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Vol. X No. 22 ~ EINet News Briefs ~ Nov 02, 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)
- Viet Nam: Avian influenza outbreaks in poultry continues
- Indonesia: Report of avian influenza H5N1 case in 3-year-old
- Indonesia: Anthrax sickens livestock and 10 villagers
- Taipei: Conjunctivitis outbreak ending
- Taipei: Rubella outbreak associated with foreign factory workers
- Thailand: Malaria resurgence posing threat to public
- Canada: Update on ongoing mumps outbreak
- USA: Pandemic drill for financial sector finds planning gaps
- USA (multistate): Frozen pizza suspected in 10-state E coli outbreak
- USA: USDA announces plans to reduce E coli contamination in ground beef
- USA/Canada: E coli in Topps beef traced to Canadian firm
- USA: Salmonella outbreak expands to 272 cases
- USA: GAO critiques anthrax vaccine procurement, management
- USA (Massachusetts): Emergence of non-vaccine strain Streptococcus pneumoniae

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

2. Articles
- Public Health Measures in an Influenza Pandemic – the importance of surveillance
- CDC EID Journal, Volume 13, Number 11--Nov 2007
- Epidemiological consequences of an incursion of highly pathogenic H5N1 avian influenza into the British poultry flock
- Neuraminidase Inhibitor-Resistant Recombinant A/Vietnam/1203/04 (H5N1) Influenza Viruses Retain Their Replication Efficiency and Pathogenicity In Vitro and In Vivo
- Reported HIV Status of Tuberculosis Patients--United States, 1993--2005

3. Notifications
- The pandemic vaccine puzzle
- Avian influenza epizootie: where do we stand in 2007
- Fact Sheet: Creating a Culture of Preparedness Among Schools
- Application Deadline for The CDC Experience Applied Epidemiology Fellowship—Dec 3, 2007
- Asia Pacific Leadership Program, East-West Center
- Invitation to AIDS ASIA eFORUM


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 / 36 (31)
Laos / 2 (2)
Nigeria / 1 (1)
Viet Nam 7 (4)
Total / 70 (46)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 333 (204). (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/WPRO 10/25/07)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 10/23/07): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 10/19/07): >http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.

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Asia
Viet Nam: Avian influenza outbreaks in poultry continues
Bird flu outbreaks have occurred in Viet Nam's northern Cao Bang Province since 10 Oct 2007, raising the total number of localities currently affected by the disease to 3. The disease has killed or infected 480 ducks and 80 chickens raised by 13 households in Trung Khanh district, the Department of Animal Health under the Vietnamese Ministry of Agriculture and Rural Development said 26 Oct 2007, noting that samples from the fowls have been tested positive to bird flu virus strain H5N1. To prevent bird flu spread, local veterinary agencies have culled all ill poultry and isolated the affected areas. Now, bird flu is hitting Cao Bang, central Quang Tri Province, and southern Tra Vinh Province.

An excellent source of information can be found in the website of FAO's Representation in Hanoi, Viet Nam, which includes a situation Update, based upon the data provided by Viet Nam's Department of Animal Health (DAH), Ministry of Agriculture and Rural Development (MARD). The update of 26 Oct 2007 is available at http://www.fao.org.vn/new1.pdf. 32 provinces (out of a total of 64) in Viet Nam have been affected by avian influenza since Dec 2006. The fifth wave of avian influenza was reported in the country from 6 May 2007, with the first occurrence 1 May 2007. Since May [2007], AI has been reported in poultry in 22 provinces. 7 human cases have been reported, of which 4 were fatal. The second AI vaccination campaign for 2007 (October) is underway in 40 provinces, where 62.65 million poultry have been vaccinated. The 1st AI vaccination campaign for 2007 was completed in Sep for 63 provinces, where a total of 164.47 million poultry have been vaccinated. In addition, almost 42.23 million doses of vaccine have been administered by private livestock firms.
(Promed 10/27/07)

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Indonesia: Report of avian influenza H5N1 case in 3-year-old
A 3-year-old Indonesian boy hospitalized in Jakarta has H5N1 avian influenza. Nyoman Kandun, director of disease control for Indonesia's health ministry, said 2 laboratory tests confirmed that the boy has the H5N1 virus. Reportedly the boy's symptoms were minor and he has recovered. He is Indonesia's 111th case. The boy is from Tangerang, Banten Province, and lives in the same neighborhood as a 5-year-old girl (previously identified as a 4-year-old) who died of an H5N1 infection on Oct 22, 2007. Kandun said there were no family links between the 2 children. Another recent case-patient in Indonesia, a 12-year-old boy who died Oct 13, also was from Tangerang. Chicken deaths were reported near the homes of the 3-year-old and the 5-year-old. Kandun said the boy had a history of contact with dead birds at his home. The boy got sick Oct 22 and was hospitalized 5 days later. Indonesia has the most H5N1 cases and deaths of any country—111 and 89, respectively.
(CIDRAP 10/26/07, 10/30/07; Promed 10/31/07)

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Indonesia: Anthrax sickens livestock and 10 villagers
Indonesia was distributing anthrax vaccines across a remote island 30 Oct 2007 after 10 villagers contracted the disease from an infected buffalo. Livestock movement in areas close to where the villagers lived on Flores Island in the far east of the country has also been banned, said Musni Suatmojo, director of animal health at the Agriculture Ministry. The 10 villagers were diagnosed with the disease 22-28 Oct 2007; officials suspected they contracted it after cutting up and eating an infected buffalo. They were diagnosed as having cutaneous anthrax, the most common form, which enters through a cut or abrasion and can cause skin rashes and swelling. They were treated with antibiotics and are now recovering. The disease is endemic across much of Indonesia. Some 20 000 doses of livestock vaccine were being distributed across the island. In Apr 2007, 5 people died after consuming infected beef on nearby Sumba Island (Tenggara province). Officials sealed off a number of villages there for several weeks.
(Promed 10/30/07)

