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Vol. VIII, No. 1 ~ EINet News Briefs ~ Jan 07, 2005


*****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:
- Canada: BSE Confirmed in Suspect Animal, Investigations Underway
- USA: CDC to Conduct Avian Influenza Pandemic Risk Assessment Experiments
- USA (Massachusetts): Exposure to rabies up as more animals test positive
- USA (Multi-state): Salmonella at Sheetz convenience stores still a mystery
- USA (Maryland): Hepatitis C fatality in Baltimore shrouded in mystery
- South and Southeast Asia: WHO Tsunami situation update
- Indonesia: Tetanus outbreak (Not yet officially recognized by WHO)
- Viet Nam: Avian influenza update—two new human avian influenza cases
- Vietnam: Chickens in Vietnam's northern region die of bird flu
- Thailand: Government to draw up bird flu vaccine trial plans
- Republic of Korea: Avian influenza report
- Malaysia (state of Kelantan, Peninsular Malaysia): No longer considered HPAI-infected zone
- Russia: Hemorrhagic Fever with Renal Syndrome in Birobijan
- Russia: Four cases of trichinosis from swine registered in Jitomirskaya region
- Russia: Outbreak of HFRS in the Nizhniy Novgorod Region
- Russia: Outbreak of Hepatitis A in Murmansk Region

1. Updates
- Cholera, Diarrhea, and Dysentery
- Dengue/DHF
- Viral gastroenteritis
- West Nile Virus

2. Articles
- CDC EID Journal, Volume 11, Number 1-January 2005
- Transmission of Malaria in Resort Areas --- Dominican Republic, 2004
- Fatal Rat-Bite Fever --- Florida and Washington, 2003
- Brief Report: Tularemia Associated with a Hamster Bite --- Colorado, 2004

3. Notifications
- Handling Bodies after Disasters: New Book Offers Guidelines
- UW South and Southeast Asia Earthquake and Tsunami Resources
- Tsunami Just-in-Time Lecture
- FAO calls for $26 million to help tsunami victims
- OIE Seminar
- Recommended Childhood and Adolescent Immunization Schedule --- United States, 2005

4. APEC EINet activities
- Tsunami disaster and APEC EINet

5. To Receive EINet Newsbriefs
- APEC EINet email list


Global
Canada: BSE Confirmed in Suspect Animal, Investigations Underway
The Canadian Food Inspection Agency (CFIA) confirmed that an older dairy cow from Alberta has tested positive for bovine spongiform encephalopathy (BSE). This is the second confirmed case of BSE in a Canadian cow. The infected animal was born in 1996, prior to the introduction of the 1997 feed ban. It is suspected that the animal became infected by contaminated feed before the feed ban. No part of the animal entered the human food or animal feed systems. This finding does not indicate an increased risk to food safety. Canada's public health safeguards have been developed on the assumption that a low, declining level of BSE remains in North America. Canada requires the removal of specified risk material (SRM) from all animals entering the human food supply. SRM are tissues that, in infected cattle, contain the BSE agent. This measure is internationally recognized as the most effective means to protect public health from BSE.

Confirming BSE in this animal is not unexpected. Canada has in place a suite of risk mitigation measures to protect public and animal health, including the removal of SRM from the human food chain, the ruminant to ruminant feed ban, the national surveillance program and import restrictions. As a result, the US continues to consider Canada as a minimal risk region. As stated in the USDA press release of 30 Dec 2004, the US would not alter the implementation of its rule to resume trade with Canada. The US is Canada's largest export market, and it will begin to accept imports of young, live cattle thought to be at low risk for the disease March 7 2005.

The infected animal was detected through the enhanced national surveillance program. Additional cases may be found as testing of high-risk cattle continues. In 2004, Canada tested over 22 000 animals. The CFIA is continuing its investigation and has determined the infected animal's farm of origin. Efforts are now underway to identify any other animals of similar risk. CFIA is focusing on recently born offspring of the infected animal and cattle born on the same farm within a year of the infected animal. The Agency has also launched a feed investigation to examine what the infected animal was fed early in its life, when infection was most likely to have occurred prior to the 1997 feed ban. Information gathered through investigations continues to suggest that the feed ban has limited the spread of BSE since its implementation.

In 1989, Canada banned further importation of cattle from the UK and traced all imported cattle to their Canadian farms of origin, where they were monitored and eventually destroyed. Before this time, when BSE had not emerged as a significant animal health threat, it is likely that some imported animals entered the North American feed system. Canada's first case of mad cow disease was found in May 2003 and cost export-dependent farmers an estimated C$5 billion (USD 4.2 billion) as trade partners closed their borders to Canadian beef/cattle. The first U.S. case, found in Washington State December 2003, also affected a cow that was born in Canada. (Promed 1/2/05)

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USA: CDC to Conduct Avian Influenza Pandemic Risk Assessment Experiments
Experts fear that we could be on the brink of an influenza pandemic sparked by the highly virulent avian flu strain in Southeast Asia. But can avian influenza A (H5N1) virus actually acquire the ability to spread easily to and among people? And if it can, how likely is that dreaded event to occur? Early in 2005, U.S. scientists will begin experiments that should provide some answers. "Like a lot of science, it's an imitation of nature," explains Dr. Frank Plummer, scientific director of Canada's National Microbiology Laboratory. "It doesn't replicate exactly what happens. But I think it gives you an idea of the propensity of the H5N1 virus to do this thing."

The researchers, from the Influenza Branch of the US CDC, will hybridize avian influenza A (H5N1) virus and human influenza viruses in a process known as sub-unit reassortment. Viable offspring will be tested in animals thought to be good surrogates for humans, to see whether the viruses can infect, can be transmitted easily from infected animals to healthy ones, and to note the severity of disease each provokes. "It's a dangerous experiment," admits Dr. Robert Webster, a world-renowned expert on influenza based at St. Jude Children's Research Hospital. Still, Webster says, "Science must gain a better understanding of the menacing H5N1 virus."

