Vol. XI, No. 19 ~ EINet News Briefs ~ Sep 19, 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)
- Indonesia: Retrospective announcement of two confirmed human avian influenza H5N1 deaths
- New Zealand: Low-pathogenic avian influenza H5N1 found in ducks
- Togo: Recent bird flu outbreak confirmed as H5N1 avian influenza

2. Infectious Disease News
- Russia (Bashkortostan): Anthrax infection confirmed in 11 persons
- Russia (Magadan): Trichinellosis outbreak hospitalizes 12
- Russia (Voronezhska): Two die of rabies virus infection
- Russia (Pskov): Three more cases of tick-born encephalitis in Pskov region
- Singapore: Chikungunya fever outbreaks continue
- Taipei (Changhua): 11 deaths attributed to hand, foot, and mouth disease in 2008
- Canada (Quebec): Shellfish harvesting sites close due to red tide
- USA: CDC reports on results for new public health gno flyh list
- USA (New York): Dialysis center shut down after patient tests positive for hepatitis C
- USA (Utah): Man dies of hantavirus pulmonary syndrome
- USA (Oklahoma): E. coli O111 outbreak continues with 291 cases, one killed
- USA (Pennsylvania): Two human salmonella cases lead to pet food recall

3. Updates

4. Articles
- Influenza vaccines: research, development and public health challenges
- Effects of school closures during the 2008 winter influenza season, Hong Kong
- Effectiveness of maternal influenza immunization in mothers and infants
- Preparing for the Real Storm during the Calm: A Comparison of the Crisis Preparation Strategies for Pandemic Influenza in China and the U.S.
- Pandemic influenza in Australia: Using telephone surveys to measure perceptions of threat and willingness to comply
- Identification of cardioviruses related to Theiler's murine encephalomyelitis virus in human infections
- Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection
- Surveillance for Waterborne Disease and Outbreaks Associated with Recreational Water Use and Other Aquatic Facility-Associated Health Events--United States, 2005--2006
- Surveillance for Waterborne Disease and Outbreaks Associated with Drinking Water and Water not Intended for Drinking--United States, 2005--2006

5. Notifications
- Public Health Informatics Fellowship Application Deadline--November 14, 2008
- International Symposium on Viral Hepatitis and Liver Disease
- Ethics and Severe Pandemic Influenza: Maintaining Essential Functions through a Fair and Considered Response
- US policy regarding pandemic influenza vaccines
- Practical Management Strategies for Avian Influenza and Emerging Infectious Diseases--The Implementation Toolkit

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 / 36 (28)

***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: 387 (245).
(WHO 9/10/08 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO (last updated 6/19/08): http://www.wpro.who.int/sites/csr/data/data_Graphs.htm

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 9/15/08): http://gamapserver.who.int/mapLibrary/

WHOfs timeline of important H5N1-related events (last updated 9/8/08): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html


Indonesia: Retrospective announcement of two confirmed human avian influenza H5N1 deaths
The Ministry of Health of Indonesia has retrospectively announced two confirmed cases of human infection with the H5N1 avian influenza virus. The first case, a 38-year-old male from Tangerang Municipality, Banten Province developed symptoms on 4 Jul 2008, was hospitalized on 9 Jul and died on 10 Jul 2008. There were free-roaming poultry throughout his neighborhood, including a commercial poultry pen owned by a neighbor. The second case, a 20-year-old male from Tangerang District, Banten Province developed symptoms on 20 Jul, was hospitalized on 29 Jul, and died on 31 Jul 2008. Reports indicate that chickens from the case's household had died in the week preceding the onset of his symptoms and that he had slaughtered and consumed some of his stock during this period. Of the 137 cases confirmed to date in Indonesia, 112 have been fatal.
(ProMED 9/12/08)


New Zealand: Low-pathogenic avian influenza H5N1 found in ducks
An avian influenza surveillance program found low-levels of the H5N1 virus in Mallard ducks in New Zealand. Known as LPAI [low pathogenic avian influenza] H5N1, the Ministry of Agriculture and Forestry states that it is different from "bird flu," which is the highly pathogenic form of the virus. Dr Andre van Haldren states that the surveillance was conducted in February and the samples were taken from healthy birds in seven different sites. There have been no reported bird deaths or disease. He asserts that this confirms that strains of non disease causing avian influenza viruses are present in New Zealand wild bird populations and that the virus that was identified in the ducks is closely related to viruses that have been found in the past and are not new to the country. New Zealand has never reported a case of highly pathogenic avian influenza in birds.

