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Vol. XI No. 3 ~EINet News Brief ~ 8 Feb 2008 ~ EINet News Briefs ~ Feb 08, 2008


*****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:

1. Influenza News
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Global: Oseltamivir resistance in seasonal influenza viruses
- Bulgaria (Shumen): H7 avian influenza virus found in wild duck
- Turkey: Outbreak of H5N1 avian influenza in northwestern village
- Bangladesh: H5N1 avian influenza spreads to 38 districts, hits Dhaka and Chittagong
- Hong Kong: Dead night heron tests positive for H5N1 avian influenza
- Indonesia: Live poultry markets, improper medical treatment blamed for high fatalities
- Pakistan (Sindh): Two outbreaks of H5N1 avian influenza in poultry
- UK (Dorset): Two more swans found positive for H5N1 avian influenza
- Indonesia: Three more cases of H5N1 avian influenza, two more deaths

2. Infectious Disease News
- Hong Kong: Officials confirm first imported case of chikungunya
- Japan: Scare over dumplings made in China
- Papua New Guinea: MDR tuberculosis causes concerns in PNG, Australia
- Philippines: Economy sees a steep rise in dengue infections
- Philippines: Typhoid infections are on the rise
- Singapore: Economy identifies its 11th case of chikungunya
- USA: FDA issues letter warning of ciguatera toxin in fish
- USA (California): Diners contract norovirus at Redwood City hotel
- USA (Minnesota): Suspected progressive inflammatory neuropathy in another pork plant worker
- USA (Hawaii): Salmonella infection from tainted fish
- USA (New Mexico): Officials identify state's first plague case of 2008
- USA: Consumer group claims Botox is deadly and should carry a stronger warning

3. Updates
- AVIAN PANDEMIC INFLUENZA

4. Articles
- U.S. flu outbreak plan criticized: It does not anticipate strain on hospitals
- Pandemic influenza preparedness and community resiliency
- Rescinding community mitigation strategies in an influenza pandemic
- Protective effect of maritime quarantine in South Pacific jurisdictions, 1918–1919
- Mutations in influenza A virus (H5N1) and possible limited spread, Turkey, 2006
- Evaluation of the safety and immunogenicity of a booster (third) dose of inactivated subvirion H5N1 influenza vaccine in humans
- Public health response to an avian influenza A (H5N1) poultry outbreak in Suffolk, United Kingdom, in November 2007
- Acute allergic-type reactions among patients undergoing hemodialysis—multiple states, 2007-2008

5. Notifications
- APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems
- Highlights from the Bangkok International Conference on Avian Influenza 2008: Integration from Knowledge to Control
- CDC Health Advisory: Influenza-associated Pediatric Mortality and Staphylococcus
- 4th International Symposium on Filoviruses


1. Influenza News

Global
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

2008
Indonesia / 9 (8)
Viet Nam / 1 (1)
Total / 10 (9)

2007
Cambodia / 1 (1)
China / 5 (3)
Egypt / 25 (9)
Indonesia / 42 (36)
Laos / 2 (2)
Myanmar / 1 (0)
Nigeria / 1 (1)
Pakistan / 1 (1)
Viet Nam 8 (5)
Total / 86 (58)

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: 359 (226).
(WHO 2.5.07 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 1.24.08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 2.7.08): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 1.30.07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: Oseltamivir resistance in seasonal influenza viruses
The main seasonal flu virus in the United States and Canada as well as parts of Europe shows higher resistance to the antiviral drug tamiflu [oseltamivir], raising questions about its potential effectiveness in a human bird flu pandemic.

The World Health Organization (WHO) reported the elevated resistance in North America on 1 Feb 2008, but said it was too early to know what the chances may be for increased tamiflu resistance in the H5N1 strain of avian influenza. It did not change its recommendation that tamiflu be used to treat human cases of bird flu. A number of governments have been stockpiling tamiflu, made by Switzerland's Roche Holding AG and Gilead Sciences Inc of the United States, for use as a first line of defense in case bird flu sparks a human influenza outbreak.

Health experts fear that the virus, which now mainly affects poultry, could mutate into a form that spreads easily among people and trigger a deadly pandemic. WHO said it was investigating the extent of resistance worldwide to tamiflu, known generically as oseltamivir, in some seasonal H1N1 flu viruses that have a mutation making them "highly resistant".

"The frequency of oseltamivir resistance in H1N1 viruses in the current influenza season is unexpected and the reason why a higher percentage of these viruses are resistant is currently unknown," WHO said. The US Centers for Disease Control and Prevention has reported a five per cent prevalence of resistance to tamiflu in samples of H1N1 virus tested. In Canada, eight out of 128 samples showed resistance, roughly six per cent, WHO spokeswoman Gregory Hartl said. "These preliminary data indicate that oseltamivir resistance in H1N1 viruses is geographically variable but not limited to Europe," the WHO said. A preliminary survey issued by the European Centre for Disease Control (ECDC) on the week of 28 Jan-2 Feb 2008 said that of 148 samples of influenza A virus isolated from 10 European countries during November and December 2007, 19 showed signs of resistance to tamiflu. Of 16 samples from Norway, 12 tested positive for resistance against tamiflu, according to the ECDC study. The new "elevated resistance to oseltamivir" appears limited to seasonal H1N1 viruses, and does not involve H3N2 or influenza B viruses which are also circulating, WHO said.

