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Vol. XI, No. 25 ~ EINet News Briefs ~ Dec 12, 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)
- Cambodia: Man confirmed to be infected with avian influenza H5N1
- Hong Kong: Avian influenza H5N1 outbreak at poultry farm confirmed
- India (Assam): Avian influenza H5N1 virus in poultry continues to spread through region
- Indonesia: Health ministry confirms two new cases of human H5N1 avian influenza
- USA: People of color lag in flu-shot coverage for elderly
- USA: Preparedness report card decries funding lag
- USA: Rand releases midseason flu vaccination status report

2. Infectious Disease News
- China (Beijing): Two children fall ill after hepatitis A vaccine
- Indonesia: Chikungunya outbreak continues to spread in Central Java
- Indonesia: Rabies outbreak in Bali
- Russia (Yaroslavskaya Oblast): Hemorrhagic fever with renal syndrome update
- Peru: Rat infestation poses risk of bubonic plague outbreak
- USA (Missouri): First human rabies death in over 50 years in Missouri
- USA (New Mexico): Reports second hantavirus death in 2008
- USA (Oklahoma): Restaurant linked to large E. coli outbreak to resume business

3. Updates
- AVIAN/PANDEMIC INFLUENZA
- DENGUE

4. Articles
- Progress in global measles control and mortality reduction, 2000-2007
- Half-Dose Influenza Vaccine: Stretching the Supply or Wasting It?
- Half- vs Full-Dose Trivalent Inactivated Influenza Vaccine (2004-2005)--Age, Dose, and Sex Effects on Immune Responses
- Update: Influenza Activity--United States, September 28--November 29, 2008
- Prevention and Treatment of Seasonal Influenza
- Community Planning for Pandemic Influenza: Lessons From the VA Health Care System
- Avian Influenza Outbreaks in Chickens, Bangladesh
- Weekly Epidemiological Record Bulletin

5. Notifications
- Grand Challenges in Global Health Initiative request for proposals
- XI International Symposium on Respiratory Viral Infections


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 / 22 (18)
Viet Nam / 5 (5)
Total / 38 (29)

***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: 389 (246).
(WHO 12/9/08 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO:
http://www.wpro.who.int/sites/csr/data/data_Graphs.htm (WHO/WPRO 9/11/08) WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 12/2/08):
http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 12/8/08):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Asia
Cambodia: Man confirmed to be infected with avian influenza H5N1
The Ministry of Health in Cambodia confirmed that a 19-year-old man is the eighth person who has been detected with confirmed avian influenza in Cambodia since early 2005. This is the first case of avian influenza detected in Cambodia in 2008. The patient is from Kandal Steung District in Kandal Province.

The patient became ill with fever, cough, muscle ache and sore throat on 28 Nov 2008 and sought medical attention at local health centers originally on 30 Nov 2008 and again on 2 Dec 2008. The patient was identified during surveillance for acute fever illness, a research study conducted in the province and confirmatory testing was done by the National Influenza Centre in Phnom Penh on 11 Dec 2008. The patient is currently being treated in Calmette hospital, Phnom Penh.

Field investigation teams, headed by MoH are in the field to identify human contacts and start prophylaxis treatment. The Ministry of Health will continue to go house to house in the affected area looking for people who have a fever, cough and contact with sick or dead chickens. Public education materials will also be distributed. The Ministry of Agriculture is conducting a detailed investigation into poultry deaths in the area around the village. This is the eighth confirmed case of human H5N1 influenza in Cambodia. All previous seven cases died. The last case occurred in April 2007.
(ProMED 12/12/08)

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Hong Kong: Avian influenza H5N1 outbreak at poultry farm confirmed
Agriculture officials in Hong Kong confirmed on 11 Dec 2008 that the avian influenza virus that recently hit a large commercial chicken farm was the H5N1 strain, as authorities vowed to explore potential protection gaps in the poultry vaccine and the possibility that smuggled eggs might be a source of the virus. The outbreak, China's first on a farm since 2003, prompted the culling of more than 80,000 birds and restrictions on poultry imports.

Jolly Choi, spokeswoman for Hong Kong's agriculture, fisheries, and conservation department said earlier tests on 9 Dec 2008 were positive for an H5 virus, but further testing showed that three chickens found dead on the farm had the H5N1 subtype. Meanwhile, York Chow, Hong Kong's secretary for food and health, stated on 9 Dec 2008 that experts are focusing on two lines of investigation: a possible biosecurity lapse at the farm and if a change in the circulating virus has hobbled Hong Kong's poultry vaccine.

