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Vol. XV No. 5 ~ EINet News Briefs ~ Mar 02, 2012
*****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:
1. Influenza News
- 2012 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO picks two new strains for 2012-2013 season's influenza vaccine
- Egypt: H5N1 avian influenza situation update
- Egypt: Another H5N1 avian influenza case detected
- Egypt: WHO confirms two H5N1 influenza deaths
- Indonesia: H5N1 avian influenza situation update
- Indonesia: H5N1 avian influenza fatal case
- Myanmar: H5N1 avian influenza resurfaces
- Viet Nam: H5N1 influenza in birds
- Viet Nam: Reports two new H5N1 influenza poultry outbreaks
- Viet Nam: Man hospitalized with H5N1 influenza infection
2. Infectious Disease News
- China: Suspected adenovirus infection outbreak confirmed by Chinese Taipei CDC
- Russia: Measles outbreak recorded in the Belgorod region
- Russia: Measles outbreak involves St. Petersburg State University
- Viet Nam: Cases of hand, foot and mouth disease rocket
- Canada: Whooping cough warning
- Chile: Hantavirus national update
- USA (Indiana): Measles case unrelated to those in metro area
- USA (South Dakota): Health officials warn about outbreak of respiratory disease that has killed two
- USA: Jimmy John's permanently dropping sprouts from menus
- USA (North Carolina): Whooping cough outbreak climbs to 82 cases
- USA (Missouri): Cases of whooping cough on the rise
- USA (Pennsylvania): A Chester County school vaccinates adults after whooping cough outbreak
- USA (Iowa): Officials warn of whooping cough
- USA (Washington): Pertussis cases at schools raise concerns
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- VECTOR-BORNE DISEASE
- Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy
- Cross-sectional survey of malaria prevalence in tsunami-affected districts of Aceh Province, Indonesia
- Prevalence of methicillin-resistant Staphylococcus aureus based on culture and PCR in inpatients at a tertiary care center in Tokyo, Japan
- Laboratory-Based Surveillance of Non-Typhoidal Salmonella Infections in Guangdong Province, China
- Nonpasteurized dairy products, disease outbreaks, and state laws¡ªUnited States, 1993¨C2006
- Pathogenesis and transmission of swine origin A(H3N2)v influenza viruses in ferrets
- Mammalian-transmissible H5N1 influenza: facts and perspective
- Seroevidence for H5N1 Influenza Infections in Humans: Meta-Analysis
- Accuracy of Rapid Influenza Diagnostic Tests: A Meta-analysis
- A distinct lineage of influenza A virus from bats
- Highly pathogenic avian influenza (H5N1) outbreaks in wild birds and poultry, South Korea
- Outbreaks of H5N1 in poultry in Thailand: the relative role of poultry production types in sustaining transmission and the impact of active surveillance in control
- 2012 International Conference on Emerging Infectious Diseases (ICEID)
- 2012 Australasian Society for Infectious Diseases Scientific Meeting
- 9th Asia Pacific Travel Health Conference
1. Influenza News
2012 Cumulative number of human cases of avian influenza A/H5N1
Cambodia / 1 (1)
China / 1 (1)
Egypt / 5 (2)
Indonesia / 3 (3)
Viet Nam / 2 (2)
Total / 12 (9)
***For data on human cases of avian influenza prior to 2011, go to: http://depts.washington.edu/einet/humanh5n1.html
Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 590 (349) (WHO 3/1/2012)
Avian influenza age distribution data from WHO/WPRO (last updated 2/7/2011): http://www.wpro.who.int/sites/csr/data/data_Graphs.htm
WHO's map showing world's areas affected by H5N1 avian influenza (status as of 2/12/2010): http://gamapserver.who.int/mapLibrary/Files/Maps/Global_H5N1Human_2010_FIMS_20100212.png
WHO’s timeline of important H5N1-related events (last updated 1/25/2012): http://www.who.int/influenza/human_animal_interface/H5N1_avian_influenza_update.pdf
Global: WHO picks two new strains for 2012-2013 season's influenza vaccine
The World Health Organization (WHO) on 23 February 2012 recommended changing two of the three strains in 2012-2013 season's influenza vaccine for the Northern Hemisphere, ending a couple of years of stability in the vaccine's makeup.
The WHO's flu experts called for changing the A/H3N2 and B components of the vaccine but continuing to use a strain of the pandemic 2009 virus for the A/H1N1 component.
Although the 2011-2012 flu season has been quiet in most of the world, the recommendation means that a significant share of flu viruses circulating in recent months don't match up very closely with those in 2012's vaccine.
The WHO recommended strains similar to the following for the 2012-13 season:
A/Victoria/361/2011 (H3N2), which replaces A/Perth/16/2009
B/Wisconsin/1/2010, which replaces B/Brisbane/60/2008
The WHO experts make their recommendations for the North Hemisphere flu vaccines in February to allow time to prepare the vaccine viruses and grow them in eggs, which takes several months. The recommendation for the Southern Hemisphere vaccine is usually made in October.
The strain changes announced by the WHO appear to be the first for the Northern Hemisphere vaccine since February 2010, when the agency recommended adding the 2009 pandemic strain to the 2010-11 vaccine.
The full article may be accessed at http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/feb2312strain.html
The full WHO report on strain selection may be accessed at http://www.who.int/influenza/vaccines/virus/recommendations/201202_recommendation.pdf
Egypt: H5N1 avian influenza situation update
The Ministry of Health and Population of Egypt has notified WHO of a new case of human infection with avian influenza A (H5N1) virus. The case is a 45 year-old female from Menofia governorate. She developed symptoms on 10 February 2012, received oseltamivir treatment on 17 February 2012 and is still recovering. The case was laboratory confirmed by the Central Public Health Laboratories; a National Influenza Center of the WHO Global Influenza Surveillance Network on 18 February 2012. Epidemiological investigation into the source of infection indicate that the case had exposure to backyard poultry. Of the 160 cases confirmed to date in Egypt, 55 have been fatal.