Findings in New Zealand's wild birds are similar to those in the United States. A 17 Sep 2008 update from the Highly Pathogenic Avian Influenza Early Detection Data System (HEDDS), representing wild-bird surveillance by US federal and state agencies, says 27,231 birds have been sampled this year. Eight samples tested positive for presumed low-pathogenic avian influenza.
(ProMED 9/18/08; CIDRAP 9/17/08)


Togo: Recent bird flu outbreak confirmed as H5N1 avian influenza
Togo state television says lab tests performed after a recent outbreak of bird flu have confirmed the presence of the H5N1 strain of the virus, which has the potential to infect humans. However, no human cases have been detected so far in Togo. State media reported 15 Sep 2008 that the lab tests were carried out by experts in Ghana and Italy after the outbreak was discovered among several thousand birds in Agbata outside the capital of Lome during the week of 8 Sep 2008. The health ministry says, "Precautionary measures have been taken to contain the situation." Togo's eastern neighbor, Benin, notified the World Organization for Animal Health of an H5N1 outbreak, reportedly starting 29 Jul 2008, on its southern border with Togo. Togo reported three H5N1 outbreaks in 2007.
(ProMED 9/17/08; CIDRAP 9/17/08)


2. Infectious Disease News

Russia (Bashkortostan): Anthrax infection confirmed in 11 persons
The Management of Rospotrebnadzor in Bashkortostan reports that anthrax cases have been confirmed and that as of 1 Sep 2008, the number of registered cases of anthrax are 11 persons. All of them are in the hospital. Since August 2008, 30 specialists have been investigating samples of soil and water collected in Yanaul and the Yanaulsky district. Work will continue up to 10 Sep 2008. Analyses are being carried out in the Centre of Hygiene & Epidemiology of Bashkortostan. 172.5 kg of meat has been removed from the population and destroyed. Anti-epidemic, preventive, and treatment measures have been employed.
(ProMED 9/7/08)


Russia (Magadan): Trichinellosis outbreak hospitalizes 12
An outbreak of trichinellosis has been registered in the settlement Myaundja of the Susumanskiy region of Magadan oblast. It involves 12 people, including three children under the age of 14. The severity of the disease has been mild to moderate. All of the cases had consumed smoked bear meat at the end of July and the beginning of August 2008. All affected people are now receiving treatment in the infectious diseases department of the regional hospital. A preventive information and education campaign is being carried out to prevent new cases.
(ProMED 9/7/08)


Russia (Voronezhska): Two die of rabies virus infection
Two people have died as a result of rabies virus infection in the Povorensk and Podgorensk districts of the Voronezhska Oblast. Neither sought medical attention for 3 days after being bitten, when it was too late for successful treatment. During the past 8 months of 2008, cases of animal bites have increased two-fold in comparison with 2007 (4599 in 2007 compared with 7982 in 2008).
(ProMED 9/17/08)


Russia (Pskov): Three more cases of tick-born encephalitis in Pskov region
Three more cases of tick-born encephalitis (TBE) have been registered in the Pskov region. As of 11 Sep 2008, 22 cases of TBE, including 3 children, have been registered in the Pskov region in 2008. Of these cases, 12 have been recorded in the city of Pskov and 10 in the Pskov region. In the Pskov region, 3612 people (909 of whom were children) have been bitten by ticks. 612 blood samples have been examined and the TBE virus was found in 7 ticks.
(ProMED 9/18/08)


Singapore: Chikungunya fever outbreaks continue
Since January 2008, Singapore has been experiencing outbreaks of both imported and local cases of Chikungunya fever. There have been an additional 28 cases (including 16 imported) since the 26 Aug 2008. As of 4 Sep 2008, a total of 178 cases have been notified this year. Of these, 86 were imported cases with history of travel to Johor (69 cases) and other states of Malaysia (8 cases), Indonesia (4 cases), Sri Lanka (2 cases), India (2 cases) and the Maldives (one case). The rest were locally acquired infections which probably occurred at 19 separate locations, including 39 cases in Kranji Way, 13 from Little India, 14 from Sungei Kadut, 5 from Pasir Panjang Wholesale market, and 6 from Lim Chu Kang Lane 2.
(ProMED 9/9/08)


Taipei (Changhua): 11 deaths attributed to hand, foot, and mouth disease in 2008
The Centers for Disease Control (CDC) reported on 9 Sep 2008, Taipeifs 11th death in 2008 from enterovirus infection (hand, foot & mouth disease). The victim was a two-year-old boy in the central county of Changhua. According to CDC Deputy Director-General Shih Wen-yi, the case was an irregular one because the enterovirus season is not at its peak in the county. "The public should not panic too much because of this case," Shih said.

The latest victim came down with a fever, vomiting, and vesicular eruptions in the mouth on 26 Aug 2008 and was hospitalized on 29 Aug 2008 when he developed a skin rash. The boy was discharged from hospital two days later, according to a report from the Changhua health authorities. However, on 1 Sep 2008, the boy was hospitalized again after he took a sudden turn for the worse and died on 4 Sep 2008. CDC statistics showed that from the beginning of 2008 to 8 Sep 2008, a total of 352 severe enterovirus infections were recorded in the country, 11 of which were fatal and 93 percent of which were caused by enterovirus type 71 (EV71). Of these 352 cases, 63 were in children under the age of one, 97 involved one-year olds, and 96 were two-year-olds. According to the CDC, the largest number of cases occurred in the central and southern parts of Taiwan, with 49 cases in Tainan County and 48 in Changhua County. While the 2008 enterovirus outbreak slowed down noticeably following the start of the summer vacation in July 2008, a new peak was expected after school reopened in September 2008. Shih, however, said no suspected cases of severe enterovirus infection have been reported since 1 Sep 2008, which indicates that the expected peak has not occurred. Shih reminded the public that sporadic enterovirus infections can occur in Taiwan even when the virus is not in season, and he advised people to maintain good hygiene to prevent infection and avoid passing the virus to young children in their families.
(ProMED 9/15/08)


