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Vol. X. NO. 16 ~ EINet News Briefs ~ Aug 03, 2007


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Global: WHO working group grappling with virus-sharing issues
- France (Moselle): Avian influenza H5N1 found in swans
- Myanmar (Yangon): New avian influenza H5N1 case confirmed in poultry
- Viet Nam (Ha Tay): Pregnant woman reportedly dies from avian influenza H5N1
- Viet Nam (Thanh Hoa): New suspected human case of avian influenza H5N1 infection
- Australia (Qeensland): Norovirus outbreak at hospitals
- Australia (South Australia): New Q fever fatality linked to abattoir
- China: Rabies still the deadliest infectious disease
- China/Taipei: Tracking down tuberculosis patients from Taipei
- China (Guangdong): Streptococcus suis diagnosed in man
- Viet Nam: Streptococcus suis kills 2 and sickens 42 persons
- Indonesia (Central Java): Burkholderia cocovenenans suspect of foodborne illness
- Philippines (Mindanao): Measles outbreak affects at least 50 persons
- Russia: Update on tick-borne encephalitis situation
- Russia (Urals): Legionnaires' disease outbreak
- USA: Acambis launches human trial of 'universal' flu vaccine
- USA: Flu vaccine distributor group reports on supply and delivery delays
- USA (Multi-state): More botulism cases reported
- USA: Update on Salmonellosis outbreak associated with veggie snack
- USA (Pennsylvania): Salmonellosis associated with unpasteurized milk
- USA (New York): E. coli O157 in ground beef sickens 7 persons
- USA (Pennsylvania): Hantavirus hospitalizes man
- USA (Maine): Paralytic shellfish poisoning hospitalizes 4 persons

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

2. Articles
- CDC EID Journal, Volume 13, Number 8—Aug 2007
- Duration of influenza A virus shedding in hospitalized patients and implications for infection control
- Molecular and antigenic evolution and geographical spread of H5N1 highly pathogenic avian influenza viruses in western Africa
- Botulism Associated with Commercially Canned Chili Sauce--Texas and Indiana, July 2007
- Cryptosporidiosis Outbreaks Associated with Recreational Water Use--Five States, 2006
- Disaster preparedness lessons learned and future directions for education: Results from focus groups conducted at the 2006 APIC Conference

3. Notifications
- New Medication for Severe Malaria Available Under an Investigational New Drug Protocol
- Public Health Informatics Fellowship Application Deadline--December 14, 2007
- Epidemic Intelligence Service Application Deadline--September 15, 2007
- Course on managing medical center outbreaks & emerging infections


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 / 13 (8)
Djibouti / 1 (0)
Egypt / 18 (10)
Indonesia / 56 (46)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 116 (80)

2007
Cambodia/ 1 (1)
China / 3 (2)
Egypt / 20 (5)
Indonesia / 27 (23)
Laos / 2 (2)
Nigeria / 1 (1)
Viet Nam 2 (0)
Total / 56 (34)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 319 (192).
(WHO 7/25/07 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO: http://www.wpro.who.int/sites/csr/data/data_Graphs.htm.
(WHO/WPRO 6/29/07)

WHO's maps showing world's areas reporting confirmed cases of H5N1 avian influenza in humans, poultry and wild birds (last updated 8/2/07): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 7/3/07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.

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Global: WHO working group grappling with virus-sharing issues
Representatives from 24 countries are meeting in Singapore this week to propose solutions to virus-sharing problems that threaten to derail global monitoring of the H5N1 avian influenza virus and stall the development of new vaccines and treatments. The meeting, sponsored by WHO, includes representatives from 4 countries in each of the WHO's 6 regions. Among the countries represented are Indonesia, Vietnam, Egypt, Thailand, Canada, Britain, and the US. In Dec 2006, Indonesia broke a long tradition of free international sharing of flu virus specimens by withholding its H5N1 virus samples as a protest against the high cost of commercial vaccines derived from such samples. In response, the World Health Assembly passed a resolution requesting that WHO establish an international stockpile of vaccines for H5N1 or other potential pandemic viruses and develop measures to ensure equitable, affordable distribution of the vaccines in the event of a pandemic.

The resolution also called for creation of an interdisciplinary working group to draw up new "terms of reference" for the sharing of flu viruses by WHO collaborating centers and reference laboratories. The terms would identify the origin of influenza viruses going into WHO Global Influenza Surveillance Network and make their use more transparent. The May WHO resolution called for an interdisciplinary working group to revise the terms of reference, devise oversight mechanisms, draft standard terms and conditions for sharing viruses, and review all relevant documents about sharing influenza viruses and sequencing data. David Heymann, head of communicable diseases for WHO, said that intergovernmental meeting would be held Nov 2007. Indonesia announced it would resume sharing its virus samples. Some researchers have voiced the concern that countries might claim their H5N1 samples are protected under intellectual property laws, which could hamper the monitoring of genetic mutations, the development of therapeutic products, and scientific work on other pathogens.
(CIDRAP 8/1/07)

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Europe/Near East
France (Moselle): Avian influenza H5N1 found in swans
2 wild swans found dead in northeastern France were carrying the H5N1 bird flu virus, the local veterinary service said 31 Jul 2007, the second outbreak of the disease in the area this month. The 2 birds were discovered 30 Jul 2007 in the Moselle region of France. Tests showed they were carrying the highly pathogenic H5N1 virus. 3 swans were killed by the H5N1 strain in Moselle at the start of Jul 2007, the first such outbreak in France in more than a year. The French government subsequently raised its alert level to "high," meaning that birds and poultry in France have had to be locked up or protected by nets to avoid all contact with wild birds.
(Promed 7/31/07)

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Asia
Myanmar (Yangon): New avian influenza H5N1 case confirmed in poultry
A new bird flu case has occurred in Myanmar's Bago division, the UN Food and Agricultural Organization (FAO) Yangon Office confirmed 31 Jul 2007. A poultry farm in the Letpadan township of the division, north of Yangon, was detected with the avian influenza 26 Jul 2007, FAO said. Confirming that the virus is H5N1, livestock authorities have taken measures including culling of a total of 3800 birds. Before the case, H5N1 virus were found in 2 poultry farms in Thanphyuzayat, Mon state 24 Jul 2007 and more than 300 chickens in the farms were slaughtered. In Jun 2007, some 4 bird flu cases occurred at farms in 3 townships of Hmawby, Insein and Bago. According to official statistics, during the bird flu outbreak period, nearly 2000 fowls died of the virus with 65 812 poultry from the affected farms and those nearby were culled. No humans have so far been detected with bird flu virus in the country.
(Promed 8/1/07)