Egypt: Another H5N1 avian influenza case detected
The Ministry of Health and Population of Egypt has notified WHO of a new case of human infection with avian influenza A (H5N1) virus. The case is a one year-old female from Gharbeia governorate. She developed symptoms on 14 February 2012 and was admitted to a hospital on 15 February 2012, where she received oseltamivir treatment upon admission. She is in good medical condition. Epidemiological investigation into the source of infection is ongoing. Preliminary investigations indicate presence of backyard poultry in her area of residence. The case was confirmed by the Central Public Health Laboratories; a National Influenza Center of the WHO Global Influenza Surveillance Network. Of the 161 cases confirmed to date in Egypt, 55 have been fatal.
Egypt: WHO confirms two H5N1 influenza deaths
Egypt's Ministry of Health and Population has confirmed that a man and woman have died of H5N1 avian flu, the World Health Organization (WHO) reported 28 February 2012. The man, 32, from Beheira governorate, fell ill 16 February 2012, was admitted to a hospital 21 February 2012 and immediately received oseltamivir (Tamiflu), and died 28 February 2012. The woman, 37, from Kafr el-Sheikh governorate, became ill 18 February 2012, received oseltamivir upon hospital admission on 23 February 2012, and died 26 February 2012. Investigations into the cases revealed that both patients had close contact with sick or dead poultry at home. The cases were confirmed by the Central Public Health Laboratories, a National Influenza Center of the WHO Global Influenza Surveillance Network. They bring the country's total H5N1 cases in 2012 to five, of which only these two have been fatal. Since 2005, Egypt has confirmed 163 cases, 57 of which were fatal. The global WHO H5N1 case count now stands at 589 cases, including 348 deaths.
Indonesia: H5N1 avian influenza situation update
The Ministry of Health of Indonesia has announced one new confirmed case of human infection with avian influenza A(H5N1) virus. The case is a 19 year-old female from Banten Province. She developed symptoms on 8 February 2012, was hospitalized on 12 February 2012 and died on 13 February 2012. Epidemiological investigation is ongoing by the Ministries of Health and Agriculture. Of the 185 cases confirmed to date in Indonesia, 153 have been fatal.
Indonesia: H5N1 avian influenza fatal case
The IHR National Focal Point in Indonesia has notified WHO of one new case of human infection with avian influenza A (H5N1) virus. The case was a 12 year-old male from Badung, Bali. He had onset of symptoms on 11 February 2012 and was admitted to a private clinic on 16 February 2012. His condition continued to worsen, resulting in severe difficulty breathing. He was referred to an avian influenza referral hospital on 20 February 2012 where he died on 21 February 2012. Epidemiological investigation into the source of infection indicated contact with poultry, though no poultry deaths within the household or neighborhood have been reported. The risk factors are still under investigation. Of the 186 cases confirmed since 2005 in Indonesia, 154 have been fatal.
Myanmar: H5N1 avian influenza resurfaces
Veterinary officials in Myanmar on 29 February 2012 reported an H5N1 avian influenza outbreak at two poultry farm establishments in the same township in Sagaing region, located in the central part of the country, according to the World Organization for Animal Health (OIE). The outbreak started on 20 February 2012, killing 61 of 1,060 susceptible birds over four days. The birds were 5- and 18-month-old chickens. The rest were culled to slow the spread of the virus. The source of the virus hasn't been established. Myanmar reported its last H5N1 outbreak in April 2011.
Viet Nam: H5N1 influenza in birds
Vietnam reported another H5N1 avian influenza outbreak, this time striking backyard birds in a village in Quang Nam province, located on the country's south-central coast, according to the World Organization for Animal Health (OIE) on 18 February 2012. The virus killed 106 of the village poultry, and 4,955 more were destroyed to slow the spread of the disease.
Viet Nam: Reports two new H5N1 influenza poultry outbreaks
Vietnam has confirmed two additional outbreaks of H5N1 avian flu in village flocks in Bac Ninh province that killed 150 poultry and led to the culling of 342 more to prevent disease spread, according to the World Organization for Animal Health (OIE) on 21 February 2012. The first outbreak, in Yen Phong district, killed 100 birds beginning on 12 February 2012, with 200 additional birds culled. The second outbreak began 17 February 2012 and led to 50 bird deaths, with 142 culled. The country has reported numerous H5N1 outbreaks in 2012.
Viet Nam: Man hospitalized with H5N1 influenza infection
A 22-year-old man in Vietnam is in critical condition with an H5N1 avian influenza infection. Nguyen Van Vin Chau, Ho Chi Minh City's director of tropical diseases, said the man is from Binh Duong province, located in the southeastern part of the country, reported 27 February 2012. He was hospitalized on 23 February 2012 after experiencing a high fever and respiratory symptoms.
Samples were positive for H5N1, and the man is receiving treatment. The investigation so far has found that during the Tet holiday the man ate chicken and duck from unknown origins in two different provinces and in Ho Chi Minh City.
As of 27 February 2012 in this year, Vietnam has reported three H5N1 infections, including two deaths, after recording none in 2011. All three cases have been in adults. If the World Health Organization confirms the new case, it will be listed as Vietnam's 122nd case, which includes 61 deaths.
2. Infectious Disease News
China: Suspected adenovirus infection outbreak confirmed by Chinese Taipei CDC
An outbreak of disease that is causing a stir in the Chinese online community is not SARS but adenovirus infection, the Chinese Taipei Centers for Disease Control (CDC) confirmed 24 February 2012 after checking with the Chinese health authorities.
China told the CDC that the suspected outbreak in Hebei Province was in fact adenovirus type 55 infection, CDC Deputy Director-General Chou Chih-Hau said. China, however, did not reveal the scale of the epidemic to Taiwan. Chou said that adenovirus infection is easy to treat and that the CDC does not need to investigate any further.
