Vol. XI, No. 22 ~ EINet News Briefs ~ Oct 31, 2008

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: 387 (245).
(WHO 9.10.08 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO: 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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Global: WHO's draft pandemic influenza guidance revises phases
The World Health Organization (WHO) has drafted a revised pandemic influenza preparedness plan that updates the definitions of pandemic phases and puts more emphasis on the social and economic effects of a global epidemic, among other changes. The plan, intended to replace the existing one published in 2005, aims to present "simpler and more precise definitions" of the six pandemic phases and groups them to emphasize planning and preparedness considerations. The draft also defines "post-peak" and "possible new wave" phases.

The WHO is seeking comments on the draft and plans to publish the final version in December. Interested people can request a copy through the WHO Web site; to file comments, they must fill out a "declaration of interest" form. Comments must be submitted by Nov 3.

The agency says it is revising its guidance to reflect scientific advances and increased practical experience in responding to human and avian influenza since 2005. Events have included the development of national antiviral stockpiles, the approval of some H5N1 vaccines, the launch of efforts to create an international H5N1 vaccine stockpile, advances in understanding of past pandemics, and more knowledge of possible control strategies, the WHO said. Also, practical experience in pandemic planning and in responding to avian flu outbreaks in the past three years has led to "a greater recognition that pandemic preparedness planning requires the involvement of both health and non-health sectors," the agency said.
(CIDRAP 10/24/08)

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Global: Drug-resistant influenza viruses cause growing concern
Health officials worldwide are becoming increasingly concerned about influenza viruses' resistance to antiviral drugs, which can shut down a flu infection or mitigate symptoms. Flu antivirals are vital for reducing severe illness and death in average flu seasons and could be essential bulwarks against an influenza pandemic if one began.

There are currently only four antiviral drugs for flu, the adamantanes (amantadine and rimantadine) and the neuraminidase inhibitors (oseltamivir, or Tamiflu, and zanamivir, or Relenza). Flu scientists have known since 2005 that seasonal flu viruses have become widely resistant to the adamantanes, with at least 90% of H3N2 strains and at least 15% of H1N1 strains impervious to the drugs. That leaves only oseltamivir and the less widely used zanamivir as treatment options and has made oseltamivir the most commonly used influenza antiviral in the world.

But speaking at a major infectious-disease meeting on 26 Oct 2008, Dr. Nila Dharan of the US Centers for Disease Control and Prevention (CDC) disclosed that 12.6% (142 of 1,124) of H1N1 isolates sent to the CDC from around the United States during the 2007-08 season were resistant to oseltamivir, versus less than 1% before 2007. And in a troubling addition, CDC found that none of the patients who gave the isolates had taken oseltamivir, casting doubt on the widely held belief that oseltamivir resistance, when it occurs, is not transmissible.

On 14 Oct 2008 the World Health Organization (WHO) announced that during the southern hemisphere flu season this past summer, oseltamivir-resistant viruses were found in South Africa, Australia, Argentina, Chile, Kenya, New Caledonia, New Zealand, and Uruguay. And last January, toward the end of the 2007-08 northern hemisphere flu season, WHO reported that surveillance networks had found oseltamivir-resistant viruses in 9 of 18 European countries surveyed.

The mutation that confers resistance also appears in areas where seasonal flu co-exists with avian influenza H5N1. "In the last year or so we have seen a massive increase in seasonal flu resistance to oseltamivir," Dr. Jeremy Farrar of the Oxford University Clinical Research Unit at Vietnam’s Hospital for Tropical Diseases said. "In Ho Chi Minh City at the moment, 60% of seasonal flu isolates are drug-resistant." Farrar was part of the treatment team for two Vietnamese H5N1 patients who were found to have the mutated virus in 2005 during treatment with oseltamivir and who died of the infection.

"There is a lot of concern about emerging resistance to oseltamivir," said Dr. Trish Perl, director of hospital epidemiology and infection control at the Johns Hopkins Hospital. If a flu pandemic begins, she said, "We may not have the luxury of immunoprophylaxis. We may have to rely on basic infection control."
(CIDRAP 10/27/08)

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Global: International avian influenza conference held in Sharm el-Sheikh
A group of international donors who met 26 Oct 2008 in the final session of an avian influenza conference in Sharm el-Sheikh, Egypt, pledged more support for avian and pandemic flu preparedness and prevention, led by $320 million from the United States. The World Bank did not name a total pledge amount, but noted that countries had an opportunity at the meeting to pledge additional support. Japan's Kyodo News Service said the total from the meeting was $350 million, including a pledge of $24 million from Japan, the second largest amount behind the United States.

Olga Jonas, the World Bank's influenza coordinator, stated, "At this point, political commitment on response and preparedness is as important as funding. The $350 million total from the donor's conference is well below the $500 million that United Nations officials had asked countries to pledge to help the world battle avian influenza and make pandemic preparations, according to previous reports. The amount pledged at this year's donor conference is also less than the $406 million raised at the 2007 conference. The European Commission, the executive branch of the European Union, had indicated earlier that it would not pledge an additional amount, because it said half of the funds had not yet been spent.

The United Nations (UN) and the World Bank, in a recent progress report, expressed concern about a growing funding gap between what's needed to control and prevent avian flu and the amount donors are pledging. The report, which was published before the meeting in Egypt was held, said donors have pledged $2.7 billion, of which $2 billion has been committed. Of that total, $1.5 billion has been disbursed, of which 59% was cash or loans and 41% was in-kind contributions. Declines in funding threaten the sustainability of control and planning investments that have already been made.

