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Vol. XI, No. 18 ~ EINet News Briefs ~ Sep 05, 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: Glaxo offers program to boost employer antiviral stockpiling
- Indonesia (West Java): Suspected human case of avian influenza

2. Infectious Disease News
- Malaysia: Chikungunya outbreak continues to spread
- Russia (Republic of Bashkortostan): Village imposes quarantine due to anthrax
- Russia: (Vladivostok): Outbreak of enterovirus infection
- Russia (Altai): Brucellosis confirmed in sheep and humans
- Singapore: New cases of Chikungunya; 150 cases to date in 2008
- Singapore: New outbreak of hand, foot & mouth disease looming
- Canada: 12 deaths reported in large Listeria outbreak
- Canada (Quebec): Salmonellosis outbreak linked to cheese
- Canada: (British Columbia): Clostridium difficile outbreak in hospital
- Canada (British Columbia): Mumps outbreak in Fraser Valley
- USA: Federal officials lift Salmonella warning on peppers
- USA: Anthrax probe prompts concerns about military labs
- USA (New York): Tenth case of Legionellosis; one killed
- USA (Oklahoma): E. coli O111 outbreak kills one, hospitalizes dozens
- USA (Nevada): Tularemia transmitted by pet cat
- USA (Illinois): 47 cases of Rocky Mountain spotted fever
- USA (Connecticut/Wyoming): Bubonic plague sickens teenager

3. Updates
- AVIAN/PANDEMIC INFLUENZA
- CHOLERA, DIARRHEA, AND DYSENTERY
- Dengue
- WEST NILE VIRUS

4. Articles
- Emerging Infectious Diseases - Volume 14, Number 9 – September 2008
- National, State, and Local Area Vaccination Coverage Among Children Aged 19--35 Months--United States, 2007
- Detection of infectious prions in urine
- Fatal Oseltamivir-Resistant Influenza Virus Infection
- The Effects of Avian Influenza News on Consumer Purchasing Behavior: A Case Study of Italian Consumers’ Retail Purchase
- Molecular epidemiology of A/H3N2 and AH1N1 influenza viruses during a single epidemic season in the United States.
- Study: Flu vaccine doesn't lower death rates in elderly
- Increased incidence of rabies in China

5. Notifications
- Public Health Informatics Fellowship Application Deadline--November 14, 2008
- Pandemic Influenza Storybook: Narratives from 1918 and 1957 pandemics
- Promising practices for pandemic planning: Berkeley officials enlist young flu fighters
- The 7th International Bird Flu Summit
- IMED 2009 website updated
- International Symposium on Viral Hepatitis and Liver Disease


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 / 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

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Global: Glaxo offers program to boost employer antiviral stockpiling
GlaxoSmithKline, maker of the antiviral drug zanamivir (Relenza), launched a program designed to help businesses stockpile the drug as a strategy to protect employees in the event of an influenza pandemic. The company said its Pandemic Readiness for Employers Program (PREP) is intended to remove some of the cost and storage barriers that make it difficult to stockpile zanamivir. Though oseltamivir (Tamiflu) is considered the first-line treatment in a pandemic, some health experts advise countries and businesses to diversify their stockpiles because of concern that viral mutations may cause resistance to antiviral medications. On Jun 26, 2008 Roche, the maker of Tamiflu, unveiled its program to support employer antiviral stockpiling. Both companies' programs permit employers to reserve a supply of the antiviral, to be stored and maintained by the manufacturer and delivered only when needed. Roche said its program would not only help businesses prepare for a pandemic, but also bolster sagging demand for the drug, which could help maintain production capacity that would be needed in a global emergency. The US government's strategic national stockpile contains 80% oseltamivir and 20% zanamivir.

Anne Moscona, a professor of pediatrics and microbiology at New York-Presbyterian Hospital/Weill Cornell Medical Center, underscored the importance of keeping a diverse antiviral stockpile. In the May 14, 2008 issue of Nature, British researchers identified certain mutations in the H5N1 avian influenza virus that make it resistant to oseltamivir but leave it sensitive to zanamivir. They advised nations not to rely on oseltamivir alone when preparing for an influenza pandemic. In June 2008 the US Department of Health and Human Services (HHS) released preliminary guidance on antiviral use and stockpiling, which recommended that businesses providing essential goods and services strongly consider antiviral prophylaxis for critical workers.

Glaxo's stockpiling program for employers offers two options. One is a preferred pricing plan that allows businesses to buy zanamivir at a discount price that includes free storage. The discount is 31% less than the wholesale price. After 5 years, companies that enroll in the program can buy replacement units for the expired drug units at the same 31% discount. Each unit represents one treatment course, and the minimum order is 500 units. The second option—the reservation plan—is intended to reduce employers' up-front expenditure and allow them to lock in a price for future zanamivir purchases, Glaxo said. An annual fee of $6 per unit reserves and stores the drug for the life of the contract, which can span up to 10 years and can be canceled without additional cost. Companies will receive their orders when they request them or when the World Health Organization (WHO) raises its pandemic alert level to stage 4 (sustained human-to-human transmission). Glaxo's reservation plan is similar to Roche's employer Tamiflu stockpiling plan.
(CIDRAP 9/3/08)

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Asia
Indonesia (West Java): Suspected human case of avian influenza
A total of five bird flu suspects were detected, and one of them was confirmed positive for the avian influenza A virus, in Malang district, East Java, during Jan-Aug 2008. The bird flu infected patient was aged 47, a resident of Bululawang. Malang health authorities had recorded 10 bird flu related cases and 13 happenings in August 2008 when a number of poultry had died. "Most of the areas infected by the bird flu virus were poultry farms where the environment was not clean," Endy Kuasaery, head of the Malang Animal Husbandry Service, said. A total of 1189 poultry died during Jan-Aug 2008, he said.
(Promed 8/30/08)

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2. Infectious Disease News
Malaysia: Chikungunya outbreak continues to spread
The chikungunya outbreak has spread widely in peninsular Malaysia over the past five months, and appears to be continuing. A total of 224 people nationwide are suspected to be down with chikungunya the week of 24-30 Aug 2008, compared with only 179 in the previous week. Health Ministry disease control director Datuk Dr Hasan Abdul Rahman said 4 Sep 2008 the cases this week were reported in five states, namely, Johor, Melaka, Perak, Penang, and Sarawak. The total number of cases nationwide is 1703 of which 996 were from Johor, Melaka (405), Perak (173), Negeri Sembilan (92), Selangor (26), Pahang (5), Putrajaya (3), Sarawak (2), and Penang (one). Dr Hasan said chikungunya was a disease [virus] that could only be spread by the Aedes mosquito.
(Promed 9/4/08)

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Russia (Republic of Bashkortostan): Village imposes quarantine due to anthrax
Quarantine has been declared in a village in the Russian Republic of Bashkortostan (RB) in the south west Urals after several humans were infected with anthrax, a spokesman for the consumer rights regulator said 29 Aug 2008. The measures were announced after 10 residents of the village, Ural, located in the Yanaulsky district, were hospitalized 27 Aug 2008. The spokesman said the residents fell ill after eating meat from an infected horse that had been killed two weeks earlier without any veterinary tests. The meat has been destroyed, and specialists are looking into how the horse became infected. Livestock has been banned from entering or leaving the village, and all local meat retail has been suspended.
(Promed 8/30/08)

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Russia: (Vladivostok): Outbreak of enterovirus infection
An outbreak of enterovirus has occurred in the city of Vladivostok. About 300 cases have been registered, 269 of whom are children. In half of the cases the disease developed into serous (aseptic) meningitis, which can have serious consequences. Reportedly, all the infections occurred as a consequence of people swimming in the sea around the shores of the territory.