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Taipei: Conjunctivitis outbreak ending
The number of people suffering from acute hemorrhagic conjunctivitis — known as pink eye — in the southern city of Chiayi, the area of Taiwan worst-hit by the outbreak, is declining, Chiayi City Director of Health Sun Shu-jung said 23 Oct 2007. A total of 157 elementary and junior high school students in the city were reported to be infected — the number marks a significant drop in comparison with the peak of the outbreak, recorded 5 Oct 2007, with 477 cases. Thanks to the drop in the number of new patients, Sun added, a Department of Health order to submit daily reports on the outbreak has been lifted from the city. In addition to Chiayi City, other affected areas include Taipei city and county as well as Yunlin and Chiayi counties. Acute hemorrhagic conjunctivitis is characterized by sudden onset of painful, swollen, red eyes, with conjunctival hemorrhaging and excessive tear [formation].
(Promed 10/25/07)

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Taipei: Rubella outbreak associated with foreign factory workers
As of 29 Jun. 2007, Taiwan CDC has confirmed 2 cases of rubella in Taoyuan and Miaoli counties. After further investigation with the local health authorities, Taiwan CDC found incidences of infection among alien workers clustered in factories in the 2 locations. Since mid-Apr 2007, 32 alien workers from a factory in Taoyuan County have developed symptoms that may be due to rubella; test results confirmed 7 positive cases. Since May 2007, 29 alien workers from a factory in Miaoli County have also developed symptoms; test results confirmed 5 positive cases. Taiwan CDC and the local health bureaus have hospitalized and quarantined all infected individuals. All workers in the 2 factories have also received emergency rubella vaccinations, with a total of 893 inoculations. So far, the outbreak has been effectively contained. After Taiwan implemented policies for MMR vaccinations, the annual inoculation coverage rate has exceeded 95%. The number of rubella cases in Taiwan has fallen to less than 10 cases per year. Taiwan CDC has appealed to physicians to pay special attention to patients with symptoms that may be caused by rubella, and to notify authorities of such patients immediately. Taiwan’s current MMR vaccine inoculation policy requires all children to receive two separate doses, one at 12-15 months after birth and another during their first grade in elementary school.
(Taiwan CDC 10/29/07)

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Thailand: Malaria resurgence posing threat to public
A resurgence in malaria [and cholera] cases after almost a decade without any major outbreaks is posing a major threat to public health. Malaria and cholera are becoming increasingly significant problems in the South and Northeast, according to the latest report on health conditions by the Thai Health Promotion Foundation. Malaria outbreaks are becoming particularly serious, especially in the southernmost border provinces where more than 3000 people have contracted the disease so far in 2007, the report said. Violence resulting from the separatist insurgency in the South is thought to have contributed to the re-emergence of malaria as well as other health problems in the troubled, predominantly rural border region. Door-to-door visits by health workers from hospitals in Narathiwat, Pattani and Yala have dropped by 70 percent since violence resurfaced in the provinces in Jan 2004. "It is obvious that the violence has affected the health of southern people. If the situation remains neglected, people will die not only from the violence but also from the diseases plaguing the area," said Supoj Sanguankittipan, chairman of the Phuket Community Institution.
(Promed 10/26/07)

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Canada: Update on ongoing mumps outbreak
Practicums for student teachers at the University of Prince Edward Island [UPEI] have been postponed after 3 students came down with the mumps. "Until further notice. . .our education students are not in the schools fulfilling practicum requirements," said Tamara Leary, acting director of student services at UPEI. Leary said the last case of mumps was diagnosed 12 Oct 2007. If no new cases are reported, UPEI education students should be back in classrooms to do practical teaching 19 Nov 2007. The 2007 Canadian mumps epidemic, originating in the province of New Brunswick, spread westwards with dispersal of university students at the end of term from the provinces of New Brunswick and Nova Scotia to Ontario, Manitoba and British Columbia. A comprehensive account of the epidemic by the Canadian Public Health Agency, updated to 12 Oct 2007, is available at http://www.phac-aspc.gc.ca/mumps-oreillons/prof_e.html.

As of 12 Oct 2007, 847 confirmed cases of mumps related to the outbreak have been reported from Nova Scotia, New Brunswick, Prince Edward Island, Newfoundland, Quebec, Ontario, Manitoba, Alberta, and British Columbia. The outbreak activity remains centered in Nova Scotia and New Brunswick localities with sporadic exportations to other provinces. All cases investigated in the outbreak could be either linked to cases in the Maritimes or are close contacts of these cases. To date, there has been no sustained transmission outside of the Maritimes related to the outbreak, although other imported or sporadic cases of mumps may also occur. The viral strain in these outbreaks is identical to the strain (genotype G) detected from the 2005-06 Nova Scotia outbreaks, the US’s multi-state outbreak in 2006 and the UK epidemic between 2004 and 2006.
(Promed 10/25/07)

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Americas
USA: Pandemic drill for financial sector finds planning gaps
The US Department of the Treasury this week announced the results of a recent exercise to test the resiliency of the nation's financial services sector in an influenza pandemic, revealing that few firms were well prepared and most needed to improve their all-hazards plans. In May 2006 the White House directed the Treasury Department to work with banking and financial services companies to boost their pandemic preparedness. The exercise was conducted Sep 24 - Oct 12 and consisted of an online program of weekly scenarios and preparedness questions. The exercise was organized by the Financial Banking Information Infrastructure Committee (FBIIC) and the Financial Services Sector Coordinating Council (FSSCC).

The simulation began with WHO announcing that human-to-human cases of H5N1 avian influenza had been reported in 5 major US cities, probably because of infected travelers arriving from Lagos, Nigeria. As the pandemic progressed, the exercise described emerging impacts on supply chains, worker absentee rates, healthcare systems, schools, transportation, financial market indicators, and market reactions. As the simulated outbreak spread across the country, companies were asked a series of preparedness questions on topics such as predicted absenteeism, the status of human resources plans for a pandemic, and plans for educating employees. Questions specifically relating to financial operations, for example, included detailed questions about predicted automatic teller machine (ATM) availability and how the companies would respond if daily security trading hours were shortened.

