1. INFECTIOUS DISEASE INFORMATION

SARS
During April 22-29, 2004, the Chinese Ministry of Health (MOH) reported a total of nine cases (one fatal) of SARS in China; seven of the patients were from Beijing, and two were from Anhui Province, located in east-central China. Two of the nine patients were graduate students who worked at National Institute of Virology Laboratory (NIVL) in Beijing, which is known to conduct research on SARS-CoV. The NIVL was closed on April 23 and remains closed to date. Possible sources of infection for the two laboratory workers, neither of whom is known to have worked directly with SARS-CoV, are being investigated. Of the seven other SARS cases, two were directly linked to close contact with one of the graduate students who worked at NIVL; these two cases were in the graduate student's mother (who died) and in a nurse who provided care to the graduate student. The remaining five cases were linked to close contact
with the nurse.

No further cases of SARS in China or anywhere else in the world have been reported since April 29, 2004. On May 18, the WHO reported on its website that the outbreak in China appears to have been contained, but that
laboratory biosafety concerns remain and further investigation is under way. CDC is in close communication with WHO and is working with its other public health partners to reinforce the need for strict adherence to
applicable biosafety precautions to reduce the risk of laboratory-related exposures to SARS-CoV.

For more information about current U.S. SARS control guidelines, see the CDC document, "In the Absence of SARS-CoV Transmission Worldwide: Guidance for Surveillance, Clinical and Laboratory Evaluation, and Reporting" at
http://www.cdc.gov/ncidod/sars/absenceofsars.htm. Additional information about SARS preparedness is available in CDC's document, Public Health Guidance for Community-Level Preparedness and Response to
Severe Acute Respiratory Syndrome (SARS) http://www.cdc.gov/ncidod/sars/sarsprepplan.htm; general information about SARS is available at http://www.cdc.gov/ncidod/sars/.

Avian Influenza A (H5N1)
Since January 2004, a total of 34 confirmed human cases of avian influenza A (H5N1) virus infections have been reported in Vietnam (22 cases, 15 deaths) and Thailand (12 cases, 8 deaths). The last case officially reported by Vietnam occurred in February 2004. One additional case was described in several media reports in mid-March in southern Vietnam http://www.who.int/csr/don/2004_03_22a/en/. All persons with confirmed
H5N1 influenza had severe illness and were hospitalized with pneumonia; most cases occurred in children and young adults who had direct close contact with live, sick, or dead poultry. There currently is no evidence of efficient human-to-human transmission of avian influenza A (H5N1) viruses. These cases were associated with widespread H5N1 poultry
outbreaks that occurred at commercial and small backyard poultry farms. Since December 2003, eight countries have reported H5N1 outbreaks among poultry. Outbreaks in South Korea and Japan were limited to commercial
farms and have been adequately contained; however, outbreaks in Vietnam, Thailand, Indonesia, Cambodia, Laos, and China have been more extensive and the degree to which they have been controlled remains uncertain. On the basis of current information, human infection with avian influenza A (H5N1) viruses remains a public health risk in these countries.

Infection control precautions for H5N1 remain unchanged from the CDC interim recommendations published on February 3, 2004 http://www.cdc.gov/flu/han020302.htm. These recommendations are further
described in the CDC guidance document, "Interim Recommendations for Infection Control in Health-Care Facilities Caring for Patients with Known or Suspected Avian Influenza" http://www.cdc.gov/flu/avian/professional/infect-control.htm.

For information about reported outbreaks of avian influenza A (H5N1) among poultry, see the web site of the World Organization of Animal Health (OIE) at http://www.oie.int/eng/AVIAN_INFLUENZA/home.htm. For information about
human H5N1 cases, see the WHO web site http://www.who.int/en/. For clinical information about human H5N1 cases, see: CDC. Cases of influenza A (H5N1) - Thailand, 2004. MMWR 2004;53:100-103. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5305a2.htm and Hien TT, Liem AT, Dung NT, et al. Avian influenza A (H5N1) in 10 patients in Vietnam. New England Journal of Medicine. 2004;350:1179-1188. For general
information about influenza, see the CDC Web site at www.cdc.gov/flu.
(CDC Health Update 6/10/04)

