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Vol. I No. 11 ~~~~~~~ EINet News Briefs ~~~~~~~ 24㪟㫺

****A free service of the APEC Emerging Infections Network*****

"EINet News Briefs" is transmitted over the EINet listserv, which was created to foster discussion, networking, and collaboration in the area of emerging infectious diseases (EIDs) among academicians, scientists, and policy makers in the Asia–Pacific region. We strongly encourage you to share their perspectives and experiences, as your participation directly contributes to the richness of the "electronic discussions" that occur. To subscribe to the listserv, see the bottom of this page.

In this edition:

  1. Enterovirus 71: Update
  2. Dengue Briefs
  3. Overview of infectious–disease information from Pro–MED and other sources
  4. Notices
  5. How to add colleagues to the EINet listserv

1. ENTEROVIRUS 71: UPDATE   As of July 1998, there have been 11 confirmed and 16 suspected cases of enterovirus 71 infections among children in Hong Kong, indicating that the virus has begun to be transmitted beyond Taiwan. The epidemic continues in Taiwan with 240 hospitalized cases and 52 deaths reported to date. Health providers and public health authorities in the region are asked to be on heightened alert for suspected cases of enterovirus 71. According to the HK Department of Health, the HK strain is of a weaker variety than the Taiwan strain and all patients have made full recovery. In Taiwan, the epidemic has already peaked; the number of suspected clinically apparent infections totaled more than 1,000 island wide, with 55 deaths. However, the DOH urges that the public continue with preventative measures such as frequently washing their hands.

Clinical Disease   The HK Department of Health asserts that definitive diagnosis of enterovirus 71 infection requires isolation of the virus from cell culture. Specimens for virus isolation include nasopharyngeal swabs, cerebrospinal fluids, rectal swabs, stool samples etc. The incubation period for enterovirus diseases is usually between 1 to 2 weeks, and viruses may be shed from the oropharynx from 2ן days before to 1מ weeks after onset of symptoms, and in feces for several weeks to months. In Taiwan, the DOH has completed examination of 108 cultured virus specimens obtained from those suspected to have died of the viral infections and those who had shown either severe or mild clinical manifestations. Among all these specimens, only 16 had shown positive reactions toward enterovirii, with 12 to enterovirus 71, two to Echo 6, and one each to Coxsackievirus Bס and Echo 4.

Although enteroviruses can cause a number of clinical diseases affecting the neurological, cardiovascular and respiratory systems, the majority of enterovirus infections in children are asymptomatic. Enteroviruses are important causes of aseptic meningitis and enchephalitis, neonatal sepsis, and acute febrile illnesses in children. They are also capable of causing paralysis and acute motor weakness. Enteroviruses are well known to cause pericarditis, myocarditis, stomatitis, hand, foot and mouth disease, haemorrhagic conjunctivitis etc.

Control and prevention efforts focus on avoiding congregations of young children, stressing handwashing, and early clinical detection and appropriate treatment. H. M. Hsu, deputy director of the Taiwan DOH's Bureau of Communicable Disease, suggested doctors check patients' brains with the aid of the magnetic resonance imaging to more effectively treat the disease. Clinical experience suggests that treating patients as though they had a primary cerebral process––i.e. by limiting intracranial swelling etc.––may enhance survival.

The Taiwanese Dept of Health has a new site on symptoms, diagnosis, treatment, and prevention at http://www.doh.gov.tw/focus/virus/english.html; the HK Department of Health has an updated clinical guide at http://www.ha.org.hk/clnguide/ev71v2.htm (or write the message GET http://www.ha.org.hk/clnguide/ev71v2.htm– to getweb@usa.healthnet.org). A comprehensive compilation of links and discussion on Enterovirus 71, HFM disease, the Malaysian, Taiwanese, and Japanese experiences can be located at http://www.geocities.com/HotSprings/2188/outbreak.html


CAN, 3㪟㫺
Nando Net, 18㪟㫺
South China Morning Post Archives, 25ע㫺
South China Morning Post Archives, 30㪞㫺
Taiwan Headline News, 29㪞㫺
Taiwan Headline News online, 3ף㫺


