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Vol. XII, No. 2 ~ EINet News Briefs ~ Jan 23, 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)
- Germany (Lower Saxony): LPAI outbreak continues in turkeys
- China: Reports three avian influenza H5N1 cases, two deaths
- China: Recent avian influenza H5N1 cases raise transmission questions
- India: Fears of avian influenza outbreak after 30 birds die due to unnatural causes
- Indonesia: Two victims of avian influenza H5N1 infection die
- Nepal: First avian influenza outbreak occurs among poultry
- USA: Experts consider 4-strain influenza vaccine to fight B viruses
- Egypt: Avian influenza H5N1 outbreaks in back yard poultry in two villages

2. Infectious Disease News
- Australia (Northern Territory): Two die in melioidosis outbreak
- China (Gansu): Malaria infection imported from Angola
- Chinese Taipei: Two cases of enterovirus infection so far in 2009
- Indonesia: Updates on chikungunya infection
- Malaysia: Malaria in Penang associated with construction workers from Myanmar
- Philippines: DOH announces measles outbreak under control, recommends vaccine efforts continue
- Russia (Moscow region): Man dies of rabies infection after a fox bite
- Russia (Kurgan): Psittacosis cases linked to bird smuggling
- Viet Nam: 19 people hospitalized after being bitten by rabid dogs
- Canada (Manitoba): Outbreak of flesh-eating bacteria among homeless population in 2008
- USA: Salmonella outbreak linked to peanut butter

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

4. Articles
- Public Health Preparedness: Strengthening CDC's Emergency Response A CDC Report on Terrorism Preparedness and Emergency Response (TPER)-Funded Activities

5. Notifications
- Weekly Epidemiological Bulletin available online
- PATH announces new website with resources for diarrheal disease control
- The Royal Government of Cambodia Awarded the “Royal Order of Sahametrei” to Dr Chinkholal Thangsing
- XI International Symposium on Respiratory Viral Infections


1. Influenza News

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

2009
China/ 3 (1)
Egypt/ 1 (0)
Total/ 4 (1)

2008
Bangladesh / 1 (0)
Cambodia/ 1 (0)
China / 4 (4)
Egypt / 8 (4)
Indonesia / 24 (20)
Viet Nam / 6 (5)
Total / 44 (33)

***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: 399 (251).
(WHO 1/22/09 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 1/19/09)

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 1/21/09):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Europe/Near East
Germany (Lower Saxony): LPAI outbreak continues in turkeys
The total number of low pathogenic avian influenza (LPAI) H5N3 outbreaks detected in Lower Saxony is now 30. The latest was confirmed on 14 Jan 2009. Since 16 Jan 2009, around 475,000 turkeys have been culled. All outbreaks except one have occurred on turkey farms. The other outbreak was on a mixed holding where turkeys were also kept, but geese and ducks were affected as well.

Germany reported to SCoFCAH (EU's Standing Committee on Food Chain and Animal Health) on 9 Jan 2009 that the majority of infected premises are within the administrative areas of Garrel and Bosel in Lower Saxony. There are three more infected premises in two other neighboring administrative areas, Saterland and Friesoythe.

The outbreak on 12 Jan 2009 is on the outskirts of the Bosel/Garrel restriction zone and will lead to a small expansion of the zone. The new outbreak on 14 Jan 2009 is in Freisoythe-Ikenbrugge, and again will lead to an expansion of the restriction zone.

On 29 Dec 2009, Poland reported suspicion of disease in turkeys on a poultry farm in Goleniowski region. Samples were taken from 10 dead turkeys, and initial laboratory tests were weakly positive for LPAI, although subsequent samples from other birds on the holding were negative. Nevertheless, Poland put disease control measures in place, and the birds (nearly 20,000) were culled on 4 Jan 2009.

Poland imposed strict disease controls on the premises, despite samples only giving a very weak signal for presence of LPAI. They did so based on epidemiological evidence of trace-back to a hatchery in Germany, in the affected region. There is no evidence that the hatchery involved was one of the infected premises, but Germany will carry out further investigations.

The strain involved in the outbreaks in Germany is causing very few or no clinical signs, but it does appear to spread quickly. Surveillance programs are designed to detect a threshold level of usually between 5 and 10 percent prevalence. It is therefore not unexpected that some cases may be detected after initial surveillance, when the disease has reached a higher level. The epidemiological pattern of these outbreaks appears to suggest silent spread of a subclinical infection, which is why it has taken some time before some outbreaks were detected.

At this stage, this incident in Germany does not change the continuous ongoing low risk of LPAI (and similarly HPAI) being detected over a wider geographic area of the EU, including the UK. So far, there is no indication that the strain has the potential to mutate to a HPAI strain.
(ProMED 1/18/09)

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Asia
China: Reports three avian influenza H5N1 cases, two deaths
China's health ministry reported three new human H5N1 avian influenza cases on 19 Jan 2009. One of the cases was fatal and the other patients are hospitalized in critical condition, according to a statement from the World Health Organization (WHO).

In the first case, a 27-year-old woman from Jinan City in Shandong province in northeastern China got sick on 5 Jan 2009, was hospitalized, and died on 17 Jan 2009. Public health officials are investigating the source of the woman's H5N1 infection.

In the second case, a two-year-old girl from Luliang City in Shanxi province began having symptoms on 7 Jan 2009, was hospitalized, and remains in critical condition. Authorities are also exploring how the girl became infected. Shanxi province is in the north central part of the country.