"This means that oseltamivir would most likely be ineffective for treating or preventing infections caused by these resistant H1N1 strains, although the drug will be effective against other influenza virus infections," it added.

A spokesman from the Centre for Health Protection (CHP) of the Department of Health, Hong Kong said the Public Health Laboratory Centre has been monitoring the local situation closely and recently detected four resistant viruses out of 45 isolates tested in January 2008. He said there had been no indication from overseas authorities so far that these oseltamivir-resistant viruses were associated with more severe illness. These viruses are sensitive to other antiviral drugs against influenza [the other anti-neuraminidase drug zanamivir (Relenza), and the adamantadines ]. CHP officials will continue to monitor H1N1 viruses for oseltamivir resistance.
(ProMED 2.2.08 & 2.3.08)

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Europe/Near East
Bulgaria (Shumen): H7 avian influenza virus found in wild duck
A case of bird flu of the H7 strain was registered in Bulgaria's northern town of Shumen, officials reported on 1 Feb 2008. The virus has been found in a dead wild duck in Kamchiya River valley, between the villages of Khan Krum and Milanovo. The authorities guaranteed they are to take immediate precautionary measures for stopping the virus' spread and called on the local people not to panic.

(Although this is not the H5N1 avian influenza virus infection, all highly pathogenic avian influenza viruses and all low pathogenic H5 or H7 avian influenza viruses must be reported to the World Organization for Animal Health (OIE). Clearly, the risk of transmission to humans from this mallard duck, which subsequently died by a gunshot wound, is not nearly as high as with H5N1 poultry flocks. However, H7 avian influenza viruses have caused human infections in various countries including the Netherlands, Canada and the UK. In fact, in the Netherlands, a previously healthy veterinarian died from an H7N7 infection obtained while working with infected poultry flocks.)
(ProMED 2.2.08 & 2.3.08)

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Turkey: Outbreak of H5N1 avian influenza in northwestern village
Turkish authorities said on 5 Feb 2008 bird flu was detected in poultry in a village in the northwest of the country. The outbreak was discovered in the village of Yenicam, Sakarya province, where dozens of chickens died, the governor's office said.

"The test results have come back positive," it said, adding that further tests were underway to determine whether the virus was the highly pathogenic H5N1 strain. A 10-km (six-mile) surveillance zone has been set up around the village, inside which vets have culled nearly 700 animals and carried out health checks on residents, the statement said. Health director Hasan Bektas said there were so far no symptoms of the disease among the local population. "All necessary measures have been taken, and there is no reason to worry," the statement from the governor's office said.

The Turkish agriculture ministry said it had also detected a bird flu outbreak in the city of Samsun on the Black Sea Coast, nearly 600 km (370 miles) east of Sakarya.
(ProMED 2.4.08 & 2.6.08)

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Asia
Bangladesh: H5N1 avian influenza spreads to 38 districts, hits Dhaka and Chittagong
The H5N1 avian influenza virus has spread to 38 out of Bangladesh's 64 districts and forced the culling of nearly 500,000 birds across the country. The latest outbreaks were reported in southwestern Gopalganj, northeastern Sylhet, southern Bagerhat district, and northern Mymensingh district. The bird flu has also spread to the Bangladesh capital Dhaka and to the port city Chittagong despite efforts by authorities to contain it, livestock officials said on 6 Feb 2008. Dozens of dead crows found over the past two days in Dhaka have tested positive for the H5N1 strain of bird flu. City authorities have ordered a ban on the sale of undressed chicken in Dhaka markets. Officials said the government was taking measures to contain the spread of the disease, but ignorance among millions of farmers across the impoverished country remained a stumbling block.
(ProMED 2.4.08 & 2.6.08)

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Hong Kong: Dead night heron tests positive for H5N1 avian influenza
A dead black-crowned night heron found earlier in southern Hong Kong has tested positive for the H5N1 bird flu virus, authorities in the neighboring region said on 1 Feb 2008.

The dead heron, collected at the Ocean Park, one of the major tourist attractions in Hong Kong, was "confirmed to be H5N1 positive after a series of laboratory tests," the Agriculture, Fisheries and Conservation Department said. The black-crowned night heron is a common resident and winter visitor, a spokesman for the Agriculture, Fisheries and Conservation Department said. Hong Kong had recently recorded several cases of dead birds testing positive for the H5N1 strain. Hong Kong has been monitoring bird movements and has many measures in place to contain the spread of the deadly virus.
(ProMED 2.4.08 & 2.6.08)

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Indonesia: Live poultry markets, improper medical treatment blamed for high fatalities
Poor management of live poultry markets and inappropriate medical treatment were the two main reasons why bird flu disease caused high fatalities in Indonesia, an Indonesian bird flu expert sad. Of 126 patients infected with bird flu disease in Indonesia since 2003, 103 have died so far. High fatality rates in Indonesia, according to Professor Widya Asmara, a member of experts panel for a committee to prevent a bird flu pandemic, was not caused by the resistance of the H5N1 virus against medicine, but rather because most of the patients were late in getting appropriate medical treatment.

