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Vol. X No. 23 ~ EINet News Briefs ~ Nov 16, 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)
- Saudi Arabia: 50,000 birds culled due to an avian influenza H5N1 outbreak
- UK: British officials confirm avian influenza H5N1 in turkey outbreak
- Indonesia (Sumatra): Man dies from avian influenza H5N1 infection, death toll hits 91
- Philippines (Sulu Islands): Capillariasis in seafood kills dozens in Zambo villages
- Viet Nam: Taiwanese man dies of suspected avian influenza H5N1 infection
- Viet Nam (Ha Nam, Ben Tre): Avian influenza H5N1 strikes ducks in two more Vietnamese provinces
- Canada (Ontario): Multidrug-resistant 19A sub-strain of pneumococcus found in toddler
- Canada (Nova Scotia): Mumps outbreak hits 715 cases
- USA (Virginia): Physician’s death may be related to botulism poisoning
- USA (Wisconsin): Tortillas suspected in school illness outbreak
- USA (Wisconsin and Ohio): Pertusis outbreak in two school districts
- USA (Hawaii): Norovirus suspected on cruise ship
- USA (Arizona): Wildlife biologist likely died from pneumonic plague
- USA (Pennsylvania): Raw milk is the culprit in Salmonella infection
- USA: FDA food safety plan taps others for inspection help
- USA: USDA vows to double inspections of Canadian meat
- USA: Vaccine deliveries set record, but will strains match?
- USA: Food safety plan calls for FDA recall power
- AVIAN/PANDEMIC INFLUENZA
- CHOLERA, DIARRHEA, AND DYSENTERY
- WEST NILE VIRUS
- Lack of Evidence of Avian-to-Human Transmission of Avian Influenza A (H5N1) Virus among Poultry Workers, Kano, Nigeria, 2006
- Avian influenza outbreak in Turkey through health personnel's views: a qualitative study
- Developing successful strategies based on knowledge and experience may play a valuable role in delaying an avian influenza pandemic. A model to control the epidemic of H5N1 influenza at the source
- Influenza in Migratory Birds and Evidence of Limited Intercontinental Virus Exchange
- Epitope Mapping of the Hemagglutinin Molecule of a Highly Pathogenic H5N1 Influenza Virus by Using Monoclonal Antibodies
- Pandemic influenza and hospital resources
- Canada, USA: Healthy people are developing MRSA infections and pig farms may be a culprit
- APEC Center for Technology Foresight: Technology Roadmapping Workshop
- Intergovernmental meeting on pandemic influenza preparedness
- The pandemic vaccine puzzle
- HHS issues guide for using call centers in emergencies
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)
ndonesia / 56 (46)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 116 (80)
Cambodia/ 1 (1)
China / 3 (2)
Egypt / 20 (5)
Indonesia / 38 (33)
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: 335 (206).
(WHO 11/12/07 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 http://www.wpro.who.int/sites/csr/data/data_Graphs.htm. (WHO/WPRO 10/23/07)
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 11/5/07):
Saudi Arabia: 50,000 birds culled due to an avian influenza H5N1 outbreak
The lethal H5N1 strain of bird flu has been detected at a poultry farm in Saudi Arabia, and 50,000 birds have been culled, the agriculture ministry announced [14 Nov 2007]. It said tests were carried out after 1500 birds died in a farm of the Al-Kharj region, 150 km south of Riyadh. All the birds on the farm were subsequently culled and the area disinfected, with measures taken to ensure other farms in the area were not affected. No human cases have been found and an investigation is taking place to determine the origin of the illness. The kingdom banned all live poultry imports after bird flu was last detected in Saudi Arabia March 2007. In Apr 2007, neighboring Kuwait culled 1.7 million birds after the strain was found, but there were no human cases.
UK: British officials confirm avian influenza H5N1 in turkey outbreak
The type of bird flu found in turkeys on a Suffolk farm is the virulent H5N1 strain, according to government vets. The virus was discovered [11 Nov 2007] at Redgrave Park Farm near Diss, where all 6500 birds, most of them turkeys, are being slaughtered.
A 3 km protection zone and a 10 km surveillance zone have been set up and the farm is co-operating with vets. Acting chief veterinary officer Fred Landeg made the announcement. All birds at the affected premises — including approximately 5000 turkeys, 1000 ducks, and 500 geese — will be slaughtered.
"It is extremely important that poultry keepers, particularly in the locality, are vigilant and on the lookout for disease, and report it quickly. In addition we want every poultry keeper in the area to be well aware of bio-security." Earlier, Mr. Landeg had said the risk of bird flu spreading was increased during the autumn months because of wild bird migration. The affected birds were free-range — meaning they had access to the outdoors and may have been of greater risk of catching the disease. Veterinary officials also [15 Nov 2007] said they suspected H5N1 avian influenza at another poultry farm.
Samples from the potentially affected British farm, in Suffolk, were sent for laboratory testing, the United Kingdom Department for Environment, Food, and Rural Affairs (DEFRA) said. The farm is within a restricted zone surrounding the site of a recently confirmed H5N1 outbreak at a turkey farm near Diss, Suffolk. It is among four nearby farms cited by DEFRA as targets for precautionary culling. All the farms—including the outbreak site near Diss—are operated by Redgrave Poultry, and authorities say workers, veterinarians, or vehicles could have spread the H5N1 virus between them. Authorities suspected the H5N1 virus at the second farm when they arrived to carry out the preventive culling and found that a number of birds were already dead. [A statement released on behalf of poultry producer Bernard Matthews said the affected farm was not owned by the company, and none of the firm's farms fell within the exclusion zone. Earlier this year , bird flu was discovered at a Bernard Matthews turkey farm in Suffolk. More than 160 000 birds were killed after an outbreak of the virulent H5N1 strain of the disease on the farm in February 2007].
