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Vol. XI No. 11 ~EINet News Brief ~ 30 May 2008 ~ EINet News Briefs ~ May 30, 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: Evolution of influenza strains points to higher risk of pandemic
- Global: WHO reports progress on intellectual property issues
- Bangladesh: WHO confirms first case of human H5N1 avian influenza infection
- China: Officials say hand-foot-mouth disease infections may have peaked
- China (Sichuan): Gas gangrene found in injured earthquake survivors
- Indonesia: Officials claim wide support for virus-sharing stance
- Indonesia (Jambi): Concern over sudden poultry deaths, avian influenza H5N1 suspected

2. Infectious Disease News
- Hong Kong: Officials confirm 12th imported dengue fever case
- Philippines: Health officials concerned over rise in dengue fever cases
- Russia: Rise in Crimean-Congo hemorrhagic fever sparks increased control efforts
- Russia (Rostov): A rise in botulism causes concern for officials
- Viet Nam (Ho Chi Minh City): Dengue fever on the rise in children
- Viet Nam: Death toll from hand-foot-mouth disease reaches 10
- Canada (Alberta): Chinook Health announces first confirmed case of hantavirus disease
- USA (Washington): New case of measles in Grant County, outbreak continues

3. Updates
- AVIAN/PANDEMIC INFLUENZA
- MEASLES

4. Articles
- The evolutionary genetics and emergence of avian influenza viruses in wild birds
- Experimental infection of cattle with highly pathogenic avian influenza virus (H5N1)
- Contemporary North American influenza H7 viruses possess human receptor specificity: Implications for virus transmissibility
- General practice and pandemic influenza: a framework for planning and comparison of plans in five countries.
- Household responses to school closure resulting from outbreak of influenza B, North Carolina
- Prevention of the spread of infection—the need for a family-centered approach to hygiene promotion
- Increased detections and severe neonatal disease associated with coxsackievirus B1 infection—United States, 2007

5. Notifications
- World Vaccine Congress Asia 2008
- International Meeting On Emerging Diseases and Surveillance (IMED 2009)


1. Influenza News

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

2008
Bangladesh / 1 (0)
China / 3 (3)
Egypt / 7 (3)
Indonesia / 16 (13)
Viet Nam / 5 (5)
Total / 31 (24)

2007
Cambodia / 1 (1)
China / 5 (3)
Egypt / 25 (9)
Indonesia / 42 (37)
Laos / 2 (2)
Myanmar / 1 (0)
Nigeria / 1 (1)
Pakistan / 3 (1)
Viet Nam 8 (5)
Total / 88 (59)

2006
Azerbaijan / 8 (5)
Cambodia / 2 (2)
China / 13 (8)
Djibouti / 1 (0)
Egypt / 18 (10)
Indonesia / 55(45)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 115 (79)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 20 (13)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 98 (43)

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

2003
China / 1 (1)
Viet Nam / 3 (3)
Total / 4 (4)

Total no. confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 383 (241).
(WHO 5.28.08 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 4.30.08)

WHO maps showing world’s areas affected by H5N1 avian influenza (last updated 5.6.08): http://gamapserver.who.int/mapLibrary/

WHO timeline of important H5N1-related events (last updated 5.20.08): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: Evolution of influenza strains points to higher risk of pandemic
Some strains of bird flu are coming ever closer to developing the traits they need to cause a human pandemic, a study released on 26 May 2008 said. Researchers who analyzed samples of recent avian flu viruses found that a few H7 strains of the virus that have caused minor, non-transmissible infections in people in North America between 2002 and 2004 have increased their affinity for the sugars found on human tracheal cells. Subsequent tests in ferrets suggested that these viral strains were not readily transmissible.

But one strain of the H7N2 virus, a low pathogenic avian flu strain isolated from a man in New York in 2003, replicated in the ferret’s respiratory tract and was passed between infected and uninfected ferrets suggesting it could be transmissible in humans.

The investigators said the evidence suggests that the virus could be evolving toward the same strong sugar-binding properties of the three worldwide viral pandemics in 1918, 1957 and 1968.

“These findings suggest that the H7 class of viruses are partially adapted to recognize the receptors that are preferred by the human influenza virus,” said Terrence Tumpey, a senior microbiologist with the US Centers for Disease Control and Prevention.

The authors said that if the viruses continue to evolve in this direction, the avian flu viruses could travel more easily between other animals and humans. They called for strict surveillance of avian flu viruses and continuing federal preparations for a possible future pandemic. The study appears in the Proceedings of the National Academy of Sciences (please refer to the Articles section of this bulletin).
(AFP 5.26.08)

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Global: WHO reports progress on intellectual property issues
The World Health Assembly (WHA) recently approved a global strategy for managing intellectual property issues and made progress on a draft action plan that was presented by a World Health Organization (WHO) working group. The WHA, which consists of delegates from all WHO member states and serves as the agency’s policymaking arm, met in Geneva from May 19 to May 23 2008.