The third patient, a 16-year-old boy from Huaihua City in Hunan province, became ill on 8 Jan 2009 and was hospitalized on 16 Jan 2009. He died on 20 Jan 2009. An investigation into the source of the boy's illness found that he was exposed to sick and dead poultry. Hunan province is in south central China.

China's national laboratory confirmed all three of the cases, according to the WHO, which added that close contacts of the three cases are under medical observation, and all remain healthy so far.

The illnesses and death raise China's H5N1 case count to 34 and fatality total to 23, and these cases bring to four the number of cases in the country in four weeks. On 7 Jan 2009, China's health ministry announced that a 19-year-old Beijing woman who got sick on Dec 24 had died from an H5N1 infection on 5 Jan 2009. The WHO said that it anticipates China will keep it updated on the new H5N1 cases and that the organization stands ready to provide China with technical assistance, if needed. It also urged people to observe routine safety precautions such as ensuring that poultry is well cooked and washing hands after contact with raw meat as more people eat chicken as part of Chinese New Year celebrations. This year's Chinese New Year celebration, which lasts for 15 days, starts on 26 Jan 2009.

In related developments, China's agriculture ministry is intensifying its efforts to reduce the spread of H5N1 in poultry. The country will strengthen poultry immunization against the virus, increase vaccine production, boost monitoring of poultry markets and other high-risk areas, and improve surveillance of poultry movements across country borders.
(ProMED 1/18/09, CIDRAP 1/19/09, CIDRAP 1/20/09)

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China: Recent avian influenza H5N1 cases raise transmission questions
China's recent spike in human H5N1 avian influenza cases appears to lack the nearby poultry outbreaks that are typical, a development that some public health officials worry could signal asymptomatic infections in birds. Veterinary experts, however, suggest the pattern could point to surveillance gaps or the consequences of routine vaccination.

York Chow, Hong Kong's secretary for food and health, has called on China to release more epidemiologic information on the recent human infections and said that an apparent lack of poultry outbreak reports against the backdrop of human cases raises questions about a possible change in the virus or that asymptomatic H5N1-infected chickens might be contributing to the spread of the virus.

Chinese officials have said they have found no evidence that the virus has mutated to allow easier human-to-human transmission.

Monitoring billions of birds
This isn't the first time that health officials have voiced their suspicions about asymptomatic poultry infections in China. In 2006, Zhong Nanshan, director of the Guangzhou Institute of Respiratory Diseases, suggested that two victims might have caught the virus from chickens that were carrying it asymptomatically.

Avian influenza experts say the size and nature of China's poultry population creates a difficult surveillance task. Jan Slingenbergh, a senior animal health officer for the United Nations Food and Agriculture Organization (FAO) said that China has roughly 4.6 billion chickens, 700 million ducks, and 300 million geese that are distributed somewhat unevenly throughout the country. He said the ducks gravitate toward the double-crop rice growing areas in southern and southeastern China, which are thought to be the main risk areas because the H5N1 virus keeps circulating in ducks. Geese head toward single-crop rice growing areas in the less rainy northeastern and extreme western part of China.

Meanwhile, he said chicken are kept everywhere people live, particularly in urban areas and coastal ports. Slingenbergh links the low level of poultry outbreak reports to China's poultry vaccination policy. He said he doubts that the H5N1 in China is evolving toward a low-pathogenic virus. "Vaccination creates a rather sparse geospatial mosaic of susceptibles, which may even enhance the pathogenicity level," he said, adding that evidence from Vietnam, where most Chinese viruses spread to, suggests that the virulence increased between 2002 and 2007 when measured by infecting and gauging shedding in young mallards.

Vincent Martin, a senior technical adviser in the FAO's Beijing office, stated that Chinese officials obtain a lot of samples from farms and live bird markets each year to monitor asymptomatic H5N1 infections among the birds. "Regularly, they find the virus but do not detect any outbreak in the surrounding areas," he said. However, a combination of factors makes detecting the virus difficult, Martin said. Several strains of the virus are circulating in China, and ducks can excrete the virus without showing symptoms or only exhibiting mild ones.

In addition, suboptimal vaccination can mask the symptoms without stopping viral shedding. More intensive surveillance and monitoring efforts are needed in China to detect new outbreaks and identify viral circulation that is going unnoticed, Martin said, "to avoid a situation where humans serve as sentinels and reveal infection in birds."

Three Chinese government ministries issued a joint order on 20 Jan 2009 for local health, agriculture, and commerce offices to work together to improve surveillance and management of the country's live poultry markets. The government urged local offices to close live poultry markets in urban areas, if possible, or disinfect the markets daily if they can't be shuttered. The offices were also ordered to conduct daily surveillance and reporting and collaborate when they detect the H5N1 virus.

The role of poultry vaccination
Les Sims, from Australia's Asia-Pacific Veterinary Information Services and a consultant to the FAO, said though humans are once again acting as sentinels for infections in poultry, so far there is no evidence to support asymptomatic disease as the reason for absence of reported poultry outbreaks in China.

"Vaccination will alter the clinical appearance of disease if the flock is infected, but on a flock basis, some disease will be detected. Infection is not silent," he said. He added that infected vaccinated flocks, for example, have lower mortality rates with fewer birds showing classical symptoms of the disease. "If vaccines are used, veterinary and medical authorities have to accept that one of the signals they used to rely on for detecting infection in poultry—high mortality—needs to be modified," Sims said.

