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Vol. VII, No. 15 ~ EINet News Briefs ~ Jul 9, 2004

A free service of the APEC Emerging Infections Network

The EINet listserve was created to foster discussion, networking, and collaboration in the area of emerging infectious diseases (EID's) among academicians, scientists, and policy makers in the Asia-Pacific region. We strongly encourage you to share your perspectives and experiences, as your participation directly contributes to the richness of the "electronic discussions" that occur. To respond to the listserve, use the reply function.

In this edition:

1. Infectious disease information
- East Asia/Avian influenza: Current evaluation of risks to humans from H5N1

- China (east): New bird flu case confirmed
- Thailand: New outbreak of bird flu suspected
- Viet Nam: Bird flu downplayed but urges vigilance
- China: Beijing schoolchildren face compulsory AIDS education
- Cambodia: Protects 75% of children against parasites—first country to reach key target
- Philippines: Malaria affects 122 persons in South Cotabato
- Hong Kong: Second Japanese Encephalitis Case Confirmed
- Russia: 19 People in Ulyanovsk Region Bitten by Rabid Dog
- Russia: Tickborne encephalitis outbreak in Republic of Altai
- Russia: HFRS a continuing problem in Udmurtia
- Russia: More victims at graduation party held in the Amur region
- USA (Colorado): First Case of Hantavirus Pulmonary Syndrome of 2004
- USA (New York): Number of possible E. coli cases at Bronx day care center rises
- USA (Florida): Malaria resurfaces in Palm Beach County
- Peru: Current Situation of Jungle Yellow Fever (JYF)

2. Updates
- Cholera, Diarrhea, and Dysentery
- Dengue/DHF
- Viral gastroenteritis
- West Nile Virus

3. Articles
- Genesis of a highly pathogenic and potentially pandemic H5N1 influenza virus in eastern Asia
- Update:
Influenza Activity—United States and Worldwide, 2003–04 Season, and Composition of the 2004—05 Influenza Vaccine
- Trends in Primary and Secondary Syphilis and HIV Infections in Men Who Have Sex with Men—San Francisco and Los Angeles, California, 1998–2002
- Updated Recommendations for Use of Pneumococcal Conjugate Vaccine: Reinstatement of the Third Dose
- Investigation of Rabies Infections in Organ Donor and Transplant Recipients:Alabama, Arkansas, Oklahoma, and Texas, 2004
- Racial Disparities in Tuberculosis:Selected Southeastern States, 1991-2002
- Surveillance Data from Public Spa Inspections— United States, May–September 2002
- AIDS epidemic grows at record rate
- China: Recent SARS outbreak--important lessons for global public health

4. Notifications
- HIV Content Guidelines Announcement
- XV International AIDS Conference

5. APEC EINet Activities

6. How to join the EINet email list


Below is a semi-monthly summary of Asia-Pacific emerging infectious diseases.


East Asia: Avian influenza

- Current evaluation of risks to humans from H5N1
In the last two weeks, avian influenza appears to have re-emerged in poultry in East Asia. These outbreaks could either be new outbreaks of Highly Pathogenic Avian Influenza A(H5N1) virus or a continuation of the outbreaks reported earlier. These events, in addition to two new research reports, about the virus becoming increasingly pathogenic and becoming more widespread in birds in the region, fuel the WHO's concern about the threat the virus poses to human health.

WHO has been concerned about influenza A(H5N1) because of its threat to humans both in farm settings in Asia and its greater, potentially global risk. Several countries in Asia have witnessed this virus crossing the species barrier, moving from infected chickens or ducks directly into humans in three documented outbreaks since 1997. These direct human infections have produced severe and sometimes fatal outcomes. Moreover, the virus has the potential to acquire the ability to spread easily from human to human, and thus, trigger a global influenza pandemic. Now, two research reports have added to our understanding of this virus. First, members of China's Ministry of Agriculture and colleagues reported in a paper published last week in the Proceedings of the National Academy of Sciences that the virus appears to be widespread in domestic ducks in southern China. Further, the scientists found that the virus is causing increasingly severe disease. However, these trials were done in mice.

This week, the journal Nature published a report which indicates domestic and wild birds in the region may have contributed to the increasing spread of the virus and suggests that the virus is gaining a stronger foothold in the region. These observations suggest that control of the virus may be even more difficult than thought in the spring. Effective risk management tools exist to control outbreaks of influenza A(H5N1) when they are detected in poultry operations. China, for example, was quick to employ these tools last week when an outbreak was discovered in Anhui province. These risk management measures include the culling of infected and exposed birds, stringent biosecurity measures and vaccination. While this approach can still take months or even years to contain the virus completely, these methods have been effective in the past.

However, tools to assess the risk to human health are less well developed. While recent reports indicate the virus has been present consistently in the environment for the last several years, it has still not acquired the ability to infect humans easily for unknown reasons. WHO urges and offers assistance that risk assessment activities, including surveillance in animals and humans, and strain analysis, be undertaken as soon as possible. More knowledge of the virus could be acquired if WHO had full access to all virus isolates and clinical specimens from recent outbreaks. All H5N1 viruses are not the same, and how they differ could provide important insights. For example, the Indonesian avian influenza virus, while belonging to the genotype of viruses seen in Viet Nam and Thailand, is also distinct. With this information, public health planners would know that they are confronting the same virus in all of the recent outbreaks in Asia.

Pandemic preparedness activities started by WHO in the wake of the outbreaks reported earlier this year continue. Less than two weeks ago, WHO hosted a meeting in Kuala Lumpur with experts from 13 countries and areas of the Asia-Pacific region. Among other activities, the meeting participants were provided with a WHO preparedness self-assessment tool. WHO is collaborating with scientists and the pharmaceutical community on a global surveillance system to monitor changes in the virus's susceptibility to known antivirals. Finally, pandemic vaccine development continues. Two vaccine manufacturers, both based in the US, have produced a supply of trial vaccine which will be tested for safety and efficacy in humans. In summary, recent developments suggest that:

(WHO 7/8/04)

China (east): New bird flu case confirmed

The national bird flu reference laboratory confirmed, 6 Jul 2004, that the latest death of chickens in east China's Anhui province was caused by H5N1 strain of bird flu virus. The case happened at a chicken farm of the Juchao District, Chaohu City, east Anhui Province. Officials with the Ministry of Agriculture said that the ministry received the report of chicken death 3 Jul 2004 and soon dispatched a group of experts to guide the relevant work of prevention and control of the disease. Sources from the ministry said that the local government has taken the necessary measures of slaughter, or quarantine to prevent a spread, and sent samples to the authorities. It has also isolated the area following the death report in accordance with China's Lawon Animal Epidemic Prevention. The local health authority killed all the poultry within a 3 km radius of the chicken farm and vaccinated all the poultry within a 5 km radius of the affected area.

