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Vol. XI, No. 24 ~ EINet News Briefs ~ Nov 28, 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: FAO--Momentum builds for “One World, One Health” concept
- India (Assam): Avian influemza scare with over 300 birds dead
- USA (Texas): Human infected with swine influenza A/H1N1 virus

2. Infectious Disease News
- Global: Passengers possibly exposed to infectious disease on commercial flight from Asia to USA
- China (Anhui): Report discusses human-to-human transmission of HGA
- Indonesia: Chikungunya virus outbreak in two territories in Central Java
- Russia (Samara Oblast): Increase in hemorrhagic fever with renal syndrome cases in 2008
- Russia (Kemerovo): Eight infected with trichinellosis from bear meat
- Russia (Moscow): Record number of cases of rabid animals
- Canada (British Columbia): New case of mad cow disease confirmed
- USA: Pew report critiques Salmonella outbreak response
- USA (South Carolina): Two people bitten by rabid fox

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

4. Articles
- Rotavirus surveillance—worldwide 2001-2008
- Continued Shortage of Haemophilus influenzae Type b (Hib) Conjugate Vaccines and Potential Implications for Hib Surveillance--United States, 2008
- Weekly Epidemiological Record Bulletin
- Cross-reactive immunity in adult and elderly patients against clade 2 influenza A H5N1 virus strains induced by Fluval, a reverse genetic-derived adjuvanted H5N1 clade 1 prototype pandemic influenza vaccine
- Guillain-Barré Syndrome and Influenza Virus Infection
- Multistate Outbreak of Salmonella Infections Associated with Frozen Pot Pies--United States, 2007
- A New Mycobacterium Species Causing Diffuse Lepromatous Leprosy

5. Notifications
- October 2008 Telemedicine and eHealth Journal available
- Upcoming eHealth conferences
- Grand Challenges in Global Health Initiative request for proposals


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 11.17.08):
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: FAO--Momentum builds for “One World, One Health” concept
At last month's avian flu conference in Egypt, participants endorsed a new strategy for fighting avian influenza and other infectious diseases, one that focuses on points where animal, human, and ecosystems meet, according to a recent statement by the United Nations Food and Agriculture Organization (FAO).

The group’s support for the "One World, One Health" (OWOH) approach, detailed in a 68-page strategy report, was overshadowed by news from the donor session of the meeting of a $350 million infusion of funds, led by the United States, toward the international fight against avian influenza, FAO said. The meeting took place late Oct 2008 and was attended by 530 participants from more than 120 countries and 26 regional and international organizations.

The main goal of the OWOH approach is to shrink the risk and global impact of disease outbreaks by improving livestock and wildlife intelligence, surveillance, and emergency response through stronger public and animal health systems, according to the FAO. The approach calls on broad cooperation among disciplines and sectors and puts a high priority on "hot spots" for emerging infectious diseases.

An emerging One World, One Health view
The Wildlife Conservation Society, a nonprofit group based in N.Y. that is active in 53 countries and manages wildlife parks and zoos, first introduced the OWOH concept at an international symposium in 2004. The ideas were presented as 12 recommendations that served as "Manhattan principles" for a more holistic approach for preventing disease epidemics and maintaining the global ecosystem to promote human and animal health, according to the report by the FAO and its colleagues.

Since then, the concept has picked up momentum through European and US initiatives, according to the strategy report. For example, the American Veterinary Medical Association (AVMA) established a task force in 2004 to address OWOH issues and frequently includes sessions on the theme at its regional and national conferences. At a December 2007 international avian flu conference, participants agreed that they needed a better understanding of the drivers surrounding emerging infectious diseases and singled out the OWOH perspectives as helpful for developing medium-term strategies to address emerging infectious diseases, according to the report.

New proposals take shape
According to the new report, the OWOH approach includes five main strategies:
• Build robust public and animal health systems that comply with the WHO's International Health Regulations and OIE standards
• Prevent and control disease outbreaks by improving national and international response capacities
• Address the needs of poor populations by shifting focuses to developing economies and locally important diseases such as Rift Valley fever, tuberculosis, and foot-and-mouth disease
• Promote collaborations across sectors and disciplines
• Conduct research that guides the development of targeted disease control programs.

A benefit of focusing on problems that affect developing world areas is not only controlling the often-neglected diseases, but also promoting infectious disease surveillance at the local level, the report said. "Surveillance systems at the grassroots level that are based on engaging poor communities by addressing their immediate disease problems are likely to generate better cooperation and will be more robust and sustainable in the long term," it said.