Infected poultry can still shed small amounts of the virus, even when the vaccine is a good match and the birds are vaccinated properly, he said. "This has always been the case and so can't explain the current situation in China." The issue of less severe infections in vaccinated poultry is creating negative sentiments about the measure, Sims said, but he added that China has maintained a close match between the circulating strains and the vaccine antigen, which greatly diminishes the viral load in poultry.

"The benefits of vaccination in reducing viral load need to be considered and balanced against the changes in disease appearance that will occur if a vaccinated flock is infected," he said. "The situation in China would almost certainly be much worse if vaccination was not used."

Sims said he's not surprised that some poultry infections go undetected, given the size and make-up of China's poultry population, along with the modified appearance of the disease in vaccinated poultry. He suspects, though, that under-reporting of the disease might be one factor that keeps the number of outbreak reports low. Farmers who raise poultry for their livelihood have little incentive to report the disease.

A seasonal surge in poultry and human H5N1 cases in the winter isn't unexpected, he said. "Winter peaks have been seen previously and are probably linked to the increased trade in poultry for various festivals and enhanced viral survival due to cooler conditions," Sims said.
(CIDRAP 1/21/09)

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India: Fears of avian influenza outbreak after 30 birds die due to unnatural causes
About 30 birds have died in Ravanga locality in South District since 16 Jan 2009 due to unnatural causes, triggering fear about a possible outbreak of bird flu in the Himalayan state. Animal Husbandry and Veterinary Services Department Director K.C. Bhutia confirmed the deaths of over two dozen birds, including chickens, due to unnatural causes in Ravangla area, but refused to confirm the outbreak of bird flu in Sikkim.

The department was closely monitoring the unnatural mortality of birds, he said. He added that he was waiting for a report from the central health authorities to confirm whether these birds died due to bird flu or to other reasons. Sikkim had banned the supply of poultry products from outside the state in December 2008 following the outbreak of bird flu in Malda district of West Bengal. The state police have been conducting searches in vehicles at Rangpo and other check posts bordering Sikkim to prevent importation of poultry products from outside.
(ProMED 1/19/09)

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Indonesia: Two victims of avian influenza H5N1 infection die
The Ministry of Health of Indonesia has announced two new confirmed cases of human infection with the H5N1 avian influenza virus. A 29-year-old female from Tangerang District, Banten Province developed symptoms on 11 Dec 2008, was hospitalized on 13 Dec 2008 and died on 16 Dec 2008. The investigation indicated that she visited a wet market to buy fresh produce, including chicken meat, on a daily basis.

The second case, a 5-year-old female from Bekasi City, West Java Province developed symptoms on 23 Dec 2008, was hospitalized on 27 Dec 2008 and died on 2 Jan 2009. The investigation indicated that she visited a wet market to buy chicken meat and eggs two days prior to symptom onset.

Laboratory tests confirmed the presence of the H5N1 avian influenza virus in both cases. Close contacts of both patients were placed under medical observation, and none developed illness.

Of the 141 cases confirmed to date in Indonesia, 115 have been fatal.
(ProMED 1/22/09)

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Nepal: First avian influenza outbreak occurs among poultry
For the first time in Nepal, avian influenza virus has been detected in Kakarbhitta in the eastern district of Jhapa. After the detection of bird flu virus on 15 Jan 2008, the government decided to cull birds within the range of 3 km from the site.

Declaring the 10 km region of Kakarbhitta 'an emergency area,' the cabinet made the decision to kill the birds since six out of every seven chickens brought from Mechi Municipality-10, Kakarbhitta, were found to have been infected with the avian flu.

Officials are on a high alert at the areas ranging 10 km from Kakarbhitta to prevent the bird flu from spreading, the minister for information and communications Krishna Bahadur Mahara said. He added that the government has also decided to direct the local administration to reuse the equipment used in slitting the birds only after sterilization.
(ProMED 1/16/09)

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Americas
USA: Experts consider 4-strain influenza vaccine to fight B viruses
Picking the influenza strains to put in the flu vaccine each year is always a gamble, given the unpredictable prevalence of different strains, but choosing the influenza B strain has become particularly vexing in recent years. Since the 2001-02 flu season, two distinct lineages of influenza B—Victoria and Yamagata—have been circulating in the United States, and experts have found it impossible to predict which one would dominate in any winter.

Because a vaccine against one lineage offers little protection against the other, the government's flu vaccine advisors have been discussing for several years the possibility of putting both lineages in the seasonal vaccine. That would turn the standard three-strain, or trivalent, vaccine into a quadrivalent vaccine. Trivalent vaccine contains two subtypes of influenza A—H3N2 and H1N1—and one of influenza B.

Putting both B families into the vaccine would offer protection against both B strains, which is regarded as particularly important for children. But the idea raises questions about the effects on vaccine manufacture and supply, cost, and side effects. Some vaccine producers are studying the possibility, but they will need a formal government recommendation before they would proceed.

Vaccine often misses
The problem with B viruses is nicely illustrated by events of the past couple of years. For the 2007-08 flu season in the United States, the government's experts picked a Victoria strain for the vaccine. But by the end of the season, 98% of the 350 B viruses that were antigenically characterized by the CDC belonged to the Yamagata family. Looking further back, CDC records show the B strain in the vaccine missed the dominant B lineage in circulation in 4 of the 7 seasons from 2001-02 through 2007-08.