Enteroviral infections are common in childhood. The enteroviruses include numerous strains of coxsackievirus, echovirus, enterovirus, and poliovirus. Enteroviral infections are most common in communities living in conditions of poor hygiene. The infection begins when material contaminated with the virus is swallowed. The virus then reproduces in the digestive tract. The body's immune defenses stop many infections at this stage, and the result is few or no symptoms. Colds and upper respiratory infections are common outcomes of infection with enteroviruses. Sometimes the virus survives and spreads into the bloodstream, resulting in fever, headache, sore throat, and, at times, vomiting. Serous (aseptic) meningitis affects the membranes covering the brain and spinal cord (meninges), causing severe headache, stiff neck, and sensitivity to light. Enteroviral infections usually resolve completely, but infections of the heart or central nervous system are occasionally fatal.
(Promed 8/31/08)

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Russia (Altai): Brucellosis confirmed in sheep and humans
A total of 35 sheep have been tested positive for brucellosis on a farm in the village Volchikha of Volchikhinskaya region. There are 701 sheep on this farm and specimens have been taken from all of them. One sheep died before being tested. The regional office of ministry of emergencies said that there are nine people who came in contact with these sheep. All these people have been tested for brucellosis as well, and three of them had positive results. Currently all sick and suspected animals have been isolated. The entire farm has been disinfected. A ruling of local government has been issued about limitations imposed on sheep in the territory because of brucellosis. Since the beginning of 2008 there have been 10 human brucellosis cases due to contaminated milk or contact with animals.
(Promed 9/2/08)

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Singapore: New cases of Chikungunya; 150 cases to date in 2008
The Ministry of Health (MOH) said a 25-year-old Bangladeshi and a 41-year-old Singaporean were infected with chikungunya. They were working in the vicinity of the Lim Chu Kang Agro Technology Park. As part of active case detection, 30 workers were screened and three more workers were found to be positive for chikungunya virus. They are a 23-year-old Malaysian, a 21-year-old Chinese national, and a 31-year-old Myanmar national. The Health Ministry said the total number of cases linked to Lim Chu Kang now stands at five. Separately, one new case was identified at the Pasir Panjang Wholesale Centre, two at Kranji Way, three at Sungei Kadut, and one each at Yishun and Tuas. To date, a total of 150 cases of chikungunya fever have been notified to MOH this year [2008]. The MOH has advised persons who develop symptoms of chikungunya to consult their doctors immediately. These include fever, joint pain, and rashes. Chikungunya fever is a mosquito-borne disease. Persons infected with chikungunya fever should be isolated from further mosquito bites so as to reduce the risk of further transmission of the virus.
(Promed 8/26/08)

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Singapore: New outbreak of hand, foot & mouth disease looming
Singapore is on the verge of a hand, foot and mouth disease (HFMD) outbreak, health officials revealed 25 Aug 2008. Last week, 553 people came down with the normally mild childhood disease that usually causes fever and rashes on the hands, feet and buttocks--just 12 fewer than the Health Ministry's official 'epidemic level.' The tally last week was up from 415 over the previous 7 days, and officials warn the numbers are likely to rise between now and October, traditionally a peak period for HFMD. This peak, though, usually affects fewer people than the first one from March to May, said Dr. Lyn James, director of the Health Ministry's communicable diseases division.

On 6 Aug 2008, Singapore registered its first death from HFMD since a severe outbreak from 2000 to 2001 killed seven children. The 3-year-old child died from a severe form of HFMD caused by a virus called EV71 [human enterovirus 71]. This virus has been of particular concern to countries in Asia in recent years. This year, it has killed 44 in China, 10 in Taiwan and 11 in Viet Nam.

The Health Ministry and the Regional Emerging Disease Intervention (Redi) Centre organised a two-day regional forum on HFMD, which was attended by more than 80 scientists and public health officers from 12 countries. Local vaccine company SingVax, Chinese vaccine company Sinovac Biotech and Taiwan's Centres for Disease Control gave updates on their progress in developing the world's first HFMD vaccine. Both SingVax and Taiwan's CDC said they have seen good results in the laboratories and hope to start clinical trials in 2009. In the absence of a vaccine, parents should ensure their children wash their hands, because the disease is often spread through saliva and faecal matter. They should also take their children to the doctor at the first sign of symptoms, and keep them away from crowded places, Dr. James said.

Enterovirus 71 (EV71) was initially identified in California in 1969 and outbreaks of EV71 infection have been recorded throughout the world since then. EV71 has been associated with acute febrile illness, myocarditis, aseptic meningitis, acute flaccid paralysis, and encephalitis as well as with HFMD. The largest EV71 epidemic to date occurred in Taiwan in 1998 with nearly 130 000 cases. Since then there have been recurrent HFMD epidemics of varying severity and intensity throughout the Asia-Pacific.
(Promed 8/26/08)

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Americas
Canada: 12 deaths reported in large Listeria outbreak
A Listeria outbreak linked to a Maple Leaf Foods meat product plant in Toronto has expanded to 26 cases, and 12 people have died, though it was not yet clear how many of the deaths were directly due to the illness. The Public Health Agency of Canada (PHAC) said 26 cases involving the outbreak strain of Listeria monocytogenes had been confirmed in Quebec, Ontario, Saskatchewan, and British Columbia. Of the 26, "there are 12 deaths associated with the outbreak strain (11 in Ontario and one in B.C.)," the agency said. "Six of these deaths, reported from Ontario, have linked listeriosis as the underlying or contributing cause of death. . ." The deaths occurred over the past several weeks. The agency said another 29 suspected cases were under investigation. All the suspected cases are known to be listeriosis, but test results were awaited to determine how many involve the outbreak strain, officials said. The agency has said the incubation period for listeriosis can be as long as 70 days.