(ProMED 11.13.07 & 11.12.07 & CIDRAP 11.15.07)
Indonesia (Sumatra): Man dies from avian influenza H5N1 infection, death toll hits 91
Indonesia confirmed [10 Nov 2007] that a 31-year-old man from Sumatra island who died last week was infected with bird flu, raising the toll in the worst-hit nation to 91. Deaths from the H5N1 virus have been steadily rising in Indonesia, where the virus is now endemic across 31 of its 33 provinces. The latest casualty was the second this month.
"Both tests are positive," Daswir Nurdin, from the ministry's bird flu information centre, said. Two tests for the H5N1 virus must be returned positive before someone is confirmed as dying of avian flu here. Nurdin said that the latest victim died [6 Nov 2007] in Pekanbaru shortly after arriving at its main hospital.
He had fallen sick 31 Oct 2007 and was admitted to a local hospital 3 days later. Identification of the source of his infection is ongoing and includes investigation into a large swallow farm in close proximity to the case's house. [The birds are undoubtedly bird nest soup swiftlets (_Collocalia fuciphaga_, although its specific and subspecific taxonomic status is debated), raised for their very expensive nests. Indonesia exports 27 tonnes of nests annually, which indicates the magnitude of this industry. The status of the swiftlets as H5N1 virus hosts is unknown and the results of the investigation will be of interest].
(ProMED 11.11.07; 11.12.07)
Philippines (Sulu Islands): Capillariasis in seafood kills dozens in Zambo villages
Health officials confirmed the capillariasis outbreak in several villages of the town of Zamboanga del Norte where more than 70 people, including children, have reportedly died. Dr. Raymund Nadela, municipal health officer, expressed alarm over the health situation in some villages, saying that the capillaria worm (Capillaria philippinensis) attack "is now an outbreak."
Based on random tests of wastes from 326 residents in the area, 81 people have been found positive for the disease, Nadela said. Emeliano Villalon, chair of Barangay Moyo, said that since late Oct , a total of 31 adults and 9 children have died of capillariasis. Nadela said the victims got the disease from eating freshwater fish and shrimps from the nearby rivers of Siayan.
"These shrimps and fish are carrying this type of worm known as capillaria, a microscopic worm that gets into the intestine and eats up all the nutrition of the person," he said. Nadela said patients found with capillaria worms showed symptoms like diarrhea, extreme abdominal pain that leads to anemia, and muscle wasting. "People think that they have gas pains, but the pain becomes excruciating coupled with a gurgling sound, then the patient could hardly eat or sleep," Nadela explained. The outbreak and the hardest hit, according to Nadela, is Moyo village where, Suasico said, a total 24 coffins were delivered last month.
Viet Nam: Taiwanese man dies of suspected avian influenza H5N1 infection
A Taiwanese man died of pneumonia in Can Tho city [5 Nov 2007], local doctors, who suspect he had contracted bird flu, said. The man was taken to the city General Hospital Monday with high fever and breathing problems. The doctors have sent his blood samples to Pasteur Institute in Ho Chi Minh City to test for the H5N1 strain of bird flu virus, which has caused 100 infections and 46 deaths in Viet Nam in the last few years. The man's family said his father in Taiwan was also suffering from pneumonia-like symptoms. [The original report of this infection (ProMED 11.8.07) incorrectly stated that a South Korean patient had died in Viet Nam as a result of suspected avian influenza and that his father was also ill.
CORRECTION: (as reported in the above article) the man and his father were both from Taiwan].
Viet Nam (Ha Nam, Ben Tre): Avian influenza H5N1 strikes ducks in two more Vietnamese provinces
Officials in Vietnam recently reported H5N1 avian influenza outbreaks at farms in two more provinces, bringing to six the number of provinces hit by the virus since early October. On Nov 7, the agriculture ministry confirmed the H5N1 virus in samples from a flock of 2-month-old ducks at a farm in Ha Nam province in the northern part of the country. The ministry's report also said the virus was found in two dead chickens that were dumped in a river in the province. The agriculture ministry has now reported another H5N1 outbreak in Ben Tre province, in southern Vietnam. The outbreak killed half of a 60-bird flock of 2-month-old ducks. Recent outbreaks have also been reported in Cao Bang and Nam Dinh in the north, Quang Tri in the central part of the country, and Tra Vinh in southern Vietnam. All involved unvaccinated ducks.
Canada (Ontario): Multidrug-resistant 19A sub-strain of pneumococcus found in toddler
Ontario warns of a new, menacing strain of bacteria that can cause severe illness, after a toddler was stricken by a mysterious "superbug."
Health Ministry spokesman David Jensen said [8 Nov 2007], "We're continuing to monitor and keep track of this strain, and we will be updating doctors and public health officials so they have the very latest information and need to be vigilant against it." Ontario has had 48 cases of 19A pneumococcus since December 2006, but only one case so far of this particular multidrug-resistant sub-strain, he said.
A 14-month-old is being treated at the Hospital for Sick Children for meningitis, an infection of the fluid around he spinal cord and brain that can lead to deafness and neurological damage. The child was healthy, fully vaccinated and had not traveled, suggesting the superbug was acquired in the Toronto region.
"This, to me, over the last 10 to 12 years is the worst one I've seen," Donald Low, chief of microbiology at Mount Sinai Hospital, said [8 Nov 2007]. "We always have to be vigilant and do surveillance; these bacteria are so adaptable." This particular sub-strain of 19A is not included in a vaccine given to children. However, the vaccine is still very powerful and protects against many other strains of pneumococcal infection. Barbara Yaffe, director of communicable disease control for Toronto Public Health, said the child was not in daycare and no contact follow-up was warranted. Neil Rau, an Oakville-based infectious-diseases specialist, dubbed the sub-strain a highly resistant 19A.
