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Vol. XII, No. 8 ~ EINet News Briefs ~ Apr 17, 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)
- Indonesia: Avian influenza continues to spread among poultry in Riau
- Canada (Onterio): Despite free access, most children not vaccinated against influenza
- Egypt: WHO to assist in determining if virulence of avian influenza H5N1 has diminished
- Egypt: Reports three fresh avian influenza H5N1 outbreaks in poultry

2. Infectious Disease News
- China: Hand foot and mouth disease spreads in multiple provinces
- Indonesia: 47 people hospitalized after eating meat from tainted cow carcass
- Russia: SARS suspected in woman’s death
- Russia (Moscow): Public health official warns of attacks by rabid dogs
- Russia (Tartarstan): Concerns of widespread West Nile Virus infection
- Russia (Udmurtia): Rare parasitic disease reported for first time in 2009
- Russia (Udmurtia): Increased incidence of HFRS reported since 2008
- Singapore: Food poisoning incident hospitalizes 48 and kills two
- USA (California): West Nile Virus found in bird, first case in Fresno County
- USA (Illinois): Hundreds possibly exposed to TB unknowingly by infected doctor
- USA (New York): Raccoon roundworm infection identified in NYC
- USA (North Carolina, Georgia): Man bit by rabid fox, suspected increase in wildlife rabies
- USA (Vermont): Five cows contract rabies, little risk to humans

3. Updates
- AVIAN/PANDEMIC INFLUENZA
- DENGUE

4. Articles
- Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Food--10 States, 2008
- The Role of Environmental Transmission in Recurrent Avian Influenza Epidemics
- Register data suggest lower intelligence in men born the year after flu pandemic
- Epidemiology of antituberculosis drug resistance 2002—07: an updated analysis of the Global Project on Anti-Tuberculosis Drug Resistance Surveillance
- Update: Influenza Activity--United States, September 28, 2008--April 4, 2009, and Composition of the 2009--10 Influenza Vaccine
- Influenza and vaccine development: a continued battle
- Current status and progress of prepandemic and pandemic influenza vaccine development
- Characterization of a highly pathogenic avian influenza H5N1 virus sublineage in poultry seized at ports of entry into Vietnam
- A Novel Small-Molecule Inhibitor of the Avian Influenza H5N1 Virus Determined through Computational Screening against the Neuraminidase

5. Notifications
- WHO Global Outbreak Alert & Response Network meets in Geneva
- London's revised pandemic flu plan envisions up to 94,000 deaths
- Conference: BIT's 2nd Annual Congress and Expo of Molecular Diagnostics (CEMD-2009)
- APEC Conference for the Surveillance, Treatment, Laboratory Diagnosis and Vaccine Development of Enteroviruses
- 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/ 12 (0)
Viet Nam/ 3 (3)
Total/ 22 (7)

***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: 417 (257).
(WHO 3/30/09 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 3/23/09)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 4/15/09): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 3/23/09):
http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Asia
Indonesia: Avian influenza continues to spread among poultry in Riau
The bird flu virus has spread within Sungai Apit district in Siak regency, Riau, following the death of a child infected with the virus at the end of March 2009, says a local official, adding prevention measures were being hampered by residents' reluctance to cull their poultry. District chief Indra Atmaja said the spread of the virus was discovered following reports of poultry dying abruptly on 4 Apr 2009.

"After checking by a team of veterinarians, two of the chickens tested positive for bird flu. A day earlier, we received reports that 12 chickens owned by other residents had died suddenly," Indra said on 8 Apr 2009. He added the virus had spread to Teluk Masjid and Teluk Batil villages and Sungai Apit subdistrict.

"Seven chickens died suddenly the previous day in Sungai Apit subdistrict, while in Teluk Masjid and Teluk Batil, the number has reached 29," he said. "Based on field tests conducted by the Siak Animal Husbandry Agency, the chickens tested positive for bird flu."

Indra said the test results had been publicized through village chiefs and neighborhood unit chiefs to raise residents' awareness of the risk of infection. The team from the Siak Animal Husbandry Agency has sprayed residents' poultry cages with disinfectant to prevent the virus from spreading further.

