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Vol. XII, No. 6 ~ EINet News Briefs ~ Mar 20, 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: WHO mulls stricter transport of bio products
- Europe: EU regulators reject Sanofi experimental pandemic flu vaccine
- Cambodia: Government launches USD11 million project to fight avian influenza
- India (West Bengal): Culling begins as avian influenza H5N1 hits Darjeeling
- Indonesia: Child suspected of contracting avian influenza H5N1
- Viet Nam: 3-year old boy tests positive for avian influenza H5N1
- USA (Alabama): Department of Public Health offering free pandemic influenza planning supplies
- Egypt: Avian influenza confirmed in 38-year-old women

2. Infectious Disease News
- Australia (Pilbarra): Mosquito-Borne Disease Risk Spreads
- China (Hong Kong): Hand, foot and mouth disease among kindergarten students
- China (Yunnan): Unknown illness identified as trichinellosis
- Chinese Taipei: Two more enterovirus cases with complications in children
- Russia (Southern Federal District): Decline in agriculture results in increased incidence of hemorrhagic fever
- Viet Nam: Eating dog or cat linked to rabies
- Mexico: 47 cases of brucellosis linked to contaminated cheese
- USA (Nebraska, Iowa): Alfalfa sprouts suspected in latest five-state Salmonella outbreak
- USA (Michigan): International airline passenger diagnosed with TB
- USA (Texas): 16 patients of Army insulin needle program test positive for hepatitis
- USA (Washington): Three botulism cases from improperly home canned green beans

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

4. Articles
- Investigation of a Genotype Cluster of Tuberculosis Cases--Detroit, Michigan, 2004--2007
- Clinical and Immunological Response to Attenuated Tissue-Cultured Smallpox Vaccine LC16m8
- Immunogenicity, Safety, and Cross Reactivity of an Inactivated, Adjuvanted, Prototype Pandemic Influenza (H5N1) Vaccine: A Phase II, Double Blind, Randomized Trial
- Seasonal Influenza in Adults and Children—Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America
- Facing pandemic influenza threats: The importance of including poultry and swine workers in preparedness plans
- The public health impact of avian influenza viruses
- Highly Pathogenic Avian Influenza Virus Subtype H5N1 in Africa: A Comprehensive Phylogenetic Analysis and Molecular Characterization of Isolates
- Trends in Tuberculosis--United States, 2008

5. Notifications
- Interim Guidance on Cleaning Transit Vehicles and Facilities during a Pandemic
- Corporate Antiviral Stockpiling: Benefits, Pitfalls, and Understanding Emerging Resistance Issues
- 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/ 7 (0)
Viet Nam/ 2 (2)
Total/ 16 (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: 411 (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 3/11/09)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 3/18/09): 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: WHO mulls stricter transport of bio products
Public health officials are studying the need for tighter controls on the transport of biological products after Baxter, the US pharmaceutical company, inadvertently supplied samples of the H5N1 bird flu virus to a series of European laboratories. Specialists from the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) are monitoring the case at a time of growing concern that existing international rules to minimize the risks of the spread of pathogens are too weak.

Their scrutiny follows an incident that recently came to light when samples of H5N1 from Baxter's Austrian labs contaminated batches of the less harmful H3N2 seasonal flu virus that it was supplying under a commercial contract to a customer, Avir Greenhills Biotechnology.

A combination of H3N2, which is highly transmissible between humans, and H5N1, which has killed hundreds of millions of chickens and other (birds) in recent years, could potentially lead to a mutated virus that forms the basis of a new human pandemic threatening millions of lives, according to scientists. Baxter stressed that the H3N2 strain had been made replication-defective, and was handled in tightly controlled laboratories purely for experiments, so there was little chance it could have led to outbreak threatening humans. It also stressed that all staff potentially exposed were tested and given antiviral treatment to prevent any infection.

Baxter said the H5N1 samples were provided for its own research into a pandemic vaccine it is developing, and were from a variant of the virus identified in Viet Nam and provided to the company by the US Centers for Disease Control. "The material was handled appropriately in all steps of the process in the right conditions," said Chris Bona, a Baxter spokesman. The experimental material was produced exclusively for laboratory testing, was not used for product production and was not for use in humans. It somehow mixed with H3N2 before distribution last December [2008] to Avir, and the more potent virus was detected by a subcontractor in the Czech Republic in February 2009 after it rapidly killed ferrets exposed to the viruses. Avir had also sent samples to Slovenia and Germany. Mr Bona stressed that Baxter had since taken corrective preventative actions and its procedures had been approved by the Austrian authorities.

The incident comes just after the conclusion of an EU-funded project on biosafety highlighted the need for improvement to national regulatory frameworks for biosafety and laboratory biosecurity.
(ProMED 3/18/09)

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Europe/Near East
Europe: EU regulators reject Sanofi experimental pandemic flu vaccine
An experimental pandemic flu vaccine from Sanofi-Aventis has been rejected by European regulators because of worries about its effectiveness. The European Medicines Agency said on 19 Mar 2009 its experts were concerned over the ability of Sanofi's H5N1 shot Emerflu to trigger the production of enough antibodies against the flu virus.