The international conference drew representatives from more than 100 nations and 20 regional and international organizations. Sessions included a review of progress, sharing of best practices, and discussion of the threat avian flu virus poses to the global community. Representatives from West Africa said their countries were vulnerable to the virus, because of porous borders, weak infrastructure, and poverty. Anna Nyamekye, Ghana's deputy agriculture minister, told the conference about the difficulty in monitoring the movement of people and animals across unapproved routes. However, some West African countries have had success controlling outbreaks quickly by offering farmers compensation for dead or culled poultry. Junaidu Maina, Nigeria's chief veterinary officer, stated that since 2006 the country has culled 1.3 million birds and paid $5.4 million in compensation. Nyamekye said Ghana also has a compensation program that provides farmers incentives to abide by national biosecurity standards.

David Nabarro, the UN's influenza coordinator, warned against complacency in the fight against avian influenza. "Things are a lot better now than they were when we started this work in 2005, but they are not good enough," he said. Nabarro pointed to difficulties in getting government departments, other than health ministries, to work on pandemic prevention and preparedness, and he called for greater international cooperation. Piers E. Merrick, who helps coordinate the World Bank's avian flu response in the East Asian and Pacific regions, said that despite some success in controlling the spread of H5N1, the disease represents the persistent threat of zoonotic diseases. "Addressing many of these infections will require a more sophisticated and comprehensive long-term action plan" he said.
(CIDRAP 10/27/08)

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With laboratory-confirmed sporadic influenza infections of various strains in circulation at the start of this autumn season, it is important to emphasize that people in the defined influenza risk groups should take up the recommendation of influenza vaccination. It is too early in the season to predict the course of the 2008/09 influenza season, and whether it will be dominated by the circulation of H1N1, H3N2, or influenza B. The Agency will be closely monitoring the characteristics of circulating isolates in order to determine the overall prevalence of drug resistant influenza A and B isolates.

Influenza virus detections across Europe have been low so far in the 2008/09 influenza season (13 through 10/25/08) and the above-mentioned H1N1 oseltamivir-resistant influenza isolate is, to the Agency's knowledge, the first detected in Europe. Influenza A oseltamivir resistance first emerged last season with a number of circulating influenza A(H1N1) isolates with the H274Y mutation, which confers resistance to oseltamivir, but not to zanamivir. By the end of the 2007/08 season, 26 out of 33 reporting European countries reported H1N1 oseltamivir resistance ranging from 4% in Spain to 67% in Norway, with 11% (38/347) in the UK. The epidemiological evidence from the 2007/08 season suggested no reported increase in morbidity associated with these confirmed oseltamivir-resistant cases.
(ProMED 10/25/08)

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At the beginning of the webcast, HHS Secretary Mike Leavitt made some opening remarks that focused on what the agency has accomplished, especially since the release of the HHS's Pandemic Influenza Plan in 2005. Leavitt also spoke to the transitions that will likely occur over the next few months as the Bush administration winds down and a new administration takes over. He said during his tenure, the HHS has planned for 15 different disaster scenarios, including pandemic influenza.

"We're due for a pandemic, but regrettably, we're still somewhat underprepared," he said. Leading the nation's pandemic preparedness efforts has required a delicate balance, Leavitt added. "You want to stimulate preparedness, but not panic." He said two events loom large during his years as HHS secretary: the re-emergence of H5N1 avian influenza virus and hurricane Katrina. The storm response was, "a remarkable shakedown of our national response plan," Leavitt said.

In terms of pandemic preparedness, Leavitt emphasized a list of the agency's accomplishments, which include an H5N1 vaccine with aggressive efforts under way to expand vaccine production technology and capacity, an antiviral stockpile that has been amplified by a state purchase incentive plan, new diagnostic testing systems, and an array of regional pandemic planning summits and formal exercises.

Leavitt said he has four recommendations for the next HHS secretary: Finish work on new vaccine facilities; Strongly defend the global influenza virus-sharing network; Continue work on countermeasure distribution, which he said is currently the "Achilles heel" of bioterror response planning; Remind states, businesses, and families about their responsibility to help prepare for an influenza pandemic.

On the vaccine-sharing issue, Leavitt said he understands the concerns that Indonesia and other countries have about access to affordable H5N1 vaccines, but he said Indonesia's apparent demand of financial compensation for sharing virus samples is a "dangerous proposition" that could open the door to endless demands. The compensation demand promotes a vaccine scarcity mentality, Leavitt said, "but we need to pursue an abundance mentality."
(CIDRAP 10/29/08)

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USA: Benefits of influenza vaccination hotly debated
The benefits conferred by influenza vaccination—to recipients and to their close contacts—were hotly disputed at an international medical meeting the week of 26 Oct 2008. Presenters at the 48th Interscience Conference on Antimicrobial Agents and Chemotherapy and the 46th annual meeting of the Infectious Diseases Society of America (ICAAC-IDSA) presented abundant but often contradictory evidence regarding flu vaccines’ direct and indirect protective abilities.

The question whether flu vaccine protects recipients both from developing flu and from serious complications of flu, as well as whether its administration protects contacts of recipients, has been an active research topic over the past year. A study published earlier this month in the New England Journal of Medicine (and placed online in September) found that giving the flu shot to pregnant women lowered both their risk of flu and also the risk for their newborns, who were too young to be vaccinated themselves. Reports in the American Journal of Respiratory and Critical Care Medicine in September and the Lancet in August contended that flu vaccine's ability to protect the elderly from death and from pneumonia has been overstated, and several papers have pointed out that, while vaccination in the elderly has increased, the mortality rate has not declined.