The ministry said the farm is located close to the wide Chaohu Lake, and all the chicks are bought from the local markets, where no avian flu case had been reported before. The experts estimated that the virus might be spread by migrants or wild water birds. The ministry has informed the Food and Agriculture Organization (FAO) of the United Nations, the World Health Organization (WHO), and the relevant authorities of Hong Kong, Macao, and Taiwan about the case.

(Promed 7/7/04)

Thailand: New outbreak of bird flu suspected

Thailand suspects a new outbreak of bird flu at a farm in a central province where thousands of chickens have died, the deputy agriculture minister said 6 Jul 2004. "I have received reports that there are suspected bird flu cases in Ayutthaya province, and the result of lab tests will be confirmed in the next couple of days,'' Newin Chidchob told reporters. "It is possible that the outbreak will return.'' An outbreak in Ayutthaya would be the second since the government declared 14 May 2004 that it was all but certain that Thailand was free of the disease following widespread outbreaks earlier in 2004. An isolated outbreak in northern Chiang Mai province in late May 2004 also raised alarms. The deadly strain of bird flu that swept through 10 Asian nations earlier in 2004 killed, or forced the cull of, more than 100 million poultry. It killed more than 37 million birds in Thailand alone, where it also jumped to humans and killed eight people. An additional 16 people died in Vietnam.

Chickens at the afflicted farm in Ayutthaya began to die during the last two weeks of Jun 2004, farm owner Veera Sripramong said. Officials from the local Livestock Office visited his farm and told him to cull all of his 43 000 chickens. "They ordered me to kill all chickens, but I don't have enough manpower, so I will do what I can,'' Veera said. He said about 7000 chickens have died during the past two weeks. Chalit Seenimanomai, the chief of the Livestock Office in Ayutthaya, said that, by law, all chickens in a radius of 3 miles around the affected farm would have to be destroyed. Fortunately, there are no other farms in that area.
(Promed 7/8/04)

Viet Nam: Bird flu downplayed but vigilance urged
Viet Nam said an emergence of bird flu in southern provinces did not mean a return of the epidemic that killed 16 people earlier in 2004, but urged farmers to remain on guard. The bird flu has caused the cull or deaths of more than 10 000 chickens in the Mekong Delta provinces of Bac Lieu and Tien Giang. "The recent incident when chickens died was just an echo of the last bird flu outbreak because there were still chickens from the infected flock," Bui Quang Anh, an agriculture ministry official said. "It cannot be called an outbreak," Anh said.

Viet Nam was struck by bird flu earlier in 2004 involving the deadly H5N1 strain that also killed eight people in Thailand. Hanoi declared the epidemic over at the end of March. Deputy prime minister Nguyen Tan Dung issued an emergency directive, published in newspapers, outlining measures to quell any recurrence of the bird flu, including immediately destroying sick fowl. The bird flu erupted across many parts of Asia from late in 2003 and killed millions of chickens and devastated poultry industries in several countries, particularly Thailand. People who got infected are believed to have caught the disease from close contact with sick birds. There were no confirmed cases of human to human transmissions. The United Nation's Food and Agriculture Organization (FAO) urged caution and more detailed testing. "Viet Nam doesn't have the capacity to analyze the samples," said Anton Rychener, Viet Nam representative of the FAO. "I have urged him (Anh) to send the samples to Hong Kong…" Rychener said. "I have said all along that the virus is continuing to exist in Viet Nam."

(Promed 7/2/04)

China: Beijing schoolchildren face compulsory AIDS education

Secondary schools in Beijing will soon be required to provide children with compulsory HIV/AIDS education. And schools in other Chinese cities are set to follow suit, according to the Ministry of Education. Beijing's municipal commission of education announced last week that the HIV/AIDS courses for secondary school students would begin this autumn. There will be four hours of HIV/AIDS-related education during each of the first three years of secondary education. Courses will cover the science of HIV/AIDS, how it spreads within populations, the social and economic threats of the disease, and information about effective disease prevention. Beijing's move follows recommendations by the education ministry that teaching on drug control and HIV/AIDS prevention should be strengthened during basic education. On 9 May 2004, the State Council demanded that secondary schools across the country should add education on HIV/AIDS prevention to their normal courses.

By the end of 2003, China had reported 840,000 HIV/AIDS carriers and patients. But researchers estimate that without effective control, that number will reach 10 million by 2010. The Chinese government has recently strengthened its efforts to prevent and control the spread of HIV/AIDS. In April, the Ministry of Health and the Ministry of Finance jointly declared to offer free HIV/AIDS drugs to low-income rural and urban AIDS patients. However, experts say education on HIV/AIDS, drug addiction, and sex are still underdeveloped in the world's most populous country. Before this year, virtually no schools in China taught pupils about HIV/AIDS. http://www.scidev.net/gateways/index.cfm?

(AIDS-Asia 7/1/04)

Cambodia: Protects 75% of children against parasites; first country to reach key target

With the recent completion of its latest treatment campaign against intestinal parasites, Cambodia has become the first country to protect 75% of school-aged children against intestinal parasites and reach WHO's anti-parasite target—six years ahead of schedule. Just five years ago, more than 70% of Cambodian children were infected with intestinal worms. Not only do affected children weigh as much as 2kg less than healthy children, they also have a much higher chance of becoming anaemic. Once anti-parasite treatment is administered, infected children show a dramatic increase in their short-and long-term memory, as well as their reasoning capacity and reading comprehension. School absenteeism drops by as much as 25%.

In 2001, WHO set a target of covering at least 75% of school-aged children with regular treatment as the global goal for parasite control for 2010. According to reports sent in from the more than 6500 schools where the campaign took place, more than 75% of Cambodia's nearly three million school-aged children have now been treated. "This is a huge step forward not only for Cambodia, but for all countries working to control intestinal parasitic diseases," said Dr Lorenzo Savioli, WHO's Coordinator of Parasitic Diseases Control.