Emerflu was expected to be used in adults to protect against pandemic flu, which many experts fear could be triggered by mutations in the H5N1 strain of virus now circulating in birds. It was only intended for use once a pandemic had been declared.
(Reuters 3/19/09)

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Asia
Cambodia: Government launches USD11 million project to fight avian influenza
The Cambodian government launched an emergency project of USD11 million for avian and human influenza control and preparedness on 17 Mar 2009.

"We have to prevent bird flu and educate our people about it regularly before it break out and kill people and poultry," said Prime Minister Hun Sen, who is also the chairman of the National Committee for Disaster Management (NCDM). We should not say we were successful in preventing bird flu after we only culled large amounts of sick poultry, he said.

Fortunately, we have good cooperation with neighboring countries, who exchange information with us to prevent avian influenza outbreak, he said. "We have to join together to prevent deadly diseases which could ruin the social order and affect the economic development," he said, adding that effective prevention will help reduce poverty and promote sustainable development.

The project will be funded by the International Development Association (IDA) with USD6 million, the Japanese government with USD3 million, and the European Union with USD2 million. Details of the project have not been publicized yet.

Since 2003, 28,428 poultry have been culled during the anti-bird flu campaign in Cambodia and seven people have died of the disease so far.
(Xinhua 3/17/09)

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India (West Bengal): Culling begins as avian influenza H5N1 hits Darjeeling
With a fresh outbreak of avian flu reported from West Bengal’s Darjeeling district, the administration began three days of culling poultry on 14 March 2009. “Culling will take place within a three kilometer radius of Naxalbari. The areas from where avian flu was detected are Panighata and Chengapani,” sub-divisional officer Dibyendu Das said in Kurseong, 480 km from Kolkata.

Buying and selling of chicken have been banned within 10 km of the affected area to avoid further spread of the disease and about 14,000-15,000 chicken will be culled. The samples of the affected birds were tested at Bhopal’s High Security Animal Diseases Laboratory, which confirmed avian flu.
(IANS 3/14/09)

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Indonesia: Child suspected of contracting avian influenza H5N1
Doctor Suroto Hospital in Ngawi is treating a 2-year-old child allegedly suffering from bird flu, reported on 17 Mar 2009. The father of the child said that doctors at Karangjati public health center transferred his child on 17 Mar 2009 after learning the patient had contact with chickens that died of avian influenza virus a week earlier.

"Officials from Ngawi Husbandry Agency declared the virus was the cause of the deaths of 30 chicken nearby our home. Three days later, my child suffered from fever and cough," the father said.

Doctor Harun Al Rasyid said that he was waiting for the blood examination result from a health laboratory to find out whether or not the patient had indeed suffered from bird flu. "We'll also do an X-ray of the patient's lungs and expect to get the results within the coming days," Harun said. If its proven that the toddler is suffering from bird flu, he added, the Suroto hospital would transfer the patient to Sudono Hospital in Madiun, as it is the only recommended hospital bird flu patient treatment in East Java.

Meanwhile, experts quoted in Poultry Indonesia, an Indonesian poultry-trade magazine, criticized the Indonesian government's policy of vaccinating poultry against H5N1 avian influenza instead of culling, saying that vaccination masks the virus. "Vaccinations press the virus and keep poultry from getting sick, but as a result, the virus is carried everywhere," said Chairul Anwar Nidom, a virologist at Airlangga University in Surabaya stated. In the same article, James McGrane of the United Nations Food and Agriculture Organization (FAO) said the overall incidence and spread of avian flu in Indonesia are decreasing, though the virus remains entrenched in some areas.
(ProMED 3/17/09, CIDRAP 3/17/09)

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Viet Nam: 3-year old boy tests positive for avian influenza H5N1
A 3-year-old boy in Viet Nam tested positive for bird flu, doctors said on 19 Mar 2009. The patient from the Mekong delta province of Dong Thap was admitted to Ho Chi Minh City's Tropical Diseases Institute on 16 Mar 2009, and on 18 Mar 2009, a test came back positive for the H5N1 strain, said Nguyen Van Chau, director of the city's health care department. "The situation of the boy is getting worse," Chau said. Another doctor, from the municipal Pasteur Institute, said the boy's sample will be tested again to confirm the infection.

Viet Nam has the world's second highest bird flu death toll after Indonesia, with 54 deaths. Since the beginning of 2009, the deaths of two people have been blamed on the virus, and the 3-year-old boy is the fourth infection reported this year.
(ProMED 3/19/09)

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Americas
USA (Alabama): Department of Public Health offering free pandemic influenza planning supplies
The Alabama Department of Public Health’s Center for Emergency Preparedness Pandemic Influenza program has purchased supplies to encourage organizations to learn about and plan for a pandemic influenza event. State Health Officer Dr. Donald Williamson said, “Preparing our state for the possibility of a global influenza pandemic is a huge responsibility, and it is one which depends on cooperation of everyone involved to be successful.”

