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Vol. XI, No. 20 ~ EINet News Briefs ~ Oct 03, 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: WHO seeks to ease worry over upcoming influenza season
- Indonesia: Suspension of activities at U.S. medical laboratory
- Viet Nam (Ca Mau): Avian influenza H5N1 found in ducks
- USA: FDA approves CDC’s new rapid influenza test
- USA: Influenza shots for small children slow to catch on
- USA: Influenza vaccine shortage left its mark

2. Infectious Disease News
- China (Tibet): Two die of pneumonic plague
- Russia (Astrakhan): Three people infected with anthrax from slaughtered cattle
- Russia (Chukchi): Trichinellosis outbreak kills two people
- Russia (Dagestan): 28 cases of botulism in 2008
- Russia (Samara and Tatarstan): HFRS epidemic continues
- Mexico (Queretaro): 290 cases in Hepatitis A outbreak
- USA (Arizona): Two women exposed to rabid bat
- USA (California): Salmonellosis outbreak attributed to handling turtles affects over 100 people
- USA (Maryland): Emergent garners $29 million for new anthrax vaccine
- USA (Michigan): 23 cases of E. coli O157:H7 infection among university students
- USA (Nevada): 90 Hepatitis C cases linked to unsafe injection anesthesia practices
- USA (New York): Campylobacter outbreak sickens 236 people
- USA (Ohio): Four cases of botulism related to home canned green beans

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

4. Articles
- Influenza-Associated Pediatric Mortality in the United States: Increase of Staphylococcus aureus Coinfection
- Tracing killer spores: the science behind the anthrax investigation
- Delinquent Mortgages, Neglected Swimming Pools, and West Nile Virus, California
- Progress Toward Measles Elimination, Japan 1999-2008
- Novel astroviruses in insectivorous bats
- Study: First flu wave in 1918 was vaccine for some
- Replacement of Sublineages of Avian Influenza (H5N1) by Reassortments, Sub-Saharan Africa
- Effects of a Reduced Dose Schedule and Intramuscular Administration of Anthrax Vaccine Adsorbed on Immunogenicity and Safety at 7 Months
- Antigenic and genetic characteristics of H5N1 viruses and candidate H5N1 vaccine viruses developed for potential use as human vaccines
- Pandemic Influenza and Excess Intensive-Care Workload

5. Notifications
- “One Health” website released
- Public health groups report preparedness gains
- American Academy of Pediatrics update recommendations for influenza vaccinations in children
- Influenza pandemic: GAO reports HHS needs to continue to finalize guidance for pharmaceutical interventions


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 / 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 10.9.08 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 9.30.08): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 9.23.08): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: WHO seeks to ease worry over upcoming influenza season
A top influenza expert with the World Health Organization sought to allay fears that the upcoming flu season in the northern hemisphere will be unusually severe. Keiji Fukuda, coordinator of the WHO's global influenza program, said northern hemisphere locations are reporting only sporadic influenza cases. "There's no real indication on how this season is going to evolve yet," he said.

Fukuda said he's not sure why rumors are circulating that the northern hemisphere is in for a severe flu season. He said some people might be interpreting the presence of three new strains in the northern hemisphere's influenza vaccine as a sign that the season might be severe. However, he said, "Change itself does not mean that the season is going to be severe."

Recent reports in the British media described fears about the likely arrival of the Brisbane strain of influenza A/H3N2 in the United Kingdom during the upcoming season. That strain circulated at the end of Australia's 2007 flu season, then unexpectedly circulated in the United States during its 2007-08 season. The latest vaccine recommendations for both hemispheres include the Brisbane strain of H3N2.

The southern hemisphere's 2008 flu season has tailed off, and it appears that its vaccine was a good match with circulating influenza strains, Fukuda said. "The season in Australia was pretty mild," he said. "This is something that we can confirm."

Fukuda promised that WHO will monitor the season closely through its Global Influenza Surveillance Network, consisting of 122 labs that span 94 countries. The labs process thousands clinical specimens each year from patients who have seasonal influenza infections.
(CIDRAP 10/2/08)

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Asia
Indonesia: Suspension of activities at U.S. medical laboratory
Indonesia has halted the activities of a U.S. naval medical lab in Jakarta following a dispute over the terms of a contract, the health minister said Sep 2008. The U.S. Naval Medical Research Unit No. 2 [NAMRU-2] has been key to efforts to track avian influenza in Indonesia, the country with the most human deaths from the H5N1 virus.

But a memorandum of understanding allowing the lab to operate in Jakarta expired two years ago and was not renewed, when a dispute arose over Indonesia's sharing of samples of H5N1 with the rest of the world. "They are not allowed to do any activities anymore," Health Minister Siti Fadillah Supari said. "The term is suspension, but there are no activities at all now." In April 2008, she said the lab was not very beneficial to Indonesia because it refused to share all of its findings with the host country.

Early in 2008, Indonesia ordered hospitals and labs in the country to stop supplying bird flu samples to the American lab and now only reports bird flu cases in humans to the public every six months, a move some scientists say could lead to delays in containing outbreaks of the disease. Jakarta has also refused to share bird flu samples, saying it wants guarantees from richer nations and drug makers that poor countries would get access to affordable vaccines developed from their samples.

International health experts say it is vital to have access to samples of the constantly mutating H5N1 virus, which they fear could change into a form easily transmissible among humans and sweep the world in months, killing millions of people. Indonesia has suffered 112 casualties from the virus.
(ProMED 9/26/08)

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Viet Nam (Ca Mau): Avian influenza H5N1 found in ducks
Vietnamese authorities have detected the H5N1 avian flu virus in a flock of ducks on a farm in the southern province of Ca Mau, a government official said 26 Sep 2008. Hoang Van Nam, deputy director of Viet Nam's Animal Health Department, said inspectors had found 22 Sep 2008 that bird flu had killed more than 50 of 500 ducks on a Ca Mau farm. All the ducks at the farm were ducklings under 45 days old, and thus had not been vaccinated yet, Nam said. Authorities have culled all the ducks at the farm.

