Vol. XII, No.4 ~ EINet News Briefs ~ Feb 20, 2009

***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: 408 (254).
(WHO 2/18/09 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 2/2/09)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 1/27/09): 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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Global: Recommended composition of influenza virus vaccines for use in the 2009-2010 northern hemisphere influenza season
Because of a suboptimal match between the 2008-2009 flu vaccine and circulating influenza B viruses, the World Health Organization (WHO) has recommended changing one of the three strains used in flu vaccines for the Northern Hemisphere for fall and winter 2009-2010.

The WHO's choices for the two influenza A strains remain the same as last year, according to new reports published on the WHO Website. The agency recommended keeping the influenza A/H1N1 and A/H3N2 variants used in this year's vaccine, both of which are labeled Brisbane strains.

The influenza B component of this year's flu vaccine was from the Yamagata lineage, but the proportion of strains from the Victoria lineage continues to increase and has become predominant in many countries, the WHO said. The US Centers for Disease Control and Prevention's (CDC's) most recent flu surveillance report, for the week of 1-7 Feb. 2009, said that of 78 influenza B viruses that were characterized, 55 belonged to the Victoria lineage.

Health officials in the US have discussed including both lineages in the seasonal vaccine to address the unpredictable prevalence of the influenza B strains, especially since a vaccine against one lineage offers little protection against the other. In 2008, the WHO recommended a total vaccine makeover for the 2008-09 flu season because of a mismatch to circulating strains the previous season.

Each February the WHO assesses the flu virus strains in circulation before picking the strains for the next Northern Hemisphere flu season. It takes about six months for vaccine manufacturers to grow the viruses in chicken eggs and formulate them into trivalent (three-strain) vaccines. Changing one or two strains is not unusual.

The WHO recommends the following for next season's vaccine:
• For the H1N1 component, a strain similar to A/Brisbane/59/2007
• For the H3N2 component, a strain similar to A/Brisbane/10/2007
• For the B component, a strain similar to B/Brisbane/60/2008-like virus, replacing B/Florida/4/2006

The Brisbane strains of H1N1 and H3N2 will be used in this year's vaccine for the Southern Hemisphere, where the flu season runs from May through October, according to the WHO. However, the influenza B component of the Southern Hemisphere's vaccine is similar to B/Florida/4/2006.

In its full report on the strain selection, the WHO said that between September 2008 and January 2009, Africa, the Americas, Asia, Europe, and Oceania all reported influenza activity. Though levels were lower than in the same period last year, activity was higher in some European countries, including the United Kingdom, Norway, Portugal, Spain, Poland, and the Netherlands.

In the Northern Hemisphere, countries such as Japan, Tunisia, and European countries reported regional outbreaks of H3N2 in December 2008 and January 2009. In the US, H1N1 viruses predominated, while in Canada, B viruses were more common. H1N1 strains that show resistance to the antiviral drug oseltamivir (Tamiflu), one of two neuraminidase inhibitors recommended for treatment, predominated in most regions of the world. No such resistance was seen in H3N2 or B viruses, and there were no reports of viruses resistant to zanamivir (Relenza).

Access the full report at http://www.who.int/csr/disease/influenza/200902_recommendation.pdf
(CIDRAP 2/13/09)

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South Korea: Low pathogenic H5 avian influenza confirmed on three chicken farms
Korea's Ministry for Food, Agriculture, Forestry and Fisheries confirmed on 18 Feb 2009 that avian influenza recently occurred on three chicken farms in Korea's Suncheon and other parts of Jeollanam-do South Jeolla Province. The Ministry said that tests carried out on blood samples taken from poultry on three chicken farms in Suncheon, Gokseong County, and Boseong County in Jeollanam-do Province confirmed that the avian influenza virus found on all three chicken farms is low pathogenic H5 subtype. A total of 22,000 chickens on the three farms have been culled.
(ProMED 2/19/09)

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Viet Nam: Confirms third human case of bird flu
A 32-year-old man from Vietnamese northern Ninh Binh Province has tested positive for the H5N1 virus, an official from the Vietnamese Ministry of Health (MOH) said on 17 Feb 2009. The patient is the third bird flu patient in Viet Nam in 2009, said the official with the Preventative Health Department under the MOH. He was taken to hospital on 13 Feb 2009 with severe breathing difficulty. He had contact with fowl before developing bird flu symptoms. The patient is currently being treated at Viet Nam's National Institute of Hygiene and Epidemiology.

So far, seven provinces of Viet Nam nationwide have been hit by the avian flu, including three provinces in Mekong Delta, namely Ca Mau, Soc Trang and Hau Giang, two northern provinces of newly-confirmed Bac Ninh and Quang Ninh; and two central provinces of Nghe An and the newly-confirmed Quang Tri, said the Department of Animal Health of Vietnamese Ministry of Agriculture and Rural Development. The re-emergence of bird flu has led to the culling of thousands of fowl in Viet Nam in 2009.

