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Vol. X. NO. 21 ~ EINet News Briefs ~ Oct 19, 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 report explores patent issues concerning influenza viruses
- Indonesia: 109th human case of avian influenza H5N1 confirmed
- Taipei: Nationwide outbreak of conjunctivitis
- USA: Report: Pandemic plans need more focus on children
- USA (multistate): E coli outbreak prompt beef recall
- USA: ConAgra recalls pot pies as Salmonella outbreak expands
- USA (Oregon): Adenovirus 14-associated pneumonia
- Scotland/USA: Eastern equine encephalitis puts man in coma
- USA (South Dakota): Hantavirus claims life in South Dakota
- Avian/Pandemic influenza updates
- Cholera, diarrhea, and dysentery
- West Nile Virus
- CDC EID Journal, Volume 13, Number 10--Oct 2007
- A comparison of the effectiveness of zanamivir and oseltamivir for the treatment of influenza A and B
- Issues Relevant to the Adoption and Modification of Hospital Infection-Control Recommendations for Avian Influenza (H5N1 Infection) in Developing Countries
- Antivirals and the Control of Influenza Outbreaks
- HIV/AIDS Among Hispanics--United States, 2001--2005
- Acute Respiratory Distress Syndrome in Persons with Tickborne Relapsing Fever--Three States, 2004-2005
- Emergence of Antimicrobial-Resistant Serotype 19A Streptococcus pneumoniae--Massachusetts, 2001--2006
- Genotype Prevalence and Risk Factors for Severe Clinical Adenovirus Infection, United States 2004-2006
- H5N1 highly pathogenic avian influenza outbreak, Holton, Suffolk, February 2007: lessons to be learned report
- Seasonal Influenza Vaccine Supply for the U.S. 2007-08 Influenza Season
- A call for a national infectious diseases strategy
- FDA Approval of alternate dosing schedule for combined Hepatitis A and B vaccine (Twinrix)
- Interactive map of ProMED reports
- National Latino AIDS Awareness Day--October 15, 2007
- Prevention of Hepatitis A after Exposure to Hepatitis A Virus and in International Travelers
- Recommended Adult Immunization Schedule--United States, October 2007--September 2008
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
Viet Nam / 3 (3)
Total / 3 (3)
Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)
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)
Cambodia/ 1 (1)
China / 3 (2)
Egypt / 20 (5)
Indonesia / 34 (30)
Laos / 2 (2)
Nigeria / 1 (1)
Viet Nam 7 (4)
Total / 68 (45)
Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 331 (203).
(WHO 10/17/07 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's maps showing world's areas affected by H5N1 avian influenza (last updated 10/11/07): http://gamapserver.who.int/mapLibrary/
WHO’s timeline of important H5N1-related events (last updated 10/8/07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.
Global: WHO report explores patent issues concerning influenza viruses
WHO released a report on patenting issues related to influenza viruses, following up on a resolution adopted by the World Health Assembly in May 2007 to address the concerns of Indonesia and other developing countries about access to pandemic flu vaccines and treatments. The report was prepared by the World Intellectual Property Organization (WIPO) and will be presented at a WHO intergovernmental meeting on virus sharing and access to vaccines, Nov 20 - 23. Indonesia stopped sending H5N1 samples to WHO Dec 2006 as a protest, saying the country couldn't afford the vaccines that drug companies would develop from the virus samples they submitted. Since then Indonesia has shared only a few samples. Indonesia's action raised the possibility that it and other countries affected by H5N1 flu might claim legal ownership of H5N1 isolates. Researchers need H5N1 samples to track the virus's evolution and drug susceptibility and to develop vaccines.
The 41-page WHO report emphasizes that its purpose is to provide technical background information on patent issues related to influenza viruses. The pace of patent activity surrounding H5N1 and other avian flu viruses has picked up dramatically. The first patent applications was made in 1983, but 35% of all patent requests referring to avian flu viruses or H5N1 were made in the first 9 months of this year. "There is considerable diversity in this activity, with publications from over 100 different actors representing a mix of private firms, individual inventors, public sector institutions, and government agencies," the report notes. In reviewing general patent law principles, the authors state that naturally occurring substances that are not altered by human interventions are not considered patentable. "Hence, a wild flu strain as such would be inherently unpatentable—put simply, it cannot be seen as an 'invention', the fit subject matter of a patent," the report says. Also, there is no international patent, the authors say.
The authors, while not making definitive legal assessments, highlight several observations:
• Early, open publication of the gene sequence of a newly isolated flu virus strain would preclude patent protection, but would facilitate broad-based research and development.
• Sequencing a gene using regular laboratory techniques is not likely to be considered inventive or nonobvious enough to warrant a patent.
• Unless there is a clearly disclosed and defined new and useful function, most countries deny patent protection for gene sequences.
• Initial searches did not find any patents for wild viruses, though there were several for newly engineered genetic materials such as synthetic virus-like particles (VLPs), methods of producing them, and vaccines produced from them.
• Patent rights are not absolute. For example, many national patent laws allow researchers to use patented inventions for certain purposes related to research but not to commercial application.
Related report: “Sharing of influenza viruses and access to vaccines and other benefits”, Oct 9, 2007 WHO director-general report http://www.who.int/gb/pip/pdf_files/PIP_IGM_4-en.pdf
Indonesia: 109th human case of avian influenza H5N1 confirmed
As of 17 Oct 2007, The Ministry of Health of Indonesia has announced the death of a previously confirmed case of H5N1 infection. The 12-year-old male from Tangerang District in Banten Province died 13 Oct 2007. Of the 109 cases confirmed to date in Indonesia, 88 have been fatal. Tangerang regency in Banten province has recorded 5 deaths from bird flu. The boy, a resident of Ceger village in Sepatan district, had suffered high fever from 30 Sep 2007 but was only admitted to Tangerang General Hospital 8 Oct 2007. The boy was then transferred to Persahabatan Hospital 9 Oct 2007 under suspicions he had contracted bird flu. The Health Ministry's research and development center confirmed the boy had been infected by the H5N1 virus. Blood samples from the victim's family members and his neighbors have been obtained to be tested at a Health Ministry laboratory. Reportedly there was a poultry-breeding business some 500 meters away from the victim's house. Banten Governor Ratu Atut Chosiah issued a bylaw on poultry restrictions on 19 Jan 2007, which included a ban on keeping backyard fowl. Unfortunately, the ordinance has yet to take effect due to prolonged protests from the Banten Council.
