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Vol. VII, No. 26 ~ EINet News Briefs ~ Dec 10, 2004


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
- USA (Wisconsin): Wisconsin girl is first unvaccinated patient to survive rabies infection
- USA (New Jersey/Florida): Tests inconclusive on source of botulism toxin
- Canada: Botulism, food recall and alert
- USA (California): More skin infections linked to pedicures reported in San Jose
- USA/Germany: Probable third imported case of West Nile virus infection since 2003
- Russia: Misinterpretation of data on isolation of avian influenza A (H5N1) virus
- Belgium/Thailand: Smuggled birds raise fears of avian flu spread
- Singapore: May test couples for HIV before marriage
- China: Global Fund chief warns of catastrophe if China eases up on AIDS efforts
- Japan: BSE's anomalous prion detected from non-SRM in dead cow
- Japan: Hepatitis E Virus Detected in Liver and Blood of Wild Boar
- Japan: Six cases of hepatitis E virus infection contracted via pork barbecue
- Indonesia: Measles outbreak kills 10 in Alor
- Philippines: Health official says meningitis-like disease not an outbreak
- Russia (Tambov): Two lethal cases of meningitis in Russia
- Russia: Cases of trichinellosis
- Russia: Two human cases of rabies contracted from pet cats in Pereslavl

1. Updates
- Cholera, Diarrhea, and Dysentery
- West Nile Virus

2. Articles
- CDC Emerging Infectious Diseases Journal, Volume 10, Number 12-December 2004
- Two Cipla AIDS medicines back on WHO prequalification list
- Replication of Norovirus in Cell Culture Reveals a Tropism for Dendritic Cells and Macrophages.
- Diagnoses of HIV/AIDS --- 32 States, 2000--2003
- Number of Persons Tested for HIV --- United States, 2002
- Salmonella Serotype Typhimurium Outbreak Associated with Commercially Processed Egg Salad --- Oregon
- Brief Report: Tuberculosis Outbreak in a Low-Incidence State --- Indiana, 2001--2004
- Acute Flaccid Paralysis Surveillance Systems for Expansion to Other Diseases, 2003--2004

3. Notifications
- Eighth Annual Conference on Vaccine Research
- Ninth International Course, Dengue and Dengue Hemorrhagic Fever
- International Wildlife Disease Association Meeting 2005
- International Conference on Diseases in Nature Communicable to Man
- EID Advanced Laboratory Training Fellowship
- EID Post-Doctoral Laboratory Research Fellowship

4. APEC EINet activities
- Zoonoses meeting in Republic of Korea

5. To Receive EINet Newsbriefs
- APEC EINet email list


Global
USA (Wisconsin): Wisconsin girl is first unvaccinated patient to survive rabies infection
A Wisconsin teenager is the first human ever to survive rabies without vaccination, the CDC said, after she received a desperate and novel type of therapy. Last month, doctors at the Children's Hospital of Wisconsin in Wauwatosa, a suburb of Milwaukee, put the critically ill girl into a drug-induced coma and gave her antiviral drugs, although it is not clear which, if any, of the four medicines contributed to her surprising historic recovery. But even the doctors who took care of her said the result would have to be duplicated elsewhere before the therapy could be considered a cure. Dr. Rodney Willoughby, the associate professor of pediatrics who prescribed the cocktail of medicines for the 15 year-old sick girl, said, "Until then, it is a miracle."

The girl was bitten by a bat at a church service 12 Sep 2004. She did not visit a doctor and so was not vaccinated. The bat drew blood, he said, but the bite was quick and small, so the girl thought she had just been scratched. Her fellow churchgoers picked it up after it flew into a window and threw it out the door. On 18 Oct 2004, she was admitted to the hospital with fluctuating consciousness, slurred speech and other symptoms typical of full-blown rabies.

Rabies is caused by a virus present in secretions from an infected animal. The vaccine, which stimulates antibodies to the virus, eliminates the chance of getting the disease if it is administered within days after the initial exposure. Once symptoms develop, generally after a few weeks, vaccination becomes much less effective. They are useless when the rabies is advanced, so doctors opted in for the experimental treatment in this girl's case. Only a handful of people have recovered after developing even the earliest symptoms of rabies, and all of those were given the vaccine. The technique of inducing comas has been used by neurologists in patients with large brain injuries from infection, injury or stroke. But it had not been tried for rabies. The girl's doctors said they would not disclose which medicines they had used until publishing their findings in a medical journal. Dr. Willoughby said he had tried to induce the coma in part because evidence suggested that rabies did not permanently damage any brain structure. Instead, death comes because the virus seems to cause temporary dysfunction of brain centers that control critical functions like breathing and swallowing.

While rabies kills tens of thousands of people in Asia, Africa and Latin America, it is rare in developed countries. Even if the girl's treatment proves successful in a second patient, it is not clear how widely it could be used, since it requires an intensive care unit with all its high technology. Still, Dr. Willoughby said he expected the girl to make a good recovery. She is already responding perfectly to questions by pointing to a message board or nodding her head. (Promed 11/26/04)

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USA (New Jersey/Florida): Tests inconclusive on source of botulism toxin
The source of botulism toxin found in four people is unknown, because tests to determine whether they contracted a potentially fatal paralyzing illness from being injected with an anti-wrinkle treatment, or got the toxin some other way, were inconclusive, officials said 7 Dec 2004. Investigators suspect that the four people, two in New Jersey and two in South Florida, may have been injected with botulinum toxin for cosmetic reasons. All four have been hospitalized since 27-28 Nov 2004. CDC tests detected botulism toxin type A in the blood from three individuals. Specimens were not available for the fourth person. "We don't know in this incident just yet what the specific cause of their condition was," Florida Health Secretary John Agwunobi said. Agwunobi noted that the toxin also causes the type of botulism that comes from eating contaminated foods, or from having a wound contaminated by botulinum bacteria. But the toxin is also used in injected cosmetic anti-wrinkle preparations, and Agwunobi noted that the four people involved "all had access to anti-wrinkle injections." Agwunobi also stated that, while the probe is ongoing, investigators have been unable to extensively question any of the four victims. The state Department of Health released a statement saying that typical botulism toxin doses contained in approved commercial anti-wrinkle preparations, when appropriately administered, have not been associated with illnesses of the severity demonstrated by the four people who were hospitalized. The department has not received reports of any additional potential cases that may be linked to the four cases, but, that epidemiologists are monitoring hospitals, labs, and poison control logs in an effort to determine whether other related cases exist. Officials also say that there is no indication the poisoning is related to bioterrorism. (Promed 12/9/04)

