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Vol. IX, No. 18 ~ EINet News Briefs ~ Sep 15, 2006


*****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:
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Global:Transfusion treatment for human avian influenza
- Russia: Avian influenza returns to the Omsk region
- Russia: 41 cases of CCHF and one fatality recorded in the Stavropol region
- Russia: Two hospital admissions for anthrax in the Tambov Region
- Russia: Meningitis outbreak in Khabarovsk
- Russia (Astrakhan): West Nile virus
- Cambodia: Research shows avian influenza doesn’t easily spread to humans
- Cambodia: New outbreak of avian influenza in ducks
- China: China acknowledges not giving WHO avian influenza samples
- Indonesia: Human-to-human transmission possible in 65th avian flu case
- Indonesia: Indonesia's 49th avian flu death confirmed
- Indonesia: Three new avian influenza cases identified retrospectively
- Indonesia: 47th and 48th avian influenza deaths reported in South Sulawesi
- Indonesia: Spread of bird flu virus in N. Sumatra still worrying
- Indonesia: Analysis of the North Sumatran Cluster
- Indonesia: Avian influenza- oseltamivir in pregnancy
- Indonesia: Outbreak of chikungunya
- China: Rabies control in Beijing; Three people die of rabies in Shanghai
- China (Shanxi, Henan): Outbreak of Japanese encephalitis
- China: Angiostrongylus meningitis from consumption of snails
- China: Pig illness in the south, agriculture ministry demands strengthened quarantine
- Taiwan: Japanese Encephalitis update
- Thailand: Hand, foot & mouth disease
- Thailand: Leptospirosis after flood-affected villages
- USA (Massachusetts): Eastern equine encephalitis
- Canada: A 2nd human case of anthrax infection has emerged in Saskatchewan.
- USA: Multistate outbreak of E. coli O157:H7
- USA: FDA launches Salinas Valley E coli probe
- USA (Pennsylvania): Low-risk H5N1 bird flu found in Pennsylvania ducks
- USA (Maryland): Low Pathogenic strain of avian influenza found in mallards
- USA (California): Paragonimiasis, Orange County, California, suspected from crabs imported
- Egypt (Sohag, Damietta): Avian influenza in domestic fowl
- Sudan: Confirmed outbreak of avian influenza in Juba
- Viet Nam: Hand, foot & mouth disease

1. Updates
- Avian/Pandemic influenza updates
- Dengue
- West Nile Virus

2. Articles
- Avian Influenza Tests Complete On Maryland Resident Wild Mallard Ducks
- Satellites help scientists track migratory birds: GPS the latest tool in fight against avian influenza
- Fatal outcome of human influenza A (H5N1) is associated with high viral load and hypercytokinemia.
- Empirical Evidence for the Effect of Airline Travel on Inter-Regional Influenza Spread in the United States
- Meta-analysis: convalescent blood products for Spanish influenza: a future H5N1 treatment?
- Live, attenuated influenza A H5N1 candidate vaccines provide broad cross-protection in mice and ferrets.

3. Notifications
- The Fifth National Conference on Quality Health Care for Culturally Diverse Populations
- 4th Annual Public Health Information Network (PHIN) Conference

4. To Receive EINet Newsbriefs
- JOIN THE E-LIST AND RECEIVE NEWSBREIFS REGULARLY


Global
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
2003
Viet Nam / 3 (3)
Total / 3 (3)

2004
Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)

2006
Azerbaijan / 8 (5)
Cambodia / 2 (2)
China / 12 (8)
Djibouti / 1 (0)
Egypt / 14 (6)
Indonesia / 46 (37)
Iraq / 2 (2)
Thailand / 2 (2)
Turkey / 12 (4)
Total / 99 (66)
Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present:246 (144).
(WHO 9/14/06 http://www.who.int/csr/disease/avian_influenza/en/index.html )

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Global:Transfusion treatment for human avian influenza
Should the world be caught without an effective vaccine or antiviral treatment for an avian flu pandemic, a last-ditch option may be to inoculate the sick with antibodies from the blood of those who are able to recover from the disease, according to a review of studies published after the 1918 Spanish influenza pandemic.

The H5N1 virus has killed 141 of the 241 people reported to have contracted it. Current manufacturing capacity could vaccinate less than 5 per cent of the world's population in the event of a pandemic, however, making alternative treatments extremely desirable. One method known to work in other viral diseases such as rabies and measles is to transfer the blood of a recovered patient to a sick one, giving the latter antibodies against the pathogen.

Transfusions were also tried in the 1918 flu pandemic but hadn't been studied extensively, so US military and biotech researchers searched the medical literature published between 1918 and 1925 for reports of the treatment. Those who received blood transfusions were 21 per cent more likely to survive a case of influenza-induced pneumonia than those who didn't receive the treatment, they found in a survey of 8 studies. Of 336 total people treated, 16 per cent died from the pneumonia compared with 37 per cent of those in control groups. Of the treated individuals, those who had received a transfusion within the first 3 days of contracting pneumonia were 41 per cent more likely to survive than those treated afterward.

"Our analysis suggests that patients with Spanish influenza pneumonia who received transfusion may have experienced a clinically important reduction in the risk for death and improvements in clinical signs and symptoms," the researchers report in a paper published online on 29 Aug 2006 in the Annals of Internal Medicine (Luke TC, Kilbane EM, Jackson JL, Hoffman SL. Meta-analysis: convalescent blood products for Spanish influenza pneumonia: a future H5N1 treatment? Ann Intern Med 2006; 145(8) http://www.annals.org/cgi/content/full/0000605-200610170-00139v1>). "Our findings are provocative, but our review has important limitations," they point out. The old studies were small and poorly done by current standards.

Nevertheless, "the concept is important and it should be explored further, especially given our lack of proven interventions to prevent or treat illness due to H5N1 influenza," writes John Treanor of the University of Rochester in an accompanying editorial. Serum from recovered patients would be technically simple to prepare and presumably in ample supply, he says, although researchers don't know if those who recover from H5N1 produce copious antibodies. He notes that "controlled clinical studies done now will probably pay a considerable dividend when the pandemic begins."

[The practicality of this approach is open to question. Post-exposure antibody-containing sera would become available in quantity only after a pandemic situation had arisen. Furthermore live H5N1 avian influenza virus can be isolated from the blood of human cases and H5N1 virus can spread via the bloodstream to parts of the body not normally attacked by influenza viruses, posing challenges for both patient treatment and reagent control (see: Avian influenza, human - worldwide (58): viremia 20060505.1307).
(Promed 8/31/06)

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Europe/Near East
Russia: Avian influenza returns to the Omsk region
During the course of laboratory investigations H5N1 avian influenza virus was isolated from the carcasses of wild birds at 14 lakes in the Omsk region.

According to the Directorate of the Federal Service for Veterinary and Phyto-sanitary Supervision for the Novosibirsk oblast, all foci of avian influenza in domestic poultry have been eradicated in the territory of the Siberian federal district in Russia.

In addition a complex of anti-epizootic measures has been implemented to eradicate avian flu foci in wild birds at one site, namely the lake of Ubsa-Nur in the Republic Tyva. [What is avian-influenza "eradication" in wild birds? Clarification would help. - Mod.AS]

Following the completion of the control measures required, quarantine measures have been withdrawn in other, earlier infected, regions of the Siberian Federal district.

