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Vol. X. NO. 17 ~ EINet News Briefs ~ Aug 17, 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)
- France (Moselle): More avian influenza H5N1 in wild ducks
- Germany (Bavaria): More dead birds test positive for avian influenza H5N1
- Indonesia (Banten, Bali): 2 New human deaths from avian influenza H5N1
- Vietnam (Cao Bang): Report of more avian influenza H5N1 in birds
- Hong Kong: 2 confirmed human cases of brucellosis
- Japan (Hiroshima): Foodborne outbreak hits prison
- Japan (Osaka): E. coli O157 infection kills child
- Russia (Khabarovsk) 2 Outbreaks of Yersiniosis
- Russia (multi-region): Update on Tickborne encephalitis cases
- Russia (Southern Federal District): Update on Crimean-Congo hemorrhagic fever situation
- Russia (Republic of Buryatia): Enterovirus outbreak affects 140 children
- USA: GSK sells more avian influenza H5N1 vaccine to US, launches trial
- USA (Georgia): Campylobacteriosis cases associated with unpasteurized milk
- USA (Pennsylvania): Salmonellosis cases associated with pet ownership
- USA (Washington): FDA links vibriosis cases to Washington oyster area
- USA (Washington): Foodborne outbreak at detention center
- USA (Utah) CDC to investigate Tularemia cluster
- USA (Midwest): Rise in Tick-borne diseases incidence
- USA (Vermont) Lyme disease cases on the rise
- USA (California): Flea-Born Typhus hospitalizes three people
- USA (multistate): Infections from contact lens solution continue to occur
- Togo (Lacs, Golfe, Zio): New cases of avian influenza H5N1 reported in poultry

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

2. Articles
- Allocating pandemic influenza vaccines in Minnesota: Recommendations of the Pandemic Influenza Ethics Work Group.
- Trivalent Live Attenuated Intranasal Influenza Vaccine Administered During the 2003–2004 Influenza Type A (H3N2) Outbreak Provided Immediate, Direct, and Indirect Protection in Children
- Vaccination Coverage Among Children in Kindergarten--United States, 2006--07 School Year
- Report says problems hobble US biosurveillance system

3. Notifications
- Revised Recommendations: To Vaccinate All Persons Aged 11--18 Years with Meningococcal Conjugate Vaccine
- Satellite Broadcast and Webcast: HIV Prevention with Hispanics/Latinos


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 / 29 (25)
Laos / 2 (2)
Nigeria / 1 (1)
Viet Nam 2 (0)
Total / 58 (36)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 321 (194).
(WHO 8/16/07 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 7/25/07)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 8/82/07): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 7/30/07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.

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Europe/Near East
France (Moselle): More avian influenza H5N1 in wild ducks
France said 14 Aug 2007 that 4 dead wild ducks found Aug 8 in the Moselle region in the eastern part of the country had tested positive for the H5N1 virus. The outbreak is the third since early Jul 2007, when dead wild swans found in Assenoncourt and Diane Capelle, both in the Moselle region, tested positive for the virus, according to a report from the World Organization for Animal Health (OIE). On 14 Aug 2007, Moselle's prefecture extended measures to protect domestic fowl from wild birds that had been put in place after the first case of swan deaths.
(CIDRAP 8/15/07; Promed 8/15/07)

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Germany (Bavaria): More dead birds test positive for avian influenza H5N1
Authorities in Bavaria have confirmed that more wild birds have been found dead in Germany due to the H5N1 bird flu virus. Movement restrictions have been put in place around the Speichersee lake where 2 out of 3 wild ducks found dead were confirmed to have been carrying the highly pathogenic virus H5N1 “Asia” type. Reportedly about 14 other birds have also been found dead in the area; however, it is not known if they are infected with the virus. Scientists suggest that it could have jumped the border from the neighbouring Czech Republic where there were infected poultry. So far in 2007 there has been 1 detection of H5N1 Asia type in domestic poultry in a small mixed (ducks and geese) poultry holding in Thuringia. All 2007 viruses in Europe are closely related which indicates that they originate from a common source.
(Promed 8/11/07)

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Asia
Indonesia (Banten, Bali): 2 New human deaths from avian influenza H5N1
For the second time in 4 days, Indonesia's health ministry announced a fatal human case of H5N1 avian influenza, this one in a 17-year-old girl from a town just west of Jakarta who died Aug 14. WHO, in a statement confirming the case, reported the girl got sick Aug 9, was hospitalized Aug 13, and died a day later. She was from Tangerang, 12 miles west of Jakarta, in Banten province. Investigators are working to determine how the girl was exposed to the virus. Her death pushes Indonesia's H5N1 case count to 104 and its death toll to 83. Joko Suyono, a health ministry spokesman, said tests from 2 local laboratories confirmed the girl was infected with the H5N1 virus.

The last previous H5N1 victim in Indonesia was a 29-year-old woman from Bali who died Aug 12 after she had contact with sick and dead chickens. The woman was from Jembrana district, where avian flu is endemic in poultry. The district is in the northwestern part of the island, far from the major tourist areas. The death is the first avian-influenza related human death on Bali. WHO reported that the woman's 3-year-old daughter had died of a respiratory illness before her mother fell ill, but officials did not suspect she had an H5N1 infection. The woman and her daughter had both been exposed to sick and dead poultry, WHO reported. Joko Suyono, a spokesman for the ministry's bird flu center, said villagers in the woman's town didn't burn the dead chickens but buried them or fed them to pigs. Indonesia is one of two countries, along with China, where pigs have been found infected with the H5N1 virus. Household and healthcare worker contacts who were exposed to the woman are being monitored, and all remain healthy, WHO said. Meanwhile, a 2-year-old girl from a neighboring home who was hospitalized Aug 10 with suspicious respiratory symptoms does not have the H5N1 virus.
(CIDRAP 8/13/07, 8/15/07, 8/16/07; Promed 8/14/07)