Taipei: Nationwide outbreak of conjunctivitis
The Chinese Nationalist Party (KMT) Legislator Hsieh Kuo-liang said the Department of Health (DOH) and the Centers for Disease Control (CDC) failed to keep the outbreak under control when a large number of conjunctivitis cases were first reported earlier Oct 2007. Hsieh said the outbreak first hit Keelung and Yunlin 4 Oct 2007, but the CDC did not collect samples from patients to determine the cause of the condition until 8 Oct 2007 although several thousand pinkeye cases had been reported. CDC confirmed 11 Oct 2007 that Coxackievirus type 24 [classified as Human coxsackievirus A24 in the ICTV nomenclature], an enterovirus, was responsible. "[The DOH and CDC] completely ignored the possible serious consequences of such an acute disease," Hsieh said, adding that the conjunctivitis outbreak has spread to Taipei and Kaohsiung. Steve Kuo the director of the CDC, said they had done their best to keep people informed. Kuo said 10 510 students nationwide had been infected with the disease as of 12 Oct 2007 with cases concentrated in Keelung, Yunlin, Taipei, Kaohsiung and Chiayi. Taipei City schools must report cases of pinkeye to help track the outbreak, a city government education official said 15 Oct 2007. Department of Education Director Wu Ching-chi recommended those affected stay at home until they fully recover. Outbreaks of conjunctivitis are frequent in some Asian countries at this time of year. Epidemic keratoconjunctivitis and the epidemic hemorrhagic conjunctivitis are self-limiting conditions that can be caused by several different enteric viruses including enterovirus 70, coxsackievirus A24, and human adenovirus types 8, 11, 19, and 37.
USA: Report: Pandemic plans need more focus on children
The US government's pandemic influenza preparedness plans need to pay more attention to children, according to a new report. The groups recommend that the federal government vastly increase its stockpile of antiviral medication for children, do more testing of pandemic vaccines for children, and increase efforts to understand and deal with the effects of school closings in a country where half of workers can't use sick leave to take time to care for sick children. "Children should be a priority, not an afterthought," said Jeffrey Levi, executive director of the nonprofit advocacy group Trust for America's Health (TFAH). TFAH issued the report in collaboration with the American Academy of Pediatrics (AAP). The report notes that almost 46% of the fatal human cases of H5N1 avian influenza, the strain considered the leading candidate to trigger a pandemic, have involved children and teenagers.
Planning gaps and problems cited in the report, titled "Pandemic Influenza: Warning, Children at-Risk," include the following: The US Strategic National Stockpile currently contains only 100,000 doses of oseltamivir (Tamiflu) formulated for children, though the country has 73.6 million children; Neither of the 2 antiviral drugs that are considered effective against H5N1—oseltamivir and zanamivir (Relenza)—is licensed for children younger than 1 year; About 30 million children rely on the National School Lunch Program, and many rely on schools nurses for healthcare, but there are no plans for providing these services if schools close during a pandemic; CDC recommends using N95 respirators in certain circumstances in a pandemic, but no such respirators are available in children's sizes.
The report makes a series of recommendations to address these and other problems. Among them: The government should stockpile enough pediatric doses of antiviral drugs to treat 25% of the nation's children and adolescents—about 18.4 million youngsters; The Department of Health and Human Services (HHS) should conduct more studies on the feasibility of extended closings of school and child care centers, including a closer assessment of the interruption of school meals programs; Educators and public health officials should plan for special "influenza-free" daycare centers to allow parents in essential jobs to continue to work. Such centers should be equipped to provide point-of-care rapid testing for sick children; HHS should conduct more studies on H5N1 vaccine efficacy in young children, support the development of more flu vaccines, and do more studies of antiviral drugs for infants; HHS should set up an independent task force to study and make recommendations on the use of surgical masks, N95 respirators, and other personal protective equipment for children; All schools should teach children about communicable diseases and infection control, including cough etiquette, handwashing, and measures that might be taken during a pandemic, such as school closings; Teachers and school administrators should be encouraged to get flu shots and should remind families about flu vaccination recommendations; Educators and public health officials should prepare to make psychologists and grief counselors available to help students cope with illness and the loss of family members and friends.
Levi said federal officials are aware of many of the problems cited in the report but need to do more about them. John S. Bradley, a member of the AAP Committee on Infectious Disease, asserted that CDC recommended closing schools and daycare centers to help combat a pandemic "without ever having talked to anyone in pediatrics to realize that closing these is not as easy as it sounds. The idea of the planners was that if you close schools and daycare you stop the spread of disease. . .But there are unlicensed daycare centers that operate under the radar, which is where all these kids would be going."
Reporters questioned the concept of influenza-free daycare centers, noting that people infected with a flu virus can spread it to others even before having any symptoms. Bradley and Henry H. Bernstein, also a member of the AAP Committee on Infectious Disease, acknowledged that keeping a daycare center free of flu would be difficult but said it would be worth trying. Bradley agreed that children can shed flu virus before becoming symptomatic but said they are far more contagious later. Levi said that though the problems concerning pandemic planning and children are complicated, certain policy changes could make a difference. "Half of all workers in the US do not have any sick leave at all," he said. "That tends to be concentrated in poorer families. And they are more likely to have the kinds of jobs where you can't telecommute." Measures to allow parents to use sick leave to care for sick children would help that situation, he suggested.
USA (multistate): E coli outbreak prompt beef recall
An Illinois company has recalled frozen ground beef products because of a possible connection with Escherichia coli O157:H7 infections. On Oct 13, 2007, J&B Meats Corp., Inc., based in Illinois, voluntarily recalled 173 554 pounds of frozen ground sirloin and beef patties that were produced Jun 12, 18, and 22, and were nationally distributed to retail stores, according to the US Department of Agriculture's (USDA's) Food Safety and Inspection Service (FSIS). The company recalled the products after FSIS received illness reports through its consumer complaint monitoring system.