Intellectual property rights have become a hot-button issue in global health circles, spurred by Indonesia’s decision in early 2007 to cease sharing its H5N1 avian influenza virus samples. The country’s stance has raised the possibility that it and other countries affected by H5N1 influenza might claim legal ownership of flu virus samples. Samples are needed to track viruses’ transmissibility and drug susceptibility and to develop vaccines. The WHO’s recent work on intellectual property issues is related to but separate from its efforts to broker a virus-sharing agreement.

When the WHO’s intellectual property working group met in early April 2008, members reached consensus on all but about 20 of 107 proposed actions. US Health and Human Services Secretary Mike Leavitt addressed the US government’s concerns in a May 19 2008 press conference during the assembly. Leavitt said the United States was eager to finalize the agreement, but was seeking to maintain strong principles on items such as the need for innovation.

“We obviously have very strong views that intellectual property is the seed or foundation for innovation, and that compromising to the point that innovation is in any way stymied will ultimately cost lives, and that’s not an area where we think compromise should be made,” he said.

Despite the lack of a final action plan, the WHA approved a strategy that defines the WHO’s roles regarding public health innovation and intellectual property. “WHO’s member states have recognized that market-driven research and development should be expanded to include additional incentives for health needs–driven research and development, and to make these advances affordable and accessible to developing countries,” the WHO said.

Aside from balancing innovation with health needs and greater access to treatments and diagnostic tools, the strategy lays out a framework to:

  • Assess developing countries’ health needs and identify research and development priorities
  • Promote work on diseases that disproportionately affect developing countries, along with those that impact vulnerable populations in all countries
  • Explore and implement, when appropriate, research and development incentives
  • Boost research and development capacity in developing countries
  • Improve, promote, and accelerate technology transfer
  • Remove access barriers to medical commodities
  • Secure research and development financing for developing countries
(CIDRAP 5.30.08)

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Asia
Bangladesh: WHO confirms first case of human H5N1 avian influenza infection
WHO on 23 May 2008 confirmed the first human case of bird flu in Bangladesh, a baby boy who has recovered, bringing the number of countries that have recorded human infections to 15. Bangladesh authorities announced the case on 22 May 2008, and the WHO said it had been confirmed by the US CDC.

“The case was confirmed by CDC in Atlanta. It is the first in Bangladesh,” WHO spokesman Gregory Hartl said.

The 16-month-old boy was infected in January 2008 and has since recovered, he said. Bangladesh authorities informed the United Nations agency promptly about the case, but it took time for the international laboratory testing to be completed, Hartl said.

The H5N1 virus was first detected in Bangladesh in Mar 2007, and since then, authorities have culled two million chickens and destroyed more than two million eggs. Avian influenza has spread through 47 of Bangladesh’s 64 districts, causing losses of about 45 billion taka (USD 650 million) for the growing poultry sector, which accounts for 1.6 percent of the impoverished nation’s gross domestic product.

“When a disease is so widespread in poultry, it is really a matter of time before you get a human case. It shows the need to control the disease in animals if you are going to reduce the chances of transmission to humans,” Hartl said.
(ProMED 5.25.08)

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China: Officials say hand-foot-mouth disease infections may have peaked
The outbreak of hand-foot-mouth (HFMD) has ebbed in east China’s Anhui Province, which was worst hit by the viral epidemic since April 2008, the provincial department of health said on 23 May 2008. The number of cases reported everyday dropped from a peak of 1160 on 1 May 2008 to 153 on 21 May 2008, and no further deaths had occurred over the past 12 days, the department said. It said 734 people were still hospitalized in Anhui, including 10 in serious or critical condition. Doctors successfully treated 10 696 HFMD patients in Anhui, although 26 died in the outbreak.

According to the Ministry of Health, HFMD can be caused by a host of intestinal viruses, but human enterovirus 71 (EV71) and coxsackievirus (Cox A16) are the most common. HFMD usually starts with a slight fever followed by blisters and ulcers in the mouth and rashes on the hands and feet. Those with EV71 often show serious symptoms. It can also lead to meningitis, encephalitis, pulmonary edema, and paralysis in some children. There is no vaccine.

Elsewhere in China, according to the city’s Health Bureau, 10 more enterovirus cases were confirmed in Macao, on 29 May 2008, bringing the total number to 283 so far. These enterovirus cases comprise cases of HFMD and cases of herpangina (mouth blisters), but none of the patients was in serious condition, the bureau said. Among the detected cases in Macao, 34 have been confirmed as EV71 infections as of 29 May 2008.

The Chinese Center for Disease Control and Prevention, in collaboration with the WHO Representative Office in China, has released a preliminary report on the HFMD outbreak due to EV71 in Fuyang City, Anhui Province, the most severely affected locale. Reporting on the occurrence of HFMD in Anhui province and the rest of the country will now take place on a monthly basis together with other notifiable diseases in China. As part of the efforts to implement the International Health Regulations, IHR (2005), China will further strengthen the early warning system by immediate notification of clustering of clinically abnormal and severe cases, as well as increasing international collaboration and information exchange. An English version of the preliminary report can be downloaded from the World Health Organization China Office website: http://www.wpro.who.int/china.
(ProMED 5.21.08 & 5.30.08)

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China (Sichuan): Gas gangrene found in injured earthquake survivors
According to sources at the Chinese Center for Disease Control and Prevention 30 patients in Sichuan University’s Huaxi Hospital have been infected with gas gangrene. An isolation ward has been set up to prevent the disease spreading. All patients injured in the quake arriving at Huaxi Hospital will be sent to the isolation ward for diagnosis on arrival.