Malaysia (Sarawak): For the first 25 weeks of this year, 665 cases of dengue were reported; only 668 were reported last year. The disease had killed two persons and caused brain damage to another, Public Health Minister Dr Soon Choon Teck disclosed. The high number of cases were attributed to an outbreak of the disease during the beginning of this year. <Sarawak Tribune Online, 9㪟㫺>

Singapore: Twenty workers from China came down with dengue fever in June at their work site at the proposed Singapore Mega Exhibition Centre. One worker died. Environment Ministry (ENV) officers found _Aedes_ mosquito breeding sites in various locations at the work site, and ordered Hyundai Engineering and Construction to stop work for 4 days to clean up the premises. The place was fogged continuously with insecticide for seven days and work teams have been set up to keep the premises clean and safe. <The Straits Times, 3ף㫺>

Singapore: Environment Ministry (ENV) officers are testing high–tech aids in the battle against mosquitoes. Closed–circuit TV cameras are used to check mosquito breeding grounds, such as roof gutters and other areas that are difficult to reach. Insecticide–spraying equipment has been modified, with hoses rigged to poles that allow roof gutters to be sprayed without the need for ladders. In a one–year pilot project, a heating element placed in the drain was switched on and off automatically twice a week, to test the effectiveness of warm water in killing mosquitoes.

In another experiment, officials found that adult mosquitoes traps were able to catch the Aedes mosquitoes only when dry ice was added, because the carbon dioxide given off attracted the mosquitoes. However, the results were three to 11 times worse than the number of mosquitoes trapped by human bait, so the traps are now being used for Anopheles mosquitoes in malaria control. <Straits Times: 17㪟㫺>

Taiwan: Hsu Hsu–mei, deputy director of the Department of Health's Bureau of Communicable Disease Control, reported that 32 cases of dengue fever have been reported in Taiwan this year, and all were contracted during visits to Southeast Asian countries. <Central News Agency, 30㪞㫺>

Thailand (Gulf Islands): Three Australian tourists who recently traveled to islands in the Gulf of Thailand developed febrile illnesses. Dengue 1 virus was isolated from all three patients. These cases highlight the need for travellers to be aware of preventive precautions required when visiting dengue endemic regions, as well as for doctors to be alert to the possibility of dengue in travelers in order to diagnose cases early. Although it is considered unlikely that dengue will become endemic in Australia, large outbreaks can result from imported cases in the dengue receptive areas. <Communicable Diseases Intelligence (Australia), Vol 22, No 6, June 11, 1998>

Vietnam 08㪟㫺: The central province of Quang Tri's healthcare sector reports that 83 of its 138 communes have nearly 4,500 dengue patients, ten times more than last year. Healthcare workers have instructed local residents in mosquito–killing methods.


Here is our weekly summary of relevant Asia–Pacific EID issues based on postings to the ProMED Electronic Network, which is a prototype for a communications system to monitor emerging infectious diseases globally as an initiative of the Federation of American Scientists (FAS) and co–sponsored by WHO. More information about PROMED can be acquired contacting the moderator. Please contact the moderator if you would like more any of the reports below:


Cambodia (Phnom Penh) – Cholera  29㪞㫺  At least 30 people died in the town of Poipet between June 14 and 29 after a suspected cholera outbreak. The deaths take the number of suspected cholera cases to 110. Verena Carrara of Medecins Sans Frontiers (MSF) added that the real magnitude of the problem was hidden due to a "quasi–total absence of public health care services in the past," which inhibited those stricken from coming forward for treatment. Maurits van Pel, the MSF country coordinator, describing Poipet as a densely populated slum area with malnourished migrant workers. <AFP, 27㪞㫺> <The Straits Times, 10ף㫺, 11ף㫺>

Japan – Vancomycin–Resistant Enterococcus, Imported Chickens  09㪟㫺  Japan has found potentially lethal bacteria in chicken meat imported from France and Thailand, and has called for the governments of both countries to investigate the matter, Japanese government officials said yesterday. The meat carried vancomycin–resistant _Enterococcus_ (VRE), an intestinal bacteria resistant to antibiotics, which could kill aged or ill people whose immune systems are weak, Japan's Health and Welfare Ministry reported. The bacteria is believed by some experts to be linked to the use of avoparcin, an antibiotic used in chicken feed to prevent a range of diseases which if used extensively, fosters bacteria resistant to antibiotics like VRE. However, both the Japanese and Thai chicken industry officially stopped using avoparcin in feed years ago. <The Straits Times Interactive, 9ף㫺>