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Viet Nam (Ha Tay): Pregnant woman reportedly dies from avian influenza H5N1
A hospital official in Vietnam said a 22-year-old woman who was 7 months pregnant died of H5N1 avian influenza, pushing the country's death toll from the disease this year to 3. Tran Thuy Hanh, director of Bach Mai Hospital in Hanoi, where the woman was a patient, said tests confirmed she was infected with the H5N1 virus. She was admitted to the hospital Jul 24 with a lung infection and breathing difficulties and was placed on a ventilator. The woman's case and 3 others (including 2 deaths) reported recently by Vietnam have not yet been confirmed by WHO. Confirmation of those cases would bring the WHO count for Vietnam to 99 cases with 45 deaths. For now WHO's Vietnam count is 95 cases with 42 deaths.

The woman was from a farm in Ha Tay province, which is the largest poultry supplier to Hanoi. She had worked as a chicken stools collector to feed fish since early 2006. Several days before the woman went to hospital, she bought chicken. All of her family ate the chicken but only the woman caught type A/H5N1 virus. Her family is now under supervision. 10 of the woman's close contacts have been monitored for symptoms of infection and given oseltamivir (Tamiflu). Pregnant women are known to be at increased risk for influenza complications, and health officials worry about how to prevent and treat pandemic influenza in this group. At least 2 other pregnant women are among WHO's confirmed H5N1 cases. 1 was a Chinese woman who was 4 months pregnant when she died Nov 2005. The other was a 22-year-old Indonesian woman who was 4 months pregnant when she died in May.
(CIDRAP 7/31/07; Promed 8/2/07)

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Viet Nam (Thanh Hoa): New suspected human case of avian influenza H5N1 infection
A student is under treatment at a Hanoi hospital for suspected bird flu. Dr Nguyen Hai Yen of the National Institute for Clinical Research of Tropical Diseases said 1 Aug 2007 the student's samples were being tested for the H5N1 virus strain. The student was transferred to the institute from a hospital in Thanh Hoa province. He had "typical" bird flu symptoms, though initial inquiries suggested he had had no contact with poultry. In Viet Nam, the virus returned strongly this year [2007], hitting scores of poultry farms in an unusual summertime outbreak. Outbreaks have been reported since early May 2007 in 18 of the country's 64 provinces and cities, mostly among unvaccinated ducks and other waterfowl. 6 human cases have also been reported. 2 of them, a 20-year-old man and a 28-year-old woman, died Jun 2007, the first fatalities since Nov 2005. Another 22-year-old woman died last week of the disease.
(Promed 8/2/07)

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Australia (Qeensland): Norovirus outbreak at hospitals
Queensland's health system is battling to cope with an outbreak of the highly infectious norovirus and anyone unwell or carrying the symptoms is being urged to stay away from hospitals. Norovirus-associated illness -- which causes vomiting, diarrhoea, nausea, stomach cramps, a fever, and headache -- has swept through staff and patients at the Royal Brisbane and Women's Hospital (RBWH). Gold Coast Hospital and the Cairns Base Hospital have also reported outbreaks of norovirus. While staff are beginning to return to work at the RBWH, the hospital is asking anyone unwell to postpone visits to the hospital. Patients with norovirus infection at the RBWH have been isolated to protect staff, patients, and visitors.

Norovirus victims remain infectious for at least 72 hours after the symptoms have gone. To reduce the chances of infection, people are advised that before handling or eating food they thoroughly wash their hands after using the toilet or changing nappies. Noroviruses are a common cause of acute gastroenteritis worldwide. Norovirus infection presents as vomiting and diarrhea and often occurs in large outbreaks propagated by fecal-oral transmission via contaminated food or water or by person-to-person contact.
(Promed 7/24/07)

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Australia (South Australia): New Q fever fatality linked to abattoir
The South Australian Health Department has confirmed that an elderly woman has died after contracting Q fever in the Riverland town of Waikerie. The outbreak has been linked to a goat abattoir and has affected 5 people who lived nearby. The disease is carried by animals and can cause flu-like symptoms in people. The abattoir stopped operations Jun 2007. The 76-year-old woman who has died had an underlying medical condition. Most patients with Q fever endocarditis are men over the age of 40, but women and children also develop this complication. Most patients with Q fever endocarditis have preexisting valve disease. Infection of humans usually occurs by inhalation of these organisms from air that contains airborne barnyard dust contaminated by dried placental material, birth fluids, and excreta of infected herd animals. Humans are often very susceptible to the disease, and very few organisms may be required to cause infection.
(Promed 7/30/07)

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China: Rabies still the deadliest infectious disease
Rabies is now the deadliest infectious disease in China. Rarely fatal in the West [because of little exposure to rabid animals, and effective post-exposure treatment], rabies is killing more than 200 people here per month, outpacing tuberculosis deaths in 13 of the last 14 months. In 1996, figures show only 163 Chinese died from rabies. Last year [2006], the disease killed 3215. "The World Health Organization is extremely concerned about the number of cases in China," says Dr. Nima Asgari, WHO's communicable disease specialist in Beijing. Last year [2006], desperate to stem the epidemic, public health officials touched off a storm of criticism by ordering a mass extermination of dogs in some areas. With the 2008 Olympics only a year away now, Beijing wants to make sure nothing goes wrong. Police have gotten tough enforcing a 2003 "one-family, one-dog" policy in 8 city districts and have rounded up unregistered dogs. More than 140 000 people turned up at city hospitals in 2006 to be treated for dog bites. In the countryside and especially in the south is where the real problem lies, says Dr. Luo Tingrong, a professor of veterinary medicine at Guangxi University. 5 key provinces -- including Guangxi -- account for more than 70 percent of the problem. The reasons for the outbreak are 3-fold, he says: rising incomes have meant a rapid increase in the number of dogs; far too many remain unvaccinated; and people in the countryside, in particular, remain unaware of the seriousness of the problem.
(Promed 7/25/07)

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China/Taipei: Tracking down tuberculosis patients from Taipei
China has tracked down 2 Taiwanese tuberculosis (TB) patients who defied a flight ban, Taiwan's Centers for Disease Control said 28 Jul 2007. The patients, a 55-year-old man suffering a drug-resistant form of TB and his 57-year-old wife who has standard TB and is infectious, were found in the eastern province of Jiangsu 27 Jul 2007, CDC said. The couple, who took a flight from the Taiwanese city of Kaohsiung to Hong Kong and then boarded a plane to Nanjing in China 25 Jul 2007, have been transferred to hospital. Health authorities in Taiwan, Hong Kong and China launched a hunt for the couple and passengers who sat near them on the flights. The man and wife had gone to stay with relatives in Nanjing. Taipei had dispatched a medical officer to help them obtain treatment in China and arrange their journey home. Taiwan prohibits people with multi-drug resistant TB from any air travel.

