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Vol. XII, No. 1 ~ EINet News Briefs ~ Jan 09, 2009


*****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
- Cumulative number of human cases of avian influenza A/(H5N1)
- China (Beijing): Woman dies of avian influenza H5N1
- China (Shenzhen)/Hong Kong: Recent avian influenza outbreak attributed to migratory birds
- India (West Bengal): Resumes culling activities with new outbreak of avian influenza H5N1
- Viet Nam: Girl confirmed to be infected with avian influenza H5N1

2. Infectious Disease News
- Australia: Travelers to Malaysia diagnosed with chikungunya infection
- China (Shenzen)/Hong Kong: Update on Streptococcus infection in patients of psychiatric ward
- Indonesia: Rabies infection suspected in death of child
- Russia: Zoonotic disease predictions for 2009
- Russia (Bashkiria): Echinococcosis cases on the increase
- Russia (Udmurtia): Hemorrhagic fever with renal syndrome outbreak at fur farm
- Singapore: Chikungunya cases on the rise in spite of a reduction in dengue fever in 2008
- Singapore: Man dies and ten others are hospitalized due to chickenpox infection
- USA: Officials probe multistate Salmonella outbreak

3. Updates
- AVIAN/PANDEMIC INFLUENZA
- DENGUE
- CHOLERA, DIARRHEA, & DYSENTERY
- TYPHOID

4. Articles
- Severe Acute Respiratory Syndrome–Associated Coronavirus Infection in Toronto Children: A Second Look
- Survey of Hospital Healthcare Personnel Response during a Potential Avian Influenza Pandemic: Will They Come to Work?
- Burden of Influenza-Like Illness and Effectiveness of Influenza Vaccination among Working Adults Aged 50–64 Years

5. Notifications
- Preparing for pandemic influenza—guidance for GP practices
- US National Center for Education Statistics releases literacy report
- US Health and Human Services secretary releases Pandemic Planning Update VI report
- XI International Symposium on Respiratory Viral Infections


1. Influenza News

Global
Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

2008
Bangladesh / 1 (0)
Cambodia/ 1 (0)
China / 4 (4)
Egypt / 8 (4)
Indonesia / 22 (18)
Viet Nam / 6 (5)
Total / 42 (31)

***For data on human cases of avian influenza prior to 2009, go to:
http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 393 (248).
(WHO 1/7/09 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 12/16/08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 12/24/08):
http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 1/5/09):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Asia
China (Beijing): Woman dies of avian influenza H5N1
A 19-year-old woman has died of bird flu in the Chinese capital Beijing. It is the first time in almost a year that someone in China has died after being infected with the H5N1 strain of avian influenza virus. It was confirmed by the World Health Organization on 7 Jan 2009 as the first human death due to avian influenza H5N1 virus in 2009. Of the 31 cases confirmed to date in China, 21 have been fatal.

The woman was admitted to hospital on 24 Dec 2008, and it was reported that she had bought a duck at a market outside of Beijing. She is thought to have become unwell after slaughtering the bird. Beijing veterinary agencies carried out a strict inspection in the area surrounding the patient's residence. The inspection found that there is no poultry raised at the patient's residence or within a 10-km area.

An epidemiological investigation of Chaoyang, Tongzhou, Miyun and other districts found no abnormal circumstances among poultry. A national immunization investigation in December 2008 showed that Beijing's avian influenza immunization density was 100 percent. The qualified (confirmed) antibody rate was 100 percent. In 2008, Beijing took a total of 41,641 surveillance samples for avian influenza and all were negative.
(ProMED 1/6/09, WHO 1/7/09)

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China (Shenzhen)/Hong Kong: Recent avian influenza outbreak attributed to migratory birds
A recent bird flu outbreak was likely caused by droppings from migrating wild birds rather than from smuggled ones, experts believe. A government-appointed committee has completed its initial investigation into the deaths of 200 chickens in a Yuen Long farm early in December 2008, which led to a cull of 100,000 birds and a 21-day ban on the sale of fresh fowl. The report will be submitted to the Food and Health Bureau this week.

The report studied several possible factors behind the contamination but concluded there was no evidence linking it to smuggling activities. It was more likely caused by contaminated feces dropped by migrating birds inside the farm or nearby area. It may have stuck onto a worker's garment and was carried into the farm, the report said.

Veterinarians and experts of the Agriculture, Fisheries and Conservation Department (AFCD) who visited the farm found room for improvement in some of the biosecurity measures already in place. They made 10 suggestions to prevent another outbreak.