The WHO has been pleading for months for qualified research facilities--of which there are few--to undertake this work. WHO would like to be able to put some kind of odds on how likely the avian H5N1 virus is to become a pandemic strain and how deadly, or not, avian H5N1 reassortment viruses might be. If none of the hybrids cause severe disease, WHO might feel comfortable with stepping down its current high level of alert, explains Dr. Klaus Stohr, director of the WHO's global influenza program. On the other hand, if researchers easily produce highly transmissible and lethal hybrids, "that would certainly add to our concern. It's about quantifying risk. Currently we do risk-speculation, but we want to do risk-assessment. And that will give us scientific evidence on the possible outcome on the emergence of a pandemic virus," Stohr says. "It will give us an opportunity to predict the probability, because we will have an understanding on the number of reassortment viruses which are viable, the percentage of those that are viable which are then transmissible, and also on the percentage of those which are viable, transmissible and pathogenic. And how pathogenic they are."

The CDC researchers will work in high containment level 3-enhanced labs, says Dr. Nancy Cox, who heads the agency's Influenza Branch. Still, lab accidents happen. Since SARS was contained in mid-2003, four lab workers in Asia have infected themselves with SARS, and one spread it beyond the walls of the lab. Earlier in 2004, a Russian lab worker died after accidentally infecting herself with Ebola virus. Given that reality, some groups have raised concern regarding this work. "If it's being done by CDC, then the good thing about that is that safety measures will properly be in place," said Dr. Albert Osterhaus, of the Erasmus Medical Centre in Rotterdam.

The CDC researchers will mix genes from the avian H5N1 virus with genes from circulating strains of human influenza virus to see which combinations produce viruses that grow and infect. Cox says influenza A (H3N2) virus, the strain that has been responsible for most human influenza in recent years, will be the first priority. However, Southeast Asia has recently seen activity with influenza A (H1N1) virus, a mild modern descendant of the strain that caused the Spanish flu of 1918. So the CDC has been sequencing H1N1 viruses recently isolated in Thailand to be able to work with it as well. Reassortment studies can be performed two ways, she explains. Scientists can use reverse genetics, a procedure that allows them to custom-tailor a virus with a predetermined constellation of genes from each parent virus. The other alternative is to simultaneously infect tissue culture with H5N1 and H3N2 viruses. That approach is more time-consuming and laborious, but more closely mimics evolution of influenza viruses in nature. "We will probably be using a combination of the two different methods…" says Cox. CDC researchers have already made hybrid viruses with H5N1, using strains of the virus isolated after it first caused human infections in 1997 in Hong Kong. (Promed 12/28/04)

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USA (Massachusetts): Exposure to rabies up as more animals test positive
With the number of confirmed rabies infections in wild animals in Barnstable now topping 40, the risk of exposure to the human residents is growing. The latest confirmed case was 27-28 Nov 2004 when a man was bitten by a rabid raccoon. Though he was the only one bitten, his wife and son are all undergoing vaccination treatments. The dog, which incapacitated the raccoon, is also receiving the shots. Charlie Lewis, Barnstable animal control officer, said that 157 animals have been prepped and sent for testing. Of these, 33 raccoons and nine skunks (total 42 animals) tested positive for the disease. Most of Barnstable, 62 square miles, has seen some evidence of rabies. He said it appears the disease is spreading along the section of town consisting of public and private open space. "The worst thing about it," the victim stated, "is the unease that is left about being so close to the woods." Their property abuts town conservation land. "In the past, I never thought twice about letting our son go outside and play. Now I am nervous." The Barnstable County Department of Health and the Environment has conducted classes for state and municipal workers likely to come in contact with animals, including those killed by motor vehicles, regarding proper handling and sanitary techniques. The oral bait program, which seeks to vaccinate the wild population of raccoons, is operated by the Tufts University School of Veterinary Medicine, the Massachusetts Department of Public Health and the Centers for Disease Control and Prevention. (Promed 12/26/04)

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USA (Multi-state): Salmonella at Sheetz convenience stores still a mystery
Investigators still do not know what caused the summer 2004 salmonella outbreak among patrons of Sheetz convenience stores that resulted in 429 confirmed cases among people in nine states. The search for the source of contamination had a setback in August 2004, when Hurricane Charley hit Florida, home of farms that likely grew the tainted tomatoes during the outbreak. But investigators eventually determined that food safety practices called for in the 1990s following tomato-related outbreaks had, in fact, been adopted. That good news about past practices, however, left officials struggling to understand the nature of the new problem.

"We don't know how the contamination moved to the produce," said Jack Guzewich, director of emergency coordination and response for the Center for Food Safety and Applied Nutrition at the FDA. "The other apparent thing is--and this isn't proven--the organism can survive in the environment, on the produce, in the face of the [safety] things that are being done..." The Sheetz outbreak had a huge local impact. In Pennsylvania, 288 salmonella cases were conclusively linked to the outbreak, although officials believe many more here were actually sickened. Coming within a year of 660 people getting sick with hepatitis A after eating green onions at the Beaver Valley Mall Chi-Chi's, the outbreak at Sheetz was yet another reason for consumers here to worry about eating produce from a food vendor. Neither the Sheetz nor the Chi-Chi's outbreak was the result of poor food handling practices at either establishment. But the green onions served at Chi-Chi's were grown in Mexico, while the tomatoes sold at Sheetz were grown in the US.