How much harm?
How much harm results when the vaccine misses the predominant B strain is not very clear, but experts say children are likely to get little protection against B viruses when this happens. The CDC now recommends that all children from age six months on up receive annual flu vaccination.

In general, B viruses cause less severe disease than influenza A, and they seem to be associated with smaller clusters or outbreaks, according to William Schaffner, president-elect of the National Foundation for Infectious Diseases and chair of the Department of Preventive Medicine at the Vanderbilt University School of Medicine in Nashville.

Dr. Anthony Fiore, a medical epidemiologist in the Influenza Division at the CDC agreed, then added, "But there are definitely deaths and severe outcomes caused by influenza B. It's generally thought of as being more a disease that circulates in children, but adults do get it and have hospitalizations and deaths from it. . . . For any given person you can have a severe illness with B and a mild illness with A. On a population level, A is more severe."

Disadvantages and uncertainties
Adding a second B strain would not be without disadvantages, experts say. "It would be more complex for the manufacturers, and it would probably cost more," said Fiore. And given that a producer can grow only so much vaccine, switching from three strains to four will mean fewer doses in the end. Donna Cary, of vaccine manufacturer Sanofi Pasteur, acknowledged that going to a quadrivalent vaccine would reduce overall production. "But we do not anticipate any supply issue in transitioning to a quadrivalent influenza vaccine," she said. "This is due to the global increase in influenza vaccine supply, as illustrated by the opening of our new influenza manufacturing facility in the US in 2009," she added, referring to Sanofi's Swiftwater, Pa., plant.

Fiore said he doesn't expect the manufacturers would face major technical challenges in making vaccine with the two B lineages: "The manufacturers know how to make both of these lineages and have done it in recent years, so it's not a big manufacturing challenge."

Other questions the prospect raises include the chance of increased side effects and whether clinical trials of a quadrivalent vaccine would be necessary. The trivalent vaccine contains 15 micrograms (mcg) of each strain, or 45 mcg total. Assuming that the same dosage would be used for a second B strain, the total amount of antigen in a dose of a four-strain vaccine would be 60 mcg.

Fiore noted that the licensed prepandemic H5N1 vaccine in the US stockpile has been tested in 90-mcg doses. "So it's not that much of an increase in volume that we'd expect to see a lot more reactogenicity," he said. "But the FDA might require some studies about that."

There has been discussion of using just 7.5 mcg of each B strain, leaving the total B content in the vaccine at 15 mcg. But some experts doubt that the reduced amount would generate an adequate immune response.

Schaffner said another question is whether adding a fourth strain to the vaccine will leave the immune response to the other three unimpaired. "That's what we anticipate, but it'll have to be formally tested," he said.

Still another question is what the World Health Organization (WHO) will do. Experts convened by the WHO make recommendations for the flu vaccine strains for the northern and southern hemispheres each season. The WHO's position is that much more information is needed, according to Gregory Hartl, the agency's infectious-disease spokesman in Geneva. "There's been a lot of discussion, but all the possibilities require safety and immune-response data which are not yet available, and after that there's regulatory approval which would be needed. So any change is not going to happen tomorrow," he said.

Other ways to cover both strains
Offering a quadrivalent vaccine to everyone is not the only way to provide some protection against both B lineages. Several other options have been proposed, including alternating lineages from year to year, making a quadrivalent vaccine intended only for children and the elderly, and offering a supplemental B vaccine to cover the strain not in the trivalent vaccine. The idea of alternating lineages would be that people who get vaccinated each year might have some residual cross-protection in case the dominant strain in a given year is not in the vaccine, said Fiore. "But there's really no way to predict what the impact of that would be," he said.
(CIDRAP 1/16/09)

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Africa
Egypt: Avian influenza H5N1 outbreaks in back yard poultry in two villages
Veterinary authorities in Egypt reported H5N1 avian influenza outbreaks in two governorates. Both of the outbreaks involved backyard poultry, according to reports by the Egypt-based Strengthening Avian Influenza Detection and Response (SAIDR). The project, funded by the US Agency for International Development with assistance from Johns Hopkins University, is designed to help Egypt coordinate avian flu efforts with its international partners.

One of the outbreaks involved 53 chickens, ducks, and geese in Reva village in Asyut governorate. The vaccination status of the birds is not known. Asyut governorate is located in the middle of Egypt on the banks of the Nile River.

In the other outbreak, the virus struck 15 chickens, ducks, and geese in Seila Ezbet Edris village in Faiyum governorate. All of the birds had been vaccinated in 2008. Faiyum governorate is in north-central Egypt, about 80 miles southwest of Cairo.
(CIDRAP 1/22/09)

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2. Infectious Disease News

Asia
Australia (Northern Territory): Two die in melioidosis outbreak
Two people have died from melioidosis in the Northern Territory (NT) this wet season. The victims were a man and a woman, one of whom was indigenous. The outbreak of the tropical disease has prompted NT health authorities to issue a warning to tourists and locals. Symptoms include fever, shortness of breath, boils, and abdominal pain.

NT Centre for Disease Control director, Dr Vicki Krause said the bacteria lived below the soil's surface during the dry season, but after heavy rainfall could be found in surface water and mud and may become airborne. "Cases tend to follow the rains and an increase in cases has been seen in past years following cyclones, heavy rains and floods," she said.

