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Vol. XI, No. 23 ~ EINet News Briefs ~ Nov 14, 2008


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

1. Influenza News
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Global: USA giving FAO $44 million for avian influenza control
- Indonesia: Update—suspected avian influenza H5N1 death attributed to pneumonia
- Indonesia: Death of teenager in Java confirmed to be avian influenza H5N1
- Thailand: Avian influenza H5N1 confirmed in poultry
- USA: GAO says Obama should address health preparedness and food safety
- USA: Google uses searches to track influenza’s spread
- USA: Firm says 'universal' influenza vaccine passed early test
- USA: Feds stage airport test of plan to slow pandemic

2. Infectious Disease News
- Australia: Acute poststreptococcal glomerulonephritis persists among indigenous communities
- China (Wan Chai): Elementary school closed due to adenovirus outbreak
- Indonesia: Eight year-old dies of rabies infection
- Malaysia: Sarawak preparing for major outbreak of hand, foot, and mouth disease in 2009
- Russia (Lipetsk Oblast): Two infected with hemorrhagic fever
- Viet Nam: Five children infected with rare meningitis in 2008
- USA: APIC sounds alarm about C difficile threat
- USA (Colorado): E coli O157 infections in children linked to elk droppings
- USA (Michigan): College closes due to suspected norovirus outbreak
- USA (South Carolina): Rabid fox attacks several people
- USA (South Dakota): Seventeen cases of pertussis confirmed in children

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

4. Articles
- Medicine in the popular press: the influence of media on perceptions of disease
- Respirator-Fit Testing: Does It Ensure the Protection of Healthcare Workers Against Respirable Particles Carrying Pathogens?
- Requiring Influenza Vaccination for Health Care Workers
- Weekly Epidemiological Record Bulletin

5. Notifications
- Obituary: Dr. Ron Davis
- CDC posts new notices related to avian influenza H5N1 on their Travelers’ Health website
- 26th Annual Behavioral Risk Factor Surveillance System (BRFSS) Conference
- Chinese Taipei takes measures for melamine-contaminated food products


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: 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 9.11.08)

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 11.11.08): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: USA giving FAO $44 million for avian influenza control
The United States will contribute another $44.4 million to the United Nations Food and Agriculture Organization (FAO) to prevent and control avian influenza. Top recipients of the money will be Egypt, Indonesia, and Vietnam; other beneficiaries will be Afghanistan, Bangladesh, Cambodia, China, India, Laos, Myanmar, Nepal, Pakistan, and the regions of South Asia, West Africa, and Central Africa.

"Although many countries have successfully managed to get avian influenza under control, the virus remains present in ten countries and is mainly entrenched in countries like Egypt, Indonesia and Vietnam," FAO Chief Veterinary Officer Joseph Domenech said. "The additional US funds will enable FAO to continue its work in support of countries that are still struggling to get the virus under control." The contribution brings total US support for the FAO's avian flu program to $112.8 million, the agency reported. The United States is the leading donor of funds for the program, which operates in 96 countries.

The FAO said funds contributed to its avian flu program total about $282.7 million. Other major donors include Sweden, Australia, Japan, the European Commission, the United Kingdom, Canada, Germany, the World Bank, the UN Development Programme, the Asian Development Bank, and France.

The FAO announcement comes less than a month after the United States pledged $320 million for avian and pandemic flu preparedness and prevention. That pledge brought the total of delivered and promised US funds for avian flu to $949 million, the US State Department said in Oct 2008.

A report released by the State Department in October 2008 gave a breakdown of the $629 million in US funds pledged through December 2007 for avian and pandemic flu efforts. It listed the following sums:
- $233 million for bilateral activities, including $51 million in bilateral cooperative agreements with national influenza centers and other laboratories in 39 countries
- $128.5 million for regional programs, including support for global disease-detection sites
- $102 million to international organizations, including $42 million to the World Health Organization and $10 million to build human vaccine production capacity in developing nations
- $66.5 million for stockpiles of nonpharmaceutical supplies, including 1.6 million personal protection kits, about 250 lab specimen collection kits, and 15,000 decontamination kits
- $66 million for international technical and humanitarian assistance and international coordination
- $17.5 million for wild-bird surveillance and international research, including the US launch of the Global Avian Influenza Network for Surveillance
- $15.5 million for global communications and outreach
(CIDRAP 11/11/08)

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Asia
Indonesia: Update—suspected avian influenza H5N1 death attributed to pneumonia
Hasan Sadikin Hospital in West Java announced on 6 Nov 2008 that a Bandung resident who was suspected to have died of avian influenza, actually died of pneumonia. Test results indicated that the man, age 32 and a resident of Jl Inhoftank Bandung, did not contract avian influenza H5N1 after all, according to the hospital. "All of the results were negative," head of Hasan Sadikin Hospital Cissy Kartasasmita said. She added that the patient's breathing problem was inflicted something else, "but the cause is yet to be determined as we need time to conclude the cause."

As reported on 4 Nov 2008, the City Agriculture office conducted rapid tests on poultry around the neighborhood of the patient's house. The results were negative. The patient and his family owned a chicken farm which supplies between 100 and 500 chickens daily.

The patient was admitted to Hasan Sadikin hospital on 2 Nov 2008 and died the following day. Doctors in their early report on 4 Nov 2008 said some of his internal organs, including his heart, lungs, and kidneys, were in bad condition at the time of death.
(ProMED 11/7/08)

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Indonesia: Death of teenager in Java confirmed to be avian influenza H5N1
A 15-year-old Indonesian girl has died of bird flu in Central Java, a health official said 12 Nov 2008. This brings the country's death toll from the disease to 113. The girl died on 7 Nov 2008 after being treated at the Doctor Karyadi hospital in Semarang. "It has been confirmed by the Health Ministry labs," said Agus Suryanto, the head of the medical team treating the girl. The girl reportedly lived near a poultry slaughterhouse. Including the latest death, the virus has now infected 388 people in 15 countries, killing 246 of them, according to data from the World Health Organisation (WHO). Indonesia has the highest toll of any nation. However, Indonesian Health Minister Siti Fadilah Supari denied the reports that the girl died of avian influenza on 13 Nov 2008. She stated that two laboratory tests came back negative, according to various reports.