Investigators believe that as many as five different strains of salmonella bacteria contaminated the tomatoes served at Sheetz, said Dr. Amy DuBois, CDC epidemic intelligence service officer. The bacterial variety virtually eliminates the chance that contamination came from an infected food-handler somewhere along the food distribution chain, DuBois said. The most common reservoirs for the roughly 2000 known strains of salmonella are wild and domestic animals, so investigators tend to think the contamination occurred either at the farm or in packing sheds. This is surely cold consolation for the owners of Coronet Foods, the company that closed after it was revealed that Coronet sliced the tomatoes served at Sheetz.

Investigators hoped they would be able to recommend safety steps like those called for in the 1990s, following two salmonella outbreaks involving tomatoes. Nearly 300 people in Midwestern states were sickened during those outbreaks, both of which involved tomatoes packed in a single facility. During this incident, investigators found that chlorine and water temperature levels were not properly monitored. When investigators visited farms that grew the Sheetz tomatoes, however, they were pleased to see that heated, chlorinated water baths were being properly used. Investigators focused on one farm in Florida, DuBois said, and the FDA might visit that operation again spring 2005 to observe conditions during the planting of tomatoes. The salmonella story is not over for the Sheetz chain either. With 307 stores in six states, Sheetz derives revenue from more services than just sandwiches, said Steve Sheetz, the company chairman. But the sandwich business was hurt, and it has not completely bounced back. (Promed 12/27/04)

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USA (Maryland): Hepatitis C fatality in Baltimore shrouded in mystery
A patient received a routine cardiac stress test at a Glen Burnie cardiology clinic October 2004. The 79-year-old retired ironworker developed a hepatitis C infection that killed him 25 Dec 2004. The patient's death, one of just six hepatitis C-related fatalities officially recorded in Maryland since 1999, is drawing attention to an unusual medical mystery. Officials have traced the patient's infection to a single vial of technetium-99m, a radioactive isotope injected into the bloodstream during stress tests and other routine diagnostic procedures. The company whose Timonium pharmacy prepared the suspect isotope said the state has identified at least 12 infected cases in the Baltimore area. The 79-year old patient is the only fatality.

Experts recall no other instance in which a common radioactive isotope has become contaminated with a hepatitis virus. "It's very unusual and not expected at all," says Fadia Shaya of the University of Maryland School of Pharmacy, who chairs the state's advisory council on hepatitis C. Hepatitis C virus is transmitted almost exclusively by parenteral exposure to blood, blood products and substances contaminated with blood. Sexual and perinatal transmission occur rarely. The majority of new infections are contracted through illicit drug use. Screening and inactivation procedures now ensure safety of the blood supply. Blood-contaminated syringes, however, have become a significant risk factor. The disease kills as many as 10 000 people in the U.S. each year.

The vial of technetium-99m that officials suspect as the cause of the infection here was prepared at a pharmacy in Timonium. Operated by Cardinal Health, the pharmacy specializes in preparing radioactive "tracers" for a variety of diagnostic tests. The company has temporarily closed the business. John Hammond, a spokesman for the Department of Health and Mental Hygiene, said the hepatitis C outbreak does not pose a public health risk and was confined to the small number of people injected with serum from the tainted vial. Maryland, he said, recorded 26 cases of hepatitis C in 2004, including those in the recent outbreak. One of the central mysteries is how the radioactive isotope could have become contaminated, especially since the preparation of technetium-99m is considered to be a straightforward process. Nicki Hilliard, a nuclear pharmacist at the University of Arkansas for Medical Sciences, said that the isotope is typically produced in a pinkie-sized container known as a radionucleotide generator.

The victim's widow said her husband received the isotope during a routine cardiac stress test at Arundel Heart Associates. Dr. Paul Young-Hyman, a cardiologist at the Glen Burnie clinic, said the suspect isotope arrived at the clinic Oct 2004 in eight individually prepared syringes, each in a lead-lined container. All eight patients who received the isotope 15 Oct 2004 tested positive for hepatitis C. All the clinic's employees have tested negative for the virus, and health officials have examined the clinic's laboratory and found it contamination free. As a precautionary measure, however, stress tests at the clinic are now being performed with a different radioactive tracer. "I'm just hoping that people who need the study don't hold back on getting it," says Young-Hyman. The circumstance whereby eight patients receiving isotope from eight individually prepared syringes delivered from a single pharmacy points to the contamination occurring at the pharmacy preparing the isotope rather than at the hospital administering the isotope. (Promed 1/5/05)

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Asia
South and Southeast Asia: WHO Tsunami situation update
Tackling urgent needs such as ensuring proper sanitation and clean water supplies and putting measures in place to try to prevent disease outbreaks is critical. As countries assess their needs, coordinating the relief and reconstruction effort and ensuring the right aid reaches the right people at the right time becomes more crucial. WHO's main concern now is to strengthen disease surveillance and an early detection warning system for potential outbreaks. Key Issues are:
• Relief efforts are still critical: Some populations in remote areas in Indonesia have still not been reached.
No outbreaks have been reported.
• Water and sanitation situation still critical. Sanitation issues are of utmost concern.
• Reconstruction efforts starting simultaneously with the relief efforts. Assessments surveys have commenced and future international relief assistance should be targeted around the results of these assessments.
• Funds for relief aid globally have been extremely generous. To adequately address the public health needs of the populations over the next 6 months, a minimum of US$67 million are urgently required. WHO is confident that the international community and donor countries will respond favourably to this appeal. WHO needs this money rapidly to be fully operational on the ground.
• Although Southeast Asia is the area most gravely affected, humanitarian attention must also be provided to Somalia and the Horn of Africa, area also impacted by the catastrophe.