"Live bird markets are the place where the viruses gather. The virus could spread to everywhere. We found many viruses, including on the floor of the cages," Asmara said. Should one chicken contract the virus and be brought to the market, the virus would spread to other chickens. To prevent the prevalence of the bird flu disease, Asmara said, "the chicken farm must be restructured and the live bird market must be controlled. The markets should stop operating at least for one day, to be disinfected so as to cut the life cycles of the virus."
(ProMED 2.2.08)

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Pakistan (Sindh): Two outbreaks of H5N1 avian influenza in poultry
Authorities confirmed on 4 Feb 2008 a fresh outbreak of the H5N1 strain of bird flu at a poultry farm on the outskirts of Karachi, the second case in four days in the city, a government official said. The new outbreak was found on a farm only 300m (0.2 mi) from where an outbreak was detected on the week of 28 Jan-3 Feb 2008.

"Samples taken from it were tested and found positive for H5N1," said Food and Agriculture Ministry official Rafiq-ul-Hassan Usmani. "Some 500 to 600 birds died of the virus and the remaining 5,500 chickens at the farm are being culled now."

Elsewhere, more than 2,000 chickens brought from Hyderabad died in Mangora, Swat. The Tehsil Municipal Authority Mangora took into custody the owner of chickens and sent specimen of the dead chickens to laboratory to check for bird flu. In Punjab 5,000 chickens perished due to bird flu virus in village Moor Charwan in Hujra Shah Moqeem.

Meanwhile, Pakistan Poultry Association (PPA) has demanded that the government provide subsidy for the import of vaccine for the prevention of bird flu. They have also demanded that the law, regarding the right distance (2 km – 1.2 mi) between two poultry farms, be implemented. PPA leaders said that 1.5 million people are associated with this industry while agricultural products, worth PKR 50 billion (about USD 800 million), were used in the poultry feed.
(ProMED 2.5.08)

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UK (Dorset): Two more swans found positive for H5N1 avian influenza
UK’s Department for Environmenta, Food and Rural Affairs (DEFRA) has confirmed that another two dead wild mute swans, collected on 28 Jan 2008 as part of wild bird surveillance in the same area in Dorset, have tested positive for highly pathogenic H5N1 avian influenza.

This brings the total number of swans confirmed with H5N1 on the site to nine. Cases identified after 1 Feb 2008 are published on the DEFRA Web site at www.defra.gov.uk/avianflu. Further cases in the coming weeks would not be unexpected. Evidence suggests that the level of infection in the mute swan population is low, and there remains no evidence of spread to other wild birds or domestic poultry. DEFRA is continuing to keep the disease risk to domestic poultry and control measures under review and will be assessing options for any changes to the current restrictions in place, should evidence continue to point to a low level of infection confined to the mute swan population.
(ProMED 2.2.08)

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Indonesia: Three more cases of H5N1 avian influenza, two more deaths
The Ministry of Health of Indonesia has announced the death of a previously confirmed case of H5N1 infection. The 31-year-old woman from East Jakarta, Jakarta Province, died on 31 Jan 2007. Two new cases of human H5N1 avian influenza infection have also been detected. The first is a 29-year-old female from Tangerang City, Banten Province who developed symptoms on 22 Jan 2008, was hospitalized on 28 Jan 2008 and died on 2 Feb 2008. Investigations into the source of her infection are ongoing. The second case is a 38-year-old female from West Jakarta, Jakarta Province who developed symptoms on 24 Jan 2008, was hospitalized on 26 Jan 2008, and is currently in hospital in a critical condition. Investigations into the source of her infection are ongoing. Of the 126 cases confirmed to date in Indonesia, 103 have been fatal.
(ProMED 2.6.08)

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2. Infectious Disease News

Asia
Hong Kong: Officials confirm first imported case of chikungunya
The Center for Health Protection of Hong Kong confirmed on 30 Jan 2008 the first imported chikungunya fever case of 2008, a 34-year-old woman who visited Sri Lanka on 20 Dec 2007 to 10 Jan 2008. According to a press release from the Information Services Department of Hong Kong Special Administrative Region government, she developed fever and joint pain on 27 Dec 2007 and then sought medical treatment from a private doctor on 16 Jan 2008 and has recovered.
(ProMED 2.1.08)

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Japan: Scare over dumplings made in China
Dozens of Japanese people say they have fallen ill after eating Chinese-made dumplings, prompting Tokyo officials to launch an inquiry. The frozen dumplings, known as gyoza in Japan, were made by Tianyang Food in China's Hebei province. Japanese officials said they contained traces of pesticide, probably added in production or packaging in China. China said no traces of pesticide had been found in pre-export inspections, but ordered a halt to production. The issue has triggered intensive media coverage in Japan and sparked public alarm. Leaders held an emergency cabinet meeting to discuss the problem. The problems emerged on 30 Jan 2008, when 10 people were reported to have fallen ill from the dumplings — thin dough packets containing ground meat and vegetables that are then fried. A five-year-old girl was in a serious condition in hospital, reports said.
(ProMED 2.5.08)

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Papua New Guinea: MDR tuberculosis causes concerns in PNG, Australia
A Queensland tuberculosis (TB) expert says a dramatic overhaul of health services in Papua New Guinea (PNG) is needed to stop multidrug TB from spreading to Australia. Dr. Graham Simpson co-authored a study published in the Medical Journal of Australia [MJA], which examined strains of Mycobacterium tuberculosis in PNG that are resistant to antibiotics. The report noted that many people with the disease go to the Torres Strait Islands under a treaty allowing free movement between the regions. Dr. Simpson said more than 70 TB patients were treated in Cairns in 2007 and about 15 cases were drug resistant. "We're going to see increasing number of cases for some years to come and I think we've just got to deal with that," he said. "It's not going to change until the facilities and the health care facilities improve dramatically. A lot of the drugs that we used to treat the drug-resistant TB are just not available at all in PNG."
(ProMED 2.6.08)

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Philippines: Economy sees a steep rise in dengue infections
Dengue cases recorded at the San Lazaro Hospital in Manila have piled up to 380 from 1-12 Jan 2008, a 211 per cent increase compared to the same period last year, Eric Tayag, chief of the Philippine National Epidemiology Center of the Department of Health (DOH) said. The San Lazaro Hospital is the main medical facility that takes in dengue cases from all over metropolitan Manila, the capital region of the country. Tayag said that of the 380 cases, five have already died. The health official said the number could rise as the DOH has yet to check other hospitals in metropolitan Manila.