News about human H5N1 infections in Indonesia since June has been difficult to evaluate, because the health ministry said then it would no longer promptly report H5N1 cases, instead giving only periodic updates. Some health officials have said the lack of prompt reporting will hamper efforts to monitor the world's pandemic risk level.

In other developments, 17 people from Sudiang subdistrict in Indonesia's South Sulawesi province have been hospitalized in Makassar for symptoms that resemble avian influenza. Thirteen of the patients are children. Andi Kurina Bintang stated that the patients had high fever, coughing, and breathing difficulty. "Rapid tests showed they may be infected with H5N1 avian influenza virus, but we are waiting for blood test results to come back from the Hasanuddin University lab," she said.

She said 31 chickens had died in the subdistrict the week before three toddlers became ill. Reportedly, rapid tests on several of the chickens were positive for the virus.
(ProMED 11/13/08, CIDRAP 11/13/08)

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Thailand: Avian influenza H5N1 confirmed in poultry
The agriculture ministry in Thailand confirmed on 10 Nov 2008 an H5N1 avian influenza outbreak in backyard birds in Sukhothai province, the country's first outbreak since January. Agriculture Minister Somsak Prisanananthakul said lab tests revealed an H5N1 infection in one chicken after 7 of 17 birds at a family home died last week. Sukothai province is in northwestern Thailand. Somsak told reporters that animal health officials culled 270 other birds in the area to control the virus. He added that officials have received no reports of suspicious human illnesses related to the poultry outbreak and that authorities were investigating the source of the outbreak.

Thailand's last outbreaks were reported in January, according to an April report from the World Organization for Animal Health (OIE). Those two outbreaks struck poultry in Nakhon Sawan and Phichit provinces, both in central Thailand. Officials culled 53,688 birds at the outbreak sites and another 5,120 birds from surrounding areas.

In addition, officials in Thailand said on 13 Nov 2008 that H5N1 avian influenza also has struck poultry in Uthai Thani, which makes it the second province to report the virus in less than a week. Sakchai Sriboonsue, director-general of the province's livestock department, said laboratory tests detected the H5N1 virus in chickens from a backyard farm after several of the birds died.

Also on 13 Nov 2008, Thailand's public health ministry put nine northern provinces under special watch for avian influenza. The Post listed the provinces as Phitsanulok, Tak, Phetchabun, Sukhothai, Uttaradit, Nakhon Sawan, Uthai Thani, Kamphaeng Phet, and Phichit. Officials also told hospitals in the provinces not to wait for lab test results before treating patients who have suspected H5N1 infections or who live in areas where birds have died.
(CIDRAP 11/10/08, CIDRAP 11/13/08)

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Americas
USA: GAO says Obama should address health preparedness and food safety
The Government Accountability Office (GAO) has listed public health emergency preparedness and food safety as two of 13 "urgent issues" that will need attention from President-elect Barack Obama and the new Congress next year. The GAO, Congress's investigative agency, calls on the government to take several specific steps to strengthen public health preparedness, especially for pandemic influenza, and to improve coordination of food safety efforts.

Listing the 13 issues, Comptroller General Gene Dodaro said, "With the serious challenges related to financial markets and the economy, the financial crisis facing the nation, two wars under way, and the first transition since 9/11 and the creation of a Department of Homeland Security, this is absolutely a unique time. . .GAO has combed through all of our recent work to help identify where our work can help address urgent challenges facing the nation now, to assist new appointees in every agency [to] zero in on the challenges of that particular agency, and to help identify areas with the potential to save the nation billions of dollars." The GAO said the 13 urgent issues are the centerpiece of a new Website it launched in an effort to help smooth the transition to the new administration and Congress. The site includes statements on each of the 13 issues.

Preparedness recommendations
The GAO makes nine recommendations for improving public health preparedness, all of them drawn from previous GAO reports. Five of these explicitly relate to the threat of a flu pandemic:
- The Homeland Security (DHS) and Health and Human Services (HHS) departments should conduct joint testing and training exercises for pandemic flu to ensure that leadership roles are clearly defined and that leaders can effectively carry out shared responsibilities.
- The Homeland Security Council should set up a process and schedule for updating the national pandemic implementation plan in a way that includes nonfederal stakeholders.
- HHS should "expeditiously" complete its guidance to help state and local public health agencies decide how to use limited supplies of antivirals and pandemic vaccines.
- In the interest of pandemic preparedness, DHS should make fuller use of the coordinating councils that were set up to facilitate joint public-private planning for critical infrastructure protection.
- HHS and DHS should hold more meetings of the states in the five pandemic planning regions to help them address gaps in their planning.

In addition, the statement says HHS should serve as a clearinghouse to enable states to share information on altered standards of care, for the sake of helping states determine how they will allocate scarce medical resources in a mass-casualty event.

Sorting out food safety efforts
In its statement on food safety, the GAO reiterates points it has made a number of times about the fragmented federal regulatory system, with 15 different agencies involved in administering food safety laws. This leads to inconsistent oversight and ineffective coordination, undermines strategic planning for food production inspections, and hinders responses to food borne disease outbreaks, the agency said.

