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Vol. XII, No. 5 ~ EINet News Briefs ~ Mar 06, 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)
- Global: OIE issues statement on poultry vaccination
- UK: Avian influenza detected on poultry farm confirmed to be H6N1
- Indonesia: Reports four avian influenza H5N1 deaths in February
- Japan: H7 avian influenza detected in Aichi
- Viet Nam: Second human death of avian influenza H5N1 in 2009
- USA: CDC reports eight more pediatric seasonal influenza deaths
- Egypt: Two-year-old boy becomes Egypt's 56th human avian influenza H5N1 case

2. Infectious Disease News
- Australia: Officials fear large outbreak of cryptosporidiosis
- China (Yunnan): Cause of workplace illness still unclear
- Chinese Taipei: Measles imported from China then transmitted locally
- New Zealand: English measles outbreak reaches 13 cases
- Philippines: Officials to cull 6000 pigs to control the spread of Ebola-Reston virus
- USA: FDA issues inspection report of peanut processing plant tied to national Salmonella outbreak
- USA (Nebraska): Salmonella outbreak baffles health officials

3. Updates
- AVIAN/PANDEMIC INFLUENZA
- DENGUE

4. Articles
- Mass Stranding of Marine Birds Caused by a Surfactant-Producing Red Tide
- Developing pandemic communication strategies: Preparation without panic
- Infections With Oseltamivir-Resistant Influenza A(H1N1) Virus in the United States
- Morbidity and Mortality Associated With Nosocomial Transmission of Oseltamivir-Resistant Influenza A(H1N1) Virus
- Live Attenuated or Inactivated Influenza Vaccines and Medical Encounters for Respiratory Illnesses Among US Military Personnel
- The Evolution of Influenza Resistance and Treatment
- Global Transmission of Oseltamivir-Resistant Influenza
- Antibody Recognition of a Highly Conserved Influenza Virus Epitope
- Distribution, Diversity, and Seasonality of Waterborne Salmonellae in a Rural Watershed

5. Notifications
- Report of the WHO Consultation on Surveillance for Pandemic Influenza
- Weekly Epidemiological Bulletin available online
- Staphylococcus Symposium 2009
- CDC Symposium on Drug-resistant and Vaccine-escape HBV Mutants


1. Influenza News

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

2009
China/ 7 (4)
Egypt/ 5 (0)
Viet Nam/ 2 (2)
Total/ 14 (6)

***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: 409 (256).
(WHO 3/2/09 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 3/5/09): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 2/23/09):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: OIE issues statement on poultry vaccination
The World Organization for Animal Health (OIE) issued a statement on 4 Mar 2009 warning that countries shouldn't depend on poultry vaccination as a long-term strategy to control the spread of the H5N1 virus, because it can mask the presence of the virus. Vaccine campaigns are warranted when countries lack the capacity to conduct surveillance and quickly respond to the outbreaks, but they should contain an "exit strategy" to return to classic disease-control measures. Some health officials have questioned the efficacy of China's vaccination program in light of several recent human cases combined with a lack of information about poultry outbreaks. Meanwhile, the agriculture ministry in Vietnam, another country that vaccinates poultry, announced the formation of five working groups to address recent flare-ups of avian flu.

The OIE statement is available at http://www.oie.int/eng/press/en_090304.htm.

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Europe/Near East
UK: Avian influenza detected on poultry farm confirmed to be H6N1
Further laboratory tests following a routine veterinary investigation at two poultry premises in East Anglia have now confirmed that the avian influenza virus present is H6N1. The H6 virus type has been isolated in domestic poultry and wild birds in Europe over the last few years. Additional lab test confirmed on 5 Mar 2009 that the serotype is of low pathogenicity. This means that the routine restrictions put in place while the investigations were ongoing are no longer required and have been lifted.
(ProMED 3/1/09, 3/5/09)

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Asia
Indonesia: Reports four avian influenza H5N1 deaths in February
An Indonesian health official said on 3 Mar 2009 that four more people died of H5N1 avian influenza in Feb 2009, as an Indonesian newspaper reported two more deaths possibly due to the disease. Bayu Krisnamurthi, head of Indonesia's National Bird Flu Commission, gave few details about the four victims. Two were siblings from the city of Bogor in West Java province, and the two others were women from Bekasi, a suburb of Jakarta, and Surabaya in East Java province.

If the World Health Organization (WHO) confirms the cases, the country's count will rise to 145 cases and 119 deaths. For now, the total stands at 141 cases and 115 deaths. Krisnamurthi said all four of the victims were believed to have had contact with sick poultry. Mike Coston, who authors the Avian Flu Diary blog, provided a round-up of additional details about the four cases, based on information that he and flu reporters at the FluWiki and FluTrackers blog sites have gleaned over the past several weeks from Indonesian media reports and other online sources. He wrote that the siblings from Bogor appear to have been a 30-year-old man and his sister who died in mid January. A third sibling reportedly had a high fever, but refused medical treatment. The woman from Surabaya was most likely an 18-year-old who died at Sutomo Hospital in Surabaya in late January, Coston wrote. He added that five healthcare workers there were reportedly quarantined with severe flulike symptoms, but there was little follow-up news other than that two of them tested negative for the H5N1 virus.