Viet Nam has reported three human cases of bird flu in 2009. They are an eight-year-old girl from northern Thanh Hoa province in early January 2009, a 23-year-old woman from northern Quang Ninh province in early February, and the newly-confirmed case. The 23-year-old woman has shown slow recovery as is still suffering severe respiratory illnesses. In 2008, bird flu killed five people in Vietnam.
(ProMED 2/17/09)

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USA: Millions in pandemic funding removed from economic stimulus bill
With money for pandemic influenza preparedness stripped from a huge economic stimulus bill that was signed into law on 17 Feb 2009, public health advocates say they have to look to the regular budgeting process for the next chance to get some pandemic funding.

The House of Representatives had included $900 million in pandemic preparedness funds in its version of the massive stimulus package, but it appeared that all but $50 million was removed by the conference committee that ironed out differences between the House and Senate versions, said Richard Hamburg, government relations director for the nonpartisan, nonprofit group Trust for America's Health (TFAH).

The $50 million left in the bill, listed as a Public Health and Social Services Emergency Fund, is for improving information technology security at the Department of Health and Human Services (HHS), Hamburg said. The sums removed included $420 million for pandemic flu and $430 million for biomedical advanced research and development, he reported. Now it's back to the regular budget process for those seeking pandemic and other public health preparedness funds, leaders of public health groups say. The Obama administration is expected to propose its 2010 budget soon.

Nothing left in pipeline
Hamburg said there is no more pandemic preparedness money in the pipeline for state and local public health. "The $600 million that was made available in December 2005, in the fiscal year 2006 emergency supplemental bill, the last of those dollars went out the door this past August," he said. In addition to the cutoff of pandemic flu funding, public health agencies have seen their "all hazards" preparedness funding drop about 25% since 2005, Hamburg said.

TFAH and its partners are advocating for another $350 million specifically for pandemic readiness and additional money for other public health emergencies, he said. Fiscal year 2009 budget legislation is still awaiting action, and it could include some pandemic money, but it would all be for federal activities, according to Hamburg.

He said President Bush's proposed 2009 budget included $507 million in one-time spending for pandemic vaccines and countermeasures, plus $312 million for annual recurring pandemic activities at HHS, but no funds for state and local activities. Hamburg expects that Congress may take up the labor and HHS funding bill, which includes that money, later this month.
(CIDRAP 2/13/09, 2/19/09)

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USA: HHS web seminar discusses mental health planning for an influenza pandemic
From stigmatization of people exposed to the virus to maintaining methadone treatment facilities, public health officials need to plan for a wide spectrum of mental health challenges that would likely emerge during an influenza pandemic, federal officials said at a US Department of Health and Human Services (HHS) live Web seminar (webinar).

Dana Taylor, chief of emergency medical services at the Substance Abuse and Mental Health Services Administration (SAMHSA), urged pandemic planners to think more broadly than just how the pandemic events will affect people's feelings and emotions. He said that public perceptions and conclusions will affect individual decision-making and behavior, which will be especially important when public health officials need their compliance with social distancing measures and other pandemic-related actions. Taylor said pandemic planners can work with their communities now to build resilience and can use a process that mental health professionals call "stress inoculation." "The more an individual knows what to expect, the more mitigation of fear and panic," said Taylor, who suggested that pandemic planners can use prepandemic stages to identify credible and trustworthy leaders who can address the public during a pandemic.

Brian McKernan, a technical assistance team manager at SAMHSA, urged webinar viewers to consider training people to provide psychological first aid, a well established, practical approach to contacting and engaging people and assessing their mental health needs in an emergency setting. Having these first aid providers will help alleviate the strain on traditional mental health providers during a pandemic, he said. In addition, it is designed to be used by “paraprofessionals.”

Linda Ligenza, a public health advisor to SAMHSA, said the Red Cross has developed a psychological first aid protocol, adding that each state has a disaster mental health coordinator. She advised pandemic planners to identify groups ahead of time who might be especially vulnerable to pandemic disruptions, such as frail, elderly people and those with disabilities or chronic illnesses who depend on other people for their care.

The experts also singled out children as another vulnerable group. Taylor urged parents and guardians to use a tone of voice that projects security when talking to children about pandemic topics and limiting the information to age-appropriate topics that they can participate in, such as instructing smaller children about proper hand-washing technique.
(CIDRAP 2/18/09)

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USA: National Governors Association releases report on workforce pandemic guidance
The National Governors Association (NGA) issued a report to help states protect their workforce and sustain key government functions such as law enforcement and water treatment during an influenza pandemic. The guidance was developed from regional pandemic preparedness workshops that the NGA conducted during 2007 and 2008, the association said. Feedback after each of the workshops revealed that one of the states' leading concerns is developing worker policies to keep government running and protect key infrastructure during a pandemic.

