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Vol. XI, No. 21 ~ EINet News Briefs ~ Oct 17, 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)
- USA: APIC seeks mandate for influenza shots in health workers
- USA: Seven states report sporadic influenza cases
- USA: Governors group identifies states' pandemic-preparedness gaps

2. Infectious Disease News
- Global: Wildlife group lists diseases that global warming may spur
- Global: Two firms win NIAID support for Ebola-Marburg vaccines
- Global: Polio vaccination may continue after wild virus fades
- Indonesia: Chikungunya virus epidemic continues to spread
- Russia (Stavropol): Increased incidence of Crimean-Congo hemorrhagic fever with six fatalities
- Russia (Perm): Tick-borne encephalitis diagnosed in 85 people
- Viet Nam: Foot-and-mouth disease outbreak continues
- Viet Nam: Woman diagnosed with hantavirus infection
- Canada: Death toll from listeriosis outbreak reaches 20
- Canada (Ontario): Streptococcal strain infects over 300 people and kills ten
- Canada (Ontario): E. coli O157:H7 outbreak sickens 50 and hospitalizes 19
- Canada (Saskatchewan): Nine babies infected in C. difficile outbreak in the regional NICU
- USA: Trial offers hope for shortening anthrax-shot series
- USA (Alaska): Adenovirus hospitalizes seven and kills one on Prince of Wales Island
- USA (Arizona): Man contracts bubonic plague
- USA (California): E. coli confirmed in the illness of 27 people
- USA (Michigan): E. coli outbreak linked to lettuce from California
- USA (Montana): 80 elementary school students exposed to dead rabid bat
- USA (Texas): Elderly man infected with rabies after bitten by kitten
- USA (New Jersey): Three die after contracting Legionnaires’ disease

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

4. Articles
- Of Milk, Health, and Trade Security
- Rand report proposes standards for mass antibiotic dispensing
- Responses to Avian Influenza and State of Pandemic Readiness: Fourth Global Progress Report

5. Notifications
- First World Congress of Vaccine conference
- Updated Recommendations for Isolation of Persons with Mumps
- Seventh International Bird Flu Summit
- Upcoming conferences on Asia-Pacific economics


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 / 20 (17)
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: 385 (243).
(WHO 9.10.08 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 10.06.08): 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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Americas
USA: APIC seeks mandate for influenza shots in health workers
In the face of chronic low influenza vaccination rates among healthcare workers, the leading US society of infection control professionals says it's time to require medically eligible workers to either get the immunization or sign a form saying they understand the risks to patients if they skip it. "As part of a comprehensive strategy, we recommend that influenza vaccine be required annually for all healthcare personnel with direct patient care," the Association for Professionals in Infection Control and Epidemiology (APIC) said in a policy statement released 9 Oct 2008. APIC urges vaccination for all medical and nonmedical personnel in contact with patients or patient samples, including physicians, nurses, physical therapists, dieticians, religious workers, and cleaning, kitchen, and laboratory personnel.

Recent national survey data show that only 42% of healthcare workers receive an annual flu shot, and the rate has not risen significantly in the past decade, the APIC statement notes. Long-standing recommendations from APIC, the Centers for Disease Control and Prevention, and other national organizations have made little difference. "Voluntary efforts are clearly not effective—it's time for hospitals and other healthcare facilities to require influenza immunization," said Linda R. Greene, lead author of APIC's position statement. The policy statement notes that health workers can transmit the flu virus to others before they have any symptoms. Further, it says multiple studies show that 70% of health workers continue to work even when sick with the flu.

APIC has strongly advocated flu shots for healthcare workers for years, along with a variety of strategies to promote them, but this is the first time the organization has used the word "require," according to Greene. She said the declination form is the major new element in APIC's recommendation, but emphasized that it should be just part of a broad strategy for encouraging immunization. "This isn't just a declination that says, 'I don't want to get it and here's the reason.' It's an informed declination, where the employee really understands that by refusing to get the vaccine for other than medical reasons, they're not only putting their patients at risk, but also themselves and their family and the community as a whole," said Greene. But other measures must be linked with informed declination, she said. There is only limited evidence on how well declination forms work, she said. "But what we see is that declination alone, if you're not going to employ the other measures, has not necessarily been particularly effective," yielding only modest increases in immunization rates.

Greene hopes for much better results with a more comprehensive approach [in 2008]. Greene said a key part of promoting flu immunization is enlisting the support of a facility's administration and other departments, so "it's not just sitting in occupational health." Administrators can promote the effort by using the flu immunization rate as an important indicator of safety and quality for the facility, she said. In New York state, informed declination has been used successfully with hepatitis B vaccine for healthcare workers, Greene said. "We've found that we have a very, very high acceptance rate for the hepatitis vaccine." The vaccine is offered to direct-care workers when they are hired, and they see it as a benefit for protecting themselves, she added.
(CIDRAP 10/10/08)

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USA: Seven states report sporadic influenza cases
In a sign that influenza season is approaching, the US Centers for Disease Control and Prevention (CDC) reported that a handful of states have seen sporadic flu cases and that the earliest signs suggest that the 2008 vaccine is a good match for circulating strains. For the week that ended 4 Oct 2008, the CDC said that seven states reported sporadic seasonal influenza activity: California, Connecticut, Florida, Hawaii, Idaho, New York, and Wyoming. Forty-one other states reported no activity, and two—Montana and Washington—did not report. The entire CDC week 40 influenza report can be found at: http://www.cdc.gov/flu/weekly/.
(CIDRAP 10/14/08)