Several reports of suspected H5N1 cases have come out of Bekasi over the past two months, making it difficult to infer the identity of the Bekasi woman mentioned in Krisnamurthi's total.

Indonesia's last H5N1 cases were reported on 22 Jan 2009. One was in a 29-year-old woman from Tangerang district in Banten province who died in mid December, and the other was in a 5-year-old girl from Bekasi who got sick in late December 2008 and died on 2 Jan 2009.

In June 2008, Indonesia announced that it would no longer provide immediate announcements of individual avian flu deaths, opting instead to give periodic updates.

In other developments, the Indonesian Republika newspaper reported two more H5N1 deaths, both which occurred over the weekend near Jakarta. The patients were a five-year-old girl from Depok and an eight-year-old boy from Bekasi. The National Bird Flu Commission said the children's samples were sent to Jakarta to confirm the cause of death.
(CIDRAP 3/3/09)

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Japan: H7 avian influenza detected in Aichi
The H7 bird flu virus has been detected at a quail farm in Toyohashi, Aichi Prefecture, the prefectural government and the farm ministry said on 27 Feb 2009. As the infected quails have not died, the virus "may be of attenuated virulence," the Agriculture, Forestry and Fisheries Ministry and the local government said, suggesting it is unlikely the infection will spread further.

Although it is rare for humans to catch the H7 virus, those who are in contact with the infected birds may show symptoms, such as in the respiratory system. The prefectural government detected the virus in February 2009 in two quails at the farm, which raises about 300,000 of the birds, during a regular inspection of three quail farms in the prefecture, when 10 birds were tested. The H7 virus had not been detected in Japan since 1925, according to the farm ministry.

Aichi Gov. Masaaki Kanda said there is no danger of infection by eating the eggs or the meat of the quail. The farm halted quail shipments on 25 Feb 2009 while authorities investigate the infection route, as well as sterilize the farm and kill the quails. The farm is located in one of the country's leading production centers for quail eggs. Transportation limits will be placed on 65 farms affecting more than 4.5 million quails and chickens, as well as their eggs and feed.
(ProMED 2/28/09)

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Viet Nam: Second human death of avian influenza H5N1 in 2009
A 32-year-old man from Vietnamese northern Ninh Binh province, who previously tested positive to the H5N1 virus, has died. The patient died on 25 Feb 2009 after 13 days of being treated at the National Institute of Infectious and Tropical Disease.

The patient was taken to hospital on 13 Feb 2009 with severe breathing difficulty. He had contact with fowl before developing bird flu symptoms. He is the third bird flu patient and second human case death as a result of H5N1 infection in Viet Nam in 2009.
(ProMED 2/27/09)

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Americas
USA: CDC reports eight more pediatric seasonal influenza deaths
The number of pediatric influenza deaths outstripped the spike during the week of 8-14 Feb 2009, and three more states reported widespread activity, the US Centers for Disease Control and Prevention (CDC) said on 27 Feb 2009. The CDC received eight reports of influenza-related deaths in children during the week ending 21 Feb2009, bringing the seasonal total to 17. Four of the deaths occurred in Texas, two in Colorado, and one each in Arizona and Massachusetts.

Bacterial coinfections have been confirmed in 10 (59%) of the 17 children. Staphylococcus aureus was identified in eight of the 10 children—three of the isolates were sensitive to methicillin, four were not, and results were not reported for one. Eight of the 10 children who had coinfections were age 12 or older.

After noting a sharp increase in the number of S aureus infections in children who had the flu during the 2006-07 season, the CDC in January 2008 released interim testing and reporting recommendations regarding influenza and bacterial coinfections in children.

In other developments, the number of states reporting widespread flu activity rose to 27, three more than the week of 8-14 Feb 2009. Seventeen states reported regional activity, which is up four from the week of 8-14 Feb 2009.

Of the influenza A/H1N1 samples from 35 states that have been tested, nearly all (98.8%) showed resistance to oseltamivir (Tamiflu). Slightly more than a third of the influenza B viruses that were tested match the Yamagata lineage included in this year's vaccine, and the remaining samples were from the Victoria lineage.
(CIDRAP 2/27/09)

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Africa
Egypt: Two-year-old boy becomes Egypt's 56th human avian influenza H5N1 case
A two-year-old Egyptian boy has contracted the bird flu virus and is in critical condition, the Health Ministry said on 1 Mar 2009. Officials reported that the boy showed symptoms after coming into contact with dead birds. He was given the antiviral drug Tamiflu and remains in critical condition on an artificial ventilator at a hospital in Cairo, according to the agency. The World Health Organization confirmed the case on 2 Mar 2009.

