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Vol. IX, No. 20 ~ EINet News Briefs ~ Oct 13, 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: WHO and sanofi-aventis expand programme to fight neglected tropical diseases
- Global: FAO launches disease crisis center
- Indonesia (West Java): Reports 70th human case of avian influenza H5N1 infection
- Indonesia: Pigs, cats found infected with H5N1
- Indonesia (Central Java): Poultry deaths and poultry vaccination
- Indonesia: Avian influenza H5N1 appears not to have undergone major genetic change
- Thailand/Viet Nam: Reports oseltamivir resistance in avian influenza H5N1 virus
- Thailand: Avian influenza education campaign launched
- China (Anhui Province): Malaria spreads in east China province
- China (Beijing): New case of Angiostrongylus meningitis (snail infection)
- China: Rabies epidemic continues
- China (Shaanxi): 3 family members contract anthrax from sick goat
- Russia (Novosibirsk): Increase in cases of Yersiniosis pseudotuberculosis
- USA (Montana): Avian influenza tests complete on wild northern pintail ducks
- USA/Canada: More cases and deaths from contaminated spinach
- USA (Wisconsin): E. coli O157 cases at fair grounds
- USA (Ohio): Foodborne illness associated with unpasteurized milk
- USA (Washington): E. coli O157 associated with unpasteurized milk
- USA (California): E. coli O157 associated with unpastuerized milk
- Canada: Carrot juice linked to 2 botulism cases
- USA (Florida/California): Fourth botulism case linked to carrot juice
- USA (Illinois): 37 confirmed mumps cases at Wheaton College
- USA (Georgia): 2 human deaths from Vibrio vulnificus
- Egypt: New human case of avian influenza H5N1
- Sudan: Excerpts from OIE report on avian influenza H5N1 in birds

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

2. Articles
- Update on Vaccine-Derived Polioviruses
- Fatal Avian Influenza A H5N1 in a Dog
- Annual Influenza Vaccination in Community-Dwelling Elderly Individuals and the Risk of Lower Respiratory Tract Infections or Pneumonia
- Targeted Social Distancing Design for Pandemic Influenza
- Avian influenza H5N1 screening of intensive care unit patients with community-acquired pneumonia
- Shiga Toxin Activatable by Intestinal Mucus in Escherichia coli Isolated from Humans: Predictor for a Severe Clinical Outcome
- Eating in Restaurants: A Risk Factor for Foodborne Disease?
- Disease Mitigation Measures in the Control of Pandemic Influenza
- Outbreaks of Multidrug-Resistant Shigella sonnei Gastroenteritis Associated with Day Care Centers --- Kansas, Kentucky, and Missouri, 2005
- Botulism Associated with Commercial Carrot Juice--Georgia and Florida, September 2006

3. Notifications
- Third International Bird Flu Summit
- International meeting on emerging diseases and surveillance (IMED 2007)
- Fifth World Melioidosis Congress
- An FAO/RAI pilot scheme for webcasting events in real time
- CDC's 60th Anniversary: Director's Perspective --- William H. Foege, M.D., M.P.H., 1977--1983
- Recommended Adult Immunization Schedule--United States, October 2006-September 2007

4. To Receive EINet Newsbriefs
- APEC EINet email list


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 / 15 (6)
Indonesia / 50 (40)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 106 (70)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 253 (148).
(WHO 10/11/06 http://www.who.int/csr/disease/avianinfluenza/en/ )

Avian influenza age & sex distribution data from WHO/WPRO (as of 10/3/06): http://www.wpro.who.int/sites/csr/data/data_Graphs.htm.
(Promed 9/28/06)

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Global: WHO and sanofi-aventis expand programme to fight neglected tropical diseases
WHO is expanding its program to fight some of the most neglected tropical diseases that destroy the lives and health of poor people. This expansion is possible thanks to a renewed collaboration with sanofi-aventis, which has agreed to donate medicines and financial support worth US$25 million over 5 years to WHO. This collaboration builds on a previous agreement between WHO and Aventis (now sanofi-aventis) to prevent deaths due to sleeping sickness. Since 2001, this work has saved the lives of an estimated 110 000 people who would otherwise have died from sleeping sickness, a disease spread by the bite of the tsetse fly which is fatal if not treated. Under the new agreement, sanofi-aventis will donate $5 million of drugs to treat sleeping sickness and a further US$20 million in financial support for the control of neglected tropical diseases. As well as sleeping sickness (also known as human African trypanosomiasis), the new project will also address leishmaniasis, Buruli ulcer and Chagas disease. All 4 diseases are among the most neglected in the world. The people who suffer from them are almost all poor inhabitants of remote, rural areas. The new project will take a common approach to detecting, preventing and treating these diseases. The key to all four is to actively seek out people who show early symptoms of the diseases. By identifying them early, people can be given effective treatment before the symptoms worsen.
(WHO 10/10/06 http://www.who.int/mediacentre/news/releases/2006/pr54/en/index.html )

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Global: FAO launches disease crisis center
To speed emergency responses to avian influenza and other animal and plant diseases, the UN Food and Agriculture Organization (FAO) inaugurated a new crisis management center (CMC) at its Rome headquarters. The center, founded with the World Organization for Animal Health (OIE), is supported by advanced communication technology and will operate around the clock, 7 days a week. The center is staffed by up to 15 specialists and veterinarians who will continuously update and monitor disease information. If a suspected outbreak is reported, the crisis management center can dispatch experts anywhere in the world in less than 48 hours. The center can react quickly to emergencies involving plant pests or food safety, as well as diseases. The CMC is headed by Dr Karin Schwabenbauer, Germany's former chief veterinary officer. Dr Gary L. Brickler, from the US Department of Agriculture, is deputy director. Animal health emergency response will be handled by the FAO's chief veterinary officer, Dr Joseph Domenech, and the FAO's Emergency and Rehabilitation Division will handle the CMC's operational support. The US donated $5.1 million and 3 veterinarians to the CMC; other donors include Germany, France, Sweden, Switzerland, Norway, Saudi Arabian, China, Greece, and Jordan.
(CIDRAP 10/12/06 http://www.cidrap.umn.edu/ )

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Asia
Indonesia (West Java): Reports 70th human case of avian influenza H5N1 infection
Health ministry official Joko Suyono said that a 67-year-old woman from West Java province is infected with the H5N1 avian flu virus. Reportedly tests were carried out by the Health Ministry Laboratory and NAMRU, the United States Naval Medical Research Unit based in Jakarta. The woman is from Bandung, where at least one other avian flu case occurred recently. If the case is confirmed by WHO, it will be Indonesia’s 70th. The woman was hospitalized in Bandung Oct 2, 2006, 2 days after she experienced flu-like symptoms, said Suyono, who added that diseased poultry were the likely cause of the woman’s infection. The woman reportedly had contact with fowl before she was admitted to hospital.
(Promed 10/11/06; CIDRAP 10/11/06 http://www.cidrap.umn.edu )

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Indonesia: Pigs, cats found infected with H5N1
Pigs and stray cats have been found infected with the H5N1 avian influenza virus in Indonesia, adding to the few previous reports of such cases. A study from Udayana University found that 2 (out of 20) pigs on the island of Bali were infected with the H5N1 virus in Jul 2006, senior agriculture minister Musni Suatmodjo said. However, the H5N1 virus was not found in the animals' tissue. Veterinary faculty from the university discovered the infected pigs in Bali's south-central Gianyar and Tabanan regencies. Experts worry about H5N1 findings in pigs because the animals can carry human as well as avian influenza viruses, which presents the viruses an opportunity to combine and form new strains that could spark a human flu pandemic. This isn't the first time that the H5N1 virus has been identified in Indonesian pigs. In 2005, a report in Nature said the virus was found in 5 of 10 healthy pigs kept near poultry farms in western Java where poultry were infected with H5N1. The report said the Indonesian government had found similar results among pigs in the same region. The H5N1 virus was also found in pigs in China in 2001 and 2003, but follow-up surveys in 2004 found no evidence of the virus, according to the Nature article.