Intestinal worm infections affect at least two billion people worldwide and are a significant public health threat in regions where sanitation and hygiene levels are inadequate. These worms can be contracted when skin comes into contact with contaminated water, soil or through ingestion. Heavy infection can impede intellectual and physical development. Symptoms include fever, chills, and muscle aches, and if left untreated, leads to irreversible organ damage. Treatment is with cheap, single dose and effective drugs between three times a year and once every two years, depending on the prevalence of infection in the area. Cambodia's success follows a progressive expansion to the national level, which now involves a twice-yearly anti-parasite campaign. Drugs are administered across all 24 provinces by thousands of teachers, who distribute the pills to students in classrooms. The campaigns were conducted by the Cambodian Ministry of Health, Education and Sport, with the support of WHO, together with UNICEF, the Japanese Embassy in Cambodia, and the Sasakawa Memorial Health Foundation. Dr Kevin Palmer, Regional Adviser in Parasitic Diseases for the Western Pacific Regional Office of WHO said, "Reaching the target this early wasn't accidental. It demonstrates what can be achieved when the political will is there together with financial support from donors and partners."

To promote campaigns against parasites in other affected countries, WHO together with UNICEF recommends that such campaigns simply be integrated into other disease campaigns. "We will never control parasitic infections until the global community starts to think and act on a large scale," said Dr Hiroyoshi Endo, WHO's Director of the Control, Prevention and Eradication of Communicable Diseases. "The best way to treat as many people as possible is to piggyback onto other disease initiatives." It is a remarkably cost-effective strategy. Anti-parasite pills cost only about two cents per tablet. "That's a very small price to pay for helping to control a public health problem," said Dr Savioli. WHO hopes that Cambodia's early success will generate momentum for other countries to combat parasitic infections.
(WHO 7/2/04)

Philippines: Malaria affects 122 persons in South Cotabato The provincial government of South Cotabato has intensified its operations against an outbreak of malaria, which has reportedly afflicted at least 122 people in five municipalities over the last few weeks. Arnold Giniseran, team leader of the provincial health office's malaria control program, said they have quarantined several upland villages in the municipalities of Lake Sebu, T'boli, Tantangan, Tupi, and Banga to prevent the further spread of malaria. Of the five municipalities, barangays Ned and Halilan in Lake Sebu were hit hardest with at least 40 people already affected by malaria. Other areas placed under quarantine were barangays Kematu, Edwards, and Zigzag in T'boli; Tacub and El Ulit in Tantangan; sitio Mambusong in barangay Cebuano, Tupi; and sitio Lambukay in barangay Lamba, Banga.

"These case numbers are quite higher than the same period last year," said Giniseran, adding that no deaths have been reported. Giniseran said they are currently conducting massive malaria eradication activities in the affected areas. These include case finding and treatment, particularly the collection of smears, treatment of symptomatic patients and confirmation of positive cases, and distributing treated mosquito nets. He said that houses of affected residents are sprayed with disinfectants. "We also conduct massive information dissemination and capability building training to rural health midwives and barangay health workers," Giniseran added.

Dr Edgardo Sandig, provincial health officer, warned residents about theresurgence of malaria due to the rainy season. He immediately directed the intensification of health education among residents on preventive measures against malaria. He attributed the high incidence of malaria in Lake Sebu and T'boli to the area's topography and high altitude, which he said are conducive for mosquitoes to thrive. Malaria is endemic on Mindanao, but the areas reporting an increase in transmission have previously been regarded as low risk areas. Overall there has been little progress in malaria control in the Philippines over the past 10 years.
(Promed 6/29/04)

Hong Kong: Second Japanese Encephalitis Case Confirmed
The Centre for Health Protection has confirmed Japanese encephalitis virus infection in a 45-year-old Yuen Long man. It is the second case reported in 2004. A hotline has been set up to offer health advice and arrange follow-up action for symptomatic people in the vicinity of Palm Springs, where the sick man lived. He developed fever, headache and drowsiness 8 Jun 2004 and was admitted to Pamela Youde Nethersole Eastern District Hospital. He is now in critical condition. A neighbourhood survey is being conducted for active case finding. The Centre for Health Protection will hold a health talk for residents and blood tests will be offered.

Centre Consultant Dr Thomas Tsang said the case is not related to the first case involving a foreign domestic helper in Kau Wa Keng San Tsuen, Kwai Chung. Dr Tsang said 518 people from 269 families have been contacted in the Kwai Chung investigation. No one has contracted the disease. Nine viral encephalitis reports have been received since the Centre, the Hospital Authority and the private medical sector established an alert system 11 Jun 2004 to monitor the occurrence of viral encephalitis cases. He said the number is similar to past trends and is within an acceptable range. Investigations into the cases are continuing.

Food & Environmental Hygiene Department Consultant Dr Ho Yuk-yin said anti-mosquito work in the area and around nearby piggeries has been stepped up, and larvicides have been applied to control breeding. He said Culex tritaeniorhychus, the key vector of Japanese encephalitis virus, is found in Tuen Mun, Yuen Long, North District, Kwai Chung, Sha Tin and Ma On Shan. These mosquitoes breed where there is abundant water and become infected by biting pigs and wild birds which have the virus. The infected mosquito can then transmit the virus to humans through a bite. Agriculture, Fisheries & Conservation Department Senior Veterinary Officer Dr Howard Wong said there are three pig farms located within 2km of the patient's residence. Routine mosquito mitigation measures have been carried out for farms, and inspections over the last two weeks have found neither sick pigs nor mosquito breeding grounds. Visits to all pig farms and mosquito surveillance will be stepped up in the coming two weeks.
(Promed 6/25/04)

Russia: 19 People in Ulyanovsk Region Bitten by Rabid Dog
In the Zavolshsk district of the Ulyanovsk region, a rabid dog has bitten 19 people, half of whom are children. The dog was brought to a veterinary service clinic where the diagnosis was confirmed. All those known to have been bitten by the dog have been vaccinated, and according to the Gazeta.Ru newspaper, their lives are no longer considered to be at risk. However, physicians are worried that other people possibly bitten by the dog might have suffered only minor injury and have not sought medical attention. As a consequence all local radio and television channels are broadcasting information warning of the danger and stressing the necessity for immediate vaccination of feral and domestic dogs.
(Promed 6/26/04)