Enhanced global collaboration among national and regional groups to improve disease surveillance and prevention will also help fight bioterrorism and agroterrorism, the report notes. The global fight against avian influenza has already improved collaboration among the world's public health and veterinary groups, but a greater focus on pooling resources and forming effective synergies as part of an OWOH strategy can lead to a better understanding of the epidemiology of emerging diseases, faster identification of reservoirs, and more efficient control and prevention, particularly in poorer countries, says the report.

To fund OWOH goals, the report suggests expanding the financial model that has been used since the January 2006 Beijing international avian influenza conference to include contributions from nonconventional donors such as groups that fight specific diseases, industry groups, and foundations. "The introduction of a special system of levies at the international level to fund public health infrastructure in several developing countries, particularly fragile states, would need to be seriously considered," the report said.

Looking forward
Canada's government has offered to host a technical meeting in early 2009 to further discuss the OWOH strategy, the FAO said. Participants, including the groups that helped author the OWOH report, will likely discuss what the next steps would be toward implementing the strategy, how the measures could be financed, and how to encourage stakeholder buy-in, according to the FAO.
(CIDRAP 11/26/08)

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Asia
India (Assam): Avian influemza scare with over 300 birds dead
More than 300 poultry birds have died in the past five days in some villages in Assam, fuelling fears of bird flu, officials said in Guwahati on 26 Nov 2008. They added that a general alert was sounded in the area. A veterinary department official said up to 300 chicken and ducks died an unnatural death in some villages around Hajo, about 35 km west of Assam's main city of Guwahati. "We have sent samples for laboratory tests to Pune and Bangalore for confirmation. We don't know for sure if the poultry deaths were due to bird flu," a veterinary department official said.

"By Thursday [27 Nov 2008] we shall be getting the laboratory test reports and maybe we have to start the culling process as there has been large-scale reports of deaths coming in from nearby areas," Kamrup district magistrate RC Jain said. A general health alert was also sounded in the area. Teams of experts are now camping in the area and were contemplating culling birds as a precautionary measure.
(ProMED 11/27/08)

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Americas
USA (Texas): Human infected with swine influenza A/H1N1 virus
The US Centers for Disease Control and Prevention (CDC), in its latest update on the nation's seasonal influenza activity, reported on a person who was infected with a swine influenza virus following several exposures to pigs, including a sick one. The CDC said the patient was infected with a swine influenza A/H1N1 virus. Although human infections with swine flu viruses are uncommon, many years bring reports of isolated cases.

The Texas Department of State Health Services, in a flu surveillance activity report for the week ending 15 Nov 2008, said the patient got sick in mid-October. The patient's specimen was collected and the virus identified during routine influenza surveillance. Texas officials, who gave no details about the patient's illness, said their investigation found no illnesses in the patient's household or close contacts.

According to the CDC's background information on swine flu, the agency receives about one human influenza isolate each year that tests positive for a swine influenza virus. H1N1 and H3N2 swine flu viruses are endemic in US pig populations. Human infections with novel influenza A subtypes are nationally notifiable diseases in the United States. Though human-to-human swine flu transmission is rare, the CDC said human infections with swine H1N1 viruses should be investigated to ensure that they are not spreading among humans -- as spread could represent a pandemic threat -- and to monitor changes in circulating viruses.

CDC said swine flu outbreaks in pigs typically occur in late fall and winter months. CDC said seasonal influenza vaccines are likely to partially protect against swine H3N2 viruses, but not the H1N1 subtype.
(ProMED 11/25/08)

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2. Infectious Disease News

Global
Global: Passengers possibly exposed to infectious disease on commercial flight from Asia to USA
A passenger with a contagious disease has been isolated during a flight from Asia to the Los Angeles International Airport (LAX), prompting federal health officials to launch an investigation, authorities said on 23 Nov 2008. The US Centers for Disease Control and Prevention (CDC) got involved soon after it was determined the passenger had some sort of food poisoning or other stomach problem, city fire officials said. Some 343 passengers and crew were held aboard the United Airlines jet for nearly an hour before they were allowed to deplane, officials said.

Los Angeles City Fire spokesman Cecil Manresa said paramedics were called to LAX Terminal 7 early 23 Nov 2008. By the time the rescue team arrived, a representative from the CDC was already on the plane's upper deck, where the sick person had been isolated by airline crew. Passengers of the United Airlines jumbo jet, inbound from Bangkok and Tokyo, were held at gate 74 while the CDC representative sought to determine whether the sick person on board was highly contagious.
(ProMED 11/25/08)

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Asia
China (Anhui): Report discusses human-to-human transmission of HGA
The first case of a tick-borne disease called human granulocytic anaplasmosis (HGA) in China that led to person-to-person transmission of the disease, is described in a study by researchers at China's National Institute of Communicable Disease Control and Prevention. It's the first known report of human-to-human transmission of HGA.