Meanwhile, researchers from the Indonesian Environment Information Center (PILI) announced that stray cats had caught the H5N1 virus from infected poultry at live markets, according to a report Oct 7, 2006 in the Jakarta Post. "We are positive that cats can have the virus, although it is yet to be proven that they can transmit the virus to other animals or humans," said PILI director Iwan Setiawan. Other instances of cats infected with the H5N1 virus have been documented: house cats in Germany, Thailand, and Austria, and a leopard and tigers at a zoo near Bangkok. But the role of cats in transmitting the H5N1 virus is not known. WHO said earlier this year that no human cases have been linked to diseased cats. However, Albert Osterhaus, a virologist with the Erasmus Medical Center in the Netherlands, said that cat-to-human transmission is theoretically possible and that cat-to-cat transmission has been shown in a laboratory setting.
(Promed 10/8/06; CIDRAP 10/10/06 http://www.cidrap.umn.edu/ )

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Indonesia (Central Java): Poultry deaths and poultry vaccination
In Central Java, many chickens have fallen ill and died in recent days in a possible outbreak of the disease. The H5N1 virus is believed to be killing poultry in 17 kampongs in the Central Java regencies of Semarang, Temanggung, Purbalingga, Pekalongan and Pemalang, according to Kurmaningsih, the head of the Central Java Livestock Husbandry Office. Rapid tests on dead chickens in Lebdosari kampong, Gisikdrono, in Semarang, indicated they had the virus. Local authorities later culled 35 other chickens in the kampong to prevent the disease from spreading.

Kurmaningsih said her office had asked for 10 million more doses of H5N1 vaccine from the central government. "We currently have 12 million doses of the vaccine, but we want more in order to be ready for a much bigger outbreak," she said. Kurmaningsih explained that despite the massive poultry vaccination drive launched earlier this year through a program called the National Movement against Avian Influenza, the infections have continued to spread. She said under the program, her office distributed 50 million doses of vaccine to poultry owners in the province in 2004, 14 million doses in 2005 and another 22 million doses this year. "We culled chickens in Boyolali in 2004. But now we have no plans to do so because the social impacts (of culling) are so widespread. Besides that we still don't know whether there will be compensation for the culled chickens," she explained. In a related development, the Ministry of Health plans to build modern laboratories in North Sumatra to diagnose bird flu infections, Aswin Soefi Lubi, dean of the School of Medicine at the Islamic University of North Sumatra, said 5 Oct 2006. They will be used to test blood from suspected bird flu victims without having to send the samples to Jakarta.
(Promed 10/6/06)

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Indonesia: Avian influenza H5N1 appears not to have undergone major genetic change
The bird flu virus that's killed one person a week in Indonesia this year hasn't mutated to become more contagious to people, the country's Agriculture Ministry said. Tests on 49 samples taken from birds on the islands of Sumatra, Java and Bali showed the H5N1 avian influenza virus has undergone no major changes, the Ministry said 5 Oct 2006. The analysis was undertaken by a World [Health?] Organization for Animal Health reference laboratory in Australia. About 300 million poultry are raised in backyards in the world's fourth-most-populous country. Samples of the H5N1 virus taken from birds were collected between Sep 2005 and Mar. Animal health authorities will dispatch samples collected in the past 6 months for analysis. Indonesia agreed to deposit avian flu genetic information in public databases, such as GenBank, to help scientists better track dominant variants of the virus and to speed preparations for vaccines to fight a human outbreak. The virus may have infected as much as 27 percent of poultry in Indonesia, Musny Suatmodjo, Indonesia's director of animal health, said. The Health Ministry and Singapore's Temasek Life Sciences Laboratory Ltd. are developing a diagnostic kit to speed the diagnosis of human H5N1 cases.
(Promed 10/6/06)

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Thailand/Viet Nam: Reports oseltamivir resistance in avian influenza H5N1 virus
The bird flu virus has already developed signs of resistance to oseltamivir, the drug widely used to treat the disease's symptoms in humans, a research study says. Yong Poovorawan said his team learned of the resistance which was reflected in [replacement?] of amino acids in the [viral neuraminidase?]. It was the first scientific study that could pinpoint such changes -- a result of genetic change of avian flu virus -- and its resistance to oseltamivir. The study will soon be published in the Emerging Infectious Diseases Journal and Journal of Virological Methods.

Avian flu resistance to oseltamivir had been confirmed in 4 bird flu patients in Viet Nam, 3 of whom died. The Viet Nam cases showed the possibility that oseltamivir might be less effective than anticipated, particularly as resistant strains of bird flu become more prevalent. Dr Yong, a virologist at Chulalongkorn University's faculty of medicine, earlier warned to exercise caution when prescribing oseltamivir in patients with influenza and bird flu-like symptoms, saying continuous and frequent use of the drug without precise diagnoses was likely to trigger viral resistance. During bird flu outbreaks, health personnel treated people with flu and bird flu-like symptoms with oseltamivir, even if they had not been in contact with poultry.

Instances of oseltamivir resistance in patients have been reported previously, but there has been no unequivocal confirmation of transmission of resistant virus from person to person. Oseltamivir (Tamiflu) and zanamivir (Relenza) inhibit the activity of the viral neuraminidase, an enzyme that enables influenza virus to escape from an infected cell and spread to other cells. Several studies suggest that viral resistance to oseltamivir may be a greater problem than previously believed. For example, in epidemics of H3N2 influenza in Japan in 2002 and 2003 about 1/5 of children developed resistance by day 4 or later during treatment with oseltamivir, and about 1/4 of children who shed virus for 3 days or more had drug-resistant influenza viruses. The neuraminidase-resistant mutations isolated were found to be from 300 to 100 000 times more resistant to oseltamivir than oseltamivir-susceptible virus. These reports of the emergence of drug resistance make the development of new anti-influenza molecules a priority.
(Promed 10/10/06)

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Thailand: Avian influenza education campaign launched
Thailand and the United Nations Children's Fund (UNICEF) launched a school-based campaign to protect children and their families from the spread of avian flu. Thailand has the third highest number of human H5N1 cases (25), and the disease has killed 17 people, including 11 children younger than 18. The campaign covers all of the country's 40,000 elementary and secondary schools. The curriculum will help ensure that children understand what they can do to help prevent the spread of avian flu, such as washing their hands frequently and reporting sick or dead poultry. 4 million posters and pamphlets containing prevention and awareness messages will be distributed; elementary schools will receive 300,000 bars of soap. The campaign was produced by UNICEF and funded by Japan.
(CIDRAP 10/12/06 http://www.cidrap.umn.edu/ )

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China (Anhui Province): Malaria spreads in east China province
Malaria is spreading in east China's Anhui Province, which reported 17 917 cases by 25 Sep 2006, according to the provincial health department. The malaria cases increased by 89.8 percent from the same period last year, said the department. The cases were mainly reported in Bozhou, Huaibei, Suzhou, Bengbu and Fuyang in the north of the province. Malaria cases have been on the rise since 2000 in these areas. The department has issued an emergency notice asking local government authorities to strengthen the monitoring of the epidemic and promote the prevention and treatment knowledge among people to curb its spread. A check on malaria prevention and control in the disease-hit areas will be carried out in the first 20 days of this month. Those officials whose lax supervision caused a spread of the disease will be severely punished. China reported 39 656 malaria cases in 2005, 45 of whom died, according to the Ministry of Health. Anhui province is regarded as a low risk area for malaria in China. It is a cause for concern that malaria is returning to an area previously regarded as very low risk.
(Promed 10/4/06)

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China (Beijing): New case of Angiostrongylus meningitis (snail infection)
Beijing has confirmed a new case of "snail infection", bringing the total number of cases to 132. The 31-year-old man was diagnosed with a type of angiostrongyliasis at Beijing Friendship Hospital. Like most of the other patients, he ate snails at the Shuguo Yanyi Restaurant 11 Jul 2006 and developed symptoms of headache and fever 27 Jul. The 8 who were hospitalized at the Friendship Hospital were recovering well. The disease caused by parasites can affect the brain and spinal cord, and also lead to meningitis. The Friendship Hospital has diagnosed 112 cases and admitted 71 patients since 24 Jun. No deaths have been reported. The Amazonian snail culprits have been traced back to southern China's Guangxi Zhuang Autonomous Region, according to the Beijing Health Bureau. Amazonian snails originated in South America and first came to China in the 1980s as a delicacy. The first report of a person falling ill after eating the snails came from Guangzhou. Until recently, the big black snails were a hot-selling aquatic product.
(Promed 10/1/06)

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China: Rabies epidemic continues
China's Ministry of Health reports that there are a total of 393 cases of rabies in Sep 2006. The figure is up by 37 per cent compared with the same period of 2005. There have been 318 human deaths. Experts say that the current rabies epidemic in China is mainly due to an apparent increase of people who raise dogs, a severe deficiency of knowledge by the public about rabies, and the failure to seek treatment by those bitten by an infected dog. China is one of the worst rabies-endemic countries in the world, second only to India. The official statistics show from Jan to Sep 2006 a cumulative figure of 2254 confirmed cases of rabies, up by 29.7 per cent compared with the same period in 2005. The ministry's website shows that 2660 people died from rabies in 2004, while in 1996 there were only 159 reported fatalities. Rabies was the second most common deadly infectious disease after tuberculosis in 2005, accounting for 19 per cent of the total deaths. China has some 150 million pet dogs, according to estimates. The ministry said that China ranks second in the world after India in terms of the number of rabies cases. Every year more than 50 000 people around the world die of the disease, with most of them living in developing countries.

