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Vol. IX, No. 21 ~ EINet News Briefs ~ Oct 27, 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 seeks urgent push for pandemic flu vaccines
- Global: Novartis claims success in trial of cell-based flu vaccine
- Global: WHO and partners unveil new approach to neglected tropical diseases
- Indonesia (Sulawesi Island): 9 suspected cases of avian influenza infection
- Vietnam: Success against avian flu may offer blueprint for others
- Hong Kong: Gastroenteritis associated with consumption of raw oysters
- Russia (Tyva): Increasing incidence of tick-borne encephalitis
- Russia (Bashkortostan): 5 deaths from hemorrhagic fever with renal syndrome
- USA (Michigan): Low pathogenic avian influenza in wild avians
- USA (Ohio): No avian influenza virus found in wild avians
- USA (California): Manure implicated in E coli outbreak
- USA (multistate): E. Coli O157 strain in spinach outbreak particularly virulent
- Canada: Seventh case of botulism associated with carrot juice
- USA: Pentagon to resume mandatory anthrax shots for some
- USA (Indiana): Human case of rabies from bat exposure

1. Updates
- Avian/Pandemic influenza updates
- Cholera, Diarrhea, and Dysentery
- Dengue
- West Nile Virus

2. Articles
- Study: Wood ducks could be sentinel for H5N1
- Study shows flu shots safe for 6- to 23-month-olds
- Subjective and objective risk as predictors of influenza vaccination during the vaccine shortage of 2004–2005
- Risk Factors for Human Infection with Avian Influenza A H5N1, Vietnam, 2004
- In case of pandemic flu majority of Americans willing to make major changes in their lives
- New Study Has Important Implications for Influenza Surveillance, Vaccine Formulation
- Anatidae migration in the Western Palearctic and spread of highly pathogenic avian influenza H5N1 virus
- STD-prevention counseling practices and human papillomavirus opinions among clinicians with adolescent patients--United States, 2004
- Update: Guillain-Barré syndrome among recipients of Menactra meningococcal conjugate vaccine--United States, June 2005-September 2006
- Vaccination Coverage among Children Entering School--United States, 2005-06 School Year
- Varicella Surveillance Practices--United States, 2004
- Brief Report: Update: Mumps Activity --- United States, January 1--October 7, 2006

3. Notifications
- Global pandemic influenza action plan to increase vaccine supply
- IMED 2007 abstract submission
- APHA Get Ready Campaign (for emerging infectious diseases)
- HEALTHmap: Current global state of infectious diseases
- Self-Study Course: Principles of Epidemiology in Public Health Practice, Third Edition

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 / 53 (43)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 109 (73)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 256 (151).
(WHO 10/16/06 http://www.who.int/csr/disease/avianinfluenza/en/ )

Avian influenza age & sex distribution data from WHO/WPRO (as of 10/16/06): http://www.wpro.who.int/sites/csr/data/data_Graphs.htm.
(WHO/WPRO 10/16/06)

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Global: WHO seeks urgent push for pandemic flu vaccines
Warning that the world is billions of doses short of the amount of vaccine needed to prepare for an influenza pandemic, WHO called for an urgent and coordinated international effort to make up the deficit. The agency recommended an immediate campaign to boost vaccine production capacity and develop vaccines that would provide broader and more durable protection. WHO estimates the cost of the needed initiatives at US $3 billion to $10 billion. The world's current production capacity for seasonal flu vaccine is estimated at 350 million doses a year, which could perhaps be pushed to 500 million doses (each dose containing 15 micrograms of antigen for each of 3 flu strains). Current expansion plans are expected to add another 280 million doses of annual capacity over the next 2 to 3 years, pushing the total to a maximum of 780 million doses. Under the most optimistic assumptions, if all facilities converted to making a single-strain pandemic flu vaccine, maximum world capacity by 2008 or 2009 would be about 2.34 billion doses. This would fall several billion doses short of the expected demand in a pandemic. The current maximum capacity to make H5N1 vaccine is only about 500 million (single-strain) doses a year. Because each person would probably need 2 doses, only 250 million people could be fully vaccinated in a year.

WHO lays out 3 main steps for closing the vaccine supply gap: 1) Increase use of seasonal flu vaccine to stimulate industry to produce more (while protecting more people from seasonal flu); 2) Increase vaccine production capacity by improving yields and building new plants; 3) Increase research to develop better vaccines that provide more protection with fewer doses and produce vaccines faster and more efficiently. The most direct way to improve production capacity is to increase the production yield and immunogenicity of H5N-based vaccines, WHO says. Several candidate vaccines containing adjuvants will be tested over the next 2 years, but funding will be needed. WHO also calls for more research on live attenuated flu vaccines, saying they may be more effective than inactivated vaccines, cost less to produce, and have higher yields. The agency also advocates further assessment of killed, whole-virus vaccines and of administering vaccines intradermally rather than intramuscularly.

WHO estimates the cost of all the strategies for boosting vaccine yields and production capacity from $2 billion to $9 billion. WHO says the ideal vaccine is one that is safe and effective in all target groups with a single dose, is easily produced on a large scale, is thermostable, provides protection for at least a year, and protects against "antigenically drifted" flu strains. WHO recommends a number of approaches for developing better vaccines: Evaluate new adjuvants; Assess the molecular basis for the immunogenicity of hemagglutinin, one of the two surface proteins on flu viruses; Develop new-generation vaccines, such as ones that target viral proteins other than hemagglutinin; Determine the potential benefits of giving a pre-pandemic vaccine to prime the immune system to respond to later vaccination with a pandemic vaccine. WHO also advocates standardizing protocols for evaluating new vaccine candidates and defining immune responses in lab animals that correlate with protection in humans.
(CIDRAP 10/23/06 http://www.cidrap.umn.edu/ )

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Global: Novartis claims success in trial of cell-based flu vaccine
Pharmaceutical maker Novartis claimed success in a phase 3 clinical trial of a seasonal influenza vaccine produced in cell culture rather than in eggs, the conventional production method. The company said volunteers who received the vaccine had at least as strong an immune response as did volunteers immunized with an egg-based vaccine containing the same flu virus strains. The company said the safety profiles of the 2 vaccines were similar. A number of companies are working on cell-based production, but no cell-based flu vaccine has yet been licensed. Novartis said it applied for European Union approval of its vaccine in June. "Novartis is committed to bring cell culture–derived influenza vaccine to market," company CEO Jorg Reinhardt said. Cell culture is seen as a slightly faster and considerably more flexible production technology than the egg-based method. Novartis said the product is a subunit vaccine, meaning it contains individual viral proteins rather than whole virus particles. In the phase 3 study, conducted in Poland in the 2004-05 flu season, 1,300 volunteers between the ages of 18 and 60 and 1,354 volunteers older than 60 were randomly assigned to receive the cell-based vaccine or an egg-based vaccine, Novartis reported. Each volunteer received 1 dose. Researchers found no difference in the immunogenicity of the 2 vaccines, both of which met all 3 immunogenicity criteria of the EU’s Committee for Medicinal Products for Human Use. Rates of local and systemic side effects were similar for the 2 vaccines in both age-groups. When asked how long it takes to produce the cell-based vaccine, company officials said, "Currently, basically the same as egg-based except lead times are much shorter and start-up is more flexible." Officials said Novartis has completed phase 1 and 2 trials of the vaccine in the US and will report the results in 2007.
(CIDRAP 10/24/06 http://www.cidrap.umn.edu/ )

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Global: WHO and partners unveil new approach to neglected tropical diseases
WHO and a group of more than 25 partner organizations unveiled a new strategy to fight some of the most neglected tropical diseases that destroy the lives and health of poor people. The approach contained in a newly published manual, Preventive Chemotherapy in Human Helminthiasis, focuses on how and when a set of low-cost or free drugs should be used in developing countries to control a set of diseases caused by worm infections. Preventive chemotherapy in this context means using drugs that are effective against a broad range of worm infections to simultaneously treat the 4 most common diseases caused by worms: onchocerciasis, lymphatic filariasis, schistosomiasis, and soil-transmitted helminthiasis. Opportunities also exist to integrate these efforts with the prevention and control of diseases such as trachoma.