As the exercise progressed, the companies responded to fluctuating market indicators and varying absenteeism rates. At the peak of the pandemic, the exercise simulated a 49% absenteeism rate. The last phase of the exercise centered on the nation's recovery from a pandemic, with preparation for a possible next wave of illnesses. The Treasury Department said 2,775 organizations registered for the exercise; 65% were banks and credit unions, 23% security firms, 11% insurance companies, and 4% other groups. "The strong public-private coordination on this exercise allowed us to reach more institutions than we ever expected," said Valerie Abend, the department's assistant secretary for critical infrastructure protection. "And by allowing almost all participants to find critical gaps in their planning, this exercise was an unquestionable success in helping the industry prepare for such a crisis."

Of the participating organizations, 64% reported they had a business continuity plan for use in a pandemic, but only 42% said they had human resources policies in place to respond to employees' needs during a pandemic. At the end of the exercise, the groups were asked how effective their business continuity plans were. Nearly 12% said their plans were very effective, 56% reported they were moderately effective, 28% rated them as minimally effective, and 4% said the plans were "not at all" effective. Most (91%) said they would refine their business continuity plans on the basis of what they learned from the exercise.

Treasury Department officials learned that: School closings as a community mitigation tactic during a pandemic would significantly or moderately affect about 72% of participating financial institutions; Establishing a telecommuting system and dividing and dispersing work units were the two most common steps companies said they would take to maintain business operations during a pandemic; Nearly 99% of respondents thought the exercise was useful for assessing pandemic preparedness.
(CIDRAP 10/26/07)

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USA (multistate): Frozen pizza suspected in 10-state E coli outbreak
General Mills recalled about 414,000 cases of frozen pizza today after officials said it could be linked to an Escherichia coli outbreak that has sickened 21 people in 10 states. The recalled products are Totino's and Jeno's pizzas that contain pepperoni topping, which could be contaminated with E coli O157:H7, General Mills said. The recalled package numbers bear the establishment number "EST. 7750" inside the USDA (US Department of Agriculture) inspection mark and have a "best if used by" date of Apr 8, 2008, according to USDA's Food Safety and Inspection Service (FSIS). The products were produced on or before Oct 30 and were distributed to retail outlets nationwide. The recall was prompted by an investigation by the Tennessee Department of Health and CDC into a multistate cluster of E coli O157:H7 illnesses. A case-control study suggested that Totino's and Jeno's brands of pizza that contained pepperoni were the likely source of the illness. However, the source of contamination has not been confirmed.

CDC said that of the 21 patients whose isolates match the outbreak strain, 8 are from Tennessee, 3 are from Kentucky, and the rest are from Missouri, New York, Ohio, Pennsylvania, South Dakota, Illinois, Wisconsin, and Virginia. 8 have been hospitalized, and 4 have been treated for hemolytic uremic syndrome (HUS), a potentially deadly kidney condition. General Mills said the earliest case reported to officials occurred Jul 20, 2007 and the latest case Oct 10, 2007. The company said it has distributed more than 120 million pizzas since Jul 1. CDC said consumers should not eat the recalled products, and those who experienced diarrhea within a week after eating them should seek care. E coli O157:H7 outbreaks are most often associated with ground beef, though some have been linked to fresh produce. The strain produces a toxin that causes diarrhea—often bloody—and abdominal cramps but typically no fever. The illness usually resolves in 5 to 10 days, but it can cause HUS in 2-7% of patients. The very young, old, and people with compromised immune systems are the most vulnerable to foodborne disease.
(CIDRAP 11/1/07; Promed 11/1/07)

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USA: USDA announces plans to reduce E coli contamination in ground beef
US Department of Agriculture's Food Safety and Inspection Service (FSIS) unveiled a host of actions that the agency hopes will blunt a recent spike in Escherichia coli outbreaks involving ground beef. FSIS said since Jan 2007 it has issued 15 recalls because of E coli O157:H7 in ground beef, of which 8 were linked to illnesses. The agency said it only issued 8 recalls for strains of E coli in ground beef in 2006, none of which were related to illnesses. Measures announced range from accelerating safety programs that were already in the works, such as a new follow-up testing program for beef plants that have had positive E coli O157:H7 tests to new initiatives such as verifying that sites are controlling the pathogen during slaughter and processing.

FSIS said that in Jun 2007 it started noticing more positive E coli O157:H7 samples in ground beef. In response, it increased the number of tests for the pathogen by 75% in July, but results didn't point to any unusual patterns. However, the issue came to a head in Sep when contaminated ground beef produced by Topps Meat sickened several people in mainly northeastern states and led to the recall of 21.5 million pounds of ground beef, one of the largest recalls in US history.

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 hemolytic uremic syndrome (HUS), potentially leading to kidney failure or death, in 2% to 7% of patients. Topps outbreak has so far been linked to 40 illnesses in 8 states. FSIS said it had already planned to launch new inspection routines that would incorporate a checklist designed to review whether suppliers and processors are taking the right steps to control for E coli contamination. Launch of the new system was scheduled for spring 2008, but it now will launch this Nov as soon as inspectors complete training on how to use the newly developed list. Checklist results will go into a database that will guide follow-up inspections.