On 7 Sep 2008, the Animal Health Department announced it had detected bird flu in a flock of 600 ducks on a farm in the southern province of Ben Tre, adjacent to Ho Chi Minh City. According to Nam, bird flu outbreaks have been detected in 26 Vietnamese provinces since the beginning of 2008, killing five people and forcing authorities to cull more than 60,000 ducks.

H5N1 mainly affects poultry and wild birds, but can infect humans who have close contact with sick fowl. Scientists fear that if it spreads unchecked, the disease could mutate into a form that could be transmitted between humans and lead to a worldwide pandemic that could kill millions. Bird flu has infected 105 people in Viet Nam and killed at least 51 of them since late 2003.
(ProMED 9/27/08)

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Americas
USA: FDA approves CDC’s new rapid influenza test
The US Food and Drug Administration (FDA) approved a new diagnostic test developed by the Centers for Disease Control and Prevention (CDC) that can quickly distinguish seasonal influenza strains from an evolving virus that might have pandemic potential in hours rather than days. The test, called the Human Influenza Virus Real-Time RT-PCR Detection and Characterization Panel (rRT-PCR Flu Panel), can detect flu viruses and differentiate between seasonal and novel influenza strains.

The device isolates and amplifies viral genetic material from patients' nose and throat samples. Then it labels the viral genetic material with fluorescent molecules. The test panel and diagnostic system can detect and characterize commonly circulating human influenza viruses, avian influenza A viruses such as H5N1, and novel viruses within four hours rather than the days it takes for conventional tests. Also, the system can test multiple samples simultaneously.

CDC-qualified labs will be able to use the new diagnostic test this fall, and some facilities will be able to receive free reagents, the US Department of Health and Human Services (HHS) said, adding that the test should ensure the accuracy of influenza testing results among the different sites that perform subtype testing. Rosemary Humes, the Association of Public Health Laboratories’ (APHL) senior advisor for scientific affairs stated that labs have been using polymerase chain reaction (PCR) testing to analyze influenza viruses for a while, but they've never had standardized reagents until now. "The speed and accuracy is a great asset," she said, adding that the APHL helped develop the test and conducted validity testing. If a lab detects a novel strain with the new diagnostic testing system, the results will be more credible, Humes said.

Mike Leavitt, HHS Secretary, said the test's ability to identify emerging influenza viruses is important. "This breakthrough allows for a more timely detection of a pandemic virus, which helps in determining when to begin broad control strategies as well as life-saving mitigation measures, such as closing schools, cancelling social gatherings, and informing businesses to begin work-at-home policies," he said.
(CIDRAP 10/1/08)

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USA: Influenza shots for small children slow to catch on
Surveys indicate that recommendations to immunize small children against influenza have been slow to catch on, according to the Centers for Disease Control and Prevention (CDC). A national survey found that only about 21% of children six to 23 months old were fully vaccinated in the 2006-07 flu season, two years after the CDC formally recommended immunization of the age-group. In addition, surveys conducted at eight sites around the country indicated that only 16.5% of children between 24 and 59 months old were fully vaccinated last season. The CDC first recommended flu vaccination for that age-group in 2006. The rate does not mark a significant increase from the previous season. Coverage varied widely by state, ranging from 8.6% in Mississippi to 47.6% in Rhode Island.

To examine immunization coverage in children from six through 59 months old in the 2007-08 season, the CDC analyzed data from its eight immunization information system (IIS) sentinel sites: parts of Arizona, Colorado, Michigan, Oregon, Wisconsin, and Minnesota, plus all of North Dakota and New York City. The CDC found that on average for the eight sites, only 16.5% of children 24 to 59 months old were fully vaccinated, while 22.2% had one or more vaccine doses. Among children in the six to 23 months old age group, an average of 22.1% were fully vaccinated and an average of 40.8% had had one or more doses.

The report on the national findings for children aged six to 23 months says that vaccination coverage for other newly recommended infant vaccines has reached about 75% within seven years. The low flu vaccination coverage suggests that factors unique to flu are at work, including the need for annual vaccination, difficulty in vaccinating so many children in a short time, uncertainties in vaccine distribution at the local level, and "a lack of parental or provider confidence or interest in influenza prevention through vaccination." The article says, "The continuing low influenza vaccination coverage described in this report underscores the need to identify innovative strategies for increasing influenza coverage among young children."

The full reports are available from the CDC in MMWR 2008 Sep 26; 57(38): http://www.cdc.gov/mmwr/.
(CIDRAP 9/26/08)

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USA: Influenza vaccine shortage left its mark
Flu immunization for adults has been somewhat slow to recover from a setback caused by a vaccine shortage four years ago, according to the Centers for Disease Control and Prevention (CDC). A national survey showed that flu immunization coverage in the 2006-07 season increased from the previous year but still did not quite match the levels of 2003-04, the season before problems at one vaccine manufacturer cut the expected flu vaccine supply nearly in half.

Immunization rates reported for the various age and risk groups were as follows: 18- to 49-year-olds: those with high-risk conditions, 35.1%; all others, 23.4%; 50- to 64-year-olds: overall, 42%; those with high-risk conditions, 54.2%; those without high-risk conditions, 37.9%; Those 65 and older: 72.1%. For all age-groups, coverage was significantly higher for non-Hispanic whites than for most other ethnic groups.