Singapore – Hand–Foot–Mouth Disease, Fatal  27㪞㫺  A 2ם/2–year–old Singapore boy has died of severe complications from hand, foot and mouth disease, the first death of its kind here since 1993. The disease is caused by a virus that is from the same family as enterovirus 71, which is linked to the deaths of 50 children in Taiwan. However, the boy and his family have not travelled to Taiwan recently, so health authorities believe the death may be a sporadic case of hand, foot and mouth disease with severe complications. According to the MOH, it has not detected any case of enterovirus 71 infection here so far this year.

Taiwan – Infectious Diseases on the Rise 10ף㫺   Following a period of scorching temperatures, a host of infectious diseases are invading the island, the Department of Health announced. So far this year, scrub typhus case counts are three times higher than the number reported in the same period last year. In addition, there have been nearly twice the number of Taiwanese infected with scarlet fever, dengue, and Japanese encephalitis compared to the same period last year. Meanwhile, malaria and typhoid fever are also on the rise in Taiwan. National Quarantine Service Director Wu Tsung–neng indicated that the warming of the climate has made the viruses and micro–organisms particularly active, while a damp environment such as Taiwan–s allows them to breed more easily.


New Zealand – Meningitis, Meningococcal   20㪟㫺   The outbreak of meningococcal meningitis that began in April has now totaled 187 cases, with 12 deaths. This represents 27 more cases, and 3 more fatalities than were experienced last year during the same time period. However, last year's outbreak was far above previous norms.

Parents have been warned to take children back to the doctor if their condition deteriorates rapidly after the initial visit. Dr. Michael Baker, of the Communicable Diseases Centre in Wellington, said that occurrence of the disease in New Zealand typically occurs in 5 to 15–year epidemics. The country is now in its 7th year of the current cycle. <Christchurch Press, 27㪞㫺>


USA (Georgia) – E. coli, Hemolytic Uremic Syndrome   26ע㫺   Georgia Public Health officials have confirmed 25 cases of E. coli 0157:H7 in children. All cases, of which 17 were from Georgia and eight from out of state, attended White Water Recreation Park on June 11, 12 or 17. Authorities believe children were infected after swimming in a pool in which an infected child defecated. Park managers acknowledged that chlorine levels in one children's pool had registered as low as one–quarter of the county's minimum standard on the days that state officials say E. coli bacteria in that pool infected several children. <David L. Swerdlow, MD, Acting Chief Acting Chief and Robert V. Tauxe, M.D., M.P.H. of the CDC>

USA (Illinois) – E. coli Foodborne Outbreak   24㪞㫺   A form of the _E. coli_ bacterium lurking in food prepared by a catering company caused more than 5,000 people to fall ill, health officials said. The Illinois case was the largest documented outbreak in the US of the strain called enterotoxigenic _Escherichia coli_, or ETEC, Cook County Health Department officials said. The bacterium was identified in stool samples from three victims of the illness known as "traveler's diarrhea," said Stephanie Smith, the department–s director of communicable disease.

So far, the most common link between patients is potato salad, though it remains only one suspect food in the investigation. Officials from the federal Centers for Disease Control and Prevention were conducting tests to isolate the bacteria in the food or water at the catering company in suburban Orland Park. Although ETEC is common in developing countries, the CDC in Atlanta has tracked just 14 ETEC outbreaks in the U.S. in the last 23 years, Smith said. <Nando net, 24㪞㫺>

USA (Illinois & Wisconsin) – Leptospirosis  18㪟㫺  The Centers for Disease Control and Prevention on Friday asked for help in warning 966 people who participated in the Springfield, Ill., Ironhorse Triathlon (a foot, bicycle, and swimming race) on June 21 and 850 athletes from the 1998 Bally Total Fitness USTS Triathlon in Madison, Wisconsin, on July 5. Five people from the competitions became ill with fever and other symptoms consistent with leptospirosis, an illness that, if left untreated, could result in liver or kidney damage. More than 1,800 participating athletes from 44 states may be at risk.