A steep rise in dengue cases in Valenzuela City had been monitored during the first three weeks of January 2008 — a 90 per cent increase in the number of reported cases compared to the figures from the same period in 2007. The Valenzuela City government has already recorded 25 dengue cases from 1-19 Jan 2008.

Cebu City has the highest fatality rate, and health officials prepare to set up a plan along with other stakeholders for the simultaneous nationwide launching of the intensified campaign drive against dengue set for this month. Department of Health (DOH-7) Regional Director Dr. Susana Madarieta, said that out of the total 6640 recorded dengue cases in Central Visayas in 2007, 148 of the victims died of the disease, constituting a 2.2 percent mortality rate.
(ProMED 1.30.08 & 2.6.08)

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Philippines: Typhoid infections are on the rise
In the municipality of Bayombong, capital of Nueva Vizcaya province, on 4 Feb 2008 reports from the provincial health office indicated that at least 100 individuals have already been affected by typhoid since 21 Jan 2008 in the mountain town of Kasibu.

More than 100 residents of the village of Kisulad here were brought to various hospitals since the week of 14-20 Jan 2008 due to the illness. Health workers confirmed the prevalence of the waterborne disease from the results of laboratory tests made on residents brought to the Davao del Sur provincial hospital in Digos City and other hospitals.

In Catanduanes there has also been an increase in the number of suspected typhoid fever cases from 1 Dec 2007 to 9 Jan 2008. The report stated that a total of 115 cases were admitted at the Eastern Bicol Medical Center during the period. A hundred cases were from the capital town of Virac. San Andres.
(ProMED 1.28.04 & 2.4.08)

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Singapore: Economy identifies its 11th case of chikungunya
The chikungunya virus has hit another person in Singapore, bringing the total number of cases to 11. The Health Ministry said the latest case detected on 25 Jan 2008 is a Singaporean with no recent travel history, who spent some time daily in the Little India area. The first 10 cases of the mosquito-borne disease have all been linked to the Clive Street area in Little India, and since 14 Jan 2008, the authorities have screened 1,795 people within a 150-meter (0.1 mi) radius of the affected section. Checks were later expanded to cover a larger area and the latest case had spent time within the extended screening area. More than 3,200 inspections have been conducted. A total of 63 breeding sites also have been found and destroyed. Of the 11 cases, nine were admitted at the Communicable Disease Centre for isolation and management. All have been discharged, except for two who are still under observation, including the latest case.
(ProMED 1.27.08)

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Americas
USA: FDA issues letter warning of ciguatera toxin in fish
The US Food and Drug Administration (FDA) on 5 Feb 2008 issued a letter to seafood processors, advising them of recent illnesses linked to consuming fish carrying the ciguatera toxin, which has led to cases of ciguatera fish poisoning (CFP) in consumers. The toxic fish were harvested in the Northern Gulf of Mexico, near the Flower Garden Banks National Marine Sanctuary, which is located in federal waters south of the Texas-Louisiana coastline. FDA had considered CFP from fish in this geographical area extremely rare until recently, when several outbreaks were confirmed in Washington, DC, and St. Louis, Missouri. The illnesses were linked to fish caught near the marine sanctuary. FDA now considers CFP to be a food safety hazard that is likely to occur in grouper, snapper and hogfish captured within 10 miles (16 km) of the marine sanctuary and amberjack, barracuda and other wide-ranging species captured within 50 miles (80 km) of the sanctuary. FDA's letter urges seafood processors who purchase reef fish and other potentially ciguatoxic fish directly from fishermen to reassess their current hazard analyses and update their Hazard Analysis Critical Control Point (HACCP) plans as necessary. FDA's seafood HACCP regulation requires processors to have and implement written plans to control food safety hazards.

Ciguatera poisoning is caused by the consumption of tropical reef fish that have assimilated ciguatoxins through the marine food chain from toxic microscopic algae. The toxins that cause ciguatera cannot be destroyed by cooking or freezing, and toxic fish do not look or taste differently from nontoxic fish. The only way to detect CFP is through laboratory testing.