China: Testing SARS Vaccine
Chinese scientists have begun testing a SARS vaccine on four volunteers at a Beijing hospital, state media said, in what appears to be the first such experiment on humans. The volunteers, all in their 20s, were injected with
the vaccine on Saturday at the Sino-Japanese Friendship Hospital under tight security, reported the Beijing Youth Daily and the Guangzhou Daily, two of China's largest newspapers. Roy Wadia, a Beijing-based spokesman
for the WHO, said he believed China is the first to get to the human testing stage. "China is on the fast track," Wadia said. "But we aren't concerned about who is first or second or third. We're concerned about the
safety process."
(Global Health Action Network Newsletter 6/2/04)

China (Liaoning): Salmonella found in food eaten by mass poisoning victims
Laboratory sample tests have found that salmonella was present in the food that poisoned 89 people a few days ago in northeast China's Liaoning province. The cause of the mass poisoning will be confirmed by further
tests on the blood of the victims, who showed symptoms after eating in a restaurant in Benxi county 24-25 May 2004. All the victims were hospitalized with sickness, diarrhea, fever and even shock. To date, nine
victims have been discharged from hospital, and the remaining inpatients are in stable condition. The restaurant has been ordered to suspend business by the local health department.
(Promed 5/29/04)

Hong Kong: Third Toddler Contracts Enterovirus 71 Infection
A third Hong Kong toddler has been confirmed with the potentially deadly enterovirus 71 in a recent outbreak at a local nursery, the Health Department stated 27 May 2004. Enterovirus 71 killed 50 children in Taiwan
in 1998, and 30 in Malaysia 1997. It is one of several viruses that causes hand, foot and mouth disease (HFMD). The latest Hong Kong enterovirus 71 case is a 2-year-old girl. She attends the same nursery as two other
toddlers who came down with the virus and went on to develop HFMD; those two children have since recovered. The press release can be viewed at <http://www.info.gov.hk/dh/new/index.htm>.

A Health Department spokesman stated that: "Enteroviruses including enterovirus 71 (EV-71) can cause a variety of illnesses primarily among young children, such as hand, foot and mouth disease (HFMD). HFMD tends to
be more common in summer months. So far this year, there were six reported cases of EV-71 affecting children below the age of five. They have all recovered and did not develop any complications." The spokesman stated that a seminar was held to promote vigilance against enteroviral infection in childcare centers, where this disease commonly occurs. Staff who attended the event were briefed on the symptoms and characteristics of the
disease, and how to take effective preventive measures in their institutions. These include: washing hands before eating and after going to toilet and changing diapers; covering mouth and nose when coughing and sneezing; maintaining good ventilation; and cleaning thoroughly toys or appliances which are contaminated by nasal or oral secretions.
(Promed 5/28/04)

Indonesia (Bandung and Jakarta): Hand, Foot & Mouth Disease Cases Reported
As of 27 May 2004, the Indonesia Ministry of Health has recorded two cases of hand, foot and mouth disease (HFMD) this year. One HFMD case was reported from Bandung, West Java province, and the other from Jakarta. So
far, there have been no deaths. HFMD is a common illness of infants and children, characterized by fever, sores in the mouth, and a rash with blisters. HFMD begins with a mild fever, poor appetite, malaise, and
frequently a sore throat. One or two days after the fever begins, painful sores develop in the mouth. The skin rash develops over one-two days with flat or raised red spots, some with blisters. HFMD usually is not serious.
Nearly all patients recover without medical treatment in 7 to 10 days. Complications are uncommon. Rarely, the patient with coxsackievirus A16 infection may also develop "aseptic" or viral meningitis, in which the
person has fever, headache, stiff neck, or back pain, and may need to be hospitalized for a few days. Another cause of HFMD, enterovirus 71 (EV71) may also cause viral meningitis and, rarely, more serious diseases, such
as encephalitis, or a poliomyelitis-like paralysis. EV71 encephalitis may be fatal. Cases of fatal encephalitis occurred during outbreaks of HFMD in Malaysia in 1997 and in Taiwan in 1998.