Dr Krause said there had been 10 cases of melioidosis already during the 2008-09 wet season, with these two deaths. She said it was important newcomers to the Top End were aware of the disease and locals did not become complacent. "Healthy people can get the disease if they are working in muddy soil without good hand and foot protection," said Dr Krause. "Cleaning up after flooding can lead to more people being exposed to the bacteria through walking in muddy water and handling water or mud-soaked items."

Some people become extremely ill within a few days of becoming infected with fevers, headaches, confusion, or breathing difficulties. Other people may present symptoms some time after exposure with weight loss, fevers, skin ulcers, boils, or chest and abdominal pain, she said.
(ProMED 1/16/09)

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China (Gansu): Malaria infection imported from Angola
Between May 2008 and Jan 10, 2009, 14 cases of malaria were identified among people who returned to China from Angola. Following effective prevention measures, malaria did not spread.

According to the Municipal Health Bureau, between May 2008 and 10 Jan 2009, Wuwei City workers returned from Angola reported a total of 14 cases of malaria, 12 of which are falciparum malaria and two have not been typed. Twelve cases were reported from Gulang County, one case from Liangzhou District, and one case from Tianzhu County. Four cases were admitted to Wuwei City People's Hospital for inpatient treatment. One of the patients died and three remain in hospital. The other 10 cases were referred to other hospitals or outpatient treatment centers.
(Pro MED 1/14/09)

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Chinese Taipei: Two cases of enterovirus infection so far in 2009
Even though the winter is not the season for enterovirus infections, according to surveillance from the Centers for Disease Control, seven cases of enterovirus infection with complications were reported in December 2008. Six of the cases were caused by enterovirus-71. There have been two cases reported so far in 2009. The etiology of these infections is still pending.

The Centers for Disease Control are concerned about the future trend of the disease. They urge parents of infants or young children and educational institutions to practice good hygiene for themselves, their children, and students to decrease the chance of enterovirus infection transmission and to avoid development of complications.

Children under the age of three are particularly at risk because of their weaker immunity. When children are diagnosed with enterovirus infections, parents should look for prodromal complications, such as drowsiness, consciousness changes, decreased activity, weakness of limbs, myoclonic jerks, continued vomiting, prolonged fever, anxiety, neck stiffness, paralysis of limbs, tachypnes or tachycardia.
(ProMED 1/18/09)

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Indonesia: Updates on chikungunya infection
Chikungunya disease has hit around 300 people in six sub districts in Madiun Regency and many of the patients are suffering from paralysis due to severe joint pain as a result of their infection.

Paramedics in Madiun said they have been overwhelmed by the number of patients since mid-December 2009. One chikungunya sufferer from Bacem Village, Kebonsari Sub-District, Nursarifah, said that her joints had been painful for the last two weeks.

Head of Health Department in Madiun, Sudijo, said that they are spreading abate powder to kill the mosquito larva. "We have not yet reached all areas," he said.

Meanwhile, as many as 1569 residents of the Indragiri Hulu Regency, Riau, [Sumatra] were attacked by chikungunya virus during the week of 28 Dec 2008. The situation was declared to be an extraordinary incident due to the illness.

Section head Kesehatan Indragiri Hulu Helmi Manaf said on 5 Jan 2009 that this infectious disease attacked 18 villages in 5 sub districts there. It was found for the first time in the Lirik Sub district, primarily in the Lambang Village.

"We had coordinated and sent blood samples for testing to the Department of Health," Helmi indicated. Results of the laboratory tests were positive and confirmed the chikungunya virus infection.

In anticipation of continued expansion of the chikungunya outbreak in this territory, Helmi confirmed dropping the team off in order to carry out mass medical treatment in the affected area. Medical treatment was given free. Moreover his group is fogging and conducting chikungunya prevention education in the outbreak area.
(ProMED 1/12/09)

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Malaysia: Malaria in Penang associated with construction workers from Myanmar
Penang is concerned about the "alarming" rate of malaria cases in the state with 13 cases reported in the first week of 2009. State Health, Welfare and Caring Society Committee chairman Phee Boon Poh said that only one of the 13 cases was a Malaysian while the rest were foreign workers, mainly Myanmars, who worked in the construction industry.

"The cases detected were mainly concentrated in the Bukit Gambier area, Bukit Papan in Bayan Lepas, Bukit Serai in Paya Terubong, and the construction sites of the Surin-Bolton Apartments project and the Taman Ratu Mutiara project in Tanjung Bungah," he stated.

Phee said most of the foreigners were believed to have contracted the vector-borne disease in the hills and jungles where their huts are located. "The next morning, when these workers come downhill for work purposes, they also indirectly help spread the disease to locals," he said.

Phee said the state Health Department was taking precautions by carrying out fogging at the affected sites while the Penang Municipal Council (MPPP) was sending out officers to the ground, especially at hill sites, to destroy mosquito breeding grounds. He advised residents living in hill sites to ensure the cleanliness of their surrounding areas and also to go to the nearest hospital for blood tests and treatment if they suspected they had contracted the disease.

He also urged clinics and doctors to cooperate and to alert the state health authorities if they came across any such cases. "These foreign workers especially the illegal ones, may try to avoid detection for fear of being deported but the state is more concerned about their health rather than their legal status," he said.

