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Vol. VII, No. 16 ~ EINet News Briefs ~ Jul 23, 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: Precautions to prevent human infection of H5N1, need for virus sharing
- Thailand: More Thai provinces confirm bird flu outbreaks
- Viet Nam: Culls bird flu-suspected chickens
- Indonesia: New outbreak of bird flu, vaccine distribution
- Malaysia: 'Trigger point' alert system if number of flu cases rise suddenly
- Japan: IPB, Shigeta Japan to produce bird flu super vaccine
- Japan: Human coronavirus NL63 detected in children
- Japan: Expert’s panel says no use testing young cows for BSE
- Hong Kong: Food poisoning, hotel restaurant
- South Korea: Hepatitis A virus infection on the increase
- China(Gansu): Man dies after catching anthrax from cow
- Papua New Guinea: 30 dead from mystery disease
- Canada: To enhance BSE feed controls
- USA: USDA and HHS strengthen safeguards against BSE
- USA: FDA recommends firms not use high-risk cattle protein in cosmetics
- USA(New Mexico): state park employee contracts hantavirus pulmonary syndrome
- USA(Virginia): Fatal Case of Hantavirus Pulmonary Syndrome
- USA(Multi-state): Salmonella investigation now focused on tomatoes
- USA(Montana): Cantaloupe blamed for E. coli illness
- Canada(Quebec): One dead, five ill from E. coli outbreak

2. Updates

- Cholera, Diarrhea, and Dysentery
- Dengue/DHF
- Viral gastroenteritis
- West NileVirus

3. Articles

- Trichinellosis Associated with Bear Meat — New Yorkand Tennessee, 2003
- Update: Investigation of Rabies Infections in Organ Donor and Transplant Recipients–Alabama, Arkansas, Oklahoma, and Texas, 2004
- Acute Hemorrhagic Conjunctivitis Outbreak Caused by Coxsackievirus A24–Puerto Rico, 2003
- The New EnglandJournal of Medicine: Early release
- CDC Emerging Infectious Disease Journal, Volume 10, Number 8—August 2004

4. Notifications

- Updated Information for Travelers about Avian Influenza A(H5N1)
- WHO publishes new guidelines on preventing mother to child transmission of HIV
-New edition of WHO prequalification list to include four new anti-AIDS medicines
- WHO Regional Committee Meetings
- International Workshop on Tuberculosis Vaccines (TBVaccines2005)
- Master of Science program in biohazardous threat agents and emerging infectious diseases
- Francis J. Curry National TB Center: Updated self-study online course on TB and HIV.
- Notice to Readers: Satellite Broadcast on Rapid Testing for HIV

5. APEC EINet Activities

6. How to join the EINet email list


1. OVERVIEW OF INFECTIOUS-DISEASE INFORMATION


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

East Asia: Precautions to prevent human infection of H5N1, need for virus sharing

WHO continues to be concerned by the simultaneous outbreaks of Highly Pathogenic Avian Influenza H5N1 in several Asian countries. While these outbreaks thus far remain restricted to poultry populations, they increase the chances of virus transmission and human infection, as well as the possible emergence of a new influenza virus strain capable of a global pandemic.

WHO re-emphasizes the necessity of protecting individuals involved in the culling of H5N1-infected poultry. Workers who might be exposed should have proper personal protective equipment since there is a high risk of exposure during the slaughtering process.

In addition to the use of personal protective equipment, WHO is recommending:

See the full list of WHO's interim recommendations for the protection of persons involved in the mass slaughter of animals potentially infected with Highly Pathogenic Avian Influenza viruses. WHO is urging countries to work on standardized procedures for sharing of all avian influenza virus strains responsible for outbreaks with WHO's international network of laboratories. WHO is depending on the collaboration of the national health and agricultural services to establish routine procedures for immediate sharing of virus samples. WHO requires such samples to provide proper vaccine prototype strains and related guidance for vaccine producers.
(WHO 7/16/04)

Thailand: More Thai provinces confirm bird flu outbreaks

Bird flu was suspected of spreading to over eight provinces, and confirmed in more than 10 provinces. Thailand Food and Drugs Agency has not approved the use of bird-flu vaccines, because research has yet to determine whether consuming vaccinated chickens would pose a health risk to humans. Chaturon has assigned Yukol Limlaethong, director-general of Livestock Development, to arrange strict measures to prevent bird flu from spreading any further. The movement of farming equipment will be prohibited, and farmers will be required to buy chickens only from closed-system production facilities. Yukol said vaccination would be a last resort. In Chiang Saen district, Chiang Rai province, police have arrested a man with 200 bottles of suspected bird-flu vaccine. He confessed to smuggling the drug in to sell in Bangkok.

The government also announced that it will set up a national-level committee for combating avian influenza and decide whether to introduce bird-flu vaccination in critical areas, Agriculture Minister Somsak Thepsuthin said. Inoculation is a subject of heated debate because some vaccinated fowl could carry the disease without showing symptoms, possibly putting humans at risk in the long run. He said the national-level committee on bird-flu would be assigned to research ways to contain and prevent outbreaks of the disease. The committee would be comprised of experts from the Veterinary Council of Thailand, the Public Health Ministry, and various universities. After the research, the bird-flu vaccine should be experimented with in some areas, Somsak said, adding that the vaccine would remain banned outside the trial areas. The Livestock Development Department said the fresh outbreaks remained restricted to small areas in 13 provinces, and is proposing a zoning plan for fowl control.
(Promed 7/19/04)

Viet Nam: Culls bird flu-suspected chickens

Viet Nam culled more than 6000 chickens showing symptoms of bird flu in Long An province 19-20 Jul 2004. It is the first case of culling poultry in the province since Viet Nam declared itself free of bird flu in March 2004. The slaughtering caused a local farmer losses of 200 million Vietnamese dong (VND) (USD 13 000). The local veterinary bureau is investigating the cause of the deaths. As of 19 Jul 2004, bird flu recurred in eight southern localities, which either killed, or led to the culling of, 35 326 fowl. All the new outbreaks have been detected in small farms that have not taken full preventive measures. Bird flu has killed 17 percent of Viet Nam 's poultry population, and claimed 16 human lives, since its outbreak in December 2003. A total of 43.2 million fowl nationwide either died or were culled, causing the local poultry industry to suffer direct losses of 1.3 trillion VND (USD 82.8 Million).
(Promed 7/21/04)