Although coverage significantly increased during the 2006-07 season compared with the previous season, it did not match the 2003-04 season. Nor did it achieve the Health People 2010 target of 60% for persons ages 18-64 with high-risk conditions and 90% for those aged 65 and older. When the vaccine supply ran short in 2004-05, the CDC recommended that healthy people aged 50 to 64 not be a priority group for vaccination. As a result, coverage dropped by about half in that group, to 21.8%; it also dropped for other adult groups that still had priority. Coverage partly rebounded in 2005-06 and improved further in 2006-07, to levels close to those before the shortage. However, the rate for 50- to 64-year-olds with high-risk conditions was still 4.6 percentage points below the 2003-04 level. The full report is available from the CDC in MMWR 2008 Sep 26; 57(38). Available at http://www.cdc.gov/mmwr/.
(CIDRAP 9/26/08)

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2. Infectious Disease News

Asia
China (Tibet): Two die of pneumonic plague
An outbreak of human plague occurred recently in Lang County of Tibet's Linzhi District. Two people contracted the pneumonic plague and died. After the outbreak, relevant authorities in the Tibet Autonomous Region undertook comprehensive plague prevention work. The district does not report any new cases indicating that the outbreak has been brought under control.

Pneumonic plague, which is transmitted to humans from infected animals, mainly by the fleas of rodents, is highly contagious. It can spread between humans by breathing in respiratory droplets from an infected person. The incubation period of the disease is between one and four days. Pubu Zhuoma, head of the Tibet health department, said cases of human plague had emerged in Tibet in the past. "Tibet's disease prevention workers have long carried out plague prevention and control work in disease areas. They have had good results in controlling epidemics among animals and there have been no epidemics among humans," he said.
(ProMED 10/1/08)

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Russia (Astrakhan): Three people infected with anthrax from slaughtered cattle
Three local residents contracted anthrax in the Astrakhan region of Russia. The patients presented with symptoms of the cutaneous form of this dangerous disease and are now in the hospital in the neighboring Volgograd region. The source of the infection has been identified as meat from slaughtered cattle. The commission of the Ministry of Health in the Astrakhan region went to the district where patients were reported to investigate the source of infection and look for other possible cases.
(ProMED 9/23/08)

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Russia (Chukchi): Trichinellosis outbreak kills two people
A trichinosis outbreak was registered in Nunligran village, Providenskiy area of Chukchi autonomous district. A total of eight people were infected with Trichinella after eating walrus meat. Of those, two died and three are in the district hospital.
(ProMED 9/19/08)

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Russia (Dagestan): 28 cases of botulism in 2008
The specialists of the Dagestan Rospotrebnadzor (Russian Sanitary Service) report that 28 cases of botulism have been registered in the region since January 2008. During the last five years, about 100 botulism cases have been registered, with 166 people affected and three fatalities. The Dagestan Rospotrebnadzor recommends avoiding buying homemade canned goods, smoked fish, and products in hermetic wrapping of unknown origin with no certificate of quality. The rural populations of Dagestan rely on these types of foods for sustenance, especially in the winter.
(ProMED 9/22/08)

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Russia (Samara and Tatarstan): HFRS epidemic continues
An increasing number of people in the Samara Oblast region have contracted hemorrhagic fever with renal syndrome (HFRS), referred to locally as "mouse fever." This is a consequence of an increasing population of rodents in the region, which are the vectors of the infection. Approximately a 100 cases of HFRS have been recorded in the region during summer 2008.

During the period 19-25 Sep 2008 a total of 29 confirmed or suspected cases of HFRS were recorded in Tatarstan: ten in Kazan, eight in Naberezhnye Chelny, three in the Nizhnekamskiy area, three in the Almetievskiy area, two in the Sabinskiy area, one in the Kukmorskiy area, one in the Leninogorskiy area, and one in the Bavlinskiy area.

An unfavorable epidemic situation with regard to HFRS infection is developing in Tatarstan. HFRS incidence in 2008 is almost seven times more than in 2007. More than 100 HFRS cases have been recorded so far in 2008, with one fatal outcome. Ninety percent of cases occurred during the period of June-August 2008 and 11 percent of the cases were registered in the capital city of Kazan.
(ProMED 9/19/08, 10/2/08)

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Americas
Mexico (Queretaro): 290 cases in Hepatitis A outbreak
The Health Department of Queretaro acknowledged that a hepatitis A outbreak in the state is spreading. There have been more than 290 cases, and approximately 26 000 persons are at risk according to the State Secretary of Health. The head of the agency, Rafael Asencio Asencio, stated that although only 14 outbreaks of hepatitis A have occurred, there are more than 290 cases [reported] in the state, which is forcing the health authorities to implement greater measures. Asencio Asencio noted that the disease trend is low; since so far in 2008 there have been 14 outbreaks reported, while in 2007 there were 29 outbreaks. The most recent outbreaks were in Tequisquiapan as a consequence of heavy rain that caused unhygienic environmental conditions, which have promoted the spread of the virus and resulted in 80 reported cases of hepatitis A in a population of 24,000 people.
(ProMED 9/27/08)

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USA (Arizona): Two women exposed to rabid bat
Two Queen Creek women are getting preventative shots after being exposed to a rabid bat after test results came back on 19 Sep 2008. One of the women found the bat and it was tested and determined to have the fatal disease. The two women must now take a series of six shots to prevent an infection. The bat was identified as a Mexican free-tailed bat. The Mexican free-tailed bat has been implicated previously in transmission of rabies to humans; in Alabama in 1994, in Texas in 1997, and in California in 2002. The Mexican free-tailed bat is a migratory species living in caves in the southern United States, Mexico, Central America, the West Indies, central Chile, and Argentina. Their colonies are believed to be the largest congregations of mammals in the world. Other species of bats known to transmit rabies to humans are the silver-haired bat and the eastern pipistrelle.