Symptoms of ciguatera poisoning include nausea, vomiting, diarrhea, numbness and tingling of the mouth, hands or feet; joint and muscle pain; headache, reversal of hot and cold sensation (such that cold objects feel hot and vice versa); sensitivity to temperature changes; vertigo, and muscular weakness. There also can be cardiovascular problems, including irregular heartbeat and reduced blood pressure. Symptoms usually appear within hours after eating a toxic fish and go away within a few weeks. However, in some cases, neurological symptoms can last for months to years. There is no antidote for CFP; symptoms can be treated most effectively if diagnosed by a doctor with 72 hours. CFP is rarely fatal.
(ProMED 2.7.08)

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USA (California): Diners contract norovirus at Redwood City hotel
Several health violations were discovered at a Redwood Shores hotel that may have contributed to a small norovirus outbreak that sickened dozens of people during the week of 21-25 Jan 2008, health officials said. Laboratory tests revealed on 31 Jan 2008 that 62 people attending a Redwood City-San Mateo County Chamber of Commerce event at Hotel Sofitel on 24 Jan 2008 were infected with the highly contagious virus, said San Mateo County director of environmental health Dean Peterson. About 200 people attended the annual dinner and awards reception banquet.

Inspectors found evidence that the Sofitel's staff were re-using dirty towels to wipe down tables, food was being kept too hot or too cold, and a dishwasher was touching clean dishes directly after touching dirty dishes, said Peterson, who added that hotel management immediately corrected the violations. While the exact method of transmission will probably never be known, investigators say it's possible the chicken or fish was contaminated either through someone's hands or through contaminated utensils. "We definitely know norovirus is killed by high searing heat from pan frying or from an oven. It may have been contaminated after it was cooked," Peterson said.
(ProMED 2.2.08)

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USA (Minnesota): Suspected progressive inflammatory neuropathy in another pork plant worker
Another meatpacker appears to have developed the neurological symptoms identified in 12 other workers that sparked a nationwide investigation. Unlike the others, however, the worker was not stationed near the high-powered air compressor system used to remove pig brain tissue at Quality Pork Processors (QPP). Rather, the worker was exposed to brain tissue in the rendering operation in the basement of the plant QPP shares with Hormel Foods. State epidemiologist Ruth Lynfield said, "We are investigating a likely additional case." As a result of the most recent suspected case, health officials are expanding the investigation to include Hormel workers in and around the rendering operation, according to a notice to employees posted in the plant on 4 Feb 2008.

QPP employs 1,300 workers and slaughters pigs on one side of the plant. On the other side, an estimated 1,400 Hormel workers process the meat into bacon and other products. Hormel owns the rendering operation. The first 12 cases of the disease involved employees working at the head table of QPP, which was spun off from Hormel in 1989. QPP halted the process of blowing out brains with the air compression system as soon as the December 2007 investigation began.

The sick meatpackers have reported fatigue, numbness and tingling in their arms and legs, with a wide range in severity. A few are severely disabled, while others have been treated and returned to work. US Centers for Disease Control and Prevention (CDC) issued a report on 31 Jan 2008 summarizing the investigation so far that gives the condition a name, progressive inflammatory neuropathy. State and federal health officials are looking into whether pig brain tissue, liquefied during removal by the air-compression system and sprayed into the air as droplets, somehow caused nerve damage in workers who were exposed to it. Investigators theorize that a protein or other substance from the animal brains triggered the workers' immune systems into mistakenly attacking their own nerve tissue.
(ProMED 2.6.08)

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USA (Hawaii): Salmonella infection from tainted fish
The state Department of Health and the USA Food and Drug Administration are investigating a series of illnesses caused by salmonella in Hawaii, Colorado and California that may be linked to imported frozen 'ahi that was consumed raw. Hawaii typically has more than 300 cases of salmonella poisoning a year, which causes a severe diarrheal gastrointestinal illness. The 32 recent cases that prompted the investigation were reported between 27 Oct and 29 Dec 2007 and stood out because they were caused by a strain of salmonella not normally seen in Hawaii, state health officials said. Outbreaks of that strain, Salmonella (enterica serotype) Paratyphi B, have been associated with smoked white fish, unpasteurized milk, goat cheese and alfalfa spouts, and normally only about 10 cases are reported here a year, said Health Department spokeswoman Janice Okubo. That particular type of salmonella also is associated with ornamental fish, turtles and reptiles. All of the cases in the Hawaii cluster were on O'ahu, and five of the 32 people here who became ill were hospitalized, according to a Health Department. An additional Hawaii case that may be caused by the same type of salmonella was reported earlier this year but has not yet been confirmed. Okubo said the Health Department will not identify any retail outlets the tainted fish could have come from because "there needs to be more product tracing in order for someone to determine the source."
(ProMED 1.27.08)

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USA (New Mexico): Officials identify state's first plague case of 2008
A 50-year-old Eddy County man has been confirmed with New Mexico's first plague case of 2008. The man was hospitalized but now is recovering at home, the state Department of Health said on 25 Jan 2008. It was the first case of plague ever reported in an Eddy County resident, the department said. The man most likely was exposed to plague while hunting and skinning rabbits a few days before falling ill, authorities said. The department plans an investigation in the area to look for plague in other rabbits. The department also reported that eight people were potentially exposed to pneumonic plague, a dangerous form of the disease, when a cat in Santa Fe County developed pneumonic plague before it died. All eight people are receiving antibiotics.
(ProMED 1.27.08)

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USA: Consumer group claims Botox is deadly and should carry a stronger warning
Researchers at the consumer group Public Citizen said Botox should carry a black box warning. They reviewed adverse event reports submitted to the FDA and found 16 deaths have been reported. The manufacturer of Botox said these risks are already listed on the drug label. Botox is famous for smoothing facial wrinkles but has also been approved for treating rigid neck muscles. Researchers at the consumer group Public Citizen said the botulinum toxin spreads inside the body causing serious problems. The report detailed cases of muscle weakness, difficulty swallowing or aspiration pneumonia, a serious condition caused by breathing a foreign material into the lungs.
(ProMED 1.27.08)

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3. Updates
AVIAN PANDEMIC INFLUENZA
- UN: http://www.un-influenza.org/ : latest news on avian influenza. UNDP recently launched a new web site for information on fund management and administrative services and includes the website of the Central Fund for Influenza Action.

- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html Read the WHO/ECDC frequently asked questions for Oseltamivir Resistance at: http://www.who.int/csr/disease/influenza/oseltamivir_faqs/en/index.html

- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Get an overview of the H5N1 situation around the world.

- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm

- US CDC: http://www.cdc.gov/flu/avian/index.htm. Read about ways to prevent transmission.

- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/. Use the toolkit to prepare your community for a possible flu pandemic.

- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html. Read about the Information Session for Owners of Small Flocks and Pet Birds.

- CIDRAP: http://www.cidrap.umn.edu/ See Pandemic preparedness tools: Find more than 130 peer-reviewed practices from 22 states and 33 counties aimed at furthering pandemic preparedness.

- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to National Influenza Centers in PAHO Member States.

- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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4. Articles
U.S. flu outbreak plan criticized: It does not anticipate strain on hospitals
Lee C. Washington Post. Saturday, February 2, 2008; Page A03

The federal government's voluminous plans for dealing with pandemic flu do not adequately account for the overwhelming strain an outbreak would place on hospitals and public health systems trying to cope with millions of seriously ill Americans, some public health experts and local health officials say. The Bush administration's plans, which run more than 1,000 pages, contemplate the nightmare medical scenarios that many experts fear, but critics say federal officials have left too much of the responsibility and the cost of preparing to a health-care system that even in normal times is stretched to the breaking point and leaves millions of people without adequate access to care.

"The amount going into actually being prepared at a community level is not enough," said Patrick Libbey, executive director of the National Association of County and City Health Officials. "We are still talking about rearranging with little additional resources the assets of a system that are built on such a thin margin now that you have significant amounts of people without access to care, and hospitals that are periodically shutting down their ERs and the like."

The Bush administration argues that it is doing a lot to help communities as part of its three-pronged strategy for dealing with the flu threat. It has doled out hundreds of millions of dollars in preparedness grants for hospitals and public health systems every year, subsidized the stockpiling of antiviral drugs, conferred with governors and encouraged resource-sharing plans among hospitals. Its larger strategy involves partnering with other countries to quickly identify and contain potential outbreaks overseas, developing vaccines and other medical measures to limit the virus's spread if it reaches US shores, and working with state and local officials to keep the economy and society functioning as normally as possible. But administration officials acknowledge that gaps remain.

"We're seeing substantial progress across the board in terms of various aspects of preparedness for flu," said William Raub, science adviser to Health and Human Services Secretary Mike Leavitt. "But I won't sugarcoat this. In virtually every area, we have a good way to go . . .It would not take much of an unmitigated pandemic to overwhelm the hospital system."

A serious outbreak and its fallout would probably overwhelm medical centers, cause lengthy delays in emergency and routine care, and trigger shortages of beds, ventilators, drugs, masks, gloves and other supplies, experts said. Unlike a hurricane or a terrorist bombing, the crisis would drag on for months and affect communities nationwide at the same time… "In a pandemic, the action is going to be in the doctor's office and in the hospital emergency room and the ICUs," he said. "It isn't going to be with the fire department intercept squad . . . You'll find that there are almost no resources going to this problem proportionate to the real risk it presents."
[Full text at:
http://www.washingtonpost.com/wpdyn/content/article/2008/02/01/AR2008020103073.html?referrer=emailarticle ]

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Pandemic influenza preparedness and community resiliency
Middaugh JP. JAMA. 2008;299(5):566-568.
http://jama.ama-assn.org/cgi/content/short/299/5/566

Introduction
Weathering a future pandemic of influenza will be a challenge unlike anything experienced in the United States since 1918. A unique strength of the country has been the sharing of common goals and aspirations. Drawing on strong ethnic identities that celebrate diversity and respect for heritage, when faced with crises, individuals throughout the United States have protected each other because of this common bond.

Responding to a future influenza pandemic will test loyalties to families, friends, neighborhoods, and communities. As planning for the national response to pandemic influenza continues, it is essential to protect against adverse, unintended consequences that could seriously threaten the fabric of US society. There has been a major shift in public health advice regarding influenza, and current national pandemic influenza planning advocates that individuals will be able to prevent influenza infection by modifying personal behaviors. Decreased person-to-person contact is recommended as an effective strategy to prevent infection. This new advice is based on limited current scientific evidence and could have serious adverse unintended consequences for the social fabric of society and community resiliency.
(CIDRAP 2.4.08)

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Rescinding community mitigation strategies in an influenza pandemic
Davey VJ, Glass RJ. Emerg Infect Dis. 2008 Mar; [Epub ahead of print]
http://www.cdc.gov/eid/content/14/3/pdfs/07-0673.pdf