Indonesia: New outbreak of bird flu, vaccine distribution

Bird flu has resurfaced in parts of Indonesia, prompting health officials to implement a massive campaign to vaccinate chickens. The latest outbreak follows a resurgence of bird flu in China, Thailand, and Viet Nam in recent weeks. Indonesian agricultural ministry officials said 21 Jul 2004 that the government plans to distribute as many as 300 million doses of vaccine to poultry farmers. Thai Health Ministry spokeswoman Nitaya Mahaphol said that the SARS outbreak in 2003 helped prepare medical officials to deal with new health threats.
Promed 7/21/04)

Malaysia: 'Trigger point' alert system if number of flu cases rise suddenly

The Health Ministry has introduced a "trigger point" to alert the authorities of the bird flu virus in the event of a sudden rise in flu cases. Its minister, Datuk Dr. Chua Soi Lek, said the authorities would be placed on high alert if more than the average number of flu cases were detected per day. He said the ministry had alerted public health clinics and hospitals to watch out for bird flu symptoms. In the event of an outbreak, Dr. Chua said farms should be cordoned off to prevent the spread of the deadly virus. "To date, no cases have been reported in Malaysia, so there is no reason to be anxious," he said, adding that the Health Ministry would work with the Agriculture, and Agro-Based Industry Ministry, to prevent the bird flu virus from entering the country.
(Promed 7/19/04)

Japan: IPB, Shigeta Japanto produce bird flu super vaccine

The Veterinary School of the Bogor Institute of Agriculture (IPB), and the institute's firm, PT Bogor Life Science and Technology, have cooperated with Japan 's Shigeta Animal Pharmaceuticals Inc. to develop a new vaccine for bird flu. Shigeta director Yoshiyuki Nishio, and PT Bogor Life director Thamrin Poeloengan, signed a memorandum of understanding and the team will work on an avian flu recombinant vaccine, which is claimed to be a modification of the existing vaccines currently used widely to deal with outbreaks of the H5N1 bird flu virus. Many experts said the existing vaccines could not prevent humans from being infected by the virus.

PT Bogor Life operational director Kamaluddin Zarkasie said that the new vaccine was the molecular modification of an organism that has high endurance. "We need the vaccine, because Indonesia has many poultry farms, with about 1 billion fowl," he added. Although no cases in humans have been found in Indonesia , 7.4 million chickens, ducks, geese, pigeons, and other birds were estimated to have died from the disease, and thousands of others culled. Ironically, as the central government, and the United Nations Food and Agriculture Organization (FAO) have revealed, bird flu could have been brought into the country via illegal vaccines, possibly from China, Mexico or Italy . FAO also suspected the virus was brought in through illegally imported livestock, and livestock products, which are widespread in Indonesia .

According to Kamaluddin, the team will produce 300 million dosages of the vaccine. "The first round of production will be carried out by Shigeta, which has the infrastructure. We shall produce it ourselves after we have all the facilities, maybe next year," he said. In the future, he added, PT Bogor Life would have the right to sell the vaccine to other neighboring countries vulnerable to the disease, including Malaysia, Myanmar, Thailand, the Philippines, and Viet Nam.
(Promed 7/16/04)

Japan: Human coronavirus NL63 detected in children

Recently, Dutch scientists announced they had identified a previously unknown coronavirus that was associated with respiratory disease in children and adults. The new coronavirus has been designated HCoV-NL63 and is clearly different from the three known human coronavirus species: Human coronavirus 229E, Humman coronavirus OC43, and the SARS coronavirus. HCoV-NL63 is associated with acute respiratory tract disease, but not the severe pneumonia associated with the SARS coronavirus. See Van der Hoek L et al., Identification of a new human coronavirus, Nature Medicine 10, 368-73, 2004 for more information.

A paper entitled "Detection of human coronavirus NL63 from children with respiratory illness in 2003 - Sendai City " has appeared on the Japanese National Institute of Infectious Diseases website <http://idsc.nih.go.jp/rapid/pr2935.html>. This novel human coronavirus, like the novel human metapneumovirus also detected first in The Netherlands, has been found also in patients in Japan, confirming its probable prevalence as a world-wide respiratory pathogen. The Virus Center of the Sendai Medical Center, a WHO designated respiratory disease center, reported the discovery of cases of respiratory illness in children caused by the NL63 isolate of human coronavirus (HCoV-NL63). RT-PCR tests were carried out on 189 randomly selected specimens from 412 cases of undiagnosed acute respiratory tract infection, in Sendai city, in 2003. Five positive results (2.6 percent) were obtained. Clinical diagnoses of the patients were "acute upper respiratory inflammation" in 4, and, "asthmatic bronchitis" in one.
(Promed 7/15/04)

Japan: Expert’s panel says no use testing young cows for BSE

A Japanese panel of experts on mad cow disease (BSE, Bovine Spongiform Encephaloapthy) said, in a draft, that testing young cattle for the disease is not technically feasible, suggesting the government's blanket screening rules could be eased. If the government adopts the report, it could also clear the way for a resumption of US beef imports, as Japan would also be likely to drop its insistence on blanket testing of all American cattle. Younger cows, particularly those younger than 30 months old, are generally not considered at risk of developing BSE, the report said 16 Jul 2004 . In any event, younger cows do not accumulate enough abnormal prions—the protein believed to cause the disease—to be detected by current tests, the report said.

