Vol. XI No. 17 ~ EINet News Briefs ~ Aug 22, 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: Expert says H9N2 avian influenza could be more common than previously thought
- Indonesia: Researchers find trends in study of Indonesia's H5N1 avian influenza cases
- USA (Rhode Island): H7N3 avian influenza found in four mute swans
- USA (Texas): DelSite Inc. applies to test nasal powder H5N1 avian influenza vaccine

2. Infectious Disease News
- Australia (Queensland): Veterinarian who contracted Hendra virus dies in Brisbane
- China: Two dead from an undiagnosed illness, two others sick
- Philippines (Zambo): Health officials probe 'severe type' of pneumonia
- Russia: 16 people sickened by foodborne toxic paroxysmal myoglobinuria, one death
- Singapore: Hand, foot and mouth death is first in seven years
- Singapore: Update on Kranji Way chikungunya cluster
- Canada (Ontario): 12 confirmed cases of listeriosis, one death
- Canada (Ontario): 10 cases of mumps found in Oxford County
- USA (New Jersey): Two people sickened from Vibrio parahaemolyticus linked to oysters
- USA (New York): 13-year-old girl infected with measles while on European vacation
- USA (Louisiana & Wisconsin): Three cases of La Crosse encephalitis confirmed in two states
- USA (Minnesota): Health officials tracking two cases of measles
- USA (Alaska): Botulism traced to traditionally prepared Native foods
- USA: Second E. coli outbreak linked to meat from Nebraska Beef
- USA (New York): Three people hospitalized with Legionellosis
- USA (California): Raw milk suspected in Campylobacteriosis outbreak
- USA: HHS evaluates proposals for new anthrax vaccine
- USA (Washington): Ellensburg police officer dies from hantavirus infection

3. Updates

4. Articles
- Emerging Infectious Diseases - Volume 14, Number 8 – August 2008
- Predominant Role of Bacterial Pneumonia as a Cause of Death in Pandemic Influenza: Implications for Pandemic Influenza Preparedness
- Planning for an Influenza Pandemic: Thinking beyond the Virus
- Neutralizing antibodies derived from the B cells of 1918 influenza pandemic survivors
- Coordinated Implementation of Community Response Measures (Including Social Distancing) to Control the Spread of Pandemic Respiratory Disease
- Avian influenza vaccines: a practical review in relation to their application in the field with a focus on the Asian experience
- Factors associated with case fatality of human H5N1 virus infections in Indonesia: a case series

5. Notifications
- One Health Initiative Task Force: Final Report
- PHI2008--Envisioning Options for Integrated Public Health Information Systems for Low Resource Settings: Components, Connections, Partners, Strategies
- The 7th International Bird Flu Summit
- No Ordinary Flu: Preparedness comic book in multiple languages

1. Influenza News

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

Bangladesh / 1 (0)
China / 3 (3)
Egypt / 7 (3)
Indonesia / 18 (15)
Viet Nam / 5 (5)
Total / 34 (26)

***For data on human cases of avian influenza prior to 2008, go to: http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 385 (243).
(WHO 6.19.08 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 6.19.08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 8.18.08): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 8.14.08): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html


Global: Expert says H9N2 avian influenza could be more common than previously thought
The H9N2 bird flu strain, identified as a possible pandemic threat, could be infecting more humans than commonly thought, but its mild symptoms mean it often goes undetected, a leading Hong Kong bird flu expert said. "It's quite possible. . .H9N2 is infecting humans quite a lot, much (more) than we appreciate merely because it is beyond the radar," Malik Peiris, a Hong Kong-based microbiologist, said. "In humans, it is very mild, so most of the time it's probably not even recognized or biologically tested," said Peiris, who has co-authored several papers on the strain in recent years.

So far, only a handful of human H9N2 cases have been documented worldwide, including four children in Hong Kong in 2003 who suffered from mild fevers and coughs -- as well as a batch in China's Guangdong province, where people often live in close proximity to poultry, Peiris said. The Hong Kong cases were only picked up by chance given the city's rigorous influenza testing regime, Peiris said. "It's quite a silent virus, it's not highly pathogenic. . .and sometimes it causes some morbidity in poultry but by and large it is just there and it's unnoticed," Peiris said of the H9N2 strain.

Most influenza experts agree that a pandemic of some kind of flu is inevitable. No one can predict what kind, but the chief suspect is the H5N1 bird flu virus, which has infected 385 people and killed 243 of them since 2003. However, flu experts at the University of Maryland, St. Jude's Children's Research hospital in Memphis and elsewhere recently wrote in the journal PLoS ONE that the H9N2 strain posed a "significant threat for humans." They found that just a few mutations could turn it into a virus that people catch and transmit easily. Peiris said that while the H9N2 strain might be more transmissible, its effects would be far less devastating than a possible H5N1 pandemic. "There are other viruses out there besides H5N1 that could be the next pandemic," Peiris said. "But I suspect (H9N2) will not be so severe in its outcome." There are hundreds of strains of avian influenza virus but only four -- H5N1, H7N3, H7N7, and H9N2 -- are known to have caused human infections, according to the World Health Organization.
(Reuters 8/15/08)


Indonesia: Researchers find trends in study of Indonesia's H5N1 avian influenza cases
Public health officials from Indonesia recently published an analysis of nearly all of the country's H5N1 avian influenza cases, revealing that death was more likely in those who received antiviral treatment late, were not part of a cluster, and lived in an urban area. The study, published online 15 Aug 2008 in The Lancet, was authored by officials from Indonesia's Directorate General of Disease Control and Environmental Health, the country's health ministry, as well as authorities from laboratories and health organizations. It includes data from public health investigations and, when available, patients' clinical information.