According to information obtained from the press-service of the Federal service for veterinary and phyto-sanitary supervision, 8 million domestic birds are maintained in the zones at risk, while more than 10 million birds have already been preventively vaccinated. This includes vaccination of poultry in 7 rural areas within the Novosibirsk region which are not regarded as being at immediate risk but are located on transit routes of poultry and poultry products.
(Promed 9/3/06)

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Russia: 41 cases of CCHF and one fatality recorded in the Stavropol region
Forty-one cases of Crimean-Congo haemorrhagic fever (CCHF), including one fatality, have been recorded in 12 districts of the Stavropol region, according to the Territorial Management of Rospotrebnadzor (Federal Service on Surveillance of Consumer Rights and Human Well-being) in Stavropol. These figures are worse than those of the preceding year when 38 cases were recorded in 15 areas of the region. Despite this, local epidemiologists consider that the CCHF epidemic season is coming to an end.

As in previous years, tick bites are the main route of infection -- accounting for 61 per cent of all cases of CCHF. Of patients exposed to infection by tick bite, 28 per cent were exposed as a consequence of their employment in agriculture and animal husbandry.

A total of 7770 people in the region sought treatment for tick bites. This number is 1500 fewer than during the corresponding period of 2005. But the 334 people admitted to hospital with suspected CCHF exceeded by 46 per cent the number admitted to hospital in 2005 on suspicion of CCHF infection.

[This year a deterioration in the CCHF situation has been observed in all regions of the Southern Federal district as well as in the Stavropol region.
(Promed 8/31/06)

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Russia: Two hospital admissions for anthrax in the Tambov Region
Two inhabitants of the Sosnovskaya district of the Tambov Region have been admitted to the Tambov Infectious Diseases hospital with a diagnosis of anthrax. The information came from Vladimir Pominov, the director in charge of the Regional Veterinary Agency, according to an ITAR TASS report.

Mr Pominov said that a man and a woman came from the villages Andreevka and Zelenoe, where a couple of days ago, cattle had been slaughtered. One of the patients, Mr Pominov said, is in a serious condition.

The response of the Veterinary Service of the Sosnovskaya district was very prompt, and the infected meat has been collected. The carcasses of the animals have been burned. Now measures are being taken to localize the source of the infection, quarantine has been established, and the places of slaughter of cattle are being covered by concrete.

According to the Ministry of Extreme Situations of Russia anthrax in cattle has been recorded in the Tambov region.

Symptoms of this disease were detected on Thursday [24 Aug 2006] in a cow in the village of Andreevka of the Sosnovskiy district in the Tambov region. The man, the owner of the sick animal, was placed in hospital for observation for symptoms of anthrax.

Now necessary sanitary and epidemiologic measures are being carried out at the focus of infection.
(Promed 8/27/06, 8/30/06)

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Russia: Meningitis outbreak in Khabarovsk
According to reports in the Russian press on Tue 29 Aug 2006, an outbreak of meningitis has occurred in the Russian Far East border region of Khabarovsk, with hundreds infected. In the 2 principal border cities of Khabarovsk and Komsomolsk-on-the-Amur, a total of over 700 people have been infected, most of them children under 14 years of age. The local authorities are considering whether to delay the start of the school year to prevent spread of the disease in schools. Local health care workers say many of the children became infected by drinking unclean water. The virus was then transmitted in the population through droplets of saliva.

About 20 new serous viral meningitis cases have been registered daily in the Khabarovsk Territory this week [13 Sep 06].

The regional government's press service told ITAR-TASS on Wednesday [13 Sep 2006] that the number of affected people had increased to 1490 since the beginning of the disease outbreak. About 400 have been hospitalized with enterovirus meningitis. Specialists of the territorial Health Department described the situation as tense. New cases have been registered in Komsomolsk-on-Amur and 3 adjacent areas.

Causes of the virus spread are bathing in the Amur river and open reservoirs, contact and aerial infection transmission. Tests revealed enterovirus ECHO-6, hepatitis A virus and rotaviruses in water samples from the Amur and in sewage.
(Promed 8/30/06)

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Russia (Astrakhan): West Nile virus
Two cases of West Nile virus were registered in Astrakhan; one of the individuals, an elderly woman, died as a result.

Older people in general are very vulnerable to the disease, which is associated with a weakened immune system. To prevent new cases of disease, preventive measures are being conducted in Astrakhan, mainly fumigating the areas of mosquito concentration, specifically near water pools, in basements, and in terrain with high grass.

In 2005 there were 73 cases of West Nile disease registered in total in Astrakhan; 3 cases were fatal.
(Promed 8/26/06)

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Asia
Cambodia: Research shows avian influenza doesn’t easily spread to humans
Researchers who tested 351 Cambodian villagers after they had extensive contact with avian influenza-infected poultry in 2005 found that none had antibodies to the H5N1 virus, suggesting that it doesn't easily spread to humans and that mild cases are rare.

"Our findings suggest that asymptomatic and mild H5N1 virus infections had not occurred in the population we investigated," states a report published by Emerging Infectious Diseases [See: Vong S, Coghlan B, Mardy S, et al. Low frequency of poultry-to-human H5N1 virus transmission, southern Cambodia, 2005. Emerg Infect Dis 2006;12(10) http://www.cdc.gov/ncidod/EID/vol12no10/06-0424.htm].
(Promed 9/7/06)

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Cambodia: New outbreak of avian influenza in ducks
A fresh outbreak of bird flu has been confirmed in ducks in eastern Cambodia where the virus re-emerged in August 2006, officials said on Tuesday. Tests confirmed the deadly H5N1 virus in live and dead ducks in the Bateay district of the eastern province of Kampong Cham where 700 birds died last week, they said. "We sent our vets to cull the rest of the live ducks after the result was confirmed on Saturday," senior agriculture official Yim Voeunthan told Reuters.

The virus could have spread from a nearby village where a bird flu outbreak killed nearly 2000 ducks last month, said Ku Chanthan, a veterinarian in Kampong Cham.

In early August, the virus was also found among 1300 ducks that died in the province of Prey Veng, 70 km (45 miles) southeast of Phnom Penh. Authorities said that infected ducks that survived the outbreak in Prey Veng may have been smuggled to Kampong Cham, where surveillance efforts against the virus have been stepped up. "We are worried that more bird flu will be found in ducks because our survey experience showed that up to 15 percent of live ducks carried the virus," Yim Voeunthan said.
(Promed 9/5/06)

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China: China acknowledges not giving WHO avian influenza samples
China acknowledged it hasn't given the World Health Organization any bird flu samples taken from poultry since 2004, blaming the long delay on talks over the protocol for how to hand over the virus to international labs. "When viral strains cross international borders, special protocols are needed and we are working to finish them," vice director of the Ministry of Agriculture's veterinary department Li Jinxiang said Tuesday.

International scientists say they need the bird flu samples from poultry to study the development of the H5N1 virus that causes avian flu and to help make drugs and vaccines to fight the disease. They're also crucial to tracking any changes that could make bird flu easy to catch from human-to-human contact, a transformation that could turn it into a pandemic capable of killing millions. Already, more than 100 people have been killed since 2003, most, if not all, from contact with infected birds. In March, China promised to hand over poultry samples to the World Health Organization.

China has shared strains of the bird flu virus found in humans, but hasn't shared any samples taken from animals since 2004, when it provided samples from 5 animals.
(Promed 9/5/06)

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Indonesia: Human-to-human transmission possible in 65th avian flu case
The World Health Organization (WHO) today recognized two cases of H5N1 avian influenza in Indonesia, including one from March that was first reported yesterday by a WHO official and one from May involving a man who may have become infected after exposure to an ill family member.

In both instances, the WHO has retroactively confirmed the cases on the basis of its new criteria for laboratory confirmation. The boy's case put Indonesia's count at 64 cases with 49 deaths, and the man, who recovered, represents the country's 65th officially confirmed case.

The 5-year-old boy from East Bekasi in West Java province became ill on Mar 4, was hospitalized 2 days later, and died on Mar 19. The WHO said test results using two different assays revealed high antibody titer for H5N1 on serum samples taken on days 11 and 15 of his illness. Field investigators had determined that the boy had been exposed to sick poultry near his home, where some birds had tested positive for the H5 virus subtype.