The report added, however, Japan 's blanket testing regime has resulted in the discovery of BSE infections in young cows, such as a 21-month-old, and a 23-month-old cow. Japan introduced measures to screen every cow slaughtered for consumption, after it became the only country in Asia to have confirmed BSE with its first case in September 2001. The panel also emphasized the importance of excluding "risk materials," such as the brain, spinal cord, and eyes, from food-distribution systems. Japanese and US officials will hold a two-day working-level talk, starting Jul 21 2004 over the beef import ban. The panel's discussion followed a series of reports saying the panel was drafting a recommendation to stop BSE screening for young cows. The draft stopped short of that, however, and Cabinet officials said they were not aware of any such report. Japan banned beef imports from the US following the BSE discovery in December 2003. Japan has argued that the US must screen all slaughtered cows for BSE. Washington has rejected Tokyo 's demand, saying the blanket testing for young cow was not scientifically meaningful.
(Promed 7/19/04)

Hong Kong: Food poisoning, hotel restaurant

A total of 91 people became sick in a food poisoning outbreak at Regal Riverside Hotel in Hong Kong, according the Hong Kong 's Department of Health. The patients, aged 6 to 80, developed diarrhea, nausea, abdominal pain, and vomiting, after a buffet dinner 7 Jul 2004 . At least 19 people sought medical treatment and are now in stable condition, while a 38-year-old man has been discharged. The Hong Kong Food and Environmental Hygiene Department ordered the temporary closure of all of the four canteens at the hotel. The Hygiene Department said that workers would be sent to monitor the situation at the Regal Riverside Hotel, before the food outlets could resume operation again. The Department of Health will also conduct further tests. Without a stated incubation period for the outbreak, it is difficult to suggest an etiology. The stated absence of fever, however, does suggest a toxin-induced disease caused by organisms such as Staphylococcus aureus, Clostridum perfringes or Bacillus cereus.
(Promed 7/13/04)

South Korea: Hepatitis A virus infection on the increase

Authorities are on high alert, as the number of patients suffering from hepatitis A virus infection reached a record level in June 2004. The Korean Center for Disease Control and Prevention (KCDC) stated that the number of patients who contracted hepatitis A in June 2004 was 76, the highest monthly figure since Jan 2001, when the KCDC began a new method of calculating disease cases based on electronic data interchange (EDI). The figure is the highest compared to the previous monthly record of 53 people in March 2003, and 50 people in June 2002. South Chungchong Province topped the list with 45 hepatitis A cases followed by Kyonggi Province with 15, Seoul with 8, Inchon with 5, Taejon with 2, and Taegu with one. The KCDC, however, conducted a separate survey showing that a total of 63 people were confirmed to have contracted hepatitis A in Kongju, South Chungchong Province, in June 2004.

A KCDC official said, "It is a rare phenomenon that hepatitis A has broken out on such a large scale in an area which has no large-scale restaurant or eating facility. The KCDC sent out a research team, comprising around 10 experts, to Kongju. The survey showed that almost 80 percent of patients who had contracted hepatitis A in June 2004 had been to the same restaurant, where the landlord and his son were also found to have contracted the disease. The underground water supply that the restaurant used is a highly possible source of the trouble." Most recent hepatitis A outbreaks worldwide have been attributed to either water-borne or food-borne infection. The current widespread outbreak in South Korea is unusual in that both water-borne and food-borne routes of transmission of infection may be involved.
(Promed 7/13/04)

China (Gansu): Man dies after catching anthrax from cow

A herdsman has died after contracting anthrax from eating beef, in a rare occurrence of the acutely infectious disease in humans in China, local health officials said. The man, a Tibetan named Sangdan, died 11 Jun 2004, seven days after coming into contact with the infected animal in northwest Gansu province. "The man ate the meat of the diseased cow and later sold the skin and got infected," said Maqu county health bureau official Ma Shuyan. 35 people, who came into contact with him, have been quarantined. The infected area has been isolated, and cattle markets have been closed. "We checked all cows that had contact with the diseased cow, and none was infected," said the official. "We didn't slaughter them; we just vaccinated them. We have burned the skin and the other leftovers of the cow." While China 's Ministry of Agriculture refused to comment, statistics on its website show a handful of anthrax cases in livestock around the country every year. There is no record of the disease being passed on to humans before.
Promed 7/14/04)

Papua New Guinea: 30 dead from mystery disease

More than 30 people have reportedly died from a mysterious malaria-like disease in Papua New Guinea 's Southern Highlands province. Senior PNG doctor Alex Peawi says he has collected blood samples from five people who had malarial symptoms, but the results proved negative. The symptoms include headaches, nausea, vomiting, and yellowish eyes. Dr. Peawi says more people are being infected, and authorities need to identify the disease. "I did the necessary tests to exclude malaria, meningitis, and typhoid, but they all turn out to be negatives," he said.
(Promed 7/21/04)

AMERICAS

Canada: To enhance BSE feed controls

The Canadian Government announced that it will introduce new animal feed restrictions to strengthen Canada 's safeguards against bovine spongiform encephalopathy (BSE). The Government intends to require the removal of bovine specified risk materials (SRM) from the animal feed chain. SRM are tissues that, in infected cattle, harbor the BSE agent. These tissues are already removed from all animals slaughtered for human consumption. This measure will add additional security to Canada 's current feed ban, which has prohibited feeding cattle with ruminant materials, including SRM, since 1997. Preventing these potentially infectious materials from entering the entire feed production chain at the start diminishes the potential for cross-contamination of ruminant animal feeds that could occur as feed is produced and distributed, as well as any inappropriate on-farm use. Based on risk analyses, removing SRM from animal feed will more quickly reduce BSE incidence in North America by preventing future disease spread.

The Canadian Food Inspection Agency will introduce a regulatory proposal to require the removal and redirection of SRM, and dead and downer cattle, from all animal feed, including pet food. Given the importance of this measure, the Government has been carefully considering various options in consultation with provincial and territorial representatives, stakeholders, and international counterparts, including officials from the US Food and Drug Administration. The Government will continue to consult widely on the scope, implementation timetable, and other operational details for this measure as it is further developed.