Russia: Tickborne encephalitis outbreak in Republic of Altai
The Republic of Altai, with its 203 000 inhabitants, is one of the most favorable places for tickborne diseases in Russia. During the second and third weeks of June 2004, the number of people bitten by ticks has increased almost 50% from 515 to 732, 154 of whom are children. The total number of patients admitted to hospital has risen to 103, which is higher than the comparable number for the corresponding period of 2003. The head of the Epidemiological Surveillance Center, Valentina Mednikova, stated that 45 residents of the Altai Republic have been diagnosed with tickborne encephalitis, 53 with tickborne typhus (rickettsiosis), and 5 with tickborne borreliosis (Lyme disease). (Promed 6/28/04) Russia: HFRS a continuing problem in Udmurtia Most of the people infected with hemorrhagic fever with renal syndrome (HFRS) were working in the basements of their houses. Basements and attics are favorite places for mice. This season the virus transmitted by these rodents appears to have enhanced virulence. Furthermore, entomologists state that 50% of mice are carrying hantavirus. Unfortunately, most homeowners have rejected disinfestation of their gardens on account of the expense involved. This has resulted in a serious outbreak of disease. So far 108 people have been admitted to hospital with HFRS. During the same period of 2003, only five people were admitted with hemorrhagic fever. Local physicians are predicting that the number of patients will increase through summer and fall. Previous posts earlier in 2004 reported a large increase in field voles, the vector of the hantavirus responsible for HFRS, which may explain to some extent the apparent severity of this outbreak.
(Promed 7/2/04)

Russia: More victims at graduation party held in the Amur region
The number of people admitted to hospital with salmonella poisoning has risen to 207. The incident of food poisoning was reported after a school graduation party, held in Tambovka, in the Amur region during the third week of June 2004. Eighty-four per cent of the patients have tested positive for salmonellosis. The rest have been diagnosed as infected with staphylococcus. Most of the patients admitted to hospital are in a satisfactory condition. Sanitary preventive measures have been taken in the settlement where the incident took place. Experts established that the infection was in egg and squid salads served at the party. Documents with the results of the medical examination have been sent to the local prosecutor's office, which will open a criminal case. The number of individuals who were at the graduation party is not stated in this report. It appears that most of the cases are due to salmonellosis, although a small percentage of cases, apparently, suffered from staphylococcal toxin illness. The illnesses should be relatively easily distinguished, as salmonellosis has an incubation period of 18 to 48 hours and is associated with fever and diarrhea, whereas staphylococcal food poisoning has an incubation period of less than 8 hours, is generally not associated with fever, and causes, primarily, vomiting, not diarrhea.
(Promed 6/30/04)


USA (Colorado): First Case of Hantavirus Pulmonary Syndrome of 2004
This year's first reported case of hantavirus infection in Colorado has resulted in the death of a Douglas County woman, health authorities said 25 Jun 2004. John Pape, an epidemiologist specializing in animal-related diseases at the Department of Public Health and Environment, said the woman lived in a more rural part of the county, and it's believed she contracted it there. "This disease is carried by deer mice, which primarily stay in more rural areas," he said. "They aren't as likely to act like the common house mouse, which will come indoors and live with you in the city." The deer mouse is brown on top with a white belly. House mice usually are gray.

Hantavirus pulmonary syndrome is a respiratory disease caused by a virus carried mostly by deer mice that can infect humans when they inhale dirt or dust contaminated with mouse urine and feces. Usually it happens when people are cleaning rodent-infested structures such as barns, garages, storage sheds, trailers or cabins. The virus was first diagnosed in the US in 1959, but the earliest case in Colorado was in 1985. In 1993, an outbreak of hantavirus infection in the four Corners area infected five Coloradoans, killing four. Since then, in Colorado there have been 35 cases of people being infected with 16 deaths, Pape said. The Pan American Health Organization reported this April that since 1993, there have been 362 cases in the US, including 132 deaths; and 1910 cases in North and South America, with 384 total deaths. During 2003 in Colorado there were five cases and one fatality. Among the counties in Colorado that have tested positive for the disease are Douglas, Jefferson, Boulder and Adams, Pape said.

If there is evidence of mice in or around your home, Pape said, remove them as soon as possible. If they are brown with a white belly, spray them with bleach, put them in a double plastic bag and place them in the outdoor trash can. He advised wearing protective gloves, making sure there is plenty of ventilation where you are working, and use face masks if possible. In North America, cases of hantavirus pulmonary syndrome are caused by infection with Sin Nombre virus, whose reservoir host is the deer mouse Peromyscus maniculatus. In the Old World other hantaviruses carried by different rodents are associated with a milder form of disease known as hemorrhagic fever with renal syndrome, of which there can be up to 200 000 cases annually.
(Promed 6/26/04)

USA (New York): Number of possible E. coli cases at Bronx day care center rises
The number of possible cases of Escherichia coli O157:H7 infection at a Bronx day care center has climbed from 18 to 26 as the center remains closed. The For Kids Only Day Care and Nursery has been closed since 1 Jul 2004, after three children were admitted to hospital. One other child, who did not attend the center, was also infected. Doctor Marguerite Mayers, who treated the kids at Montefiore Medical Center, says the condition of all of the children was serious but all were stabilized and released. The center hired a private team to run tests in order to determine where the bacterium came from. In addition, New York City Department of Health inspectors say the center will be thoroughly sterilized before kids can step foot back inside. Experts say there is really no way to protect against E. coli but add that proper hygiene can help. Health officials say parents should be on the lookout for symptoms such as abdominal pain, diarrhea that becomes bloody, fever and irritability. They say the infection is caused by poor hand washing, handling of diapers and unsafe food preparation.

Some levels of E. coli bacteria are normally found in the intestines of humans and animals. Although most strains are harmless, E. coli 0157:H7 can cause a diarrheal illness that sometimes leads to kidney damage and severe illness. The spread of infection is usually caused by poor sanitary practices like inadequate handwashing and the unsafe preparation of food.
(Promed 7/2/04, 7/6/04)

USA (Florida): Malaria resurfaces in Palm Beach County
The Palm Beach County Health Department has identified a person with malaria who may have infected mosquitoes. This occurrence could leave other residents at risk at this time. Residents are being asked to protect against mosquito bites and report to a medical provider any symptoms of high fever and teeth-chattering chills. The Health Department has launched a full-scare awareness campaign in the hopes of identifying other potential cases, creating awareness of the situation, and contacted mosquito control to increase spraying and trapping of mosquitoes.