The Chinese team launched an investigation after a cluster of HGA cases occurred in health-care workers and family members following exposure to a patient with disease symptoms consistent with HGA. The female patient was bitten by a tick 12 days before the onset of fever and hemorrhage. She was admitted to a regional hospital in Anhui province and later died. Of 28 people who had close contact (51 cm or less) with the patient during the final 12 hours of her life, nine became infected with the type of bacteria (Anaplasma phagocytophilum) that causes HGA. All nine reported contact with the patient's blood, and seven had contact with her respiratory secretions.

"The most remarkable aspect of these cases was that transmission was very unlikely to be tick-borne, but was closely associated with blood or respiratory secretion from hemorrhage," the researchers wrote. "Although it is likely that routine blood and fluid precautions will protect against such future events, strict adherence to protective protocols is mandatory even if communicability is deemed unlikely."

The researchers added that the lessons of this case study "remain relevant to the daily hospital and health care unit operations to prevent any additional hospital outbreaks of HGA. HGA was identified in the United States in 1990 and in Europe in 1997. The number of infections reported each year in the United States is rising, with infection rates in endemic areas as high as 15 percent to 36 percent.

The report was published in the 19 Nov 2008 issue of the Journal of the American Medical Association.
(ProMED 11/20/08)

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Indonesia: Chikungunya virus outbreak in two territories in Central Java
In the Pesawahan village, Rawalo Banyumas in Central Java, dozens of people have been afflicted with chikungunya illness. From the available data at the Rawalo Community Health Centre, approximately 50 people were recorded as having been affected by the chikungunya virus. According to the latest information, five people were still being treated at the community health centre. According to one of the infected residents, the signs of the illness started in one resident on 15 Nov 2008. After that, dozens of other residents quickly became ill and were treated at the community health centre or in their houses.

The head of the Rawalo Community Health Centre, Dr Hendro Harjito said the Rawalo Community Health Centre's integrated team and Dinkes Health Service, Kabupaten Banyumas have entered the location of the chikungunya outbreak. They immediately collected data on all the residents affected by the virus. The plan is to carry out fogging or spraying of the mosquitoes breeding sites all over the Pesawahan Village territory, he added.

He stated that this is the first time that chikungunya virus has occurred in the area. "Our area is not endemic for chikungunya or dengue fever. We suspected that this illness was brought in by one of the residents from outside the village, because of our findings. This was the first extraordinary incident [health emergency] in our territory," he explained. In the meantime, Pesawahan villagers are worried that the chikungunya outbreak will spread.
(ProMED 11/19/08)

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Russia (Samara Oblast): Increase in hemorrhagic fever with renal syndrome cases in 2008
More residents in the Samara Oblast are contracting hemorrhagic fever with renal syndrome, also known as mouse fever. The number of cases has increased three-fold since 2007. Investigation showed that 28 percent of rodents that transmit the infection to humans are infected. During the first ten months of 2008, there have been 222 hemorrhagic fever cases, compared with 70 in all of 2007.
(ProMED 11/18/08)

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Russia (Kemerovo): Eight infected with trichinellosis from bear meat
A total of eight people including four children have been hospitalized in the hospital of Novokuznetsk with trichinellosis. "All the patients ate bear's meat," stated Alexander Kultzev, the main physician of the eighth infectious disease hospital of Novokuznetsk. The diagnosis "trichinosis" has been confirmed in seven patients, but was unconfirmed in the eighth patient who was a 2-year-old child.
(ProMED 11/23/08)

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Russia (Moscow): Record number of cases of rabid animals
The number of rabid animals has sharply increased in 2008 in the Moscow region. According to the sanitary authorities, the 2008 indexes are the highest for the last 25 years. To date, 173 rabies cases in animals have officially been recorded, exceeding the previous record in 1984 of 134 cases.

The Raccoon dog has become the main vector of rabies in the region, replacing the fox. This animal was introduced into central Russia from the Far East in the middle of the 1900s for fur farming purposes. It has become an invading species during the last several tens of years, rapidly multiplying, replacing foxes in relevant habitats. Out of two human deaths caused by rabies in 2008, one case was related to a raccoon dog's bite when a 50-year-old man, in Ruzskom, found the animal inside his summer house.
(ProMED 11/23/08)

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Americas
Canada (British Columbia): New case of mad cow disease confirmed
The Canadian Food Inspection Agency [CFIA] confirmed on 17 Nov 2008 a new case of mad cow disease (bovine spongiform encephalopathy or BSE) in a 7-year-old dairy cow born well after Ottawa banned feed practices thought to spread the disease. It is the country's fifteenth case. The animal was discovered on a farm in the pacific province of British Columbia. The agency said no part of the animal's carcass entered the human food or animal feed supply. It also added that regulators are also tracking down other animals in the cow's herd when it was born.