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Vietnam (Cao Bang): Report of more avian influenza H5N1 in birds
Vietnam's agriculture ministry announced the detection of a poultry outbreak of H5N1 avian influenza in a province bordering China. The outbreak occurred at a farm in the northern province of Cao Bang, where 89 chickens and ducks died recently. Tests confirmed the birds had the H5N1 virus. This is the country’s second infection among poultry so far this month. The previous poultry outbreak was detected 2 Aug 2007 in the northwestern province of Dien Bien. Vietnam has had 7 human H5N1 cases this year, including 4 deaths. However, 5 of the cases have not yet been confirmed by WHO, whose current avian flu tally for Vietnam is 95 cases with 42 deaths.
(CIDRAP 8/15/07; Promed 8/15/07)

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Hong Kong: 2 confirmed human cases of brucellosis
The Center for Health Protection has confirmed brucellosis infection in a 56 year old Tsuen Wan man and his wife. The man developed fever, headache, malaise, and urinary symptoms May 2007. He was admitted to hospital twice between 31 May and 15 Jun 2007 and is now in a stable condition. His 54 year old wife developed similar symptoms and was admitted to hospital 13 Jul 2007. She was discharged 18 Jul 2007. The 2 traveled to Guangzhou for 2 days in Apr 2007. Their family members have no symptoms. A total of 3 brucellosis cases were reported in 2006. Brucellosis is considered to be a Category B bioterrorism agent which is, in nature, acquired as a zoonotic infection by humans. Its manifestations are protean, including undulant fever, with positive blood and/or bone marrow cultures, and it is a cause of localized disease in many organ systems including skeletal, urinary tract, central nervous system, liver, cardiac and lung.
(Promed 8/6/07)

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Japan (Hiroshima): Foodborne outbreak hits prison
More than 500 inmates at a prison in Hiroshima have contracted food poisoning. None of them are in a serious condition. The Hiroshima Municipal Health Center has ordered Hiroshima Prison to temporarily close its kitchen. Inmates began to complain of high fever and diarrhea 1 Aug 2007. The prison authorities later confirmed that 542 of its 1559 inmates are suffering from food poisoning.
(Promed 8/3/07)

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Japan (Osaka): E. coli O157 infection kills child
A 3 year old girl infected with the O157 strain of Escherichia coli died 6 Aug 2007, the city government of Osaka said. 4 other children between the ages of 10 months and 5 years who attended the same nursery school were also infected: 2 are still receiving hospital treatment, while the other 2 are recuperating at home. The girl was hospitalized 29 Jul 2007 with severe stomach pains and diarrhea. O157 had been detected in a stool sample. Officials said the girl died of multiple organ failure and brain damage. Officials said they suspect all 5 were fed the same food at the school, but they are also investigating whether the source of infection was from outside the school. A total of 31 infants and pupils up to age 7 attend the Popora Osaka Tenrokuen nursery center. According to data from the Infectious Disease Surveillance Center, 1376 cases of this infection were reported between Jan and mid-July 2007. The center advised staff at nursery schools and facilities for senior citizens to be thorough when washing hands and using disinfectant after changing diapers and before eating.
(Promed 8/7/07)

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Russia (Khabarovsk) 2 Outbreaks of Yersiniosis
A pair of outbreaks of pseudotuberculosis [Yersinia pseudotuberculosis] is being investigated in Khabarovsk region. A total of 16 people including 13 disabled children were admitted to the central district hospital, infectious diseases department from a psychoneurological hostel with the diagnosis of "Far-Eastern scarlatine fever" (pseudotuberculosis) during 19 to 21 Jul 2007. Sanitary violations were found in the hostel. Laboratory tests of the samples taken from the hostel have shown presence of pseudotuberculosis. The second cluster involved 30 people, including 17 children that were resting in summer camp. The camp is currently closed for quarantine. Infection with Yersinia pseudotuberculosis is a zoonosis with reservoirs in many animals, including rodents, rabbits, deer, and various birds. Most individuals affected are children or young adults. The most common presentation of this infection is mesenteric lymphadenitis, with fever and right lower quadrant abdominal pain.
(Promed 8/3/07)

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Russia (multi-region): Update on Tickborne encephalitis cases
By 6 Aug 2007, 2124 cases of [suspected] tickborne encephalitis (TBE) had been recorded; of those, 1588 have been confirmed by laboratory diagnosis. The corresponding figures for 2006 were 1661 and 934, respectively. Out of 33 fatal cases 7 occurred in the Novosibirsk Region, 5 in Primorskiy Krai, 5 in Krasnoyars Krai, 2 in the Omsk Region, 3 in Archangelsk Region, 2 in Chita Region, 2 in Kemerovo Region, 1 in the Sverdlovsk Region, 1 in Perm Krai, 1 in the Tomsk Region, 1 in the Kurgan Region, 1 in the Khabarovsk Region, 1 in Irkutsk Region, and 1 in Republic of Buryatia.
(Promed 8/10/07)

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Russia (Southern Federal District): Update on Crimean-Congo hemorrhagic fever situation
As of 6 Aug 2007, 224 cases of Crimean-Congo hemorrhagic fever (CCHF), including 5 child cases, have been registered in 8 regions of the Southern Federal District [Okrug], compared with 191 cases, including 4 children, that were registered during the same period of 2006. Information on fatal cases: 1 fatality in each of the regions of Volgograd, Rostov, Republic of Ingushetia, and the Republic of Kalmykia; 2 fatal cases in Kalmykia and 1 each in the regions of Stavropol, Rostov, and Astrakhan. The situation in the Stavropol, Volgograd and Astrakhan regions remains unsatisfactory, where levels of morbidity are 1.5 times or more than those observed in the preceding year [2006]. Insufficient expenditure on measures to control exposure of cattle and other livestock to tick infestation in natural foci of CCHF infection has contributed to expansion of CCHF infection in several regions of the Southern Federal Region.
(Promed 8/8/07)