HFMD is moderately contagious. Infection is spread from person to person by direct contact with nose and throat discharges, saliva, fluid from blisters, or stool. A person is most contagious during the first week of
the illness. HFMD is not transmitted to or from other animals. These sporadic cases of HFMD, though insignificant in number, may be the forerunners of a more serious epidemic, particularly if Enterovirus 71 proves to be the etiologic agent. Epidemics of HFMD in recent years have tended to be more serious in East Asia than elsewhere in the world.
(Promed 5/28/04)

Russia (Stavropol): About 80 Suspected Cases of Crimean-Congo Hemorrhagic
Fever
About 80 residents of the Stavropol Region have been hospitalized with suspected Crimean-Congo hemorrhagic fever (CCHF). The diagnosis has been confirmed in nine cases. So far, about 2000 residents of Stavropol have
been referred to hospital for treatment of tick bites. During the past six years, 170 people had contracted hemorrhagic fever, 12 of whom had died. At the present time, (CCHF) virus is present in 11 small towns and three
large cities in the region. At a Sanitary Epidemiologic Center meeting, participants at the meeting considered that an allocation of 24 million rubles (US$827 000) has not been sufficient to achieve prevention and treatment of this dangerous disease. The prognosis for the current season was not favorable. CCHF has been a continuing
problem in the Stavropol region of Russia that does not appear to have been diminished by previous attempts at containment by control of the tick vector.
(Promed 6/10/04)

Russia (Udmurtia and Krasnoyarsk): Tick-borne encephalitis
At least 240 people have contracted tick-borne encephalitis as a result of tick bites in Udmurtia since the beginning of the tick season. According to the State Sanitary Epidemiological Surveillance Centre, 2600 people including 758 children have suffered tick bites. Health officials are warning people to take care in forested areas. Udmurtia is an ideal environment for ticks due to its favorable climate; the incidence of tick-borne encephalitis is on average six times higher than in the rest of Russia.

In the Krasnoyarsk region, the last 10 days of May have seen a peak in tick activity. It has been reported that an average of 60 ticks/km have been recorded along trails in the "Stolbi" nature reserve in the Krasnoyarsk region. The number of people seeking medical attention for tick bites has risen to 2411. 43 people have been hospitalized with a preliminary diagnosis of tick-borne encephalitis virus infection. So far 26 people registered in the Krasnoyasrk region have a confirmed diagnosis of tick-borne encephalitis virus infection.
(Promed 5/28/04, 5/31/04)

Russia (Bashkiriya): Epidemic of Hemorrhagic Fever Threatens City of Ufa
A hemorrhagic fever outbreak is thought to be imminent in the capital of Bashkiriya. Medical specialists in Ufa made this prediction, since there are already 44 cases of infection with this dangerous virus not
identified, a number four times greater than in 2003. The inhabitants of Bashkiriya have a greater risk of contracting hemorrhagic fever than those in other regions of Russia. Field voles are particularly abundant in the
lime tree forests of Bashkiriya. The climate this year is also favorable for these rodents: warm winter, dry spring and autumn with little flooding are ideal conditions for multiplication of these rodents. Health professionals are warning people be especially careful in the countryside: store food products in places inaccessible for rodents, do not lie in
grass, and wash your hands often.

Bashkortostan (earlier Bashkiriya), its capital Ufa, and the surrounding area is well-known for the prevalence of hemorrhagic fever with renal syndrome (HFRS) caused by the hantavirus _Puumala virus_. This is the same large focus which extends from Samara, on the river Volga, and surrounding areas east to Bashkortostan and south to
Uralsk on the Kazakhstan side. The carrier of _Puumala virus_ is the bank vole _Clethrionomys glareolus_. Usually, the HFRS caused by _Puumala virus_ peaks in autumn to early winter due to the seasonal dynamics of
bank voles.
(Promed 6/1/04, 6/2/04)

Russia (Kamchatka): Rubella outbreak
The number of people who have contracted rubella has risen to 73 in the village of Sobolevo in the Kamchatskiy region. 68 of them are children. Another two cases of rubella have been reported in a neighboring village.
The source of infection is reported to be a child from Vladivostok attending a summer camp. According to the chief of the Sanitary Epidemiological center, the situation began to stabilize when 130 dozes of vaccine were delivered several days ago. The late delivery of this vaccine is partially responsible for the rise in the number of cases. Currently,
the two villages have been placed under quarantine. This incident illustrates the need to maintain comprehensive vaccine coverage to achieve adequate protection, especially where composite vaccines, such as MMR, are
not in routine use.
(Promed 6/2/04)

USA: Government begins expanded mad cow testing
The United States Department of Agriculture (USDA) began expanded national testing for Bovine Spongiform Encephalopathy (BSE, or mad cow disease), intending to test about 220 000 animals for the disease over the next year
to 18 months. Officials said the department was able to handle the first day's samples even though most of the dozen regional laboratories are not yet ready to perform the initial tests. The government conducted tests on cattle tissues for BSE from 20 543 animals in 2003, virtually all of them that could not stand or walk. After the nation's first BSE case in December 2003, the department initially doubled the number of animals to be tested this year to 40 000. With many foreign governments still reluctant to ease bans on U.S. beef, the testing program was expanded at a
cost of $70 million to include as many as 220 000 slaughtered animals, following recommendations from an international scientific review panel. About 35 million head of cattle are slaughtered each year in the US.