Investigators identified the second case, in a 27-year-old man from Solok in West Sumatra province, when they traced contacts of the man's 15-year-old sister who had a confirmed H5N1 infection in May. Her brother spent 6 days caring for her during her hospitalization. On May 28 he experienced mild cough and abdominal discomfort but no fever. His symptoms improved and he recovered in a few days.

Despite his mild and atypical symptoms, the brother was tested as part of the health ministry's contract tracing and management program. He was given a 5-day course of oseltamivir beginning Jun 1 and was placed in voluntary isolation during his recovery.

Initial samples were negative for H5N1 infection; however, in August, follow-up testing of paired-serum samples found a fourfold rise in neutralization antibody titer for H5N1, a result that meets WHO's new criteria for laboratory confirmation.

The man reported no contact with diseased or dead poultry before he became ill. Investigators determined that human-to-human transmission resulting from exposure to his sister could not be ruled out. The WHO issued a report confirming his sister's H5N1 infection on May 29. It said she remained hospitalized, but no details were available on the outcome of her illness.
(CIDRAP 9/14/06 http://www.cidrap.umn.edu)

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Indonesia: Indonesia's 49th avian flu death confirmed
The World Health Organization (WHO) has retrospectively recognized another case of H5N1 avian influenza in Indonesia, involving a 5-year-old boy from West Java who died in March, according to news services. The boy's death was added to the WHO case registry after the agency revised its definition of human H5N1 avian flu cases, according to a Bloomberg News report that quoted Sari Setiogi, a WHO spokeswoman in Jakarta. The agency had not yet noted the case on its Web site at this writing. With the boy's case, Indonesia has had 64 cases with 49 deaths. Runizar Ruesin, head of the Indonesian government's avian flu information center, told Bloomberg the boy was from Bekasi, east of Jakarta, and died on Mar 19. Poultry deaths were reported in the boy's neighborhood, Ruesin said. No one else in the boy's family was known to be infected, and the source of his infection was unclear, according to a Reuters report today. (CIDRAP 9/13/06 http://www.cidrap.umn.edu)

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Indonesia: Three new avian influenza cases identified retrospectively
As of Fri 8 Sep 2006, The Ministry of Health in Indonesia has confirmed a new case of human infection with the H5N1 avian influenza virus. The case is a 14-year-old female from Makassar, South Sulawesi Province. She developed symptoms on 18 Jun 2006, was hospitalized on 23 Jun 2006 and died on 24 Jun 2006. The case had contact with poultry near her home. This case was detected through the Ministry's routine influenza surveillance system.

The South Sulawesi governor and the family of the latest confirmed bird flu victim expressed regret Friday that the Health Ministry did not immediately disclose the cause of the 14-year-old's death.

In addition to the above case and following the recent revision of case definitions for H5N1 infection, WHO is adding 2 cases in Indonesia, dating back to June and November of 2005. Inclusion of these 2 cases now aligns figures given for Indonesia in the WHO cumulative table of laboratory-confirmed cases with those officially issued by the Ministry of Health. Prior to the revision, the cases did not meet the WHO case definition for serologically confirmed avian influenza H5N1 infection.

The first retrospectively confirmed case was an 8-year-old female from Tangerang in Banten Province. She developed symptoms on 24 Jun 2005 and died on 14 Jul 2005. She was part of a family cluster reported to WHO in July 2005.

The second retrospectively confirmed case is a 45-year-old male from Magelang, Central Java Province. He developed symptoms on 25 Nov 2005 following direct contact with diseased poultry and subsequently recovered.

The retrospectively confirmed cases bring the total in Indonesia to 63. Of these cases, 48 have been fatal.
(Promed 9/8/06, 9/9/06)

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Indonesia: 47th and 48th avian influenza deaths reported in South Sulawesi
Indonesia confirmed on Thursday [7 Sep 2006] another person had died of bird flu as the nation hardest-hit by H5N1 continues to battle a disease that experts fear could one day spark a global pandemic. Indonesia's 47th fatality from the virus was a woman from South Sulawesi province, said Health Minister Siti Fadillah Supari, adding that infected birds had been found dead in the same area. "This we knows from the results of the (tests by the) Health Ministry's Research and Development Board last night (Wednesday)," Supari was quoted by AFP as telling journalists.

"We did not send (the samples) to the WHO (World Health Organisation) because our positive results are usually positive results at the WHO," she added. Up until now, Indonesia has always sent blood and tissue samples from suspected human bird flu cases to a WHO laboratory in Hong Kong for confirmation. Sari Setiogi, the WHO spokesperson in Indonesia, said that under a new arrangement Jakarta could confirm infections after 2 local tests showed the person to have contracted H5N1.

The minister said that they would soon carry out poultry culling in the area where the case was found. "We will soon do 'stamping out', because they found dead birds in the area," Supari said.

Both were identified as avian influenza fatalities on the basis of local laboratory tests, a practice now apparently endorsed by WHO. However, confirmation of these results has yet to appear on the WHO web-site. Clarification is awaited.
(Promed 9/7/06)

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Indonesia: Spread of bird flu virus in N. Sumatra still worrying
The spread of the bird flu (avian influenza/AI) virus in North Sumatra is still worrying despite the cull of some 73 096 poultry in the province recently, a provincial government official said. The poultry cull was intended to break the chain of the HN51 virus's transmission, a spokesman of the North Sumatra Administration said here on Wednesday [6 Sep 2006]. Of the total 73 096 culled poultry, some 37 458 were in Karo District, 20 012 in Simalungun, 14 727 in Dairi and 899 in Deli Serdang District. For every chicken or bird culled, the government provided compensation worth Rp 12 500 [USD 1.37] each.
(Promed 9/7/06)

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Indonesia: Analysis of the North Sumatran Cluster
Officials from the World Health Organization (WHO), drawing on sophisticated computer modeling of a theoretical bird flu outbreak in Southeast Asia, have suggested that a pandemic could be thwarted through a rapid containment effort in the affected area, including the right mix of drugs, quarantines and other social controls. To succeed, the anti-viral drug Tamiflu would have to be distributed to 90 percent of the targeted population, roughly defined as those within at least a 3-mile radius of each case. The drug would have to be administered within 21 days from the "timely detection" of the initial case of an epidemic strain. Residents would have to stay home, limit contact with others and take the medicine as prescribed. In the case of the North Sumatra cluster, almost none of this happened, according to extensive interviews with health officers, family members and villagers. The underlying problem was that most family members and villagers were convinced that magic, not flu, was to blame.

Health investigators have concluded that the 8-person cluster in Sumatra began with [Dowes] Ginting's older sister, who fell ill in late April [2006]. They suspect she was infected with bird flu from live chickens sold in a market where she peddled oranges, limes and chili peppers or from contaminated poultry droppings in manure used in her garden. She died and was buried before any samples were taken to confirm bird flu. Several days after she became sick, the extended family had gathered in the village of Kubu Sembilang for a feast of roast pig and chicken curry to celebrate the annual harvest festival. That night, many of the relatives slept in the same small room with the sister, who had developed a serious cough. By the time she died, a sister, a brother, 2 sons, a niece and a nephew had become ill. Flu specialists said the final victim, her brother Dowes Ginting, in turn probably caught the virus from his infected son. Health experts have concluded this was the 1st time the bird flu virus had been passed from one person to another and then on to a 3rd person.
(Promed 9/4/06)

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Indonesia: Avian influenza- oseltamivir in pregnancy
A woman who miscarried after taking Tamiflu (oseltamivir) is being monitored by health officials, but her doctor said there was no evidence the anti-bird flu drug was to blame. The World Health Organization and the Swiss-based drug manufacturer Roche Holding AG say they have inadequate data on the use of Tamiflu in pregnant women, so the significance of the miscarriage is not immediately clear.

