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Vol. IX, No. 24 ~ EINet News Briefs ~ Dec 08, 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: World Bank says cost of battling avian flu rising
- Global: Global strategy aims for effective malaria vaccine by 2025
- Philippines: Mass burials in natural disasters unnecessary, says WHO
- Asia Pacific: WHO calls for accountability in the fight against HIV/AIDS
- Chinese Taipei: Chikungunya case from Singapore
- Australia (West Australia): Salmonellosis associated with papaya
- Russia (Tumen): 13 human cases of toxocariasis so far in 2006
- Russia (Kaluga): Human case of rabies
- USA: CDC funds work on rapid tests for avian influenza
- Canada: Pandemic triage plan addresses tough ventilator decisions
- USA: Imported cases of Chikungunya from Asia and Africa
- USA: Second Salmonella outbreak linked to tomatoes
- USA: FDA joins probe as E coli outbreak widens
- Canada (Alberta): E. coli O157 infections associated with donairs
- USA: 600 Sickened After Eating at N.Y. Bar
- USA: Norovirus outbreak affects more than 380 passengers on cruise ship
- USA: Saudi man has third vCJD case found in US
- USA (North Carolina): Chickenpox outbreak in schools
- Chile (Libertador): Case of Hantavirus pulmonary syndrome

1. Updates
- Avian/Pandemic influenza updates
- Cholera, diarrhea & dysentery
- Dengue
- West Nile Virus

2. Articles
- Recent H5N1 avian Influenza A virus increases rapidly in virulence to mice after a single passage in mice
- Impact of the 2004 Influenza Vaccine Shortage on Repeat Immunization Rates
- Improving Influenza Vaccination Rates of High-Risk Inner-City Children Over 2 Intervention Years
- Safety, Efficacy, and Effectiveness of Cold-Adapted Influenza Vaccine-Trivalent Against Community-Acquired, Culture-Confirmed Influenza in Young Children Attending Day Care
- Tabletop exercises for pandemic influenza preparedness in local public health agencies
- Poultry most likely to bring H5N1 to Americas
- Respiratory Syncytial Virus Activity--United States, 2005--2006
- A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States
- Missed opportunities for earlier diagnosis of HIV infection--South Carolina, 1997-2005
- Certified managers may reduce restaurant food hazards
- Gene chip test can identify wide range of pathogens

3. Notifications
- 10th International Dengue Course, Dengue Symposium
- Epidemiology in Action: Intermediate Analytic Methods Course
- NWCPHP: New online module "Introduction to Outbreak Investigation"

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 / 55 (45)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 111 (76)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 258 (154)
(WHO 11/29/06 http://www.who.int/csr/disease/avianinfluenza/en/ )

Avian influenza age & sex distribution data from WHO/WPRO: http://www.wpro.who.int/sites/csr/data/data_Graphs.htm.
(WHO/WPRO 11/29/06)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 12/7/06): http://gamapserver.who.int/mapLibrary/

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Global: World Bank says cost of battling avian flu rising
The World Bank estimates it will cost between $1.2 and $1.5 billion to fight avian influenza over the next 2 to 3 years, a sizable increase since last January. The institution announced the total in a Nov 30, 2006 report in advance of a donors' conference to be held in Bamako, Mali, Dec 6-8. The conference, a follow-up to one held in Beijing in Jan 2006, is hosted by the government of Mali, the African Union, and the European Commission, with support from the International Partnership on Avian and Pandemic Influenza. Of nearly $1.9 billion pledged in Beijing, donors have committed $1.4 billion. $242 million of the commitment consists of loans and credits, rather than grants, from multilateral development banks.

David Nabarro, the UN’s senior coordinator for avian and pandemic flu, said Dec 1 that $800 million of the amount pledged at the Beijing meeting has been spent so far. The new World Bank estimate of need is about 17% more than the needs presented at the Beijing conference and reflects avian flu developments of the past year. It says the virus has spread to 39 more countries this year, the number of human deaths has risen steadily, and the fatality rate has increased from 53% to 60%. "The largest increases in needs are in Sub-Saharan Africa, the Middle East, and North Africa, which reflects both the spread of the disease to those regions and the relatively poor conditions of veterinary and public health services," the report states.

At the Beijing conference, only about $94 million (18%) in committed funds were earmarked for African or Middle Eastern countries; these countries were thought to be at low risk because they had not yet experienced any H5N1 outbreaks. The World Bank estimates Africa will need $466 million to finance its avian influenza activities. The goal for the Middle East and North Africa is $70 to $113 million. Because African countries are economically weaker and less able to respond to avian flu threats, the World Bank is urging donor countries to focus on significant grant funding rather than loans for them. The report says the needs of eastern and southern Asia will remain high, estimating the total at about $935 million. That includes at least $200 million for Indonesia, where 57 people have died of avian flu. The World Bank says recent poultry outbreaks of H5N1 in India also contribute to the sustained funding needs for the region.
(CIDRAP 12/4/06 http://www.cidrap.umn.edu/ )

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Global: Global strategy aims for effective malaria vaccine by 2025
A report by the world's leading international health organizations calls for joint action to accelerate the development and licensing of a highly effective malaria vaccine. The Malaria Vaccine Technology Roadmap, a new global strategy, is being launched at the Global Vaccine Research Forum, 3-6 Dec 2006. The Roadmap is a pathway towards reaching the goal of developing a malaria vaccine by 2025 that would have a protective efficacy of more than 80% against clinical disease and would provide protection for longer than 4 years. An interim landmark is to develop and license a first-generation vaccine by 2015 with 50% protective efficacy against severe disease and death that would last longer than 1 year. Every year, there are 300-500 million cases of malaria and the disease kills more than 1 million people. The plan calls for the malaria vaccine community to work together to develop an effective vaccine that prevents severe disease and death caused by Plasmodium falciparum, the most deadly form of the malaria parasite.

More than 230 experts representing 100 organizations from 35 countries collaborated to develop the Roadmap over a 2-year period. Challenges include: scientific unknowns such as the lack of full understanding of mechanisms of malaria infection, disease and immunity, inadequate resources, limited private-sector involvement, and uncertain mechanisms for procuring and distributing a successful vaccine. The Roadmap puts into motion a strategic plan for aligning research and for developing and making available a safe, effective and affordable vaccine to prevent malaria in children under 5 years of age in highly endemic regions. It presents 11 priorities within 4 major areas of work that must be undertaken, in a more coordinated manner than previously, by diverse parties towards the development of a malaria vaccine:

• Research: standardizing procedures to compare immune responses generated by vaccine candidates, using state-of-the-art approaches and sharing information via the web to strengthen the connection between laboratories and clinics.
• Vaccine development: including pursuing multi-antigen, multi-stage, and weakened whole-parasite vaccine approaches.
• Key capacities: establishing readily accessible formulation and scale-up development capacity, and building good clinical practice clinical trial capacity in Africa and other malaria-endemic areas.
• Policy and commercialization: dialoguing with countries and providing data to facilitate policy decisions; securing sustainable financing; and developing novel regulatory strategies to expedite the approval of a safe vaccine.