County officials are warning people not to pick up or touch wild or unfamiliar animals, especially those that appear sick. Bites or scratches should be reported to health officials right away. Domestic pets should be vaccinated. Rabies is fatal to people once symptoms appear.
(ProMED 9/21/08 and 9/24/08)

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USA (California): Salmonellosis outbreak attributed to handling turtles affects over 100 people
A multistate outbreak of salmonellosis among people handling turtles, that includes California and Los Angeles County, was announced on 23 Sep 2008 by officials at the County of Los Angeles Department of Public Health Veterinary Public Health. Over 100 people, mostly children were infected by the same strain and 24 of them had to be hospitalized, the US Centers for Disease Control and Prevention (CDC) reported. Eleven cases of the infection were reported in Southern California that included eight cases in Los Angeles County, officials at County Public Health reported.

Symptoms include bloody diarrhea, abdominal cramps, fever, and vomiting. The CDC and local health officials interviewed potential cases to determine the cause of the outbreak. Of those interviewed, 59 percent reported turtle exposure during the seven days before the illness onset. Further study confirmed that turtle exposure was strongly association with the outbreak. Many human exposures were indirect. A baby became ill after being bathed in a sink where turtle feces had been discarded. Two girls fell ill after swimming in a non-chlorinated pool where turtles had been swimming.

"Turtles are natural carriers of salmonella bacteria," said DPH spokeswoman Sarah Kissell. "So we strongly urge parents not to buy those small turtles you might find in a dime store as pets for their children." Kissell said if people do have pet turtles, they should take extra precautions to practice good hygiene. "It's very important to wash your hands after handling turtles and other reptiles. So parents need to educate their children on how to safely handle these animals."
(ProMED 9/24/08)

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USA (Maryland): Emergent garners $29 million for new anthrax vaccine
Emergent BioSolutions announced on 26 Sep 2008 that it received a $29.7 million contract from the US federal government to continue work on another of its next-generation anthrax vaccine candidates. Emergent, based in Rockville, MD, announced the contract from the Biomedical Advanced Research and Development Authority (BARDA) and the National Institute of Allergy and Infectious Diseases (NIAID). The company makes BioThrax, the nation's only licensed anthrax vaccine, and is also developing a recombinant anthrax vaccine and an anthrax monoclonal antibody to block the anthrax toxin.

Of the three-year contract, $24.9 million will cover the manufacturing of clinical lots, nonclinical safety and efficacy studies, and stability studies to determine if the vaccine can be stored without refrigeration, which is a key requirement for the new vaccine. The remaining $4.8 million would fund a phase one clinical trial if the company and the government exercise that option.

A next-generation anthrax vaccine would help the US military more easily inoculate troops. Soldiers in high-risk areas such as the Middle East typically receive six doses of BioThrax over 18 months, followed by annual boosters. The military has said a next-generation anthrax vaccine should ideally require fewer doses and have fewer side effects. On Sep 3, Emergent announced that it had won a $24.3 million federal contract for an anthrax monoclonal antibody treatment called AVP-21D9. The company said it was also developing a polyclonal anthrax immunoglobulin candidate for intravenous treatment for patients who have anthrax infections.
(CIDRAP 9/26/08)

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USA (Michigan): 23 cases of E. coli O157:H7 infection among university students
Public health officials, with support from Michigan State University (MSU), have identified a brand of lettuce as the source of the recent multi-statewide outbreak of E. coli O157 that sickened a number of MSU students. The lettuce, which had been distributed nationally by Detroit-based vendor Aunt Mid's Produce Company, is identified as shredded and chopped iceberg lettuce. The affected lettuce products were immediately removed from MSU's dining halls, even though there have been no new cases with symptom onset reported at the university since 20 Sep 2008.

On 26 Sep 2008, the Michigan Department of Community Health reported 26 cases of genetically linked E. coli were spread throughout eight Michigan counties. In addition, that same strain has also been identified in cases in Illinois, New York, Ohio, and Oregon. Health officials said it was the out-of-state cases that helped to track down a common distributor of the affected food.
(ProMED 9/27/08)

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USA (Nevada): 90 Hepatitis C cases linked to unsafe injection anesthesia practices
The Las Vegas Endoscopy Center of Southern Nevada so far has been linked to almost 90 cases of hepatitis C. The figure, however, should continue to rise as more of the 50,000 patients notified by the clinic are tested for possible exposure to the virus. The case could surpass the damages caused by a similar incident in Nebraska in 2000, considered the nation's largest health care-related outbreak, with 99 reported infections.

In February 2008, the Southern Nevada Health District advised patients who received injected anesthesia medication at the Endoscopy Center of Nevada of a risk for possible exposure to hepatitis C and other bloodborne pathogens. At that time, the health district had received notification of three acute cases of hepatitis C in January 2008 and had identified a total of six other cases; five of these cases had procedures requiring injected anesthesia on the same day. Following a joint investigation with the Nevada State Bureau of Licensure and Certification (BLC) and with consultation from the Centers for Disease Control and Prevention, the health district determined that unsafe injection practices related to the administration of anesthesia medication might have exposed patients to the blood of other patients.
(ProMed 9/28/08)

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USA (New York): Campylobacter outbreak sickens 236 people
The tally of people who got sick after eating food from Hinerwadel's Grove in Clay (Onondaga County) earlier in September 2008 rose to 236 by 23 Sep 2008, but public health officials say the outbreak is leveling off. "The numbers have really slowed down and I do not expect this to significantly increase," said Dr Cynthia Morrow, Onondaga County's health commissioner. She said three of the people who became sick were hospitalized, but have recovered and been discharged.