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USA: Governors group identifies states' pandemic-preparedness gaps
State pandemic preparedness has improved over the past few years, but gaps remain, particularly in areas that don't relate directly to healthcare such as continuing government operations, maintaining essential services, and coordinating with the private sector, according to a recent report from the National Governors Association (NGA). The 18-page report details what the group learned from participants during nine regional pandemic preparedness workshops that involved all 50 states, the District of Columbia, and four of five US territories. According to the NGA report, which was released in mid September, the workshops focused on areas that are common to all states: healthcare, commerce, education, and public safety. Access the entire report: http://www.nga.org/Files/pdf/0809PANDEMICASSESSMENT.PDF.
(CIDRAP 10/16/08)

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2. Infectious Disease News

Global
Global: Wildlife group lists diseases that global warming may spur
The Wildlife Conservation Society (WCS) has included avian influenza, Ebola fever, Rift Valley fever, and plague on a list of 12 diseases and pathogens that it believes may spread to new regions as a result of climate change. The report, titled "The Deadly Dozen: Wildlife Diseases in the Age of Climate Change," gives examples of diseases that may increase their ranges in response to changing temperatures and precipitation patterns, threatening wildlife and human health and causing economic damage.

More than melting ice caps
In releasing the WCS report, Steven E. Sanderson, president of the group, said, "The term 'climate change' conjures images of melting ice caps and rising sea levels that threaten coastal cities and nations, but just as important is how increasing temperatures and fluctuating precipitation levels will change the distribution of dangerous pathogens." The best defense against the problem is to monitor wildlife to detect how the diseases are moving, so that health professionals can prepare to mitigate their impact, the group said. WCS cautioned that its list does not include all pathogens that may be spurred by climate change—and that future studies could cross some of them off the list. The group made the following observations about specific diseases:

• Avian influenza: Currently the poultry business largely drives the geographic movement of H5N1 avian flu, "but changes in climate such as severe winter storms and droughts can disrupt normal movements of wild birds and can bring both wild and domestic bird populations into greater contact at remaining water sources."
• Ebola hemorrhagic fever: There is evidence that outbreaks of the deadly Ebola fever and its cousin, Marburg fever, are related to unusual variations in seasonal rainfall patterns. "As climate change disrupts and exaggerates seasonal patterns, we may expect to see outbreaks of these deadly diseases occurring in new locations and with more frequency."
• Plague: Changes in temperature and rainfall are expected to change the distribution of rodent populations, which would affect the range of rodent-borne diseases such as plague. The disease is caused by Yersinia pestis, which is spread by rodents and their fleas.
• Rift Valley fever, a viral hemorrhagic fever. The disease causes abortions and high death rates in livestock in Africa and the Middle East and can be fatal in humans. Climate change raises concern about the disease because it is spread by mosquitoes.

Other diseases and pathogens on the WCS list are babesiosis, cholera, intestinal and external parasites, Lyme disease, harmful algal blooms called red tides, trypanosomiasis, tuberculosis, and yellow fever. The list does not include some other mosquito-borne diseases that have often been mentioned as candidates to increase their ranges in a warming world, such as dengue fever, malaria, and chikungunya fever.
(CIDRAP 10/8/08)

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Global: Two firms win NIAID support for Ebola-Marburg vaccines
Two biotechnology companies—Crucell, based in the Netherlands, and Integrated BioTherapeutics, based in the USA—recently announced that they have received $30 million and $22 million contracts, respectively, from the National Institutes of Allergy and Infectious Diseases (NIAID) to develop single vaccines that would protect against both Ebola and Marburg viruses. The two hemorrhagic fever viruses are sources of emerging infectious diseases in humans, particularly in sub-Saharan Africa, and are considered category A bioterrorism agents by the US government. Both diseases are known for their high case-fatality rates, and there are no specific treatments or vaccines for Marburg and Ebola fevers.
(CIDRAP 10/8/08)

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Global: Polio vaccination may continue after wild virus fades
Teams of researchers from several countries report positive results in the long battle to eradicate polio. At the same time, they acknowledge that the international campaign faces an extraordinary challenge of both biology and economics: while circulation of wild poliovirus may cease, polio vaccination may need to continue for an indefinite period of time.

Writing in the New England Journal of Medicine, researchers from Imperial College London, the World Health Organization (WHO), and the National Primary Health Care Development Agency of Nigeria say that an oral vaccine containing a single strain of poliovirus produces four times greater immunity in children than the long-used three-strain vaccine does. Separately, a multinational team led by experts from the Egyptian government, two Egyptian universities, and a Cairo hospital say that the single-strain or monovalent oral vaccine not only produces superior immunity, but also reduces the likelihood that recipients will shed vaccine virus after being dosed.

Those two findings are good news for the WHO, which pushed for development of a monovalent vaccine and considers its deployment since 2005 a key element in the eradication struggle. But an accompanying editorial says these results represent only limited gains—because in order to finish the job of eradication and protect against its aftereffects, the campaign must abandon the oral vaccine and begin using the much more expensive injectable version. "Poliovirus will not go away after circulation of wild-type virus is halted, and a high level of immunity in the global population must be maintained—and not just in high-income countries that have already switched to the safer but more expensive" injectable vaccine, Ellie Ehrenfeld, of the National Institutes of Health, and Konstantin Chumakov, of the Food and Drug Administration stated.
(CIDRAP 10/16/08)

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Asia
Indonesia: Chikungunya virus epidemic continues to spread
Chikungunya virus has infected a total of 5200 villagers in Pangke, Kabupaten Tanjung Balai Karimun, of Kepulauan Riau province. The residents could not take medicine because they did not have the funds to cover the cost. The illness became epidemic in Pangke Village beginning in July2008, but many residents did not realize it. Moreover, their village was under the jurisdiction of a community health centre ten kilometers away, which made procuring medicine difficult.