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Russia (Republic of Buryatia): Enterovirus outbreak affects 140 children
An outbreak of enteroviral infection has been reported in 7 settlements in the Republic of Buryatia, affecting 140 children under 18. Reportedly the outbreak investigation has indicated that swimming in the river Selenga and in other bodies of water is the source of the outbreak. All affected children had been admitted to hospital, and contacts were being followed up. Disinfection procedures have been undertaken, and drinking water supplies and pond water are being sampled.
(Promed 8/15/07)

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Americas
USA: GSK sells more avian influenza H5N1 vaccine to US, launches trial
The British pharmaceutical company GlaxoSmithKline (GSK) recently announced another major order of prepandemic H5N1 influenza vaccine from the US Department of Health and Human Services (HHS), along with plans to launch a North American clinical trial of the vaccine. HHS ordered enough vaccine in bulk form to provide 22.5 million 15-microgram (mcg) doses. The order is in addition to the bulk equivalent of 5 million 15-mcg doses that HHS ordered in Nov 2006. The cost of the new vaccine order is $97 million, according to Marc Wolfson, a spokesman for the HHS Office of the Assistant Secretary for Preparedness and Response in Washington, DC.

The new order includes 9 million doses produced in the 2006 "manufacturing campaign" and 13.5 million doses to be produced in the 2007 campaign. The vaccine is based on clade 2 strain of the H5N1 virus. GSK will make the bulk vaccine at its facility in Quebec, and store it in Pennsylvania. The vaccine contract provides that HHS may direct the company to formulate the bulk vaccine into doses in the future, GSK said. In addition, HHS has an option to buy the vaccine in combination with one of the company's proprietary adjuvants, or immune-boosting chemicals, which could reduce the amount of vaccine antigen needed to induce a protective immune response.

GSK also announced the start of the first North American clinical trial of its prepandemic H5N1 vaccine. The trial is described as a phase1/2 study that will compare the safety and immunogenicity of the H5N1 antigen alone and in combination with one of GSK's adjuvant systems in 675 adult volunteers. Inchausti said the trial will be conducted at sites in Montana, California, Florida, Georgia, Alabama, Kansas, and Nevada and in Halifax and Quebec, Canada. Last March, GSK reported that in a clinical trial, one of its adjuvanted H5N1 vaccines triggered a strong immune response with two 3.8-mcg doses, or about half of the 15-mcg dose typically used for each viral strain in seasonal flu vaccines. The company also said tests showed that the vaccine, based on a Vietnam strain of H5N1, generated cross-reactive immunity against an Indonesian strain.
(CIDRAP 8/16/07)

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USA (Georgia): Campylobacteriosis cases associated with unpasteurized milk
Raw milk sold as pet food sickened 3 Georgia families who drank the milk this summer, sending at least 1 child to the hospital. The families were sickened by campylobacteriosis, one of the most common causes of foodborne illness. All of the patients have since recovered. 1 incident occurred early Jun 2007 and another early Jul 2007. A health department investigation led to a farm selling unpasteurized milk labeled as pet food. But often, such milk is bought for human consumption. FDA and the state Division of Public Health say that drinking raw milk is dangerous because it can harbor harmful bacteria. There were 45 outbreaks of foodborne illness tied to raw milk between 1998 and 2005, with 1007 illnesses and 2 deaths, according to CDC. FDA bans the sale of raw milk for interstate commerce, but leaves it up to states to decide how to regulate the product within their borders. Raw milk is a well-documented cause of enteric infections and was first recognized as such about 100 years ago. Pathogens that infect humans, including Campylobacter, 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 milk contamination. Pasteurization decreases the number of pathogenic organisms, prevents transmission of pathogens, and has been determined to improve the safety of raw milk more than other measures, including certification of raw milk.
(Promed 8/3/07)

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USA (Pennsylvania): Salmonellosis cases associated with pet ownership
Human cases of a rare type of salmonellosis have caused the Pennsylvania Department of Health to issue a warning to pet owners. The health department says 21 cases of the illness in Pennsylvania residents might be linked to dry dog food and advises using safe buying and handling practices. The illness being investigated by the health department is caused by an uncommon strain called Schwarzengrund. Most of the infections occurred in households with pets or where people are in close contact with pets, but there is no evidence any human consumed pet food. Many of the salmonella cases linked to the strain have occurred in infants and young children, who are particularly vulnerable to infection.

The health department recommends the following to reduce risk of infection: purchase canned or bagged products with no signs of damage to the packaging; if possible, feed pets in an area other than the kitchen; before and after feeding pets food and treats, wash hands for 20 seconds with hot water and soap; wash pet bowls and scooping utensils with soap and hot water after each use; if possible, don't wash them in a kitchen sink, or properly sanitize the sink area after pet food dishes are cleaned and removed; don't use a pet's feeding bowl to scoop food; throw away old or spoiled pet food in a safe manner, in a securely tied plastic bag in a covered trash receptacle; don't store or handle pet food in areas where human food is prepared because it increases the chance of cross-contamination; promptly refrigerate or discard leftover wet pet food; Set refrigerators at 4 C and periodically check a refrigerator's temperature setting; store dry pet food and treats in a cool, dry place; store dry pet food in its original bag inside a clean plastic container with a lid, keeping the top of the bag folded closed; keep pets away from food-storage and preparation areas; keep pets away from garbage and household trash.
(Promed 8/13/07)