"This sub-strain is much more resistant than I would usually see in my infectious-diseases practice," he said. This case points to the need for a province-wide surveillance system for tracking these types of infections, similar to that of the U.S. Centers for Disease Control and Prevention. "It speaks to the need for good surveillance," Dr. Rau said. "Is it the first time we've had meningitis from this strain? It may well be. But without a good surveillance system, I can't say for sure."
Canada (Nova Scotia): Mumps outbreak hits 715 cases
There are nine new cases of mumps in Nova Scotia this week, bringing the total number to 715 since the outbreak began last winter, the Department of Health Promotion and Protection said [2 Nov 2007].
Dr Shelly Sarwal, the province's medical officer of health, said last week that between 10 and 20 new cases have been reported each week since the outbreak started in February, with a jump since students went back to class. Mumps can be spread through coughing, sneezing and exchanging of saliva through kissing or sharing drinks. Symptoms include aches, pains, fever and loss of appetite. In extreme cases, mumps can lead to meningitis, inflammation of the testicles or ovaries, hearing loss and, according to the Canadian Medical Association Journal, reduced male fertility.
USA (Virginia): Physician’s death may be related to botulism poisoning
A Roanoke physician who died [12 Nov 2007] may be the first death from food-borne botulism poisoning in Virginia since 2002. A relative said that medical authorities told the family of the 57-year-old female physician that her death may be related to botulism poisoning. The doctor's younger brother said the family is still awaiting laboratory results to confirm that the death was caused by botulism. The brother said the state health department approached the family last week about the doctor's illness. The doctor's husband is also ill and was still hospitalized, he said, and added that he doesn't know whether that illness is also related to botulism. The relative's comments come a day after the Virginia Department of Health said it is investigating two reported cases of possible food-borne botulism in the Alleghany-Roanoke City Health District, which includes Roanoke County, where the couple lives.
USA (Wisconsin): Tortillas suspected in school illness outbreak
Del Rey Tortilleria, Inc. is recalling several products after health officials in Wisconsin suspected a link between flour tortillas and an outbreak of illness at three schools. The Chicago-based company told the state of Wisconsin it will voluntarily recall the products as a precaution while the Food and Drug Administration (FDA) continues to investigate. But the company is still not sure its products caused the reported symptoms, said Marcy Toledo, Del Rey's general manager.
More than 80 students at three schools in Racine reported flu-like symptoms earlier in November 2007 that included vomiting, according to health officials. The Racine Unified School District closed two middle schools and an elementary school for a day for disinfection. Health officials in Wisconsin said [9 Nov 2007] they suspected soft flour tortillas may be responsible for the outbreak. An exact cause of the outbreak has still not been found. State health officials said Del Rey made the flour tortillas served at the schools where llnesses were reported. The products in question were distributed nationwide through food distributors and grocery stores. Del Rey has not specified states involved in the recall beyond Illinois and Wisconsin. Consumers should immediately return any product that is subject to the recall to the store where they purchased it for a full refund or replacement.
The recall includes flour tortillas of all sizes: White Flour Tortillas; Tortillas de Harina (6 inch); Burritos 2, 3, and 4; and Fajita 8 inch size. The recalled tortillas all have the name "Del Rey" on the label and are stamped with one of these Date Codes: OCT/17/07; OCT/20/07; OCT/24/07; NOV/04/07; NOV/10/07; or NOV/11/07.
USA (Wisconsin and Ohio): Pertusis outbreak in two school districts
The Columbus (Ohio) Health Department [5 Nov 2007] confirmed that 46 students in the Worthington City School district have been diagnosed with whooping cough. The outbreak started in early October 2007 and additional students were being tested for the disease. In October 2007, the Columbus Health Department confirmed that five students at Worthington Kilbourne High School were diagnosed with whooping cough. The school district confirmed more cases late last week. At least one student at Thomas Worthington High School was diagnosed with whooping cough. Clark County (Wisconsin) school officials say an outbreak of whooping cough, has more than 1/3 of Greenwood Junior High and High School students staying home today [8 Nov 2007]. County Health Officials say 32 cases have now been confirmed, and the school district is fighting to contain the disease. Greenwood High School officials say when an outbreak of illness in the school was recently diagnosed as whooping cough, they asked for guidance from the health department.
"Our county health officials are screening students, encouraging them, sometimes demanding they go in and be tested to make sure they're not a carrier for us," says High School Principal Jim Haines.
(ProMED 11.6.07 & 11.11.07)
USA (Hawaii): Norovirus suspected on cruise ship
Cruise Ship Norwegian Cruise Line (NCL) said about a sixth of the 2500 passengers on board its Pride Of Hawaii cruise ship became sick [5-9 Nov 2007]. The passengers fell ill with the stomach flu after leaving Honolulu Harbor [5 Nov 2007].
On [9 Nov 2007], NCL said the outbreak has been confined to just the one ship [i.e., the Pride of Hawaii]. It said the "Pride of Aloha" and "Pride of America" are not affected. Passengers who became ill with nausea, vomiting and diarrhea were asked along with their cabinmates to remain quarantined in their rooms for 24 hours. [Outbreaks of norovirus-associated gastroenteritis have been frequent, particularly during winter months in the Northern hemisphere and have been designated accordingly "winter-vomiting disease." Outbreaks occur frequently in closed communities such as schools, health care centres, hotels and prisons on land and in naval ships and cruise liners on the seas. Because of the antigenic and genetic heterogeneity of noroviruses, recovery from a recent bout of norovirus-associated gastroenteritis may not confer protection against a subsequent infection].
USA (Arizona): Wildlife biologist likely died from pneumonic plague
A wildlife biologist at Grand Canyon National Park most likely died from the plague contracted while performing a necropsy on a mountain lion that later tested positive for the disease, officials said [9 Nov 2007].
The 37-year-old, who worked in the park's cougar collaring program, became ill [30 Oct 2007] and called out sick from for a couple of days before being found dead in his home [2 Nov 2007]. Tests were positive for pneumonic plague. Officials said 49 people who came in contact with York were given antibiotics as a precaution. None have shown symptoms of the disease.