In addition, the allocation of funds among agencies is skewed: the US Department of Agriculture regulates about 20% of the food supply but gets most of the money for food safety inspections, while the Food and Drug Administration oversees about 80% of the food supply with only 24% of the money. "Congress and the executive branch should create the environment needed to look across the activities of individual programs and toward the goals the federal government is trying to achieve," the statement says. Specifically, the agency says:
- The president should reconvene the President's Council on Food Safety or create another forum in the short term. For the long term, the president should consider other structures to promote interagency coordination on food safety.
- The executive branch should develop a "governmentwide performance plan" that provides a cross-agency perspective to help ensure agencies' goals are complementary and help leaders balance trade-offs in allocating resources.
- Congress should assign the National Academy of Sciences or an expert panel to analyze alternative food safety organizational structures.
- Congress should pass "comprehensive, uniform, and risk-based food safety legislation."
(CIDRAP 11/7/08)

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USA: Google uses searches to track influenza’s spread
There is a new common symptom of the flu, in addition to the usual aches, coughs, fevers and sore throats. Turns out a lot of ailing Americans enter phrases like “flu symptoms” into Google and other searchengines before they call their doctors. That simple act, multiplied across millions of keyboards in homes around the country, has given rise to a new early warning system for fast-spreading flu outbreaks, called Google Flu Trends.

Tests of the new Web tool from Google.org, the company’s philanthropic unit, suggest that it may be able to detect regional outbreaks of the flu a week to 10 days before they are reported by the Centers for Disease Control and Prevention (CDC). In early February 2008, for example, the CDC reported that the flu cases had recently spiked in the mid-Atlantic states. But Google says its search data show a spike in queries about flu symptoms two weeks before that report was released. Its new service at google.org/flutrends analyzes those searches as they come in, creating graphs and maps of the country that, ideally, will show where the flu is spreading.

The CDC reports are slower because they rely on data collected and compiled from thousands of health care providers, labs and other sources. Some public health experts say the Google data could help accelerate the response of doctors, hospitals and public health officials to a nasty flu season, reducing the spread of the disease and, potentially, saving lives.

“The earlier the warning, the earlier prevention and control measures can be put in place, and this could prevent cases of influenza,” said Dr. Lyn Finelli, lead for surveillance at the influenza division of the CDC. From 5 to 20 percent of the nation’s population contracts the flu each year, she said, leading to roughly 36,000 deaths on average. The service covers only the United States, but Google is hoping to eventually use the same technique to help track influenza and other diseases worldwide. “From a technological perspective, it is the beginning,” said Eric E. Schmidt, Google’s chief executive.

The article can be accessed at http://www.nytimes.com/2008/11/12/technology/internet/12flu.html.
(New York Times 11/11/08)

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USA: Firm says 'universal' influenza vaccine passed early test
A vaccine designed to offer protection against many strains of influenza viruses appeared safe in low doses and triggered a satisfactory immune response in a phase one clinical trial, the vaccine's developer announced. The vaccine, made by VaxInnate Inc., targets the M2 protein of influenza A viruses, a surface protein that differs little among different strains of type A. Existing flu vaccines target hemagglutinin (HA), a flu surface protein that often mutates, making it necessary to change the vaccine each year to cover the predominant strains in circulation. A vaccine targeting a protein found in all or most flu strains could reduce or eliminate the need to change the vaccine each year.

The company reported the results in a 2008 Oct 26 press release and at the Interscience Conference on Antimicrobial Agents and Chemotherapy/Infectious Diseases Society of America (ICAAC/IDSA), held 2008 Oct 24-28.

"VaxInnate's M2e universal flu vaccine candidate has passed a critical initial test," said David Taylor, the company's chief medical officer. "We're encouraged by these data, which demonstrate that the vaccine is safe and elicits potent immune responses at doses below a microgram [mcg] of vaccine antigen, and does so without the use of conventional adjuvants."

'Encouraging but not definitive'
Dr. Kristin Nichol, an experienced flu immunization researcher who was not involved with the study, described VaxInnate's results as promising but advised a wait-and-see attitude. She is associate chief of staff for research at the Minneapolis VA Medical Center. "The notion of a universal influenza vaccine or any kind of influenza vaccine that reduces the need for annual vaccination or provides better or more reliable protection against influenza viruses—that will be very useful to us," she said. "Until a vaccine goes all the way through phase three clinical trials and we have good evidence about actual protection, the verdict is out. But certainly there are a number of kinds of vaccines in development, such as this one, that are exciting with regard to the prospect of a more universal kind of vaccine."

Nichol said the measures of immune response used by VaxInnate are reasonable and generally correlate with actual protection, but do not guarantee it. "It's encouraging but not definitive until we see the clinical protection data," she said.

Plans for targeting type B
The M2e vaccine targets influenza A but not influenza B, the other major type. Type A viruses generally cause more severe illness than type B. Seasonal flu vaccines normally target two type A subtypes—H1N1 and H3N2—and one type B strain, all of which typically circulate each season.

While acknowledging that the M2e vaccine would not cover type B viruses, VaxInnate's Taylor stated that the company also hopes to develop a second-generation universal vaccine that would target both A and B. Meanwhile, he suggested possible uses for the M2e vaccine by itself, assuming it is successful. "Should M2e be shown to be protective for influenza A, it’s possible that other universal antigens could be developed for influenza B," Taylor said. "In the developing world, where influenza vaccine is not available, M2e could be a cost-effective way to provide influenza A coverage.

"VaxInnate is working to develop a second-generation universal vaccine that has M2e and another conserved antigen that will address influenza B strains, as well as influenza A strains. Efficacious universal vaccines for influenza that cover both A and B strains could potentially replace the more standard HA vaccine in some markets and market segments, even in the developed world." Taylor also said that in countries where conventional seasonal flu vaccines are available, the M2e vaccine could be used in combination with them to provide increased protection in case the strains in the seasonal vaccine don't match well with circulating strains.

