Vol. X No. 25 ~ EINet News Briefs ~ Dec 14, 2007

2007
Cambodia/ 1 (1)
China / 5 (3)
Egypt / 20 (5)
Indonesia / 40 (34)
Laos / 2 (2)
Nigeria / 1 (1)
Viet Nam 7 (4)
Total / 76 (50)

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)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)

2004
Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

2003
Viet Nam / 3 (3)
Total / 3 (3)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 339 (208).
(WHO 12.13.07 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 11.12.07)

WHO maps showing world's areas affected by H5N1 avian influenza (last updated 12.10.07):
http://gamapserver.who.int/mapLibrary/

WHO timeline of important H5N1-related events (last updated 12.5.07):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: Donors pledge 406 million USD to fight avian influenza
International donors at this week's New Delhi conference on avian and pandemic influenza pledged about 406 million USD, including 195 million USD from the United States, to fight H5N1 avian flu.

The latest pledges will bring the total promised by donors and multilateral development banks (MDBs) in the past two years to about 2.7 billion USD. A report released by the United Nations and the World Bank said a total of about 2.3 billion USD was pledged at conferences in Beijing in January 2006 and in Bamako, Mali, in December 2006.

When the New Delhi conference opened 4 Dec 2007, the World Bank predicted a need for 1.2 billion USD to help countries battle avian flu over the next two to three years, according to a 6 Dec 2007 report by Agence France-Presse (AFP).

Peter Harrold, acting vice president of the World Bank, called the new pledges a "very encouraging response," AFP reported. "There is still a gap, but this is more than what we had anticipated," he said.

The United States had previously pledged 434 million USD to the avian flu fight. In New Delhi, US officials promised another 195 million USD, raising the total to 629 million USD. Of the 2.3 billion USD previously pledged for the avian flu battle, 1.7 billion USD (72%) has been committed and more than 1 billion USD (43%) has been paid out, according to the UN–World Bank report, which was released 29 Nov 2007 in advance of the conference. About 600 million USD remained uncommitted as of the end of June.

Long-term efforts needed:
A major theme of the conference, as well as of the UN-World Bank report, was the need to shift from focusing on emergency responses to avian flu to developing medium- and long-term strategies to deal with H5N1 and the threat of a human flu pandemic. The UN report says many countries have improved their responses to avian flu in the past year, but the disease remains entrenched in several countries and the threat of a pandemic is the same now as it was in mid 2005, when it became a high-profile issue.

John E. Lange, who headed the US delegation to the conference, said in a 4 Dec 2007 speech there, "While we have made progress in the years since the virus first appeared, we now need to shift some of our efforts from the 'emergency' phase of identifying and dealing with avian outbreaks to a greater emphasis on long-term capacity-building to improve both animal and human health systems as they relate to the H5N1 avian influenza virus and other emerging and re-emerging infectious and zoonotic diseases."

Lange also touched on the dispute with Indonesia over the sharing of H5N1 virus samples, though he didn't name the country. "We call on all countries to share virus samples freely, without encumbrances, for the benefit of global health," he said.

Other findings cited in the report:

• 144 countries have prepared an avian flu plan, a pandemic plan, or an integrated plan for both threats
• 27% of countries said they have no capacity to detect and confirm human H5N1 cases
• 41% of countries have tested pandemic plans in simulation exercises
• 50% of countries have done some planning for maintaining their infrastructure during a pandemic

At the end of the conference, the Indian government released a suggested planning template for countries to use in preparing for avian and pandemic flu. The "Vision and Road Map" includes 21 goals that India proposes countries try to accomplish by the end of 2008.
(CIDRAP 12.7.07)

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As for wild birds, the number of bird flu cases in Poland has risen to five. Vets pronounced three wild birds in the village of Krzykaly, northeast Poland, to be infected with the H5N1 virus. Three birds from the bird recovery centre in Krzykaly died of bird flu. The presence of the virus was confirmed in detailed medical examinations in the National Veterinary Institute in Pulawy, eastern Poland. There are more birds left in the recovery center, among them two cranes, a white stork and mute swan. As these are all protected species the decision whether to cull them will have to be consulted with the Minister of the Environment. A 10-km exclusion zone has been set out around the last bird flu focus. There are several chicken farms in the area with around 45,000 birds on them. No human has been infected, Polish authorities said.

With 230,000 metric tons of poultry exports in 2006, Poland is considered one of the major poultry suppliers in the European Union, which last week suspended imports from Poland for thirty days. Russia, Ukraine, Belarus and Hong Kong were among countries that imposed a ban on poultry imports from Poland. Police sealed off the Plock region, introducing check disinfection points for people and vehicles and banning transport of meat.
(ProMED 12.10.07)

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Saudi Arabia (Al-Kharj): H5N1 avian influenza outbreak at an egg production farm
In Saudi Arabia, the agriculture ministry announced an H5N1 outbreak at an egg production farm south of Riyadh. The ministry said the farm, in the Alsahba area in Al-Kharj governorate, has about 400,000 hens.
(ProMED 12.13.07)

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Saudi Arabia: Suspected H5N1 avian influenza virus kills imported wild falcon
Tests were carried out at the Central Veterinary Research Laboratory in Dubai on an imported wild saker falcon (Falco cherrug) from Saudi Arabia, reported Wildlife Middle East News.

The Highly Pathogenic Avian Influenza H5N1 was diagnosed in the falcon, which died shortly after being admitted to a falcon hospital in Riyadh. No post-mortem examinations or diagnostic tests were carried out to establish the cause of death. The falcon showed non-specific signs, including low appetite, regurgitation and passing of green-colored liquids.

According to the report the diagnosis included high white cell count. Samples have been sent to the Friedrich-Loeffler Institute in Germany for further virus identification studies. The falcon was part of a large group of wild-caught sakers imported into the kingdom from Central Asia. According to reports, a large proportion of these falcons died showing similar symptoms.
(ProMED 12.12.07)

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Russia: H5N1 avian influenza found in Rostov region, 450,000 hens slated to be destroyed
A comprehensive analysis of the pathological material of poultry that died at the Gulyay-Borisovskaya battery farm in the Zernograd district, Rostov region, has detected bird flu virus H5N1, Krasnodar Territory Chief Veterinary Vladimir Shevkoplyas said. "The All Russian Animal Health Protection Institute conducted this analysis detecting bird flu virus H5N1."