The evaluation covered all confirmed human cases between 22 Jun 2005, when Indonesia recorded its first H5N1 infection, to 1 Feb 2008. Included were 127 patients, 103 (81%) of whom died. The case-fatality rate (CFR) rose from 65% in 2005 to 86.8% in 2007. However, Indonesian officials say the rate has declined so far in 2008. According to a report that appeared 15 Aug 2008 on the Web site of the health ministry's avian influenza committee, the CFR from January through July was 84.2%, based on the 19 cases and 16 deaths recognized by the nation (as of this writing, the World Health Organization has recognized 18 cases with 15 deaths). Only two of Indonesia's 127 infected patients were not hospitalized. One had a mild infection and received outpatient care, and one refused treatment and died at home.

Most patients were hospitalized too late and received oseltamivir too late, the group says. "Training and equipping of all H5N1 referral hospitals across Indonesia, together with increasing the number of referral hospitals, is in progress to address this issue." The authors emphasize that early identification is often difficult, but more information from agricultural officials about local poultry outbreaks could help healthcare workers increase their index of suspicion for H5N1 infections. Other measures that could help reduce the country's CFR from H5N1 infections include rapid diagnostic tests for field use and better case-management training for healthcare workers, they write.

In a commentary accompanying the Lancet report, two British researchers say more uniform and complete data are needed to shed more clarity on trends emerging from Indonesia's cases—which account for a third of cases worldwide. "Basic clinico-epidemiological data are an essential adjunct to virological surveillance," they write. For example, exposures to the H5N1 should be clearly specified, including dates, they say, adding that lack of full data raises questions about such issues as whether the time frame between H5N1 disease onset and hospital admission has decreased over time. "Indonesia, with the most extensive experience of human H5N1 patients, has a crucial clinical, epidemiological, and scientific role to play in the world's response to this potentially devastating infection," write the researchers.
(CIDRAP 8/18/08)


USA (Rhode Island): H7N3 avian influenza found in four mute swans
A bird flu virus strain has been found in four mute swans collected from the Seekonk River -- near the Swan Point Cemetery -- as part of routine state Department of Environmental Management (DEM) surveillance. While the DEM says the strain is not harmful to humans, it is suggesting that all poultry owners should have their flocks tested. Tests by the U.S. Department of Agriculture (USDA) detected that the swans, part of a sample of 11 birds, were infected with the H7N3 strain of avian influenza virus. But the DEM emphasized in a news release on 21 Aug 2008 that it was not the same strain that has infected people in Asia and Europe since 2003, and there is no known significant health risk to people who are exposed to this strain of the virus. There are no associated food safety concerns either, the DEM said. Every year, State Veterinarian Scott Marshall at the state's Department of Environmental Management said on 21 Aug 2008, a single duck or bird tests positive for this flu. But in 2008, several birds tested positive for the virus. "That's what we find a little more alarming," he said.
(ProMED 8/21/08)


USA (Texas): DelSite Inc. applies to test nasal powder H5N1 avian influenza vaccine
DelSite Inc. has announced DelSite Biotechnologies, Inc., its wholly-owned subsidiary, filed an Investigational New Drug (IND) application with the FDA for its lead product candidate GelVac(tm) nasal powder H5N1 influenza vaccine. The IND application is for a Phase I safety and immunogenicity study of this influenza vaccine in healthy volunteers. The filing initiates a 30-day review period by the FDA. The FDA may request additional information and clarification before the clinical study can begin. Leading up to this IND application, DelSite completed a series of development milestones, including animal toxicology studies, a Phase I safety study of GelVac(tm) nasal powder without an antigen and pilot cGMP manufacturing of the vaccine product suitable for clinical studies.

The GelVac(tm) nasal powder platform combines the advantages of nasal immunization and powder formulation and brings distinct benefits to the vaccine products and patients. These include room temperature stability, cold chain-free distribution and needle-free administration, making this vaccine particularly well-suited for influenza pandemic preparedness, as well as epidemic control. Dr. Carlton Turner, CEO of DelSite, commented, ``I believe the GelVac(tm) platform facilitates the beginning of a true paradigm shift away from needles for the delivery of vaccines. GelVac(tm) is a powder formula that can be self-administered nasally using a unit dose device. The nasal powder formulation needs no preservatives, no adjuvants, no needles and cold storage is not required. Since one kilogram of the GelSite(r) polymer in the GelVac(tm) formula can make more than 8 million doses, the cost per vaccine dose can be significantly reduced. DelSite has one influenza vaccine that has been stable for over 3 years at room temperature.
(Globe Newswire 8/20/08)


2. Infectious Disease News

Australia (Queensland): Veterinarian who contracted Hendra virus dies in Brisbane
A Brisbane vet who fell ill with Hendra virus infection has died in hospital. The veterinarian and a nurse contracted the virus infection in July 2008 after treating horses at the Redlands Veterinary Clinic in Brisbane's east. The doctor died in the Princess Alexandra Hospital overnight, clinic owner David Lovell said on 21 Aug 2008. Lovell said, "He was the first person who became infected in this outbreak and he's been very, very seriously ill in hospital."

A second veterinary nurse remains in hospital with the disease but Dr. Lovell believes her condition is improving. Dr Lovell said he could not go into details about [the] nurse's condition but "some good news there, she's doing quite well." Also infected with the virus were five horses from the Redlands Clinic. Four have died or been euthanized. One horse surviving the infection has been euthanized as a disease security measure.
(ProMED 8/21/08)


China: Two dead from an undiagnosed illness, two others sick
A fourth child has fallen ill with a mystery virus that is suspected to have killed two children and left one in serious condition, health officials said on 21 Aug 2008. The latest patient, a three-year-old boy, was admitted to hospital on 19 Aug 2008 with fever and vomiting. His condition worsened after convulsions, and he fell into a coma, the Centre for Health Protection said. His condition was said to be critical on 21 Aug 2008, with signs of blood poisoning and brain abnormalities.