Phee also said the state was closely monitoring the three reported chikungunya cases here especially those in the sensitive areas in the North-East, South-West, and Central Seberang Prai (SPT) districts. "The first week of the year [2009] also saw 60 dengue cases being reported with nine confirmed cases," he said. He said the state Health Department and the MPPP were taking the necessary measures by carrying out fogging and clean-up activities.
(ProMED 1/12/09)

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Philippines: DOH announces measles outbreak under control, recommends vaccine efforts continue
The Department of Health (DOH) Western Visayas declared that the measles outbreak in Moises Padilla, Negros Occidental has been controlled. The DOH said that in October 2008 laboratory results from the Research Institute of Tropical Medicine (RITM) in Manila confirmed three measles cases in Moises Padilla among children aged 16 years, 9 years, and 18 months. These cases occurred in barangays Guinpana-an, Montilla, and Odiong.

Aside from the three confirmed cases, 70 cases manifested the same symptoms as those confirmed cases like fever, non-vesicular rashes, runny nose, and cough. The DOH also noted that those affected were not immunized against measles. DOH reported that logistic support like vaccine, syringes, advisory notices, and other medicines were immediately provided to Moises Padilla town. A thorough operation to identify unimmunized children was done and vaccinations were conducted by Rural Health Unit personnel to all unimmunized children aged between nine months and 15 years. Vitamin A capsules were also given to all children aged six months to 71 months.

The DOH said, however, that although the outbreak was controlled, measles virus is still circulating in the area and the possibility of an outbreak may occur if targeted children are not immunized. The DOH strongly recommended the different local governments strengthen programs for routine immunization in hard to reach areas and intensify their information dissemination regarding the importance of immunization.

The DOH also strongly advised parents to bring their children below one year old to the nearest health center or hospital in their area to receive free immunization against TB, measles, diphtheria, pertussis, tetanus, hepatitis B, and poliomyelitis.
(ProMED 1/15/09)

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Russia (Moscow region): Man dies of rabies infection after a fox bite
An emergency situation has been declared in the Noginsk area of the Moscow region where a fatal case of rabies has been reported. All of those who have had contact with the fatal case are under observation. It is inferred that the deceased patient, a 42-year-old man, contracted rabies in August 2008 when he was bitten by a sick fox. He did not immediately seek medical treatment and was admitted to hospital only much later, when his condition had deteriorated. He died on 31 Dec 2008.
(ProMED 1/15/09)

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Russia (Kurgan): Psittacosis cases linked to bird smuggling
Twenty-one cases of the respiratory infection psittacosis were reported in the Petuhovsky district of the Kurgan region, from 30 Dec 2008 to 13 Jan 2009. All the cases are hospitalized, but none is in serious condition.

The situation is under investigation and the source of the outbreak appears to be parrots and canaries, from a large illegal group of birds captured from smugglers at a check point on the Russian - Kazakhstan border. In November-December 2008, 15 cases of the infection were recorded in the Akbulaksky district of the Orenburg region. The earlier cases were also connected with parrots and canaries, which were confiscated from smugglers that were detained trying to bring more than 1500 birds into Russia from the Republic of Kazakhstan.
(ProMED 1/16/09)

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Viet Nam: 19 people hospitalized after being bitten by rabid dogs
Nineteen people from a commune in the central province of Binh Thuan were hospitalized on9 Jan 2009 after being attacked by rabid dogs, Ho Chi Minh City doctors said. All the victims, from Binh Thuan's Tan Phuc Commune, were listed as being in critical condition because of delays in transferring them to Ho Chi Minh City [HCM] Hospital for Tropical Diseases, they added.

Head of the hospital's Examination Department, Mai Xuan Thong, said it was the first time the hospital received so many people from one place bitten by rabid dogs in separate attacks. Doctors said "mad" dogs had attacked 57 people in Tan Phuc over the past six months, with two victims dying from rabies because of improper care and treatment.
(ProMED 1/11/09)

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Americas
Canada (Manitoba): Outbreak of flesh-eating bacteria among homeless population in 2008
An outbreak of potentially deadly flesh-eating disease erupted among Winnipeg's homeless population in 2008, infecting 12 people with an invasive bacteria that spreads rapidly and causes severe pain and disfiguration. Winnipeg health officials did not publicly disclose that a cluster of cases was reported in the city area between April and October 2008 until questioned by the Winnipeg Free Press this week.

Dr Pierre Plourde, a Winnipeg medical officer of health, said inner-city shelters were alerted about the spike in cases and told to watch for anyone with wounds or sore throats who may be at an increased risk of developing the infection. He said there were four or five strains of flesh-eating disease that were reported, and there was no evidence that anyone infected transmitted the disease to another person.

Nine of the 12 people infected had recently suffered a major injury, including one person who was severely burned in a fire. Manitoba's chief medical examiner Dr. Thambirajah Balachandra confirmed a total of five people died from flesh-eating disease in 2008, including one death each in August, October and November 2008, the same time the outbreak occurred in downtown Winnipeg. Plourde could not confirm whether any patients had limbs amputated.

Plourde said the bacteria can infect anyone, but people who have weakened immune systems or open wounds or who have recently undergone surgery are more at risk. He said the city's homeless population tends to delay seeking medical treatment until they're in dire need.