Organizations such as churches, banks, grocery stores, or gas stations that write a Continuity of Operations Plan and receive pandemic preparedness education from Public Health are eligible to receive free supplies. The plan must include the specific names, resources, supplies and descriptions of how the organization will continue to operate during a pandemic. Organizations that already have a plan in place may need to add a few specific elements to ensure it covers a pandemic. A pandemic plan is different from other emergency plans in several ways. For example, all organizations may have up to 40 percent absenteeism, which will affect all counties and sectors at about the same time, and there may be economic and social disruptions.

There are two free supply programs available. Free Personal Protective Equipment (PPE) supplies include items such as masks, gloves, sterilizing products and face shields. The free Comfort Care Center (CCC) supply includes fever/pain reducer medications, electrolyte drink, antidiarrheal medication, inflatable mattresses, disposable pillows and blankets. The operational plans will be reviewed by local public health area emergency preparedness teams who will also provide the free education.
(CIDRAP 3/17/09)

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Africa
Egypt: Avian influenza confirmed in 38-year-old women
A 38-year-old woman was confirmed with avian influenza infection H5N1 on 18 Mar 2009. She began experiencing symptoms on 14 Mar 2009 and was admitted to Assiut Fever Hospitaland and given Tamiflu. She reported contact with dead and sick poultry prior to illness. She was reported clinically free and in a good general condition on 18 Mar 2009.
(CIDRAP 3/19/09)

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2. Infectious Disease News

Asia
Australia (Pilbarra): Mosquito-Borne Disease Risk Spreads
The Department of Health has reiterated its warning to people living and vacationing in Western Australia's north to take extra care against mosquito bites because of the risk of mosquito-borne viruses. Medical Entomologist Dr Michael Lindsay said that the department's surveillance program (undertaken by The University of Western Australia) had now detected activity of the rare, but potentially fatal, Murray Valley Encephalitis (MVE) virus in the Pilbara region for the first time in the 2008-2009 wet season. Kunjin virus, a related mosquito-borne virus, which can cause milder human disease has also been detected in the Pilbara.

This new activity is in addition to recent and ongoing activity of MVE virus at several locations in the Kimberley and indicates that the area of virus activity has increased following the widespread rains in the north of Western Australia over the past few weeks. "MVE is a rare disease but can be very severe or fatal, so it is important that people take particular care to avoid mosquito bites for the next few weeks," Dr Lindsay said. "Initial symptoms of MVE include fever, drowsiness, headache, stiff neck, nausea and dizziness and people experiencing these symptoms should seek medical advice quickly. In severe cases, people may experience fits, lapse into a coma, may be left with permanent brain damage or die. In young children, fever might be the only early sign, so parents should see their doctor if concerned, and particularly if their child is drowsy, floppy, irritable, feeding poorly or is generally distressed." Dr Lindsay said people most likely to be affected by the MVE virus were newcomers to affected regions, such as babies, young children, tourists or new employees, but anyone experiencing these symptoms should seek medical advice quickly.

"Wet season activity of other mosquito-borne viruses is also continuing in the north, with more than 25 cases of Ross River and Barmah Forest virus infections being reported from the Kimberley and Pilbara since the start of the year [2009]," he said. "There are no specific cures or vaccines for MVE, Kunjin, Ross River or Barmah Forest viruses so it is very important that people take care to prevent being bitten by mosquitoes." The warning particularly applies to people living, visiting or camping near swamp and river systems and rain affected areas during the evening and night through the Kimberley and Pilbara. However, the viruses may be active elsewhere in the north of the state, especially where mosquitoes are abundant.

"Controlling mosquitoes in most rural regions of Western Australia is generally not possible because of the large size and inaccessibility of natural mosquito breeding habitat," he said. "It is also important that communities prevent mosquitoes breeding in man-made sites around the home or workplace because these types of mosquitoes can also be disease carriers in some situations."

People do not need to alter their plans to visit the Kimberley or Pilbara but it is important to avoid mosquito bites by taking a few simple steps, such as:

- avoiding outdoor exposure from dusk and at night
- wearing protective (long, loose-fitting) clothing when outdoors
- using a personal repellent containing diethyl toluamide (DEET) or picaridin. The most effective and long-lasting formulations are lotions or gels. Most natural or organic repellents are not as effective as DEET or picaridin - ensuring insect screens are installed and completely mosquito-proof: use mosquito nets and mosquito-proof tents
- ensuring infants and children are adequately protected against mosquito bites, preferably with suitable clothing, bed nets or other forms of insect screening.
(ProMED 3/14/09)

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China (Hong Kong): Hand, foot and mouth disease among kindergarten students
The Center for Health Protection (CHP) of Hong Kong's Department of Health called on people to maintain strict personal and environmental hygiene to prevent hand, foot and mouth disease (HFMD) on 12 Mar 2009, following an outbreak of the disease involving 20 students. The affected children of the kindergarten in Tai Po, Hong Kong, aged between 2 and 5 years, came from four different classes. They developed fever, oral ulcers and rash over hands or feet starting on 22 Feb 2009. The children sought medical consultation, and no hospitalization was required. All children are in stable condition.
(ProMED 3/12/09)