The woman was 2 months pregnant when she was admitted to Adam Malik Hospital in North Sumatra's capital Medan on 22 Aug 2006, said Dr Nur Rasyid Lubis, adding that although she had symptoms of bird flu she later tested negative.

The 35 year old woman came from an area hard hit by the disease, so was given Tamiflu as a precaution, he said, adding that he did not believe her miscarriage had anything to do with the drug. The woman was "bleeding from her womb" when she arrived at the hospital and the fetus "was very weak," he noted.

WHO says that until more data on pregnant women are available, Tamiflu should only be prescribed when the potential benefit to the mother justifies the possible risk to the unborn child.
(Promed 9/2/06)

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Indonesia: Outbreak of chikungunya
Indonesian health authorities have contained an outbreak of the chikungunya virus in a village in South Sumatra after about 1/6 of the population there was infected, a doctor said Monday.

He told AFP that the outbreak began at the end of May 2006 and infected more than 500 people in village of some 3000. He said that teams had sprayed the village to rid it of the mosquitoes that transmit the virus and infected villagers had been given medical treatment.

Chikungunya is a tropical infectious disease transmitted by mosquitoes. It causes extreme pain in the joints and leaves the sufferer weak for a few days [to weeks] but is not considered to be fatal.
(Promed 9/7/06)

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China: Rabies control in Beijing; Three people die of rabies in Shanghai
More than 100 000 stray dogs roaming the city of Beijing are increasing the risk of a rabies epidemic. Officials of the Agricultural and Domestic Animal Bureau in Beijing say that they cannot guarantee how many of the 100 000 stray dogs within the metropolitan area have all been properly vaccinated, so Beijing is under a threat of a potential rabies epidemic.

According to statistics compiled from the beginning of this year [2006], more than 60 000 people have been bitten by cats or dogs in Beijing. One person was bitten by a rabid dog in the outskirts of Beijing and died shortly without seeking medical treatment. The Beijing municipal government has not yet introduced any effective measures to deal with stray dogs or to initiate any public awareness campaign to reduce the risk of a rabies epidemic.

Last week [7-13 Aug 2006], 16 human deaths from rabies were recorded in the province of Shandong. In response to this situation, the provincial authorities carried out the destruction of more than 500 000 dogs, an event that attracted [unfavorable] global media attention.

Recently in Yunan province, 3 people died as a result of rabies contracted by dog bites. Similarly, in this province, the local authorities responded with the violent destruction of approximately 50 000 dogs.

The 3 fatal cases of rabies were recorded in the Jinshan, Nanhui and Minsing Districts. The Jinshan case was caused by the victim's own dog as a result of a bite sustained at the beginning of this month [August 2006]. The fatal outcome was a consequence of delayed [post exposure] medical treatment. The other 2 fatal cases involved 2 migrants not native to Shanghai who succumbed to rabies also due to delayed [post exposure] treatment.
(Promed 8/27/06)

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China (Shanxi, Henan): Outbreak of Japanese encephalitis
The death toll from an outbreak of encephalitis B [the current name: Japanese encephalitis or JE], has risen to 19, with 38 people infected in Yuncheng City of Shanxi Province, the local health authorities said on Saturday [12 Aug 2006].

The city reported the summer's 1st case of encephalitis B [JE] on 13 Jul 2006, said the city's disease prevention and control center. Nine out of the 13 counties of the city, which has a population of 5 million, have reported cases of encephalitis B [JE], said the center.

Among the 12 patients who are being treated at the No. 2 Hospital of Yuncheng, 8 are in serious condition, and doctors are trying to save their lives, said Zhang Dinglin, deputy head of the hospital.

The people in Yuncheng are being told in a media blitz to clean up their neighborhoods by sweeping away pools of standing water in which mosquitoes can breed. Yunchang's hot weather and frequent rains have provided ideal conditions for mosquitoes to breed. As temperatures drop next month [September 2006], so will the number of cases of encephalitis, said Feng Lizhong, an official with the Shanxi Provincial Health Department.

An outbreak of mosquito-borne encephalitis B [JE] has killed another 14 people in China, adding to 26 deaths already reported, a state newspaper said on Friday [25 Aug 2006].

Health authorities in central Henan province said the fatalities were among 437 people who had been infected [by JE] since July 2006, a sharp jump from the number of infections reported in the 1st half of the year, the Beijing News said.

Earlier this month [August 2006], Chinese media reported that the disease had killed 19 people in the northern province of Shanxi and 7 in neighboring Shaanxi, infecting more than 200 others in both provinces.
(Promed 8/27/06)

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China: Angiostrongylus meningitis from consumption of snails
The number of people confirmed to have fallen ill after eating raw or half-cooked snails contaminated with parasites at a Beijing restaurant has risen from 70 to 87, the Beijing Health Bureau reported yesterday. Meanwhile, the Beijing restaurant that sold parasite-contaminated snails made an official apology to customers yesterday.

Qu Chuangang, spokesman for Shuguoyanyi Restaurant, which serves Sichuan-style dishes, said it will assume responsibility for the incident and try to deal with the problems caused. The restaurant admitted that the snails had not been processed correctly, which was the main reason customers had fallen sick.

[Angiostrongyliasis is caused by _Angiostrongylus cantonensis_. In the previous report, "fushouluo" was erroneously used to refer to the giant African snail. Instead, it refers to the Amazonian snail, which is distinctly smaller. This moderator apologizes for the mistake. Also, fushouluo lays bright pinkish, round, hard-shelled eggs that cling to the lower parts of aquatic plants, while the giant African snail lays beige hard-shelled eggs in a shallow pit on land.
(Promed 8/26/06)

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China: Pig illness in the south, agriculture ministry demands strengthened quarantine
In response to the recent occurrence of pig illness in the south, the General Office of the Ministry of Agriculture issued a notice yesterday [31 Aug 2006] requiring legally-compliant control and prevention against transmission or expansion of the disease; requiring increased quarantine dynamics at sites of production and slaughter; and resolutely implementing the "four impermissibles, one disposal" for all diseased pigs: no butchery, no eating, no sale, no transport, and safe onsite disposal.

Since June 2006, a pig disease characterized by rising body temperature, redness of the skin, and rapid breathing has occurred in portions of Anhui, Jiangxi, Zhejiang, Hunan, Hubei, Jiangsu, and other provinces. The Agriculture Ministry's notice requires conscientious implementation of all control measures: emphasize improvement of disease control and hoghouse hygiene among small and mid-size breeders (households) and breeding districts; establish sound disease control systems; strengthen disease surveillance and epidemiological investigations; promptly find and report disease; promptly eliminate hidden risks for disease; be strict with disease handling work; actively undertake appropriate treatment of diseased pigs; carry out cremation, burial and other safe disposal of dead pigs; appropriately select vaccines to conduct immunization work; promptly control and stamp out disease; strengthen supervision over animal hygiene production, sale and distribution; prohibit pigs that have not passed quarantine from entering distribution or slaughter; strike hard against illegal trafficking of diseased pigs and byproducts.
(Promed 9/3/06, 9/8/6)

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Taiwan: Japanese Encephalitis update
Based on the notifiable disease surveillance system in Taiwan, during the 35th epidemiological week (Aug 27 to Sep 2), seven Japanese Encephalitis (JE) cases were reported in Taiwan. As of Sep 2, there had been 188 reported cases of JE nation-wide this year, of those, 20 had been confirmed. So far this year (2006), two JE deaths have been reported.