Five patients diagnosed with gas gangrene disease on 14 May 2008 are in a stable condition, according to Shi Yingkang, the dean of Huaxi Hospital. Gas gangrene is a bacterial infection that produces gas within gangrenous tissue. People with open fractures are particularly susceptible. It is caused by the clostridium bacteria and if left untreated is usually fatal within 12 hours. Isolation of patients and effective disinfection can prevent cross infection. It takes about five minutes to diagnose the disease by testing wound secretions.

There have been no cases of cross infection in Huaxi Hospital so far. But rescuers in the quake-hit region have been warned not to make direct contact with survivors’ skin, and to follow effective disinfection procedures.

Experts from Chinese Center for Disease Control and Prevention say isolation wards should be set up in all hospitals receiving patients from the quake-hit area. All injured persons transferred from the quake area should be first sent to isolation wards to be checked for gas gangrene. If gas gangrene is suspected, treatment must begin immediately. Thoroughly cleaning wounds, removing foreign objects and dead tissue is the best way to prevent clostridium infection.
(ProMED 5.22.08)

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Indonesia: Officials claim wide support for virus-sharing stance
Indonesia’s health minister asserted that 112 other nations at a meeting in Geneva during the week of 19 May 2008 expressed support for her country’s position on avian influenza virus sharing. At a press conference on 26 May 2008, Siti Fadilah Supari said support for Indonesia’s sample-sharing proposals came on May 21 2008 at a Non-Aligned Movement (NAM) health ministers meeting, which was held alongside the WHO’s annual meeting in Geneva, the Jakarta Post reported. The NAM, founded in 1955, is an organization of countries that consider themselves not aligned with or against any superpower. Supari said representatives of 112 countries at the NAM health ministers meeting supported Indonesia's demands.

“We received moral and political support from health ministers from England, Russia, Iran, and Australia,” Supari said. The NAM Web site does not list England or Australia among its 118 member countries.

During the WHO’s annual World Health Assembly, Supari urged world health officials to replace the WHO’s virus-sharing system, saying it favors developed nations. Also during the meeting, she met with US Health and Human Services Secretary Mike Leavitt to discuss possible solutions to the virus-sharing impasse, in a continuation of talks that had begun in April 2008. Leavitt mentioned the latest talks at a May 19 2008 press conference.

“Actually, not a great deal changed as a result of our meeting today,” he told reporters, according to a transcript published on the US State Department Web site. He emphasized that the United States wants to help forge needed improvements in the sample-sharing system. “What we aren’t willing, of course, to do is engage in any system that would involve compensation for virus samples,” he said. “This is a 60-year-old tradition. That’s one of the greatest public health successes in history.”

A progress report on multilateral efforts to settle the sample-sharing issue, including ideas raised at the World Health Assembly, is expected in July 2008, Leavitt said. A WHO working group dedicated to solving the problem, which has met several times, will meet again in November. “And we’re hopeful that by November of this year we’ll have a protocol under which that (virus sharing) can be done,” Leavitt said.

In a recent book, Supari accused the United States of planning to make a biological weapon out of the H5N1 virus and charged that the United States and the WHO have conspired to profit from H5N1 vaccines.

Indonesia recently announced it would begin sharing H5N1 viral sequences with a new public database, the Global Initiative on Sharing Avian Influenza Data (GISAID), which was formed by a group of 70 scientists and health officials to promote greater sharing of H5N1 sequences. GISAID has said the public can freely access the database, which includes both human and animal H5N1 sequences, after they register and agree to share and credit the use of others’ data, analyze findings jointly, publish results collaboratively, and refrain from pressing intellectual property rights issues that relate to diagnostic, drug, and vaccine developments.

Experts have praised the new development, but some have said that having actual H5N1 isolates is more useful because they are needed to make seed strains for vaccines and are critical for determining antigenicity, transmissibility, and pathogenicity.
(CIDRAP 5.27.08)

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Indonesia (Jambi): Concern over sudden poultry deaths, avian influenza H5N1 suspected
The highest bird flu alert status has been declared in Rimbo Mulyo village in Rimbo Bujang district, Tebo regency, Jambi province (on the east coast of central Sumatra), after the sudden deaths of thousands of domestic birds in the area. The alert means local people, especially those living on Jalan 15 and Jalan 23, where the sudden deaths occurred, are obliged to report to the local community health center every hour as a precaution. The regency health office has set up a special task force to anticipate the possible transfer of the bird flu virus to humans by conducting door-to-door health checks.