The frozen beef patties, sold under the Topps and Sam's Choice brands, bear the establishment number "Est. 5712" on their package labels. J&B Meats said the beef patties were made for Topps Meat Co., though J&B is not a subsidiary of Topps. The latter company in late Sep announced a recall of 21.7 million pounds of ground beef because of potential E coli contamination. Tests conducted on opened and unopened packages of Topps brand frozen ground beef patties yielded E. coli O157 isolates with several different "DNA fingerprint" patterns. As of 9 Oct 2007, 35 cases of E. coli O157:H7 infection have been identified with PFGE (pulsed field gel electrophoresis) patterns that match at least one of the patterns of E. coli strains found in Topps brand frozen ground beef patties. The Topps recall is the fifth largest involving ground beef and E coli in US history. Topps, founded in 1940, announced it was going out of business immediately.
A few days after the Topps Meat recall, Cargill Meat Solutions of Wisconsin recalled about 845,000 pounds of frozen ground beef. The recall was announced after Minnesota health officials linked 3 illness reports to the company's beef patties, which were sold through Sam's Club stores. The ground beef was sold nationwide through retail stores, restaurants, and institutions. The Minnesota Department of Health said 4 cases of E coli O157:H7 had been linked to eating American Chef's Selection Angus Beef Patties, one of the brands implicated in Cargill's beef recall. All the patients were children who ate patties purchased from Sam's Club Stores in Aug and Sep 207. 2 of the patients were hospitalized with HUS. Wisconsin Department of Health and Family Services said an 18-year-old woman has tested positive for the same E coli strain that infected the Minnesota children.
In the Topps outbreak, the number of related illness cases has risen to 38 in 8 states, according to CDC. The first reported illness began on 5 Jul 2007, and the last began 23 Sep 2007. Most of the patients sickened in the Topps outbreak are from the Northeast. Of 26 people for whom hospitalization status was known, 17 (65%) were hospitalized, and 1 had hemolytic uremic syndrome (HUS). No deaths have been reported. E coli O157:H7 produces a toxin that causes diarrhea, often bloody, and abdominal cramps but usually no fever. The illness usually resolves in 5 to 10 days, but it can cause HUS, potentially leading to kidney failure or death, in 2% to 7% of patients. Health officials are concerned about what appears to be a surge in the number of ground beef recalls for E coli O157:H7 contamination.
(CIDRAP 10/9/07, 10/15/07; Promed 10/7/07, 10/10/07)
USA: ConAgra recalls pot pies as Salmonella outbreak expands
ConAgra recalled all of its pot pie varieties, including beef, as the number of people sickened in a Salmonella outbreak rose. Salmonellosis typically causes fever and nonbloody diarrhea that resolves in a week. Investigators have not found the outbreak strain at the company's factory or in any product samples, but ConAgra said it recalled the products to make it more clear to consumers that they should not eat them. On Oct 9, 2007 when ConAgra issued its first consumer advisory, it advised retail stores not to sell its chicken or turkey pot pies and recommended that consumers refrain from eating them while federal officials investigated. The outbreak is believed to be linked to chicken and turkey pot pies, but the company said the beef variety was included in the recall to simplify the message for consumers.
Affected products have the establishment code "P9" or "Est. 1059" printed kage, according to the US Department of Agriculture's (USDA's) Food Safety and Inspection Service (FSIS). They include Banquet pot pies and the following brands: Albertson's, Hill Economy Fare, Food Lion, Great Value, Kirkwood, Kroger, Meijer, and Western Family. The products were distributed throughout the USA, Puerto Rico, and the Caribbean islands.
Health officials recently approached ConAgra with their suspicions that several clusters of Salmonella infections were linked to the company's chicken and turkey pot pies. CDC is coordinating a case-control study that has associated Banquet pot pies with the Salmonella cases. CDC has said that the outbreak involves Salmonella enterica serotype I,4,,12:i:-, and it has collected at least 165 matching isolates from case-patients. The outbreak began Jan 2007 and appears to be ongoing. Nationally, at least 211 people from 35 different states have become ill from the pot pies. At least 33 people have been hospitalized. No deaths have been reported. Salmonellosis typically causes fever and nonbloody diarrhea that resolves within a week.
ConAgra, in its initial public health advisory, said it believed the illnesses were probably due to consumer undercooking of the products. Microwave ovens vary in strength and can cook products unevenly. The company said that before returning the product to the market, it will revise cooking directions on packages to clarify safe preparation steps.
(CIDRAP 10/12/07; Promed 10/16/07, 10/18/07)
USA (Oregon): Adenovirus 14-associated pneumonia
A potentially deadly form of community acquired pneumonia linked to adenovirus type 14 has emerged in the Pacific Northwest. First encountered in 2005 in Oregon, the viral pneumonia frequently leads to hospitalization and has a 20 per cent fatality rate, Paul Lewis of the Oregon State Public Health Department said at the Infectious Diseases Society of America (IDSA) meeting. "We recommend obtaining a viral culture in pneumonia patients who lack a specific etiology, especially those with severe disease," said Dr Lewis. Recognition of the adenoviral pneumonia began with 4 patients hospitalized simultaneously at a Portland hospital. Upon comparing notes with physicians at area hospitals, Dr Lewis and colleagues "almost fell out of our chairs because every hospital we called had recent severe and fatal cases of adenovirus disease." Investigators followed up the communication with a systematic review of all cases of adenovirus disease identified by Oregon clinical laboratories from Nov 2006 to Apr 2007. 6 months of active surveillance revealed what appeared to be a winter-spring predominant adenovirus disease, as the number of reported cases increased from Jan through Apr. Isolates from the sickest patients were sent to CDC, which found that almost all the cases involved adenovirus 14, a serotype identified more than 50 years ago but rarely detected since then and never in association with outbreaks.