Malaria vaccine funders' group are: WHO, PATH MVI, the Bill & Melinda Gates Foundation and the Wellcome Trust, together with representatives of the European and Developing Countries Clinical Trials Partnership (EDCTP), the European Malaria Vaccine Initiative (EMVI), the European Commission (Directorate General for Research), the US National Institute for Allergy and Infectious Diseases (NIAID), and the US Agency for International Development (USAID) form part of a malaria vaccine funders' group, with the WHO Initiative for Vaccine Research as its focal point.
(WHO 12/4/06 http://www.who.int/mediacentre/news/notes/2006/np35/en/index.html )

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Asia
Philippines: Mass burials in natural disasters unnecessary, says WHO
WHO Regional Office for the Western Pacific has issued recommendations and guidelines to dispel myths in the aftermath of typhoon Reming (Durian) that has claimed many lives. Dr Art Pesigan, WHO Regional Adviser in Emergency and Humanitarian Action, emphasized that survivors, and not the dead, are more likely to be the source of disease outbreaks if public health care strategies for the survivors and their families are not made a priority. WHO issued the clarification after local officials involved in rescue efforts ordered the mass burial of bodies to prevent an epidemic. "Epidemics do not spontaneously occur after a disaster and dead bodies will not lead to catastrophic outbreaks of diseases," Dr Pesigan said. The key to preventing disease, he explained, is to educate the public and improve sanitary conditions, including the provision of safe water and food. Rescue workers began to bury hundreds of victims of landslides on the slopes of Mount Mayon in Albay Province triggered by the typhoon. With many more people unaccounted for, local officials fear the death toll could exceed 1000.

WHO issued the following guidelines: The body of a person killed as a result of a disaster does not pose a risk for infection; Mass graves should not normally be used for burying disaster victims; Under no circumstances should mass cremation of bodies take place when this goes against the cultural and religious practices of those affected; Every effort should be made to identify bodies. As a last resort, unidentified corpses should be buried in identified burial ground, in individual bags with photos and proper tagging. Dr Pesigan also explained that the identification of bodies is essential for prompt recovery among survivors from the severe stress and personal losses caused by sudden natural disasters. The inability to mourn a relative can contribute to the many potential mental health problems associated with disasters and make the rehabilitation process that follows more difficult.
(WHO/WPRO 12/7/06 http://www.wpro.who.int/media_centre/press_releases/pr_20061207.htm )

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Asia Pacific: WHO calls for accountability in the fight against HIV/AIDS
Urging enhanced accountability, WHO warned that the HIV/AIDS situation will further worsen unless political leaders meet their promises to step up efforts to stop the virus from spreading. "The number of people living with HIV continues to grow," warned Dr Shigeru Omi, WHO Regional Director for the Western Pacific. "High-risk behaviour, such as injecting drug use, unprotected paid sex and unprotected sex between men, is especially evident in the HIV epidemics in some regions, including Asia." In 2006, an estimated 8.6 million people were living with HIV in Asia, 960 000 of whom were infected in the past year, WHO said. In China, an estimated 650 000 people were living with HIV at the close of 2005. In Viet Nam, the number of people living with HIV has doubled since 2000 and reached an estimated 260 000 people in 2005. In Papua New Guinea, the number of HIV/AIDS cases has dramatically increased, with HIV prevalence rates among the adult population in excess of 1% since 2003.

Even as authorities have greatly expanded the national response to HIV/AIDS in China, the virus is spreading constantly from most-at-risk populations to the general population. Half of the new infections in 2006 occurred through unprotected sex. An estimated 44% of the people living with HIV are believed to have been infected while injecting drugs. National surveillance data noted that as many as 11% of drug users also engage in high-risk sexual activities. In Viet Nam, the use of non-sterile injecting equipment is also widespread, with large proportions of male injecting drug users engaging in unprotected sex.

Considering the implications of such risks of an HIV epidemic, "accountability" has been chosen as the theme of World AIDS Day 2006. The campaign calls on political leaders to support programmes in the fight against HIV/AIDS and to raise greater awareness of HIV/AIDS, including evidence-based interventions for most at risk populations. Dr Omi said, "Strategies to prevent HIV transmission among populations that are often difficult to reach, including sex workers, men who have sex with men, intravenous drug users and mobile populations, should include efforts to reduce their stigmatization, discourage sharing of drug paraphernalia, and promote voluntary counselling and testing, as well as more appealing marketing of condoms. In addition, HIV policies and law enforcement approaches should be supportive of these strategies. Knowledge and awareness of HIV needs to be increased as well."
(WHO/WPRO 11/30/06 http://www.wpro.who.int/media_centre/press_releases/pr_20061130.htm )

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Chinese Taipei: Chikungunya case from Singapore
A Taiwanese student who had been studying in Singapore since last year and who recently returned to Taipei was confirmed 24 Nov 2006 to have contracted chikungunya fever while in Singapore. The 13 year old student was detected with high fever at Taiwan Taoyuan International Airport 20 Nov upon his return from Singapore. At that time, he was suffering from fever and fatigue, according to Chou Chih-hao, deputy director general of the Center for Disease Control. After examining a blood sample from the boy, the CDC announced that the boy had contracted chikungunya fever -- a viral disease transmitted through mosquito bites -- making him the first confirmed chikungunya fever case in Taiwan medical history, Chou said.

Chikungunya virus infection can cause a debilitating illness, characterized by fever, headache, fatigue, nausea, vomiting, muscle pain, rash, and particularly joint pain. The student's fever has passed and he is now recovering. 5 of his family members have also been examined and monitored, but none of them has had any symptoms of chikungunya fever. When the patient entered Taiwan, heat-registering cameras at the airport indicated that he had a fever. If the virus is still in its incubating phase, it is impossible to detect carriers at the airport. Like dengue-fever sufferers who are stopped at the airport, the chikungunya sufferer was allowed to enter Taiwan with no restrictions on movement. However, the sufferer and his family will be monitored and the environs of his home sprayed for mosquitoes to prevent the potential spread of the disease. So far, none of his family have come down with the disease. Chikungunya virus infections have been a recurrent problem in Indonesia and have occurred in northern Malaysia.
(Promed 11/26/06)

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Australia (West Australia): Salmonellosis associated with papaya
3 West Australians have been treated in hospital after an outbreak of a rare form of salmonella infection linked to paw paw (a tropical fruit papaya). The Health Department said 11 people had been struck down with Salmonella [enterica serotype] Litchfield, an uncommon strain of the bacteria which is usually only seen in 2 to 5 people a year. Those infected range from babies through to an 86-year-old, including 4 young children and a 22-year-old pregnant woman. Authorities have not been able to trace the source of the contaminated fruit. All paw paw sold in WA is grown locally but there are several suppliers. Most of the people affected had eaten paw paw which was bought already cut into pieces. Authorities have warned that contaminated product might still be out in the market. Director of communicable disease control Paul Van Buynder said investigations had shown a significant link between illness from this type of salmonella and eating cut paw paw. He said the department was advising people to use food safety measures when handling the fruit, including washing them thoroughly under running water before eating.
(Promed 12/1/06)

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Russia (Tumen): 13 human cases of toxocariasis so far in 2006
The number of toxocariasis cases has increased in the Tumen region of Russia. 13 cases of toxocariasis have been registered for 9 months of 2006 versus 1 case for the same period of 2005. Reportedly this is the result of increased surveillance for toxocariasis. At room temperature, eggs of Toxocara spp. can develop and be viable all the year round. Children 3-5 years of age, veterinarians, workers of nurseries, circuses, zoos; and people with a low level of hygienic skills; owners of personal plots, the persons engaged in hunting are in the groups of risk of toxocariasis. Toxocariasis is caused by the larvae of the nematode species Toxocara cani and cati. Toxocara canis and T. cati are widespread in temperate climates. Dogs and cats are the main hosts, and the eggs are shed in feces; they can stay alive for months in the environment depending on temperature and humidity. The clinical picture for humans is called "visceral larval migrans," which has unspecific symptoms; occasionally eye symptoms may result when the worm is located in the eye. Though cases of toxocariasis appear all year, the highest number of cases is registered during the summer-autumnal period when the number of eggs in the ground is highest and contact with them is maximal.
(Promed 12/5/06)