TB is a highly infectious disease that is spread by coughing and sneezing. It kills about 1.6 million people a year. 1 in 3 people worldwide is infected with dormant TB bacteria but it is only when a person's immunity is low that the TB bacteria becomes active. TB is acquired through inhalation of aerosolized respiratory secretions that contain Mycobacterium tuberculosis from a contagious person who is coughing, talking, or sneezing. The risk of transmission is related to the infectiousness of the person with TB, the duration of exposure, the proximity to the source person, and the ventilation. Taiwan CDC states that the duration of each flight was less than 8 hours and therefore they believe that risk to other passengers is negligible. The Taiwan CDC consequently "does not recommend the passengers and crew to immediately undergo medical examination or X-ray examination."

In response to reports in the 1990's of the transmission of TB during long flights from contagious travelers to other passengers and crew, WHO published regulations for travelers, physicians and health authorities, and airline companies: http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.363_eng.pdf These regulations state clearly that: "People known to have infectious TB must not travel by public air transportation until at least 2 weeks of adequate treatment have been completed. Patients with MDR-TB should not travel until they have been proved to be non-infectious (that is, culture-negative)."
(Promed 7/27/07, 7/28/07)

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China (Guangdong): Streptococcus suis diagnosed in man
A 49-year-old man from south China's Shenzhen city has been diagnosed with Streptococcus suis, a pig-borne bacterial disease that can be fatal. The patient is receiving treatment and is in stable condition. The man, who lives in Bao'an District, felt sick 19 Jul 2007 and went to a local clinic for treatment. His condition improved after treatment, but he fell into a coma 21 Jul 2007 and was sent to Longhua Hospital for treatment. He has since been transferred to Shenzhen People's Hospital, and the Shenzhen Disease Control and Prevention Center diagnosed him with the disease. The local government did not reveal how the man contracted the disease but did say that health and agricultural authorities had strengthened inspections of meat products. The man's family members, colleagues and roommates have shown no symptoms of the disease, and no epidemic has been found among pigs in the Shenzhen. Initial symptoms of Streptococcus suis are fever, headaches and dizziness and it can cause meningitis and arthritis.
(Promed 7/26/07)

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Viet Nam: Streptococcus suis kills 2 and sickens 42 persons
A pig disease in Viet Nam that has sickened 42 people and killed 2 has the government calling for speedier investigations and urgent measures to control the bacteria. Cao Duc Phat, the agriculture minister, said that initial assessments showed the disease caused by Streptococcus suis bacteria had spread in the country. The bacteria came to light after 22 people in the northern provinces became infected, followed by 20 in the southern region. Animal health authorities should increase disease surveillance, work out treatment measures for pigs, and publish information to raise public awareness, Phat said. People can be infected after coming into direct contact either by hand or eating pork from a sick pig, Nguyen Hong Ha, deputy head of the National Institute for Infectious and Tropical Diseases, said. Person-to-person spread does not seem to occur. The bacteria causes rapid internal haemorrhage and high fever and can [progress to] meningitis, septicaemia, and endocarditis in the next stage leading to death or deafness if the victim survives.
(Promed 7/21/07, 7/26/07)

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Indonesia (Central Java): Burkholderia cocovenenans suspect of foodborne illness
Preliminary tests by the Health Ministry point to food poisoning in the mysterious deaths of 10 people in Magelang regency, Central Java, an official said 31 Jul 2007. "Before becoming ill, the victims ate tempe gembus (fermented soybean pulp) that was contaminated with the toxin producing Pseudomonas cocovenenans bacterium [now Burkholderia cocovenenans or B. gladioli pathovar cocovenenans]," Health Minister Siti Fadilah Supari said. The ministry's director general of disease control and environmental health, Nyoman Kandun, said his office would announce its final conclusions within the next 2 weeks. There have in the past been reported deaths in Central Java caused by the consumption of food contaminated with Pseudomonas cocovenenans. Most of these incidents were the result of people eating tempe bongkrek (soybean cake made with coconut pulp). The bacterium produces a lethal toxic substance that damages human cells. On 23 and 24 Jul 2007, 10 residents of Beran hamlet in Kanigoro village in Magelang died after complaining of similar symptoms, stomach pain, nausea and headaches. A total of 20 others with similar symptoms are being treated. "Our team has found Pseudomonas cocovenenans in food samples and in the victims' vomit, but we still have to cross-check the results with other laboratories," Kandun said.
(Promed 8/2/07)

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Philippines (Mindanao): Measles outbreak affects at least 50 persons
A measles outbreak that downed at least 50 residents in some areas of Zamboanga City since last week [16-22 Jul 2007] has been traced to "conflict" areas in Mindanao, such as Basilan province. On 25 Jul 2007, Health Secretary Francisco Duque III blamed the conflict in [this] area, which he said interrupted his department's measles vaccination program there. Basilan is now the site of ongoing pursuit operations by the military against the killers of 14 Marines during an encounter in Tipo-Tipo 10 Jul 2007. Reportedly, 40 were cases reported last week [16-22 Jul 2007], and another 10 were reported from "sporadic" areas of Sta. Barbara, Sangali, and Canelar. Children 6 years old and below are the main targets of the immunization drive. He said the spread of measles in the city started when Basilan [province] had experienced an outbreak.
(Promed 7/25/07)

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Russia: Update on tick-borne encephalitis situation
A total of 2 new cases of tick-borne encephalitis (TBE) have been registered in the Irkutsk Oblast during the past week [8-15 Jul 2007]. Altogether, 60 cases of TBE have been recorded since the beginning of the season [10 Apr 2007]. A total of 40 cases of TBE have been confirmed now among 97 patients hospitalized on suspicion of having contracted the disease in the Arkhangelsk Oblast. Since 10 Apr 2007, 26 573 inhabitants of the Kemerovo Oblast have sought medical treatment, including 5539 children. A total of 56 cases of TBE have been laboratory confirmed and 2 people have died. All this is happening against the background of global shortage of specific immune globulin, which helps to prevent infection and improve survival. TBE, also known as Russian spring-summer encephalitis, is a flavivirus infection of the central nervous system. Human infections are acquired through bites of infected ticks or, rarely, by ingesting unpasteurized dairy products primarily from infected goats, sheep, or cows.
(Promed 7/21/07)