Lewis et al. at the state health department reviewed specimens dating back to 1993 and found a few cases of adenoviral disease almost every year. Beginning in 2005, adenovirus 14 was the predominant serotype identified. Comparison of 31 patients with adenovirus 14 disease and 14 patients with other adenovirus serotypes showed that adenovirus 14 tended to infect older men (median age 52.9), and almost half the cases involved smokers. Most strikingly, adenovirus 14 was associated with a hospitalization odds ratio of 15.9 compared with other adenovirus serotypes. Chest x-rays were abnormal in 23 of 24 cases. All patients received broad spectrum antibiotics. Dr Lewis said 22 of the 31 patients with adenovirus 14 disease were hospitalized, and 16 required ICU (intensive care unit) care. 7 patients (22 per cent) died.
Scotland/USA: Eastern equine encephalitis puts man in coma
A Briton who is in a coma after being bitten by a mosquito is thought to have become the first European victim of the deadly eastern equine encephalitis (EEE) virus. The man, 35, began to feel tired after he returned from a fishing holiday in the north east US, with [mosquito] bites around his ankles. When the man went to see his general practitioner (GP), he suffered a seizure and then lost consciousness. If he lives, he is expected to be severely disabled for the rest of his life. The EEE virus is regarded as one of the most serious mosquitoborne diseases in North America. It is found mainly in the eastern US.
The man had traveled to the US July . He spent 6 weeks with family and friends in Rhode Island and stayed in a log cabin in northern New Hampshire. He fell ill 31 Aug , a day after flying home. Within 2 days, he had lost consciousness and was transferred to the intensive care unit of Western General Hospital. The rare condition was diagnosed 13 Sep 2007. Reportedly he was the first case of EEE to be discovered in Europe. The man is being cared for at the hospital's neurological unit, where he remains unconscious and unresponsive. US health records show that there were 220 confirmed cases of EEE between 1964 and 2004, an average of 5 per year. According to reports there has been 1 death in 2007 in the US, a 6 year old boy in Alabama.
The EEE virus is maintained through a bird-mosquito cycle that increases throughout the summer, as more birds and mosquitoes become infected. Transmission to humans is rare; it generally takes from 3 to 10 days to develop symptoms. Many infected people have no apparent illness; for those who do become ill, symptoms range from mild flu-like illness to inflammation of the brain, coma and death. There is no specific treatment. Up to 35 per cent of victims die. A vaccine is available to protect horses but not human beings. CDC recommends that people use repellents to avoid mosquito bites.
USA (South Dakota): Hantavirus claims life in South Dakota
The South Dakota Health Department says hantavirus has caused the death of a McCook County resident. A total of 2 other lives in south eastern South Dakota have been claimed by the virus in the past 3 years.
Hantavirus, which is carried by rodents, attacks the lungs and blood vessels. The primary carrier of the disease in South Dakota is the deer mouse. People are infected when they breathe in the aerosolized virus from droppings, urine or saliva of rodents. State epidemiologist Lon Kightlinger says rodent control is prudent in the fall when mice begin moving indoors.
Avian/Pandemic influenza updates
- UN: http://www.un-influenza.org/ : progress report on avian influenza. 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. Link to supplement to Journal of Wildlife Diseases on avian influenza.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm
- US CDC: http://www.cdc.gov/flu/avian/index.htm.
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html.
- 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 19 Oct 2007 with information on H7N3 outbreak in Canada.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)
Cholera, diarrhea, and dysentery
The Centre for Health Protection is investigating a cholera case involving a 29 year old Shenzhen woman, who visited Thailand with her husband 27 Sep to 1 Oct 2007. The woman came down with diarrhea and vomiting 1 Oct 2007 and was admitted to a Shenzhen hospital. She is in hospital and in stable condition. Tests showed she had infection with Vibrio cholerae O1 El Tor Ogawa. Her close contacts in Shenzhen showed no symptoms. Her 49 year old husband, living in Hong Kong, also had diarrhea and vomiting 1 Oct 2007, but the symptoms subsided. He was admitted to hospital for observation.
The producers of dairy products appear to be responsible for a large-scale outbreak of dysentery in Stavropol. The cases began in Lermontov 3 Oct 2007, when children from 3 kindergartens started to come to a number of hospitals. Later, a new locus of infection emerged in Kislovodsk. Reportedly 624 people, including 572 children younger than 14, contracted the infection as of 7 Oct 2007. A total of 396 people, including 356 children, have been taken to hospital. This is the fourth outbreak of intestinal infection on the Stavropol territory since July 2007. Tests confirm the outbreak as dysentery. It appears that all the affected people had consumed products of the dairy company "Vita." Reportedly this link has been established in 454 cases. The management of the dairy company said that they have stopped the production and tests are being carried out from product samples and on specimens from personnel.
The number of residents affected by diarrhea in a barangay [village] in Gen. Trias town in Cavite continues to rise. From 315 cases reported by 12 Oct 2007, the number of residents in Barangay Panungyanan affected by diarrhea rose to 359 cases 13 Oct 2007. Dr. Abe Escario, municipal health officer, said that residents downed by diarrhea may have drank "stock water" which may have been contaminated water. Health authorities also warned that contraction of diarrhea by other residents may continue even if the water supply has been fixed since diarrhea may be communicated to others. They said this was proven when some residents were affected even if they did not drink from the contaminated water lines. Health workers in General Trias are spreading advisories to all the residents to first boil their drinking water or treat it first with sodium hypochloride tablets that should be dissolved in water.
Dengue has been detected in the Jose R Mijares, Polvorera, Camilo Torres and other bordering neighborhoods [which] are being fumigated in order to protect the inhabitants [from dengue virus transmission]. There are about 40 [dengue] cases.
The government has issued a nationwide dengue fever alert after recording more than 4000 cases in the second week of Sep 2007, the health department said 3 Oct 2007. It had recorded 24 689 cases of the mosquitoborne disease in all since Jan 2007, with 283 deaths. Health officials have urged the public to implement the 4-S in the campaign against dengue: search and destroy breeding sites of mosquitoes, seek immediate consultation, self protection and saying "no" to indiscriminate fogging unless there is a dengue outbreak in the area.