The outbreak prompted Maple Leaf Foods, Canada's largest food processor, on Aug 20, 2008 to announce a recall of products made on two production lines at its plant in Toronto. On Aug 23 the company expanded the recall to include all products produced at the plant since Jan 2008. Products made there carry the number 97B on their labels. Maple Leaf shares have dropped 18 per cent since 19 Aug 2008, the day before the company expanded a recall of some of its meat products. Maple Leaf said that the recall will cost about CAD 20 million (USD 19.1 million) and said its first priority is to restore consumers' confidence in its products. Maple Leaf said none of the suspect meat had crossed the border into the US.

L monocytogenes can grow on refrigerated meat and cause serious illness in pregnant women, elderly people, and others with weak immune systems. The US Food and Drug Administration (FDA) says these groups should not eat hot dogs or deli meats unless they are reheated, nor should they eat refrigerated meat spreads, refrigerated smoked seafood unless cooked, or products containing unpasteurized milk. Symptoms of the illness include fever, muscle aches, and sometimes nausea or diarrhea. The current outbreak apparently is one of the larger ones in North America in recent years.
(CIDRAP 8/26/08; Promed 8/25/08, 8/28/08)

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Canada (Quebec): Salmonellosis outbreak linked to cheese
One person has died and 87 cases of salmonellosis have been linked to three brands of contaminated cheese in Quebec, authorities said 29 Aug 2008 in announcing a recall. The cases occurred in Chaudiere-Appalaches, Estrie-Mauricie, and Centre-du-Quebec, Dr Horacio Arruda, the province's director of public health, said. The areas experienced an unusually high incidence of cases recently. Quebec normally sees 1000 cases of salmonellosis province-wide every year. The death was an elderly person; about 40 per cent of the people infected had to be treated in hospital for at least a day, Arruda said.

The Quebec Department of Agriculture, Fisheries and Food, in co-operation with Fromages la Chaudiere of Lac-Megantic, warned consumers not to eat any of the non-refined hard cheeses called La Chaudiere, Polo, and Tradition because they might contain Salmonella. Products produced between 24 Jul 2008 and 24 Aug 2008 have been recalled. At the beginning of the investigation, anecdotal information and questionnaires pointed to cheese being involved in the outbreak, Arruda said. "We immediately ordered a special study of the patients as well as other individuals in the region who could have eaten the same food in order to identify the cause," Arruda said. "We found a similar genetic print in many of these cases."
(Promed 9/2/08)

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Canada: (British Columbia): Clostridium difficile outbreak in hospital
Officials say eight patients at Nanaimo Regional General Hospital [NRGH] are currently infected with the Clostridium difficile bacterium. Vancouver Island Health Authority spokeswoman Lesley Moss said 29 Aug 2008 that a total of 57 people have become ill since Apr 2008. She said there are usually two to three cases in such a period. A total of three people have died since Jun 2008. "The elderly are far more vulnerable than anybody else." Moss said if the infection is caught early enough, patients respond well to treatment. "We have increased our infection control measures in the hospital in order to help control this disease," Moss said. It's not clear where the patients got the illness; Moss said, "Lots of the general population have this bacteria growing in their intestine and when they start on antibiotics for different reasons this bacteria then flares up."

The C. difficile bacterium is commonly found in hospitals and long term care facilities. It can be spread through contact with surfaces by people who have not washed their hands after using the bathroom, Moss said. The infection causes swelling and irritation of the large intestine and symptoms can include diarrhea, fever and cramps. Moss said the hospital is being thoroughly cleaned and epidemiologists were at NRGH reviewing charts, touring the hospital and examining patient flow and transmission in an attempt to determine how the bacteria spread.

Clostridium difficile is the most common cause of bacterial diarrhea and pseudomembranous colitis in hospitalized patients, and antimicrobial drug therapy is the most important risk factor. Preventing the spread of C. difficile in health care facilities involves clinical and microbiologic surveillance of hospitalized patients with diarrhea for C. difficile and heightened infection control measures, including prompt isolation of patients with C. difficile-positive diarrhea or cohorting, combined with emphasis on hand hygiene and control of the inappropriate use of antimicrobial agents.
(Promed 9/1/08)

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Canada (British Columbia): Mumps outbreak in Fraser Valley
A growing mumps outbreak has been reported in the Fraser Valley. About 200 people have been verified to have the virus, Dr Elizabeth Brodkin, medical health officer for the Fraser Health Authority, said. In an average year, fewer than 100 cases are reported in Canada. The British Columbia Centre for Disease Control is convening a provincial task force to develop a strategy for combating the outbreak. Mumps is spread through saliva, and health officials warned against the sharing of water bottles, drinking cups, musical instruments, and cigarettes as well as coughing and sneezing without covering the nose and mouth. The virus arrived in British Columbia from Alberta, where 300 people were infected, and spread through a Fraser Valley religious group that shuns immunization, Brodkin said. "This outbreak, at least, got going because it took hold in an unimmunized community, so they are the ones who are really sitting ducks for infection." About a third of those who are infected with the virus don't have any symptoms but could still be spreading it. Symptoms include swelling of the glands under the jaw and chin and can be as severe as meningitis or inflamed testicles. Immunity to mumps dissipates over time, and people who've had the disease 30 years ago could contract it again unless they are revaccinated, Brodkin said.
(Promed 8/27/08)

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USA: Federal officials lift Salmonella warning on peppers
Federal officials lifted their warning about eating raw jalapeno and Serrano peppers from Mexico and said the nation's largest foodborne illness outbreak, which was linked to an uncommon Salmonella strain, appears to be over. Robert Tauxe, deputy director of the Centers for Disease Control and Prevention's (CDC's) Division of Foodborne, Bacterial and Mycotic Diseases, said the CDC and state health departments would continue to conduct surveillance for more infections with the Salmonella enterica serotype Saintpaul outbreak strain. In Aug 2008, the number of new Salmonella Saintpaul illnesses has dropped to a level that officials typically expect to see outside of an outbreak. "Also, the last cluster was reported in early July, which is another important indicator that the outbreak is over," he said.

David Acheson, commissioner for foods at the US Food and Drug Administration (FDA), said peppers from two Mexican farms implicated in the outbreak are no longer in circulation. He said the FDA has stepped up surveillance of produce coming across the border from Mexico and that some shipments have been turned back because some were contaminated with Salmonella, but not the national outbreak strain. CDC and FDA also released an epidemiologic report on the outbreak, which appears in the current issue of Morbidity and Mortality Weekly Report (http://cdc.gov/mmwr/preview/mmwrhtml/mm5734a1.htm ). As of Aug 25, 1,442 cases have been linked to the outbreak, which has sickened patients in 43 states, the District of Columbia, and Canada. So far at least 286 patients have been hospitalized. No deaths have been connected directly to the outbreak, but illnesses may have contributed to the death of two older men.