The cumulative number of JE confirmed cases has decreased by 39.3 percent compared with the same period last year (2005, 33 cases). Among thisyear’s cases, one was classified as imported case and 19 were domestic cases. The origin of the imported case was from Vietnam.
(Taiwan IHR Focal Point Report 9/8/06)

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Thailand: Hand, foot & mouth disease
A total of 1009 cases of hand, foot, and mouth disease (HFMD) have been detected in Thailand so far in 2006, the Director-general of the Disease Control Department said on Saturday [2 Sep 2006]. Doctor Thawat Sunthajan, the Director-general, said the cases were reported by public health clinics nationwide between January and the end of July [2006].

Thawat said 4 children died of the disease and most of the patients were between 2 and 5 years old.
(Promed 9/7/06)

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Thailand: Leptospirosis after flood-affected villages
Deputy Public Health Minister Anuthin Chanweerakul yesterday, 10 Sep 2006, warned flood-affected villagers of leptospirosis, after 1400 cases were found in the past 8 months resulting in 31 deaths.

Anuthin insisted the disease could be prevented if people refrained from wading through floodwater and muddy ground with bare feet, as leptospirosis enters the body via wounds and scratches. He urged flood-affected people to wear plastic boots and said the ministry had prepared medication and supplies for the timely treatment of leptospirosis patients.

Director-general of the Disease Control Department Dr Thawat Sunthrajarn said 60 people in Nan province had contracted leptospirosis; 44 were now hospitalized and 6 had died. Since the diagnosis took some time to confirm, people with leptospirosis symptoms would immediately be given antibiotics. Most people were cured if they sought medical attention early enough, he said.
(Promed 9/12/06)

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USA (Massachusetts): Eastern equine encephalitis
A 9-year-old boy developed a fever on 18 Aug 2006 and was hospitalized 2 days later. He died Thursday [31 Aug 2006] afternoon, said Christine Powers-Perry, a spokeswoman for Children's Hospital in Boston.

Middleborough [where the boy lived] was among the communities in southeastern Massachusetts that have undergone 2 rounds of aerial spraying to kill the mosquitoes that carry the virus. The 1st round of spraying on 8 Aug 2006 reduced the mosquito population by at least 60 percent, officials said.

Two other people [in Massachusetts] -- a 52-year-old woman from Lakeville and a 23-year-old man from Acushnet -- have contracted the virus this year [2006].
(Promed 9/4/06)

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Americas
Canada: A 2nd human case of anthrax infection has emerged in Saskatchewan.
More than 663 animals have died in what health officials have called the worst anthrax outbreak in decades. However, human infections are much more rare.

A Yorkton-area veterinarian contracted the cutaneous type of the disease last week and is being treated with antibiotic ointment. He said he scratched some welts on his ankle after he had been testing dead cattle for anthrax. He said he must have had anthrax spores on his fingers at the time and that's how he got an infection.

Officials with the Canadian Food Inspection Agency say the outbreak is slowing. There had been no new cases of animal deaths in Saskatchewan in CFIA's last report on Tuesday.
(Promed 8/26/06)

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USA: Multistate outbreak of E. coli O157:H7
Consumers should avoid eating fresh bagged spinach after an outbreak of _E. coli_ in 8 states killed 1 person and sickened at least 49, federal health officials announced Thu night, 14 Sep 2006. The outbreak involves a virulent strain of E. coli known as O157:H7, which produces a toxin that can lead to bloody diarrhea, kidney failure and, in rare cases, death.

State and federal health officials have used genetic screening tools to confirm that all 50 people sickened by the disease suffered from the same bacteria, said Dr. David Acheson of the Center for Food Safety and Applied Nutrition at the FDA. But health officials still have no idea which food manufacturer may be to blame. The 1st case was reported on 23 Aug 2006 and the most recent on 3 Sep, Dr. Acheson said. "It's increasing by the day," Dr. Acheson said. "We may be at the peak, we may not. We're giving preliminary data here."

Dr. Acheson described the outbreak as "significant." It is broadly distributed across the country. Twenty cases -- including the only confirmed death -- occurred in Wisconsin. There were 11 cases in Utah, 5 in Oregon, 4 in Indiana, 3 each in Idaho and Michigan, 2 in New Mexico and 1 in Connecticut, he said. Most of those affected have been women. Although this strain of _E. coli_ commonly affects children, many patients have been older than 20, Dr. Acheson said.

Health officials are by no means certain that bagged spinach is the culprit. When patients have a confirmed case of the disease, health officials ask the victims many questions about what they ate over the previous weeks. Bagged fresh spinach is the only food that patients so far have had in common, Dr. Acheson said. Asked if consumers should also avoid bagged salads, Dr. Acheson answered somewhat tentatively, saying, "At this point, there is nothing to implicate bagged salad."
(Promed 9/15/06, CIDRAP 9/15/06 http://www.cidrap.umn.edu)

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USA: FDA launches Salinas Valley E coli probe
Outbreaks of Escherichia coli in recent years have spurred federal and California officials to launch a broad investigation into farms and processors of lettuce and other leafy greens in California's Salinas Valley, according to the US Food and Drug Administration (FDA) and news sources.

Of 19 US outbreaks of E coli O157:H7 from lettuce and spinach since 1995, eight have been traced to Salinas Valley, dubbed the "Salad Bowl of the World," according to a Sep 11 Los Angeles Times article. These eight outbreaks have affected 217 people in eight states, including two elderly patients from northern California who died in 2003.

In response to these outbreaks, the FDA announced its Lettuce Safety Initiative on Aug 23 of this year. In its announcement, the FDA said it will, in conjunction with California agencies, "visit farms and cooling and packing facilities, and inspect processors, focusing on good agricultural practices and good manufacturing practices," identifying "practices that potentially lead to product contamination."
(CIDRAP 9/14/06 http://www.cidrap.umn.edu)

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USA (Pennsylvania): Low-risk H5N1 bird flu found in Pennsylvania ducks
Mallard ducks in Pennsylvania have tested positive for a low-pathogenic strain of the H5N1 bird flu virus, the U.S. Agriculture and Interior departments said on Saturday [2 Sep 2006], adding to cases detected recently in Maryland and Michigan.

A strain of the H5N1 avian influenza virus was found in wild ducks sampled 28 Aug 2006 in Crawford County in northwestern Pennsylvania.

"Testing has ruled out the possibility of this being the highly pathogenic H5N1 strain that has spread through birds in Asia, Europe and Africa," USDA and Interior said in a statement.

The government said it was conducting additional tests to determine, in part, whether the ducks had H5N1 or 2 separate strains with one virus contributing H5 and the other N1. A 2nd round of tests could take 5 to 10 more days to confirm whether it was low-pathogenic H5N1 bird flu.
(Promed 9/4/06)

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USA (Maryland): Low Pathogenic strain of avian influenza found in mallards
Mallard ducks in Maryland have tested positive for bird flu, apparently a common, less pathogenic strain that poses no risk to humans, the United States Agriculture and Interior departments said on Friday.

The H5N1 avian influenza virus was found in fecal samples from "resident wild" mallards in Queen Anne's County in Maryland, on the US central Atlantic coast.

"Testing has ruled out the possibility of this being the highly pathogenic H5N1 strain that has spread through birds in Asia, Europe and Africa," said the United States Department of Agriculture. "Test results thus far indicate this is low pathogenic avian influenza, which poses no risk to human health."