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Russia (Urals): Legionnaires' disease outbreak
A total of 3 people have died and more than 100 others ranging in age from 18 to 81 have been hospitalized in Russia with Legionnaires' disease. The outbreak is confined to an area some 6 miles from Yekaterinburg in the Urals region, it was reported 30 Jul 2007. An official of the regional health ministry says all of the victims are local residents and most are showing improvement with antibiotic therapy. Authorities say the infection likely was spread through the water supply system. Legionnaire's disease is a type of pneumonia caused by breathing in mist from water that contains the bacteria Legionella. Legionnaires' disease is the acute pneumonic form of disease caused by Legionella, usually Legionella pneumophila. L. pneumophila grows best in warm water and are intracellular parasites of amebas that are found in biofilms that line piping in warm water plumbing systems. Aerosols can be generated by a building's faulty air conditioning systems, shower heads, misters, whirlpool spas, and other such devices.
(Promed 7/31/07)

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Americas
USA: Acambis launches human trial of 'universal' flu vaccine
Acambis, a British biotechnology company, recently announced the launch of a phase 1 clinical trial of an influenza vaccine designed to provide a stable shield against seasonal and pandemic flu strains and eliminate the need to overhaul the flu vaccine each year. Known as ACAM-FLU-A, the vaccine is designed to target all influenza A virus strains, Acambis said. If successful, the product will mark a major step toward a universal flu vaccine—one that would protect against all strains of both influenza A and B. The randomized, double-blind, placebo-controlled, multicenter trial will be conducted in the US. Investigators will assess the vaccine's safety, tolerability, and ability to generate an immune response in up to 80 healthy volunteers between ages 18 and 40, the company said.

The trial will also assess the effectiveness of 2 adjuvants (immune-boosting chemicals): aluminum hydroxide and QS-21 Stimulon, an investigational adjuvant. Michael Watson, Acambis' executive vice-president for research and development, said an effective universal vaccine will not require reengineering each time the virus mutates. Such a vaccine could be manufactured continuously, and people could be immunized any time of year. Frequent minor changes in flu viruses involve 2 surface proteins, hemagglutinin and neuraminidase, represented by the H and N in virus names. Because the H and N components are highly mutable, vaccine makers must adjust the flu shot components every year to match circulating strains. However, Acambis's vaccine involves a more stable viral protein called M2, the ion channel protein. The company said the key component in its flu vaccine is M2e, the extracellular domain of M2, which is specific to influenza A. The hope is that M2e will produce an immune response against all influenza A stains. Acambis also said it is searching for a similarly conserved region on influenza B virus strains so that it can offer a vaccine that protects against all human seasonal flu strains.
(CIDRAP 7/30/07)

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USA: Flu vaccine distributor group reports on supply and delivery delays
The Health Industry Distributors Association (HIDA), a group that includes 600 companies that distribute half of the US’s flu vaccine supply, released a report to help shed light on some of the supply chain obstacles that have delayed vaccine shipments to doctors' offices. During the 2006-07 season, influenza vaccine producers made a record 120.9 million flu vaccine doses, but 18.4 million of them went unsold amid complaints from many physicians that they received their supplies too late.

Earlier this year, officials said the vaccine glut was caused by a combination of record production, distribution delays, and a mild flu season. Sanofi, the largest producer of flu vaccines for the US market, had attributed some of the delay to a slow-growing influenza (H3N2) strain. GlaxoSmithKline and Novartis also said they had problems growing the strain. "The supply came later than expected or arrived in several staggered and/or partial shipments during peak periods of demand," the HIDA report says. Last season manufacturers shipped 50% of the flu vaccine supply to customers; distributors delivered the other half, which was up from the 35% they supplied the 2005-06 season, the report states.

The vaccine manufacturing process is a 5- to 8-month process that incorporates at least 15 weeks of lot testing by the US Food and Drug Administration (FDA), the HIDA report says. Scientists must test the safety and potency of each lot of vaccine. This season, vaccine manufacturers have projected they will make 127 million to 132 million doses for the US market for the 2007-08 flu season, another record, according to CDC. Production for 2007-08 could be even higher if the FDA approves a seasonal flu vaccine from a fifth manufacturer, CSL Biotherapies, the US branch of an Australian company. CDC and has pushed for later flu vaccination clinics to help providers and their patients better adjust when vaccine supplies are delayed. Though many flu vaccination efforts focus on early autumn, CDC says administering the flu vaccine in November, December, January, and beyond is consistent with the recommendations from the Advisory Committee on Immunization Practices.
(CIDRAP 7/27/07)

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USA (Multi-state): More botulism cases reported
Since the US Food and Drug Administration (FDA) warned of a link between 4 botulism cases and contaminated chili sauce 2 weeks ago, state health departments have confirmed 1 additional botulism case and reported at least 3 more suspected cases. The initial recall, issued Jul 19, 2007, involved canned hot-dog chili sauce made at a Castleberry Foods production facility. A few days later the recall was expanded to more than 80 of the company's products, which included chili, hash, barbecue meat products, and a few pet food products. The expanded recall includes Great Value chili sold in Canada. The recall now covers 2 years' production, a tally that spirals into the tens of millions of cans. Spot checks by officials continue to turn up recalled products for sale in stores. A full list of recalled products can be found at: www.castleberrys.com.

The 4 previous patients included 2 Texas children and an Indiana couple. CDC said the children, who are siblings, were hospitalized Jun 29 and received botulinum antitoxin Jul 7. Initial stool cultures did not reveal the pathogen, and stool and serum cultures taken 9 days after symptom onset were negative for botulinum toxin. Both are still hospitalized. The Indiana couple became ill Jul 7 and were hospitalized 2 days later. They received botulinum antitoxin Jul 11.The man's serum sample tested positive for botulinum toxin type A. The woman's serum sample was also positive, but the scant volume didn't allow the laboratory to determine the toxin type. Samples from leftover chili sauce also tested positive for botulinum toxin type A. The patients remained hospitalized.