Tauxe said officials still suspect that contaminated tomatoes played a role earlier in the outbreak, but said microbiologic and epidemiologic findings revealed jalapeno and Serrano peppers as the sources. The first case-control study, which was conducted in mid May, showed that infections were significantly associated with raw tomatoes, but not with salsa or guacamole. A month later, a case cluster investigation revealed a connection between illnesses and eating salsa, which included raw tomatoes and raw jalapeno peppers. In late June, another case cluster study showed a connection to eating salsa at a Mexican restaurant chain; the salsa was made from canned tomatoes and raw jalapenos. The following week, officials investigated another case cluster that linked illnesses only to raw jalapenos. In July, investigation of a case cluster revealed an association with guacamole, but it contained Serrano peppers, not jalapenos.

According to the trace-back investigation, FDA officials traced jalapenos from Texas case clusters to a distributor in Texas, where they found a positive jalapeno sample, and then to a farm in Tamaulipas, Mexico, that also grew Serrano peppers and Roma tomatoes. Though FDA officials didn't isolate the outbreak strain from that farm, they did find the pathogen on a Serrano pepper and in irrigation water on another farm from the same state. The second farm grew only jalapeno peppers. Tauxe said contamination could have occurred on the farm or during distribution. Acheson said the two farms are about 100 miles away from each other and that cattle grazed nearby.

The CDC authors didn't rule out the possibility of multivehicle contamination. "Finding the outbreak strain on two types of peppers from two farms supports the possibility of contamination of other produce items, including tomatoes, during growing, processing, or distribution," they wrote. Acheson said several specific measures could help prevent future produce outbreaks. He said Congress should give the FDA the authority to regulate high-risk products and that technological advancements could help inspectors detect pathogens more quickly. Better tracking systems from the food industry could help speed trace-back investigations, and federal agencies can improve their outbreak response systems.
(CIDRAP 8/28/08)

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USA: Anthrax probe prompts concerns about military labs
US Navy and Air Force officials recently reported a suspension of work in their biodefense laboratories to allow a thorough review of safety procedures, following the Army's announcement August 2008 that it would review security measures at the lab that housed the work of the late Bruce E. Ivins, whom federal officials believe played a role in the 2001 anthrax attacks. The FBI's conclusion that Ivins was responsible for the attacks came nine days after he apparently committed suicide. Ivins had worked at the US Army Medical Research Institute of Infectious Diseases (USAMRIID) for years, doing research that included work on anthrax vaccines. After the 2001 attacks he had also helped the FBI analyze anthrax samples.

The FBI's allegations about Ivins raised questions about how secure the USAMRIID facility was. Reports of Ivins' past mental health problems also prompted questions about how well lab employees are screened before they are cleared to work with bioterror agents. Officials from the Navy and Air Force said they were temporarily stopping shipments of bioterror agents coming in and out of their research facilities. The stoppage will allow the military branches to review safety rules. Navy and Air Force authorities also said they wouldn't allow their employees to work with "select agents" unless they enroll in a special program that allows them clearance or their work is supervised by another employee who is enrolled in the program. The Army also reportedly froze shipments in and out of its labs from Aug 8 to 14, which allowed it to review and strengthen some of its security protocols.

A few days after the FBI released its conclusions about Ivins, the Army appointed a team of medical and military experts to review security protocols at USAMRIID. Two lawmakers also announced they were expanding their congressional investigation into risks associated with the nation's biodefense labs.
(CIDRAP 8/8/26/08)

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USA (New York): Tenth case of Legionellosis; one killed
New York’s Chemung County health officials report a 10th case of Legionnaires' disease among senior citizens who live in Elmira's Flannery Towers housing complex. Health officials say all 10 people, including one who died, acquired the disease before protective measures went into place at the towers. The bacterial infection most often it affects older people, which is why James Mirando from the Elmira Housing Authority said they suspended the use of hot water in the senior housing complex (Tests revealed Legionella pneumophila in the hot water system). Health officials have been advising residents to take sponge baths instead of showers to avoid breathing in water vapor. Residents have been provided with bottled water. Workers were continuing to flush the water tanks at the complex. "The guidelines from the county and the state were to superheat the water. The return water has to be 140 F. By the direction, this should kill the bacteria," Mirando said.
(Promed 8/24/08)

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USA (Oklahoma): E. coli O111 outbreak kills one, hospitalizes dozens
Hospital and school officials said 26 Aug 2008 that children are among the growing number of victims of an intestinal illness outbreak in north east Oklahoma. The Oklahoma State Department of Health (OSDH) reports that a 26-year old has died and at least 176 persons have become ill as a result of the E. coli O111 outbreak. Cases include 128 adults and 48 children. The department says victims have experienced severe and bloody diarrhea, and most had eaten recently at the Economy Cottage buffet restaurant in Locust Grove, Oklahoma. The restaurant is closed while the investigation continues. OSDH laboratory analysis of water samples taken from a private well on the restaurant property is continuing; however, health officials believe it is unlikely that any well water contamination is the source of the outbreak.

So far, 50 have had to be hospitalized. St Francis Hospital in Tulsa reported 26 Aug 2008 that 13 children have been admitted, and four are in the pediatric intensive care unit. Three children, ages 18 months to 12 years, are undergoing dialysis at Children's Hospital at St Francis, said Dr William Banner, co-director of the hospital's pediatric intensive care unit. Two other children were transferred to Oklahoma City for similar treatment, Banner said. Health officials say E. coli 0111 is a rare type not normally associated with an outbreak this large. Although much attention has been paid to O157:H7 strains of E. coli that cause enterohemorrhagic disease with or without hemolytic-uremic syndrome (HUS), other serotypes of E. coli, as seen in this outbreak, have been associated with this illness.
(Promed 9/2/08)

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USA (Nevada): Tularemia transmitted by pet cat
Smith Valley has the first case in Nevada of tularemia transmitted from a cat to a human in 50 years. A woman took her sick cat to the vet; it was misdiagnosed with kidney problems and sent home with medication. The woman gave the pet its pills using her finger to force them down its throat; little did she know that a small cut on her finger would be the avenue for which tularemia would enter her body. The patient is now recovering. The tularemia infected her finger, which became painful and inflamed, then she started running a high fever, she went to the emergency room on several separate occasions where she was given antibiotics, which seemed to calm the symptoms for several days and then the whole thing would flare up again. Her sick cat had died weeks before. The woman's neighbor is a physician who told her things did not look well. She went to his office where he opened up her finger and sent a culture to the lab. It was at this point that the tularemia was pinpointed and a correct course of treatment started.
(Promed 8/25/08)

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USA (Illinois): 47 cases of Rocky Mountain spotted fever
A total of seven cases of Rocky Mountain spotted fever have been confirmed in Hardin County, but officials have yet to attribute the death of a Southern Illinois resident to the tick-borne illness. Melaney Arnold, spokeswoman for the Illinois Department of Public Health, said the Hardin County diagnoses are among the 47 cases of the fever confirmed statewide. "We know it's been in Southern Illinois for a while, but the number of cases in the counties vary from year to year" she said. Early treatment is vital to overcoming the illness. "There is a 3 to 5 percent mortality rate overall, but it can range from 13 to 25 percent in those who go untreated," she said.