He also commented that VaxInnate is developing seasonal flu vaccines in which its recombinant-bacteria technology is used to make both the A and B components. A vaccine targeting a Solomon Islands strain of H1N1 is currently in clinical testing, and a type B vaccine may become available next year, he said.
(CIDRAP 11/11/08)

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USA: Feds stage airport test of plan to slow pandemic
Officials from several agencies recently converged on Miami's international airport to take part in a full-scale exercise of the federal government's risk-based strategy to slow the spread of a future pandemic influenza virus across US borders.

Christine Pearson, a spokeswoman for the US Department of Health and Human Services (HHS), attended the first day of the two-day drill on 2008 Nov 5 and stated that, unlike previous tabletop discussions to test the risk-based border strategy (RBBS), the exercise at Miami included a real plane and actors who played the role of passengers in an airport setting. "It provided a level of realism that we hadn't had in past exercises, which had mostly been facilitated discussions," she said.

The RBBS is a short-term strategy that the federal government will use in the initial states of a pandemic to delay the spread of the virus enough to afford officials a little extra time to educate the public on how to protect themselves from the disease, produce and distribute vaccine, and position medication and supplies, Pearson said. The strategy involves screening international air passengers to gauge if they are sick or have potentially been exposed to others who are sick with the pandemic virus.

The system would begin when it's clear that a pandemic influenza virus is spreading globally and would end as soon as the virus begins causing illnesses in the United States. Many public health experts have supported keeping borders open in a pandemic setting, because they don't believe closure would block the spread of the virus and because keeping borders open would preserve the flow of crucial supplies and soften a pandemic's impact on national economies.

Pearson said last week's drill was a joint exercise that involved the HHS, the Centers for Disease Control and Prevention (CDC), the Department of Homeland Security (DHS), Customs and Border Protection, the Department of Transportation (DOT), along with numerous state, local, and airline-industry partners. The scenario involved a novel and lethal human influenza strain that emerged in Southeast Asia and spread quickly and efficiently among humans, she said. The playbook had the World Health Organization (WHO) identifying a human-to-human H5N1 variant that spread to areas of Thailand, Laos, Vietnam, and Cambodia. The WHO declared a severe (phase 6) pandemic, prompting the United States to raise its response stage to 3 and the secretaries of DHS, HHS, and DOT to enact nationwide RBBS activities.
(CIDRAP 11/12/08)

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2. Infectious Disease News

Asia
Australia: Acute poststreptococcal glomerulonephritis persists among indigenous communities
The Northern Territory Government has reported an outbreak of a potentially deadly disease in the Borroloola community, about 850 km south east of Darwin. Acute poststreptococcal glomerulonephritis (AGSN) has been wiped from most developed nations except for Australia, where remote indigenous communities have the highest rates of the disease in the world.

The Menzies School of Health Research's Catherine Marshall co-authored the report and says the illness has been identified as a precursor to kidney disease. "We think that there are a lot of cases of subclinical diseases where children may not have a lot of symptoms, and I guess it's important for clinicians to be aware of the condition," she said. "[Clinicians should] monitor children who have skin sores and also that may have blood in their urine and other symptoms of this condition." She said the outbreak could have significant long term effects, as the illness has been identified as a precursor to chronic kidney disease. "One of the important things is that this is related to skin infections, which I think [are] probably in part related to the living conditions in indigenous communities," she said. "It's one reason why we need to sort of work on improving the issues of overcrowding and living conditions in communities in the Northern Territory."
(ProMED 11/8/08)

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China (Wan Chai): Elementary school closed due to adenovirus outbreak
The Centre for Health Protection (CHP) of the Department of Health advised a kindergarten with an outbreak of upper respiratory tract infections to suspend classes for one week to enhance infection control measures on 12 Nov 2008.

The school concerned is St Margaret Mary's Catholic Kindergarten in Wan Chai. A total of 34 children aged from four to five developed symptoms of upper respiratory tract infection, including fever, sore throat and cough, between 3 Nov and 11 Nov 2008. Of these, five were hospitalized for further management. They are in stable condition and one of them has been discharged. Laboratory tests on nasal pharyngeal aspirates samples of two hospitalized children showed positive results to adenovirus.

A CHP spokesman said that the kindergarten was advised to suspend classes for one week, until 19 Nov 2008 for thorough disinfection to prevent further spread of the diseases in the school. He said, "The school management had stepped up cleansing and infection control measures according to CHP's advice following the Centre's visit. Parents are advised to pay attention to the health condition of their children, and to remind them to observe good personal and environmental hygiene."

The CHP spokesman said, "Adenovirus is a group of viruses that commonly cause viral infection in children. The symptoms may vary from respiratory symptoms such as fever, cough, sore throat to gastroenteritis illnesses such as vomiting and diarrhea. Conjunctivitis may also be associated with the disease. "Adenovirus infection is usually transmitted by direct contact or fecal-oral transmission. It can occur throughout the year," he said. The spokesman said while most infections were mild and required no therapy or only symptomatic treatment, strict attention to good hygiene practices was effective for preventing adenovirus-associated disease.
(ProMED 11/13/08)

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Indonesia: Eight year-old dies of rabies infection
An eight year-old pupil at Ende III Catholic Elementary School in Ende, East Nusa Tenggara died on 4 Nov 2008 after being bitten in September 2008 by a suspected rabid dog. There have been 135 such fatalities in the province over the past ten years, with three of those in 2008.

"The victim's family said [the boy was bitten] in September [2008]," said Yosep Deo of the Ende Health Agency. "At the time, the victim did not receive any treatments such as anti-rabies serum or vaccine at the local Puskesmas [community health center] or hospital." Yosep said the boy later received a vaccine, but by then, he was in a critical phase. "[He] had entered the fourth stage when he was brought to the hospital. He was afraid of water, wind, and light, just like other people infected by rabies," Yosep said.