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Russia (Kaluga): Human case of rabies
A case of human rabies has been recorded in the Mosal district of the region of Kaluga. Reportedly a man from the village of Gulino contracted rabies from a dead fox as a result of skinning the animal. The victim was not wearing protective gloves. Medical assistance was sought only 21 days after exposure. Travellers visiting areas outside the major cities should be aware that rabies is rife in wild mammals throughout Russia and care should be exercised in approaching both wild and domestic animals. Medical attention for post-exposure vaccination should be sought immediately if any injury or contact is sustained.
(Promed 12/7/06)

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Americas
USA: CDC funds work on rapid tests for avian influenza
CDC has awarded 4 contracts worth $11.4 million in an effort to develop a 30-minute test for H5N1 avian influenza. CDC said it awarded the funds to spur development of tests that doctors and field epidemiologists could use to test patients for both H5N1 and other flu viruses. Currently, testing for H5N1 in the US must be done in 1 of about 100 designated laboratories and takes from 4 to 24 hours. Last month WHO listed a rapid diagnostic test as priorities in avian and pandemic flu research. CDC said it hopes a rapid test can be ready and licensed within 2 to 3 years. The 4 companies, their tests, and the contract amounts are as follows: Cepheid—GeneXPert Flu assay, $2.4 million; Iquum—LIAT, Lab-in-a-Tube, $3.8 million; MesoScale—Multi-Array Detection, $706,241; Nanogen—a novel point-of-care immunoassay system, $4.5 million. Over the next year, the companies will work to develop tests that can detect flu viruses and distinguish seasonal strains from H5N1 within 30 minutes. Existing rapid tests can tell only if a patient has a seasonal flu A or B virus. The goal for the first two phases is to produce a prototype test that can be evaluated by the CDC, said Dr. Rueben Donis, chief of the molecular virology and vaccines branch in the CDC's influenza division.
(CIDRAP 12/4/06 http://www.cidrap.umn.edu/ )

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Canada: Pandemic triage plan addresses tough ventilator decisions
Canadian infectious disease and critical care experts have developed one of the first triage plans for pandemic influenza. The protocol is designed to guide clinicians' triage decisions for patients with and without influenza during the first days and weeks of a pandemic when the critical care system is overwhelmed and resources are scarce. The pandemic triage plan has 4 components: inclusion criteria, exclusion criteria, minimum qualifications for survival, and a color-coded prioritization tool. The inclusion criteria identify patients who may benefit from critical care treatment, focusing on respiratory failure. Exclusion criteria place patients in 3 different categories: those who have a poor prognosis despite critical care, those whose care demands resources that can't be provided during a pandemic, and those who have underlying advanced medical conditions that complicates their critical influenza status. The "minimum qualifications for survival" component attempts to place a limit on the resources used for any one patient. In the triage protocol, patients are reassessed at 48 and 120 hours to identify early those who are improving and those likely to have a poor outcome. A tool for prioritizing patients for admission to the intensive care unit (ICU) and access to ventilation is based on a color scheme: blue or black, red, yellow, and green. The prioritization tool incorporates the Sequential Organ Failure Assessment (SOFA), which allows emergency department personnel to assign patients a score on the basis of physiologic parameters and simple lab tests.

Though they consulted a bioethics guide to develop the triage protocol, the authors note that limited resources during a pandemic will mean not all patients receive the intensive care they need. Communities should review, discuss, and refine the protocol before it is implemented in a pandemic setting, they say. 2 bioethicists from Dalhousie University say it isn't clear how bioethics principles shaped the development of the pandemic triage protocol, which they say gives the document a utilitarian focus. They commend the protocol developers for calling for more community involvement but say the document does not address how to accomplish this goal.

Christian MD et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ 2006;175(11):1377-1381. http://www.cmaj.ca/cgi/content/full/175/11/1377
Melnychuk RM, Kenny NP. Pandemic triage: the ethical challenge. (Editorial) CMAJ 2006;175(11):1393. http://www.cmaj.ca/cgi/content/full/175/11/1393
(CIDRAP 12/1/06 http://www.cidrap.umn.edu/ )

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USA: Imported cases of Chikungunya from Asia and Africa
At least 2 Coloradans returned home recently from Asia and East Africa with chikungunya, an infectious disease transmitted by mosquitoes. The disease can cause fever, headache, nausea, joint pain and other symptoms. No deaths related to the infection have been documented in the US. Chikungunya is among several types of mosquitoborne diseases that people can contract when they travel abroad, said John Pape, an epidemiologist with the Colorado Department of Public Health and Environment. At least 28 cases have been confirmed in the US in 2006. In India and islands of the Indian Ocean, an outbreak of chikungunya has afflicted more than 1.4 million people since Mar 2005. Both vectors of chikungunya, Aedes aegypti and Ae. albopictus, are present and even abundant in some areas of the US.
(Promed 11/25/06)

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USA: Second Salmonella outbreak linked to tomatoes
Federal officials are investigating a second Salmonella outbreak linked to restaurant tomatoes that has sickened 106 people in 19 states. The outbreak, first reported Nov 28, 2006, involves restaurant tomatoes contaminated with Salmonella enterica serotype Newport. The organism typically causes fever and nonbloody diarrhea that resolves in a week. Early Nov 2006, CDC confirmed that an outbreak of Salmonella enterica serotype Typhimurium was linked to restaurant tomatoes.

Christine Olson, an epidemiology intelligence service officer of CDC, said the outbreak was detected by PulseNet, an electronic network for sharing molecular fingerprinting data. She said the outbreak began Jun 2006 and appears to have ended in Oct. She said the bulk of cases occurred in Aug and Sep. A case-control study CDC launched in response to the S Newport outbreak revealed that about 35% to 40% of patients were hospitalized, she said. Most of the S Newport cases occurred on the East Coast. Pennsylvania, with 20 cases, had the highest number of illnesses. Though the S Newport outbreak geographically overlaps the S Typhimurium outbreak somewhat, she said CDC wasn't aware of any people who were coinfected with both strains. Olson said S Newport has been associated with tomatoes before. A multidrug resistant strain of S Newport has been responsible for cases of ground beef contamination in recent years. FDA spokesperson Michael Herndon said the agency would not be conducting a traceback investigation. He said FDA decided not to do a traceback because it lacked a well-defined cluster of cases. "Given the serotype and PFGE type and time frame and distribution, we are going to assume the tomatoes are from the eastern shore of Virginia," he said. It is notable that salmonellae can survive inside the ripening tomato, as shown experimentally in Guo X, Chen J, Brackett RE and Beuchat LR: Survival of salmonellae on and in tomato plants from the time of inoculation at flowering and early stages of fruit development through fruit ripening. Appl Environ Microbiol 2001;67: 4760-64.
(Promed 12/2/06; CIDRAP 12/1/06 http://www.cidrap.umn.edu/ )

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USA: FDA joins probe as E coli outbreak widens
The US Food and Drug Administration (FDA) announced it was joining the probe of a growing Escherichia coli O157:H7 outbreak associated with Taco Bell restaurants in the Northeast. The agency said 43 probable cases were linked to the outbreak, in which green onions are a suspected cause. Cases include 20 in New Jersey, 15 in New York, 7 in Pennsylvania, and 1 in Connecticut. Additional cases are suspected in all 4 states. 35 people have been hospitalized, including 3 with hemolytic uremic syndrome. CDC reports that the first reported onset of illness connected with this outbreak occurred 20 Nov 2006; the latest 2 Dec 2006. The number of cases has grown to 99 and the outbreak involves additional restaurants, a second food distributor, and a food processing plant that supplied green onions to at least one of the two distributors that supplied the implicated Taco Bell restaurants with produce, including green onions.