Egypt is one of the only countries affected by bird flu that does not offer compensation for farmers when poultry is destroyed, which many experts say is the best way to ensure rapid detection of new outbreaks. Over five million Egyptian households depend on poultry as a main source of food and income.
(ProMED 3/1/09, 3/3/09)

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2. Infectious Disease News

Asia
Australia: Officials fear large outbreak of cryptosporidiosis
An outbreak of cryptosporidiosis could soar into the thousands, with almost 250 cases already confirmed. Fearing an outbreak of the bug, which 10 years ago left more than 1000 people ill after swimming, health officials warned the public to be cautious on 27 Feb 2009.

At least 19 pools have been ordered to super-chlorinate their water after infected people identified they became sick after swimming. The germ spreads with such ferocity, especially in summer and in pools, that 44 cases were identified in just one day.

NSW Health's director of communicable diseases Dr Jeremy McAnulty said anyone who had diarrhea in the past two weeks needed to stay out of pools. "While there is no common link among most cases, some have reported swimming in common pools," he said. "Pools can be easily contaminated by infectious swimmers, and so it is vital that people take care."

NSW Health said there was no evidence that these pools were the cause of any infection. Most of the affected pools are from western Sydney. NSW Health is refusing to name them individually, fearing it will lay blame and cause further panic. All pools associated with the bug have been tested, but no evidence of contamination has been found.

Cryptosporidiosis is a diarrheal disease caused by a parasitic infection of the intestine. It surges in summer, usually because people are outdoors drinking contaminated water and playing with animals. Children are most susceptible with half of the confirmed cases under five years.

Dr McAnulty said the number of cases had doubled since January 2009, sparking concern it could soon mirror the large outbreak of 1998. "Cryptosporidiosis is a bug that lives in animals, and people can carry it. Once it gets into swimming pools, then it can really amplify." The last major outbreak was the summer of 1998. The same year, panic gripped Sydney when bugs, giardia and cryptosporidiosis were found in the Prospect water filtration plant. It became known as Sydney's water crisis, and households were ordered to boil water.

There is no treatment for the infection. Symptoms include diarrhea, stomach cramps, fever, nausea and vomiting, which can last weeks and sometimes even months. Some persons do not present any symptoms. If symptoms are present, they often last about two weeks.
(ProMED 3/1/09)

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China (Yunnan): Cause of workplace illness still unclear
Tests did not show why one person died and nine others at the same workplace became sick in Lanping County, in southwest China's Yunnan Province. "No evidence was found to substantiate an epidemic through tests of the patient's blood and urine samples as well as tests of the drinking water," the county's health bureau said on 28 Feb 2009.

All of the patients were workers at a construction site near Biyuhe Village in Lanping County. They developed symptoms including numb limbs, dizziness, fever, diarrhea, and vomiting in early Feb 2009. As of 28 Feb 2009, one person had died and three others had life-threatening conditions. The remaining five were under medical observation. Local health authorities were investigating the cause of their illness, but failed to draw a conclusion.
(ProMED 3/3/09)

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Chinese Taipei: Measles imported from China then transmitted locally
The Chinese Taipei Centers for Disease Control (CDC) is continuing to investigate two import-related measles outbreaks in northern and central Taipei that started in early February 2009. As of 2 Mar 2009, 11 cases had been confirmed, aged eight months to nine years. None of them had received measles-containing vaccines.

The index case of the northern outbreak was reported on 11 Feb 2009. Because significant effort had been focused on eliminating measles, Taipei CDC started an extensive investigation to find the source of the infection. The source case was later identified to be a girl who had shared the same room in a community hospital with the index case, and had traveled to China during the possible exposure period. In addition, six more cases were confirmed through contact tracing.

The index case of the central-Taipei outbreak traveled to China during the period 18 Dec 2008 to 3 Feb 2009, and had rash on 7 Feb 2009. Two of his contacts turned out to be confirmed cases. All of these cases were infected in the hospital. Phylogenetic tree analysis confirmed that these two outbreaks are caused by two distinct viruses of the H1 genotype.

The coverage rate of first dose MMR (measles, mumps and rubella) vaccine in Taipei is above 95 percent. However, the frequent traveling between Taipei and China places Taipei at continual risk of imported measles and further import-related clusters among the unvaccinated population.

Taipei CDC had implemented strategies targeting four main aspects of disease control. The first is to start contact tracing to give proper post-exposure prophylaxis and education. So far, more than 700 had been contacted. The second is to minimize nosocomial transmission of the disease by alerting all the hospitals and clinics. The hospital where the northern outbreak took place had set up a screening station for all children with fever and rash, as well as a special clinic for those who need post-exposure prophylaxis.