Canada (Quebec): Shellfish harvesting sites close due to red tide
A toxic algal bloom, also known as red tide, some 600 square kilometers in size, developed in early August 2008 in the St. Lawrence Estuary (SLE), Quebec, Canada, and resulted in an unprecedented faunal mortality event in the SLE. Alexandrium tamarense, a toxic dinoflagellate, naturally present in the SLE and Gulf of St. Lawrence can bloom when the temperature rises and salinity decreases in surface waters as a result of increased freshwater runoff in the St. Lawrence River and coastal tributaries. Alexandrium tamarense produces saxitoxin that affects the nervous system and can cause paralytic shellfish poisoning (PSP) following consumption of toxin-contaminated organisms.

At the end of July and in early August 2008 heavy precipitation, warm temperatures, and calm surface waters favored the blooming of the dinoflagellate. On 8 Aug 2008 about 100 dead birds (8 different species) were first observed by Parks Canada staff near Tadoussac at the confluence of the Saquenay River and St. Lawrence Estuary. Numerous dead fish, birds, whales and seals were observed floating dead or stranded dead on shore. The bloom dissipated due to strong winds during the week of 18 Aug 2008 as it reached the Gulf of St. Lawrence.

During the toxic algal bloom the Canadian Department of Fisheries and Oceans (DFO) closed all the shellfish harvesting areas in the affected zone to protect public health. The Canadian Food Inspection Agency (CFIA) monitors various shellfish sites in the SLE and advises closure when levels of toxin in shellfish exceed the accepted norm. As a precaution the CFIA and Health Canada advised the public against eating the liver and viscera of fish and invertebrates caught in the SLE during the red tide event and advised against eating the viscera of waterfowl hunted this fall. Saxitoxin accumulates in the digestive system of affected organisms but not in the flesh.
(ProMED 9/13/8)


USA: CDC reports on results for new public health gno flyh list
The US Centers for Disease Control and Prevention (CDC) released a report detailing the first year of its public health "do not board" (DNB) list, a new tool designed to prohibit those with serious communicable diseases from flying into or out of the country. Data from the first year of the program, from June 2007 to May 2008, appeared in the 19 Sep 2008 issue of Morbidity and Mortality Weekly Report (MMWR). "State and local health departments in the United States and other countries should be aware of this new public health tool," the CDC said in the report, adding that the list is designed to provide a backup measure when local public health efforts aren't strong enough to keep certain people who are contagious from boarding commercial flights. The CDC said it developed the DNB list in June 2007.

The list is managed by the CDC and the US Department of Homeland Security (DHS), though it said the DHS defers public health decisions and actions to the CDC. According to the provisions of the DNB list, state and local health officials must contact their local CDC quarantine station to place a person on the DNB list. Then the CDC determines if the person is: likely contagious with a communicable disease that presents a serious public health threat; unaware of or likely to not comply with public health recommendations and medical treatment; likely to try boarding a commercial aircraft. The CDC said it has several criteria for deciding when to add or remove people from the DNB list. Once public health officials determine a patient is not contagious, the CDC and DHS remove the person from the list, usually within 24 hours. The CDC also said it reviews the list each month to determine if anyone on the list is eligible for removal.

According to the MMWR report, the CDC received 42 requests to add persons to the DNB list, all of whom had suspected or confirmed pulmonary tuberculosis (TB). The agency approved 33 (79%) of the requests. Of the 9 people who were not added to the list, 4 were subject to other local public health actions such as isolation orders, 3 agreed not to fly, and 2 were determined to be noncontagious. Of the 33 people who were added to the list, 28 were placed by public health departments in the US. Fourteen of the 33 were placed on the list while they were outside of the country. Two of the 33 people who were placed on the DNB list attempted to evade the air travel restriction, and both were detained by border officials and were taken to local hospitals for evaluation and treatment of TB. CDC said judicious use of the DNB list could help avoid the human and economic burdens of contact investigations that result when people with communicable diseases fly.
(CIDRAP 9/18/08)


USA (New York): Dialysis center shut down after patient tests positive for hepatitis C
A New York City dialysis center was shut down by the state health department after one patient tested positive for hepatitis C. According to a CBS news, nearly 700 patients of the Life Care Dialysis Center in Manhattan are being urged to get tested for both hepatitis B and C virus strains, as well as HIV. The health department said they uncovered poor conditions, including "blood on the treatment chairs and dialysis machines, lack of proper hand hygiene, and inadequate disinfection of equipment." But the exact source of the contamination has not been identified. State health officials said that anyone treated at the center between 23 Jan 2004 and the present should contact their physicians to be tested. According to the National Institute of Health, an estimated 180 million people worldwide have chronic hepatitis C, with more than 4 million of these cases in the United States.
(ProMED 9/17/08)