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China (Yunnan): Unknown illness identified as trichinellosis
Lanping County's 'infectious disease of unknown origin' has been identified as trichinellosis. On 5 Mar 2009, the provincial Center for Disease Control (CDC) reported that it had completed investigation of the group illness in Lanping County. Nine cases of trichinellosis had been confirmed and there was one other death due to severe illness. Surviving patients have improved after aggressive treatment and the situation has been brought under control.
(ProMED 3/7/09)

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Chinese Taipei: Two more enterovirus cases with complications in children
The Chinese Taipei Centers for Disease Control (CDC) confirmed two more cases of enterovirus infections with severe complications on 10 Mar 2009 in children aged 2.5 years and 3 years. Both children were infected with enterovirus 71. The children lived in Southern Taipei, and attended the same nursery in the same class. The nursery with infected children has been closed for a total of 10 days, since 6 Mar 2009. Health officials had asked contacts to watch for similar symptoms. The CDC is asking families with infants and young children, daycare centers, and kindergartens to practice good hygiene and wash hands frequently in order to decrease the likelihood of enterovirus infection. Also, if children have symptoms suspicious of severe infections, they should be transferred to hospitals immediately.
(ProMED 3/12/09)

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Russia (Southern Federal District): Decline in agriculture results in increased incidence of hemorrhagic fever
The head of Rospotrebnadzor (the Federal Service for Consumer Affairs and Human Welfare), Gennady Onishenko, has issued a document stating that the increase in incidence of Crimean-Congo hemorrhagic fever has been facilitated by the increase of vegetation as a consequence of a decline in sheep rearing and grazing in the Southern Federal Okrug district.

He also stated that virus circulation has risen because of high temperatures, which have remained above 15C during the spring months in recent years. During the past 10 years, 1217 people contracted Crimean-Congo hemorrhagic fever in the Southern Federal District, of which 60 died. Two hundred twelve cases were registered in South Russia in 2008, including 12 fatalities. The number of cases in 2008 increased by 52 percent in Rostov Oblast region and by 26 percent in Stavropol region compared to 2007.

More than 90 percent of cases were rural residents, who worked in animal husbandry, in gardens, or in the fields. The urban population contracted infection during visits to country homes and the countryside. In most cases infection was the result of tick bites or by removal of ticks with bare hands. High rates of tick infestation have occurred in early autumn creating potential for epidemic development in 2009. Activation of ticks and their first contacts with people are expected at the end of March and beginning of April 2009. Onishenko recommends immediate initiation of tick control measures such as treatment of all farm animals and all recreational areas.
(ProMED 3/16/09)

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Viet Nam: Eating dog or cat linked to rabies
A new study has detailed how two people in Asia contracted rabies after eating dog or cat meat. A report published in the journal PLoS Medicine describes how two patients in Hanoi, Viet Nam, died from laboratory-confirmed rabies. Health experts claim their symptoms developed after butchering, preparing, and consuming either a dog or a cat. The researchers were unable to test the butchered animals for rabies, so could not be entirely certain the animals were the source of the rabies. However, they caution that butchering of unvaccinated dogs and cats in rabies-endemic countries should be considered a risk factor for rabies transmission.
(ProMED 3/18/09)

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Americas
Mexico: 47 cases of brucellosis linked to contaminated cheese
The sale of contaminated cheese, mainly in the Hidalgo Market has generated 47 cases of brucellosis, also called "Malta fever" in the state capital of Guanajuato, according to the head of the Sanitary Jurisdiction No. 1, Rafael Sanchez Leyva.

This led to the seizure of approximately 800 kilograms (approximately 1765 lb) of cheese contaminated with the bacterium causing brucellosis and a fine of approx. USD 34,000 to the producer from a facility in Silao. The seizure took place in late Feb 2009 at the Hidalgo Market.

Without specifying the name of the factory or its owner, the official said that all merchandise was picked up and destroyed. He added, "the man from the cheese factory deceived us, by pasteurizing 1000 liters of milk and mixing it with 9000 liters of non-pasteurized milk."

It appears the products were distributed in the municipalities of Silao, Leon, and Romita; however, it is not known whether there were affected individuals due to consumption of contaminated cheese in these towns.

Given the situation, Sanchez Leyva warned people not to consume milk products of dubious sources, because the products may not be pasteurized putting them at higher risk for disease.
(ProMED 3/13/09)

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USA (Nebraska, Iowa): Alfalfa sprouts suspected in latest five-state Salmonella outbreak
Five states have reported Salmonella Saintpaul bacterial infections thought to be linked to sprouts from SunSprout Enterprises Inc. of Omaha, Nebraska. Although laboratory testing did not confirm sprouts as the source, as a precautionary measure, the company voluntarily recalled its alfalfa, onion, and gourmet sprouts.