Abstract
Using a networked, agent-based computational model of a stylized community, we evaluated thresholds for rescinding 2 community mitigation strategies after an influenza pandemic. We ended child sequestering or all-community sequestering when illness incidence waned to thresholds of 0, 1, 2, or 3 cases in 7 days in 2 levels of pandemic severity. An unmitigated epidemic or strategy continuation for the epidemic duration served as control scenarios. The 0-case per 7-day rescinding threshold was comparable to the continuation strategy on infection and illness rates but reduced the number of days strategies needed by 6% to 32% in mild or severe pandemics. If cases recurred, strategies were resumed at a predefined 10-case trigger and epidemic recurrence was thwarted. Strategies were most effective when used with high compliance and when combined with stringent rescinding thresholds. The need for strategies implemented for control of an influenza pandemic was reduced, without increasing illness rates.
(CIDRAP 2.4.07)

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Protective effect of maritime quarantine in South Pacific jurisdictions, 1918–1919
McLeod MA, et al. Emerg Infect Dis. 2008 Mar; [Epub ahead of print]
http://www.cdc.gov/eid/content/14/3/pdfs/07-0927.pdf

Abstract
We reviewed mortality data of the 1918–1919 influenza pandemic for 11 South Pacific Island jurisdictions. Four of these appear to have successfully delayed or excluded the arrival of pandemic influenza by imposing strict maritime quarantine. They also experienced lower excess death rates than the other jurisdictions that didn’t apply quarantine measures.
(ProMED 2.3.08)

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Mutations in influenza A virus (H5N1) and possible limited spread, Turkey, 2006
Altiok E, et al. Emerg Infect Dis. 2008 Mar; [Epub ahead of print]
http://www.cdc.gov/eid/content/14/3/pdfs/06-1237.pdf

Abstract
We report mutations in influenza A virus (H5N1) strains associated with 2 outbreaks in Turkey. Four novel amino acid changes (Q447L, N556K, and R46K in RNA polymerase and S133A in hemagglutinin) were detected in virus isolates from 2 siblings who died.

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Evaluation of the safety and immunogenicity of a booster (third) dose of inactivated subvirion H5N1 influenza vaccine in humans
Zangwill MK, et al. The Journal of Infectious Diseases 2008;197:000-000. DOI: 10.1086/526537
http://www.journals.uchicago.edu/doi/abs/10.1086/526537

Abstract
Previously, we evaluated 2 doses of H5N1 influenza vaccine in persons 18-64 years of age (placebo and 7.5-, 15-, 45-, or 90-mug doses), separated by 28 days. In this study, 337 participants received a third dose, 6 months thereafter. Microneutralization (MN) and hemagglutination-inhibition geometric mean titers (GMTs) of antibody declined before the third dose. Twenty-eight days after the third dose, 78%, 67%, 43%, and 31% of recipients in the 90-, 45-, 15-, and 7.5-mug-dose groups had a MN GMT >/=1:40, respectively. Five months later, MN GMTs were significantly greater than those after the second dose.
(CIDRAP 2.3.08)

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Public health response to an avian influenza A (H5N1) poultry outbreak in Suffolk, United Kingdom, in November 2007
Brown G, et al. Eurosurveillance. 2008;13(5). Published online January 2008
http://www.eurosurveillance.org/edition/v13n05/080131_3.asp

Introduction
An outbreak of highly pathogenic avian influenza (HPAI) H5N1 in a poultry farm in Suffolk, United Kingdom, in November 2007 prompted a comprehensive public health response to stop the transmission of avian influenza to humans. A total of 176 of 178 potentially exposed (99%) received oseltamivir prophylaxis. The majority of them, 169 people (96%), received the influenza vaccine during the outbreak. Thirty people who had been given post-exposure prophylaxis were actively followed up for one week. None of them developed symptoms suggestive of influenza-like illness. Serological investigation (28-day testing) of those who reported symptoms is ongoing.
(CIDRAP 2.2.08)

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Acute allergic-type reactions among patients undergoing hemodialysis—multiple states, 2007-2008
MMWR. February 1, 2008 / 57 (Early Release);1-2

CDC is investigating an outbreak of acute allergic-type reactions among patients who have undergone hemodialysis since November 19, 2007. The majority of reactions have occurred among adult hemodialysis patients, with onset within minutes of initiating a hemodialysis session. Although the cause of the outbreak is unknown and remains under investigation, the majority of reactions occurred in patients who received intravenous heparin produced by Baxter Healthcare Corporation (Deerfield, Illinois). Baxter voluntarily recalled nine lots of heparin multidose vials after learning of these adverse events among patients who received heparin during dialysis. This report describes the ongoing investigation.
[Full Text at: http://www.cdc.gov/mmwR/preview/mmwrhtml/mm57e201a1.htm ]
[(ProMED 2.6.08)

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5. Notifications
APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems
APEC EINet is pleased to host a special videoconference on pandemic influenza preparedness. This videoconference is a follow-up to our first “virtual symposium”, which was conducted in January 2006 with great success (participating economies were Australia, Canada, China, Korea, Philippines, Singapore, Chinese Taipei, Thailand, USA, and Viet Nam). You can view a five-minute videoclip of our previous virtual symposium at: http://depts.washington.edu/einet/symposium.html. Our upcoming videoconference will be held in late May 2008. It will take place during the evening hours of 29 May in the Americas and in the morning hours of 30 May in Asia, for approximately 3.5 hours. Our objective is to describe how private and public sectors in the APEC region can cooperate and work effectively to prepare for and respond to an influenza pandemic.

