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Vol. IX, No. 22 ~ EINet News Briefs ~ Nov 10, 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: FAO and OIE recommend increased surveillance when vaccinating
- Global: Margaret Chan confirmed as head of WHO
- Italy: Confirmation of low pathogenic avian influenza H5 strain in birds
- Indonesia: Avian influenza infection suspected in a teenager
- China: Scientists report bird flu in sparrows from 2004
- Malaysia: 3 cases of Legionellosis in tourists
- Philippines (Mindanao): Typhoid outbreak
- Viet Nam (Ho Chi Minh City): Foodborne disease outbreak in a factory
- Australia (Eastern): Salmonella outbreak with 100 confirmed human cases
- Russia (North Ossetia-Alania): 2 human deaths due to anthrax
- Russia (Rostov): More than 20 cases of botulism in 2006
- Russia (Mariy El): Cases of hemorrhagic fever with renal syndrome increasing
- Russia (St. Petersburg): Food-borne outbreak in military academy
- Chinese promise H5N1 samples, deny claim of new strain
- USA (California): Wild boar, water cited in E coli outbreak
- USA/Canada: Tomatoes confirmed as source of Salmonella outbreak
- USA (South Carolina): Salmonellosis associated with boiled peanuts
- USA (Massachusetts): Pertussis outbreak in children’s hospital
- Canada (Quebec): Clostridium difficile outbreak kills 11
- USA (Wyoming): 2 cases of tularemia so far in 2006
- USA (Indiana): Girl dies from rabies associated with bat bite
- USA: FDA orders delay of anthrax vaccine trial

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

2. Articles
- Collecting, preserving and shipping specimens for the diagnosis of avian influenza A(H5N1) virus infection: Guide for field operations
- Chinese scientists identify unique gene in H5N1
- Preparing for pandemic flu: a call to action
- Surveillance for Foodborne-Disease Outbreaks --- United States, 1998--2002
- Outbreaks of enteric disease associated with animal contact: not just a foodborne problem anymore
- The Emerging Clinical Importance of Non-O157 Shiga Toxin–Producing Escherichia coli
- Evaluating Detection of an Inhalational Anthrax Outbreak
- Isolation from cattle of a prion strain distinct from that causing bovine spongiform encephalopathy

3. Notifications
- Public Health Informatics Fellowship Application Deadline
- Clean hands leading to safer health care for half the world’s population
- Pioneers in TB control from Africa and India receive awards for outstanding achievements
- Revised Definition of Extensively Drug-Resistant Tuberculosis
- Improved supply of meningococcal conjugate vaccine

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 (7)
Indonesia / 53 (43)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 109 (74)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 256 (152).
(WHO 10/31/06 http://www.who.int/csr/disease/avianinfluenza/en/ )

Avian influenza age & sex distribution data from WHO/WPRO (as of 10/31/06): http://www.wpro.who.int/sites/csr/data/data_Graphs.htm.
(WHO/WPRO 10/31/06)

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Global: FAO and OIE recommend increased surveillance when vaccinating
According to a report in last week's Proceedings of the National Academy of Sciences on the identification of a new H5N1 virus sublineage in poultry, the spread of this new virus sublineage appears to have become the dominant one of the H5N1 avian influenza circulating in parts of Asia. If the report is confirmed, this does not come as a surprise, the Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (OIE) said. While there is a wide variety of Avian influenza strains in animals, and influenza viruses in general have a high rate of change from season to season and from year to year, OIE Director-General Bernard Vallat and FAO's Chief Veterinary Officer Joseph Domenech warn that with new antigens developing continually in avian influenza viruses, vaccines currently in use for poultry need to be assessed regularly. The two organizations continue to recommend that vaccination control measures need to be accompanied by surveillance and post-vaccination monitoring. They also stressed the need to immediately report to veterinary authorities any unexpected poultry deaths.

Vaccination remains part of the FAO-OIE strategy to contain avian influenza and both organizations say that vaccination campaigns should be applied appropriately and carefully monitored according to the FAO and OIE technical guidelines. Vaccination must be carried out along with other disease control measures, such as improved hygiene at the farm, animal movement management or market inspection and culling in case of outbreaks. According to Dr Vallat, “Commitment is needed from all governments to implement prevention and control programs such as surveillance of virus circulation and where appropriate, vaccination programs in countries where the virus is endemic or where there is a high risk of introduction of the virus.” FAO and OIE are already supporting such programs in key countries where the virus is still circulating. But, they say more information on control programs based on vaccination is needed and urge more research to better understand the H5N1 virus.

FAO, the OIE, and a myriad of scientific experts on avian influenza have repeatedly called upon the scientists around the world to share their findings and virus strains in a timely and transparent fashion. The OIE/FAO Avian Influenza Laboratory Network (OFFLU - www.offlu.net ) is a platform where member countries and scientists can share valuable information with the international veterinary and medical community. It is imperative that global health concerns and timely information sharing should override lags in the scientific publications approval process which may take from a few months to more that a year. It is essential during outbreaks that pathogens be isolated from clinical cases and that any changes in the character of the virus be monitored to ensure that vaccine manufacturers are producing vaccines complying with OIE standards which are effective against virus strains in circulation. Should the changes be significant enough to warrant reformulation of the vaccine, FAO and the OIE say it would be in the best interest of global health for this to be done by national governments and commercial vaccine companies.
(OIE 11/8/06 http://www.oie.int/eng/press/en_061108_fujian.htm )

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Global: Margaret Chan confirmed as head of WHO
Dr. Margaret Chan, a former Hong Kong health official who has battled H5N1 avian influenza and SARS, won election as the next director-general of WHO. Chan received 150 votes in a closed meeting of the 193-nation World Health Assembly. WHO's executive board nominated her earlier to succeed Dr. Lee Jong-wook, who died May 2006. Chan, with WHO since 2003, has been serving as the director-general's representative for pandemic influenza and as assistant director general for communicable diseases. Her term as director-general will run until Jun 2012. In accepting her election, Chan said her top goals will be to improve the health of Africans and of women around the world. She also said she would set her Chinese nationality aside as she works to combat major threats such as avian flu.

Chan is the first Chinese to become the head of a major UN agency. China has been accused of being slow to share H5N1 avian flu data and virus samples, especially with regard to poultry outbreaks. Chan promised to use her influence with Beijing in the battle with avian flu. As Hong Kong's director of health in 1997, Chan led the city's effort to stop the first major H5N1 outbreaks in poultry and the first human cases. Her decision to quickly slaughter all 1.5 million poultry in the district has been credited with stopping the outbreak and possibly preventing a major international health crisis. Chan was also in charge when SARS spread through Hong Kong in 2003.
(CIDRAP 11/9/06 http://www.cidrap.umn.edu/ )