Another source said biosecurity and vaccines are the two most important things farms need to control in order to prevent bird flu outbreaks. It is questionable whether all chickens on the farm were vaccinated, but that trying to identify the real cause of the infection was challenging since much of the evidence had been lost during the cull. The owner, Wong Yee-chuen, said the farm is still being sanitized and cannot resume operations until the government is satisfied with the hygiene conditions.

The AFCD suggested that a metal cover be built for the chicken houses to avoid droppings of migrating birds. It also suggested workers change gloves when handling different lots of chickens to prevent cross contamination. Wong said he welcomed all suggestions made by the committee as long as they were viable and reasonable. Workers, from now on, will wear thin plastic gloves on top of cotton ones. He said the outbreak and the aftermath has cost him HKD 2 million to HKD 3 million (USD 257,949 to USD 386,934).
(ProMED 1/6/09)

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India (West Bengal): Resumes culling activities with new outbreak of avian influenza H5N1
A fresh outbreak of bird flu was reported in Darjeeling on 7 Jan 2009, prompting the authorities to restart culling operations, an official said. "We have started culling operations at Rangli Ranglikot area of Darjeeling. This time, a total of 7000 poultry will be culled," district magistrate Surendra Gupta stated.

Gupta said the blood samples of dead poultry from the area sent to the High Security Disease Diagnostic Laboratory in Bhopal had tested positive for the H5N1 strain of avian flu. About 31,000 poultry have already been culled at Matigara in Siliguri subdivision and Pubang in Takdah of Darjeeling sub-division of the same district after avian flu was confirmed in the areas on 3 Jan 2009.
(ProMED 1/8/09)

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Viet Nam: Girl confirmed to be infected with avian influenza H5N1
An 8-year-old Vietnamese girl from the country's northern Thanh Hoa Province has been infected with bird flu and hospitalized, said an official with the National Steering Committee for Avian Influenza on 6 Jan 2009. The WHO confirmed the infection on 7 Jan 2009. The girl ate chicken before being hospitalized, the official stated. Specimens from poultry raised in Dien Chung town, where the girl is from, have recently tested positive for bird flu virus, the official added. The girl is now being treated at the Viet Nam National Institute of Hygiene and Epidemiology and is in stable condition.

The patient’s older sister died with similar symptoms during the week of 29 Dec 2008, and the director of the hospital where she was treated said she probably also had avian flu. "We suspect that it was bird flu that caused her death," said Truong Thi Mau, director of the Ba Thuoc district hospital. "But we can't be 100 percent sure because there was no sample for tests. At the time, we thought her illness was something else," Mau said. Both girls had eaten duck and chicken raised on the family farm, Mau said.

The 13-year-old developed a high fever and severe cough on 25 Dec 2008 and died in the district hospital on 2 Jan 2009, Mau said. After her 8-year-old sister was confirmed to be infected with H5N1, about 50 children with flu symptoms were brought in by nervous parents in the area, but tests for avian influenza were negative on all of them, she said.

The failure to retain clinical samples from the 13-year-old sister of the confirmed case of avian H5N1 influenza implies that this case will likely remain a suspected case only. The presumed infection of two members of the same family does not necessarily imply human-to-human transmission, as both girls had contact with the same diseased birds.

Five Vietnamese people died of bird flu in 2008 out of 6 reported H5N1 infections, all in the north of the country, in the first quarter of the year, when cooler temperatures allow the virus to thrive. About 7800 poultry have been culled in Dien Chung Town to prevent the spread of the disease. This is the first human case reported in the country in 2009.
(ProMED 1/6/09, WHO 1/7/09, ProMED 1/9/09)

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2. Infectious Disease News
Australia: Travelers to Malaysia diagnosed with chikungunya infection
Two Australian travelers who recently returned to Brisbane from Sibu Island off the east coast of Malaysia have been diagnosed with chikungunya virus infection. Dr. Susan Vlack from Moreton Bay Public Health Unit said that the 56-year-old woman and her 53-year-old male companion fell ill within five days of arriving in Sibu, Johor province for a holiday. Both were exposed to mosquito bites and contracted similar symptoms of fever, joint pain and rash.

Viral RNA recovered from patient serum was analyzed by RT-PCR and nucleotide sequencing. Results indicate that the partial E1 gene sequence obtained from the imported Malaysian strain was 100 percent homologous with previous Indian and Italian 2007 imported strains and contained one nucleotide difference compared to 2006 strains from Mauritius and Reunion Island.
(ProMED 12/31/08)

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China (Shenzen)/Hong Kong: Update on Streptococcus infection in patients of psychiatric ward
A spokesperson for Tai Po Hospital (TPH) issued an update regarding reports that males in the psychiatric ward have presented with symptoms of skin abscess and whose test results have been confirmed to be positive with Streptococcus pyogenes (also called group A Streptococcus) on 22 Dec 2008.