Chow said Hong Kong been using an H5N2 vaccine manufactured in the Netherlands since 2003. "Over the last few years it has been proven to be effective, but we also think that because of the change of the virus, we might have to look for a more appropriate vaccine," he said. The Chinese mainland has been using H5N1 vaccine for poultry over the past few years, which is modified periodically, Chow said, adding that veterinary officials have contacted mainland authorities to explore if a switch to the H5N1 vaccine would be more protective. He said that government officials would also be seeking guidance from experts at Hong Kong University, where vaccine studies in poultry have already been under way since June 2008.

In July 2008, Yuen Kwok-yung, who heads the University of Hong Kong's microbiology department, warned that the poultry vaccine has lost its effectiveness over the past seven years of use. He said that the virus in Hong Kong had shifted away from the Fujian strain that the vaccine was developed for and advised officials to ban live poultry from Hong Kong markets before the vaccine becomes completely ineffective. One month earlier, animal health officials had detected the H5N1 virus in poultry feces at several market stalls, but could not determine the source of the virus.

So far there is no evidence that the virus has spread to other farms, Chow said. Investigators have collected samples from farms to conduct polymerase chain reaction (PCR) testing, and the results should be available soon.

In other developments, poultry trade representatives in Hong Kong said on 11 Dec 2008 that smuggled fertilized eggs from China could be the source of the recent H5N1 outbreak. The Hong Kong Poultry Wholesalers Association said smuggling has become more common since the government banned the import of one-day-old chickens from China as an H5N1 prevention measure earlier in 2008.

The South China Morning Post reported that the eggs, ostensibly imported as food, contain potentially infected embryos that are less than a week from hatching. However, the owner of the farm that was struck by the H5N1 virus denied having smuggled any fertilized eggs from mainland China. According to a 5 Feb 2008 report from the World Organization for Animal Health (OIE), the H5N1 virus is common and present year-round in Hong Kong, occurring in resident and migratory birds. The report said poultry farms are constantly monitored with serologic and virologic testing.
(CIDRAP 12/9/08, 12/11/08)

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India (Assam): Avian influenza H5N1 virus in poultry continues to spread through region
Health ministry officials in India said on 11 Dec 2008 that the H5N1 avian influenza virus has now spread to six of 27 districts in Assam state. Parthajyoti Gogoi, a health ministry official, stated that more than 200,000 chickens and ducks have been culled since the outbreak was first detected two weeks ago. The culling activities have affected 200 villages in Kamrup (Metro), Kamrup (Rural), Dibrugarh, Nalbari, Barpeta, and Chirang districts. He said teams of doctors and paramedics are taking measures to prevent human H5N1 infections.
(CIDRAP 12/11/08)

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Indonesia: Health ministry confirms two new cases of human H5N1 avian influenza
The World Health Organization (WHO) said that Indonesia's health ministry has notified it of two new human H5N1 avian influenza cases, a 9-year-old girl who has recovered and a 2-year-old girl who died. The announcements come as health officials from Indonesia and other nations are meeting in Geneva this week to work on an agreement for sharing H5N1 virus samples.

The WHO said the 9-year-old girl from Riau province got sick on 7 Nov 2008, was hospitalized five days later, and was released from the hospital on 27 Nov 2008. Few other details were available about the girl's illness. The WHO said an investigation into the source of the girl's infection revealed poultry deaths on 2 Nov 2008 at her family's home.

In the second case, the 2-year-old girl who died was from East Jakarta. The WHO said the girl got sick on 18 Nov 2008, was hospitalized eight days later, and died on 29 Nov 2008. The WHO said initial investigations indicate that the girl may have been exposed to the virus at a live bird market.

The two cases bring Indonesia's H5N1 case count to 139, including 113 deaths.

Today's statement from the WHO didn't address previous media reports on the death of a 15-year-old girl from central Java who—according to a local medical official and a doctor who treated her—died of an H5N1 infection on 7 Nov 2008. However, on 13 Nov 2008 Indonesia's health minister, Siti Fadilah Supari, denied reports that the girl had H5N1 and said tests from two laboratories came back negative.

