, vomiting, abdominal cramps, diarrhoea, lack of appetite and fever.

USA (Pennsylvania)
The Allegheny County Health Department reported that a third round of laboratory tests indicate that norovirus infection was, after all, the cause of the outbreak of intestinal illness that affected the Cornell School District during March 2004. The latest tests, performed by the Pennsylvania Department of Health using more sensitive test kits supplied by CDC, detected norovirus in five of 11 stool samples taken from ill persons. Norovirus is highly contagious, and can spread easily from person to person as a result of direct contact or through contaminated surfaces and objects in the environment. Health officials suspect that the 200 cases reported in the outbreak were transmitted from person to person. The reported cases include 130 students, 16 staff and 54 others who are related to the affected students and staff, an indication the illness also spread within families and households. No new cases have been reported since the school re-opened early in April 2004. The symptoms of norovirus illness typically last one or two days and include nausea, vomiting, diarrhea and stomach cramping. People are contagious for about two days after recovery, so good hand-washing habits are extremely important after recovering.
(Promed 4/21/04)

Dengue/DHF update:

Venezuela
During the first 13 weeks of 2004, 11639 cases of dengue fever were reported in Venezuela, with a peak of 1,211 cases during epidemiological week 3 (18-25 Jan 2004). 677 cases were reported during epidemiological week 12, and 579 cases during epidemiological week 13. During the first 13 weeks of 2004, there were 738 cases of dengue hemorrhagic fever, with three deaths.

El Salvador
This report is for the first 14 epidemiologic weeks — the period 4 Jan through 10 Apr 2004.

As stated on the El Salvador Ministry of Health Dengue Report, the dengue incidence rate is increasing, compared to the last two years. For the first 14 weeks of 2004, with 655 cases reported (including 23 DHF), incidence is 9.9 per 100 000 population; the rates for epidemiological weeks 1-14 in 2002 and 2003 were 8.0 and 5.5 per 100 000 population, respectively. There has been one death reported in 2004 (compared with four during 2003 and two in 2002). The reported rates of DHF per 100 000 population for comparable time periods are: 0.7 (2002), 0.4 (2003), and 0.3 (2004). So far in 2004, 632 persons have been affected by classic dengue fever, double the number reported on the same date in 2003. 23 percent of the patients to whom diagnostic tests are performed have positive results for classic dengue and dengue hemorrhagic fever.

Indonesia
A widespread dengue fever outbreak has killed 634 people in Indonesia so far this year 2004 and is still far from over, the health ministry said. It said the number of infections, at 54176, was greater than for the whole of last year, when Indonesia recorded almost 53000 infections and 792 deaths. "The dengue fever outbreak is still far from over," said Rita Kusriastuti, coordinator of an anti-dengue team. "The rainy season is not yet over and is only expected to end sometime in May." However, Kusriastuti said the outbreak of the mosquito-borne disease, which has hit most parts of the world's largest archipelago, had peaked and the number of new infections was declining. She said the figure for deaths was 1.2 percent of those infected, lower than 2003's 1.5 percent. Kusriastuti said the government was trying to bring the fatality rate below one percent, but it could not reduce the rate of infection — 25 for every 100 000 people — without the help of the community in keeping surroundings free from stagnant water, in which mosquitoes breed.
( Promed 4/18/04)

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4. ARTICLES

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Evidence of Airborne Transmission of the Severe Acute Respiratory Syndrome Virus

Ignatius T.S. Yu, M.B., B.S., M.P.H., Yuguo Li, Ph.D., Tze Wai Wong, M.B., B.S., Wilson Tam, M.Phil., Andy T. Chan, Ph.D., Joseph H.W. Lee, Ph.D., Dennis Y.C. Leung, Ph.D., and Tommy Ho, B.Sc.