Lab tests have identified Campylobacter, which could be a major cause of the outbreak. Evidence of that bacterium was found in six of seven stool samples collected from people who got sick. The germ is one of the most common causes of diarrhea, affecting more than 2.4 million Americans every year, according to the US Centers for Disease Control and Prevention (CDC). The bacterium is most commonly found in poultry, but 10 to 15 percent of clams and oysters can be contaminated with it. People usually become infected by eating undercooked chicken, beef, or seafood.

Officials suspect raw mahogany clams caused the outbreak of gastrointestinal illness among Hinerwadel's patrons because the vast majority of people who became sick said they ate them. However, that link has not been proven because results of lab tests on the clams will not be available until later, Morrow said.

Hinerwadel's stopped serving mahogany clams after the outbreak investigation began and switched to little neck clams. Hinerwadel's purchased the mahogany clams from a supplier in Maine who is being investigated by the state Health Department and Department of Environmental Conservation. The Health Department has not found any evidence of wrongdoing at Hinerwadel's, Morrow said. The department has interviewed more than 550 people who were exposed to the outbreak. Morrow also advised people not to eat raw clams because doing so increases the risk of getting sick.
(ProMED 9/24/08)

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USA (Ohio): Four cases of botulism related to home canned green beans
A man and his grandson remain in the hospital after coming down with food-borne botulism during the weekend of 13-14 Sep 2008. The man is listed in critical condition at MedCentral/Mansfield Hospital and his grandson is in serious condition at Akron Children's Hospital after eating home-canned green beans. Two granddaughters were also treated for botulism and released from Akron Children's Hospital.

Stephanie Zmuda, the Environmental Health Director at the Galion City Health Department, said that in ten years in the field, this is the first time she's dealt with such cases of contamination. "Botulism is a type of food poisoning and is the most dangerous," she said. "Six organisms is the infectious dose. So just a little bit of this germ can get you sick. You do not have to have a whole serving of the food to get sick." Zmuda said home-canning is by far the most common way to get botulism. Botulism can block nerve function and lead to musculoskeletal and respiratory paralysis, which can be fatal. Even after being treated with an antitoxin obtained from the CDC in Atlanta, GA, those with severe botulism often require a breathing machine and intensive medical care for weeks afterward. Botulism survivors may feel fatigued and short of breath for years to come.

"The processing is what is generally not done correctly," Zmuda said of food that is preserved at home. Liz Smith of the Ohio State University Wyandot County Extension said there are two different ways to can: by pressure cooker and by the boiling water method. "It can be a very complicated process," Smith said. "If you don't have the proper temperature or amount of time, the can will not seal correctly. If you use the boiling method, and don't boil the proper length of time, again, it will not seal correctly."
(ProMED 9/19/08)

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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
Hong Kong
The Centre for Health Protection (CHP) of the Hong Kong Department of Health urged members of the public to observe personal and food hygiene following the notification of 19 cases of laboratory-confirmed bacillary dysentery (shigellosis) so far in September 2008. Initial investigations by the CHP indicated that 18 of these cases acquired infection locally while the remaining one was an imported case. These cases, comprising ten females and nine males betwee the ages of two and 58, developed gastrointestinal symptoms including fever, diarrhea, vomiting, and abdominal pain from 26 Aug 2008 to 12 Sep 2008. All of them have recovered and their stool samples were positive for Shigella sonnei.

According to food histories provided, five of the local cases involved had taken meals from a fast food restaurant in Tsuen Wan one to four days before onset of symptoms.
(ProMED 10/2/08)

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DENGUE
Malaysia (Perak)
The dengue outbreak in Perak has badly hit the blood supply in hospitals in Ipoh, Malaysia and in Manjung district, which recorded the highest number of dengue cases. Health, Environment and Human Resource Committee chairman A. Sivanesan urged the public to donate blood at Hospital Raja Perempuan Bainun [in Ipoh] and at Seri Manjung Hospital. "The blood bank is depleted. The situation is bad," he said. It had been reported that Perak recorded four dengue deaths in the first nine months of 2008 with all cases reported in Manjung district. (ProMED 9/29/08)

Mexico (Jalisco)
After having confirmed the occurrence of 50 new dengue cases, for a total of 265 infected people so far in 2008, with four dengue hemorrhagic fever (DHF) cases, Norma Elizabeth Jacobo Hernandez, director of Vectors and Zoonoses of the Jalisco Secretariat of Health said that these figures are still much lower than in previous years. "There have been [dengue] outbreaks more important for the state, such as in Puerto Vallarta. The current outbreak is not different, except that it is in the Guadalajara metropolitan area. In 1988 there were 4508 laboratory confirmed [dengue] cases in the metropolitan area, the same as in Zapopan, one of the affected areas," she pointed out. In September 2007 more than 500 dengue cases had been identified. Against this background, Jacobo Hernandez insisted that nothing will be enough if you do not have social support. Actions to clean up and spray mosquito breeding sites will continue, especially in the Zapopan municipality, which up to 27 Sep 2008 has had a total of 185 dengue virus infected patients, of whom three had DHF.
(ProMED 9/29/08)

Mexico (Sonora)
The Sonora Secretariat of Public Health (SSP) declared a red alert in the state after the confirmation of six cases of classical dengue in the municipalities of Benito Juarez, Cajeme, and Navojoa, due to the rains caused by tropical storm Lowell, for a cumulative number of 23 affected people in the area in 2008. The secretary of public health, Raymundo Lopez Vucovich, assured the public that the "clean patios" strategy would be reinforced for the "Everyone Against Dengue" campaign in the region to avoid the spread of the disease, and issued a call to the community to help by cleaning up their patios and streets of standing water that could serve as breeding sites for the mosquito vector, thereby reducing the risk of dengue virus transmission to the populace.