“We're also calling on all members of the community to report to the community health centers should their neighbors, friends, or family members become sick,” head of Tebo health office Haflin said 20 May 2008. Haflin said his office has worked hand-in-hand with the husbandry office to take preventive measures including providing (veterinary) vaccines, spraying disinfectant, and culling possibly infected poultry. Disinfectant has been sprayed and medicine distributed within a 1 km radius of the areas where the sudden deaths occurred.
(ProMED 5.8.08)

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2. Infectious Disease News
Hong Kong: Officials confirm 12th imported dengue fever case
The Centre for Health Protection on 20 May 2008 confirmed the year’s 12th imported dengue fever case involving a 39-year-old man who traveled to the Maldives 5-13 Apr 2008. He was admitted to St Teresa’s Hospital on 28 Apr 2008 and has been discharged. He came down with a fever, sore throat, joint pain and a rash on 22 Apr 2008. His four travel companions also had similar symptoms. Of them, a 30-year-old man was confirmed to have dengue fever on 30 Apr 2008.
(ProMED 5.25.08)

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Philippines: Health officials concerned over rise in dengue fever cases
The Department of Health (DOH) expressed concern over the rising number of dengue cases in 2008, saying authorities have recorded nearly 10,000 dengue cases from January 2008 to April 2008 alone. In a surveillance report, the DOH National Epidemiology Center (NEC) indicated that the cases covering 1 Jan-10 Apr 2008 already hit 9,555. This is higher by almost 30 percent compared to the number of cases during same period in 2007.

“This is 29.4 percent higher compared to the same period last year (2007), when it stood at 7384 cases,” the report stated. The report also noted that deaths due to dengue stood at 111, which is higher by as much as 29 fatalities as compared to 2007, the report said.

According to the report, National Capital Region (NCR) posted the bulk of the dengue cases with 2,443 victims. Of the 2,443 Metro victims, the city of Manila had the most number of cases with 687 followed by Quezon City and Caloocan City with 362 and 328, respectively. The same report also showed that Central Visayas (1384), Central Luzon (1221), Calabarzon (881), Zamboanga (805), and Soccsksargen (655) likewise recorded high number of dengue cases. Dr Lyndon Lee Suy, DOH Emerging and Reemerging Disease Prevention National Program manager, advised the public to continuously search for areas where dengue-carrying mosquitoes thrive and subsequently clean such breeding grounds.

“We must always practice the search and destroy strategy. It remains to be the best way to combat dengue fever,” Lee Suy told reporters, adding that the public to continue self-protection measures and immediately seek medical consultation at the first signs of dengue.
(ProMED 5.19.08)

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Russia: Rise in Crimean-Congo hemorrhagic fever sparks increased control efforts
The second fatal case of tick-borne Crimean-Congo hemorrhagic fever (CCHF) has been registered in Stavrapol Krai. According to the report of the regional Rospotrebnadzor (Federal Trade and Public Health Inspection Authority), “a 39-year-old woman has died in the hospital.” The first fatal case was a man who died mid May 2008. The level of CCHF morbidity is now higher than for the same period of 2007 by 1.7 times. As of 26 May 2008, seventeen patients have been registered in 12 regions, mainly rated as moderate to severe cases. A total of 3,305 people applied for medical care because of tick-bites. The highest level of tick activity and, accordingly, human morbidity is expected during May and June 2008. In all, 133 people from 25 territories have been admitted to hospitals, which is 70 percent more than during 2007. The regional administration of Rospotrebnadzor stated that the specialist staff of the Centre of Hygiene and Epidemiology examined a total of 4,000 ticks and virus found in ticks from the Aapanasenkovskoe and Turkmenskoe regions. In order to control the spread of the disease, anti-tick treatments of farm animals were carried out in combination with cattle and pasture management activities. Several educational campaigns have been organized for the local population.

In another case an 11-year-old girl contracted CCHF following a tick bite and died subsequently. The diagnosis was established only after the worsening of the girl’s condition. Her parents sought medical treatment for her in the local health clinic, but the tick bite was not detected immediately.

(According to Internet sources, four fatal cases of CCHF have been registered in the South Federal Okrug so far the 2008 season. This is equal to the mortality rate for CCHF for the whole of 2007. Morbidity has increased 1.7-fold in comparison to 2007. The low ranking of CCHF in differential diagnosis has contributed to the death of the child in Kalmykia and the woman in Stavrapol. In some situations where there is no history of tick bite, physicians need to be more aware of the possibility of CCHF.)
(ProMED 5.28.08)

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Russia (Rostov): A rise in botulism causes concern for officials
The administration of Rospotrebnadzor (Federal Trade and Public Health Inspection Authority) for Rostov region (oblast) reports that the epidemic situation is alarming in the region due to many cases of food-borne botulism. There were 24 botulism cases in the region in 2006 and five of them died. The numbers for 2007 are 24 affected people including one fatal case. The numbers for 2008 so far are 12 cases and two deaths.