According to earlier reports, 450,000 hens are slated to be destroyed in the Zernograd district, Rostov region because of the die-off of birds that began last week.
(ProMED 12.12.07)

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To celebrate the 24-year-old's acceptance to a school of continuing education, his mother and father took him and his girlfriend to Nanjing's most bustling Confucian temple. At the temple's restaurant, the four of them ate Beggar's Chicken, which was surrounded by thick mud. According to analyzes, perhaps because the mud on the outside was too thick the chicken inside was not thoroughly cooked. On the second day after eating the chicken, the young man began feeling feverish. His body temperature rose quickly and he was taken for emergency treatment to Jiangsu Provincial People's Hospital. In the end, he could not be saved.

The odd thing is that although four people ate chicken (at the temple), only the two men fell ill and the two women are well. Reports say that the girlfriend ate a lot of chicken but is fine. Sources say that the 24-year-old's mother also has no similar symptoms but has been isolated for observation.

A comment on the Jiangsu cases from ProMED:

• It has been clearly proven that the H5N1 avian influenza virus infects humans through the respiratory pathway, not the oral pathway. Therefore, the Chinese authorities should try to find other possible sources of infection (other than in the mud).

• Our past experience with the very first human cases (and family cluster) in Indonesia, as well as the famous Karo/Kabanjahe cluster is that genetic susceptibility seems to play a very important role. In the first cluster, the father and his two daughters died, but his wife and son have shown no clinical symptom at all. In the Karo cluster, only blood-related family members were affected, while other people attending the same party were not. It is possible that in this Jiangsu case, the man shared genetic susceptibility with his father, and not with his mother and certainly not with his girlfriend.

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Hong Kong: Grey Heron infected with H5N1 avian influenza
Mai Po Nature Reserve will close 21 days after a Grey Heron found in Lok Ma Chau tested positive for H5N1 avian influenza, the Agriculture, Fisheries and Conservation Department said.

The department will monitor the situation and review the closure period. The bird was found sick and was collected 5 Dec 2007 at the wetland compensation area of the MTR Lok Ma Chau Spurline. The bird was kept in a cage and died the next day. There are no chicken farms within three km of where the bird was found. The department will remind poultry farmers, bird shop owners, license holders of pet poultry and racing pigeons to strengthen precautionary and biosecurity measures. It will also conduct frequent inspections of poultry farms and wholesale markets, and will continue wild bird monitoring and surveillance.
(ProMED 12.13.07)

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Indonesia (Jakarta): 47-year-old man from Tangerang treated for H5N1 avian influenza
An Indonesian man from an area west of the capital has tested positive for bird flu and is being treated at a hospital in Jakarta, a health ministry official said 12 Dec 2007.

Joko Suyono, an official at the health ministry's bird flu center, said the 47-year-old man from Tangerang kept ducks at his home and had recently traveled to the cities of Medan in Sumatra and Pandeglang in West Java.

"Two tests have confirmed that he suffered from H5N1 and the agriculture ministry has taken samples from the ducks and is still investigating where he may have contracted the virus," Suyono said.

Contact with sick fowl is the most common way of contracting bird flu, which is endemic in bird populations in most parts of Indonesia. Mukhtar Ikhsan, an official at Jakarta's Persahabatan hospital, said the man was being treated in an emergency unit and was on a respirator.
(ProMED 12.12.07)

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Indonesia (Jakarta): Woman from Tangerang dies from H5N1 avian influenza
A 28-year-old woman from the outskirts of the Indonesian capital has been confirmed as dying of bird flu the health ministry said 11 Dec 2007.

The two laboratory tests on the woman, who died 10 Dec 2007 at a hospital in Jakarta, showed that she was infected with the highly pathogenic virus. Two positive tests results on blood and tissue samples from a victim are needed before Indonesian authorities confirm a bird flu infection.

Muhammad Nadhirin, an official at the center, said that a team of experts had been dispatched to the victim's neighborhood. The team said that "the source of infection could be from poultry 100 meters away from the victim's house, but we're waiting for test results on whether the poultry is infected with the virus," Nadhirin said.

He said the victim, who had sold ornamental plants, bought plant fertilizer from the neighbor which may have been contaminated by the feces of infected birds. No birds, however, had died in the area in the past six months and the poultry appeared healthy, he added. The victim lived in the satellite city of Tangerang, just west of Jakarta, where three other bird flu deaths have been reported since October 2007.
(ProMED 12.12.07)

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Pakistan (Peshawar): H5N1 avian influenza claims two lives in Mansera
For the first time in the history of Pakistan, bird flu influenza has been confirmed among human beings after two brothers died at a local hospital in Peshawar.

According to a spokesman of the Health Ministry, two brothers working in a poultry farm in Mansera suffered from flu that later turned out to be influenza H5N1. They were admitted to a local hospital in Peshawar where on 10 Dec 2007 they died. After the blood samples of both the brothers were sent for formal testing in a laboratory, it was found that both brothers died due to bird flu virus H5N1. I

The death is the first human case due to bird flu in Pakistan. The spokesman for the Health Ministry confirmed the death due to bird flu adding that both brothers were working in a poultry farm in Mansera and had direct links with the chickens that resulted in the transmission of the virus H5N1.

This is the first report of human cases of H5N1 avian influenza in the Indian Sub-continent. Confirmation of the diagnosis by an independent laboratory is pending. No information is provided in this report on the presence of disease in poultry or of the occurrence of non-fatal cases of human avian influenza.
(ProMED 12.13.07)

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Viet Nam (Bac Giang): H5N1 avian influenza hits poultry farm
Bird flu has recurred in Viet Nam's northern Bac Giang province, raising the total number of localities currently affected by the disease to two. Bird flu virus strain H5N1 has killed over 1,000 ducks in the two districts of Viet Yen and Yen Dung. Viet Nam is focusing on intensifying disease surveillance, monitoring of poultry raising, transport and trade, and vaccination among fowls nationwide.
(ProMED 12.13.07)

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The desk officer in charge of animal health in the Yobe State office, Dr. Yusuf Iliyasu, who led the team of health officers to kick start the project at the Damaturu poultry market, said the initiative was to reduce risk of viral, bacteria and fungal infections "due to massive movement of poultry for celebrations of Sallah, Christmas and New Year’s expected to commence soon."

He said the avian influenza office had received large stocks of medicines that would be used to disinfect markets, stores, cages, slaughter slabs and vehicles that transport poultry from within and outside Yobe State.

Dr. Iliyasu, who described the fight against bird diseases as "an open project for everybody," said his office had trained poultry dealers in Damaturu and other locations on how to disinfect their businesses. He added that efforts are underway to construct a modern poultry "dressing center," also known as abattoir, so as to "discourage consumers from carrying live poultry to their houses to slaughter by themselves."
(ProMED 12.10.07)

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China: Unsafe chemicals in canned meat, officials vow to tighten controls
Exports from one of China's best-known food makers were stopped 7 Dec 2007 after Hong Kong authorities said they found unsafe chemicals in canned luncheon meat.