Health officials are already conducting an investigation into the illnesses after the deaths last week of two girls, nine and three, who suffered from inflammation of the heart and blood poisoning. A third girl, seven, is in critical condition, suffering from brain inflammation. Thomas Tsang Ho-fai, controller of the Centre for Health Protection, said it was not known whether one single virus or different viruses were responsible and an investigation was ongoing.
(ProMED 8/21/08)


Philippines (Zambo): Health officials probe 'severe type' of pneumonia
Zamboanga City's health office was reported to be studying a severe type of pneumonia among its residents. 1,500 patients suspected to be affected by the severe pneumonia were subjected to a series of tests by the Department of Health [DOH]. City health officer Rodel Agbulos said that a recent study by DOH among pneumonia patients showed that a "vectoral viral strain" was present. Agbulos said they have already coordinated with the regional health office on how to further study the disease. Agbulos, however, said that residents have nothing to worry about since the virus is a common upper respiratory tract infection although, he also said, it is stronger than ordinary pneumonia and is not common to local residents. The virus could have been brought by those who are coming in and out of Zamboanga City including deportees from Malaysia.
(ProMED 8/18/08)


Russia: 16 people sickened by foodborne toxic paroxysmal myoglobinuria, one death
A total of 16 people have suffered from eating fish from Lake Kotokel. 12 are in the hospital, three have been discharged, and one person has died as a result of foodborne toxic paroxysmal myoglobinuria. It is an acute disease that sporadically takes place among predator fish. The etiology of the disease is unknown, but the ill fish can be toxic for people. The first outbreak of the disease was registered in Gaff [Haff] bay. The cause of the disease in fish are plant toxins and can lead to mass deaths of fish. A state of emergency has been declared in this location.
(ProMED 8/18/08)


Singapore: Hand, foot and mouth death is first in seven years
A three-year-old boy died on 6 Aug 2008 after being diagnosed with hand, foot and mouth disease (HFMD), the first fatality here since 2001. His elder sister has also been infected, but no details are available on her condition. Elias Kindergarten in Woodlands, where the boy was a pupil, has been told to close for 10 days for a clean-up, and to help stop the disease spreading among children there. The Health Ministry said on 7 Aug 2008 15 children at the kindergarten have been diagnosed with HFMD.
(ProMED 8/8/08)


Singapore: Update on Kranji Way chikungunya cluster
The Ministry of Health (MOH) was notified of eight additional cases of chikungunya fever involving six foreign workers and two locals working at Kranji Way. Of the foreign workers five are working and residing at the site in Kranji Way, while the remaining worker commutes daily from Malaysia. The total number of cases linked to Kranji Way currently stands at 28.

NEA officers have been conducting intensive mosquito control operations within the vicinity of the cases' workplace and residences, and the areas that they frequent. More than 28 premises have been inspected in the Kranji Way area and a total of 16 premises were found breeding the Aedes mosquito. Outdoor and indoor fogging of insecticide has been carried out for all the premises checked. Residents and premise owners in the vicinity of Kranji Way have all been advised to check their premises daily to remove any stagnant water that may breed mosquitoes.

Singapore on 16 Aug 2008 reported nine new cases of mosquito-borne chikungunya fever, bringing to 117 the total number of such cases this year.
(ProMED 8/12/08, 8/14/08, 8/17/08)


Canada (Ontario): 12 confirmed cases of listeriosis, one death
At least one person is dead and 16 others ill across Canada from a bacterial infection that can be fatal to the infirm, the elderly, and unborn children -- and could be linked to a massive, nationwide recall of ready-to-eat meat products made by food giant Maple Leaf Foods. Health authorities in Ontario are dealing with 12 confirmed cases of listeriosis, a disease caused by the bacterium Listeria monocytogenes -- often found in soil, vegetation, animal feed, and feces, and recently in certain processed meats produced by a Maple Leaf plant in Toronto. Listeriosis was the "underlying cause of death" in the case of the one known fatality, said Dr David Williams, Ontario's acting chief medical officer of health. The number of confirmed cases, which seem to consist primarily of nursing home residents, could grow as health units across the province continue to submit reports on the disease, he added. "The pattern was people in certain long-term care facilities" across southern Ontario, Williams said. "The median age in the males is 76 and in the females is 80."

Nursing homes, deli counters, and restaurants are among the establishments where the meat products -- which include turkey, ham, corned beef, and roast beef -- were distributed. Maple Leaf spokeswoman Linda Smith said the company is taking all the necessary precautions, including shutting down the plant, providing additional food safety training for employees, and ensuring the public is aware of the situation. "This is a company that has a culture of food safety," Smith said. "We're taking appropriate, broad, comprehensive, and definitive action as it relates to this facility. This involves people -- we want people to understand there's a recall, we want people to have that information." The recall is costing the company approximately [CAD] 2 million [USD 1.9 million], Smith added.
(ProMED 8/21/08)


Canada (Ontario): 10 cases of mumps found in Oxford County
Public health officials have scheduled two immunization clinics following an outbreak of mumps in Oxford County, Ontario, Canada. A total of 10 cases of mumps have been confirmed, primarily in Norwich Township. A percentage of the Netherlands Reformed community who live there have not received the MMR vaccine that protects against measles, mumps and rubella. "All 10 were unimmunized people," said Mike Bragg, director of Oxford County Public Health and Emergency Services. In 2005, an outbreak of measles spread quickly throughout the unimmunized population of Rehoboth Christian School in Norwich, whose 651 pupils are members of the Netherlands Reformed community. A final tally of lab-confirmed reports topped out at 283 cases of rubella within county borders.
(ProMED 8/10/08)


USA (New Jersey): Two people sickened from Vibrio parahaemolyticus linked to oysters
New Jersey state officials shut down the Delaware Bay oyster beds on 19 Aug 2008 after two people were sickened from Vibrio parahaemolyticus linked to oysters from those waters. The state Department of Environmental Protection (DEP) temporarily closed New Jersey coastal waters from the Maurice River Cove south of Port Norris northwest to Artificial Island, Salem County. The DEP dubbed the closure a "precautionary" measure as waters are tested.