Through this videoconference, we hope to promote regional information sharing and collaboration to enhance pandemic preparedness. In order to improve preparedness regionally, it is vital to understand how each economy in the region is undertaking this task. In this process, EINet will:

  1. Bring together economies in a dynamic, real-time discussion on preparedness through the collaboration of the health and the business/trade sectors, with a focus on critical systems continuity.
  2. Share specific examples of current practices — e.g. scenario exercises, communication drills and policy evaluation.
  3. Use innovative technologies (e.g. Access Grid) for real-time, virtual interchange, enhancing their utility for future collaboration and response in the event of a pandemic.
Videoconferencing offers an alternative to in-person conferencing. It reduces the time and cost of traditional conferences requiring long-distance travel. Simultaneous communication with multiple sites is possible, with numerous visualization options. Real-time Web-based information exchange is also possible, and, during an actual pandemic, the virtual medium would be a safe way to communicate when international travel is limited or prohibited.

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Highlights from the Bangkok International Conference on Avian Influenza 2008: Integration from Knowledge to Control
http://www.biotec.or.th/aiconf2008/home/index.asp

The Bangkok meeting drew about 500 experts from 40 countries to discuss research and ideas on a wide range of topics. Some other topics discussed included the idea that some human cases of H5N1 avian influenza escape detection due to mild or absent symptoms, stockpiling vaccine adjuvants to prepare for a pandemic, the use of engineered human antibodies as a defense against the H5N1 virus, and the high H5N1 case-fatality rate in Indonesia.
(CIDRAP 1.25.08)

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CDC Health Advisory: Influenza-associated Pediatric Mortality and Staphylococcus
US Centers for Disease Control and Prevention (CDC) is requesting that states report all cases of influenza-related pediatric mortality during the 2007-2008 influenza season. This health advisory contains updated information about influenza and bacterial co-infections in children and provides interim testing and treatment recommendations.

Background
Since 2004, the Influenza-Associated Pediatric Mortality Surveillance System, part of the Nationally Notifiable Disease Surveillance System, has collected information on deaths among children due to laboratory-confirmed influenza, including the presence of other medical conditions and bacterial infections at the time of death. From 1 Oct 2006 through 30 Sep 2007, 73 deaths from influenza in children were reported to CDC from 39 state health departments and two city health departments. Data on the presence (or absence) of bacterial co-infections were recorded for 69 of these cases; 30 (44 percent) had a bacterial co-infection, and 22 (73 percent) of these 30 were infected with Staphylococcus aureus.

The number of pediatric influenza-associated deaths reported during 2006-07 was moderately higher than the number reported during the two previous surveillance years; the number of these deaths in which pneumonia or bacteremia due to S. aureus was noted represents a five-fold increase. Only one S. aureus co-infection among 47 influenza deaths was identified in 2004-2005, and three co-infections among 46 deaths were identified in 2005-2006. Of the 22 influenza deaths reported with S. aureus in 2006-2007, 15 children had infections with methicillin-resistant S. aureus (MRSA). The median age of children with S. aureus co-infection was older than children without S. aureus co-infection (10 years versus 5 years, p < 0.01) and children with co-infection were more likely to have pneumonia and acute respiratory distress syndrome (ARDS). Influenza strains isolated from these children were not different from common strains circulating in the community, and the MRSA strains have been similar to those associated with MRSA skin infection outbreaks in the United States.

Recommendations
Health care providers should test persons hospitalized with respiratory illness for influenza, including those with suspected community-acquired pneumonia. Health care providers should be alerted to the possibility of bacterial co-infection among children with influenza, and request bacterial cultures if children are severely ill or when community-acquired pneumonia is suspected. Health care providers should be aware of the prevalence of methicillin-resistant S. aureus strains in their communities when choosing empiric therapy for patients with suspected influenza-related pneumonia. Clinicians, health care providers, and medical examiners are asked to contact their local or state health department as soon as possible when deaths among children associated with laboratory-confirmed influenza are identified. CDC requests that state health departments report all cases of pediatric influenza-associated deaths to CDC through about bacterial pathogens isolated from sterile sites and/or from sputum or endotracheal aspirates be completed on the Influenza-Associated Pediatric Mortality Surveillance System case report form. If the influenza death was complicated by S. aureus infection, state health departments are asked to please contact the clinical agency that reported the case to determine if the S. aureus isolate is available. CDC will receive S. aureus isolates in order to better characterize those S. aureus isolates from children who have died from influenza. If you have any questions about this health advisory notice, please call the Influenza Division, Epidemiology and Prevention Branch at 404-639-3747.
(ProMED 2.5.08)

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4th International Symposium on Filoviruses
Date: Thu 31 Jan 2008
From: Jean Paul Gonzalez
Location: Libreville, Gabon
Venue: Centre Culturel Francais, Libreville, Gabon
Dates: 26-28 Mar 2008

Following previous symposia held in Marburg, Germany (2000), in Bethesda, USA (2003), and in Winnipeg, Canada (2006), the "4th International Symposium on Filoviruses" will take place in Libreville, Gabon, on 26-28 Mar 2008. Gabon, the heart of the Ebola virus endemic domain, will be the place to synthesize knowledge on filoviruses in their natural environment, and to propose, to the most exposed countries, strategies and tools for prevention and therapy. The symposium will be divided into three sessions:

  • Environment and filovirus
  • Cell system and filovirus interaction; and
  • Filovirus treatment and prevention.
For more details about the symposium please visit the Internet symposium site at
<http://www.ird.fr/filomeeting2008/>
(ProMED 1.31.08)

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 apecein@u.washington.edu