WHO Situation updates as of 1/6/05 by Economy/economy (presented as: Homeless / Injured / Missing / Deaths):

Indonesia : 517,064 / 1176 inpatients and 2355 outpateints / 6,700 / 94,200
Sri Lanka: 835,028 / 15,683 / 3,858 / 30,229
India: 627,119 / 3,281 in Tamil Nadu only / 6011 / 9,691
Thailand: 8,500 evacuated to other / 8,475 / 3,716 / 5,288
Maldives: 21,663 / 2,214 / 26 / 82
Malaysia: unknown / 73 in-patient/ 694 outpatient / unknown / 68
Myanmar: 3,205 homeless from 638 households / 43 / 3 / 59
Somalia: unknown / 283 / unknown / 46

Communicable Diseases --Countries are on the alert for possible disease outbreaks and are monitoring through disease surveillance and verification.
Indonesia: No outbreaks have been reported. Surveillance starting today. Case definitions and forms were agreed upon and distributed by WHO/MOH teams as they travel through the field. Surveillance catchment is expected to increase as the teams reach new health care delivery points. Reports will be weekly, with a telephone alert system for diseases with outbreak potential. WHO guidelines for disease control and SPHERE are being distributed by CD-ROM. The MoH is starting a measles vaccination campaign in affected areas on 6 January. However, this campaign will most likely not commence outside of Banda Aceh for another week. Nine cases of tetanus were reported in Bande Aceh. WHO tetanus antitoxin arrived in Aceh today.
Sri Lanka: No report of outbreak of diseases in any of the camps. Sufficient vaccines are available in the Ampara district should there be an outbreak.
India: No outbreak of communicable diseases has been reported by any of the government agencies operating in the rescue and relief operations in affected states of Andhra Pradesh, Tamil Nadu, Kerala or Andaman and Nicobar Islands. Thirteen sporadic measles cases have been identified, including eight cases in children less than five. This has prompted measles vaccination campaigns.
Thailand: 77 diarrhoea , 8 influenza, 4 pneumonia, 1 dengue, and 18 wounds cases seeking care were reported on January 5. This gives cumulative totals of 1159 cases seeking care, the largest causes being acute diarrhoea , pneumonia, DHF, PUO, and 299 wound cases with 2 deaths. No outbreaks have been reported. Three cases of malaria were detected in Phuket province, but these are believed to be unrelated to the tsunami disaster. Vector control teams are working in the area. Number of DHF in Phuket Province was 16 cases in the past 10 days which exceeded the average of 4 cases per week warranted control measure.
Maldives: 483 diarrhoea , 83 acute respiratory infection, 322 viral fever, and 16 viral fever with vomiting have been reported. No report of outbreak. (WHO 1/6/05)

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Indonesia: Tetanus outbreak (Not yet officially recognized by WHO)
A tetanus outbreak is killing Indonesians who survived last week's tsunamis, as many had not been immunized against the potentially fatal infection, a South African humanitarian organisation said 5 Jan 2005. "There is a full-blown outbreak and people have started to die," said Global Relief spokesperson Murray Louw. At this stage the case numbers or the number of deaths from this disease is unclear. There is also a shortage of tetanus immune globulin in the area. Louw said tetanus can infect even minor cuts and scratches. Symptoms of the infection include muscle rigidity and spasms, particularly of the face and jaw, hence its common name, lockjaw. Global Relief is to send another team to Indonesia while other teams are to leave South Africa for Sri Lanka and India in the coming weeks.

Although the public tends to associate tetanus with injuries such as stepping on a rusty nail, the injury itself can be minor, and no signs of local infection/injury may be present. Tetanus is an intoxication due to the elaboration of tetanus toxin by Clostridium tetani. Universal immunization with the toxin in early childhood will prevent it, and boosters are recommended once per decade after the primary series. Postinjury prophylaxis uses tetanus immunoglobulin and tetanus toxoid booster. In a mass injury situation, this is difficult to accomplish. (Promed 1/6/05, 1/7/05)

*For children the tetanus vaccine is usually given together with diphtheria and pertussis vaccines in a shot called DTaP. For adults it is usually given together with diphtheria vaccine in a shot called Td. More information, including vaccine schedule, can be viewed at the CDC website: http://www.cdc.gov/nip/vaccine/tetanus/default.htm.

*For additional resources on the Tsunami disaster, please read our APEC EINet Alerts available at: http://depts.washington.edu/einet/

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Viet Nam: Avian influenza update—two new human avian influenza cases
WHO has received reports of laboratory tests conducted in Ho Chi Minh City, Viet Nam, indicating two new human cases of infection with avian influenza. Both patients have died. Initial tests have identified the H5 subtype of avian influenza virus. Further testing is under way. The first patient was a 6-year-old boy from the southern province of Dong Thap. He died 30 December. The second patient was a 9-year-old boy from Tra Vinh Province, also located in the southern part of the country. He was hospitalized 2 January and died 4 January. The additional recent case in Viet Nam, reported in late December 2004, remains hospitalized in critical condition. All three of these most recent cases have occurred in the southern part of the country, where poultry outbreaks have been recurring since December 2004. Close contacts of these cases are being monitored for any signs of illness. Health authorities in Viet Nam, supported by WHO staff, have undertaken several measures to strengthen case detection. Avian influenza viruses become more active when temperatures turn cooler. Activities associated with the approach of the Lunar New Year festivities in early February may also increase the risk of further human cases. The cases reported here remain sporadic and so far there is no indication of efficient person-to-person transmission of avian influenza virus in the human population. (WHO 1/6/05; Promed 1/6/05)

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Vietnam: Chickens in Vietnam's northern region die of bird flu
Some 500 chickens in Vietnam's northern Nam Dinh province have just died of bird flu, making it more urgent for the country to beef up preventive measures, according to local newspaper Vietnam Agriculture Friday. Samples from dead fowl in Truc Ninh district tested positive to the H5 strain of the bird flu virus. The local veterinarian bureau has culled the remainder of the affected flock of 917 chickens. Also early this week, southern Long An province spotted new outbreaks that killed and led to the culling of 3871 chickens and ducks. Some 450 affected chickens have been recently reported in two other southern provinces, Dong Thap and Tien Giang. Vietnam's Department of Animal Health said outbreaks happened in seven wards and communes in the six southern localities of Can Tho, Bac Lieu, Long An, Tra Vinh, Hau Giang and Binh Phuoc between 1-10 Dec 2004, killing and leading to the culling of nearly 11 000 fowls.