The Beijing municipal government requires rabies cases or suspected rabies cases to be immediately reported to the health department. Dog owners in Beijing will face harsh penalties in the future if they raise their pets in violation of regulations. Their dogs may be confiscated and they may be fined up to 5000 yuan (625 US dollars) if they keep a dog without a permit, fail to carry out annual health checks on their pets, keep big dogs in downtown areas, have more than one dog at one home, or take them to places where dogs are not permitted. The health ministry will also strengthen prevention of rabies in rural areas, where dogs are not widely vaccinated and medical treatment for people is inadequate. Compulsory vaccination and registration of pet dogs have been the 2 most effective measures for control of rabies in endemic countries.
(Promed 10/1/06, 10/10/06)

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China (Shaanxi): 3 family members contract anthrax from sick goat
Reportedly 3 members of a family in Xinmin Township of Bin County in Shaanxi Province contracted anthrax after eating a sick dead goat. The 3 patients are still in isolation and treatment at a local hospital. Health departments from provincial, municipal, and county levels carried out burning and burial of remaining diseased dead goat(s). Those infected with anthrax are members of 1 family in Baozi Village in Xinmin Township. The 3 patients were admitted 28 Sep 2006 and at present, they are stable, but they will remain in hospital for treatment and observation. Anthrax is an acute, febrile, septicemic, zoonotic infectious disease caused by anthrax bacteria. The most susceptible animals are sheep, cow, horse, and other grass-eating livestock. Uncoagulated blood from the corpses of animals killed by anthrax often flows from natural orifices, releasing large numbers of bacteria. Anthrax bacteria can survive in soil for tens of years and remains highly virulent. The mortality rate from this disease is extremely high.
(Promed 10/2/06)

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Russia (Novosibirsk): Increase in cases of Yersiniosis pseudotuberculosis
According to the Deputy Minister of Public Health, a serious epidemiological situation caused by a high level of morbidity from various infectious diseases -- including that caused by Yersinia pseudotuberculosis -- has developed in Russia due to rodent vectors. Rodent numbers have considerably increased above normal. In Saint Petersburg, it is estimated that there are 1.7 rodents/1000 sq. meter, in seaports of the Krasnodar region - 7.5 rodents/1000 sq. meter, in cities of the Jewish Autonomous Region (Birobidzhan) - 16 rodents/1000 sq. meter, and in Novosibirsk - 0.7 rodents/1000 sq. meter (the standard rate - 0.5). Even though the rodent numbers are lower for Novosibirsk than for the other regions mentioned, 590 cases of pseudotuberculosis have already been registered there in 2006 (versus 610 cases in all of 2005). Rodents are a main source of contamination, both in produce storehouses and in the home. Sanitary epidemiological services should pay attention to conditions and duration of storage of vegetables in both commercial and home areas. Infection with Y. pseudotuberculosis is a zoonosis with reservoirs in many animals and various birds. Most individuals affected are children or young adults.
(Promed 9/29/06)

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Americas
USA (Montana): Avian influenza tests complete on wild northern pintail ducks
The US Departments of Agriculture (USDA) and Interior (DOI) announced 8 Oct 2006 final test results, which confirm that a low pathogenic H5 avian influenza virus was found in samples collected last month from wild northern pintail ducks in Montana. This type of avian influenza has been detected several times in wild birds in North America and poses no risk to human health. The USDA National Veterinary Services Laboratories (NVSL) confirmed the presence of low pathogenic H5N3 avian influenza through virus isolation in 2 of the 16 samples collected from wild pintails in Cascade County, Montana. Initial screening results indicated that H5 and N1 subtypes might be present in the collected samples, but further testing was necessary to confirm the H and N subtypes as well as pathogenicity.

The initial rapid screening tests are highly sensitive and can detect active and inactive viruses in samples. Varieties of this test can screen for the presence of all strains of avian influenza virus. Because these rapid screening tests are highly sensitive, it is not uncommon to have positive results for a specific subtype on the initial screen test and yet not be able to isolate a virus of that subtype. This was the case for the N1 subtype in this sample, which tested as a weak positive in the initial screen test. During confirmatory testing, an N1 subtype was not isolated, but instead an N3 was found. Genetic testing ruled out the possibility that the samples carried the highly pathogenic strain of H5N1 avian influenza that is circulating overseas.

Low pathogenic strains of avian influenza occur naturally in wild birds and typically cause only minor sickness or no noticeable signs of disease in birds. In most cases, they cause no signs of infection or only minor symptoms in birds. Previous tests on birds from Michigan, Maryland, and Pennsylvania have been positive only for the low pathogenic "North American" strain of H5N1. Highly pathogenic strains of avian influenza spread rapidly and are often fatal to chickens and turkeys.
(Promed 10/9/06; CIDRAP 10/10/06 http://www.cidrap.umn.edu/ )

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USA/Canada: More cases and deaths from contaminated spinach
Meanwhile, the number of sickened people in the nationwide outbreak of O157:H7 linked to fresh spinach grew to 199, representing an increase of 7 since Oct 4. 102 people (51%) were hospitalized, and 1 more case of hemolytic uremic syndrome (HUS), a serious kidney condition, has been reported, bringing that total to 31. The outbreak has affected people in 26 states and 1 Canadian. 3 deaths have now been linked to the outbreak strain; newly added to the count are a 2-year-old Idaho boy (20 Sep 2006, from kidney failure) and an elderly Nebraska woman Health officials are awaiting results on a fourth possible outbreak-related death, that of an elderly woman from Maryland. 13 product samples have now been confirmed to contain the outbreak strain, 2 more than previously reported. FDA has said that all spinach connected to the current outbreak has been traced to Natural Selection Foods, a company that packages more than 30 brands of fresh spinach and that supplies spinach to other produce companies. The company recalled its products on Sep 15; four other companies recalled products because they had received spinach from Natural Selection Foods. FDA said federal and state authorities are still doing inspections, collecting samples, and studying animal management and water use in the production and growing areas that have been traced to the E coli outbreak.

Investigators narrowed the potential source of the outbreak to 12 fields on 9 farms in California's Salinas Valley and have collected hundreds of water, soil, plant and animal waste samples, which are still being analyzed. The 8 samples that tested positive for E. coli O157:H7 were taken from cattle feces collected from pastures adjacent to spinach fields on 2 of the farms, Kevin Reilly, a top California food safety official, said 3 Oct 2006. The discovery of this particularly toxic strain of E. coli in cattle feces "was not a big surprise," Reilly said. E. coli is normally found in the digestive system of humans and other warm-blooded animals. The question for investigators, he said, is whether there is "any link between this particular finding and the outbreak strain." E. coli in pastures could potentially contaminate spinach growing nearby if it ends up in irrigation water or runoff, Reilly said. The latest E. coli outbreak is the 20th associated with leafy greens over the past 10 years and the ninth traced to the Salinas Valley. FDA said it and the state of California expect the industry to develop comprehensive plans to minimize the risk of another outbreak. Implementing the plans will be voluntary, but the FDA and the State of California said they haven’t ruled out the possibility of future regulatory changes.