Following the detection of BSE in North America, the international team of animal health experts that reviewed the Canadian BSE situation strongly endorsed removal and redirection of SRM from the animal feed chain. A similar recommendation was made by the team that reviewed the American BSE experience. Feed restrictions are universally recognized as the critical measure to contain the spread of BSE. Canadian and American authorities have worked cooperatively to develop coherent approaches to address BSE in North America . This effort reflects the integrated nature of the North American market and the shared commitment of both countries to implement science-based safeguards to protect animal health. Since detecting BSE in North America in 2003, the Government has taken significant steps to strengthen Canada 's BSE safeguards. Canada has excluded SRM from human food, is enhancing animal identification, and intensifying BSE surveillance. The additional feed controls will further strengthen the health of the national herd and complete Canada 's response to the key recommendations of the international team.
(Promed 7/13/04)

USA: USDA and HHS strengthen safeguards against BSE

HHS Secretary Tommy G. Thompson and Agriculture Secretary Ann M. Veneman announced 13 Jul 2004 that three actions being taken to further strengthen existing safeguards that protect consumers against the agent that causes bovine spongiform encephalopathy (BSE):

Import controls on live cattle, and certain ruminant products, were put in place more than 15 years ago in the US . In 1997, FDA finalized its animal feed ban, which has been the critical safeguard to stop the spread of BSE through the U.S. cattle population by prohibiting the feeding of most mammalian protein to cattle and other ruminant animals. USDA implemented additional measures January 2004 to ensure that no cattle tissues known to be high-risk for carrying the BSE agent are included in USDA-regulated products. Finally, as became evident last December 2003, there is a contingency response plan that is launched immediately to contain any potential damage after a BSE positive animal is found.

To allow interested parties and stakeholders the opportunity to comment on the additional regulatory and policy measures under consideration, USDA's APHIS and FSIS, along with the FDA, developed an advance notice of proposed rule-making [ANPRM] that includes several additional actions the federal government is considering regarding BSE. The ANPR also provides the public a succinct report on the work of the international review team (IRT) to review the U.S. response to the single US case of BSE. FSIS continues to seek and address comments on actions taken in relation to the BSE mitigation measures put in place January 2004. FSIS is also specifically seeking comments on whether a country's BSE status should be taken into account when determining whether a country's meat inspection system is equivalent to the U.S. regulations, including the provisions in the FSIS interim final rules. APHIS is specifically seeking comments on the implementation of a national animal identification system. In April 2004, USDA announced the availability of USD 18 million in Commodity Credit Corporation funding to expedite development of a national animal identification system. APHIS is inviting comments on when, and under what circumstances, the program should move from voluntary to mandatory, and, which species should be covered now and over the long term.

The ANPRM also requests comment on the following measures related to animal feed:

FDA has reached a preliminary conclusion that it should propose to remove SRM's from all animal feed. FDA also issued an interim final rule that prohibits the use of cattle-derived materials that can carry the BSE-infectious agent in human foods, including certain meat-based products and dietary supplements, and, in cosmetics. These high-risk cattle-derived materials include SRM's that are known to harbor concentrations of the infectious agent for BSE. Although FDA's interim final rule has the full force and effect of law and takes effect immediately upon publication in the Federal Register, FDA is also asking for public comment on it.

FDA is also proposing to require that manufacturers and processors of FDA-regulated human food and cosmetics containing cattle-derived material maintain records showing that prohibited materials are not used. Comments should be submitted as directed in the addresses section of each document. For more information, please visit http://www.fda.gov/oc/opacom/hottopics/bse.html
(Promed 7/13/04)

USA: FDA recommends firms not use high-risk cattle protein in cosmetics

The FDA is urging cosmetic firms to not use certain cattle-derived substances, because consumers run a slight risk in acquiring the human version of mad cow disease if they apply cosmetics tainted with bovine spongiform encephalopathy (BSE) to open cuts. The FDA notes that the primary path of human exposure to BSE is through ingesting beef, and other food, from cattle, but points out that small doses of the infectious prions can be found in cosmetics. But, "large uncertainties" exist about the number of cosmetic products that may pose a risk to human health, the agency says, adding, that any estimate of the risk would be imprecise. Moreover, the agency points out that considerable doubt exists about the origin of protein used in making cosmetics, the effect of processing on prion concentrations, and the transmission rates for dermal and ocular exposure. The FDA's assessment is qualitative, but it provides a "logical structure that a quantitative model could use if one were constructed," according to the agency. Some of the agency's uncertainties may affect both sides of a cost-benefit analysis, the FDA says. "…if there is not substantial use of cattle-derived protein in making cosmetics, then there will be little exposure, and, also, little economic consequence from regulating use. Conversely, high use would require substantial substitution and alternative means of animal-by-product disposal."
(Promed 7/19/04)

USA(New Mexico): state park employee contracts hantavirus pulmonary syndrome

The victim of New Mexico 's second case of hantavirus pulmonary syndrome, in 2004, has been identified as a state park employee who may have contracted the respiratory illness during the course of his employment. New Mexico State Parks Director Dave Simon identifies the man as a 54-year-old male, a 13-year veteran of the New Mexico State Parks. The park employee is believed to have contracted the illness in a maintenance unit at Fenton Lake State Park . He lives in Sandoval County and is at the University of New Mexico Hospital in critical condition. A San Miguel woman contracted a milder form of hantavirus infection in January 2004. She has recovered. The state's public health veterinarian is warning New Mexicans to take precautions against the disease. The virus is passed to humans who breathe in particles of urine or feces from infected rodents, especially deer mice. Early symptoms are fever and muscle aches, possibly with chills, headaches, nausea or vomiting, abdominal pain, and coughing.
(Promed 7/14/04)

USA (Virginia): Fatal Case of Hantavirus Pulmonary Syndrome

Health officials confirmed 16 Jul 2004 that a Virginia Tech graduate student died of a rare exposure to hantavirus, which causes severe pneumonia and sudden respiratory problems. The victim, a 32-year-old master's student in Tech's Department of Fisheries and Wildlife Sciences, is only the second case of hantavirus pulmonary syndrome (HPS) in Virginia . The other case, in 1993, involved a hiker on the Appalachian Trail who survived the disease.