The recent relapse of bird flu in both southern and northern localities (it has not been active in the northern region for some four months) has prompted stronger preventive measures. Cities and provinces will carry out decontamination and clean-up operations in high-risk areas more frequently and keep closer surveillance on transport and sales of poultry, especially during the upcoming Lunar New Year Festival. Local experts express concerns over the relapse of bird flu among fowl as well as humans. Bird flu started to break out in Vietnam December 2003. To date, it has killed 20 people and led to the slaughter of more than 40 million poultry in the country. (Promed 12/31/04)

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Thailand: Government to draw up bird flu vaccine trial plans
Thai government officials are to meet to determine the zones for avian flu vaccine trials, the Director of the government's avian flu operation centre, Dr. Charal Trinvuthipong, revealed 24 Dec 2004. Dr. Charal was quoted as saying that the meeting 27 Dec 2004 would select zones which had been affected by the bird flu pandemic, but said that the government had not yet decided which provinces it would choose. He said the test would be conducted in areas where outbreaks of the bird flu occurred earlier this year. He also revealed that government study tours to Vietnam and China had shown that several practices to stamp out avian flu used in those two countries could be adapted for use in Thailand. He said that Thailand's image as a country where the pandemic was rife was largely a result of the government's widespread and open reporting. The decision falls in line with the recent views of OIE/WHO/FAO, which published updated recommendations at the end of Nov 2004. The document included the following statement: "Such control needs to consider all suitable measures ranging from the safe and swift elimination of affected poultry, through strict biosecurity, movement and market control and if relevant, to vaccination and its close monitoring". (Promed 12/25/04)

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Republic of Korea: Avian influenza report
A heightened awareness campaign is being implemented from November 2004 to February 2005 to prevent reintroduction and resurgence of highly pathogenic avian influenza (HPAI). As part of this campaign, sero-surveillance focused on breeding and broiler ducks, considered as major reservoirs and important risk factors for HPAI, is being conducted both in farms and slaughterhouses, and virological tests are being carried out on feces sampled in migratory birds' habitats. During this heightened sero-surveillance, avian influenza antibody-positive samples were detected on 1 Dec 2004 in a breeding duck farm in Kwangju Province through agar-gel precipitation (AGP) test carried out by the Kwangju Provincial Veterinary Laboratory.

Following this finding and subsequent pathogenicity test, the National Veterinary Research and Quarantine Service (NVRQS) identified this case by 23 Dec 2004 as low pathogenic avian influenza subtype H5N2, through AGP test, haemagglutinin inhibition test, neuraminidase inhibition test, PCR(1), embryo inoculation and haemagglutinin cleavage site sequencing. The NVRQS identified H5N2 subtype through serological tests and PCR on 22 Dec, and on 23 Dec confirmed low pathogenicity with a weak response in embryo inoculation test and with the sequence of the amino acid at the haemagglutinin cleavage site of PQKETK/GLF. Approximately 13 000 ducks were being raised in this farm and no clinical signs were found, there was no drop in the egg production rate, nor were there any deaths.

This is the first detection of H5N2 subtype in the Republic of Korea, and the Ministry of Agriculture and Forestry implemented stamping out of the infected flock in accordance with the HPAI contingency plan, and will further expand sero-surveillance to adjacent farms and epidemiological contact farms as well as conduct an investigation into the source of virus. (OIE, Promed 12/25/04)

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Malaysia (state of Kelantan, Peninsular Malaysia): No longer considered HPAI-infected zone
The first ever outbreak of H5N1 highly pathogenic avian influenza (HPAI) in Peninsular Malaysia was 17 August 2004. The outbreak occurred in the northern part of the state of Kelantan, which borders Thailand, and involved village chickens. Subsequently, eight more outbreaks occurred and two detections of HPAI virus infection without clinical signs were made in the same state. On 19 November 2004, H5N1 avian influenza virus was detected within the framework of surveillance within a 10-km radius area around the outbreaks. Based on an egg inoculation study, the last avian influenza virus detected 19 November 2004 was of low pathogenicity. A stamping-out policy was adopted to eradicate the HPAI infection. All chickens, ducks and birds within a 1-km radius around clinical outbreaks and virus infection foci were culled. The farmers and owners of the chickens, ducks and birds were compensated. The premises and surrounding areas were cleaned and disinfected. The last culling and disinfection were completed 22 November 2004. No new clinical or infection cases have been detected since that date. In accordance with Article 2.7.12.3. of the Terrestrial Animal Health Code, the state of Kelantan in Peninsular Malaysia is no longer considered an HPAI-infected zone. (OIE 1/7/05)

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Russia: Hemorrhagic Fever with Renal Syndrome in Birobijan
Four cases of hemorrhagic fever with renal syndrome (HFRS) have been registered during December 2004 in the Jewish Autonomous Region (Birobijan), while only nine cases were recorded in the preceding 11 months of 2004. No fatal cases have been reported. The outbreak of disease is due to the onset of frosts, said Vyacheslav Chaban, Head of the Department of Disinfestation and Sterilization of the State Epidemiological surveillance Centre in Birobijan. Frosts cause the red-backed vole and other small rodents (vectors of HFRS) to invade human habitations. Also, rodent control has been declining in recent years, because this service is no longer free. Practically no rodent control is being undertaken in rural areas. All four cases recorded in December 2004 have been rural inhabitants. The Jewish Autonomous Region is situated in the southern part of the far east of Russia, close to the Pacific Ocean. (Promed 12/25/04)