Absences from illness, the need to care for family members, and fear of exposure create three main challenges during a pandemic: maintaining government continuity and the delivery of essential services such as law enforcement and firefighting, developing policies that protect state government workforce, and setting policies to address worker shortages.

Some of the toughest issues will involve state employees who work in institutional settings such as prisons or state hospitals or those who have face-to-face contact with the public, the report said.

The NGA guidance advises states to take three steps for developing government continuity plans:
• Form multiagency, multisector work groups to identify key services
• Determine which workers are needed to maintain the key services
• Develop alternate workplace strategies for as many of these workers as possible

The NGA also advises states to assess if any leave policy changes are needed to maximize productivity while allowing workers to stay home if they are sick or need to take care of their families. To promote social distancing, states could consider enhancing their paid-leave programs, establishing leave policies that provide partial or reduced pay, incorporating donated leave programs, and ensuring that sick employees receive care.

To address workforce shortages, particularly in critical areas, the NGA urges states to identify ways to "backfill" certain positions. For example, states can cross-train employees now to ensure that key positions will be filled, and recently retired workers could help supplement the state workforce.

Access the full report at http://www.nga.org/Files/pdf/0902PANDEMICWORKFORCEPLAN.PDF.
(CIDRAP 2/19/09)

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USA (Georgia): Outbreak of Legionnaire’s disease at hospital
Officials say Grady Memorial Hospital, Atlanta's largest hospital, has confirmed finding Legionella bacteria in patient rooms that likely caused four cases of Legionnaire's disease in patients. Grady Memorial Hospital officials said on 12 Feb 2009 that lab tests showed Legionella bacteria in water samples taken from patient rooms on the 11th and 12th floors of a hospital tower. The positive samples were taken from bathroom areas, not air vents. Four of the patients who had stayed in rooms in that area have come down with Legionnaire's disease since 1 Jan 2009, which is as many cases as the hospital saw in all of 2008. No Legionella bacteria were found in other parts of the hospital. The water system is being flushed with hyperchlorinated water, but patients still are not being allowed in the areas.

Legionnaire's Disease is a type of pneumonia that is treated with antibiotics. The condition can be deadly, but it isn't transmitted by drinking water or from person to person. "It has to get into the lungs; [they] have to inhale the mist. Taking a shower, that would be a place people could potentially get it," said Dr. Curtis Lewis, Chief Medical Officer.
(ProMED 2/7/09, 2/12/09)

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The initial symptoms of measles are fever, lethargy, runny nose, cough, and sore red eyes followed a few days later by a red blotchy rash. The rash starts on the face and then spreads to the chest and the rest of the body. Measles is extremely contagious and is spread through coughing and sneezing. Measles can be complicated by pneumonia and encephalitis (inflammation of the brain).

"I would urge people to be particularly aware of any signs of infection in themselves or their children," he said. "Anyone who develops a fever, cough, runny nose and eyes, and a blotchy red rash over the next few weeks should seek advice from their local doctor. However, it is very important that people ring ahead to the doctor's surgery to say they could have measles, so that precautions can be taken to avoid spreading the disease to others." They should then stay home until their doctor has excluded measles.

"Queensland Health will continue to follow up people who may have been exposed and undertake steps to prevent further spread," he said. Two doses of a measles-containing vaccine (MMR -- measles, mumps, rubella) are strongly recommended to prevent the disease. The first dose is currently recommended at 12 months of age and the second at four years of age. "Immunisation is the best protection against measles, so parents should ensure that their children are vaccinated on time," Dr Beard said. "Adults born after 1965 should also be vaccinated, unless their records show that they have had 2 doses of measles vaccine in the past."
(ProMED 2/8/09)

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New Zealand: English measles confirmed in child prompts warning to airline passengers and medical center patients
Patients at a Wellington medical centre and passengers on several international and domestic flights may have been exposed to highly infectious English measles. Wellington Regional Medical Officer of Health Annette Nesdale issued a warning on 7 Feb 2009 after a child who returned from Viet Nam on 29 Jan 2009 was diagnosed with the disease. Dr Nesdale said people who came in contact with the child needed to watch for symptoms including fever, tiredness, runny nose, coughing, and sore red eyes.

Measles was rare in New Zealand due to immunization but the disease could spread rapidly among unimmunized groups, she said. "We are really wanting to get this information out to people over the long weekend as if they develop symptoms it is important they get medical advice to ensure they don't inadvertently spread measles further."

The child flew from Ho Chi Minh City, Viet Nam, to Singapore via Singapore Airlines on 29 Jan 2009. That evening the child left Singapore for Auckland then boarded a connecting Air New Zealand flight to Wellington on 30 Jan 2009. The child was also seen at the Wellington Hospital Emergency Department on the afternoon of 1 Feb 2009 and the morning of 3 Feb 2009 and at the Karori Medical Centre on 2, 3 and 4 Feb 2009.