Adenovirus type 55 infection was first discovered in China’s Shaanxi Province in 2006. Of 254 high school students treated for the infection, only one died.
There is no record of adenovirus type 55 infection in Taiwan, according to CDC statistics.
Many Chinese citizens have voiced concern over a possible pandemic of SARS in a military hospital in Hebei. Bloggers alleged that hundreds have been hospitalized in isolation wards and that at least one person has died of the disease.
(Focus Taiwan 2/24/2012)
Russia: Measles outbreak recorded in the Belgorod region
Nine members of staff and patients in the Chernyansky district hospital of the Belgorod oblast region have contracted measles. As of 13 February 2012, the nine measles cases include three unimmunized children under two years of age.
It was reported that a 22 year old woman from Chernyanka is considered to be the source of the outbreak. According to the regional Rospotrebnadzor (health and welfare surveillance service), this woman had contracted the infection in Moscow and had returned home before symptoms developed. Her condition was not immediately diagnosed and nosocomial spread of infection occurred as a result of laxity on the part of the local medical staff. All appropriate control measures are now in place to prevent further spread of infection.
Russia: Measles outbreak involves St. Petersburg State University
There has been an increasing incidence of measles virus infection in St. Petersburg. Apart from a few dozen cases of infection admitted to the No.1 Children's Hospital, cases of measles have been recorded now in a dormitory at St. Petersburg State University, which is under quarantine.
Several affected students are accommodated in a dormitory at Building 20 of the Naval University; a few are seriously ill. The dormitory has been placed under quarantine for the period 10 February to 2 March 2012. As a consequence admission of new students to this hostel is strictly prohibited, since they might contract the infection from the resident students and staff.
It has been established that there are now several hundred cases of measles in St. Petersburg. More than 80% of the cases are children. In previous years there had been few cases of measles in St. Petersburg, which has resulted in reduced surveillance.
The source of the present outbreak is believed to be a teenager, who came from a southern region, and who had contracted the disease from his younger sister. However, as a result of poor assessment of his condition, the youth was admitted to a hospital ward housing infants who have not yet been vaccinated against the disease. Before his condition was correctly diagnosed, he had spread the infection to others.
The federal authorities warn that there is a likelihood of further spread of measles in St. Petersburg due to the large number of persons who remain unvaccinated against the disease.
Viet Nam: Cases of hand, foot and mouth disease rocket
The developments of the disease since mid-January 2012 show that the illness would likely be more serious than 2011, when about 100,000 people suffered from the disease and nearly 200 children died, Tran Thanh Duong, deputy head of the department, warned. In 2011, hand, foot and mouth disease (HFMD) peaked in April-May and again in August-September, but in 2012 the disease has sharply increased in the first months, prompting the belief that a more complex and serious epidemic situation may be developing, he said.
According to the ministry's statistics, high numbers of HFMD patients since mid-January 2012 have been recorded in ten provinces and cities, namely Hai Phong, Dong Thap, Khanh Hoa, Kien Giang, Can, Tho, Ca Mau, Dak Lak, An Giang, Vinh Long and Hau Giang.
As of 21 February 2012 this year, 124 children in Ho Chi Minh City have suffered from the disease, an increase of 18 patients compared to the same period in 2011. The number of wards or communes having at least two patients has increased to 28 from 13 the week of 6 February 2012. With four patients, Binh Chanh District's Binh Hung commune has led the city in the number of HMFD sufferers so far.
As of mid-February 2012, the number of children with HMFD in Vinh Long was 128, an increase of 40 from 2011, and one of them has died.
In Can Tho, 600 children have been admitted to the Can Tho Pediatrics Hospital since the beginning of 2012, and three of them have died. The local health authorities have cleaned the environment and sprayed antiseptic at affected areas and their surroundings. Can Tho authorities have also launched a campaign for environmental hygiene across the city, especially in schools, kindergartens and families with children under five years old.
Meanwhile, patient overload has occurred in the Obstetrics-Pediatrics Center of the Da Nang General Hospital in the central city of Da Nang, where 140 children have been hospitalized despite the center having only 40 official sickbeds. These children were not only from the city but also from Quang Nam and Quang Ngai provinces.
Dr Nguyen Tam Lang, head of the Epidemiology and Entomology Department at the center, forecast that HFMD will have unforeseen developments in 2012 and the disease will spread widely in central provinces.
From 6 January to 12 February 2012, the city had 46 children with HFMD, while during February 2011, only four children were found to have contracted the disease, the doctor said. As of 19 February 2012 the number of HFMD patients had increased to 61, he added.
During the week of 20 February 2012, the ministry will send five working teams to the affected localities to assist local authorities in controlling, preventing and driving back the epidemic, said Deputy Health Minister Nguyen Thanh Long. The Preventive Health Department will also set up 12 additional teams to give support to local authorities, Duong said. Long requested local health authorities strengthen their efforts to combat the epidemic and that hospitals review their therapy regimens to make them more appropriate for each type of patient. The ministry will report the epidemic situation to the government and propose that it establish an interdisciplinary steering board to fight the epidemic nationwide, he said.
The full article may be accessed at http://www.promedmail.org/direct.php?id=20120221.1048374
Canada: Whooping cough warning
Canadian health officials have issued a warning over whooping cough as the disease continues to sweep through parts of British Columbia. There have been more than 140 suspected or confirmed cases of the illness since early December 2011, according to the Fraser Health Authority.
Hotspots for the outbreak include the Hope, Chilliwack and Agassiz areas, but officials said it has also spread to other communities.
With this in mind, anyone traveling into the region might want to double check what their pre-existing medical travel insurance covers, just in case the worst happens.
The authority said the genuine number of cases is likely to be considerably higher because of those that are yet to be reported.
Chief Medical Health Officer Dr. Paul Van Buynder has said the best way to safeguard against whooping cough is to get vaccinated, especially for people who have contact with children. Dr. Buynder has called for adults who had the vaccination as a child to book a booster shot and parents to make sure their children are also vaccinated.