Taco Bell Corp announced it was removing green onions from all of its 5,800 restaurants after its own preliminary tests indicated E coli O157:H7 in some samples. However, the company has not confirmed the results. "In view of this, FDA is continuing to explore the possibility of other food commodities being the source of the E coli," FDA said. FDA said it was testing samples of all nonmeat items served at Taco Bell that could carry E coli O157:H7, including cilantro, cheddar cheese, blended cheese, green onions, yellow onions, tomatoes, and lettuce. A New York laboratory confirmed the outbreak strain in 3 of 4 green onions from a previously unopened package from a Taco Bell restaurant. The number of people who have fallen ill in recent weeks is minuscule given the number of people who eat at Taco Bell, which the company estimates at 5000 to 7000 a week at a given store.

Federal and state officials are investigating 2 New Jersey suppliers to Taco Bell: McLane Foodservice and Ready Pac Produce. McLane is the sole distributor of ingredients including cheese, meat and produce for Taco Bell stores in New Jersey, Pennsylvania and Delaware and on Long Island. Ready Pac Produce cuts, washes, and sanitizes green onions that are sent to some distributors that service Taco Bell outlets in the Northeast. Ready Pac bought the onions from Boskovich Farms, a California producer. Boskovich said it was working closely with Taco Bell during the investigation.

Infection with E. coli O157 causes diarrhea, often bloody. Although most healthy adults can recover completely within a week, some people can develop hemolytic uremic syndrome. HUS is most likely to occur in young children and the elderly. The condition can lead to serious kidney damage and even death. In recent years, the number of outbreaks from contaminated produce has far surpassed those from beef and poultry and has drawn nearly even with those linked to seafood, according to the Center for Science in the Public Interest, a nutrition advocacy group. While there are more food-borne outbreaks related to seafood, far more people get sick from produce outbreaks, the group found.
(Promed 12/7/06; CIDRAP 12/7/06 http://www.cidrap.umn.edu/ )

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Canada (Alberta): E. coli O157 infections associated with donairs
People are being warned not to eat donairs distributed by an Edmonton company over E. coli contamination, after several illnesses were reported. The Canadian Food Inspection Agency and Athena Donair Distributors Ltd. are warning donair establishments and restaurants in Alberta not to use or sell Athena Donair Distributors Ltd. donair cones because the product may be contaminated with the E. coli O157:H7 bacterium. There have been several reported illnesses associated with the consumption of this product, CFIA said. Food contaminated with E. coli O157:H7 may not look or smell spoiled. Consumption of food contaminated with this bacteria may cause serious and potentially life-threatening illnesses. The manufacturer is voluntarily recalling the affected product from the marketplace.
(Promed 11/30/06)

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USA: 600 Sickened After Eating at N.Y. Bar
At least 600 people came down with a gastrointestinal illness after eating at a biker bar and restaurant, officials said 1 Dec 2006. Bacteria have been ruled out as the cause, meaning last weekend's outbreak linked to the Dinosaur Bar-B-Que is probably viral and could have spread through air particles, said Cynthia Morrow, health commissioner of Onondaga County. CDC was notified because the people who may have been affected were from across the country. Patrons from as far away as Massachusetts, New Jersey, Vermont and California have reported symptoms. Some were sickened after eating at the restaurant, while others became ill after being exposed to those who had. The most common symptoms include nausea, vomiting, diarrhea, abdominal cramps and chills lasting 12 to 48 hours. The county health department ordered the restaurant closed for at least 72 hours on 30 Nov 2006. No specific foods have been implicated.
(Promed 12/6/06)

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USA: Norovirus outbreak affects more than 380 passengers on cruise ship
More than 380 passengers and crew aboard a cruise ship were affected by a virus infection during a 7-day Caribbean cruise, cruise officials said 3 Dec 2006. The outbreak struck Royal Caribbean Cruises Ltd.'s "Freedom of the Seas," which returned to Miami 3 Dec 2006. The ill passengers received over-the-counter medication, and crew members sanitized frequently touched surfaces after the short-lived outbreak began. The company said that 338 of the ship's 3823 passengers and 46 of its 1402 crew came down with what was believed to be a norovirus infection, an ailment brought on board by a passenger.

Noroviruses, characterized by gastric flu-like symptoms, affect about 23 million Americans annually, according to CDC. Outbreaks of norovirus-associated viral gastroenteritis in cruise ships continue to occur regularly, despite awareness of the problem and thorough and efficient decontamination of vessels between cruises. Noroviruses may exhibit significant antigenic heterogeneity, and mini-epidemics can result from circumstances in which groups of individuals from different backgrounds congregate together. Fortunately, viral gastroenteritis caused by norovirus infection is short-lived and has no serious outcome.
(Promed 12/4/06)

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USA: Saudi man has third vCJD case found in US
A third case of variant Creutzfeldt-Jakob disease (vCJD) has been reported in a US resident, but health officials believe he contracted the disease in Saudi Arabia when he was a child. The patient is a young man who has lived in the US since 2005 but was born and raised in Saudi Arabia. The man occasionally stayed in the US for up to 3 months at a time since 2001 and made a shorter visit in 1989. The disease is believed to be caused by eating meat products from cattle infected with bovine spongiform encephalopathy (BSE), or mad cow disease. The diagnosis was confirmed Nov 2006 by the University of California San Francisco Memory and Aging Center. The man has no history of receiving blood, having neurosurgery, or living in or visiting European countries. The view that he was probably exposed during childhood is based on the record of a previously reported Saudi case who was thought to have consumed BSE-contaminated meat in Saudi Arabia and on the fact that the incubation period for food-related vCJD is longer than 7 years, CDC said.

The previous case of vCJD in a resident of Saudi Arabia was a 33-year-old man who was hospitalized in Saudi Arabia. He likely contracted the disease in Saudi Arabia after eating BSE-contaminated cattle products imported from the UK. The 2 previous vCJD cases in the US involved people who were thought to have contracted the disease in their native Britain during the country's BSE outbreak in the 1980s and 1990s. 200 people with vCJD have been reported worldwide, including 164 diagnosed in the UK, 21 in France, 4 in Ireland, 3 in the US (including the current patient), 2 in the Netherlands, and 1 each in Canada, Italy, Japan, Portugal, Saudi Arabia, and Spain. Of all reported vCJD patients, all but 10 had lived either in the UK or France for at least 6 months between 1980 and 1996.
(CIDRAP 12/5/06 http://www.cidrap.umn.edu/ )

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USA (North Carolina): Chickenpox outbreak in schools
Parents and school officials are on alert as dozens of children in 3 Yadkin County elementary schools are being treated for chickenpox (varicella), and one 8-year-old has died while recovering from a mild case of the disease. At Jonesville Elementary school, almost 60 of the school's 480 students have been diagnosed with or displayed symptoms of chickenpox over the past month. The exact cause of the child's death has not been determined, but local officials say they doubt chickenpox is to blame. According to the school's principal, the outbreak isn't limited just to students who haven't been vaccinated.