HPS, which is not contagious from human to human, is caused by exposure to hantavirus-contaminated rodent feces, urine or saliva. There have been 318 known HPS cases in the US in recorded history through 2002 with a mortality rate of 37 percent, according to the CDC. Officials believe the student most likely came into contact with hantavirus while researching small-mammal communities in a forest in Randolph County, West Virginia . Concern was heightened when it was announced that a second man known to frequent Randolph County was hospitalized with HPS. Health officials said there is no evidence that the two cases are linked. Officials said there are no signs of a hantavirus outbreak in Virginia . However, if anybody is close to rodents, especially if they are cleaning up rodent feces, they need to take precautions, including wetting the area with a bleach and avoiding stirring particles into the air by sweeping.

The student died at Montgomery Regional Hospital 8 Jul 2004 as a result of pneumonia and acute respiratory distress. Eric Hallerman, an associate professor in the Department of Fisheries and Wildlife Sciences, said the department is compiling a list of everywhere the student worked during the previous 35 days as well as everyone with whom he worked and the animal species he may have handled. Those who worked with the student are being urged to watch closely for possible HPS symptoms. All students who enter the department are instructed in the safety precautions that must be taken while handling wild animals.
(Promed 7/17/04, 7/20/04)

USA(Multi-state): Salmonella investigation now focused on tomatoes

The U.S. Food and Drug Administration has begun trying to find the sources of the tomatoes, used in sandwiches at Sheetz convenience stores, to determine what might have caused a regional salmonella outbreak. FDA is moving ahead with the trace-back—even though public health officials haven't yet determined whether tomatoes or some other food product was the vehicle for the salmonella contamination, said Ellen Morrison, director of crisis management at FDA. State officials found 19 Jul 2004, that one tomato sample from Sheetz was contaminated with salmonella. But, it turned out that it was a different strain of the bacteria than the one blamed in the multistate outbreak, which has sickened roughly 160 people. The number of Pennsylvanians sickened grew to 130 cases, with anywhere from 16 to 50 people with salmonella in other states linked to the outbreak. Morrison noted there may never be a finding of just how food served at

Sheetz became contaminated. Sheetz purchased 99 percent of the sliced Roma tomatoes from Coronet Foods. FDA officials have visited Coronet Foods.
(Promed 7/21/04)

USA(Montana): Cantaloupe blamed for E. coli illness

Yellowstone City County Health Department deduced that the tainted melon was the likely source of an E. coli O157:H7 infection that sickened at least six children, ages 18 months to 5 years, at the Little Seeds Early Childhood Center. Dr. Doug Moore, chief medical director and assistant health officer for the Yellowstone City-County Health Department, said that how the cantaloupe became infected with the bacteria is still under study and may never be known. In some cases, E. coli O157:H7 has been known to cause serious illness in children: none of the Little Seeds youngsters needed hospital care. In May, June, July 2004, similar outbreaks occurred at day-care centers in Missouri and New York . While investigating the E. coli outbreak, the health department also discovered 8 cases of campylobacteriosis in children associated with the day-care center, which cares for 80 youngsters, infants up through age five.

Melons can be the source of enteric pathogens when the outside rind is contaminated, and, then, by cutting into the melon, the bacteria are introduced into the part of the melon that is eaten. Salmonella enteritidis serotype Poona has been linked to cantaloupes in the past.
(Promed 7/22/04)

Canada(Quebec): One dead, five ill from E. coli outbreak

In Quebec, a woman is dead, and five people are in the hospital, after handling ground beef contaminated with E. coli. The woman who died was in her 80s. The others were all very sick, according to health officials in Saint-Eustache, where the outbreak occurred. One patient remains in the hospital, but his/her life is not in danger. One of the patients apparently ate some of the meat without cooking. Health officials said the infections occurred between 4 Jul and 11 Jul 2004, adding that the bacteria was traced to a slaughterhouse.

An immediate recall was issued at the grocery store where some of the meat was bought, a Metro Plus Famille Martel in Saint-Eustache. There were similar recalls issued in nearby Rawdon and Mirabel. "This is probably a serious outbreak, because cases of E. coli are usually under-reported," says Doug Powell of the Canadian Food Safety Network. Meanwhile, the Canadian Food Inspection Agency has recalled ground beef from three stores in Quebec , and, from one in Labrador . The move comes after an inspection turned up E. coli in a batch of meat from Alberta . It's still not clear whether the E. coli outbreak in Quebec is linked to the Albertan shipment of contaminated meat. As Alberta 's beef industry struggles to put itself back into consumers' good graces, any doubt about the safety of its product is a big concern.
(Promed 7/21/04)

2. UPDATES

*Cholera, Diarrhea, and Dysentery *

Hong Kong
The Hong Kong Center for Health Protection is investigating a suspected food poisoning outbreak involving 39 people who ate at a hotel 7 Jul 2004 . The patients, aged 6 to 80, developed diarrhea, nausea, abdominal pain, and vomiting after the buffet dinner, but their symptoms were generally mild. 19 sought medical treatment and are now in stable condition, while a 38-year-old man was admitted to Princess Margaret Hospital . The center believes that this may be a bacterial food poisoning outbreak, and more affected people may be found as the investigation proceeds. Officers are interviewing and examining victims. Further investigations are in progress to determine the number affected, and to confirm the outbreak source.
(Promed 7/10/04)

South Korea
The number of food poisoning patients surged to a record monthly high of 2678 in May 2004, the Korea Food and Drug Administration (KFDA) reported. Authorities are taking measures to prevent a massive outbreak of food poisoning ahead of the hot summer season. Some 2336 people were found to have contracted the disease in June 2004. However, the number is likely to rise. A total of 88 food poisoning outbreaks occurred, creating 6074 patients in the first half of 2004. The number is almost the same as 6242 patients, from 79 outbreaks, during the same period of 2003. The food administration officials pointed out the need to improve meal services at schools.
(Promed 7/10/04)