The two people fell sick from Vibrio parahaemolyticus infection after eating New Jersey oysters in a Maryland restaurant, according to Dawn Thomas, a spokeswoman for the NJ Department of Health and Senior Services. Health officials traced the oysters back to the Ship John and Shellrock oyster beds in the upper Delaware Bay, according to Barney Hollinger, head of the DEP's Delaware Bay Shellfish Council.
(ProMED 8/21/08)


USA (New York): 13-year-old girl infected with measles while on European vacation
On Long Island [New York state], a 13-year-old girl from Babylon became ill with measles, setting off a health alert in Suffolk County. The girl apparently visited the Bay Shore shopping mall on 29 Jul 2008. Health officials say she likely caught measles while traveling through Europe. The 13-year-old patient was presumably unvaccinated and at risk of infection during travel outside the United States. Currently, measles outbreaks are occurring sporadically throughout Europe, and measles has recently become endemic again in the United Kingdom 14 years after local transmission had been halted by vaccination.
(ProMED 8/17/08)


USA (Louisiana & Wisconsin): Three cases of La Crosse encephalitis confirmed in two states
In Louisiana, a Rapides Parish teenager has been diagnosed with a rare [strain] of encephalitis carried by mosquitoes, according to a report filed on 5 Aug 2008 by the Louisiana Department of Health and Hospitals. The strain, called the La Crosse virus, was recently discovered in a 13-year-old currently under treatment for the disease, said state epidemiologist Dr Raoult Ratard. No further information about the Rapides teenager is being released by state officials, including the severity of the infection.

In Wisconsin, a local health department has confirmed two cases of Lacrosse encephalitis. The patients are two adults from Polk County. Public Health Supervisor Bonnie Leonard hasn't released the identities, ages, or the gender of either patient. She also won't say which communities they're from. Both cases were confirmed in July 2008 in separate areas of the county. Leonard says one of the patients will make a full recovery, the other; she hasn't gotten a hold of.
(ProMED 8/8/08 & 8/22/08)


USA (Minnesota): Health officials tracking two cases of measles
Measles is back in Minnesota. For the first time since 2001, a child in the state has picked up the infectious disease from someone in the community, adding one more case to what health officials say is a worrisome number nationally. The Minnesota child, who lives in Hennepin County but who has not been identified, is 10 months old -- too young to have received a measles vaccine that is typically given at 12 months. The child contracted it from an unidentified person in the community, said Ruth Lynfield, state epidemiologist. That's a rare way for the disease to spread in Minnesota, where the handful of cases in recent years has resulted after travel to areas where measles is more common.

But it fits a concerning trend nationally. Between January and July 2008, 127 measles cases in 15 states were reported to the Centers for Disease Control and Prevention [CDC], the largest number in the past seven years. So far, no child has died. Most cases have occurred in children whose parents decided against having them vaccinated for religious reasons or because of concerns about the safety of vaccines.
(ProMED 8/8/08)


USA (Alaska): Botulism traced to traditionally prepared Native foods
Rural Alaskans continued to experience a high rate of food-borne infections, including botulism; 10 cases of botulism were reported in Alaska in 2007. All but one of the botulism cases occurred in Southwest Alaska, according to the state epidemiology section. Each case was traced to traditionally prepared Alaska Native foods, including specific problems with fermented beluga, fermented beaver tail, fermented seal flipper, seal blubber, whale blubber and fermented fish heads. One person died from botulism.

Foodborne botulism has often been from home-canned foods with low acid content, such as asparagus, green beans, beets and corn. However, botulism also occur from more unusual sources, such as chopped garlic in oil, chili peppers, tomatoes, carrot juice, improperly handled baked potatoes, and home-canned or fermented fish. Nine of the 10 botulism cases in Alaska have been from home-prepared food.
(ProMED 8/11/08)


USA: Second E. coli outbreak linked to meat from Nebraska Beef
Nebraska Beef, Ltd., a processor based in Omaha, has recalled 1.2 million pounds of its beef after federal and state officials linked its products to a second multistate Escherichia coli O157H7 outbreak that has so far sickened 31 people in 12 states and Canada. An earlier E coli O157:H7 outbreak traced to contaminated meat from Nebraska Beef led to the recall of more than five million pounds of beef produced in May and June 2008. So far, that outbreak has sickened 49 patients in seven states, most of them in Michigan and Ohio, according to an 18 Jul 2008 update from the Centers for Disease Control and Prevention (CDC).

On the same day as the Nebraska Beef recall, Whole Foods Market, a natural and organic food market, announced that it recalled fresh ground beef sold under the Coleman Natural Beef label from its stores in 23 states, the District of Columbia, and Canada. The company said in an 8 Aug 2008 statement that though only illnesses in Massachusetts and Pennsylvania have been linked to Whole Foods Market, the company broadened its recall as a precaution. Whole Foods Market said it based its recall on findings from state E coli O157:H7 outbreak investigations in Virginia, Ohio, Massachusetts, and Pennsylvania.

Officials from the Massachusetts Department of Public Health (MDPH) said on 8 Aug 2008 that it has so far linked seven cases to the latest E coli outbreak, and interviews with the patients revealed that they ate ground beef products from Whole Foods Market outlets during July 2008. The seven people range from three to 60 years of age. At least five of the patients were hospitalized.
(CIDRAP 8/11/08)


USA (New York): Three people hospitalized with Legionellosis
The Chemung County Health Department and [New York] State Health Department are investigating a reported outbreak of Legionnaires' disease that has sickened three people at the Edward Flannery Apartments senior housing facility on South Main Street in Elmira, NY. All three are hospitalized, but their conditions aren't available because of privacy laws, said Melissa Klossner, Chemung County Heath Department clinical coordinator for public health.