Indonesia has been hit harder than any other country by the H5N1 virus. However, the country has stopped sharing H5N1 samples to protest the lack of access to and affordability of avian influenza vaccines and treatments. Indonesia also said in June that it would no longer promptly report H5N1 cases and would give only periodic updates. The country released its last update in early September 2008. Today's announcement of the two new Indonesian cases raises the global H5N1 count to 389 cases and 246 deaths.
(CIDRAP 12/9/08)

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Americas
USA: People of color lag in flu-shot coverage for elderly
A report from the AARP Public Policy Institute says elderly African-Americans and Hispanics lag well behind elderly whites in influenza vaccination rates, even though the federal Medicare program fully covers the shots. In 2006, 67% of whites aged 65 and older received flu shots, versus 47% of African-Americans and 45% of Hispanics in that age-group, according to the report. The figures were drawn from the Centers for Disease Control and Prevention's (CDC's) National Health Interview Survey.

All the rates were well below the federal government's Healthy People 2010 goal of 90% flu immunization coverage among the elderly. It was prepared by the policy research arm of AARP, a nonprofit, nonpartisan organization for people aged 50 and older.

Citing a 2007 study published in Preventive Medicine, the report says that eliminating racial and ethnic disparities in flu vaccine coverage would prevent an estimated 1,880 minority deaths every year. (The 2007 study was based on slightly different immunization rate estimates than those from the National Health Interview Survey.) The AARP also says that the two minority groups lag well behind whites in pneumococcal pneumonia vaccination coverage in the elderly, with rates of 36% for African-Americans, 33% for Hispanics, and 62% for whites.

The report says researchers have cited several contributors to the low flu and pneumonia immunization rates among minority groups, including:
• Individuals' lack of awareness of the need for the vaccinations
• Individuals' fear that the vaccines will cause "severe illness"
• Healthcare providers' underestimation of the safety and efficacy of the vaccines
• Providers' lack of familiarity with age-based immunization recommendations
• Providers' failure to recommend the shots to older adults and to use standing orders to promote them

Dr. Jeanne Santoli of the CDC commented, "We know that minority groups often experience more medical consequences from influenza. One example is [that] Hispanics 65 years of age and older often suffer from more chronic health conditions such as diabetes and heart disease, which makes them more susceptible to flu-related complications that can lead to hospitalization and even death."

The AARP report also reviews various federal, state, and private-sector efforts to improve immunization rates among minorities. One program that achieved some success was the CDC's Racial and Ethnic Adult Disparities in Immunization Initiative, or READII, a three-year program that was launched in 2002 to address racial and ethnic differences in immunizations rates for Medicare recipients at five sites around the country. Overall, the program decreased gaps in flu and pneumonia immunization at all five sites, but the difference was not statistically significant. However, certain initiatives that targeted providers were more successful. For example, clinics in Rochester, N.Y. monitored seniors, provided telephone and mail reminders to patients, and notified providers about unvaccinated patients.

Over 2 years, these efforts led to "substantial increases" in flu vaccination across racial groups and raised pneumococcal vaccine coverage to 80%. The report says that other programs and practices that may help boost immunization coverage among minorities include vaccine clinics at or near polling places, using pharmacists as immunizers, and using flu-immunization coverage among Medicare enrollees as a quality measure for healthcare institutions. It also suggests that elderly people who have been vaccinated against flu before are much more likely to do it again.
(CIDRAP 12/8/08)

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USA: Preparedness report card decries funding lag
The 2008 report card from Trust for America's Health (TFAH) on state and national public health emergency preparedness shows some signs of progress along with major gaps, sagging funding, and worry that the current economic crisis will bring deeper spending cuts.

The report finds that "progress made to better protect the country from disease outbreaks, natural disasters, and bioterrorism is now at risk, due to budget cuts and the economic crisis," TFAH, a nonprofit, nonpartisan advocacy group stated. In addition, the report concludes “that major gaps remain in many critical areas of preparedness, including surge capacity, rapid disease detection, and food safety."

TFAH found that more than half of states met seven or fewer of ten key preparedness criteria used in this year's assessment. The states performed best on planning for distribution of emergency medical products from the Strategic National Stockpile: All 50 have an adequate plan. On the other hand, 26 states lack laws offering liability protection to organizations that provide relief services in public health emergencies.

Major findings of the report include that the nation has become complacent in terms of public health emergency preparedness and that preparedness levels vary greatly by state. The chief recommendations of the report can be categorized overall as clarification of agency roles. Specific recommendations include:
• Federal, state, and local funding for preparedness should be restored to 2005 levels.
• The Obama administration should clarify the relative preparedness roles and responsibilities of the departments of Health and Human Services and Homeland Security.
• Federal, state, and local governments and healthcare providers must do a better job of addressing altered standards of care, liability protection, and surge workforce issues.
• Preparedness should be incorporated into healthcare reform.
• The federal government should provide for emergency health insurance coverage and paid sick leave during a flu pandemic or bioterrorist attack.