Across the state, the current class of kindergartners was the first required by law to be vaccinated for chickenpox. In Sep 2006, the state issued a recommendation urging parents to get a second booster shot. Because the disease appears to be so widespread, the Yadkin County Health Department has sent out a letter to notify parents and doctors. All over North Carolina, parents are being urged to make sure their children have both the vaccine and the booster. Health officials say that since state law doesn't require chickenpox cases to be recorded, they don't know whether 60 cases in one county in one month is odd. According to CDC, chickenpox-related deaths happened in about 100 people a year before 1995, prior to introduction of an improved vaccine. CDC states that about 40 percent of deaths due to chickenpox happen in children younger than age 10. The current vaccine is about 85 percent effective in preventing an outbreak.
(Promed 12/6/06)

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Chile (Libertador): Case of Hantavirus pulmonary syndrome
A 15 year old girl infected with Hantavirus in Rancagua [capital of Libertador (6th Region)] is still seriously ill and hospitalized. She was diagnosed with Hantavirus infection 10 Nov 2006. The girl's home and school have been ruled out as the source of the infection. Reportedly the patient began experiencing hantavirus infection symptoms 3 Nov 2006, and this may be the first case of this infection during this season in the 6th Region. The Chilean Government Ministry of Health, Department of Epidemiology (MINSAL), in its Hantavirus Epidemiological Bulletin Update of 22 Nov 2006 reports the situation this year as 33 confirmed cases of hantavirus cardiopulmonary syndrome, and a case/fatality rate of 44 percent (14 deaths). The number of confirmed cases for Nov 2006 is within the expected range for this time of the season. Total number of observed cases in 2006 is lower than expected (55 cases); however, because of the elevated mortality rate this year, it is of paramount importance to reinforce strict surveillance.
(Promed 11/25/06)

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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. Findings from the International Conference on Avian Influenza in Mali.
- OIE: http://www.oie.int/eng/en_index.htm.
- US CDC: http://www.cdc.gov/flu/avian/index.htm
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/.
- 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.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Global updates.
(WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; AVMA; USGS)

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Cholera, diarrhea & dysentery
Australia (New South Wales)
The New South Wales Health Department is warning against eating raw whitebait after a possible outbreak of cholera in inner Sydney. Tests are being carried out on 3 Sydney women who are showing symptoms of cholera. The women became ill after buying raw whitebait, which is believed to have been sourced from China, from fish shops in the inner city over the last few days. The Health Department's director of communicable diseases, Dr Jeremy McAnulty, says the women are being tested. Dr McAnulty says health officials are working with food authorities to withhold the whitebait from sale. (Promed 11/28/06)

USA (Wyoming)
The number of people coming down with shigellosis, has grown to at least 35 as of 20 Nov 2006. The disease causes diarrhea, fever, stomach cramping, and sometimes bloody stools, said Kelly Weidenbach, surveillance epidemiologist with the Wyoming Department of Health. "A Shigella outbreak of this size is considered rare in Wyoming," Weidenbach said. At least 12 local children have been hospitalized over the past few months because of the disease. Weidenbach said the majority of the cases have been among elementary school-aged children. Since the infection can be spread with a very low inoculum of organisms, shigellosis can be spread directly from person-to-person easily.
(Promed 11/28/06)

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Dengue
Chinese Taipei
Based on the notifiable disease surveillance system in Taiwan, during the 47th epidemiological week (Nov 19 to 25, 2006), 92 dengue fever (DF) cases were reported in Taiwan, of which 57 were laboratory confirmed, including 1 dengue hemorrhagic fever (DHF) case. As of Nov 25, there had been 2,051 reported cases of DF nation-wide this year, of those, 864 had been confirmed, including 16 DHF cases. So far this year, 2 DF deaths have been reported from Kaohsiung City. The cumulative number of dengue confirmed cases has increased by 233.6 percent compared with the same period last year (2005, 259 cases). Among this year’s cases, 97 were classified as imported cases and 767 were domestic cases. The origins of the imported cases were as follows: 32 from Vietnam; 18 from Indonesia; 13 from the Philippines; 10 from Thailand; 8 from Cambodia; 5 from Malaysia; 4 from Bangladesh; 3 from India; 2 from Myanmar; 1 from El Salvador; and 1 from Madagascar. Of the domestic cases, the main serotype (304 cases) of circulating DF virus is DEN-3, followed by 30 cases of DEN-2, and 1 case of DEN-1. The case distribution was mainly in southern Taiwan, including Kaohsiung City, Kaohsiung County, Tainan City, Tainan County, and Pingtung County. In the north, there was 1 case in Taipei County and 1 case in Keelung City. Since 18 Nov 2006, both Kaohsiung County and City health authorities have reinforced implementation of a mosquito-elimination campaign. The government re-emphasizes that collaborative efforts between health authorities and local residents are key for effective control of the outbreak.
(Promed 11/26/06; Taiwan IHR Focal Point 12/7/06)

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West Nile Virus
USA
Human Cases have been reported from:
State / Neuroinvasion* / *West Nile* fever** / Other*** / Total **** / Fatalities

Alabama / 7 / 0 / 0 / 7 / 0
Arizona / 48 / 58 / 41 / 147 / 6
Arkansas / 23 / 5 / 0 / 28 / 3
California / 79 / 180 / 11 / 270 / 6
Colorado / 63 / 269 / 0 / 332 / 7
Connecticut / 7 / 2 / 0 / 9 / 1
District of Columbia / 0 / 1 / 0 / 1 / 0
Florida / 3 / 0 / 0 / 3 / 0
Georgia / 2 / 5 / 1 / 8 / 1
Idaho / 111 / 752 / 26 / 889 / 14
Illinois / 116 / 70 / 24 / 210 / 9
Indiana / 26 / 7 / 42 / 75 / 3
Iowa / 21 / 13 / 2 / 36 / 0
Kansas / 17 / 13 / 0 / 30 / 4
Kentucky / 5 / 1 / 0 / 6 / 1
Louisiana / 88 / 81 / 0 / 169 / 0
Maryland / 7 / 1 / 2 / 10 / 0
Massachusetts / 2 / 1 / 0 / 3 / 0
Michigan / 46 / 2 / 2 / 50 / 6
Minnesota / 30 / 35 / 0 / 65 / 3
Mississippi / 84 / 89 / 0 / 173 / 10
Missouri / 47 / 12 / 1 / 60 / 3
Montana / 12 / 21 / 1 / 34 / 0
Nebraska / 43 / 208 / 0 / 251 / 1
Nevada / 34 / 75 / 14 / 123 / 1
New Jersey / 2 / 2 / 1 / 5 / 0
New Mexico / 3 / 5 / 0 / 8 / 0
New York / 16 / 7 / 0 / 23 / 4
North Dakota / 20 / 117 / 0 / 137 / 1
Ohio / 36 / 11 / 0 / 47 / 4
Oklahoma / 26 / 18 / 3 / 47 / 5
Oregon / 7 / 50 / 12 / 69 / 0
Pennsylvania / 8 / 1 / 0 / 9 / 2
South Dakota / 38 / 75 / 0 / 113 / 3
Tennessee / 15 / 2 / 0 / 17 / 1
Texas / 210 / 103 / 0 / 313 / 28
Utah / 56 / 101 / 0 / 157 / 5
Virginia / 0 / 0 / 4 / 4 / 0
Washington / 0 / 3 / 0 / 3 / 0
West Virginia / 1 / 0 / 0 / 1 / 0
Wisconsin / 11 / 9 / 0 / 20 / 1
Wyoming / 15 / 40 / 10 / 65 / 2
TOTALS / 1386 / 2445 / 197 / 4028 / 135