Those waiting for blood tests at the medical centre may also have been exposed. Dr Nesdale said anyone with symptoms should seek immediate medical advice but should also call ahead to warn doctors about the possibility of measles.
(ProMED 2/7/09)

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The Court of Claims weighs complaints brought by citizens under the National Vaccine Injury Compensation Program, a federal no-fault program set up in 1986 to reduce the number of lawsuits against physicians and vaccine makers. As of May 2008, more than 12,800 cases had been filed under the program, 5,365 of those related to autism. Since 1988, the program has paid out more than $859 million to a total of 956 claimants, according to Court of Claims documents.

The decision came in three test cases based on one of three "causation theories" proposed by parents of children with autism: that MMR vaccines and thimerosal-containing vaccines can combine to cause autism. Thimerosal is a mercury-containing compound that is used as a preservative in some vaccines, including some influenza vaccines. Hearings in the three cases were held in 2007.

Federal officials and public health and medical groups welcomed today's rulings, while saying that the search for the cause of autism must continue. "Hopefully, the determination by the Special Masters will help reassure parents that vaccines do not cause autism," the Department of Health and Human Services (HHS) said. The American Medical Association hailed the rulings, stating: "Autism is a heart-wrenching condition, and the upheaval felt by parents whose children suffer with autism is understandable—as is their search for answers. We need ongoing research into the causes of autism, but cannot let unfounded myths keep us from giving our children the proven protection they need against infectious diseases."

But SafeMinds, an autism advocacy group, criticized the decision, saying the deck is stacked against claimants because HHS funds vaccine safety research and is the defendant in vaccine injury cases. The group commented, "The denial of reasonable compensation to families was based on inadequate vaccine safety science available to the court. The Department of Health and Human Services (HHS) is the defendant in vaccine injury cases and is also responsible for carrying out the very vaccine safety research that should be integral to court decisions. This conflict of interest means the deck is stacked against families when they enter 'vaccine court' and is yet one more reason for parents to doubt the integrity of the National Immunization Program."

One of the three families involved in the cases claimed that vaccines containing thimerosal can cause immune dysfunction and that MMR vaccine can cause both autism and gastrointestinal dysfunction, according to the decision document. But Special Master George Hastings wrote that the "evidence was overwhelmingly contrary to the petitioners' contentions." In another case, parents argued that a combination of thimerosal-containing vaccines and the measles component of the MMR vaccine caused their son to suffer a "pervasive developmental disorder," similar to autism spectrum disorder. Special Master Denise Vowell wrote that the evidence presented was "voluminous and extraordinarily complex"—but unpersuasive.
(CIDRAP 2/12/09)

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USA: Second peanut processing plant implicated in Salmonella outbreak
The US Food and Drug Administration (FDA) offered additional evidence on 17 Feb 2009 that the Peanut Corp of America (PCA) plant in Blakely, Ga., may not be the only PCA facility that has contributed to the nationwide Salmonella outbreak linked to peanut products. FDA spokesman Sebastian Cianci said that Salmonella Typhimurium matching the national outbreak strain was found in an opened jar of peanut butter that a Colorado patient had bought from Vitamin Cottage Natural Foods, a retailer that made peanut butter from peanuts supplied by PCA's processing plant in Plainview, Tex.

Vitamin Cottage, based in Lakewood, CO., and the Colorado Department of Public Health and Environment (CDPHE) announced two weeks ago that the company was recalling its fresh-ground peanut butter because the CDPHE had determined that three patients infected with the outbreak strain of Salmonella had eaten the company's peanut butter.

"The peanuts used to make it originated from the PCA plant in Plainview, TX, and since they announced the recall, the same strain of Salmonella Typhimurium was identified in an open container of peanut butter that came from one of the individuals who became ill," Cianci said. He said the Centers for Disease Control and Prevention (CDC) had confirmed the finding by 13 Feb 2009.

Kemper Isely, co-president of Vitamin Cottage, said the FDA had informed him of the positive finding on 17 Feb 2009. "Of two consumer samples, they found one of them to have Salmonella in it. It [the jar] was open," he said. He said FDA officials had visited the company's facility and tested its peanut grinding machines without finding any contamination. "They swabbed six of our machines and didn't find Salmonella in them," nor did they find the pathogen in new peanut butter samples, he said.

Cianci and Isely said that because the peanut butter from the patient's home had been opened, officials couldn't exclude the possibility that the product somehow became contaminated after it was produced. Cianci said he couldn't speculate as to why the Salmonella found in the Colorado peanut butter matched the national outbreak strain even though it was made from peanuts that did not come from the Blakely, GA, peanut processing plant. "There may be reasons for that other than just coincidence. I don't know what the shipping patterns were," he said.

Until recently, the Blakely plant was regarded as the sole source of the outbreak. But the Texas facility came under scrutiny after the outbreak triggered investigation of the company. It was reported that the Texas plant had operated for several years with no license and no government health inspections. Although initial inspections reportedly revealed no contamination problems in the plant, the president of a private laboratory told a congressional committee that his firm had found Salmonella in a product sample from the plant on 8 Feb 2009.