Canada has been deemed a "controlled risk" country for mad cow disease by the World Organization for Animal Health (OIE) because of its surveillance and control measures. The CFIA said the new case should not affect that classification.
(ProMED 11/19/08)

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USA: Pew report critiques Salmonella outbreak response
The nationwide Salmonella Saintpaul outbreak in summer 2008, exposed several gaps in the nation's food safety system, including poor organization and confusing risk communications, according to a report by the Produce Safety Project (PSP), an initiative of the Pew Charitable Trusts. The authors of the 32-page report said that their goal was to frame questions for public health officials who will review the response to the outbreak, a probe that congressional leaders and produce industry representatives have requested.

The outbreak, first reported in early June 2008, sickened more than 1,400 people and badly hurt the fresh-tomato industry before authorities determined several weeks into the trace-back investigation that tainted jalapeno and Serrano peppers were the culprits.

The PSP's findings and recommendations are based on an extensive review of outbreak-related public records, including those of the Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and congressional hearings. Jim O'Hara, director of the PSP, stated that the problems identified in the report are nothing new. "If we pass up this opportunity to learn from this most recent outbreak, we will keep repeating the same costly mistakes—for public health and industry alike."

Who has power to mandate produce safety?
During the outbreak, FDA officials said mandatory safety controls for produce were needed, but they were waiting on Congress to give them the authority. However, the PSP report says the FDA has used its existing statutory authority before to set Hazard Analysis and Critical Control Point (HACCP) regulations: in 1995 for seafood and again in 2001 for juice. The report states that the FDA has also proposed on-farm safety measures for shell eggs.

However, the document also notes that the FDA's attempts to enact produce safety regulations as part of its 2007 Food Protection Plan, using its existing authority, have been ignored by the Department of Health and Human Services (HHS). At a House subcommittee hearing on the Salmonella outbreak in late July 2008, David Acheson, the FDA's associate commissioner of foods, said that the FDA, in proposing its Food Protection Plan last fall, asked for ten specific legislative authorities. Of those, "probably the one that's most important is the one that requires preventive controls [in food production and processing]. That's absolutely critical across the board," he said. The PSP authors write, "The lack of federal action has resulted in a patchwork-quilt approach to fresh produce safety. Moreover, federal inaction may well be eroding public confidence in the safety of the food supply."

Problems with coordination and capacity
Another shortcoming that came to light was a lack of organization, capacity, and coordination that hurt the effectiveness of the outbreak response. The authors state that their review of the outbreak raises questions as to whether public health agencies shared data in a timely manner and whether poor communication between the agencies could have delayed the identification of peppers as the vehicle for Salmonella contamination.

Problems with coordination and capacity showed up in the CDC's epidemic curve. When the FDA issued its nationwide advisory about tomatoes on 7 Jun 2008, officials originally reported that 145 people had been infected at that time, but the epi curve they issued later showed that more than 800 people—55% of the outbreak total—had illness onsets before that date. Also, the CDC acknowledged that the delays in reporting cases were signs that response capacity was strained.

State public health departments acted quickly to respond and inform the CDC, but the CDC could have acted more quickly to inform the FDA, which is responsible for leading multi-agency and trace-back investigations. Also, big, multistate investigations such as the S Saintpaul outbreak reveal a disconnect between the epidemiological and trace-back efforts.

Mixed and confusing messages
In reviewing the public health messages that came from various agencies during the outbreak, the authors concluded that messages were frequent but inconsistent, pointing toward a need for officials to establish risk-communication strategies before an outbreak occurs. For example, a lack of detail about early case clusters hampered the tomato industry's efforts to determine if there was a connection between illnesses and tomato distribution patterns.

O'Hara called on the incoming Obama administration to make mandatory, enforceable safety standards for fresh produce a food-safety priority and to take steps to fix the nation's broken outbreak response system. The report can be accessed at http://www.producesafetyproject.org/reports?id=0001.
(CIDRAP 11/18/08)

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USA (South Carolina): Two people bitten by rabid fox
On 3 Nov 2008 a red fox, a normally a timid species, chased down and bit a 9-year-old boy who was on his way to catch the morning bus. Jeff Davis, a neighbor, ran outside and called the boy into the Davises' house. When Davis and several others went out on the raised porch, the fox screamed and snarled below, then burst up the stairs and into the house. The fox latched onto Davis' foot and bit him too, before Davis pulled the animal from his foot and threw it into another room. There, the animal churned, throwing itself against the windows before falling asleep on a dog bed, where animal control snared it.