The majority of tests will be on animals considered most likely have BSE—those showing any sign of brain disorder, unable to stand on their own or deemed unfit for human consumption for other reasons. Tissue samples from those animals would be tested, as would samples from animals that die on farms. The department's testing plans also include about 20 000 animals that appear healthy but are at least 30 months old. The 12 state-operated labs will perform the initial tests on brain and central nervous system tissue from slaughtered cattle for BSE. Results from those
tests will allegedly be returned in 24 to 72 hours. If that rapid-response test indicates the animal may have BSE, tissue samples will then be sent to the department's National Veterinary Services Laboratory (NVSL) for
confirmatory testing that could take four to eight days.
(Promed 6/3/04)

USA (Nebraska): Rocky Mountain spotted fever
Two cases of Rocky Mountain spotted fever have been identified in Jefferson County, the first cases this year. Both of the individuals are under 19 years of age. Rocky Mountain spotted fever (RMSF) is spread by
the bite of an infected tick. In Nebraska, the American dog tick is the most common carrier. The people most at risk are those who have exposure to tick-infested habitats, such as wooded and grassy areas. "With summer
here, people will be outdoors more, doing activities like camping, fishing, hunting, and picnicking," said Dr. Richard Raymond, the state's Chief Medical Officer. "That places them at risk of being bit by ticks.
Having two cases so early this year, when we usually only have three to six cases per year, is worrisome."

Symptoms usually appear within two weeks of the bite of an infected tick. They include the sudden onset of a moderate to high fever, severe headache, fatigue, deep muscle pain, chills and rash. Antimicrobials can
treat the disease. Despite its name, the disease is most common in the middle-Atlantic states of the USA. Cases occur in practically every USA state. "Wearing mosquito repellent containing DEET or insecticide
containing permethrin are vitally important, both because we are facing Rocky Mountain spotted fever and also West Nile virus," said Dr. Raymond. West Nile is passed by the bite of a mosquito. Mosquitoes can also carry
Western equine encephalitis and St. Louis encephalitis.
(Promed 6/1/04)

Mexico: Update on Measles (updated 3 Jun 2004)
As of 17 May 2004, the Mexican Secretariat of Health has reported 64 cases of measles this year, all linked to an imported strain with origins in Asia. The cases have occurred in five areas: the Federal District and the states of Mexico, Hidalgo, Campeche, and Coahuila. Mexico reported only 44 cases of measles in 2003, no cases in 1997 and 1999, and few cases during intervening years. Most of the persons affected have been older than 15 years of age. The Mexican government has launched a vaccination campaign and enhanced surveillance in response.

On 14 May 2004, the Mexican Secretariat of Health reported two cases of measles in Coahuila state across the border from Del Rio, Texas. In response to the two border cases, Texas Department of Health (TDH) issued
a notice asking Texas doctors and others to be alert for possible cases of measles along the state's border with Mexico. The TDH notice recommends that persons visiting Mexico follow the standard ACIP recommendations for
international travelers. Persons who travel or live abroad and who do not have acceptable evidence of immunity should be vaccinated with MMR (measles, mumps, and rubella vaccine). In general, people can be
considered immune to measles if they have documentation of physician-diagnosed measles, laboratory evidence of measles immunity, or proof of receipt of 2 doses of live measles vaccine on or after their
first birthday. Most people born before 1957 are likely to have had measles disease and generally are not considered susceptible.