The 124-page report, titled "Ready or Not? Protecting the Public's Health from Diseases, Disasters, and Bioterrorism," was cosponsored by the Robert Wood Johnson Foundation (RWJF). It is available at http://healthyamericans.org/reports/bioterror08/.
(CIDRAP 12/9/08)

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USA: Rand releases midseason flu vaccination status report
The Rand Corporation released its first-ever midseason survey on the uptake of the current influenza vaccine on 10 Dec 2008, which found that public officials still have a tall task in front of them to administer this year's record vaccine supply. The survey indicated that about 30% of US adults had received a flu shot by mid-November 2008, but more than half of those surveyed said they didn't plan to get the immunization.

William Schaffner, MD, president-elect of the National Foundation for Infectious Diseases, responded to the report, "This is a first-time opportunity to give ourselves a report card in the middle of the season, and we'll do what we have to do to improve uptake." He also chairs the Department of Preventive Medicine at the Vanderbilt University School of Medicine.

The release of the study is among several nationwide initiatives this week to support National Influenza Vaccination Week, designated by the Centers for Disease Control and Prevention (CDC) to raise public awareness of the importance of flu vaccination and to urge providers to extend their vaccination efforts into December and through the rest of the flu season.

Additional information on the survey results and methodology available at http://www.rand.org/health/projects/flu_survey/.
(CIDRAP 12/10/08)

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2. Infectious Disease News

Asia
China (Beijing): Two children fall ill after hepatitis A vaccine
On 6 Dec 2008, the Jinghua Times reported that the daughter of a resident of Chaoyang District has suffered fever for two days since receiving a hepatitis A vaccination at a Balizhuang neighborhood clinic. Prior to this case, a second girl suffered fever and died after receiving hepatitis A vaccine from the same lot at an unidentified clinic in Fengtai District.

As of the announcement, the city's Bureau of Health had not yet received a report from disease control agencies. The bureau stated that the fevers could not yet be positively attributed to the vaccines. This lot of vaccine will not be suspended from citywide use. Beijing's disease control agencies will closely follow the use of this lot of vaccine.

An official from disease control and the prevention department of the Bureau of Health said that all vaccines in Beijing are sourced via established channels and purchased through government tender.
(ProMED 12/9/08)

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Indonesia: Chikungunya outbreak continues to spread in Central Java
An emergency has been declared due to the increasing number of areas experiencing chikungunya epidemics in Boyolali district, Central Java. The seasonal transition period has lasted longer than usual, which favors the development of the vectors that transmit the virus.

During November 2008, four foci were discovered among 172 people infected with the chikungunya virus. During 2008, 456 residents have been recorded with chikungunya virus infections. The usual seasonal transition period is January until March, while the current transition period started early in September 2008.

"In no cases have the victims died because the disease does generally not endanger lives. However, the economic impact is more striking than the symptoms of dengue fever as chikungunya's effects remain afterward, with pain in the joints and muscles that can last up to months, or even longer," said the head of field and disease prevention and environmental health, in the District Health Office, Boyolali.
(ProMED 12/11/08)

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Indonesia: Rabies outbreak in Bali
Health authorities in Western Australia (WA) have issued a warning about an outbreak of rabies in Bali. The Indonesian government has confirmed the presence of the disease in the Kuta area, and local media are reporting that several Balinese people showing rabies symptoms have died after being bitten by dogs. Bali had previously been considered rabies-free, but two dogs have been confirmed as having the disease.

Paul Van Buynder from the Washington Health Department says the symptoms can take up to eight weeks to develop and include headaches, fevers, tingling and confusion. "Cases that develop clinical symptoms almost invariably die," he said. He says anyone bitten or scratched by a dog, monkey or cat in Bali since August 2008 should see their doctor. Dr Van Buynder says those who are planning to travel to the island should avoid direct contact with animals while on the island.
(ProMED 12/11/08)

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Russia (Yaroslavskaya Oblast): Hemorrhagic fever with renal syndrome update
Two cases of hemorrhagic fever with renal syndrome (HFRS) have been registered in the Danilovsk region. Rodents are the source of this infection. While the situation is not yet an epidemic, officials are concerned. The risk of infection increases in autumn, when plant and hay storage facilities are full.