The last cases were in the Morozowsk settlement in April 2008. Two people fell sick after eating dried bream. The last outbreak was in the city of Belaya Kalitwa, where three people got sick and two of them died. Rospotrebnadzor reports that the most common food that causes botulism is homemade products like dried fish, mushroom marinades, and vegetable cans. These dangerous goods are also sold in local non-authorized markets.

The testing of food specimens taken from cases revealed botulinum toxin in 70-75 percent of cases and the producing organism in 10-30 percent of cases. The epidemiological analysis showed that the most risk for botulism is coming from homemade products for self-use and from products sold in non-authorized markets.
(ProMED 5.16.08)

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Viet Nam (Ho Chi Minh City): Dengue fever on the rise in children
More than 3,000 children have dengue fever in Ho Chi Minh City, twice the number seen in 2007, the city’s Health Department reported 20 May 2008. Dr. Bich Lien, head of the Children Hospital 1’s Dengue Fever Department, said last week she was admitting 20-30 patients daily, but that had gone up to 40-60 now. Children Hospital 2 is treating around 60 children at the moment. Mekong Delta provinces also have been hit hard by the disease, with more than 10,000 cases reported so far in 2008. The Viet Nam Drug Administration instructed local health agencies and drug firms to stock up on drugs to respond to the current escalation.
(ProMED 5.25.08)

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Viet Nam: Death toll from hand-foot-mouth disease reaches 10
Southern Viet Nam has 500 hand-foot-mouth disease (HFMD) patients hospitalized. According to the HCM City Pasteur Institute, the region has recorded 10 deaths by the disease so far in 2008, nearly two times more than the number claimed by petechial fever.

Dr. Luong Chan Quang of the HCM City Pasteur Institute warned that it is difficult to diagnose HFMD in children because not all patients have typical symptoms — water spots on their bodies. Patients who experience mental complications or encephalitis may suffer after-effects though they recover. Quang said that seven of the 10 deaths from HFMD in the south were in HCM City. The doctor said that this epidemic boomed in HCM City for the first time in 2003, returned to the city for the second time in 2006 and broke out again in late 2007. Most southern provinces don’t have supervising systems for this epidemic. So far this year, only seven of 20 southern provinces have released reports on HFMD: Ben Tre with 215 patients, Can To 124, Dong Nai 197, Dong Thap 322, Kien Giang 261, HCM City 1018 and Vinh Long 220.

The HCM City Pasteur Institute set up a network to supervise the disease early in 2008. According to reports from three large hospitals in HCM City Children’s Hospitals 1 and 2 and the Tropical Disease Hospital the total number of HFMD patients in 2007 was 2,988, a 30 percent from 2006. The local department of health said that 16 died from the disease in 2007 and only three in 2006. By 8 May 2008, the city had 755 children with HFMD.
(ProMED 5.17.08)

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Americas
Canada (Alberta): Chinook Health announces first confirmed case of hantavirus disease
Chinook Health recently announced that the first case of hantavirus disease has been confirmed in this region, although since 1989, twenty-eight cases throughout Alberta have been reported. Dr. Vanessa Maclean, acting medical officer of health, said given the largely rural population, the potential for someone to contract the virus is always a possibility. Maclean adds the individual has since recovered, but the public needs to remain cautious, as the virus can be aggressive and has a fatality rate of 30 percent.

Contracted primarily when an individual inhales rodent urine and feces, Chinook Health says it's important to not disturb contaminated dry materials.

“Any time people are working in areas inhabited by mice they need to be extra cautious,” says Maclean. The affected individual contracted the virus when cleaning out a barn. Chinook Health says the most effective precaution against infection is to keep rodents out of homes and work areas.
(ProMED 5.17.08)

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USA (Washington): New case of measles in Grant County, outbreak continues
The Grant County Health District has confirmed a new case of measles, making a total of 16 cases in the county. All are residents of Moses Lake and occurred in unvaccinated individuals. A children’s group at the “Say Yes Lord Ministries” bible study, which meets at Chief Joseph Middle School, has been identified as a site where recent exposures have occurred. Public Health officials are working with the exposed families to assure they have access to the MMR (measles, mumps, and rubella) vaccine.
(ProMED 5.22.08)

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3. Updates
AVIAN/PANDEMIC INFLUENZA
(UN; WHO; FAO, OIE; CDC; CIDRAP; PAHO; USGS)

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MEASLES
USA (Measles – United States, 1 Jan 2008-25 Apr 2008)
Measles, a highly contagious acute viral disease, can result in serious complications and death. As a result of a successful US vaccination program, measles elimination was declared in the United States in 2000. The number of reported measles cases has declined from 763,094 in 1958 to fewer than 150 cases reported per year since 1997. During 2000-2007, a total of 29-116 measles cases (mean: 62, median: 56) were reported annually. However, during 1 Jan 2008-25 Apr 2008, a total of 64 confirmed measles cases were preliminarily reported to CDC, the most reported by this date for any year since 2001. Of the 64 cases, 54 were associated with importation of measles from other countries into the United States, and 63 of the 64 patients were unvaccinated or had unknown or undocumented vaccination status. This report describes the 64 cases and provides guidance for preventing measles transmission and controlling outbreaks through vaccination, infection control, and rapid public health response. Because these cases resulted from importations and occurred almost exclusively in unvaccinated persons, the findings underscore the ongoing risk for measles among unvaccinated persons and the importance of maintaining high levels of vaccination.