The head of the Pangke Village, Bakhtiar, urged the government to help immediately. The residents have relied only on traditional medicine to cure this illness thus far. In addition, at least ten residents of Pangke Village, Kecamatan Meral, Karimun were attacked by chikungunya virus. "The illness began to spread, since a week ago, in the Meral Subdistrict. The data collected indicate that [people in] two villages have already been infected with the illness, first in the Pangke Village totaling ten people and in the Sidorejo Village totaling seven people," said the Head of the Meral Community Health Centre, Rusdi Hendra, in the Meral Community Health Centre, on 7 Oct 2008.

The incubation period is approximately two to four days. The virus that causes the spread of the disease is an alphavirus transmitted by bites of the Aedes aegypti species of mosquitoes. Symptoms typically resolve on their own and without intervention.

He explained that the 17 residents who are suffering from chikungunya disease are currently recuperating. Asked about the characteristics of the disease, he explained, the patient initially experiences high fever, followed by pain in muscles and joints, and lymph gland enlargement. Not infrequently, the symptoms of pain in the joints and muscles are very intense and enough to cause temporary paralysis. In addition, he said although the disease is not as dangerous as dengue fever, authorities still are taking preventative steps and are spraying and treating water catchments with abate in two of the villages.
(ProMED 10/10/08, 10/14/08)

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Russia (Stavropol): Increased incidence of Crimean-Congo hemorrhagic fever with six fatalities
The incidence of Crimean-Congo hemorrhagic fever (CCHF) has increased by one-and-a-half times despite an increase in funding and implementation of preventive measures. In 2008, the level of morbidity in the Stavropol Krai region is the highest it has been in the past 10 years. This year, the incidence is the highest ever for the whole of Russia. In total, 80 persons have contracted the disease, six of whom have died. A total of 8 million rubles (USD 307,000) have been allocated for preventive measures. But it was not in sufficient time, and tick control measures were not initiated until the peak of the tick season.

In five of the six fatal cases, the patients were admitted for medical treatment promptly (i.e. on the first or second day following the onset of symptoms). But unfortunately, diagnosis of CCHF was delayed, and appropriate treatment was not initiated early enough. In the Levokumsky district, the diagnosis of CCHF was not confirmed until one month after the death of one patient. Recently, CCHF has been diagnosed in two physicians in the same hospital. In 2006 and 2007, 41 and 64 cases of CCHF were recorded in the Stavropol Krai region respectively.
(ProMED 10/5/08)

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Russia (Perm): Tick-borne encephalitis diagnosed in 85 people
A total of 17,926 persons have experienced tick bites in 2008 in the Perm Krai region. This is 4000 fewer than in 2007. Tick-borne encephalitis (TBE) virus infection was diagnosed in 85 inhabitants of the region, including 31 children. None of these individuals had been vaccinated. TBE is a serious acute central nervous system infection that may result in death or long-term neurological sequelae in 35-58 percent of patients. The fatality rate associated with clinical infection is 0.5-20 percent. The proportion of cases involving subclinical infection varies between 70 percent and 98 percent. Symptomatic infection occurs in all age groups.
(ProMED 10/7/08)

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Viet Nam: Foot-and-mouth disease outbreak continues
Foot-and-mouth disease occurred in the central province of Quang Tri on 24 Sep 2008. The samples taken from 15 infected cattle at three animal breeding households in Duy Tan hamlet, Lao Bao town, Huong Hoa district have tested positive to the virus causing foot-and-mouth disease. The Quang Tri Veterinary service has isolated all of the cattle for treatment. After 21 days, only Quang Tri province is still free from the disease.
(ProMED 10/6/08)

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Viet Nam: Woman diagnosed with hantavirus infection
A 25-year-old woman who lives in District 12 of Ho Chi Minh City (HCMC) has been diagnosed with hantavirus infection. The infection is transmitted by inhaled dust exposed to rodent feces or urine or rodent bites, according to Phan Ngoc Nam, head of Internal Medicine and Infectious Disease at People's Hospital 115. The woman fell ill in late September 2008, but was not diagnosed correctly until early October, as the disease is very rare in Viet Nam, he said.

The woman fell ill with a high fever on 20 Sep 2008 and was diagnosed with dengue fever by her doctor. Since the fever had not subsided three days later, she was hospitalized with viral fever. The patient then began having kidney problems, difficulty breathing, and blood showed in her urine, plus her stomach swelled and her lungs began to fill with fluid. She was moved to the cardiovascular department when her heartbeat slowed. She also had polyuria (excessive urination), fluid leakage in the outer cardiac membrane, and other lung problems.

On 3 Oct 2008, the patient was diagnosed with hantavirus infection at HCMC Pasteur Institute. The patient said she had seen mouse feces in her home. The institute has given her family eight mousetraps to catch mice in her house and also some nearby residences.