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Russia: Four cases of trichinosis from swine registered in Jitomirskaya region
Four cases of trichinellosis have been registered in Jitomirskaya region. According to the Ministry of Agriculture, the infection came from a pig raised in the village of Korostishko, and the farmer had slaughtered the pig for private consumption. 11 people shared meat from the infected pig, and four were hospitalized with trichinellosis. Measures to prevent further spread have been taken by authorities. Pigs from small farms raised for private consumption do not always undergo the legally required veterinary inspection. These pigs are usually fed kitchen waste, including meat, and could be one source of infection, as could small rodents. Trichinella is widespread in Russia, and products made from pigs in backyard holdings and slaughtered for private consumption are not always tested; consuming such products should be avoided. (Promed 12/28/04)

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Russia: Outbreak of HFRS in the Nizhniy Novgorod Region
The Committee of the State Veterinary Commission of the Nizhniy Novgorod Region states that in 2004 the largest number of cases of hemorrhagic fever with renal syndrome (HFRS) in 20 years was registered. In 2003 the number of HFRS cases increased almost two-fold, and for the first eight months of 2004, 13-fold. The increased number of cases in 2004 was attributed to increased migration of rodents into inhabited buildings. The State Veterinary Service is expanding the range of veterinary services, veterinary-sanitary surveillance, and containment of the rodent populations that are the vectors of HFRS. Prevalence of HFRS in general is determined predominantly by the size of the rodent vector population. (Promed 12/28/04)

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Russia: Outbreak of Hepatitis A in Murmansk Region
The city of Apatit in the Murmansk region is experiencing a serious outbreak of hepatitis A. The first patients were admitted to the hospital two months ago. At the present, 130 people in the city of Apatit have been diagnosed with hepatitis A. The number is increasing daily, and many children are among the infected. Epidemiologists suggest that water is the source of the outbreak. A regulation improving the chlorination of water supplies was issued recently, but so far this measure has not produced the expected result. Infection is spreading by contact. Yuriy Evdokimov, the Mayer of Murmansk, is appealing to the population to observe simple rules such as careful hand washing and avoidance of visits to neighbors/relatives in Apatit. If these simple rules are not observed, emergency measures will be implemented and a state of quarantine will be declared in Apatit. The officials had allocated 4.5 million rubles (USD 162 000) for urgent vaccination of the population. According to the Chief of the City Health Department, several vaccination centers are being opened throughout the city. (Promed 12/31/04)

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1. Updates
Cholera, Diarrhea, and Dysentery
Russia (Krasnoyarsk region)
In the Lazarevo settlement of the Abanskiy area, Krasnoyarsk region, 15 persons, including six children, were ill with dysentery 3-21 Dec 2004, stated the Siberian regional center of the Ministry of Emergency Measures. 10 persons, including six children, have been hospitalized in the central regional hospital. Two children (one-and-a-half-years old and one-month-old) have died. The diagnosis has been confirmed by the laboratory. Experts from the state center for sanitary and epidemiological supervision are carrying out an investigation of the outbreak. (Promed 12/27/04)

Russia (Maritime region)
A total of 107 people have fallen ill with enteric infection in Russia's Maritime region over the third week of December 2004. Medics believe that impure water and low-quality dairy products are behind the outbreak. Sources from the regional sanitary and epidemiological service stated 27 Dec 2004, that dozens of cases had been registered in Vladivostok, Nakhodka, Spassk-Dalny, and Ussuriisk, as well as in four districts of the Maritime region. Ahead of the New Year holidays, specialists urge local residents to drink only boiled or bottled water, to use only fresh dairy products, as well as to thermally treat cottage cheese and milk. (Promed 12/27/04)

Russia (Karachayevo-Cherkessia)
An outbreak of dysentery, type Shigella sonnei (shigellosis), has been reported in the south region of Karachayevo-Cherkessia. 71 people are hospitalized; 55 of them children. The outbreak was due to consumption of impure milk products. (Promed 12/27/04)

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Dengue/DHF
Malaysia (Selangor and Kuala Lumpur)
There is a dengue alert in Selangor and Federal Territory as 100 suspected cases of the disease are being reported daily. Dr Ramlee Rahmat, the Health Ministry's Communicable Disease Control Division director, said the sudden rise in dengue cases was seen after Hari Raya last month [the first two days of Shawal, the 10th month of the Muslim lunar calendar, is Hari Raya Puasa and marks the end of Ramadan]. He said hospitals and health authorities were directed to thoroughly check all people showing signs of dengue fever. He said all state and district health departments have been directed to step up their checks and take action against those found breeding Aedes mosquitos. Local authorities in Selangor and Kuala Lumpur have also been enlisted to clean up drains and areas with stagnant water. In the first 9 months of 2004, 10 472 premises were issued notices carrying fines totaling RM 1.6 million [USD 420 000]. Between January and September [2004], 8273 suffered from dengue fever and 360 from dengue haemorrhagic fever. In that time, 38 people died from dengue haemorrhagic fever. (Promed 1/5/05)

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Viral gastroenteritis
USA (New Mexico)
The investigation into what caused patrons of a local restaurant to become ill is focusing on a viral infection, according to the New Mexico Environment Department. Frank Fiore, staff manager for the agency's Las Cruces and Alamogordo field office, said 21 Dec 2004 that the cause of the illness that has affected more than 50 customers of Margo's in Alamogordo appears to be a norovirus. Noroviruses are a group of related viruses that cause acute gastroenteritis in humans. The symptoms of norovirus-associated illness include nausea, vomiting, diarrhea, and some stomach cramping. People also have a low-grade fever, chills, headache, muscle aches and a general feeling of tiredness. The illness usually begins suddenly and the infected person may feel very sick. Symptoms usually last about one - two days. Fiore said the staff and owners of Margo's have been sanitizing the entire restaurant in preparation for reopening. Interviews are still being conducted with staff to determine how the illness might have been spread. Until samples from staff members come back from the lab, those employees will not be allowed to return to work. Because humans can carry norovirus and not know it, taking samples from employees is very important, according to Fiore. It appears that the outbreak has ended, and Fiore said the number of affected persons has not risen in recent days. (Promed 12/30/04)