"Preventive chemotherapy does not necessarily stop infection taking place but it can help to reduce transmission. The benefit of preventive chemotherapy is that it immediately improves health and prevents irreversible disease in adults," says Dr Lorenzo Savioli, Director of the WHO Department for the Control of Neglected Tropical Diseases. “In the same way as we protect people against a number of vaccine-preventable diseases throughout their lives, the regular and coordinated use of a few drugs can protect people against worm-induced disease. . ." The new approach provides a critical first step in combining treatment regimens for diseases which, although different in themselves, require common resources and delivery strategies for control or elimination. The second key component of the strategy brings together for the first time dozens of agencies, NGOs, pharmaceutical companies and others into a coordinated assault on neglected diseases. These organizations are integrating their expertise and resources to deliver the manual’s protocols for wide-scale drug use.

More than 1 billion people are afflicted by these diseases. Their impact can be measured in the impaired growth and development of children, complications during pregnancies, underweight babies, significant and sometimes disabling disfigurements, blindness, social stigma, and reduced economic productivity and household incomes. These effects can now be dramatically reduced by scaling up interventions using highly effective drugs of proven quality and excellent safety record -- the majority donated free by companies or costing less than US$ 0.40 per person per year, including the cost of the drugs and their delivery.
(WHO 10/26/06)

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Asia
Indonesia (Sulawesi Island): 9 suspected cases of avian influenza infection
Tests for bird flu are being run on 9 people from a province of Indonesia's eastern island of Sulawesi, where one of the patients, a 1-year-old boy, probably died of the virus this week. The child from the South Sulawesi district of Maros died 17 Oct 2006, hours after he was admitted to the Wahidin Sudirohusodo Hospital in Makassar with flu-like symptoms. Samples from the boy are being tested for H5N1.

Tests for the H5N1 virus are being run on 8 others being treated in the Wahidin Sudirohusodo Hospital. They are all from South Sulawesi province, where the disease is known to have infected poultry. It wasn't immediately known whether the patients are related. The virus is reported to have killed a person every 4 days worldwide this year, more than double the 2005 rate, creating more chances for it to become more contagious to people. At least 256 people in 10 countries have caught H5N1 since late 2003, WHO said 16 Oct 2006. Almost all human H5N1 cases have been linked to close contact with sick or dead birds. While the virus doesn't spread easily between people, some human-to-human transmission may have occurred.

Reportedly, in an effort to stop avian flu outbreaks, Indonesian officials said they plan to bar people in major cities from keeping free-roaming poultry. The health minister said the ban could be modeled on similar laws in Thailand and Hong Kong. No date was set for imposing it.
(Promed 10/20/06; CIDRAP 10/25/06 http://www.cidrap.umn.edu/ )

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Vietnam: Success against avian flu may offer blueprint for others
Among countries affected by avian influenza H5N1, Vietnam stands out twice over. It was one of the first hit by the virus in the current outbreak and it was one of the hardest hit. But it has also controlled the virus more successfully than any other country where the disease became endemic, with no new human cases since last Nov and only a handful of infected birds this year—12 farm chickens and ducks, and a small flock of tame storks in an amusement park. The shift is so striking that international health authorities are asking whether Vietnam's success can be replicated elsewhere. But reproducing its efforts faces an unusual hurdle: sorting out which of its aggressive interventions actually made a difference.

After responding to its 2004 outbreaks mainly by culling infected flocks, Vietnam in 2005 became the first country to institute mandatory nationwide poultry vaccination. In addition—and almost simultaneously—the national government banned poultry rearing and live-market sales in urban areas; restricted commercial raising of ducks and quail, which can harbor the virus asymptomatically; imposed strict controls on poultry transport within Vietnam and agreed to examine illegal cross-border trade; and launched an aggressive public education campaign. The country also compensated farmers for birds that had to be killed—initially at 10% of the birds' market value, and now at 75%.

"Who knows what impact any of these interventions had? This is a natural experiment" that lacks controls that could measure impact, said Dr. David Dennis, the Hanoi-based Vietnam influenza coordinator for the US CDC. "How much [of the reduction in cases] is due to the natural history of this organism in birds? We don’t know." Outside the country, experts presume the engine of flu control to be the pervasive influence of Vietnamese-style socialism, which extends from the national government through provinces, districts, and communes to individual "neighborhood committees." But within Vietnam, workers in avian-flu control say the country's success depends as much on the population's support as it does on political coercion. "What makes the system work is not that it is top-down, but that it achieves consensus at every level," said Don Douglas, chief of party for Mekong Region avian flu efforts at Abt Associates, a US consulting firm that was awarded a 3-year contract for avian flu assistance in north Vietnam. "Imagine the stigma associated with being the farm that lets everyone down and causes all its neighbors' chickens to be culled."
(CIDRAP 10/25/06 http://www.cidrap.umn.edu/ )

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Hong Kong: Gastroenteritis associated with consumption of raw oysters
Hong Kong has issued a health alert after 46 people who ate oysters in recent weeks fell sick. The southern Chinese territory's Centre for Health Protection stated 19 Oct 2006 the victims had all suffered abdominal pain, diarrhoea, vomiting and fever after eating raw oysters sold in 5 different food premises between 22 Sep and 11 Oct 2006. The Center announced 20 Oct 2006 that test results of 22 raw oyster samples previously collected from a food supplier and 4 food premises showed no presence of pathogens. The center said that in investigating suspected food poisoning cases, the CFS would take into account a number of factors (e.g. clinical and epidemiological data, hygiene condition of the food premises, sources and distribution of food concerned, and test results of food samples). ". . . Investigations into the clinical and food history of the patients revealed that the cases might be related to consumption of raw oysters. The stool sample of one of the patients was tested positive for norovirus. This virus usually exists in raw oysters," a spokesman said. As to the source of oysters in question, the CFS is following up with the Chilean Consulate General as the supplier claimed that the oysters concerned were frozen half-shells imported from Chile.

Hong Kong is subject to frequent food scares as unlicensed goods smuggled from China -- where quality control checks are lax -- find their way into public markets and restaurants. Gastroenteritis associated with consumption of raw oysters is common throughout the world. Previously oysters imported into Hong Kong from both the Republic of Ireland and from Singapore have been associated with outbreaks of gastroenteritis. This global trade in oysters represents an unusual route for transmission of enteric viruses and may be responsible for the frequent recurrence of epidemics of shellfish-associated gastroenteritis.
(Promed 10/19/06, 10/21/06)

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Russia (Tyva): Increasing incidence of tick-borne encephalitis
56 inhabitants of the Republic of Tyva have contracted tick-borne encephalitis since the beginning of 2006. During the past 10 years a high level of tick-borne encephalitis morbidity has prevailed throughout the Republic, despite preventive measures to contain this disease. Since 1997 tick-borne encephalitis morbidity has increased 7.4-fold, with 708 persons affected by the disease and 6 fatalities. So far during 2006, 56 people have contracted tick-borne encephalitis, giving a morbidity in 2006 of 18.2 per 100 000 inhabitants, which is 6.2 times the average index of morbidity for the whole of Russia.