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Europe/Near East
Italy: Confirmation of low pathogenic avian influenza H5 strain in birds
The low-pathogenic H5 strain detected was obtained as a result of surveillance efforts from a premise rearing birds. The farm contained 1600 mallard breeders (Anas platyrhynchos), 8310 mallards for release in the wild, 100 pheasants (Phasianus colchicus), 4 teals (Anas crecca), 6 Mandarin ducks (Aix galericulata), 3 Swan geese (Cygnopsis cygnoides), 9 Canada geese (Branta canadensis) and 1 African grey parrot (Psittacus erithacus). None of these birds are to be considered wild birds as they were all reared in captivity, and none of them exhibited any clinical signs. The H5 virus was detected by real-time PCR, and sequence analysis of the cleavage site confirms the low pathogenic nature of the strain. Additional testing by molecular methods indicates that the virus does not belong to the N1 subtype. Virus isolation attempts are in progress. The affected holding is located in a wetland, and there are no industrial poultry farms within a 10-km radius. A 1km restriction zone has been established. Rural farms in the restriction zone will be tested. The detection of a low pathogenicity avian influenza virus in mallards farmed in a wetland is a normal finding.
(Promed 11/5/06)

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Asia
Indonesia: Avian influenza infection suspected in a teenager
An Indonesian teenager who came into contact with sick poultry has died of suspected bird flu infection at a hospital in Central Java province. The 17-year-old died 6 Nov 2005, 1 day after he had been admitted to hospital, an official at the National Bird Flu Information Center said 7 Nov 2006. Samples were sent to a Jakarta laboratory to confirm whether the teen had bird flu. Reportedly the victim was admitted to hospital with "high fever, difficulty of breathing, and other bird flu symptoms." The patient's family said that he had been in contact with sick birds 1 month before he fell sick on 27 Oct 2006. Positive results from 2 Indonesian laboratories will mean WHO includes the case in its records. Indonesia is grappling with ongoing outbreaks of the H5N1 virus in poultry and has reported 55 human deaths among its 72 cases.
(Promed 11/7/06)

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China: Scientists report bird flu in sparrows from 2004
Chinese scientists said they had found the H5N1 bird flu virus in sparrows 2 years ago, the first time it has been detected in non-migratory birds in China. Researchers at the Wuhan Institute of Virology found the virus in sparrows' excrement following an outbreak of bird flu in a county in Henan province. "There's no need for the public to panic. The findings are 2 years old, and there is no indication that sparrows pose a risk," Li Tianxian, a researcher at the institute, reportedly said. Chinese officials have in the past blamed outbreaks of bird flu in the country on migratory birds, but the findings indicate that the virus could also be among local birds common in urban areas. China has already seen dozens of outbreaks of the virus in birds and at least 21 human cases, of whom 14 have died.
(Promed 11/6/06)

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Malaysia: 3 cases of Legionellosis in tourists
The number of people confirmed with Legionnaires' disease after a war veterans' trip to Malaysia has risen; 3 members of the 115-strong King's Own Scottish Borderers' party have been struck with the disease. 1 of the people affected is still in Malaysia, 1 is in Australia and the third is hospitalized in Scotland. All 3 are said to be responding to treatment. Tests are being carried out on a fourth group member thought to have contracted the disease. 2 of the confirmed cases are wives who accompanied their husbands on the trip, while the other is a veteran from Hawick, UK. He is being treated at hospital -- it is thought he has a history of kidney trouble, making him more vulnerable.
(Promed 10/27/06)

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Philippines (Mindanao): Typhoid outbreak
Typhoid fever has so far stricken 478 people in Agusan del Sur, a number of them confined in hospitals. Provincial health workers have been deployed to 2 communities in Barangay Libertad, Bunawan town, where the typhoid outbreak was reported 31 Oct 2006. Reportedly at least 202 typhoid-stricken residents were brought to the Bunawan district hospital. Of the patients, at least 29 were released the following day. Health authorities said contamination of deep wells might have caused the outbreak.
(Promed 11/6/06)

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Viet Nam (Ho Chi Minh City): Foodborne disease outbreak in a factory
On 26 Oct 2006, 472 workers at a Ho Chi Minh City garment factory suffered from food poisoning and had to be given emergency medical treatment. The Nobland Vietnam No 3 company workers ate fried eggs, stir-fried cabbage, tofu, and vegetable soup for lunch, supplied by an outside caterer hired by the company. Soon after, all suffered headaches, dizziness, diarrhea, and vomiting. They were taken to health centers. City Health Department inspectors said the company's canteens fell short of hygiene standards. In the first 6 months of 2006 there were 12 cases of food poisoning affecting 786 people, 4 of them in schools, and the rest in factories. With a short incubation, the illness may have been caused by pre-formed bacterial toxins such as those produced by Staphylococcus aureus, Bacillus cereus, Clostridium perfringens or other toxic substances. These illnesses may cause vomiting, diarrhea, or both and are usually short in duration and not associated with prominent fever. Longer incubation periods (more than 24 hours) are often caused by true infections due to bacteria (salmonella, shigella, campylobacter) or viruses (norovirus, rotavirus).
(Promed 10/28/06)

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Australia (Eastern): Salmonella outbreak with 100 confirmed human cases
Health authorities are investigating a possible link between a salmonella outbreak in Australia's eastern states and rockmelons (cantaloupes) from north Queensland. There has been a dramatic surge in salmonella food poisoning around the country, with about 100 confirmed cases in the past month. New South Wales has been hardest hit with 50 cases and 4 confirmed cases in the Australian Capital Territory (ACT). In most cases, victims had reported eating rockmelons in the days before falling ill. ACT chief health officer Dr Paul Dugdale says people should be extra vigilant with food hygiene when eating fresh fruit. "The salmonella is known to be something that can contaminate the skin of the rockmelon so it sits outside of the rockmelon and it's when you cut into it the knife then carries the salmonella onto the flesh, which you then eat," he said. New South Wales Health Department director of communicable diseases, Dr Jeremy McAnulty, says the strain of the bug identified is Salmonella [enterica serotype] Saint-Paul and 90 per cent of victims reported eating rockmelon before getting sick. Environmental officers are taking samples from farms and suppliers in northern Queensland to determine if rockmelons grown there are the source of the outbreak.
(Promed 10/28/06)

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Russia (North Ossetia-Alania): 2 human deaths due to anthrax
The Mozdok regional government in Russia's North Ossetia region confirmed 9 Nov 2006 that 2 women had died of anthrax after coming into contact with the carcass of a cow, probably brought into Mozdok from the neighboring Stavropol region. The deaths were reported 25 Oct 2006 and 7 Nov 2006. 1 of the women who died was engaged in purchasing meat in the Stavropol region and selling it at the market in Mozdok, and the regional government said she had brought the infected meat from Stavropol. The government also said it was impossible to establish whether the woman sold any of the infected meat before she died. The market in Mozdok has been disinfected and cattle in the region are being monitored for signs of the disease.
(Promed 11/9/06)

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Russia (Rostov): More than 20 cases of botulism in 2006
More than 20 cases of botulism, including 5 fatalities have been registered in the Rostov region since the beginning of 2006. Botulism is reported from the Rostov region frequently. Cases of disease connected with the consumption of dried and smoked fish are prevalent in the southern areas of the region located in a steppe zone and on the coast of the Taganrog Gulf of the Azov sea. Botulism connected with the consumption of canned mushrooms more often is registered in northern forest-steppe areas. The disease linked to the consumption of home-canned vegetable occurs everywhere.
(Promed 11/8/06)