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Canada: Botulism, food recall and alert
The Canadian Food Inspection Agency and Akita Food Inc are warning people not to consume Compliments brand Citrus Infusion Dipping Oil, because the product may contain bacteria responsible for botulism. The affected product was prepared for Sobeys Inc. It is packed in a 375 ml glass bottle bearing UPC 0 55742 35526 0. All lot codes are affected. The manufacturer, Akita Food Inc, of Delson, Quebec, is voluntarily recalling the product. Clostridium botulinum is the bacteria responsible for producing the botulinum toxin. Consumption of contaminated food products is one method of introducing the toxin into the body. (Promed 11/29/04)

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USA (California): More skin infections linked to pedicures reported in San Jose
The number of women believed to have developed serious skin infections after receiving pedicures in San Jose, California has risen, and there are new ideas about how bacteria is spreading despite attempts by many nail salon owners at following state cleanliness guidelines. Santa Clara County Public Health Department spokeswoman Joy Alexiou said there are now 40 cases being investigated, a jump of 10 cases reported in a single day. Health officials began receiving reports from local doctors as early as May 2004 regarding an influx of patients with boils and skin ulcers on their feet and lower legs. It was determined that the women received pedicures prior to the infections, which likely stemmed from using a whirlpool foot bath, which are notorious breeding grounds for bacteria.

The infection stems from the spread of a nontuberculous mycobacterium, a microbe that causes painful open sores that have forced some women in years past to undergo reconstructive surgery to hide the scars. In 2001, the state cosmetology board adopted new regulations to ensure that foot spa equipment is properly maintained. Between each customer, the foot spa must be drained and cleaned with approved disinfectant as well as soap, according to state cosmetology board spokeswoman Patti Roberts. Roberts said at the end of each day the foot spa screen, along with any debris, must be removed before cleaning the basin with soap and water. Every other week, the basin must be cleaned and soaked with a bleach solution for at least six hours. Still, the bacteria could hide in the foot spa's jets. Each foot spa should be run for 10 minutes while being soaked in approved disinfectant, eliminating the hiding bacteria. (Promed 12/3/04)

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USA/Germany: Probable third imported case of West Nile virus infection since 2003
Transmission of West Nile virus infection within Germany via bites from mosquitoes that have had contact with migrating birds is thought to be a possibility, although no such transmission has been reported. Imported cases are also possible in people returning from areas of high virus prevalence. In 2003, a 77 year old man from Lower Saxony and a 51 year old woman from Bavaria became ill with West Nile virus infection after traveling in areas of high prevalence in the USA. A third probable case has recently been discovered. A 77 year old woman from Weimar became ill 20 Sep 2004 during a tourist trip to California 4 Sep - 4 Oct 2004. She developed acute encephalitis with fever, and experienced continuous impaired consciousness over a few days. The patient was treated in a US hospital from 20 - 30 Sep 2004, and West Nile virus infection was suspected. After her return to Germany, she experienced further symptoms of memory impairment and muscle weakness and was treated in hospital 11 Oct 2004. The results of serological tests indicated an acute West-Nile infection: anti-flavivirus IgM ELISA test of blood serum and cerebrospinal fluid was positive, and according to hemagglutination tests, the anti-West Nile IgG titre in cerebrospinal fluid was 1:160 positive and in serum 1:2560/5120. In view of the results, clinical presentation, and the case history (the patient reported an insect bite during a stay in an epidemic area), West Nile virus infection is very likely, but further confirmation is still awaited. The patient is currently recovering in a rehabilitation clinic. West Nile virus fever is not currently notifiable in Germany, so cases are notified as "health threats". (Promed 12/8/04)

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Asia
Russia: Misinterpretation of data on isolation of avian influenza A (H5N1) virus
Russia: Misinterpretation of data on isolation of avian influenza A (H5N1) virus A recent report in the media indicated that an avian influenza A (H5N1) virus had been isolated from migrating birds in the Novosibirsk region of Russia (see EINet bulletin Vol. VII, No. 23 Oct 29, 2004). The report is a misinterpretation of the scientific data. In a joint avian influenza project in wild birds between laboratories at the "Vector" State Virology and Biotechnology Institute, the Ivanovski Institute of Virology and the U.S. Department of Agriculture, several avian influenza viruses including H5-type influenza viruses have been isolated from migratory birds in Russia over the past four years. In 2003, an H5 avian influenza A virus was isolated by the Laboratory for Investigation and Surveillance of Emerging Zoonotic Diseases (Novosibirsk, Russia) from a wild mallard duck on lake Chany in the south of Western Siberia and sequenced to determine relatedness to other H5-type avian influenza A viruses in Asian poultry. The /mallard/Chany/9/03 avian influenza A virus was related to, but was not identical to current avian influenza A (H5N1) viruses circulating in domestic poultry in Asia.