Shanghai-based Maling Food Co. issued a statement saying it had sent top executives to Hong Kong to assist with an investigation into allegations that a shipment of its meat was contaminated with the antibiotic nitrofurans, which is thought to cause cancer.

The investigation comes amid a slew of findings of potentially unsafe foods and other products. Chinese officials have vowed to tighten controls on food processors, slaughterhouses and other suppliers to help improve safety. China closed more than 6,000 slaughterhouses and created a database of 23,052 slaughterhouses across the country as part of its campaign to improve food safety. Various scandals both at home and abroad over products tainted with chemicals and other toxins have prompted renewed vigilance over widespread violations of safety standards, such as adding water to dead pigs to raise their weight.

Maling is one of China's best-known food companies, with shares in its Shanghai Maling Aquarius Co. traded on the Shanghai Stock Exchange. The company issued a statement earlier this week saying it did not plan to recall lunch meat sold in the Chinese mainland because it was produced separately. But a report said the product had been pulled from local supermarket shelves. That report quoted a Maling safety official saying the pork might have been contaminated before it reached the factory. The export suspension applies to all of Maling's canned food products, which include meat, seafood, fruits and vegetables.
(ProMED 12.8.07)

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China: Brucellosis continues to spread
The Ministry of Health said 4 Dec 2007 that human brucellosis continues to increase in China and case numbers in Heilongjiang are particularly high. The Ministry of Health has asked all locales to strengthen prevention work.

Statistics from the Ministry of Health show that China's prevention and control of human brucellosis is in serious circumstances, and occurrence in cow and sheep producing regions is a grave concern. A trend has emerged in which the disease is spreading from herding and semi-herding regions to farming regions and even urban areas. Other than Chongqing, Guizhou and Hainan, all provinces and centrally administered municipalities have reported human brucellosis.

The top 10 provinces and autonomous regions by number of cases are Inner Mongolia, Heilongjiang, Shanxi, Hebei, Shaanxi, Jilin, Liaoning, Xinjiang, Henan, and Shandong, which together account for 98.15 percent of reported cases nationally. By the end of September 2007, there were a total of 18,116 brucellosis cases in 2007 nationally, an increase of 2.6 percent over 2006's 17,644 cases.

Brucellosis is considered to be a Category B bioterrorism agent which is, in nature, acquired as a zoonotic infection by humans. Its manifestations are protean, including undulant fever, with positive blood and/or bone marrow cultures, and it is a cause of localized disease in many organ systems including skeletal, urinary tract, central nervous system, liver, cardiac and lung.
(ProMED 12.7.07)

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Indonesia (Jakarta): Koja hospital overwhelmed by patients seeking diarrhea care
Overwhelmed by the number of diarrhea patients seeking care, Koja Hospital in North Jakarta has transferred patients to some nearby hospitals.

The city-run hospital had received as many as 350 diarrhea patients since 27 Nov 2007. Most of them came from Lagoa and Rawa Badak subdistricts. As of 29 Nov 2007, nine patients had died.

"All of them were children under one year old," Koja vice director Caroline K said. The hospital on 29 Nov 2007 treated 76 patients, 67 children, and nine adults. As of last week it had transferred some 100 patients to other hospitals.

Atmajaya Hospital in Pluit treated 54 children with diarrhea on 29 Nov 2007. It has been receiving cases from Koja since 27 Nov 2007. "There are 14 patients who have recovered and none of them died," said Sri, spokeswoman at Atmajaya. Tanjung Priok Port Hospital, which began receiving patients from Koja on 27 Nov 2007, had 24 diarrhea patients, mostly children.

"All of them were treated in the emergency room," said Norma, a nurse. As of 2 Dec 2007, the Sukapura Jakarta Islamic Hospital in Cilincing had treated about 70 patients with the ailment, which is believed to have caused the death of a nine-month-old baby last week. Most of the patients come from Cilincing, Koja and Rawa Badak areas.
(ProMED 12.4.07)

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Indonesia: Chikungunya hits four areas

1. The illness chikungunya has become an epidemic in Padang City. The illness was found in 77 cases in three outbreak areas. As prevention efforts, the Health Service did fogging (fumigation) and provided medical treatment to the sufferers.
2. Dozens of residents in the Krasak Village, Kecamatan Brebes, Kabupaten Brebes, were attacked by chikungunya virus. They experienced high fever and painful joints. Moreover, some residents could not walk. This illness has been spreading very quickly. At this time, more than 20 residents have been attacked by the illness.
3. Chikungunya illness in Pekalongan City is now regarded as an extraordinary incident. More than 100 residents in five districts have been attacked by the illness.
4. The attack of chikungunya in the Kepanjen Subdistrict territory, Kebupaten Malang, continued to increase. Moreover, since 1 Dec 2007, the Kepanjen Community Health Centre was appointed as an emergency unit.

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Papua New Guinea (Daru): November typhoid cases more than double
There has been an increase in the number of typhoid cases November 2007 in Daru, Western province. A total of 59 cases were reported, more than double the usual number. Dr John Konga, the CEO of Daru General Hospital, said normally, the number of cases reported would be between 20 and 25. He said the lack of clean water supply and poor sanitation led to the increase.
(ProMED 12.3.07)

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Singapore: Salmonellosis found in Prima Deli chocolate cakes, 143 cases detected
The Ministry of Health (MOH) and the Agri-Food and Veterinary Authority (AVA) reported that chocolate cakes from the bakery chain Prima Deli are likely to contain the bacteria Salmonella [enterica serotype] Enteritidis, which has caused some people to get food poisoning.

So far, 106 people have reported getting food poisoning after eating the cakes; six had to be hospitalized, but have since been discharged. They tested positive for S. Enteritidis. The effects are felt usually six to 72 hours after eating contaminated food.

The MOH was first notified of a food poisoning incident on 23 Nov 2007. As more cases of food poisoning were reported, investigations showed that the common food item in the various incidents were Prima Deli chocolate cakes bought as early as 19 Nov 2007. Preliminary results suggest Salmonella is the likely culprit.

Prima Food has been told to stop the production of all chocolate cakes and to recall all these cakes from distribution and sale. Meanwhile, food handlers are being screened and investigations are being conducted to determine the source of the contamination. In the latest update, the MOH and AVA said that the number of cases has jumped to 143, of which 11 had to be hospitalized; all have been discharged, except one. Four more food handlers at the Prima Deli factory have also tested positive for the bacteria.
(ProMED 12.3.07, 12.6.07)

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Dr. Karen Grimsrud, acting chief medical officer of health, said on 11 Dec 2007 that about 62,800 people between the ages of 17 and 26 have been vaccinated across the province since the program began in November 2007. Only two to five serious reactions are expected in one million vaccinations, said Grimsrud.