The third strategy aims at increasing the vaccination coverage by contacting all children aged above 12 months-old to get their first dose of MMR on time. Policy to vaccinate infants 9 to 12 months and a catch-up campaigning is also under consideration. Lastly, Taipei CDC provides a 24/7 hotline, among other public communication measures, for all related inquiries.

These outbreaks highlight the importance of imported measles in Taipei. Taipei CDC alerted all parents that children should keep their vaccinations up to date, particularly before entering China. For these two outbreaks, active surveillance will continue up until the end of March 2009.
(ProMED 3/3/09)

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New Zealand: English measles outbreak reaches 13 cases
An English measles (as opposed to German measles) outbreak which began early in February 2009 has now affected 13 Otago people aged from 4 to 22 years. Medical Officer of Health for Otago Southland Dr John Holmes said new cases could all be linked to the original four that turned up in an unvaccinated family that had traveled to Viet Nam in January 2009. Dr Holmes said he was keeping an open mind on the possibility of more cases and that it was important that if doctors thought an illness as measles that they order relevant blood tests. Measles is considered rare in New Zealand, with 12 cases recorded in 2008.
(ProMED 3/1/09)

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Philippines: Officials to cull 6000 pigs to control the spread of Ebola-Reston virus
Philippine health and agriculture officials arrived at a farm in Pandi near Manila on 1 Mar 2009, to begin slaughtering approximately 6000 pigs to prevent the spread of the Ebola-Reston virus.

Security was tight, with police checkpoints set up in Bulacan province to prevent reporters from getting close to the farm where traces of the non-lethal virus had been detected. Even houses near the farm were being secured by police to keep outsiders away.

Eric Tayag, head of the National Epidemiology Center, told reporters that an electric stun-gun would be used to kill the pigs, after which the carcasses would be burned and then buried. He said they expected to cull only about 500 pigs on 1 Mar 2009, but hoped later to slaughter 1000 a day and to complete the process within a week. Aircraft were prevented from flying over the farm, Tayag said.

According to the World Health Organization, the strain infecting the pigs is not dangerous to humans, unlike the four deadly Ebola subtypes found in Africa. So far, six farm workers and butchers have been found with the antibodies to Ebola Reston, and scientists are still trying to determine whether the six caught the virus from pigs. If such a link is proven, it would be the first time humans have contracted the disease from pigs.
(ProMED 3/1/09)

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Americas
USA: FDA issues inspection report of peanut processing plant tied to national Salmonella outbreak
Inspectors at a Texas peanut processing plant tied to the current nationwide Salmonella outbreak found dead mice, mouse droppings, roof leaks, gooey buildups on equipment, and other sanitation problems, according to the US Food and Drug Administration (FDA).

The problems in the Peanut Corp. of America's (PCA's) Plainview, Tex., plant are detailed in a seven-page inspection report posted online on 4 Mar 2009 by the FDA. The Plainview plant was the second of two PCA facilities tied to the outbreak, which involves at least 677 illnesses in 45 states.

The outbreak, which publicly surfaced in early January 2009, has been blamed mainly on PCA's processing plant in Blakely, Ga. But in February 2009, the outbreak strain of Salmonella Typhimurium was found in products from the Texas plant.

Texas officials on 12 Feb 2009 reported finding dead rodents, rodent excrement, and feathers in a crawl space above a production area of the Plainview plant. The newly released FDA report offers more details. It says inspectors found abundant evidence of mice in processing areas of the plant, including:
- Six dead mice in a crawl space above the ceiling over the kitchen and blanching area of the plant
- A dead mouse stuck to a glue trap in a room off the kitchen
- Rodent pellets on a countertop, under a sink, and in cabinets in various rooms in the kitchen area

The inspectors also found various other problems:
- Buildups of "peanut fines, meal, chunks, or paste (some gooey other solidified)" on numerous pieces of processing equipment
- A failure to operate ventilation equipment in a way that minimized the risk of contamination of food and food-contact surfaces
- Several roof leaks that allowed rainwater to drip into peanut processing areas
- Storage of recalled peanut products from the Blakely plant among Plainview products awaiting shipment to customers, without separation and labeling to guard against inadvertent shipment of the recalled Blakely products

The report did not describe the peanut products that had been shipped to Plainview from the Blakely plant. A PCA e-mail that surfaced during a 11 Feb 2009 congressional hearing on the outbreak indicated that tons of raw peanuts had been shipped from Blakely to Plainview, but did not mention any processed products having been shipped there.

The Plainview plant blanched, split, granulated, and roasted peanuts, according to the FDA. After the discovery of unsanitary conditions there, Texas officials ordered PCA to shut the plant down and recall all products made there. The total number of products recalled because of the current outbreak stood at 3,076, according to the FDA.
(CIDRAP 3/4/09)

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USA (Nebraska): Salmonella outbreak baffles health officials
Nebraska state officials admit they are baffled by a spike in Salmonella cases across eastern Nebraska. State Epidemiologist Dr Tom Safranek says 14 cases have been reported just since 21 Feb 2009, and there are likely more out there that will be reported in the days ahead.