The A/mallard/Chany/9/03 avian influenza virus has hemagglutinin sequence similarity in the 90-95 percent range to the current Asian influenza A (H5N1) virus, which is similar to sequences of other Eurasian H5-type avian influenza viruses, including A/duck/Potsdam/1402-6/86 (H5N2) and A/turkey/England/50-92/91 (H5N1). These data emphasize the need for continuing surveillance of migratory birds for avian influenza viruses, and studies of such viruses will increase our understanding of avian influenza viruses, especially in transfer of such viruses between migratory birds and domestic poultry. However, the A/mallard/Chany/9/03 avian influenza virus is not the same virus as the Asian H5N1, and is not evidence of infection and spreading of the current Asian H5N1 avian influenza virus by migratory birds. (Promed 11/30/04)

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Belgium/Thailand: Smuggled birds raise fears of avian flu spread
When customs officials opened a small suitcase being carried through the Brussels airport by a Thai traveler 18 Oct 2004, they found two rare small eagles, weak but healthy-looking, taped inside lengths of PVC pipe. Four days later, test results showed that the smuggled birds were infected with avian influenza H5N1. The finding launched a frantic hunt for the man who carried the eagles, the officials who inspected them, and the 135 passengers who shared the man's two flights. 23 people were tested; 652 birds that had been in the airport, including the eagles, were destroyed. The episode did not spark an outbreak, but it shook international health authorities. It demonstrated that trade in smuggled wildlife could become an inadvertent and efficient ally in moving a lethal disease globally. Underscoring that fear, three weeks later, customs officials in Taipei found 28 parrots packed into PVC pipe in a piece of hand luggage that had been carried from Indonesia. "…There are almost certainly others that have not been caught," said Dr Peter Daszak, executive director of the Consortium for Conservation Medicine in New York. The US Fish and Wildlife Service, the primary federal entity charged with intercepting smuggled wildlife, has only 100 inspectors spread among US ports, airports, and border crossings. "The resources that are put into trying to police the illegal trade are minuscule," said Peter Knights of the anti-smuggling organization WildAid. "We seem to be extremely worried about anthrax and bioterrorism, but there is a risk here that we are not taking seriously enough."

So far in 2004, avian influenza H5N1 has caused illness in 44 humans in Thailand and Viet Nam, killing 32 of them, as well as causing the slaughter, or death from illness, of more than 100 million birds, but it has not moved beyond eight South East Asian countries. On 29 Nov 2004 a WHO official warned that, if avian flu gains the genetic ability to move easily from person to person, it could cause up to 100 million deaths around the world. Last month, WHO summoned vaccine manufacturers to its Geneva headquarters for an emergency summit, warning that the world's capacity for making pandemic flu vaccine stands at only 330 million doses. (Promed 12/7/04)

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Singapore: May test couples for HIV before marriage
Couples in Singapore may face mandatory HIV tests before marrying, Singapore media reported, a week after the government said all pregnant women would be screened for HIV/AIDS to stem a rise in new infections. Health Minister Khaw Boon Wan said Singapore planned to seek public feedback on the pre-marital HIV tests in Singapore. "I think we are more likely to succeed if we treat this as a purely public health problem, so let's take away the morality and religion from all this," he said. Although Singapore has one of Asia's lowest levels of HIV infection, it is tightening defenses after data from health workers showed women and girls in Asia increasingly at risk of becoming infected with HIV. Khaw said Singapore was at the beginning of a second wave in the development of HIV, where more women are becoming infected. Singapore media reports have recently focused on the problem of men visiting prostitutes while travelling in Asia. The number of new infections is already at a record high this year with 257 cases reported in the first 10 months of 2004, topping the 242 new cases reported for all of 2003. Health officials say Singapore, a tiny island of 4.2 million people, could face 1,000 new cases a year by 2010 according to current trends. To date, Singapore has recorded a total of 2,332 HIV infections, of which 874 have died. Activists say AIDS awareness efforts are undermined in Singapore by antiquated laws that make gay sex illegal between men. (SEA-AIDS eForum 2004: sea-aids@eforums.healthdev.org 12/8/04)

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China: Global Fund chief warns of catastrophe if China eases up on AIDS efforts
The head of the Global Fund to Fight AIDS, Tuberculosis and Malaria praised China for its efforts in addressing HIV/AIDS, but warned that any letup could prove catastrophic. "We have seen an impressive turnaround in China over the past year," the Fund's executive director Richard Feachem said here. "China has realized that widespread epidemics, such as HIV/AIDS, TB and malaria, pose a serious threat against economic development, poverty reduction and a stable society." He pointed to China moving to put anti-discrimination laws into practice and initiating prevention activities in the fight against AIDS. But he cautioned of "an urgent need" to ensure political commitment at all levels, to increase HIV testing and to improve planning or face disastrous consequences. "It would be fantastic if China could show the world how to contain the epidemic," he said. "However should we fail, the consequences would not only be catastrophic for China -- they would be felt all over the world." While China's AIDS crisis was sparked by illegal blood sales in the 1980s and 1990s, the problem areas now were also related to intravenous drug use and unsafe sex, he said. China estimates it has 840,000 HIV/AIDS sufferers although international AIDS experts say the actual number is much higher. Premier Wen Jiabao admitted last week China faces a "stark situation" in tackling the epidemic and called for greater efforts in creating public awareness and fighting the disease. China for years denied AIDS was an issue and only started seriously addressing the problem in the past two years. Since it was created in January 2002, the Global Fund has so far given 113 million dollars to China to fight HIV/AIDS, tuberculosis and malaria. Feachem said that if the grants show agreed results in their first two years, another 160 million dollars would be made available. (SEA-AIDS eForum 2004: sea-aids@eforums.healthdev.org 12/8/04)

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Japan: BSE's anomalous prion detected from non-SRM in dead cow
The National Institute of Animal Health announced 1 Nov 2004 that it had detected the anomalous prion protein that is the etiologic agent of BSE from the peripheral nerve tissue and the suprarenal gland of the BSE positive 94 month old cow that had died 9 Mar 2004. The removal of specified risk material (SRM), such as the head, the spinal cord, the vertebral column, and the small intestine, which are known to accumulate the anomalous prion protein, is compulsory in Japan as a BSE control measure. The reported detection of the BSE prion from a tissue different from SRM prescribes the review of the listed specified risk material by the Japanese Government. The statement of the Ministry of Health, Labor, and Welfare (only in Japanese) is to be found at http://www.maff.go.jp/www/press/cont2/20041101press_7.htm (Promed 12/8/04)

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Japan: Hepatitis E Virus Detected in Liver and Blood of Wild Boar
Government researchers have detected the RNA of hepatitis E virus in wild boars trapped in four prefectures, Health, Labor and Welfare Ministry research groups have reported. The RNA that was detected is very similar to that found in hepatitis E virus-infected patients who contracted the virus in 2003 in Hyogo and Tottori prefectures, strongly suggesting that the people contracted the virus from wild boar meat. Noting that heat kills the virus, the ministry has urged people to cook wild boar thoroughly and avoid eating it raw or rare.