Although flesh-eating disease is considered rare, Plourde said the province recorded 16 cases in 2008, four times the number that is typically reported. Manitoba Health disease statistics show the number of flesh-eating cases has skyrocketed in the past three years: 56 cases were reported between 2006 and October 2008, compared to only 12 total cases in 2005 and 2004. At least seven Manitobans infected with the invasive bacteria have died since 2006. Officials are still reviewing one suspected death from 2008.

Plourde said it's difficult to explain the recent outbreak but emphasized that diseases tend to come in waves, and more people may be carrying strep throat bacteria. He said shelter overcrowding and lack of proper hygiene among inner-city homeless could explain the rash of cases.

Flesh-eating disease is a bacterial infection that quickly destroys tissue and muscles, and originates from the same bacteria that causes strep throat (Streptococcus pyogenes), also called group A streptococcus or GAS. It can cause death in as little as 12 to 24 hours but can be treated with heavy doses of antibiotics and with surgery to remove diseased tissue. Often, afflicted limbs are amputated to save someone's life.
(ProMED 1/18/09)

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USA: Salmonella outbreak linked to peanut butter
Salmonella found in an unopened container of peanut butter in Connecticut has been genetically matched to the nationwide disease outbreak, confirming that it stems from a Peanut Corp. of America (PCA) facility in Georgia, the Food and Drug Administration (FDA) announced on 19 Jan 2009.

Minnesota officials had previously tied Salmonella found in some PCA-made peanut butter to the outbreak, but the container had been opened, leaving the possibility of cross-contamination. The finding of the outbreak strain in an unopened container "has now led FDA to confirm that the source of this outbreak is peanut butter and peanut paste produced by PCA at its Blakely, Ga., processing plant," the FDA said in an update on the investigation.

The Salmonella outbreak case count has risen to 486 in 43 states and Canada, according to a Centers for Disease Control and Prevention (CDC) update posted on 21 Jan 2009. About 23% of patients were hospitalized, and the illness was a possible factor in six deaths. The latest illness onset date was 9 Jan 2009.

PCA has recalled all peanut butter and peanut paste produced at the Blakely facility since Jul 1, 2008. The products were distributed to institutions, food services, and companies in 24 states, Canada, Korea, and Haiti, according to the CDC. The FDA said the company has stopped production at the plant as the outbreak investigation continues.

As of 21 Jan 2009, more than 125 products, including a few pet foods, have been included in recalls prompted and the list continues to grow. PCA peanut butter and peanut paste were distributed to more than 70 companies according to Stephen Sundlof, DVM, of the US Food and Drug Administration (FDA).

"We currently have more than 125 recalled products listed on the FDA site, and we expect that number to continue to increase as we continue to get more product information," said Sundlof, director of the FDA's Center for Food Safety and Applied Nutrition. Consumer products recalled include cookies, crackers, candy, and ice cream. PCA does not sell peanut butter directly to consumers, and the FDA has said no national peanut butter brands sold in retail stores have been tied to the outbreak.

A few pet food products, including Great Choice dog biscuits, sold by PetSmart, are now included in the recalls, Sundlof reported. "There is risk to humans from handling these products," and people should wash their hands after feeding treats to pets, he said.

Consumers can find a complete list of products recalled at:
http://www.accessdata.fda.gov/scripts/peanutbutterrecall/index.cfm.

Salmonella in plant
In response to questions, Sundlof said the Salmonella isolates found in the Blakely plant recently "were not what I believe to be the same strain as what's causing the outbreak, but it still indicates there is Salmonella in the plant." He said the contamination was found in a floor crack near a washroom and on a floor elsewhere in the plant.

Sundlof said good manufacturing practices should keep Salmonella out of food processing plants. "The fact that the strains don't match is not really relevant from a regulatory standpoint. Having Salmonella in a plant is not supposed to happen," he said. He said that several lines of evidence point to the Blakely facility as the source of the outbreak, though the outbreak strain has not been found there.
(CIDRAP 1/20/09, 1/21/09)

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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
Dengue sickened more than 100 people in north eastern Australia, marking the worst outbreak of the potentially lethal mosquito borne disease since 2004. In Cairns, Queensland state, 97 people were ill, while 350 km south in Townsville, an unrelated outbreak of a different strain of the virus struck six people, said Brian Montgomery, a senior medical entomologist with Queensland Health. More than 10 people have been hospitalized, though none has died, he said. An outbreak in 2003 and 2004 ailed almost 900 people, killing one.

Health officials are concerned the two outbreaks may merge, raising the risk that the epidemic will turn deadly. While people infected with one type of dengue develop lifelong immunity to that virus, studies have shown subsequent infection with a different strain makes a person more susceptible to a complication called dengue hemorrhagic fever, which can kill.
(ProMED 1/11/09)

Indonesia
The dengue fever outbreak in the Bone Regency, South Sulawesi, on 9 Jan 2009 was designated by the Kesehatan local health service as an extraordinary emergency. The data of the Health Service showed hundreds of residents had become infected with dengue fever. Moreover, three children under the age of five years died.

