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Vol. I, No. 18 ~ EINet News Briefs ~ December 08, 1998

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

The EINet listserv 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 their perspectives and experiences, as your participation directly contributes to the richness of the "electronic discussions" that occur. To respond to the listserv, use the reply function.

In this edition:

  1. Vaccination against Japanese Encephalitis
  2. Overview of infectious–disease information from PRO–MED and other sources
  3. Updates from previous bulletins
  4. Notices
  5. How to add colleagues to the EINet listserv

apanese Encephalitis has been in the news recently following an outbreak in Malaysia, and this has brought attention to the important role that vaccination may play in preventing and controlling further spread of the disease. The Malaysian government promptly vaccinated more than 142 pig farm workers and took control measures to prevent vector transmission by eliminating breeding sites. The importance of vaccination was also demonstrated by Australia's recent inclusion of the vaccine in the Australian Vaccination Schedule. The vaccine is a highly purified formalin inactivated virus preparation derived from mouse brain and is widely used in Asia. The vaccine is given in 3 doses on days, 0, 7, and 30 and protection can be expected 10 days following the last dose. A shorter course of vaccination (Day 0, 7, and 14) can be used, but protection and duration is less than the normal schedule. A protective efficacy of 91% has been shown in children receiving 2 doses. The vaccine should be considered for persons traveling to endemic regions, and is not recommended for travelers under 1 year of age. Immunization of pigs has also shown to have a significant effect on preventing epidemics.

2. OVERVIEW OF INFECTIOUS–DISEASE INFORMATION FROM PROMED   Here is our regular 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), co–sponsored by WHO.


A dengue fever epidemic in Demak regency, and greater Semarang area is expected, following the deaths of six children from the same. 140 people have been treated for the potentially deadly illness in the last four weeks. Central Java authorities have begun fumigation with insecticides to avert the epidemic, but admitted that their scope was limited by the administration's budget.
[The Jakarta Post, 4/12/98]

Phase II trials of a dengue vaccine were commenced last month by Thai researchers in Nakorn Pathom. The vaccine was developed at Mahidol University, west of Bangkok, and is two to five years from commercial use. The Thai project, initiated in 1976 by the regional office of the World Health Organization, chose to make a live attenuated virus vaccine, an approach used successfully against poliomyelitis, measles and mumps. In seeking a strategic partner, the university signed a contract with the French company Pasteur Merieux Connaught, giving it a 20–year exclusive production and marketing license worldwide. However, the contract also includes a clause that says the vaccine would be affordable to children in developing countries. The Mahidol researchers are now also working in collaboration with the US Public Health Service on a ''second–generation'' dengue vaccine based on molecular biology techniques.
[Philippine Daily Inquirer, 20/11/98]

A medical team is investigating an unidentified illness that has killed five people and left 34 others sick in central Vietnam. The fatalities occurred over the past week in Suoi Da village, and the main symptoms were headcahe, chest pain, vomiting and coma. It is uncertain whether the disease was related to water contaminated by flooding two weeks ago that killed 14 people in the province.
[Nando Times, 5/12/98]


Japanese Encephalitis vaccine will be included on the Standard Australian Vaccination Schedule, following a recommendation from the National Health and Medical Research Council. The vaccine will be provided free to children aged one year and older, living in the high–risk communities in the Torres Strait and northern Cape York. The first cases of Japanese Encephalitis were reported from Badu Island in the Torres Strait in 1995, two of which were fatal. Following this outbreak, nearly 9,000 doses of inactivated vaccine were administered to the residents of the central and northern Torres Straits islands. A booster dose of JE vaccine was recently given to residents in the islands about three years after the primary series, in anticipation of the 1998/99 wet season (which has just begun). The first mainland case was diagnosed in Queensland in March 1998. This is the second case for this year, the other being an unvaccinated child from Badu Island. Seropositivity among pigs in these regions suggest that JE virus may have become epizootic, or perhaps even enzootic, in northern Australia, and this poses a significant threat to Australia due to the prevalence of suitable vector mosquitoes and vertebrate hosts throughout most of the mainland.
[Australia's Commonwealth Department of Health and Aged Care Website]
[ProMed, 28/11/98]

Papua New Guinea has been identified as a hot spot where co–epidemics of HIV/AIDS and TB have reached crisis levels. New estimates show HIV incidence in PNG last year as two per 1000 adults, and seven per 1000 for tuberculosis. These proportions are still well below those in Cambodia, which is now recording worse incidence rates than in East Africa. Papua New Guinea has only one anti–TB pilot project and while it may need the help and expertise of Australia, the Australian Government aid agency, AusAID is reluctant to commit to any new medical projects because of Papua New Guinea Government's corruption and unreliability. AusAID continues to support a Sexual Health Project, and has made a commitment to back the current project next year with a nationwide project. In the past ten years, a total of 1,346 people have been infected with HIV, and 133 out of 490 victims of full blown AIDS have succumbed to the disease. 40% of the 490 people affected with AIDS were between the ages of 15 and 25 years. Of the country's total population of 4.5 million, more than 40% are in this age group. Women tend to be the most vulnerable population with an infection rate of 63%.
[The National, 27/11/98, 1/12/98, 2/12/98]