The incident is similar to the malaria outbreak of eight cases in 2003. No one died during last year's outbreak, but it lasted more than 3 months and was finally controlled in October. During last year's outbreak, investigators never identified the index case. Last year's outbreak is unrelated to this case, although both are the mild strain of the virus. Molecular typing of the cases in 2003 showed that all had been infected from the same source, but the source was never identified. Molecular typing of the parasites in this patient will show whether they are closely related to last year's patients or whether there is another source.

The current case had active malaria in early June. He was hospitalized at Delray Beach Medical Center from June 4 to 7 and is now cured. The cycle to infect another person is about 30 days. Given this time frame, the potential for infection is very high, according to health director, Jean Malecki, MD: "We know last year's carrier had the disease in June and the first two local cases were exposed around the 4 July holiday. The potential exists for this cycle to begin now.”

Malaria is a parasitic disease transmitted by the anopheles mosquitoes and can be treated. The symptoms vary depending on which of the four human malaria strains has been contracted. Symptoms include; headache, aching in the bones, anorexia, vomiting, teeth-chattering chills coupled with sensations of heat and high fever and sweating. The onset of symptoms can be as early as 7 days and as long as several months. People exhibiting any signs or symptoms of the disease should report to their nearest hospital.
(Promed 7/3/04)

Peru: Current Situation of Jungle Yellow Fever (JYF)
Up to 23 Jun 2004, the Ministries of Health of Colombia, Peru, Brazil and Bolivia reported to the Pan American Health Organization (PAHO) the occurrence of 86 confirmed cases of Jungle Yellow Fever (JYF), with 41 deaths. In all the countries, cases occurred predominantly among males over the age of 15 who work in the countryside. The case distribution by Epidemiological Week and by country is shown in a figure available at the following web site: <http://www.paho.org/English/AD/DPC/CD/eid-eer-24-jun-2004.htm#jyf>.

Peru has reported 52 cases, with a case-fatality rate of 52 percent. Another 31 suspected cases are undergoing epidemiological and laboratory investigation.

Considering the extensive infestation by Aedes aegypti in all the countries of the Region, with the exception of the continental part of Chile, the occurrence of outbreaks increases the risk of the re-urbanization of yellow fever. The PAHO Technical Advisory Group (TAG) on Vaccinations has systematically recommended that the countries vaccinate all persons residing in enzootic areas in the Americas for yellow fever, as well as all travelers to those areas, and introduce routine vaccination for children against the disease. Also highly recommended is putting into place control measures against A. aegypti in accordance with PAHO recommendations for the control of this vector. Evidence of the spread of yellow fever, through the confirmation of at least one human case and of epizootics (dead monkeys), is sufficient grounds for initiating outbreak-control measures in the affected municipality and immediate vicinity. These measures include vaccinating all residents who lack proof of previous inoculation against yellow fever, vaccinating all those traveling to the area, actively searching for suspected cases, putting into place surveillance of both febrile icteric syndrome and epizootics, in addition to declaring epidemiological alerts. If new cases are identified in other municipalities of the Region, the vaccination ring should be expanded along with other control measures.
(Promed 6/25/04)


Cholera, Diarrhea, and Dysentery
Dozens of children under the age of 5 are being treated for diarrheal diseases in several hospitals in Bogor, which suggests that residents may lack access to clean water and basic information on good hygiene and health. Spokesman of the Indonesia Red Cross (PMI) Hospital in Bogor, Andi Mukti, said the hospital had treated 104 children since early Jun 2004, 94 of whom were outpatients. Officials of the city health agency expressed concern that the number of patients with diarrheal diseases would increase during the dry season, which will start in Jul-Aug 2004. "Not only children, but adults will be affected by the proliferation of E. coli that causes diarrhea," said head of the infectious disease eradication unit at the agency, Eddy Darma. Data from the Indonesia Demographic and Health Survey (SDKI) shows that in 2002 and 2003, about 11 per cent of children aged below 5, most of whom were from low-income families, suffered from diarrheal diseases. The percentage has not changed since 1997.

Health officials are investigating an outbreak of gastroenteritis among guests at two weddings held at the Boat House By The Lake restaurant 26 Jun 2004. Deputy chief health officer Dr Charles Guest said that 40 out of 80 guests at the lunchtime wedding developed symptoms such as diarrhea and vomiting. Some guests at the evening wedding also became ill, but health officials were still attempting to ascertain the illness' attack rate. One of the weddings was between a Department of Defense worker and a Department of Foreign Affairs and Trade employee and had a number of high-profile people on the guest list.

The bride and groom are still recovering from food poisoning themselves during their honeymoon. Overall, six guests were treated at hospital emergency departments within 48 hours of the wedding. Dr Guest said he could not say at this stage whether food poisoning or viral gastroenteritis had caused the illness, but gastroenteritis had been "very common" in the region this year. He said health officials had no reason to close the Boat House By The Lake because there was no ongoing public health hazard. Dr Guest said six functions were held at the restaurant, but the outbreak of gastroenteritis was confined to the two weddings. The investigation was focusing on common threads such as the health status of staff who worked both functions and food served at both weddings.

It was reported 2 Jul 2004 that 96 people were hospitalized at the district hospital in Permaisuri, Setiu, following a dengue outbreak. Meanwhile, State Health director Datuk Dr. Ahmad Razin Ahmad Maher said the situation in Kelantan was under control, with a small number of cases reported so far. Local councils have been directed to take immediate precautionary measures against a dengue outbreak in the Setiu district of Terengganu.

The government declared the dengue fever outbreak over and lifted the red alert status in 12 provinces, as the prevalence rate had decreased to a baseline level. Minister of Health Achmad Suyudi said the number of dengue cases had been decreasing since mid-April 2004. "In May, there were only 506 cases with 4 casualties deaths, far below the 3616 cases recorded a month earlier, with 25 people succumbing to the disease. We can see that the number has declined significantly," Suyudi said 16 Jun 2004. He added that the outbreak had slowed faster than the government had expected. In May last year 2003, 6425 cases were recorded, of which 78 died.