According to the Food and Drug Administration (FDA) spokesman Mike Herndon, an inspection at Sun Sprout was ongoing, but no cause of the salmonella outbreak had been found so far. The outbreak began the week of 23 Feb 2009, and investigators suspect it was linked to alfalfa sprouts. Company officials said sprouts were distributed to food distributors in Iowa and Nebraska who sell the product to restaurants and retail stores.

The sprouts were sold refrigerated under the SunSprout label in four-ounce clear plastic clamshell containers. The alfalfa sprouts are also packaged in bulk 2.5-pound and 5-pound cases for use in restaurants. The onion sprouts and gourmet sprouts are not packaged in bulk form.

The five states have reported about 50 cases of salmonella infection. They are Kansas, Nebraska, South Dakota, Iowa, and Missouri.
(ProMED 3/10/09)

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USA (Michigan): International airline passenger diagnosed with TB
A passenger on Northwest Airlines Flight 51 from Frankfurt to Detroit on 10 Mar 2009 was found to have tuberculosis (TB), the airline said on 15 Mar 2009. The Centers for Disease Control (CDC) is attempting to contact 17 passengers seated near the infected person, CDC spokeswoman Shelly Diaz said.

"The risk of TB transmission is very low," she said. The CDC is gathering passenger contact information and passing that along to state and local health departments to have people tested for the disease. "Northwest has been proactively working with the CDC to contact passengers who may be at risk," spokeswoman Leslie Parker said. Passengers who have questions should contact the CDC or their local health department.

Tuberculosis is caused by Mycobacterium tuberculosis and is spread through the air by those with an active form of the disease. About a third of the world's population is infected with this bacterium, according to the World Health Organization. Not everyone who is infected becomes sick. The US had 13,299 cases of TB in 2007, a CDC spokeswoman said.
(ProMED 3/17/09)

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USA (Texas): 16 patients of Army insulin needle program test positive for hepatitis
Army officials say 16 patients exposed to a mismanaged insulin needle program at a military hospital in Texas have tested positive for hepatitis B or C virus infection. The patients at the William Beaumont Army Medical Center were among more than 2000 diabetics who may have been exposed to blood-borne illnesses because multiple patients were given injections from the same insulin pen. Officials at the Army hospital at Fort Bliss have said it's unclear if the patients contracted hepatitis from the injections that were performed from August 2007 to January 2009.
(ProMED 3/11/09)

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USA (Washington): Three botulism cases from improperly home canned green beans
Health officials and food preservation experts are warning home canners to follow strict safety rules after a Spokane woman and two young children were sickened by botulism from improperly canned green beans from a home garden.

The Spokesman-Review reports the victims were a nurse over 30 years and two children younger than 10 years. She remains on a ventilator and is recovering slowly. The children suffered milder symptoms. The three were given an antitoxin that was flown to Spokane from a special storage facility in Seattle.

Epidemiologist Dorothy MacEachern with the Spokane Regional Health District is concerned that people have been responding to difficult economic times by canning more of their food perhaps improperly. Food safety experts say special precautions must be taken when canning low-acid foods such as green beans and asparagus.
(ProMED 3/10/09)

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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
Queensland Health has confirmed an elderly woman has died from dengue fever in Cairns, the first fatality since the epidemic began late in 2008. Queensland Health said the woman from Manoora died early in the week of 8 Mar 2009 in Cairns Base Hospital. The statement says although the woman had other health problems, she tested positive for dengue, and the disease probably contributed to her death.

More than 600 cases of the mosquito-borne viral disease have been reported in recent months, with 556 in Cairns. The epidemic has also seen outbreaks in Townsville, Port Douglas, Yarrabah, Injinoo and Innisfail. Queensland Health says it is doing all it can to try to contain the outbreak.

"Dengue outbreaks have become more and more common here in the past two decades, particularly with the increase in international travel," Dr Hanna said. "This means more north Queenslanders will be at risk of developing dengue fever and its complications."

He says Queensland Health has been working with several other agencies such as local councils on intensive mosquito control measures since the epidemic began. "This means getting rid of mosquito breeding sites in your yard, such as pot plant bases, discarded tires and any other water-holding containers," he said. "People should also use surface spray in their house, wear insect repellent and see their doctor if they have any of the symptoms of dengue fever." Symptoms of dengue include fever, pain in muscles and bones, skin rash, headache (usually behind the eyes), diarrhea and vomiting.

This outbreak is the first time all four types of dengue virus have been recorded at the same time.
(ProMED 3/9/09)

Peru
Peru registered 5000 cases of dengue fever during January and February 2009, which has become a public health problem, Health Minister Oscar Ugarte said on 9 Mar 2009. Ugarte stated that 13,500 people were infected in 2008. He announced the launching of a campaign against dengue designed to raise public awareness of the importance of clearing stagnant water or hidden water deposits where the Aedes aegypti mosquito, a dengue virus carrier, breeds. "We have an enormous responsibility to combat dengue because it is lethal. . .a high social cost on human lives," Ugarte said.