To date, the SSP has confirmed seven dengue cases in the municipality of Navojoa, five in Navojoa town, five in Guaymas, three in Hermosillo, two en Benito Juarez, and one more from the adjacent state of Chihuahua, which requested medical assistance from Navojoa.
(ProMED 9/29/08)

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WEST NILE VIRUS
Canada
Date: 14 Sep – 20 Sept 2008:
Human cases: no new cases reported
Total human cases in 2008: 36

USA
Date: 24-30 Sep 2008
States newly reporting new human cases: Virginia
The only states not reporting West Nile Virus presence are: Alaska, Hawaii, and Maine. There have been a total of 918 human cases and 19 fatalities to date in 2008.
(ProMED 10/1/08)

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4. Articles
Influenza-Associated Pediatric Mortality in the United States: Increase of Staphylococcus aureus Coinfection
Finelli, Lyn et al. Pediatrics. 2008 Oct; 122(4); 805-811. Available at http://pediatrics.aappublications.org/cgi/content/abstract/122/4/805.

Abstract
OBJECTIVE. Pediatric influenza-associated death became a nationally notifiable condition in the United States during 2004. We describe influenza-associated pediatric mortality from 2004 to 2007, including an increase of Staphylococcus aureus coinfections. METHODS. Influenza-associated pediatric death is defined as a death of a child who is younger than 18 years and has laboratory-confirmed influenza. State and local health departments report to the Centers for Disease Control and Prevention demographic, clinical, and laboratory data on influenza-associated pediatric deaths. RESULTS. During the 2004–2007 influenza seasons, 166 influenza-associated pediatric deaths were reported (n = 47, 46, and 73, respectively). Median age of the children was 5 years. Children often progressed rapidly to death; 45% died within 72 hours of onset, including 43% who died at home or in an emergency department. Of 90 children who were recommended for influenza vaccination, only 5 (6%) were fully vaccinated. Reports of bacterial coinfection increased substantially from 2004–2005 to 2006–2007 (6%, 15%, and 34%, respectively). S aureus was isolated from a sterile site or endotracheal tube culture in 1 case in 2004–2005, 3 cases in 2005–2006, and 22 cases in 2006–2007; 64% were methicillin-resistant S aureus. Children with S aureus coinfection were significantly older and more likely to have pneumonia and acute respiratory distress syndrome than those who were not coinfected. CONCLUSIONS. Influenza-associated pediatric mortality is rare, but the proportion of S aureus coinfection identified increased fivefold over the past 3 seasons. Research is needed to identify risk factors for influenza coinfection with invasive bacteria and to determine the impact of influenza vaccination and antiviral agents in preventing pediatric mortality.

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Tracing killer spores: the science behind the anthrax investigation
Analytical Chemistry. 2008 Sep 18. Available at http://pubs.acs.org/journals/ancham/news/2008/09/18/cp_anthrax.html.

This is a referenced review of the microbial forensics involved in the FBI investigation. It is fully referenced and clarifies many of the confusions engendered in past weeks. If you have been following the news and scientific journal reports it will not contain much that it is new, but it is straightforward.

The FBI conclusions about the anthrax letter spores attributed primarily or solely to scientific analyses:
1. They were produced in recent times (ca. 1999-2001).
2. They were grown in two different batches.
3. No substances were added to the spores postproduction to make them more dispersible.
4. Silicon and oxygen were present on the inside (coat) of the spores, not the outside (exosporium).
5. They contained mostly the wild-type Bacillus anthracis 'Ames' but had significant numbers of phenotypic variants or substrains.
6. The unique phenotypic variants could be detected by a combination of assays for four different insertion/deletion polymorphisms.
7. Out of the 1070 samples collected in the repository of Ames samples, eight contained all four of the polymorphisms; none contained three out of four mutations, and a few contained one or two of the mutations.
(ProMED 9/24/08)

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Delinquent Mortgages, Neglected Swimming Pools, and West Nile Virus, California
Reisen, Willaim K et al. Emerg Infect Dis. 2008 Nov; [epub ahead of print]. Available at http://www.cdc.gov/eid/content/14/11/pdfs/08-0719.pdf.

Adjustable rate mortgages and the downturn in the California housing market caused a 300% increase in notices of delinquency in Bakersfield, Kern County. This led to large numbers of neglected swimming pools, which were associated with a 276% increase in the number of human West Nile virus cases during the summer of 2007.

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Progress Toward Measles Elimination, Japan 1999-2008
US Centers for Disease Control and Prevention. MMWR 2008 Sep 26; 57(38); 1049-1052. Available at http://www.cdc.gov/mmwr/.

In 2005, the Regional Committee of the World Health Organization (WHO) Western Pacific Region (WPR) set a target date of 2012 for measles elimination in all WPR member states. In Japan, measles control strategies have included 1) a nationwide public awareness campaign implemented in 2001 to promote timely vaccination with the first dose of measles-containing vaccine (MCV1) administered on or after age 12 months, and 2) a 2-dose MCV schedule with the second dose (MCV2) administered at age 5--6 years, adopted in 2006 in accordance with the recommended WPR measles elimination strategy. However, during 2007--2008, Japan experienced a large measles outbreak, which resulted in exportation of measles cases from Japan into countries where measles elimination had been achieved. This report describes the epidemiology of measles in Japan during 1999--2008 and approval of a National Measles Elimination Plan in December 2007 that includes recommendations for immunization strategies, case-based measles surveillance, and monitoring to ensure elimination of measles by 2012. Measles continues to be endemic in Japan, with most cases occurring in children before school entry, except for 2007 and 2008, when a shift to an older age group was observed. With implementation of the National Measles Elimination Plan, Japan is expected to make progress toward achieving the WPR measles elimination goal.