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Russia (Mariy El): Cases of hemorrhagic fever with renal syndrome increasing
Last week 8 cases of hemorrhagic fever with renal syndrome (HFRS) were reported in the Republic of Mariy El. Half of the patients are residents of Ioshkar Ola. According to Rospotrebnadzor [Territorial Directorate of the Federal Service for Surveillance in the Field of Consumer Rights' Protection and Human Well-being] HFRS is contracted most often by gardeners. The number of people in the Republic of Mariy El who contract HFRS disease each year is increasing. In 2005, 168 people contracted HFRS in the Republic of Mariy El; morbidity there exceeded the all-Russian morbidity rate almost 5-fold and was 23.3 per 100 000 inhabitants. Up to 11 Oct 2006, 92 cases of HFRS have already been registered in the Republic this year. An increase in HFRS morbidity frequently occurs in the autumn when rodents, the reservoirs of HFRS virus, move closer to human habitations. Insufficient rodent control and an increase in the number of waste-dumps are encouraging an increase in rodents.
(Promed 10/27/06)

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Russia (St. Petersburg): Food-borne outbreak in military academy
Typhoid fever and salmonellosis struck cadets of Mojayskiy Military Cosmic Academy mid Sep 2006. The spread of infection was not stoppable because the doctors made a wrong diagnosis initially. Initially, the patients had been receiving treatment for acute respiratory disease. By mid Oct 2006, 286 cadets were admitted to hospital, 67 of them diagnosed with typhoid fever. Initially, the supposed source of this outbreak was a woman cook, ill with typhoid fever, from Kyrgyzia, who was working in a company that has been supplying food for school canteens. After repeated tests on this cook, neither typhoid nor salmonellosis was found. It seemed that the cadets did not contract the infection from her. There are 2 canteens in the Academy. 3rd-year cadets have meals on one side. Among those who contracted the infection, all had meals in this part of the canteen; none of the cadets who had meals next to it got the infection. Each of the canteens has its own kitchen, but the food comes from the same source, that is, food preparation is the same for both canteens. Reportedly, Salmonella poisoning had been confirmed in 57 cases.
(Promed 11/6/06)

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Chinese promise H5N1 samples, deny claim of new strain
China said it would share more avian influenza virus samples, despite reported misuse of some shared previously, and repeated its rejection of a report that a new strain of H5N1 virus has spread through southern China. WHO said China is sending 20 H5N1 avian flu virus samples to the US CDC. Henk Bekedam, WHO representative in Beijing, said the samples are from 2004 and 2005. Reportedly, China's promise to share more avian flu samples comes on the heels of a WHO apology to China for the misuse of previous samples that the country provided. Jia Youling, China's chief veterinarian, said that Bekedam had apologized for the incidents. Jia said foreign research institutions improperly used Chinese samples in 2 cases. In one instance, a research paper reportedly attributed the Chinese samples to other countries. One of the coauthors of the paper, Robert Webster, of St. Jude Children's Research Hospital, also reportedly apologized to the Chinese institution involved. In the second case, foreign researchers reportedly cited a Chinese sample without giving credit to the Chinese. Jia rebuffed criticisms that China hasn't shared its avian flu samples with the world. He said the country sent 5 samples to WHO Jun 2005 and sent the CDC another 20 samples this year. CDC reported Sep 2006 that 20 samples expected from China had been delayed because of a disagreement over the mailing protocol but that the problem had been resolved.

It's unclear if the new batch of Chinese samples will shed new light on claims by US and Hong Kong researchers that a new subtype of H5N1 avian flu virus, the "Fujian-like" strain, has become predominant in southern China over the past year. Researchers writing Oct 30 in the Proceedings of the National Academy of Sciences (PNAS) suggested that the strain may be resistant to Chinese poultry vaccines and that it has been found in human H5N1 cases in China. Chinese officials rejected the study, and Jia reportedly said, "There is no such thing as a new 'Fujian-like' virus variant at all." Chen Hualan, director of the National Bird Flu Reference Laboratory at the Chinese Academy of Agricultural Sciences, said genetic analysis showed that the so-called Fujian-like virus "shares high conformity with the H5N1 virus that was isolated in Hunan when bird flu broke out in early 2004." She added that samples from every domestic avian flu outbreak are sent to her lab for isolation and genetic sequencing. Chen said that in 2005 and 2006 the lab isolated viruses from waterfowl in southern China and reported the results to the UN Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE). "These viruses all remain steady in gene type, and there is no marked change in their biological characteristics," she said.

Chen also contested the PNAS report's suggestion that the Fujian-like strain may be resistant to the Chinese poultry vaccine. She said the researchers did not specify the locations and vaccination status of the chickens they tested, and pointed to decreasing numbers of avian flu cases as evidence of the vaccine's effectiveness. The Chinese Ministry of Agriculture said 95% of domestic poultry were vaccinated between Jan and Oct 2006. Shu Yuelong, director of the National Influenza Center at the Chinese Centre for Disease Control and Prevention, said the claim that 5 people in southern China were infected by the Fujian-like strain was wrong. "15 out of the 16 variants were isolated from [human] cases in southern China and they belong to the same gene type. There is no proof that 5 of them were infected by a new mutated virus," Yuelong said.
(CIDRAP 11/10/06 http://www.cidrap.umn.edu/ )

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Americas
USA (California): Wild boar, water cited in E coli outbreak
6 more samples of the Escherichia coli O157:H7 strain that killed 3 people who ate raw spinach have been found on a ranch in California's Salinas Valley area. Kevin Reilly, deputy director of prevention services for the California Department of Health Services, said the newly identified matching samples are from creek water, a wild boar, and 4 pieces of cow manure. All samples are from the same farm where investigators had already found 3 manure samples with E coli that matched the outbreak strain, bringing the total to 9. Food and Drug Administration (FDA) had previously traced the tainted spinach to 1 infected lot that contained spinach from 4 different farms. Reilly said sampling from the other 3 ranches has turned up E coli O157:H7, but it is not the strain linked to the outbreak. Reilly said E coli O157:H7 is not an unusual finding around cattle and other ruminant species. A total of 750 environmental samples have been taken so far from the 4 farms. The outbreak sickened 204 people, killed 3, and spanned 26 states and 1 Canadian province. 31 patients developed hemolytic uremic syndrome, and 104 were hospitalized.

All evidence indicates that the outbreak is over, though some illness cases are still under investigation. The ranch where all the matching samples have been found consists of a pasture where cattle graze and a spinach growing area that is fenced off from the pasture. Investigators found areas where the fence was broached, with animal tracks leading from the pasture onto the spinach fields. He said all the positive samples were from the pasture area, located within a half-mile of the spinach field. “That’s where the investigation is centered right now: how it moved from the pasture and onto the [spinach] field,” he said. “There’s evidence that the [wild] pigs could be one of the means, but we’re still investigating.” The wild boar sample that tested positive for the outbreak strain was taken from a boar that had been killed on the property; pigs can be colonized with O157:H7. The stream that the positive water sample came from is within a mile of wells used for irrigation. Investigators are trying to determine if the O157:H7 in the stream contaminated the aquifer that supplies irrigation water.
(Promed 10/27/06; CIDRAP 10/27/06 http://www.cidrap.umn.edu/ )

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USA/Canada: Tomatoes confirmed as source of Salmonella outbreak
Officials said they have zeroed in on restaurant tomatoes as the cause of a recent nationwide Salmonella outbreak. Christopher Braden, MD, chief of outbreak response and surveillance in the foodborne disease branch of CDC, said 183 Americans from 21 states were sickened in the outbreak. 2 Canadians also fell ill--1 each in New Brunswick and Prince Edward Island. 22 (12%) patients were hospitalized, which Braden said was typical for a Salmonella enterica serotype Typhimurium outbreak. The organism typically causes fever and nonbloody diarrhea that resolves in a week. It can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems.