Meanwhile, regional health directors (DIRESA) of Lambayeque sent a brigade of specialists to evaluate the situation in the Naupe area, in the Olmos district, in response to a suspected dengue outbreak. The head of the Lambayeque DIRESA, Victor Echeandia Arellano, announced that so far in 2009, three positive dengue cases have been registered, and there are another 16 possible cases under study. "In Naupe, the locality where supposedly there is a dengue outbreak, there is just one positive case, and while checking the outbreak fumigation will proceed," he added.

In Lambayeque department, there are 20 confirmed dengue cases and 187 cases under study.
(ProMED 3/9/09, 3/14/09)

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CHOLERA, DIARRHEA, DYSENTERY
Philippines
In five villages of Villareal town, Samar province, six people have died while 49 others got sick with diarrhea. According to Roque Barbo, rural sanitary inspector of the town, most of those who fell ill were children and the elderly whose immune systems are not strong enough to fight the bacterial infection. The disease affected the villages of Igot, Macopa, Ulayan, Conant, and Tayud. Health authorities suspect that contaminated drinking water might have caused the spread of diarrhea in those areas. "They get their water from an open deep well, which might have been contaminated," Barbo said. Barangay Igot chairwoman Liliosa Brillantes urged officials to help residents find an alternative water source.
(ProMED 3/10/09)

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4. Articles
Investigation of a Genotype Cluster of Tuberculosis Cases--Detroit, Michigan, 2004--2007
US Centers for Disease Control and Prevention. MMWR. 13 Mar 2009; 58(9): 226-229. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5809a2.htm.

In August 2007, the Detroit Department of Health and Wellness Promotion, Michigan Department of Community Health (MDCH), and CDC investigated a genotype cluster of eight tuberculosis (TB) cases in U.S.- born patients in the Detroit metropolitan area. The cases had been reported during December 2004--April 2007. The first case was reported in a patient (the index patient) whose drug-susceptible TB subsequently developed multidrug resistance. Seven additional cases were reported in patients with Mycobacterium tuberculosis genotypes that matched the genotype of the index patient. These included one case of multidrug-resistant (MDR) TB in a young relative of the index patient and one case in the index patient's parent, who died from TB meningitis. This report describes the investigation and illustrates the importance of ensuring that each case of TB disease is promptly recognized and successfully treated and that all close contacts of TB patients are identified, evaluated, and treated for latent TB infection if indicated. (References removed.)

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Clinical and Immunological Response to Attenuated Tissue-Cultured Smallpox Vaccine LC16m8
Saito T et al. JAMA. 2009; 301(10): 1025-1033. Available at http://jama.ama-assn.org/cgi/content/full/301/10/1025.

Context. The attenuated, tissue-cultured, third-generation smallpox vaccine LC16m8 was administered to vaccinia-naive infants in Japan during the 1970s without serious adverse events. It is a good candidate for use as part of a prevention plan for bioterrorism.

Objective. To assess the immunogenicity and frequency of adverse events of LC16m8 vaccine in unvaccinated and previously vaccinated adults.

Design, Setting, and Participants. Between 2002 and 2005 we vaccinated and revaccinated 1529 and 1692 adults, respectively, in the Japan Self-Defense Forces with LC16m8 vaccine, given intraepidermally using a bifurcated needle. Vaccinees were examined 10 to 14 days after vaccination to determine if they had developed a major skin reaction ("take"). Neutralizing antibody responses among 200 participants were assessed using a plaque-reduction neutralization test 30 days postvaccination. We monitored vaccinees for adverse events for 30 days postvaccination.

Main Outcome Measures. Documentation of a vaccine take, presence of neutralizing antibody response, and frequency of adverse events.

Results. The proportions of take in vaccinia-naive and previously vaccinated individuals were 1443 of 1529 (94.4% [95% confidence interval {CI}, 93.2%-95.9%] and 1465 of 1692 (86.6% [95% CI, 85.0%-88.2%]), respectively. Seroconversion or an effective booster response among the individuals with take was elicited in 37 of 41 (90.2% [95% CI, 81.2%-99.3%]) vaccinia-naive participants and in 93 of 155 (60.0% [95% CI, 52.3%-67.7%]) previously vaccinated participants. One case of allergic dermatitis and another of erythema multiforme, both of which were mild and self-limited, were suspected to be caused by vaccination. No severe adverse events were observed.

Conclusion. Administration of an attenuated tissue-cultured smallpox vaccine (LC16m8) to healthy adults was associated with high levels of vaccine take and seroconversion in those who were vaccinia-naive and yielded an effective booster response in some previously vaccinated individuals.

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Immunogenicity, Safety, and Cross Reactivity of an Inactivated, Adjuvanted, Prototype Pandemic Influenza (H5N1) Vaccine: A Phase II, Double Blind, Randomized Trial
Wu J et al. Clinic Infect Dis. 2009; 48: 1087-1095. Available at http://www.journals.uchicago.edu/doi/abs/10.1086/597401.

Background. Avian influenza A virus H5N1 has the potential to cause a pandemic. Adjuvants and whole virion vaccines are regarded as antigen sparing for pandemic vaccines.