"Obviously, our level of concern was great, and this is above what we would expect to be a normal rate of anaphylaxis in MMR (measles-mumps-rubella)," she said after the decision to suspend the program was made in conjunction with Health Canada.

Anaphylaxis is a serious reaction that can cause wheezing, swelling of the throat and collapse. All five people, who all had a history of allergic reactions, were treated immediately and have fully recovered.

Grimsrud stressed that most of these reactions would happen immediately and at most 24 hours after the vaccine, so the tens of thousands of people who have recently been vaccinated are safe. Millions of doses of the vaccine have been administered in Canada since 1988, and there have been only 21 reports of anaphylaxis following immunization.

Alberta officials have been in contact with federal health officials since the first three cases were reported on 26 Nov 2007. When the fifth case came to light on 10 Dec 2007, they decided to act. All five cases came from one lot of vaccine, but two other lots were also produced from the same bulk products. Alberta had purchased about 200,000 of the 250,000 doses from the three lots made by MerckFrosst Canada, and it was decided to suspend the use of those vaccines, severely limiting the supply in the province. They have warned other provinces that may have bought the other 50,000 not to use those lots.

The province is still conducting vaccinations for one-year-old children from unaffected lots, said Grimsrud. But all vaccinations for young adults and children in kindergarten have been suspended in order to conserve the doses. Other provinces have also been contacted to ask for extra doses to tide the province over until health officials can find a new supplier, said Grimsrud. The province still hopes to re-launch vaccinations for young adults in the 2008, but will only be able to do that when a safe supply has been found.
(ProMED 12.13.07)

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Canada (Alberta): Mumps outbreak continues
Public health officials are still trying to contain an outbreak of mumps, after almost 100 cases of the virus were confirmed in southern Alberta.

In the Chinook Health Region, which covers the Lethbridge area, most of the 38 confirmed and 21 suspected cases are connected to the University of Lethbridge and Lethbridge College. In the Calgary area, 57 cases have been reported between January and October 2007; 43 of those cases were identified in October 2007 alone. Six of the recent cases were players on the University of Calgary's Dino's hockey team. Health officials are now warning all hockey players in the city not to share water bottles or mouth guards.

The province is offering free mumps immunizations in two phases: first to post-secondary students, then to everyone in the high-risk population between the ages of 17 and 26. People in this age group received only one dose of the mumps vaccine when they were children, which is now thought to have worn off. Those born before 1970 are assumed to have been exposed to the mumps virus at some point in their life and are therefore immune. Children younger than 17 have been vaccinated twice.
(ProMED 12.2.07)

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USA (Nevada): Mumps make comeback in southern Nevada
There have been six cases of mumps reported in Clark County over the past several weeks.

This is drawing a concern from the Southern Nevada Health District. The health department says these recent cases prove the virus is in circulation locally. The health district says in terms of mumps, six cases are more than they would want to see in the county. The department is asking people to get vaccinated. And even if they have been vaccinated, there is still a small chance of getting the virus.
(ProMED 12.13.07)

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USA: Government officials announce food safety pact with China
Under a food safety agreement announced by US officials, the Chinese government pledges to register exporters of food to the United States, inspect shipments before they leave China, and set up a system to trace food products through the production system.

The agreement announced by the US Department of Health and Human Services (HHS) also provides for increased information sharing between the two countries and better access for US officials to inspect food processing sites in China, HHS officials said.

The pact was triggered by a series of tainted-import incidents in recent months, including chemically contaminated pet food and seafood containing unauthorized drugs. HHS simultaneously announced an agreement with China to enhance the safety of Chinese drugs and medical devices exported to the United States.

Asserting that the accords will make "scores" of imported household items safer, HHS Secretary Mike Leavitt said, "The agreements satisfy our firm principle that any country that desires to produce foods for American consumers must do so in accordance with American standards of quality and safety. To help accomplish this, the two documents apply a three-pronged strategy of registration, certification and verification."
(CIDRAP 12.11.07)

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USA (Arizona): 14 people struck with powerful form of Salmonella
At least 14 people in Arizona have been struck with a particularly powerful strain of Salmonella with about half them needing hospital care, state health officials said.

Workers inside the state health lab have been tracking the outbreak since late October 2007. They are growing samples of the Salmonella bacteria taken from those people who have been ill from the germ to see if they have the same genetic fingerprint as the Salmonella that has made people sick in California, Nevada and Idaho, said Ken Komatsu, Arizona Department of Health Services epidemiologist.

"This particular strain has a fairly high rate of hospitalization," Komatsu said. "Half of our cases have been hospitalized."

The latest outbreak is showing another unusual characteristic. Komatsu said the ability of the strain to resist antibiotics may partly explain why so many people who are getting it need hospital care. It is also unusual because cases are more likely to occur in summer than late fall or winter. Experts said they think the outbreak started when many people bought and ate some kind of food product that was sold by a chain store. The product involved has not yet been identified.
(ProMED 12.13.07)

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USA (New York): More hepatitis cases follow Long Island needle scare
Authorities say they have found more hepatitis infections among patients of a doctor accused of spreading the disease through slipshod injection techniques. But it may never be clear whether the newly diagnosed cases are linked to the doctor's practices.

The Nassau County Health Department says recent tests have found six hepatitis B cases and six hepatitis C cases among Dr. Harvey Finkelstein's patients. State Health Department spokeswoman Claudia Hutton says that because the virus can mutate in people's bodies, it's too late for genetic tests to establish whether the infections stemmed from Finkelstein's needle technique.

Health officials have said an earlier investigation showed the Long Island anesthesiologist infected at least one person with hepatitis by plunging syringes more than once into vials of medicine, contaminating the drugs. Finkelstein has said he has stopped doing so.

The 12 new cases of hepatitis described in this report are a considerable increase over the five cases identified in June 2007, although none can be unequivocally related to the original incident.
(ProMED 12.7.07)

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USA and Canada: Metromint-flavored water may contain Bacillus cereus
Dr. Mark Horton, director of the California Department of Public Health (CDPH), on 5 Dec 2007 warned consumers not to drink Metromint-brand flavored water because it may be contaminated with a bacterium called Bacillus cereus, a micro-organism that may cause vomiting or diarrhea.

Soma Beverage Co., LLC., of San Francisco is voluntarily recalling all bottles of Metromint-brand flavored water (peppermint, spearmint, orange mint and lemon mint) with a "Best Before" date prior to 21 Dec 2008 and produced at its California facility because they may be contaminated.