Hantavirus disease has an incubation time of nine to 35 days in humans before symptoms of infection occur, according to Nam. No specific medications for the disease are available now, although ribavirin, an anti-viral drug, is effective in the first stage of treatment in helping to decrease the likelihood of death, Nam said. He added that the most effective treatment is intensive care, respiratory support, and the timely treatment of cardiovascular problems. Hantavirus infection has historically killed more than half of those infected since its discovery in 1993.
(ProMED 10/9/08)

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Americas
Canada: Death toll from listeriosis outbreak reaches 20
The number of deaths from a listeriosis outbreak that have been linked to contaminated meat products has reached 20, Canadian health officials said on 1 Oct 2008. The latest death occurred in Ontario, where 15 of the deaths have been reported. Two deaths occurred in the western province of British Columbia, with one each in Alberta, Quebec, and New Brunswick. The health agency said six other deaths under investigation may also have resulted from the outbreak. The disease originated from the Toronto deli-meat processing branch of Maple Leaf Foods plant, Canada's biggest food company. The Listeria bacterium was found deep inside slicing equipment. The plant reopened 4 weeks after being closed on 20 Aug 2008. Several class-action suits are being planned as a result of the outbreak, which has led to one of the most serious food crises in recent Canadian history.
(ProMED 10/5/08)

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Canada (Ontario): Streptococcal strain infects over 300 people and kills ten
A deadly outbreak of streptococcal infections that's killed ten people in northern Ontario is likely to spread but doesn't pose a widespread threat because it appears to be clustered around distinct groups of people, the province's chief medical officer of health said 9 Oct 2008. "It doesn't seem to be showing and spreading throughout the community there, but spreading within a very specific subgroup of the community," Dr. David Williams said a day after Thunder Bay's public health unit announced the deaths. "It seems to be a very limited part of the community. . . Some related with homeless, some with an intravenous drug user group, some related with some urban populations we're trying to follow up on. For the province at wide, I would say no, it's not a big concern."

The city's officials also said they've treated another 75 people with invasive Group A streptococcal infections over the past year. Cases of Group A strep began surfacing in the Thunder Bay area in late summer 2007, which wasn't particularly unusual for an infectious disease that's known as the cause of strep throat. But cases continued to rise, growing beyond the normal six cases and one death per year. When the local health unit recognized an influx of more severe cases Feb 2008, officials began their probe and found about half of the cases belonged to a strain never seen before in the province, said health unit epidemiologist Lee Sieswerda. The strain, called emm-59, was already known in the western provinces.

Starting in 2006, a smattering of victims across the West became infected with the bug that's now linked to more than 300 cases in the region, said Greg Tyrrell, director of Edmonton's National Centre for Streptococcus. At its worse, the Group A streptococci bacterium causes life-threatening illnesses such as necrotizing fasciitis (commonly known as flesh-eating disease) and streptococcal toxic shock syndrome. In Thunder Bay, the infected group ranges in age from the mid-20s to the mid-50s and is comprised of about 60 percent men. About 38 percent are classified as intravenous drug users and another 15 percent are "underhoused," Sieswerda said. Although he didn't know the breakdown of the dead, he said they ranged in age from 39 to 77.

"The risk to the general public is very low," Sieswerda said, adding he stands by the health unit's decision to not notify the public until this week. Health officials have worked to contain the outbreak by providing intensive followups, tracing the closest contacts of the infected people and increasing street outreach, he said. But Sieswerda, Williams, and a prominent microbiologist all agree there's a strong possibility the infection will continue to spread. "We've seen it in Western Canada, we're seeing it move east," said Dr. Donald Low, chief microbiologist at Toronto's Mount Sinai Hospital. Low said he wouldn't be surprised if the infection migrated by the end of October or November 2008. "There's a lot of movement of individuals from city to city, so there may well be an opportunity for this thing to hitchhike along with somebody and be introduced into a new community of individuals that are susceptible," he said.
(ProMED 10/11/08)

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Canada (Ontario): E. coli O157:H7 outbreak sickens 50 and hospitalizes 19
An E. coli outbreak that may have sickened more than 50 people who ate at an Ontario Harvey's restaurant will grow in the coming days, health officials warned on 15 Oct 2008, as they scrambled to determine the source of the contamination and who else may be at risk. Fourteen people were confirmed to have fallen ill from E. coli O157:H7 bacteria after eating at a North Bay Harvey's franchise. Another 38 illnesses linked to the same restaurant are under investigation to determine whether they are also the result of E. coli contamination. But health officials fear that that number could climb significantly because it can take several days for people to feel ill after coming in contact with E. coli. In addition, people who are ill could unwittingly infect family members and friends.

A total of 19 people have been hospitalized since the outbreak began 11-12 Oct 2008. Nine remained in hospital as of 15 Oct 2008, but none have been admitted to the intensive care unit. The people affected range in age from 9 to 84. While all of the cases of illness have been linked to one restaurant, it is possible the outbreak is part of a larger problem that could affect people in other communities, said Doug Powell, associate professor of food safety at Kansas State University. For instance, a product such as lettuce, which is usually shipped to food retailers across a large area, could be the source of contamination.
(ProMED 10/16/08)

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Canada (Saskatchewan): Nine babies infected in C. difficile outbreak in the regional NICU
The Regina Qu'Appelle Health Region is hoping to give the neo-natal intensive care unit (NICU) at the Regina General Hospital a clean bill of health following an outbreak of Clostridium difficile by Oct 17, 2008. "A total of nine babies tested positive for [C. difficile]. The first case was identified on 2 Oct 2008. Of those nine babies, five have completed their treatment and their symptoms have cleared,'' Jim Slater, executive director of diagnostic services stated on 14 Oct 2008. The other four babies are in their final days of treatment and have been symptom-free for over 48 hours, Slater said.