He said some 50,000 out of 200,000 dogs in Flores (where Ende regency is located) and Lembata islands had yet to be vaccinated. Rabies is an acute viral disease that attacks the nervous system and is usually transmitted through the bite of an infected animal. Other animals that can transmit the virus include bats, cats, foxes, raccoons and skunks.
(ProMED 11/9/08)

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Malaysia: Sarawak preparing for major outbreak of hand, foot, and mouth disease in 2009
Sarawak is bracing for a major outbreak of hand, foot, and mouth disease (HFMD) in 2009, said the state Environment and Public Health Minister Datuk Seri Wong Soon Koh. This is based on the cycle of HFMD outbreaks, which have occurred every three years in the state of Sarawak. "Monitoring of HFMD is ongoing and will be intensified in anticipation of the outbreak in 2009," he said.

In addition, Wong said the Sarawak Health Department had intensified visits to child-care centers and kindergartens to raise awareness of HFMD and implement measures to control it. A program by the Sarawak Health Department and the Institute of Health and Community Medicine at Universiti Malaysia Sarawak discovered outbreaks of HFMD every three years in 1997, 2000, 2003, and 2006.

The outbreak in 1997 was due to EV71 (enterovirus 71), which killed 30 children aged below five years. It was the first time that EV71 was recognized in Malaysia. Wong said that, from 30 Dec 2007 to 18 Oct 2008, 6666 cases were reported compared to 6332 for the corresponding period in 2007-08. "Kuching recorded the highest number with 2417 cases followed by Miri (1027), Bintulu (828), and Sibu (761)," he said, adding that one death had been reported in Sibu.

As of 24 Oct 2008, a total of 52 kindergartens, child-care centres, and pre-schools had been served with closure orders or closed voluntarily. Wong advised parents and child-care centers to practice good hygiene and observe cleanliness to prevent the disease from spreading.
(ProMED 11/12/08)

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Russia (Lipetsk Oblast): Two infected with hemorrhagic fever
The first two cases of hemorrhagic fever with renal syndrome (HFRS) of the fall of 2008 have been registered in Lipetsk Oblast. The patients are a 30-year-old man and a 5-year-old boy from Dankovsky district -- a father and son from the village of Perehval. They are currently receiving treatment at the Central District hospital.

The risk of airborne infection has increased greatly as a consequence of the increased numbers of rodents that transmit the virus responsible for HFRS. Due to the onset of colder weather rodents are moving closer to human habitations. People should take measures to protect themselves from these rodents by eliminating them from yards and gardens. Local authorities should implement rodent control measures.
(ProMED 11/12/08)

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Viet Nam: Five children infected with rare meningitis in 2008
Meningitis caused by Angiostrongylus cantonensis, a very rare disease, is becoming increasingly common in Viet Nam, said Dr Nguyen Van De, chief of the Parasitology Faculty of Hanoi Medical University. From 1995-2000, Viet Nam recorded only 15 cases, but there have been five cases so far in 2008. All are children under 15 years old in Hanoi.

The children caught the disease when the Angiostrongylus cantonensis worm got into their brain, causing meningitis. Angiostrongylus cantonensis is a nematode (parasitic worm) of rats. The adult form of the parasite can be found only in rodents. Infected rats pass larvae of the parasite in their feces. By ingesting the rat feces, snails and slugs get infected with the larvae. Then, the larvae mature in snails and slugs but do not develop into adult worms. When rats eat infected snails or slugs, the larvae mature into adult worms in the rats.

People can become infected by eating raw or undercooked snails, slugs, freshwater prawns, crabs, or frogs infected with this parasite, but fish cannot transmit this parasite to humans. There is no known human-to-human transmission of this parasite either. Typical meningitis symptoms include fever, headache, vomiting, convulsions, and squinty eyes.
(ProMED 11/13/08)

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Americas
USA: APIC sounds alarm about C difficile threat
Clostridium difficile, rapidly gaining as a source of hospital-acquired infections, is sickening from six to 20 times more patients than previously thought, according to a survey released by the Association for Professionals in Infection Control and Epidemiology (APIC).

Kathy Warye, APIC's chief executive officer, stated that the study is the first to reveal the true magnitude of C difficile infections in hospitals. The survey represents a one-day snapshot of all patients with C difficile infections in 648 participating hospitals. The pathogen causes diarrhea and other, more serious intestinal problems.

C difficile is the second most common and troublesome nosocomial infection, raking right behind methicillin-resistant Staphylococcus aureus (MRSA), she said. In 2007, APIC commissioned a similar hospital snapshot study of MRSA, which she said was a wake-up call for health officials that triggered increased attention and resources needed to slow rising illness rates. Based on extrapolation of the results to the entire US inpatient population, the APIC authors estimated that on any given day, 7,178 patients have C difficile and an average of 301 die of it. They project that these cases lead to an average of 40,197 extra hospital days and about $32.1 million in healthcare costs.

Infections can be fatal
C difficile is a gram-positive bacterium—transmitted by hand contact with objects contaminated with feces—that causes diarrhea and potentially fatal conditions such as colitis, toxic megacolon, and sepsis, according to APIC. Infections are associated with previous antibiotic use and are most common in older patients and others who have been in a hospital, nursing home, or other healthcare settings. Over the past 30 years the pathogen has emerged as one of the leading causes of infections acquired in healthcare settings. In the past 5 years, a more virulent, antibiotic-resistant strain of C difficile has evolved, known as the North American pulse-field type 1 (NAP1).