In Canada, Ontario health officials have reportedly ruled out contaminated spinach as the cause of E coli outbreaks in 2 cities. Between Sep 21 and Sep 26, 20 residents of Hamilton, near Toronto, were diagnosed with E coli infections. Over the same time period, cases were also found in Sudbury, about 240 miles north of Toronto. Officials suspect a link between the illnesses and believe it may be food, but they have not yet determined the source.
(Promed 10/4/06, 10/5/06, 10/6/06; CIDRAP 10/9/06 http://www.cidrap.umn.edu/ )

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USA (Wisconsin): E. coli O157 cases at fair grounds
The Manitowoc County (WI) Health Department has determined the probable source of infection for 6 of the 7 E. coli [O157:H7] cases reported to the department between 30 Aug and 11 Sep 2006, according to the department, 6 Oct 2006. 1 case, involving the death of a 77-year-old woman, was linked to the multi-state spinach outbreak, 1 to animal exposure at a private farm, and 4 to exposure at the Manitowoc County Expo Grounds during the Manitowoc County Fair. Of the 4 individuals linked to the Manitowoc County Expo Grounds, 2 had direct contact with animals and the others had no direct exposure to animals. Officials collected samples from 50 sites in the dairy and show barns and tested them for E. coli bacteria. 2 samples collected in the bleachers of the show barn were positive for E. coli and matched bacteria from 2 of the cases and was similar to a third. Additionally, the environmental isolates matched 2 samples of E. coli from Washington County, from people who attended an event at the Manitowoc County Expo Grounds 1 Jul 2006. Based on this information, the probable source of infection for the 3 Manitowoc County and 2 Washington County cases was transfer from the environment, according to the health department. The fourth fair attendee had no laboratory connection to any other case or environmental sample. The public works department cleaned the bleachers with a disinfecting cleaner after the samples were taken. Additional measures to prevent disease associated with animals in public settings will be implemented (including posting signs that warn Expo attendees not to eat while in the barns).
(Promed 10/6/06; CIDRAP 10/9/06 http://www.cidrap.umn.edu/ )

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USA (Ohio): Foodborne illness associated with unpasteurized milk
Ohio has revoked the milk-producing license of a western Ohio dairy farmer whose farm sold raw milk, the agriculture department said. Farmers in Ohio cannot sell raw milk for human consumption, although they can drink the unpasteurized milk from their own cows. A farm in Darke County also did not properly label its product and processed milk without a license to do so, the Ohio Department of Agriculture said. Agriculture officials said they began investigating after a 63-year-old man and a 4-year-old boy who drank raw milk from the farm became ill. Hundreds of people have protested the state's crackdown on those who sell raw milk, for which customers are willing to pay as much as $12 a gallon. Supporters of raw milk say it's full of vitamins and does not bother those who are lactose intolerant. Health officials warn milk that hasn't been pasteurized to kill E. coli and other bacteria could make drinkers sick.
(Promed 9/29/06)

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USA (Washington): E. coli O157 associated with unpasteurized milk
2 children have been sickened by E. coli bacteria in a case associated with unpasteurized milk, the state Health Department said 28 Sep 2006. The milk came from Grace Harbor Farms, a dairy operation in Whatcom County. Testing confirmed both cases were caused by the same strain of E. coli O157:H7. The Health Department said both children drank milk from the dairy, whose products are available in several counties through health food stores, PCC Natural Markets and Whole Foods Market. The children were identified only as a King County boy and a Snohomish County girl. The boy remains hospitalized in Seattle.

"Consuming raw milk can be risky," especially for children, the elderly and people with other health problems, said Janet Anderberg, a specialist with the agency's Food Safety Program. The state Department of Agriculture is investigating the dairy and its operations. Grace Harbor is a licensed raw milk producer and has been very cooperative during this investigation. The milk in question is already off store shelves, the Health Department said, but it encouraged consumers to return or dispose of any Grace Harbor raw milk they may have. The Health Department noted that recommendation does not involve Grace Harbor pasteurized milk products. An E. coli O157:H7 outbreak late in 2005 also was linked to raw milk, which prompted the Legislature to toughen regulation of the industry.
(Promed 9/29/06)

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USA (California): E. coli O157 associated with unpastuerized milk
California state officials continued their quarantine of raw, unpasteurized milk products produced by Organic Pastures of Fresno because 4 children, including two 8-year-olds in San Diego County, became ill after consuming them. The quarantine began 21 Sep 2006 after stool samples from 3 of the 4 youngsters revealed E. coli 0157:H7. People affected by this bacteria can suffer severe diarrhea and other potentially fatal complications. One of the affected children drank colostrum; the other 3 drank raw milk, state officials said. 2 of the patients -- a 7-year-old boy in Riverside County and a 10-year-old girl in San Bernardino County -- remain hospitalized. State officials urge people who recently purchased Organic Pastures' raw milk products to return them to the retailer for a full refund.
(Promed 9/29/06)

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Canada: Carrot juice linked to 2 botulism cases
2 botulism cases in Toronto have been linked to carrot juice from a California company, raising the number of people sickened by the juice to 6. 2 Toronto residents were paralyzed after drinking carrot juice from Bolthouse Farms, USA. They are ventilated and in the intensive care unit. Following the 30 Sep 2006 recall by the Canadian Food Inspection Agency, the possibility of botulism from carrot juice was investigated by Toronto Public Health. Both cases live in the same household and consumed from the same bottle of 1 of the 3 recalled carrot juices. A sample of the leftover juice was obtained from the refrigerator of the cases. It was sent to the botulism reference lab 5 Oct along with clinical samples from both patients. The juice was found refrigerated in the cases' house. There was no evidence of lack of refrigeration by the cases. The carrot juice tested positive for botulism toxin A 7 Oct, and one of the cases had clinical samples that were positive for toxin, 6 weeks since onset of symptoms. This case received anti-toxin.

Since the recall, there have been no additional cases reported to date. Toronto Public Health has been sending public health inspectors into food premises to ensure the 3 recalled juices are not available for sale or consumption. As of 11 Oct, of 1288 establishments inspected, 11 stores still had the juice available for sale. CFIA is enhancing its communication channels to distributors and doing effectiveness checks. Product has been prohibited from coming across the border. An additional 1250 establishments will be inspected by Toronto Public Health over the next few days to ensure the recalled brands are not available for consumption. The provincial Ministry of Health also had inspectors fan out across the province from other health units. Additional testing of recalled bottles of carrot juice are planned to be submitted.
(Promed 10/12/06; CIDRAP 10/10/06 http://www.cidrap.umn.edu/cidrap )

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USA (Florida/California): Fourth botulism case linked to carrot juice
The Food and Drug Administration (FDA) has warned consumers not to drink some carrot juice products from a Bakersfield, Calif., company after a fourth case of botulism was linked to the company's juice. FDA advised 29 Sep 2006 consumers to throw out any Bolthouse Farms Carrot Juice in 450-ml and 1-liter plastic bottles with a "best if used by" date of Nov. 11, 2006, or earlier. The agency also advised that all carrot juice, whether pasteurized or not, must be properly refrigerated. The most recent botulism case involves a Florida woman, who is now suffering from paralysis and on a ventilator. 3 people in Georgia became ill early Sep 2006 after drinking the carrot juice. Bolthouse Farms says the company has recalled all its 100% carrot juice products from the market in the US, Canada, Mexico, and Hong Kong because of the FDA's concern that consumers may be exposed to botulism if the juice is not refrigerated.

FDA has attributed at least one of the earlier cases to improper refrigeration of the juice at home. Other consumers who purchased the juice within the same period did not get sick, Georgia health officials said, suggesting that the botulinum toxin developed in the juice after it was sold. Droopy eyelids, double vision, slurred speech, and difficulty swallowing or speaking are some of the symptoms of botulism poisoning, as well as difficulty breathing and paralysis on both sides of the body, starting in the neck.

Botulinum toxin is produced by Clostridium botulinum. Spores of the bacteria can occur naturally in carrot juice and other foods that have not undergone retort canning, which involves high temperature and pressure, the CDC said. Temperatures above 39ºF, along with certain other conditions, can promote the growth of C botulinum and production of the toxin. The recalled carrot juice products carry the labels "Bolthouse Farms 100% Carrot Juice," "Earthbound Farm Organic Carrot Juice," and "President's Choice Organics 100% Pure Carrot Juice," according to the CDC.
(Promed 10/12/06; CIDRAP 10/3/06, 10/10/06 http://www.cidrap.umn.edu/cidrap )

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USA (Illinois): 37 confirmed mumps cases at Wheaton College
The total number of confirmed mumps cases at Wheaton College has now reached 37, officials said 20 Sep 2006. The cases at Wheaton College have all been reported since 7 Sep 2006. Of the 37 students with mumps and 3 additional suspected cases, 23 have returned to class after completing the required 9-day isolation period. A case of mumps was also reported at Benedictine University in Lisle. The DuPage County Health Department said that prevention measures have been employed vigilantly at both campuses.