USA (Indiana) – E. coli, Foodborne Outbreak   25㪞㫺   In May, the Indiana State Department of Health investigated an outbreak of E. coli O157:H7. Twenty–seven confirmed cases were eventually identified. None developed HUS (hemolytic uremic syndrome), and none died. A case control study identified one particular franchise of a restaurant chain as the source and implicated cole slaw as the food vehicle responsible. A consumer sample of cole slaw yielded E. coli O157:H7 which shared the same PFGE (pulsed field gel elecctrophoresis) pattern as the cases.

A review of cole slaw preparation procedures at the restaurant revealed that food service workers at the implicated restaurant were removing the outer leaves but were not washing cabbage heads prior to shredding, which was not consistent with the restaurant chain's standard operating procedures, which requires the washing of cabbage prior to shredding. The CDC and FDA are collaborating on the cabbage traceback investigation and environmental sampling.

USA (Wyoming) – E. coli Infections, Unknown Source   14㪟㫺  According to the Wyoming Dept of Health, as of July 13, 11 people have tested positive for _E. coli_ (0157:H7) poisoning in the Star Valley area, 4 of which were hospitalized. However, everyone confirmed to have the infection had onset between June 28–July 3, indicating there is no continuing source of contamination. A total of 48 people displayed symptoms of the infection and the additional cases are still under investigation. Officials in Alpine, Wyoming have no clue about the source of the bacteria, but are looking at the water supply, which is not routinely chlorinated. <Green River Star newspaper, July>

US – Hepatitis C & Transfusions   8㪟㫺   The U.S. government has begun the first phase in notifying people who may have been accidentally infected with the hepatitis C virus during blood transfusions. Letters will be mailed to those who received transfusions from blood donors who have since tested positive for the virus. People who received blood before June 1992, when the most reliable screening test was instituted, are at risk.

Screening tests for the virus were implemented after 1990, greatly reducing the risk of transfusion–borne viral transmission. Experts believe the chance of such transmission today is between 1–in㪢,000 and 1–in𤩔,000. Last year, a government panel composed of liver experts and medical ethicists estimated that 290,000 people may have contracted the potentially serious liver infection during pre� transfusions.


ARTICLE: Korea – Malaria   "Reemergence of Plasmodium vivax Malaria in the Republic of Korea" Emerging Infectious Diseases, Feighner et al., U.S. Army, Republic of Korea – 4(2):295𤬙, 1998, CDC.

Plasmodium vivax malaria reemerged in the Republic of Korea in 1993. The number of cases has tripled each year since, with more than 1,600 cases reported in 1997. All 27 cases in U.S. troops resolved uneventfully with chloroquine/primaquine therapy. Disease is localized along the western Demilitarized Zone and presents minimal risk to tourists. Full article at http://www.cdc.gov/ncidod/EID/vol4no2/feighner.htm

UK – Transfusion–Transmitted Virus, (TTV), Research   17㪟㫺   A newly–discovered virus that may infect up to one in 10 of the (British) population. The virus, known as TTV, was discovered in Japan a year ago. But two British studies about to be published will reveal for the first time that the infection is probably worldwide. One study found that TTV was present in two per cent of blood donors in Scotland, that half of the blood products were contaminated with it, and that one in five sufferers of severe hepatitis were infected. The second study found TTV in one in 10 healthy people in England. Researchers concluded that TTV probably does not cause chronic liver disease and does not seem to be connected to any other illness.

The PROMED moderator (CHC) noted that thus far no one has shown that this DNA is infectious, so its status as a virus is unclear. <Daily Telegraph, London, 17㪟㫺>


ASTWeb,  the Web site of the APEC Industrial Science and Technology Working Group (ISTWG), has been revised with new features. The site offers information, resources and discussion fora for individuals and organizations with an interest in the ISTWG's vision of sustainable economic prosperity built on industrial science and technology (including policies oriented toward human health). Visit http://www.apecst.org and use the "guest" login.

5. HOW TO JOIN THE EMAIL LIST and receive EINet News Briefs 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 own material with their colleagues in the Asian–Pacific Rim. To subscribe (or unsubscribe), please contact Nedra Floyd Pautler at pautler@u.washington.edu. Further information about the APEC Emerging Infections Network is available at http://www.apec.org/infectious.

July 24, 1998

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