New Zealand
Christchurch Hospital is urging people with vomiting and diarrhoea to stay away from its emergency department (ED) as it battles to contain an outbreak of norovirus infection. The hospital is warning those with the symptoms of the infection to call or see their GP or 24-hour medical centre first rather than turning up at the hospital. Norovirus infection swept through Princess Margaret Hospital earlier this year, closing several wards and infecting 200 patients and staff. It has now hit Christchurch Hospital, forcing the temporary closure of two wards to new admissions and the introduction of strict infection control measures. In a worrying development, the ED was seeing an increasing number of people with vomiting and diarrhoea. At this time of year, when people were prone to over-indulge or fall victim to food poisoning, it was difficult to distinguish norovirus infection from other [forms of gastroenteritis], but the hospital was erring on the side of caution and imposing strict infection control measures. Healthy people who contracted norovirus infection normally recovered within 48 hours, but the virus can be more harmful to children, the elderly and the infirm. Dr Chambers, the Christchurch Hospital's clinical director, said if people were being brought into the Emergency Department for any medical reason, it was important to restrict the number of people travelling with them. (Promed 12/30/04)

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West Nile Virus
Mexico
The most recent data in the Resumen Epidemiologico file in Mexico have not been updated since 9 Dec 2004. These data were posted on 25 Dec 2004 as part of West Nile virus update 2004 - Western Hemisphere <http://www.cenave.gob.mx/von/archivos/ResumenCASOSVON.xls>. As of 9 Dec 2004, the cumulative total of human tests carried out in Mexico remains at 387, and no additional seropositive individuals have been detected: in total, 387 individuals resident in 29 of the 32 states have been tested for evidence of West Nile virus infection; 386 were seronegative and asymptomatic, and one individual in the state of Sonora exhibited signs of disease. (Promed 12/31/04)

USA (New York)
Cases of West Nile virus infection plummeted in New York State in 2004. The mosquito-borne illness prompted some panic when it first hit America in 1999, but drew little attention this year in New York. In all, 10 people tested positive statewide for the virus in 2004, compared with 71 in 2003. Around 200 birds had confirmed West Nile in 2004, down from 1367 in 2003. Experts are not sure yet whether cases will remain scarce or whether the drop is simply part of a "down" cycle in the virus' lifespan. Still, officials say the virus, which is transmitted from birds to people by mosquitoes, is not going anywhere. West Nile virus spread to the New York City area in September 1999 and soon migrated to other states. The disease rarely causes serious symptoms. But for about one percent of the population, it causes possibly fatal encephalitis or meningitis. The drop occurred across the Northeast, with Delaware, Massachusetts, Rhode Island, and Vermont reporting no human cases of West Nile virus infection. (Promed 12/31/04)

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2. Articles
CDC EID Journal, Volume 11, Number 1-January 2005
CDC Emerging Infectious Diseases Journal, Volume 11, Number 1-January 2005 issue now available at: http://www.cdc.gov/ncidod/eid/index.htm. The following expedited article is also available: Human Disease from Influenza A (H5N1), Thailand, 2004, T. Chotpitayasunondh et al.

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Transmission of Malaria in Resort Areas --- Dominican Republic, 2004
“Malaria is caused by any of four Plasmodium parasites carried by Anopheles mosquitoes and usually is transmitted by the bite of an infective female Anopheles. In rural areas of the Dominican Republic, P. falciparum malaria is endemic, with the highest risk in the far western region of the country, and prophylactic medication with chloroquine is recommended for incoming travelers. Conversely, urban and resort areas in the Dominican Republic have been considered nonmalarious, and prophylactic medication has not been recommended for persons traveling to these areas. However, since November 2004, CDC has received reports of three malaria cases in U.S. travelers returning from areas in La Altagracia and Duarte provinces previously considered nonmalarious. An additional 14 cases of malaria in La Altagracia Province, in the far eastern region of the country, have been reported in European and Canadian travelers. This report describes three of these 17 malaria cases and summarizes the overall investigation, which led to expansion of CDC recommendations for chloroquine prophylaxis to include all of La Altagracia and Duarte provinces.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5351a1.htm (MMWR January 7, 2005 / 53(51 & 52);1195-1198)

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Fatal Rat-Bite Fever --- Florida and Washington, 2003
“Rat-bite fever (RBF) is a rare, systemic illness caused by infection with Streptobacillus moniliformis. RBF has a case-fatality rate of 7%--10% among untreated patients. S. moniliformis is commonly found in the nasal and oropharyngeal flora of rats. Human infection can result from a bite or scratch from an infected or colonized rat, handling of an infected rat, or ingestion of food or water contaminated with infected rat excreta. An abrupt onset of fever, myalgias, arthralgias, vomiting, and headache typically occurs within 2--10 days of exposure and is usually followed by a maculopapular rash on the extremities. This report summarizes the clinical course and exposure history of two rapidly fatal cases of RBF identified by the CDC Unexplained Deaths and Critical Illnesses (UNEX) Project in 2003. These cases underscore the importance of 1) including RBF in the differential diagnoses of acutely ill patients with reported rat exposures and 2) preventing zoonotic infections among persons with occupational or recreational exposure to rats.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5351a2.htm (MMWR January 7, 2005 / 53(51 & 52);1198-1202)

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Brief Report: Tularemia Associated with a Hamster Bite --- Colorado, 2004
“In April 2004, the Colorado Department of Public Health and Environment (CDPHE) was notified about a boy aged 3 years with diagnosed tularemia associated with a hamster bite. Tularemia has not been associated previously with pet hamsters. CDPHE conducted an investigation to determine whether other owners of hamsters were at risk. Clinicians and public health officials should be aware that pet hamsters are a potential source of tularemia.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5351a3.htm (MMWR January 7, 2005 / 53(51 & 52);1202-1203)