USA (Utah): Man dies of hantavirus pulmonary syndrome
A Utah man died of hantavirus pulmonary syndrome after apparent exposure to rodent droppings, officials said 11 Sep 2008. The last confirmed hantavirus infection in Utah occurred in 2004, the Utah Department of Health said. The man, of Duchesne County between the ages of 19-29 years, appeared to be otherwise healthy before he became ill. He was hospitalized 2 Sep 2008 and died the next day.

Health officials are investigating the death but suspect the man was exposed to a hantavirus while cleaning up rodent droppings. Hantaviruses are shed in the urine and fecal droppings of rodents. Humans can become infected by inhaling dust that contains dried contaminated rodent urine or feces. The health department said extreme care should be taken when cleaning up rodent droppings. Clean up rodent droppings using a wet method such as spraying disinfectant, such as diluted bleach, prior to cleaning. Then use a wet mop or towel moistened with disinfectant to clean, the agency said. Do not clean up rodent droppings using a dry method, such as sweeping and vacuuming.
(ProMED 9/14/08)


USA (Oklahoma): E. coli O111 outbreak continues with 291 cases, one killed
The Oklahoma E. coli O111 outbreak continues to get worse and as of 16 Sep 2008, the total number of cases was near 300. Oklahoma state health officials increased the number of confirmed cases to 291. This marks a huge spike in the number of cases, as well under 250 were reported just days prior. The outbreak has been linked to those who ate at the Economy Cottage restaurant in Locust Grove, Oklahoma. Out of the 291 sickened by the E. coli outbreak, 227 are adults and 46 are children. So far, around 70 people have had to be hospitalized. One 26-year-old man has died.

The Oklahoma State Department of Health (OSDH) reported on 4 Sep 2008 that laboratory analysis of water samples taken from a private well on the property of the Economy Cottage restaurant in Locust Grove, OK has found no disease-causing bacteria. "The well water is not the source of this outbreak," said State Epidemiologist Dr. Kristy Bradley. "We are continuing our efforts to conduct microbiological testing of food preparation and serving surfaces in the restaurant, and we continue to interview cases, as we try to establish an association with those who became ill and a potential source."

"This appears to be the largest E. coli O111 outbreak ever reported in the USA," Bradley stated. "The complexity of this outbreak and the necessity to be extremely thorough in our investigation means we still have more questions than answers." OSDH investigators, along with staff from the Tulsa Health Department and area local county health departments have interviewed more than 500 persons in an effort to identify the source of the outbreak. The restaurant is closed while the investigation continues. Not all persons who ate at the restaurant have become ill. No other restaurant or food service outlet in the area has been linked to the outbreak.

Health officials say E. coli O111 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 9/8/08, 9/16/08)


USA (Pennsylvania): Two human salmonella cases lead to pet food recall
Two isolated cases of a type of bacterium known as Salmonella (enterica serotype) Schwarzengrund in humans has caused a Pennsylvania pet food manufacturer to recall a number of dry dog and cat food brands nationwide. Mars Inc.'s Mars Petcare is reportedly recalling cat and dog food made at its Everson facility. While Mars Inc. maintained that no direct connection has been made between illness in either animals or humans and its pet food product, the possibility that two humans may have contracted salmonella caused the recall, which began at the beginning of August 2008.

The same serotype of S. Schwarzengrund and the same manufacturer were involved in another situation in 2007. It is not clear whether the same plant was involved or whether the bacterial strains are genetically linked. The relationship between the two human cases and the dog food is also unclear.
(ProMED 9/15/08)


3. Updates
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDPfs 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.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The Influenza Virus Tracking System can be accessed at: www.who.int/fluvirus_tracker.
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza.
- 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: 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fs website for pandemic/avian flu: http://www.pandemicflu.gov/. View archived Webcasts on influenza pandemic planning.
- CIDRAP: http://www.cidrap.umn.edu/ See information on the upcoming gAvoiding the Big 7 Pandemic-Planning Mistakesh 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 National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds and poultry.


Philippines (Pangasinan)
Pangasinan province is being threatened by a possible outbreak of cholera disease. Health officials said cholera is now the major concern due to the "dramatic" increase in the number of cases of the disease in the western and central areas of the province. Provincial health office records show that the number of cholera victims has increased to 57, with one death in Bayambang town. Bayambang town has the largest number of cholera cases, followed by Aquilar and Bolinao.