The biologist, whose family lives in Massachusetts, had skinned the cougar and was exposed to its internal organs during the necropsy he performed 3 days before developing symptoms, said David Wong, an epidemiologist for the US Public Health Service. The cougar, which had died from the plague, was believed to have remained in back-country areas where park visitors wouldn't normally go, officials said. An average of 13 plague cases are reported in the USA each year. A total of 14 percent of cases are fatal, according to the CDC. While Arizona health officials say the disease appears to be on the rise in the state, CDC spokeswoman Lola Russell said plague cases weren't on the rise nationally.
Plague is transmitted primarily by fleas and direct contact with infected animals. When the disease causes pneumonia, it can be transmitted from an infected person to a non-infected person by airborne cough droplets. Cases are treatable with antibiotics.
USA (Pennsylvania): Raw milk is the culprit in Salmonella infection
In February 2007, the Pennsylvania Department of Health received reports, through routine electronic laboratory disease reporting, of 2 persons with recent laboratory-confirmed infections with Salmonella enterica serotype Typhimurium. Both persons had reported drinking raw (unpasteurized) milk from the same York County, Pennsylvania, dairy (dairy A).
S. Typhimurium isolates from these persons had pulsed-field gel electrophoresis (PFGE) patterns that were indistinguishable by use of the XbaI restriction enzyme. The same month, the Pennsylvania Department of Agriculture (PDA) received reports of illness from raw milk customers of dairy A. PDA obtained milk samples from the raw milk bulk tank at dairy A, which yielded S. Typhimurium with a PFGE pattern that was identical to the pattern from patient isolates. 8 PDA inspections of dairy A conducted during January-April 2007 revealed improper cleaning of milking equipment, insufficient supervision of workers, unspecified illness among lactating cows, and bird and rodent infestation. On at least 2 inspections, the required public notice regarding the potential hazards of drinking raw milk was not visible at the dairy A retail store. The findings underscore the need to inform policy makers and the public of the potential health risks associated with raw milk consumption.
USA: FDA food safety plan taps others for inspection help
A new food protection plan from the US Food and Drug Administration (FDA), released as part of a comprehensive import safety plan, places a heavy emphasis on preventing food contamination by enlisting other groups to help the agency focus inspection efforts on high-risk food products.
The FDA's 25-page plan spells out a host of actions it will take, such as writing food protection guidelines for industry and helping foreign countries enhance their regulatory systems. It also specifies new legislative authority it will need to pursue several other safety initiatives, such as enhancing access to a food company's records during emergencies. The plan identifies several trends that present food safety challenges. An aging US population will be increasingly susceptible to foodborne illnesses, and Americans eat more fresh fruit and vegetables and rely more on convenience foods that carry a greater risk of cross-contamination. The number of domestic and foreign food production businesses that are subject to FDA inspections is growing faster than the FDA can manage on its own, the report notes.
The plan asks Congress to allow the FDA to accredit third parties, or to recognize another agency that accredits third parties, to handle some inspection duties. Third-party inspectors could be federal, state, local, or foreign government agencies or private entities that don't have conflicts of interest, the report said.
The FDA would not be bound by their inspection findings. Several of the plan's components increase the responsibility of companies for preventing foodborne illnesses, and some would require legislative action. For example, the FDA would like the authority to require some food supply companies to implement specific safety measures to guard against intentional adulteration. The authority would apply to vulnerable bulk or batch links in the food supply chain, such as requiring locks on tanker trucks that transport food. "This approach shares the burden of ensuring the safety of food products with the exporting country. Shipments that fail to meet the requirements would be refused entry," the FDA report says.
USA: USDA vows to double inspections of Canadian meat
Starting 9 Nov 2007, US inspection and testing of imported Canadian meat and poultry products will roughly double and will include a category of beef products that has not previously been subject to testing, the US Department of Agriculture (USDA) said.
The USDA announced Nov 3 it would increase inspections and testing of Canadian products this week, after beef trim from an Alberta meat producer was implicated in an E coli O157:H7 outbreak linked to ground beef sold by Topps Meat Co. of Elizabeth, N.J. The USDA released more information today in a letter from Dr. William James of the agency's Food Safety and Inspection Service (FSIS) to the Canadian Food Inspection Agency (CFIA).
The letter, published online by the FSIS, said the agency would:
• Increase inspections of Canadian meat, poultry, and pasteurized egg products
• Increase testing of raw ground beef for E coli O157:H7
• Begin E coli testing of raw beef trim, boxed beef, and "subprimals" (smaller cuts of meat from the major carcass components, such as loin, chuck, and round) normally sent for grinding
• Increase testing of ready-to-eat products for Listeria monocytogenes and Salmonella.
The increased inspections, ground beef testing for E coli, and testing of ready-to-eat products "will be at the rate of approximately double that of the past year for Canada," James's letter states. "The measures are a reflection of our concern about the Canadian inspection system based on the audit findings of May 1–June 6, 2007, and the circumstances related to the unsafe practices employed by Rancher's Beef, Ltd.," the Balzac, Alta., packing plant whose products were linked to the contaminated Topps ground beef, James wrote.
USA: Vaccine deliveries set record, but will strains match?
Deliveries of seasonal influenza vaccine have already outpaced the number of doses ever distributed in a single season, officials from the US CDC said, but they voiced concerns about a possible mismatch of one of the strains. So far 103 million doses of the vaccine have been distributed to clinics and other providers, the most ever delivered, said Jeanne Santoli, deputy director of the CDC's immunization services division.
By the end of the season, 132 million doses of the vaccine will be shipped, which is 10 million more than ever produced before in the United States, she added. Some providers may not have received their complete order yet, but all should have enough of the vaccine to launch their annual flu vaccine campaigns, Santoli said. Despite the plentiful supply of the vaccine early in the season, she said the CDC is working to raise awareness that flu vaccination in December or later still offers protection in advance of the flu season's January-February peak.