Rabies is 100 percent fatal if left untreated before symptoms arise. Infected animals usually die within six to ten days of developing symptoms. By the time an animal is visibly sick, enough virus exists for the disease to be transmitted through saliva. A total of 13 animals in Charleston County have tested positive for rabies in 2008, half of last year's total of 26. Statewide, 162 animals were confirmed rabid in 2007.

Immediately following the attack, Jeff Davis and the boy began inoculations, which are nearly 100 percent effective in preventing rabies if administered prior to the development of symptoms. The first shot consists of immune globulin and a dose of vaccine, followed by four more vaccinations. Immune globulin is a blood product created from a healthy person who has been vaccinated against rabies. This shot is given at the site of exposure, if it's known, and the rest of the injections are given in an arm. About 400 South Carolinians undergo preventive treatment for rabies annually, said Sue Ferguson with DHEC.
(ProMED 11/21/08)

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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 their new report: Pandemic Influenza, Electricity, and the Coal Supply Chain.
- 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
Philippines
At least two people have died and more than 1500 are hospitalized following a suspected outbreak of cholera in the southern Philippines. National Epidemiology Centre chief Eric Tayag said the patients "were showing cholera symptoms" and most came from the settlement of Tagoloan in southern Misamis Oriental, where heavy rains could have contaminated the drinking water supply. A Red Cross official stated it was confirmed that two people had died and that nine out of the ten villages in Tagoloan were reporting suspected cholera cases.
(ProMED 11/18/08)

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DENGUE
American Samoa
American Samoa's dengue count has risen to 400 confirmed cases since January 2008 with the emergency room and various other clinics at the hospital and in outlying health centers being swamped daily with people seeking advice and treatment for dengue-like symptoms and for dengue follow-up treatment, which includes platelet count and intravenous fluids if needed. To date they have had one dengue related death, a ten-year-old boy. Ages of dengue patients range from a two-year-old to a 73-years-old. There has been little to no travel associated with this outbreak since it began in January of 2008.
(ProMED 11/18/08)

Indonesia
The Health Office of Banyumas Regency, Central Java, has classified the status of the current dengue fever outbreak as an extraordinary event. The number of dengue cases has increased by a factor of two since 2007. Up until mid-November 2008 there have been 551 cases recorded with five deaths. The budget for mosquito insecticide application to control the outbreak was exhausted in October 2008.

The head of the health service of Banyumas, Gempol Suwandono, said that the outbreak was classified as an extraordinary event because there are increasing cases and the number is twice those of months or years earlier. In 2007, the number of cases was 241 with two deaths. "This year [2008] there are increasing cases by more than 100 percent, hence the extraordinary event status of our state as a dengue outbreak in the region of Banyumas," said Gempol.

In the near future the health service will be fogging or fumigating in a number of locations where there are known dengue cases, but acknowledged that the funds have been out since October 2008. The agency has to apply for additional funds from the Banyumas regional government.
(ProMED 11/18/08)

Malaysia
Stricter enforcement and better cooperation from the public have helped reduce the number of dengue fever cases in the state in 2008 by more than 55 percent. As of 8 Nov 2008, only 1044 cases were recorded, compared with 2338 cases within the same period in 2007. Only one death was reported in 2008, compared with four fatalities in the corresponding period in 2007.

State health director Datuk Dr Rosnah Ismail said 54 percent of the dengue fever cases were reported in Kuantan and Temerloh. Dr Rosnah said health officials had checked a total of 423,699 premises so far in 2008, and found 5276 to contain dengue mosquito breeding grounds. "Our records show that 90 percent of the victims were infected with dengue fever at home," she said, adding that only 30 percent sought treatment within three days of having fever.

She said the delay in getting treatment could lead to complications and in some cases the victims could die from the disease. Such a delay could also spread the disease, as the victims could be bitten by other Aedes mosquitoes, which could transfer the virus to others in the neighborhood.
(ProMED 11/18/08)

Viet Nam
Hospitals in Hanoi have treated more than 500 dengue fever cases since 5 November 2008, causing alarm over outbreaks of diseases following recent floods in the capital. Hospitals report that the patients are mainly young people and the number is two times higher than the same period in 2007. Many of the recent cases are serious, said Bui Nguyen Kiem, the head of Saint Paul Hospital's Internal Medicine Department No. 2. Kiem said many of the patients did not use mosquito nets and delayed their visit to the hospital instead of checking in as soon as they had fever. "The initial symptoms of this fever are similar to other kinds offevers, so many people were only taken to the hospital when their fevers became serious and difficult to treat," said Kiem.
(ProMED 11/24/08)

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WEST NILE VIRUS
Canada
Date: 19 Nov 2008:
Human cases: no new cases reported since 8 Oct 2008
Total human cases in 2008: 35
It appears that the West Nile transmission season for 2008 has ended in Canada.