The number of territories [of the Republic] reporting cases of tick-borne encephalitis during the past 10 years has increased 2-fold. Since the beginning of 2006, some 1019 people in the Republic of Tyva have experienced tick-bites (compared with 889 in 2005) and sought medical treatment. The principal causes of high tick-borne encephalitis morbidity are reductions in tick control activities, the limited extent of preventative vaccination and lack of availability of [immunoglobulin preparations] for emergency treatment. Only 4647 individuals were vaccinated in 2006 compared with 11 567 in 2003. Only 22.5 percent of people who suffered tick-bite were vaccinated and only 30.1 percent received specific antibody treatment. The funding allocated by the Ministry of Health of the Republic of Tyva did not fully cover the purchase of immunological preparations.

The high level of morbidity in Tyva (18.2 per 100 000 inhabitants) is the result of increases in tick activity, changes in climatic and other factors, and deficiencies in tick control activities and heath care. These problems are not confined to the Republic of Tyva, and tick-borne encephalitis, a vaccine-preventable disease, remains a problem throughout much of central Russia.
(Promed 10/24/06)

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Russia (Bashkortostan): 5 deaths from hemorrhagic fever with renal syndrome
Since the beginning of 2006, 5 fatalities from hemorrhagic fever with renal syndrome (HFRS) have been recorded in the Republic of Bashkortostan, according to Gennadiy Minin, head of the Center of Hygiene and Epidemiology in the Republic. From the beginning of 2006, more than 2000 cases of HFRS have been recorded in the region; 5 patients with the severe form of the disease are receiving intensive care, and 4 require kidney dialysis treatment. Marked increases in HFRS-related morbidity are being recorded for the first time in other regions of Russia, in particular in Chuvashia, where morbidity is approaching that observed in Bashkortostan, and in the Orenburg region. Minin stated that the "red field vole" is the main vector of HFRS virus in Bashkortostan.

Bashkortostan is one of 3 foci of HFRS virus, the other 2 being the Primorsk region of Russia, and South Korea. An abundance of deciduous (lime) trees and suitable weather conditions favor the spread of the red field-vole in these regions. The average cost of treatment of a patient is 12-20 000 rubles [USD 447-745]. Rodent control measures around and in houses remains the sole means of combating the red field vole, the vector of HFRS. About 4 700 000 rubles [USD 175 000] have been allocated from the budget of the Republic for this purpose in 2006. However, payment of much of the funding has been delayed.

During Oct 2006, the number of patients suffering from HFRS in Bashkortostan had increased by more than 300. The peak of HFRS morbidity usually occurs during September/October, and a further increase in the number of HFRS patients must be expected. In 2005, a total of 2300 people contracted HFRS in the Republic. Diagnosis of HFRS has been a problem in the past. Now, a rapid diagnostic technique developed by the Tarasevich Institute of Standardization and Control has passed clinical tests and is available for use.
(Promed 10/25/06)

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Americas
USA (Michigan): Low pathogenic avian influenza in wild avians
The U.S. Department of Agriculture (USDA) and Department of the Interior (DOI) announced a detection of H5 and N1 avian influenza subtypes in a wild Green-winged teal sample from Tuscola County, Mich., that was killed by hunters. Initial test results indicated the presence of low pathogenic avian influenza (LPAI) virus. On 15 Oct 2006, 51 bird samples were collected through a partnership between USDA and the Michigan Department of Natural Resources. Of the 51 samples collected from a number of wild bird species, 5 were sent to USDA's National Veterinary Services Laboratories (NVSL) for confirmatory testing. One sample tested positive for both H5 and N1 subtypes. This does not mean these birds are infected with an H5N1 strain. It is possible that there could be 2 separate avian influenza viruses, one containing H5 and the other containing N1. Confirmatory testing underway at NVSL will clarify whether one or more strains of the virus are present, the specific subtype, as well as confirm the pathogenicity.

Low pathogenic avian influenza commonly occurs in wild birds. It typically causes only minor sickness or no noticeable signs in birds. There is no known health risk to hunters or hunting dogs from contact with low-pathogenic forms of avian influenza virus. Nevertheless, hunters are always encouraged to use common-sense sanitation practices, such as hand washing and thorough cooking, when handling or preparing wildlife of any kind. DOI has issued guidelines for safe handling and preparation of wild game.
(Promed 10/21/06)

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USA (Ohio): No avian influenza virus found in wild avians
The National Veterinary Services Laboratories (NVSL) confirmed that there was no avian influenza present in samples collected from wild Northern pintail ducks in Ottawa County, Ohio. The initial screening tests performed on the Ohio samples resulted in a weak positive for both H5 and N1. During confirmatory testing, H5 and N1 subtypes were not found; no virus could be grown during the virus isolation test.

To date, USDA and DOI have announced 12 presumptive positive and/or confirmatory test results in 6 states (MI, MD, PA, MT, IL and OH). As the expanded surveillance of wild birds for highly pathogenic avian influenza increases in the coming months, USDA and DOI expect additional detections of the "North American strain" of low pathogenic H5N1 avian influenza. Because these LPAI H5N1 detections are common and pose no threat to human health , USDA and DOI are transitioning to a new method of notifying the public. In an effort to maintain transparency, USDA and DOI will post all future suspected LPAI H5N1 detections on the Internet. DOI will maintain a list of all such routine detections as part of the National Highly Pathogenic Avian Influenza Early Detection Data System (HEDDS). The low path H5N1 detection list can be accessed at http://wildlifedisease.nbii.gov/ai/LPAITable.pdf . A link also will be at http://www.usda.gov/birdflu . In the event of a presumptive H5N1 test result involving a large number of sick or dead birds, or other circumstances that suggest the possibility of a highly pathogenic virus, USDA and DOI will issue a news release or conduct a briefing to notify the media and the public.
(USDA 10/26/06 http://www.usda.gov/wps/portal/usdahome )

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USA (California): Manure implicated in E coli outbreak
Investigators seeking the contamination source in a nationwide Escherichia coli O157:H7 outbreak have genetically matched an E coli strain found in manure from a California cattle ranch near spinach fields with the strain isolated from sick patients and their leftover spinach. US Food and Drug Administration (FDA) said the investigation points to one infected lot of contaminated spinach that contained spinach from fields on 4 different farms. Thus, FDA has narrowed its investigation from 9 farms to 4, which are located in Monterey and San Benito counties. Media reports say 3 manure samples tested positive for the outbreak strain and that investigators have so far taken 650 samples from soil, water, and manure on the farms.

Kevin Reilly, deputy director of prevention services for the California Department of Health Services, said the results don't prove that the manure was responsible for the outbreak. The manure samples that tested positive for the outbreak strain were located between a half mile and a mile from a spinach field. However, federal and state investigators still don't know how the feces contaminated the spinach. Media reports said this is the first time investigators have been able to link an outbreak strain of E coli to a farm where contaminated spinach or lettuce was grown. The positive finding is significant but is just one aspect of the investigation, FDA said. "While the focus of this outbreak has narrowed to these four fields, the history of E coli O157:H7 outbreaks linked to leafy greens indicates an ongoing problem," FDA said. The outbreak has sickened 199 people and killed 3, and has spanned 26 states and 1 Canadian province. Since 1995, 20 E coli outbreaks have been traced to leafy greens.

The pasture where the contaminated manure was found is part of a ranch that leases fields to spinach growers. Fences on the property had been penetrated by wild pigs, and investigators are assessing whether the pigs might have spread the bacteria from the cattle pasture to the spinach field. Reilly said the farm where matching manure was found did not fully follow voluntary guidelines that growers use to prevent contamination of leafy greens. He said concerns include the proximity of the cattle to spinach fields and the failure of fences to keep wildlife out. Reportedly the closeness of cattle to leafy greens farms is not uncommon in Salinas Valley. Not all 4 of the suspected farms have both livestock and produce operations.