William Jarvis, principal investigator for the study and president and cofounder of Jason and Jarvis Associates, a healthcare epidemiology firm, said previous studies on C difficile rates were incidence studies based primarily on patient discharge data. For example, he said two earlier studies revealed 60 and 76 ill patients, respectively, per 10,000 discharges. Jarvis said the current survey gauges prevalence and was able to capture detailed clinical information that helped reveal patterns about the patients' illness. Jarvis and his colleagues found that 13 of every 1,000 patients covered in the survey were either infected or colonized with C difficile, for a total of 1,443 patients. Most (94.4%) were infected.

Illness patterns emerge
Detailed data were provided for 1,062 patients, which Jarvis said revealed some notable patterns. For example, 54% were diagnosed with C difficile infection within 48 hours after hospital admission, which initially suggested some had acquired the infection during a previous hospital stay or in the community. Of the group, about 85% were hospitalized for other conditions, and about 68% had comorbid conditions such as renal failure or diabetes. "C difficile isn't just a surgical disease," Jarvis stated. Nearly 80% of the patients had been on antibiotics before they got sick with C difficile; in 17% of the cases, the antibiotics were for preventing surgical infections.

A hard-to-kill bug
Jarvis said the study has several practical implications for infection control specialists. The spore-forming form of C difficile is one of the more difficult organisms to kill, as bleach is the only cleaner that can kill it. However, only 65% of the survey participants said they used bleach to combat C difficile outbreaks.

Also, more "antibiotic stewardship" programs are needed to reduce antibiotic use in hospitals. The survey showed only 50% of facilities have such programs. "We're hoping that this will be a call for action, not just for infection control experts but also hospital administrators who are in position to provide the resources," Jarvis said. "We need a bundle of practices, not just one." For hand hygiene, he said alcohol gels won't kill C difficile spores, and vigorous hand washing with soap and water is needed.

APIC published an executive summary of the survey on its Web site, and Warye said the complete report will appear in an early spring issue of the American Journal of Infection Control.
(CIDRAP 11/11/08)

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USA (Colorado): E coli O157 infections in children linked to elk droppings
The Jefferson County Department of Health and Environment and the Colorado Department of Public Health and Environment are investigating an outbreak of Escherichia coli O157 infections among children in the Evergreen mountain area. On 7 Nov 2008, the state laboratory reported that specimens obtained from elk droppings in the Evergreen area have tested positive for the same strain of E. coli O157 bacteria that was identified in the children.

A total of eight illnesses have been identified among children aged 4-12 years, six in Jefferson County and one in each of Clear Creek and Park Counties. Illness among the children has occurred sporadically throughout the summer and early fall, beginning in July 2008 and most recently in late October 2008.

"Today's lab results tell us it is very likely the children acquired the E. coli infection from exposure to elk droppings in the environment," said Alicia Cronquist, epidemiologist at the state health department. "This is a highly unusual situation, and public health officials are continuing to investigate how the elk in the area may have been exposed."

The outbreak investigation is continuing. Local public school and parks and recreation authorities have been informed. The epidemiological investigation will include phone surveys of some residents.
(ProMED 11/8/08)

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USA (Michigan): College closes due to suspected norovirus outbreak
The Ottawa County Health Department has ordered Hope College to close because of a suspected norovirus outbreak. As many as 140 of the 2500 students on campus have reported symptoms including nausea, vomiting and diarrhea. Crews will spend the weekend of 8-9 Nov 2008 scrubbing down public areas. It has forced the cancellation of athletic events, a parents weekend, and all other gatherings. Police even plan to break up student parties to halt the spread of the contagious disease.

The decision to close came after the number of affected students rose sharply. President James Bultman says closing isn't easy, but it's prudent. The plan is to reopen on 11 Nov 2008 in the morning. Hope officials are conferring with other schools that have had similar outbreaks, including the University of California at Los Angeles and the University of Southern California, on how to handle the situation.
(ProMED 11/9/08)

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USA (South Carolina): Rabid fox attacks several people
The gray fox that attacked several members at an Inman church on 5 Nov 2008 was rabid, a health official said on 7 Nov 2008. Spartanburg County environmental enforcement director Don Arnold said tests conducted on the fox by the South Carolina Department of Health and Environmental Control [DHEC] came back positive for rabies.

The fox bit a six-year-old girl several times on the leg after first attacking a 20 year-old woman. The fox attacked the woman when she opened a door at the church's family life center. The fox also bit another woman's ankle several times and scratched at least four people at the Bishop Road church. "This fox was so aggressive, so persistent, I've never seen anything like it," David Duncan, the church pastor, stated on 6 Nov 2008. "The fox couldn't be spooked."

Arnold said DHEC will notify the persons who were bitten or scratched about vaccinations that will be required to prevent the disease from harming them. DHEC spokesman Thom Berry said that victims will be given six vaccinations over a 28-day period. Eight cases of rabies have been confirmed in animals in Spartanburg County in 2008. In 2007, South Carolina recorded 162 confirmed cases of rabies in animals.
(ProMED 11/9/08)

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USA (South Dakota): Seventeen cases of pertussis confirmed in children
Health officials say 17 cases of whooping cough have been confirmed in eastern South Dakota and are tied to Madison Elementary in Huron, where ten of the cases have been reported. Another seven cases were reported in Lake Preston. Health officials say the cases involve children appropriately vaccinated for their ages, though they note that youngsters are not fully immunized until 4 to 6 years of age, and they emphasized the need for booster shots due to the fact that immunity wanes over time.
(ProMED 11/7/08)