Test results of three more patients from the ward in question have been confirmed to be positive for Streptococcus pyogenes. In addition, test results of a 74-year-old patient in another male psychiatric ward have also confirmed him to be positive for the bacteria. Up to now, the test results of 15 patients (aged from 20-76) in total in the psychiatric unit have been confirmed to be positive for the bacteria.

All patients are now being treated under isolation and in stable condition. Admission and visiting to the wards concerned will continue to be suspended. Infection control measures have been stepped up and all patients are under close surveillance. The TPH Infection Control Team has reported the case to the Hospital Authority and the Centre for Health Protection.
(ProMED 12/31/08)

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Indonesia: Rabies infection suspected in death of child
A four-year-old boy, who was suspected of contracting rabies after a dog bit him in June 2008, died in Sanglah Hospital on 30 Dec 2008. The Badung health authority did not inform about the boy's death. The information came from an anonymous source and media was able to get official confirmation of the death on 5 Jan 2009.

The boy was a resident of Kutuh village, South Kuta, which has been classified as a rabies-prone area. It is not yet clear whether the boy had in fact died of rabies, as hospital officials could not provide laboratory results yet, but observations indicated the boy had shown symptoms similar to rabies-infected patients prior to his death, including fear of water, uncontrollable convulsions and excessive drooling.

"Public testimonies and the physician in the South Kuta public health center said the boy was exhibiting symptoms of rabies infection, but he died before the laboratory results had come back," said I Ketut Suiadnyana, head of Disease Observation and Prevention at the Badung Health Agency. "We are currently working to gather the boy's medical history." Kutuh village Chief I Wayan Litra confirmed the boy had been bitten by a dog six months ago, and the dog that had bitten him died a week later. "Soon after, the boy came down with a high fever but was nursed back to health. Then last week, he began convulsing uncontrollably, so his parents took him to Sanglah Hospital, where he died," Litra said.

Head of South Kuta's public health center, Sastrawan, said he planned to interview the boy's parents to verify whether the boy had been bitten a second time and to gather other relevant medical information.

Four people are believed to have died from rabies in the last few months of 2008. The alleged victims all died after being bitten by dogs. Of the four individuals, only one showed clinical symptoms specific to rabies-infected patients. The discovery of a rabid canine on 26 Nov 2008 and the number of deaths have prompted Bali Governor Made Mangku Pastika to declare south Kuta a rabies-prone area.

The province conducted a mass culling and vaccination program in the area, which was recently expanded to include south Denpasar, the area adjacent to south Kuta. Banners and billboards have been put up in the area to warn people against transporting dogs, cats, or primates into and out of Bali until the rabies situation is under control.

Also, 503 wild dogs have been culled from south Kuta since the outbreak. I Gusti Ngurah Mahardika, a veterinarian and rabies management team member, said rabies was 100 percent preventable if an infected person was immediately vaccinated and the bite wound immediately cleaned with soap. "The most important thing is to not let dogs roam wild outside the house. One infected dog can transmit the disease to 10 other dogs within a week," he said.
(ProMED 1/6/09)

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Russia: Zoonotic disease predictions for 2009
Tick-borne diseases
In 2009, the probability of natural-focus infections is enhanced as the result of the increase in above normal temperatures in the autumn-winter months of 2008. In the European territory of the country, it was abnormally warm in November-December 2008, and the presence of a large forage reserve due to a high grain and forest mast yield will likely lead to increased rodent populations. This increase in the population of carriers in the natural foci results in an increased probability of tick-borne diseases for 2009.

While the vectors of concern are wild rodents transmitting tick-borne encephalitis virus (a flavivirus), the same prediction could be made for the hantaviruses associated with hemorrhagic fever with renal syndrome, transmitted not by ticks, but by dust contaminated with the carrier rodents' urine and feces.

Anthrax
In 2009, the occurrence of epizootic foci of anthrax is probable in territories of the Southern, Central, Volga, and Siberian Federal Districts, possibly caused by cattle being pastured on livestock burial grounds, with animal cases leading to subsequent human infection.

However, risky cattle graves tend to be the exception, not the rule. A grave will only pose a risk if the carcass had been scavenged or butchered/necropsied before burial. Additional risk factors include inadequate vaccination, non-reporting of unexpected livestock deaths, and ongoing recontamination following field-butchering sick and dead cattle.