In February 2004, the government placed Nanggroe Aceh Darussalam, Jakarta, West Java, Central Java, Yogyakarta, East Java, Banten, Bali, West Nusa Tenggara, East Nusa Tenggara, South Kalimantan, and South Sulawesi under extraordinary status due to the high number of people affected by dengue fever. The ministry recorded 59 321 cases and 669 deaths during this year's 2004 outbreak.

Four distinct, but closely related, serotypes cause dengue, with the _Aedes aegypti_ mosquito being the vector. All 4 serotypes—DEN-1, DEN-2, DEN-3, and DEN-4—were found in dengue patients here, said I Nyoman Kandun, the ministry's expert staff member on environment, health and epidemiology. Blood samples from 10 Jakarta hospitals revealed that two thirds of total patients were affected by DEN-3. Recovery from an infection caused by a particular serotype results in a lifelong immunity against that serotype, but provides only a partial, transient protection against subsequent infections by any of the other serotypes, he said.

Despite the normal status, the minister called on people to maintain precautionary measures, as the country was not yet dengue-free. The government has long urged public participation in its dengue eradication program through a change in household habits, such as draining open tanks, covering vats of bathing and standing water, and burying used cans—locally called the 3M measures—to eliminate the breeding grounds of Aedes aegypti.
(Promed 7/7/04)

Viral gastroenteritis
New Zealand
In the last posting, there was a suspected Norovirus outbreak in Dunedin, New Zealand. Norovirus has been isolated from specimens. A further 32 staff and 13 patients have been notified as of 1200 NZST 25 Jun 2004.
(Promed 6/23/04, 7/6/04)

West Nile Virus
During June 30–July 6, a total of 21 human cases of West Nile virus (WNV) illness were reported from two states (Arizona and California). During 2004, eight states have reported a total of 78 human cases of WNV illness to CDC through ArboNET. Of these, 57 (73%) were reported from Arizona. Forty-seven (61%) of the 78 cases occurred in males; the median age of patients was 53 years (range: 1-84 years); the dates of illness onset ranged from April 23 to June 28; and one case was fatal. A total of 20 presumptive West Nile viremic blood donors (PVDs) have been reported to ArboNET. Of these, 19 were reported from Arizona, and one was reported from New Mexico. Of the 20 PVDs reported to ArboNET, one person aged 69 years subsequently had neuroinvasive illness, and four persons aged 22, 51, 52, and 57 years subsequently had West Nile fever. In New Mexico, the first reported human WNV infection in 2004 was in a PVD; in Arizona, three of the first seven reported human WNV infections of 2004 were in PVDs.

In addition, during 2004, a total of 861 dead corvids and 86 other dead birds with WNV infection have been reported from 24 states, and 42 WNV infections in horses have been reported from 11 states (Alabama, Arizona, California, Idaho, Missouri, North Carolina, Oklahoma, South Dakota, Tennessee, Texas, and Virginia). WNV seroconversions have been reported in 110 sentinel chicken flocks from four states (Arizona, California, Florida, and Louisiana). Three seropositive sentinel horses were reported from Puerto Rico. A total of 226 WNV-positive mosquito pools have been reported from 12 states (Arizona, California, Illinois, Indiana, Louisiana, Michigan, Missouri, New Jersey, Ohio, Pennsylvania, Texas, and Virginia). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5326a5.htm (MMWR July 9, 2004 / 53(26);586)

The number of confirmed West Nile virus-positive birds is 49 (and presumed positives from 4 to 9). Manitoba, Ontario, Quebec and Saskatchewan remain the only provinces to report West Nile virus-positive birds, so far, in 2004. So far, there has been no report of human cases of West Nile virus infection or of infection of any other species of animal.
(Promed 7/8/04)


Genesis of a highly pathogenic and potentially pandemic H5N1 influenza virus in eastern Asia Abstract:
"A highly pathogenic avian influenza virus, H5N1, caused disease outbreaks in poultry in China and 7 other east Asian countries between late 2003 and early 2004; the same virus was fatal to humans in Thailand and Viet Nam. Here, we demonstrate a series of genetic reassortment events traceable to the precursor of the H5N1 viruses that caused the initial human outbreak in Hong Kong in 1997, and, subsequent avian outbreaks in 2001 and 2002. These events gave rise to a dominant H5N1 genotype (Z) in chickens and ducks that was responsible for the regional outbreak in 2003 - 2004. Our findings indicate that domestic ducks in southern China had a central role in the generation and maintenance of this virus, and, also, that wild birds may have contributed to the increasingly wide spread of the virus in Asia. Our results suggest that H5N1 viruses with pandemic potential have become endemic in the region and are not easily eradicable. These developments pose a threat to public and veterinary health in the region, and, potentially, the world, and suggest that long-term control measures are required."
(Promed 7/8/04)

Update: Influenza Activity—United States and Worldwide, 2003–04 Season, and Composition of the 2004–05 Influenza Vaccine
“During the 2003–04 influenza season, influenza A (H1), A (H3N2), and B viruses co-circulated worldwide, and influenza A (H3N2) viruses predominated. Several Asian countries reported widespread outbreaks of avian influenza A (H5N1) among poultry. In Vietnam and Thailand, these outbreaks were associated with severe illnesses and deaths among humans. In the United States, the 2003–04 influenza season began earlier than most seasons, peaked in December, was moderately severe in terms of its impact on mortality, and was associated predominantly with influenza A (H3N2) viruses. This report 1) summarizes information collected by World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories, state and local health departments, health-care providers, vital statistics registries, and CDC and 2) describes influenza activity in the United States and worldwide during the 2003--04 influenza season and the composition of the 2004--05 influenza vaccine.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5325a1.htm (MMWR July 2, 2004 / 53(25);547-552)

Trends in Primary and Secondary Syphilis and HIV Infections in Men Who Have Sex with Men: San Francisco and Los Angeles, California, 1998–2002 “Because syphilis infection facilitates acquisition and transmission of human immunodeficiency virus (HIV), recent outbreaks of syphilis among men who have sex with men (MSM) in major U.S. cities, including San Francisco and Los Angeles, and reported increases in sexual risk behavior have raised concerns about potential increases in HIV transmission. In 2002, MSM accounted for the majority of primary and secondary (P&S) syphilis cases in men reported in San Francisco (93%) and Los Angeles (81%). To investigate a potential change in HIV incidence associated with the syphilis outbreaks in the two cities, local, state, and federal health officials analyzed data from HIV counseling and testing centers and a municipal sexually transmitted disease (STD) clinic. This report describes the results of that investigation, which indicated that, as of 2002, the outbreaks of syphilis had not had a substantial impact on HIV incidence among MSM in these two cities. However, the continued increase in syphilis cases in MSM underscores the need for integrated HIV- and STD-prevention strategies to control syphilis outbreaks and prevent potential increases in HIV infections and for further systematic studies of HIV incidence among MSM infected with syphilis.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5326a1.htm (MMWR July 9, 2004 / 53(26);575-578)