An outbreak of E. coli has affected at least 28 children in a day care in Calgary. Public health officials were notified only eight days after the first case was detected on Nov.10. Health authorities are in the process of contacting and testing hundreds of children, their friends and families. The day care has 70 children and 17 staff. Hospital emergency departments have been alerted to watch for the disease. More cases are expected in the coming days as the outbreak could have spread to other day care centers or work sites where food is prepared. The origin of the outbreak is unknown. The last comparable outbreak was in 1996 when 23 cases were confirmed at a southwest Calgary day care. Prior to this outbreak, there have been 48 isolated cases of E. coli confirmed in Calgary this year.
[FSNET & The Calgary Herald, 25/11/98]

An outbreak of Yersinia pseudotuberculosis in the Vancouver area has become a cause for concern among epidemiologists in British Columbia. 40 cases, (60% being children below 3 years of age) have been identified so far, and the suspected source of contamination is food. Unpasteurised milk and undercooked pork have known to be associated with this disease which mimics appendicitis. The bacterium produces infection of the bowels, and has no relation to tuberculosis as its name might suggest. Fever, vomiting, diarrhea, and lower abdominal pain are common symptoms. The bacterium is found in farm animals, particularly pigs, as well as pets and wild animals. Scientists will begin testing food samples and interviewing people this week but it may take weeks to track the source. Being an uncommon disease, scientists lack enough expertise in this organism, especially since the average number of cases that have been reported each year are only five.
[GPHIN, 1/12/98]

An outbreak of haemorrhagic conjunctivitis has affected 11,465 people this year, 99% of cases being reported after June. Last year only 816 cases of haemorrhagic conjunctivitis were recorded, reflecting on a sharp increase this year. The disease is characterised by swelling and bleeding in the eyes, but the causative agent has not been reported as yet.
[Reforma, 2/12/98]

Continuing transmission of TB in the US even after implementation of DOTS was demonstrated in a prospective cohort study done in Baltimore, Maryland. 64 patients infected with clustered strains had no epidemiological links with each other, but shared the same risk factors as 20 other patients with the same clustered strains and were found to be geographically clustered on the periphery of the areas where the latter lived. This brings to attention the need to target neighbourhoods where transmission is occurring for active case finding, upper–room germicidal irradiation, screening, and preventive treatment.
[Eurosurveillance Weekly, Vol. 2, Issue 48, 26/11/98]


Epidemics of cholera, leptospirosis, and haemorrhagic dengue have been reported in Guatemala, Nicaragua, and Honduras, following Hurricane Mitch. The health authorities in these countries are taking great effort to improve epidemiological surveillance, that in turn has increased epidemiological reporting. The risk of leptospirosis is greatest in Nicaragua, and the Ministry of Health has responded by strengthening medical services, carrying out environmental health campaigns, using rodenticides, and identifying potential animal hosts. The cumulative number of cases of leptospirosis for the post–Mitch period is 523, and 7 deaths with a case–fatality rate of 1.3%. Guatemala has recorded 1,362 suspected cases of cholera in the first three weeks following Hurricane Mitch. 17 deaths and a case–fatality rate of 1.25% were reported. 1,165 suspected cases of classic dengue, 49 confirmed cases of haemorrhagic dengue, and 4 deaths have been reported in Honduras. El Salvador and Belize have reported outbreaks of cholera that are under control now. PAHO continues to recommend intensive epidemiological surveillance and vector activities, both in populations exposed to the open and those in shelters. More details on the epidemiological situation in Central America following Hurricane Mitch can be found at http://www.paho.org/english/ped/pedep30.htm

Investigations of an outbreak of MDRTB among 24 patients in Buenaventura, Colombia, in October 1997, revealed an evident lack of coordination and effective communication between personnel at local health posts. A wide gap between theoretical knowledge and practice in case finding, surveillance, management, and treatment of patients was found. Patients were responsible for sputum collection and transport of specimens. An analysis of the clinical management of the patients with resistance showed that only two thirds of the patients had been prescribed DOTS correctly, and none had been given the correct treatment regime after a failing DOTS treatment. The median elapsed time since first TB diagnosis was 4 years, and 100% of patients had at least a 2–year history of TB. 92% had TB medications improperly added and subtracted from their treatment regimes; only 72% of individuals who had abandoned treatment for 1 month or more had a smear done upon their return treatment; and 79% of the patients had abandoned treatment at least one time. Findings from this investigation have led to improvements in TB control efforts in Buenaventura in the form of structural changes, training for physicians and healthcare workers, use of DOT for both MDRTB and other patients, and new treatment regimes based on drug susceptibility testing results. Other recommendations that were added to the report focused on laboratory capabilities, infection control programs, and health education.
[CDC TB Notes Newsletter, No.3, 1998]