“Background There is uncertainty about the mode of transmission of the severe acute respiratory syndrome (SARS) virus. We analyzed the temporal and spatial distributions of cases in a large community outbreak of SARS in Hong Kong and examined the correlation of these data with the three-dimensional spread of a virus-laden aerosol plume that was modeled using studies of airflow dynamics. Methods We determined the distribution of the initial 187 cases of SARS in the Amoy Gardens housing complex in 2003 according to the date of onset and location of residence. We then studied the association between the location (building, floor, and direction the apartment unit faced) and the probability of infection using logistic regression. The spread of the airborne, virus-laden aerosols generated by the index patient was modeled with the use of airflow-dynamics studies, including studies performed with the use of computational fluid-dynamics and multizone modeling. Results The curves of the epidemic suggested a common source of the outbreak. All but 5 patients lived in seven buildings (A to G), and the index patient and more than half the other patients with SARS (99 patients) lived in building E. Residents of the floors at the middle and upper levels in building E were at a significantly higher risk than residents on lower floors; this finding is consistent with a rising plume of contaminated warm air in the air shaft generated from a middle-level apartment unit. The risks for the different units matched the virus concentrations predicted with the use of multizone modeling. The distribution of risk in buildings B, C, and D corresponded well with the three-dimensional spread of virus-laden aerosols predicted with the use of computational fluid-dynamics modeling. Conclusions Airborne spread of the virus appears to explain this large community outbreak of SARS, and future efforts at prevention and control must take into consideration the potential for airborne spread of this virus”
http://content.nejm.org/cgi/content/abstract/350/17/1731
(The New England Journal of Medicine)

Nosocomial Transmission of Mycobacterium tuberculosis Found Through Screening for Severe Acute Respiratory Syndrome — Taipei, Taiwan, 2003
“The emergence of severe acute respiratory syndrome (SARS) has highlighted the importance of hospital infection-control programs. Prevention of Mycobacterium tuberculosis transmission also requires effective infection control in health-care facilities. In Taipei, Taiwan, an area with moderate to high incidence of tuberculosis (TB) (50--74 cases per 100,000 population), health-care workers (HCWs) are at increased risk for M. tuberculosis (Taiwan Center for Disease Control, unpublished data, 2002). In April 2003, SARS-related screening in a hospital in Taipei resulted in the detection of suspected TB among HCWs. This report summarizes how SARS screening led to the discovery of 60 cases of TB. HCWs in Taiwan should remain vigilant for cases of TB so persons suspected of having TB are evaluated and treated promptly.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5315a5.htm
(MMWR April 23, 2004 / 53(15);321-322)

Brief Report: Vancomycin-Resistant Staphylococcus aureus — New York, 2004
“Staphylococcus aureus is a common cause of hospital- and community-acquired infections. The development of vancomycin-resistant enterococci in 1988 led the way to the emergence of vancomycin-resistant S. aureus (VRSA) (minimum inhibitory concentration [MIC] >32 µg/mL), first recognized in 2002. This report describes the third documented clinical isolate of VRSA from a patient in the United States and provides evidence of failure to detect this VRSA by commonly used automated antimicrobial susceptibility testing... The patient remains in a long-term — care facility, and NYSDOH is investigating the case. The goals of the investigation include assessment of infection-control practices and whether transmission to other patients, health-care providers, family, and other contacts has occurred. Previous investigations of VRSA demonstrated no transmission among contacts.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5315a6.htm
(MMWR April 23, 2004 / 53(15);322-323)

Update: Multistate Investigation of Measles Among Adoptees from China — April 16, 2004
“CDC recently published information about six confirmed and three suspected cases of measles among children who were adopted in China. Preliminary investigation into the source of measles exposure among the recent U.S. adoptees has traced the presumed source of the outbreak to an orphanage in China where an outbreak of measles has been reported. While control measures are being implemented, CDC recommends that adoption proceedings of children from the affected orphanage be suspended temporarily. The children departed for the United States with their families on March 26. Four of these children probably were infectious while traveling from China to the United States. The Chinese Ministry of Health and the Central China Adoption Agency are aware of the problem and are investigating further. CDC is collaborating with these agencies and other partners in China to initiate measures to control and prevent further spread of measles among adopted children. The public health response to this outbreak is similar to the activities conducted after an outbreak of measles among adoptees from China in 2001. Prospective parents who are traveling internationally to adopt children and their household contacts should ensure that they have a history of natural disease or have been vaccinated according to guidelines of the Advisory Committee on Immunization Practices. Prospective parents of international adoptees from China should stay informed as more information becomes available about the measles outbreak. Additional information about this outbreak and information for prospective parents adopting children internationally is available from CDC at http://www.cdc.gov/travel/other/adoption.htm.”