When the female tick harboring the organism attaches to a passing human, she usually starts low on the body after transferring from grassy vegetation or from a dog. After attaching, it generally takes as many as 24 hours to activate and transmit the rickettsial organism. For this reason, daily or twice daily tick checks with removal will minimize disease transmission. The incubation period of the disease is about a week after the tick exposure, long after the tick has detached. The presenting illness is generally nonspecific, fever, muscle pains, headache. Rash begins in day 3 of illness, purpura usually are not seen before day 6. Empiric treatment for this infection should always be begun in people with compatible symptoms, inhabiting endemic areas, during the spring and summer, even if no tick bite is known.
(Promed 8/25/08)

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USA (Connecticut/Wyoming): Bubonic plague sickens teenager
An 18 year old boy scout from Connecticut is recovering at home after becoming infected with bubonic plague, possibly in Wyoming. The teenager was among hundreds of scouts who built trails and did other service work in July 2008. The teenager traveled to multiple sites in the area, including Yellowstone National Park. Infection usually comes after being bitten by a rodent flea that is carrying the plague bacterium or handling an infected animal. Each year, 10 to 20 cases occur in the US according to the Centers for Disease Control and Prevention (CDC). About one in seven cases in the USA is fatal.

Wyoming Department of Health will participate in an investigation with other agencies to look for fleas and animal carcasses in areas where the individual visited. While the risk for humans to contract plague is relatively low in Wyoming, the disease has been documented in animals in 22 of Wyoming's 23 counties since records were kept. This is the sixth human case of plague thought to have been acquired in Wyoming since 1978. Yersinia pestis, the plague bacillus, is not endemic in the eastern USA.
(Promed 8/27/08)

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3. Updates
AVIAN/PANDEMIC INFLUENZA
- 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 information on the upcoming “Big 7 Pandemic-Planning Mistakes” Webinar (October 9, 2008).
- 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.
(UN; WHO; FAO, OIE; CDC; CIDRAP; PAHO; USGS)

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CHOLERA, DIARRHEA, AND DYSENTERY
Viet Nam
Over the past month, 390 more cases of acute diarrhea disease have been reported nationwide, 73 of them tested positive for the cholera, according to the Ministry of Public Health. Since early 2008, over 4500 cases have contracted acute diarrhea; 722 of them tested positive for cholera.
(Promed 8/25/08)

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Dengue
Indonesia (North Sumatra)
Dengue has struck Tanjungbalai city residents from Jan 2008 and continues to increase. Until now, the number of victims reached 165 and 44 people are still under intensive care, according to Dr T Mansyur Siagian. This August [2008], there have been 70 cases. To prevent the [spread of dengue], said Dr Siagian, residents must continue to maintain the cleanliness of their environment and carry out the "3 Ms", [closing, draining, and burying in the local language] the mosquito breeding places.
(Promed 8/26/08)

Malaysia
The director of the Disease Control Division of the Health Ministry, Datuk Dr Hasan Abdul Rahman, said 27 Aug 2008 that four deaths due to dengue fever had been reported, one in each of Selangor, Kuala Lumpur, Melaka, and Johor in the 17-23 Aug [2008] period. He said in the same period 1003 cases of dengue fever had been reported, representing a drop of 36 cases from the previous week. "Although there is a drop in cases it is still about 10 per cent higher than the same period last year [2007]. . ." he said. Dr Hasan said seven states -- Perak, Selangor, Negeri Sembilan, Melaka, Johor, Terengganu, and Kelantan -- and the federal territories of Putrajaya and Labuan had recorded increases in dengue cases. He said these areas had 74 per cent or 743 cases of the total cases reported and to date a total of 29 942 cases of dengue fever with 71 deaths had been reported. He said inspections revealed that residences and shops were primary breeding grounds of the Aedes mosquito that spreads the dengue fever [virus].
(Promed 9/1/08)

Philippines (Pangasinan)
A dengue outbreak has been officially declared [in Calasiao] with 23 of the 24 barangays reporting a total of 118 confirmed dengue patients with one death. Mayor Roy Macanlalay made the declaration and said his administration is set to address the problem and stop the further spread. The last time a dengue outbreak broke out in the town was in 1998 [and it] claimed 271 victims. In 2007, for the period Jan to 15 Aug, only six cases were reported. Macanlalay said the local government is now making representations with the provincial office for free hospitalization for the patients at the Pangasinan Provincial Hospital. Full blast fogging operations were conducted in the schools [in Calasiao] during the week of 18 Aug 2008. The hardest hit barangays in 2008 are San Miguel with 15 [dengue cases]; Malabago, 14; and Lasip, 11. Most of the victims are children; the lone casualty was a teenager.
(Promed 9/1/08, 8/26/08)

Philippines (Negros Oriental)
The Department of Health [DOH] in Negros Oriental has noted an increase in the number of dengue cases recorded in the province this year [2008]. Dr Socrates Villamor, Jr, provincial DOH chief, disclosed that 567 dengue cases were reported from Jan to 10 Aug 2008. Of the total, Dumaguete City had the highest number of cases with 172, followed by Bais City with 71; Tanjay City, 58; Sibulan town, 56; and Mabinay town with 32 cases. Villamor said the total number of dengue cases in 2008 is already about 16 percent above those of last year's [2007]. He said that, due to climate change, the occurrence of dengue cases has become unpredictable unlike in the past years. Back then, the majority of cases were reported during the rainy season, sometime between June-September, but that is no longer true, he said.
(Promed 8/26/08)

Taipei
The Taipei City Government urged residents 19 Aug 2008 to cooperate with its disinfection measures against dengue fever after declaring an epidemic red alert. Taipei Mayor Hau Lung-bin called on residents to clean up their surroundings and report any cases to the City's Health Department after the confirmation of three recent indigenous cases in Shezidao of Shilin District during the week of 10 Aug 2008 in addition to eight patients testing positive 16-17 Aug 2008.

Seeking to control the spread of the disease, the department set up a blood testing station in Shezidao, testing 230 residents in the area 16-17 Aug 2008. Commissioner of the department, Allen Chiu, said eight people tested positive for the disease. To reduce the number of mosquitoes in the district, the city government has dispatched staff to spray insecticide indoors and outdoors in areas within 200m of buildings with confirmed dengue fever cases, while conducting additional outdoor spraying in 10 boroughs near infected areas, Chiu said. The city government is still inspecting patients who reportedly had fevers in municipal hospitals from 18 Jul-20 Aug 2008. Chiu also reminded those who develop early symptoms of dengue fever such as a fever, joint pain, or a skin rash to seek medical treatment.