Philippines(Pangasinan)
Pangasinan is in trouble as cholera stalks the province, said Department of Health Region One Director Eduardo Janairo. Janairo said not only Pangasinan but the whole Philippines is in trouble with cholera. WHO demanded the reporting of cholera cases in the Philippines, and WHO is now helping the Philippines stop cholera through donations of equipment and facilities. "This is a bad, very bad impression again on the Philippines …Politically and economically, it has affected us," he said. The cholera outbreak started 31 May 2004 , in Malasiqui, then spread to Calasiao, Basista, Urbiztondo, Sta. Barbara, Binmaley, Bugallon, Mangaldan, San Fabian, and San Carlos City . Of the 2055 reported cases of gastroenteritis in all the affected locales of Pangasinan, 81 were confirmed cholera cases. San Carlos appeared to be the worst affected, accounting for 654 cases and 7 deaths. Of the cases, some 45 were confirmed. Janairo said Pangasinan was a potential area for cholera, because in a survey conducted in 2000, only 75 percent of the population was using water-sealed toilets, and only 75 percent had been using a potable water supply.
(Promed 7/19/04)

*Dengue/DHF*

Hong Kong

The Hong Kong Centre for Health Protection has confirmed another imported case of dengue fever, in a 41-year-old man. This brings the total number of cases in 2004 to 15. The man developed joint pain, fever and rash 23 Jun 2004 , but recovered without hospitalization. He traveled within Asia 11 Jun 2004 , returning to Hong Kong 16 Jun 2004 . All the cases confirmed so far this year are imported cases. The center urged the public to stay alert to the threat of dengue fever and help in the reduction of mosquito breeding.
(Promed 7/16/04)

*Viral gastroenteritis*

USA
More than 130 visitors and workers became ill in Yellowstone National Park in late June 2004 during an outbreak of a highly infectious virus at Old Faithful and Lake . The cause of the illnesses appears to be a norovirus, which caused earlier outbreaks at Yellowstone and Grand Canyon National Parks . The virus can cause vomiting, diarrhea, nausea, and stomach cramping. Symptoms can come on quickly, and, usually, last one to two days. Investigators said it appears that the virus spread person-to-person, and, through contact with objects. Park officials said 53 visitors became ill, together with 71 concession employees and eight Park Service workers. Park officials responded quickly to the outbreak, and, got cooperation from the Wyoming Department of Health and the concession company. Norovirus makes an estimated 23 million people ill every year, according to CDC. The virus is most commonly spread through eating contaminated food, touching contaminated surfaces, and having direct contact with people with symptoms.
(Promed 7/16/04)

Australia (New South Wales)

More than 6000 people in New South Wales (NSW) have been hit by a virus infection in 2004, in what health authorities are calling a gastroenteritis epidemic. 2004's outbreak of norovirus infection had already overtaken 2003's total of 3570 cases. The health authority's communicable disease director, Dr. Jeremy McAnulty, said the increased incidence of the virus was placing added pressure on hospital emergency departments. Nursing homes, hospitals, child-care centers and schools were worst affected, with the upsurge possibly due to better reporting practices within those institutions. In the worst case, dehydration from vomiting and diarrhea could be fatal for anyone who was frail, but most people recovered within a few days. There's no specific treatment except for re-hydration. Exposure to the virus could be reduced by thoroughly washing hands before handling and eating food and before and after using a toilet.
(Promed 7/16/04)

New Zealand

An ESR scientist confirmed that viruses found in sewage have been identified in shellfish at the Bay of Islands . People are reporting bouts of food poisoning from pipi and cockles in Te Haumi and Waitangi and the shellfish are being tested as part of a study. Gail Greening said samples taken at the sites earlier this year show the presence of viruses that cause gastroenteritis. Greening said the study is testing shellfish from around New Zealand for viruses and other organisms that could be used as an indicator that viruses are present. Health protection officer, Tahi Morton, says people should not eat pipis, cockles or other kaimoana from Opua to Te Haumi, for at least a month. He says sewage pollution in the area is ongoing. One Bay of Islands woman said she has been campaigning for years against sewage pollution saying her people are regularly poisoned by it. The viruses found in shellfish around Paihia and Waitangi can cause severe vomiting and diarrhoea. The organism is likely to be a member of the norovirus family.
(Promed 7/16/04)

*West Nile Virus*

United States, July 14—20, 2004
During the week of July 14–20, a total of 74 cases of human West Nile virus (WNV) illness were reported from seven states ( Arizona, California, Florida , New Mexico, New York, South Dakota, and Texas ). During 2004, a total of 12 states have reported a total of 182 cases of human WNV illness to CDC through ArboNET. Of these, 125 (69%) were reported from Arizona . A total of 94 (54%) of the 182 cases occurred in males; the median age of patients was 51 years (range: 1–84 years); the dates of illness onset ranged from April 23 to July 14; and four cases were fatal. A total of 23 presumptive West Nile viremic blood donors (PVDs) have been reported to ArboNET in 2004. Of these, 21 (91%) were reported from Arizona, and one each was reported from Iowa and New Mexico . Of the 23 PVDs, two persons aged 66 and 69 years subsequently had neuroinvasive illness, and five persons (median age: 52 years [range: 22--63 years]) subsequently had West Nile fever. 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/mm5328a4.htm)

3. ARTICLES

Trichinellosis Associated with Bear Meat — New Yorkand Tennessee, 2003

“Trichinellosis is a parasitic infection caused by tissue-dwelling Trichinella roundworms and is associated traditionally with ingestion of pork from infected domestic swine. As a result of improvements in swine production, trichinellosis has declined steadily in the United States . However, infection also can result from eating the meat of wild animals. During 1997–2001, a total of 72 cases of trichinellosis (median: 12 cases annually; range: 11–23 cases) were reported to CDC; the majority of these infections were associated with eating wild game, predominantly bear. This report describes three cases of trichinellosis associated with eating undercooked bear meat reported from New York and Tennessee in 2003. To prevent trichinellosis, persons should cook meat, particularly wild game, to an internal temperature of 160 º F (71 º C)…”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5327a2.htm MMWR July 16, 2004/ 53(27);606-610)