CDC detected the outbreak 2 weeks ago through PulseNet, an electronic network for sharing molecular fingerprinting data. At the same time, states were noticing clusters of patients who had the same strain and genetic fingerprint. CDC said cases in the outbreak have been reported since Sep 1, 2006. Most of the states affected are in the eastern half of the nation. CDC and the Food and Drug Administration (FDA) now consider the outbreak over, and they don't believe the public is at risk. David Acheson, MD, chief medical officer for the FDA's Center for Food Safety and Applied Nutrition, said all of the tomatoes associated with the outbreak have been destroyed, thrown out, or eaten by now.

A case-control study helped CDC narrow the cause to restaurant tomatoes; the contaminated products were not linked to a specific chain or type of restaurant or a specific growing region. Acheson said the next step is a trace-back investigation to determine where and when the restaurants purchased the tomatoes and to try to identify the involved production facilities and farms. Several disease outbreaks involving contaminated tomatoes have occurred in the past 7 or 8 years. The Salmonella outbreak is the second major produce-contamination event in recent months. In Aug and Sep 2006, fresh spinach contaminated with Escherichia coli O157:H7 sickened 204 people. Acheson said he's not sure if produce contamination is increasing or if more outbreak reports are due to better recognition of illness or higher consumption of fresh produce. Braden said another factor may be the increased centralization of the fresh produce industry over the past several decades. Larger food-processing operations, he said, may face a greater risk of cross-contamination than smaller, less centralized operations.

Salmonella enterica serotype Typhimurium is one of the most common serotypes of salmonellae found in the USA representing as many of 30 percent of isolates reported to CDC. Health officials estimate that more than 1.4 million cases of salmonella infection occur in the US each year, about 1.3 million of them from food. Tomatoes are particularly susceptible to contamination as salmonella can form during flowering and grow inside as the fruit develops, rendering external washing useless. In light of recent outbreaks, FDA continues to emphasize consumer advice to reduce the risk of foodborne illness, including Salmonella-related illness, from fresh produce. The food safety reminders can be viewed at the FDA website: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01503.html.
(Promed 10/30/06, 11/01/06, 11/3/06, 11/4/06; CIDRAP 11/3/06 http://www.cidrap.umn.edu/ )

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USA (South Carolina): Salmonellosis associated with boiled peanuts
Two dozen people sickened with salmonella in northwestern South Carolina likely ate bad boiled peanuts from a festival. "We never heard of salmonella in boiled peanuts before. It appears to be an isolated, very unusual event," Department of Health and Environmental Control spokesman Adam Myrick said. While the boiling would have killed any of the bacteria on the peanuts, salmonella could have ended up back on the nuts during refrigeration, packaging or shipping, Myrick said. Scientists were able to match the type of salmonella in the affected people to a bag of boiled peanuts in a patient's refrigerator. The boiled peanuts were sold at the mid-Oct 2006 Pumpkin Festival in Pumpkintown. DHEC officials have talked to the seller about how to handle food safely. The vendor won't be punished. The 2 dozen people sickened by the peanuts have all recovered. DHEC said there is no new danger from eating the salty legumes.
(Promed 11/2/06)

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USA (Massachusetts): Pertussis outbreak in children’s hospital
8 more staff members at Children's Hospital Boston have tested positive for whooping cough, bringing to 33 the number of workers infected, authorities reported 7 Nov 2006. The outbreak at Children's Hospital is the largest in recent memory at a Boston healthcare facility. With the latest confirmatory lab results, the Children's outbreak has now eclipsed the outbreak in Sep 2006 at St. Vincent Hospital in Worcester, Massachusetts, where 30 staff members were diagnosed with pertussis (thus marking the second time in 2 months that a Massachusetts hospital has faced an outbreak of pertussis.). According to the state Department of Public Health, 15 to 35 healthcare workers statewide come down with the disease during a typical year. Investigators said they believe pertussis was carried into Children's Hospital by a 19-month-old patient. They continue to investigate whether a 3-year-old girl who has the illness contracted it at the hospital or before she arrived there. The 8 additional cases reported do not reflect recent infections. Instead, most of those staff members began displaying symptoms mid-Oct 2006. So far, no hospital workers or patients have faced life-threatening complications. The hospital is continuing to encourage staff members who show any signs of the disease, which in its earliest phase mimics the common cold, to come forward. Workers with symptoms are sent home for 5 days and told to take the antibiotic azithromycin before they can return to their jobs. Yesterday, 138 staff members were still furloughed. "It's certainly putting pressure on the system, but we're meeting the needs" of patients, a Children's spokeswoman said.

State law requires that suspected cases of many infectious diseases, including whooping cough, be reported to the local board of health within 24 hours of being identified, a measure designed to contain dangerous outbreaks. The number of infants dying from pertussis, while still small, has been increasing, with 54 deaths between 1980 and 1989, but 92 deaths in the first half of this decade. Children today routinely get a series of 5 vaccinations against pertussis. The vaccine's effectiveness wanes within 5-10 years, leaving recipients vulnerable. In 2005, US health regulators approved the first pertussis booster shot for adults and adolescents, a lower dose than what is given to infants and, thus, less likely to cause adverse effects.
(Promed 11/2/06, 11/9/06)

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Canada (Quebec): Clostridium difficile outbreak kills 11
Another person has died after contracting Clostridium difficile at a Quebec hospital where an outbreak of the bacterium was spread in part by a "significant breach" in basic hygiene, the province's health minister said 7 Nov 2006. That brings the death toll to 11 since the outbreak took hold at the Honore-Mercier Hospital in Saint-Hyacinthe Jul 2006. The bacterium, which thrives in the human gut, overwhelmed more than a dozen elderly patients, many of whom were on antibiotics. Hospital officials insist the latest victim to die from the outbreak was infected before the institution implemented decontamination measures.

Reportedly, substandard hygiene practices were in place at the hospital during the outbreak, including: bed sharing: 3 patients who died from the infection used the same room and the same bed [not at the same time -- it implies inadequate decontamination after use]; washroom disinfection: 5 washrooms used by patients and emergency room visitors were cleaned once a day, despite provincial standards that require disinfection every hour when C. difficile is detected in a hospital; and sharing supplies: Some medical supplies were shared among infected patients without disinfection between uses. Officials believe the outbreak may have started when an already-infected patient was admitted to hospital. The hospital says the outbreak is under control, but a team from the regional health authority will continue to work on site until the province is satisfied that proper hygiene standards have been restored. The environmental form of C. difficile is a spore which is highly stable. Aggressive control of C. difficile requires not only environmental controls -- as well as aggressive hand-washing between patient contacts by staff -- but also rational use of antimicrobials.
(Promed 10/29/06, 11/9/06)

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USA (Wyoming): 2 cases of tularemia so far in 2006
Several outbreaks of tularemia around Wyoming have state health officials cautioning hunters and recreationists to take basic precautions. Tularemia typically infects rabbits, hares and rodents. People and domestic animals can become infected through contact with the bacteria or through bites from deer flies. In 2006, Wyoming has documented rabbit die-offs in northeast Wyoming, according to wildlife disease specialist Hank Edwards. Additional dead rabbits are being spotted in other regions. Edwards' office randomly surveys carnivores for tularemia and sees the bacteria in about 20 to 30 percent of samples each year, although most carnivores don't die from tularemia. "They act as sentinels so we can see what the level of a particular disease is in the field," Edwards said. "We see the same basic level across the state."