Perinatal HIV transmission will be receiving more attention from the Thai government following Princess Soamsawali's recommendations. Better follow–up of HIV–infected mothers and their children will be facilitated by extension of the ministry's free infant formula programme to children beyond one year of age. While both the ministry, and the Thai Red Cross Society have allocated more money and anti–retroviral drugs to HIV–positive women, the society provides therapy for a longer period (from 14㪺 weeks of pregnancy until delivery and intravenously to newborns)than the ministry. Thailand has experienced a dramatic reduction in unsafe sex practices during the past 6ף years following campaign efforts by the government. There is a potential for a change in behavior as the HIV/AIDS epidemic may not be perceived as a threat anymore. The economic crisis may also increase the number of sex workers in the country, some of whom may be coming from across the border in Vietnam and Cambodia. Other concerns have to do with targeting married women who have been infected by their husbands, and the long term consequences for HIV–positive women who are currently enrolled in clinical trials once they have been taken off AZT.
[Sea–aids, 25/11/98, 27/1//98]


Cultural beliefs about blood donation may make it harder for China to implement voluntary blood donation while attempting to eliminate illegal blood trade at the same time. Blood is equated with health in China, and blood donation is considered disrespectful to ancestors and parents. The Chinese Government has banned the sale of blood as of October 1 in an effort to reduce the spread of blood–borne diseases, especially HIV.
[U.S. News and World Report, 09/11/98]

The outbreak of E. coli in Yamaguchi Prefecture has affected 36 people so far, with 4 deaths, and one person in a critically ill condition. The source of contamination was found to be a daikon–tuna salad served in the nursing home which was consumed by 52 people, giving an attack rate of 69.2%. The salad contained daikon, lettuce, wakame, tuna, and non–oil salad dressing. The Health Department could not identify which food item was actually contaminated with E. coli O157:H7.
[Various Japanese news media, translated, 29/1//98]

The outbreak of Japanese Encephalitis in Perak has been brought under control following efforts by State health officials to eliminate breeding grounds of the Culex mosquito, the carrier of the virus. No new cases have been reported in the last few weeks, but health officials continue to monitor the situation. The Institute for Medical Research has confirmed the cause of the illnesses as Japanese Encephalitis virus.
[New Straits Times, 25/11/98]

The first day of the Global Congress on Lung Health was devoted to DOTS, TB/HIV, and MDRTB. Global targets for TB control would be reached only in 2025 due to the current slow expansion of DOTS strategy (2% per year), and thus the value of DOTS was emphasized with reference to cure rates of 78% in areas where it was used. Duration, and advances in treatment for patients co–infected with TB and HIV were discussed, and a clear message was that, standard duration of short course chemotherapy was adequate for TB/HIV patients. Preventive therapy was addressed in great detail, following which a symposium on rifapentine, a new drug, was held, and treatment outcomes were discussed. Failure rates with this drug are considerably lower than with rifampicin. The third day of the conference included a report on sequencing of the M. tuberculosis genome that will allow researchers to identify specific genes responsible for latency, virulence, resistance, and immunity. New diagnostic tools, drugs and vaccines were also part of the report. The human rights aspects of TB were also addressed in a symposium on patient organisations. Detailed reports on particular topics can be accessed at http://www.south–asia.com/ngo–tb/index.htm


The WHO Western Pacific Office (WPRO) Web site can now be visited at: http://www.who.org.ph/ STD, HIV and AIDS information can be accessed directly at http://www.who.org.ph/technical/programme/std.htm

Antibiotic susceptibility reports from volunteer laboratories in the U.S., Australia, South America, and Israel, are available on the ID Links web site. Standardized antibiograms show local and regional trends in antimicrobial resistance which would be useful to infectious disease specialists, clinical microbiologists, pharmacists and infection control practitioners. More antibiograms are welcomed to improve this site which can be accessed at http://www.idlinks.com tb.net

"People at Risk, Rights at Risk" is the title of the third tb.net conference and will focus on TB and Human Rights. The conference will be held in Kathmandu, Nepal from 24㪲 February 1999. The conference will have three groups of subjects; 1. Presentations and discussions on TB in groups of people often denied their basic rights; for example refugees, prisoners, and migrants 2. Debates on aspects of TB control that have been accused of denying basic human rights, such as; DOT, HIV testing, unavailability of treatment for MDR–TB 3. Workshops to empower organisations and individuals to take effective action to promote human rights; advocacy, social mobilization, andresearch The conference is open to all, and registration fee is $50. For more information, please contact Ms Upasana Shrestha, tb.net '99 conference manager at: Address: UMN PO Box 126, Kathmandu, Nepal Tel: 00977 1 613048 Fax: 00977 1 225559 Email: tb@mos.com.np

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 Asia–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.

December 08, 1998

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