Early diagnosis is difficult because of non-specific signs and symptoms. Epidemiologists recommend that particular attention be paid to possible contacts with rodents. In addition, three more regions are also affected by HFRS: the Uglichskoe, Rostovskoe and Lyubimskoe regions. The public health authorities forecast that incidence rates will decrease during the winter but will increase again in spring when rodents begin to breed again.
(ProMED 11/29/08)

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Americas
Peru: Rat infestation poses risk of bubonic plague outbreak
Mr Manuel Aguinaga-Perez, mayor of Oyotun, reported on 3 Dec 2008 that the city council of Oyotun, a district located 83 km east from Chiclayo, is declaring an emergency alert because of the risk for a potential outbreak of bubonic plague as a result of the presence of a "massive" number of rats that have destroyed 360 hectares (890 acres) of crops in this area.

Mr Aguinaga reported that specialists from the Ministry of Health had found up to 25 Asiatic rat fleas (Xenopsylla cheopis), vectors of bubonic plague, per rat. For this reason, he declared that they fear the occurrence of an outbreak of plague. A similar situation occurred 14 years ago in Morrope District, where more than 100 people died. "This phenomenon alarmed local health authorities, and we are working alongside every involved area in order to prevent the occurrence of a deadly epidemic," he declared.

Even though Mr Aguinaga pointed out that to date not a single case of plague has been reported in Oyotun, he said "there is a potential threat that may expand and burst like a flame, and this is an important reason for concern." He indicated that the communities of Campo Nuevo, Zorronto, Pan de Azucar, Macuaco, and Espinal had lost about 360 hectares of crops, mainly cornfields, because of the massive presence of rats, and this has caused serious economical problems for local farmers.

"We are requesting from the regional government financial support, particularly seeds for affected farmers," Mr Aguinaga added. He also observed that the presence of a large number of rats had been reported since June 2008, and now has spread to the higher parts of the district.

Mr Aguinaga pointed out that, under the leadership of the Ministry of Health, a coordinated plan was elaborated with the participation of the agricultural sector and the district municipality, since massive rodent elimination may lead fleas to feed on other warm-blooded mammals.
(ProMED 12/8/08)

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USA (Missouri): First human rabies death in over 50 years in Missouri
State health officials report Missouri's first human death from rabies in nearly a half-century. The victim is identified only as a 55-year-old southern Missouri man who died 30 Nov 2008, about six weeks after he was bitten by a bat.

The Missouri Department of Health and Senior Services called it the state's first human rabies death since 1959. That one occurred in Pulaski County. Officials say the latest victim was bitten on the left ear by a bat in mid-October 2008 and became ill with rabies symptoms 19 Nov 2008.

The Centers for Disease Control and Prevention confirmed last week that the man had a rabies virus associated with silver-haired and eastern pipistrelle bats. Rabies isn't spread by casual human contact. But five people who might have had contact with the bat or the patient are receiving preventive treatment.
(ProMED 12/2/08)

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USA (New Mexico): Reports second hantavirus death in 2008
The New Mexico Department of Health has just announced the state's second hantavirus death in the state in 2008, confirming that a 22-year-old woman from Otero County has died.

"Hantavirus is caused by rodents and rodent dropping so what people need to do is they need to be very careful when they are cleaning out places. They need to use disinfectant, they need to air them out and they really need to take a lot of precaution," said Chris Minnick with the New Mexico Department of Health. In 2007, New Mexico had three cases of Hantavirus with one death.
(ProMED 12/6/08)

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USA (Oklahoma): Restaurant linked to large E. coli outbreak to resume business
The Oklahoma State Department of Health announced on 29 Nov 2008 that the Economy Cottage restaurant in Locust Grove, Oklahoma has undergone a rigorous inspection process and has been cleared to resume normal business operations. The restaurant had been closed since 25 Aug 2008 after being identified as the source of a large food borne outbreak in northeastern Oklahoma resulting in severe diarrheal illness.

The restaurant passed an inspection conducted by state and local health inspectors on 12 Nov 2008. The inspection included environmental swabbing of 35 locations within the restaurant, and no E. coli O111 contamination was identified. The outbreak was linked in August 2008 to contamination by E. coli O111, a rare toxin-producing bacterium not normally associated with a food borne outbreak of the magnitude experienced in Oklahoma. While no single food item was found to be the source of illness at the restaurant, the Oklahoma State Department of Health believes several different foods became contaminated with the E. coli O111 bacteria, leading to exposure of restaurant customers from 15-24 Aug 2008.

Health officials note that toxin-producing E. coli are notoriously difficult to culture from food or the environment. This provided a challenge throughout the investigation. Despite testing numerous surfaces within the restaurant, various food items, stool specimens from food handlers, and well water specimens, no specimen yielded the E. coli O111 bacteria.