Despite an intense investigation, Safranek says health officials are "scratching their heads" and are now doing more detailed interviews with the victims trying to figure out if there is some sort of common thread with the cases, like where the victims ate or shopped and what they ate. Dr Safranek says, "These individuals have a common exposure, whether it was the same venue, a restaurant, or in a distributed fashion or common food item."

Of the 14 confirmed cases, 11 are women 20 to 49 years of age. Eight are in Douglas County, four in Sarpy, 1 in Cass, and 1 in Lancaster County. Two were hospitalized.
(ProMED 3/3/09)

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3. Updates
AVIAN/PANDEMIC INFLUENZA
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services and includes the website of the Central Fund for Influenza Action. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html The (interim) Influenza Virus Tracking System can be accessed at: www.who.int/fluvirus_tracker.
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help hospital administrators and state and local health officials prepare for the next influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.pandemicflu.gov/. View archived Webcasts on influenza pandemic planning.
- CIDRAP: http://www.cidrap.umn.edu/ Find their new report: Pandemic Influenza, Electricity, and the Coal Supply Chain.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds and poultry.
(UN; WHO; FAO, OIE; CDC; CIDRAP; PAHO; USGS)

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DENGUE
Australia
North Queensland's dengue fever epidemic broke new territory on 26 Feb 2009 as health officials confirmed a fourth strain of the virus in the region. Dengue cases have been reported in Cairns, Townsville, Port Douglas, and for the first time in recorded history, at Yarrabah, Injinoo, and Innisfail.

The number of Cairns people infected soared to 513 as of 26 Feb 2009, making it the city's worst outbreak of the potentially deadly disease. "That's over a period of three months compared to previous outbreaks of 14 months," said Queensland Health physician Frank Beard. "The rapid spreading nature of the outbreak is a first for us. We haven't seen anything quite like this."

Townsville has recorded 70 cases, two in Port Douglas, two in Yarrabah, and Injinoo and Innisfail both have one case each.

Authorities have linked the latest case in Innisfail to a traveler from Vanuatu. That case introduced the fourth strain of the virus in the north, a fact that is causing major concerns of people contracting the more serious form of the disease, dengue hemorrhagic fever (DHF). "We now currently have all four types of dengue circulating in north Queensland, which is the first time ever," Dr Beard said. "If you get two doses of dengue [virus infection] of different types, then you're at higher risk of serious complications.”

Meanwhile, a Cairns resident was fined AUD 400 [USD 260] this week after mosquito larvae were found in water-filled tires on a property. Cairns Regional Council health officers issued the on-the-spot fine, the first under heavy penalties aimed at deterring dengue mosquito breeding.
(ProMED 3/2/09)

Indonesia
A dengue fever outbreak claimed 104 lives in Indonesia's Banten province in February 2009, health officials said on 24 Feb 2009. Ignatius Darya, a spokesman for Misi Rangkasbitung Hospital, said the number is expected to increase through March 2009, the month the disease traditionally peaks for the year. "The number of dengue patients treated at the hospital has increased by a third this month [February 2009] to 90 cases when compared to last month, [January 2009]," Darya said.

However, those patients were recovering after being treated quickly and properly, he said. "The residents here don't really understand the illness and how to prevent it,” he added.
(ProMED 3/2/09)

Malaysia
For the week ending 7 Feb 2009, three more people have died from dengue fever, bringing the total deaths so far in 2009 to 18 compared to seven for the corresponding period in 2008.

Health Minister Datuk Liow Tiong Lai said, 1232 cases were reported that week compared to 1013 cases the previous week ending 31 Jan 2009, an increase of 219 cases of which 50 percent were from Selangor.

Thirteen new "hot dengue areas" had been identified bringing the total to 39. Selangor had the largest number with 33, followed by Wilayah Persekutuan Kuala Lumpur-Putrajaya with four, while Johor and Sarawak had one each.

Liow said checks by local authorities found that 1672 premises were breeding grounds for Aedes mosquitoes. He urged State Health Departments to step up prevention and control efforts aimed at reducing the number of "hot dengue areas.”
(ProMED 2/23/09)

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4. Articles
Mass Stranding of Marine Birds Caused by a Surfactant-Producing Red Tide
Jessup DA et al. PLoS. 23 February 2009. Available at http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0004550.

Abstract
In November-December 2007 a widespread seabird mortality event occurred in Monterey Bay, California, USA, coincident with a massive red tide caused by the dinoflagellate Akashiwo sanguinea. Affected birds had a slimy yellow-green material on their feathers, which were saturated with water, and they were severely hypothermic. We determined that foam containing surfactant-like proteins, derived from organic matter of the red tide, coated their feathers and neutralized natural water repellency and insulation. No evidence of exposure to petroleum or other oils or biotoxins were found. This is the first documented case of its kind, but previous similar events may have gone undetected. The frequency and amplitude of red tides have increased in Monterey Bay since 2004, suggesting that impacts on wintering marine birds may continue or increase.