Santoli announced that the CDC will sponsor its second annual National Influenza Vaccination Week, from Nov 26 to Dec 2. So far, the CDC has noted low levels of flu activity in the United States, which is normal for the start of a new flu season, said Joe Bresee, chief of epidemiology and prevention for the CDC's immunization services division. Only 2.5% of specimens tested have been positive for influenza, and of those, 90% were influenza A, he said. Outpatient visits for influenza-like illnesses are low in all parts of the country except for the mountain region, where the number is slightly higher.
USA: Food safety plan calls for FDA recall power
A new food protection plan released by the Bush administration proposes giving the Food and Drug Adminstration (FDA) the power to require companies to recall unsafe foods, among a number of other steps. The FDA can force a prescription drug off the market by withdrawing its approval, but it currently cannot compel a company to recall a hazardous food, a fact that consumer groups have often decried. The agency has maintained that companies in the vast majority of cases recall such products voluntarily. But officials acknowledged that the mandatory recall authority would sometimes be useful. "The mandatory recall authority that we're requesting here would be used in situations where manufacturers don't want to make a voluntary recall," said Dr. David Acheson, the FDA's assistant commissioner for food safety. "We've had situations where it hasn't worked, where there have been delays or refusal. This allows us to plug that hole." (CIDRAP 11.8.07)
- 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
- 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/ http://www.pandemicflu.gov/
Public Comments Sought on Draft of Flu Vaccine Allocation Plan.
-Health Canada: information on pandemic influenza:
Updates on Saskatchewan avian influenza outbreak
- CIDRAP: http://www.cidrap.umn.edu/: Read the series, “The Pandemic Vaccine Puzzle”.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm
- US Geological Survey, National Wildlife Health Center Avian Influenza Information:
Updated 2 Nov 2007.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)
According to the statistics collected by the notifiable disease surveillance system in Taiwan, 2,365 cases of dengue fever have been reported since Jan 2007. As of Oct 31, 2007, 1,170 cases have been laboratory confirmed, reflecting a 73.1% increase over the same period last year (595 cases were laboratory confirmed in 2006). Of the 1,170 cases confirmed to date, 1,030 were classified as indigenous cases. In addition most of the indigenous cases (1,014 cases) occurred after the summer. The main serotype of circulating DF virus in Taiwan this year is dengue type one virus and the case distribution was mainly concentrated in the southern region, including Tainan City, Tainan County, and Kaohsiung City. Among this year’s confirmed cases, 140 cases were imported, a 50.5% increase over the same period last year. More precisely, only 93 imported cases were reported in 2006. For 2007, the origins of the imported cases were as follows: Indonesia, Vietnam, the Philippines, Cambodia, Thailand, Malaysia, Myanmar, China, Singapore, Laos, and India. This report can also be found on Taiwan CDC’s website at http://www.cdc.gov.tw/en/index.asp.
CHOLERA, DIARRHEA, AND DYSENTERY
The Centre for Health Protection has confirmed a cholera case involving a
43-year-old Eastern District woman. She was admitted to Princess Margaret
Hospital 12 Nov 2007 after traveling to India. She is in stable condition. So
far 3 cholera cases, including 2 imported ones, have been reported in 2007.
There was one case in 2006, 5 in 2005, 5 in 2004, 7 in 2003, and 4 in 2002.
At least one person died while 45 others were hospitalized after cases of
diarrhea rose significantly in Itogon town in Benguet province. Citing initial
reports from the Cordillera regional health department, the report said
authorities suspect "half-cooked" pork and carabao meat as well as contaminated
water may have caused the latest diarrhea cases. Health officials said that as
of [15 Nov 2007], 11 of the hospitalized remained confined at the hospital
while the other 34 were allowed to go home. Furthermore, at least one resident
has died while at least 105 others were affected in a diarrhea outbreak that
started in Northern Samar province two weeks ago. Provincial health officer Mary
Ann Avalon said her staff recorded at least 106 cases since 27 Oct 2007, with
the lone fatality so far being a 47-year-old woman. She said the outbreak could
have stemmed from a water supply contaminated by human and animal waste, and
spread by recent rains.
The epidemic of acute diarrhea is still raging in the North and creating panic
in the South of Viet Nam. On November 10th, a further 100 cases were reported in
hospitals in the northern provinces. Of these, 31 cases were developed in Ha Tay
province, announced Dr. Nguyen Huy Nga of the Ministry of Health. Tests carried
out by the Central Institute of Epidemic Prevention reported a further 42
patients suffering from cholera, taking the total number of cholera sufferers to
201. After three weeks fighting against the outbreak, the Ministry of Health is now
considering further measures and may distribute vaccine to people living in
high-risk and flood-stricken areas.