FDA investigators believe Castleberry's failed to properly cook some or all the products, allowing the Clostridium botulinum bacteria to survive the canning process. In the oxygen-free and moist environment of the sealed cans, the bacteria thrive and produce a toxin that causes botulism. Botulinum toxin is a nerve poison produced by Clostridium botulinum, a bacterium commonly found in soil. Botulism symptoms include double or blurred vision, droopy eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness. If untreated, the illness can progress to paralysis of the limbs, trunk, and breathing muscles. CDC said it receives about 110 reports of botulism each year, of which about 25% are foodborne. Outbreaks of foodborne botulism typically involve two or more people and are usually caused by contaminated home-canned foods. The extremely potent toxin can also infect people if it is inhaled, swallowed or absorbed through the eye or breaks in the skin.

Mark Horton, director of the California Department of Public Health (CDPH), said tests confirmed that a 51-year-old San Diego woman has botulism poisoning. State health authorities were investigating whether her illness was linked to the contaminated products. The woman reported buying and eating one of the recalled products, Kroger Chili with Beans, early Jul. However, she threw the product away before it could be tested. She had been hospitalized but was recovering at home. On Jul 27 the Hawaii Department of Health (HDH) said it was investigating a possible case of botulism poisoning on Maui. The patient met some of the clinical criteria for botulism and was being treated pending laboratory confirmation. In addition, Indiana media reported Jul 31 that a resident was hospitalized with suspected botulism poisoning. Doctors at Logansport Memorial Hospital had noticed the patient had some botulism symptoms, though it was not clear if the patient had consumed any of the recalled products. Reportedly CDC provided botulism antitoxin for the patient. Elsewhere, officials in New Mexico said a 52-year-old man from Sandoval County was paralyzed with botulism poisoning. Officials were trying to determine if he ate food included in the national recall. The man was hospitalized Jul 26 and is in serious condition.
(CIDRAP 7/20/07, 7/23/07, 8/2/07; Promed 7/25/07, 7/30/07)

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USA: Update on Salmonellosis outbreak associated with veggie snack
As of 18 Jul 2007, 65 persons infected with Salmonella enterica serotype Wandsworth have been reported to CDC from 20 states. Among the patients for whom clinical information is available, all had diarrhea, 76 percent had bloody stools, and 6 patients were hospitalized. No deaths have been attributed to these infections. 91 percent of cases have occurred in children aged 10 months to 3 years. A multi-state case-control study demonstrated a strong association between illness and consumption of Veggie Booty, a snack of puffed rice and corn with a vegetable coating. The company that manufactures the product issued a voluntary recall 28 Jun 2007. None of the 65 known illnesses from S. Wandsworth began after the product was recalled.

Officials at CDC and health departments, FDA, and the marketing and manufacturing companies are working collaboratively to learn more about production of Veggie Booty to determine how it may have become contaminated. The Minnesota Department of Agriculture Laboratory (MDAL) has isolated the outbreak strain of S. Wandsworth from sealed bags of Veggie Booty. The outbreak strain has also been isolated from sealed bags of Veggie Booty by the FDA laboratory and the New York State Department of Health. MDAL also isolated S. Typhimurium, a different strain of Salmonella, from a sealed bag of Veggie Booty. PulseNet identified 10 persons who had illness caused by this strain of S. Typhimurium between 1 Jun and 27 Jun 2007. 8 of the 10 ill persons with this strain of S. Typhimurium had consumed Veggie Booty during the week before their illnesses began. On 2 Jul 2007, the company expanded the recall to include Super Veggie Tings Crunchy Corn Sticks. This was done due to the company's concern that Veggie Booty and Super Veggie Tings share ingredients that could be contaminated.
(Promed 7/21/07)

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USA (Pennsylvania): Salmonellosis associated with unpasteurized milk
Stump Acres Dairy has stopped giving away raw milk after some customers became sick and were diagnosed with salmonella. This marks the third time in 2007 that the North Codorus Township dairy has stopped selling or giving away raw milk because of customers becoming ill. Consumers who got raw milk from the dairy Jul 2007 experienced gastrointestinal illness and have been diagnosed with salmonella, according to the Pennsylvania Department of Agriculture and the Pennsylvania Department of Health. The Department of Health is advising customers to discard any raw milk or any products made with the raw milk that came from the dairy. The agriculture and health departments have asked the dairy to halt sales of the raw milk. Pathogens that infect humans, including Salmonella, are shed in the feces of cows and can contaminate milk during the milking process. Using standard hygiene practices during milking (such as washing hands, keeping equipment clean, and keeping the milking area separated from other areas) can reduce but not eliminate the risk for contamination. Pasteurization decreases the number of pathogenic organisms, prevents transmission of pathogens, and has been determined to improve the safety of raw milk. To prevent infections, consumers should not drink raw milk.
(Promed 7/22/07)

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USA (New York): E. coli O157 in ground beef sickens 7 persons
A total of 7 people in Suffolk County (NY) were sickened in recent weeks after eating undercooked ground beef contaminated with E. coli, officials said 23 Jul 2007. In one case, a visiting 8-year-old North Carolina girl was hospitalized after her kidneys shut down, said Patricia Dillon, director of communicable diseases for Suffolk's health department. The girl remained hospitalized. All the victims said they ate hamburgers. Officials said the meats were of different brands and were purchased at several supermarkets, grocery stores, and local butcher shops throughout the county. Test results identified the bacteria strain as E. coli O157. Analysis showed that 2 of Suffolk's cases matched cases reported in Minnesota and California. A third Suffolk case matched those reported in Michigan. Dillon said the analysis showed that the meats that sickened people [in Suffolk] were contaminated in the production chain outside Suffolk. "The meats consumed by people in Suffolk, California, and Minnesota all came from the same source of contamination," Dillon said. The men, women, and children who fell ill in Suffolk ranged in age from 8 to 72, and reported symptoms such as diarrhea or bloody diarrhea.
(Promed 7/25/07)

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USA (Pennsylvania): Hantavirus hospitalizes man
A man contracted and recovered from hantavirus pulmonary syndrome, a rare and potentially fatal pneumonia-like virus carried by rodents, the state health department said 24 Jul 2007. The 40-year-old man worked at a Boy Scout camp in Clearfield County. He was hospitalized after falling ill earlier Jul 2007 but has since been discharged. The camp has since cleaned rodent droppings in buildings, put in traps and poison bait to reduce rodent populations, and sealed openings to prevent rodents from entering. Because the camp took immediate steps to avoid further exposures, it was allowed to remain open. The syndrome begins with fever, muscle aches, nausea and vomiting and can lead to respiratory failure and shock. Although there is no specific treatment, early diagnosis is important for recovery.
(Promed 7/26/07)