Two research groups captured 85 wild boars in Nagano, Aichi, Wakayama, Hyogo and Nagasaki prefectures between November 2003 and April 2004. The researchers detected the virus' RNA in the liver and blood of eight boars; three each in Hyogo and Nagasaki prefectures, and one each in Aichi and Wakayama prefectures. Among these, the RNA found in boar in Aichi, Wakayama and Hyogo prefectures was virtually identical to that found in the patients. In Nagasaki and Tottori prefectures during 2003, the virus was discovered in a number of people, each of whom had eaten wild boar meat and liver. The boar meat had been strongly suspected as the cause, but until now, researchers had not found any decisive evidence.

Hepatitis E virus (HEV) is globally distributed and is transmitted enterically as well as between humans and animals. Phylogenetic analysis has identified five distinct HEV genotypes (types III and V have been confirmed as present in Japan). In developing countries HEV is transmitted principally by the fecal-oral route, and water-borne epidemics are common. In industrialized countries zoonotic transmission may be more usual. Sporadic cases of hepatitis E have been reported in Japan in the past, and widespread infection of HEV has been reported among wild rats in different parts of the country. (Promed 11/27/04)

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Japan: Six cases of hepatitis E virus infection contracted via pork barbecue
Six people who ate pork liver August 2004 at a barbecue restaurant in Kitami, Hokkaido, contracted hepatitis E virus infection, and one of them died of fulminant hepatitis. One of the six also donated blood prior to confirmation of infection and was responsible for transmission of the virus to transfusion recipients according to the Ministry of Health, Labor and Welfare. This is the first reported case in Japan of the hepatitis E virus being transmitted to people via ordinary food. The six were related and went to the restaurant with seven other relatives in mid-August 2004. There, they reportedly ate pork liver and other organs, in addition to beef and chicken. Among them, a man in his 60s developed symptoms of fulminant hepatitis and was hospitalized in late September 2004. Hepatitis E virus was detected in his blood, and the man died several days later. Since recipients of the blood donated by his son were later found to be infected with the virus, the Ministry and blood experts decided to test the blood of the surviving 12 relatives. Subsequently, they detected hepatitis E virus nucleic acid in the son's blood and antibody against the virus in his and five other relatives' blood.

Since the disease has an average latent period of about six weeks, it is normally difficult to determine which food is the source of contagion. However, as a result of thorough interviews, the Ministry and others found that most of the six people who contracted hepatitis E ate both barbecued pork liver and organs. The seven others who did not contract hepatitis E did not eat both of them, according to health officials. Since the meal at the barbecue restaurant was the only time the 13 relatives had eaten together in the relevant time frame, the Ministry concluded that one of the pork dishes, most probably the liver, was the source of infection. At this restaurant, patrons barbecue the meat themselves, and many patrons are said to prefer eating the dish rare.

Though no other patrons have been reported to be infected yet, their health, along with that of employees at the restaurant, is being monitored, and sanitation measures at the restaurant are being examined. In past cases, groups of people were reportedly infected with hepatitis E virus as a result of eating improperly cooked wild boar or deer meat. "It is important to realize the dangers of eating raw meat of not only wild, but also domestic animals," said a hepatitis E specialist. "Research has shown that infection is likely to take place only if a food contains a large amount of hepatitis E virus. Infection can be prevented if the meat is heated enough." Jaundice and other symptoms of the disease develop in 15 to 50 days after infection, but most patients recover naturally without developing chronic hepatitis. The mortality rate is said to be one percent, but pregnant women have a higher mortality rate, according to the experts. (Promed 11/28/04)

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Indonesia: Measles outbreak kills 10 in Alor
An outbreak of measles has hit the Alor regency, with 10 people in Padangsul Tamalabang sub-district reportedly dying of the disease and 149 others seriously ill, an official said 8 Dec 2004. "The residents reported the fatalities to us and we dispatched a team of doctors to treat the victims and offer immunizations," said Alor Health Office head Paul Manumpil. The outbreak of measles, first reported in the area in October 2004, does not appear to have been controlled, and it must be presumed that the population remains poorly vaccinated. The high number of fatalities is not unusual for measles outbreaks in poorly immunized communities in this part of the world. The extent of the outbreak is obscured by the absence of a denominator. (Promed 12/9/04)

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Philippines: Health official says meningitis-like disease not an outbreak
A health official in the Philippines said that a meningitis-like disease that killed eight people is not an outbreak, despite 18 new cases recorded in Nov 2004. Health authorities in the northern mountain resort city of Baguio declared 19 Nov 2004 an outbreak of meningococcemia, an airborne bacterial infection of the blood that can be spread by coughing, kissing, or other exchanges of respiratory and throat secretions. But Dr Luningning Villa, head of the Philippine health department's infectious disease unit, denied that it was an outbreak. "We call it an unusual increase of cases," Villa said. Villa said the "sporadic cases come from incidental transmission." Baguio has recorded 12 meningococcemia cases, including five deaths, since the start of November 2004. Six cases have been reported in Manila, including three deaths. Hong Kong's Center for Health Protection is investigating reports of an unusual occurrence of meningococcemia, the government said 23 Nov 2004. Travelers to Baguio, the Philippines, and Filipinos returning to their homeland, are reminded to observe good personal hygiene to avoid the illness. Returning travelers should seek medical advice if they become ill, and, disclose their recent travel history to their doctor. The WHO and Philippine health authorities are investigating the Baguio City situation; however, no travel advice has been issued. In Hong Kong, between three and 14 cases of meningococcal infection were reported yearly from 2000 to 2003. (Promed 11/29/04)