Methods. A double blind, randomized trial was performed from 28 August to 22 December 2007 in 402 adults; 301 adults were randomly assigned to receive 2 doses of an inactivated, aluminum adjuvanted, whole virion H5N1 vaccine containing 5, 10, or 15 μg of hemagglutinin per dose 28 days apart, and 101 of them received 2 doses of 10 μg of vaccine 14 days apart. The vaccine was manufactured from the recombinant A/Vietman/1194/2004 (NIBRG14) strain. Blood samples were collected for hemagglutination inhibition and microneutralization assays.

Results. All formulations were well tolerated, with no serious adverse events. Most local and systemic reactions were mild or moderate. Immune responses were induced after 1 dose in all vaccination groups. The highest immune response was seen after 2 doses of 15 μg of vaccine, with 90% and 100% seroconversion rates and 90% and 100% of participants having a titer of 1:40 for hemagglutination inhibition and microneutralization assays, respectively. Both the 10 and 15 μg doses met or exceeded European Union licensure criteria. Generally, higher immune responses were elicited in participants vaccinated 28 days apart than those vaccinated 14 days apart. Cross reaction assays showed that after 2 doses of 10 μg of vaccine, 98% and 87% of participants had a microneutralization titer of 1:40 against heterologous Indonesia and Anhui strains, respectively.

Conclusions. The inactivated, aluminum adjuvanted, whole virion H5N1 vaccine not only showed good immunogenicity and safety but also elicited significant cross reactivity against heterologous H5N1 strains in clade 2.

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Seasonal Influenza in Adults and Children—Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America
Harper SA et al. Clinic Infect Dis. 2009; 48: 1003-1032. Available at http://www.journals.uchicago.edu/doi/abs/10.1086/598513.

Guidelines for the treatment of persons with influenza virus infection were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence based guidelines encompass diagnostic issues, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal (interpandemic) influenza. They are intended for use by physicians in all medical specialties with direct patient care, because influenza virus infection is common in communities during influenza season and may be encountered by practitioners caring for a wide variety of patients.

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Facing pandemic influenza threats: The importance of including poultry and swine workers in preparedness plans
Gray GC et al. Poult Sci. Keynote symposium, April 2009. Available at http://ps.fass.org/cgi/content/abstract/88/4/880.

Abstract
Recent research has shown that poultry and swine workers, especially those with intense exposures, are at increased risk of zoonotic influenza virus infections. In multiple studies, US poultry workers and poultry veterinarians have evidence of previous infections with avian influenza virus. Similarly, US swine workers have strong evidence of previous and acute infections with swine influenza viruses. Mathematical modeling has demonstrated that such workers may accelerate the spread of pandemic viruses in their rural communities. Because these workers may contribute to the novel generation of viruses and serve as a bridging population in the cross-species sharing of influenza viruses, it seems prudent to include poultry and swine workers in influenza preparedness programs. Possible preventive and control interventions include special education programs to increase workers’ use of personal protective equipment such as gloves, increased surveillance for influenza viruses among workers and their animals, recommendations that workers seek medical attention should they develop influenza-like illness, and workers’ priority receipt of annual and pandemic influenza vaccines.

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The public health impact of avian influenza viruses
Katz JM et al. Poult Sci. Keynote symposium, April 2009. Available at http://ps.fass.org/cgi/content/abstract/88/4/872.

Abstract
Influenza viruses with novel hemagglutinin and 1 or more accompanying genes derived from avian influenza viruses sporadically emerge in humans and have the potential to result in a pandemic if the virus causes disease and spreads efficiently in a population that lacks immunity to the novel hemagglutinin. Since 1997, multiple avian influenza virus subtypes have been transmitted directly from domestic poultry to humans and have caused a spectrum of human disease, from asymptomatic to severe and fatal. To assess the pandemic risk that avian influenza viruses pose, we have used multiple strategies to better understand the capacity of avian viruses to infect, cause disease, and transmit among mammals, including humans. Seroepidemiologic studies that evaluate the frequency and risk of human infection with avian influenza viruses in populations with exposure to domestic or wild birds can provide a better understanding of the pandemic potential of avian influenza subtypes. Investigations conducted in Hong Kong following the first H5N1 outbreak in humans in 1997 determined that exposure to poultry in live bird markets was a key risk factor for human disease. Among poultry workers, butchering and exposure to sick poultry were risk factors for antibody to H5 virus, which provided evidence for infection. A second risk assessment tool, the ferret, can be used to evaluate the level of virulence and potential for host-to-host transmission of avian influenza viruses in this naturally susceptible host. Avian viruses isolated from humans exhibit a level of virulence and transmissibility in ferrets that generally reflects that seen in humans. The ferret model thus provides a means to monitor emerging avian influenza viruses for pandemic risk, as well as to evaluate laboratory-generated reassortants and mutants to better understand the molecular basis of influenza virus transmissibility. Taken together, such studies provide valuable information with which we can assess the public health risk of avian influenza viruses.