WEST NILE VIRUS
Human cases were reported for week 44 (as of 3 Nov 2007) from the following provinces:
Province / Neurological / Non-Neurological / Unclassified-Unspecified / Total / Asymptomatic
Nova Scotia / 0 / 0 / 1 / 1 / 0
Quebec / 2 / 0 / 0 / 2 / 0
Ontario / 1 / 10 / 0 / 11 / 3
Manitoba / 58 / 481 / 36 / 575 / 8
Saskatchewan / 40 / 419 / 951 / 1410 / 14
Alberta / 21 / 297 / 0 / 318 / 3
British Columbia / 8 / 8 / 2 / 18 / 0
TOTALS / 133 / 1215 / 990 / 2335 / 28
Human cases have been reported from:
State / Neuroinvasion / West Nile fever / Other, Unspecified / Total / Fatalities
Alabama / 16 / 6 / 0 / 22 / 3
Arizona / 39 / 22 / 24 / 85 / 1
Arkansas / 13 / 6 / 0 / 19 / 1
California / 151 / 213 / 7 / 371 / 16
Colorado / 96 / 459 / 0 / 555 / 6
Connecticut / 4 / 1 / 0 / 5 / 0
Delaware / 1 / 0 / 0 / 1 / 0
Florida / 3 / 0 / 0 / 3 / 1
Georgia / 23 / 21 / 3 / 47 / 2
Idaho / 7 / 100 / 2 / 109 / 1
Illinois / 55 / 25 / 13 / 93 / 4
Indiana / 12 / 7 / 3 / 22 / 1
Iowa / 10 / 12 / 2 / 24 / 2
Kansas / 13 / 26 / 0 / 39 / 2
Kentucky / 3 / 0 / 0 / 3 / 0
Louisiana / 20 / 9 / 0 / 29 / 0
Maryland / 6 / 3 / 1 / 10 / 0
Massachusetts / 3 / 3 / 0 / 6 / 0
Michigan / 12 / 0 / 1 / 13 / 2
Minnesota / 45 / 54 / 0 / 99 / 2
Mississippi / 42 / 82 / 0 / 124 / 3
Missouri / 56 / 12 / 0 / 68 / 2
Montana / 37 / 160 / 0 / 197 / 4
Nebraska / 18 / 126 / 0 / 144 / 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 / 2
North Carolina / 3 / 2 / 0 / 5 / 0
North Dakota / 49 / 312 / 0 / 361 / 2
Ohio / 13 / 7 / 1 / 21 / 2
Oklahoma / 51 / 40 / 1 / 92 / 8
Oregon / 7 / 19 / 0 / 26 / 0
Pennsylvania / 5 / 4 / 0 / 9 / 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 / 114 / 30 / 0 / 144 / 10
Utah / 27 / 33 / 0 / 60 / 2
Virginia / 2 / 1 / 0 / 3 / 0
Wisconsin / 5 / 5 / 0 / 10 / 0
Wyoming / 15 / 152 / 13 / 180 / 1
TOTALS / 1082 / 2146 / 76 / 3304 / 93
Lack of Evidence of Avian-to-Human Transmission of Avian Influenza A (H5N1) Virus among Poultry Workers, Kano, Nigeria, 2006
Ortiz JR, Katz MA, et al. The Journal of Infectious Diseases. 2007;196:1685-1691 http://www.journals.uchicago.edu/JID/journal/issues/v196n11/38639/38639.html?erFrom=-2587013136050731587Guest
Abstract: Background: In February 2006, poultry outbreaks of highly pathogenic avian influenza A (H5N1) virus were confirmed in Nigeria. A serosurvey was conducted to assess H5N1 transmission among poultry workers and laboratory workers in Nigeria.
Methods: From 21 March through 3 April 2006, 295 poultry workers and 25 laboratory workers with suspected exposure to H5N1 virus were administered a questionnaire to assess H5N1 exposures, medical history, and health care utilization. A serum specimen was collected from participants to test for H5N1 neutralizing antibodies by microneutralization assay. Results: The 295 poultry workers reported a median of 14 days of exposure to suspected or confirmed H5N1-infected poultry without antiviral chemoprophylaxis and with minimal personal protective equipment. Among 25 laboratory workers, all handled poultry specimens with suspected H5N1 virus infection. All participants tested negative for H5N1 neutralizing antibodies.
Conclusions: Despite widespread exposure to poultry likely infected with H5N1 virus, no serological evidence of H5N1 virus infection was identified among participants. Continued surveillance for H5N1 cases in humans and further seroprevalence investigations are needed to assess the risk of avian-to-human transmission, given that H5N1 viruses continue to circulate and evolve among poultry.
Avian influenza outbreak in Turkey through health personnel's views: a qualitative study
Sarikaya O, Erbaydar T. BMC Public Health 2007, 7:330 [doi:10.1186/1471-2458-7-330] http://www.biomedcentral.com/1471-2458/7/330/abstract
Abstract: Background: Avian influenza threatens public health worldwide because it is usually associated with severe illness and, consequently, a higher risk of death. During the first months of 2006, Turkey experienced its first human avian influenza epidemic. A total of 21 human cases were identified, 12 of which were confirmed by the National Institute for Medical Research. Eight of the cases, including the four fatal ones, were from the Dogubeyazit-Van region. This study aims to evaluate the efforts at the avian influenza outbreak control in the Van-Dogubeyazit region in 2006 through the experiences of health personnel. Methods: We conducted in-depth interviews with seventeen key informants who took active roles during the avian influenza outbreak in East Turkey during the first months of 2006. We gathered information about the initial responses, the progress and management of the outbreak control, and the reactions of the health professionals and the public. The findings of the study are reported according to the topics that appeared through thematic analysis of the interview transcripts. Results: Following the first suspected avian influenza cases, a Van Crisis Coordination Committee was formed as the coordinating and decision-making body and played an important role in the appropriate timing of decisions. The health and agriculture services could not be well coordinated owing to the lack of integrated planning in preparation for outbreak and of integrated surveillance programs. Traditional poultry practice together with the low socio-economic status of the people and the lack of health care access in the region seemed to be a major risk for animal to animal and animal to human transmission. The strengths and weaknesses of the present health system — primary health care services, national surveillance and notification systems, human resource and management — affected the inter organizational coordination during the outbreak. Open communication between the government and the public played an important part in overcoming difficulties. Conclusion: Although there were problems during the avian influenza outbreak in Turkey, the rapid responses of the central and regional health authorities and the performance of the health workers were the key points in controlling the epidemic. The lessons from this outbreak should provide an opportunity for integrating the preparation plans of the health and agricultural organizations, and for revising the surveillance system and enhancing the role of the primary health care services in controlling epidemic disease.