Dengue has claimed 3 young lives in Aklan since its outbreak. According to Dr. Maria Magpusao, Chief of the Technical Services Division of the Provincial Health Office said based on their records [in 2007], the month of August had the highest number of dengue cases with 198 while from 1-22 Sep 2007, there were 145 cases. Dr. Magpusao said the figures have not gone beyond outbreak level compared with the past years'  record of the province, however, she advised that patients suspected of having dengue must seek medical attention right away. Dr. Magpusao said all areas where there were dengue deaths had the presence of the dengue mosquito vector, Aedes aegypti. The households also stored water in uncovered containers, which were used as breeding areas by the mosquitoes. The Department of health (DOH) has issued a nationwide dengue fever alert and has asked hospitals to designate fast lanes for dengue patients. According to a DOH report, Region 6, where Aklan belongs, has the most number of dengue victims, followed by Region 7, and NCR (National Capital Region).
(Promed 10/8/07, 10/17/07)
The Tainan city government reported 12 Oct 2007 that the number of confirmed cases of dengue fever has broken the 500 mark and now stands at 511, making it the city's worst ever outbreak of the disease. City government officials said they discovered clusters of dengue fever infection in individual households in both northern and eastern parts of the city and urged the public to be on guard.
Viet Nam (Ho Chi Minh City)
The Ho Chi Minh City (HCMC) Hospital for Tropical Diseases has lately been receiving huge patient loads, with an average of around 70-100 dengue fever cases per week. This disease, which typically affects young children, is increasingly being diagnosed in adults. Regardless of age, the hospital is not equipped to handle the numbers. The districts in the inner city such as Binh Thanh, Tan Binh, Districts 8 and 11, and others are now reported as epidemic areas. Around 300 dengue cases are being hospitalized every week for diagnosis in the city. The patients are mostly immigrants who come from other provinces and cities looking for work, and most are living in the slums. Since the beginning of 2007, the epidemic has killed 6 including 2 adults. The Steering Committee for Dengue Fever Protection asked the localities and health centers to help curb the spread of dengue fever by providing knowledge and education about the disease, transmission, and prevention to all people. The committee also mandates that people who have a fever come to health centers immediately for timely treatment.
Dengue cases up sharply in Latin America, Asia
Global health officials have noted sharp rises in the number of dengue fever cases in recent months, particularly in Lain American, Caribbean, and Asian countries where the disease is endemic. A recent surveillance update from WHO reported that Thailand has more than 40,000 cases so far this year, reflecting a 27% increase over 2006. Indonesia's total of 100,000 cases represents a 10% increase over last year, and Myanmar has reported almost 12,000 cases—a third more than it reported in 2006. The Pan American Health Organization (PAHO) reported Oct 4 that the disease is reaching epidemic levels in some of the locations it monitors. The organization said it has recorded 630,356 cases so far this year, an 11% increase from 2006. Of this year's cases, 12,147 were the more severe dengue hemorrhagic fever (DHF), and 183 cases were fatal.
Dengue fever is a flu-like illness transmitted by certain species of Aedes mosquitoes. Symptoms include headaches, rashes, cramps, and back and muscle pain. DHF, a potentially deadly complication, is characterized by high fever, bleeding, thrombocytopenia, increased vascular permeability, and in particularly severe cases, circulatory failure. No effective treatment or preventive vaccine is available.
Jarbas Barbosa da Silva, PAHO's manager of health surveillance and disease management, said that all four dengue serotypes were in circulation, "which increases the risk for appearance of the most serious forms of the disease—namely, dengue hemorrhagic fever and dengue shock syndrome." Southernmost Latin American countries have accounted for 60% of the region's dengue cases. The Andean region has had 19% of the cases. PAHO's report says Mexico has reported 67,563 dengue cases, of which 5,212 involved hemorrhagic fever. Health officials in Nuevo Laredo, Mexico, on the US border, recently reported 71 pending or confirmed dengue fever cases. Puerto Rico's health department is recording 500 cases a week, with a cumulative of 6,175 cases and 4 deaths this year. John Ehrenberg, a WHO regional adviser, said several factors were contributing to the spread of dengue: population explosion, migration, and rapid urban growth, all of which strain public health services and access to clean water.
West Nile Virus
Human cases were reported for week 36 (as of 8 Sep 2007) from the following provinces: Province / Neurological / Non-Neurological / Unclassified-Unspecified / Total / Asymptomatic
Quebec / 1 / 0 / 0 / 1*/ 1*
Ontario / 2 / 10 / 0 / 12 / 3
Manitoba / 58 / 383 / 117 / 558 / 8
Saskatchewan / 40 / 419 / 869 / 1328 / 14
Alberta / 19 / 286 / 0 / 305 / 2
British Columbia / 6 / 7 / 4 / 17* / 0
TOTALS / 126 / 1105 / 990 / 2221 / 27
* Infection acquired while traveling outside the province
2007 West Nile virus activity in the United States (through 18 Sep 2007)
State / Neuroinvasion/West Nile fever/ Other, Unspecified/ Total/ Fatalities:
Alabama / 12 / 3 / 0 / 15 / 3
Arizona / 28 / 14 /20 / 62 / 0
Arkansas / 9 / 4 / 0 / 13 / 1
California / 135 / 179 / 8 / 322 / 14
Colorado / 88 / 418 / 0 / 506 / 5
Connecticut / 3 / 1 / 0 / 4 / 0
Delaware / 1 / 0 / 0 / 1 / 0
Florida / 3 / 0 / 0 / 3 / 1
Georgia / 20 / 16 / 2 / 38 / 2
Idaho / 6 / 96 / 2 / 104 / 1
Illinois / 36 / 16 / 8 / 60 / 4
Indiana / 6 / 4 / 0 / 10 / 1
Iowa / 7 / 10 / 2 / 19 / 1
Kansas / 10 / 19 / 0 / 29 / 1
Kentucky / 3 / 0 / 0 / 3 / 0
Louisiana / 1 / 1 / 0 / 2 / 0
Maryland / 3 / 3 / 1 / 7 / 0
Massachusetts / 2 / 2 / 0 / 4 / 0
Michigan / 11 / 0 / 1 / 12 / 0
Minnesota / 39 / 54 / 0 / 93 / 0
Mississippi / 39 / 69 / 0 / 108 / 3
Missouri / 48 / 8 / 0 / 56 / 2
Montana / 33 / 152 / 0 / 185 / 3
Nebraska / 9 / 72 / 0 / 81 / 3
Nevada / 2 / 5 / 4 / 11 / 0
New Mexico / 33 / 18 / 0 / 51 / 3
New York / 9 / 1 / 0 / 10 / 1
North Dakota / 48 / 295 / 0 / 343 / 2
Ohio / 6 / 3 / 1 / 10 / 0
Oklahoma / 45 / 31 / 1 / 77 / 7
Oregon / 4 / 18 / 0 / 22 / 0
Pennsylvania / 2 / 3 / 0 / 5 / 0