On12 Feb 2009, the Texas Department of State Health Services (DSHS) ordered PCA to recall all products ever shipped from the Plainview plant. The agency said dead rodents, rodent excrement, and bird feathers had been found in a crawl space above a production area there. State inspectors also found that the plant's air-handling system was pulling debris from the infested crawl space into production areas of the plant, the DSHS said.

The Salmonella outbreak involves 636 cases in 44 states and one in Canada, according to the latest count from the Centers for Disease Control and Prevention (CDC). The FDA's recall database page says the outbreak has triggered 2,226 product recalls, though no national brands of peanut butter have been recalled.

Meanwhile, a survey by the Harvard School of Public Health found some gaps in the public's understanding of the peanut product recalls. More than 90% of respondents were aware of the recalls, and 61% said they had taken one or more steps to reduce their risk of getting sick from contaminated peanut products, according to a Harvard news release. But among those aware of the recall, 25% mistakenly believed that major brands of peanut butter were involved.

Also, while 70% knew that peanut butter crackers were recalled, fewer than half knew that several other peanut butter products, such as snack bars, cakes, and cookies, were recalled, the release states. The survey of a national random sample of 1,283 adults was conducted 4-8 Feb 2009.
(CIDRAP 2/16/09, 2/17/09)

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USA (Colorado): E coli outbreak likely connected to stock show
At least 11 kids have been sickened by E. coli O157:H7 bacteria, likely transmitted during field trips to the National Western Stock Show in January 2009. There are 12 lab-confirmed cases and eight others are pending, according to Denver Public Health. Just one of the 12 individuals is an adult.

So far, all confirmed and probable cases live in Front Range counties, from Boulder to El Paso County, Denver Public Health reports. The pattern of transmission suggests that some kids who went to the stock show with their teachers contracted the bacteria, and then spread it at child-care, pre-school, or school settings. Any child with diarrhea who attended the stock show should see a doctor before returning to child-care, health officials said. Any child with bloody diarrhea, whether or not he or she attended the stock show, should see a doctor.

Dr Chris Urbina, executive director of Denver Public Health, said standards of cleanliness are set for stock shows and that the National Western has always been good at complying. Children are allowed to pet animals at the stock show, and the mere petting of animals whose hides are dirty is one way for the hand to pick up the bacterium. Investigators continue to talk to National Western officials and to the children to better get a sense of how the bacteria were transmitted, Urbina said. They'll ask sufferers what they ate, where they went, what animals they petted, and so forth.
(ProMED 2/6/09)

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USA (Pennsylvania): Possible fourth case of meningitis at university
The Philadelphia Health Department is investigating a fourth possible case of meningococcal meningitis at the University of Pennsylvania, officials said on 16 Feb 2009. The university would not comment on the investigation but did release a statement saying the three students who were hospitalized with the disease last week are showing improvement.

Two additional students who are from the same social circle were hospitalized over the weekend with flu-like symptoms. Their conditions are also improving, officials said. Doctors have been closely monitoring their conditions to ensure they did not in fact contract meningitis. Penn officials believe the disease has been spread through the university's fraternity and sorority system. As a precaution, all on and off-campus parties were shut down this past weekend. More than 2100 students have received preventive antibiotics since the first report of a meningitis outbreak was released.

Meningitis is spread through close, prolonged contact like sharing toothbrushes or utensils, kissing, or sexual contact. University officials say it is not uncommon for more than one case to pop up on campuses. Early symptoms of infection include fever, severe headache, stiff neck, nausea, vomiting, rash, lethargy and sensitivity to bright light.
(ProMED 2/18/09)

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DENGUE
Australia
Health authorities in far north Queensland say there is a danger dengue fever could spread through Port Douglas, north of Cairns, after its first case was confirmed on 6 Feb 2009. There have been 277 confirmed cases in Cairns and 47 in Townsville.

Entomologist Brian Montgomery says people need to take precautions to stop the spread of the disease. "We've had dengue outbreaks before in Port Douglas so there's certainly a risk that it will spread," he said. "They have a very pro-active program with assessing hotspots there, so it's always encouraging if the public are well educated."

Travelers arriving at Cairns airport should be screened for dengue fever, an infectious disease specialist said. James Cook University medicine professor James McBride said the government should consider installing a thermal scanner to identify dengue fever cases. The clinical microbiologist said although the technology would not stop all dengue fever outbreaks, it had the potential to reduce the incidence of the virus. The federal government dismissed the suggestion, despite having 25 unused portable scanners purchased in response to the threat of pandemic influenza, saying current screening was sufficient.