No confirmed illnesses in California associated with Metromint have been reported. An illness complaint in Illinois is possibly linked to consumption of this product. The Canadian Food Inspection Agency (CFIA) is also urging consumers to steer clear of two types of Metromint water. The CFIA says two of those flavors, spearmint and peppermint, were distributed across Canada.

Illness caused by Bacillus cereus may be either a vomiting or a diarrheal type. The vomiting type is characterized by nausea and vomiting within 30 minutes to six hours after consumption of contaminated foods. Duration of symptoms is generally less than 24 hours. The diarrheal type usually includes onset of abdominal cramps and watery diarrhea six to 15 hours after consumption of contaminated food. Symptoms may last for 24 to 48 hours.
(ProMED 12.7.07)

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USA (Guam): Six-year-old child diagnosed with cholera
The Department of Public Health and Social Services reported a cholera infection in a six-year-old male child. The cholera infection has been confirmed by a reference laboratory although biotype and toxin production studies are not complete, according to epidemiologist Robert L. Haddock of the DPHSS (Department of Public Health and Social Services) Office of Epidemiology and Research. The infected child and his family had traveled to Saipan for a family event the weekend before becoming ill. Neither Guam nor the CNMI (Commonwealth of the Northern Mariana Islands) has observed an increase in diarrheal illnesses or detected additional possible cholera cases.
(ProMED 12.7.07)

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USA (Kansas): Raw milk is the culprit in campylobacteriosis outbreak
Dozens of people in Kansas became ill from raw milk. At least 87 people became ill in two separate outbreaks of campylobacteriosis.

Kansas allows raw milk to be sold within the state, but health officials warn people of the health risks that come with consuming raw milk. Campylobacteriosis is an intestinal infection caused by the bacterium Campylobacter. Infection often causes diarrhea, fever, abdominal pain, nausea, headache and muscle pain.

In the first outbreak in southwest Kansas, 68 people became ill after eating cheese made from raw (unpasteurized) milk donated by a local dairy for a community celebration; 19 people were ill enough to seek medical attention, and two people were hospitalized. Of these persons four tested positive for Campylobacter jejuni; no other food items served at the event were associated with illness. The second outbreak is linked to a dairy in south-central Kansas that sells raw milk directly to consumers. As of 30 Nov 2007, 19 cases of campylobacteriosis had been reported. Each person reported drinking raw milk purchased from the dairy.

Although most people with campylobacteriosis recover within seven to 10 days, rare complications such as reactive arthritis, hemolytic uremic syndrome and Guillian-Barre syndrome can develop. Pasteurization is the only effective method for eliminating disease-causing bacteria in raw milk and milk products.
(ProMED 12.5.07)

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USA (Minnesota): Undiagnosed neurological illness in pork processing plant workers
State health officials are investigating what they describe as a cluster of unusual neurological illnesses at a southern Minnesota pork processing facility. In the past year, 11 workers at Quality Pork Processors in Austin have developed inflammatory diseases characterized by muscle weakness and severe fatigue; two workers were hospitalized.

Department investigators have been pouring over the cases. They have determined that the workers experienced an inflammatory response to some kind of trigger. But they have not yet identified the trigger. It could be an infectious agent within the plant, or even a chemical exposure.

Officials do not know what is causing the illnesses. But they say there is no evidence that the general public or the food supply is at risk. Investigators are still trying to interview some of the sick workers, but they say at least five of the cases appear to be consistent with an uncommon disease called chronic inflammatory demyelinating polyneuropathy, or CIDP, an autoimmune disease, meaning that the immune system mistakenly attacks peripheral nerves. Commissioner Sanne Magnan says generally the workers' symptoms include a feeling of numbness and heaviness in the lower extremities, along with a strong sense of fatigue. All 11 employees worked in the same room at the plant. It's an area where meat and other tissues are extracted from the heads of slaughtered hogs.

Kelly Wadding, president and CEO of Quality Pork Processors, said the company has taken several precautions to make sure that other workers are not exposed to whatever is causing the illnesses. Quality Pork Processors is Austin's second-largest employer, behind Hormel Foods, with some 1,300 employees. It slaughters and processes up to 16,000 hogs a day for Hormel and several other companies. Officials say there is no evidence that those products are affected in any way by the illnesses at the Austin plant.
(ProMED 12.4.07)

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USA (New Mexico): Third hantavirus case this year
The New Mexico Department of Health announced that a 34-year-old man from McKinley County was diagnosed with the state's third case of hantavirus pulmonary syndrome this year. The man was hospitalized and is now recovering at home.

"People are usually exposed to hantaviruses around their homes, especially when they clean out enclosed areas that have lots of mouse droppings," said Dr. Paul Ettestad, the Department of Health’s state public health veterinarian. Hantavirus causes a deadly disease transmitted by infected rodents through urine, droppings or saliva. People can contract the disease when they breathe in aerosolized virus. The deer mouse is the main reservoir for hantavirus in New Mexico.

Early symptoms of hantavirus infection are fever and muscle aches, possibly with chills, headache, nausea, vomiting, diarrhea, abdominal pain and cough. Symptoms develop one to five weeks after rodent exposure. Although there is no specific treatment for hantavirus infection, chances for recovery are better if medical attention is sought early.

To protect against hantavirus, avoid contact with mice and other rodents. Other important steps are:

• Air out closed up buildings before entering.
• Seal up homes and cabins so mice can't enter.
• Trap mice until they are all gone.
• Clean up nests and droppings using a disinfectant.
• Put hay, wood and compost piles as far as possible from your home.
• Get rid of trash and junk piles.
• Don't leave your pet food and water where mice can get to it.

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Canada
Update on findings from the avian influenza H7N3 poultry outbreak
The specific origin of the virus that caused the H7N3 infection is undetermined. There were sufficient opportunities for a virus to enter this operation from a variety of sources due to insufficient biosecurity measures being in place. The paper awaiting publication concerning the homology of the H7N3 in Saskatchewan with other H7 subtypes that have been previously isolated will allow speculation about the most probable source of the virus. No evidence of another H7 subtype in the domestic poultry population in Saskatchewan was found in the surveillance that was conducted following the discovery. There was no epidemiological linkage to another domestic flock outside of Saskatchewan as this was a closed flock prior to the discovery. Although the virus was an H7N3 subtype of influenza A, it did not have a close phylogenetic relationship to the HPNAI (highly pathogenic notifiable avian influenza) H7N3 subtype found in British Columbia in 2004.
(ProMED 12.7.07)

USA
Influenza Activity — September 30–December 1, 2007I
During September 30–December 1, 2007, influenza activity remained low in the United States. This report summarizes US influenza activity since September 30, the start of the 2007–08 influenza season.