Rabies
An increase in the average long-term amount of rabies is predicted among animals mainly in the Central, Volga and Southern Federal Districts, where there will be a consequent high risk for human cases. The greatest number of victims will likely be observed among city dwellers, due to population movements, and an increasing number of wild carnivorous animals and neglected pets.

In response to this prediction, perhaps the authorities will step up vaccination of dogs and cats in at-risk regions. In addition, if foxes are a main wildlife reservoir in Russia, public health officials could consider an oral vaccination program similar to the successful ones carried out in other European countries.
(ProMED 1/4/09)

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Russia (Bashkiria): Echinococcosis cases on the increase
For the last two years Bashkiria has experienced a serious rise in echinococcosis cases. During 2008 there were 53 cases identified, which is 1.7 times higher than 2007. People who are most at risk are those who are in contact with cattle or other domestic animals

The danger of the disease is that it can be latent for years and then reveal itself. Preventive measures include: limiting contact with dogs, washing hands after each contact with animals, washing hands after work in an orchard (where cattle have wandered), not using unwashed greens or vegetables, and not drinking water from natural or untreated sources.

Echinococcosis has been known for more than 2000 years and is a still an important human health problem. More than 500 cases are registered in Russia annually. Fatal cases are associated with late diagnosis. For example, in 2005 there were three fatal cases due to echinococcosis. A high rate of infection among animals is seen if control measures and dog deworming are not performed regularly.
(ProMED 12/29/08)

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Russia (Udmurtia): Hemorrhagic fever with renal syndrome outbreak at fur farm
The number of workers at a fur farm in the Mozhayskiy District of Udmurtia admitted to the hospital with a diagnosis of hemorrhagic fever with renal syndrome (HFRS) has reached 16. Specialists predict an increase in the number of HFRS cases. Airborne transmission of infection during the processing of fur pelts from slaughtered animals is thought to be the source of the infection.

The removal of fat from skins at the fur farm is carried out using sawdust obtained from a storehouse in a nearby forest area. According to Nailya Bogdanova, a pest control specialist in the infection control department of Rospotrebnadzor (Federal Services for Consumer Protection and Human Welfare), it is likely that forest rodents, which are the vector of HFRS] live in the stored sawdust. At least 100 persons are engaged in the processing of the furs of the slaughtered animals, which leads to the prediction that the number of cases will increase.
(ProMED 1/2/09)

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Singapore: Chikungunya cases on the rise in spite of a reduction in dengue fever in 2008
With intensified efforts in 2008, Singapore's fight against dengue appears to have paid off, with 25 percent fewer cases than 2007. However, a newly emerged Aedes mosquito-borne illness is causing fresh concerns. Chikungunya cases continued their upward trend, with more than 40 cases a week in the past since the beginning of December 2008.

Of the 43 cases diagnosed during the week of 14 Dec 2008, 39 caught the virus locally, while the other four imported cases were from Malaysia. On 19 Dec 2008, the Ministry of Health made chikungunya a notifiable disease. Although doctors have already been informing the ministry of all cases since the end of 2006, when Singapore saw its first imported chikungunya case, the change means that doctors could be penalized with fines or jail terms for not doing so. A ministry spokesman said this will enable the ministry to monitor the disease more closely. A circular has gone out to all doctors informing them of the change.

The appearance of locally transmitted chikungunya infections in Singapore this year also worries infectious diseases experts. Although no one has died of the infection, chikungunya, unlike dengue, can be very debilitating. There is also the risk that it could become endemic with no chance of wiping it out. The Health Ministry said the disease has not become endemic yet, as a large number of cases are still from overseas.

Prior to 2008, the few cases were all imported. But by the middle of December 2008, 388 people had caught the virus locally. An additional 158 people who were infected were bitten by mosquitoes while overseas, primarily in Malaysia. The areas in Singapore where people are getting bitten by the Aedes mosquito have also spread from the northern part of the island to places such as Bedok Reservoir and Tampines in the east.

Cases have also been on the increase, rising sharply since the end of July 2008. Given the current rates of infection, Singapore is likely to end the year with more than 600 chikungunya cases. A spokesperson for the National Environment Agency (NEA) said the Aedes albopictus mosquito, which is the main carrier of this virus, lives in forests and other heavily vegetated areas.

This makes it "a challenge to remove as many breeding habitats as possible in such areas," she said. She added that the current rainy season is unlikely to be the cause of the increased rates. Instead, it has more to do with "the movement of infected cases and the susceptibility of the population". The NEA spokesperson said it is fighting chikungunya the same way it does dengue -- by finding and destroying mosquito breeding spots and educating the public about stagnant water.