Developing successful strategies based on knowledge and experience may play a valuable role in delaying an avian influenza pandemic. A model to control the epidemic of H5N1 influenza at the source
Guan Y, Chen H, et al. BMC Infectious Diseases 2007, 7:132doi:10.1186/1471-2334-7-132 http://www.biomedcentral.com/1471-2334/7/132/abstract
Abstract: Background: No country is fully prepared for a 1918-like pandemic influenza. Averting a pandemic of H5N1 influenza virus depends on the successful control of its endemicity, outbreaks in poultry and occasional spillage into human which carries a case-fatality rate of over 50%. The use of perimetric depopulation and vaccination has failed to halt the spread of the epidemic. Blanket vaccination for all poultry over a large geographical area is difficult. A combination of moratorium, segregation of water fowls from chickens and vaccination have been proved to be effective in the Hong Kong Special Administrative Region (HKSAR) since 2002 despite endemicity and outbreaks in neighbouring regions. Systematic surveillance in southern China showed that ducks and geese are the primary reservoirs which transmit the virus to chickens, minor poultry and even migratory birds. Presentation of the hypothesis: We hypothesize that this combination of moratorium, poultry segregation and targeted vaccination if successfully adapted to an affected district or province in any geographical region with high endemicity would set an example for the control in other regions. Testing the hypothesis: A planned one-off moratorium of three weeks at the hottest month of the year should decrease the environmental burden as a source of re-infection. Backyard farms will then be re-populated by hatchlings from virus-free chickens and minor poultry only. Targeted immunization of the ducks and geese present only in the industrial farms and also the chickens would be strictly implemented as blanket immunization of all backyard poultry is almost impossible. Freely grazing ducks and geese would not be allowed until neutralizing antibodies of H5 subtype virus is achieved. As a proof of concept, a simple mathematical model with susceptible-infected-recovered (SIR) structure of coupled epidemics between aquatic birds (mainly ducks and geese) and chickens was used to estimate transmissibility within and between these two poultry populations. In the field the hypothesis is tested by prospective surveillance of poultry and immunocompetent patients hospitalized for severe pneumonia for the virus before and after the institution of these measures. Implications of the hypothesis: A combination of targeted immunization with the correct vaccine, segregation of poultry species and moratorium of poultry in addition to the present surveillance, biosecurity and hygienic measures at the farm, market and personal levels could be important in the successful control of the H5N1 virus in poultry and human for an extensive geographical region with continuing outbreaks. Alternatively a lesser scale of intervention at the district level can be considered if there is virus detection without evidence of excess poultry deaths since asymptomatic shedding is common in waterfowls.
Influenza in Migratory Birds and Evidence of Limited Intercontinental Virus Exchange
Krauss S, Obert CA, Franks J, Walker D, Jones K, et al. (2007) PLoS Pathog 3(11): e167 doi:10.1371/journal.ppat.0030167 http://pathogens.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.ppat.0030167
Abstract: Migratory waterfowl of the world are the natural reservoirs of influenza viruses of all known subtypes. However, it is unknown whether these waterfowl perpetuate highly pathogenic (HP) H5 and H7 avian influenza viruses. Here we report influenza virus surveillance from 2001 to 2006 in wild ducks in Alberta, Canada, and in shorebirds and gulls at Delaware Bay (New Jersey), United States, and examine the frequency of exchange of influenza viruses between the Eurasian and American virus clades, or superfamilies. Influenza viruses belonging to each of the subtypes H1 through H13 and N1 through N9 were detected in these waterfowl, but H14 and H15 were not found. Viruses of the HP Asian H5N1 subtypes were not detected, and serologic studies in adult mallard ducks provided no evidence of their circulation. The recently described H16 subtype of influenza viruses was detected in American shorebirds and gulls but not in ducks. We also found an unusual cluster of H7N3 influenza viruses in shorebirds and gulls that was able to replicate well in chickens and kill chicken embryos. Genetic analysis of 6,767 avian influenza gene segments and 248 complete avian influenza viruses supported the notion that the exchange of entire influenza viruses between the Eurasian and American clades does not occur frequently. Overall, the available evidence does not support the perpetuation of HP H5N1 influenza in migratory birds and suggests that the introduction of HP Asian H5N1 to the Americas by migratory birds is likely to be a rare event.
Epitope Mapping of the Hemagglutinin Molecule of a Highly Pathogenic H5N1 Influenza Virus by Using Monoclonal Antibodies
Kaverin NV, Rudneva IA, et al. Journal of Virology, December 2007, p. 12911-12917, Vol. 81, No. 23 [doi:10.1128/JVI.01522-07]
We mapped the hemagglutinin (HA) antigenic epitopes of a highly pathogenic H5N1 influenza virus on the three-dimensional HA structure by characterizing escape mutants of a recombinant virus containing A/Vietnam/1203/04 (H5N1) HA and neuraminidase genes in the genetic background of A/Puerto Rico/8/34 (H1N1) virus. The mutants were selected with a panel of eight anti-HA monoclonal antibodies (MAbs), seven to A/Vietnam/1203/04 (H5N1) virus and one to A/Chicken/Pennsylvania/8125/83 (H5N2) virus, and the mutants’ HA genes were sequenced. The amino acid changes suggested three MAb groups: four MAbs reacted with the complex epitope comprising parts of the antigenic site B of H3 HA and site Sa of H1 HA, two MAbs reacted with the epitope corresponding to the antigenic site A in H3 HA, and two MAbs displayed unusual behavior: each recognized amino acid changes at two widely separate antigenic sites. Five changes were detected in amino acid residues not previously reported as changed in H5 escape mutants, and four others had substitutions not previously described. The HA antigenic structure differs substantially between A/Vietnam/1203/04 (H5N1) virus and the low-pathogenic A/Mallard/Pennsylvania/10218/84 (H5N2) virus we previously characterized (N. V. Kaverin et al., J. Gen. Virol. 83:2497-2505, 2002). The hemagglutination inhibition reactions of the MAbs with recent highly pathogenic H5N1 viruses were consistent with the antigenic-site amino acid changes but not with clades and subclades based on H5 phylogenetic analysis. These results provide information on the recognition sites of the MAbs widely used to study H5N1 viruses and demonstrate the involvement of the HA antigenic sites in the evolution of highly pathogenic H5N1 viruses, findings that can be critical for characterizing pathogenesis and vaccine design.