2 new cases of illness from the E. coli bacterium linked to spinach have been reported in Illinois. The 2 newest cases involve a woman from downstate Illinois and a child from the northeast part of the state.
(Promed 10/13/06, 10/20/06; CIDRAP 10/13/06 http://www.cidrap.umn.edu/ )

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USA (multistate): E. Coli O157 strain in spinach outbreak particularly virulent
2006's lethal outbreak of E. coli in fresh spinach from the Salinas Valley was caused by a particularly malevolent breed of the bacteria that had previously sickened 109 Americans. Scientists have been tracking outbreaks of E. coli O157:H7 since it appeared in undercooked hamburger in 1982. Within this microbial family, scientists have since recorded the genetic fingerprints of 20 000 subtypes. All of the victims in the spinach outbreak this summer were sickened by a single subtype labeled EXHX01.0124. It may be the most dangerous strain of O157:H7 yet detected. "This bacterium is clearly more virulent than those in other outbreaks," said Kevin Reilly, deputy director for prevention services at the California Department of Health Services. Half of those made ill by the bacteria were hospitalized, kidney failure rates in children were more than triple the norm, and 3 people have died.

Disease detectives first booked No. 0124 into the CDC's genetic fingerprint computer in Dec 1998, when it turned up in 3 cases in Massachusetts. It popped up again in 2000, causing a single illness in Kansas. There were 5 states affected in 2001 and 37 states in 2005. Before a single case of spinach-related illness was logged in 2006, there were already 34 cases in 17 states -- all of them caused by the same strain. The 0124 subtype accounts for less than 1 percent of the strains reported each year, but it has been increasingly prevalent, said Dr. Peter Gerner-Smidt, who tracks the subtypes of E. coli at the CDC as chief of a the surveillance program PulseNet.

Each year, laboratories in state health departments throughout the country log several thousand cases of E. coli infection, and submit the genetic fingerprints of each case to PulseNet. There are 73 000 cases of E. coli O157:H7 food poisoning each year, but seldom do they appear in clusters large enough to trigger closer scrutiny. Typically, E. coli O157:H7 causes severe cramping and bloody diarrhea, and about 10 percent of children who get it develop a life-threatening kidney damage called hemolytic uremic syndrome. Of the 199 confirmed cases in the spinach outbreak, however, 39 percent of children afflicted developed the kidney condition, as have about 10 percent of adults.

One possible explanation for 0124's unusual punch lies in its molecular makeup. All E. coli O157:H7 strains are dangerous because they are armed with toxins similar to those found in the intestinal disease shigellosis. Most strains carry 2 kinds, known as Shiga Toxin Types 1 and 2. But the spinach outbreak strain appears to carry only Type 2. Early research on E. coli suggests that Type 2 toxins are more potent than Type 1, and that strains that carry Type 2 alone are more dangerous than those that carry only Type 1 or both. The unusual severity of illness found in the spinach outbreak is consistent with those laboratory findings. In 8 of 9 years prior to this summer's outbreak of a particularly virulent strain of E. coli O157:H7 among consumers of fresh spinach, CDC had detected the same microbe in 109 patients scattered through 31 states.
(Promed 10/20/06)

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Canada: Seventh case of botulism associated with carrot juice
A Quebec resident has contracted botulism after drinking carrot juice, public health officials said 20 Oct 2006. The provincial Agriculture and Health departments urged the public not to drink certain brands of the juice they may have in their homes. 2 cases of botulism associated with carrot juice have been identified in Ontario; 4 others have taken place in the USA. The products subject to the Quebec notice that are sold in 1 liter and 450 mL bottles are: Bolthouse Farms 100 percent Carrot Juice; Earthbound Farm Organic Carrot Juice; President's Choice Organics 100 percent Carrot Juice. All of the products have already been removed from store shelves. Consumers who have these products should throw away the bottles.

The cases in the USA were reported to be associated with a nonrefrigerated product, and the previous 2 cases from Ontario, Canada were alleged to be linked to juice that was properly refrigerated (at least in the home). The USA's FDA and CDC launched an investigation of Bolthouse Farms after the juice was voluntarily recalled by the company. Several bottles of the company's carrot juice were tested for the toxin, and all bottles came back with negative results. The 2 Toronto patients, who remain seriously ill in hospital, live together, and both ingested the toxic carrot juice before falling ill. Toronto Public Health sent a sample of the carrot juice that was left in the refrigerator to a lab in Ottawa, where it tested positive for botulism.
(Promed 10/16/06, 10/21/06)

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USA: Pentagon to resume mandatory anthrax shots for some
The Pentagon announced that it will resume, after a 2-year hiatus, mandatory anthrax vaccination for troops and other personnel stationed in the Middle East and South Korea. The program also will include units involved in "homeland bioterrorism defense," the statement said. "The anthrax vaccine will protect our troops from another threat—a disease that will kill, caused by a bacteria that already has been used as a weapon in America. . .” said Dr. William Winkenwerder Jr., assistant secretary of defense for health affairs. Winkenwerder said "several hundreds of thousands" of troops will receive the vaccine.

Soldiers concerned about the vaccine's side effects sued to stop the program several years ago, arguing that the Food and Drug Administration (FDA) had never specifically approved the vaccine for preventing inhalational anthrax. In Dec 2003 a federal judge ordered the program stopped. FDA quickly responded with an affirmation that the vaccine was safe and effective for all forms of anthrax disease, and the judge then lifted his injunction. But in Oct 2004 he stopped the program again, ruling that FDA had not followed proper procedures in issuing the new approval. In Jan 2005, FDA granted a Pentagon request for emergency authority to restart the vaccination program, but said the shots had to be voluntary. DoD has been giving the shots on a voluntary basis since Apr 2005. In Dec 2005, the FDA completed a final investigation of the vaccine and reaffirmed its earlier finding that it was safe and effective. Under the voluntary policy, about 50% of the affected service members have accepted anthrax vaccination, Winkenwerder reported. He commented, "This rate of vaccination not only put the service members at risk, but also jeopardized unit effectiveness and degraded medical readiness."

Critics of the program have said the vaccine—Anthrax Vaccine Adsorbed—can cause problems like infertility and autoimmune disorders, such as multiple sclerosis and lupus. Reportedly some soldiers died after being vaccinated, but the Pentagon said that no causal link to the vaccine was established. "The vaccine has been thoroughly reviewed by several independent outside groups" and the FDA, Winkenwerder said. "In all the studies we have performed, looking very, very thoroughly at the vaccine, there is no increase in mortality, there is no increase in morbidity, there is no increase in hospitalizations." The mandatory vaccination program should restart in 30 to 60 days.
(CIDRAP 10/19/06 http://www.cidrap.umn.edu/ )

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USA (Indiana): Human case of rabies from bat exposure
For the first time since 1959, there's a human case of rabies in Indiana. A 10-year-old in Marshall County was bitten by a bat Jun 2006 and just recently started showing symptoms that led to encephalitis. The child is now in the hospital. "Historically it's a near fatal disease and so it's always touch and go, but given treatment today we're hopeful that this individual is going to survive this case," said Dr. Judith Monroe, Indiana State Department of Health. The health department says if you've been bitten by a bat or other wild animal you should go to the doctor and report it to the health department. (It is not clear whether this patient received post-exposure immunisation at an early enough stage to abort rabies virus infection.)
(Promed 10/18/06)

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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 “EMPRES WATCH: Evolution of Highly Pathogenic Avian Influenza type H5N1 in Europe: review of disease ecology, trends and prospects of spread in autumn-winter 2006” (11pgs, pdf).
- OIE: http://www.oie.int/eng/en_index.htm. Basic information about the upcoming conference (20-22 Mar 2007), “Vaccination, a tool for the control of avian influenza” is available.
- 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.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html. Information on avian influenza: http://www.hc-sc.gc.ca/dc-ma/avia/index_e.html.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and journal 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: 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. Includes wild bird test results from US, Philippines, and Australia.
(WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; AVMA; USGS)