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Highly Pathogenic Avian Influenza Virus Subtype H5N1 in Africa: A Comprehensive Phylogenetic Analysis and Molecular Characterization of Isolates
Cattoli G et al. PLoS ONE. 17 March 2009; 4(3). Available at http://www.plosone.org/article/info:doi/10.1371/journal.pone.0004842.

Abstract
Highly pathogenic avian influenza virus A/H5N1 was first officially reported in Africa in early 2006. Since the first outbreak in Nigeria, this virus spread rapidly to other African countries. From its emergence to early 2008, 11 African countries experienced A/H5N1 outbreaks in poultry and human cases were also reported in three of these countries. At present, little is known of the epidemiology and molecular evolution of A/H5N1 viruses in Africa. We have generated 494 full gene sequences from 67 African isolates and applied molecular analysis tools to a total of 1,152 A/H5N1 sequences obtained from viruses isolated in Africa, Europe and the Middle East between 2006 and early 2008. Detailed phylogenetic analyses of the 8 gene viral segments confirmed that 3 distinct sublineages were introduced, which have persisted and spread across the continent over this 2-year period. Additionally, our molecular epidemiological studies highlighted the association between genetic clustering and area of origin in a majority of cases. Molecular signatures unique to strains isolated in selected areas also gave us a clearer picture of the spread of A/H5N1 viruses across the continent. Mutations described as typical of human influenza viruses in the genes coding for internal proteins or associated with host adaptation and increased resistance to antiviral drugs have also been detected in the genes coding for transmembrane proteins. These findings raise concern for the possible human health risk presented by viruses with these genetic properties and highlight the need for increased efforts to monitor the evolution of A/H5N1 viruses across the African continent. They further stress how imperative it is to implement sustainable control strategies to improve animal and public health at a global level.

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Trends in Tuberculosis--United States, 2008
US Centers for Disease Control and Prevention. MMWR. 20 Mar 2009; 58(10); 249-253. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a2.htm?s_cid=mm5810a2_e.

In 2008, a total of 12,898 incident tuberculosis (TB) cases were reported in the United States; the TB rate declined 3.8% from 2007 to 4.2 cases per 100,000 population, the lowest rate recorded since national reporting began in 1953. This report summarizes provisional 2008 data from the National TB Surveillance System and describes trends since 1993. Despite this overall improvement, progress has slowed in recent years; the average annual percentage decline in the TB rate decreased from 7.3% per year during 1993--2000 to 3.8% during 2000--2008. Foreign-born persons and racial/ethnic minorities continued to bear a disproportionate burden of TB disease in the United States. In 2008, the TB rate in foreign-born persons in the United States was 10 times higher than in U.S.-born persons. TB rates among Hispanics and blacks were nearly eight times higher than among non-Hispanic whites, and rates among Asians were nearly 23 times higher than among non-Hispanic whites. In 2008, among persons with TB whose country of origin was known, approximately 95% of Asians, 76% of Hispanics, 32% of blacks, and 18% of whites were foreign born. Among U.S.-born racial and ethnic groups, the greatest racial disparity in TB rates was for U.S.-born blacks, whose rate was seven times higher than the rate for U.S.-born whites. Intensified efforts are needed to address the slowing decline in TB incidence and the persistent disparities that exist between U.S.-born and foreign-born persons and between whites and minorities in the United States. (Excerpt.)

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5. Notifications
Interim Guidance on Cleaning Transit Vehicles and Facilities during a Pandemic
The US Department of Health and Human Services (HHS) has released seven guidance documents on cleaning of transportation vehicles and facilities during an influenza pandemic. The recommendations cover trucks, aircraft, passenger and cargo ships, transit stations, passenger rail cars, port-of-entry detention facilities, and ambulances. The aircraft guidance, for example, spells out which parts of the airplane should be cleaned and disinfected after a passenger has arrived in the United States with a potential case of pandemic flu.

Available at http://pandemicflu.gov/plan/workplaceplanning/transit_guidance.html.

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Corporate Antiviral Stockpiling: Benefits, Pitfalls, and Understanding Emerging Resistance Issues
Live Webinar
31 March 2009

Antiviral drugs have been widely discussed as a key measure to blunt the impact of the next influenza pandemic. In fact, in most developed countries the availability and use of antivirals may be the only real tool that a company will have in the first six months of a pandemic. Given the recent reports about antiviral resistance, the questions are mounting.

To date, more than 350 companies have purchased antivirals; however, any comprehensive plan for using antivirals for employees (and potentially for their families) will mean substantial financial outlays and will require difficult logistical, legal, and ethical decisions.

Join us as two internationally respected authorities in corporate preparedness combine their years of expertise and integrity to equip you with the definitive "need-to-know" information in a lively interactive Webinar. Widely known for their candor, vision, and drive for results, Michael T. Osterholm, PhD, MPH, and Dr. Doug Quarry, MBBS, MSc (Community Health), will fortify you with insights, energy, and real-world action steps.

Additional information available at http://online.krm.com/iebms/coe/coe_p2_details.aspx?oc=10&cc=00279763&eventid=15605.

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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