Rhode Island / 0 / 1 / 0 / 1 / 0
South Carolina / 2 / 2 / 0 / 4 / 0
South Dakota / 44 / 152 / 0 / 196 / 4
Tennessee / 4 / 1 / 1 / 6 / 1
Texas / 83 / 19 / 0 / 102 / 5
Utah / 20 / 24 / 0 / 44 / 1
Virginia / 2 / 1 / 0 / 3 / 0
Wisconsin / 2 / 3 / 0 / 5 / 0
Wyoming / 15 / 147 / 14 / 176 / 1
TOTALS / 873 / 1865 / 65 / 2803 / 70
West Nile Virus Update--United States, January 1--October 16, 2007
This report summarizes 2007 West Nile virus (WNV) surveillance data reported to CDC as of Oct 16, 2007. A total of 42 states have reported 3,022 cases of human WNV illness to CDC. A total of 1,646 (55%) cases for which such data were available occurred in males; median age of patients was 51 years (range: 15 months--97 years). Dates of illness onset ranged from Jan 8 to Oct 9; a total of 76 cases were fatal. Of the total 265 presumptive West Nile viremic blood donors (PVDs) reported during 2007, 2 persons (median age: 66 years [range: 60--71 years]) subsequently had neuroinvasive illness, and 52 persons (median age: 48 years [range: 18--79 years]) subsequently had West Nile fever.
(MMWR October 19, 2007 / 56(41);1084-1085)
CDC EID Journal, Volume 13, Number 10--Oct 2007
CDC Emerging Infectious Diseases Journal Oct 2007 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. Special issue on Global Poverty and Human Development. Policy Review article: Global Public Health Security by G. Rodier et al. Perspective: Preparedness for Highly Pathogenic Avian Influenza Pandemic in Africa by R.F. Breiman et al. Expedited articles can be viewed at: http://www.cdc.gov/ncidod/eid/upcoming.htm.
A comparison of the effectiveness of zanamivir and oseltamivir for the treatment of influenza A and B
Naoki Kawai et al. Journal of Infection- 16 October 2007 (DOI: 10.1016/j.jinf.2007.09.002) http://www.journalofinfection.com/article/PIIS0163445307007578/abstract
Summary Objective To compare the effectiveness of zanamivir with oseltamivir for influenza A and B. Methods 1113 patients with influenza A or B were enrolled in the 2006–2007 influenza season. The duration of fever (temperature, ≧37.5°C) and the percentage of patients afebrile at 24 and 48h after the first dose of zanamivir or oseltamivir were calculated. Virus persistence after zanamivir therapy was also evaluated. Results There were marginally significant differences between the duration of fever after the first dose of zanamivir (31.8±18.4h) and oseltamivir (35.5±23.9h) for influenza A (p<0.05). The duration of fever after starting zanamivir therapy (35.8±22.4h) was significantly shorter than that of oseltamivir (52.7±31.3h) for influenza B (p<0.001). There were no significant differences between influenza A and B in the percentage of patients afebrile at 24 or 48h after the first inhalation of zanamivir. The reisolation rate after zanamivir therapy showed marginally significant differences between influenza A and B (<0.05). By multiple regression analysis, therapy (zanamivir or oseltamivir) was the major determinant affecting the duration of fever for influenza B. Conclusion Zanamivir therapy is more effective than oseltamivir for the treatment of influenza B infection.
Issues Relevant to the Adoption and Modification of Hospital Infection-Control Recommendations for Avian Influenza (H5N1 Infection) in Developing Countries
Anucha Apisarnthanarak et al. Clinical Infectious Diseases 2007;45:000.
Abstract: The reemergence of avian influenza (H5N1 infection) has heightened concern for a potential human influenza pandemic. Recommendations regarding preparation for a global avian influenza pandemic are available, and it is imperative that health care workers participate in preparedness planning and training. In developing countries, health care worker preparedness training should address the modes of avian influenza transmission and specify how to implement appropriate infection-control strategies to prevent and control the spread of avian influenza. We provide evidence for avian influenza transmission methods and identify prevention strategies relevant to infection control for hospitals in developing countries. Pandemic influenza preparedness plans must include health care administrative support, mechanisms to rapidly create temporary isolation facilities, systems to restrict access to exposed health care workers, and plans to involve specialists to screen and identify cases early, to provide for continuous monitoring to ensure adherence to optimal infection-control practices, and to provide regular feedback to health care workers.
Antivirals and the Control of Influenza Outbreaks
Susy Hota and Allison McGeer. Clinical Infectious Diseases. 2007;45:000.
Abstract: During annual influenza epidemics, outbreaks of influenza in closed institutions are common. Among healthy children or young adults, such outbreaks are uncommonly associated with serious morbidity or mortality; however, in hospitals and nursing homes, attack rates as high as 60% and case-fatality rates as high as 50% have been reported. Annual influenza vaccination of both patients or residents and hospital and nursing home staff has had a substantial impact on mortality and has reduced the number of outbreaks. Nonpharmacologic interventions (e.g., handwashing and contact isolation of case patients) may reduce the spread of influenza, although evidence for their efficacy is lacking. Nonetheless, long-term care facilities for the elderly population with high vaccination rates and better-than-average infection-control programs have a 25%–50% chance of experiencing an influenza outbreak each year, with an expected resident attack rate of 35%–40%. Thus, antiviral drugs have been increasingly used to mitigate the impact of influenza outbreaks. There are 2 classes of antiviral drugs that are active against influenza: adamantanes and neuraminidase inhibitors. Drugs of the 2 classes appear to be equally effective for the treatment and prophylaxis of susceptible influenza A virus strains. However, adamantanes are not active against influenza B virus, and an increasing proportion of influenza A isolates are resistant to adamantanes. Adamantanes are associated with higher rates of adverse events than are neuraminidase inhibitors. There is substantial evidence that antiviral prophylaxis is effective in terminating outbreaks of seasonal influenza in closed institutions. If stockpiles are adequate, antiviral drugs are likely to be even more important in mitigating the impact of influenza transmission in health care institutions during the next influenza pandemic.