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USA (Maine): Paralytic shellfish poisoning hospitalizes 4 persons
On 31 Jul 2007, 4 persons from a Washington County fishing household were hospitalized with symptoms of paralytic shellfish poisoning (PSP) within several hours of sharing a meal of mussels. Samples of mussels taken from the home were highly contaminated with the toxin that causes paralytic shellfish poisoning. Maine Center for Disease Control and Prevention (Maine CDC) sent a health alert to health care providers 1 Aug 2007. Maine CDC is now assisting the Maine Department of Marine Resources (DMR) to determine the source of the implicated mussels and to assure that any harvested shellfish available to the public continue to be safe to eat. PSP -- also called red tide -- is a marine biotoxin that is associated with certain types of algae blooms in coastal waters. Bivalve shellfish eat and filter the toxic algae, and the concentrations of the toxin can cause serious illness or death if eaten by humans. Symptoms of PSP include tingling of face and neck areas, headaches, nausea, and muscle weakness. In extreme cases, these symptoms can lead to respiratory failure. Symptoms usually occur within 2 hours of eating contaminated shellfish.
(Promed 8/2/07)

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1. Updates
Avian/Pandemic influenza updates
- UN: http://influenza.un.org/. UN response to avian influenza and the pandemic threat. Also, http://www.irinnews.org/Birdflu.asp provides information on avian influenza.
- 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.
- OIE: http://www.oie.int/eng/en_index.htm.
- US CDC: http://www.cdc.gov/flu/avian/index.htm. News on federal updates.
- 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.
- CIDRAP: http://www.cidrap.umn.edu/.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Updated 27 Jul 2007.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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Cholera, Diarrhea, Dysentery
China (Guandong)
On 19 Jun 2007, Guandong Provincial Health Bureau announced 2 confirmed cases of cholera. Both patients serve as nannies. On 13 Jun 2007, they developed low-grade fever, diarrhea, and other symptoms. Lab analysis was positive for Vibrio cholerae (Inaba type). Prior to becoming ill, the patients had eaten blue crab, freshwater prawns, and other food. There is a high likelihood that food was the source of infection.
(Promed 7/20/07)

Indonesia (Banten)
A total of 4 children have now died in an outbreak of diarrhea in Tangerang regency, which has affected 5 districts. The head of the communicable diseases prevention unit at the regency's health agency, Yuliah Iskandar, said 16 Jul 2007 that 2 children in Lebak Wangi village and another in Sarakan village, both in Sepatan district, had died of dehydration. The first death was of a 2-year-old girl 12 Jul 2007. According to the agency, 487 people, mostly children, have been treated for diarrhea at public health clinics. While Regent Ismet Iskandar earlier blamed residents and their lack of understanding of proper sanitation for the outbreak, Yuliah said the outbreak was not caused by contaminated water used in their homes. The outbreak began early the week of 8-14 Jul 2007 in Sepatan district, spreading to Sepatan Timur, Pakuhaji, Rajeg, and Sukadiri districts. The Tangerang regency administration has declared the diarrhea outbreak an "extraordinary occurrence" in the 5 districts.
(Promed 7/20/07)

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Dengue
Philippines (Caraga)
At least 678 persons, most of them minors, reportedly fell ill from dengue and got confined at sentinel hospitals in 3 cities and 4 provinces of Caraga Region, the Department of Health (DOH) Caraga Regional Office said. Hard hit are Butuan City with 173 cases, Surigao del Sur, 175 cases, and Agusan del Norte with 84 cases. Surigao City has 38 cases of dengue, Bislig City has 18, while Surigao del Norte has 30 cases. The reported dengue cases are from Jan 2007 to 14 Jun 2007.
(Promed 7/30/07)

Viet Nam
The number of dengue cases in Vietnam has soared by 40 percent this year to 32 900, including 34 fatalities. Experts have feared that this year could be the worst year on record for the mosquito-borne disease as hot weather and rising rainfall have created thriving mosquito populations. Most cases have been reported in the country's southern Mekong Delta. The delta's Tien Giang province has seen 4800 infection cases, including 5 deaths. Out of Dong Thap province's 4600 infections 4 people have died while Kien Giang's 3200 cases have included 6 deaths. Viet Nam is recording 3000 new dengue infections every week, an increase of over 33.3 percent year-on-year. Vietnam reported over 77 800 cases of dengue fever infections in 2006, including 68 fatalities.
(Promed 7/30/07)

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West Nile Virus
Canada
Human cases were reported for week 27 (as of 7 Jul 2007) from the following provinces:
Province / Neurological / Non-Neurological / Unclassified-Unspecified/ Total/ Asymptomatic
Manitoba / 0 / 6 / 0 / 12 / 1
Saskatchewan / 0 / 1 / 0 / 3 / 0
TOTALS / 0 / 7 / 0 / 15 / 1
(Promed 8/1/07)

USA
Human cases have been reported from (through 10 Jul 2007): State / Neuroinvasion/West Nile fever/ Other, Unspecified/ Total/ Fatalities:
Alabama / 2 / 2 / 0 / 4 / 2
Arizona / 0 / 1 / 6 / 7 / 0
Arkansas / 1 / 0 / 0 / 1 / 0
California / 17 / 24 / 1 / 42 / 2
Colorado / 2 / 8 / 0 / 10 / 0
Idaho / 0 / 8 / 0 / 8 / 0
Illinois / 2 / 0 / 1 / 3 / 0
Iowa / 1 / 1 / 0 / 2 / 0
Kansas / 2 / 1 / 0 / 3 / 0
Minnesota / 3 / 1 / 0 / 4 / 0
Mississippi / 5 / 8 / 0 / 13 / 1
Missouri / 0 / 2 / 0 / 2 / 0
Nebraska / 0 / 12 / 0 / 12 / 0
Nevada / 0 / 1 / 0 / 1 / 0
New Mexico / 2 / 0 / 0 / 2 / 0
North Dakota / 4 / 10 / 0 / 14 / 0
Ohio / 1 / 0 / 0 / 1 / 0
South Dakota / 12 / 26 / 0 / 38 / 1
Texas / 4 / 2/ 0 / 6 / 0
Utah / 1 / 1 / 0 / 2 / 0
Virginia / 1 / 0 / 0 / 1 / 0
Wyoming / 0 / 9 / 0 / 9 / 0
TOTALS / 60 / 117 / 8 / 185 / 5
(Promed 8/1/07)