"We're just starting the investigation and we're taking samples in a lot of different places in Elmira," Klossner said. Besides living in Flannery, the three sickened people have other factors in common such as age, health and activities, Klossner said. Robert Page, Chemung County director of public health, said finding common factors is major thrust of the investigation. "We're looking at the building and potential sources and trying to identify if they can find a cause or source of it," Page said. "We're also looking at people who were ill, trying to find common factors. . ." he said.
(ProMED 8/14/08)


USA (California): Raw milk suspected in Campylobacteriosis outbreak
Alexandre Family EcoDairy Farms ended its raw milk supply after several people who consumed the product got sick, including a Crescent City woman who remains in intensive care and is partially paralyzed. The Del Norte County Department of Public Health suspects at least 15 people who ingested raw milk contracted campylobacteriosis, a common bacterial infection found in domesticated animals that can cause gastrointestinal illness in people.

Three cases of Campylobacter infections have been documented by Del Norte County health officials since late June 2008, and the other 12 are awaiting confirmation. The Crescent City woman was the only person who became severely ill. The outbreak occurred between 10 May 2008 and 5 Jun 2008, and officials say it is no longer a risk to the public because the source of the raw milk believed to have caused the infections, Alexandre EcoDairy north of Fort Dick, voluntarily stopped the supply.
(ProMED 8/17/08)


USA: HHS evaluates proposals for new anthrax vaccine
Two Maryland pharmaceutical companies recently announced that they have submitted proposals to produce and deliver at least 25 million doses of a next-generation anthrax vaccine to the nation's Strategic National Stockpile. Both companies—Emergent BioSolutions and PharmAthene—announced in 31 Jul 2008 statements that they submitted responses to a request for proposal (RFP) from the US Department of Health and Human Services (HHS). The RFP was issued in February 2008 and seeks 25 million doses of recombinant protective antigen (rPA) anthrax vaccine, based on a key anthrax protein, with a shelf life of at least two years. Robin Robinson, director of the HHS Biomedical Advanced Research and Development Authority (BARDA), said the agency received multiple offers and that they appear promising. Robinson said that BARDA expects to allocate $1.5 billion toward adding anthrax vaccines to the national stockpile. The government has said it wants to boost the national anthrax vaccine stockpile from 18.2 million doses to enough to protect 300 million, the report said.

The contract would require companies to secure Food and Drug Administration approval for the rPA anthrax vaccine. Initially, the vaccine would be used for pre-exposure prophylaxis in adults, with a future label extension to allow postexposure prophylaxis alongside antibiotics. Federal officials have been seeking a new vaccine formulation that can provide immunity in three doses, rather than the six doses required for the licensed vaccine, and that will cause fewer side effects. The anthrax vaccine currently in the national stockpile, Anthrax Vaccine Adsorbed (AVA), was developed in the 1950s and is produced by Emergent BioSolutions. The product, required for US military personnel serving in high-risk areas, is given in six doses over 18 months, followed by an annual booster. A number of service members have reported serious side effects from the vaccine, and some sued to shelve the program.

Emergent BioSolutions said its new vaccine candidate is a reformulated and more stable version of the rPA 102 vaccine that was originally developed at the US Army Medical Research Institute of Infectious Diseases. It said phase 1 and 2 studies involving 700 human subjects suggest that its rPA anthrax vaccine is safe and well tolerated and produces a protective immune response.
(CIDRAP 8/12/08)


USA (Washington): Ellensburg police officer dies from hantavirus infection
An Ellensburg police officer died on 15 Aug 2008 from what is believed to have been a deadly hantavirus [infection], a rare illness contracted from inhaling airborne urine and feces of mice. The policeman, [age] 34, died at Yakima Valley Memorial Hospital, barely 48 hours after suffering symptoms. Victims of a hantavirus infection may suffer flu-like symptoms and die of suffocation. Police said it's unknown at this time when or exactly where the officer contracted the rare, but often fatal disease.
(ProMED 8/19/08)


3. Updates
- UN: http://www.undp.org/mdtf/influenza/overview.shtml 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. This site also includes a list of useful links to governments, international agencies, NGOs, and scientific organizations.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The Influenza Virus Tracking System is now live and can be accessed by the public at: www.who.int/fluvirus_tracker.
- UN FAO: http://www.fao.org/avianflu/en/maps.html. View the latest cumulative highly pathogenic avian influenza outbreak maps.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: http://www.cdc.gov/flu/avian/index.htm. Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help hospital administrators and state and local health officials prepare for the next influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.pandemicflu.gov/. View the factsheet "Control of Pandemic Flu Virus on Environmental Surfaces in Homes and Public Places" at: http://www.pandemicflu.gov/plan/individual/panfacts.html
- CIDRAP: http://www.cidrap.umn.edu/ See "Promising Practices: 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 the Avian Influenza Portal at: http://influenza.bvsalud.org/php/level.php?lang=en&component=19&item=1. The Portal is a developing project for the operation of product networks and information services, for specialists, authorities and the general public.
- 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 and poultry.


Philippines (Sultan Kudarat)
A total of 18 people have died as a result of a cholera outbreak in two tribal communities in Palimbang, Sultan Kudarat. The victims were residents of the hamlets of Sagpaw and Biao in Barangay Milbuk, which are Manobo communities. The first victims of the cholera outbreak were initially reported by the villagers during the week of 28 Jul-3 Aug 2008 when several people started complaining of diarrhea. The two hamlets are located several kilometers away from the Milbuk village proper. Residents have to walk down from their mountain location to reach the village health center.
(ProMED 8/11/08)

Viet Nam (Thanh Hoa)
An acute diarrheal disease has recurred in Thanh Hoa province. The first patient who tested positive for the cholera bacterium in the province lives in the Truong Son ward, Thanh Hoa city. Earlier, the patient was on board a ship to go out to sea with five fishermen who later suffered from acute diarrhea. After that 12 more people were reported sick with the disease, six of whom tested positive for cholera. In late July 2008, some patients with acute diarrhea were reported in Hai Ha, Truong Lam, Hai Thuong, and Nghi Son communes of Tinh Gia district, thus bringing the total of patients in the province to 19, 13 of whom tested positive for cholera.
(ProMED 8/11/08)