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Russia (Tambov): Two lethal cases of meningitis in Russia
Two adolescents died from a generalized form of meningitis in the central rayon hospital of Jerdevka (Tambov region). Officials are conducting necessary quarantine measures to prevent the spread of infection. The health condition of relations and classmates of victims is under observation of health professionals. The regional epidemiological surveillance center will send vaccines to Jerdevka for prophylactic vaccination. There is no information about the source of infection or the type of the causal agent, but it is probably meningococcal. (Promed 11/29/04)

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Russia: Cases of trichinellosis
For the first time during the last three years, cases of trichinellosis have been found in the Kabardino-Balkaria district. The three local patients come from the same family, and they were apparently infected via pork meat purchased at the local market. They are now hospitalized. The seller lacked the necessary documentation to prove the meat had been tested for Trichinella. Also, a family of hunters residing in the Chistoozernaya district of the Novosibirsk region has been affected by trichinellosis. Two family members were admitted to hospital in serious condition. According to the newspaper Vesti Novosibiskaya, only 11 cases were registered in Novosibirsk during 2003, while five times as many cases have already been registered in 2004. Health officials are recommending that the public beware of meat that has not passed veterinary inspection. Trichinella infection is widespread in Russia. Domestic pigs can be infected from rats and mice, offal from slaughterhouses and households, garbage, and cannibalism. (Promed 12/1/04, 12/7/04)

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Russia: Two human cases of rabies contracted from pet cats in Pereslavl
In Pereslavl, two women were infected with rabies. In both cases, the women contracted infection from pet cats which had bitten and scratched them. After several days, the animals became ill and died. Laboratory analysis confirmed that the cats had died as a result of rabies virus infection. The two women received post exposure rabies therapy immediately. At the present time, it is impossible to determine precisely the origin of the rabies in Pereslavl. It has been suggested that the virus was introduced by rodents. The most recent case of human rabies in Pereslavl occurred in 2003, when a 53 year old man died of rabies after being bitten by a feral dog. Rabies in cats is not rare. In the most recently available WHO World Survey of Rabies (1999) there have been, worldwide, 7578 and 1157 laboratory confirmed cases in dogs and cats, respectively. In the Russian Federation, the figures for 1999 were 465 and 253. See http://www.who.int/emc-documents/rabies/docs/wsr99/Table2.pdf (Promed 11/29/04)

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1. Updates
Cholera, Diarrhea, and Dysentery
Philippines (Negros)
The Department of Health (DOH) has declared a cholera alert in Negros Occidental and Bacolod City, which was also designated a cholera hotspot, after confirming 31 cases of the disease in 2004. DOH regional epidemiologist Jessie Glen Alonsabe, who led a team that arrived to conduct a medical survey of the disease, said 27 of the 31 confirmed cases were registered in Bacolod and mostly involved residents along the city's shoreline. The confirmed cases are among the 84 suspected cholera cases recorded by the Provincial Health Office (PHO) as of 27 Nov 2004. Although Provincial Health Officer Luisa Efren said the cases recorded this year were triple the number in 2003, they were not declaring the situation an outbreak, which she explained entailed cases in a geographical cluster. So far, 2004's cases have been scattered. Alonsabe said the cholera that has shown up here is the milder Ogawa strain, not the deadlier El Tor. (Promed 12/3/04)

Philippines (Cebu)
Capitol lawyers will look into the liability of the Moalboal Water District management, with 23 new cases of gastroenteritis recorded 28 Nov 2004 by the Badian District Hospital. Two men have died since the outbreak started 23 Nov 2004. As of 28 Nov 2004, Integrated Provincial Health Office (IPHO) Chief Dr. Cristina Giango said there were already 239 reported cases. Moalboal's elected officials are also contemplating taking over its management and operations, as Gov. Gwendolyn Garcia is alarmed by complaints she received from resort owners that tourists are pulling out of the diving hub. "We may take over, with the governor's help," said Mayor Inocentes Cabaron, adding that the water firm is even operating in a barangay in Badian that is no longer part of its franchise and where residents are also suffering from diarrhea. The 25-bed Badian District Hospital remained packed with 46 patients as of 28 Nov 2004. Patients who came in were advised to bring their own folding beds as well as a hammer and nail, so medical personnel could hang their dextrose bottles from the hospital walls. (Promed 12/3/04)

Philippines (Lampung)
The torrential rain storms in Sukarame, North and West Telukbetung, and Panjang districts 25 Nov 2004 swamped houses and caused the second flood in two weeks to submerge the area. "Most of the cholera sufferers are those from flooded areas, as the sanitary conditions are quite poor," said Dr. Reliani, director of Abdoel Moeloek General Hospital in Bandarlampung, Lampung province. Those affected by cholera included residents who have relied on tap water from Way Rilau, the state-owned tap water company. Managing director of the Way Rilau tap water company, Mr. Sudjaswadi, said that they were not able to fulfill the needs of customers because the company was facing a shortage of water, in addition to broken pipes. Data at the Abdoel Moeloek hospital showed that four children had died from complications related to severe diarrhea, believed to be cholera, over the past two weeks. Two were from Bandarlampung city and the two others from Tulangbawang regency. There have been more than 40 children treated for cholera since 19 Nov 2004, while around 3000 children were reportedly suffering from severe diarrhea. Thousands in Tulangbawang regency fell ill after consuming river water. The Urip Sumaharjo General Hospital has been treating 50 children with cholera, three more were reported at the Abdoel Moeloek hospital, and two more at the Advent Hospital. The number of patients at government hospitals or clinics complaining of severe diarrhea were 1900 in Aug 2004, 1600 in Sep, 1500 in Oct and 1300 patients from 1 to 23 Nov 2004. (Promed 12/3/04)