"Observational studies have greatly exaggerated vaccination benefits in the elderly," Lone Simonsen, PhD, of George Washington University said 28 Oct 2008. She wrote a controversial paper challenging flu-mortality estimates for the elderly in 2005 while serving as a National Institutes of Health senior scientist. Such studies distort reality, she said, by assigning any deaths in winter to flu—including deaths that occur before the flu season begins—and do not make sense given what is known about age-related decay of the immune system. She proposed that flu researchers tackle the problem of making separate, more immunogenic vaccine formulas for seniors, and stressed the importance of indirect protection via vaccines given to child and adult contacts of the elderly. But vaccinating children to protect others was challenged in a separate presentation, with Catherine Weil-Oliver of the Universite de Paris arguing that indirect benefit "has not been demonstrated in schoolchildren in any European study. . .In children younger than two, no indirect benefit has been recorded at all."

Looking to flu vaccine to prevent death among the elderly may be focusing on the wrong benefit, Dr. Kristin Nichol of the University of Minnesota said. While studies of reductions in mortality may have been clouded by selection bias, she said, studies that show decreases in rates of respiratory diseases and hospitalizations look solid. "We need to remember that the vaccine also reduces influenza illness and it reduces hospitalization, and so while we explore the controversy we need to continue to vaccinate the elderly," she said.
(CIDRAP 10/30/08)

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"Business as usual won't stop the next AIDS or SARS," Dr. Larry Brilliant, Google.org executive director stated. "The teams we're funding today are on the frontiers of digital and genetic early detection technology. We hope that their work, with partners across environmental, animal, and human health boundaries, will help solve centuries-old problems and save millions of lives."

The statement said three of the grants are for efforts to use mapping and weather and climate data to help predict where and when disease outbreaks will occur:
- The Woods Hole Research Center in Falmouth, Mass., will receive $2 million to support satellite mapping of forests to improve monitoring of forest loss and settlement expansion in tropical countries.
- Columbia University International Research Institute for Climate and Society will get $900,000 to improve the use of forecasts, rainfall data, and other climate information in East Africa and to link weather and climate experts to health specialists.
- University Corporation for Atmospheric Research in Boulder, Colo., is awarded $900,000 to develop a system for using weather projections to inform and target responses to disease threats in West Africa. "For Rift Valley fever and malaria, long-term weather forecasts and deforestation maps can show us where to look for outbreaks, up to six months in advance," said Frank Rijsberman, director of the grant program for Google.org.

The other three grants are for projects designed to detect early signals of possible epidemics through blood sampling, molecular diagnostics, mining of digital data, and other surveillance efforts:
- The Global Viral Forecasting Initiative (GVFI) will receive $5.5 million for collecting and analyzing blood samples from humans and animals in hot spots in Cameroon, the Democratic Republic of Congo, China, Malaysia, Lao PDR, and Madagascar. The grant will be matched by the Skoll Foundation. Dr. Nathan Wolfe, GVFI's founder and director, said the project's aim is to monitor the movement of viruses from animals into people.
- Columbia University Mailman School of Public Health, New York City, is awarded $2.5 million to support research to speed the discovery of new pathogens and promote rapid regional responses to outbreaks by establishing molecular diagnostics in hot spot countries, including Sierra Leone and Bangladesh. Columbia's Dr. Ian Lipkin and colleagues already have discovered more than 75 viruses.
- Children's Hospital Corp., in Boston, will receive $3 million to combine the online disease-detection efforts of HealthMap with ProMED-mail's global network of human, animal, and ecosystem health specialists who report disease outbreaks. The project will assess emerging-disease reporting systems, expand networks in Africa and Southeast Asia, and develop news tools to improve outbreak detection.
(CIDRAP 10/21/08)

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Global: Experts stress vigilance over emerging, unpredictable diseases
Health authorities must remain alert to new and renascent disease threats, experts warned this week at an international medical meeting. In a series of briefings and presentations of data, speakers at the 48th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) and the 46th annual meeting of the Infectious Diseases Society of America (IDSA) ticked off a long list of bacterial, viral, and fungal pathogens whose recent behavior has taken scientists and public health authorities by surprise. There was abundant evidence at the meeting of pathogens' ability at taking advantage of changes in the human environment, from increased travel and trade to the growth of mega-cities to climate change.

The chikungunya experience
Dr. Harold Townson of the Liverpool School of Tropical Medicine outlined the unexpected behavior of chikungunya, a mosquito-borne virus that causes debilitating joint pain that lasts for months or years. The virus was identified in Africa in 1952, and moved to India and Asia along trade routes. Mutations in the virus identified in 2005 and 2007 have caused additional challenges. The adaptation allowed more copies of the virus to move into mosquito salivary glands and deliver a larger dose to victims. With no effective treatment and no vaccine, Townson said, the only feasible strategy for blocking chikungunya is mosquito control. But it must be practiced routinely, a painstaking, expensive undertaking that is beyond the resources of many areas in the developing world. "Chikungunya poses a major public health problem for authorities throughout the world, because by the time you discover it, it is too late for environmental control measures to be effective," he said on 27 Oct 2008.

Mosquito control and dengue
The low-tech but often unachievable measures of spraying pesticides and eliminating standing water are essential to controlling the mosquito-borne disease dengue and its most serious form, dengue hemorrhagic fever, said Dr. Duane Gubler of the Asia-Pacific Institute of Tropical Medicine and Infectious Diseases in Singapore. The disease has been amplified by the ferocious growth of Asian mega-cities, where new construction provides an almost endless series of pools and puddles for mosquitoes to breed, and has expanded its range around the world.