So far, 2 people in Wyoming contracted tularemia in 2006, said Jamie Snow, a public health veterinarian for the Wyoming Department of Health. The first, a woman in Baggs, was bitten in the hand by a cat. The feline had likely been chewing on an infected rabbit and carried the disease on. The woman had a "pretty severe" infection in her hand, and has suffered some lasting complications. The second victim was a Big Horn County teenager who came down with a high fever, body ache and chills after skinning an infected rabbit. His illness was treated effectively with antibiotics. Also in 2006, so far, 3 cats, 1 foal and a cottontail rabbit tested positive for tularemia at the state veterinary lab.

People should stay away from all sick-looking wildlife, and take cats and dogs to a veterinarian immediately if they notice signs of sickness. Normal precautions against disease should be practiced: Wear gloves when handling dead animals and wash hands well with soap and water after contact. In the winter, infection tends to be associated with rabbit hunting and in the summer, with tick or deer fly bites.
(Promed 11/1/06)

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USA (Indiana): Girl dies from rabies associated with bat bite
A 10-year-old girl who was being treated for the first confirmed case of rabies in Indiana since 1959 has died. The girl died at Riley Hospital for Children in Indianapolis. She was hospitalized Oct 2006 after being bitten Jun 2006 by a rabid bat. More than 30 relatives, friends and classmates of the girl were offered injections to prevent the spread of the disease. Some parents whose children attend the girl's school worried about possible exposure since rabies can stay dormant for more than a year. Human to human transmission of rabies is only possible through direct contact with saliva. Rabies is a viral disease transmitted to humans and other animals through saliva, usually in a bite. It attacks the brain and nervous system and typically leads to death once symptoms appear.
(Promed 11/3/06)

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USA: FDA orders delay of anthrax vaccine trial
VaxGen Inc., which is developing a new anthrax vaccine for the US civilian stockpile, announced it was postponing the latest clinical trial because of potential problems with the vaccine's shelf life. The company said the Food and Drug Administration (FDA) ordered the delay because it was concerned about a possible decline in the vaccine's potency during the immunization phase of the phase 2 clinical trial. "The notification is not related to any adverse event or preclinical finding related to the vaccine," VaxGen said. The delay prompted the US Department of Health and Human Services (HHS) to issue VaxGen a "cure notice," which says HHS may cancel the vaccine contract if the company doesn't solve the problem promptly.

In 2004, HHS awarded VaxGen an $877.5 million contract, the first awarded under Project BioShield, to develop an anthrax vaccine for the civilian stockpile. The contract was to produce 75 million doses, enough to vaccinate 25 million people. The VaxGen anthrax vaccine is intended to replace Anthrax Vaccine Adsorbed (AVA), an older, whole-microbe anthrax vaccine used primarily by the US military. The older vaccine, controversial because of reported side effects, requires 6 doses over 18 months, whereas the VaxGen anthrax vaccine is expected to require 3 doses. The delay of the clinical trial is the second major setback for VaxGen this year. In May the company announced that the delivery of its vaccine would be delayed at least a year beyond the original target date of Nov 2006. In Mar 2006, the company said the vaccine lost strength within a few months. Also in May, the Government Accountability Office issued a report that said the government's contract with VaxGen was too rigid and might discourage other biotechnology companies from pursuing Project BioShield contracts. In Sep 2006 HHS held a workshop to hear the concerns of biotechnology firms, academic institutions, and the medical community regarding the BioShield program.
(CIDRAP 11/6/06 http://www.cidrap.umn.edu/ )

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1. Updates
Avian/Pandemic influenza updates
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html. Link to the report: “Collecting, preserving and shipping specimens for the diagnosis of avian influenza A(H5N1) virus infection”.
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html.
- 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/.
- 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. Posted: “Recommendation for Use of Amantadine for Treatment and Prevention of Influenza (2006-11-01)”.
- 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. Updates: USDA expands plan for low-pathogenic 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; Health Canada; CIDRAP; PAHO; AVMA; USGS)

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Dengue
Chinese Taipei
During the 43rd epidemiological week (Oct 22-28, 2006), 133 dengue fever (DF) cases were reported in Taiwan, of which 58 were laboratory confirmed, including 1 dengue hemorrhagic fever (DHF) case. As of Oct 28, there had been 1,549 reported cases of DF nation-wide this year, of those, 74 had been confirmed, including 8 DHF cases. So far in 2006, 1 DF death has been reported from Kaohsiung City. The cumulative number of dengue confirmed cases has increased by 233.7 percent compared with the same period last year (2005, 172 cases). Among this year’s cases, 89 were classified as imported cases and 485 were domestic cases. The origins of the imported cases: 30 from Vietnam; 17 from Indonesia; 12 from the Philippines; 10 from Thailand; 8 from Cambodia; 5 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 (205 cases) of circulating DF virus is DEN-3, followed by 19 cases of DEN-2, and 1 case of DEN-1. The case distribution was mainly in southern Taiwan. In the north, there were 1 case in Taipei County and 1 case in Keelung City.
(Taiwan IHR Focal Point 11/3/06)

Chinese Taipei
The Center for Disease Control confirmed the first case of dengue fever involving a military serviceman on active duty, making the 25-year-old man the sixth person in 2006 to have caught the fever by traveling to southern Taiwan. CDC Deputy Director Chou Jih-haw said the man, who has been doing his military service in Taipei City since summer, was likely to have been affected when he went to Kaohsiung City Oct 2006 between the 12th and 25th. The man did not show any fever symptoms until he returned to the barracks 26 Oct 2006, where he was immediately taken to the Armed Forces Sungshan Hospital. So far, the man has not been discharged from hospital. A blood test confirmed he had contracted dengue type 3. After confirmation of the man's condition, the CDC and Kaohsiung health sprayed both areas with anti-dengue chemicals (presumably insecticides). No other cases of dengue fever have been reported at the man's barracks. However, the barracks will not be declared dengue-free until after a 1-week incubation period.
(Promed 11/7/06)

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West Nile Virus
Canada
Human cases were reported for week 43 (as of 28 Oct 2006) from the following provinces:
Province / Neurological / Non-Neurological / Unclassified; Unspecified / Total* / Asymptomatic**
Alberta / 1 / 23 / 0 / 24 / 0
Ontario / 16 / 24 / 1 / 41 / 0
Manitoba / 15 / 28 / 7 / 50 / 1
Saskatchewan / 2 / 9 / 0 / 11 / 0
TOTALS / 34 / 85 / 8 / 127 / 1