In order to prevent the occurrence of dengue fever outbreaks, Taiwan CDC (Centers for Disease Control) often appeals to communities and members of the public to mobilize cleanup efforts to eliminate vector breeding sites. Insecticide spraying is a short term emergency measure implemented in Taiwan to prevent further transmission of dengue viruses and occurrence of dengue epidemics.
(Promed 9/1/08, 8/26/08)

Thailand
The mosquito-carried virus [that causes] dengue fever is raging with massive force in Thailand and Southeast Asia. The latest official figures from the Thai authorities show that so far 41 307 persons have been infected with dengue fever [viruses] in 2008. The actual figure is at least 10 times higher, as the vast majority will never be registered. There are 48 reported deaths so far in 2008, compared to 29 deaths throughout the whole year 2007, according to the Thai newspaper The Nation.
(Promed 8/26/08)

Viet Nam
Ho Chi Minh City [HCMC] and some Mekong Delta provinces have experienced an influx in the number of cases of dengue fever. According to a Health Ministry report, nearly 36 900 people across the country have been infected with the disease so far in 2008. Of those infected this year [2008], 33 have died. The ministry said that southern provinces and cities have been hardest hit accounting for 80 to 85 per cent of reported cases. HCMC has reported the highest number of dengue cases, with more than 6100 patients infected so far in 2008, followed by Ca Mau, Soc Trang, and Tien Giang provinces.

The HCMC-based Pediatrics Hospital No. 2 said 26 Aug 2008 that about 80 dengue fever patients, mostly children, were being treated at the hospital. Le Hoang Son, director of Can Tho City Pediatrics Hospital, said 40 children had been admitted with the disease. Son said 30 per cent of the children were from Can Tho while the rest were from neighboring provinces. In July 2008, a large number of dengue fever cases caused several hospitals in the Mekong Delta region to become overloaded.

In Hanoi, more than 222 people have been infected with dengue fever so far in 2008, a 21 per cent year-on-year decrease. Nguyen Trung Nghia, director of the Can Tho City Preventive Health Center, said the city and Mekong Delta provinces were mobilizing local families to breed guppies to help eliminate mosquito larvae. In Ben Tre Province, authorities have provided residents in dengue-hit areas with more than 50 000 guppies over the past seven months.
(Promed 9/1/08)

Viet Nam
The Ministry of Health has approved the testing of a dengue fever vaccine on locals in the southern province of An Giang. The ChimeriVax vaccine, produced by Sanofi Pasteur, will undergo a six year trial to test its seroconversion rate (ability to produce antibodies) against four dengue virus serotypes. The safety of the drug will also be evaluated during the trial. The Pasteur Institute of Ho Chi Minh City will conduct the trial on 180 healthy people of different ages in the province through 2014. Sanofi Pasteur has already completed two trial phases of the tetravalent vaccine. The latest test results were presented Sep 2007 with a 100 per cent seroconversion rate reported for all four dengue serotypes.
(Promed 9/1/08)

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WEST NILE VIRUS
Canada
Date: 17-23 Aug 2008:
Human cases: Saskatchewan 3 cases, Alberta 1 case
Total human cases in 2008: 11

USA
Date: 27 Aug-2 Sep 2008
States newly reporting new human cases: No new states reported human cases.
There have been a total of 413 human cases and 5 fatalities to date in 2008.
(ProMED 9/3/08)

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4. Articles
Emerging Infectious Diseases - Volume 14, Number 9 – September 2008
The September 2008 issue online at: http://www.cdc.gov/ncidod/eid/. Included is the expedited article, “Spinach-associated Escherichia coli O157:H7 Outbreak, Utah and New Mexico, 2006” by J. Grant et al.

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National, State, and Local Area Vaccination Coverage Among Children Aged 19--35 Months--United States, 2007
“The National Immunization Survey (NIS) provides vaccination coverage estimates among children aged 19--35 months for each of the 50 states and selected urban areas. This report describes the results of the 2007 NIS, which provided coverage estimates among children born during January 2004--July 2006. Healthy People 2010 established vaccination coverage targets of 90% for each of the vaccines included in the combined 4:3:1:3:3:1 vaccine series and a target of 80% for the combined series. Findings from the 2007 NIS indicated that >90% coverage was achieved for most of the routinely recommended vaccines. The majority of parents were vaccinating their children, with less than 1% of children receiving no vaccines by age 19--35 months. The coverage level for the 4:3:1:3:3:1 series remained steady at 77.4%, compared with 76.9% in 2006. Among states and local areas, substantial variability continued, with estimated vaccination coverage ranging from 63.1% to 91.3%. Coverage remained high across all racial/ethnic groups and was not significantly different among racial/ethnic groups after adjusting for poverty status. However, for some vaccines, coverage remained lower among children living below the poverty level compared with children living at or above the poverty level. Maintaining high vaccination coverage and continued attention to reducing current poverty disparities is needed to limit the spread -preventable diseases and ensure that children are protected. . .”
http://cdc.gov/mmwr/preview/mmwrhtml/mm5735a1.htm
(MMWR September 5, 2008 / 57(35);961-966; references removed)

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Detection of infectious prions in urine
Gonzalez-Romero D, Barria MA, Leon P, Morales R, Soto C. FEBS Lett. 2008 Aug 13.

Abstract: Prions are the infectious agents responsible for prion diseases, which appear to be composed exclusively by the misfolded prion protein (PrP(Sc)). The mechanism of prion transmission is unknown. In this study, we attempted to detect prions in urine of experimentally infected animals. PrP(Sc) was detected in approximately 80% of the animals studied, whereas no false positives were observed among the control animals. Semi-quantitative calculations suggest that PrP(Sc) concentration in urine is around 10-fold lower than in blood. Interestingly, PrP(Sc) present in urine maintains its infectious properties. Our data indicate that low quantities of infectious prions are excreted in the urine. These findings suggest that urine is a possible source of prion transmission.

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Fatal Oseltamivir-Resistant Influenza Virus Infection
Erhard van der Vries, Bart van den Berg, Martin Schutten. NEJM. Volume 359:1074-1076. September 4, 2008. Number 10. http://content.nejm.org/cgi/content/full/359/10/1074

To the Editor: “The incidence of influenza A (H1N1) viruses that carry the neuraminidase H274Y mutation has increased by 30% this year in the Netherlands. Influenza A (H1N1) viruses that carry this mutation are resistant to oseltamivir but remain sensitive to zanamivir. However, these mutant viruses are considered to have attenuated pathogenicity. A 67-year-old man who had received a diagnosis of chronic lymphocytic leukemia 3 years earlier was admitted to the hospital because of dyspnea, dry cough, and fever. One week before admission, he had received a course of cyclophosphamide, vincristine, and prednisolone chemotherapy. At admission, his white-cell count was 137,000 per cubic millimeter, with 99% lymphocytes and no neutrophils. Because of acute respiratory failure, empirical antibacterial therapy was initiated, and mechanical ventilation was required by the second hospital day (Figure 1). Computed tomography (CT) revealed patchy infiltrates in both lungs, and influenza A (H1N1) virus was detected in respiratory secretions. During the entire hospital course, no other respiratory pathogens were detected in bronchoalveolar-lavage specimens. The only other pathogens identified in blood cultures were Candida albicans and Enterococcus faecium, for which fluconazole and vancomycin were given. . .”