Keeping an eye on hot spots
Assessing new disease threats requires investment in new tools, said Dr. Ian Lipkin of Columbia University's Mailman School of Public Health. Lipkin directs a World Health Organization collaborating center on diagnostics for emerging infections and recently received a Google.org philanthropic grant aimed at early detection.

To be as prepared for new threats as possible, it is necessary to get even further forward of the epidemic curve, by keeping an eye on the "hot spots" where concentrations of humans and animals are likely to birth new diseases, Dr. Jeremy Farrar said. Farrar, the director of the Oxford University Clinical Research Unit at the Hospital for Tropical Diseases in Ho Chi Minh City, has been at the forefront of treating human victims of avian influenza H5N1. As examples of the unpredictability of pathogens' behavior in such hot spots, he offered the experience of Streptococcus suis, a bacterium commonly found in pigs in Southeast Asia. S suis is a frequent cause of mild meningitis in humans in Asian pig-growing areas, but in 2005 it changed its behavior, roaring into an acute infection that killed more than 30 people.

Emerging drug resistance
Still, the most important emerging threat may not be any one disease, but the growing resistance of many diseases to the drugs used against them, he said. He pointed to evidence presented at the conference of a malaria cluster in Cambodia that is resistant to artesunate, a botanically based compound that is the centerpiece of malaria treatment in much of the developing world. "The most important emerging disease of all is drug resistance, in which Asia leads the world," he said. "The emergence of drug resistance, which is somewhat insidious and which does not get the headlines it deserves, is going to challenge us more in the 21st century, I suspect, than any individual disease."
(CIDRAP 10/29/08)

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The Department is attempting to contact those passengers on Royal Brunei Airways flight BI516 departing Thailand on 30 Sep 2008 and connecting Flight BI76 departing Brunei on 1 Oct 2008 who are at greatest risk of developing measles because of their age or seating arrangements. Dr Effler said it is important that all people on these flights and those who attended the funeral service be aware of the possibility of measles illness. "Individuals who develop a fever and cough or runny nose in the next several weeks should stay at home and promptly consult their GP," he said.

Measles is a highly contagious viral illness that can cause serious disease. Early symptoms include fever, cough, runny nose, and sore eyes followed by a red blotchy rash about three days later. Complications following measles can be very serious and may include ear infections and pneumonia in about one in every 25 cases. About one person in every 2000 infected will develop encephalitis, an inflammation of the brain. All children who have not been vaccinated against measles should be considered at risk. The first measles vaccination is usually given at 12 months followed by a second dose at four years.
(ProMED 10/23/08)

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China (Fujian): Outbreak of hand, foot and mouth disease kills three children
Three children have died in eastern China from hand, foot and mouth disease in the country's second outbreak of the potent toddler virus of 2008, state media reported on 20 Oct 2008. Health officials warned that the disease was epidemic in some parts of the coastal Fujian province, with 113 cases reported since the start of October 2008. The three victims were all less than one year old and from the Jian'ou City. A flare-up of the virus infection in southern China killed at least 42 people in April and May 2008, and an additional 27,500 cases, primarily among toddlers, were reported. Hand, foot and mouth disease is a common childhood illness, but the outbreaks in China have been linked with enterovirus 71 (EV71), which can cause a severe form of the disease characterised by high fever, paralysis, and meningitis. There is no vaccine for the disease, and, normally patients recover within a week to ten days. Enteroviruses spread mostly through contact with infected blisters or feces.
(ProMED 10/20/08)

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China (Guangdong): Vaccination efforts successful in reducing measles incidence
On 20 Oct 2008, Shenzhen's Center for Disease Control announced that from January to September 2008, there were 2156 cases of measles in Shenzhen [sub-province of Guangdong province], an incidence rate of 25/100 000. The number of cases had declined 50% over the same period in 2007. Sources say that over the past two years, due to the high incidence of disease in the migrant population, measles incidence in Shenzhen and Guangdong province has ranked high. From January to March 2008, there was a substantial increase in measles in Shenzhen. As a result of more vigorous vaccination efforts, disease incidence in Shenzhen gradually declined after May 2008 and has been held at a relatively low level.

Sources say that 76% of reported measles cases in Shenzhen in 2008 were in populations under two years of age and over 20 years of age. Of these, 17% were infants less than eight months old who could not have been protected by vaccination because their immune systems are too young for the vaccine to take. Experts from the city's Center for Disease Control said that from 2001 to 2007, measles incidence in Shenzhen generally increased. In 2007, measles accounted for 18% of Class A and B infectious diseases in Shenzhen, and measles cases increased over 130 percent in 2006.

In 2008, after a supplementary immunization campaign, implementation of national immunization policies, and other methods of control and prevention, the number of measles cases in Shenzhen was effectively reduced. In order to expand immunization work in Shenzhen more thoroughly, the Shenzhen Bureau of Health launched a four-day full-scale investigation of the immunization status of the city's children on 20 Oct 2008.