Experts say that the mumps outbreak that began in Iowa Dec 2005 and spread to other Midwest states is considered to be the largest in nearly 20 years. It has not been determined if the DuPage County cases have a connection to an outbreak in Iowa. If a person is vaccinated against mumps, his or her risk of getting mumps is very low. It is important, however, to be aware of the signs and symptoms of mumps, because a person can still get mumps, regardless of age or vaccination status. Symptoms of mumps infection include swollen glands near the jaw, fever, headache or muscle aches. Complications of mumps infection are rare, and can include deafness, meningitis/encephalitis, or inflammation of the testicles, ovaries, or breasts. With the exception of deafness, these complications are more common among adults than children.

The first cases in this multistate outbreak were detected on a college campus in eastern Iowa in December 2005; the source of these initial cases is unknown. As a consequence updated recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Control and Elimination of Mumps were published Jun 2006. During the first 4 months of 2006, 11 states reported 2597 cases of mumps. 8 states (Illinois, Iowa, Kansas, Missouri, Nebraska, Pennsylvania, South Dakota, and Wisconsin) reported mumps outbreaks with ongoing local transmission or clusters of cases; 3 states (Colorado, Minnesota, and Mississippi) reported cases associated with travel from an outbreak state. The majority of mumps cases (1487 [57 per cent]) were reported from Iowa; states with the next highest case totals were Kansas (371), Illinois (224), Nebraska (201), and Wisconsin (176). Although the age group most affected (38 per cent of cases) has been young adults aged 18 to 24 years, the outbreak has spread to all age groups. 12 mumps viral isolates from 6 states were characterized; all were mumps genotype G. The genotype of the mumps virus responsible for the outbreak at Wheaton College has yet to be established.
(Promed 10/3/06)

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USA (Georgia): 2 human deaths from Vibrio vulnificus
Raw oysters linked to the deaths of 2 Chatham County women are believed to have come from the Gulf of Mexico. The source is still being investigated, said Coastal District Health Director Dr. Doug Skelton. But knowing the source may not help authorities prevent others from becoming infected, he said. The deaths are believed to have been caused by Vibrio vulnificus, a naturally occurring marine microorganism. It is not normally a threat to healthy people, but can cause serious illness in people whose immune systems are impaired because of conditions such as liver disease, AIDS, hemochromomatosis, or who are undergoing chemotherapy or taking steroids for asthma. On average, only 35 people contract the infection from shellfish annually in the US. The bacterium is associated with oysters raised in the Gulf of Mexico -- the source of most raw oysters consumed in the US -- and other warm waters. To kill dangerous microorganisms, oysters must be cooked to 145 degrees for 15 seconds. Vibrio vulnificus can still be present if oysters are undercooked. Restaurants that serve raw oysters are required to post warnings for consumers. They are also required to keep shellfish tags for 90 days. The tag's information enables investigators to trace any bag of oysters back to the growing area and harvester. Although oysters can be harvested legally only from waters free from fecal contamination, even legally harvested oysters can be contaminated with V. vulnificus because the bacterium is naturally present in marine environments. V. vulnificus does not alter the appearance, taste, or odor of oysters.

V. vulnificus can cause disease in those who eat contaminated seafood or have an open wound that is exposed to seawater. Among healthy people, ingestion of V. vulnificus can cause vomiting, diarrhea, and abdominal pain. In immunocompromised persons, particularly those with chronic liver disease, V. vulnificus can infect the bloodstream, causing a severe and life-threatening illness. V. vulnificus bloodstream infections are fatal about 50 percent of the time. V. vulnificus can also cause an infection of the skin when open wounds are exposed to warm seawater; these infections may lead to skin breakdown and ulceration. If V. vulnificus is suspected, treatment should be initiated immediately because antibiotics improve survival.
(Promed 9/30/06)

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Africa
Egypt: New human case of avian influenza H5N1
WHO announced that a 39-year-old Egyptian woman has H5N1 avian influenza. The Egyptian patient, from the Gharbiya governorate in the Nile Delta, about 60 miles northwest of Cairo, fell ill Sep 30 and was hospitalized Oct 4. She has pneumonia and remains hospitalized in stable condition. Reportedly, the woman has been treated with oseltamivir and that her family was being tested for the virus. The woman had recently slaughtered and plucked about a dozen ducks after illness and deaths started occurring in the flock. The woman is Egypt’s 15th avian flu case-patient and the first since May. All of the country's previous cases, 6 of which were fatal, occurred between late Mar and May. With the Egyptian case, the WHO's global avian flu count rose to 253 cases with 148 deaths. Avian flu in poultry resurfaced in Egypt Sep 5, when the country’s agriculture minister confirmed an H5N1 case on a farm in the province of Sohag, about 305 miles south of Cairo. Another outbreak was reported in Sep among domestic birds at a home near Aswan. Egypt has culled 30 million birds since Feb 2006 to contain the virus. The vast majority of Egyptian commercial poultry flocks have been vaccinated, while about 20 per cent of domestic birds had received vaccines.
(Promed 10/11/06; CIDRAP 10/11/06 http://www.cidrap.umn.edu )

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Sudan: Excerpts from OIE report on avian influenza H5N1 in birds
Information received 2 Oct 2006 (and up to 30 Sep 2006) from Dr Bashir Taha Mohamed Taha, undersecretary, Federal Ministry of Animal Resources: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 20 Feb 2006. Nature of diagnosis: clinical and laboratory. New outbreaks: 6 outbreaks in Juba, Central Equatoria state. Of 5000 susceptible birds, there were 50 cases and 50 deaths; 20 were ducks and 30 were chickens. Description of affected population: poultry in backyard systems 1600 km south of Khartoum. Laboratory where diagnostic tests were performed: Veterinary Laboratory Agency, Weybridge, UK. Results: RT-PCR positive 8 Sep 2006. Control measures undertaken: total depopulation of all infected and in-contact birds in Juba town; total ban of movement of live birds and poultry meat from Juba town to other areas and counties in southern Sudan. The disease is now confined to Khartoum, Gezira, River Nile and Central Equatoria States.
(Promed 10/12/06)

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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 about the new Crisis Management Centre launched by FAO. Read the article, “Bird flu a 'marker' for the future”, comments by the U.N. system coordinator for influenza, David Nabarro.
- OIE: http://www.oie.int/eng/en_index.htm.
- US CDC: http://www.cdc.gov/flu/avian/index.htm
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/. You can now select a US map that will take you to a page with links to state pandemic planning information, state pandemic Web site information, and local state contacts.
- 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. New updates--Avian influenza backgrounder; USDA, DOI expand wild bird monitoring for avian influenza.
- 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
Chinese Taipei
Based on the notifiable disease surveillance system in Taiwan, during the 39th epidemiological week (Sep 24 to 30), 119 dengue fever (DF) cases were reported in Taiwan, of which 55 were laboratory confirmed. As of Sep 30, there had been 1,084 reported cases of DF nation-wide this year, of those, 367 had been confirmed, including 5 dengue hemorrhagic fever (DHF) cases. So far in 2006, no DF deaths have been reported. The cumulative number of dengue confirmed cases has increased by 193.6 percent compared with the same period last year (2005, 125 cases). Among this year’s cases, 78 were classified as imported cases and 289 were domestic cases. The origins of the imported cases: 26 from Vietnam; 15 from Indonesia; 12 from the Philippines; 10 from Thailand; 5 from Cambodia; 3 from Malaysia; 2 from Myanmar; 1 from El Salvador; 1 from India; 1 from Bangladesh; 1 from Madagascar; and 1 was from unknown origin. Of the domestic cases, the main serotype of circulating DF virus is DEN-3, and only 6 cases are DEN-2. The case distribution was mainly in southern Taiwan.
(Taiwan IHR Focal Point 10/11/06)

Chinese Taipei
There has been a constant increase in the number of people infected with domestic dengue fever since summer. Taiwan CDCs predicts that on average 41 new dengue fever cases will occur weekly, with the number of confirmed indigenous dengue fever cases to exceed 300 by Oct 7. In order to control the epidemic, the ExecutiveYuan established the Central Epidemic Command Center for Dengue fever, Oct 2, to supervise and formulate an overall plan for dengue fever prevention strategies. The Minister of the Department of Health (DOH) has been appointed as commander of this program, with the Minister of the Environmental Protection Administration acting as co-commander. The deputy ministers from these two organizations will supervise the situation in southern Taiwan. Additionally, the deputy director of Taiwan CDCs will act as frontline commander, moving to southern Taiwan.