Pandemic influenza and hospital resources
Nap RE, Andriessen MPHM, Meessen NEL, van der Werf TS. Emerg Infect Dis. 2007 Nov [date cited]. http://www.cdc.gov/EID/content/13/11/1714.htm
Abstract: Using estimates from the Centers for Disease Control and Prevention, the World Health Organization, and published models of the expected evolution of pandemic influenza, we modeled the surge capacity of healthcare facility and intensive care unit (ICU) requirements over time in northern Netherlands (≈1.7 million population). We compared the demands of various scenarios with estimates of maximum ICU capacity, factoring in healthcare worker absenteeism as well as reported and realistic estimates derived from semistructured telephone interviews with key management in ICUs in the study area. We show that even during the peak of the pandemic, most patients requiring ICU admission may be served, even those who have non–influenza-related conditions, provided that strong indications and decision-making rules are maintained for admission as well as for continuation (or discontinuation) of life support. Such a model should be integral to a preparedness plan for a pandemic with a new human-transmissible agent.
Canada, USA: Healthy people are developing MRSA infections and pig farms may be a culprit
A new study published in Veterinary Microbiology found methicillin-resistant _Staphylococcus aureus_ (MRSA) is widely common in Canadian pig farms and pig farmers, signaling to some that animal agriculture as a source of the deadly bacteria. The Veterinary Microbiology study (Khanna et al. Veterinary Medicine 2007) is the first to show that North American pig farms and farmers commonly carry MRSA. Researchers looked for MRSA in 285 pigs in 20 Ontario farms and found MRSA at 45 percent of farms (9/20) and in nearly one in 4 pigs (71/285). One in 5 pig farmers studied (5/25) also were found to carry MRSA, a much higher rate than in the general North American population. The strains of MRSA bacteria found in Ontario pigs and pig farmers included a strain common to human MRSA infections in Canada. A study published last month [October 2007] in the Journal of the American Medical Association (JAMA) (Klevens et al: Invasive methicillin-resistant _Staphylococcus aureus_ infections in the United States JAMA 2007; 298: 1753-1771) estimated almost 100 000 MRSA infections in 2005, and nearly 19,000 deaths in the United States. In comparison, HIV/AIDS killed 17,000 people that year. With the recent outbreak of the deadly disease researchers generally believed MRSA as an opportunistic infection occurring mainly in hospitals. However more information is coming to light that finds even healthy people are developing MRSA infections and pig farms may be a possible culprit. Now some experts in the in the medical, agriculture, and environmental industries are calling for Congress to compel the US Food and Drug Administration (FDA) to study whether the use of human antibiotics in animal agriculture is contributing to the reported surge in MRSA infections and deaths in the United States. Proposed federal legislation: The Preservation of Antibiotics for Medical Treatment Act would phase out the use of antibiotics that are important in human medicine as animal feed additives within two years.
APEC Center for Technology Foresight: Technology Roadmapping Workshop
The APEC second technology roadmapping workshop on "Converging technologies to Combat Emerging Infectious Diseases" in Chinese Taipei (as a part of APEC-wide project) was recently completed with success. The final stage of this project are now being planned. The final symposium, which aims to discuss longer term perspective to enhance the region’s capacity in development and utilization converging technologies that contribute to the successful prevention and management of emerging infectious diseases. The details can be found in the following links:
Ponpiboon Satangput, Ph.D., Policy Researcher, APEC Center for Technology Foresight www.apecforesight.org ; E-mail: firstname.lastname@example.org
Intergovernmental meeting on pandemic influenza preparedness
Date: 20-23 November 2007 Place: Geneva, Switzerland
A four-day meeting will take place at the WHO headquarters in Geneva from 20 to 23 November 2007. The meeting aims to report on progress achieved in strengthening procedures for the sharing of influenza viruses and to discuss the benefits of virus sharing, which include increased access to vaccines.
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 6 explored the potential of novel vaccine technologies such as using whole flu viruses or growing vaccines in cell cultures instead of in eggs.
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?
Part 6: Looking to novel vaccine technologies
Part 7: Reinforcing the research agenda
HHS issues guide for using call centers in emergencies
The Department of Health and Human Services (HHS) recently released a guide to help communities retool their health-related call centers into systems for meeting the needs of the public in homes or shelters during emergencies such as a pandemic or bioterrorist attack. Published by the HHS Agency for Healthcare Research and Quality (AHRQ), the 224-page guide is aimed at boosting the capabilities of poison-control centers, nurse advice lines, drug information centers, and health agency hotlines. It focuses on four main scenarios: anthrax attacks, pandemic influenza, plague, and food contamination.
"Community call centers have long been a credible source that people can turn to for health information," said AHRQ Director Carolyn M. Clancy, MD, in an Oct 26 press release from the agency. "Leveraging these existing resources will allow clinics, outpatient departments, and emergency departments to devote their attention to caring for those in most need of help."
The report was developed for the AHRQ by Denver Health, a member of the agency's Accelerating Change and Transformation in Organizations and Networks (ACTION) project, the press release said. A national advisory panel of experts in emergency call center services, public health, preparedness planning, and other fields helped draft the guidance. Few resources exist to guide the development of emergency call centers, the report says. However, the authors were able to draw from published reports on the experiences of officials in Toronto and Taiwan during the SARS epidemic. Guidance in the report assumes that the community infrastructure would remain intact so that call centers would be operable. Though the document doesn't address absenteeism among call-center workers, it covers features, such as interactive response systems, that might reduce the number of employees needed to staff the centers. For communities that have little healthcare call-center capacity, the authors offer suggestions on how to enlist the help of local corporate call-center systems.