Measles cases in the United States are reported by state health departments preliminarily to CDC, and confirmed cases are reported officially via the National Notifiable Disease Surveillance System, using standard case definitions and case classifications. Cases are considered importation associated if they are: 1) acquired outside the United States (that is, international importation), or 2) acquired inside the United States and either epidemiologically linked via a chain of transmission to an importation or accompanied by virologic evidence of importation (that is, a chain of transmission from which a measles virus is identified that is not endemic in the United States). Other US cases are classified as having an unknown source.

Between 1 Jan 2008-25 Apr 2008, a total of 64 preliminary confirmed measles cases were reported from the following areas: New York City (22 cases), Arizona (15), California (12), Michigan and Wisconsin (4 each), Hawaii (3), and Illinois, New York state, Pennsylvania, and Virginia (1 each). Patients ranged in age from five months to 71 years; 14 patients were aged <12 months, 18 were aged 1-4 years, 11 were aged 5-19 years, 18 were aged 20-49 years, and 3 were aged >50 years, including one US resident born before 1957. Fourteen (22 percent) patients were hospitalized; no deaths were reported. Transmission occurred in both health-care and community settings. One of the 44 patients for whom transmission setting was known was an unvaccinated health care worker who was infected in a hospital. Seventeen (39 percent) were infected while visiting a health care facility, including a child aged 12 months who was exposed in a physician’s office when receiving a routine dose of measles, mumps, and rubella (MMR) vaccine.

Fifty-four (84 percent) of the 64 measles cases were importation associated: 10 (16 percent) of the 64 were importations (5 in visitors to the United States and 5 in US residents traveling abroad) from Switzerland (3), Israel (3), Belgium (2), and India and Italy (one each); 29 (45 percent) cases were epidemiologically linked to importations; and 15 (23 percent) cases had virologic evidence of importation. The remaining 10 (16 percent) cases were from unknown sources; however, all occurred in communities with importation-associated cases. Specimens from 14 patients were genotyped at CDC, and four different genotypes were identified: three from Arizona (genotype D5), three from California (D5), five from New York City (one in a case epidemiologically linked to an imported case from Belgium and four in cases in communities where importations from Israel had occurred; all D4), two from Wisconsin (H1), and one from Michigan (D5).

Fifty-six of the 64 measles cases reported in 2008 have occurred in five outbreaks (defined as three or more cases linked in time or place). In New York City, an outbreak of 22 cases has been reported, including four importations and 18 other cases (10 importation associated). In Arizona, 15 cases have been reported; the index patient was an unvaccinated adult visitor from Switzerland. In San Diego, California, 11 cases have been reported, and an additional case spread to Hawaii; the index patient in the San Diego outbreak was an unvaccinated child who had traveled to Switzerland. In Michigan, four cases have been reported; the index patient was an unvaccinated youth aged 13 years with an unknown source of infection. In Wisconsin, four cases have been reported; the index patient was a person aged 37 years with unknown vaccination status who likely was exposed to a Chinese visitor with measles-compatible illness. 63 of the 64 patients were unvaccinated or had unknown or undocumented vaccination status, and one patient had documentation of receiving two doses of MMR vaccine. None of the five patients who were visitors to the United States had been vaccinated. Among the 59 patients who were US residents, 13 were aged <12 months and too young to be vaccinated routinely, seven were children aged 12-15 months and had not yet received vaccination, 21 were children aged 16 months-19 years, including 14 (67 percent) who claimed exemptions because of religious or personal beliefs. Among the 18 patients aged >20 years, 14 had unknown or undocumented vaccination status, two had claimed exemptions and acquired measles in Europe, one had evidence of immunity because of birth before 1957, and one had documentation of receiving two doses of MMR vaccine.

Of the five US residents with measles who were vaccine eligible and had traveled abroad, all were unvaccinated. One was a child aged 15 months who was not vaccinated before travel, and two were adults who were unvaccinated because of personal belief exemptions. For two adults, the reason for not being vaccinated was unknown.
(ProMED 5.17.08)

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4. Articles
The evolutionary genetics and emergence of avian influenza viruses in wild birds
Dugan VG, et al. PLoS Pathog. 2008;4(5):e1000076.
http://www.plospathogens.org/article/info%3Adoi%2F10.1371%2Fjournal.ppat.1000076

Abstract We surveyed the genetic diversity among avian influenza virus (AIV) in wild birds, comprising 167 complete viral genomes from 14 bird species sampled in four locations across the United States. These isolates represented 29 type A influenza virus hemagglutinin (HA) and neuraminidase (NA) subtype combinations, with up to 26% of isolates showing evidence of mixed subtype infection. Through a phylogenetic analysis of the largest data set of AIV genomes compiled to date, we were able to document a remarkably high rate of genome reassortment, with no clear pattern of gene segment association and occasional inter-hemisphere gene segment migration and reassortment. From this, we propose that AIV in wild birds forms transient “genome constellations,” continually reshuffled by reassortment, in contrast to the spread of a limited number of stable genome constellations that characterizes the evolution of mammalian-adapted influenza A viruses.
(CIDRAP 5.29.08)