* 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 12/7/06)

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2. Articles
Recent H5N1 avian Influenza A virus increases rapidly in virulence to mice after a single passage in mice
Masaji Mase et al. J Gen Virol. 2006 Dec;87(Pt 12):3655-9.
Abstract: “To evaluate the potential pathogenicity to mammals of the recent H5N1 avian Influenza A virus, viruses recovered from dead mice infected with A/chicken/Yamaguchi/7/2004 isolated in Japan were examined. All recovered viruses from the brains of dead mice infected with this strain (without any prior adaptation to mice) had substituted the amino acid at position 627 of the PB2 protein from glutamic acid to lysine. Their mouse lethality had increased by approximately 5x104 times over that of the original virus. Histopathological analysis reinforced the finding that these variants caused more rapid and severe damage to mice than the original virus. This revealed that it might be useful to characterize the recovered virus to assess its potential pathogenicity to mammals.”
http://vir.sgmjournals.org/cgi/content/abstract/87/12/3655

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Impact of the 2004 Influenza Vaccine Shortage on Repeat Immunization Rates
Charles P. Schade and Karen L. Hannah. Annals of Family Medicine 4:541-547 (2006)
Abstract: “PURPOSE We assessed the impact of the severe influenza vaccine shortage of 2004 on individual physicians’ immunization performance. METHODS Using 1998–2004 Medicare claims data, we monitored the physician continuity rate (proportion of patients receiving influenza immunization from a physician in 1 year who received a subsequent immunization from the same physician the subsequent year) and other clinician rate (proportion of patients with claims from 1 physician in 1 year with a claim from another clinician the subsequent year) in West Virginia Medicare beneficiaries from 2000–2004. We examined vaccine claim trends by clinician and surveys of self-reported immunization to determine whether patients received vaccine from nonphysician clinicians or went without immunization each year. RESULTS Claims-based influenza vaccination rates increased from 35.5% to 41.3% from 2000–2003, reflecting historical trends, before declining 14.1% in 2004. Median continuity rates among the 723 to 849 physicians claiming 25 or more influenza immunizations from 2000–2003 increased from 47% in 2000–2001 to 54% in 2002–2003; then fell to 3% in 2003–2004. The number of physicians filing 100 or more claims declined from 337 in 2003 to 130 in 2004. More than 25% of physicians had no repeat vaccinations of the same beneficiaries in 2004. Trends in clinician type and survey data indicated a shift of many beneficiaries to mass vaccinators and institutional providers; however, compared with previous years, there was an estimated 8% increase in 2004 in the number of West Virginia beneficiaries who did not receive vaccine. CONCLUSIONS The 2004 vaccine shortage had a severe impact on influenza immunization rates in private physician’s offices, disrupting continuity of care.”
http://www.annfammed.org/cgi/content/abstract/4/6/541

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Improving Influenza Vaccination Rates of High-Risk Inner-City Children Over 2 Intervention Years
Richard K. Zimmerman et al. Annals of Family Medicine 4:534-540 (2006)
Abstract: “PURPOSE Influenza immunization rates among children with high-risk medical conditions are disappointingly low, and relatively few data are available on raising rates, particularly over 2 years. We wanted to determine whether interventions tailored to individual practice sites improve influenza immunization rates among high-risk children in inner-city health centers over 2 years. METHOD A before-after trial to improve influenza immunization of children was conducted at 5 inner-city health centers (residencies and faith-based). Sites selected interventions from a menu (eg, standing orders, patient and clinician reminders, education) proved to increase vaccination rates, which were directed at children aged 2 to 17 years with high-risk medical conditions. Intervention influenza vaccination rates and 1 and 2 years were compared with those of the preintervention year (2001–2002) and of a comparison site. RESULTS Influenza vaccination rates improved modestly from baseline (10.4%) to 13.1% during intervention year 1 and to 18.7% during intervention year 2 (P <.001), with rates reaching 31% in faith-based practices. Rates increased in all racial and age-groups and in Medicaid-insured children. The increase in rates was significantly greater in intervention health centers (8.3%) than in the comparison health center (0.7%; P <.001). In regression analyses that controlled for demographic factors, vaccination status was associated with intervention year 1 (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.6–2.2) and with intervention year 2 (OR, 2.8; 95% CI, 2.3–3.4), as well as with practice type. Adolescents had lower vaccination rates than children 2 to 6 years old (OR, 0.6; 95% CI, 0.5–0.7). CONCLUSIONS Tailored interventions selected from a menu of interventions modestly increased influenza vaccination rates over 2 years at health centers serving children from low-income families. We recommend this strategy for faith-based practices and residencies with 1 practice site, but further research is needed on multisite practices and to achieve higher influenza vaccination rates.”
http://www.annfammed.org/cgi/content/abstract/4/6/534

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Safety, Efficacy, and Effectiveness of Cold-Adapted Influenza Vaccine-Trivalent Against Community-Acquired, Culture-Confirmed Influenza in Young Children Attending Day Care
Vesikari, T et al. PEDIATRICS Vol. 118 No. 6 December 2006, pp. 2298-2312.
Abstract: “OBJECTIVE. The goal was to evaluate the safety, tolerability, and efficacy of an investigational, refrigerator-stable formulation of live attenuated influenza vaccine (cold-adapted influenza vaccine-trivalent) against culture-confirmed influenza, acute otitis media, and effectiveness outcomes in young children in day care over 2 consecutive influenza seasons. METHODS. Children 6 to <36 months of age who were attending day care were assigned randomly in year 1 to receive 2 doses of vaccine or placebo intranasally, 35 ± 7 days apart. In year 2, subjects received 1 dose of the same treatment as in year 1. RESULTS. A total of 1616 subjects (vaccine: 951 subjects; placebo: 665 subjects) in year 1 and 1090 subjects (vaccine: 640 subjects; placebo: 450 subjects) in year 2 were able to be evaluated for efficacy. The mean age at first vaccination was 23.4 ± 7.9 months. In year 1, the overall efficacy of the vaccine against influenza subtypes similar to the vaccine was 85.4%; efficacy was 91.8% against A/H1N1 and 72.6% against B. In year 2, the overall efficacy was 88.7%; efficacy was 90.0% against H1N1, 90.3% against A/H3N2, and 81.7% against B. Efficacy against all episodes of acute otitis media associated with culture-confirmed influenza was 90.6% in year 1 and 97.0% in year 2. Runny nose or nasal discharge after dose 1 in year 1 was the only reactogenicity event that was significantly more frequent with cold-adapted influenza vaccine-trivalent (82.3%) than placebo (75.4%). CONCLUSIONS. Cold-adapted influenza vaccine-trivalent was well tolerated and effective in preventing culture-confirmed influenza illness in children as young as 6 months of age who attended day care.”
http://pediatrics.aappublications.org/cgi/content/abstract/118/6/2298

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Tabletop exercises for pandemic influenza preparedness in local public health agencies
HHS report published Dec 5, 2006. Contents include: Preface; Summary; Introduction; Overview; Issue Areas; Design and Methodology; Exercise Objectives; Suggested Participants; General Exercise Framework; After Action Report; Tabletop Exercise; General Description; Template Exercise Slides.
(Pandemicflu.gov http://pandemicflu.gov/plan/states/tr319.html )