Scott Ritchie, director of medical entomology at Tropical Population Health Services in Cairns, said the current dengue virus was the most rapidly moving he had seen. Dr Ritchie said the transmission rate for this form of virus was as short as nine days, compared with 17 days during the 2003 outbreak. He said the virus could not be eradicated until winter, when it would be too dry and too cold for mosquitoes to breed and the virus to spread.
(ProMED 2/10/09)

Indonesia
A dengue fever outbreak killed one person and infected 26 others in Mamuju District, West Sulawesi Province, a local health official said. The Mamuju health office declared the disease outbreak in the district as an emergency to anticipate the spreading of dengue fever, Firmon, the Mamuju health service head, said on 7 Feb 2009. The 26 patients were being hospitalized in Mamuju Public Hospital, he said.

The health office has distributed powder to kill the eggs of Aedes aegypti mosquitoes, which are usually laid on the surface of stagnant water, and sprayed mosquito repellent, he said. The local health office also set up 27 command posts in every community health center and hospitals in the district to monitor the disease outbreak.

In addition, during January 2009, 102 cases of dengue fever occurred in the Pacitan Regency, East Java caused the Health Service to declare a health emergency there as well, said the head of Disease Control, Environment and Sanitation of Pacitan, Hendra Purwaka, on 3 Feb 2009. The dengue attack this time has experienced a change in the pattern" he said. "The Health Service found inconsistency," shock to the sufferer on day 3-5, which usually happens on day 5-7.

He made a plea to the wider community to be more on the alert with the change in the pattern of this attack of dengue fever. He said the high number of dengue cases was also due to the lack of social involvement by the community to be aware of the need for environmental sanitation that should be carried out constantly, but especially before the rainy season.

To anticipate increase in cases, the Pacitan Health Service will carry out monitoring activity and fumigation in the endemic territory where the illness is spreading. Moreover, there will be eradication of the mosquito breeding sites using the "3M" approach consisting of drained water catchments, closed water storage containers, and buried trash to combat mosquitoes. The efforts are to be carried out periodically in areas of all of the social strata.
(ProMED 2/10/09)

Malaysia
The number of dengue cases nationwide has doubled in the first five weeks of 2009 compared with the same period in 2008. And Selangor still has the highest number of cases. By 6 Feb 2009, about 6623 cases had been recorded and 18 people had died. In the same period in 2008, the numbers were 3829 cases and 9 deaths.

These numbers are concerning for Selangor and Hulu Langat district, which contains 15 of the 40 hotspots identified in the state. In 2008, Selangor recorded 21,262 cases, almost half of the 49,335 cases nationwide.

Speaking at an anti-dengue campaign at Taman Taming Jaya in Balakong on 7 Feb 2009, health minister Datuk Liow Tiong Lai said although Selangor has shown an increase when compared with 2008, since December the number of cases has dropped by 38 percent." People need to be quicker in consulting a doctor when they have symptoms. Many people delay treatment," Liow said. Only 35 per cent of people nationwide are diagnosed with dengue within three days.

He said the ministry has registered 11,892 volunteers in its Communication for Behavioural Impact (Combi) program launched in 2008. It is aimed at turning awareness into community action against dengue. They have been sent to 585 locations around the country. "We need help from local councils and residents associations as well. If we had enough machines we could fog all areas on a weekly basis. But we don't have sufficient machines or manpower," he said.
(ProMED 2/10/09)

Peru
The forested region of Ucayali, which is on the border with Brazil, was declared in emergency status due to an outbreak of classical dengue and dengue hemorrhagic fever (DHF), according to an article published on 4 Feb 2009 in the official newspaper, El Peruano. The Ucayali Regional Council reported a shortage of personnel and equipment to combat the propagation of this disease. As a result, there was a ruling to adopt corresponding actions in order to finance measures with the goal of avoiding additional spread of the disease. The rainy season in the mountains and savannas in Peru falls between the months of December and March, and during this period many populated areas in downstream lowland areas are isolated by floods making surveillance and mosquito vector control extremely difficult.
(ProMED 2/10/09)

Thailand
The Public Health Ministry has set up a national war room to control the spread of dengue fever across the country after learning the situation will be far worse than in 2008. So far, 1675 people have fallen victim to the fever in 2009, said the minister, Witthaya Kaewparadai.

The ministry's deputy permanent secretary, Dr. Paijit Warachit will chair the war room, teaming up with agencies including the Bangkok Metropolitan Administration's Health Department, the World Health Organization (WHO), and a joint activity of the Ministry of Public Health of Thailand and the US Centers for Disease Control and Prevention (CDC), to monitor the spread of disease within Thailand and neighboring countries. They will meet at least once a week to keep a close watch on any possible outbreak.

Citing Bureau of Epidemiology records, Paijit said in January 2009, 1675 people had been infected with dengue fever and two had died. The figure for the same period in 2008 was 1553 dengue fever cases reported and two lives lost. The Central region was the hardest hit with 886 patients, the Southern region suffered the second worst outbreak with 546 patients and Bangkok, 303. Songkhla, Pattani, and Yala were the worst affected provinces. Nearly half the patients so far in 2009 have been over 15 years old.