Chile: Hantavirus national update
The number of hantavirus infection cases increases to 18, after the Institute of Public Health confirmed one case in the Bio Bio region and another in Los Lagos.
In order to decentralize the diagnostic capacity of the Ministry of Health, on 17 February 2012, this capacity will now include five of the most capable laboratories in the country.
The new case in the Bio Bio region was a 21-year-old young man, who had contracted the infection in a supermarket where he worked as a restocking clerk. He is in serious condition in the Concepcion Regional Hospital.
The second case is a 20-year-old young man from the city of Maullin, in the Los Lagos region, whose case as a hantavirus infection was confirmed by the Molecular Microbiology Laboratory of the Universidad Austral of Valdivia.
These two new cases related to the virus are added to the 16 previous ones, and the Institute of Public Health hopes that the number will not increase. For this reason, together with the Ministry, on Friday, 17 February 2012, the last of the five diagnostic laboratories was inaugurated.
USA (Indiana): Measles case unrelated to those in metro area
A new case of measles confirmed in northeastern Indiana is unrelated to an outbreak in the Indianapolis metro area, the Indiana State Department of Health announced 27 February 2012.
An unvaccinated resident of Adams County, south of Fort Wayne, was exposed to measles while traveling overseas, Department of Health spokeswoman Amy Reel said.
That person may have exposed other people to the highly infectious respiratory disease during a trip to the emergency room at Bluffton Regional Medical Center on the evening of 20 February 2012, Reel said. Bluffton is in Wells County, also south of Fort Wayne.
The Adams County patient took steps to limit contact with others after being notified by a group the patient had traveled with overseas of possible exposure to measles, Reel said. The patient no longer is contagious.
In Central Indiana, 16 linked cases have been confirmed in Boone and Hamilton counties. Other cases resulting from exposure to those cases still could develop through 14 March 2012, officials said.
(Indianapolis Star 2/28/2012)
USA (South Dakota): Health officials warn about outbreak of respiratory disease that has killed two
A doctor with Sanford Children's Hospital in Sioux Falls, SD, says an outbreak of a respiratory disease has forced the hospital to find more beds for sick children. Health officials say the number of cases of respiratory syncytial virus (RSV) infection has been on the rise in recent weeks. They say 2012's outbreak is particularly severe. State epidemiologist Lon Kightlinger says two people have died from it as of 21 February 2012 this year in South Dakota.
Joe Segeleon is a pediatrics critical care physician with Sanford Children's Hospital. He says that the hospital has seen an "extraordinary jump" in the number of RSV cases. He says the hospital had to open up an auxiliary wing in the main part of the hospital because of the outbreak.
The full article may be accessed at http://www.promedmail.org/direct.php?id=20120221.1048240
USA: Jimmy John's permanently dropping sprouts from menus
Jimmy John's Gourmet Sandwich franchise owners and customers are being told the chain is permanently dropping sprouts from the menu.
Jimmy John's restaurants are currently associated with a five-state outbreak of the rare O26 strain of E. coli. It is the fifth outbreak involving sprouts traced back to Jimmy John's franchises since 2008.
While there has been no public comment by Jimmy John's since the outbreak was announced 15 February 2012, a Kirkville, MO franchise owner says "Jimmy himself" has ordered all sprouts permanently removed from the menu. "Jimmy decided he was tired of the negative press from it and he thinks sprouts aren't necessary for Jimmy John's to rock," franchise owner Will Aubuchon said in Kirksville, MO.
And Linda DeGraaf, a Jimmy John's customer from Omaha who was sickened in the 2009 outbreak, was told that sprouts have been dropped. "We no longer serve sprouts because supplies are too inconsistent," wrote a Jimmy John's spokeswoman.
After a 2010 outbreak, founder Jimmy John Liautaud switched the sandwich chain to clover sprouts after Salmonella illnesses were associated with alfalfa sprouts. At the time, he said clover sprout seeds were smoother and would be easier to clean.
Jimmy John's is not alone among sandwich chains that have decided sprouts are too risky. The 230-unit Jason's Deli dropped sprouts for at least the balance of 2012 as a food safety concern. And the current O26 outbreak prompted the seven-state Erbert and Gerbert's Sandwich Shops to drop sprouts.
Jimmy John's recent history includes five major outbreaks associated with spouts. Only the latest involves E coli O26.
More details on past Jimmy John’s foodborne outbreaks may be accessed at http://www.foodsafetynews.com/2012/02/jimmy-johns-gourmet-sandwich-franchise/
(Food Safety News 2/20/2012)
USA (North Carolina): Whooping cough outbreak climbs to 82 cases
The Alamance County Health Department announced 23 February 2012 that it has lifted restrictions on who can receive the Tdap (tetanus, diphtheria, and pertussis) vaccine. The pertussis vaccine, which is usually 35 dollars, is now free for a limited time, and the department will be holding a communitywide vaccination clinic in March 2012.
The decision follows a countywide pertussis outbreak that has 82 confirmed, probable, suspected, or epidemiologically linked cases of pertussis, commonly known as whooping cough, since the middle of December 2011.
"Epi-link" cases refer to pertussis cases in which the disease develops in a person who had been in close contact with someone who had a lab-confirmed case. "Probable" defines a case of pertussis in which the patient has not been in close contact with a lab-confirmed case but has exhibited symptoms for two or more weeks, said Communicable Disease Program Coordinator Ayo White.
As of 25 February 2012, said White, there have been 15 lab-confirmed, 31 epi-linked, three probable, and three suspected cases in Alamance County. “These are the numbers up to this point, and are expected to change quickly,” she said. White acknowledged that 82 is a high number of pertussis cases and said, “This is more than usual.” Medical Director. Dr Kathleen Shapley-Quinn said, "In the ten years I've worked here, I've never had an outbreak (in Alamance County)."