During September 30–December 1, 2007, World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System collaborating laboratories in the United States tested 24,897 respiratory specimens for influenza viruses, and 559 (2.2%) were positive. Of these, 515 (92%) were influenza A viruses, and 44 (8%) were influenza B viruses. One hundred thirty-five (26%) of the 515 influenza A viruses were subtyped; 112 (83%) of these were influenza A (H1) viruses, and 23 (17%) were influenza A (H3) viruses. Influenza virus-positive tests have been reported from the District of Columbia (DC) and 32 states in all nine surveillance regions since September 30.

To date, CDC has antigenically characterized 27 influenza viruses; 19 (70%) of these were influenza A (H1) isolates, five (19%) were influenza A (H3) isolates, and three (11%) were influenza B isolates. Other isolates received since September 30 are being grown and characterized. All of the 19 influenza A (H1) viruses were A/Solomon Islands/3/2006-like, a recent antigenic variant of A/New Caledonia/20/99 and the strain recommended by WHO as the influenza A (H1) component for both the 2007-08 Northern Hemisphere influenza vaccine and the 2008 Southern Hemisphere influenza vaccine. Two influenza A (H3) isolates were A/Wisconsin/67/2005-like, the strain included in the 2007-08 Northern Hemisphere vaccine formulation. Three influenza A (H3) isolates were antigenically similar to A/Brisbane/10/2007, the strain recommended as the 2008 A (H3) component of influenza vaccines for the Southern Hemisphere.

One case of novel influenza A infection was reported from Michigan during the week ending November 3, 2007; a child aged 18 months was infected with swine influenza A (H1N2) virus in August 2007 after attending an agricultural event where swine were exhibited. The child walked through a barn containing pigs but was reported to have had no direct contact with the animals. The child recovered from the illness; no contacts of the child were reported to be ill.

For the week ending December 1, 2007, pneumonia and influenza (P and I) was listed as an underlying or contributing cause of death for 6.1% of all deaths reported through the 122 Cities Mortality Reporting System. This percentage is below the epidemic threshold of 6.4% for that period. During the 2007-08 influenza season, the weekly percentage of deaths attributed to P and I has ranged from 5.7% to 6.1%. The percentage of deaths attributed to P and I exceeded the epidemic threshold for three consecutive weeks during September 30-October 20 but has remained below the epidemic threshold since the week ending October 27.

No influenza-associated pediatric hospitalizations have been reported from NVSN this season. During September 30–November 24, 2007, the preliminary laboratory-confirmed influenza-associated hospitalization rate reported by EIP for children was within the expected range for this time of year. For children aged 0–17 years, the influenza-associated hospitalization rate was 0.006 per 10,000. For children aged 0–4 years and 5–17 years, the rates were 0.01 and 0.003 per 10,000, respectively.

One influenza-associated pediatric death occurring during the 2007–08 season has been reported to CDC through the National Notifiable Diseases Surveillance System. The death occurred in Texas during the week ending November 10, 2007, and was reported to CDC during the week ending December 1. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5649a3.htm
(MMWR December 14, 2007 / 56(49);1287-1291)

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CHOLERA
Viet Nam
Concern over the epidemic of serious gastric illness and diarrhea in the provinces surrounding Hanoi has abated. The National Institute of Infectious and Tropical Diseases head, Nguyen Tran Hien, said all samples of water and food in Hanoi and Ha Tay Province tested negative. The Department of Preventative Healthcare head, Nguyen Huy Nga, said nearly 2,000 cases of serious diarrhea were reported over 40 days. 293 cases were cholera.
(ProMED 12.7.07)

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DENGUE
Indonesia

1. Jakarta: According to the Department of Health data entered up to 5 Dec 2007, 134,847 cases that were reported, 30,469 cases were from Jakarta. More than 30 percent of the cases of dengue fever came from Jakarta, the Head of Health Service Special Capital District, Dr. Wibowo Sukijat, said 6 Dec 2007. This year, of the 30,469 dengue fever sufferers who were treated, 81 died.
2. Central Java: The spread of dengue fever in Jombang is increasingly worrisome. As of 8 Dec 2007, 537 dengue fever sufferers were given intensive treatment in the Community Health Centre and the Hospital in Jombang. Moreover, emergency status was given due to the increase in dengue fever cases. This case figure is more than twice that compared with 2006. Moreover, the level of spread of the illness has not stopped throughout 2007. Usually in the period from May to August no cases occur.
3. East Java: The Health Service indicated that the Bondowoso Regency responded to the serious dengue fever epidemic in the Dadapan Village, Kecamatan Grujugan after dozens of villagers underwent the intensive treatment in the Daerah Hospital.
4. East Kalimantan: During the Period January-November 2007, as many as 89 East Kalimantan residents died from dengue fever. The number has increased compared to 2006, which totaled 80 people from January to December. This year, 4,276 people were infected by dengue fever; whereas in 2006, 2,838 people were infected by dengue fever.
5. South Sulaweisi: The number of dengue patients in RSU Wahidin Sudirohusodo continued to increase, on the basis of review of the number of patients from October to the end of November 2007. The number of dengue patients in October totaled 54, in November was 100 and in December to date (5 Dec 2007) there have been five cases.
6. North Sulaweisi: Dengue fever and dengue hemorrhagic fever is raging in North Sulawesi. Many patients (in general children) suffered from dengue in Manado City, Kabupaten Bolmong, Sangihe and in a part of Minahasa. At this time more than one hospital was filled with dengue patients.
   (ProMED 12.11.07)

   Philippines
   Dengue cases in the Antique province surged to 463 as of 26 Nov 2007 said Mildred Quilino, Information Officer, Provincial Health Office. The municipality of Tobias Fornier has the highest number of cases with 123, San Jose with 119, Hamtic with 51, Anini-y, 47 and Bugasong, 14 cases. Despite surging cases, Quilino said that most cases are being managed and treated in the local hospitals. Only few and extreme cases are brought to Iloilo for treatment.