Indonesia
Thousands of people in South Sulawesi, Central Java, and North Sulawesi provinces have been treated for diarrhea recently. In South Sulawesi province, at least 15 people have died of the disease, as of 22 Nov 2004. Local government data show that over 6200 people were treated for diarrhea between 1 and 22 Nov 2004 in the province. The deputy chief of the South Sulawesi health office warned residents that the problem could worsen in the next few weeks as the annual rains began to fall. Cumulative data has shown that the number of people treated for diarrhea generally surges during the rainy season. In Central Java, cases of diarrhea emerged in several areas three months ago, including Tegal, Solo, and Semarang municipalities. Some 120 people have been treated monthly at Tegal's Kardinal Hospital, while Solo's Moewardi Hospital has also treated a similar number of patients monthly. In Semarang, Tugurejo Hospital has treated about 40 people for diarrhea each month; however, there have been no reports of fatalities. In North Sulawesi, one person has died and 150 others have been admitted to hospitals in South Minahasa regency since 17 Nov 2004. Dozens of people were transferred to Bethesda Hospital in Tomohon, as South Minahasa hospitals could not accommodate any more inpatients. (Promed 11/29/04)

Indonesia (East Java)
At least 10 children died and another 1300 were admitted to hospital after an acute diarrhea outbreak hit East Java in the third week of Nov 2004. The Health Office in the Central Java province of Khrisnajaya said that more than 600 villages across the province are vulnerable to the disease. The worst cases were reported in Makassar and Surabaya, the provincial capitals of South Sulawesi and East Java, respectively. Local heath authorities said that, in Makassar, more than 2000 diarrhea patients are suffering from stomachaches and vomiting. Other cases have been reported in Solok, West Sumatra Province: 332 people had to be hospitalized, another 10 died. Siti Fadillah Supeni, Indonesia's Health Minister, expressed her concern about delays in treatment that resulted in many patients dying of dehydration. (Promed 11/29/04)

Russia (Buryatiya)
19 cases of dysentery due to Shigella sonnei have been reported in Barguzinsk region of Buryatiya, including 12 children. Of these cases, seven are children from a kindergarten, five schoolboys, one worker in an eating establishment, and six adults. All patients are in Bargyzinsk regional hospital; their condition is reported as satisfactory. It is felt that the source was a woman working in an eating establishment. An epidemiological investigation is proceeding. (Promed 12/3/04)

Hong Kong
Another 42 people have fallen ill after eating at a Mong Kok noodle shop, bringing the total number affected to 102 in Hong Kong. The 41 men and 61 women, aged 15 to 73, developed fever and diarrhea, abdominal pain and vomiting up to 37 hours after dining at the shop between 20-28 Nov 2004. 66 sought treatment from private doctors and public hospitals. Two were admitted to a private hospital and subsequently discharged. The Center for Health Protection said the outbreak was related to bacterial food poisoning. Further investigations are underway. (Promed 12/3/04)

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West Nile Virus
Canada and USA
Regular reporting has ceased with the onset of colder weather.

Mexico
The following updated figures have been extracted from the Resumen Epidemiologico file: <http://www.cenave.gob.mx/von/archivos/ResumenCASOSVON.xls> As of 2 Dec 2004, the cumulative total of human tests carried out in Mexico has increased by 161 from 226 to 387, and no additional seropositive individuals have been detected: in total, 387 individuals resident in 29 of the 32 states have been tested for evidence of West Nile virus infection; 386 were seronegative and asymptomatic, and one individual in the state of Sonora exhibited signs of disease. (Promed 12/10/04)

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2. Articles
CDC Emerging Infectious Diseases Journal, Volume 10, Number 12-December 2004
CDC Emerging Infectious Diseases Journal, Volume 10, Number 12-December 2004 issue now available at: http://www.cdc.gov/ncidod/eid/index.htm. The entire volume is dedicated to the topic of zoonosis. The following expedited articles are also available at http://www.cdc.gov/ncidod/EID/index.htm:
- Border Screening for SARS, R.K. St. John et al.
- A Novel Paramyxovirus?, C.F. Basler et al.
- SARS-CoV Sampling from 3 Portals, T.R. Tong

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Two Cipla AIDS medicines back on WHO prequalification list
The WHO is reinstating two antiretrovirals manufactured by Cipla Ltd., India, in its list of prequalified medicines. The two medicines (which are used in the treatment of AIDS) had been delisted by WHO in May 2004 due to non-compliance with international standards at the contract research organizations (CROs) hired by Cipla to conduct bioequivalence tests on the products. As a consequence of WHO's delisting, the manufacturer carried out new bioequivalence studies to confirm that the two medicines are as effective as their respective brand-name counterparts. Further WHO scientific assessment and inspections have validated the compliance of these new studies, including the CROs involved, with all international requirements. The two medicines--Lamivudine 150mg tablet from Cipla Ltd, Kurkumbh, blister pack of 10; and Lamivudine 150mg plus Zidovudine 300mg tablet, Cipla Ltd, Vikhroli, blister pack of 10--are widely used by patients in developing countries. "This shows that generic manufacturers are reacting responsibly to recent de-listings," said Vladimir Lepakhin, Assistant Director-General for Health Technology and Pharmaceuticals. "The prequalification process does work. As well as a list of validated products, it is also a much-needed capacity building effort to promote quality and safety of medicines in developing countries." A number of new antiretrovirals, including fixed-dose combinations, are currently in the pipeline for WHO assessment. (WHO 11/30/04; http://www.who.int/mediacentre/news/releases/2004/pr87/en/print.html)

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Replication of Norovirus in Cell Culture Reveals a Tropism for Dendritic Cells and Macrophages.
Wobus CE et al.
”Noroviruses are understudied because these important enteric pathogens have not been cultured to date. We found that the norovirus murine norovirus 1 (MNV-1) infects macrophage-like cells in vivo and replicates in cultured primary dendritic cells and macrophages. MNV-1 growth was inhibited by the interferon-alphabeta receptor and STAT-1, and was associated with extensive rearrangements of intracellular membranes. An amino acid substitution in the capsid protein of serially passaged MNV-1 was associated with virulence attenuation in vivo. This is the first report of replication of a norovirus in cell culture. The capacity of MNV-1 to replicate in a STAT-1-regulated fashion and the unexpected tropism of a norovirus for cells of the hematopoietic lineage provide important insights into norovirus biology.” (http://biology.plosjournals.org/plosonline/?request=get-document&doi=10.1371/journal.pbio.0020432, PLoS Biol. 2004 Nov 30;2(12):e432)