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Experimental infection of cattle with highly pathogenic avian influenza virus (H5N1)
Kalthoff D, et al. Emerg Infect Dis. 2008 Jul; [Epub ahead of print]
http://www.cdc.gov/eid/content/14/7/pdfs/07-1468.pdf

Abstract
Four calves were experimentally inoculated with highly pathogenic avian influenza virus A/cat/Germany/R606/2006 (H5N1) isolated from a cat in 2006. All calves remained healthy, but several animals shed low amounts of virus, detected by inoculation of nasal swab fluid into embryonated chicken eggs and onto MDCK cells. All calves seroconverted.
(CIDRAP 5.28.08)

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Contemporary North American influenza H7 viruses possess human receptor specificity: Implications for virus transmissibility
Belser JA, et al. PNAS. 2008;105(21):7558-7563
http://www.pnas.org/cgi/content/full/105/21/7558

Abstract
Avian H7 influenza viruses from both the Eurasian and North American lineage have caused outbreaks in poultry since 2002, with confirmed human infection occurring during outbreaks in The Netherlands, British Columbia, and the United Kingdom. The majority of H7 infections have resulted in self-limiting conjunctivitis, whereas probable human-to-human transmission has been rare. Here, we used glycan microarray technology to determine the receptor-binding preference of Eurasian and North American lineage H7 influenza viruses and their transmissibility in the ferret model. We found that highly pathogenic H7N7 viruses from The Netherlands in 2003 maintained the classic avian-binding preference for 2–3-linked sialic acids (SA) and are not readily transmissible in ferrets, as observed previously for highly pathogenic H5N1 viruses. However, H7N3 viruses isolated from Canada in 2004 and H7N2 viruses from the northeastern United States isolated in 2002–2003 possessed an HA with increased affinity toward 2–6-linked SA, the linkage type found prominently on human tracheal epithelial cells. We identified a low pathogenic H7N2 virus isolated from a man in New York in 2003, A/NY/107/03, which replicated efficiently in the upper respiratory tract of ferrets and was capable of transmission in this species by direct contact. These results indicate that H7 influenza viruses from the North American lineage have acquired sialic acid-binding properties that more closely resemble those of human influenza viruses and have the potential to spread to naïve animals.
(CIDRAP 5.28.08)

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General practice and pandemic influenza: a framework for planning and comparison of plans in five countries.
Patel MS, et al. PLoS ONE. 2008;3(5):e2269.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0002269

Background
Although primary health care, and in particular, general practice will be at the frontline in the response to pandemic influenza, there are no frameworks to guide systematic planning for this task or to appraise available plans for their relevance to general practice. We aimed to develop a framework that will facilitate planning for general practice, and used it to appraise pandemic plans from Australia, England, USA, New Zealand and Canada.

Methodology/Principal Findings
We adapted the Haddon matrix to develop the framework, populating its cells through a multi-method study that incorporated the peer-reviewed and grey literature, interviews with general practitioners, practice nurses and senior decision-makers, and desktop simulation exercises. We used the framework to analyze 89 publicly available jurisdictional plans at similar managerial levels in the five countries. The framework identifies four functional domains: clinical care for influenza and other needs, public health responsibilities, the internal environment and the macro-environment of general practice. No plan addressed all four domains. Most plans either ignored or were sketchy about non-influenza clinical needs, and about the contribution of general practice to public health beyond surveillance. Collaborations between general practices were addressed in few plans, and inter-relationships with the broader health system, even less frequently.

Conclusions
This is the first study to provide a framework to guide general practice planning for pandemic influenza. The framework helped identify critical shortcomings in available plans. Engaging general practice effectively in planning is challenging, particularly where governance structures for primary health care are weak. We identify implications for practice and for research.
(CIDRAP 5.28.08)

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Household responses to school closure resulting from outbreak of influenza B, North Carolina
Johnson AJ, et al. Emerg Infect Dis. 2008 Jul; [Epub ahead of print]
http://www.cdc.gov/eid/content/14/7/pdfs/08-0096.pdf

Abstract
School closure is a proposed strategy for reducing influenza transmission during a pandemic. Few studies have assessed how families respond to closures, or whether other interactions during closure could reduce this strategy’s effect. Questionnaires were administered to 220 households (438 adults and 355 children) with school-age children in a North Carolina county during an influenza B virus outbreak that resulted in school closure. Closure was considered appropriate by 201 (91%) households. No adults missed work to solely provide childcare, and only 22 (10%) households required special childcare arrangements; two households incurred additional costs. Eighty-nine percent of children visited at least one public location during the closure despite county recommendations to avoid large gatherings. Although behavior and attitudes might differ during a pandemic, these results suggest short-term closure did not cause substantial hardship for parents. Pandemic planning guidance should address the potential for transmission in public areas during school closure.
(CIDRAP 5.28.08)