West Nile Virus Update--United States, January 1--July 24, 2007
This report summarizes 2007 West Nile virus (WNV) surveillance data reported to CDC through ArboNET as of July 24, 2007. A total of 19 states have reported 122 cases of human WNV illness to CDC. A total of 68 (56%) cases for which such data were available occurred in males; median age of patients was 48 years (range: 15 months--96 years). Dates of illness onset ranged from Mar 25 to Jul 18; 3 cases were fatal. A total of 23 presumptive West Nile viremic blood donors (PVDs) have been reported to ArboNET during 2007. Of the 23 PVDs, 7 persons (median age: 38 years [range: 18--79 years]) subsequently had West Nile fever. For more information: http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and http://westnilemaps.usgs.gov.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5629a4.htm
(MMWR July 27, 2007 / 56(29);740-741)

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2. Articles
CDC EID Journal, Volume 13, Number 8—Aug 2007
CDC Emerging Infectious Diseases Journal Aug 2007 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. Expedited articles can be viewed at: http://www.cdc.gov/ncidod/eid/upcoming.htm.

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Duration of influenza A virus shedding in hospitalized patients and implications for infection control
Leekah S, et al. Infect Control Hosp Epidemiol 2007 Sep;28(9)
Abstract: “OBJECTIVE. To assess the duration of shedding of influenza A virus detected by polymerase chain reaction (PCR) and cell culture among patients hospitalized with influenza A virus infection. SETTING. Mayo Clinic (Rochester, Minnesota) hospitals that cater to both the community and referral populations. METHODS. Patients 18 years old and older who were hospitalized between December 1, 2004, and March 15, 2005, with a laboratory-confirmed (ie, PCR-based) diagnosis of influenza A virus infection were consecutively enrolled. Additional throat swab specimens were collected at 2, 3, 5, and 7 days after the initial specimen (if the patient was still hospitalized). All specimens were tested by PCR and culture (both conventional tube culture and shell vial assay). Information on demographic characteristics, date of symptom onset, comorbidities, immunosuppression, influenza vaccination status, and receipt of antiviral treatment was obtained by interview and medical record review. Patients were excluded if informed consent could not be obtained or if the date of symptom onset could not be ascertained. RESULTS. Of 149 patients hospitalized with influenza A virus infection, 50 patients were enrolled in the study. Most patients were older (median age, 76 years), and almost all (96%) had underlying chronic medical conditions. Of 41 patients included in the final analysis, influenza A virus was detected in 22 (54%) by PCR and in 12 (29%) by culture methods at or beyond 7 days after symptom onset. All 12 patients identified by culture also had PCR results positive for influenza A virus. CONCLUSION. Hospitalized patients with influenza A virus infection can shed detectable virus beyond the 5- to 7-day period traditionally considered the duration of infectivity. Additional research is needed to assess whether prolonging the duration of patient isolation is warranted to prevent nosocomial outbreaks during the influenza season.”
(CIDRAP 8/1/07)

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Molecular and antigenic evolution and geographical spread of H5N1 highly pathogenic avian influenza viruses in western Africa
M. F. Ducatez, et al. Journal of General Virology, 88, 2297-2306, 2007: <http://jgv.sgmjournals.org/cgi/content/abstract/88/8/2297>
“In Africa, highly pathogenic avian influenza H5N1 virus was first detected in northern Nigeria and later also in other regions of the country. Since then, seven other African countries have reported H5N1 infections. This study reports a comparison of full-length genomic sequences of H5N1 isolates from seven chicken farms in Nigeria and chicken and hooded vultures in Burkina Faso with earlier H5N1 outbreaks worldwide. In addition, the antigenicity of Nigerian H5N1 isolates was compared with earlier strains. All African strains clustered within three sublineages denominated A (south-west Nigeria, Niger), B (south-west Nigeria, Egypt, Djibouti) and C (northern Nigeria, Burkina Faso, Sudan, Côte d'Ivoire), with distinct nucleotide and amino acid signatures and distinct geographical distributions within Africa. Probable non-African ancestors within the west Asian/Russian/European lineage distinct from the south-east Asian lineages were identified for each sublineage. All reported human cases in Africa were caused by sublineage B. Substitution rates were calculated on the basis of sequences from 11 strains from a single farm in south-west Nigeria. As H5N1 emerged essentially at the same time in the north and south-west of Nigeria, the substitution rates confirmed that the virus probably did not spread from the north to the south, given the observed sequence diversity, but that it entered the country via three independent introductions. The strains from Burkina Faso seemed to originate from northern Nigeria. At least two of the sublineages also circulated in Europe in 2006 as seen in Germany, further suggesting that the sublineages had already emerged outside of Africa and seemed to have followed the east African/west Asian and Black Sea/Mediterranean flyways of migratory birds.”
(Promed 7/29/07)

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Botulism Associated with Commercially Canned Chili Sauce--Texas and Indiana, July 2007
“On July 7 and July 11, 2007, public health officials in Texas and Indiana, respectively, reported to CDC 4 suspected cases of foodborne botulism, 2 in each state. Investigations conducted by state and local health departments revealed that all 4 patients had eaten brands of Castleberry's hot dog chili sauce before illness began. Botulinum toxin type A was detected in the serum of 1 Indiana patient and in a leftover chili mixture obtained from his home. CDC informed the Food and Drug Administration (FDA) of the apparent link between illness and consumption of the chili sauce. On Jul 18, FDA issued a consumer advisory, and the manufacturer, Castleberry's Food Company. . .subsequently recalled the implicated brand and several other products produced in the same set of retorts. . .at the same canning facility. Examination of the canning facility in Georgia during the outbreak investigation had identified deficiencies in the canning process. On July 19, the U.S. Department of Agriculture Food Safety and Inspection Service (FSIS) announced a recall of chili and certain meat products from the Castleberry canning facility and provided recommendations to consumers. That recall was expanded on July 21 to include additional canned products. A fifth case of botulism potentially linked to one of the recalled products is under investigation in California. This report describes the ongoing investigation. . .and the measures undertaken to control the outbreak, which is the first outbreak of foodborne botulism in the United States associated with a commercial canning facility in approximately 30 years. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a4.htm
(MMWR August 3, 2007 / 56(30);767-769)