Updated Recommendations for Use of Pneumococcal Conjugate Vaccine: Reinstatement of the Third Dose “In February 2004, production of the 7-valent pneumococcal conjugate vaccine (PCV7), marketed as Prevnar® and manufactured by Wyeth Vaccines (Collegeville, Pennsylvania), failed to meet demand, resulting in shortages. To conserve the limited supply, CDC recommended that the fourth dose of PCV7 be withheld from healthy children. In March, because evidence indicated that production would be curtailed for several months, CDC recommended that the third dose also be withheld. Production problems now appear to have been resolved. As a result, deliveries are projected during the near term to permit the recommendation that every child receive 3 doses. Some providers might have short-term difficulties obtaining vaccine because of distribution delays; however, every effort will be made to provide sufficient vaccine to all providers.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5326a7.htm (MMWR July 9, 2004 / 53(26);589-590)

Investigation of Rabies Infections in Organ Donor and Transplant Recipients in Alabama, Arkansas, Oklahoma, and Texas, 2004
“On June 30, 2004, CDC confirmed diagnoses of rabies in three recipients of transplanted organs and in their common donor, who was found subsequently to have serologic evidence of rabies infection. The transplant recipients had encephalitis of unknown etiology after transplantation and subsequently died. Specimens were sent to CDC for diagnostic evaluation. This report provides a brief summary of the ongoing investigation and information on exposure risks and postexposure measures.

Organ Donor
The organ donor was an Arkansas man who visited two hospitals in Texas with severe mental status changes and a low-grade fever. Neurologic imaging indicated findings consistent with a subarachnoid hemorrhage, which expanded rapidly in the 48 hours after admission, leading to cerebral herniation and death. Donor eligibility screening and testing did not reveal any contraindications to transplantation, and the patient's family agreed to organ donation. Lungs, kidneys, and liver were recovered. No other organs or tissues were recovered from the donor, and the donor did not receive any blood products before death. The liver and kidneys were transplanted into three recipients on May 4 at a transplant center in Texas. The lungs were transplanted in an Alabama hospital into a patient who died of intraoperative complications.

Liver Recipient
The liver recipient was a man with end-stage liver disease. The patient did well immediately after transplantation and was discharged home on postoperative day 5. Twenty-one days after transplant, the patient was readmitted with tremors, lethargy, and anorexia; he was afebrile. The patient's neurologic status deteriorated rapidly during the next 24 hours; he required intubation and critical care support. A lumbar puncture indicated a mild lymphocytic pleocytosis (25 white blood cells/mm3) and a mildly elevated protein. Magnetic resonance imaging (MRI) of the brain indicated increased signal in the cerebrospinal fluid. His neurologic status continued to deteriorate. Six days after admission, a repeat MRI indicated diffuse encephalitis. The patient subsequently died.

Female Kidney Recipient
The first kidney recipient was a woman with end-stage renal disease caused by hypertension and diabetes. She had no postoperative complications and was discharged home on postoperative day 7. Twenty-five days after transplant, she was readmitted with right-side flank pain and underwent an appendectomy. Two days after this procedure, she had diffuse twitching and was noted to be increasingly lethargic. Neurologic imaging with computed tomography and MRI indicated no abnormality. During the next 24–48 hours, the patient had worsening mental status, seizures, hypotension, and respiratory failure requiring intubation. Her mental status continued to deteriorate, and cerebral imaging 2 weeks after admission indicated severe cerebral edema. The patient subsequently died.

Male Kidney Recipient
The second renal recipient was a man with end-stage renal disease caused by focal, segmental glomerulosclerosis. His posttransplant course was complicated briefly by occlusions of an arterial graft leading to infarction of the lower pole of the transplanted kidney. The patient was discharged home 12 days after transplantation. Twenty-seven days after transplantation, he visited a hospital emergency department and was then transferred to the transplant center with myoclonic jerks and altered mental status; he was afebrile. An MRI of the brain performed on admission revealed no abnormalities. His mental status deteriorated rapidly during the next 24 hours. A lumbar puncture revealed mild lymphocytic pleocytosis (16 white blood cells/mm3) and a mildly elevated protein. His mental status continued to deteriorate, leading to respiratory failure requiring intubation. A repeat MRI performed 10 days after admission indicated diffuse edema. The patient subsequently died.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d701a1.htm (MMWR July 1, 2004 / 53(Dispatch);1-3)

Racial Disparities in Tuberculosis: Selected Southeastern States, 1991–2002
“Despite substantial declines in tuberculosis (TB) in the United States, in 2002, non-Hispanic blacks continued to have TB at rates eight times greater than non-Hispanic whites. To better understand racial disparities in TB, CDC analyzed surveillance data collected during 1991–2002, comparing TB cases in seven southeastern states where TB rates were higher than the national average with TB cases in the rest of the United States. This report summarizes the results of that analysis, which indicated that TB rates among non-Hispanic blacks in the seven southeastern states continued to exceed those among non-Hispanic whites but were similar to rates among non-Hispanic blacks in the rest of the country. In addition, non-Hispanic blacks with TB in the southeastern states were more likely than non-Hispanic whites to report certain risk factors, suggesting that differences in socioeconomic status might create barriers to diagnosis and treatment. The continued disparity in TB cases underscores the need for effective, targeted strategies to prevent TB in non-Hispanic blacks.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5325a3.htm (MMWR July 2, 2004 / 53(25);556-559)