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Prevention of the spread of infection—the need for a family-centered approach to hygiene promotion
Bloomfield S, et al. Euro Surveill. 2008;13(22):pii=18889
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18889

Abstract
Infectious diseases circulating in the home and community are a continuing and significant burden on the health and prosperity of the European community. They could, however, be significantly reduced by better standards of hygiene. Across Europe, public health is currently structured such that the separate aspects of hygiene in different settings (food hygiene, personal hygiene, hand-washing, pandemic flu preparedness, patient empowerment etc.) are dealt with by separate agencies. If efforts to promote hygiene at community level are to be successful in changing behavior, we need a concerted family-centered approach to ensure that a basic understanding of infectious disease agents and their mechanisms of spread, together with an understanding of a risk-based approach to hygiene, are promoted as part of the school curriculum and as part of public health campaigns. Alongside this, we also need unambiguous communication with the public on issues such as the hygiene hypothesis and environmental issues.
(CIDRAP 5.29.08)

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Increased detections and severe neonatal disease associated with coxsackievirus B1 infection—United States, 2007
MMWR. 2008;57(20):553-556
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5720a4.htm?s_cid=mm5720a4_e

Introduction
Enteroviruses generally cause mild disease; however, neonates are at higher risk for severe illness because of the immaturity of their immune systems. Neonatal systemic enterovirus disease, characterized by multi-organ involvement, is among the most serious, potentially fatal conditions associated with enterovirus infection. Typical clinical presentations include encephalomyocarditis (characteristic of group B coxsackieviruses) and hemorrhage-hepatitis syndrome (typical of echovirus 11). To describe the severity of neonatal illness associated with coxsackievirus B1 (CVB1) infection, CDC analyzed case reports and preliminary data from the National Enterovirus Surveillance System (NESS) for 2007. This report describes the results of that analysis, which indicated that, in 2007, CVB1 for the first time was the predominant enterovirus in the United States, accounting for 113 (25 percent) of 444 enterovirus infections with known serotypes. In addition, phylogenetic analysis of the 2007 CVB1 strains suggested that the cases resulted from widespread circulation of a single genetic lineage. Health-care providers and public health departments should be vigilant to the possibility of neonatal disease caused by CVB1. Testing for enteroviruses in clinically compatible cases and reporting of identified enteroviruses to NESS should be encouraged.
(ProMED 5.22.08)

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5. Notifications
World Vaccine Congress Asia 2008
http://www.terrapinn.com/2008/wvcasia/

2-5 June 2008; Singapore
World Vaccine Congress Asia 2008 is an annual meeting place where vaccine buyers and sellers, health authorities, financing institutions, regulators, big and small vaccine producers and manufacturers, technology providers and other stakeholders come together to discuss industry trend, market and partnership opportunities, new vaccines and new technology innovations across Asia.

Meet vaccine experts from NGOs (e.g. Bill & Melinda Gates, PATH, WHO, IVI) and top vaccine companies such as Green Cross, 9Bio, Novartis, Intercell, Dynavax, Sanofi Pasteur, CNBG, AdImmune, NasVax, Vaxine, Serum Institute of India, IVAC, Shantha Biotechnics, Panacea Biotec and more.

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International Meeting On Emerging Diseases and Surveillance (IMED 2009)
http://imed.isid.org

13-16 Feb 2009; Vienna, Austria
Emerging infectious diseases are at the center of the world’s attention. The threats of pandemic influenza and bioterrorism, and the realization that new infectious diseases may be recognized at any time, in any place, have dramatically raised our awareness. What are the most important emerging disease threats? How can we quickly detect their occurrences in order to respond in a timely and appropriate way?

ProMED, the Program for Monitoring Emerging Diseases, is pleased to invite you to the International Meeting on Emerging Diseases and Surveillance 2009. Along with our co-sponsors, the European Centers for Disease Control, the World Organization for Animal Health, the European Commission, and the Wildlife Conservation Society, we are developing a conference that will bring together the public health community, scientists, health care workers and other leaders in the field of emerging infectious diseases. The meeting will embrace the ‘One Medicine, One Health’ concept recognizing that, just as diseases reach across national boundaries, so do they transcend species barriers. We therefore welcome the full participation of both the human and animal health communities.

IMED 2009 will be organized by the International Society for Infectious Diseases, which has over 20 years experience in planning and implementing international biomedical meetings. Because of the enthusiastic response to the inaugural meeting, IMED 2007, which attracted over 600 participants from 65 countries, IMED 2009 will expand to three full days of sessions and include more opportunities for oral presentations of submitted abstracts.

Abstract Submission: The deadline for abstract submission is December 1, 2008.

Target Audience: ProMED-mail participants, physicians, veterinarians and other health care workers, public health workers, scientists, pharmaceutical and biotechnology industry, journalists, other interested persons.
(ProMED 5.19.08)

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 apecein@u.washington.edu