This strain of C. difficile is easily treated, he added, noting that none of the babies have been seriously ill or died from this bacterial infection. This outbreak is not the same strain of the bacterial infection identified as a factor in hundreds of deaths in immune-compromised patients in Ontario hospitals over the past two years. The particular strain of C. difficile in the Ontario outbreak did not respond well to antibiotics, Slater said

C. difficile, one of the most common infections found in hospitals and long-term care facilities, causes diarrhea, fever, loss of appetite, nausea, and cramps. The bacteria which cause the infection is found in feces and can be spread if people touch items or surfaces that are contaminated with the bacterium or its spores and then touch their mouths or noses. It can also be spread through hand contact as a result of improper hand washing technique.
(ProMED 10/16/08)

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USA: Trial offers hope for shortening anthrax-shot series
An interim report from a major study of the US's only licensed anthrax vaccine suggests it may be possible to reduce local side effects without sacrificing effectiveness by changing the injection route and using fewer doses. The standard regimen for the vaccine—required for US military personnel deployed in the Middle East—is six subcutaneous doses over an 18-month period, followed by annual boosters. Many military members have complained of side effects over the years. The vaccine, called anthrax vaccine adsorbed (AVA), or BioThrax, is made by Emergent BioSolutions Inc.

In the study, volunteers who received three or four intramuscular (IM), instead of subcutaneous, doses over six months had about the same antibody responses at seven months as did volunteers who received the standard regimen, involving four subcutaneous doses in the first six months. In addition, those who received four IM doses had fewer negative effects at the injection site than did those who received four subcutaneous doses. "Changing the injection route from SQ [subcutaneous] to IM may increase vaccine acceptability," stated the report, published in the 2008 Oct 1 Journal of the American Medical Association. "Reducing the number of doses in the AVA regimen would have the added benefit of increasing the number of doses available for prophylactic use."
(CIDRAP 10/6/08)

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USA (Alaska): Adenovirus hospitalizes seven and kills one on Prince of Wales Island
A respiratory illness likely caused by a virus circulating on Prince of Wales Island in Southeast Alaska has killed one person and put another on a ventilator in an Anchorage hospital, the state Division of Public Health said on 6 Oct 2008. Genetic testing on samples taken from patients indicates the cause of the outbreak is adenovirus 14, a particularly virulent version of a common bug best known for causing "that respiratory crud in the winter," said division epidemiologist Beth Funk. "It's a fairly common virus, but this particular type, adenovirus 14, hasn't been seen commonly up until lately," Funk said.

Indications are that the virus is responsible for causing pneumonia in at least 32 people on the island and sickening an untold number of others who did not go to a clinic seeking medical treatment, she said. Seven of the 32 cases were severe enough to warrant medivacs to hospitals in surrounding communities, including one patient who was taken to Alaska Native Medical Center in Anchorage to be put on a ventilator. One woman died, she said. "That individual also had fairly significant underlying lung disease -- chronic obstructive lung disease -- and it would have put that person at a higher risk for a bad outcome with any other infection on top of that," Funk said.

The virus spreads similarly to the common cold. It is transferred from person to person by coughing and sneezing, and it can also be contracted by touching an object, like a doorknob, that has the virus on it and then touching one's mouth, nose or eyes, according to the CDC. As with other viruses, there's no cure for adenovirus; it moves through a community and will eventually cycle itself out, Funk said. Because there is a fair amount of travel to and from the island, particularly to Ketchikan, there was some concern the illness could spread to other communities, she said. But there have been no reports of widespread illness off of the island.

"Nationally, it's been seen only rarely until the past year, where there have been a number of outbreaks," she said. "It seems like it may be what we call an emerging infection." In the past two years, there have been outbreaks of the virus in Oregon, Washington and Texas. Funk believes that the number of illnesses reported from the very ill is only capturing the "tip of the iceberg."
(ProMED10/7/08, 10/15/08)

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USA (Arizona): Man contracts bubonic plague
A northeast Arizona man has contracted bubonic plague and health agencies are urging four corners residents to help prevent the spread of the disease. The Apache County man who contracted the disease began showing symptoms in late September 2008, the Navajo Nation said. Symptoms included a 103-degree fever, chills, diarrhea and groin tenderness. The man was responding to treatment and doing well as of 6 Oct 2008, said Jenny Notah, a spokeswoman for Navajo Area Indian Health Service. The Navajo Nation also said plague likely killed a number of prairie dogs east of Flagstaff, Ariz. Humans can contract plague by touching bodily fluids of infected animals or after being bitten by fleas that have contracted it from infected rodents, according to the U.S. Department of Health and Human Services.
(ProMED 10/12/08)

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USA (California): E. coli confirmed in the illness of 27 people
Health officials who suspected tainted tri-tip sickened at least 27 people in September 2008 now have some evidence. E. coli bacteria found on frozen leftover meat perfectly matches the bacteria found in stool samples taken from several people who became ill, said Dr Mark Lundberg, Butte County health officer. It's still unclear how the meat became contaminated.