   Dengue has also afflicted 45 residents in Mountain Province, and the number is rising, health officials said. Nenita Lizardo, head of the provincial health office, said health personnel earlier recorded 30 cases in September 2007, but this went up to 45 in October 2007 with 55 percent of these cases from Bontoc. Lizardo said that there is a need to advocate the 4-S program against dengue. The 4-S means' search and destroy' eliminating all breeding sites for the mosquito, proper waste disposal, covering of water containers and cleaning of roof gutters and drains.
   (ProMED 12.3.07)

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   4. Articles

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   Earth monitoring: Vigilance is not enough
   Boyce W. Nature 450, 791-792 (6 December 2007) | doi:10.1038/ http://www.nature.com/nature/journal/v450/n7171/full/450791a.html

   “Another influenza pandemic seems inevitable, and without a generic vaccine, our best chance of being prepared is to identify, track and stop the spread of viruses such as highly pathogenic H5N1. Two years ago, some believed that H5N1 viruses were poised to spread around the globe on the wings of migrating wild birds. A massive effort was mounted to track their movement but, as of September 2007, very few positive birds have been found in tests of over 300,000 healthy wild birds from more than 40 countries. Several hundred infected birds (almost all of them dead) were found in endemic and outlying areas, but dead birds do not tell us about the birds that don't get sick when infected — those that could spread H5N1 over longer distances. . .”

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   Phylogenetic analyses of highly pathogenic avian influenza virus isolates from Germany in 2006 and 2007 suggest at least three separate introductions of H5N1 virus
   E. Staricka, M. Beera. Veterinary Microbiology. doi:10.1016/j.vetmic.2007.10.012

   Abstract: In spring 2006, highly pathogenic avian influenza virus (HPAIV) of subtype H5N1 was detected in Germany in 343 dead wild birds, as well as in a black swan (Cygnus atratus) kept in a zoo, three stray cats, one stone marten (Martes foina), and in a single turkey farm. In June–July, 2007 the virus re-occurred in 96 wild birds at six geographically separate locations in the southeast of Germany. In addition, a backyard mixed duck and goose holding was affected. Real-time RT-PCR and nucleotide sequencing confirmed that these H5-viruses belonged to the Qinghai lineage of HPAIV H5N1 (clade 2.2). For a more detailed analysis, the hemagglutinin and neuraminidase genes of 27 selected German H5N1 viruses isolated 2006 or 2007 and originating from different regions and animal species were sequenced and analyzed phylogenetically. As a result, three closely related but distinguishable H5N1 subclades could be defined: In 2006 a ‘Northern type’ (subclade 2.2.2), representing virus isolates from the German federal states Mecklenburg-Western Pomerania, Schleswig-Holstein, Brandenburg, and Lower Saxony, and a ‘Southern type’ (subclade 2.2.1) from Baden-Württemberg and Bavaria were detected. Interestingly, representatives of both types were present in central Germany and caused the outbreak in turkeys (subclade 2.2.2) and in a case in a tufted duck (Aythya fuligula) (subclade 2.2.1) in Saxony. Furthermore, one isolate from the south of Germany was identified as 2.2.2 and vice versa a 2.2.1-like isolate was found in northern Germany. H5N1 viruses isolated in 2007 belonged to a third type (subclade 2.2.3) which was not detected in 2006. Our data suggest the introduction of three distinct H5N1 variants into the wild bird population of Germany. The source of these viruses and the exact time of introduction remain obscure. Based on the identification of closely related H5N1 viruses from southern and central Russia, a recent introduction via wild birds on winter escape from these regions, early in 2006 constitutes the most likely scenario for the 2006 outbreaks. The viruses detected in 2007 most likely represent another new incursion from an as yet unknown source.

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   A general model of prion strains and their pathogenicity
   Collinge J. Science. 2007; 318(5852) 930 – 936 DOI: 10.1126/science.1138718 http://www.sciencemag.org/cgi/content/abstract/318/5852/930

   Abstract: Prions are lethal mammalian pathogens composed of aggregated conformational isomers of a host-encoded glycoprotein and which appear to lack nucleic acids. Their unique biology, allied with the public-health risks posed by prion zoonoses such as bovine spongiform encephalopathy, has focused much attention on the molecular basis of prion propagation and the "species barrier" that controls cross-species transmission. Both are intimately linked to understanding how multiple prion "strains" are encoded by a protein-only agent. The underlying mechanisms are clearly of much wider importance, and analogous protein-based inheritance mechanisms are recognized in yeast and fungi. Recent advances suggest that prions themselves are not directly neurotoxic, but rather their propagation involves production of toxic species, which may be uncoupled from infectivity.

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   Chikungunya in northeastern Italy: an outbreak summary
   Angelini R. Eurosurveillance weekly release, 2007 12(11) http://www.eurosurveillance.org/ew/2007/071122.asp#2

   Laboratory results:
   The first outbreak of autochthonously transmitted chikungunya virus (CHIKV) in Europe, which recently occurred in the province of Ravenna in northeastern Italy, has been completely controlled: the last case's onset occurred on 28 Sep 2007 in the town of Rimini, and in October no cases were confirmed. Of the 334 suspected or probable CHIKV cases involved in the outbreak, samples were examined of 281 and 204 were laboratory-confirmed by PCR [polymerase chain reaction], hemagglutination-inhibition or both. Reasonably, the number of laboratory-confirmed cases most likely constitutes an underestimate of the extent of the outbreak, since blood or serum samples were not available for all of the individuals who fulfilled the clinical and/or epidemiological criteria of the case-definition.

   Geographical distribution of cases:
   Most cases were reported among persons living in or visiting the initially affected villages of Castiglione di Cervia and Castiglione di Ravenna. Also detected were four smaller clusters of local transmission in four towns in the same region (Cervia, Cesena, Ravenna and Rimini), which are located nine to 49 km (5.6-30 mi) from the initially affected villages. For at least three of the four clusters, population movement (persons who visited the area that was primarily affected or persons from the primarily affected area who visited one of the four towns) can be reasonably assumed to have been the main determinant of local transmission. However, if this was the case, the question arises as to why no previous outbreaks of CHIKV occurred in other Italian regions in 2005-2006 (after the epidemic in Reunion), when at least 30 infected travelers returned to locations infested by mosquito vector populations; the same question arises for several hundred cases reported among travelers returning from affected areas to a number of European countries in the same period. Possible explanations include: 1) high concentration of vectors in the affected towns; 2) highly viremic persons exposing themselves to aggressive Aedes albopictus populations as a consequence of the structures of houses and/or behavioral factors (spending time outdoors in houses' surroundings).

   Overall, the epidemic in Italy can be said to be the result of the combined effect of the globalization of vectors and humans, which occurred through a two-step process: 1) the introduction and adaptation of the vector Ae. albopictus to a new environment (a temperate climate); and 2) the introduction of CHIKV in a previously infection-free country, with totally susceptible subjects, as the result of population movement (traveling human hosts, acting as a sort of Trojan horse). However, the epidemic was limited in space and time, with a marked decay rate since the adoption of appropriate control measures (albeit they were taken at different times in different locations). In addition, there is probably a time-limited capacity of the vector to sustain infection transmission beyond the hot season in a country with a temperate climate.