Disease control experts say that all children of suitable age can receive free nationally-mandated immunizations at hospitals and neighborhood health centers near to where they live, regardless of whether they hold Shenzhen residence permits or whether they live in Shenzhen temporarily or permanently. From 1 Sep 2008, when Shenzhen formally launched the national immunization campaign, there has been a clear increase in the number of children receiving nationally-mandated free immunizations or boosters. Now, Shenzhen offers 11 types of immunizations free of charge for suitably-aged children.
(ProMED 10/22/08)

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China (Yunnan): 11,000 dogs culled after six people die from rabies infection
Officials in a rural county of south-western China's Yunnan province ordered the culling of more than 11,000 dogs after rabies killed six people, the state media said on 26 Oct 2008. Of the more than 90,000 dogs in Yunnan's Mi'le County, some 84,000 had been vaccinated against rabies and another 11,500 unprotected dogs were culled. The county government threatened to fine people who failed to hand over their dogs, but some locals protested that the policy of culling all unprotected dogs was heavy handed, arguing that people in remote areas relied on guard dogs. Local government officials said the culling was essential to prevent the spread of the rabies virus. After the first death in late July 2008, workers killed all cats and dogs within a 5-kilometer radius of the victim's home.

The number of deaths from rabies has risen in China in recent years, with more than 3000 deaths reported in 2006, and some experts put part of the blame on a higher rate of dog ownership. Dogs are commonly kept as pets or guards in many rural areas of China but were banned in cities until recently. Some breeds are also popular for their meat in many areas of China.
(ProMED 10/28/08)

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Russia (Omsk): Increased incidence of tick-borne encephalitis
According to the Omsk Oblast Center for Hygiene and Epidemiology, 159 patients attended the Centre for Rapid Tick-borne Encephalitis (TBE) Diagnosis in September 2008, compared with 71 in August 2008. One hundred twenty-six of patients had received tick bites. Ticks were investigated, and five were discovered with TBE virus antigen, showing they were infected. Thirty-two samples of serum were also investigated for the presence of TBE virus antibodies, and four gave positive results. The positive ticks originated from the Omsk Novovarshavsk region, and the positive humansera were determined in patients from the Omsk Gorkovsk region.
(ProMED)

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Thailand (Narathiwat): Nearly 200 infected in Chikungunya outbreak
The Department of Disease Control of the Thai Ministry of Public Health (MOPH) has released the information regarding the chikungunya outbreak that has been ongoing since 14 Oct 2008. In summary, confirmation of an outbreak of chikungunya in one village of Narathiwat province by HI (hemagglutination inhibition) and PCR (polymerase chain reaction) from the serum of almost 40 patients. PCR conducted on a pool of Aedes albopictus caught in the affected village was also positive for chikungunya virus.

The major clinical symptoms seen are fever, rash, and persistent polyarthralgia with arthritis. The nearby province has been alerted and and MOPH received information on some other similar cases from a nearby area. The total number of reported cases is now close to 200 cases. The vector control and education program for villagers is ongoing. The MOPH has shared information on this outbreak with SEARO (SouthEast Asian Regional Office of the World Health Organization) and all the MBDS countries as well.
(ProMED 10/28/08)

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Canada (Ontario): E. coli outbreak linked to fast food restaurant continues
The number of people who became sick with E. coli O157 after eating at a Harvey's restaurant in North Bay, ON, has risen to 36, the Ontario region's health authority reported 22 Oct 2008. The North Bay/Parry Sound District Health Unit said in a statement that it was now investigating a total of 190 E. coli cases, 36 of which have been lab-confirmed to have originated from the fast-food restaurant. These new cases show a dramatic increase from the number of cases reported earlier in the week of 19 Oct 2008. "We believe the increase in the number of cases is largely due to people who are still reporting symptoms and are within the expected time frame of the outbreak," the statement said.

The total number included eight cases in other Ontario health unit districts and one in Quebec. The majority were linked to the North Bay Harvey's restaurant, which has been closed since 19 Oct 2008. The E. coli patients range in age from 12 months to 90 years. Food samples taken from the restaurant on the night it was closed have tested negative for the bacteria.
(ProMED 10/23/08)

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USA: ACIP opens door to anthrax shots for first responders
The federal Advisory Committee on Immunization Practices (ACIP) has opened the door to voluntary anthrax vaccination for first responders, revising an 8-year-old recommendation against that step. The committee said the risk of anthrax exposure for emergency responders is low but "may not be zero," and therefore first-responder agencies may want to offer the vaccine on a voluntary basis. The CDC routinely adopts the ACIP's recommendations.

Anthrax vaccination—which currently involves six doses over 18 months, followed by annual boosters—is required for US military personnel serving in the Middle East and other high-risk areas. Nearly two million service members have been vaccinated under the program, according to ACIP reports. However, a number of military members have complained of negative side effects from the shot, and a lawsuit by several of them interrupted mandatory vaccinations for about two years starting in October 2004.
(CIDRAP 10/23/08)

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USA (Massachusetts): Man infected with eastern equine encephalitis
A 73-year-old Massachusetts man is suffering from eastern equine encephalitis [EEE], the first time in two years that a Bay State resident has been diagnosed with the highly lethal mosquito-borne illness. The Essex County man developed symptoms 21 Sep 2008 while vacationing in Maine. During the two weeks before falling ill, the man had traveled extensively in Maine and New Hampshire, enjoying the outdoors. While it is impossible to determine where the man was exposed to the viral disease, Massachusetts health authorities said, it appears likely he caught the illness in another state.