Viet Nam (north)
Acute diarrhea has recurred in northern cities and provinces, including Hanoi, Nam Dinh, and Hai Duong, said the Ministry of Health on Sun 3 Aug 2008. In Nam Dinh, 287 people have been hospitalized so far in 2008, 124 have tested positive for cholera. Patients contracted the disease in Hanoi after eating uncooked food and raw vegetables.
(ProMED 8/11/08)


An imported dengue case from Cote d'Ivoire was diagnosed 26 Jun 2008 in Japan. Chikungunya virus was negative by PCR. The patient was a 65-year-old man who stayed in Abidjan from 19 May 2008 to 17 Jun 2008. He arrived in Japan 19 Jun 2008 and was hospitalized for eight days because of high fever, myalgia, thrombocytopenia, and hemorrhagic tendency. Dengue virus type 3 was detected by real-time PCR and isolated by cell culture. The E gene of the isolated virus was sequenced; the virus was shown with 99.4 percent homology to the isolate (GenBank AM746229) of Saudi Arabian (Jeddah) in 2004.
(ProMED 8/18/08)

In EW [epidemiological week] 31 (27 Jul-2 Aug 2008), 20 cases of classical dengue have been reported by the Directorate General of Epidemiology. The accumulated recorded [dengue] cases at the national level are 9,529 cases of classic dengue through EW 31 (2008), of which 2,268 cases were laboratory confirmed, 5,091 are classified as probable cases, and 2,170 have been discarded.

Cases of DHF [dengue hemorrhagic fever] through EW 31 include reports of 27 cases with 16 being reported as confirmed. There are still six classified as probable cases and five have been discarded.
(ProMED 8/18/08)

Thailand (Rayong)
The Rayong provincial administration announced that the province is a dengue disaster zone after 1,397 people were infected and two of them were killed by dengue in 2008. Rayong deputy governor Siripong Hantrakul said declaring a disaster zone allowed the provincial administration to spend its emergency fund of Bt 50 million [USD 1,484,340] to fight the dengue spread. He said Rayong remained at the top of the list of provinces with the highest dengue spread rate.
(ProMED 8/11/08)


Date: 9 August 2008: 3 WNV human cases

Date: 13-19 Aug 2008
States newly reporting new human WNV cases: Montana, New Mexico There have been a total of 238 human cases and 2 fatalities to date in 2008.
(ProMED 8/20/08)


4. Articles
Emerging Infectious Diseases - Volume 14, Number 8 – August 2008
The August 2008 issue online at: http://www.cdc.gov/ncidod/eid/. Several articles of interest are listed below:

- Sirenda Vong et al. Environmental contamination during influenza A virus (H5N1) outbreaks, Cambodia, 2006. http://www.cdc.gov/eid/content/14/8/1303.htm
- Kirk M et al. Obligations to report outbreaks of foodborne disease under the International Health Regulations (2005). http://www.cdc.gov/eid/content/14/9/pdfs/08-0468.pdf
- Uchida Y et al. Highly pathogenic avian influenza virus (H5N1) isolated from whooper swans, Japan. http://www.cdc.gov/eid/content/14/9/pdfs/08-0655.pdf
- Toby Leslie et al. Knowledge, attitudes, and practices regarding avian influenza (H5N1), Afghanistan. http://www.cdc.gov/eid/content/14/9/pdfs/07-1382.pdf


Predominant Role of Bacterial Pneumonia as a Cause of Death in Pandemic Influenza: Implications for Pandemic Influenza Preparedness
Morens DM, et al. The Journal of Infectious Diseases. 2008;198:000–000 http://www.journals.uchicago.edu/doi/full/10.1086/591708

Despite the availability of published data on 4 pandemics that have occurred over the past 120 years, there is little modern information on the causes of death associated with influenza pandemics.

We examined relevant information from the most recent influenza pandemic that occurred during the era prior to the use of antibiotics, the 1918–1919 “Spanish flu” pandemic. We examined lung tissue sections obtained during 58 autopsies and reviewed pathologic and bacteriologic data from 109 published autopsy series that described 8398 individual autopsy investigations.

The postmortem samples we examined from people who died of influenza during 1918–1919 uniformly exhibited severe changes indicative of bacterial pneumonia. Bacteriologic and histopathologic results from published autopsy series clearly and consistently implicated secondary bacterial pneumonia caused by common upper respiratory–tract bacteria in most influenza fatalities.

The majority of deaths in the 1918–1919 influenza pandemic likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory–tract bacteria. Less substantial data from the subsequent 1957 and 1968 pandemics are consistent with these findings. If severe pandemic influenza is largely a problem of viral-bacterial copathogenesis, pandemic planning needs to go beyond addressing the viral cause alone (e.g., influenza vaccines and antiviral drugs). Prevention, diagnosis, prophylaxis, and treatment of secondary bacterial pneumonia, as well as stockpiling of antibiotics and bacterial vaccines, should also be high priorities for pandemic planning.
(CIDRAP 8/18/08)


Planning for an Influenza Pandemic: Thinking beyond the Virus
McCullers JA. The Journal of Infectious Diseases. 2008;198:000-000 http://www.journals.uchicago.edu/doi/full/10.1086/592165?cookieSet=1 (references removed)

R. Théophile H. Laennec was the first to describe the pathology of pandemic influenza. The inventor of the stethoscope and of the technique of auscultation, Laennec published in the early 19th century a series of observations on diseases of the chest which remain relevant reading today. Among his many contributions to science was his recognition while practicing in Paris during the 1803 pandemic that pneumonia was a frequent, fatal complication of influenza. He described an increase in expectoration of yellow to greenish-tinged sputum, an increased frequency of “double” pneumonia, and noted that in most fatal cases, the lungs were at the early pneumonic stage of “engorgement” when examined by autopsy.