DOH has focused on dengue fever prevention measures. In the beginning of the year, DOH invested more than NT$40,000,000 in clearing mosquito breeding sources in southern Taiwan. DOH invested a further approximate NT$10,000,000 in Kaohsiung city and county after the domestic dengue fever outbreak was found this summer. Following a 3-month effort from local units, it is obvious that, although the epidemic situation is not fully controlled, the prevention work has slowed down the spread of disease in comparison to the epidemic situation that occurred in 2002. DOH expects to invest a further NT$30,000,000 in the prevention fund, and to assign 30 vector prevention, epidemiological, and medical specialists to southern Taiwan to expand the active disease prevention team and to assist the related prevention strategies.

The deputy head of the CDC, Chou Chih-hao, spoke of the government's novel and more aggressive approach toward dengue prevention. "Those who allow mosquito breeding grounds to persist on their property or ... who hamper public sanitation efforts are now liable to be fined," he said. The objective of the new anti-dengue center is to keep the number of cases below 500 this year.
(Taiwan IHR Focal Point 10/5/06; Promed 10/6/06)

Chinese Taipei
A dengue fever outbreak in southern Taiwan could have been triggered by dengue virus transmitted from Vietnam. CDC tallies show that from the start of summer until 3 Oct 2006, the number of indigenous dengue fever cases has totaled 291 in the country, all in southern Taiwan. According to CDC Deputy Director-General Chou Chih-hao, people over the age of 65 are the main age group affected by the disease this year, and the dengue virus type 3 strain has been found in most of the patients. An RNA comparison indicates that the virus strain discovered in the Taiwan patients is 99.4 per cent similar to the strain prevalent in Vietnam, which shows that Vietnam could be the source of the outbreak, Chou said. He reasoned that some travelers to Vietnam could have been carrying the disease when entering the country but were not detected by quarantine authorities because they were not displaying any obvious symptoms. He noted that almost all indigenous dengue fever outbreaks occurring each year in Taiwan have been traced to imported cases and that the Philippines has been identified as the source of the outbreaks in previous years.
(Promed 10/6/06)

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West Nile Virus
Canada
Human cases reported for week 38 (as of 23 Sep 2006):
Province / Neurological / Non-Neurological / Unclassified; Unspecified / Total* / Asymptomatic**

Alberta / 1 / 23 / 0 / 27 / 0
Ontario / 13 / 13 / 1 / 23 / 0
Manitoba / 13 / 24 / 12 / 49 / 1
Saskatchewan / 3 / 7 / 0 / 10 / 0
TOTALS / 30 / 67 / 13 / 110 / 1

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

USA
Reported Human Cases:
State / Neuroinvasion* / West Nile fever** / Other*** / Total **** / Fatalities

Alabama / 4 / 0 / 1 / 5 / 0
Arizona / 15 / 14 / 16 / 45 / 0
Arkansas / 18 / 5 / 0 / 23 / 0
California / 62 / 162 / 13 / 237 / 3
Colorado / 54 / 219 / 0 / 273 / 3
Connecticut / 6 / 2 / 0 / 8 / 1
District of Columbia / 0 / 1 / 0 / 1 / 0
Florida / 3 / 0 / 0 / 3 / 0
Georgia / 2 / 4 / 1 / 7 / 1
Idaho / 94 / 542 / 6 / 642 / 10
Illinois / 105 / 49 / 22 / 176 / 9
Indiana / 11 / 5 / 12 / 28 / 0
Iowa / 15 / 12 / 0 / 27 / 0
Kansas / 14 / 9 / 0 / 23 / 3
Kentucky / 4 / 1 / 0 / 5 / 1
Louisiana / 66 / 49 / 0 / 115 / 0
Maryland / 2 / 0 / 1 / 3 / 0
Michigan / 27 / 2 / 7 / 36 / 3
Minnesota / 28 / 34 / 0 / 62 / 3
Mississippi / 73 / 73 / 0 / 146 / 6
Missouri / 37 / 10 / 1 / 48 / 2
Montana / 10 / 19 / 1 / 30 / 0
Nebraska / 33 / 123 / 0 / 156 / 1
Nevada / 34 / 73 / 14 / 121 / 1
New Jersey / 2 / 2 / 1 / 5 / 0
New Mexico / 1 / 2 / 0 / 3 / 0
New York / 7 / 3 / 1 / 11 / 1
North Dakota / 19 / 113 / 0 / 132 / 1
Ohio / 23 / 6 / 0 / 29 / 2
Oklahoma / 19 / 9 / 1 / 26 / 5
Oregon / 2 / 19 / 1 / 22 / 0
Pennsylvania / 7 / 1 / 0 / 8 / 2
South Dakota / 36 / 67 / 0 / 103 / 2
Tennessee / 7 / 1 / 0 / 8 / 1
Texas / 163 / 71 / 0 / 234 / 23
Utah / 42 / 77 / 0 / 119 / 4
Virginia / 0 / 0 / 2 / 2 / 0
Washington / 0 / 2 / 0 / 2 / 0
West Virginia / 1 / 0 / 0 / 1 / 0
Wisconsin / 10 / 8 / 0 / 18 / 1
Wyoming / 11 / 27 / 24 / 62 / 2
TOTALS / 1069 / 1817 / 125 / 3011 / 94

* 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.
(Promed 10/6/06)

As of Oct 10, 2006. A total of 41 states and the District of Columbia had reported 3,135 cases of human WNV illness to CDC. A total of 1,717 (55%) cases for which such data were available occurred in males; median age of patients was 50 years (range: 3 months--99 years). Dates of illness onset ranged from Jan 6 to Sep 25; a total of 97 cases were fatal. A total of 260 presumptive West Nile viremic blood donors (PVDs) have been reported during 2006. Of these, 40 were reported from Nebraska; 27 from Texas; 24 from Utah; 21 from Colorado; 15 from California; 14 from Louisiana; 11 each from North Dakota and South Dakota; 10 each from Iowa and Wisconsin; 9 each from Arizona, Mississippi, and Oklahoma; 8 from Kansas; 6 from Idaho; 5 each from Minnesota and Virginia; 4 each from Kentucky and Missouri; 3 each from Illinois, Montana, and Nevada; 2 from Michigan; and 1 each from Arkansas, Maryland, New York, Ohio, Oregon, Pennsylvania, and Wyoming. Of the 260 PVDs, 3 persons (median age: 73 years [range: 26--74 years]) subsequently had neuroinvasive illness, 1 person aged 41 years had other illness, and 54 persons (median age: 46 years [range: 17--70 years]) had West Nile fever. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5540a4.htm
(MMWR October 13, 2006 / 55(40);1097-1098)

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2. Articles
Update on Vaccine-Derived Polioviruses
“In 1988, the World Health Assembly resolved to eradicate polio worldwide. The Global Polio Eradication Initiative (PEI) of the World Health Organization (WHO) has led to a decline in global polio incidence, from an estimated 350,000 cases in 1988 to fewer than 2,000 reported cases in 2005, and polio remains endemic to only four countries (Afghanistan, India, Nigeria, and Pakistan). However, two additional obstacles to global eradication involve vaccine-derived polioviruses (VDPVs). Polio outbreaks continue to be associated with circulating vaccine-derived polioviruses (cVDPVs) in areas with low oral poliovirus vaccine (OPV) coverage. In addition, long-term excretion of neurovirulent immunodeficiency-associated vaccine-derived polioviruses (iVDPVs) can lead to poliovirus spread to contacts. Overcoming these obstacles is challenging. High rates of OPV coverage will prevent all poliovirus spread, including spread of VDPVs, but will not prevent establishment of prolonged VDPV infections in certain persons with B-cell immunodeficiencies (i.e., having defects in antibody production). Inevitable gaps in vaccination coverage will give rise to cVDPVs as long as OPV use continues. This report updates a previous report on VDPVs and describes the potential implications of VDPVs in the final stages of global polio eradication. The findings underscore the critical need to strengthen strategies to prevent emergence of VDPVs and to stop all OPV use once wild polioviruses (WPVs) are eradicated. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5540a3.htm
(MMWR October 13, 2006 / 55(40);1093-1097)