The best way to stop the spread of the disease is to prevent mosquitoes from breeding. This year, the National Environment Agency has a team of 500 people doing just that. A mosquito needs just a small spoonful of stagnant water to breed. The A. aegypti breeds well in indoor receptacles but the A. albopictus prefers forests and places with high vegetation.
(ProMED 12/26/08)

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Singapore: Man dies and ten others are hospitalized due to chickenpox infection
A twenty-eight-year-old man was found dead in his dormitory room on 28 December 2008. Co-workers indicated that he had been sick for six days with chickenpox infection. He had made arrangements to obtain medical care, but other dormitory residents thought that he was sleeping and did not want to disturb him. Ten other workers were hospitalized for treatment of fever and rashes due to chickenpox.

The workers, all Bangladeshi men aged between 20 and 35, were living in two dormitories in Tagore Industrial Avenue. Workers said they worked for Gates Offshore, a ship repair and dormitory services company. They said the deceased man was also a company employee. They indicated that their main recourse when they fall ill is to call their employer and hope to be attended to. They said that their quarters had neither a sick bay nor a supervisor to check on their health.

Chickenpox can become deadly if it infects many organs in the body, especially the lungs, liver and nervous system, which causes them to fail. With their immune systems weakened by chickenpox, patients could contract another infection and die from the combined effects.
(ProMED 12/30/08)

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Americas
USA: Officials probe multistate Salmonella outbreak
An official at the US Centers for Disease Control and Prevention (CDC) has reported that the agency is investigating a Salmonella enterica serotype Typhimurium outbreak that has sickened 388 people in 42 states.

Frederick Angulo, the CDC's deputy chief of enteric diseases, said the source of the outbreak has not been determined and that the CDC has activated its emergency network to investigate the outbreak. He said all the cases have matching DNA fingerprints.

Yesterday the Ohio Department of Health (ODH) said that it was assisting in the investigation of the outbreak, which has sickened 50 state residents since October 2008. The ODH said Ohio had the nation's second highest number of cases.

"The lead hypothesis [about the Salmonella source] is chicken, but it's a hard thing to prove," the CDC's Angulo stated. "Everybody eats chicken."

Salmonellosis typically causes fever and nonbloody diarrhea that resolves in a week. Serotypes Typhimurium and Enteritidis are most the common strains of Salmonella bacteria in the United States, according to the CDC. In April 2008, an outbreak involving S Typhimurium was linked to contamination in the water system of Alamosa, Colorado. The same serotype was responsible for a 2006 outbreak linked to tomatoes.
(CIDRAP 1/7/09, CIDRAP 1/8/09)

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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
North Queensland is heading for its worst dengue fever outbreak in five years, with 52 cases already confirmed. Six people have been admitted to the hospital, while seven others are awaiting test results. Queensland Health senior medical entomologist, Brian Montgomery, said the dengue fever season in Cairns started two months earlier than usual. This suggested it would be a bad year for the mosquito-borne virus.

"The escalation in numbers is the quickest it's been since 2003-04," he said. In that year, two people died of the most serious form of the disease, dengue haemorrhagic fever [DHF], the first such deaths in more than a century in Queensland. Mr. Montgomery said the dengue mosquito, Aedes aegypti, is an "urban mosquito" which usually breeds in containers around people's homes and tended to be daytime biters.

"One infected mosquito has a very high strike rate of being able to infect humans," he said. "They tend not to fly more than 100m or 200m [110 or 120 yards], so by paying attention to what happens in your yard, you can exert some level of control over your exposure. "The messages are all about emptying pot-plant bases and old tires and tarps that hold water, flushing out bird baths and unblocking roof gutters." More than 800 people were infected in Cairns, Townsville and the Torres Strait during the 2003-04 season.
(ProMED 12/29/08)

Cambodia
The head of the Health Ministry's anti-dengue fever program credits better education and treatment for the decline in dengue incidence. A Health Ministry official announced on 29 Dec 2008 a steep decline in the number of infections and deaths from dengue fever countrywide in 2008.

Ngan Chantha, director of the ministry's anti-dengue fever program, said 65 people had died from the disease so far in 2008, compared with 407 deaths in 2007. He said 9300 people contracted the disease in 2008, down from 39,851 cases in 2007.

Ngan Chantha credited greater funding and educational programs for the drop in infection rates and deaths. "We have a preventative program in place to check the spread of dengue fever," he said, adding that the government has also received support from the World Health Organisation, the World Bank, the Asian Development Bank, and the US Agency for International Development.