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USA (Washington): FDA links vibriosis cases to Washington oyster area
The US Food and Drug Administration (FDA) recently warned consumers to avoid eating raw oysters harvested from the southern tip of Hood Canal in Washington state after receiving at least 6 reports of patients who contracted vibriosis. The 6 ill patients are from Washington and California. States are investigating additional cases. Oysters from the affected area were distributed in California, Florida, Hawaii, Idaho, New York, Oregon, Washington, British Columbia, Hong Kong, Malaysia, and Singapore. Vibriosis is a bacterial illness caused by Vibrio parahaemolyticus, which naturally occurs in seawater. The pathogen can reach high levels in summer. Symptoms include watery diarrhea, nausea, vomiting, and chills, which usually occur within 24 hours of eating contaminated oysters, FDA said. Vibriosis usually resolves without treatment after about 3 days. Severe disease is rare but can occur in people who have weakened immune systems; the FDA says these people should avoid raw oysters regardless of their source. The Washington Department of Health (WDH) said it has closed 2 growing areas on the southern tip of Hood Canal and has asked the shellfish industry to recall oysters from these areas. WDH said it usually records about 20 vibriosis cases each season. In 2006 at least 60 cases were reported, marking one of the worst vibriosis outbreaks in the last decade.
(CIDRAP 8/14/07)

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USA (Washington): Foodborne outbreak at detention center
About 300 immigrants being held at the Northwest Detention Center in Tacoma spent the early part of this week recovering from suspected food poisoning. Tacoma-Pierce County Health Department officials said they were contacted 11 Aug 2007, after about 180 detainees were treated for diarrhea, nausea and vomiting at the detention center clinic. The immigrants had been served 3 meals that day. Most began showing symptoms 11 Aug 2007, Department of Homeland Security spokeswoman Lorie Dankers said, adding that detention center staff, who sometimes eat there, also got ill. Health officials were at the detention center 12 - 14 Aug 2007 to try to determine what made so many people sick. By 14 Aug 2007, most people appeared to have recovered. The detention center primarily houses immigrants from Washington, Oregon and Alaska facing deportation.
(Promed 8/16/07)

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USA (Utah) CDC to investigate Tularemia cluster
CDC is now leading the environmental investigation into a tularemia cluster that may have afflicted as many as 17 Utahns, traced to the west side of Utah Lake. According to the Utah Department of Health, 8 cases have been confirmed and another 8 are classified as probable. From ongoing and future efforts, health experts hope to learn more about the actual ecology of the illness, how it dissipates, and the course of recovery. They also want to know what puts people at greater risk. Hundreds of people were in the area at the time of the cluster, but only a small number became ill or developed lesions. CDC is testing the field specimens collected as part of the investigation and will work with Brigham Young University to monitor flying insects in the area.

Tularemia is a bacterial infection caused by Francisella tularensis, found in animals, particularly rabbits. It's typically transmitted by flea, deerfly, or horsefly bite, but can be spread by direct contact with an infected animal (including eating meat that's not well cooked). It can be spread by drinking contaminated water or inhaling contaminated air, as well. It doesn't pass person to person. People made ill in the cluster were at the lake between mid-June and the first week of July 2007. The first 3 cases reported were linked to a youth camp at the lake. Utah usually has only a few cases statewide each year.
(Promed 8/9/07)

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USA (Midwest): Rise in Tick-borne diseases incidence
Reported cases of tick-borne diseases have jumped this year [2007] in Missouri. Driven in large part by increased recognition from doctors and more houses built in old forests, the diseases are being reported at a rate far higher than the 5-year average. The state has received reports of 117 cases of ehrlichiosis compared to the annual average of 40; 186 cases of Rocky Mountain spotted fever, compared with the normal 64; 18 cases of tularemia, compared to 12; and 35 cases of Lyme disease instead of the usual 22. Kansas has fewer wooded areas than Missouri, so the number of reported cases is lower. Still, the 13 Kansas cases of tick-borne diseases are more than double the normal amount.
(Promed 8/13/07)

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USA (Vermont) Lyme disease cases on the rise
The number of reported cases of Lyme disease, an infection transmitted by the bite of deer ticks ("black-legged ticks"), has doubled in Vermont in the past 2 years. Data from the Vermont Department of Health show that in 2005, 29 Vermonters contracted Lyme disease from Vermont ticks. In 2006, the number rose to 62. So far this year [2007], 71 cases of Lyme disease in humans have been reported. The highest concentration of cases is in the southern part of the state. The peak season for the onset of the disease in Vermont mirrors the peak season nationally - June through August. That time of year is when the nymphal stage ticks are active, and because they're so small and hard to see, people get tick bites and don't realize the tick is there. Ticks that are attached for less than 24 hours don't have time to transmit the disease. Ticks are active at any temperature above 40 degrees. The best defense against Lyme disease is taking steps to prevent infection, and a key to prevention is doing a full body tick check every day.
(Promed 8/9/07)

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USA (California): Flea-Born Typhus hospitalizes three people
Orange County health officials warned people to control fleas, in the wake of endemic typhus cases that led to hospital stays for an adult and a minor in Westminster and a Huntington Beach resident. The 3 victims are back home recovering from the flea-born illness that can lead to meningitis and encephalitis, but is not fatal without underlying health issues, said Howard Sutter of the Orange County Health Care Agency. Endemic typhus occurs naturally in Southern California, and 2 cases were reported in Orange County earlier this year [2007], Sutter said. Other cases have been reported in Long Beach and other locations in Los Angeles County, he said. The disease, which is detected through a blood test, is transmitted by the bite of infected fleas that may be found on opossums, rodents and cats, he said. It is not transmitted from person to person and is treatable with antibiotics, Sutter said, adding that symptoms include fever, headache, muscle ache and rash. Fewer than 50 cases with clinical and epidemiologic findings consistent with murine typhus are reported in the United States annually, mainly from southern California. The illness usually resolves within 3 weeks, even if untreated. However about 10 percent of patients are sick enough to be hospitalized in an intensive care unit and up to 4 percent of hospitalized patients will die from the infection. Treatment is doxycycline.
(Promed 8/16/07)