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Cholera, Diarrhea, and Dysentery
China (Sichuan)
Bacillary dysentery has broken out among over 100 students at Yuquan School in Mianzhu City, Sichuan Province. A total of 143 students have symptoms of illness. Since 10 Oct 2006, nausea, vomiting, abdominal pain, low fever, diarrhea and other symptoms have appeared among students at Yuquan School, and they have sought treatment at hospitals. On 11 Oct 2006, Mianzhu City quickly put an emergency response plan into action. The preliminary diagnosis is bacillary dysentery. On the day of the outbreak, over 500 students ate at the school. A portion of students who did not eat at the school have shown similar symptoms. Relevant departments have obtained samples from the school cafeteria and food stalls near the school.
(Promed 10/20/06)

China (Anhui)
On 15 Oct 2006, bacillary dysentery was recently detected at Xincang Middle School in Taihu County's Xincang Township, Taihu County, Anhui Province. 34 students remained hospitalized. None are in critical condition. Investigations indicate that the disease was caused by students drinking unclean water. According to the Anhui Provincial Health Bureau, on 13 Oct 2006 Xincang Middle School discovered that some students had diarrhea. On 14 Oct 2006, there was a gradual increase in students with diarrhea at the school. The Taihu County Committee and county government put an emergency response plan into action. 100 students with similar symptoms were examined in hospitals. Of these, 70 were admitted for treatment and observation. Anhui Province health departments are actively treating students who have diarrhea. Shigella sonnei was identified in the stool of patients. Total bacteria count and E. coli in the school's tap water exceed limits. All students with diarrhea are undergoing active treatment. The health department provided preventive medicine to those who are in close contact with the students.
(Promed 10/20/06)

Indonesia (West Java)
As of 6 Oct 2006, 238 people were ill and 5 dead from an illness producing diarrhea and vomiting. According to the Garut Regent, Agus Supriadi, 124 patients are still being treated in DPT Limbangan Community Health Center. The regent believes these cases may be related to the source of water and is seeking an alternative large clean source for the community. The Garut Regional Government will increase assistance and supplies of clean water there. Results could be expected from the laboratory on several samples as early Dr Hendi Buniman, who is with the sanitation department, said that E. coli was suspected. Dr Hendi believes part of the problem may be environmental sanitation. He reported that only 43 per cent of the households in Garut have a family toilet. There is also concern about sanitation in the home. Many people in the area still defecate in the river and in gardens, from where food is consumed. He said that the diarrhea illness and vomiting was in north Garut territory.
(Promed 10/13/06)

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Dengue
China
China's Health Ministry issued an alert for dengue fever as the peak season continues in south China. Mao Qun'an, the ministry's spokesman, warned that south China is still at the peak season for dengue fever outbreaks as the average temperature of 28 C is prime mosquito breeding weather. Mao urged the public to clean up the environment. China reported 502 dengue cases Sep 2006 (no fatal cases). Most of the cases occurred in south China's Guangdong Province, where 492 cases have been reported. Sporadic cases occurred in other provinces but they were mainly brought by people traveling from south China. (Promed 10/24/06)

Chinese Taipei
Based on the notifiable disease surveillance system in Taiwan, during the 42nd epidemiological week (Oct 15 to 21), 102 dengue fever (DF) cases were reported in Taiwan, of which 52 were laboratory confirmed. As of Oct 21, there had been 1,416 reported cases of DF nation-wide this year, of those, 516 had been confirmed, including 7 dengue hemorrhagic fever (DHF) cases. So far this year (2006), no DF deaths have been reported. The cumulative number of dengue confirmed cases has increased by 235 percent compared with the same period last year (2005, 154 cases). Among this year’s cases, 86 were classified as imported cases and 430 were domestic cases. The origins of the imported cases were as follows: 29 from Vietnam; 17 from Indonesia; 12 from the Philippines; 10 from Thailand; 8 from Cambodia; 3 from Malaysia; 2 from Myanmar; 2 from India; 1 from El Salvador; 1 from Bangladesh; and 1 from Madagascar. Of the domestic cases, the main serotype (181 cases) of circulating DF virus is DEN-3, followed by 20 cases of DEN-2, and 2 cases of DEN-1. The case distribution was mainly in southern Taiwan, including Kaohsiung City, Kaohsiung County, Tainan City, Tainan County, and Pingtung County.
(Taiwan IHR Focal Point 10/27/06)

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West Nile Virus
Canada
Human cases were reported for week 40 (as of 07 Oct 2006) from the following provinces:
Province / Neurological / Non-Neurological / Unclassified; Unspecified / Total* / Asymptomatic**
Alberta / 1 / 23 / 0 / 24 / 0
Ontario / 15 / 22 / 1 / 38 / 0
Manitoba / 15 / 26 / 9 / 50 / 1
Saskatchewan / 3 / 7 / 1 / 11 / 0
TOTALS / 34 / 78 / 11 / 123 / 1

* 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 / 1 / 5 / 0
Arizona / 24 / 27 / 32 / 83 / 4
Arkansas / 21 / 5 / 0 / 26 / 0
California / 70 / 171 / 12 / 253 / 4
Colorado / 60 / 250 / 0 / 310 / 4
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 / 108 / 710 / 6 / 824 /11
Illinois / 111 / 58 / 23 / 192 / 9
Indiana / 22 / 5 / 29 / 56 / 2
Iowa / 17 / 12 / 0 / 29 / 0
Kansas / 14 / 10 / 0 / 24 / 3
Kentucky / 5 / 1 / 0 / 6 / 1
Louisiana / 66 / 49 / 0 / 115 / 0
Maryland / 2 / 1 / 1 / 4 / 0
Massachusetts / 2 / 1 / 0 / 3 / 0
Michigan / 31 / 2 / 7 / 40 / 3
Minnesota / 29 / 34 / 0 / 63 / 3
Mississippi / 74 / 84 / 0 / 158 / 7
Missouri / 46 / 11 / 1 / 58 / 3
Montana / 12 / 22 / 1 / 34 / 0
Nebraska / 33 / 123 / 0 / 156 / 1
Nevada / 34 / 74 / 14 / 122 / 1
New Jersey / 2 / 2 / 1 / 5 / 0
New Mexico / 1 / 3 / 0 / 4 / 0
New York / 7 / 3 / 1 / 11 / 2
North Dakota / 20 / 115 / 0 / 135 / 1
Ohio / 29 / 7 / 0 / 36 / 4
Oklahoma / 22 / 12 / 1 / 35 / 5
Oregon / 4 / 42 / 8 / 54 / 0
Pennsylvania / 7 / 1 / 0 / 8 / 2
South Dakota / 37 / 73 / 0 / 110 / 3
Tennessee / 7 / 2 / 0 / 9 / 1
Texas / 191 / 89 / 0 / 280 / 25
Utah / 50 / 93 / 0 / 143 / 4
Virginia / 0 / 0 / 4 / 4 / 0
Washington / 0 / 3 / 0 / 3 / 0
West Virginia / 1 / 0 / 0 / 1 / 0
Wisconsin / 11 / 8 / 0 / 19 / 1
Wyoming / 14 / 36 / 11 / 61 / 2
TOTALS / 1199 / 2145 / 154 / 3498 / 108

* 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 by state and local health departments.
(Promed 10/19/06)