Among the new measures to target E coli contamination, FSIS said it would:
• Require beef plants to verify that that they are controlling E coli O157:H7 and provide processors with specific examples of controls that meet its safety criteria
• Test more domestic and imported ground beef components, in addition to beef trim, which the FSIS began testing for in March
• Issue more rapid ground beef recalls when E coli contamination is suspected
• Begin routine, targeted sampling for E coli O157:H7 at slaughtering and grinding facilities starting in January 2008; larger facilities will be tested more often, and data from inspector checklists will determine frequency at other sites
• Notify countries that export beef to the United States about new policies and programs to control E coli
• Conduct outreach and training sessions for small producers in October and November
• Convene a meeting of experts and stakeholders on E coli O157:H7 issues later this fall
• Hold a meeting this winter for state and local public health officials on how to improve outbreak investigations
(CIDRAP 10/23/07)

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USA/Canada: E coli in Topps beef traced to Canadian firm
The source of Escherichia coli O157:H7 that recently spurred a massive recall of ground beef by Topps Meat Co. probably was contaminated beef trim from a Canadian firm, the US Department of Agriculture (USDA) announced. DNA fingerprinting has linked the strain of E coli O157:H7 found in trim from the Canadian company to an E coli outbreak involving 40 illnesses in 8 US states and 45 illnesses and 1 death in 5 Canadian provinces, according to USDA's Food Safety and Inspection Service (FSIS). E coli in samples from the Canadian company also matched the strain that officials in New York found in intact and opened packages of Topps ground beef from the homes of patients.

The company that supplied Topps with the contaminated beef was Ranchers Beef, Ltd., based near Calgary, Alberta. The firm ceased operations Aug 15, 2006, but the Canadian Food Inspection Agency (CFIA) obtained and tested some of the company's product that had been in storage and then notified US officials of its E coli O157:H7 findings. On Sep 25, Topps said it was going out of business immediately because it could not handle the economic burden of recalling 21.7 million pounds of ground beef. FSIS said it had delisted Ranchers Beef Oct 20, meaning none of the company's products have been eligible for import since that date. The agency announced that it was placing a hold on Ranchers beef, along other products made from Ranchers beef, until the USDA and CFIA complete their investigation.

The Topps recall was the largest of several recalls related to E coli in ground beef this year. Federal investigators at the Topps plant found that the company had reduced its microbial testing on finished ground beef from once a month to 3 times a year. The company also had failed to require adequate testing on beef from its domestic suppliers, and, like other producers, had increased its purchases of meat from overseas, where testing is not always required. On the 3 days when the company was known to have produced contaminated batches of beef, it was grinding both domestic and foreign trimmings. USDA is requiring more testing of domestic and imported ground beef components and will notify countries that export beef to the US about new policies and programs to control the pathogen. In related developments, New Jersey officials announced recently that its inspectors were able to buy boxes of the recalled Topps beef at a retail store 4 weeks after the product was recalled.
(CIDRAP 10/29/07)

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USA: Salmonella outbreak expands to 272 cases
A Salmonella outbreak associated with pot pies from ConAgra Foods has increased to 272 cases in 35 states, CDC reported. At least 65 people have been hospitalized in the outbreak, but none have died. The latest case count is close to double the 139 cases reported by CDC in its first notice about the outbreak Oct 9. CDC said at least 272 isolates collected from patients were identified as Salmonella serotype I4,[5],12:i:- and had matching genetic fingerprints. A CDC case-control study has linked salmonellosis cases with eating Banquet brand pot pies, and the outbreak strain has also been found in 3 pot pies bought by patients. ConAgra first issued a consumer advisory about the outbreak Oct 9 and followed up with a recall of all varieties of its pot pies Oct 11, though cases had been linked only to chicken and turkey pies.

The recall includes Banquet pot pies and those sold under the following labels: Albertson's, Food Lion, Great Value, Hill Economy Fare, Kirkwood, Kroger, Meijer, and Western Family. The 7-ounce pies bear the establishment number "P-9" or "Est. 1059" on the side of the package. Of the states affected by the outbreak, Washington has had the most cases with 27. Wisconsin has had 24 cases, while California, Missouri, and Pennsylvania have had 18 each.
(CIDRAP 10/30/07)

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USA: GAO critiques anthrax vaccine procurement, management
The US government's attempt to add a next-generation anthrax vaccine to its stockpile failed because of a premature contract award, unrealistic expectations, and confusion about how the vaccine would be used, according to the Government Accountability Office (GAO), the investigative agency of Congress. GAO also concluded that the government lacks a strategy for preventing waste and duplication in managing its stockpile of the existing anthrax vaccine, which could result in annual $100 million losses as stored vaccine lots expire. The findings were detailed in a report GAO released Oct 23. 4 members of Congress had requested the investigation after the Department of Health and Human Services (HHS) cancelled an $877 million contract with VaxGen last Dec. The company had failed to meet certain project milestones.

"The failure of this procurement effort raised larger questions regarding the country's ability to develop a new anthrax vaccine and robust and sustainable biodefense medical countermeasure industry," the report states, adding that the problems cast doubt on the government's ability to spell out the requirements of future contracts with its industry partners. The VaxGen rPA vaccine was expected to provide immunity in 3 doses, rather than the 6 doses required for the licensed vaccine, and to cause fewer side effects. Avecia, a biotechnology company, is also developing an rPA anthrax vaccine with grant support from the National Institutes of Health. VaxGen had announced that it hoped to license its rPA vaccine to another company in hopes that the product could someday be added to the national stockpile.

HHS awarded its first contract to VaxGen for the rPA vaccine at a very early development stage, before critical issues such as stability could be addressed, GAO says. The award also interrupted an existing development contract VaxGen had with the National Institute for Allergy and Infectious Diseases (NIAID). HHS officials told GAO that they felt an urgency to tell the public an improved anthrax vaccine was on the horizon and that they were 80% to 90% confident in VaxGen's ability to successfully develop and produce the vaccine. Industry experts told GAO that, given the early stage of development, the expectation that VaxGen could deliver 75 million doses of the vaccine was unrealistic.