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USA (multistate): Infections from contact lens solution continue to occur
CDC continues to receive reports from ophthalmologists that cases of Acanthamoeba keratitis, a potentially blinding infection, are occurring in the US. Multiple cases of infection caused by Acanthamoeba have occurred since 26 May 2007, the day FDA announced the outbreak and the manufacturer issued a recall of the implicated multipurpose contact lens solution. The contact lens user in at least 4 of these cases continued to use AMO Complete MoisturePlus multi-purpose contact lens solution and subsequently developed symptoms after the recall. CDC has also learned during the interview stage of its investigation that many contact lens users do not know that AMO Complete MoisturePlus multi-purpose contact lens solution has been recalled from the market because of its association with Acanthamoeba keratitis.
(Promed 8/4/07)

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Africa
Togo (Lacs, Golfe, Zio): New cases of avian influenza H5N1 reported in poultry
3 new cases of the H5N1 strain of bird flu have been detected in poultry on farms in the west African nation of Togo, a report said 11 Aug 2007. The new cases were found in dead birds on farms in the Lacs, Golfe and Zio regions east of the capital Lome. In late Jun 2007, testing confirmed the presence for the first time in Togo of the H5N1 strain in poultry in Sigbehoue, 45 km east of the capital. About 8000 poultry birds were slaughtered in the area, and local poultry markets were closed. Togolese authorities also stepped up controls on poultry imports. Togo in Oct 2006 banned the import of live poultry and poultry products from countries affected by the virus.
(Promed 8/12/07)

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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. Link to National Influenza Centers in PAHO Member States.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Updated 17 Aug 2007.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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Cholera, Diarrhea, Dysentery
Thailand (Tak)
Officials are on alert for a possible cholera outbreak along the Thai-Burmese border in Tak as nearly 500 people, mostly migrant workers, have been treated in the past 2 months. Earlier in Jul 2007, there were reports that hundreds of Burmese people in border areas opposite Tak province were suffering from cholera. Many of them were sent to hospitals. As of 27 Jul 2007 there are 77 patients who were treated at the Thai district hospitals and in the Migrant camp. On every case diagnosed in the hospital, a Surveillance and Rapid Response Team (SRRT) was sent out to do active case finding by examining and doing rectal swab cultures on family members and neighborhood contacts. Another 120 confirmed cases who had diarrheal symptoms were found along with 283 asymptomatic carriers. Adding these 3 categories there are a total of 480 persons with positive rectal swab cultures of which all were treated with antibiotics. So far there have been no deaths confirmed attributable to cholera. 84 percent of the cases are ethnic migrant workers and can easily cross the Thai-Myanmar border. Major risk factors for infection are unsanitary living conditions, drinking from unsafe water sources and eating without proper hand washing.
(Promed 8/4/07)

Hong Kong
The Centre for Health Protection has confirmed an imported case of cholera involving a 30 year old man who returned to Hong Kong 2 Aug 2007. He had traveled alone to India from 4 Jul to 1 Aug 2007 and developed abdominal cramps and diarrhea 1 Aug 2007. He attended hospital 6 Aug 2007 and is now in stable condition. Laboratory tests were positive for Vibrio cholerae O1 El Tor Ogawa. [The patient] lives in Tuen Mun and his home contacts did not have cholera symptoms. This is the first cholera case reported in 2007. There was 1 case in 2006, 5 in 2005, 5 in 2004, 7 in 2003, and 4 in 2002.
(Promed 8/10/07)

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Dengue
Hong Kong (imported)
The Centre for Health Protection has confirmed 2 dengue fever cases, 1 imported and the other under investigation. A 21-year-old man came down with fever, muscle pain and tiredness 30 Jul 2007 and was admitted to hospital 4 Aug 2007. He was discharged 8 Aug. He travelled to Indonesia with 9 people 6 Jul - 4 Aug 2007. His family members and travel companions have no symptoms. The second case involved a 57-year-old man. He came down with fever, headache and a skin rash 31 Jul 2007. He was sent to hospital 4 Aug 2007 and was discharged 9 Aug. He visited Macau 23 Jul - 1 Aug [2007]. His family members have no symptoms. Prior to these 2 new cases, 19 imported cases had been reported this year.
(Promed 8/16/07)

Malaysia and Southeast Asia
In Malaysia, nearly 70 people have died of dengue this year. The high number of deaths recorded up to the first week Aug 2007 is causing concern as authorities battle to control the outbreak. The 67 deaths recorded thus far in 2007 have surpassed the 54 deaths recorded for the same period last year. A total of 31 279 dengue cases were reported between Jan and 4 Aug [2007]. There were only 21 117 cases in the same period last year. The Health Ministry's disease control director said the outbreak could only be contained if the public co-operated by keeping their surroundings clean and free of Aedes [mosquito] breeding grounds. The states with the highest number of dengue cases are Selangor, Kelantan, Johor and Kuala Lumpur.

The number of reported cases of dengue has increased in Indonesia, Myanmar and Thailand [to date in 2007]. Indonesia has had twice the number, compared to 45 777 during the same period in 2005. More than 1000 people have been killed by dengue fever in Indonesia alone in 2007. Myanmar and Thailand are seeing increases of 29 percent and 17 percent respectively.
(Promed 8/16/07)

Philippines (North Samar)
A town in Northern Samar in Eastern Visayas experienced a surge in dengue cases Jul 2007. Reportedly, Pambujan town in Northern Samar noted a rapid rise in dengue cases, from 1 case as of 3 Jul to 24 cases as of 25 Jul [2007]. It said that at least 2 girls aged 5 and 7 had succumbed to the disease, adding that the town had recorded at least 255 cases since the start of 2007.
(Promed 8/6/07)