HIV/AIDS Among Hispanics--United States, 2001--2005
In the US, Hispanics are affected disproportionately by HIV infection and AIDS. Although Hispanics accounted for 14.4% of the U.S. population in 2005, they accounted for 18.9% of persons who received an AIDS diagnosis. The rate of HIV diagnosis among Hispanics also remains disproportionately high; in 2005, the annual rate of HIV diagnosis for Hispanics was 3 times that for non-Hispanic whites. To better characterize HIV infection and AIDS among Hispanics in the US, CDC analyzed selected characteristics of Hispanics in whom HIV infection was diagnosed during 2001--2005 and those living with AIDS in 2005. The results indicated that the mode of HIV infection for Hispanics varied by place of birth, suggesting that all HIV-prevention measures might not be equally effective among Hispanics and that HIV educational activities should address cultural and behavioral differences among Hispanic subgroups.
(MMWR October 12, 2007 / 56(40);1052-1057)
Acute Respiratory Distress Syndrome in Persons with Tickborne Relapsing Fever--Three States, 2004-2005
“Tickborne relapsing fever (TBRF) is a bacterial illness caused by certain species of Borrelia and transmitted through brief and painless bites from Ornithodoros ticks (1,2). Illness usually is characterized by intermittent periods of fever, fatigue, and muscle aches. In April 2005, CDC received reports of two cases of severe TBRF associated with acute respiratory distress syndrome (ARDS) in residents of California and Nevada. After a report describing these cases was posted on CDC's Epidemic Information Exchange (Epi-X), health officials in Washington reported a third severe case associated with ARDS. This report summarizes these three cases and the results of the subsequent epidemiologic investigations. The findings indicate that ARDS might occur more frequently in patients with TBRF than previously recognized. Optimal management of TBRF requires both prompt diagnosis and careful observation during the initial phases of treatment. . .”
(MMWR October 19, 2007 / 56(41);1073-1076)
Emergence of Antimicrobial-Resistant Serotype 19A Streptococcus pneumoniae--Massachusetts, 2001--2006
“Streptococcus pneumoniae (pneumococcus) is a leading cause of otitis, sinusitis, pneumonia, and meningitis worldwide. Treatment of the most serious type of pneumococcal infection, invasive pneumococcal disease (IPD), is complicated by antimicrobial resistance. Widespread introduction in 2000 of heptavalent pneumococcal conjugate vaccine (PCV7) against serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F resulted in a decline in antimicrobial-nonsusceptible IPD in the United States, including in Massachusetts. However, development of antimicrobial resistance in serotypes not covered by PCV7 is a growing concern. In Massachusetts during 2001--2006, IPD surveillance identified an increased number of cases in children caused by pneumococcal serotypes (most notably 19A) not covered by PCV7 and an associated increase in antimicrobial resistance among these isolates. This report examines these trends and clinical characteristics of Massachusetts patients with antimicrobial-nonsusceptible, non--PCV7-type IPD. The findings indicated that, despite increases in incidence of antimicrobial-nonsusceptible IPD, overall rates of IPD remained stable during 2001-2006. In addition, persons with IPD caused by antimicrobial-nonsusceptible S. pneumoniae had clinical outcomes comparable to persons with IPD caused by antimicrobial-susceptible serotypes. Although PCV7 is effective in preventing IPD, these results confirm that antimicrobial resistance among serotypes not covered by PCV7 remains a concern. . .”
(MMWR October 19, 2007 / 56(41);1077-1080)
Genotype Prevalence and Risk Factors for Severe Clinical Adenovirus Infection, United States 2004-2006
Gregory C. Gray et al. Clinical Infectious Diseases. 2007;45:1120-1131. http://www.journals.uchicago.edu/CID/journal/issues/v45n9/51088/brief/51088.abstract.html
“Background. Recently, epidemiological and clinical data have revealed important changes with regard to clinical adenovirus infection, including alterations in antigenic presentation, geographical distribution, and virulence of the virus. Methods. In an effort to better understand the epidemiology of clinical adenovirus infection in the United States, we adopted a new molecular adenovirus typing technique to study clinical adenovirus isolates collected from 22 medical facilities over a 25-month period during 2004–2006. A hexon gene sequence typing method was used to characterize 2237 clinical adenovirus-positive specimens, comparing their sequences with those of the 51 currently recognized prototype human adenovirus strains. In a blinded comparison, this method performed well and was much faster than the classic serologic typing method. Results. Among civilians, the most prevalent adenovirus types were types 3 (prevalence, 34.6%), 2 (24.3%), 1 (17.7%), and 5 (5.3%). Among military trainees, the most prevalent types were types 4 (prevalence, 92.8%), 3 (2.6%), and 21 (2.4%). Conclusions. For both populations, we observed a statistically significant increasing trend of adenovirus type 21 detection over time. Among adenovirus isolates recovered from specimens from civilians, 50% were associated with hospitalization, 19.6% with a chronic disease condition, 11% with a bone marrow or solid organ transplantation, 7.4% with intensive care unit stay, and 4.2% with a cancer diagnosis. Multivariable risk factor modeling for adenovirus disease severity found that age <7 years (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4–7.4), chronic disease (OR, 3.6; 95% CI, 2.6–5.1), recent transplantation (OR, 2.7; 95% CI, 1.3–5.2), and adenovirus type 5 (OR, 2.7; 95% CI, 1.5–4.7) or type 21 infection (OR, 7.6; 95% CI, 2.6–22.3) increased the risk of severe disease.”