However, measles or MMR vaccine may be given to this group of people if there is reason to believe they might be susceptible. Children who travel or live abroad should be vaccinated at an earlier age than recommended for
children remaining in the US. Although vaccination against measles, mumps, or rubella is not a requirement for entry into any country (including the US), U.S. residents traveling internationally to any destination or living
abroad should ensure that they are immune to all 3 diseases. Measles is still common in many countries, including developed countries in Europe and Asia. For more information, see
<http://www.cdc.gov/nip/menus/diseases.htm#measles>.
(Promed 6/5/04)

*Dengue/DHF*

Hong Kong
The Department of Health confirmed two more imported cases of dengue fever, which involved a 10-year-old boy and a 21-year-old woman. So far, 14 dengue fever cases have been reported in Hong Kong, all imported. The
boy had visited a Southeast Asian country. He developed fever, tiredness and a rash and was admitted to Kwong Wah Hospital in stable condition. The second patient also traveled to a Southeast Asian country and developed
headache, fever and muscle pain. She is now receiving treatment in Princess Margaret Hospital in stable condition. The department called on the public to stay alert to the threat of dengue fever. The latest information on dengue fever in other places can be found under "Outbreak News" on the department's Hong Kong Travellers' Health Service website
<http://www.info.gov.hk/trhealth/e_HKTHS.htm>.
(Promed 6/3/04)

Vietnam
Up to 10 270 people in Viet Nam's southern region were registered as suffering from dengue fever between January and early May 2004, a year-on-year rise of 48.6 percent since 2003. A local newspaper quoted sources from Ho Chi Minh City-based Pasteur Institute as saying that 16 people died of the disease during that period. Most of dengue fever
sufferers live in Ho Chi Minh City and the provinces of Tien Giang, Dong Thap, Kien Giang and Bac Lieu, whose weather is most favorable for the development of mosquitoes. The country detected 35 073 cases of dengue fever, including 58 fatalities, in2003. To curb the spread of the disease, centers have continually called for local people to use mosquito nets and keep the environment clean.
(Promed 6/3/04)

Indonesia (central Java)
Dengue fever is still spreading in Central Java province. The health office has recorded 7160 dengue fever cases and 130 deaths in Central Java Province so far in 2004. The disease morbidity is 2.5 per 10 000 and the
case fatality rate 1.82 percent. The health office recorded 2825 dengue cases in March 2004 with 33 deaths. Meanwhile, in April 2004 there are 841 cases with 18 deaths, at the end of April the cases began to decrease and
in mid-May the local health office registered 256 cases of dengue with six deaths (nationwide the epidemic is decreasing]. DHF is still increasing in Bengkulu province. At least 30 cases of DHF were treated in
the Yunus Hospital at Bengkulu city last week. During this period one patient died. From February to March 2004, DHF has affected 92 patients in that province; three of them died. From 1 Jan to 30 Apr 2004, a total of
58 301 cases of dengue fever and DHF and 658 deaths have been registered with the Indonesian Ministry of Health. The case-fatality rate of 1.1 percent is lower than in previous years. Outbreaks with significant numbers of DF and DHF cases have been reported from 293 cities and districts in 17 provinces in the country, although all 30 provinces have
been affected.
(Promed 5/29/04, 6/3/04)

*Viral gastroenteritis*

Australia (NSW)
The city of Dubbo is in the grip of a gastroenteritis epidemic, with almost 300 cases of highly-contagious "gastric flu" reported to health services in the last two weeks. The outbreak has impacted Dubbo Base Hospital, contributing to its busiest period in five years, while some aged-care facilities have banned visitors for fear of importing the virus. The highly contagious virus is believed to be the same strain of viral gastroenteritis that temporarily shut down Lithgow and Molong hospitals. The main symptoms of the virus are watery diarrhoea and vomiting; other symptoms may include nausea, fever, abdominal pain, headache and muscle aches.

Macquarie Area Health Service (MAHS) issued a public health warning. The MAHS Centre for Population Health has urged people who have had the illness to avoid work, child-care centres and aged care facilities to halt
its spread. People who fall ill with the virus should try to quarantine themselves for two days after recovering, according to MAHS director of population health Dr Tony Brown. He said the virus infection is very contagious from person-to-person and was not related to food consumption. "The message we want to reinforce is there is a lot of it in the
community, most people who get it will get better quickly without too much problem provided they keep their fluids up, but let's not spread it around," he said. "If someone in the family gets it we are advising people to take extra care with hygieneThe regional outbreak is believed to be part of a wider epidemic striking many areas of NSW," he explained. "The number of viral gastroenteritis cases usually increase in winter and are common within families and group settings including nursing homes, hospitals, residential care, child-care centres and schools." The characteristics of this outbreak of gastroenteritis suggest that the etiologic agent is a norovirus — sometimes termed as the "winter vomiting
bug".