Ngan Chantha said provinces hardest hit by dengue include Kampong Cham, Kampong Thom, Kandal, and Siem Reap, and that the disease finds a strong foothold in areas suffering from poor sanitation. However, Ngan Chantha identified a new, troubling trend in the spread of the disease. "Now, it is not only the children who get infected. It is also older men between 20 and 50," he said, adding that the ministry did not have data on infection rates among adults but that it would conduct studies in the future.
(ProMED 1/5/08)

Indonesia
The East Kalimantan health service has reported that 172 people out of every 100,000 East Kalimantan residents contract dengue fever each month, which is over eight times the national average of 20 cases for every 100,000 residents.

A total of 101 East Kalimantan residents died of dengue fever between January and November of 2008, an East Kalimantan health services representative Jurnanto said on 31 Dec 2008, bringing the monthly average in the province to nine. These newly released 2008 figures put the dengue fever death rate at 1.9 percent, which is roughly double the national average below 1 percent.

A total of 5270 dengue fever cases were reported during the 11-month period, with the number spiking in April 2008 at 746.
(ProMED 1/5/09)

Singapore
With intensified efforts in 2008, Singapore's fight against dengue appears to have paid off, with 25 percent fewer cases than in 2007. A spokesman for the National Environment Agency (NEA) added that the early and intensive exercise against the Aedes mosquito in 2008 has staved off an anticipated dengue epidemic. Dengue epidemics tend to come in 5-6 year cycles.

So far in 2008, 6424 people have become sick with dengue and dengue haemorrhagic fever (DHF), 2183 fewer than last year. "Earlier this year [2008], it was predicted that Singapore would experience major dengue outbreaks and the situation would be worse than last year [2007]," she said.

But instead of going up, the number of infections had gone down significantly, due to the significant investments Singapore has made in fighting the scourge this year [2008]. "This reversal in dengue trend, the first time in three decades, is a result of the enhanced dengue control strategy put in place by NEA," said the spokesman.

The best way to stop the spread of the disease is to prevent mosquitoes from breeding. This year [2008], the NEA has a team of 500 people doing just that.
(ProMED 12/29/08)

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CHOLERA, DIARRHEA, & DYSENTERY
Hong Kong
The Centre for Health Protection (CHP) of the Hong Kong Department of Health is investigating a confirmed case of cholera and reminds people to observe good personal, food and environmental hygiene, whether in Hong Kong or traveling abroad.

The case under investigation is a 35-year-old woman who developed vomiting and diarrhea on 10 Dec 2008 and was admitted to a private hospital the following day. She is now being isolated in Princess Margaret Hospital for treatment and in stable condition. Laboratory tests showed that her stool specimen yielded a positive result for Vibrio cholerae Ogawa.

CHP's investigation revealed that she had traveled to India from 27 Nov 2008 to 8 Dec 2008 with four family members. This is the sixth case of cholera reported in 2008 in Hong Kong. There were three cholera cases in 2007, one in 2006, five in 2005, five in 2004 and seven in 2003.
(ProMED 12/29/08)

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TYPHOID
China (Hubei)
A recent typhoid fever outbreak affecting 81 students in a middle school in central China's Hubei Province was controlled, local authorities said 26 Dec 2008.

Eighty-one students from Bajiao Middle School in the Bajiao Township of Tong Minority were hospitalized on 21 Dec 2008. All of them, aged between 13 and 15, suffered sustained fever, headache and diarrhea, Xiang Shilian, vice mayor of Enshi City, stated. Sixty-three of them were confirmed as typhoid fever cases by the morning of 26 Dec 2008. They are now in stable condition after treatment in the Central Hospital of Enshi.

Local medical staff started to control the outbreak immediately after the cases were found. All the patients were treated for free and the rest of the students received vaccinations to prevent the disease, Xiang said.
(ProMED 12/29/08)

Papua New Guinea
Authorities in Alotau have revealed at least 20 confirmed cases of typhoid fever from areas around Losuia station on Kiriwina Island in the Milne Bay Province. Most cases reported to the Losuia Health Center have been treated and listed for follow-up and close monitoring.

The Trobriand Islands people typically manage without proper toilets, but health authorities are moving into the area to encourage proper hygiene and emphasize the importance of proper toilet facilities. Milne Bay Provincial Health Advisor Jack Purai said they have to work fast to contain the infection, and a team from his office has been on the island since the beginning of December 2008.