GAO assert that VaxGen took several "unrealistic" risks in accepting the HHS contract: the delivery deadline was too aggressive, the company lacked in-house technical expertise to address vaccine stability and formulation issues, and it had few resources to pay for additional testing to meet regulatory requirements. Another problem was that HHS did not tell VaxGen how it planned to use the vaccine, because at the start of the contract the FDA was still defining the data and testing requirements for the rPA anthrax vaccine as part of its new guidance on emergency use authorization for unlicensed products in the Strategic National Stockpile. GAO says HHS has announced that it will issue another rPA anthrax vaccine proposal but has not formally reviewed what went wrong with the VaxGen contract. "They may repeat their mistakes in the absence of a corrective plan," the report says.

In examining how the government manages the current anthrax vaccine in the national stockpile—anthrax vaccine adsorbed (AVA), developed in the 1950s—investigators raised 2 main concerns. One is that HHS doesn't have a strategy to minimize wasted vaccine. The report says $12 million worth of vaccine has already expired, and without an effective management plan, $100 million more per year could be lost as vaccine lots in the stockpile expire. HHS recently announced that it awarded the manufacturer of the AVA vaccine, Emergent BioSolutions, a contract worth up to $448 million for 18.75 million doses of the AVA vaccine, which would allow the agency to maintain a 10 million-dose stockpile through 2011. The report says HHS could minimize the waste by developing a single inventory that can be shared with the Department of Defense (DoD), which has a mandatory anthrax vaccination program. However, HHS responded that it explored the vaccine rotation option in 2004, but identified funding, legal, and logistical obstacles. GAO's second concern about management of the existing anthrax vaccine stockpile is that HHS planned to use vaccine that had expired in 2006 and 2007, which would violate FDA rules.
(CIDRAP 10/31/07)

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USA (Massachusetts): Emergence of non-vaccine strain Streptococcus pneumoniae
A new strain of bacteria is emerging as a major cause of childhood infections but even drug-resistant versions of the bug can be killed off with the right antibiotics, doctors said 18 Oct 2007. Doctors and parents should be aware of it, however, and switch antibiotics for children with severe infections who do not respond quickly to standard therapy. The bacterium is a type of Streptococcus pneumonia[e] that is not 1 of the 7 strains covered in a routine childhood vaccine [Prevnar, the heptavalent conjugate pneumococcal polysaccharide vaccine], a team at Boston University and the Massachusetts health department reported. "I think clinicians should be aware that the vaccine, as effective as it is, still leaves children at risk for invasive pneumococcal disease," Dr. Stephen Pelton, chief of pediatric infectious disease at Boston University, said.

Wyeth's Prevnar, given routinely to young children, protects against 7 strains of S. pneumoniae (4, 6B, 9V, 14, 18C, 19F, and 23F), known commonly as pneumococcal bacteria. These germs cause ear infections, meningitis, pneumonia, and blood infections. The Massachusetts team found the 19A strain was becoming more common. "It causes about 40 percent of pneumococcal infections in children under the age of 18 in Massachusetts," Pelton said. He said the percentage was similar across the US. In 2001-2002, just 10 percent of cases were caused by the 19A strain. And 15 percent were resistant to another antibiotic called ceftriaxone. For the drug-resistant strains of S. pneumoniae, Pelton said the antibiotic vancomycin will work, or combination therapy with vancomycin and cefotaxime or ceftriaxone. Healthy children are not considered at serious risk from the infection but Pelton said children with sickle cell disease, HIV infection, lung disease, diabetes, or kidney disease need special attention.

Wyeth, the pharmaceutical firm that manufactures Prevnar, noted that serotype 19A is emerging globally in both regions where Prevnar is available, as well as regions where it is not widely used, and an increase in disease caused by 19A occurred in Korea even prior to the introduction of Prevnar, perhaps representing emergence of an antibiotic-resistant strain of a non-vaccine serotype due to overuse of antibiotics, not vaccine use.
(Promed 10/22/07)

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1. Updates
Avian/Pandemic influenza updates
- UN: http://www.un-influenza.org/ : latest news 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. Read about the 15-17 Nov 2007 event in Beijing, China: 1st Meeting of the Asia-Pacific Working Group on Migratory Waterbirds and 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/. Public Comments Sought on Draft of Flu Vaccine Allocation Plan.

- Health Canada: information on pandemic influenza:
http://www.influenza.gc.ca/index_e.html. Updates on Saskatchewan avian influenza outbreak

- CIDRAP: http://www.cidrap.umn.edu/.

- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.

- US Geological Survey, National Wildlife Health Center Avian Influenza Information:
http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Updated 2 Nov 2007.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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Cholera, diarrhea, and dysentery
Thailand (northeast)
A resurgence in cholera cases after almost a decade without any major outbreaks is posing a major threat to public health, a recent nationwide survey found, according to the latest report on health conditions by the Thai Health Promotion Foundation. In the north east, severe diarrhea caused by Vibrio cholerae Ogawa is plaguing local communities due to the consumption of raw cockles, poorly prepared som tam, and fast food. There had been 200 infections and a death reported in Khon Kaen so far in 2007 and another 22 infections in Maha Sarakham. About 630 people in 23 provinces across the country have been treated in 2007 for severe diarrhea caused by the El Tor Ogawa strain, according to the Public Health Ministry. 2 people have died of dehydration caused by the illness.
(Promed 10/30/07)

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Dengue
Philippines
The Philippines National Epidemiology Center (NEC) of the DOH has reported 12 734 dengue cases with 130 deaths nationwide since Jan 2007 up to 28 Jul 2007. This figure, however, is 1.5 percent lower compared to the same last year [2006], which listed 12 932 cases. To win the battle against dengue, Duque advised the public to continue following the 4-S campaign of the DOH, which is to search and destroy possible breeding grounds of dengue-carrying mosquitoes like old tires, broken vases and bottle caps; wear long sleeve shirts and pants for self-protection; seek health professionals for fever 2 days or more; and saying no to indiscriminate fogging.