In 2008, there were a total of 91,003 patients and 65,581 cases in 2007.
(ProMED 2/10/09

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Perspective Two years ago, a nationwide outbreak of Shiga toxin–producing Escherichia coli O157:H7 enteritis linked to consumption of contaminated spinach from one California supplier captured the attention of the national media for weeks. It was at least the 26th reported U.S. outbreak of E. coli infection that had been traced to contaminated leafy green vegetables since 1993. Each year, approximately 110,000 persons acquire endemic toxigenic E. coli infection, and 50 of them die, despite greatly intensified efforts during the past decade on the part of our federal food-safety agencies — the U.S. Department of Agriculture (USDA), the Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC) — to prevent the spread of such infections.

Now we are confronted by two large nationwide outbreaks of salmonella infection. Between April and August 2008, Salmonella Saintpaul enteritis was diagnosed in 1407 persons in 43 states, the District of Columbia, and Canada. Ultimately, 282 patients were hospitalized, and 2 elderly patients died. Initial epidemiologic investigations by state health departments and the CDC suggested that contamination of tomatoes grown in the southwestern United States was the cause, although this was never proved microbiologically. Predictably, tomato consumption plummeted, and the industry lost an estimated $200 million. After several months of investigation, the outbreak strain was isolated from jalapeńo and serrano peppers that had been grown on one Mexican farm, and the CDC concluded that the outbreak derived from contamination of peppers that were eaten raw — probably in many cases with tomatoes, which might explain the misleading results from the initial case–control studies.

Except with references removed.

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Highly Pathogenic Avian Influenza Virus (H5N1) Outbreak in Captive Wild Birds and Cats, Cambodia
Desvaux S et al. Emerg Infect Dis. March 2009 (early online publication). Available at http://www.cdc.gov/eid/content/15/3/pdfs/07-1410.pdf.

From December 2003 through January 2004, the Phnom Tamao Wildlife Rescue Centre, Cambodia, was affected by the highly pathogenic influenza virus (H5N1). Birds from 26 species died. Influenza virus subtype H5N1 was detected in 6 of 7 species tested. Cats from 5 of 7 species were probably infected; none died. We report the results of a retrospective investigation of this outbreak.

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Relation of study quality, concordance, take home message, funding, and impact in studies of influenza vaccines: systematic review
Jefferson T et al. BMJ. 12 Feb 2009. Available at http://www.bmj.com/cgi/content/abstract/338/feb12_2/b354.

Objective To explore the relation between study concordance, take home message, funding, and dissemination of comparative studies assessing the effects of influenza vaccines.

Design Systematic review without meta-analysis. Data extraction Search of the Cochrane Library, PubMed, Embase, and the web, without language restriction, for any studies comparing the effects of influenza vaccines against placebo or no intervention. Abstraction and assessment of quality of methods were carried out.

Data synthesis We identified 259 primary studies (274 datasets). Higher quality studies were significantly more likely to show concordance between data presented and conclusions (odds ratio 16.35, 95% confidence interval 4.24 to 63.04) and less likely to favour effectiveness of vaccines (0.04, 0.02 to 0.09). Government funded studies were less likely to have conclusions favouring the vaccines (0.45, 0.26 to 0.90). A higher mean journal impact factor was associated with complete or partial industry funding compared with government or private funding and no funding (differences between means 5.04). Study size was not associated with concordance, content of take home message, funding, and study quality. Higher citation index factor was associated with partial or complete industry funding. This was sensitive to the exclusion from the analysis of studies with undeclared funding.

Conclusion Publication in prestigious journals is associated with partial or total industry funding, and this association is not explained by study quality or size.

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Sequencing and Analyses of All Known Human Rhinovirus Genomes Reveals Structure and Evolution
Palmenberg AC et al. Science. 12 Feb 2009. Available at http://www.sciencemag.org/cgi/content/abstract/1165557.

Infection by human rhinoviruses (HRVs) is a major cause of upper and lower respiratory tract disease worldwide and displays significant phenotypic variation. We examined diversity by completing the genome sequences for all known serotypes (n = 99). Superimposition of capsid crystal structure and optimal-energy RNA configurations established alignments and phylogeny. These revealed conserved motifs, clade-specific diversity including a potential new species (HRV-D), mutations in field isolates, and recombination. In analogy with poliovirus, a hypervariable 5'UTR tract may affect virulence. A configuration consistent with nonscanning internal ribosome entry was found in all HRVs and may account for rapid translation. The data density from complete sequences of the reference HRVs provided high resolution for this degree of modeling and serves as a platform for full genome-based epidemiologic studies and antiviral or vaccine development.

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International travels and fever screening during epidemics: a literature review on the effectiveness and potential use of non-contact infrared thermometers
Bitar D et al. Eurosurveillance. 12 Feb 2009; 14(6). Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19115.