The Maryland mallards did not appear sick so the samples, collected on 2 Aug 2006 as part of a research project, were not given high priority when sent to USDA labs for testing. "The birds are alive and well," said a USDA spokeswoman.
(Promed 9/2/06, CIDRAP 9/13/06 http://www.cidrap.umn.edu/)

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USA (California): Paragonimiasis, Orange County, California, suspected from crabs imported
We have recently had several domestically acquired cases of paragonimiasis associated with consumption of raw freshwater crab imported from Japan. We are currently investigating the extent of distribution and consumption of these raw crabs. Currently, there are several other people who have admitted to consuming the freshwater crab raw. As this is a rare disease in the United States, we are looking for advice from specialists in an area where paragonimiasis is endemic on the following questions:
1. For an asymptomatic person, would you test (serum for Ab, stool O&P) after consumption of raw freshwater crab? If yes, how soon after ingestion would you test?
2. If initial testing on an asymptomatic exposed person is negative, would you do follow-up testing and when?
3. If testing is positive on an asymptomatic person, would you treat them?
4. Have cases been identified with history of consumption of flash-fried crabs (unclear duration of frying but brief)?
5. Does the high efficacy of treatment of pulmonary paragonimiasis with praziquantel mean that those treated have little or no sequelae or just that the parasite is killed/cleared?
6. If there are any paragonimiasis experts from endemic countries, especially Japan, reading this query, we would appreciate additional assistance with specific questions about the crab in question and the area where it is farmed.

Response:
There are a number of species of Paragonimus which can infect humans. These are as follows (according to geographical locales):

China: _P. westermani_, _P. skrjabini_, _P. heterotremus_ and _P. hueitugensis_
Japan: _P. westermani_, _P. miyazakii_
Cameroon: _P. africanus_ and _P. uterobilateralis_
Vietnam: _P. heterotremus_
Ecuador and Peru: _P. mexicanus_

However, these parasites may be found in other countries as well. _P. westermani_ is endemic in China, Korea, Japan, Taiwan, and the Philippines and has been detected in other countries including India. The life cycle of this trematode includes 2 intermediate hosts. The first are snails and the second are crabs and crayfishes, where the infective stage of the parasite (the metacercariae) are encysted. The major intermediate hosts which can transmit the infection to humans are crabs of the genera Eriocheir, Potamon and Sundathelphusa and crayfishes of the genus _Cambaroides_. If cooking of these is proper before eating there is no chance of infection being transmitted. Generally, in the endemic countries, crabs etc. are eaten either raw, in alcohol, or undercooked and this then can easily transmit the infection to humans.

After the ingestion of the cysts (metacercariae), they excyst in the stomach and the larvae come out, penetrate the gut wall, and migrate through the mesentery and diaphragm to reach the lungs, where they mature into the adult worms and after fertilization start to lay eggs. This normally takes about 3 months. The worms can lead to pulmonary paragonimiasis or can also reach aberrant sites and can cause cerebral, cutaneous paragonimiasis.

Therefore:
1. For an asymptomatic person it would be better to go for serology, as this would be positive well before the worms mature and lay eggs.
2. If initial serology is negative it can be repeated after 10-14 days.
3. If serology is positive in a non-endemic area, take it to be probable infection and it would be advisable to follow up and treat.
4. Regarding the moderator's previous query, I have no knowledge regarding cases after flash-fried crabs, but it would be possible, as temperature inside the muscle tissue of the crab may not reach the level necessary to kill the metacercariae.
5. Earlier treatment should prevent scarring and sequelae
(Promed 8/29/06, 9/2/06)

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Africa
Egypt (Sohag, Damietta): Avian influenza in domestic fowl
Egypt uncovered new cases of bird flu in domestic fowl, the health ministry said on Thursday. Birds tested positive for the lethal H5N1 strain in locations in the southern province of Sohag and the Mediterranean coastal province of Damietta, the ministry said.

"Teams were culling the infected birds in both locations," it said in a statement on the state news agency MENA. The ministry on Tuesday announced Egypt's 1st discovery of infected birds in months, raising concerns over a return of the virus with the start of the migration season.

Since the disease broke out in the country in early March 2006, 6 people died of bird flu in Egypt, sparking a massive cull of poultry across the country.

The last human case of H5N1 reported in Egypt dates back to May 2006. Out of the 14 human cases of avian influenza that have been reported among Egyptians since mid-March 2006, 6 turned out to be fatal, and 8 people recovered after being treated with the drug Tamiflu (oseltamivir).
(Promed 9/3/08, 9/8/06)

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Sudan: Confirmed outbreak of avian influenza in Juba
There is a confirmed outbreak of bird flu (Avian Influenza) in Juba, Southern Sudan, the Ministry of Health has announced.

The chairperson of the National Task Force on Bird Flu, Dr. Sam Okware, said yesterday [10 Sep 2006] the outbreak was confirmed on 6 Sep 2006, and is affecting local chickens.

He directed the district health officers and district veterinary officers in Nebbi, Arua, Koboko, Yumbe, Moyo, Adjumani, Pader, Gulu, Kitgum, Lira. Apac, Kaabong, Kotido and Moroto districts to strengthen their task forces on bird flu to enhance surveillance and public education.

"In addition, the people at the country borders should be on high alert for any suspicious birds or poultry products being brought into the country," Okware said in a press release yesterday.

[On 19 Apr 2006, Sudan's Federal Ministry of Animal Resources notified the OIE of the diagnosis of HPAI, subtype H5, in the provinces Khartoum and Gezira. In subsequent notifications, in May and July, additional outbreaks in the same provinces and in the province River Nile were reported, and the causal agent was finally confirmed as H5N1. - Mod.AS]
(Promed 9/12/06)

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Viet Nam: Hand, foot & mouth disease
Hand, foot & mouth infection among children in Ho Chi Minh City [HCMC] has doubled in August over July [2006], a hospital official reported Friday [8 Sep 2006].

Truong Huu Khanh, head of the Pediatric Hospital Oneis contagions-neurology department, said the hospital had received 120 children suffering from the disease in just the last fortnight, against 116 in the whole of July [2006]. Around 30 percent of the patients had suffered from complications in the brain and nervous system, he said.

HCMC had registered 811 infections this year [2006], Nguyen Dac Tho, deputy director of the municipal Center for Disease Control and Prevention, said.
(Promed 9/9/06, 9/13/06)

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1. Updates
Avian/Pandemic influenza updates
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html.
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html Read the latest issue of FAOAIDEnews, a situation update on avian influenza outbreaks throughout the world (9/12/06).
- OIE: http://www.oie.int/eng/en_index.htm. Read about the animal health news this week (9/14/06)
- US CDC: http://www.cdc.gov/flu/avian/index.htm
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and scholarly articles.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- American Veterinary Medical Association: http://www.avma.org/public_health/influenza/default.asp.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Very frequent news updates.
(WHO; FAO, OIE; CDC; CIDRAP; PAHO; AVMA; USGS)

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Dengue
China: Guangdong
The number of dengue fever cases in China's southern Guangdong province has more than doubled to 219 in the past week, half of whom are still in hospital, Xinhua news agency said late on Monday [4 Sep 2006].

Of the 219 people infected, mostly since June, 192 were in the provincial capital Guangzhou, a city of 10 million, Xinhua said."They are in stable conditions and there have been no fatalities," the provincial health bureau said of the patients, according to Xinhua.

The cases involved the least dangerous form of the virus, which is endemic to the tropics. Dengue is carried by the Aedes aegypti mosquito, which transmits the virus that causes fever, severe headache, joint and muscular pains, vomiting and rashes.
(Promed 9/11/06) Taiwan
Dengue fever update from Taiwan-Week 36, 2006

Based on the notifiable disease surveillance system in Taiwan, during the 36th epidemiological week (Sep 3 to 9), 83 dengue fever (DF) cases were reported in Taiwan, of which 25 were laboratory confirmed, including one dengue hemorrhagic fever (DHF) case. As of Sep 9, there had been 804 reported cases of DF nation-wide this year, of those, 227 had been confirmed, including four DHF cases. So far this year (2006), no DF deaths have been reported.

The cumulative number of dengue confirmed cases has increased by 122.5 percent compared with the same period last year (2005, 101 cases). Among this year’s cases, 65 were classified as imported cases and 162 were domestic cases. The origins of the imported cases were as follows: 25 from Vietnam; 13 from Indonesia; nine from Thailand; nine from the Philippines; three from Cambodia; two from Malaysia; one from Myanmar; one from El Salvador; one from India; and one from Madagascar.