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Poultry most likely to bring H5N1 to Americas
Poultry infected with H5N1 avian influenza pose the greatest risk of bringing the disease to the Americas, according to a new study by British and US researchers. Once on this continent, avian flu is likely to spread to migratory birds that will cross US borders—but the greatest risk will be birds from Central and South America that are not sampled in current wild-bird testing, they said. The study employs a complex analytic method that compares the migratory routes of wild birds thought to be the main reservoirs of avian flu with data on legal trade in poultry and wild birds and avian-flu gene sequences. Plotting those pieces of data against each other allowed the researchers to hypothesize whether migratory birds, wild bird trade, or poultry were responsible for H5N1 influenza's past spread across the globe. Heading their conclusions: The combination of poultry trade and bird migrations allowed the virus to spread much farther than either would have allowed on its own. Heading their predictions: The greatest threat to the US will be the arrival of avian flu in Central and South America—where poultry trade is less restricted than in North America—via live poultry imports from countries where avian flu has affected either domesticated or wild birds. Strict regulation of poultry trade across US borders will not be adequate protection, they concluded.

"The question is not just who you trade with, but who your neighbors trade with," A. Marm Kilpatrick, a scientist with the Consortium for Conservation Medicine and the lead author of the study, said. The findings challenge previous conclusions on the routes by which some countries were infected. The researchers' method—which combined estimates of "infectious bird days" (the product of the number of birds entering a country, the prevalence of infection in those populations, and the number of days birds are likely to shed virus) with data on trade and migration from U.S. and international agencies—does not consider the possible influence of the illegal trade in poultry and wild birds. But the analysis points so strongly to the influence of legal trade in spreading the pathogen that it argues for implementing trade controls, he said. "Although the risk of H5N1 introduction into the mainland United States by any single pathway is relatively low, the risk of introduction by poultry to other countries in the Americas, particularly Canada, Mexico and Brazil, is substantial unless all imported poultry are tested for H5N1 or trade restrictions on imports from the old world are imposed," the report says.

But the research implicitly challenges the focus of the $29 million migratory-bird testing effort being conducted in the US by the departments of Interior and Agriculture. Since Apr 2006 that effort has tested more than 21,000 samples from wild birds in the US, primarily in Alaska, without finding any high-pathogenic avian flu. Because the wild birds sampled to date have shown such low prevalence of all avian flu strains surveillance should refocus on dead birds, the researchers said. But scientists at the National Wildlife Health Center—which leads the US sampling effort—said the study lacks enough data to persuade them to shift their efforts. "A model is only as good as the assumptions you make and the data you put into it," said Leslie Dierauf, VMD, the center's director. "There may be better data we can obtain on trade in domestic fowl. There is certainly in my mind at this point not good enough data for migratory birds." Nevertheless, Dierauf said the analysis raises questions that are vital for avian flu prevention and control.

Kilpatrick AM, Chmura AA, Gibbons DW, et al. Predicting the global spread of H5N1 avian influenza. Proc Nat Acad Sci 2006 (In press). http://www.pnas.org/cgi/content/abstract/0609227103v1
(CIDRAP 12/5/06 http://www.cidrap.umn.edu/ )

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Respiratory Syncytial Virus Activity--United States, 2005--2006
(References removed)
“Respiratory syncytial virus (RSV) is a major cause of lower respiratory tract infections (LRTIs). . .among young children in the United States. RSV also causes severe respiratory disease and a substantial number of deaths among older adults and persons with compromised respiratory, cardiac, or immune systems. . .In temperate climates, peak RSV activity typically occurs during the winter. This report presents preliminary data on RSV activity reported to the National Respiratory and Enteric Virus Surveillance System (NREVSS) for the weeks ending July 8--November 18, 2006, indicating the onset of the 2006--2007 RSV season, and summarizes RSV trends during July 2005--June 2006. Health-care providers should consider RSV in the differential diagnosis for persons of all ages with LRTIs and implement appropriate isolation precautions to prevent nosocomial transmission from RSV-infected patients. Immune prophylaxis should be considered for certain infants and young children at high risk for complications from RSV infection (e.g., certain premature infants or infants and children with chronic lung and heart disease). . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5547a5.htm
(MMWR December 1, 2006 / 55(47);1277-1279)

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A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States
Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: Immunization of Adults: Hepatitis B vaccination is the most effective measure to prevent hepatitis B virus (HBV) infection and its consequences. In adults, ongoing HBV transmission occurs primarily among unvaccinated persons with behavioral risks for HBV transmission (e.g., heterosexuals with multiple sex partners, injection-drug users [IDUs], and men who have sex with men [MSM]) and among household contacts and sex partners of persons with chronic HBV infection. This report, the second of a two-part statement from the Advisory Committee on Immunization Practices (ACIP), provides updated recommendations to increase hepatitis B vaccination of adults at risk for HBV infection. The first part of the ACIP statement, which provided recommendations for immunization of infants, children, and adolescents, was published previously.

In settings in which a high proportion of adults have risks for HBV infection (e.g., sexually transmitted disease/human immunodeficiency virus testing and treatment facilities, drug-abuse treatment and prevention settings, health-care settings targeting services to IDUs, health-care settings targeting services to MSM, and correctional facilities), ACIP recommends universal hepatitis B vaccination for all unvaccinated adults. In other primary care and specialty medical settings in which adults at risk for HBV infection receive care, health-care providers should inform all patients about the health benefits of vaccination, including risks for HBV infection and persons for whom vaccination is recommended, and vaccinate adults who report risks for HBV infection and any adults requesting protection from HBV infection. To promote vaccination in all settings, health-care providers should implement standing orders to identify adults recommended for hepatitis B vaccination and administer vaccination as part of routine clinical services, not require acknowledgment of an HBV infection risk factor for adults to receive vaccine, and use available reimbursement mechanisms to remove financial barriers to hepatitis B vaccination.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a1.htm
(MMWR December 8, 2006 / 55(RR16);1-25)

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Missed opportunities for earlier diagnosis of HIV infection--South Carolina, 1997-2005
(References removed)
“In September 2006, CDC published revised recommendations for human immunodeficiency virus (HIV) testing in health-care settings to 1) increase early detection of HIV infection by expanding HIV screening of patients and 2) improve access to HIV care and prevention services. . .HIV screening is now recommended for patients aged 13--64 years in all health-care settings after patients are notified that testing will be performed unless they decline (opt-out screening). This represents a substantial change from earlier recommendations to 1) offer HIV testing routinely to all patients only in health-care settings with high HIV prevalence and 2) conduct targeted screening on the basis of risk behaviors for patients in low-prevalence settings. This report examines HIV and. . .AIDS case reporting in South Carolina before the 2006 recommendations were published. During 2001--2005, a total of 4,315 cases of HIV infection were reported in South Carolina. Of these, 41% were in persons (referred to as late testers) in whom AIDS was diagnosed within 1 year of their initial HIV diagnosis. Of these late testers, 73% made a total of 7,988 visits to a South Carolina health-care facility during 1997--2005 before their first reported positive HIV test. The diagnoses reported for 79% of these visits were not likely to prompt HIV testing under a risk-based testing strategy. These findings suggest that routine, opt-out HIV screening of all patients in health-care settings, rather than risk-based HIV testing, might result in substantially earlier HIV diagnoses in South Carolina. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5547a2.htm
(MMWR December 1, 2006 / 55(47);1269-1272)