Unofficial records show that there are already 6000 cases of acute gastroenteritis in the province. The provincial health office is now providing chlorine solution to barangays with contaminated shallow tube wells to alleviate the number of cholera cases.
(ProMED 9/15/08)


Mexico (Jalisco)
From 2007-2008, dengue outbreak foci have been in the coastal municipalities of Jalisco. As of 9 Sept 2008, there is a dengue alert in metropolitan Guadalajara, where there are the greatest concentration of cases. For 2008, Zapopan is the municipality in metropolitan Guadalajara with the greatest concentration of reported cases, containing 47 of the 86 reported cases.

Norma Jacobo Hernandez, Chief of the Department of Vectors and Zoonoses of the state Secretariat of Health (SSJ) recognized that, in concentrating their efforts in coastal communities, preventive actions in Metropolitan Guadalajara have been relaxed. "In coastal areas, in contrast to Zapopan, there have been frequent and continuous efforts to eliminate mosquito breeding sites within houses and we have not carried out this activity with such frequency in Metropolitan Guadalajara," said Jacobo Hernandez. She indicated that the factor which most favors the presence of the mosquito vector of dengue disease virus is the presence in homes of containers where clean water is stored, which is an ideal site for mosquito breeding. Up until now, the actions and operations have not been sufficient to eliminate all of the mosquito breeding sites. For this reason, community participation is necessary so that every person does their part in the elimination of breeding sites in their homes. "The idea that simply applying insecticides can control dengue outbreaks is false, but it is simply not that way, it requires the participation of the community, because I could apply insecticides that would give me results for a week, but if people don't eliminate breeding sites, we will have problems with dengue again a week later," she emphasized.

The mosquitoes have great reproductive capacity. Vector mosquitoes located in Zapopan increases the possibility that the outbreak might extend to other municipalities in the metropolitan area. The mosquito can fly up to 200 meters, but it is also possible that they can travel greater distances. For example, people can transport them in their cars to other places by accident. The collective municipalities within metropolitan Guadalajara essentially present one large populated area and there would be few barriers to inhibit the spread of the vectors or the viruses within it.
(ProMED 9/9/08)

Vietnam (Ho Chi Minh City)
In the first eight months of 2008, more than 7290 people have been hospitalized for dengue fever in Ho Chi Minh City. This is an increase of 60 percent compared with the same period in 2007, according to the Ho Chi Minh City Preventive Medicines Centre. From 4-11 Sept 2008, the number of dengue patients increased sharply, with more than 250 cases. The southern province of Tien Giang was particularly hard hit by the disease, with 3500 people afflicted and three deaths so far in September 2008.
(ProMED 9/12/08)

Vietnam (Hanoi)
A new kind of mosquito with the scientific name of Aedes albopictus and causing dengue fever has been found in the inner area of the capital city of Ha Noi. A year ago, this kind of mosquito only occurred in the suburb of the capital, where there were many stagnant ponds and dirty channels. According to the Bach Mai Hospital, the number of patients with the viral fever is increasing, from 20 total cases in August 2008 to 5-7 cases per day in early September 2008. Other hospitals such as Saint Paul, Dong Da, and Buu Dien are overloaded with patients with the viral fever. Doctors have said that if this disease is not treated in time, patients have a high risk of death.

However, there is no data to suggest that dengue virus infections caused by different members of the Aedes species of mosquitoes are more severe than others. The A. albopictus mosquito has been a rural and suburban mosquito, whereas the A. aegypti mosquito is an urban mosquito.
(ProMED 9/12/08)


Date: 31 Aug – 6 Sept 2008:
Human cases: Manitoba 2 cases, Saskatchewan 1 case
Total human cases in 2008: 20

Date: 10-16 Sep 2008
States newly reporting new human cases: Delaware, Georgia
The only states not reporting West Nile Virus presence are: Alaska, Hawaii, and Maine.
There have been a total of 712 human cases and 11 fatalities to date in 2008.
(ProMED 9/17/08)


4. Articles
Influenza vaccines: research, development and public health challenges
Osterhaus ADME & Poland G, Eds. Vaccine. 12 Sep 2008; 26(4): D1-D74. http://www.sciencedirect.com/science/journal/0264410X
A special issue of the journal Vaccine addressing the research, development, and public health challenges of influenza vaccines.


Effects of school closures during the 2008 winter influenza season, Hong Kong
Public health officials in Hong Kong made headlines in March when they closed schools for two weeks to put a damper on an influenza epidemic, but a new report says the measure appears to have had little effect. Researchers from Hong Kong explored flu surveillance data gathered before, during, and after the outbreak that led to the school closure and reported their findings in an early online edition of Emerging Infectious Diseases (Cowling BJ et al. Emerg Infect Dis 2008 Oct; 14(10)).

On 12 Mar 2008 after three children died, apparently from seasonal flu, Hong Kong's government announced that all primary schools, special schools, kindergartens, and day nurseries would close for two weeks, the authors reported. The closure, which came a week before the start of the annual week-long Easter break, occurred during the peak of the area's winter flu season. The closure was Hong Kong's first since the SARS (severe acute respiratory syndrome) epidemic of 2003, and it affected nearly 560,000 children.