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5315a7.htm
(MMWR April 23, 2004 / 53(15);323-324)

Progress Toward Measles Elimination — Region of the Americas, 2002–2003
“In 1994, countries in the Region of the Americas adopted the goal of eliminating endemic measles transmission in the Western hemisphere by 2000. Since 1994, rapid progress has been made. The number of measles cases has declined >99%, from approximately 250,000 in 1990 to 105 confirmed cases † reported in six countries in 2003. During 2003, only Mexico and the United States reported outbreaks. The three chains of transmission in Mexico and two U.S. outbreaks were import-related; a third U.S. outbreak was of unknown source. Since November 2002, no transmission of the D6 and D9 genotypes has been reported; these genotypes were responsible for several large outbreaks in the region during 1997–2002. This report summarizes the epidemiology of measles in the Americas during 2002–2003 and highlights progress toward measles elimination, including the lowest ever number of reported measles cases in the region. Because the region is under constant threat of measles importation from regions where the disease is endemic, countries must maintain high population immunity to measles and sensitive surveillance to ensure the timely detection of imported cases and allow for rapid implementation of control measures.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5314a2.htm
(MMWR April 16, 2004 / 53(14);304-306)

Measles Outbreak in a Boarding School — Pennsylvania, 2003
“Measles has not been endemic in the United States since 1997, although limited outbreaks continue to be caused by imported cases. In 2003, CDC assisted in investigating the largest school outbreak of measles in the United States since 1998. The outbreak consisted of 11 laboratory-confirmed cases: nine cases in a boarding school in eastern Pennsylvania and two epidemiologically linked cases in New York City (NYC). This report summarizes the results of the outbreak investigation, which indicated that measles continues to be imported into the United States and that high coverage with 2 doses of measles-containing vaccine (MCV) among students was effective in limiting the size of the outbreak. Health-care providers should maintain a high index of suspicion for measles, especially in those who have traveled abroad recently, and recommendations for 2 doses of MCV in all school-aged children should be followed.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5314a3.htm
(MMWR April 16, 2004 / 53(14);306-309)

Vaccination Week of the Americas, April 24–30, 2004
“During April 24--30, all 42 countries in the Region of the Americas will participate in Vaccination Week of the Americas (VWA). The objective is to vaccinate susceptible populations by improving access among underserved populations, keeping vaccination programs on the political agendas of countries in the Western Hemisphere, and promoting cooperation among countries in the region. By ensuring the vaccination of susceptible persons, health authorities will maintain measles-elimination programs in the region and support implementation of rubella and congenital rubella syndrome–elimination plans.

During VWA, surveillance gaps will be identified through active searches for unreported cases of measles, rubella, and acute flaccid paralysis. The target group to be vaccinated during this week is children aged <5 years who have incomplete vaccination series and adults, including women of childbearing age (WCBA), with no previous contact with the vaccination program. The total population to be vaccinated is estimated at 40 million persons. Countries with vaccination activities scheduled for 2004 will conduct these activities during VWA. Other countries of the region will intensify vaccination efforts among children aged <5 years and WCBA. Additional information is available from the Pan American Health Organization at http://www.paho.org/english/dd/pin/sv_2004.htm.”