USA
Date: 5-18 Nov 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 1301 human cases and 24 fatalities to date in 2008.

Although nationally 2008 appears to have been one of the milder WNV years since 2002/2003, this did not appear to be true in the mid-Atlantic area based on mosquito surveillance results and the number of human cases reported to date: Maryland has had 14 human cases so far in 2008, the most reported since 2004. The District of Columbia (DC) has reported seven confirmed human cases so far, the most reported since 2002. New Jersey has seven human cases confirmed to date, the most reported since 2003.
(ProMED 11/20/08)

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4. Articles
Rotavirus surveillance—worldwide 2001-2008
US Centers for Disease Control and Prevention. MMWR. 21 Nov 2008; 57(46): 1255-1257. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5746a3.htm?s_cid=mm5746a3_e.

Rotavirus infection is the leading cause of severe acute diarrhea among young children worldwide. An estimated 527,000 children aged <5 years die from rotavirus diarrhea each year, with >85% of these deaths occurring in low-income countries of Africa and Asia. Two licensed rotavirus vaccines have shown efficacy of 85%--98% against severe rotavirus diarrhea in trials conducted in the Americas and Europe, and they have been introduced into routine immunization programs in 11 countries in these regions and in Australia. Additional trials of these vaccines are ongoing to assess efficacy in low-income countries of Asia and Africa, where vaccine performance might be affected by factors such as concurrent enteric infections, greater prevalence of malnutrition, and a greater prevalence of unusual rotavirus strains. Results of these additional trials are expected within the next 1--2 years. To collect epidemiologic and burden-of-disease data that could form the basis of vaccination policy worldwide, beginning in 2001, the World Health Organization (WHO), in collaboration with partners, established networks of hospital-based sentinel surveillance sites for detection of rotavirus diarrhea and characterization of rotavirus strains. This report presents an analysis of results from the WHO surveillance networks for 2001--2008, which indicated that approximately 40% of diarrhea hospitalizations among children aged <5 years worldwide were attributed to rotavirus infection. The most common rotavirus strains found were G1, G2, G3, G4, and G9, and the distribution of strains varied markedly across regions. These data demonstrate the substantial burden of rotavirus diarrhea worldwide and highlight the potential health impact of vaccination.

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Continued Shortage of Haemophilus influenzae Type b (Hib) Conjugate Vaccines and Potential Implications for Hib Surveillance--United States, 2008
US Centers for Disease Control and Prevention. MMWR. 21 Nov 2008; 57(46): 1252-1255 Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5746a2.htm?s_cid=mm5746a2_e.

In December 2007, Merck & Co., Inc. (West Point, Pennsylvania) announced a voluntary recall of certain lots of two Haemophilus influenzae type b (Hib) conjugate vaccines, PedvaxHIB® (monovalent Hib vaccine) and Comvax® (Hib-HepB vaccine) and suspended production of both vaccines, disrupting the U.S. supply of Hib vaccine. When the recall was announced, Merck projected restoration of these vaccines to the U.S. market in late 2008. To ensure that enough vaccine would be available for all U.S. children to complete the primary Hib vaccination series, on December 18, 2007, CDC recommended that providers defer the booster dose of Hib vaccine (scheduled for administration at age 12--15 months) for all children except those at increased risk for invasive Hib disease. On October 17, 2008, Merck announced that restoration of the two vaccines to the market would be delayed until mid-2009. Because the continued delay might result in an increase in Hib disease, national surveillance for invasive Hib disease has become particularly important. To assess the current status of surveillance for Hib nationally, CDC reviewed 4,657 cases of invasive H. influenzae infection reported during January 2007--October 2008, including 748 cases among children aged <5 years. Of those 748 cases, 45 (6.0%) were Hib (serotype b), and 278 (37.2%) were missing serotype information. The continued vaccine shortage heightens the need for timely reporting and investigation of H. influenzae cases and accurate serotyping of all invasive H. influenzae isolates in children aged <5 years.

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Weekly Epidemiological Record Bulletin
WHO. 21 Nov 2008, 83(47): 421-428. Available at http://www.who.int/wer.