This general pattern of increased incidence, increased mortality, and typical pathologic findings of bacterial pneumonia was repeated in virtually all of the generally recognized epidemics and pandemics through the modern era, when rigorous pathologic examination of fatal pneumonia cases fell out of use as a diagnostic modality. Indeed, Edwin O. Jordan, in his comprehensive survey of all literature relevant to the 1918 pandemic, argued that the general clinical and epidemiologic character of the pandemics of 1889–1890 and 1918–1919 were indistinguishable, including the disproportionately high attack rate in young adults which has been regarded to be pathognomonic of the 1918 pandemic. This contention runs counter to the prevailing view espoused in both the scientific and lay media that the 1918 pandemic strain was uniquely virulent, and that factors intrinsic to the behavior of the virus and the pathogenesis of the viral infection must account for the strikingly high worldwide mortality associated with this pandemic.
(CIDRAP 8/18/08)


Neutralizing antibodies derived from the B cells of 1918 influenza pandemic survivors
Yu X, et al. Nature. Advance online publication 17 August 2008. http://www.nature.com/nature/journal/vaop/ncurrent/abs/nature07231.html

Investigation of the human antibody response to influenza virus infection has been largely limited to serology, with relatively little analysis at the molecular level. The 1918 H1N1 influenza virus pandemic was the most severe of the modern era. Recent work has recovered the gene sequences of this unusual strain, so that the 1918 pandemic virus could be reconstituted to display its unique virulence phenotypes. However, little is known about adaptive immunity to this virus. We took advantage of the 1918 virus sequencing and the resultant production of recombinant 1918 haemagglutinin (HA) protein antigen to characterize at the clonal level neutralizing antibodies induced by natural exposure of survivors to the 1918 pandemic virus. Here we show that of the 32 individuals tested that were born in or before 1915, each showed seroreactivity with the 1918 virus, nearly 90 years after the pandemic. Seven of the eight donor samples tested had circulating B cells that secreted antibodies that bound the 1918 HA. We isolated B cells from subjects and generated five monoclonal antibodies that showed potent neutralizing activity against 1918 virus from three separate donors. These antibodies also cross-reacted with the genetically similar HA of a 1930 swine H1N1 influenza strain, but did not cross-react with HAs of more contemporary human influenza viruses. The antibody genes had an unusually high degree of somatic mutation. The antibodies bound to the 1918 HA protein with high affinity, had exceptional virus-neutralizing potency and protected mice from lethal infection. Isolation of viruses that escaped inhibition suggested that the antibodies recognize classical antigenic sites on the HA surface. Thus, these studies demonstrate that survivors of the 1918 influenza pandemic possess highly functional, virus-neutralizing antibodies to this uniquely virulent virus, and that humans can sustain circulating B memory cells to viruses for many decades after exposure—well into the tenth decade of life.
(CIDRAP 8/17/08)


Coordinated Implementation of Community Response Measures (Including Social Distancing) to Control the Spread of Pandemic Respiratory Disease
Developed by: Public Health and Law Enforcement Emergency Preparedness Workgroup. July 2008. http://www2a.cdc.gov/phlp/docs/CRM%20MOU%20Final.pdf

This document was developed during 2007-2008 by the Public Health and Law Enforcement Emergency Preparedness Workgroup (hereinafter the Workgroup). The Workgroup received resource support from the Coordinating Office for Terrorism Preparedness and Emergency Response of the Centers for Disease Control and Prevention (CDC) and was established by CDC’s Public Health Law Program in partnership with the U.S. Department of Justice’s Bureau of Justice Assistance. The Workgroup’s composition included experts from local, state, and national organizations representing the sectors of public health, law enforcement, corrections, and the judiciary.

Workgroup members developed three documents to strengthen cross-sector coordination in public health emergency preparedness, including:

- a broad framework report on improving cross-sector coordination;
- a model memorandum of understanding (MOU) addressing joint public heath and law enforcement investigations of bioterrorism; and
- this guide for developing an MOU for strengthening coordinated cross-sector response to contagious respiratory diseases such as pandemic influenza.
(CIDRAP 8/14/08)


Avian influenza vaccines: a practical review in relation to their application in the field with a focus on the Asian experience
Peyre M, et al. Epidemiology and Infection. Published online, 14 August 2008. http://journals.cambridge.org

Vaccination can be a useful tool for the control of avian influenza (AI) outbreaks, but its use is prohibited in most of the countries worldwide because of its interference with AI surveillance tests and its negative impact on poultry trade. AI vaccines currently in use in the field increase host resistance to the disease but have a limited impact on the virus transmission. To control or eradicate the disease, a carefully conceived vaccination strategy must be accompanied by strict biosecurity measures. Some countries have authorized vaccination under special circumstances with contradictory results, from control and disease eradication (Italy) to endemicity and antigenic drift of the viral strain (Mexico). Extensive vaccination programmes are ongoing in South East Asia to control the H5N1 epidemic. This review provides practical information on the available AI vaccines and associated diagnostic tests, the vaccination strategies applied in Asia and their impact on the disease epidemiology.
(CIDRAP 8/14/08)


Factors associated with case fatality of human H5N1 virus infections in Indonesia: a case series
Kandun IN, et al. The Lancet. Early online publication, 15 August 2008. http://www.thelancet.com/journals/lancet/article/

Indonesia has had the most human cases of highly pathogenic avian influenza A (H5N1) and one of the highest case-fatality rates worldwide. We described the factors associated with H5N1 case-fatality in Indonesia.

Between June, 2005, and February, 2008, there were 127 confirmed H5N1 infections. Investigation teams were deployed to investigate and manage each confirmed case; they obtained epidemiological and clinical data from case-investigation reports when possible and through interviews with patients, family members, and key individuals.