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5314a6.htm
(MMWR April 16, 2004 / 53(14);310)

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4. NOTIFICATIONS

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APEC Health Task Force (HTF) Meeting

The APEC Health Task Force (HTF) will be meeting April 26 – 27, 2004, at the Grand Formosa Regent in Taipei. The objectives are:

• To enhance APEC cooperation and integration of health-related efforts across relevant APEC sectors and fora
• To implement explicit priorities of Leaders and Ministers
• To take a primarily strategic (rather than opportunistic) and efficient approach to determining priorities for cooperation, taking into account capacity and volunteers readily available among APEC members
• To complement and not duplicate the work of the World Health Organization (WHO) and other relevant international and/or regional organizations
  (APEC HTF)

Updated information on the SARS situation in China can be viewed at:

(WHO): http://www.who.int/csr/sars/en/index.html

(United States CDC): http://www.cdc.gov/ncidod/sars/situation.htm

National Infant Immunization Week
Vaccination, an Act of Love: Love them, Protect Them, Immunize Them

April 25 – May 1, 2004
This annual observance emphasizes immunizing infants against 12 vaccine preventable diseases by the age of two. Over 500 communities across the country are expected to participate by planning community awareness and media events to promote infant immunizations to parents, caregivers, providers, and their communities. This year during NIIW, the US will join the Pan American Health Organization and the U.S.-Mexico Border Health Commission in support of Vaccination Week in the Americas to promote immunization in all countries of the Americas.
http://www.cdc.gov/nip/events/niiw/
(CDC)

Fifty-seventh World Health Assembly
17-22 May 2004
HIV/AIDS, avian influenza and human health, and the Global Strategy on Diet, Physical Activity and Health are just some of the highlights of this year's World Health Assembly agenda. For more information, please visit the website at: http://www.who.int/gb/
(WHO)

GIDEON: Infectious Disease and Epidemiology database
GIDEON, the Infectious Disease and Epidemiology database, is being offered on a 30 day trial basis. 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. If you have any questions, please contact Adrienne Rutledge at: Tel: 1-888-644-3366 or 1-510-430-9594 or email: rutledge@GIDEONonline.com.

13th International Symposium on HIV & Emerging Infectious Diseases (ISHEID)
Due to an unprecedented high number of submitted abstracts to the forthcoming "13th International Symposium on HIV & Emerging Infectious Diseases" (ISHEID) to be held in France (3-5 Jun 2004), ISHEID has implemented a new online abstract submission system in order to facilitate submission and extended the deadline to 30 Apr 2004. Please visit the website at: http://www.isheid.com
(Promed 4/14/04)

Diagnosis and Management of Foodborne Illnesses — A Primer for Physicians and Other Health Care Professionals
“Foodborne illness is a serious public health problem. CDC estimates that each year 76 million people get sick, more than 300,000 are hospitalized, and 5,000 die as a result of foodborne illnesses. Primarily the very young, the elderly, and the immunocompromised are affected. Recent changes in human demographics and food preferences, changes in food production and distribution systems, microbial adaptation, and lack of support for public health resources and infrastructure have led to the emergence of novel as well as traditional foodborne diseases. With increasing travel and trade opportunities, it is not surprising that now there is a greater risk of contracting and spreading a foodborne illness locally, regionally, and even globally.

This primer is intended to provide practical and concise information on the diagnosis, treatment, and reporting of foodborne illnesses. It was developed collaboratively by the American Medical Association, the American Nurses Association-American Nurse Foundation, CDC, the Food and Drug Administration's Center for Food Safety and Nutrition, and the United States Department of Agriculture's Food Safety and Inspection Service. Clinicians are encouraged to review the primer and participate in the attached continuing medical education (CME) program. This primer is directed to primary care and emergency physicians, who are likely to see the index case of a potential food-related disease outbreak. It is also a teaching tool to update physicians and other health care professionals about foodborne illness and remind them of their important role in recognizing suspicious symptoms, disease clusters, and etiologic agents, and reporting cases of foodborne illness to public health authorities. This document provides detailed summary tables and charts, references, and resources for health care professionals. Patient scenarios and clinical vignettes are included for self-evaluation and to reinforce information presented in this primer.” http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5304a1.htm
(MMWR April 16, 2004 / 53(RR04);1-33)

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