He said they are working meticulously to undertake field investigations, case diagnosis and conduct community mobilization and awareness prevention campaign programs.
(ProMED 12/29/08)

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4. Articles
Severe Acute Respiratory Syndrome–Associated Coronavirus Infection in Toronto Children: A Second Look
Bitnun A et al. Pediatrics. 1 January 2009; 123(1): 97-101. Available at http://pediatrics.aappublications.org/cgi/content/abstract/123/1/97.

OBJECTIVES. During the severe acute respiratory syndrome outbreak of 2003, there was an impetus to provide clinical information to the medical community in a timely manner. Accordingly, a preliminary report of our experience of suspected severe acute respiratory syndrome–associated coronavirus infections in children was published without microbiological findings. This report provides an update on pediatric severe acute respiratory syndrome–associated coronavirus infections in Toronto, Ontario, Canada, that includes microbiological findings.

METHODS. All of the children admitted to the Hospital for Sick Children between March 14 and June 15, 2003, with suspect severe acute respiratory syndrome–associated coronavirus infection were included. A proven case was defined as one that fulfilled the clinical criteria for suspect severe acute respiratory syndrome–associated coronavirus infection and demonstrated a serologic response to severe acute respiratory syndrome–associated coronavirus. Serology results, from a neutralizing antibody assay, were considered positive if the sera inhibited the development of a severe acute respiratory syndrome–associated coronavirus-specific cytopathic effect at a dilution of 1:8.

RESULTS. Neutralizing antibody to severe acute respiratory syndrome–associated coronavirus was demonstrated in 8 of 25 children admitted with suspect severe acute respiratory syndrome–associated coronavirus infection. In 3 of these 8 children, severe acute respiratory syndrome–associated coronavirus was also detected by reverse-transcription polymerase chain reaction in the stool. All 8 had documented exposure to 1 severe acute respiratory syndrome–associated coronavirus-infected adults residing in the same household. Exposure that was limited to visiting a Toronto hospital at which severe acute respiratory syndrome–associated coronavirus-infected patients were admitted or travel from a country in which severe acute respiratory syndrome had been reported did not result in documented infection in any of our cases. On the basis of our clinical case definition, 6 of 8 microbiologically confirmed case had been classified as having probable severe acute respiratory syndrome–associated coronavirus infection. Clinical disease was mild, nonspecific, and self-limited and was indistinguishable from that reported with other common respiratory viruses.

CONCLUSIONS. The factor most strongly associated with severe acute respiratory syndrome–associated coronavirus infection in Toronto children was a history of close contact with an adult severe acute respiratory syndrome–associated coronavirus case. This serves to reinforce the importance of routinely obtaining a thorough epidemiologic travel and exposure history for all subjects with suspected infectious diseases.

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Survey of Hospital Healthcare Personnel Response during a Potential Avian Influenza Pandemic: Will They Come to Work?
Irvin CB et al. Prehosp Disaster Med. 2008; 23(4): 328-335. Available at http://pdm.medicine.wisc.edu/23-4%20PDFs/irvin.pdf.

Abstract

INTRODUCTION. In order to prepare for pandemics, it is important to assess the likelihood that hospital personnel would report to work and to identify the issues that may affect this decision.

OBJECTIVE. To survey hospital personnel regarding their attendance at work in the hypothetical event of avian influenza pandemic, and what factors might influence this decision.

METHODS. A voluntary, confidential, institutional review board-approved survey was offered to a convenience sample of hospital workers regarding their willingness to report to work and what issues would be important in making this decision. Surveys not returned and individuals declining to participate were recorded.

RESULTS. Of 187 surveys offered, 169 were completed (90% response rate): 34% were doctors, 33% were nurses, and 33% were clerical and other associates (other). The average age of the participants was 38 years, and 32% were males. Participants were asked: “In the event of an avian pandemic, and patients were being treated at this hospital, would you report to work as usual?”. Of those who responded to the survey, 50% reported “yes”, 42% reported “maybe”, and 8% reported “no”. Doctors were more likely than nurses or others to respond “yes” (73%), as were males (66%). For the “maybe” responders, the most important factor (83%) was: “How confident I am that the hospital can protect me”. For 19% of the “maybe” responders, financial incentives would not make a difference for them to work, even up to triple pay.

CONCLUSIONS. Personnel absenteeism during a pandemic due to fear of contracting an illness may result in a significant personnel shortage. Ensuring worker confidence in adequate personal protection may be more important than financial incentives.