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The Effects of Avian Influenza News on Consumer Purchasing Behavior: A Case Study of Italian Consumers’ Retail Purchase
Robert H. Beach, Fred Kuchler, Ephraim Leibtag, and Chen Zhen. Economic Research Report No. (ERR-65) 31 pp, August 2008

“To better understand how information about potential health hazards influences food demand, this case study examines consumers’ responses to newspaper articles on avian influenza, informally referred to as bird flu. The focus here is on the response to bird flu information in Italy as news about highly pathogenic H5N1 avian influenza (HPAI H5N1) unfolded in the period October 2004 through October 2006, beginning after reports of the first outbreaks in Southeast Asia, and extending beyond the point at which outbreaks were reported in Western Europe. Estimated poultry demand, as influenced by the volume of newspaper reports on bird flu, reveals the magnitude and duration of newspaper articles’ impacts on consumers’ food choices. Larger numbers of bird flu news reports led to larger reductions in poultry purchases. Most impacts were of limited duration, and all began to diminish within 5 weeks.”
(USDA http://www.ers.usda.gov/publications/err65/ )

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Molecular epidemiology of A/H3N2 and AH1N1 influenza viruses during a single epidemic season in the United States.
Nelson MI et al. PLoS Pathog 2008;4(8) http://www.plospathogens.org/article/info:doi/10.1371/journal.ppat.1000133

Abstract: To determine the spatial and temporal dynamics of influenza A virus during a single epidemic, we examined whole-genome sequences of 284 A/H1N1 and 69 A/H3N2 viruses collected across the continental United States during the 2006–2007 influenza season, representing the largest study of its kind undertaken to date. A phylogenetic analysis revealed that multiple clades of both A/H1N1 and A/H3N2 entered and co-circulated in the United States during this season, even in localities that are distant from major metropolitan areas, and with no clear pattern of spatial spread. In addition, co-circulating clades of the same subtype exchanged genome segments through reassortment, producing both a minor clade of A/H3N2 viruses that appears to have re-acquired sensitivity to the adamantane class of antiviral drugs, as well as a likely antigenically distinct A/H1N1 clade that became globally dominant following this season. Overall, the co-circulation of multiple viral clades during the 2006–2007 epidemic season revealed patterns of spatial spread that are far more complex than observed previously, and suggests a major role for both migration and reassortment in shaping the epidemiological dynamics of human influenza A virus.

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Study: Flu vaccine doesn't lower death rates in elderly
Some healthcare experts have wondered if large mortality reductions among older people who receive seasonal influenza immunizations are real or if the findings are biased by a "healthy-user" effect. But now a study that more rigorously controlled for confounders suggests that the benefits are overstated. The study, by Canadian researchers who evaluated data from patients admitted to six Capital Health hospitals in Alberta, appeared in the Sep 1, 2008 issue of the American Journal of Respiratory and Critical Care Medicine. It revealed no statistical difference between in-hospital mortality rates of elderly patients receiving seasonal flu vaccination and of those not vaccinated. It is the latest among a handful of recent studies that have cast doubt on the benefits of flu vaccines for older people and may call for a reexamination of public policy on flu vaccination among the elderly.

The research group pointed out that most evidence on the benefit of influenza vaccines in older patients is based on observational studies that suggest a 50% mortality rate reduction. However, they said many experts have suspected that such a high benefit is implausible. For example, they wrote that though vaccination rates in the United States' elderly population have risen from 15% to 65% over the over the past 20 years the increase has not been matched by decreasing hospitalization and mortality rates. "Previous studies were likely measuring a benefit not directly attributable to the vaccine itself, but something specific to the individuals who were vaccinated—a healthy-user benefit or frailty bias," said Dean T. Eurich, the study's first author.

Also, the researchers wrote that other studies have detected similar mortality reductions during the times of year when influenza viruses aren't circulating. Sumit Majumdar, principal investigator, and colleagues hypothesized that if a healthy-user effect was responsible for mortality benefits, then the same benefit would be seen during the "off season," when the influenza virus wasn't circulating. The researchers had access to a large database that allowed them a unique opportunity to explore the bias, because it included a number of potential healthy-user indicators such as smoking and functional status.

They analyzed data from 704 patients ages 65 and over who were admitted to the hospital for community-acquired pneumonia during non-flu season intervals from 2000 through 2002. Researchers matched 352 patients who had received their flu vaccines against 352 controls who did not. When the group looked at in-hospital death rates, they found that vaccinated patients were about half as likely to die as those who weren't vaccinated (28 [8%] versus 53 [15%]), which is consistent with past studies. However, when they adjusted for the healthy-user effects, the benefit was much smaller, and didn't reach statistical significance. The authors concluded that a healthy-user effect is present, and other analyses of vaccine benefit during influenza season probably overestimate the benefit. However, they cautioned that their findings might not be generalized to healthier, lower-risk patients in a nonhospital setting.

The findings have broad implications for public health, the authors wrote. Patients with chronic diseases, as well as their contacts, should still get their annual flu vaccines, Majumdar said. Inflated mortality reductions noted in previous studies could hamper efforts to develop better vaccines, particularly for use in elderly populations, they wrote. Evidence-based findings, however, may help policymakers to direct their efforts more toward hand-washing and vaccinating children and healthcare workers, they added.

Eurich DT, et al. Mortality reduction with influenza vaccine in patients with pneumonia outside 'flu' season: pleiotropic benefits or residual confounding? Am J Respir Crit Care Med 2008 Sep 1;178(5):527-33. http://ajrccm.atsjournals.org/cgi/content/abstract/178/5/527
(CIDRAP 8/29/08)

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Increased incidence of rabies in China
A new Chinese study has reported a dramatic spike in rabies. The research shows that in some provinces of China the number of human rabies cases has jumped since the new millennium. Jia-Hai Lu, from Sun Yat-Sen University, led a team of researchers who studied the rabies trend in China between 1990 and 2007. Lu describes: "In China, human rabies was largely under control during the years 1990-1996, via nation-wide rabies vaccination programmes. Since the end of the century, however, cases of human rabies have jumped high enough to trigger a warning sign for control and prevention."

Rabies, an infection of the nervous system transmitted by animal bites, causes over 50 000 deaths each year around the world. During recent years, most of the research on control of rabies has concentrated on the development of post-exposure prophylaxis. According to the researchers, "The use of human and equine rabies immunoglobulins (HRIG/ERIG) has saved the lives of countless patients who would have died if treated with vaccine alone. However, both products are often in short supply worldwide and are virtually unaffordable in developing countries." Data from 22 527 human rabies cases from January 1990 to July 2007 were obtained from a surveillance database from the Ministry of Health of China. The authors found that human rabies was under control from 1990 to 1996, when only 159 cases of rabies were reported, but this figure had leapt to 3279 cases in 2006.