A total of 341 outbreak-related cases were reported; 56 were children less than 18 years of age. The age range of cases was 3 months to 88 years. Seventy-two persons were hospitalized and one person died.
(ProMED 12/1/08)

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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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DENGUE
Australia
Health authorities expect there will be more cases of dengue fever in Cairns, in far north Queensland, after two people were diagnosed with the mosquito-borne disease virus. An outbreak has been declared, with the Tropical Population Health Service also investigating another five suspected cases.

Medical entomologist Dr Scott Ritchie says the infections are centered in the Cairns north area. "The worrisome thing about this is it's in an area of older housing and with the rains that we've had in the last fortnight, we suspect there's a fair amount of mosquito breeding going on in the area," he said.

It has been four years since the last outbreak of dengue fever in Cairns, when 29 people fell ill.
(ProMED 12/5/08)

Cambodia
Cambodian health officials have warned of a possible outbreak of dengue fever in 2009 as the number of children seeking treatment continues into the disease's low season, state media reported.

"Every day, the hospital still receives more than 20 children with dengue fever," said Lam Eng Hour, deputy director of Phnom Penh's Kantha Bopha children's hospital. "We are worried this is a sign that the number (of infections) will be higher next year [2009]," he added.

According to Lam Eng Hour, Kantha Bopha hospitals in both Phnom Penh and Siem Reap have received 5552 dengue cases so far in 2008, of which 43 have been fatal. He said that despite being a dramatic decrease from the 23,000 cases of 2007, children lining up for dengue treatment this late in the year is a bad sign for 2009. "An outbreak can happen every two years," he said.

National statistics from January to November 2008 showed that throughout the country 8783 cases have been recorded by national and Kntha Bopha hospitals, said Ngan Chantha, the national dengue control program director at the Ministry of Health.
(ProMED 12/8/08)

Viet Nam
National
The Health Ministry said on 24 Nov 2008 that more than 78,500 dengue fever cases were recorded so far in 2008, with 79 people who died.

The number of dengue fever patients in October 2008 grew by over 20 percent while the number of deaths was reduced by seven compared with 2007. In November 2008, the disease spread widely in many provinces and cities, resulting in 15,000 new cases and 15 deaths.

The Hanoi Department of Health said Hanoi had nearly 1700 patients in November 2008 with no deaths. Dengue fever patients in the capital city live in 170 communes and wards of 21 districts. Around 81 percent of them are in the inner city.

Ho Chi Minh City
Dengue fever patients have overloaded the Ho Chi Minh City Hospital for Tropical Diseases recently, with between 30 and 50 adult patients admitted every day. Ho Chi Minh City doctors have reported an alarming increase in the number of dengue fever cases, up to three times the number of cases usually reported at this time of year.

HCMC Hospital for Tropical Diseases Deputy Director Tran Tinh Hien said the hospital had admitted between 150 and 200 dengue fever patients. Hien said, "Most patients come from District 2, District 7, and Tan Binh District. The number of cases is double or sometimes triple the number we had at the same time last year [2007]."

Until October 2008, the hospital, the city's main facility for treating dengue patients, had admitted 9600 dengue cases, 70 percent of which were adults. Hien said patients admitted were as old as 50 years when typically the maximum age for dengue patients is 25.

The increase in the number of cases has been blamed for the extended rainy season, which usually ends in late October and the increasingly polluted urban environment that has created ideal conditions for mosquitoes to breed.
(ProMED 12/5/08)

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4. Articles
Progress in global measles control and mortality reduction, 2000-2007
US Centers for Disease Control and Prevention. MMWR. 5 Dec 2008; 57(48): 1303-1306. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5748a3.htm?s_cid=mm5748a3_e. (references removed)

Despite the availability of a safe and effective vaccine since 1963, measles has been a major killer of children in developing countries (causing an estimated 750,000 deaths as recently as 2000), primarily because of underutilization of the vaccine. At the World Health Assembly in 2008, all World Health Organization (WHO) member states reaffirmed their commitment to achieving a 90% reduction in measles mortality by 2010 compared with 2000, a goal that was established in 2005 as part of the Global Immunization Vision and Strategy. This WHO-UNICEF comprehensive strategy for measles mortality reduction focuses on 47 priority countries. The strategy's components include 1) achieving and maintaining high coverage (>90%) with the routinely scheduled first dose of measles-containing vaccine (MCV1) among children aged 1 year; 2) ensuring that all children receive a second opportunity for measles immunization (either through a second routine dose or through periodic supplementary immunization activities [SIAs]); 3) implementing effective laboratory-supported disease surveillance; and 4) providing appropriate clinical management for measles cases. This report updates previously published reports and describes immunization and surveillance activities implemented during 2007. Increased routine measles vaccine coverage and SIAs implemented during 2000--2007 resulted in a 74% decrease in the estimated number of measles deaths globally. An estimated 197,000 deaths from measles occurred in 2007; of these, 136,000 (69%) occurred in the WHO South-East Asian Region. Achievement of the 2010 goal will require full implementation of measles mortality reduction strategies, especially in the WHO South-East Asian Region.