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Diagnoses of HIV/AIDS --- 32 States, 2000--2003
“An estimated 850,000--950,000 persons in the United States are living with human immunodeficiency virus (HIV), including 180,000--280,000 who do not know they are infected. To examine trends of diagnoses for 2000--2003, CDC analyzed HIV and acquired immunodeficiency syndrome (AIDS) together as HIV/AIDS (i.e., HIV infection with or without AIDS), counted by the year of earliest reported diagnosis of HIV infection. From 2000 to 2003, in 32 states that used confidential, name-based reporting of HIV and AIDS cases for >4 years, the overall annual rate of diagnosis of HIV/AIDS remained stable. However, rates among non-Hispanic black females were 19 times higher than rates among non-Hispanic white females, underscoring the need for continued emphasis on programs targeting females in racial/ethnic minority populations to reduce the number of cases of HIV/AIDS.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5347a3.htm (MMWR December 3, 2004 / 53(47);1106-1110)

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Number of Persons Tested for HIV --- United States, 2002
“Strategies for preventing infection with human immunodeficiency virus (HIV) emphasize testing to identify infected persons and ensure access to appropriate medical care, treatment, and prevention services. To determine the number of persons who were tested for HIV during the preceding 12 months, CDC analyzed data from both the 2002 National Health Interview Survey (NHIS) and the 2002 Behavioral Risk Factor Surveillance System (BRFSS) survey. This report summarizes the results of these analyses, which indicated that, in 2002, approximately 10%--12% of persons aged 18--64 years in the United States reported being tested for HIV during the preceding 12 months, an estimated 16--22 million persons. Continued measurement of HIV testing by health surveys such as BRFSS and NHIS can be used in combination with program data and other surveys of populations at high risk to determine the impact of HIV strategies on increasing testing.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5347a4.htm (MMWR December 3, 2004 / 53(47);1110-1113)

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Salmonella Serotype Typhimurium Outbreak Associated with Commercially Processed Egg Salad --- Oregon
“On September 24, 2003, Oregon epidemiologists noted an increase in Salmonella enterica serotype Typhimurium isolates tested during September at the Oregon State Public Health Laboratories. Of 16 isolates, six had matching pulsed-field gel electrophoresis (PFGE) patterns. The laboratory findings prompted an investigation by Oregon Health Services and CDC that identified 18 cases of infection with S. Typhimurium linked to kits for making egg salad that were distributed by a vendor to a supermarket chain. The Food and Drug Administration (FDA) conducted an environmental investigation but was unable to determine the mechanism of contamination. This was the first reported S. Typhimurium outbreak associated with a commercially processed, widely distributed, hard-boiled egg product. Epidemiologists and other public health staff should continue to investigate apparent clusters of salmonellosis and be aware that even commercially processed egg products can be a source of Salmonella.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5348a3.htm (MMWR December 10, 2004 / 53(48);1132-1134)

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Brief Report: Tuberculosis Outbreak in a Low-Incidence State --- Indiana, 2001--2004
“States with fewer than 3.5 cases of tuberculosis (TB) per 100,000 population are designated as states with low incidence for TB, corresponding to CDC's interim target rate for 2000, with a goal to eliminate TB in the United States by 2010. Indiana is a low-incidence state, with a TB case rate of 2.3 per 100,000 population in 2003. However, during 2000--2002, Allen County, Indiana, exceeded the state TB case rate with a mean case rate of 2.9 (range: 2.7--3.0) per 100,000 population. The TB case rate in Allen County increased to 4.7 per 100,000 population (with 16 patients reported with TB disease) in 2003 and to 7.0 per 100,000 population (with 12 patients reported with TB disease) during the first half of 2004. The Allen County Department of Health (ACDH), the Indiana State Department of Health, and CDC are investigating this ongoing TB outbreak. This report describes the preliminary results of the investigation, the efforts of ACDH to restructure its TB program, and the importance of maintaining TB-control efforts in low-incidence states.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5348a4.htm (MMWR December 10, 2004 / 53(48);1134-1135)

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Acute Flaccid Paralysis Surveillance Systems for Expansion to Other Diseases, 2003--2004
“Since the 1988 World Health Assembly resolution to eradicate poliomyelitis, the number of countries where polio is endemic has decreased from 125 in 1988 to six at the end of 2003. As part of the eradication strategy, a global surveillance system was established to 1) identify acute flaccid paralysis (AFP) cases in children aged <15 years and 2) deploy a network of accredited laboratories to perform virologic testing of stool specimens to determine whether the paralysis resulted from poliovirus infection. As AFP surveillance systems matured, countries increasingly applied AFP surveillance strategies and infrastructure to detect other diseases (2). This report describes the status of global AFP surveillance, including its expansion or use as a model in 131 (66%) of 198 countries for the reporting of measles and other vaccine-preventable diseases. As poliomyelitis is eradicated, AFP surveillance systems in these and other countries might be further expanded and adapted to improve the detection of and response to other diseases.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5347a5.htm (MMWR December 3, 2004 / 53(47);1113-1116)

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3. Notifications
Eighth Annual Conference on Vaccine Research
The Eighth Annual Conference on Vaccine Research will be held May 9--11, 2005, in Baltimore, Maryland. The largest scientific conference devoted exclusively to vaccinology, it features both submitted abstracts and invited presentations across many disciplines to encourage the exchange of ideas and approaches for immunization against diverse human and veterinary pathogens and conditions. The conference is cosponsored by CDC, the National Foundation for Infectious Diseases (NFID), and 10 other national and international agencies, institutes, and organizations. A new travel grants program, sponsored by the Bill and Melinda Gates Foundation, offers financial support to researchers in resource-limited countries to present their work at the conference. Deadline for submission of application is January 3, 2005. Conference attendees can register online now. Deadline for online submission of abstracts for oral and poster presentations is February 7, 2005. More information is available at http://www.nfid.org/conferences/vaccine05; from NFID, Suite 750, 4733 Bethesda Avenue, Bethesda, MD 20814-5278; telephone 301-656-0003, ext. 19; fax 301-907-0878; or e-mail vaccine@nfid.org. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5348a5.htm (MMWR December 10, 2004 / 53(48);1135-1136)

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Ninth International Course, Dengue and Dengue Hemorrhagic Fever
Pedro Kouri Tropical Medicine Institute, Habana, Cuba, 8-19 Aug 2005.