Contents of this issue:1) Global networks for surveillance of rotavirus gastroenteritis, 2001-2008; 2) Performance of acute flaccid paralysis (AFP) surveillance and incidence of poliomyelitis, 2008

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Cross-reactive immunity in adult and elderly patients against clade 2 influenza A H5N1 virus strains induced by Fluval, a reverse genetic-derived adjuvanted H5N1 clade 1 prototype pandemic influenza vaccine
Fazekas, György et al. Clin Vaccine Immunol. 19 Nov 2008. Available at http://cvi.asm.org/cgi/content/abstract/CVI.00327-08v1.

Abstract
High fatality rates and multiple cases of transmission of avian H5N1 influenza viruses to humans illustrate the urgent need for an efficacious, cross-protective vaccine against H5N1 strains. Extensive genetic characterization of H5N1 strains has elucidated the natural evolutionary relationship of these strains, linking groups known as ‘clades’ to a common ancestor. Although the clades and subclades probably differ sufficiently in their antigenic structure to warrant the preparation of different vaccines, there is some evidence that cross reactive immunity can be afforded. We aimed to assess the immunogenicity of a clade 1 H5N1 (NIBRG-14) whole virus aluminum phosphate adjuvanted vaccine and determine whether it can induce cross-reactive immunity against antigenically drifted clade 2 H5N1 strains of both reverse genetics derived and wild type isolated origin. A total of 88 (44 adult and 44 elderly) subjects were studied, who received one dose (6 micrograms) of the vaccine. As judged by US and European licensing criteria based on hemagglutination inhibition, the subjects developed cross-reactive immunity against all studied H5N1 strains belonging to a different clade than the strain utilized to produce the vaccine. Our findings highlight the importance of stockpiling, since cross immune reactions induced by prepandemic vaccines will likely reduce morbidity and mortality in case of a pandemic.

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Guillain-Barré Syndrome and Influenza Virus Infection
Sivadon-Tardy, Valérie et al. Clin Infect Dis. 24 Nov 2008. Available at http://www.journals.uchicago.edu/doi/abs/10.1086/594124.

Background. In Western countries, the cause of 60% of all Guillain-Barré syndrome (GBS) cases remains unidentified. The number of cases of unidentified cause peaks in winter, and these cases are commonly preceded by respiratory tract infection or influenza-like illness. We investigated the triggering role of influenza virus infection.

Methods. Of 405 patients with GBS who were admitted to a French reference center during 1996–2004, 234 had cases caused by an unidentified agent. We used time-series methods to study the correlation between the monthly incidence of such cases and influenza-like illnesses reported by the Sentinelles surveillance network. We analyzed anti-influenza antibodies using complement fixation testing and hemagglutination-inhibition assays. We studied etiological subgroups using Wilcoxon and Fisher's exact tests.

Results. We found a positive association between the monthly incidence of GBS caused by an unidentified agent and reported influenza-like illnesses. Of 73 patients whose cases occurred during periods in which there was a possible link to influenza, 10 (13.7%) had serological evidence of recent influenza A, and 4 (5.5%) had serological evidence of influenza B. Eight of 10 influenza A–related cases occurred during “major” influenza seasons, and antibodies specific to the current epidemic strain were found in 9 cases. Most patients with influenza A–related cases were aged <65 years, and none had antiganglioside antibodies. Influenza-related cases differed both from Campylobacter jejuni–related cases, with regard to the lack of need for mechanical ventilation (p=0.014), and from the cases caused by an unidentified agent, with regard to the presence of preceding influenza-like illness or respiratory tract infection (p=0.015) and longer time from the infectious event to GBS onset (p=0.04).

Conclusions. Influenza viruses are infrequent triggering agents of GBS but may play a significant role during major influenza outbreaks. Influenza-related GBS displays specific features and is not associated with antiganglioside antibody response, which suggests the presence of underlying immune mechanisms.

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Multistate Outbreak of Salmonella Infections Associated with Frozen Pot Pies--United States, 2007
US Centers for Disease Control and Prevention. MMWR. 28 Nov 2008; 57(47): 1277-1280 Available at http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5747a3.htm.