* Neurological syndrome + Non-Neurological syndrome + Unclassified +Unspecified = Total
** Most identified through blood donor testing; not included in total cases
(Promed 11/9/06)

USA
Jan 1--Nov 7, 2006: A total of 41 states and the District of Columbia had reported 3,830 cases of human WNV illness to CDC. A total of 2,093 (55%) cases for which such data were available occurred in males; median age of patients was 51 years (range: 3 months--99 years). Dates of illness onset ranged from Jan 6 to Oct 22; a total of 119 cases were fatal. A total of 306 presumptive West Nile viremic blood donors (PVDs) have been reported in 2006. Of these, 3 persons subsequently had neuroinvasive illness, 2 persons subsequently had other illness, and 65 persons (median age: 47 years [range: 17--71 years]) subsequently had West Nile fever. In addition, 3,214 dead corvids and 745 other dead birds with WNV infection have been reported in 42 states and New York City in 2006. WNV infections have been reported in horses in 34 states, in 1 squirrel in Kansas, and in 2 unidentified animal species in North Carolina and Wyoming. WNV seroconversions have been reported in 846 sentinel chicken flocks in 12 states. A total of 10,759 WNV-positive mosquito pools have been reported from 38 states, the District of Columbia, and New York City.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5544a5.htm
(MMWR November 10, 2006 / 55(44);1204-1205)

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2. Articles
Collecting, preserving and shipping specimens for the diagnosis of avian influenza A(H5N1) virus infection: Guide for field operations
WHO document released Nov 6, 2006; this document is a work in progress and is based on the best information available at the time of production. The document will be updated regularly. Contents: 1. Introduction; 2. Safety; 3. Taking specimens from patients and contacts; 4. Storing specimens; 5. Taking aliquots of specimens; 6. Packing specimens and shipping them by air; 7. References. Annexes: Links to key documents; Checklist for specimen handling and shipment; Form to accompany specimens shipped by air; Content of the AI investigation kit; Hand hygiene technique; Respiratory protection; Disinfection; Viral transport medium (VTM); Field data sheets; Guidance on regulations for the Transport of Infectious Substances; Dry shippers; Samples from animals and the environment.
(WHO http://www.who.int/csr/disease/avian_influenza/en/index.html )

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Chinese scientists identify unique gene in H5N1
Chinese scientists have identified a gene in the H5N1 bird flu virus which they say is responsible for its virulence in poultry. There are many different strains of H5N1, some of which are very virulent, while others do little or no harm. "We cannot understand how this virus becomes lethal and the molecular basis for its pathogenicity," said Bu Zhigao at the Harbin Veterinary Research Institute. The researchers zeroed in on the virulent gene after analyzing 2 closely related strains of H5N1 obtained from infected geese in Guangdong province in 1996, 1 highly pathogenic in chickens and the other harmless. Differences between the 2 strains were located in 4 genes, they found. The scientists designed 4 genetically modified viruses, each containing 1 of the 4 genes in question, and tested them on lab chickens. Only chickens infected with the modified virus containing the highly pathogenic gene died. The other chickens had no signs of disease, the scientists wrote in the Nov 2006 issue of the Journal of Virology. "Now that we know the special role of the (highly pathogenic) NS1 gene, we can think about developing a vaccine," Bu said, adding that a vaccine which neutralizes the gene known as NS1 could be designed. The scientists are from the Ministry of Agriculture's Animal Influenza Laboratory, the National Key Laboratory of Veterinary Biotechnology, Chinese Academy of Agricultural Sciences, and the Harbin Veterinary Research Institute.

The report is published in the Nov 2006 issue of the Journal of Virology, Vol. 8, No. 22, pp 11115-11123, 2006: <http://jvi.asm.org/cgi/content/abstract/80/22/11115>. Title: "The NS1 Gene Contributes to the Virulence of H5N1 Avian Influenza Viruses”; authors are Zejun Li and 9 others. This is a significant finding indicating that a single amino acid substitution in the NS1 protein of H5N1 avian influenza virus disables the interferon response in infected chickens, a factor contributing to the pathogenicity of the virus. This does not necessarily confer enhanced vaccine potential, and the abstract does not claim this.
(Promed 11/6/06)

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Preparing for pandemic flu: a call to action
From Blue Ribbon Commission on Mega-Catastrophes of the Financial Services Roundtable, published 1 Nov 2006. Sections include:
I. The Pandemic Threat (Potential Mortality Impact; Potential Economic Impact)
II. Addressing the Pandemic Threat (Monitoring; Containment; Perfect Match Vaccines and Concerns)

Preparing for Pandemic Flu: A Call to Action: 1. Successful Vaccination Delivery Must Be Earlier; 2. Vaccine: Other Technologies; 3. Vaccine: Production Possibilities; 4. Vaccination Prioritization; 5. Flu Shots for Everyone; 6. Paying for the Research (Other Vaccines; Anti-Viral Medications); 7. Meeting the Costs; 8. Research and Development: Exploring Additional Options; 9. Acquisition and Deployment of Medical Equipment; 10. Deployment of Medical Personnel; 11. Care of the Stricken (Social Distancing; Minimizing Disruptions in Operations; Continuity of Operations); 12 and 13. Simulations and Monitoring of Pandemic (Preparedness Plans; The Federal Government’s Role; Private Industry’s Role); 14 and 15. Collaboration for Critical Infrastructure (Cohesiveness; The Federal Government’s Role; Private Industry’s Role; Role of the Financial Sector); 16. A Game Plan; 17. Communications Plan; 18. The Federal Reserve’s Role; 19. The Role of Congress; 20. Licensing: Ensuring Maximum Coverage; 21. Production: Ensuring Maximum Coverage; 22. Funding Recommendations.
(CIDRAP http://www.cidrap.umn.edu/ )