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Developing pandemic communication strategies: Preparation without panic
Jones SC et al. J Bus Res. 27 Feb 2009.

Abstract Communication in the media regarding a potential avian influenza epidemic can serve to accurately and effectively inform the public OR misinform and contribute to unnecessary public panic and subsequent undesirable responses. Governments have time to develop communication strategies and specific messages that can effectively convey desired information at different stages of the anticipated pandemic. Effective social marketing incorporates the concepts of formative research, audience segmentation, and consumer focus. Based on the findings from earlier research on public awareness and understanding of bird flu, the collaborators of the project developed evidence-based advertising messages for two primary time-points in pandemic preparation and tested in a series of focus groups; modified them based on the findings; and then re-tested the final campaign. These findings provide important recommendations for the development of future social marketing campaigns in the event of pandemics or other public health crises.

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Infections With Oseltamivir-Resistant Influenza A(H1N1) Virus in the United States
Dharan NJ et al. JAMA. 2009; 301(10). Available at http://jama.ama-assn.org/cgi/content/full/2009.294.

Context. During the 2007-2008 influenza season, oseltamivir resistance among influenza A(H1N1) viruses increased significantly for the first time worldwide. Early surveillance data suggest that the prevalence of oseltamivir resistance among A(H1N1) viruses will most likely be higher during the 2008-2009 season.

Objectives. To describe patients infected with oseltamivir-resistant influenza A(H1N1) virus and to determine whether there were any differences between these patients and patients infected with oseltamivir-susceptible A(H1N1) virus in demographic or epidemiological characteristics, clinical symptoms, severity of illness, or clinical outcomes.

Design, Setting, and Patients. Influenza A(H1N1) viruses that were identified and submitted to the Centers for Disease Control and Prevention by US public health laboratories between September 30, 2007, and May 17, 2008, and between September 28, 2008, and February 19, 2009, were tested as part of ongoing surveillance. Oseltamivir resistance was determined by neuraminidase inhibition assay and pyrosequencing analysis. Information was collected using a standardized case form from patients with oseltamivir-resistant A(H1N1) infections and a comparison group of patients with oseltamivir-susceptible A(H1N1) infections during 2007-2008.

Main Outcome Measures. Demographic and epidemiological information as well as clinical information, including symptoms, severity of illness, and clinical outcomes.

Results. During the 2007-2008 season, influenza A(H1N1) accounted for an estimated 19% of circulating influenza viruses in the United States. Among 1155 influenza A(H1N1) viruses tested from 45 states, 142 (12.3%) from 24 states were resistant to oseltamivir. Data were available for 99 oseltamivir-resistant cases and 182 oseltamivir-susceptible cases from this period. Among resistant cases, median age was 19 years (range, 1 month to 62 years), 5 patients (5%) were hospitalized, and 4 patients (4%) died. None reported oseltamivir exposure before influenza diagnostic sample collection. No significant differences were found between cases of oseltamivir-resistant and oseltamivir-susceptible influenza in demographic characteristics, underlying medical illness, or clinical symptoms. Preliminary data from the 2008-2009 influenza season identified resistance to oseltamivir among 264 of 268 influenza A(H1N1) viruses (98.5%) tested.

Conclusions. Oseltamivir-resistant A(H1N1) viruses circulated widely in the United States during the 2007-2008 influenza season, appeared to be unrelated to oseltamivir use, and appeared to cause illness similar to oseltamivir-susceptible A(H1N1) viruses. Circulation of oseltamivir-resistant A(H1N1) viruses will continue, with a higher prevalence of resistance, during the 2008-2009 season.

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Morbidity and Mortality Associated With Nosocomial Transmission of Oseltamivir-Resistant Influenza A(H1N1) Virus
Gooskens J et al. JAMA. 2009; 301(10). Available at http://jama.ama-assn.org/cgi/content/full/2009.297.

Context. The sudden emergence and rapid spread of oseltamivir-resistant influenza A(H1N1) viruses with neuraminidase (NA) gene H274Y amino acid substitution is the hallmark of global seasonal influenza since January 2008. Viruses carrying this mutation are widely presumed to exhibit attenuated pathogenicity, compromised transmission, and reduced lethality.

Objective. To investigate nosocomial viral transmission in a cluster of patients with influenza A(H1N1) virus infection.