Update: Investigation of Rabies Infections in Organ Donor and Transplant Recipients— Alabama, Arkansas, Oklahoma, and Texas, 2004

“On July 1, 2004, CDC reported laboratory confirmation of rabies as the cause of encephalitis in an organ donor and three organ recipients at Baylor University Medical Center (BUMC) in Dallas, Texas. Hospital and public health officials in Alabama, Arkansas, Oklahoma, and Texas initiated public health investigations to identify donor and recipient contacts, assess exposure risks, and provide rabies postexposure prophylaxis (PEP). As of July 9, PEP had been initiated in approximately 174 (19%) of 916 persons who had been assessed for exposures to the organ recipients or the donor. As a result of its public health investigation, the Arkansas Department of Health determined that the donor had reported being bitten by a bat (Frank Wilson, M.D., Arkansas Department of Health, personal communication, 2004)…”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5327a5.htm (MMWR July 16, 2004/ 53(27);615-616)

Acute Hemorrhagic Conjunctivitis Outbreak Caused by Coxsackievirus A24—Puerto Rico, 2003

“Acute hemorrhagic conjunctivitis (AHC) is an epidemic form of highly contagious conjunctivitis and is characterized by sudden onset of painful, swollen, red eyes, with conjunctival hemorrhaging and excessive tearing. Since 1981, when AHC was first detected in the Western Hemisphere, three major epidemics had occurred until 2003, all affecting the Caribbean . During August--October 2003, a fourth epidemic occurred in Puerto Rico (2000 population: 3.8 million). This report summarizes the outbreak investigation conducted by the Puerto Rico Department of Health (PRDOH), which documented an estimated 490,000 persons with illness, including >51,000 cases reported by physicians; demonstrated laboratory evidence of Coxsackievirus A24 (CA24); and determined that school-aged children (i.e., aged 5–18 years) and those living in crowded urban areas were at highest risk. To control outbreaks of AHC, prevention methods (e.g., frequent hand washing and avoidance of sharing towels and bedding) should be targeted to groups at highest risk, and information should be disseminated after the first report of AHC in the area…”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5328a2.htm (MMWR July 23, 2004/ 53(28);632-634)

The New England Journal of Medicine: Early Release

To coincide with presentations at the 15th International AIDS Conference, the following articles and related editorial have been published early at www.nejm.org:

CDC Emerging Infectious Disease Journal, Volume 10, Number 8—August 2004

August 2004 issue now available at : http://www.cdc.gov/ncidod/EID/index.htm

4. NOTIFICATIONS

Updated Information for Travelers about Avian Influenza A(H5N1)

In recent weeks, the World Organization for Animal Health (OIE; http://www.oie.int) has received reports of confirmed highly pathogenic avian influenza A (H5N1), among poultry in Indonesia, Vietnam, Thailand, and China. No associated human H5N1 cases have been reported during this period. In response, the four countries have instituted control measures and increased surveillance for H5N1 among poultry. While it is unusual for humans to get influenza virus infections directly from poultry, rare human infections and outbreaks caused by certain avian influenza A viruses have been reported to the WHO. All patients with confirmed H5N1 were severely ill, and many had a history of exposure to sick or dead poultry. Investigations showed no conclusive evidence of human-to-human transmission. CDC continues to recommend measures which specifies enhanced surveillance for suspected H5N1 cases among travelers with severe unexplained respiratory illness returning from H5N1-affected countries.

Travelers to Vietnam, Thailand, Indonesia, Cambodia, Laos, and China are advised to follow standard health recommendations for that region and, as a precaution, avoid places such as poultry farms and bird markets and avoid contact with sick or dead poultry. As with other infectious illnesses, one of the most important and appropriate preventive practices is careful and frequent hand washing. For more information about CDC’s health recommendations for travel to Asia, see http://www.cdc.gov/travel/seasia.htm and http://www.cdc.gov/travel/eastasia.htm.

The WHO summary also makes recommendations to countries about measures to prevent and control the disease: http://www.who.int/csr/don/2004_07_08/en/. For avian influenza health updates, see http://www.phppo.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00204

For previous avian influenza outbreaks see, http://www.cdc.gov/flu/about/avianflu.htm. For information about the embargos, see http://www.cdc.gov/flu/avian/embargo.htm.
(CDC 7/14/04, ProMed 7/17/04)

WHO publishes new guidelines on preventing mother to child transmission of HIV

The WHO has published new guidelines underlining the effectiveness of antiretroviral drugs to prevent the transmission of HIV from seropositive mothers to their children. These are the key recommendations from Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants:

Drug resistance linked to short-course regimens to prevent mother to child transmission that do not fully suppress the virus has been known since early 2000. Programs to prevent mother to child transmission and treat AIDS are rapidly expanding and antenatal clinics are able to identify more women who are HIV positive. Since these women are all expected to eventually require treatment, potential resistance has become a far greater concern. However, concerns about resistance need to be balanced with the simplicity and practicality of delivering single-dose nevirapine. Antiretroviral prophylaxis using single-dose maternal and infant nevirapine remains a practical alternative when provision of more effective regimens is not feasible. WHO will regularly review the evidence base for the guidelines and will issue updated recommendations.
http://www.who.int/mediacentre/releases/2004/pr50/en/print.html (WHO 7/14/04)

New edition of WHO prequalification list to include four new anti-AIDS medicines

Four new AIDS medicines are being added to the WHO prequalification list, thus further increasing access to a choice of quality products. Product assessment reports on quality and bioequivalence of triple fixed-dose combination (FDCs) antiretrovirals already prequalified will be made public. Manufacturing site inspection findings will soon also be published, which will make the WHO prequalification the most transparent of all similar quality assurance programs to date. The four new products being added to the list are: lamivudine (150 mg tablet) from a newly prequalified generic manufacturer and the antifungal fluconazole in three different strengths (50 mg, 150 mg, 200 mg capsules) also by a generic manufacturer. The lamivudine tablet is an alternative to the product manufactured by Cipla that was recently delisted due to lack of proof of bioequivalence. The new listing therefore expands the range of choice for that particular product to those programs wishing to use lamivudine. The current prequalified list now offers four different manufacturers for lamivudine; and seven fluconazole products in different strengths.