After being hospitalized for several weeks in Maine, the man was transferred to a Massachusetts hospital, where his prognosis remains guarded, state disease trackers said. Eastern equine encephalitis is the deadliest of the viruses spread by mosquitoes, killing up to half of people who develop symptoms. From 2004 through 2006, 13 Massachusetts residents contracted the virus, resulting in six deaths.
(ProMED 10/28/08)

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USA (Washington): E. coli outbreak sickens 17 people
Of 17 cases of E. coli O157:H7 infection in Snohomish County, 13 have been linked to a Lake Stevens restaurant, according to the Snohomish Health District. The 13 people ate at Ixtapa Restaurant between 2 and 13 Oct 2008. People began experiencing symptoms between 7 and 17 Oct 2008. The cases were first reported during the week of 13 Oct 2008; two people were hospitalized briefly, but both are now recovering at home. The 13 people who became ill after eating at the restaurant range in age from 9 to 75. Health inspectors continue to interview those who became ill to determine the source of the infection. Of the four others believed to have the infection, three have no connection to the restaurant. The other has not yet been interviewed. Where they may have contacted in infection is unknown. No new cases have been reported in Snohomish County since 20 Oct 2008.
(ProMED 10/22/08)

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DENGUE
Chinese Taipei
Taiwan's Disease Control Department of Health warned on 21 Oct 2008 that Kaohsiung County and Kaohsiung City's local dengue fever cases have been on an upward trend with the increase in the last three weeks reaching a total of 33 cases. As the territory of the epidemic continues to expand, there will be risk of cross-spread coupled with cross-infection with different dengue virus serotypes, making the patients more prone to an infection that can lead to the more serious dengue haemorrhagic fever (DHF).

Taiwan's "News" reported that despite the autumn season, the dengue fever outbreak on the island is on an increasing trend and concentrated in the cities of Kaohsiung. In Taipei-based monitoring of the health sector, 11 Kaohsiung City Administrative Region of China, there has been a total of 146 cases of indigenous dengue fever confirmed; Kaohsiung County has a total of 30 cases. Taipei health authorities worried that with the first epidemic of dengue in Kaohsiung City and Kaohsiung County, the risk of the disease has spread in other districts. Taiwan's health authorities called on local people to remove mosquito-breeding sites so as not to have dengue fever become a New Year’s epidemic.
(ProMED 10/28/08)

Viet Nam
The number of cases of dengue fever has surged since 2007 and health officials say the disease is now showing greater complications. Dengue fever in Ho Chi Minh City (HCMC) has increased dramatically in 2008, with more than 10,000 cases and five deaths reported so far, according to the HCMC Preventive Health Center. Now, 242 out of around 320 wards and communes in the city have reported outbreaks of the disease.

Nguyen Tran Chinh, director of the HCMC Hospital for Tropical Diseases said that in September 2008 they admitted 1000 adults and 532 children with dengue, nearly a 300 percent increase compared to 2007. In October 2008, 1164 more patients have been hospitalized, compared with 716 admitted in October 2007. More than 100 in-patients were undergoing treatment at the hospital on 22 Oct 2008. Dr Nguyen Thi Kim Loan of the hospital's Pediatrician Department A said 42 children were currently being treated for dengue and 7 to 8 of them were in danger of going into shock.

Tran Thi Thuy, deputy head of Children Hospital No. 2's Infectious Disease Department, said on 23 Oct 2008 that since the end of November 2007, they have admitted 718 children, a 20 percent year-on-year increase. Eighty percent of patients were from HCMC. The department admits between 30 and 60 patients per day, Thuy said. Each day, there are between 100 and 130 in-patients, of which 10-12 percent are in critical condition. On 22 Oct 2008, 15 children with dengue were listed in critical condition.

The signs and symptoms of dengue fever patients are also showing more complications than before, according to doctors. More patients are listed in critical condition and are suffering longer bouts of fever, up to 10 days in some cases. Bloody diarrhea, loss of consciousness, respiratory failure, and problems with the liver, kidneys, and brain are other symptoms cropping up in greater numbers than before.

According to the HCMC Preventive Health Center, efforts to curb the disease from June 2008 to August 2008 have been largely ineffective. Until 25 Sep 2008, more than 56,100 cases of dengue fever and 52 deaths had been reported nationwide, the Ministry of Health reported. While the number of cases nationally has decreased by 22 percent, and deaths have decreased by 15 percent year-on-year, 13 provinces and cities have suffered from greater outbreaks than in previous years. The southern provinces of Ca Mau and Binh Phuoc and the central province of Nghe An are among the localities with the highest incidence rates, including deaths.
(ProMED 10/28/08)

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WEST NILE VIRUS
Canada
Date: 5-11 Oct 2008:
Human cases: no new cases reported
Total human cases in 2008: 35

USA
Date: 15-21 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 1141 human cases and 25 fatalities to date in 2008.
(ProMED 10/24/08)

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Anaplasma phagocytophilum, a gram-negative, obligate intracellular bacterium of neutrophils, causes human anaplasmosis, a tickborne rickettsial disease formerly known as human granulocytic ehrlichiosis. In November 2007, the Minnesota Department of Health was contacted about an A. phagocytophilum infection in a hospitalized Minnesota resident who had recently undergone multiple blood transfusions. Subsequent investigation indicated the infection likely was acquired through a transfusion of red blood cells. This report describes the patient's clinical history and the epidemiologic and laboratory investigations.

Although a previous case of transfusion-transmitted anaplasmosis was reported, this is the first published report in which transfusion transmission of A. phagocytophilum was confirmed by testing of the recipient and a donor. Although polymerase chain reaction (PCR) assays provided reliable evidence of transmission in this case, no cost-effective method for screening blood donors for A. phagocytophilum exists. Screening donors for a recent history of tick bite is not likely to be sensitive or specific because such exposures are common and often not recalled by persons with anaplasmosis. Physicians should consider the possibility of anaplasmosis in patients who develop posttransfusion acute thrombocytopenia, especially if accompanied by fever, and should report suspected transfusion-associated cases to health authorities. . .