The outbreak is a big one, hitting five elementary schools, four middle schools, two day cares, and three other individuals in the county.
The health department has been administering azithromycin, an antimicrobial, to confirmed cases and Shapley-Quinn said the department has taken a targeted approach when giving the antibiotic to suspect cases. She said those at the highest risk take precedence, such as those children who have been in close proximity to confirmed cases and have poor immune systems.
Health officials are concentrating their efforts on immunizing as many people as possible, especially those at higher risk. Immunization Program Coordinator Christie Sykes said infants less than 12 months, immunocompromised individuals, and pregnant women are considered high risk.
USA (Missouri): Cases of whooping cough on the rise
The Springfield-Greene County Health Department said 27 February 2012, that it is seeing an increase in cases of whooping cough. The health department said it has confirmed four cases of whooping cough in recent weeks. Three of the cases were infants less than a year old; the other was an adult.
"While the number of cases is not especially large, any such spike is notable because of the highly contagious nature of the disease,” the health department said. The situation is compounded by an alarming lack of immunizations among infants in these recent cases."
Infants and young children are at the highest risk of life-threatening consequences. More than half of infants younger than one year of age who get the disease must be hospitalized. Of those infants who are hospitalized for pertussis, about one in five will get pneumonia and about one in 100 will die, according to the CDC.
USA (Pennsylvania): A Chester County school vaccinates adults after whooping cough outbreak
There has been a confirmed outbreak of whooping cough at a Chester County public school. Valley Forge Elementary School has had two confirmed cases of pertussis, and that is enough to constitute an "outbreak," according to Betsy Walls, bureau director for personal health services at the Chester County Health Department.
"All of the kids were protected (vaccinated)," she says, "but that's because of their age and school requirements. It was the faculty that didn't have it -- in adults it's not a required vaccine. And so that what was we were doing there on 4 February 2012. We thought we would have some students, but we had all adults needing to be vaccinated." One of those diagnosed with the ailment is a student, the other is not.
USA (Iowa): Officials warn of whooping cough
The Scott County Health Department in eastern Iowa is sending out an alert that there are more whooping cough cases in area schools. It was reported that ten cases were reported the week of 20 February 2012 alone. Iowa has seen a jump in whooping cough cases in recent years.
USA (Washington): Pertussis cases at schools raise concerns
As of 24 February 2012, six students on Vashon Island have confirmed cases of whooping cough, prompting King County health officials to issue a letter urging parents and teachers to be on alert for the highly contagious disease. The public health agency, in a letter to all parents and staff at Vashon's three public schools, says adults should pay attention to cold symptoms among children, noting they could be the 1st signs of pertussis, or whooping cough.
Those adults who have contact with babies or young children, considered the most vulnerable to severe infection from the disease, should take extra precautions to ensure they don't get the illness. Babies, according to Eileen Benoliel, a public health nurse in the Communicable Disease Epidemiology & Immunization Program at Public Health, Seattle & King County, can die from pertussis.
The letter was issued late 25 February 2012, after officials learned there are four confirmed cases of pertussis at the Vashon School District and two confirmed cases of the disease in school-age children who attend a private school on Vashon. School officials believe there's a linkage to those cases, or "evidence of contagion," as Sarah Day, Vashon's school nurse, put it.
According to recently tabulated numbers, 33% of the students in the Vashon school district have not been fully vaccinated against whooping cough. What's more, according to health officials, the immunization is not highly effective or long-lasting. Health officials believe the pertussis vaccine is only 59 to 89% effective in preventing the disease.
According to the state Department of Health, there were 728 cases of pertussis in Washington from 1 January to 17 December 2011. This compares with 529 cases in the same period in 2010. 86 infants under one had the illness and 29 were hospitalized, including 23 who were under three months. Two infants died. In King County, there were 98 confirmed cases in 2011, according to James Apa, the communications manager for county health department.
Vashon School District currently has 75 students who don't have either a record of their immunizations or a signed waiver on file, Soltman said. During the week of 27 February 2012, he said, the district will issue letters to the parents or guardians of those students, telling them that they have 30 days to submit documentation of immunization or a waiver to the district. Those students whose families don't comply, he said, won't be allowed to attend public school.
"In light of the concerns from the county health department," Soltman said, "we need to get Vashon's schools in compliance with the state's immunization laws."
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions:
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
International Health Regulations (IHR) at http://www.who.int/ihr/en/index.html.
- WHO regional offices
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Western Pacific: http://www.wpro.who.int/health_topics/h1n1/
- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: http://www.flu.gov
MOH México: http://portal.salud.gob.mx/index_eng.html
PHA of Canada: http://fightflu.ca
- Other useful sources
CIDRAP: Influenza A/H1N1 page:
WHO H1N1 pandemic influenza update 115: http://www.who.int/csr/don/2010_08_27/en/index.html
CDC Teleconference results: Healthcare groups need to share emergency plans:
American Academy of Pediatrics Policy Statement: Recommendations for Prevention and Control of Influenza in Children, 2010-2011:
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza H5N1.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help health officials prepare for an influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.flu.gov/. “Flu Essentials” are available in multiple languages.
- CIDRAP: Avian Influenza page: http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- Link to the Avian Influenza Portal at:
http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on avian influenza H5N1 in wild birds and poultry.
Australia (Cairns, Queensland state)
Far Northern health officials have warned residents of dengue after two cases at Manunda (suburb of Cairns) were confirmed 14 February 2012. The man and woman are the first cases of locally acquired dengue in the city for almost a year, although there have been nine other patients treated in Cairns in 2012 who contracted the disease overseas.
Dengue cases recorded a 40% jump from January to 18 February 2012 compared to the same period in 2011. Executive councilor Dr. Xavier Jayakumar said 1,581 cases have been reported in Selangor compared to 1,126 in 2011. “The districts with the most number of reported cases are Petaling (479), Hulu Langat (430), Klang (328) and Gombak (173),” said the Seri Andalas assemblyperson on Wednesday, 22 February 2012.