Several countries plan to introduce non-contact infrared thermometers (NCIT) at international airports in order to detect febrile passengers, thus to delay the introduction of a novel influenza strain. We reviewed the existing studies on fever screening by NCIT to estimate their efficacy under the hypothesis of pandemic influenza. Three Severe Acute Respiratory Syndrome (SARS) or dengue fever interventions in airports were excluded because of insufficient information. Six fever screening studies in other gathering areas, mainly hospitals, were included (N= 176 to 72,327 persons; fever prevalence= 1.2% to 16.9%). Sensitivity varied from 4.0% to 89.6%, specificity from 75.4% to 99.6%, positive predictive value (PPV) from 0.9% to 76.0% and negative predictive value (NPV) from 86.1% to 99.7%. When we fixed fever prevalence at 1% in all studies to allow comparisons, the derived PPV varied from 3.5% to 65.4% and NPV was >=99%. The low PPV suggests limited efficacy of NCIT to detect symptomatic passengers at the early stages of a pandemic influenza, when fever prevalence among passengers would be =<1%. External factors can also impair the screening strategy: passengers can hide their symptoms or cross borders before symptoms occur. These limits should be considered when setting up border control measures to delay the pandemic progression.

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Methicillin-Resistant Staphylococcus aureus Central Line–Associated Bloodstream Infections in US Intensive Care Units, 1997-2007
BurtonDC et al. JAMA. 2009; 301(7): 727-736. Available at http://jama.ama-assn.org/cgi/content/full/301/7/727.

Abstract

Context Concerns about rates of methicillin-resistant Staphylococcus aureus (MRSA) health care–associated infections have prompted calls for mandatory screening or reporting in efforts to reduce MRSA infections.

Objective To examine trends in the incidence of MRSA central line–associated bloodstream infections (BSIs) in US intensive care units (ICUs).

Design, Setting, and Participants Data reported by hospitals to the Centers for Disease Control and Prevention (CDC) from 1997-2007 were used to calculate pooled mean annual central line–associated BSI incidence rates for 7 types of adult and non-neonatal pediatric ICUs. Percent MRSA was defined as the proportion of S aureus central line–associated BSIs that were MRSA. We used regression modeling to estimate percent changes in central line–associated BSI metrics over the analysis period.

Main Outcome Measures Incidence rate of central line–associated BSIs per 1000 central line days; percent MRSA among S aureus central line–associated BSIs.

Results Overall, 33 587 central line–associated BSIs were reported from 1684 ICUs representing 16 225 498 patient-days of surveillance; 2498 reported central line–associated BSIs (7.4%) were MRSA and 1590 (4.7%) were methicillin-susceptible S aureus (MSSA). Of evaluated ICU types, surgical, nonteaching-affiliated medical-surgical, cardiothoracic, and coronary units experienced increases in MRSA central line–associated BSI incidence in the 1997-2001 period; however, medical, teaching-affiliated medical-surgical, and pediatric units experienced no significant changes. From 2001 through 2007, MRSA central line–associated BSI incidence declined significantly in all ICU types except in pediatric units, for which incidence rates remained static. Declines in MRSA central line–associated BSI incidence ranged from –51.5% (95% CI, –33.7% to –64.6%; P < .001) in nonteaching-affiliated medical-surgical ICUs (0.31 vs 0.15 per 1000 central line days) to –69.2% (95% CI, –57.9% to –77.7%; P < .001) in surgical ICUs (0.58 vs 0.18 per 1000 central line days). In all ICU types, MSSA central line–associated BSI incidence declined from 1997 through 2007, with changes in incidence ranging from –60.1% (95% CI, –41.2% to –73.1%; P < .001) in surgical ICUs (0.24 vs 0.10 per 1000 central line days) to –77.7% (95% CI, –68.2% to –84.4%; P < .001) in medical ICUs (0.40 vs 0.09 per 1000 central line days). Although the overall proportion of S aureus central line–associated BSIs due to MRSA increased 25.8% (P = .02) in the 1997-2007 period, overall MRSA central line–associated BSI incidence decreased 49.6% (P < .001) over this period.

Conclusions The incidence of MRSA central line–associated BSI has been decreasing in recent years in most ICU types reporting to the CDC. These trends are not apparent when only percent MRSA is monitored.

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Contents of this issue
57 Progress towards measles elimination in WHO's European Region, 2005-2008
64 WHO web sites on infectious diseases

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Staphylococcus Symposium 2009
Location: Honolulu, HI
Dates: 11-14 Mar 2009

This meeting will assemble an outstanding group of leaders, practitioners, and investigators to share understanding, insight, and management advice regarding the evolving epidemic of MRSA.

You can view the program and register on the website at http://www.staph2009.com.

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CDC Symposium on Drug-resistant and Vaccine-escape HBV Mutants
Location: Atlanta, Georgia, USA
Venue: CDC Roybal Campus
Dates: 4-5 Jun 2009
Registration is free

Program and online registration details available at http://www.cdc.gov/hepatitis/hbvsymposium2009.

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