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Genetic evidence of intercontinental movement of avian influenza in a migratory bird: the northern pintail (Anas acuta)
Koehler, Anson V et al. Molecular Ecology. 17 (21); 4754-4762. Available at http://www3.interscience.wiley.com/journal/121482481/abstract?CRETRY=1&SRETRY=0.

Abstract
The role of migratory birds in the movement of the highly pathogenic (HP) avian influenza H5N1 remains a subject of debate. Testing hypotheses regarding intercontinental movement of low pathogenic avian influenza (LPAI) viruses will help evaluate the potential that wild birds could carry Asian-origin strains of HP avian influenza to North America during migration. Previous North American assessments of LPAI genetic variation have found few Asian reassortment events. Here, we present results from whole-genome analyses of LPAI isolates collected in Alaska from the northern pintail (Anas acuta), a species that migrates between North America and Asia.

Phylogenetic analyses confirmed the genetic divergence between Asian and North American strains of LPAI, but also suggested inter-continental virus exchange and at a higher frequency than previously documented. In 38 isolates from Alaska, nearly half (44.7 percent) had at least one gene segment more closely related to Asian than to North American strains of LPAI. Additionally, sequences of several Asian LPAI isolates from GenBank clustered more closely with North American northern pintail isolates than with other Asian origin viruses. Our data support the role of wild birds in the intercontinental transfer of influenza viruses, and reveal a higher degree of transfer in Alaska than elsewhere in North America.

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Progress Toward Elimination of Rubella and Congenital Rubella Syndrome--the Americas, 2003—2008
US Centers for Disease Control and Prevention. MMWR. October 31, 2008: 57(43); 1176-1179. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5743a4.htm?s_cid=mm5743a4_e.

In 2003, the Pan American Health Organization (PAHO) adopted a resolution calling for rubella and congenital rubella syndrome (CRS) elimination in the Americas by the year 2010. Elimination was defined as the interruption of endemic rubella virus transmission in all countries of North America, Central America, South America, and the Caribbean for more than 12 months and no occurrence of CRS cases attributed to endemic transmission. To accomplish this goal, PAHO developed a rubella and CRS elimination strategy to 1) introduce rubella-containing vaccine (RCV) into routine vaccination programs of all countries for children aged 12 months and reach >95% coverage in all municipalities, 2) conduct a one-time mass campaign among adolescents and adults and periodic follow-up campaigns among children aged <5 years, and 3) integrate rubella surveillance with measles surveillance and initiate CRS surveillance. During 1998--2006, confirmed rubella cases decreased 98% (from 135,947 to 2,998) in the Americas. However, in 2007, rubella outbreaks with a total of 13,014 cases occurred in three countries (Argentina, Brazil, and Chile), primarily in males not included in previous vaccination campaigns. This report summarizes overall progress toward reaching the 2010 goal of eliminating rubella and CRS. With completion of campaigns in Argentina, Brazil, and Haiti, all countries will have implemented the recommended PAHO strategy by the end of 2008, with the expectation of reaching the 2010 rubella and CRS elimination goal.

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The Effect of Universal Influenza Immunization on Mortality and Health Care Use
Kwong, Jeffrey C et al. PLoS Med. Oct 2008; 5(10): 1440-52. Available at http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050211&ct=1.

Background
In 2000, Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free influenza vaccines for the entire population aged 6 mo or older. Influenza immunization increased more rapidly in younger age groups in Ontario compared to other Canadian provinces, which all maintained targeted immunization programs. We evaluated the effect of Ontario's UIIP on influenza-associated mortality, hospitalizations, emergency department (ED) use, and visits to doctors' offices.

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Health Benefits of Universal Influenza Vaccination Strategy
Viboud, Cecile et al. PLoS Med. Oct 2008; 5(10): 1423-1425. Available at http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/oct2908ontario.html.

Most countries in Europe and North America target influenza immunization to persons at highest risk for complications, including seniors 65 years and older, those with certain chronic illnesses, and young children. Despite increases in vaccination rates in these high-risk groups over the last few decades, morbidity and mortality from influenza remain high.

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Using Internet Searches for Influenza Surveillance
Polgreen, Philip M et al. Clinical Infectious Diseases 2008; 47. Available at http://www.journals.uchicago.edu/doi/abs/10.1086/593098.

The Internet is an important source of health information. Thus, the frequency of Internet searches may provide information regarding infectious disease activity. As an example, we examined the relationship between searches for influenza and actual influenza occurrence. Using search queries from the Yahoo! search engine (http://search.yahoo.com) from March 2004 through May 2008, we counted daily unique queries originating in the United States that contained influenza-related search terms. Counts were divided by the total number of searches, and the resulting daily fraction of searches was averaged over the week. We estimated linear models, using searches with 1–10-week lead times as explanatory variables to predict the percentage of cultures positive for influenza and deaths attributable to pneumonia and influenza in the United States. With use of the frequency of searches, our models predicted an increase in cultures positive for influenza 1–3 weeks in advance of when they occurred (p<.001), and similar models predicted an increase in mortality attributable to pneumonia and influenza up to 5 weeks in advance (p<.001). Search-term surveillance may provide an additional tool for disease surveillance.

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Vaccine Effectiveness Against Laboratory-Confirmed Influenza in Children 6 to 59 Months of Age During the 2003–2004 and 2004–2005 Influenza Seasons
Eisenberg, Katherine W et al. Pediatrics. November 2008; 124(5): 911-919. Available at http://pediatrics.aappublications.org/cgi/content/abstract/122/5/911.

OBJECTIVE. The goal was to estimate the effectiveness of influenza vaccination against laboratory-confirmed influenza during the 2003–2004 and 2004–2005 influenza seasons in children 6 to 59 months of age.