Cases of dengue fever continue to rise in Region VI. But health authorities ruled out an outbreak, although an employee of the Regional Epidemiology and Surveillance Unit (Resu) said that the region has the highest number of dengue cases in the country. At the latest count by the Resu, there are already 5064 dengue cases in Western Visayas as of 30 Sep [2007]. There are 63 deaths, up 3-fold from last year's 12. However, the figures show a downward trend in the new cases. "There is a downward trend in the number (of) dengue cases starting from the 34th morbidity week (from 19-25 Aug [2007])," said the report. At the same time, the Resu noted that "there are no clustering of cases or outbreaks within the region." Within Western Visayas, the provinces of Negros Occidental and Iloilo and Bacolod and Iloilo Cities "have the most number of dengue cases," according to Resu. However, "there is a considerable decline in the number of cases reported from these areas," the report states.
(Promed 10/22/07)

Viet Nam
The Ministry of Health has ordered provinces and cities to adopt stringent measures to prevent and control dengue fever as the risk of new outbreaks is high in flood-prone areas. Nearly 80 000 cases of mosquitoborne dengue fever have occurred nationwide this year [2007], 68 of them fatal. The southern provinces of Dong Thap, Tien Giang, and An Giang continue to lead the country in the number of cases. Ho Chi Minh City remains in the grip of dengue fever with 400 patients admitted to hospital last week. The city's center for preventive health care said there had been 6000 cases since the beginning of the year.
(Promed 10/22/07, 10/30/07)

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West Nile Virus
Canada 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 / 1 / 10 / 0 / 11 / 3
Manitoba / 64 / 459 / 47 / 570 / 8
Saskatchewan / 40 / 419 / 938 / 1397 / 14
Alberta / 19 / 299 / 0 / 318 / 3
British Columbia / 8 / 8 / 2 / 18* / 0
TOTALS / 133 / 1195 / 987 / 2315 / 29
* Infection acquired while traveling outside the province
(Promed 10/31/07)

USA
2007 West Nile virus activity in the United States (through 18 Sep 2007) State / Neuroinvasion/West Nile fever/ Other, Unspecified/ Total/ Fatalities:
Alabama / 15 / 4 / 0 / 19 / 3
Arizona / 32 / 16 / 26 / 74 / 1
Arkansas / 13 / 5 / 0 / 18 / 1
California / 148 / 203 / 9 / 360 / 16
Colorado / 95 / 449 / 0 / 544 / 6
Connecticut / 4 / 1 / 0 / 5 / 0
Delaware / 1 / 0 / 0 / 1 / 0
Florida / 3 / 0 / 0 / 3 / 1
Georgia / 22 / 20 / 3 / 45 / 2
Idaho / 7 / 100 / 2 / 109 / 1
Illinois / 51 / 20 / 14 / 85 / 4
Indiana / 11 / 6 / 2 / 19 / 1
Iowa / 10 / 12 / 2 / 24 / 2
Kansas / 11 / 26 / 0 / 37 / 1
Kentucky / 3 / 0 / 0 / 3 / 0
Louisiana / 20 / 9 / 0 / 29 / 0v Maryland / 6 / 3 / 1 / 10 / 0
Massachusetts / 3 / 3 / 0 / 6 / 0
Michigan / 12 / 0 / 1 / 13 / 2
Minnesota / 42 / 57 / 0 / 99 / 2
Mississippi / 41 / 80 / 0 / 121 / 3
Missouri / 54 / 10 / 0 / 64 / 2
Montana / 36 / 159 / 0 / 195 / 4
Nebraska / 18 / 122 / 0 / 140 / 3
Nevada / 1 / 6 / 4 / 11 / 0
New Jersey / 1 / 0 / 0 / 1 / 0
New Mexico / 38 / 22 / 0 / 60 / 3
New York / 12 / 2 / 0 / 14 / 1
North Dakota / 49 / 312 / 0 / 361 / 2
Ohio / 12 / 6 / 1 / 19 / 2
Oklahoma / 48 / 37 / 1 / 86 / 7
Oregon / 4 / 18 / 0 / 22 / 0
Pennsylvania / 4 / 3 / 0 / 7 / 0
Rhode Island / 0 / 1 / 0 / 1 / 0
South Carolina / 2 / 2 / 0 / 4 / 0
South Dakota / 48 / 159 / 0 / 207 / 6
Tennessee / 4 / 2 / 1 / 7 / 1
Texas / 105 / 27 / 0 / 132 / 8
Utah / 24 / 28 / 0 / 52 / 1
Virginia / 2 / 1 / 0 / 3 / 0
Wisconsin / 3 / 3 / 0 / 6 / 0
Wyoming / 15 / 151 / 13 / 179 / 1
TOTALS / 1030 / 2085 / 80 / 3195 / 87
(Promed 10/31/07)

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2. Articles
Public Health Measures in an Influenza Pandemic – the importance of surveillance
A Nicoll on behalf of the Influenza Project Team, European Centre for Disease Prevention and Control
Eurosurveillance weekly releases 2007.Volume 12 / Issue 11. http://www.eurosurveillance.org/ew/2007/071101.asp#4
“One of the most controversial aspects of planning for a pandemic concerns the role and application of public health measures that could reduce its impact. There are many measures it is proposed could be taken (Table 1) with the aim of achieving a reduction of the peak levels of transmission in a pandemic in the European Union and push back the bulk of transmission towards the natural decline that occurs in the warmer summer months, and when specific pandemic vaccines start becoming available. . .”

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CDC EID Journal, Volume 13, Number 11--Nov 2007
CDC Emerging Infectious Diseases Journal Nov 2007 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. Selected expedited articles: Studies of Reservoir Hosts for Marburg Virus, by R. Swanepoel et al. Bartonella australis sp. nov. from Kangaroos, Australia, by P.-E. Fournier et al. Other expedited articles can be found at : http://www.cdc.gov/ncidod/EID/upcoming.htm.