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2. Articles
Study: Wood ducks could be sentinel for H5N1
Researchers from the University of Georgia report that wood ducks and laughing gulls are highly susceptible to H5N1 avian influenza, which suggests those 2 species could be sensitive indicators of the virus's presence in wild birds. In a lab, the researchers exposed 6 species of wild birds—5 duck species and laughing gulls—to the lethal Asian H5N1 virus. All the birds became infected, but only the wood ducks and laughing gulls became ill or died, according to their report in the November issue of Emerging Infectious Diseases (http://www.cdc.gov/ncidod/EID/vol12no11/06-0652.htm ). The findings come amid this year's greatly expanded federal and state program to look for H5N1 avian flu in wild birds in the US. The Asian strain of H5N1 has not yet been found in North America. "If you're looking for highly pathogenic H5N1 in wild birds, it would really pay to investigate any wood duck deaths because they seem to be highly susceptible," David Stallknecht, a study coauthor, commented. Besides wood ducks, the ducks used in the study were mallards, Northern pintails, blue-winged teal, and redheads. Those species are the most likely to bring H5N1 to North America, given their behavior and habitat use, lead author Dr. Justin Brown said. The researchers found that the birds studied had more virus in their mouth and throat secretions than in feces. In contrast, said Stallknecht, birds infected with low-pathogenic avian flu viruses shed more virus in their feces.
(CIDRAP 10/25/06 http://www.cidrap.umn.edu/ )

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Study shows flu shots safe for 6- to 23-month-olds
A study has strengthened the evidence that influenza vaccination is safe for those 6 to 23 months old, an age-group for whom the US government began recommending flu immunization 2 years ago. The study included 45,356 children at 8 managed care organizations who received 69,359 doses of trivalent inactivated influenza vaccine (TIV) between Jan 1991 and May 2003. The 8 organizations are part of the Vaccine Safety Datalink project. The researchers recorded any event that required medical follow-up during 4 intervals after vaccination: 0 to 3 days, 1 to 14 days, 1 to 42 days, and 15 to 42 days. They also included 2 control periods, one before vaccination and the other after 42 days postvaccination.

One diagnosis, gastritis/duodenitis, was more likely to occur within 14 days of vaccination, but after reviewing patient charts to exclude other possible causes of the condition, the researchers determined that the association was not significant. Yet they said they could not rule out a reaction to the vaccine and cautioned that the possible relationship bears watching as vaccination rates for young children increase. 13 diagnoses were less likely to occur after vaccination, including acute upper respiratory tract infection, asthma, bronchiolitis, and otitis media.

The Vaccine Adverse Event Reporting System (VAERS) has reported that the most frequently reported adverse effects in children who receive the TIV are fever, rash, injection site reactions, and a small number of seizures, most of which were febrile. The researchers found that most (22 of 24) seizures that occurred within 2 weeks of vaccination were febrile. Children often receive the influenza and measles-mumps-rubella (MMR) vaccines at the same time, and the MMR vaccine is known to increase the risk of febrile seizures. The authors observed that seizures were not seen in children who didn't receive an MMR shot the same day as their flu shot, which suggested that the seizures were related to MMR vaccination. They also found that only 2 of the children had Guillain-Barré syndrome (GBS), and neither was diagnosed with the condition during any of the study intervals. They found no evidence of conjunctivitis or eye symptoms following vaccination in the study group.

Recent CDC recommendations urge healthcare workers to promptly report to VAERS all clinically significant adverse events after influenza vaccination. The authors concluded that the study provides reassurance to parents and physicians regarding the safety of flu vaccination for this age-group. In 2004 the CDC formally recommended flu shots for 6- to 23-month-old children. Recent survey results indicated that 33.4% of those children received at least one dose of flu vaccine for the 2004-05 season, compared with 17.5% the previous season, according to CDC.

Hambidge SJ et al. Safety of trivalent inactivated influenza vaccine in children 6 to 23 months old. JAMA 2006;296(16):1990-7.
(CIDRAP 10/25/06 http://www.cidrap.umn.edu/ )

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Subjective and objective risk as predictors of influenza vaccination during the vaccine shortage of 2004–2005
Noel T. Brewer and William K. Hallman. Clinical Infectious Diseases. 2006;43:000.
http://www.journals.uchicago.edu/CID/journal/issues/v43n11/40395/brief/40395.abstract.html
Abstract: “Background. We aimed to identify the role of objective risk status and subjective risk beliefs in influenza vaccination decisions during the recent rationing of influenza vaccine. Method. A random sample of 300 Americans, obtained through random-digit dialing, was interviewed regarding influenza vaccination practices and beliefs in September 2004 and again in March 2005. Results. One-half of individuals at high risk of influenza did not know that they were at high risk and, therefore, were not vaccinated. Respondents at high objective risk were more likely to report having been vaccinated than respondents who were not at high objective risk (36% vs. 6%, respectively; odds ratio, 8.31; 95% confidence interval, 3.65–18.88). However, a more powerful predictor of self-reported vaccination was subjective risk (64% vs. 7%, respectively; odds ratio, 24.02; 95% confidence interval, 12.18–48.09). Subjective risk fully mediated the relationship between objective risk and vaccination. Other predictors of vaccination included physician recommendation, habit, prior vaccination intention, belief that the influenza vaccine is safe and effective, perceived likelihood of getting influenza, and trait neuroticism. Conclusion. Health communication efforts must be more effective in persuading adults with chronic illness and individuals in contact with persons at risk that they should be vaccinated against influenza.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Risk Factors for Human Infection with Avian Influenza A H5N1, Vietnam, 2004
Pham Ngoc Dinh et al. EID Volume 12, Number 12–December 2006.
http://www.cdc.gov/ncidod/EID/vol12no12/06-0829.htm
Abstract: “To evaluate risk factors for human infection with influenza A subtype H5N1, we performed a matched case-control study in Vietnam. We enrolled 28 case-patients who had laboratory-confirmed H5N1 infection during 2004 and 106 age-, sex-, and location-matched control-respondents. Data were analyzed by matched-pair analysis and multivariate conditional logistic regression. Factors that were independently associated with H5N1 infection were preparing sick or dead poultry for consumption <7 days before illness onset (matched odds ratio [OR] 8.99, 95% confidence interval [CI] 0.98–81.99, p = 0.05), having sick or dead poultry in the household <7 days before illness onset (matched OR 4.94, 95% CI 1.21–20.20, p = 0.03), and lack of an indoor water source (matched OR 6.46, 95% CI 1.20–34.81, p = 0.03). Factors not significantly associated with infection were raising healthy poultry, preparing healthy poultry for consumption, and exposure to persons with an acute respiratory illness.”
(CIDRAP http://www.cidrap.umn.edu/ )

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In case of pandemic flu majority of Americans willing to make major changes in their lives
The latest national survey conducted by the Harvard School of Public Health (HSPH) Project on the Public and Biological Security finds that when faced with a serious outbreak of pandemic flu, a large majority of Americans are willing to make major changes in their lives and cooperate with public health officials' recommendations. However, the survey also finds that a substantial share of Americans would have no one to care for them if they become ill or would face serious financial problems if they had to stay home from work for a week or more. This is the first report to attempt to tap the public's intentions when faced with the specific circumstances of an outbreak. The people interviewed were first read a scenario about an outbreak of flu that spreads rapidly among humans and causes severe illness. They were then asked how they would respond to and be affected by the circumstances that would arise from such an outbreak. For more information visit: http://www.hsph.harvard.edu/.

More than 75% of Americans say they would cooperate if public health officials recommended that for 1 month they curtail various activities of their daily lives. 94% say they would stay at home away from other people for 7-10 days if they had pandemic flu. 85% say they and all members of their household would stay at home for that period if another member of their household was sick. 90% say that if public health officials recommended that they and the other members of their household stay in their town or city, they were likely to stay. The area where anticipated cooperation is lowest involved the workplace. While 57% of employed adults say they would stay home from work if public officials said they should, even if their employers told them to come to work, about 35% say they would go to work.