METHODS. We conducted a case-control study with children with medically attended, acute respiratory infections who received care in an inpatient, emergency department, or outpatient clinic setting during 2 consecutive influenza seasons. All children residing in Monroe County, New York, Davidson County, Tennessee, or Hamilton County, Ohio, were enrolled prospectively at the time of acute illness and had nasal/throat swabs tested for influenza with cultures and/or polymerase chain reaction assays. Children with laboratory-confirmed influenza were case subjects and children who tested negative for influenza were control subjects. Child vaccination records from the parent and the child's physician were used to determine and to validate influenza vaccination status. Influenza vaccine effectiveness was calculated as (1 – adjusted odds ratio) x 100.

RESULTS. We enrolled 288 case subjects and 744 control subjects during the 2003–2004 season and 197 case subjects and 1305 control subjects during the 2004–2005 season. Six percent and 19% of all study children were fully vaccinated according to immunization guidelines in the respective seasons. Full vaccination was associated with significantly fewer influenza-related inpatient, emergency department, or outpatient clinic visits in 2004–2005 (vaccine effectiveness: 57%) but not in 2003–2004 (vaccine effectiveness: 44%). Partial vaccination was not effective in either season.

CONCLUSIONS. Receipt of all recommended doses of influenza vaccine was associated with halving of laboratory-confirmed influenza-related medical visits among children 6 to 59 months of age in 1 of 2 study years, despite suboptimal matches between the vaccine and circulating influenza strains in both years.

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Influenza Vaccination in Adolescents With High-Risk Conditions
Nakamura, Mari M et al. Pediatrics. November 2008; 5(122): 920-928. Available at http://pediatrics.aappublications.org/cgi/content/abstract/122/5/920.

OBJECTIVES. We assessed influenza vaccination rates from 1992 to 2002, individual continuity of vaccination, and missed opportunities for vaccination in adolescents with high-risk conditions.

METHODS. We performed a retrospective observational study of 18 703 adolescents with high-risk conditions who were enrolled in a large health maintenance organization and received care at a multisite practice for >=1 influenza season and the preceding year, between 1992 and 2002, was performed. Subjects were identified as having a high-risk condition if they had >=1 visit with an associated International Classification of Diseases, Ninth Revision, Clinical Modification code during the season or previous year. Influenza vaccination rates were compared by season in logistic regression analyses, using generalized estimating equations for repeated measurements of subjects enrolled for multiple seasons. Vaccination continuity was measured for adolescents who were enrolled for 4 consecutive seasons (1999–2002) as the number of seasons during which vaccine was received. Missed opportunities were defined as visits during the first 4 months of influenza season at which an unvaccinated adolescent did not receive vaccine.

RESULTS. For adolescents with high-risk conditions, influenza vaccination rates varied from 8.3% to 15.4%. Rates improved significantly from 1992 to 1993, from 8.3% to 12.8%, and again in 2001, reaching 15.4%. Only 11.1% of those enrolled continuously from 1999 to 2002 received vaccine during all 4 seasons. According to season from 1992 to 2002, 45.7% to 53.6% of unvaccinated subjects had >=1 missed opportunity.

CONCLUSIONS. Influenza vaccination rates in adolescents with high-risk conditions improved from 1992 to 2002 but were still low in recent years. Individual vaccination continuity was poor. Numerous opportunities already exist for improving coverage.

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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 at: http://www.new-fields.com/birdflu7/index.php.

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GAO releases report saying tighter security needed at two BSL-4 labs
Two of the nation's five biosafety level 4 (BSL-4) labs lack outer-ring security controls to protect against a terrorist attack or theft of some of the world's most dangerous pathogens, such as the Ebola and smallpox viruses, according to a new report from the Governmental Accountability Office (GAO). In the report, the GAO recommended that the US Centers for Disease Control and Prevention (CDC) implement specific perimeter security controls for all of the country's BSL-4 labs. Currently, the CDC's Select Agent regulations don't specify the perimeter controls that should be in place at the labs, which has resulted in varying security levels among the BSL-4 labs, the report said.

The GAO releases its findings on 16 Oct 2008. The report is available at http://www.gao.gov/new.items/d081092.pdf.
(CIDRAP 10/22/08)

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Public health survival: Leadership in a falling market
What: US National Live Webcast
Date: December 15, 2008
Time: 2:00 pm Eastern
1:00 pm Central
12:00 pm Mountain
11:00 am Pacific
For: Public health leaders and policy-makers, managers and supervisors, agency planners, community leaders, and anyone concerned about public health in tough economic times.

Sponsored by the North Carolina Institute for Public Health and the Public Health Leadership Institute. Additional information available at www.sph.unc.edu/nciph.

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Websites provide tools for pandemic planning
The Spatiotemporal Epidemiological Modeler (STEM) tool is designed to help scientists and public health officials create and use spatial and temporal models of emerging infectious diseases. These models can aid in understanding and potentially preventing the spread of such diseases.

Policymakers responsible for strategies to contain disease and prevent epidemics need an accurate understanding of disease dynamics and the likely outcomes of preventive actions. In an increasingly connected world with extremely efficient global transportation links, the vectors of infection can be quite complex. STEM facilitates the development of advanced mathematical models, the creation of flexible models involving multiple populations (species) and interactions between diseases, and a better understanding of epidemiology.

Additional information on the tools available at http://wiki.eclipse.org/index.php/STEM and http://wiki.eclipse.org/Estimating_Model_Parameters_from_External_Data.

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