Viral gastroenteritis is a common infection of the gut. The main symptoms of viral gastroenteritis are watery diarrhoea and vomiting; other symptoms may include nausea, fever, abdominal pain, headache and muscle aches.
Dehydration can follow. Symptoms can take between one and three days to develop and usually last between one and two days, sometimes longer. The illness is highly infectious and is spread by the vomit or feces from an
infected person by person-to-person contact, for example shaking hands with someone who has been sick and has the virus on their hands. It can also be transmitted through contaminated food, drink or surfaces.
Infection can occur possibly through the air when people vomit. In most cases, the spread occurs from a person who has symptoms, but asymptomatic people can still pass on the infection, particularly in the first 48 hours
after recovery. The infection can be prevented by washing your hands thoroughly with soap and running water for at least 15 seconds and dry them with a clean towel after using the toilet, changing diapers and
before eating or preparing food.
(Promed 5/31/04)

New Zealand (Wellington)
A virus running rampant in the community over recent weeks has now infected Newtown and Kenepuru hospitals. By 28 May 2004, norovirus infection had affected 40 people at these hospitals, giving them vomiting
and diarrhoea, infectious diseases physician Doctor Tim Blackmore stated. "For most people it will be a 24-hour bug, however, it can be quite debilitating for the very old, the very young and those with compromised immune systems," he says. Health board interim chief operating officer John Peters says these hospitals have stepped up measures to control the virus by isolating infected patients and sending home staff with any signs of infection.

Norovirus is a reasonably common illness, which typically affects places where large numbers of people are in close contact, such as schools, rest homes or cruise ships. It surfaces in the greater Wellington region most winters.
(Promed 5/31/04)

Australia (Tasmania)
The Royal Hobart Hospital (RHH) created a gastroenteritis isolation ward, after 14 patients have been admitted and staff sick leave has increased due the viral gastroenteritis outbreak, says RHH chief executive officer
Ted Rayment. "Because of the highly contagious nature of the disease, one ward of the hospital has been declared an isolation ward to handle the gastroenteritis admissions. Because we have isolated one full ward from
the normal operation of the hospital, we need to postpone some elective surgery cases from tomorrow," he said. The virus is suspected to be a strain of norovirus, a virus which caused major problems at the hospital in November 2003.
(Promed 5/31/04)

Canada
A mountain resort has been reopened after a scrubdown following an outbreak of norovirus infection. Emerald Lake Lodge in Yoho National Park, west of Banff National Park in the Canadian Rockies, was reopened on 7 Jun
2004 after workers completed a top-to-bottom disinfection effort under the supervision of public health officials. Health Canada tests of Emerald Lake's water supply have come back negative, a boil-water order has been
lifted and no new cases of the illness have been reported since 31 May 2004. Investigators determined a gastrointestinal illness that beset as many as 250 guests and employees during May 2004 was caused by norovirus
infection. Symptoms included severe diarrhea and vomiting lasting up to several days.
(Promed 5/31/04, 6/10/04)

Canada
The cruise ship Island Princess left Whittier 6 Jun 2004 after the vessel was scrubbed down following a norovirus outbreak that affected more than 400 passengers and crew members. The Princess Cruises ship is heading to Vancouver, British Columbia, with a new set of passengers. So far, there are no signs of another outbreak. On the previous voyage last week, 375 passengers and 49 crew members complained of norovirus-like symptoms. That
trip was cut early to give crews time to fully sanitize the ship before new passengers boarded. Altogether, 2018 passengers and 896 crew members made the voyage from Vancouver to Whittier. The first signs of illness
surfaced early in the trip. Princess officials said on-board testing confirmed the presence of norovirus infection. The virus can cause diarrhea, stomach pain and vomiting for 24 to 48 hours. It is spread through food, water and close contact with infected people or items they have touched. CDC is investigating the outbreak. CDC said that
investigators had just returned and still must review ship medical logs and other information to try to determine the source of the virus. The leading theory is that about 10 passengers were exposed to the virus when
they traveled through an area of the Canadian Rocky Mountains where a recent outbreak prompted Canadian officials to close a resort. These passengers were among the first to become ill on board.
(Promed 6/10/04)