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   Outbreak of Cutaneous Larva Migrans at a Children's Camp — Miami, Florida, 2006
   On July 19, 2006, the director of a children's aquatic sports day camp notified the Miami–Dade County Health Department (MDCHD) of three campers who had received a diagnosis of cutaneous larva migrans (CLM), or "creeping eruption," a skin condition typically caused by dog or cat hookworm larvae of the genus Ancylostoma. MDCHD conducted an investigation to determine the source and magnitude of the outbreak and prevent additional illness. This report summarizes the results of that investigation, which identified exposure to cat feces in a playground sandbox as the likely source of infection. Although CLM outbreaks are reported rarely to the Florida Department of Health, evidence indicates that CLM is a potential health hazard in Florida. This disease cluster highlights the importance of appropriate environmental hygiene practices and education in preventing CLM.
   http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5649a2.htm
   (MMWR December 14, 2007 / 56(49);1285-1287)

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   5. Notifications

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   Second International Conference on Health and Biodiversity, Ireland, February 2008
   Location: Galway, Ireland; Dates: 25-28 Feb 2008

   Conference sessions will explore how health aspects of the UN Millennium Development Goals are influenced by the status of global biodiversity, and will review the impacts and implications of the Millennium Ecosystem Assessment. The conference will also look at the outputs of other relevant programs and mechanisms, including the recent reports from the Intergovernmental Panel on Climate Change, and outputs of other related conferences and initiatives. The over-riding focus will be on experience sharing, with the aim of encouraging greater cross-sector and inter-disciplinary co-operation on issues at the interface of the health and ecological sciences.

   Parallel workshops at the conference will focus on three key areas:

   • Disaster prevention, relief, and recovery — harnessing ecosystem services for crisis prevention, recovery and redevelopment programs.
   • Emerging infectious diseases — integrating biodiversity conservation and ecosystem management into disease prevention and control programs.
   • Food resources, diet, and nutrition — meeting nutrition security and poverty challenges with biodiversity.
   For full details of the conference, please visit http://www.cohabnet.org/cohab2008 or contact the conference organizing committee at conference@cohabnet.org
   Information about the COHAB Initiative is available online at http://www.cohabnet.org
   (ProMED 12.4.07)

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   Second International Conference on Dengue/Dengue Hemorrhagic Fever, Thailand, October 2008
   Location: Phuket, Thailand; Dates: 15-17 Oct 2008

   The Ministry of Public Health, Thailand will organize the Second International Conference on Dengue Fever and Dengue Hemorrhagic fever next year. Under the theme of "Global Innovation for Combating Dengue Infection," the conference will serve as a forum for exchanging comprehensive information, practical experience, new skills and techniques, and for conceptualizing and integrating approaches to the prevention and control of the disease. Priorities for research needed to contain the spread of the virus and its vectors will be defined and agreed upon, all with the aim of reducing morbidity and mortality in endemic countries. Improved surveillance and better estimation of disease burden will be stressed, along with methods of improving public commitment to the control and eventual elimination of the disease, a major threat to public health around the world. More information is available at http://www.dengue2008phuket.com
   (ProMED 12.3.07)

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   2008 International Conference On Biocontainment Facilities
   Date:12 Dec 2007; Location: Washington, DC 21-22 Apr 2008

   What is on the agenda?

   • Latest lessons learned on biosafety and security
   • Facility operating plans
   • Design and construction details
   • Risk-based planning and management
   • Personnel training and material handling procedures – tracking, SOPs, etc.
   • Construction cost and contracting strategies
   • Commissioning and validation processes
   • New regulatory guidelines and certification requirements

   What types of facilities?

   • High containment for research
   • Animal research and diagnostics
   • Biocontainment Patient Care Units (BPCUs) – planning, design and operation
   • Vaccine development and production
   Full agenda details will be available in January 2008. If you have questions or would like a copy of the program, email BIO2008@tradelineinc.com or call (011) 925 254 1744. For registration information, see: http://www.TradelineInc.com/BIO2008
   (ProMED 12.12.07)

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   Occupational HIV Exposures
   In 1996, the US Public Health Service first recommended using antiretrovirals as postexposure prophylaxis (PEP) after occupational exposure to HIV. Since the updated HIV PEP recommendations in 2005, two important changes to antiretroviral use have occurred that affect the management of occupational exposures.

   First, Kaletra, a combination protease inhibitor, is no longer available in its original formulation: capsules containing 133 mg of lopinavir and 33 mg of ritonavir. Although the recommended daily prescribed amount of Kaletra ingredients is unchanged, the dosing regimen has changed as a result of the new Kaletra formulation. The previous dosing regimen for the capsule formulation was three capsules twice daily. Kaletra is now manufactured only in tablet form, with each tablet containing 200 mg of lopinavir and 50 mg of ritonavir. To achieve the same recommended daily prescribed amount of the tablet formulation, two tablets of 200 mg of lopinavir and 50 mg of ritonavir should be taken twice daily. Health-care providers should not prescribe three tablets twice a day of the new Kaletra formulation; that dose would be the equivalent of 1,200 mg of lopinavir and 300 mg of ritonavir daily, a higher dose than the recommended 800 mg of lopinavir and 200 mg of ritonavir daily.

   Second, on September 10, 2007, Pfizer, Inc. issued a letter warning health-care providers about the use of Viracept (nelfinavir), another protease inhibitor, because the Viracept manufactured in Europe contained high levels of ethyl methane mesylate (EMS). EMS is a byproduct of the manufacturing process and a known animal carcinogen, mutagen and teratogen. The level at which EMS might become carcinogenic or teratogenic in humans is not known. The warning in the letter applies to pregnant women and states that information about the ability of EMS to cross the placenta or to enter breast milk is currently unknown. A review of data from the Antiretroviral Pregnancy Registry, which collects data on approximately 6,000 HIV-infected pregnant women, indicated that, during January 1989–January 2007, no statistically significant difference was observed in the prevalence of birth defects among the infants of women who used Viracept compared with those whose mothers used other antiretroviral therapies. Nonetheless, the Food and Drug Administration (FDA) recommends that pregnant women limit their exposure to EMS during pregnancy. Until further notice, pregnant women who need to begin antiretroviral therapy or HIV PEP should not be offered regimens containing Viracept. As a precautionary measure, pregnant women currently receiving Viracept should be switched to an alternative antiretroviral therapy while Pfizer and FDA work to implement a long-term EMS specification for Viracept. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5649a4.htm
   (MMWR December 14, 2007 / 56(49);1291-1292)

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