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Burden of Influenza-Like Illness and Effectiveness of Influenza Vaccination among Working Adults Aged 50–64 Years
Nichol KL et al. Clin Infect Dis. 30 December 2008. Available at http://www.journals.uchicago.edu/doi/abs/10.1086/595842?journalCode=cid.

Abstract

BACKGROUND. Uncertainties regarding influenza disease impact and benefits of vaccination may contribute to low vaccination rates among adults aged 50–64 years.

METHODS. This prospective cohort study assessed the burden of influenza-like illness (ILI) among working adults aged 50–64 years and the effectiveness of influenza vaccination in reducing the rate of ILI and productivity losses. Employees of the University of Minnesota (Minneapolis) were invited via e-mail to participate in the study during October 2006. The study data were collected using internet-based surveys at baseline (October 2006) and during the follow-up period (from November 2006 through April 2007). Months included in the 2006–2007 influenza season were identified retrospectively from Minnesota Department of Health surveillance data. Vaccine effectiveness for reducing the rate of ILI, ILI-associated health care use, the number of days of illness, work loss, and reduced on-the-job productivity during the influenza season were assessed using multivariable regression models after controlling for important confounders.

RESULTS. Four hundred ninety-seven persons were included in the study, 85 (17.1%) of whom experienced an ILI. Among unvaccinated participants, ILI was responsible for 45% of all days of illness during the influenza season, 39% of all illness-related work days lost, and 49% of all days with illness-related reduced on-the-job productivity. In the multivariable regression analyses, vaccination was associated with a significant reduction in the rate of ILI (adjusted odds ratio, 0.48; 95% confidence interval, 0.27–0.86) and fewer days of illness, absenteeism, and impaired on-the-job performance.

CONCLUSION. ILIs were common among our study participants, accounting for a large portion of illness, work loss, and impaired work performance during the influenza season. Vaccination was associated with substantial health and productivity benefits. Vaccine delivery should be improved for this high-priority group.

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5. Notifications
Preparing for pandemic influenza—guidance for GP practices
This document advises practices on what they need to do now and in the future in order to prepare for, and respond to, a pandemic flu outbreak in the UK.

The guidance is for general practitioners (GPs) and their staff in general practice. Practice managers in particular should find it helpful. It will also be of use to primary care organizations (PCOs) and is relevant to patients. The document sets out guidelines for business continuity planning within GP practices and introduces new systems and procedures, such as the National Pandemic Flu Line, which will operate in an influenza pandemic. It also explains why there is a need to take action and how this will help minimize the spread of flu in a pandemic and make the best use of limited health resources.

This is the first issue of this guidance document. Some aspects of planning for and responding to a flu pandemic have not yet been decided or agreed. This document will be regularly reviewed to include decisions as they are agreed plus any relevant changes, which relate to general practice. It is intended to be a living document to be revisited regularly.

The document is available at http://www.bma.org.uk/health_promotion_ethics/influenza/panfluguiddec08.jsp?page=1.

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US National Center for Education Statistics releases literacy report
The US National Center for Education Statistics (NCES) released a new literacy report on 8 Jan 2009 entitled National Assessment of Adult Literacy: Indirect County and State Estimates of the Percentage of Adults at the Lowest Literacy Level for 1992 and 2003, from the National Assessment of Adult Literacy (NAAL). The report provides the only available snapshot of adult literacy rates for individual states and counties. The report, based on the 2003 NAAL and the 1992 National Adult Literacy Survey (NALS), serves as an important source of literacy information for policymakers and researchers. The report is supplemented by an interactive web tool that shows data for all states and counties. The tool also provides the ability to compare states, counties, and progress in states and counties over time. Literacy rates are important considerations when producing health education or preparedness materials.

The report is available at http://nces.ed.gov/naal/estimates/index.aspx.

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US Health and Human Services secretary releases Pandemic Planning Update VI report
Message from the secretary (excerpt)
The story of our country’s pandemic preparations is, at its center, a story about individuals and their sense of commitment to a common goal. It is a story of shared responsibility, of people working together to prepare their families, their communities, workplaces, cities, and states for the eventuality of a pandemic.

At each level of this combined effort, the Department of Health and Human Services (HHS) has taken steps so that those involved had the information, guidance, and support to work together to prepare for a pandemic. Individuals, too, within the Federal government are working together to take the broader actions that can only be done from a central, national vantage point.

After three years of intense effort by these individuals and groups throughout the country, many results of this unique national effort are now emerging. At the same time, the next steps needed to continue this effort and improve upon it are coming into sharper focus.

The full report can be accessed at http://pandemicflu.gov/plan/panflureport6.html.

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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