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3. Updates
AVIAN/PANDEMIC INFLUENZA
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services and includes the website of the Central Fund for Influenza Action. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The (interim) Influenza Virus Tracking System can be accessed at: www.who.int/fluvirus_tracker.
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help hospital administrators and state and local health officials prepare for the next influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.pandemicflu.gov/. View archived Webcasts on influenza pandemic planning.
- CIDRAP: http://www.cidrap.umn.edu/ Find more than 150 peer-reviewed practices from 25 US states and 37 cities and counties aimed at furthering pandemic preparedness in public health and allied fields.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds and poultry.
(UN; WHO; FAO, OIE; CDC; CIDRAP; PAHO; USGS)

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CHOLERA, DIARRHEA, AND DYSENTERY
China (Hainan)
An eight-year-old girl died of complications due to a cholera outbreak in Hainan Province in late October 2008. There have been a confirmed 30 cases and 297 others, which are suspected to be cholera in Danzhou City. The Danzhou Hsingyin Hospital set up five temporary tents to treat the increase in patients. As of 22 Oct 2008, there have been 135 people hospitalized with cholera or are suspected of cholera infection. Sixty patients are currently in the Hsingyin Hospital.

Local doctors said that Huangyu Village is one of the most severely hit areas. Many villagers have suffered from persistent and frequent diarrhea accompanied by vomiting. An eight-year-old girl was sent to the emergency room at the First People's Hospital due to severe dehydration resulting from the diarrhea and later died from complications.

Experts believe that the flood caused by heavy rainfall in the south in October 2007 is the cause of the cholera outbreak. It is reported that the earliest cholera case occurred four months ago. On 12 Jun 2008, a patient, along with 57 others ate food at Heili Village in Haikou City; 26 of them later suffered from diarrhea. The patient was transferred from local clinic to Haikou City People's Hospital for emergency care due to severe symptoms. On 19 Jun 2008, the Disease Control Center confirmed that the patient was infected with Vibrio cholerae.
(ProMED 11/12/08)

Viet Nam
As many as 35 people in Ha Tinh City have been stricken with acute diarrhea. The latest information from the province’s Preventive Healthcare Centre said that of those affected by acute diarrhea, 11 have tested positive for Vibrio cholera bacteria.

Thach Kim Commune in Loc Ha District is the hardest hit with 30 people hospitalized as of 10 Nov 2008. Two household wells in the commune were tested by the centre and found to contain the bacteria. The epidemic may have originated from Quynh Phuong Commune, Quynh Luu District of Nghe An Province, according to Nguyen Luong Tam, vice director of the centre. The first patient was hospitalized 2 Nov 2008. It appears he contracted the disease while fishing in Thach Kim Commune, Loc Ha District.

Dao Van The, director of the Preventive Healthcare Centre of Loc Ha District, said that about 2500 people in Thach Kim Commune were living without toilets and often relieved themselves on the beach. "A more serious concern is that residents often wash fish with the local water source and sell them to other areas," said The.
(ProMED 11/12/08)

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Dengue
Viet Nam
Heavy rains have hit northern Viet Nam again, following the worst floods to hit the region in over 35 years. At least 82 people have been killed since unseasonal rains started in north-central Viet Nam and the capital Hanoi in late Oct 2008.

Many residents complain of receiving little help from emergency workers or soldiers as their neighborhoods disappeared under a metre of brown floodwater, trapping thousands of people in their houses. Authorities in the capital say they are trying to contain the spread of dengue fever after 180 cases of the mosquito-borne disease were reported by Hanoi hospitals over a six day period.
(ProMED 11/11/08)

Mexico
There are already 32 cases of classical dengue fever that have been confirmed in Parque Hundido and surrounding neighborhoods of the Gomez Palacio municipality. The authorities have requested the collaboration of neighbors in prevention tasks. Rosa Lilia Lopez Moreno, jurisdiction chief of Health Jurisdiction No. 2, signaled that the sanitary cordon actions put in place since the confirmation of the first dengue patients will continue.

The Parque Hundido neighborhood continues to be the area most affected by dengue, not only in the Gomez Palacio area, but in the whole of the Comarca Lagunera. According to the authorities in Torreon, there has been no confirmation of the ailment there. Comarca Lagunera is a large metropolitan area located on the border between the states of Coahuila and Durango that includes 15 municipalities, including Gomez Palacio. Torreon is adjacent to Gomez Palacio.

Loreno emphasized the need to eliminate all possible water catchments, such as buckets, tubs, flower vases, and bottles; clean up patios. She also recommended additional measures such as putting abate (mosquito larvicide) in water-based heat pump systems, opening windows when the insecticide fumigation machines pass by, and using insect repellants and insecticides in the house. "We continue to request collaboration from the citizens, which is required to obtain good results. Up until now, all of the [dengue] cases that we have encountered have been in the Parque Hundido neighborhood and the surrounding residential sectors," she said.
(ProMED 11/11/08)

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4. Articles
Medicine in the popular press: the influence of media on perceptions of disease
Young ME, Norman GR, Humphreys KR. PloS. October 29, 2008; 3(10). Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0003552.

Abstract
In an age of increasing globalization and discussion of the possibility of global pandemics, increasing rates of reporting of these events may influence public perception of risk. The present studies investigate the impact of high levels of media reporting on the perceptions of disease. Undergraduate psychology and medical students were asked to rate the severity, future prevalence and disease status of both frequently reported diseases (e.g. avian flu) and infrequently reported diseases (e.g. yellow fever). Participants considered diseases that occur frequently in the media to be more serious, and have higher disease status than those that infrequently occur in the media, even when the low media frequency conditions were considered objectively ‘worse’ by a separate group of participants. Estimates of severity also positively correlated with popular print media frequency in both student populations. However, we also see that the concurrent presentation of objective information about the diseases can mitigate this effect. It is clear from these data that the media can bias our perceptions of disease.