The course is addressed to physicians, microbiologists, infectious disease specialists, biochemists, epidemiologists, entomologists, and behavioral scientists working on dengue and dengue control. Subjects included are: virology, immunology, epidemiology, vector control, sociology, behavioral sciences, and medical care. Visit the Course web site: http://www.ipk.sld.cu/cursos/dengue2005/index.htm. Or contact: Maria G. Guzman, PhD., PO Box 601, Marianao 13, Ciudad de La Habana, Cuba. Phone: (537) 202-0633; Fax: (537) 2046051; email: lupe@ipk.sld.cu (Promed 11/30/04)

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International Wildlife Disease Association Meeting 2005
Cairns, Australia, 26 Jun - 1 Jul 2005

The International Wildlife Disease Association Conference will be hosted by the Australasian Section of the Wildlife Disease Association in Cairns, Australia. Symposia and themes include: the ecology of introduced wildlife diseases, lessons learned from management of diseases in wildlife, the health of marine ecosystems, amphibian diseases and population declines, environmental drivers of emerging infectious diseases and wildlife health in the tropics. The Australian Society for Veterinary Pathology will hold their Annual Conference in Cairns the preceding weekend, to facilitate attendance at both meetings. For more information: http://www.rainforest-crc.jcu.edu.au/events/WDAConf.htm Requests to contribute a paper or poster as well as accompanying abstracts, should be received by no later than 31 Jan 2005. http://www.rainforest-crc.jcu.edu.au/events/WildlifeDiseasesAssocConf/CallForPapers.htm (Promed 12/4/04)

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International Conference on Diseases in Nature Communicable to Man
Calgary, Alberta, Canada, 7-9 Aug 2005

Abstracts as oral presentations or posters are invited for the 60th meeting of INCDNCM. The conference is multidisciplinary in scope and covers infectious agents such as viral, bacterial, parasitic, and prion-related diseases acquired by humans from natural sources, including animals (wild or domestic), contaminated water or food supplies, arthropod vectors, and other sources. Invited speakers will open a symposium followed by presentations related to that theme. Conference themes include: avian influenza, West Nile virus, BSE, zoonotic bacterial, and viral and parasitic diseases. Conference, registration and abstract information is available at http://secure.provlab.ab.ca/bugs/incdncm or by contacting: Kevin Fonseca or Reeta Padamsey, Provincial Laboratory for Public Health (Microbiology), 3030 Hospital Drive NW Calgary, Alberta, Canada. T2N 4W4. Email Contacts:k.fonseca@provlab.ab.ca, r.padamsey@provlab.ab.ca (Promed 12/9/04)

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EID Advanced Laboratory Training Fellowship
This is a one-year fellowship program designed for bachelor's or master's level scientists, with emphasis on the practical application of technologies, methodologies, and practices related to emerging infectious diseases. Applicants must have completed a bachelor's or master's degree in biology, microbiology, biochemistry, virology or a related discipline, or completed an accredited medical technologist program by program initiation. Applicants must be US citizens and must be able to start their appointment at the host laboratory, as well as participate in an orientation session at CDC Atlanta, following the program timeline. Please visit: http://www.aphl.org/Education_Training/Fellowships/index.cfm?FellowshipID=1 Application Deadline: February 18, 2005

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EID Post-Doctoral Laboratory Research Fellowship
This is a two-year fellowship program designed for doctoral level (PhD, MD, or DVM) scientists. The program has an emphasis on research or professional development in infectious diseases. Fellowships will be awarded to conduct applied research or development in areas relevant to public health laboratory practice. Possible areas of research include: development and evaluation of diagnostic and subtyping techniques; antimicrobial sensitivity and assessment of mechanisms of resistance; principles and practices of vector or animal control; emerging pathogens; and laboratory-epidemiology interaction. Applicants must have received a PhD, MD, or DVM, or have completed all requirements for such a degree prior to program orientation. Applicants must be US citizens and be able to start appointment at the host laboratory, as well as participate in an orientation session at CDC Atlanta following the program timeline. Please visit: http://www.aphl.org/Education_Training/Fellowships/index.cfm?FellowshipID=2 Application Deadline: February 18, 2005 (University of Washington, Department of Epidemiology).

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4. APEC EINet activities
Zoonoses meeting in Republic of Korea
The University of Washington's APEC EINet Director, Dr. Ann Marie Kimball, traveled to the Republic of Korea to attend and speak at the International Zoonoses meeting and to discuss strategies on biopreparedness in early December. Tabletop exercises and other preparedness tools were discussed with members of the Ministry of Health and Welfare, among others. Discussions with Hawaii’s Tripler Army Medical Center (TAMC) and other organizations are ongoing. The EINet team is currently preparing for a teleconference with the U.S. Department of Health and Human Services and another videoconference with TAMC regarding biopreparedness topics. The US Trade and Development Agency also announced 19 Nov 2004 that they will fund the first phase of a two-phase technical assistance program to support the APEC Health Initiative. The initiative is a companion activity to our ongoing APEC EINet Bio-Preparedness Initiative. For the press release please visit: http://www.ustda.gov./USTDA/Press%20Release%20Archive/Press%20Releases/2004/November/Nov19_04APEC.htm

Our new APEC EINet website will be updated and made public January 1, 2005.

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5. To Receive EINet Newsbriefs
APEC EINet email list
The APEC EINet email list 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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 apecein@u.washington.edu