*West Nile Virus*

South Dakota: First Human Case
Confirmation of South Dakota's first case of human West Nile virus infection in 2004 brought with it a reminder that people need to protect themselves from this disease. A Jackson County child under 10 years of age
was hospitalized briefly with the virus and has since recovered, Lon Kightlinger, state Health Department epidemiologist. It is the first confirmed case from 245 human samples tested. Tests on 13 birds and 122
mosquito pools also have been negative. The mosquito-borne disease killed 14 people in South Dakota during 2003 and sickened more than 1000 others. South Dakota joins New Mexico, Arizona and Wyoming with confirmed human
cases of West Nile virus infection in 2004. "It's about 6 weeks earlier than our first human case last year. And for northern-tier states, it's very early, too," he said. The Health Department did extra testing and
consulted with CDC to verify the results because it's so early, and there was some indication it may have been a carry-over from 2003. The early case suggests an infected mosquito survived winter and bit the youngster
around the second week of May. People over age 50 are at the greatest risk of developing severe complications from the virus, and those over age 70 are at the greatest risk of dying, Kightlinger said. Anyone who contracts the virus —even in its mildest forms—develops antibodies and is considered to have lifetime immunity.
(Promed 6/10/04)

"As of June 8, two states had reported a total of seven human cases of West Nile virus (WNV) illness to CDC through ArboNET. Six cases were reported from Arizona and one case from New Mexico. Four (57%) of the
cases occurred in males; the median age of patients was 53 years (range: 22–69 years), and the dates of onset of illness ranged from May 9 to June 1. In addition, during 2004, a total of 334 dead corvids and 55 other dead
birds with WNV infection have been reported from 16 states, and seven WNV infections in horses have been reported from three states (Alabama, Arizona, and Texas). WNV seroconversions have been reported in 64 sentinel
chicken flocks from four states (Arizona, California, Florida, and Louisiana), and 58 WNV-positive mosquito pools have been reported from six states (Arizona, California, Illinois, Indiana, Louisiana, and Pennsylvania). Additional information about national WNV activity is available from CDC at http://www.cdc.gov/ncidod/dvbid/westnile/index.htm
and at http://westnilemaps.usgs.gov."
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5322a7.htm
(MMWR June 11, 2004 / 53(22);484)

Outbreak of Salmonella Serotype Enteritidis Infections Associated with Raw
Almonds — United States and Canada, 2003–2004
"On May 12, 2004, the Oregon State Public Health Laboratory identified a cluster of five patients infected with Salmonella enterica serotype Enteritidis (SE) isolates that were matched by using two-enzyme pulsed-field gel electrophoresis (PFGE). The five patients were from four Oregon counties; their onsets of illness occurred during February–April 2004. A subsequent investigation, still ongoing, has identified a total of 29 patients in 12 states and Canada with matching SE isolates, since at least September 2003. Seven patients have been hospitalized; no one has died. Raw almonds distributed throughout the United States and internationally have been implicated as the source of the SE infections. As of May 21, approximately 13 million pounds of raw almonds had been recalled by the producer. . . Efforts to identify specific production lots associated with illness, based on almond purchase dates and locations and store inventory data, are ongoing. On May 18, Paramount announced a nationwide recall of all raw almonds sold under the Kirkland Signature,
Trader Joe's, and Sunkist labels. Costco mailed 1,107,552 letters to members known to have purchased the recalled product in the United States. The recall was expanded subsequently to include nuts sold in bulk to approximately 50 other commercial customers, some of whom repackaged almonds for sale under other brand names. In addition to sales in the
United States, almonds were exported to France, Italy, Japan, Korea, Malaysia, Mexico, Taiwan, the United Kingdom. The majority of the recalled almonds likely were consumed months ago; however, raw almonds have a shelf life of >1 year, and consumers might still have the implicated products.."
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5322a8.htm
(MMWR June 11, 2004 / 53(22);484-487)

National Laboratory Inventory for Global Poliovirus Containment —United
States, November 2003
"In anticipation of the interruption of wild poliovirus (WPV) transmission, the United States has joined 122 other poliomyelitis-free countries in taking steps to minimize the risk for reintroducing WPV from laboratories to communities. In October 2002, a nationwide survey of laboratories and biomedical institutions (e.g., universities) that oversee
multiple laboratories was conducted to identify those that might be holding WPV-containing materials and to establish a national inventory of institutions and laboratories retaining such materials (1). A total of
32,429 laboratories and biomedical institutions listed in multiple databases were mailed letters to alert laboratories of the impending global eradication of polio and encourage disposal of unneeded WPV-containing materials. The national inventory is a list of institutions and laboratories whose staff will be kept informed of eradication progress and appropriate WPV-containment procedures. This report summarizes use of the survey to create the national inventory." http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5321a4.htm
(MMWR June 4, 2004 / 53(21);457-459)