According to the research group's review of the surveillance data, the flu season was already waning when officials decided to close the schools. Their review of outpatient consultation data revealed that the 2008 winter flu season was moderately severe compared with the previous nine years. The authors found that routine surveillance did not show a large effect from the school closures. They concluded that epidemic curves based on the surveillance data showed that a decline in flu cases after the school closure might have occurred even without any intervention, though they warned that changes in an epidemic curve may lag behind changes in transmission dynamics, as had been shown for SARS.

Their results should be interpreted cautiously, the researchers wrote. "In particular, influenza might have continued to circulate for a longer period had the school closures not been implemented." The authors also acknowledged that other studies suggest school closures can mitigate flu epidemics. Public officials who decided to close the Hong Kong schools might not have known from the data they had that the flu season was moderate and might have already been declining naturally, the report says. Surveillance system improvements, particularly real-time or near real-time reporting, could help officials make more informed decisions, it adds.

Jeffrey Duchin, chief of communicable disease control for Seattle King County Public Health in Washington, told CIDRAP News that it isn't surprising that the study didn't detect a benefit from school closure late in a flu season. "After all, most persons in the community would have already been infected," he said. Given the relative mildness of the season, indirect indicators of flu activity would have been less sensitive, he said, adding that it's difficult to study the impact of school closures on transmission retrospectively, because schools typically close late in the flu season. gThe cost-benefit of closing schools in seasonal epidemics that are not at the high end of the severity scale is probably low, and few if any close early [in the season]," Duchin said. Real-time surveillance might be especially important in more severe flu epidemics, in which officials would need to gauge the impact of school closure, he said.
(CIDRAP 9/12/08)


Effectiveness of maternal influenza immunization in mothers and infants
Zamen, K et al. NEJM. 17 Sep 2008. http://content.nejm.org/cgi/content/full/NEJMoa0708630.

Abstract: Background Young infants and pregnant women are at increased risk for serious consequences of influenza infection. Inactivated influenza vaccine is recommended for pregnant women but is not licensed for infants younger than 6 months of age. We assessed the clinical effectiveness of inactivated influenza vaccine administered during pregnancy in Bangladesh. Methods In this randomized study, we assigned 340 mothers to receive either inactivated influenza vaccine (influenza-vaccine group) or the 23-valent pneumococcal polysaccharide vaccine (control group). Mothers were interviewed weekly to assess illnesses until 24 weeks after birth. Subjects with febrile respiratory illness were assessed clinically, and ill infants were tested for influenza antigens. We estimated the incidence of illness, incidence rate ratios, and vaccine effectiveness. Results Mothers and infants were observed from August 2004 through December 2005. Among infants of mothers who received influenza vaccine, there were fewer cases of laboratory-confirmed influenza than among infants in the control group (6 cases and 16 cases, respectively), with a vaccine effectiveness of 63% (95% confidence interval [CI], 5 to 85). Respiratory illness with fever occurred in 110 infants in the influenza-vaccine group and 153 infants in the control group, with a vaccine effectiveness of 29% (95% CI, 7 to 46). Among the mothers, there was a reduction in the rate of respiratory illness with fever of 36% (95% CI, 4 to 57). Conclusions Inactivated influenza vaccine reduced proven influenza illness by 63% in infants up to 6 months of age and averted approximately a third of all febrile respiratory illnesses in mothers and young infants. Maternal influenza immunization is a strategy with substantial benefits for both mothers and infants.


Preparing for the Real Storm during the Calm: A Comparison of the Crisis Preparation Strategies for Pandemic Influenza in China and the U.S.
Peng, Zongchao. Journal of Homeland Security and Emergency Management. 2008; 5(1). http://www.bepress.com/jhsem/vol5/iss1/47.

Abstract: Humanity is facing the rapid spread of avian flu and the potential severe threat of a future global pandemic flu. The World Health Organization (WHO) and the governments of various countries and regions have proposed plans for managing a pandemic flu. China and the U.S. also issued their own preparation plans in September and November, 2005, respectively. This article asks whether there are vulnerabilities or shortcomings inherent in either preparation plan, and if so, what measures should be taken to improve them. The article first provides a theoretical analysis of the issues of crisis preparation, chiefly from the perspective of a real crisis. Second, it does some crisis analysis of a pandemic flu and proposes preliminary preparation strategies to deal with it. More importantly, it compares the United States and China concerning their crisis preparation strategies, including the process of forming strategies, cognition of risks, choices of goals, basic principles, framework, and implementation. Finally, it concludes by making some suggestions for crisis policy formulation regarding a pandemic flu.