Hundreds of people attended a barbecue on 6 Sep 2008 that raised money for the volunteer fire department in Forest Ranch. Afterward, a number of people became sick with severe stomach cramps and diarrhea. Four people got so ill they had to be hospitalized. Health officials learned that the sickness was caused by a dangerous strain called E. coli O157:H7. Interviews with people who attended the event led officials to conclude the tri-tip was contaminated and made people sick. However, they couldn't be sure until the link was proven by test results from the state lab, Lundberg said 6 Oct 2008. It's still not known how the cooked meat became contaminated, he said, and it may never be known.

Food preparers at the event had the right equipment and seemed to do everything right, he said, but obviously something went wrong. When large amounts of food are prepared there is the potential for contamination, he said. It's possible the cooked meat came into contact with juices from the raw meat. Or possibly, he said, someone who helped prepare the food was sick and didn't wash his or her hands properly.
(ProMED 10/7/08)

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USA (Michigan): E. coli outbreak linked to lettuce from California
Jennifer Holton, spokeswoman for the Michigan Department of Agriculture, said that based on shipping and delivery dates, illness onset dates and other traceback information investigators have determined that iceberg lettuce from California is believed to be the source of the outbreak of E. coli O157 in late Sep 2008. The Michigan Department of Community Health linked the outbreak to bagged, industrial-size packages of iceberg lettuce on 26 Sep 2008 and named Detroit processor Aunt Mid's as the distributor. However, Aunt Mid's was sourcing from multiple growers in multiple states, including California, when the outbreak started, and it was unclear at that time where the tainted product was sourced.

Holton said on 14 Oct 2008 that it remained unclear where in the supply chain the product was contaminated. Dominic Riggio, Aunt Mid's president, said the company resumed processing iceberg lettuce 9 Oct 2008. Holton said that Aunt Mid's will test each lot of the product for 30 days and report the findings to the state department of agriculture, which also will perform random tests during that period. There have been 38 reported illnesses in Michigan and 21 hospitalizations. There also have been nine illnesses reported in Illinois and three in Ontario. No deaths have been associated with the outbreak.
(ProMED 10/15/08)

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USA (Montana): 80 elementary school students exposed to dead rabid bat
A parent brought a dead bat to Stevensville Elementary School, and school officials are encouraging any child who touched the bat to get a series of rabies shots. Stevensville Superintendent Kent Kultgen said the woman brought the dead bat to school on 29 Sep 2008 morning and showed it to the kindergarten and 5th-grade classmates of her children. She talked about the bat and allowed students to touch the dead animal. She gave them hand sanitizer to wash their hands.

When school officials were notified, they called county and state health officials, sent letters home with every student who may have been exposed and sent the bat to a laboratory for testing. The bat tested positive for rabies. Rabies is a fatal neurological virus that can be spread through saliva, usually through a bite. While the risk of contracting the disease from the dead bat is low, Kultgen said the 80 students who touched the bat are "strongly encouraged" to get the shots. Their parents must give permission.

The exposed students will receive six shots of anti-rabies vaccine. School officials say they will use liability insurance to pay up to USD 70 000 for the exposed children to be vaccinated. The overall cost could surpass USD 150 000.The school has since set a policy requiring that anyone visiting the school obtain a visitor pass.
(ProMED 10/4/08, 10/9/08)

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USA (Texas): Elderly man infected with rabies after bitten by kitten
An elderly man who fed stray cats in his Oak Hills neighborhood was bitten by a kitten that has tested positive for rabies, health officials said on 1 Oct 2008. It was the second rabid cat identified in Bexar County in 2008 and a highly unusual occurrence. Furthermore, it comes as a nationwide shortage of human post-exposure rabies vaccine is worsening.

Texas health officials have been rationing access to rabies vaccine since the two worldwide manufacturers have seen their supplies dwindle. Problems began in the summer of 2007 when one of the manufacturers, Sanofi Pasteur, began renovating its plant in France to comply with Food and Drug Administration regulations. The Centers for Disease Control and Prevention (CDC) reports that the shortage is unlikely to be resolved until mid- to late 2009.
(ProMED 10/4/08)

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USA (New Jersey): Three die after contracting Legionnaires’ disease
A third patient has died after contracting Legionnaires' disease at a New Brunswick hospital. The unidentified woman died on 3 Oct 2008 at Saint Peter's University Hospital. A hospital spokeswoman said she was being treated for a separate, unspecified illness. Eight patients of the hospital have been diagnosed with Legionnaires' disease since mid-September 2008. All were staying in the same oncology wing. One male patient died on 12 Sep 2008, and another man died on 22 Sep 2008. Officials say two patients have recovered from the disease.

Legionnaires' disease is a form of pneumonia that can be spread through plumbing and air conditioning systems. Hospital officials traced the outbreak to a decrease in chlorine levels in the hospital's water system. The cause of the decrease was under investigation.
(ProMED 10/5/08)

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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
China
The Center for Health Protection of the Department of Health of Hong Kong has confirmed a cholera case involving a six-year-old local boy. A spokesman for the center said on 13 Oct 2008 that laboratory tests on stool specimens taken from the boy who was admitted to Pamela Youde Nethersole Eastern Hospital during the week of 6 Oct 2008 for suspected cholera have yielded positive result for Vibrio cholera serotype Ogawa.