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Fatal Avian Influenza A H5N1 in a Dog
Thaweesak Songserm et al. EID. Volume 12, Number 11–November 2006
http://www.cdc.gov/ncidod/EID/vol12no11/06-0542.htm
Abstract: “Avian influenza H5N1 virus is known to cross the species barrier and infect humans and felines. We report a fatal H5N1 infection in a dog following ingestion of an H5N1-infected duck during an outbreak in Thailand in 2004. With new reports of H5N1 virus continuing across Asia, Europe, and Africa, this finding highlights the need for monitoring of domestic animals during outbreaks.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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Annual Influenza Vaccination in Community-Dwelling Elderly Individuals and the Risk of Lower Respiratory Tract Infections or Pneumonia
Bettie C. G. Voordouw, et al. Arch Intern Med. 2006;166:1980-1985.
http://archinte.ama-assn.org/cgi/content/abstract/166/18/1980
Abstract: “Background Influenza vaccination has been associated with a reduction in the number of hospitalizations for respiratory conditions in elderly persons over the period from 1996 to 2002. Little is known, however, about the effect of influenza vaccination on the whole range of severity of respiratory tract infections. Methods We investigated the effect of annual influenza vaccination on the occurrence of lower respiratory tract infections (LRTIs) in community-dwelling elderly individuals. From 1996 to 2002, we performed a population-based cohort study, using the computerized Integrated Primary Care Information database in the Netherlands, of community-dwelling subjects who were 65 years or older on January 1 of the year of study entry. For each year, the individual cumulative exposure to influenza vaccination since study entry was computed. We compared the risk of LRTI after a first vaccination or revaccination with the risk for no vaccination using a time-varying multivariate Cox proportional hazard model, adjusted for age, sex, smoking, and underlying disease. Results In the study population of 26 071 subjects, 3412 developed LRTIs during follow-up. During the influenza epidemic periods, a first vaccination did not reduce risk for LRTI. In the total population, the hazard ratio following a first vaccination was 0.86 (95% confidence interval [CI], 0.71 to 1.05); in the population without or with comorbidity, these ratios were 0.90 (95% CI, 0.56 to 1.45) and 0.83 (95% CI, 0.66 to 1.04), respectively. During epidemic periods, revaccination reduced risk of LRTI by 33% (95% CI, 8% to 52%) in individuals without comorbidity. In individuals with comorbidity, the risk reduction of 5% was nonsignificant (95% CI, –10% to 18%). Conclusion In this study, annual influenza revaccination was associated with a reduction in LRTI in community-dwelling elderly individuals.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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Targeted Social Distancing Design for Pandemic Influenza
Robert J. Glass et al. EID. Volume 12, Number 11¨CNovember 2006.
http://www.cdc.gov/ncidod/EID/vol12no11/06-0255.htm
Abstract: ¡°Targeted social distancing to mitigate pandemic influenza can be designed through simulation of influenza¡¯s spread within local community social contact networks. We demonstrate this design for a stylized community representative of a small town in the United States. The critical importance of children and teenagers in transmission of influenza is first identified and targeted. For influenza as infectious as 1957¨C58 Asian flu (¡Ö50% infected), closing schools and keeping children and teenagers at home reduced the attack rate by >90%. For more infectious strains, or transmission that is less focused on the young, adults and the work environment must also be targeted. Tailored to specific communities across the world, such design would yield local defenses against a highly virulent strain in the absence of vaccine and antiviral drugs.¡±
(CIDRAP http://www.cidrap.umn.edu/index.html )

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Avian influenza H5N1 screening of intensive care unit patients with community-acquired pneumonia
Anucha Apisarnthanarak et al. EID. Volume 12, Number 11–November 2006.
http://www.cdc.gov/ncidod/EID/vol12no11/06-0443.htm
Abstract: “From February 1, 2005, to January 31, 2006, we screened 115 adults for avian influenza (H5N1) and influenza A if admitted to an intensive care unit with pneumonia. Using reverse transcription-PCR, viral culture, and serologic testing for anti-H5 antibody, we identified 8 (7%) patients with influenza A (H3N2); none had H5N1. Estimated costs for H5N1 screening were $7,375. The ongoing avian influenza (H5N1) pandemic poses risks to both human and animal health. The potential exists for cross-species transmission of avian influenza to humans and subsequent reassortment of avian and human influenza viruses in coinfected persons. Although atypical presentations of avian influenza (H5N1) have been reported, in most H5N1 case-patients pneumonia was the primary condition. To assess the prevalence of avian influenza (H5N1) and influenza A pneumonia, we screened adults admitted to a medical intensive care unit (ICU) with community-acquired pneumonia (CAP) for H5N1 and calculated the cost estimates for H5N1 screening in a tertiary care center of an H5N1-endemic area in Thailand.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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Shiga Toxin Activatable by Intestinal Mucus in Escherichia coli Isolated from Humans: Predictor for a Severe Clinical Outcome
Martina Bielaszewska et al. Clinical Infectious Diseases. 2006;43:1160-1167
http://www.journals.uchicago.edu/CID/journal/issues/v43n9/40120/brief/40120.abstract.html
Abstract: “Background. Some Escherichia coli produce Shiga toxin (Stx) in which cytotoxicity is increased (activated) by intestinal mucus and elastase (Stx2dactivatable). These strains are highly virulent in mice, but their association with human disease is poorly understood. We investigated the prevalence of Stx2dactivatable among Stx-producing E. coli (STEC) isolated from humans and the association between production of this Stx and the clinical outcome of infection. Methods. A total of 922 STEC isolates obtained from patients with hemolytic uremic syndrome or bloody or nonbloody diarrhea or from asymptomatic carriers were tested for the gene encoding Stx2dactivatable by PCR and PstI restriction analysis. The toxin activatibility by human and mouse intestinal mucus and by an elastase was determined by quantifying the cytotoxicity using the Vero cell assay. Results. The stx2d-activatable gene was identified in 60 (6.5%) of 922 STEC strains; in 31 of these strains, it was the sole stx gene. Thirty of these 31 strains produced Stx2dactivatable. All of them lacked the intimin-encoding eae gene. Among eae-negative STEC, which typically cause mild diarrhea or asymptomatic infection, production of Stx2dactivatable was significantly associated with the ability to cause severe disease, including bloody diarrhea (P < .001), and with systemic complications, such as hemolytic uremic syndrome (P < .001). Conclusions. Production of Stx2dactivatable by the infecting STEC may predict a severe clinical outcome of the infection, with progression to hemolytic uremic syndrome. A prompt and comprehensive subtyping of stx genes in STEC isolates is necessary to alert the treating physician that a patient is at risk of developing hemolytic uremic syndrome, even though the infecting STEC lacks eae.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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Eating in Restaurants: A Risk Factor for Foodborne Disease?
Timothy F. Jones and Frederick J. Angulo. Clinical Infectious Diseases. 2006;43:000 http://www.journals.uchicago.edu/CID/journal/issues/v43n10/40365/brief/40365.abstract.html
Abstract: “Foodborne disease is a common, but preventable, burden of illness worldwide. Almost one-half of every dollar spent on food in the United States is spent on food from restaurants. A growing body of data from foodborne disease outbreaks and studies of sporadic (non–outbreak-associated) gastrointestinal disease of various etiologies suggest that eating food prepared in restaurants is an important source of infection. These data suggest a critical need for action that is focused on preventing disease transmission within the food service industry. Clinicians should report all suspected foodborne disease to public health authorities to ensure appropriate epidemiologic investigation.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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Disease Mitigation Measures in the Control of Pandemic Influenza
Thomas V. Inglesby. BIOSECURITY AND BIOTERRORISM: BIODEFENSE STRATEGY, PRACTICE, AND SCIENCE. Volume 4, Number 4, 2006
Abstract: “The threat of an influenza pandemic has alarmed countries around the globe and given rise to an intense interest in disease mitigation measures. This article reviews what is known about the effectiveness and practical feasibility of a range of actions that might be taken in attempts to lessen the number of cases and deaths resulting from an influenza pandemic. The article also discusses potential adverse second- and third-order effects of mitigation actions that decision makers must take into account. Finally, the article summarizes the authors’ judgments of the likely effectiveness and likely adverse consequences of the range of disease mitigation measures and suggests priorities and practica actions to be taken.”
(CIDRAP http://www.cidrap.umn.edu/index.html ; pdf format)