Design, Setting, and Patients. Descriptive outbreak investigation of 2 hematopoietic stem cell transplant recipients and an elderly patient who developed hospital-acquired influenza A virus infection following exposure to an index patient with community-acquired H274Y-mutated influenza A(H1N1) virus infection in a medical ward at a Dutch university hospital in February 2008. The investigation included a review of the medical records, influenza virus polymerase chain reaction and culture, phenotypic oseltamivir and zanamivir susceptibility determination, and hemagglutinin chain 1 (HA1) gene and NA gene sequence analysis.

Main Outcome Measure. Phylogenetic relationship of patient cluster influenza A(H1N1) viruses and other 2007-2008 seasonal influenza A(H1N1) viruses.

Results. Viral HA1 and NA gene sequence analysis from the 4 patients revealed indistinguishable nucleotide sequences and phylogenetic clustering of H274Y-mutated, oseltamivir-resistant influenza A(H1N1) virus, confirming nosocomial transmission. Influenza virus pneumonia (3 patients) and attributable mortality (2 patients) during active infection was observed in patients with lymphocytopenia at onset.

Conclusion. Seasonal oseltamivir-resistant influenza A(H1N1) viruses with NA gene H274Y mutation are transmitted and retain significant pathogenicity and lethality in high-risk patients.

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Live Attenuated or Inactivated Influenza Vaccines and Medical Encounters for Respiratory Illnesses Among US Military Personnel
Wang Z et al. JAMA. 2009; 301(9): 945-953. Available at http://jama.ama-assn.org/cgi/content/full/2009.265.

Context. Since 2004, increasing numbers of military personnel have been immunized with the intranasal live attenuated influenza vaccine (LAIV) while most others received the trivalent inactivated vaccine (TIV). However, data about live virus vaccine effectiveness among healthy adults are limited.

Objective. To monitor the effectiveness of vaccines to better inform military vaccination policy.

Design, Setting, and Participants. Surveillance of population-based, propensity-matched, and/or vaccine-naive cohorts of more than a million active-duty, nonrecruit military service members aged 17 to 49 years stationed in the United States during the 2004-2005, 2005-2006, or 2006-2007 influenza season.

Main Outcome Measures. Incidence of health care encounters resulting in a primary diagnostic code consistent with pneumonia or influenza. Incident hospitalizations was a secondary outcome.

Results. In all 3 seasons, immunization with TIV was associated with lower incidence rates of health care encounters for pneumonia and influenza when compared with no immunization: 8.6 vs 19.4 for 2004-2005, 7.8 vs 10.9 for 2005-2006, and 8.0 vs. 11.7 per 1000 person-years for 2006-2007 (all P < .001). Similar estimates were obtained from propensity-matched and/or vaccine-naive cohorts. Consistently lower vaccine effect following LAIV immunization was only seen during the 2006-2007 influenza season in the total (10.7; 95% confidence interval [CI], 2.72 to 18.1; P = .03) and propensity-matched cohorts (11.8; 95% CI, 0.85 to 21.5; P = .04), and was less than effect from TIV (TIV vs LAIV, 19.8; 95% CI, 13.6 to 25.5; P < .001). Among vaccine-naive service members, however, estimates for LAIV effect were more robust for both the 2005-2006 and 2006-2007 seasons (P = .01) and were comparable with TIV (eg, LAIV, 30.2; 95% CI, 11.2 to 45.2; vs TIV, 35.3; 95% CI, 25.9 to 43.6; in 2005-2006).

Conclusions. Vaccination with TIV was associated with fewer medical encounters related to pneumonia and influenza compared with LAIV or no immunization. In this annually immunized population, this effect was less apparent in those vaccinated with LAIV.

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The Evolution of Influenza Resistance and Treatment
Weinstock DM, Zuccotti G. JAMA. 2009; 301(10) Available at http://jama.ama-assn.org/cgi/content/full/2009.324.

Editorial
In February 2006, the US Centers for Disease Control and Prevention (CDC) reported that 92.3% of the circulating influenza A(H3N2) at that time was resistant to the adamantanes (amantadine and ramantidine), 1 of 2 pharmacological classes available for the treatment of influenza. The resistant viruses harbored an S31N amino acid substitution in the influenza M2 protein that confers resistance but does not affect virulence. Although resistance to adamantanes increased to 14.5% in the prior year, the dramatic increase in 2005-2006 came as a shock to both the medical and scientific communities and the public.
(Excerpt with references removed.)

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Global Transmission of Oseltamivir-Resistant Influenza
Moscona A. New Eng J Med. 5 Mar 2009; 360(10):953-956. Available at http://content.nejm.org/cgi/content/full/NEJMp0900648.

Perspective
Seemingly from one influenza season to the next, we have lost the use of our leading antiviral influenza drug because of resistance. This winter, the circulating strain of seasonal influenza A virus (H1N1) is resistant to the neuraminidase inhibitor oseltamivir. Moreover, rather than emerging under selective pressure of drug use, as many antibiotic-resistant bacteria do and as has been the concern for influenza, this resistant strain seems to be a natural, spontaneously arising variant. Nevertheless, science has given us the tools with which to anticipate these events — and should allow us to develop new clinical solutions that build on our knowledge of the biology of RNA viruses.