The boy arrived from Nepal on 3 Oct 2008 and his travel companions have no symptoms. He is now in stable condition. According to the center, this is the fifth cholera case reported in 2008 in the city, and there were three in 2007.
(ProMED 10/14/08)

Viet Nam
More than 50 people in Quynh Luu district of Viet Nam's central Nghe An Province have recently been hospitalized with acute diarrhea and 23 patients tested positive for cholera, the Viet Nam News reported on 14 Oct 2008. The local health department said the Mai Giang River, which runs through the district, is the main cause of the epidemic, as Vibrio cholerae bacteria was discovered in the river. Many of the seafood sourced from the river, including fish and oysters, have been found to be infected with the bacteria. Viet Nam, which has been stricken by cholera since late in 2007, reported more than 700 cholera cases in the first eight months of 2008.
(ProMED 10/14/08)

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DENGUE
Indonesia
The change in the climate from hot to rainy in mid-October-November is believed to cause many illnesses. Section Head of Health Services (Dinkes) in Batam City Mawardi Badar reminded residents to maintain their health and increased awareness, especially concerning the spread of dengue fever. "I made a circular for the community. The frequency and levels of rainfall lately have increased. Residents must maintain their environments and immediately drain places where water accumulates to avoid the proliferation the vector mosquito," Mawardi said on 8 Oct 2008.

According to Mawardi, for all of September 2008, the number of dengue cases in Batam reached 110. This figure was classified as high compared to previous months. "The number of dengue cases has been fluctuating, but this past September [2008], it was moderately high. In October 2008, we also have made a high prediction.” Mawardi said that residents maintaining an environment free of mosquito breeding sites is the only effective method of addressing the increase in dengue cases in Batam.
(ProMED 10/13/08)

Malaysia
Malaysia is considering imposing a quarantine in a small northern town in the state of Perak as part of efforts to stem a dengue fever outbreak, a news report said 10 Oct 2008. Health Minister Liow Tiong Lai said 175 people in the northern Manjung town were treated for suspected dengue fever from 18 Aug-4 through Oct 2008, more than double the 77 patients recorded during the same period in 2007. A total of four patients have died from the mosquito-borne disease this year, he said.

Out of the 175 cases, more than half were dengue haemorrhagic fever, which can be fatal if not treated early. He said there have been a total of 35 227 dengue cases and 78 deaths nationwide so far in 2008. The government has been holding campaigns to educate the public as well as conduct checks for mosquito-breeding sites on residential and construction sites to try to stem dengue cases. Despite the efforts, the number of cases and deaths continues to rise each year.
(ProMED 10/13/08)

Singapore
According to a report in the New England Journal of Medicine that identifies vulnerability in the nation's blood supply, three people contracted the potentially lethal dengue virus from a blood donor in Singapore in 2007. Scientists led by Paul Tambyah at the National University of Singapore said in the report, two men, aged 64 and 72, suffered fever, muscle pain and fluid build-up in their chests after receiving blood donated by a 52-year-old man. A third man, 74, was infected without suffering any symptoms. All three were discharged from hospital in good health, the report said.

Dengue, the world's most common mosquito-borne disease, is endemic in Singapore, where it has infected more than 4600 people in 2008. "Although screening is expensive, confidence in the blood supply could outweigh cost-effectiveness considerations,'' Tambyah and colleagues stated. Singapore doesn't screen blood donors for dengue because available tests would take 4 weeks, rendering blood platelets that must be used within five days useless, said Tan Hwee Huang, deputy division director of blood supply at the Health Sciences Authority.

Singapore's Health Sciences Authority rejects blood donors showing symptoms of dengue, and asks those who may have been exposed to defer giving blood. It also removes blood donations from people subsequently diagnosed with an infection or who show symptoms.
(ProMED 10/7/08)

Thailand
According to the data from the Ministry of Public Health Thailand as of 1 Oct 2008, there were a total of 66,976 cases and 77 deaths reported that were attributable to dengue virus infection since the beginning of 2008. This included 27,786 cases and five deaths due to dengue fever; 38,245 cases and 22 deaths with dengue hemorrhagic fever; 945 cases and 50 deaths with dengue shock syndrome.
(ProMED 10/7/08)

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WEST NILE VIRUS
Canada
Date: 28 Sep – 4 Oct 2008:
Human cases: no new cases reported
Total human cases in 2008: 35

USA
Date: 8-14 Oct 2008
States newly reporting new human cases: None
The only states not reporting West Nile Virus presence are: Alaska, Hawaii, and Maine.
There have been a total of 1108 human cases and 22 fatalities to date in 2008.
(ProMED 10/15/08)

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4. Articles
Of Milk, Health, and Trade Security
Bell, David M. Far Eastern Economic Review. Oct 2008.

The article is intended to raise awareness among trade and tourism stakeholders that they have an interest in the successful implementation of the revised International Health Regulations (IHR). The focus of the latest IHR shifted to prevention, detection, reporting and containment of public health emergencies that have an international impact while discouraging trade and travel restrictions disproportionate to the threat.

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Rand report proposes standards for mass antibiotic dispensing
The Rand Corp., responding to a request from the US Department of Health and Human Services (HHS), recently unveiled a set of proposed standards for cities to use as they establish plans to distribute antibiotics to the public in the event of a bioterrorist attack or other public health emergency. The 133-page technical report covers four main topics: the number and location of points of dispensing (PODs), internal POD operations, staffing, and security. PODs are places where members of the public would go to receive antibiotics or other countermeasures in an emergency.