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Surveillance for Foodborne-Disease Outbreaks --- United States, 1998--2002
Abstract: “Problem/Condition: Since 1973, CDC has maintained a collaborative surveillance program for collection and periodic reporting of data on the occurrence and causes of foodborne-disease outbreaks (FBDOs) in the United States. Reporting Period Covered: 1998--2002. Description of System: The Foodborne Disease Outbreak Surveillance System reviews data on FBDOs, defined as the occurrence of two or more cases of a similar illness resulting from the ingestion of a common food. State and local public health departments have primary responsibility for identifying and investigating FBDOs. State, local, and territorial health departments use a standard form to report these outbreaks to CDC. In 1998, CDC implemented enhanced surveillance for FBDOs by increasing communication with state, local, and territorial health departments and revising the outbreak report form. Since 2001, reports of FBDOs are submitted through a web application on the Internet called the electronic Foodborne Outbreak Reporting System (eFORS). Results: During 1998--2002, a total of 6,647 outbreaks of foodborne disease were reported (1,314 in 1998, 1,343 in 1999, 1,417 in 2000, 1,243 in 2001, and 1,330 in 2002). These outbreaks caused a reported 128,370 persons to become ill. Among 2,167 (33%) outbreaks for which the etiology was determined, bacterial pathogens caused the largest percentage of outbreaks (55%) and the largest percentage of cases (55%). Among bacterial pathogens, Salmonella serotype Enteritidis accounted for the largest number of outbreaks and outbreak-related cases; Listeria monocytogenes accounted for the majority of deaths of any pathogen. Viral pathogens, predominantly norovirus, caused 33% of outbreaks and 41% of cases; the proportion of outbreaks attributed to viral agents increased from 16% in 1998 to 42% in 2002. Chemical agents caused 10% of outbreaks and 2% of cases, and parasites caused 1% of outbreaks and 1% of cases. Interpretation: Following implementation of measures to enhance outbreak surveillance, the annual number of FBDOs reported to CDC increased during this period compared with previous years. Viral pathogens accounted for an increased proportion of outbreaks each year during this reporting period and a higher proportion of outbreaks of known etiology during this reporting period than preceding reporting periods, probably reflecting the increased availability of improved viral diagnostic tests. S. Enteritidis continued to be a major cause of illness and L. monocytogenes was a major cause of death. In addition, multistate outbreaks caused by contaminated produce and outbreaks caused by Escherichia coli O157:H7 remained prominent. Public Health Actions: Methods to detect FBDOs are improving, and several changes to improve the ease and timeliness of reporting FBDO data have been implemented (e.g., a revised form to simplify FBDO reporting by state health departments and improved electronic reporting methods). State and local health departments continue to investigate and report FBDOs as part of efforts to better understand and define the epidemiology of foodborne disease in the United States. At the regional and national levels, surveillance data provide an indication of the etiologic agents, vehicles of transmission, and contributing factors associated with FBDOs and help direct public health actions to reduce illness and death caused by FBDOs.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5510a1.htm
(MMWR November 10, 2006 / 55(SS10);1-34)

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Outbreaks of enteric disease associated with animal contact: not just a foodborne problem anymore
Nicole Steinmuller et al. Clinical Infectious Diseases. 2006;43:000.
http://www.journals.uchicago.edu/CID/journal/issues/v43n12/40156/brief/40156.abstract.html
Abstract: “In the past 10 years, an increasing number of outbreaks of enteric disease associated with animals in public settings, such as fairs and petting zoos, have been reported. Fifty-five of these outbreaks that occurred in the United States during 1991–2005 are reviewed in this article. Lessons learned from these outbreaks and recommendations for prevention are also discussed. Physicians should be aware of this important public health problem and play an active role in prevention of human illness associated with animals in public settings.”

Also informative is the article, “Don't Eat the Spinach--Controlling Foodborne Infectious Disease”, by Dennis G. Maki. NEJM. Volume 355:1952-1955. November 9, 2006. Number 19. http://content.nejm.org/cgi/content/full/355/19/1952. The author describes the changes in the manufacturing processes, the impact of food-borne diseases on public health, and proposes irradiation of produce.
(CIDRAP http://www.cidrap.umn.edu/ )

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The Emerging Clinical Importance of Non-O157 Shiga Toxin–Producing Escherichia coli
Kristine E. Johnson, Cheleste M. Thorpe, and Cynthia L. Sears. Clinical Infectious Diseases. 2006;43:000.
http://www.journals.uchicago.edu/CID/journal/issues/v43n12/39467/brief/39467.abstract.html
Abstract: “In 1982, hemorrhagic colitis and hemolytic-uremic syndrome were linked to infection with Escherichia coli O157:H7, a serotype now classified as Shiga toxin–producing E. coli (STEC). Thereafter, hemorrhagic colitis and hemolytic-uremic syndrome associated with non-O157 STEC serogroups were reported, with the frequency of non-O157 STEC illness rivaling that of O157:H7 in certain geographic regions. In the United States, non-O157 E. coli may account for up to 20%–50% of all STEC infections. A high index of suspicion, paired with options to test for non-O157 STEC infection, are necessary for early recognition and appropriate treatment of these infections. Supportive care without the use of antibiotics is currently considered to be optimal treatment for all STEC infections. This commentary provides a perspective on the non-O157 STEC as human pathogens, how and when the clinician should approach the diagnosis of these organisms, and the challenges ahead.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Evaluating Detection of an Inhalational Anthrax Outbreak
Buckeridge DL et al. EID Journal. Volume 12, Number 12–December 2006.
http://www.cdc.gov/ncidod/EID/vol12no12/06-0331.htm.
Abstract: “Timely detection of an inhalational anthrax outbreak is critical for clinical and public health management. Syndromic surveillance has received considerable investment, but little is known about how it will perform relative to routine clinical case finding for detection of an inhalational anthrax outbreak. We conducted a simulation study to compare clinical case finding with syndromic surveillance for detection of an outbreak of inhalational anthrax. After simulated release of 1 kg of anthrax spores, the proportion of outbreaks detected first by syndromic surveillance was 0.59 at a specificity of 0.9 and 0.28 at a specificity of 0.975. The mean detection benefit of syndromic surveillance was 1.0 day at a specificity of 0.9 and 0.32 days at a specificity of 0.975. When syndromic surveillance was sufficiently sensitive to detect a substantial proportion of outbreaks before clinical case finding, it generated frequent false alarms.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Isolation from cattle of a prion strain distinct from that causing bovine spongiform encephalopathy
Vincent Béringue et al. PLoS Pathogens 2(10); published ahead of print.
http://pathogens.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.ppat.0020112
Abstract: “To date, bovine spongiform encephalopathy (BSE) and its human counterpart, variant Creutzfeldt-Jakob disease, have been associated with a single prion strain. This strain is characterized by a unique and remarkably stable biochemical profile of abnormal protease-resistant prion protein (PrPres) isolated from brains of affected animals or humans. However, alternate PrPres signatures in cattle have recently been discovered through large-scale screening. To test whether these also represent separate prion strains, we inoculated French cattle isolates characterized by a PrPres of higher apparent molecular mass—called H-type—into transgenic mice expressing bovine or ovine PrP. All mice developed neurological symptoms and succumbed to these isolates, showing that these represent a novel strain of infectious prions. Importantly, this agent exhibited strain-specific features clearly distinct from that of BSE agent inoculated to the same mice, which were retained on further passage. Moreover, it also differed from all sheep scrapie isolates passaged so far in ovine PrP-expressing mice. Our findings therefore raise the possibility that either various prion strains may exist in cattle, or that the BSE agent has undergone divergent evolution in some animals.”
(Promed 11/6/06)

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3. Notifications
Public Health Informatics Fellowship Application Deadline
CDC offers a 2-year postgraduate fellowship in public health informatics, the systematic application of information technology to public health practice, research, and learning. Fellows receive training in both informatics and public health, are assigned to teams involved in research and development of CDC information systems, and are given the opportunity to lead one or more major projects during their fellowships. Deadline to apply for the fellowship period beginning Jul 2007 is Dec 15, 2006. Applications are available at https://www.orau.gov/cdc/phip/login.asp. For more information: by telephone: 404-498-6129; e-mail: phitpepo@cdc.gov and bmcdonnell@cdc.gov.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5544a6.htm
(MMWR November 10, 2006 / 55(44);1205)

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Clean hands leading to safer health care for half the world’s population
Half the people in the world can look forward to cleaner and safer care and a lowered risk of becoming ill with an infection as a result of their health care. That is because they live in countries whose governments have pledged to become part of a worldwide movement to address health-care associated infections under the Global Patient Safety Challenge: Clean Care is Safer Care. 22 countries, representing 55% of the world’s population, have signed on to the Global Patient Safety Challenge since it was launched Oct 2006. On 10 Nov, 13 more countries--Australia, Belgium, Bhutan, Bulgaria, Costa Rica, Germany, Kenya, Finland, Luxembourg, Singapore, Sudan, Uganda and the US--will pledge commitment to the initiative. 7 countries and regions--Bangladesh, Hong Kong SAR, China, Gulf Cooperation Council (GCC) States, Ireland, Italy, Scotland, Spain--will report on their first year of achievements.