Peru (Junin region)
As of 17 February 2012 in this year, 18 people with dengue have been reported in the provinces of Chanchamayo and Satipo.
Philippines (Southern Mindanao)
Dr. Lalaine Calonzo, acting head of the General Santos City Integrated Health Services Office (CIHSO), said on 16 February 2012 they have recorded 32 confirmed cases of dengue within the city's 26 neighborhoods. She said most of the confirmed dengue cases were recorded in Barangays City Heights, Labangal, Apopong, and San Isidro, where several housing subdivisions and crowded residential communities are situated.
Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy
Pearson ML, Selby JV, Katz KA, et al. PLoS ONE. 25 January 2012. 7(1): e29908. doi:10.1371/journal.pone.0029908.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0029908
Background. Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies.
Methods. A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006–2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin.
Results. We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17–93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin.
Conclusions. This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation.
Cross-sectional survey of malaria prevalence in tsunami-affected districts of Aceh Province, Indonesia
Muriuki D, Hahn SA, Hexom B, Allan R. Int J Emerg Med. 21 February 2012. 5(1):11.
Available at http://www.ncbi.nlm.nih.gov/pubmed/22353602
Background. Malaria is endemic to Indonesia. However, there are few prevalence data available from Aceh Province due to the long-standing separatist conflict and decentralization of the public health system. The Mentor Initiative, which specializes in malaria control in humanitarian emergencies, was one of the non-governmental organizations to respond to the 2004 Indian Ocean Tsunami in Aceh. Data on malaria prevalence were gathered to guide and evaluate programmatic efforts.
Findings. The Mentor Initiative conducted community-based malaria prevalence surveys in 2005 and 2006 in five districts along the tsunami-affected western coastline. 11,763 individuals in 3771 households were tested. The overall slide positivity rate in 2005 and 2006 for all Plasmodium species was 2.1% (n= 252, 95% CI 1.9% - 2.4%). Slide positivity rates ranged from 0 to 55% among villages. Overall, 57% of the 252 cases were infected with P. falciparum (n=144, 95% CI 51.0% - 63.3%), and 40.1% were infected with P. vivax (n=101, 95% CI 34.0% - 46.1%), with 0.03% (n=7, 95% CI 0.8% - 4.8%) being mixed infections. Males were significantly more likely to be affected than females (2.8% vs 1.5%, p < 0.01). Infection was more common in those over the age of 5 (2.3% vs. 0.6%, p < 0.01).
Conclusions. Local prevalence data is needed to design effective community-based malaria control programs, as endemnicity varies greatly within districts. Certain villages were found to be hyperendemic, with slide positivity rates far higher than average in Indonesia. There is a need for ongoing malaria surveillance in Aceh Province to monitor prevention and treatment efforts.
Prevalence of methicillin-resistant Staphylococcus aureus based on culture and PCR in inpatients at a tertiary care center in Tokyo, Japan
Taguchi H, Matsumoto T, Ishikawa H, et al. J Infect Chemother. 23 February 2012. doi: 10.1007/s10156-012-0385-8.
Available at http://www.springerlink.com/content/6641t28688488115/
Abstract. We investigated active screening for colonization with methicillin-resistant Staphylococcus aureus (MRSA) on admission and weekly follow-up surveillance after admission to a tertiary care center (TCC) between June 2007 and 31 December 2007. Eleven percent (30/267) of patients were found to be positive for MRSA by polymerase chain reaction (PCR) and/or culture on admission; 5% (12/267) became positive during the TCC stay. The major primary diagnoses in MRSA-positive patients were pneumonia and cerebrovascular diseases. Twenty-two (52%) of 42 patients were found to be MRSA positive by both PCR and culture, compared with 19 (45%) of 42 who were PCR positive and culture negative. These findings suggest that active surveillance with PCR is highly sensitive and useful for the detection of MRSA colonization. To our knowledge, this is the first report of active surveillance of MRSA by PCR and bacterial culture in critically ill inpatients in Japan.
Laboratory-Based Surveillance of Non-Typhoidal Salmonella Infections in Guangdong Province, China
Deng X, Ran L, Wu S, et al. Foodborne Pathog Dis. 22 February 2012. doi:10.1089/fpd.2011.1008.
Available at http://www.ncbi.nlm.nih.gov/pubmed/22356574
Abstract. Salmonella is one of the most common foodborne pathogens in humans. Laboratory-based surveillance for non-typhoidal Salmonella infection was conducted in Guangdong Province, China to improve understanding about the disease burden and detection of dispersed outbreaks. Salmonella isolated from patients with diarrhea were sent from 16 sentinel hospitals to local public health laboratories for confirmation, serotyping, antimicrobial susceptibility testing, and pulsed-field gel electrophoresis (PFGE). PFGE patterns were analyzed to identify clusters representing potential outbreaks. Between September 2009 and October 2010, 352 (4%) Salmonella isolates were obtained from 9167 stool specimens. Salmonella enterica serotype Typhimurium (45%) and Salmonella enterica serotype Enteritidis (13%) were the most common serotypes, and multidrug resistance was high, especially in Salmonella Typhimurium isolates. PFGE patterns of obtained Salmonella isolates were found to be diverse, but a unique PFGE pattern comprising 53 Salmonella Typhimurium isolates were found to occur almost exclusively in infants. Epidemiologic studies are ongoing to determine whether a common exposure is the source of the Salmonella Typhimurium strain frequently isolated from infants.
Nonpasteurized dairy products, disease outbreaks, and state laws¡ªUnited States, 1993¨C2006
Langer AJ, Ayers T, Grass J, et al. Emerg Infect Dis. March 2012. doi:10.3201/eid1803.111370.