The Pandemic and All-Hazards Preparedness Act of 2006 requires HHS to develop performance standards for public health preparedness, and the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR) asked Rand to develop the proposed standard. The standards are geared toward 72 cities that take part in the federal government's Cities Readiness Initiative (CRI), a program launched by the Centers for Disease Control and Prevention (CDC) in 2004 to prepare major cities and metropolitan areas to distribute antibiotics from the Strategic National Stockpile within 48 hours of a federal order to release them.

Though federal law mandates that the standards be evidence-based, the Rand authors pointed out that the rarity of large-scale public health disasters means there is little evidence to base the standards on. Instead, the authors developed the standards by talking to practitioners, reviewing existing literatures, using mathematical modeling, and seeking feedback from an expert panel. The standards are designed to allow communities to be flexible and innovative in how they meet the 48-hour dispensing goal, the report says. "Moreover, the standards are intended to provide minimal requirements and should not discourage CRI sites from exceeding them," it states.

The entire report is available http://www.rand.org/pubs/technical_reports/TR553/.
(CIDRAP 10/15/08)

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Responses to Avian Influenza and State of Pandemic Readiness: Fourth Global Progress Report
UN System Influenza Coordination and the World Bank. Oct 2008. Available at http://un-influenza.org/files/ProgressReport2008.pdf.

It is now nearly five years since H5N1 highly pathogenic avian influenza (HPAI) spread across Southeast Asia and then to the rest of Asia, Europe, and Africa. The rapid spread, significant economic losses, numerous human deaths, and the potential threat of a human pandemic influenza triggered concerted global action to control the disease and prepare for the next influenza pandemic.

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5. Notifications
First World Congress of Vaccine conference
Theme: Build an Olympian Meeting Platform for Future Vaccine World
Date: 1-5 Dec 2008
Venue: Fontainebleau Hotel, Foshan, China

More information available at http://www.bitlifesciences.com/WCV2008.

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Updated Recommendations for Isolation of Persons with Mumps
US Centers for Disease Control and Prevention. MMWR. 10 Oct 2008; 57(40). Available at http://www.cdc.gov/mmwr/PDF/wk/mm5740.pdf.

Based on this review, CDC, AAP, and HICPAC now recom¬mend a 5-day period after onset of parotitis for 1) isolation of persons with mumps in either community or health-care settings and 2) use of standard precautions and droplet pre¬cautions. Postexposure recommendations remain unchanged. HCP with no evidence of mumps immunity who are exposed to patients with mumps should be excluded from duty from the 12th day after first exposure through the 26th day after last exposure.

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Seventh International Bird Flu Summit
November 13-14, 2008
Monte Carlo Resort
Las Vegas, Nevada, USA

This summit is designed to help you understand the threats of avian flu pandemic in your country, as well as meet your planning requirements on time, under budget, and with a minimum of disruption to your operations.

Confirmed speakers include:
• H.E. Dimitris Avramopoulos, Ministry of Health and Social Solidarity of Greece
• Hon. Dennis Wolff, Secretary, Pennsylvania Department of Agriculture
• Jonathan Sleeman, VetMB, Dipl. ACZM, MRCVS, RCVS, Wildlife Veterinarian and President
• Capt. Francis Doris, MSM,MMS,USN, US Homeland Defense Planning and Pandemic
• Brit Oiulfstad, DVM, MPH, Director of Pandemic Influenza Planning

An updated full agenda and additional information is available on the event website at: http://www.new-fields.com/birdflu7/index.php.

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Upcoming conferences on Asia-Pacific economics
Asia-Pacific Economic Association (APEA) conferences in 2008 and 2009: APEA conference, Beijing, December 13-14, 2008.

This conference, the fourth annual conference of the association to be hosted by the Central University of Finance and Economics (CUFE), will be held on the campus of the university. For a tentative list of participants and to keep abreast of conference developments, please visit http://apeaweb.org/confer/bei08/index.htm.

APEA conference, Santa Cruz, June 26-27, 2009
Call for papers

The fifth conference of APEA will be hosted by Department of Economics and Santa Cruz Center for International Economics (SSCIE), University of California, Santa Cruz, USA. The Federal Reserve Bank of San Francisco and the Bank of Korea are the sponsors of the conference.

Economics are invited to submit papers or extended abstracts for presentation considerable or to organize sessions of common themes. The deadline for submission is January 31, 2009. Additional information submitting papers or organizing a session can be found at http://www.apeaweb.org/confer/cruz09/index.htm.

Trade workshops in Beijing, November 22, 2008 and Hong Kong, February 28, 2009 The Research Center of International Economics at the University of Washington (RCIE @ UW), the Research Center of International Economics at the University of International Economics (RCIE @ UIBE), and the Department of Economics, Hong Kong Baptist University (HKBU) are jointly organizing a workshop series on international trade and related fields. The first one will be held on the campus of UIBE, Beijing, on November 22, 2008 and the second one on the campus of HKBU on February 28, 2009. Economists are welcome to come and present their previous work and current research. For more information, please visit http://www.rcie-cn.org.

KEBA-DGI conference in Daegu, Korea
Call for papers

The Korea Economics and Business Association (KEBA) and Daegu-Gyeongbuk Development Institute (DGI) are organizing an international conference on Knowledge Economy, Regional Development, and Free Economic Zones in Daegu, Korea on November 14-15, 2008. Economists are invited to submit papers. For more information, please visit. http://faculty.washington.edu/karyiu/confer/daegu08/index.htm

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 apecein@u.washington.edu