Pandemic influenza in Australia: Using telephone surveys to measure perceptions of threat and willingness to comply
Barr, Margo et al. BMC Infectious Diseases. 2008; 8(117). http://www.biomedcentral.com/1471-2334/8/117/abstract

Abstract: Background: Baseline data is necessary for monitoring how a population perceives the threat of pandemic influenza, and perceives how it would behave in the event of pandemic influenza. Our aim was to develop a module of questions for use in telephone health surveys on perceptions of threat of pandemic influenza, and on preparedness to comply with specific public health behaviors in the event of pandemic influenza. Methods: A module of questions was developed and field tested on 192 adults using the New South Wales Department of Health's in-house Computer Assisted Telephone Interviewing (CATI) facility. The questions were then modified and re field tested on 202 adults. The module was then incorporated into the New South Wales Population Health Survey in the first quarter of 2007. A representative sample of 2,081 adults completed the module. Their responses were weighted against the state population. Results: The reliability of the questions was acceptable with Kappa ranging between 0.25 and 0.51. Overall 14.9% of the state population thought pandemic influenza was very or extremely likely to occur; 45.5% were very or extremely concerned that they or their family would be affected by pandemic influenza if it occurred; and 23.8% had made some level of change to the way they live their life because of the possibility of pandemic influenza. In the event of pandemic influenza, the majority of the population were willing to: be vaccinated (75.4%), be isolated (70.2%), and wear a face mask (59.9%). People with higher levels of threat perception are significantly more likely to be willing to comply with specific public health behaviors. Conclusion: While only 14.9% of the state population thought pandemic influenza was very or extremely likely to occur, a significantly higher proportion were concerned for self and family should a pandemic actually occur. The baseline data collected in this survey will be useful for monitoring changes over time in the population's perceptions of threat, and preparedness to comply with specific public health behaviors.


Identification of cardioviruses related to Theiler's murine encephalomyelitis virus in human infections
Chiu, Charles Y et al, PNAS, 16 Sep 2008; 105 (37). http://www.pnas.org/content/early/2008/09/02/0805968105.full.pdf+html

Abstract: Cardioviruses comprise a genus of picornaviruses that cause severe illnesses in rodents, but little is known about the prevalence, diversity, or spectrum of disease of such agents among humans. A single cardiovirus isolate, Saffold virus, was cultured in 1981 in stool from an infant with fever. Here, we describe the identification of a group of human cardioviruses that have been cloned directly from patient specimens, the 1st of which was detected using a pan-viral microarray in respiratory secretions from a child with influenza-like illness. Phylogenetic analysis of the nearly complete viral genome (7961 bp) revealed that this virus belongs to the Theiler's murine encephalomyelitis virus (TMEV) subgroup of cardioviruses and is most closely related to Saffold virus. Subsequent screening by RT-PCR [reverse transcriptase polymerase chain reaction] of 719 additional respiratory specimens [637 (89 percent) from patients with acute respiratory illness] and 400 cerebrospinal fluid specimens from patients with neurological disease (aseptic meningitis, encephalitis, and multiple sclerosis) revealed no evidence of cardiovirus infection. However, screening of 751 stool specimens from 498 individuals in a gastroenteritis cohort resulted in the detection of 6 additional cardioviruses (1.2 percent). Although all 8 human cardioviruses (including Saffold virus) clustered together by phylogenetic analysis, significant sequence diversity was observed in the VP1 gene (66.9 percent-100 percent pairwise amino acid identities). These findings suggest that there exists a diverse group of novel human Theiler's murine encephalomyelitis virus-like cardioviruses that hitherto have gone largely undetected, are found primarily in the gastrointestinal tract, can be shed asymptomatically, and have potential links to enteric and extra intestinal disease.


Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection
Summary: Serologic testing for hepatitis B surface antigen (HBsAg) is the primary way to identify persons with chronic hepatitis B virus (HBV) infection. Testing has been recommended previously for pregnant women, infants born to HBsAg-positive mothers, household contacts and sex partners of HBV-infected persons, persons born in countries with HBsAg prevalence of >8%, persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (e.g., needlestick injury to a health-care worker or sexual assault), and persons infected with human immunodeficiency virus. This report updates and expands previous CDC guidelines for HBsAg testing and includes new recommendations for public health evaluation and management for chronically infected persons and their contacts. Routine testing for HBsAg now is recommended for additional populations with HBsAg prevalence of >2%: persons born in geographic regions with HBsAg prevalence of >2%, men who have sex with men, and injection-drug users. Implementation of these recommendations will require expertise and resources to integrate HBsAg screening in prevention and care settings serving populations recommended for HBsAg testing. This report is intended to serve as a resource for public health officials, organizations, and health-care professionals involved in the development, delivery, and evaluation of prevention and clinical services.
(MMWR September 19, 2008 / 57(RR08);1-20) http://cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm


Surveillance for Waterborne Disease and Outbreaks Associated with Recreational Water Use and Other Aquatic Facility-Associated Health Events--United States, 2005--2006
During 1920–1970, statistical data regarding waterborne-disease outbreaks (WBDOs) in the United States were collected by different researchers and federal agencies. Since 1971, CDC, the U.S. Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have collaboratively maintained the Waterborne Disease and Outbreak Surveillance System, a surveillance system that tracks the occurrences and causes of WBDOs and cases of disease associated with drinking water. In 1978, WBDOs associated with recreational water were added to the surveillance system. The types of outbreaks and disease case reports included in the Surveillance Summaries have expanded multiple times to more accurately reflect the scope of waterborne disease in the United States. Outbreaks of Pontiac fever were added in 1989, outbreaks of Legionnaires’ disease were added in 2001, and single cases of Vibrio illness reported to the Cholera and Other Vibrio Illness Surveillance System that were associated with recreational water use were added in 2003.
(MMWR September 12, 2008 / 57(SS09);1-29) http://cdc.gov/mmwr/preview/mmwrhtml/ss5709a1.htm