Available at http://wwwnc.cdc.gov/eid/article/18/3/11-1370_article.htm
Abstract. Although pasteurization eliminates pathogens and consumption of nonpasteurized dairy products is uncommon, dairy-associated disease outbreaks continue to occur. To determine the association of outbreaks caused by nonpasteurized dairy products with state laws regarding sale of these products, we reviewed dairy-associated outbreaks during 1993¨C2006. We found 121 outbreaks for which the product¡¯s pasteurization status was known; among these, 73 (60%) involved nonpasteurized products and resulted in 1,571 cases, 202 hospitalizations, and 2 deaths. A total of 55 (75%) outbreaks occurred in 21 states that permitted sale of nonpasteurized products; incidence of nonpasteurized product¨Cassociated outbreaks was higher in these states. Nonpasteurized products caused a disproportionate number (¡Ö150¡Á greater/unit of product consumed) of outbreaks and outbreak-associated illnesses and also disproportionately affected persons <20 years of age. States that restricted sale of nonpasteurized products had fewer outbreaks and illnesses; stronger restrictions and enforcement should be considered.
Pathogenesis and transmission of swine origin A(H3N2)v influenza viruses in ferrets
Pearce MB, Jayaraman A, Pappas C, et al. PNAS. 21 February 2012. doi: 10.1073/pnas.1119945109.
Available at http://www.pnas.org/content/early/2012/02/13/1119945109.abstract
Abstract. Recent isolation of a novel swine-origin influenza A H3N2 variant virus [A(H3N2)v] from humans in the United States has raised concern over the pandemic potential of these viruses. Here, we analyzed the virulence, transmissibility, and receptor-binding preference of four A(H3N2)v influenza viruses isolated from humans in 2009, 2010, and 2011. High titers of infectious virus were detected in nasal turbinates and nasal wash samples of A(H3N2)v-inoculated ferrets. All four A(H3N2)v viruses possessed the capacity to spread efficiently between cohoused ferrets, and the 2010 and 2011 A(H3N2)v isolates transmitted efficiently to naïve ferrets by respiratory droplets. A dose-dependent glycan array analysis of A(H3N2)v showed a predominant binding to α2-6–sialylated glycans, similar to human-adapted influenza A viruses. We further tested the viral replication efficiency of A(H3N2)v viruses in a relevant cell line, Calu-3, derived from human bronchial epithelium. The A(H3N2)v viruses replicated in Calu-3 cells to significantly higher titers compared with five common seasonal H3N2 influenza viruses. These findings suggest that A(H3N2)v viruses have the capacity for efficient replication and transmission in mammals and underscore the need for continued public health surveillance.
Mammalian-transmissible H5N1 influenza: facts and perspective
Osterholm MT, Kelley NS. 24 February 2012. mBio. 3(2):e00045-12. doi:10.1128/mBio.00045-12.
Available at http://mbio.asm.org/content/3/2/e00045-12.full
Abstract. Two recently submitted (but as yet unpublished) studies describe success in creating mutant isolates of H5N1 influenza A virus that can be transmitted via the respiratory route between ferrets; concern has been raised regarding human-to-human transmissibility of these or similar laboratory-generated influenza viruses. Furthermore, the potential release of methods used in these studies has engendered a great deal of controversy around publishing potential dual-use data and also has served as a catalyst for debates around the true case-fatality rate of H5N1 influenza and the capability of influenza vaccines and antivirals to impact any future unintentional or intentional release of H5N1 virus. In this report, we review available seroepidemiology data for H5N1 infection and discuss how case-finding strategies may influence the overall case-fatality rate reported by the WHO. We also provide information supporting the position that if an H5N1 influenza pandemic occurred, available medical countermeasures would have limited impact on the associated morbidity and mortality.
Seroevidence for H5N1 Influenza Infections in Humans: Meta-Analysis
Wang TT, Parides MK, Palese P. Science. 23 February 2012. Doi:10.1126/science.1218888.
Available at http://www.sciencemag.org/content/early/2012/02/22/science.1218888.abstract
Abstract. The prevalence of avian H5N1 influenza A infections in humans has not been definitively determined. Cases of H5N1 infection in humans confirmed by the World Health Organization (WHO) are fewer than 600 in number, with an overall case fatality rate of >50%. We hypothesize that the stringent criteria for confirmation of a human case of H5N1 by WHO does not account for a majority of infections, but rather, the select few hospitalized cases that are more likely to be severe and result in poor clinical outcome. Meta-analysis shows that 1 to 2% of more than 12,500 study participants from 20 studies had seroevidence for prior H5N1 infection.
Accuracy of Rapid Influenza Diagnostic Tests: A Meta-analysis
Chartrand C, Leeflang MMG, Minion J, et al. Ann Intern Med. 27 February 2012. [Epub ahead of print].
Available at http://www.annals.org/content/early/2012/02/27/0003-4819-156-7-201204030-00403.abstract
Background. Timely diagnosis of influenza can help clinical management.
Purpose. To examine the accuracy of rapid influenza diagnostic tests (RIDTs) in adults and children with influenza-like illness and evaluate factors associated with higher accuracy.
Data Sources. PubMed and EMBASE through December 2011; BIOSIS and Web of Science through March 2010; and citations of articles, guidelines, reviews, and manufacturers.
Study Selection. Studies that compared RIDTs with a reference standard of either reverse transcriptase-polymerase chain reaction (first choice) or viral culture.
Data Extraction. Reviewers abstracted study data by using a standardized form and assessed quality by using Quality Assessment of Diagnostic Accuracy Studies criteria.
Data Synthesis. There were 159 studies that evaluated 26 RIDTs, and 35% were conducted during the H1N1 pandemic. Failure to report whether results were assessed in a blinded manner and the basis for patient recruitment were important quality concerns. The pooled sensitivity and specificity were 62.3% (95% CI, 57.9% to 66.6%) and 98.2% (CI, 97.5% to 98.7%), respectively. The positive and negative likelihood ratios were 34.5 (CI, 23.8 to 45.2) and 0.38 (CI, 0.34 to 0.43), respectively. Sensitivity estimates were highly heterogeneous, which was partially explained by lower sensitivity in adults (53.9% [CI, 47.9% to 59.8%]) than in children (66.6% [CI, 61.6% to 71.7%]) and a higher sensitivity for influenza A (64.6% [CI, 59.0% to 70.1%) than for influenza B (52.2% [CI, 45.0% to 59.3%).