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Half-Dose Influenza Vaccine: Stretching the Supply or Wasting It?
Falsey AR. Arch Intern Med. 2008; 168(22):2402-2403. (references removed)

Editorial
Seasonal influenza is responsible for 200 000 to 400 000 hospitalizations and 20 000 to 40 000 deaths annually in the United States. At present, the cornerstone of influenza control is vaccination. Groups recommended by the Advising Committee on Immunization Practices (ACIP) to be vaccinated yearly include all adults older than 50 years, children aged 6 to 23 months, chronically ill persons, and health care workers. Although an effective live attenuated vaccine is approved for persons aged 5 to 49 years, trivalent inactivated vaccine (TIV) remains the primary method of vaccination for the majority of at-risk populations. The production of adequate supplies of yearly influenza vaccine is challenging for a number of reasons, including the need to anticipate new circulating strains in advance, adaptation of new variants for growth in embryonated hens' eggs, and an expanding target population. These issues are further complicated by the exodus of US vaccine manufacturers.

Full letter available at http://archinte.ama-assn.org/cgi/content/extract/168/22/2402.

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Half- vs Full-Dose Trivalent Inactivated Influenza Vaccine (2004-2005)--Age, Dose, and Sex Effects on Immune Responses
Engler, RJM et al. Arch Intern Med. 2008; 168(22): 2405-2414. Available at http://archinte.ama-assn.org/cgi/content/short/168/22/2405.

Background Optimal public health strategies for managing influenza vaccine shortages are not yet defined. Our objective was to determine the effects of age, sex, and dose on the immunogenicity of intramuscular trivalent inactivated vaccine (TIV).

Methods Healthy adults aged 18 to 64 years, stratified by age (18-49 and 50-64 years) and sex, were randomized to receive full- or half-dose TIV. Hemagglutination inhibition titers against vaccine antigens were measured before and 21 days after immunization. A primary outcome of noninferiority was defined as a difference of less than 20% in the upper 95% confidence interval (CI) of the proportion of subjects with strain-specific hemagglutination inhibition antibody titers of 1:40 or higher after vaccination. Secondary outcomes included geometric mean titers, after vaccination side effects, and occurrences of influenza-like illnesses.

Results Among previously immunized subjects (N = 1114) receiving half- vs full-dose TIV (age, 18-49 years, n = 284 [half] and n = 274 [full]; and age 50-64 years, n = 276 [half] and n = 280 [full]), CIs for proportions of subjects with hemagglutination inhibition antibody titers of 1:40 or higher excluded substantial reduction for all antigens in the 18- to 49-year age group and for B/Shanghai/361/2002 (B) and A/Fujian/411/2002 (A/H3N2) in the 50- to 64-year age group. Geometric mean titer in the female 18- to 49-year age group exceeded male responses for all strains: responses to half-dose TIV that were comparable with male full-dose responses for A/New Caledonia/20/99 (A/H1N1) antigen, 25.4 (95% CI, 20.9-30.9) vs 25.6 (95% CI, 21.3-30.9); A/H3N2 antigen, 60.8 (95% CI, 50.8-72.7) vs 44.1 (95% CI, 37.6-51.8); and B antigen, 64.4 (95% CI, 53.9-76.9) vs 60.7 (95% CI, 51.4-71.7) (findings were similar for the 50- to 64-year age group). Some injection site and systemic reactions (myalgias and/or arthralgias [P < .05], headache [P < .001], and impact of fatigue [P < .05]) were significantly lower in men. The relative risk of medical visits and hospitalizations for influenza-like illnesses were similar in the half- and full-dose groups regardless of age.

Conclusions Antibody responses to intramuscular half-dose TIV in healthy, previously immunized adults were not substantially inferior to the full-dose vaccine, particularly for ages 18 to 49 years. Significantly higher geometric mean titer responses in women were identified for all ages, regardless of dose or influenza strain. Half-dose vaccination may be an effective strategy for healthy adults younger than 50 years in the setting of an influenza vaccine shortage.

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Update: Influenza Activity--United States, September 28--November 29, 2008
US Centers for Disease Control and Prevention. MMWR. 12 Dec 2008; 57(49): 1329-1332. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5749a3.htm.