In keeping with the World Health Assembly resolution, WHO has taken measures to make public the assessment reports. The public assessment reports include information about products’ compliance with international standards for quality, safety and efficacy as well as bioequivalence for generic products. This information will be particularly useful to developing country regulatory authorities, procurement agencies and non-governmental organizations.

The WHO public assessment reports (WHOPARs) will assist in establishing the acceptability and appropriateness of a medicine and will provide indirect training and capacity building to regulators in countries that do not have sufficient regulatory capacity to fully assess products and determine their acceptability before licensing. The prequalification project will make available the findings resulting from inspections carried out at production sites according to Good Manufacturing Practices standards. No other quality assurance program makes both the assessment reports and inspection findings available to the public.
http://www.who.int/mediacentre/releases/2004/pr49/en/print.html (WHO 7/13/04)

WHO Regional Committee Meetings

WHO Regional Committees will meet to set policy and approve budgets and programs of work for each WHO region.

International Workshop on Tuberculosis Vaccines (TBVaccines2005)

The Cuban Society for Immunology and the Latin American Association of Immunology (ALAI), are organizing the "International Workshop on Tuberculosis Vaccines (TBVaccines2005)," 8-12 May 2005, at Varadero Beach, Cuba . The objective of the workshop is to exchange information about, and to discuss aspects related to, tuberculosis vaccine development for human and veterinary application, and, to have the opportunity to identify common interests for the implementation of international collaborative projects. The workshop will contain a Keynote Address, Interactive Workshops, and Poster Sessions, and will give a unique opportunity for discussion and cooperation to all colleagues from academia, industry, governmental services, and research institutes who are interested in sharing information about the latest developments in these fields. For comprehensive information about the workshop, please visit the "TBVaccines2005" website: http://www.finlay.edu.cu/tbvaccines2005/ or contact: Dr. Maria Elena Sarmiento, MD, Ph.D. Secretary, TBVaccines2005 Organizing Committee <tbvaccines@finlay.edu.cu>
(Promed 7/13/04)

Master of Science program in biohazardous threat agents and emerging infectious diseases

Georgetown University is initiating a Master of Science program in Biohazardous Threat Agents and Emerging Infectious Diseases. The program is sponsored by the Department of Microbiology and Immunology at the School of Medicine and is being coordinated by Dr. Leonard Rosenthal. The one-year course of study is intended to provide a thorough introduction to biodefense and emerging infections for persons planning careers in medicine, scientific research, or public policy. The program, which begins 1 Sep 2004, includes the following courses:

It also includes several seminars that will provide in-depth discussions of biological and chemical threats and biosurveillance. Electives are also available in the Department of Microbiology and Immunology and in the Department of Biochemistry and Molecular Biology. The deadline to register for fall term is 16 Aug 2004. A brochure for the program can be obtained at:
http://microbiology.georgetown.edu/Brochure_-_MS_in_Biohazardous_Threat_Agents_and_Emerging_Infectious_Diseases.pdf. Visit http://microbiology.georgetown.edu/education/msemphasis.html or call 202 687-3422.
(Promed 7/14/04)

Francis J. Curry National TB Center: Updated self-study online course on TB and HIV.

TB and HIV: An Online Course for Clinicians describes the transmission, pathogenesis, epidemiology, screening, diagnosis, and treatment of TB and HIV-1 coinfection, including information on treatment of latent tuberculosis infection and treatment of active tuberculosis disease in the presence of protease inhibitors. A set of brief "review cases" and a full-length interactive "case study" challenge the user to apply the content they have learned in the text.

To take the course, open the following link: http://www.nationaltbcenter.edu/tbhiv_course. The course is approved for 1.0 continuing medical education hours and 2.4continuing education credits for nurses. Credit is awarded to clinicians with a U.S. license only.
(WashingtonState Department of Health, 7/20/04)

Notice to Readers: Satellite Broadcast on Rapid Testing for HIV

CDC and the Public Health Training Network will present a satellite broadcast and webcast, "Rapid Testing: Advances for HIV Prevention," November 18, 2004 1 p.m. EST. The 2-hour forum will cover types of rapid tests for HIV, implementation considerations such as testing women in labor, confirmatory testing, and quality assurance. A panel of experts will answer viewers' questions, which can be sent via fax during the broadcast or by e-mail after the broadcast. Additional information for continuing education is available at http://www.cdcnpin-broadcast.org. Organizations are encouraged to register their sites as soon as possible so that persons who wish to view the broadcast can access information online. Directions for establishing and registering a viewing site are available on the broadcast website. The broadcast also can be viewed live or later on computers at http://www.cdcnpin-broadcast.org. Videotapes and CD-ROMs of the broadcast can be ordered 800-458-5231.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5328a5.htm

5. APEC EINet Activities

The APEC EINet team held a point-to-point video conference discussion with Taipei 's National Applied Research Laboratories (NARL) and Taipei Department of Health experts on 13 Jul 2004 . The successful one hour virtual meeting was held utilizing high quality Access Grid node technology. Topical disease priorities for bio-preparedness, such as SARS and avian influenza, were discussed, in addition to biopreparedness efforts currently practiced in Taipei and the USA . Additional point-to-point video conference meetings are currently being scheduled. The plenary in the future is envisioned involving all interested APEC economies over time.

6. JOIN THE E-LIST AND RECEIVE EINet NEWS BREIFS REGULARLY

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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©2004 University of Washington
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Last updated: 20 August, 2004