Of the 127 patients with confirmed H5N1 infections, 103 (81%) died. Median time to hospitalisation was 6 days (range 1–16). Of the 122 hospitalised patients for whom data were available, 121 (99%) had fever, 107 (88%) cough, and 103 (84%) dyspnoea on reaching hospital. However, for the first 2 days after onset, most had non-specific symptoms; only 31 had both fever and cough, and nine had fever and dyspnoea. Median time from onset to oseltamivir treatment was 7 days (range 0–21 days); treatment started within 2 days for one patient who survived, four (36.4%) of 11 receiving treatment within 2–4 days survived, six (37.5%) of 16 receiving treatment within 5–6 days survived, and ten (18.5%) of 44 receiving treatment at 7 days or later survived (p=0.03). Initiation of treatment within 2 days was associated with significantly lower mortality than was initiation at 5–6 days or later than 7 days (p<0.0001). Mortality was lower in clustered than unclustered cases (odds ratio 33.3, 95% CI 3.13–273). Treatment started at a median of 5 days (range 0–13 days) from onset in secondary cases in clusters compared with 8 days (range 4–16) for primary cases (p=0.04).

Development of better diagnostic methods and improved case management might improve identification of patients with H5N1 influenza, which could decrease mortality by allowing for earlier treatment with oseltamivir.
(CIDRAP 8/15/08)


5. Notifications
One Health Initiative Task Force: Final Report
http://www.avma.org/onehealth/ (full text)

The convergence of people, animals, and our environment has created a new dynamic—one in which the health of each group is inextricably interconnected. The challenges associated with this dynamic are demanding, profound, and unprecedented. While the demand for animal-based protein is expected to increase by 50% by 2020, animal populations are under heightened pressure to survive, and further loss of biodiversity is highly probable.

Compounding that is the fact that, of the 1,461 diseases now recognized in humans, approximately 60% are due to multi-host pathogens characterized by their movement across species lines. And, over the last three decades, approximately 75% of new emerging human infectious diseases are defined as zoonotic. Our increasing interdependence with animals and their products may well be the single most critical risk factor to our own health and well-being with regard to infectious diseases.

The words of Dr. Gro Harlem Brundtland, former director of the World Health Organization (WHO), were indeed prophetic. In her speech at the United Nations Global Leadership Awards on April 19, 2001, she stated that in a modern world, bacteria and viruses travel almost as fast as money. With globalization, a single microbial sea washes over all humankind and there are no health sanctions. In actuality, that sea washes not over just all humankind, but also across all animal and environmental domains.

Beyond infectious diseases, it is important to note that "noncommunicable" conditions and risks are crossing species and adversely affecting both animal and human health. Examples include obesity and exposure to secondhand tobacco smoke among pets, pet-owners, and their children.

There is nothing on the horizon to suggest that any of these factors are abating. In fact, these factors are likely to accelerate in intensity and complexity, and will surely create consequences and implications of unprecedented scope and scale and global economic devastation much greater than any previous time in history. By adopting the tenets of One Health, we can devise integrated strategies to control that sea and prevent these threats from crossing domains.


PHI2008--Envisioning Options for Integrated Public Health Information Systems for Low Resource Settings: Components, Connections, Partners, Strategies

Dates: 18-19 September 2008
Location: Seattle, USA

PHI2008 will be hosted by Global Partners in Public Health Informatics (GPPHI) at the Center for Public Health Informatics (CPHI) at the University of Washington, Seattle, WA, USA. The idea of creating a partnership of governmental and non-governmental organizations, academic institutions and companies to define and develop a vision for addressing health challenges in low-resource settings through information and communications technologies was first articulated at PHI2007: Building a Global Partnership in Public Health Informatics. PHI2007 brought together nearly 200 individuals from across the globe who created the impetus for the Global Partners in PHI.

The Rockefeller Foundation recently funded the UW Center for Public Health Informatics to begin the planning process for the Global Partners organization. That process will take place over the coming year through an invitational meeting on Public Health Informatics at the Rockefeller Foundation conference center in Bellagio, Italy as well as at the second annual GPPHI meeting -- PHI2008 -- to be held in September 18-19, 2008 at the Bell Harbor Conference Center, Seattle, Washington, USA. The theme for the PHI2008 meeting is "Envisioning Options for Integrated Public Health Information Systems for Low Resource Settings: Components, Connections, Partners, Strategies."

- Keynote addresses by leading international experts
- Plenary presentations: National approaches from countries leading the development of integrated public health information systems; Creative approaches to collecting and linking data and systems to improve public health practice; Strategies for compiling and delivering contextually relevant information for decision support
- Poster sessions presenting research and applied methodologies and results from public health informatics interventions in low-resource settings throughout the world
- Panelist discussions of funding opportunities for research and applications development
- Information exchange and networking opportunities


The 7th International Bird Flu Summit

November 13-14, 2008 in Las Vegas, Nevada. The two-day event will draw on first-hand best practices to create solid business continuity plans that companies and organizations need to prepare for, respond to, and survive a pandemic. Public Health Officials, Top leaders and key decision-makers of major companies representing a broad range of industries will meet with distinguished scientists, law enforcers, first responders, and other experts to discuss pandemic prevention, preparedness, response and recovery at the two day summit.

Discussions topics:
* Surveillance and Data Management
* Preparing Communities Strategies; Local Partnership and Participation
* Delivery of Vaccine and Antiviral Medication
* National Pandemic Influenza Medical Countermeasure
* Socio Economic Impact on Poultry Industry
* Benefit-risk Assessment: Public Health, Industry and Regulatory Perspectives
* Prevention Education Efforts and Risk Communication
* Command, Control and Management
* Emergency Response Management
* Business-Based Planning
* School-Based Planning
* Community-Based Planning and more!

New Fields
1001 Pennsylvania Avenue, NW
6th Floor South
Washington, DC 20004
Tel: (202) 536-5000; Fax: 202.280.1239; email: sharon.villalon@new-fields.com


No Ordinary Flu: Preparedness comic book in multiple languages
To promote pandemic flu preparedness, Public Health - Seattle & King County has developed a 12-page comic book on pandemic flu. Targeting readers of all ages, this story tells the tale of a family’s experience of the 1918 influenza pandemic. It also explains the threat of pandemic flu today, illustrates what to expect during a pandemic (such as school closures), and offers tips to help households prepare. You can order copies (or download) all 12 language versions of the comic (PDF format) at the above link.