During September 28--November 29, 2008, influenza activity remained low in the United States. Of the few influenza viruses characterized thus far this season, most are antigenically related to the strains included in the 2008--09 influenza vaccine. Oseltamivir-resistant influenza A (H1N1) viruses have been detected, but currently available data are insufficient to predict their prevalence for the 2008--09 season. This report summarizes U.S. influenza activity since the last update and reviews new influenza vaccine recommendations for the current season.

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Prevention and Treatment of Seasonal Influenza
Glezen WP. NEJM. 11 Dec 2008; 359(24): 2579-2585. Available at http://content.nejm.org/cgi/content/full/359/24/2579.

Abstract
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

In February 2007, fever developed in a previously healthy 15-year-old girl, with a peak temperature of 102°F (38.9°C) and mild upper respiratory congestion. The next day she was seen by her primary care physician. A rapid screening test for group A streptococcus was negative, and oseltamivir was prescribed. After two doses, she continued to have fever and also had nausea and emesis, malaise, and restlessness but could not get out of bed. Two days later, she was taken to the local emergency room, where she was found to be hypotensive. Despite intensive resuscitative efforts, she died 12 hours later; the postmortem examination showed necrotizing pneumonia and extensive alveolar hemorrhage. A viral culture confirmed an influenza A (H1N1) infection, and methicillin-resistant Staphylococcus aureus was isolated from a tracheal aspirate. Could this death have been prevented?

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Community Planning for Pandemic Influenza: Lessons From the VA Health Care System
Lurie N et al. Disaster Med and Public Health Prep. 2008; 2(4): 251-257. Available at http://www.dmphp.org/cgi/content/abstract/2/4/251.

Abstract
Background Coordination and communication among community partners—including health departments, emergency management agencies, and hospitals—are essential for effective pandemic influenza planning and response. As the nation’s largest integrated health care system, the US Department of Veterans Affairs (VA) could be a key component of community planning.

Purpose To identify issues relevant to VA–community pandemic influenza preparedness.

Methods As part of a VA–community planning process, we developed and pilot-tested a series of tabletop exercises for use throughout the VA system. These included exercises for facilities, regions (Veterans Integrated Service Networks), and the VA Central Office. In each, VA and community participants, including representatives from local health care facilities and public health agencies, were presented with a 3-step scenario about an unfolding pandemic and were required to discuss issues and make decisions about how the situation would be handled. We report the lessons learned from these pilot tests.

Results Existing communication and coordination for pandemic influenza between VA health care system representatives and local and regional emergency planners are limited. Areas identified that would benefit from better collaborative planning include response coordination, resource sharing, uneven resource distribution, surge capacity, standards of care, workforce policies, and communication with the public.

Conclusions The VA health system and communities throughout the United States have limited understanding of one another’s plans and needs in the event of a pandemic. Proactive joint VA–community planning and coordination—including exercises, followed by deliberate actions to address the issues that arise—will likely improve pandemic influenza preparedness and will be mutually beneficial. Most of the issues identified are not unique to VA, but are applicable to all integrated care systems.

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Avian Influenza Outbreaks in Chickens, Bangladesh
Biswas PK et al. Emerg Infect Dis. Dec 2008. 14(12). Available at http://www.cdc.gov/eid/content/14/12/1909.htm.

Abstract
To determine the epidemiology of outbreaks of avian influenza A virus (subtypes H5N1, H9N2) in chickens in Bangladesh, we conducted surveys and examined virus isolates. The outbreak began in backyard chickens. Probable sources of infection included egg trays and vehicles from local live bird markets and larger live bird markets.

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Weekly Epidemiological Record Bulletin
WHO. 12 Dec 2008, 83(50): 449-460. Available at http://www.who.int/wer. Contents of this issue:1) Outbreak news: cholera in Zimbabwe; 2) Update on progress controlling yellow fever in Africa, 2004-2008; 3) Global leprosy situation, 2008

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5. Notifications
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 vaccine delivery. Visit www.mrcglobal.org/rfp for further information. The deadline to submit proposals is January 16, 2009.

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XI International Symposium on Respiratory Viral Infections
Dates: 19-22 February 2009
Location: Bangkok, Thailand

World opinion leaders will address key topics including epidemiology, pathogenesis, clinical, vaccinology and prevention, antivirals and therapeutics, as well as a minisymposium on avian influenza H5N1 animal-human interface.

Additional information available at www.themacraegroup.com.

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 apecein@u.washington.edu