Neuraminidase cleaves sialic acid residues on the cellular receptor that bind the newly formed virions to the cell and to one another, enabling infection to spread to new host cells and ongoing infection to be established. The neuraminidase inhibitors mimic neuraminidase's natural substrate and bind to the active site, preventing the enzyme from cleaving host-cell receptors, thereby preventing infection of new host cells and halting the spread of infection. The two licensed neuraminidase inhibitors, zanamivir (Relenza) and oseltamivir (Tamiflu), have very little toxicity and are effective against all neuraminidase subtypes and, therefore, against all strains of influenza virus. (Excerpt.)

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Antibody Recognition of a Highly Conserved Influenza Virus Epitope
Ekiert DC et al. Science. 26 Feb 2009. Available at http://www.sciencemag.org/cgi/content/abstract/1171491.

Influenza virus presents a significant and persistent threat to public health worldwide, and current vaccines provide immunity to viral isolates similar to the vaccine strain. High-affinity antibodies against a conserved epitope could provide immunity to the diverse influenza subtypes and protection against future pandemic viruses. Co-crystal structures were determined at 2.2 and 2.7 Å resolutions for broadly neutralizing human antibody CR6261 Fab in complexes with the major surface antigen (hemagglutinin, HA) from viruses responsible for the 1918 H1N1 influenza pandemic and a recent lethal case of H5N1 avian influenza. In contrast to other structurally characterized influenza antibodies, CR6261 recognizes a highly conserved helical region in the membrane-proximal stem of HA1/HA2. The antibody neutralizes the virus by blocking conformational rearrangements associated with membrane fusion. The CR6261 epitope identified here should accelerate the design and implementation of improved vaccines that can elicit CR6261-like antibodies, as well as antibody-based therapies for the treatment of influenza.

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Distribution, Diversity, and Seasonality of Waterborne Salmonellae in a Rural Watershed
Haley BJ et al. Appl Environ Microbiol. March 2009; 75(5): 1248-1255. Available at http://aem.asm.org/cgi/content/abstract/75/5/1248.

Abstract
Salmonella outbreaks from contaminated water and nonanimal foods (e.g., produce) are increasingly reported. To address the environment as a potential source of pathogenic Salmonella, we investigated levels of salmonellae and the geographic and temporal variation of Salmonella serotypes from surface waters in a region of Georgia (United States) with a history of high salmonellosis case rates. Monthly water samples were collected from six stations in the Little River (Upper Suwannee Basin) for 12 months (April 2005 to April 2006). Salmonellae were enumerated using a three-step most-probable-number (MPN) assay. Salmonellae were detected in 57 of the 72 water samples collected (79.2%). Monthly Salmonella densities ranged from an MPN of 2.5 liter in April 2005 to 36.3 liter in August 2005; concentrations were significantly higher in the summer months compared to other seasons (P < 0.05). Concentrations were not significantly different between stations. Levels of salmonellae were correlated with average daily watershed rainfall for the 1 and 2 days preceding each sample collection (r = 0.77 and 0.68, respectively; P < 0.005). Additionally, water temperature was also positively associated with total Salmonella levels (r = 0.44; P < 0.05). In total, 13 S. enterica serotypes were identified among 197 Salmonella isolates. Eighty (40.6%) were identified as S. enterica subsp. arizonae. Muenchen and Rubislaw were the most frequently identified serotypes of the remaining 117 isolates (28 and 26 isolates, respectively). Serotype diversity peaked in the summer, with 9 serotypes observed in August compared to only one serotype (S. enterica subsp. arizonae) observed in April (2005 and 2006) (P < 0.05). Furthermore, all samples collected in August (6/6) contained multiple serotypes (two to five per sample). The results of this study suggest that Salmonella abundance and diversity in the environment vary temporally and are strongly influenced by seasonal precipitation and water temperature. (References removed.)

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5. Notifications
Report of the WHO Consultation on Surveillance for Pandemic Influenza
The World Health Organization (WHO) convened a technical consultation on surveillance for pandemic influenza from 10 to 12 December 2007. The consultation, attended by 97 experts and key stakeholders from 25 countries, considered what information would be needed during a pandemic, whether existing surveillance systems would be capable of collecting this information, and ways to analyze and disseminate key information during a pandemic.

Full 33-page report is available at
http://www.who.int/csr/disease/avian_influenza/DecReport180209Final.pdf.

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Weekly Epidemiological Bulletin available online
WHO. 6 Mar 2009; 84(10): 77-84. Available at http://www.who.int/wer.

Contents of this issue
77 Progress towards poliomyelitis eradication in Afghanistan and Pakistan, 2008
83 Poliomyelitis in Sudan: heightened risk of international spread
84 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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 apecein@u.washington.edu