Singapore
A construction site has become the second most active dengue cluster in Singapore. Authorities found 33 new cases during 23-27 Jul 2007. The Varsity Park construction site is believed to be the area of the cause. Elsewhere in Singapore, the total number of new dengue cases has dipped. As of 28 Jul 2007, 322 cases were reported that week. That is lower than the 363 cases recorded in the week before.
(Promed 8/6/07)

Viet Nam
Dengue fever has killed 35 people in Viet Nam so far this year [2007], and nearly 33 000 others have been infected with the mosquitoborne disease, officials said 30 Jul 2007. The number of cases was 41 per cent higher in the period from Jan to Jun 2007 than in the same period last year [2006], said the General Statistics Office (GSO). The illness has spread rapidly in Viet Nam's central and southern Mekong Delta provinces. WHO has expressed concerns that Asia could see a dengue epidemic this year [2007] on a par with that of 1998, when nearly 1500 people died.
(Promed 8/6/07)

USA (Texas)
Dengue fever is gaining a firmer foothold in southern Texas, putting residents at risk for the most dangerous form of the disease, dengue hemorrhagic fever (DHF), CDC reported. A dengue outbreak in the Brownsville, Tex., area in 2005 involved 25 hospital cases, 16 of which were classified as DHF, CDC reports. Dengue fever is a mosquito-borne viral disease found in most tropical and subtropical regions of the world. The virus occurs in 4 serotypes, and infection with any one of these induces immunity only to that serotype. A second infection with a different serotype increases a person's risk for DHF, which involves the possibility of life-threatening shock.

The 2005 outbreak in the Brownsville area was heralded by a DHF case in a woman who fell ill. When she was hospitalized, doctors missed the dengue diagnosis, even though her clinical characteristics met WHO criteria for DHF. CDC says the woman's illness marked the first DHF case in a Texas resident native to the Texas-Mexico border area. About 2 months after the Brownsville woman's case, Mexican officials in Tamaulipas state, across the border from Brownsville, told their Texas counterparts that a dengue fever outbreak in the state had grown to 1,251 cases. Those included 223 cases (17.8%) classified as DHF. In the previous 5 years, 541 dengue cases, including just 20 DHF cases, had been reported in the state. Health officials on both sides of the border subsequently increased their surveillance. In Dec, officials reviewed the records of 129 patients who had been hospitalized with evidence of dengue fever, including 25 patients in Cameron County, Tex., and 104 treated in Matamoros, Mexico. 16 of the 25 Cameron County cases and 34 of the 104 Matamoros cases met the WHO criteria for DHF. 11 of the 50 DHF cases were classified as dengue shock syndrome.

In Matamoros, 101 of 131 people tested had IgG antibodies to dengue, signaling a weighted prevalence of 76.6%. In Brownsville the investigators found IgG antibodies in 47 of 141 people tested, for a weighted prevalence of 38.2%. "Entomologic, serologic and virologic conditions are now such that locally acquired DHF can occur in south Texas," CDC asserts. 2 mosquito species that spread the virus, Aedes aegypti and Aedes albopticus, are well established there. The report adds, "The finding that 38% of surveyed Brownsville residents have IgG antibodies to dengue indicates that a substantial proportion of the city population has been infected with the dengue virus and might be more susceptible to DHF if they receive a second infection" with a different serotype. Clinicians and the public in southern Texas should be aware of the risk of dengue and DHF, CDC advises.

CDC. Dengue hemorrhagic fever—U.S.-Mexico border, 2005. MMWR 2007 Aug 10;56(31):785-9
http://cdc.gov/mmwr/preview/mmwrhtml/mm5631a1.htm
(CIDRAP 8/9/07)

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West Nile Virus
Russia (Southern Federal District)
A total of 3 cases of West Nile fever has been registered this year in the Rostov Oblast. West Nile fever is prevalent in summer and early autumn. The reservoirs of infection are predominantly birds. West Nile fever affects rural populations living close to rivers and lakes where there is an abundance of wild waterfowl and mosquitoes, and to a lesser extent city dwellers visiting summer residences and camp-sites. West Nile fever is annually registered in the Astrakhan Oblast. This year 2 cases had been observed there already. A total of 14 cases were recorded in 2006, including 1 fatality.
(Promed 8/14/07)

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/ Travel related
Manitoba / 3 / 14 / 21 / 38 / 0 / 1
Saskatchewan / 1 / 15 / 10 / 26 / 1 / 3
Alberta / 0 / 9 / 0 / 9 / 1 / 0
British Columbia / 0 / 1 / 0 / 1 / 1 / 0
TOTALS / 4 / 39 / 31 / 74 / 3 / 4
(Promed 8/16/07)

USA
Human cases have been reported from (through 10 Jul 2007):
State / Neuroinvasion/West Nile fever/ Other, Unspecified/ Total/ Fatalities:
Alabama / 5 / 2 / 0 / 7 / 1
Arizona / 10 / 4 / 2 / 16 / 0
Arkansas / 2 / 0 / 0 / 2 / 1
California / 32 / 51 / 3 / 96 / 5
Colorado / 10 / 62 / 0 / 72 / 1
Connecticut / 2 / 0 / 0 / 2 / 0
Georgia / 1 / 1 / 1 / 3 / 0
Idaho / 1 / 12 / 0 / 13 / 0
Illinois / 6 / 1 / 1 / 8 / 1
Iowa / 1 / 1 / 0 / 2 / 0
Kansas / 2 / 3 / 0 / 5 / 0
Minnesota / 8 / 7 / 0 / 15 / 0
Mississippi / 6 / 8 / 0 / 14 / 1
Missouri / 1 / 3 / 0 / 4 / 0
Montana / 1 / 5 / 0 / 6 / 0
Nebraska / 0 / 12 / 0 / 12 / 0
Nevada / 0 / 2 / 0 / 2 / 0
New Mexico / 5 / 3 / 0 / 8 / 0
North Dakota / 7 / 44 / 0 / 52 / 1
Ohio / 1 / 0 / 0 / 1 / 0
Pennsylvania / 1 / 0 / 0 / 1 / 0
South Dakota / 19 / 43 / 0 / 62 / 2
Texas / 4 / 3 / 0 / 7 / 0
Utah / 1 / 1 / 0 / 2 / 0
Virginia / 1 / 0 / 0 / 1 / 0
Wyoming / 5 / 27 / 2 / 34 / 1
TOTALS / 136 / 299 / 9 / 444 / 15
(Promed 8/16/07)