The authors found that rabies was most frequently encountered in the southwestern and southern territories of China, especially in highly populated areas. Lu said, "The 4 rabies-endemic provinces lacked strictly enforced measures to eliminate dog rabies or an ample supply of modern cell culture rabies vaccines for humans." Most of the patients were children or teenagers, and most contracted the disease after being bitten by a dog. According to the authors, "In the worst-affected province, Guangdong, 62.5 percent of patients did not receive proper treatment on their wounds, 92.5 percent did not receive adequate post-exposure vaccination, and 91.25 percent did not receive any anti-rabies immunoglobulin." The authors recommend that the current rabies control programme be improved by increasing supervision, improving the interaction between local and national authorities, increasing rabies awareness, and altering urban planning and development to balance the interaction between humans and animals.

Han Si, et al. “Rabies trend in China (1990-2007) and post-exposure prophylaxis in the Guangdong province.” BMC Infectious Diseases (in press). http://www.biomedcentral.com/content/pdf/1471-2334-8-113.pdf.
(Promed 8/26/08)

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5. Notifications
Public Health Informatics Fellowship Application Deadline--November 14, 2008
CDC offers a two-year postgraduate fellowship in public health informatics, the systematic application of information technology to public health practice, research, and learning. Fellows receive training in both informatics and public health, are assigned to teams involved in research and development of CDC information systems, and are given the opportunity to lead one or more major projects during their fellowships. The deadline to apply for the fellowship period beginning Jul 2009 is Nov 14, 2008.

Additional information regarding the application process: http://www.cdc.gov/epo/phifp/appinfo.htm. Additional information regarding the program: http://www.cdc.gov/epo/phifp, by telephone, 404-498-6219, or by e-mail, phifp@cdc.gov (subject line: request info). http://cdc.gov/mmwr/preview/mmwrhtml/mm5735a4.htm
(MMWR September 5, 2008 / 57(35);970-971)

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Pandemic Influenza Storybook: Narratives from 1918 and 1957 pandemics
The need for the Pandemic Influenza Storybook became evident as the Centers for Disease Control and Prevention (CDC) conducted Crisis and Emergency Risk Communication (CERC) throughout the country for public health professionals involved with a variety of emergency response communications activities. The “Basic” CERC course debuted in 2002 and two additional modules have been added; “Leaders for Leaders” and “Pandemic Influenza”. The storybook is a resource tool for the latter module for certified CERC trainers and trainees. The online storybook contains narratives from survivors, families, and friends who lived through the 1918 and 1957 pandemics. Additionally, stories from the 1968 pandemic will be added to this resource as they become available.

The 1918 influenza pandemic killed more than 50 million people worldwide including an estimated 675,000 people in the United States, and it is one of the touchstones for today’s public health preparedness initiatives. The 1957 Influenza Pandemic caused at least 70,000 U.S. deaths and 1–2 million deaths worldwide. Improvements in scientific technology made it possible to more quickly identify that pandemic when compared with the 1918 event. These first-person and family accounts contained herein provide an intimate, personal view of the 1918 and 1957 pandemics that goes beyond the staggering statistics associated with those events and, therefore, can help planners re-energize their efforts and fight preparedness fatigue and apathy.
http://www.pandemicflu.gov/storybook/index.html

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Promising practices for pandemic planning: Berkeley officials enlist young flu fighters
In 2004 when the nation faced an influenza vaccine shortage, public health officials in Berkeley, Calif., saw an opportunity to put a different kind of dent in the flu season: they taught some of the city's youngest children how to WHACK the flu. Tanya Bustamante, a pandemic influenza program specialist with the city of Berkeley's public health division, said that officials developed a skit to teach kids in kindergarten through third grade how to avoid getting sick with the flu. Because children are efficient "disease spreaders," an intervention focused on their actions is designed to reduce the flu burden in schools and in the general community. The city's public health planners built a flu prevention outreach activity around the word "whack" for its high-energy, cartoonish appeal for kids and because it offers a mnemonic device that teaches students good hand hygiene habits:

- W, wash your hands often
- H, home is where you stay when you're sick
- A, avoid touching your eyes, nose, and mouth
- C, cover your coughs and sneezes, and
- K, keep your distance from people who are coughing or sneezing

The activity consists of a 15-minute classroom skit performed by three University of California, Berkeley students. The student-actors explain the steps to the children with an engaging dialogue and a catchy, age-appropriate song. The characters in the skit, which the students portray with hand puppets, are Jane, a girl who is coughing and sneezing, her friend Mary, and Fred the Flu Germ, who keeps pestering Jane. The girls show the children how to avoid Fred and his friends by covering their coughs and sneezing into their elbows. During the song part of the skit, the actors pretend to wash their hands, while inviting the children to follow along with the same hand motions while sitting at their desks.

The program—held in October before flu season starts—is flexible and varies from classroom to classroom. During the first year, the WHACK the Flu program made it to only a handful of schools, but since then they typically make it to eight of the city's 11 elementary schools, Bustamante said. Bustamante said the program costs are reasonable and allow the city to maximize and modify what they've found is a fun and powerful public health tool. Other communities are starting to adapt the WHACK the Flu theme, especially in California.
(CIDRAP 9/2/08)

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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 http://www.new-fields.com/birdflu7/
1001 Pennsylvania Avenue, NW
6th Floor South
Washington, DC 20004
Tel: (202) 536-5000; Fax: 202.280.1239; email: sharon.villalon@new-fields.com

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IMED 2009 website updated
The planning for IMED 2009 is now well under way. The program promises to be of great interest to those involved in the detection of emerging disease threats and those who respond to these threats. The IMED 2009 website is now available, with additional program information. Registrations are being accepted, and the abstract submission process will begin on 1 Sep 2008. Visit the website at: http://imed.isid.org for more information. It will be continuously updated as additional program and speaker information becomes available.
(Promed 8/24/08)

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International Symposium on Viral Hepatitis and Liver Disease
The 13th International Symposium on Viral Hepatitis and Liver Disease (ISVHLD) will bring together the entire community involved in viral hepatitis research, to promote better understanding of the viruses that cause hepatitis in humans, as well as the pathogenesis, natural history, complications, treatment, and prevention of the diseases they cause. The virology, immunology, epidemiology, diagnosis, treatment, and prevention of each hepatitis virus will be covered, along with a cross-cutting series on hepatocellular cancer, cirrhosis, HIV co-infection, and liver transplantation. Symposium website: <http://www.isvhld2009.org> ; abstract submission deadline: 14 Oct 2008
(Promed 9/5/08)

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 apecein@u.washington.edu