On June 6, 2007, a cluster of four human Salmonella serotype I 4,5,12:i:-* infections sharing a pulsed-field gel electrophoresis (PFGE) pattern was identified by the Pennsylvania Department of Health and reported to PulseNet. Initial investigations conducted during June--September 2007 by state and local health departments in collaboration with CDC did not identify a source of infection. This report summarizes the results of subsequent investigations of the outbreak, which determined that 401 cases of salmonellosis occurred in 41 states during 2007, with 32% of ill persons hospitalized. A multistate case-control study conducted during October 3--13 indicated that illness was associated with consumption of Banquet® brand frozen, not-ready-to-eat pot pies (odds ratio = 23.6; p<0.001). Further investigation determined that 77% of patients who ate these pies cooked them in microwave ovens and that consumer confusion regarding microwaving instructions might have resulted in a failure to cook the product properly. A voluntary recall was issued by the manufacturer (ConAgra Foods Inc., Omaha, Nebraska) on October 11, 2007, for all nine brands of pot pies produced at the implicated plant (plant A). The outbreak strain was isolated from 13 samples of unopened Banquet pot pies collected from the homes of patients. This outbreak highlights the need to cook not-ready-to-eat frozen foods thoroughly; these products should be clearly labeled as requiring complete cooking, and cooking instructions should be validated to account for variability in microwave wattage and common misconceptions among consumers regarding the nature of not-ready-to-eat foods.

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A New Mycobacterium Species Causing Diffuse Lepromatous Leprosy
Han, Xiang Y et al. Amer J Clin Pathol. Dec 2008; 130(6): 856-864. Available at http://ajcp.metapress.com/app/home/contribution.asp?referrer=parent&backto=issue,3,20;journal,1,107;linkingpublicationresults,1:300401,1.

Abstract
Mycobacterium leprae causes leprosy. M leprae strains collected worldwide have been genetically clonal, which poorly explains the varying severity and clinical features of the disease. We discovered a new Mycobacterium species from 2 patients who died of diffuse lepromatous leprosy (DLL). The Mycobacterium was purified from heavily infected, freshly frozen autopsy liver tissue followed by DNA extraction in 1 case. Paraffin-embedded skin tissue was used for DNA extraction in another case. Six genes of the organism were amplified by polymerase chain reaction, sequenced on cloning or from amplicons, and analyzed. Significant genetic differences with M leprae were found, including a 2.1% divergence of the 16S ribosomal RNA (rRNA) gene, a highly conserved marker of bacterial evolution, and 6% to 14% mismatches among 5 less conserved genes. Phylogenetic analyses of the genes of 16S rRNA, rpoB, and hsp65 indicated that the 2 most related organisms evolved from a common ancestor that had branched from other mycobacteria. These results and the unique clinicopathologic features of DLL led us to propose Mycobacterium lepromatosis sp nov. This species may account for some of the clinical and geographic variability of leprosy. This finding may have implications for the research and diagnosis of leprosy.

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5. Notifications
October 2008 Telemedicine and eHealth Journal available
Vol. 14, No. 8. Available at http://www.liebertonline.com/toc/tmj/14/8.

Included in this volume: New Frontiers in Telemedicine: Early-Phase R&D Promises Exciting New Telemedicine Tools; Comparative Study of Connectivity in Telemedicine.

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Upcoming eHealth conferences
eTELEMED 2009
Location: Cancun, Mexico
Dates: 1 - 6 February 2009
Additional information at http://www.iaria.org/conferences2009/eTELEMED09.html.

Revolutionizing Health Care with Informatics: From Research to Practice
Location: Victoria, Canada
Dates: 19 - 22 February 2009
Additional information available at http://itch.uvic.ca/.

Med@Tel conference in Luxembourg
Dates: 1-3 April 2009
Call for abstracts: Deadline: 20 December 2008
Submission information available at http://www.medetel.lu/index.php?rub=educational_program&page=call_for_abstracts.

Topics include: eHealth and telemedicine implementation in low resource settings; eHealth integration into routine medical practice; eHealth master plan development for developing countries; eLearning and distance education; electronic health records and personal health records; mobile/wireless healthcare; opportunities for and barriers to eHealth and telemedicine implementation; standardization and interoperability.

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Grand Challenges in Global Health Initiative request for proposals
The McLaughlin-Rotman Centre for Global Health (MRC) and its Ethical,Social and Cultural Program (ESC) for the Grand Challenges in Global Health (GCGH) Initiative are pleased to invite individuals, institutions, organizations and companies from the developing world to submit proposals to carry out projects that will facilitate the implementation and use of technologies in the developing world that arise from the GCGH projects.

The goal of this Request for Proposals (RFP) is to select and commission research on strategies that will facilitate the implementation and appropriate use in the developing world of technologies that arise from the GCGH projects related to diagnostics, modified insect vectors, nutritionally enhanced foods, and vaccinedelivery. Visit www.mrcglobal.org/rfp for further information. The deadline to submit proposals is January 16th, 2009.

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 apecein@u.washington.edu