85% say they would be able to take care of sick household members at home for 7-10 days, if public health officials recommended it. However, 76% say they would be worried that if they stayed at home with a household member who was sick from pandemic flu, they themselves would get sick from the disease. 73% say they would have someone to take care of them at home if they became sick with pandemic flu and had to remain at home for 7-10 days.

If schools and daycare were closed for 1 month, 93% of adults who have major responsibility for children under age 5 in daycare or age 5 to 17 and have at least 1 employed adult in the household think they would be able to arrange care so that at least 1 employed adult in the household could go to work. 86% would be able to do so if schools were closed for 3 months. However, 60% say that at least 1 employed person would have to stay home if schools were closed for a month. Only 25% of employed people who have major responsibility for children under age 5 in daycare or age 5-17 in their household say that if schools and daycare closed for 1 month, they would be able to work from home and take care of the children.

95% of adults with major responsibility for children age 5 to 17 report that they would be willing to give school lessons at home if schools were closed for 3 months. 85% of these adults also think that if schools were closed for 3 months and public health officials recommended it, they would be able to keep their children from taking public transportation, going to public events, and gathering outside home while schools were closed. 64% of these adults would need only a little or no help at all in order to deal with the problems of having to stay home and keep children at home for a long period of time.

25% of employed people believe they would have serious financial problems if they missed 7-10 days of work. 57% think they would have serious financial problems if they had to miss work for 1 month, and 76% think they would have such problems if they were away from work for 3 months. 29% say that if they had to stay away from the workplace for 1 month, they would be able to work from home for that long. 19% are aware of any plan at their workplace to respond to a serious outbreak of pandemic flu. 22% of employed adults are very or somewhat worried that their employer would make them go to work even if they were sick. 50% believe that their workplace would stay open if public health officials recommended that some businesses in their community should shut down.

The survey was conducted with a representative national sample of 1,697 adults age 18 and over, including an oversample of adults who had children under age 18 in their households. Altogether 821 such adults with children were interviewed. In the overall results, this group was weighted to its actual proportion (38%) of the total adult population. The margin of error for the total sample is plus or minus 2.4 percentage points. Possible sources of non-sampling error include non-response bias, as well as question wording and ordering effects. Non-response in telephone surveys produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, sample data are weighted to the most recent Census data available from the Current Population Survey for gender, age, race, region, and education. Other techniques, including random-digit dialing, replicate subsamples, callbacks staggered over times of day and days of the week, and systematic respondent selection within households, are used to ensure that the sample is representative. http://www.eurekalert.org/pub_releases/2006-10/hsop-ico102406.php
(CIDRAP http://www.cidrap.umn.edu/ )

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New Study Has Important Implications for Influenza Surveillance, Vaccine Formulation
Researchers are reporting results of a study that substantially alters the existing understanding of how the influenza virus evolves and that could have important implications for monitoring changes to the virus and predicting which strains should be used for flu vaccine. The study, which will be published in the online journal Biology Direct [http://www.biology-direct.com/] Oct. 26, 2006, was conducted by researchers from the National Library of Medicine’s National Center for Biotechnology Information (NCBI) and Fogarty International Center. The study, titled “Long Intervals of Stasis Punctuated by Bursts of Positive Selection in the Seasonal Evolution of Influenza A Virus,” is authored by Yuri Wolf et al.

In an effort to better understand how seasonal influenza evolves into new strains, the researchers analyzed the genomic sequences of a large and representative collection of the two most common flu strains (called H3N2 and H1N1) from the 1995-2005 flu seasons in New York state and New Zealand. The sequence data was obtained from the Influenza Genome Sequencing Project, which recently generated over 1,000 fully sequenced influenza genomes from clinical isolates. The analysis revealed a picture of flu evolution that was surprisingly different from the prevailing conception of how the virus changes. Evolution of influenza A virus is commonly viewed as a typical Darwinian process. In this mode of evolution, the virus’ main surface protein, hemagglutinin (HA), is thought to continually change to evade human immune response, resulting in new dominant strains that eliminate all competitors in a series of rapid successions. Unexpectedly, however, the study found that the periods of intense Darwinian selection accounted for only a relatively small portion of H3N2 flu evolution during the 10-year period examined.

The study found that much of the time the H3N2 virus seemed to be “in stasis”; that is, the HA gene showed no significant excess of mutations in the antigenic regions (those recognized by the immune system). During these stasis periods, none of the co-circulating strains is significantly more fit than others, apparently because multiple mutations are required to substantially improve the virus’ ability to evade the immune system. As a result, an increased variety of strains accumulates. Ultimately, however, one of the variants will come within one mutation of achieving higher fitness and becoming dominant. Once the crucial last mutation does occur, virus evolution shifts from stasis to a brief interval of rapid Darwinian evolution, where the new dominant virus rapidly sweeps through the human population and eliminates most other variants. Because the periods of stasis allow the proliferation of many small groups of related viruses, any of which could become the next dominant virus strain, the authors suggest that sequencing much larger numbers of representative isolates could be helpful in augmenting current surveillance methods.
(http://www.pandemicflu.gov/ 10/25/06; http://www.nih.gov/news/pr/oct2006/nlm-25.htm)

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Anatidae migration in the Western Palearctic and spread of highly pathogenic avian influenza H5N1 virus
Marius Gilbert et al. EID. Volume 12, Number 11–November 2006.
http://www.cdc.gov/ncidod/EID/vol12no11/06-0223.htm
Abstract: “During the second half of 2005, highly pathogenic avian influenza (HPAI) H5N1 virus spread rapidly from central Asia to eastern Europe. The relative roles of wild migratory birds and the poultry trade are still unclear, given that little is yet known about the range of virus hosts, precise movements of migratory birds, or routes of illegal poultry trade. We document and discuss the spread of the HPAI H5N1 virus in relation to species-specific flyways of Anatidae species (ducks, geese, and swans) and climate. We conclude that the spread of HPAI H5N1 virus from Russia and Kazakhstan to the Black Sea basin is consistent in space and time with the hypothesis that birds in the Anatidae family have seeded the virus along their autumn migration routes.”
(CIDRAP http://www.cidrap.umn.edu/ )

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STD-prevention counseling practices and human papillomavirus opinions among clinicians with adolescent patients--United States, 2004
(references removed)
“In 2000, an estimated 18.9 million new cases of sexually transmitted diseases (STDs) occurred in the United States. Although young persons aged 15-24 years represented only 25% of the sexually active population, approximately 48% of STD cases in 2000 occurred in this age group. The most common sexually transmitted infection in persons aged <24 years was attributed to human papillomavirus (HPV). . . In June 2006, the Food and Drug Administration licensed the first HPV vaccine for females aged 9--26 years for the prevention of cervical cancer. . . , precancerous genital lesions, and genital warts associated with HPV types included in the vaccine. . .To assess 1) STD risk assessment, counseling, and education practices of U.S. health-care providers during routine adolescent check-ups and 2) provider opinions regarding methods to prevent HPV acquisition, CDC and Battelle Centers for Public Health Research and Evaluation surveyed clinicians who provided adolescent primary care. The results of this survey indicated that most of the clinicians assessed STD risk in their adolescent patients, addressed STD prevention, and recommended various STD-prevention methods; however, clinician opinions varied regarding the effectiveness of methods for preventing HPV infection and whether their patients would adopt these methods for the long term. Clinicians periodically should assess STD risk in their adolescent patients and provide STD counseling and education to reduce the incidence of STDs in this age group at high risk. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5541a1.htm
(MMWR October 20, 2006 / 55(41);1117-1120)