Of the domestic cases, the main serotype of circulating DF virus is DEN-3, and only one case is DEN-2. The case distribution was mainly in southern Taiwan, including Kaohsiung City, Kaohsiung County, Tainan City, and Pingtung County.
(Taiwan IHR Focal Point 9/15/06, Promed 9/15/06)

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West Nile Virus
Canada
Human cases were reported for week 35 (as of 2 Sep 2006) from the following provinces:

Province / Neurological / Non-Neurological / Unclassified; Unspecified / Total* / Asymptomatic**

Alberta / 0 / 3 / 0 / 3 / 0
Ontario / 0 / 3 / 1 / 4 / 0
Manitoba / 4 / 3 / 9 / 16 / 0
Saskatchewan / 1 / 3 / 0 / 4 / 0

* Neurological syndrome + Non-Neurological syndrome + Asymptomatic Infections ** Most identified through blood donor testing.

USA
Human Cases have been reported from:

State / Neuroinvasion* / *West Nile* fever** / Other*** / Total **** / Fatalities

Alabama / 4 / 0 / 0 / 4 / 0
Arizona / 7 / 4 / 2 / 13 / 0
Arkansas / 7 / 2 / 0 / 9 / 0
California / 42 / 108 / 9 / 96 / 2
Colorado / 18 / 57 / 0 / 75 / 1
Connecticut / 5 / 2 / 0 / 7 / 1
District of Columbia / 0 / 1 / 0 / 1 / 3 / 0
Georgia / 2 / 2 / 1 / 5 / 1
Idaho / 62 / 257 / 6 / 325 / 5
Illinois / 53 / 30 / 11 / 94 / 4
Indiana / 1 / 0 / 0 / 1 / 0
Iowa / 12 / 7 / 0 / 19 / 0
Kansas / 13 / 9 / 0 / 22 / 3
Louisiana / 38 / 26 / 0 / 64 / 0
Maryland / 0 / 0 / 1 / 1 / 0
Michigan / 10 / 0 / 1 / 14 / 0
Minnesota / 22 / 30 / 0 / 52 / 3
Mississippi / 34 / 36 / 0 / 70 / 3
Missouri / 18 / 5 / 1 / 24 / 2
Montana / 3 / 7 / 0 / 10 / 0
Nebraska / 15 / 41 / 0 / 56 / 1
Nevada / 30 / 60 / 9 / 99 / 1
New Jersey / 1 / 1 / 1 / 3 / 0
New Mexico / 1 / 2 / 0 / 3 / 0
New York / 5 / 2 / 1 / 8 / 0
North Dakota / 13 / 88 / 0 / 101 / 1
Ohio / 8 / 3 / 0 / 11 / 0
Oklahoma / 15 / 6 / 1 / 22 / 5
Oregon / 2 / 19 / 1 / 22 / 0
Pennsylvania / 5 / 1 / 0 / 6 / 1
South Dakota / 30 / 56 / 0 / 86 / 1
Texas / 106 / 23 / 0 / 129 / 13
Utah / 34 / 47 / 0 / 81 / 3
West Virginia / 1 / 0 / 0 / 1 / 0
Wisconsin / 3 / 3 / 0 / 6 / 0
Wyoming / 8 / 17 / 4 / 29 / 1

* Cases with neurologic manifestations (such as WN encephalitis, meningitis* and myelitis)
** Cases with no evidence of neuroinvasion.
*** Cases for which insufficient clinical information was provided.
**** Total number of human cases of WNV illness reported to ArboNET by state and local health departments.
(Promed 9/15/06)

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2. Articles
Avian Influenza Tests Complete On Maryland Resident Wild Mallard Ducks
The U.S. Departments of Agriculture and Interior today announced final test results that confirm that an H5N1 avian influenza virus detected in fecal samples collected last month from resident wild mallard ducks in Maryland is a low-pathogenic subtype. This strain has been detected several times in wild birds in North America and poses no threat to human health.

The USDA National Veterinary Services Laboratories (NVSL) confirmed the presence of the "North American strain" of low-pathogenic H5N1 avian influenza through virus isolation in samples collected from the resident wild mallards in Queen Anne's County, Maryland. Test results announced on 1 Sep 2006 indicated that an H5N1 avian influenza subtype was present in 9 of the collected samples, but further testing was necessary to confirm pathogenicity. As previously announced, genetic testing ruled out the possibility that the samples carried the specific highly pathogenic strain of H5N1 avian influenza that is circulating overseas.

Low pathogenic strains of avian influenza commonly occur in wild birds and typically cause only minor sickness or no noticeable signs of disease in birds. Low-pathogenic H5N1 is very different from the more severe highly pathogenic H5N1 circulating in parts of Asia, Europe and Africa. Highly pathogenic strains of avian influenza spread rapidly and are often fatal to chickens and turkeys.

The Departments of Agriculture and Interior are working collaboratively with States and academic institutions to sample wild birds throughout the United States for the presence of highly pathogenic avian influenza. More than 21 000 wild birds have been tested so far this year and none have been infected with highly pathogenic avian influenza.
(USDA http://www.usda.gov/birdflu 9/12/06, Promed 9/13/06)

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Satellites help scientists track migratory birds: GPS the latest tool in fight against avian influenza
In August, a team of international scientists from FAO and the U.S. Geological Survey (USGS) joined the Wildlife Conservation Society (WCS) and Mongolian Academy of Sciences (MAS) in the surveillance project, which is part of the Wild Bird Global Avian Influenza Network for Surveillance (GAINS) programme funded by USAID. The team attached the GPS transmitters to wild whooper swans in an effort to track the birds to their wintering grounds.

Such research is providing information on migration routes and informs governments about potential threats from diseases such as highly pathogenic avian influenza (HPAI). The HPAI strain known as H5N1 is highly lethal for a variety of species, especially poultry and some waterfowl species. When transmitted to people through close contact with infected birds, the virus can be deadly. Leaders across the world are concerned about a potential pandemic threat should the virus become transmissible among humans.
(FAO 9/6/06 http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html)

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Fatal outcome of human influenza A (H5N1) is associated with high viral load and hypercytokinemia.
De Jong MD, Simmons CP, Thanh TT, et al. Nature Med 2006 Sep 10 (early online publication)
Abstract: Avian influenza A (H5N1) viruses cause severe disease in humans1, 2, but the basis for their virulence remains unclear. In vitro and animal studies indicate that high and disseminated viral replication is important for disease pathogenesis3, 4, 5. Laboratory experiments suggest that virus-induced cytokine dysregulation may contribute to disease severity6, 7, 8, 9. To assess the relevance of these findings for human disease, we performed virological and immunological studies in 18 individuals with H5N1 and 8 individuals infected with human influenza virus subtypes. Influenza H5N1 infection in humans is characterized by high pharyngeal virus loads and frequent detection of viral RNA in rectum and blood. Viral RNA in blood was present only in fatal H5N1 cases and was associated with higher pharyngeal viral loads. We observed low peripheral blood T-lymphocyte counts and high chemokine and cytokine levels in H5N1-infected individuals, particularly in those who died, and these correlated with pharyngeal viral loads. Genetic characterization of H5N1 viruses revealed mutations in the viral polymerase complex associated with mammalian adaptation and virulence. Our observations indicate that high viral load, and the resulting intense inflammatory responses, are central to influenza H5N1 pathogenesis. The focus of clinical management should be on preventing this intense cytokine response, by early diagnosis and effective antiviral treatment.
(CIDRAP 9/11/06 http://www.cidrap.umn.edu)