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Epidemiological consequences of an incursion of highly pathogenic H5N1 avian influenza into the British poultry flock
Kieran J. Sharkey et al. Proc R Soc B. DOI: 10.1098/rspb.2007.1100; Online Date: October 23, 2007 http://www.journals.royalsoc.ac.uk/content/9v0jtp1465266263

Abstract: Highly pathogenic avian influenza and in particular the H5N1 strain has resulted in the culling of millions of birds and continues to pose a threat to poultry industries worldwide. The recent outbreak of H5N1 in the UK highlights the need for detailed assessment of the consequences of an incursion and of the efficacy of control strategies. Here, we present results from a model of H5N1 propagation within the British poultry industry. We find that although the majority of randomly seeded incursions do not spread beyond the initial infected premises, there is significant potential for widespread infection. The efficacy of the European Union strategy for disease control is evaluated and our simulations emphasize the pivotal role of duck farms in spreading H5N1.

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Neuraminidase Inhibitor-Resistant Recombinant A/Vietnam/1203/04 (H5N1) Influenza Viruses Retain Their Replication Efficiency and Pathogenicity In Vitro and In Vivo
Hui-Ling Yen et al. Journal of Virology, November 2007, p. 12418-12426, Vol. 81, No. 22 http://jvi.asm.org/cgi/content/abstract/81/22/12418

Abstract: Effective antiviral drugs are essential for early control of an influenza pandemic. It is therefore crucial to evaluate the possible threat posed by neuraminidase (NA) inhibitor-resistant influenza viruses with pandemic potential. Four NA mutations (E119G, H274Y, R292K, and N294S) that have been reported to confer resistance to NA inhibitors were each introduced into recombinant A/Vietnam/1203/04 (VN1203) H5N1 influenza virus. For comparison, the same mutations were introduced into recombinant A/Puerto Rico/8/34 (PR8) H1N1 influenza virus. The E119G and R292K mutations significantly compromised viral growth in vitro, but the H274Y and N294S mutations were stably maintained in VN1203 and PR8 viruses. In both backgrounds, the H274Y and N294S mutations conferred resistance to oseltamivir carboxylate (50% inhibitory concentration [IC50] increases, >250-fold and >20-fold, respectively), and the N294S mutation reduced susceptibility to zanamivir (IC50 increase, >3.0-fold). Although the H274Y and N294S mutations did not compromise the replication efficiency of VN1203 or PR8 viruses in vitro, these mutations slightly reduced the lethality of PR8 virus in mice. However, the VN1203 virus carrying either the H274Y or N294S mutation exhibited lethality similar to that of the wild-type VN1203 virus. The different enzyme kinetic parameters (Vmax and Km) of avian-like VN1203 NA and human-like PR8 NA suggest that resistance-associated NA mutations can cause different levels of functional loss in NA glycoproteins of the same subtype. Our results suggest that NA inhibitor-resistant H5N1 variants may retain the high pathogenicity of the wild-type virus in mammalian species. Patients receiving NA inhibitors for H5N1 influenza virus infection should be closely monitored for the emergence of resistant variants.

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Reported HIV Status of Tuberculosis Patients--United States, 1993--2005
Knowing the human immunodeficiency virus (HIV) status of tuberculosis (TB) patients is essential to optimal patient management. TB is an acquired immunodeficiency syndrome (AIDS)-defining opportunistic condition. Patients with both TB and HIV infection are 5 times more likely to die during anti-TB treatment than patients who are not HIV infected. . .HIV infection is the greatest known risk factor for progression from latent TB infection to TB disease. In the United States, after TB exposure and infection, HIV-infected persons who do not receive appropriate treatment progress to TB disease over 5 years at a rate 10 times greater than that for persons not infected with HIV. In 1989, CDC recommended that all TB patients be offered HIV testing and, in 2006, called for routine HIV screening of all TB patients after the patient is notified that testing will be performed, unless the patient declines (opt-out screening). . .To assess reported HIV status of TB patients and selected characteristics of TB patients with HIV infection, CDC analyzed data from the U.S. National TB Surveillance System for the period 1993--2005. This report summarizes the results of that analysis, which indicated that 1) reporting of HIV status among TB patients increased from 35% in 1993 to 68% in 2003, 2) HIV status of 31% of TB patients was unknown in 2005, 3) 9% of TB patients were HIV positive in 2005, and 4) groups of TB patients at greater risk for HIV infection included injection-drug users (IDUs), noninjection-drug users (NIDUs), homeless persons, non-Hispanic blacks, correctional-facility inmates, and alcohol abusers. Increased promotion of routine HIV testing and rapid HIV tests might increase acceptability of testing, which would allow health-care providers to know the HIV status of a greater percentage of TB patients and enable them to provide optimal care. http://cdc.gov/mmwr/preview/mmwrhtml/mm5642a2.htm
(MMWR October 26, 2007 / 56(42);1103-1106)

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3. Notifications
The pandemic vaccine puzzle
This is a seven-part series investigating the prospects for development of vaccines to head off the threat of an influenza pandemic posed by the H5N1 avian influenza virus. The series puts promising advances in vaccine technology in perspective by illuminating the formidable barriers to producing large amounts of an effective and widely usable vaccine in a short time frame. Part 1 described how flu research has been a relatively low priority until very recently, which has left many important scientific questions unanswered. Part 2 discussed the huge gap between current global vaccine production capacity and the likely demand for vaccine in the event of a pandemic. Part 3 discussed the immunologic challenges posed by the H5N1 virus, including its poor immunogenicity when incorporated in vaccines and the difficulty of assessing immune responses to the vaccines. Part 4 examined the possibility of using adjuvants to stretch the supply of pandemic vaccines and the regulatory barriers to that strategy. Part 5 looked at the idea of vaccinating people before a pandemic with a best-guess vaccine and following up later with a vaccine matched to the emergent pandemic strain.