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Novel astroviruses in insectivorous bats
Chul, DKW et al. J. Virol. 2008 Sep; 82(18): 9107-14. Available at http://jvi.asm.org/cgi/content/abstract/82/18/9107.

Abstract
Bats are increasingly recognized to harbor a wide range of viruses, and in most instances these viruses appear to establish long-term persistence in these animals. They are the reservoir of a number of human zoonotic diseases including Nipah, Ebola, and severe acute respiratory syndrome. We report the identification of novel groups of astroviruses in apparently healthy insectivorous bats found in Hong Kong, in particular, bats belonging to the genera Miniopterus and Myotis. Astroviruses are important causes of diarrhea in many animal species, including humans. Many of the bat astroviruses form distinct phylogenetic clusters in the genus Mamastrovirus within the family Astroviridae. Virus detection rates of 36% to 100% and 50% to 70% were found in Miniopterus magnater and Miniopterus pusillus bats, respectively, captured within a single bat habitat during four consecutive visits spanning 1 year. There was high genetic diversity of viruses in bats found within this single habitat. Some bat astroviruses may be phylogenetically related to human astroviruses, and further studies with a wider range of bat species in different geographic locations are warranted. These findings are likely to provide new insights into the ecology and evolution of astroviruses and reinforce the role of bats as a reservoir of viruses with potential to pose a zoonotic threat to human health.

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Study: First flu wave in 1918 was vaccine for some
Barry JM, Viboud C, Simonsen L. Cross-protection between successive waves of the 1918-1919 influenza pandemic: epidemiological evidence from US Army camps and from Britain. J Infect Dis 2008 Nov 15;198 (early online publication).

Abstract
Background. The current worst-case scenario for pandemic influenza planning is based on the catastrophic 1918–1919 pandemic. In this article, we examine the strength of cross-protection between successive waves of the 1918–1919 pandemic, which has remained a long-standing issue of debate. Method. We studied monthly hospitalization and mortality rates for respiratory illness in 37 army camps, as well as the rates of repeated episodes of influenza infection during January-December 1918 in 8 military and civilian settings in the United States and Britain. Results. A first wave of respiratory illness occurred in US Army camps during March-May 1918 and in Britain during May-June, followed by a lethal second wave in the fall. The first wave was characterized by high morbidity but had a lower fatality rate than the second wave (1.1% vs. 4.7% among hospitalized soldiers; p<0.001). Based on repeated illness data, the first wave provided 35%–94% protection against clinical illness during the second wave and 56%–89% protection against death (p<0.001). Conclusion. Exposure to influenza in the spring and summer of 1918 provided mortality and morbidity protection during the fall pandemic wave. The intensity of the first wave may have differed across US cities and countries and may partly explain geographical variation in pandemic mortality rates in the fall. Pandemic preparedness plans should consider that immune protection could be naturally acquired during a first wave of mild influenza illnesses.

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Replacement of Sublineages of Avian Influenza (H5N1) by Reassortments, Sub-Saharan Africa
Owoade AA et al. Emerg Infect Dis. 2008 Nov; (early online publication). Available at http://www.cdc.gov/eid/content/14/11/pdfs/08-0555.pdf.

Abstract
Eight new full-length sequences from highly pathogenic avian influenza (H5N1) viruses from 4 states in southwest Nigeria were analyzed. All gene sequences were more closely related to the first strains found in Nigeria in 2006 than to any strain found outside the country. Six viruses had evolved by at least 3 reassortment events (AC HA/NS, AC NS) from previously identified sublineages A (EMA 2) and C (EMA 1). Our results suggest that highly pathogenic avian influenza (H5N1) viruses initially imported into Nigeria in 2006 have been gradually replaced by various reassortments. In all reassortants, nonstructural genes were derived from sublineage C with 2 characteristic amino acids (compared with sublineage A). If the high prevalence of reassortants was typical for West Africa in 2007, the absence of such reassortants anywhere else suggests that reintroductions of influenza A (H5N1) from Africa into Eurasia must be rare.

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Effects of a Reduced Dose Schedule and Intramuscular Administration of Anthrax Vaccine Adsorbed on Immunogenicity and Safety at 7 Months
Marano, Nina et al. JAMA 2008; 300(13); 1532-1543. Available at http://jama.ama-assn.org/cgi/content/abstract/300/13/1532.

Abstract
Context In 1999, the US Congress directed the Centers for Disease Control and Prevention to conduct a pivotal safety and efficacy study of anthrax vaccine adsorbed (AVA). Objective To determine the effects on serological responses and injection site adverse events (AEs) resulting from changing the route of administration of AVA from subcutaneous (SQ) to intramuscular (IM) and omitting the week 2 dose from the licensed schedule. Design, Setting, and Participants Assessment of the first 1005 enrollees in a multisite, randomized, double-blind, noninferiority, phase 4 human clinical trial (ongoing from May 2002). Intervention Healthy adults received AVA by the SQ (reference group) or IM route at 0, 2, and 4 weeks and 6 months (4-SQ or 4-IM; n = 165-170 per group) or at a reduced 3-dose schedule (3-IM; n = 501). A control group (n = 169) received saline injections at the same time intervals. Main Outcome Measures Noninferiority at week 8 and month 7 of anti–protective antigen IgG geometric mean concentration (GMC), geometric mean titer (GMT), and proportion of responders with a 4-fold rise in titer (%4xR). Reactogenicity outcomes were proportions of injection site and systemic AEs. Results At week 8, the 4-IM group (GMC, 90.8 µg/mL; GMT, 1114.8; %4xR, 97.7) was noninferior to the 4-SQ group (GMC, 105.1 µg/mL; GMT, 1315.4; %4xR, 98.8) for all 3 primary end points. The 3-IM group was noninferior for only the %4xR (GMC, 52.2 µg/mL; GMT, 650.6; %4xR, 94.4). At month 7, all groups were noninferior to the licensed regimen for all end points. Solicited injection site AEs assessed during examinations occurred at lower proportions in the 4-IM group compared with 4-SQ. The odds ratio for ordinal end point pain reported immediately after injection was reduced by 50% for the 4-IM vs 4-SQ groups (P < .001). Route of administration did not significantly influence the occurrence of systemic AEs. Conclusions The 4-IM and 3-IM regimens of AVA provided noninferior immunological priming by month 7 when compared with the 4-SQ licensed regimen. Intramuscular administration significantly reduced the occurrence of injection site AEs.