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Outbreaks of Multidrug-Resistant Shigella sonnei Gastroenteritis Associated with Day Care Centers --- Kansas, Kentucky, and Missouri, 2005
“Infection with Shigella sonnei that is resistant to antibiotics commonly used in pediatric practice has become more common during the past decade. In 2005, Kansas, Kentucky, and Missouri reported increases in shigellosis cases associated with day care centers caused predominantly by multidrug-resistant (MDR) (i.e., resistant to ampicillin and trimethoprim-sulfamethoxazole [TMP/SMX]) strains of S. sonnei. Pulsed-field gel electrophoresis (PFGE) patterns for isolates from Kansas and Missouri were similar, suggesting a common outbreak in the Kansas City area, whereas isolates from Kentucky had a different pattern. This report describes the investigation of two outbreaks of MDR shigellosis associated with day care centers and reviews measures for prevention and control of S. sonnei infection in these settings. Given the current rates of resistance to antibiotics available to treat children with shigellosis safely, public health measures initiated during shigellosis outbreaks should focus on promoting appropriate handwashing and diapering practices in day care centers. Shigellosis is a reportable disease in all three states. A confirmed case is defined as illness in a person with S. sonnei isolated from a clinical specimen, and a probable case is defined as clinically compatible symptoms in a person who was epidemiologically linked to a confirmed case. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5539a3.htm
(MMWR October 6, 2006 / 55(39);1068-1071)

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Botulism Associated with Commercial Carrot Juice--Georgia and Florida, September 2006
“On September 8, 2006, the Georgia Division of Public Health (GDPH) and CDC were notified of three suspected cases of foodborne botulism in Washington County, Georgia. On September 25, the Florida Department of Health and CDC were notified of an additional suspected case in Tampa, Florida. This report describes the joint investigation and control measures undertaken by state and local health departments, CDC, and the Food and Drug Administration (FDA). . .On September 29, GDPH and the Georgia Department of Agriculture recommended that Georgia residents not purchase or consume Bolthouse Farms carrot juice. The same day, the FDA warned consumers not to drink Bolthouse Farms carrot juice with "best if used by" dates of November 11, 2006 or earlier (i.e., all bottles produced before the date the warning was issued), and Bolthouse Farms issued a voluntary recall of these products. Additional information regarding the recall is available from the Bolthouse Farms website at http://www.bolthouse.com/bolthouserecallFAQ.pdf or from FDA (telephone, 888-723-3366). . .Additional information on botulism is available at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/botulism_g.htm. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55d106a1.htm
(MMWR October 6, 2006 / 55(Dispatch);1-2)

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3. Notifications
Third International Bird Flu Summit
The 3rd International Bird Flu Summit will take place in Geneva, Switzerland, 14-15 November 2006. The purpose of the summit is to prepare the World to fight this potentially infectious disease. For more information, visit: http://www.new-fields.com/birdflu3/index.asp.
(Bird Flu )

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International meeting on emerging diseases and surveillance (IMED 2007)
Vienna, Austria; 23-25 Feb 2007. http://imed.isid.org/preliminary_schedule.shtml
The first international emerging disease and surveillance meeting sponsored by ProMED is now inviting abstract submissions through: http://ww2.isid.org/abstracts/Conference_login.lasso?cid=022. Abstracts may relate to any aspect of emerging diseases or their surveillance, and submissions for (a limited number) of oral abstracts as well as posters are sought. Along with our co-sponsors, the European CDC, the World Organization for Animal Health (OIE), the European Commission and the WHO Regional Office for Europe, ProMED is proud to invite our reader/participants to this exciting conference.

- Dr David L. Heymann: Acting Assistant Director-General for Communicable Diseases and Representative of the Director-General for Pandemic Influenza and the Representative of the Director-General for Polio Eradication at the WHO.
- Dr Adriano Duse: NHLS and School of Pathology of the University of Witwatersrand Clinical Microbiology & ID, Johannesburg, South Africa.
- Dr Antoine Flahault: Professor, University Pierre et Marie Curie, Paris.
- Dr Daniel Lucey: Adjunct Professor, Georgetown Program Threat Agents and Emerging Infectious Diseases.

The meeting will embrace the "One Medicine" concept, recognizing that just as diseases reach across national boundaries, so do they cross species barriers. We therefore welcome the full participation of both the human and animal health communities. IMED 2007 will be organized by the International Society for Infectious Diseases, which has over 20 years experience in planning and implementing international biomedical meetings. With outstanding plenary speakers, symposia by expert panels, and invited abstracts, IMED 2007 is certain to be the year's major conference for those involved in the study, detection, and monitoring of emerging pathogens and to those in the front lines of response. For more information: http://imed.isid.org. Abstracts are invited and online abstract submission is available now.
(Promed 9/29/06)

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Fifth World Melioidosis Congress
From: Kanokwan Suwannarong: kanokwan27@yahoo.com
21-23 Nov 2007; http://www.wmc2007.org/.
On behalf of the Organizing Committee of the 5th WMC, it is a pleasure to invite you to come to Khon Kaen, Thailand to celebrate again the major scientific gathering on melioidosis that takes place every 3 years. This provides a unique opportunity for you to update your knowledge in cutting edges areas of melioidosis and to meet the internationally renowned leaders in the field of melioidosis and related areas. It is also an ideal opportunity to use this as a forum to discuss your own research problems with your old acquaintances and to make new contacts with leaders in the field.
(Promed 9/30/06)

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An FAO/RAI pilot scheme for webcasting events in real time
Important events at FAO headquarters in Rome can be viewed live on the UN agency’s web site, as well as on the RAI Portal, under a pilot scheme launched by FAO and RaiNet. This new joint project makes it possible to broadcast information in audio and video form using the latest webcast technology. The launch of the Crisis Management Centre 12 Oct 2006 will be the first of a series of live events to be webcast this month. The celebration of World Food Day will follow on Monday, October 16, as well as the presentation of FAO’s “The State of Food Insecurity” report (SOFI 2006) on Monday, October 30. “The use of digital technology allows for greater access to information, not only for media specialists, but for millions of people who daily browse the net,” said Nick Parsons, Director of FAO Information Division.

A High-band streaming signal will be available for the users with an ADSL Internet connection. For those using a normal Internet connection (ISDN or Modem), a Low-band streaming signal will be available. Videos and audios will be in both English and Italian. “This is the result of a longstanding collaboration between FAO and RAI,” said Alberto Contri, Managing Director of RaiNet. “We have tried to capitalize on the possibilities that this new technology offers to help to draw public attention to important social issues such as world food insecurity and the threats posed by international animal diseases.”
(FAO 10/11/06 http://www.fao.org/Webcast/index.asp?lang=EN )

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CDC's 60th Anniversary: Director's Perspective --- William H. Foege, M.D., M.P.H., 1977--1983
Read the CDC’s former director’s perspective on CDC’s 60th anniversary and public health (Expansion of Public Health; Changing CDC Priorities and Structure; Solving New Problems; Redefining the Unacceptable and; Science Versus Politics).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5539a4.htm
(MMWR October 6, 2006 / 55(39);1071-1074)

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Recommended Adult Immunization Schedule--United States, October 2006-September 2007
The Recommended Adult Immunization Schedule has been approved by the Advisory Committee on Immunization Practices, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians. The standard MMWR footnote format has been modified for publication of this schedule. Suggested citation: Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule---United States, October 2006--September 2007. MMWR 2006;55:Q1--Q4. The Advisory Committee on Immunization Practices (ACIP) annually reviews the recommended Adult Immunization Schedule to ensure that the schedule reflects current recommendations for the licensed vaccines. In June 2006, ACIP approved the Adult Immunization Schedule for October 2006--September 2007. This schedule has also been approved by the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5540a10.htm
(MMWR October 13, 2006 / 55(40);Q1-Q4)

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4. To Receive EINet Newsbriefs
APEC EINet email list
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