Part 1: Flu research: a legacy of neglect http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/oct2507panvax1.html
Part 2: Vaccine production capacity falls far short http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/oct2607panvax2.html
Part 3: H5N1 poses major immunologic challenges http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/oct2907panvax3.html
Part 4: The promise and problems of adjuvants http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/oct3007panvax4.html
Part 5: What role for prepandemic vaccination? http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/oct3107panvax5.html
Part 6: Looking to novel vaccine technologies http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/nov0107panvax6.html
Part 7: Reinforcing the research agenda

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Avian influenza epizootie: where do we stand in 2007
View the slides from the 2007 Snowdon lecture, presented by Dr Bernard Vallat, Director General of World Organisation for Animal Health — Office Internationale des Epizooties (OIE). (46 pages). The Snowdon Lecture is held every one to two years in honour of Dr Bill Snowdon, the foundation chief of the Australian Animal Health Laboratory (AAHL) and is made possible with the support of the Australian Society for Microbiology. The 2007 Snowdon Lecture, titled Avian influenza epizootie: where do we stand in 2007 was delivered 11 July by Dr Bernard Vallat, Director General, World Animal Health Organisation, the Office Internationale des Epizooties (OIE). The lecture provided an insight into the global threat posed by the current epidemic of H5N1 avian influenza. This PDF file contains PowerPoint slides of Dr Bernard Vallat's lecture. The lecture can also be watched on video in ten chapters.
http://www.csiro.au/resources/SnowdonLecture2007.html

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Fact Sheet: Creating a Culture of Preparedness Among Schools
The US Department of Homeland Security (DHS) offers a wide-range of emergency preparedness resources to help schools create safe and secure environments for their students. Emergency preparedness is an important responsibility shared by all individuals as well as communities, including schools. In order to advance school preparedness nationwide, DHS offers several planning and training resources to help local schools prepare comprehensive all-hazard emergency preparedness plans that are exercised regularly and developed in partnership with their community leaders and first responders: Safe School Initiative; Protecting Our School’s Infrastructure; Protecting Against Man-Made or Terrorist Incidents; School Preparedness Training Courses; Lessons Learned Information Sharing (LLIS); DHS “READY” Campaign; Citizen Corps; Funding and Additional Resources.
(HHS 10/30/07 http://www.dhs.gov/xnews/releases/pr_1193754645157.shtm )

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Application Deadline for The CDC Experience Applied Epidemiology Fellowship—Dec 3, 2007
The CDC Experience is a 1-year fellowship in applied epidemiology that is tailored for rising third- and fourth-year medical students and aims to develop a pool of physicians with a population-based health perspective. 8 competitively selected fellows spend 10-12 months at CDC in Atlanta, Georgia, where they conduct epidemiologic analyses in areas of public health that interest them. The fellowship provides multiple opportunities to enhance skills in research and analytic thinking, written and oral scientific presentations, and the practices of preventive medicine and public health. Applicants do not need experience in public health to apply for this program. Through this training, fellows acquire practical tools for approaching population-based health problems, whether in an entire community or among their own community of patients. Graduates of The CDC Experience have an appreciation of the role of epidemiology in medicine and health and are able to apply their knowledge and skills to enhance their clinical acumen. Information on applying for The CDC Experience is available at http://www.cdcfoundation.org/thecdcexperience.

Applications for The CDC Experience fellowship class of 2008-09 must be postmarked by Dec 3, 2007. Questions can be addressed to Catherine Piper, program coordinator, at e-mail, cpiper@cdc.gov.
http://cdc.gov/mmwr/preview/mmwrhtml/mm5642a6.htm
(MMWR October 26, 2007 / 56(42);1114)

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Asia Pacific Leadership Program, East-West Center
Entering its eighth year, the Asia Pacific Leadership Program (APLP) is the center of excellence for leadership education in the Asia Pacific region. The APLP is a graduate certificate program combining the development of regional expertise with the enhancement of individual leadership capacity. Based at the East-West Center in Honolulu, Hawaii, the program is creating a network of dynamic leaders who are familiar with the critical issues of the Asia Pacific region. All participants receive an APLP Entrance Fellowship valued at approximately $10,000.

The Asia Pacific Leadership Program seeks outstanding individuals with leadership experience or high leadership potential from across Asia Pacific, the US, and beyond. All participants have at least a Bachelors degree with the majority having graduate degrees as well. At least 20 countries are represented in each cohort. APLP fellows come together from all walks of life, including government, business, NGOs, health, sciences, media, monastic orders, and the academe. APLP fellows gain a broad regional perspective, become knowledgeable about the critical challenges facing the Asia Pacific region, and are trained to exercise collaborative leadership and promote cooperation toward the well-being of the countries and peoples of the region. The APLP empowers future leaders with the knowledge, skills, experiences and supportive community needed to successfully navigate personal and regional change in the 21st century.

For more information about the Asia Pacific Leadership Program, application forms and an array of supplemental scholarships, please visit our website at: http://www.eastwestcenter.org/aplp. If you have specific questions, contact Christina Monroe at MonroeC@EastWestCenter.org. Recruitment for 2008-09 is open. The deadline is Dec 1, 2007
(East-West Center Association 10/22/07)

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Invitation to AIDS ASIA eFORUM
[AIDS ASIA eFORUM] is an e-forum committed to the development of an Asian perspective on AIDS prevention and care issues. HIV/AIDS does not recognize national boundaries. As Asia-Pacific countries are increasingly interconnected through migration and trade, it is imperative to generate a regional perspective on HIV/AIDS related issues. A forum for critical analysis of issues, events and programs, which has implications on, our ability to address HIV/AIDS prevention and care issues across the region. More than 7,600 subscribers are using this FORUM. Strategic HIV information and communication support to promote the capacity of Asian leaders, activists and people living with HIV/AIDS, to facilitate their engagement and networking, to highlight their experiences and the solutions they are offering to address HIV/AIDS issues in this region. Please review the archived messages on the following url:
http://health.groups.yahoo.com/group/AIDS_ASIA/
Dr. Joe Thomas, Editor, AIDS ASIA e FORUM
(AIDS ASIA 11/1/07)

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 apecein@u.washington.edu