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Cryptosporidiosis Outbreaks Associated with Recreational Water Use--Five States, 2006
(References removed)
“Cryptosporidiosis is a gastrointestinal illness caused by parasitic protozoa of the genus Cryptosporidium and can produce watery diarrhea lasting 1-3 weeks; 1 or 2 cases per 100,000 population are reported annually in the United States. Fecal-oral transmission of Cryptosporidium oocysts occurs through ingestion of contaminated drinking or recreational water, consumption of contaminated food, and contact with infected persons or animals. . .Cryptosporidium oocysts are resistant to chlorine disinfection and can survive for days in treated recreational water venues. . .For 2006, a total of 18 cryptosporidiosis outbreaks have been reported (as of Jul 24, 2007) to CDC's U.S. Waterborne Disease and Outbreak Surveillance System. . .This report describes 5 laboratory-confirmed cryptosporidiosis outbreaks in 2006 that involved public recreational water use. The popularity of recreational water venues, the number and geographic distribution of recent cryptosporidiosis outbreaks, and the resistance of Cryptosporidium to chlorination suggest that treatment strategies for recreational water facilities need to be improved. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5629a1.htm
(MMWR July 27, 2007 / 56(29);729-732)

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Disaster preparedness lessons learned and future directions for education: Results from focus groups conducted at the 2006 APIC Conference
Rebmann T, English JF, Carrico R. Am J Infect Control. 2007 Aug;35(6):374-81.
Abstract:“BACKGROUND: Infection control professionals (ICP) who have experienced disaster response have not been assessed in terms of the lessons they have learned, gaps they perceive in disaster preparedness, and their perceived priorities for future emergency response training. METHODS: Focus groups were conducted at the APIC 2006 Conference to evaluate ICPs' perceived needs related to disaster planning topics, products they feel are needed for education and reference materials, and lessons learned from past disasters. RESULTS: ICPs' role in disaster preparedness and response is essential, even in noninfectious disease emergencies. Infection control issues in shelters, such as overcrowding, foodborne illness, lack of restroom facilities, inadequate environmental cleaning procedures and products, difficulty assessing disease outbreaks in shelters, inability to isolate potentially contagious patients, and too few hand hygiene supplies can contribute to secondary disease transmission. Other important topics on which ICPs need to be trained include surge capacity, employee health and safety, incident command system, educating responders and the public on disaster preparedness, addressing changing standards/recommendations, and partnering with public health. ICPs need quick reference materials, such as checklists, templates, tool kits, and algorithms to better equip them for disaster response. CONCLUSION: Infection control must continue to partner with public health and other responding agencies to address gaps in disaster planning.”

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3. Notifications
New Medication for Severe Malaria Available Under an Investigational New Drug Protocol
On Jun 21, 2007, CDC's Investigational New Drug Application (IND) for intravenous artesunate went into effect. This IND allows for use of an investigational antimalarial medication (intravenous artesunate) under a protocol entitled "Intravenous Artesunate for Treatment of Severe Malaria in the United States." Artesunate is in the class of medications known as artemisinins, which are derivatives from sweet wormwood plant (Artemisia annua). Only the CDC Drug Service and CDC Quarantine Stations will be permitted to release the medication for use. Approximately 1,400 cases of malaria (nearly all imported) are diagnosed in the US each year. Intravenous quinidine gluconate also has antimalarial properties and is the only parenteral drug approved by FDA for treatment of severe malaria that is available in the US. However, quinidine has cardiotoxic effects and has become less available in U.S. hospitals. Since 2000, WHO has recommended artesunate in preference to quinidine for treatment of severe malaria. CDC's IND protocol provides a mechanism for investigational use of intravenous artesunate for patients with severe malaria in the US.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a5.htm
(MMWR August 3, 2007 / 56(30);769-770)

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Public Health Informatics Fellowship Application Deadline--December 14, 2007
CDC offers a 2-year postgraduate fellowship in public health informatics, the systematic application of information technology to public health practice, research, and learning. Fellows receive training in both informatics and public health, are assigned to teams involved in research and development of CDC information systems, and are given the opportunity to lead one or more major projects during their fellowships. The deadline to apply for the fellowship period beginning Jul 2008 is Dec 14, 2007. Applications are available online at https://www.orau.gov/cdc/phip/login.asp. For more information: tel: 404-498-6219; e-mail: phifp@cdc.gov (subject line: Request info) and mph4@cdc.gov.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5629a6.htm
(MMWR July 27, 2007 / 56(29);742)

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Epidemic Intelligence Service Application Deadline--September 15, 2007
The Epidemic Intelligence Service (EIS) is a 2-year, postgraduate program of service and on-the-job training for health professionals interested in the practice of epidemiology. Each year, EIS provides approximately 80 persons from around the world opportunities to gain hands-on experience in epidemiology at CDC or state or local health departments. The EIS experience is useful for health professionals who would like to gain a population-based perspective on public health practice. Persons with a strong interest in applied epidemiology who meet at least one of the following qualifications may apply to EIS: Physicians with >1 year of clinical training; Persons with a doctoral degree in epidemiology, biostatistics, the social or behavioral sciences, natural sciences, or the nutrition sciences; Dentists, physician assistants, and nurses with a master of public health (MPH) or equivalent degree; Veterinarians with an MPH or equivalent degree or relevant public health experience. Applications are being accepted for the Jul 2008-Jun 2010 EIS program. Deadline for submitting application materials is Sep 15, 2007. Application information and EIS program details are available at http://www.cdc.gov/eis, by tel (404-498-6110), or via email (eisepo@cdc.gov).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5629a5.htm
(MMWR July 27, 2007 / 56(29);741)

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Course on managing medical center outbreaks & emerging infections
There will be a full-day course on the impact of emerging infectious diseases on healthcare entitled "Lessons From The Field: First-Hand Experience Managing Outbreaks And Emerging Infections In Medical Centers" in Vancouver, Canada 24 Oct 2007. This course is being held in conjunction with the ICOH 7th International Conference on Occupational Health for Health Care in Vancouver from 26-28 Oct 2007. There will be a pre-conference workshop on the topic of "Managing Occupational Infectious Agents & Diseases in Workplaces" 25 Oct 2007. For more information: http://www.acoem.org/icoh.aspx.

From Barbara S. Choyke, Director of Education and Meeting Services, American College of Occupational and Environmental Medicine; bchoyke@acoem.org
(Promed 8/2/07)

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 apecein@u.washington.edu