West Nile Virus Update--United States, Jan 1-Aug 14, 2007
This report summarizes 2007 West Nile virus (WNV) surveillance data reported to CDC through ArboNET as of Aug 14, 2007. A total of 27 states have reported 444 cases of human WNV illness to CDC. A total of 241 (54%) cases for which such data were available occurred in males; median age of patients was 48 years (range: 2--96 years). Dates of illness onset ranged from Mar 25 to Aug 5; 15 cases were fatal. A total of 49 presumptive West Nile viremic blood donors (PVDs) have been reported during 2007. Of these, 19 were reported from California; 7 from Texas; 5 each from Colorado and North Dakota; 3 each from Kentucky and South Dakota; 2 from Minnesota; and 1 each from Arizona, Iowa, New Mexico, North Carolina, and South Carolina. Of the 49 PVDs, 15 persons (median age: 49 years [range: 18--79 years]) subsequently had West Nile fever. For more information on WNV activity: http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and http://westnilemaps.usgs.gov.

http://cdc.gov/mmwr/mmwr_wk.html
(MMWR August 17, 2007 / 56(32);821-822)

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2. Articles
Allocating pandemic influenza vaccines in Minnesota: Recommendations of the Pandemic Influenza Ethics Work Group.
Vawter DE, Gervais KG, Garrett JE. Vaccine. 2007 Aug 29;25(35):6522-36. Epub 2007 Jun 14.
Abstract: A public-private, multidisciplinary work group developed recommendations for rationing vaccines in Minnesota during a worst-case influenza pandemic. The recommendations encompass an ethical framework of principles, goals, and strategies. The primary goal is to maximize Minnesotans' chances of surviving both the pandemic and the years immediately thereafter and to limit two major causes of death: (a) influenza and complications of influenza, and (b) disruption of basic health care, public health, and public safety infrastructures. The work group also developed a sample rationing plan, but stressed that any final plan must reflect the best available evidence during an actual pandemic.

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Trivalent Live Attenuated Intranasal Influenza Vaccine Administered During the 2003–2004 Influenza Type A (H3N2) Outbreak Provided Immediate, Direct, and Indirect Protection in Children
Pedro A. Piedra et al. PEDIATRICS (doi:10.1542/peds.2006-2836) published online Aug 13, 2007.
Abstract: OBJECTIVE. Live attenuated influenza vaccine may protect against wild-type influenza illness shortly after vaccine administration by innate immunity. The 2003–2004 influenza A (H3N2) outbreak arrived early, and the circulating strain was antigenically distinct from the vaccine strain. The objective of this study was to determine the effectiveness of influenza vaccines for healthy school-aged children when administered during the influenza outbreak. DESIGN/METHODS. An open-labeled, nonrandomized, community-based influenza vaccine trial was conducted in children 5 to 18 years old. Age-eligible healthy children received trivalent live attenuated influenza vaccine. Trivalent inactivated influenza vaccine was given to children with underlying health conditions. Influenza-positive illness was compared between vaccinated and nonvaccinated children. Medically attended acute respiratory illness and pneumonia and influenza rates for Scott and White Health Plan vaccinees were compared with age-eligible Scott and White Health Plan nonparticipants in the intervention communities. Herd protection was assessed by comparing age-specific medically attended acute respiratory illness rates in Scott and White Health Plan members in the intervention and comparison communities. RESULTS. We administered 1 dose of trivalent live attenuated influenza vaccine or trivalent inactivated influenza vaccine to 6569 and 1040 children, respectively (31.5% vaccination coverage), from October 10 to December 30, 2003. The influenza outbreak occurred from October 12 to December 20, 2003. Significant protection against influenza-positive illness (37.3%) and pneumonia and influenza events (50%) was detected in children who received trivalent live attenuated influenza vaccine but not trivalent inactivated influenza vaccine. Trivalent live attenuated influenza vaccine recipients had similar protection against influenza-positive illness within 14 days compared with >14 days (10 of 25 vs 9 of 30) after vaccination. Indirect effectiveness against medically attended acute respiratory illness was detected in children 5 to 11 and adults 35 to 44 years of age. CONCLUSION. One dose of trivalent live attenuated influenza vaccine was efficacious in children even when administered during an influenza outbreak and when the dominant circulating influenza virus was antigenically distinct from the vaccine strain. We hypothesize that trivalent live attenuated influenza vaccine provides protection against influenza by both innate and adaptive immune mechanisms.