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Certified managers may reduce restaurant food hazards
Restaurants that have a certified kitchen manager (CKM) seem to have a lower risk of serving food that triggers infectious illnesses, according to a study comparing restaurants that were involved in disease outbreaks with those that were not. "We were much less likely to find a certified kitchen manager in a restaurant that experienced an outbreak," said Craig W. Hedberg, lead author of the research report in the Nov issue of the Journal of Food Protection. Certified kitchen managers—those who have completed a food safety training course—are required in some states but not all. Hedberg et al. examined 22 restaurants involved in disease outbreaks between Jun 2002 and Jun 2003 and 347 restaurants with no recent outbreaks. Nonoutbreak restaurants were defined as those with no history of outbreaks for the preceding 3 years and no complaints of food-related illness within the past year. Outbreak and nonoutbreak restaurants were similar in many respects, but 71% of the nonoutbreak restaurants (243 of 347) had a CKM, versus 32% (7 of 22) of outbreak restaurants. In particular, CKMs seemed to be associated with a lower risk of outbreaks linked to norovirus and Clostridium perfringens, 2 of the 3 most common outbreak pathogens. Also, bare-hand contact with food was less likely to be a factor in outbreaks in restaurants that had CKMs.

The researchers found that most restaurants had policies requiring food workers to report illnesses and barring staff members from working while sick, but those policies appeared to make little or no difference in the rate of outbreaks or in the role of infected food handlers as contamination sources. Most restaurants, both outbreak and nonoutbreak, did not offer sick leave for food workers. The findings suggest that food safety training programs need to put more emphasis on managing food worker illnesses, the authors say. On the basis of previous studies on gastrointestinal illness, they estimate that 50,000 US food workers are likely to work while infected with norovirus. Carol Selman of CDC, senior author of the study, said the Food and Drug Administration (FDA) has recommended that all states require restaurants to have CKMs. However, while the findings suggest that CKMs may help prevent norovirus outbreaks, "the key determinant appears to be the presence of an infected food worker," the researchers write.

Hedberg CW, Smith SJ, Kirkland E, et al. Systematic environmental evaluations to identify food safety differences between outbreak and nonoutbreak restaurants. J Food Protection 2006 Nov;69(11):2697-702
http://www.ingentaconnect.com/content/iafp/jfp/2006/00000069/00000011/art00018
(CIDRAP 11/28/06 http://www.cidrap.umn.edu/ )

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Gene chip test can identify wide range of pathogens
A new diagnostic tool that involves thousands of fragments of genetic material on a glass slide can identify a vast range of different pathogens, including viruses, bacteria, fungi, and parasites. The "GreeneChip system" was successfully tested on samples from patients with respiratory disease, hemorrhagic fever, tuberculosis, and urinary tract infections, researchers from Columbia University and several WHO reference laboratories reported. The GreeneChip is a slide with more than 29,000 probes, or short strips of genetic material, attached. "When human fluid and tissue samples are applied to the chip, these probes will stick to any closely related genetic material in the samples," the National Institute of Allergy and Infectious Diseases (NIAID), which supported the research, said. "This allows the rapid and specific identification of any pathogens therein—even those related to but genetically distinct from the ones represented on the chip."

The technology can yield a result in as little as 6 hours, said Dr. W. Ian Lipkin, senior author of the report. The test can be used on a variety of samples, including respiratory secretions, tissue, blood, urine, and stool. The sequences "represent all recognized 1,710 vertebrate viral species and 135 bacterial, 73 fungal, and 63 parasite genera." The resulting "panmicrobial array" contained 29,495 probes. The system was initially tested on material from cultured cells infected with 49 different viruses, all of which were accurately identified. The pathogens identified included human enterovirus A, respiratory syncytial virus, influenza virus, Marburg virus, SARS coronavirus, lactobacillus, mycobacteria, and gammaproteobacteria. The authors write that the use of microarrays in disease surveillance "has been limited because of low sensitivity and unwieldy analytical programs." They say the GreeneChip system offers improved sensitivity and more user-friendly software. Lipkin said his lab is already making the GreeneChip available to people involved in global surveillance networks, such as the CDC, WHO, and state laboratories.

Palacio G, Quan P-L, Jabado OJ, et al. Panmicrobial oligonucleotide array for diagnosis of infectious diseases. Emerg Infect Dis 2007 Jan;13(1). http://www.cdc.gov/ncidod/EID/13/1/73.htm
(CIDRAP 12/7/06 http://www.cidrap.umn.edu/ )

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3. Notifications
10th International Dengue Course, Dengue Symposium
The Pedro Kouri Tropical Medicine Institute (IPK) is pleased to announce its 10th International Dengue Course, from 6-17 Aug 2007, and its Symposium "25 Years of Experience Struggling against Dengue," from 9-11 Aug 2007, which will be held at IPK's facilities, Havana, Cuba. Both the Course and the Symposium invite all professionals working on or researching dengue and hemorrhagic dengue (physicians, virologists, immunologists, sociologists, epidemiologists, entomologists, health managers, and others interested in this field). Prestigious worldwide professors will be lecturing during these 2 events, providing participants with the most up-to-update and advanced knowledge about this disease.

For more information, contact: Prof. Maria G. Guzman, MD, PhD.
Head of the Virology Department, Pedro Kouri Tropical Medicine Institute (IPK)
Director of the WHO/PAHO Center for the Study of Dengue and its Vector
Phone: (537) 202-0450; Fax: (537) 204-6051; lupe@ipk.sld.cu

The Course and Symposium website at: http://www.ipk.sld.cu/cursos/dengue2007/index.htm>.
(Promed 11/29/06)

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Epidemiology in Action: Intermediate Analytic Methods Course
CDC and Emory University's Rollins School of Public Health will cosponsor the course Epidemiology in Action: Intermediate Analytic Methods, Feb 26--Mar 2, 2007, at Emory University, Rollins School of Public Health. The course is designed for practicing public health professionals who have had training and experience in basic applied epidemiology and would like training in additional quantitative skills related to analysis and interpretation of epidemiologic data. The course includes a review of the fundamentals of descriptive epidemiology and biostatistics, measures of association, normal and binomial distributions, confounding, statistical tests, stratification, logistic regression models, and computer programs as used in epidemiology. The prerequisite is an introductory course in epidemiology, such as Epidemiology in Action or the International Course in Applied Epidemiology. The application deadline is Jan 26, 2007, or until all slots have been filled. For more information: Emory University, Hubert Global Health Dept (Attn: Pia), 1518 Clifton Rd. NE, Rm. 746, Atlanta, GA 30322; telephone, (404) 727-3485; fax (404) 727-4590; http://www.sph.emory.edu/epicourses or email pvaleri@sph.emory.edu. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5547a6.htm
(MMWR December 1, 2006 / 55(47);1279)

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NWCPHP: New online module "Introduction to Outbreak Investigation"
The Northwest Center for Public Health Practice is happy to announce the launch of a new online module, Introduction to Outbreak Investigation. It is narrated by Dr. Jeff Duchin, Chief, Communicable Disease Control, Epidemiology and Immunization Section, Public Health - Seattle & King County. This FREE course takes approximately 1 hour to complete. Participants who successfully complete the course are eligible to receive 1.0 CNE contact hours (1.0 clock hours). Please use the following link to access the course description page: www.nwcphp.org/outbreak.
(NWCPHP Nov 2006)

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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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