At any given moment some 1.4 million people worldwide are ill because of infections acquired in hospitals. In developed countries the toll is 5% to 10% of patients. In some developing countries, as many as a quarter of patients may be affected. One of the most powerful approaches to fighting health care-related infection is also the simplest: healthcare providers need to clean their hands every time they see a patient. Many countries have already substantially improved hand hygiene practices among health professionals. During a recent 4-month hand hygiene campaign in Switzerland, for example, compliance with good practices increased 25% among doctors and nurses working in 2 cantonal hospitals. Based on the results of that study it has been estimated that the Swiss could avert 17 000 nosocomial infections each year if hospitals nationwide achieved comparable improvements. "With 33 countries committing to 'Clean Care is Safer Care' over the last year, we have proof of the global political commitment to dramatically reduce deaths and suffering from infections acquired in health care facilities. I urge countries throughout the world to follow the example of those who have already committed to "Clean Care is Safer Care," Sir Liam Donaldson, Chair of the WHO World Alliance for Patient Safety and Chief Medical Officer for England.
(WHO 11/10/06 http://www.who.int/mediacentre/news/releases/2006/pr67/en/index.html)

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Pioneers in TB control from Africa and India receive awards for outstanding achievements
2 individuals who helped transform tuberculosis (TB) control in their home countries have become the first winners of a prestigious international health prize, to mark their contribution to improved TB control. The Stop TB Partnership Kochon Prize was inaugurated this year, and will be awarded for the first time, at the 37th Union World Conference on Lung Health, Palais des Congrès, Paris. The 2006 prize winners were announced by the Stop TB Partnership and the Kochon Foundation. They are Mr Winstone Zulu, a TB/HIV activist from Zambia, and Dr L.S. Chauhan, National TB Control Programme Manager from India. Mr Zulu is a dynamic and tireless advocate on behalf of people co-infected with TB and HIV. He himself was cured of tuberculosis, although all of his 4 brothers died of the disease. He is a co-founder of Kara-Kabwe Programmes for Kara Counselling, a provider of HIV/AIDS counselling in Zambia, and was Co-President of TBTV.org, one of the first global organizations of people with TB and HIV/AIDS. Dr Chauhan is Deputy Director-General (Tuberculosis) and Programme Manager of the National TB Control Programme in India. Since 2002 he has overseen the rapid expansion of the DOTS TB-control program in India, a remarkable accomplishment in the country that bears the world's highest TB burden.

The Stop TB Partnership is a network of more than 500 organizations. The Secretariat is housed within the headquarters of the WHO. The Kochon Foundation was created in 1973 by the now-deceased Chong-Kun Lee, Chairman of the Chong Kun Dang Pharmaceutical Corp., which is one of the first TB drug manufacturers in Korea. Tuberculosis is a global public health menace of catastrophic proportions. 5,000 people die of TB, a curable disease, every day. By awarding this annual prize the Stop TB Partnership and the Kochon Foundation wishes to recognize and encourage those at the forefront of the campaign to accelerate the battle to Stop TB.
(WHO 11/1/06 http://www.who.int/mediacentre/news/releases/2006/pr62/en/index.html )

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Revised Definition of Extensively Drug-Resistant Tuberculosis
The Mar 24, 2006 MMWR reported that CDC, in collaboration with WHO and participating supranational reference laboratories, had agreed to define extensively drug-resistant tuberculosis (XDR TB) as cases of TB disease in persons whose Mycobacterium tuberculosis isolates were resistant to isoniazid and rifampin and at least 3 of the 6 main classes of second-line drugs aminoglycosides, polypeptides, fluoroquinolones, thioamides, cycloserine, and para-aminosalicyclic acid). Since that original publication, additional reports have documented the presence of XDR TB in Iran and South Africa with high mortality among persons infected with HIV who are benefiting from antiretroviral therapy.

The emergence and transmission of these strains of M. tuberculosis highlight the urgency of strengthening national TB and HIV/AIDS control programs worldwide, particularly in settings with high HIV prevalence. An initial consultation was convened by the South Africa Medical Research Council Sep 6-7, 2006. A 7-point emergency action plan to combat XDR TB was issued by agencies represented at this meeting (http://www.mrc.ac.za/pressreleases/2006/8pres2006.htm). Subsequently, WHO organized the first meeting of the Global XDR TB Task Force Oct 8-9, 2006. As a result of the meeting, participants agreed upon a revised case definition of XDR TB. Drug-susceptibility testing to fluoroquinolones and second-line injectable drugs (i.e., amikacin [aminoglycoside], kanamycin [aminoglycoside], or capreomycin [polypeptide]) yields reproducible and reliable results, whereas drug-susceptibility testing to other second-line drugs is less reliable. Additionally, investigators have observed that resistance to these drugs (fluoroquinolones and second-line injectable drugs) has been associated with poor treatment outcomes. Accordingly, the new agreed-upon definition of XDR TB is the occurrence of TB in persons whose M. tuberculosis isolates are resistant to isoniazid and rifampin plus resistant to any fluoroquinolone and at least 1 of 3 injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin).

Health-care providers and local health departments in the US should collect all second-line drug-susceptibility results obtained at diagnosis and during treatment of persons with TB disease and report these results to their local and state health department TB programs. Complete capture of these results will allow health departments and CDC to accurately identify XDR TB cases and monitor trends.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5543a4.htm
(MMWR November 3, 2006 / 55(43);1176)

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Improved supply of meningococcal conjugate vaccine
In Jan 2005, a tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4) (Menactra, Sanofi Pasteur, Inc.) was licensed for use among persons aged 11--55 years. The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination with MCV4 for children aged 11-12 years at their regular health-care visit and, if not previously vaccinated with MCV4, of adolescents at high-school entry, of college freshmen living in dormitories, and of other persons at increased risk for meningococcal disease. In May 2006, CDC, in consultation with ACIP, the American Academy of Pediatrics, American Academy of Family Physicians, American College Health Association, and Society for Adolescent Medicine, recommended deferral of MCV4 vaccination of children aged 11--12 years in response to vaccine supply limitations. Currently, Sanofi Pasteur reports that limitations in the MCV4 supply have resolved. Therefore, CDC recommends resuming routine vaccination for all recommended groups according to ACIP recommendations, including children aged 11-12 years and, if not previously vaccinated with MCV4, of adolescents at high-school entry, of college freshmen living in dormitories, and of other persons at increased risk for meningococcal disease. Where possible, providers who deferred vaccination of children aged 11-12 years should recall those patients for vaccination. Providers who have questions about the vaccine may contact Sanofi Pasteur at 1-800-VACCINE or at http://www.vaccineshoppe.com.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5543a5.htm
(MMWR November 3, 2006 / 55(43);1177)

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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