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Empirical Evidence for the Effect of Airline Travel on Inter-Regional Influenza Spread in the United States
Brownstein JS, Wolfe CJ, Mandl KD. PLoS Med 2006 Oct;3(10)
Abstract: Background: The influence of air travel on influenza spread has been the subject of numerous investigations using simulation, but very little empirical evidence has been provided. Understanding the role of airline travel in large-scale influenza spread is especially important given the mounting threat of an influenza pandemic. Several recent simulation studies have concluded that air travel restrictions may not have a significant impact on the course of a pandemic. Here, we assess, with empirical data, the role of airline volume on the yearly inter-regional spread of influenza in the United States. Methods and Findings: We measured rate of inter-regional spread and timing of influenza in the United States for nine seasons, from 1996 to 2005 using weekly influenza and pneumonia mortality from the Centers for Disease Control and Prevention. Seasonality was characterized by band-pass filtering. We found that domestic airline travel volume in November (mostly surrounding the Thanksgiving holiday) predicts the rate of influenza spread (r2 = 0.60; p = 0.014). We also found that international airline travel influences the timing of influenza mortality (r2 = 0.59; p = 0.016). The flight ban in the US after the terrorist attack on September 11, 2001, and the subsequent depression of the air travel market, provided a natural experiment for the evaluation of flight restrictions; the decrease in air travel was associated with a delayed and prolonged influenza season. Conclusions:We provide the first empirical evidence for the role of airline travel in long-range dissemination of influenza. Our results suggest an important influence of international air travel on the timing of influenza introduction, as well as an influence of domestic air travel on the rate of inter-regional influenza spread in the US. Pandemic preparedness strategies should account for a possible benefit of airline travel restrictions on influenza spread
(CIDRAP 9/12/06 http://www.cidrap.umn.edu)

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Meta-analysis: convalescent blood products for Spanish influenza: a future H5N1 treatment?
Luke TC, Kilbane EM, Jackson JL, et al. Ann Intern Med 2006 Oct 17;145(8) (early online publication)
Abstract:
Background: Studies from the Spanish influenza era reported that transfusion of influenza-convalescent human blood products reduced mortality in patients with influenza complicated by pneumonia. Treatments for H5N1 influenza are unsatisfactory, and convalescent human plasma containing H5N1 antibodies could be an effective therapy during outbreaks and pandemics.
Purpose: To see whether transfusion with influenza-convalescent human blood products reduced the risk for death in patients with Spanish influenza pneumonia.
Data Sources: Manual search of English-language journals from 1918 to 1925. Citations from retrieved studies were also searched.
Study Selection: Published English-language studies that had at least 10 patients in the treatment group, used convalescent blood products to treat Spanish influenza pneumonia in a hospital setting, and reported on a control or comparison group.
Data Extraction: Two investigators independently extracted data on study characteristics, outcomes, adverse events, and quality.
Data Synthesis: Eight relevant studies involving 1703 patients were found. Treated patients, who were often selected because of more severe illness, were compared with untreated controls with influenza pneumonia in the same hospital or ward. The overall crude case-fatality rate was 16% (54 of 336) among treated patients and 37% (452 of 1219) among controls. The range of absolute risk differences in mortality between the treatment and control groups was 8% to 26% (pooled risk difference, 21% [95% CI, 15% to 27%]). The overall crude case-fatality rate was 19% (28 of 148) among patients who received early treatment (after <4 days of pneumonia complications) and 59% (49 of 83) among patients who received late treatment (after 4 days of pneumonia complications). The range of absolute risk differences in mortality between the early treatment group and the late treatment group was 26% to 50% (pooled risk difference, 41% [CI, 29% to 54%]). Adverse effects included chill reactions and possible exacerbations of symptoms in a few patients.
Limitations: Studies were few and had many methodologic limitations. No study was a blinded, randomized, or placebo-controlled trial. Some pertinent studies may have been missed.
Conclusions: Patients with Spanish influenza pneumonia who received influenza-convalescent human blood products may have experienced a clinically important reduction in the risk for death. Convalescent human H5N1 plasma could be an effective, timely, and widely available treatment that should be studied in clinical trials.
(CIDRAP 9/8/06 http://www.cidrap.umn.edu)

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Live, attenuated influenza A H5N1 candidate vaccines provide broad cross-protection in mice and ferrets.
Suguitan AL, McAuliffe J, Mills KL, et al. PLoS Med 2006 Sep;3(9)
Abstract:
BACKGROUND: Recent outbreaks of highly pathogenic influenza A H5N1 viruses in humans and avian species that began in Asia and have spread to other continents underscore an urgent need to develop vaccines that would protect the human population in the event of a pandemic. METHODS AND FINDINGS: Live, attenuated candidate vaccines possessing genes encoding a modified H5 hemagglutinin (HA) and a wild-type (wt) N1 neuraminidase from influenza A H5N1 viruses isolated in Hong Kong and Vietnam in 1997, 2003, and 2004, and remaining gene segments derived from the cold-adapted (ca) influenza A vaccine donor strain, influenza A/Ann Arbor/6/60 ca (H2N2), were generated by reverse genetics. The H5N1 ca vaccine viruses required trypsin for efficient growth in vitro, as predicted by the modification engineered in the gene encoding the HA, and possessed the temperature-sensitive and attenuation phenotypes specified by the internal protein genes of the ca vaccine donor strain. More importantly, the candidate vaccines were immunogenic in mice. Four weeks after receiving a single dose of 10(6) 50% tissue culture infectious doses of intranasally administered vaccines, mice were fully protected from lethality following challenge with homologous and antigenically distinct heterologous wt H5N1 viruses from different genetic sublineages (clades 1, 2, and 3) that were isolated in Asia between 1997 and 2005. Four weeks after receiving two doses of the vaccines, mice and ferrets were fully protected against pulmonary replication of homologous and heterologous wt H5N1 viruses. CONCLUSIONS: The promising findings in these preclinical studies of safety, immunogenicity, and efficacy of the H5N1 ca vaccines against antigenically diverse H5N1 vaccines provide support for their careful evaluation in Phase 1 clinical trials in humans.
(CIDRAP 9/13/06 http://www.cidrap.umn.edu)

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3. Notifications
The Fifth National Conference on Quality Health Care for Culturally Diverse Populations
Building the Essential Link between Quality, Cultural Competence, and Disparities Reduction
October 17-October 20, 2006
Renaissance Seattle Hotel, 515 Madison Street , Seattle, Washington
For detailed information about the conference, including a draft conference agenda with session titles and presenters, and instructions for making hotel reservations, please visit the conference website: http://www.diversityrx.org/CCCONF/06/index.html

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4th Annual Public Health Information Network (PHIN) Conference
This conference will be held at the Hyatt Regency Atlanta in Atlanta, Georgia from Sept. 25-27, 2006.
The PHIN Conference is one opportunity to advance the PHIN vision with partners and share experiences in implementing PHIN. The PHIN vision encompasses the development and use of information systems addressing a number of public health areas including: early event detection, surveillance and monitoring, epidemiologic case investigation and outbreak management, partner communications and alerting, countermeasure/response administration, distance learning and knowledge management, and laboratory and clinical data management from both the public and private sectors.
For more information visits http://www.cdc.gov/phin/06conference/index.html

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4. To Receive EINet Newsbriefs
JOIN THE E-LIST AND RECEIVE NEWSBREIFS REGULARLY
The APEC EINet email list was established to enhance collaboration among health, commerce, and policy professionals concerned with emerging infections in APEC member economies. Subscribers are encouraged to share their material with colleagues in the Asia-Pacific Rim. To subscribe, go to: http://depts.washington.edu/einet/?a=subscribe or contact apecein@u.washington.edu. Further information about APEC EINet is available at http://depts.washington.edu/einet/.

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 apecein@u.washington.edu