H5N1 highly pathogenic avian influenza outbreak, Holton, Suffolk, February 2007: lessons to be learned report
UK DEFRA report released Oct 11, 2007 on the Suffolk avian influenza H5N1 outbreak: http://www.defra.gov.uk/animalh/diseases/notifiable/disease/ai/pdf/holton-lessonslearned030807.pdf
Seasonal Influenza Vaccine Supply for the U.S. 2007-08 Influenza Season
Questions and Answers by CDC on the seasonal flu vaccine supply for the current influenza season: http://www.cdc.gov/flu/about/qa/vaxsupply.htm
A call for a national infectious diseases strategy
Oct 18, 2007 report released as part of National Infectious Diseases Day in Canada
FDA Approval of alternate dosing schedule for combined Hepatitis A and B vaccine (Twinrix)
In Apr 2007, GlaxoSmithKline Biologicals received approval from the Food and Drug Administration (FDA) for an alternate schedule for Twinrix, a combined hepatitis A and hepatitis B vaccine. Twinrix was first licensed by FDA in 2001 on a 3-dose schedule (0, 1, and 6 months) for vaccination of persons aged >18 years. Using the newly licensed, alternate 4-dose schedule, Twinrix doses can be administered at 0, 7, and 21--30 days, followed by a dose at 12 months. In immunogenicity studies among adults aged >18 years, the first 3 doses of the alternate schedule provided equivalent protection to the first 2 doses in the standard 3-dose Twinrix series. The first 3 doses of the alternate schedule also have proven effective in providing protection equivalent to a single dose of monovalent hepatitis A vaccine and to 2 doses of monovalent hepatitis B vaccine. Thus, the alternate 4-dose schedule can be useful if vaccination with Twinrix has been initiated and travel or other potential exposure is anticipated before the second dose of Twinrix (or monovalent hepatitis B vaccine) is due, according to the standard 3-dose schedule (i.e., 1 month after the first dose).
(MMWR October 12, 2007 / 56(40);1057)
Interactive map of ProMED reports
From Larry Madoff, Editor, ProMED-mail, firstname.lastname@example.org: We are pleased to announce that a mapping system for visualizing ProMED-mail reports is now available at <http://healthmap.org/promed>. It can also be accessed via the "Maps of Outbreaks" link on the left hand side of the ProMED-mail website. This system, developed by HealthMap in collaboration with ProMED-mail, automatically places links to ProMED-mail reports on a world map. Clicking on a map marker will access a list of reports corresponding to the selected location. These in turn can be clicked to link back to the original ProMED-mail report. The map can be zoomed and panned, and specific diseases and date ranges selected. In some countries, reports are mapped to the state or province level (with increased global geographic resolution in progress). The map currently incorporates English-language ProMED-mail reports as well as ProMED-ESP and can be viewed in English or Spanish. This mapping system is part of an ongoing collaboration between ProMED-mail and HealthMap, which is based at Children's Hospital Boston, Harvard Medical School and the Harvard-MIT Division of Health Sciences and Technology. A link to other HealthMap data sources is provided under "Feeds."
National Latino AIDS Awareness Day--October 15, 2007
Oct 15 marks the fifth National Latino AIDS Awareness Day (NLAAD). Initiated by the Latino Commission on AIDS and the Hispanic Federation in partnership with faith and community organizations, NLAAD raises awareness of HIV/AIDS in the Hispanic/Latino population living in the US and abroad. In 2005, Hispanics accounted for approximately 14.4% of the U.S. population but 18.9% of persons who received an AIDS diagnosis in the US. Modes of HIV infection among Hispanics have been determined to vary by place of birth. Taking into account these and other varying risk behaviors among subgroups of Hispanics is an important consideration in developing prevention programs. Information regarding NLAAD: http://nlaad.org. Information regarding CDC activities supporting NLAAD: http://www.cdc.gov/hiv/nlaad.htm.
(MMWR October 12, 2007 / 56(40);1057)
Prevention of Hepatitis A after Exposure to Hepatitis A Virus and in International Travelers
In 1995, highly effective inactivated hepatitis A vaccines were first licensed in the US for preexposure prophylaxis against hepatitis A virus (HAV) among persons aged >2 years. In 2005, vaccine manufacturers received Food and Drug Administration approval for use of the vaccines in children aged 12--23 months. The Advisory Committee on Immunization Practices (ACIP) issued recommendations for preexposure use of hepatitis A vaccine in 1996, 1999, and 2006. Currently, ACIP recommends hepatitis A vaccination of all children at age 12--23 months, catch-up vaccination of older children in selected areas, and vaccination of persons at increased risk for hepatitis A (e.g., travelers to endemic areas, users of illicit drugs, or men who have sex with men). For decades, immune globulin (IG) has been recommended for prophylaxis after exposure to HAV. IG also has been recommended in addition to hepatitis A vaccine for preexposure prophylaxis for travelers to countries with high or intermediate hepatitis A endemicity who are scheduled to depart <4 weeks after receiving the initial vaccine dose. This report details updated recommendations for prevention of hepatitis A after exposure to HAV and in departing international travelers and incorporates existing ACIP recommendations for prevention of hepatitis A.
(MMWR October 19, 2007 / 56(41);1080-1084)
Recommended Adult Immunization Schedule--United States, October 2007--September 2008
The Advisory Committee on Immunization Practices (ACIP) annually reviews the recommended Adult Immunization Schedule to ensure that the schedule reflects current recommendations for the licensed vaccines. In Jun 2007, ACIP approved the Adult Immunization Schedule for Oct 2007--Sep 2008. Additional information is available as follows: schedule (in English and Spanish) at http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm; adult vaccinations at http://www.cdc.gov/vaccines/default.htm; ACIP statements for specific vaccines at http://www.cdc.gov/vaccines/pubs/acip-list.htm; and reporting adverse events at http://www.vaers.hhs.gov or by telephone, 800-822-7967.
(MMWR October 19, 2007 / 56(41);Q1-Q4)