Medical Examiners, Coroners, and Biologic Terrorism: A Guidebook for Surveillance and Case Management
"Medical examiners and coroners (ME/Cs) are essential public health partners for terrorism preparedness and response. These medicolegal investigators support both public health and public safety functions and investigate deaths that are sudden, suspicious, violent, unattended, and unexplained. Medicolegal autopsies are essential for making organism-specific diagnoses in deaths caused by biologic terrorism. This report has been created to 1) help public health officials understand the role of ME/Cs in biologic terrorism surveillance and response efforts and 2) provide ME/Cs with the detailed information required to build capacity for biologic terrorism preparedness in a public health context. This report provides background information regarding biologic terrorism, possible biologic agents, and the consequent clinicopathologic diseases, autopsy procedures, and diagnostic tests as well as a description of biosafety risks and standards for autopsy precautions. ME/Cs' vital role in terrorism surveillance requires consistent standards for collecting, analyzing, and disseminating data. Familiarity with the operational,
jurisdictional, and evidentiary concerns involving biologic terrorism-related death investigation is critical to both ME/Cs and public health authorities. Managing terrorism-associated fatalities can be expensive and can overwhelm the existing capacity of ME/Cs. This report describes federal resources for funding and reimbursement for ME/C preparedness and response activities and the limited support capacity of the federal Disaster Mortuary Operational Response Team. Standards for communication are critical in responding to any emergency situation. This report, which is a joint collaboration between CDC and the National Association of Medical Examiners (NAME), describes the relationship between ME/Cs and public health departments, emergency management agencies, emergency operations centers, and the Incident Command System." http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5308a1.htm
(MMWR June 11, 2004 / 53(RR08);1-27)

Update: Measles Among Children Adopted from China
"As of May 24, 2004, investigators have identified 10 confirmed measles cases associated with adoptees who traveled to the United States from China during March 2004 (1,2). No cases have been reported since April 18, and all the ill persons have recovered without complications. CDC is now recommending that the temporary suspension of adoptions from the affected orphanage in China be ended and standard adoption procedures be resumed. The 10 cases included nine imported cases among adopted children aged 12–18 months who acquired their infections while still in China and then traveled to three states (Maryland, New York, and Washington) during March 26–27, and one importation-linked case in a female student aged 19 years from California. The student had close contact with an adoptee aged 18 months during a visit to Washington when the child was infectious with measles. The student had a nonmedical exemption and had not received measles-containing vaccine; upon her return to California, she was quarantined in her off-campus home. She had onset of rash 14–16 days
after contact with the adopted child, and measles was diagnosed. No other cases linked to this outbreak have been identified.
The cases in adoptees were associated with the Zhuzhou Child Welfare Institute in Hunan Province. On May 24, Chinese authorities reported that the last patient with measles at the orphanage had rash onset on April 23, and that the recommended vaccination campaign for all eligible children at the orphanage had been completed. Because no cases of measles were reported from the orphanage during the next 21 days (i.e., one incubation period), the outbreak appears to have been controlled. As a result, CDC is recommending that standard adoption procedures for children from the
orphanage be resumed."
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5321a5.htm
(MMWR June 4, 2004 / 53(21);459)

Emerging Infectious Diseases (EID): Two expedited articles related to SARS:
- SARS Control and Psychological Effects of Quarantine, Toronto, Canada,
L. Hawryluck et al.

- Collecting Data To Assess SARS Interventions, R.D. Scott II et al.
http://www.cdc.gov/ncidod/EID/index.htm
(CDC EID)

5. APEC ACTIVITIES

The APEC EINet team, in collaboration with several economies in the Asia Pacific, are preparing point-to-point discussions over the next few weeks. The aim of these discussions is to prepare an agenda for a broader plenary discussion of bio-preparedness practices and topical disease priorities. These virtual meetings will utilize existing video-conferencing facilities and will test the existing level of communications network technologies