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Antigenic and genetic characteristics of H5N1 viruses and candidate H5N1 vaccine viruses developed for potential use as human vaccines
World Health Organization, September 2008. Available at http://www.who.int/csr/disease/avian_influenza/guidelines/h5n1virus/en/index.html.

This summary describes the current status of the development of new candidate H5N1 vaccine viruses and is meant to provide guidance for national authorities and vaccine companies on the selection of candidate viruses for use in vaccine development. The selection of H5N1 vaccine viruses should consider the geographical spread, epidemiology, and antigenic and genetic properties of recently circulating H5N1 viruses.

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Pandemic Influenza and Excess Intensive-Care Workload
Nap, Raoul E et al. Emerg Inf Dis. 2008; 14(10). Available at http://www.cdc.gov/eid/content/14/10/1518.htm#cit.

Abstract
In the Netherlands a major part of preparedness planning for an epidemic or pandemic consists of maintaining essential public services, e.g., by the police, fire departments, army personnel, and healthcare workers. We provide estimates for peak demand for healthcare workers, factoring in healthcare worker absenteeism and using estimates from published epidemiologic models on the expected evolution of pandemic influenza in relation to the impact on peak surge capacity of healthcare facilities and intensive care units (ICUs). Using various published scenarios, we estimate their effect in increasing the availability of healthcare workers for duty during a pandemic. We show that even during the peak of the pandemic, all patients requiring hospital and ICU admission can be served, including those who have non–influenza-related conditions. For this rigorous task differentiation, clear hierarchical management, unambiguous communication, and discipline are essential and we recommend informing and training non-ICU healthcare workers for duties in the ICU.

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5. Notifications
“One Health” website released
The pro bono "One Health" team of Laura H Kahn, MD, MPH, MPP, Bruce Kaplan, DVM, and Thomas P Monath, MD announces that an autonomous free access 'One Health' website is now available online at http://www.onehealthinitiative.com. The developers envision this website as a method of providing worldwide 'One Health' Initiative information for the general public, political and governmental leaders, news media, and all 'One Health' professionals, advocates, and supporters.

The 'One Health Newsletter' and its links will be prominently featured on the site as a major 'One Health' international educational publication. In addition, there will be links to the AVMA 'One Health' task force recommendations published in the Journal of the AVMA (JAVMA) and other pertinent 'One Health' publications. All stakeholder organizations, their leaders, and individual advocates are requested to notify the website of any suggested corrections, changes, or additions (such as news items, publications, and future 'One Health' symposia or events).

Contact will be via Dr Kaplan at .
(ProMED 10/2/08)

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Public health groups report preparedness gains
Four organizations that represent many of the nation's public health officials issued a report detailing how six years of federal funding has improved preparedness, though serious challenges remain, such as hiring and training lab workers and local preparedness planners. The report compiles results from member surveys from each of the four groups: the Association of State and Territorial Health Officials (ASTHO), the Association of Public Health Laboratories (APHL), the Council of State and Territorial Epidemiologists (CSTE), and the National Association of County and City Health Officials (NACCHO).

The report focuses on funding from the Center for Disease Control and Prevention's (CDC's) Public Health Emergency Program (PHEP), a cooperative grant program designed to help state and local public agencies build the capacity to respond to health emergencies such as pandemic influenza and bioterrorist attacks. According to the report, the CDC has distributed $4.9 billion in PHEP funds from fiscal years 2002 through 2007. Four accomplishment and challenge areas are addressed in the report: preparedness planning, evaluation and improvement, disease detection and investigation, and response and recovery.

The full report is available at http://www.astho.org/pubs/PHEPPartnersReport.pdf.
(CIDRAP 9/30/08)

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American Academy of Pediatrics update recommendations for influenza vaccinations in children
The purpose of this statement is to update current recommendations for routine use of influenza vaccine in children and adolescents, which originally were published in a comprehensive format in Pediatrics in April 2008. The full policy statement can be found at http://pediatrics.aappublications.org/cgi/content/full/peds.2008-2449v2.

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Influenza pandemic: GAO reports HHS needs to continue to finalize guidance for pharmaceutical interventions
US Government Accountability Office recommends that the US Department of Health and Human Services (HHS) expeditiously finalize guidance to assist state and local jurisdictions to determine how to effectively use limited supplies of antivirals and pre-pandemic vaccine in a pandemic, including prioritizing target groups for pre-pandemic vaccine. In comments on a draft of this report, HHS described additional actions it has taken and plans to take relating to GAO’s recommendation, including releasing for public comment in the near future proposed guidance on pre-pandemic vaccine allocation.

The complete report can be found at http://www.gao.gov/new.items/d08671.pdf.

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 apecein@u.washington.edu