Limitation. Incomplete reporting limited the ability to assess the effect of important factors, such as specimen type and duration of influenza symptoms, on diagnostic accuracy.
Conclusion. Influenza can be ruled in but not ruled out through the use of RIDTs. Sensitivity varies across populations, but it is higher in children than in adults and for influenza A than for influenza B.
A distinct lineage of influenza A virus from bats
Tong S, Li Y, Rivailler P, et al. PNAS. 27 February 2012. doi:10.1073/pnas.1116200109.
Available at http://www.pnas.org/content/early/2012/02/17/1116200109.abstract?sid=8355f955-01dd-414c-8831-508fead5430e
Abstract. Influenza A virus reservoirs in animals have provided novel genetic elements leading to the emergence of global pandemics in humans. Most influenza A viruses circulate in waterfowl, but those that infect mammalian hosts are thought to pose the greatest risk for zoonotic spread to humans and the generation of pandemic or panzootic viruses. We have identified an influenza A virus from little yellow-shouldered bats captured at two locations in Guatemala. It is significantly divergent from known influenza A viruses. The HA of the bat virus was estimated to have diverged at roughly the same time as the known subtypes of HA and was designated as H17. The neuraminidase (NA) gene is highly divergent from all known influenza NAs, and the internal genes from the bat virus diverged from those of known influenza A viruses before the estimated divergence of the known influenza A internal gene lineages. Attempts to propagate this virus in cell cultures and chicken embryos were unsuccessful, suggesting distinct requirements compared with known influenza viruses. Despite its divergence from known influenza A viruses, the bat virus is compatible for genetic exchange with human influenza viruses in human cells, suggesting the potential capability for reassortment and contributions to new pandemic or panzootic influenza A viruses.
Highly pathogenic avian influenza (H5N1) outbreaks in wild birds and poultry, South Korea
Kim H-R, Lee Y-J, Park C-K, et al. Emerg Infect Dis. March 2012. 18(3). doi: 10.3201/eid1803.111490.
Available at http://wwwnc.cdc.gov/eid/article/18/3/11-1490_article.htm
Abstract. Highly pathogenic avian influenza (H5N1) among wild birds emerged simultaneously with outbreaks in domestic poultry in South Korea during November 2010–May 2011. Phylogenetic analysis showed that these viruses belonged to clade 2.3.2, as did viruses found in Mongolia, the People’s Republic of China, and Russia in 2009 and 2010.
Outbreaks of H5N1 in poultry in Thailand: the relative role of poultry production types in sustaining transmission and the impact of active surveillance in control
Walker P, Cauchemez S, Hartemink N, et al. J R Soc Interface. 22 February 2012. doi: 10.1098/rsif.2012.0022.
Available at http://rsif.royalsocietypublishing.org/content/early/2012/02/21/rsif.2012.0022.abstract
Abstract. H5N1, highly pathogenic avian influenza, continues to pose a public health risk in the countries of southeast Asia where it has become endemic. However, in Thailand, which experienced two of the largest recorded epidemics in 2004-2005, the disease has been successfully reduced to very low levels. We fitted a spatio-temporal model of the spread of infection to outbreak data collected during the second wave of outbreaks to assess the extent to which different poultry types were responsible for propagating infection. Our estimates suggest that the wave of outbreaks would not have been possible without the contribution of backyard flocks to the susceptibility of a sub-district. However, we also estimated that outbreaks involving commercial poultry, a much larger sector in Thailand than in neighbouring countries, were disproportionately infectious, a factor which was also crucial in sustaining the wave. As a result, implemented measures that aim to reduce the role of commercial farms in the spread of infection, such as the drive to bring aspects of the supply chain 'in house', may help to explain the subsequent success in controlling H5N1 in Thailand. We also found that periods of active surveillance substantially improved the rate of outbreak detection.
2012 International Conference on Emerging Infectious Diseases (ICEID)
Atlanta, Georgia, United States, 11 to 14 March 2012
The ICEID was first convened in 1998; ICEID marks its eighth occurrence. The conference brings together public health professionals to encourage the exchange of scientific and public health information on global emerging infectious disease issues. The program will include plenary and panel sessions with invited speakers as well as oral and poster presentations on emerging infections. Major topics to be included are current work on surveillance, epidemiology, research, communication and training, bioterrorism, and preventions and control of emerging infectious diseases, both in the United States and abroad.
Additional information at http://www.iceid.org/
2012 Australasian Society for Infectious Diseases Scientific Meeting
Fremantle, Western Australia, 21 to 25 March 2012
The meeting’s focus is to explore what the future holds for infectious diseases. Specific topics will include the origins and spread of new infectious diseases, how host factors may determine outcomes from infection, what tools we can use to predict, diagnose, manage and monitor infections, as well as a range of other topics including malaria, travel-related infections, viral hepatitis, antimicrobial use and abuse, current controversies in infectious diseases and the emergence and spread of multi-resistant organisms in the community.
Additional information at http://www.asid.net.au/Default2.aspx?active_page_id=337
9th Asia Pacific Travel Health Conference
Singapore, Singapore, 2 to 5 May 2012
The Asia Pacific Travel Health Conference 2012 is aimed at regional clinicians, physicians and any other healthcare professionals working in the field of travel medicine covering fields such as emerging infectious diseases, preventive medicine, primary health care and vaccinology. The conference will give an opportunity to exchange and get the most up-to-date information on travel medicine in the Asia Pacific region.
Additional information at http://www.apthc2012.org