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Respirator-Fit Testing: Does It Ensure the Protection of Healthcare Workers Against Respirable Particles Carrying Pathogens?
Lee MC et al. Infect Control Hosp Epidemiol. 11 Nov 2008. Available at http://www.journals.uchicago.edu/doi/abs/10.1086/591860.

Objective. Respiratory protection programs, including fit testing of respirators, have been inconsistently implemented; evidence of their long-term efficacy is lacking. We undertook a study to determine the short- and long-term efficacy of training for fit testing of N95 respirators in both untrained and trained healthcare workers (HCWs).

Design. Prospective observational cohort study.

Methods. A group of at-risk, consenting HCWs not previously fit-tested for a respirator were provided with a standard fit-test protocol. Participants were evaluated after each of 3 phases, and 3 and 14 months afterward. A second group of previously fit-tested nurses was studied to assess the impact of regular respirator use on performance.

Results. Of 43 untrained fit-tested HCWs followed for 14 months, 19 (44.2%) passed the initial fit test without having any specific instruction on respirator donning technique. After the initial test, subsequent instruction led to a pass for another 13 (30.2%) of the 43 HCWs, using their original respirators. The remainder required trying other types of respirators to achieve a proper fit. At 3 and 14 months' follow-up, failure rates of 53.5% (23 of 43 HCWs) and 34.9% (15 of 43 HCWs), respectively, were observed. Pass rates of 87.5%-100.0% were observed among regular users.

Conclusions. Without any instruction, nearly 50% of the HCWs achieved an adequate facial seal with the most commonly used N95 respirator. Formal fit testing does not predict future adequacy of fit, unless frequent, routine use is made of the respirator. The utility of fit testing among infrequent users of N95 respirators is questionable.

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Requiring Influenza Vaccination for Health Care Workers
Anikeeva, Olga et al. AJPH First Look. 13 Nov 2008 [published online ahead of print]. Available at http://www.ajph.org/cgi/content/abstract/AJPH.2008.136440v1.

Abstract
Annual influenza vaccination for health care workers has the potential to benefit health care professionals, their patients, and their families by reducing the transmission of influenza in the health care setting. Furthermore, staff vaccination programs are cost-effective for health care institutions because of reduced staff illness and absenteeism.

Despite international recommendations and strong ethical arguments for annual influenza immunization for health care professionals, staff utilization of vaccination remains low. We have analyzed the ethical implications of a variety of efforts to increase vaccination rates, including mandatory influenza vaccination.

A program of incentives and sanctions may increase health care worker compliance with fewer ethical impediments than mandatory vaccination.

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Weekly Epidemiological Record Bulletin
WHO. 14 Nov 2008, 83(46): 413-420. Available at http://www.who.int/wer. This issue includes an Update: “WHO-confirmed human cases of avian influenza A(H5N1) infection, November 2003-May 2008”.

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5. Notifications
Obituary: Dr. Ron Davis
Dr. Ron Davis, past president of the American Medical Association (AMA) and advocate of the AMA’s One Health principles, has died of complications related to pancreatic cancer. The One Health Initiative obituary can be accessed at http://www.onehealthinitiative.com/news.php.

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CDC posts new notices related to avian influenza H5N1 on their Travelers’ Health website
Outbreak Notice Human Infection with Avian Influenza A (H5N1) Virus: Advice for Travelers http://wwwn.cdc.gov/travel/contentAvianFluAsia.aspx

Outbreak Notice Guidelines and Recommendations: Interim Guidance about Avian Influenza (H5N1) for U.S. Citizens Living Abroad http://wwwn.cdc.gov/travel/contentAvianFluAmericansAbroad.aspx

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26th Annual Behavioral Risk Factor Surveillance System (BRFSS) Conference
Responding to Changes in the Survey Environment
Dates: March 14-18, 2009
Location: Atlanta, Georgia

Call for BRFSS Conference Abstracts
Online Abstract Submission at: http://apps.nccd.cdc.gov/BRFSSAbstractSubmission

The BRFSS Conference Committee seeks abstracts for oral and poster presentations. Abstracts related to topics in survey research, epidemiology, and public health are welcome for consideration.

We are particularly interested in research related to our conference theme: Responding to Changes in the Survey Environment.

Abstract submission deadline: 19 December 2008, 11:59 p.m. EST

Questions concerning the proposal submission process should be directed to BRFSSquestions@cdc.gov.

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Chinese Taipei takes measures for melamine-contaminated food products
On September 12, 2008, Chinese Taipei received China’s notification concerning its export of Sun Lu milk powder contaminated by melamine to Chinese Taipei. The Department of Health (DOH), Chinese Taipei, immediately traced its use and sale and reported it to INFOSAN, WHO. The manufacturers and retailers of Chinese Taipei voluntarily examined all relevant ingredients imported from China. One company found its ingredients to be contaminated and subsequently recalled a series of seven instant coffee products that contained contaminated non-dairy creamer from China.

The Chinese Taipei government formed a cross-agency taskforce on September 24, consisting of representatives from 7 ministries, to supervise the overall plan for the control measures. The taskforce endorsed the recall of all the products containing non-dairy creamer ingredient imported from China; these products were not admitted to be sold on the market until tested negative of melamine. On September 27, the government dispatched an expert group to China to understand China’s local food manufacturing process and quality control measures. A direct reporting system with designated official for food safety was thus established between Chinese Taipei and China.

From October 16 to 17, Chinese Taipei held the “International Experts Conference on Control Measures of Melamine Presence in Foods” in Taipei. Representatives from Australia, Belgium, France, and New Zealand shared relevant experiences and reached a tentative agreement: (1) Addition of melamine into food is not permitted under any circumstances; (2) Prevention of food safety risk can be enhanced by mechanisms of food import/export control between countries; (3) Risk communication between the government and the public is an important measure in incidents of food safety threats.

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 apecein@u.washington.edu