Surveillance Data from Public Spa Inspections in the United States, May–September 2002
“Approximately 5 million public and private hot tubs, whirlpools, and spas are used in the United States. Extensive spa use combined with inadequate maintenance contribute to recreational water illnesses (RWIs) caused by pathogens such as Pseudomonas spp., Legionella spp., and Mycobacterium spp. In the United States, local environmental health inspectors periodically inspect public spas to determine their compliance with local or state health regulations. During inspections for regulatory compliance, data pertaining to spa water chemistry, filtration and recirculation, and management and operations are collected. This report summarizes spa inspection data from six sites in the United States during May 1–Sept. 1, 2002. The findings underscore the utility of these data for public health decision-making and the need for increased training and vigilance by operators to ensure high-quality spa water for use by the public.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5325a2.htm (MMWR July 2, 2004 / 53(25);553-555)

AIDS epidemic grows at record rate
The AIDS epidemic is continuing to grow at a record rate with roughly 4.8 million people becoming infected last year with the virus that causes AIDS, according to a United Nations report <http://www.unaids.org/en/other/functionalities/ViewDocument.asp?href=http://gva-doc-owl/WEBcontent/Documents/pub/Media/Press-Releases02/PR_Globalreport2004_06Jul04_en.pdf>.
That is the largest increase in any year since the global outbreak began.

Thirty-eight million people are living with HIV, as the epidemic continues to deepen in sub-Saharan Africa, by far the hardest hit region, and new epidemics seem to be swelling unchecked in Asia and Eastern Europe. Life-prolonging drugs are not getting to those who need them most. Some 400 000 people in the developing world have access to the drugs out of 6 million who need them. Most global epidemic in history is also becoming increasingly feminine. Now, nearly half of all people infected between the ages of 15 and 49 are women.

The report comes at a time when the world has significantly boosted its commitment and resources to HIV/AIDS, but the need is still far greater, according to the fourth global report by the Joint United Nations Program on HIV/AIDS released in advance of the 15th International AIDS Conference. "Over 20 years of AIDS provides us with compelling evidence that unless we act now we will be paying later—a trenchant message for the countries of Asia and the Pacific," said Peter Piot, the program's executive director, in the report.

In Asia, with 60% of the world's population, 7.4 million people are living with HIV. One of every 4 newly-infected people is Asian. The epidemic is fueled by drug use, sex work, and sex between men, but it is fast moving into the general population. China and India have severe epidemics in a number of provinces, territories, and states. In Indonesia and Vietnam, infections among injecting drug users have soared. "There's a . . . window of opportunity to get prevention programs up to scale in Asia," said Kathleen Cravero, the program's deputy executive director. "If we miss it, we will see an epidemic the likes of which we never imagined despite what has happened in Africa."
(Promed 7/6/04)

China: Recent SARS outbreak: important lessons for global public health
It has been more than two months since the Ministry of Health of China notified WHO and the world about an outbreak of SARS in Beijing and Anhui Province. Since then, WHO experts have been supporting the Chinese authorities in their investigation into the cause of the laboratory-acquired cases, and in assessing the effectiveness of measures taken to control the outbreak. On 1 Jul 2004, the Ministry of Health of China released its status report on the investigation. The outbreak has now been successfully contained, but initial findings from the investigation and the assessment of control measures have raised several important lessons for global public health. WHO/WPRO Press release is available at http://www.wpro.who.int/sars/docs/update/update_07022004.asp.

Topics included are: Investigation into the source of the outbreak, biosafety concerns raised by the outbreak, and assessment of effectiveness of outbreak control measures. WHO emphasizes that scientists working with highly pathogenic viruses such as SARS need to handle inactivated material with the utmost caution. WHO recommends that:

There are a number of lessons from this outbreak that are important globally, for member states and for WHO itself:

(Promed 7/4/04)


HIV Content Guidelines Announcement
The Centers for Disease Control and Prevention (CDC) has published two notices in the Federal Register requesting public comments on proposed revisions of the Interim HIV Content Guidelines, revised in 1992. The first notice requests comment on the Guidelines, entitled "Content of AIDS-related written materials, pictorials, audiovisuals, questionnaires, survey instruments, marketing, advertising and website materials, and educational sessions in CDC regional, state, territorial, local, and community assistance programs." The second notice requests comments on new Interim Guidelines, entitled "Content of AIDS-related written materials, pictorials, audiovisuals, questionnaires, survey instruments, marketing, advertising and website materials, and educational sessions in CDC school-based assistance programs."

The public comment period ends August 16, 2004. Please visit http://www.cdc.gov/nchstp/od/content_guidelines/default.htm

(CDC) XV International AIDS Conference
11-16 July 2004, Bangkok

The theme for this year's event is "Access for all", reflecting the need for all groups, including scientists, community workers and leaders, to have access to all resources such as education, information and medication. Also, on 10 July 2004, WHO and UNAIDS will release the "3 by 5" Progress Report and "HIV Plan". What progress has been made in scaling up treatment six months on, and what more needs to be done? What is the WHO plan to continue to assist countries to increase access to prevention, treatment and care for HIV/AIDS? The reports include the latest treatment data from regions (up to June 2004). WHO will also issue 26 country profiles.

What: Press conference on the "3 by 5" Progress Report and HIV Plan When: Saturday, 10 July 2004 from 12:00 noon to 1:00 pm (Bangkok time)

Where: Royal Orchid Sheraton Hotel, Ballroom 2, Bangkok (address: Siphya Road, 2 Captain Bush Lane Bangkok, phone (66) (2) 266-0123)

Speakers: Dr Jack Chow, Assistant Director-General, HIV/AIDS, Tuberculosis and Malaria, WHO Dr Peter Piot, Executive Director, UNAIDS Dr Jim Kim, Director of HIV Department, WHO Rolake Odetoyinbo Nwagwu - Activist, Treatment Action Movement, Nigeria http://www.aids2004.org/

5. APEC EINet Activities

The APEC EINet team will be holding a point-to-point video conference discussion with Taipei health and informatics workers on 13 Jul 2004. The aim of the discussion is to prepare an agenda for a broader plenary discussion of bio-preparedness practices and topical disease priorities. This virtual meeting will utilize Access Grid and will test the existing level of communications network technologies. The plenary in the future is envisioned involving all interested economies over time.


The APEC EINet listserv was established to enhance collaboration among academicians and public health professionals in the area of emerging infections surveillance and control. Subscribers are encouraged to share their material with colleagues in the Asia-Pacific Rim. To subscribe (or unsubscribe), contact apec-ein@u.washington.edu. Further information about the APEC Emerging Infections Network is available at http://depts.washington.edu/apecein/.

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