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3. Notifications
Handling Bodies after Disasters: New Book Offers Guidelines
The Pan American Health Organization (PAHO) has published a new manual that dispels myths about the handling and the effects of mass casualties following a natural disaster, such as the December 26 earthquake and tsunami in South Asia. For more information, please view: http://www.paho.org/English/DD/PIN/pr050104.htm (PAHO 1/4/05)

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UW South and Southeast Asia Earthquake and Tsunami Resources
University of Washington’s (Seattle, USA) Library offers a comprehensive South and Southeast Asia Earthquake and Tsunami Resources website, with News Sources, Additional Information, and Giving and Aid. http://www.lib.washington.edu/mcnews/newsflash/tsunami/

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Tsunami Just-in-Time Lecture
Below message from Ron LaPorte of SuperCourse: “The Tsunami in Asia was horrendous, and we wanted to do something to help. One of the major problems of Tsunami is "ignorance about Tsunami". This ignorance can lead to fear, and errors in actions. Ali Ardalan from Iran, Eugene Shubnikov from Russia, Faina Linkov, Eric Noji and Ron LaPorte, from the USA created with you a Tsunami Scientific lecture as we did for earthquakes. This lecture is designed to provide to educators across the world the best possible scientific lecture on Tsunamis. We also obtained input from meteorologists and seismologists world wide. The lecture can be found at: http://www.pitt.edu/~super1/lecture/lec18071/index.htm

If you would like the powerpoint files, please contact me (ronlaporte@aol.com). This is a part of our Supercourse, which is the global sharing of powerpoint lectures on prevention. www.pitt.edu/~super1/ Thanks so much. We would appreciate any comments. Please distribute this to the other members of your department.”

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FAO calls for $26 million to help tsunami victims
FAO launched an urgent appeal for $26 million for farmers and fisher folk hit by the South-Asian tsunami disaster, the agency said on the occasion of the international disaster summit in Indonesia. Funds are needed to finance emergency rehabilitation projects over the next six months. "The tsunami tidal waves have destroyed the livelihoods and the economic basis of many coastal communities in terms of death, injury, unemployment, loss of assets and migration," said Fernanda Guerrieri, Chief of FAO's Emergency Operations Service. "Fisheries and aquaculture are the sectors most seriously hit by the disaster with a devastating effect on many millions of mostly small-scale fishers who are dependent on a daily fish catch for food and sale," she said.

"The need for emergency rehabilitation of agriculture and fisheries in the region is enormous and will be definitely much higher than the amount we are asking for now," Guerrieri said. "Our assessment teams are currently out in the region to obtain a clear picture of the damage." FAO's initial call for international assistance is part of the United Nations flash appeal for tsunami victims in Asia. FAO has already provided a total of around $1.5 million from its own funds as emergency aid for agriculture and fisheries in Indonesia, the Maldives, Sri Lanka and Thailand. First assessment of the tsunami damages to fisheries and aquaculture, and other relevant reports, are available at: http://www.fao.org/tsunami/ (FAO 1/6/05)

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OIE Seminar
Challenges in responding to new international and social demands on the veterinary profession The 28th World Veterinary Congress will take place in Minneapolis, USA 16-20 July 2005 and will be held in conjunction with the American Veterinary Medical Association’s Annual Convention. For more information on this event, please visit: http://www.oie.int/downld/WVA_OIE_Semn.pdf (OIE)

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Recommended Childhood and Adolescent Immunization Schedule --- United States, 2005
Harmonized Childhood and Adolescent Immunization Schedule, 2005 “The Advisory Committee on Immunization Practices (ACIP) periodically reviews the recommended childhood and adolescent immunization schedule to ensure that the schedule is current with changes in vaccine formulations and reflects revised recommendations for the use of licensed vaccines, including those newly licensed. Recommendations and format of the childhood and adolescent immunization schedule for July--December 2004 were approved by ACIP, the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP) and were published in April 2004. That schedule updated previous ones by adding the recommendation that, beginning in fall 2004, healthy children aged 6--23 months, as well as household contacts and out-of-home caregivers for healthy children aged 0--23 months, receive annual influenza vaccine. The childhood and adolescent immunization schedule for 2005 is unchanged from that published in April 2004. In addition, the catch-up immunization schedule for children and adolescents who start late or who are >1 month behind remains unchanged from that published in January 2004 and again in April 2004. The childhood and adolescent immunization schedule and the catch-up immunization schedule for 2005 have been approved by ACIP, AAFP, and AAP.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5351-Immunizationa1.htm (MMWR January 7, 2005 / 53(51);Q1-Q3)

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4. APEC EINet activities
Tsunami disaster and APEC EINet
APEC EINet is on heightened alert and is monitoring the media and relevant sources for a rise in the incidence of infectious disease in the tsunami-affected region. We will continue to provide you with special updates to keep you informed about infectious disease news in the region. Currently we are also discussing other ways in which we can be of assistance by communicating with our partners at Hawaii's Tripler Army Medical Center (http://www.pacom.mil/special/0412asia/) and Uplift International, based in Seattle, USA (http://www.upliftinternational.org/).

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5. To Receive EINet Newsbriefs
APEC EINet email list
The APEC EINet email list was established to enhance collaboration among academicians and public health professionals in the area of emerging infections surveillance and control. Subscribers are encouraged to share their material with colleagues in the Asia-Pacific Rim. To subscribe (or unsubscribe), contact apec-ein@u.washington.edu. Further information about the APEC Emerging Infections Network is available at http://depts.washington.edu/einet/.

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 apecein@u.washington.edu