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Vaccination Coverage Among Children in Kindergarten--United States, 2006--07 School Year
“Healthy People 2010 objectives include increasing vaccination coverage among children in kindergarten and first grade. For these children, the target is >95% vaccination coverage for the following: hepatitis B vaccine; diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids and acellular pertussis vaccine, or diphtheria and tetanus toxoids vaccine (DTP/DTaP/DT); poliovirus vaccine; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine. To assess progress toward national goals and determine vaccination coverage among children in kindergarten, data were analyzed from reports submitted to CDC by 49 states and the District of Columbia (DC) for the 2006--07 school year. This report summarizes findings from that analysis, which indicated that approximately 75% of states have reached the 2010 objective of at least 95% coverage for all of the vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for children in kindergarten. These results underscore the effectiveness of school-entry requirements in increasing vaccination coverage but highlight a need for more standardized vaccination reporting among states. . .Among the reporting states, coverage ranged from 32 (74%) states with >95% coverage for varicella vaccine to 35 (83%) states with >95% coverage for hepatitis B vaccine. . .Thirty-five (70%) states reported >95% coverage for MMR. Thirteen of the reporting states did not meet the 95% coverage target for one or more of the vaccines. . .”
http://cdc.gov/mmwr/preview/mmwrhtml/mm5632a3.htm
(MMWR August 17, 2007 / 56(32);819-821)

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Report says problems hobble US biosurveillance system
3 years ago President Bush directed the Department of Homeland Security (DHS) to consolidate biosurveillance data to improve the nation's ability to detect bioterrorism and other infectious disease threats, but federal auditors warned that leadership problems have seriously hampered the program. Problems surrounding the implementation of the $14.3 million program, called the National Bio-Surveillance Integration System (NBIS), were detailed in a 38-page report by the DHS Inspector General's office. The program is a massive information technology project that will combine biosurveillance information from 14 federal agencies as well as several industry and other outside sources. The NBIS is designed to sift through a large amount of data to enable analysts to quickly recognize biological attacks on a range of targets and provide early warning of possible pandemics.

"NBIS, a key element of DHS' bioprotection program, is falling short of its objectives," the report states. Though the program began with a clear mandate and strong support, implementation efforts have suffered from numerous shifts within DHS departments. The system initially flourished under the agency's science and technology department, but lost momentum less than a year later when DHS transferred program responsibilities to its information analysis and infrastructure department. In a subsequent shift, the NBIS was placed under the department of the chief medical officer, where the focus on situational awareness was reduced and the program became more medical-based and less willing to share information, the report says. Under the new arrangement, the NBIS benefited from more senior-level support, which helped beef up staffing and bring in additional contractor expertise. But as a result of all the management changes, the NBIS has not developed adequate planning documents, and the development of interagency partnerships—crucial for incorporating data into the system—has languished, the report asserts.

NBIS has not yet acquired the federal data it needs to test and further develop the system, the Inspector General's Office found. Another key problem has been a lack of guidance for NBIS contractors, the report says. For example, when the contractors were developing the system, DHS made it difficult for them to seek user feedback from the analysts who will be working with the system. The report says the date set for the NBIS to begin initial operations was pushed back to Jun-Jul 2007, which could delay the contractor's scheduled Mar 2008 delivery of the system and add $2.8 million to the project's price tag. DHS projects NBIS will be fully operational by Sep 2008. In an accompanying letter responding to the inspector general's report, Jeffrey Runge, DHS's chief medical officer, agreed with most of the findings, but made several clarifications. He wrote that his department has already made progress toward hiring more staff and has hired a contractor to establish a master schedule to monitor workflow. Runge also said his department has secured the participation of more NBIS partners.

See DHS Report: http://www.dhs.gov/xoig/assets/mgmtrpts/OIG_07-61_Jul07.pdf
(CIDRAP 8/16/07)

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3. Notifications
Revised Recommendations: To Vaccinate All Persons Aged 11--18 Years with Meningococcal Conjugate Vaccine
In Jan 2005, a quadrivalent meningococcal polysaccharide-protein conjugate vaccine (MCV4) (Menactra, Sanofi Pasteur, Inc.) was licensed for use among persons aged 11--55 years. In May 2005, the Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination with 1 dose of MCV4 for persons aged 11--12 years, persons entering high school if not previously vaccinated with MCV4, and other persons at increased risk for meningococcal disease. In Jun 2007, ACIP revised its recommendation to include routine vaccination of all persons aged 11--18 years with 1 dose of MCV4 at the earliest opportunity. ACIP continues to recommend routine vaccination for persons aged 19--55 years who are at increased risk for meningococcal disease: college freshmen living in dormitories, microbiologists routinely exposed to isolates of Neisseria meningitidis, military recruits, travelers to or residents of countries in which N. meningitidis meningitis is hyperendemic or epidemic, persons with terminal complement component deficiencies, and persons with anatomic or functional asplenia.

The ACIP goal is routine vaccination of all adolescents with MCV4 beginning at age 11 years. Because the incidence of meningococcal disease increases during adolescence, health-care providers should vaccinate previously unvaccinated persons aged 11--18 years with MCV4 at the earliest possible health-care visit. ACIP encourages health-care providers to vaccinate with MCV4 throughout the year. Vaccine providers should administer MCV4 and Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccine to persons aged 11--18 years during the same visit if both vaccines are indicated and available. Persons with a history of GBS might be at increased risk for postvaccination GBS; therefore, a history of GBS is a relative contraindication to receiving MCV4. Meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative for short-term protection against meningococcal disease (3--5 years). Providers who have questions may contact Sanofi Pasteur by telephone at 1-800-VACCINE or online at http://www.vaccineshoppe.com.
http://cdc.gov/mmwr/preview/mmwrhtml/mm5631a3.htm
(MMWR August 10, 2007 / 56(31);794-795)

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Satellite Broadcast and Webcast: HIV Prevention with Hispanics/Latinos
CDC and the Public Health Training Network will present the satellite broadcast and live webcast, Current Challenges and Successes in HIV Prevention with Hispanics/Latinos, Nov 15, 2007, at 1:00 p.m. EST. The 2-hour broadcast will highlight relevant research and examples of effective HIV-prevention programs in the US. A panel will answer viewer questions, which can be sent by fax during the broadcast or by e-mail during and after the broadcast. For additional information to to: http://www.cdcnpin-broadcast.org. The broadcast will be available at http://www2a.cdc.gov/phtn. DVDs can be ordered by telephone, 800-458-5231.
http://cdc.gov/mmwr/preview/mmwrhtml/mm5631a4.htm
(MMWR August 10, 2007 / 56(31);795)

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 apecein@u.washington.edu