In the meantime, the number of dengue fever patients in the Tenriawaru Hospital continued to increase. After the rooms of the wards filled, dengue fever patients crowded in the hospital corridor. At least 17 subdistricts in the Bone Regency are affected by dengue fever illness. The most seriously affected subdistricts were Lappariaja, Cenrana, Dua Boccoe, Tellu Siattinge, and Barebbo.
(ProMED 1/19/09)

Mexico
Health authorities have detected 35 suspected dengue cases so far in 2009. There are 19 neighborhoods in the southern zone at high risk of dengue. On 15 Jan 2009, the Health authorities held a meeting with personnel from the southern zone to reinforce actions to combat dengue in eight neighborhoods in Tampico, eight in Madero and two in Altamira, where the suspected dengue cases have occurred. According to Ernesto Lavin, who is in charge of the unit, the presence of the dengue virus mosquito vector has increased in the first weeks of January 2009, due to the prevalence of hot weather that favors its reproduction.

Alfredo Rodriguez Trujillo, epidemiologist with the state Secretariat of Health, said that they have been working closely in the 43 Tamaulipas municipalities, where they have asked the populace to undertake actions to combat dengue by means of cleaning up homes and avoiding accumulation of rain water in containers, which is where the dengue mosquito vector reproduces.

He explained that in 2008, Tamaulipas recorded a reduction in the numbers of dengue cases by almost 50 percent, with just 1100 cases of dengue, in comparison with 2007 with more than 2000 cases.
(ProMED 1/19/09)

Peru
The Lambayeque Regional Health Directorate (DIRESA), in coordination with the Illimo municipal district, is evaluating the initiation of fumigation of dwellings where two confirmed non-fatal dengue cases occurred. Victor Echeandia Arellano, the official in charge of this DIRESA, stated that the Aedes index (the number of vector mosquitoes per house) is high, necessitating that they proceed with fumigation, as was done in early 2008 in Olmos district.
(ProMED 1/19/09)

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CHOLERA, DIARRHEA, & DYSENTERY
Philippines
Health officials noted a cholera outbreak since the end of December 2008 in Ticao Island, Masbate after having recorded 124 cases and two fatalities in the towns of Monreal and San Fernando, the Department of Health in Bicol reported on 9 Jan 2009.

Nestor Santiago Jr., Bicol health director, stated that in Monreal town, most of the cases were seen in the village of Guinhadap, with a total of 96. There were four cases in the village of Morocborocan and nine in the village of Poblacion. In San Fernando town, all 15 cases were seen in the village of Ipil.

Most of the victims were children and adolescents. Initial laboratory tests through stool culture revealed three of the 124 cases as positive for V. cholerae Ogawa. Santiago Jr. said their study of the trend of cholera occurrence in the Bicol region showed a reemergence every three to four years.
(ProMED 1/10/08)

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4. Articles
Public Health Preparedness: Strengthening CDC's Emergency Response A CDC Report on Terrorism Preparedness and Emergency Response (TPER)-Funded Activities
Released on 16 Jan 2009. Available at http://www.bt.cdc.gov/publications/jan09phprep/.

CDC's Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER) has released its inaugural report on CDC activities in public health emergency preparedness. The report, Public Health Preparedness: Strengthening CDC's Emergency Response, explains the key role CDC plays in preparing the public health infrastructure to respond effectively to all types of hazards, and provides an overview of the broad range of preparedness activities receiving Terrorism Preparedness and Emergency Response (TPER) funding. CDC accomplishments in preparedness are described. The report also details how CDC is addressing challenges to achieve its overarching public health preparedness goal: "People prepared for emerging health threats - people in all communities will be protected from infectious, occupational, environmental, and terrorist threats." The report is an important part of CDC’s overall focus to demonstrate results, drive program improvements, and increase accountability for the country’s investment in public health preparedness activities.

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5. Notifications
Weekly Epidemiological Bulletin available online
WHO. 16 January 2009; vol. 84(3): p17-28. Available at http://www.who.int/wer.

Contents of this issue
Conclusions and recommendations of the Advisory Committee on Poliomyelitis Eradication, November 2008

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PATH announces new website with resources for diarrheal disease control
PATH is pleased to announce the launch of a new website, Resources for Diarrheal Disease Control. This resource-rich site provides tools that advocates and practitioners can use in spreading the word about the deadly toll of diarrheal disease and the solutions to stop it.

In addition to established interventions that include oral rehydration therapy, breastfeeding, clean water, and hygiene, new tools like zinc and diarrhea vaccines bring new opportunities to re-invigorate interest and investments toward addressing the second-leading cause of child death.

Presented in partnership with UNICEF (United Nations Children's Fund), the website includes key documents and links to information on these simple, lifesaving interventions, as well as highlights of in-country programs that are putting them in the hands of mothers and caregivers.

Website is available at http://www.eddcontrol.org.

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The Royal Government of Cambodia Awarded the “Royal Order of Sahametrei” to Dr Chinkholal Thangsing
In Phnom Penh on 21 January 2009, the Royal Government of Cambodia awarded the prestigious "Royal Order of Sahametrei " to Dr.Chinkholal Thangsing, the Asia Pacific Bureau Chief of AIDS Healthcare Foundation.

The “Royal Order of Sahametrei” is a medal of honor conferred primarily on foreigners who have rendered distinguished services to the King and to the Nation by Royal Decree of His Majesty the King of Cambodia. The award recognizes Dr. Chinkholal Thangsing’s exemplary contribution and dedication to the humanitarian services rendered by him and the organization for the people living with HIVAIDS and general public in Cambodia.

The selfless and passionate mission of the organization has saved many lives and restores dignity and hope for many people infected and affected by the HIV epidemic in Cambodia.

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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