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Update: Guillain-Barré syndrome among recipients of Menactra meningococcal conjugate vaccine--United States, June 2005-September 2006
(references removed)
“In October 2005, reports indicating a possible association between Guillain-Barré Syndrome (GBS) and receipt of meningococcal conjugate vaccine (MCV4) (Menactra, Sanofi Pasteur, Inc., Swiftwater, Pennsylvania) were made to the Vaccine Adverse Event Reporting System (VAERS). GBS is a serious neurologic disorder involving inflammatory demyelination of the peripheral nerves. During March 2005--February 2006, 8 confirmed cases had occurred within 6 weeks (i.e., the time window of elevated risk noted for GBS after administration of other vaccines) after MCV4 vaccination. This report summarizes 9 additional GBS cases reported to VAERS during March--September 2006. This report also provides a preliminary analysis of data from VAERS and the Vaccine Safety Datalink (VSD) since MCV4 became available in the United States in March 2005 and includes all 17 cases of GBS reported since June 2005. Although these data suggest a small increased risk for GBS after MCV4 vaccination, the inherent limitations of VAERS and the uncertainty regarding background incidence rates for GBS require that these findings be viewed with caution. Because of the risk for meningococcal disease and the associated morbidity and mortality, CDC continues to recommend routine vaccination with MCV4 for adolescents, college freshmen living in dormitories, and other populations at increased risk. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5541a2.htm
(MMWR October 20, 2006 / 55(41);1120-1124)

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Vaccination Coverage among Children Entering School--United States, 2005-06 School Year
(references removed)
“One of the national health objectives for 2010 is to achieve and sustain >95% vaccination coverage among children in kindergarten through first grade for the following vaccines: hepatitis B vaccine; diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids and acellular pertussis vaccine, or diphtheria and tetanus toxoids vaccine (DTP/DTaP/DT); poliovirus (polio) vaccine; measles, mumps, and rubella vaccines; and varicella vaccine. To determine vaccination coverage among children entering kindergarten, data were analyzed from reports submitted to CDC by states and the District of Columbia (DC) for the 2005--06 school year. This report summarizes the results of that analysis, which indicated that coverage for each vaccine was reported to have exceeded 95% in more than half of the states. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5541a3.htm
(MMWR October 20, 2006 / 55(41);1124-1126)

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Varicella Surveillance Practices--United States, 2004
(references removed)
“Varicella became a reportable disease in the United States in 1972, with states reporting weekly aggregate data to the National Notifiable Disease Surveillance System (NNDSS). In 1981, varicella reporting was removed from the national notifiable diseases list because reporting of this common disease was becoming a burden in the absence of a vaccine. This action was followed by additional changes in varicella surveillance practices. In 1995, varicella vaccine was licensed and added to the routine childhood vaccination schedule. . .in 2003, varicella again was added to the national notifiable diseases list to allow for monitoring of the effect of varicella vaccine on varicella incidence. In 2004, to assess the progress in varicella surveillance in the United States, CDC surveyed immunization program managers in selected public health jurisdictions. This report describes the results of that survey, which indicated that substantial progress has been made toward the implementation of case-based surveillance as recommended by CSTE in 2002. As of 2004, however, 28 jurisdictions still had not implemented case-based surveillance. To monitor the effect of the vaccination program on the changing epidemiology of varicella disease, every state should now be conducting case-based surveillance for varicella. This is particularly important in light of the 2006 recommendation by the Advisory Committee on Immunization Practices for a routine second dose of varicella vaccine for children aged 4--6 years because enhanced surveillance is needed to further monitor varicella epidemiology. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5541a4.htm
(MMWR October 20, 2006 / 55(41);1126-1129)

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Brief Report: Update: Mumps Activity --- United States, January 1--October 7, 2006
(references removed)
“During January 1--October 7, 2006, a total of 45 states and the District of Columbia reported 5,783 confirmed or probable mumps cases to CDC. This includes 2,597 cases previously reported by 11 states during January 1--April 29, 2006. This report summarizes the epidemiology of mumps cases in the United States during 2006. With low levels of reported mumps continuing, health-care workers should remain alert to suspected mumps, conduct appropriate laboratory testing, and use every opportunity to ensure adequate immunity, particularly among populations at high risk for mumps. Cases of mumps are reportable through the National Notifiable Diseases Surveillance System (NNDSS). Reports are transmitted electronically via NNDSS to CDC each week and include individual case information such as age, sex, date of symptom onset, vaccination status, and complications of illness. Mumps cases included in this report are those with onset from January 1 (week 1) through October 7, 2006 (week 40). . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a3.htm
(MMWR October 27, 2006 / 55(42);1152-1153)

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3. Notifications
Global pandemic influenza action plan to increase vaccine supply
New WHO guidelines were released Oct 23, 2006. Contents include: Introduction; Overall objectives; The present situation and current challenges; Major approaches to increase supplies of pandemic influenza vaccine; Conclusion; References.
http://www.who.int/csr/resources/publications/influenza/WHO_CDS_EPR_GIP_2006_1/en/index.html
(CIDRAP http://www.cidrap.umn.edu/ )

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IMED 2007 abstract submission
ISID - IMED 2007 Abstract Submission Available
Vienna, Austria; 23-25 Feb 2007
The first international emerging disease and surveillance meeting sponsored by ProMED-mail is now inviting abstract submissions through their online site: http://ww2.isid.org/abstracts/Conference_login.lasso?cid=022. (deadline: 1 Dec 2006). 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. Co-sponsors include the European CDC, the World Organization for Animal Health (OIE), the European Commission and the WHO Regional Office for Europe. The preliminary program is now available online: http://imed.isid.org/preliminary_schedule.shtml. The meeting will embrace the "One Medicine" concept, recognizing that just as diseases reach across national boundaries, so do they cross species barriers. For more information visit: http://imed.isid.org.
(Promed 10/14/06)

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APHA Get Ready Campaign (for emerging infectious diseases)
APHA is pleased to inform you about the launch of our new Get Ready campaign. Get Ready will help Americans prepare for a potential influenza pandemic and other emerging infectious disease outbreaks and features a blog, fact sheets and podcasts. Please find yesterday's press release link below. To find out more about the campaign, visit www.getreadyforflu.org.
http://www.wspha.org/APHA_Get_Ready_News_Rls.pdf
(Washington State Public Health Association 10/23/06)

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HEALTHmap: Current global state of infectious diseases
HEALTHmap brings together disparate data sources to achieve a unified and comprehensive view of the current global state of infectious diseases and their effect on human and animal health. This freely available Web site integrates outbreak data of varying reliability, ranging from news sources (such as Google News) to curated personal accounts (such as ProMED) to validated official alerts (such as WHO). Through an automated text processing system, the data is aggregated by disease and displayed by location for user-friendly access to the original alert. HEALTHmap provides a jumping-off point for real-time information on emerging infectious diseases and has particular interest for public health officials and international travelers. Go to: http://www.healthmap.org/. HEALTHmap is a Linux/Apache/MySQL/PHP application.
*The website is similar to gapminder.com.
(University of Washington International Health Program 10/23/06)

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Self-Study Course: Principles of Epidemiology in Public Health Practice, Third Edition
The introductory self-study course, Principles of Epidemiology in Public Health Practice, Third Edition, is now available. The course is designed for public health professionals at the state and local level who have, or expect to have, responsibility for outbreak investigations or public health surveillance. The course provides an introduction to applied epidemiology and biostatistics; it consists of 6 lessons: Introduction to Epidemiology, Summarizing Data, Measures of Risk, Displaying Public Health Data, Public Health Surveillance, and Investigating an Outbreak. The self-study course (SS1000) is available at no charge at http://www2a.cdc.gov/phtnonline. A printed copy of the course can be ordered from http://bookstore.phf.org, or at telephone, 877-252-1200 (US) or 301-645-7773 (international).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a5.htm
(MMWR October 27, 2006 / 55(42);1154)

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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