Surveillance for Waterborne Disease and Outbreaks Associated with Drinking Water and Water not Intended for Drinking--United States, 2005--2006
Statistical data on waterborne-disease outbreaks (WBDOs) in the United States have been collected since 1920. Researchers reported these statistics during 1920–1936, 1938–1945, 1946–1960, and 1961–1970. Since 1971, CDC, the U.S. Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have maintained a collaborative Waterborne Disease and Outbreak Surveillance System (WBDOSS), which tracks the occurrences and causes of WBDOs and cases of disease associated with drinking water. The history of WBDO surveillance in the United States is summarized in the 2003–2004 WBDOSS Surveillance Summary. The 2005–2006 Surveillance Summary presents data on 28 WBDOs reported by public health departments in the states, territories, and localities that occurred during January 2005–December 2006, and four previously unreported WBDOs that occurred during 1979–2002.
(MMWR September 12, 2008 / 57(SS09);39-62) http://cdc.gov/mmwr/preview/mmwrhtml/ss5709a4.htm


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)


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)


Ethics and Severe Pandemic Influenza: Maintaining Essential Functions through a Fair and Considered Response
Kass, Nancy E. et al. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 1 Sep 2008; 6(3): 227-236. http://www.liebertonline.com/doi/abs/10.1089/bsp.2008.0020

This article provides ethics guidance for pandemic planning, response, and resource allocation—that is, what ethical considerations determine which public health responses are implemented, who will be restricted and who will be helped, what will be communicated to the public, and how will the public be included in decisions and responses?

The response to severe pandemic influenza will be managed by experts in public health and infectious disease and by government officials to whom the public will turn for information and direction. Nonetheless, there remain important ethical considerations that can shape what goals are given priority, how scarce resources are distributed, how the public is included, and how we treat the most vulnerable in our response to a pandemic. This article assumes that the secondary consequences of severe pandemic influenza could be greater than deaths and illness from influenza itself. Response plans then, must consider threats to societal as well as medical infrastructures. While some have suggested that scarce medical countermeasures be allocated primarily to first responders and then to the sickest, we suggest that an ethical public health response should set priorities based on essential functions. An ethical response also will engage the public, will coordinate interdependent sectors as a core preparedness priority, and will address how plans affect and can be understood by the least well off.
(CIDRAP 9/17/08)


US policy regarding pandemic influenza vaccines
Congressional Budget Office report. Sep 2008. http://www.cbo.gov/ftpdocs/95xx/doc9573/09-15-PandemicFlu.pdf

This paper from the Congressional Budget Office (CBO) focuses on the governmentfs role, under the U.S. Department of Health and Human Servicefs (HHS) plan to prepare for and combat an influenza pandemic, in the development of new vaccines and the capacity to manufacture them. It provides information on progress and on the potential cost of achieving HHSfs vaccine-related goals, the continuing expenditures that are likely to be needed to maintain preparedness, and the experience of other countries in preparing for a possible pandemic. It also presents options for modifying HHSfs 2005 plan. The work is based on a review of the academic literature, on industry data, and on interviews with government and industry experts who are working to improve the response of vaccine producers to a potential influenza pandemic.
(CIDRAP 9/15/08)


Practical Management Strategies for Avian Influenza and Emerging Infectious Diseases--The Implementation Toolkit
The second workshop on “Practical Management Strategies for Avian Influenza and Emerging Infectious Diseases Ethe Implementation ToolkitEwas held in Hanoi, Vietnam from 10-11 September 2008. The Workshop was convened by the Australian Government Department of Agriculture, Fisheries and Forestry, in conjunction with the Asia Pacific Economic Cooperation Agricultural Technical Cooperation Working Group (APEC ATCWG). The aims of the workshop were to obtain member economy feedback on the draft “Implementation Toolkit,Econsider progress on the development of the toolkit, share information on successful initiatives of member economies that will be featured in the toolkit, and further identify specific needs, materials, and experiences that member economies want included in the toolkit. The workshop also identified information gaps and areas for future work.

Participants identified specific materials and examples to be included in the toolkit. The toolkit is designed to be a ‘one stop shopEfor sharing experiences and accessing materials used by other countries. There was consensus that the value of the website would be enhanced by an interactive forum that allowed information and resource sharing and discussion. Participants also agreed that it was extremely important that work continue to collect and document country experiences to develop case studies for the website, as very little of this information has been documented or shared in other places. The toolkit launch will take place at the next global Ministerial Conference for Avian and Pandemic Influenza scheduled for 24-26 October in Sharm El-Sheikh, Egypt.