Indra also urged residents to cull their poultry. However, he said only few residents were willing, while most would only do so if paid to. "It's not that we don't want to, but the district office has no such budget for the purpose. For now, we can only remind the residents, including through sermons at mosques, of the risks of bird flu. We cannot force the residents to cull their poultry if they don't want to," he said.
(ProMED 4/13/09)

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Americas
Canada (Onterio): Despite free access, most children not vaccinated against influenza
Most Ontario children for whom influenza vaccination is recommended are not getting vaccinated, even though flu immunization is free to all in the province, according to a report from the Toronto-based Institute for Clinical Evaluative Sciences (ICES). In a telephone survey during the 2006-07 flu season, the researchers found that only 30.8% of children with high-risk medical conditions had received flu vaccine and that only 10% of 6- to 23-month-old children had received the recommended two doses of vaccine. The survey targeted the caregivers of 4,854 children between 6 months and 11 years old. "This study shows that just making flu shots freely and easily available to the entire population may not be enough for reaching certain high risk groups," said Dr. Jeff Kwong, one of the authors.
(CIDRAP 4/14/09)

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Africa
Egypt: WHO to assist in determining if virulence of avian influenza H5N1 has diminished
Egypt asked the World Health Organization [WHO] to help investigate an outbreak of bird flu after a dozen non-fatal human cases of the disease in 2009 prompted speculation the virus may be becoming less virulent. Two WHO doctors and a scientist will travel to Cairo at the request of Egypt's Ministry of Health, said Gregory Hartl, a spokesman for the United Nations agency in Geneva, on 13 Apr 2009. The UN team will assist local authorities to identify how the patients were infected with the H5N1 strain of avian influenza and whether there have been any significant changes in disease patterns in the virus itself.

Scientists have been following H5N1 for more than a decade because of concern it could spark a pandemic if it becomes as infectious for humans as it is for poultry. Ironically, its very virulence has provided an important safeguard. It did not get much chance to infect other people when it killed its victims swiftly, but now it has much more of a chance to mutate and be passed on.

The WHO fears that the recent rise in infections among small children, without similar cases being seen in older people, raises questions about whether adults are being infected but not falling ill, so acting as symptomless carriers of the disease. Its investigation, due to start this summer, will see whether this is happening by testing the blood of people who may have been in contact with infected birds but who have not themselves become sick.

None of the 12 Egyptian cases reported to the WHO in 2009 has been fatal. These data do indeed suggest that there may have been a reduction in the virulence of the outbreak strain, and there is a perceived risk of progression of the virus to a less virulent but more transmissible form, the International Society for Infectious Diseases said on 13 Apr 2009. The survival of H5N1 patients in Egypt also may reflect early treatment with antiviral medicines.

H5N1 is continuing to circulate in poultry in Egypt, though there is no evidence so far of any significant changes in the virus, said Joseph Domenech, chief veterinary officer with the Food and Agriculture Organization [FAO]. The Rome-based UN agency has also agreed to a request by Egypt's government to provide technical assistance, Domenech said on 13 Apr 2009.
(ProMED 4/12/09, 4/13/09)

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Egypt: Reports three fresh avian influenza H5N1 outbreaks in poultry
Animal health officials in Egypt reported that H5N1 avian influenza broke out in three governorates, according to Strengthening Avian Influenza Detection and Response (SAIDR). An outbreak in Giza governorate, detected through active surveillance, struck 25 mixed variety backyard birds. Officials in Kafr el Sheikh governorate reported an outbreak in 70 backyard chickens, and authorities in Sharkia governorate reported that preslaughter testing at a commercial farm in Mafarik Khodeir village detected the virus in some of the facility's 3,500 chickens. The vaccination status of the birds wasn't available in any of the three outbreaks.
(CIDRAP 4/16/09)

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2. Infectious Disease News

Asia
China: Hand foot and mouth disease spreads in multiple provinces
Thirty-three children in two crowded rural provinces of China have died in an outbreak of hand, foot and mouth disease (HFMD) that could claim more victims as it spreads in summer heat, state media reported on 7 Apr 2009. The disease, a common childhood illness, is rarely fatal but can cause fever, mouth sores and blisters. Severe forms of the illness can be deadly if not properly treated.

Eighteen children have died from the disease in central Henan province with at least 15 deaths in eastern Shandong province in 2009, the Xinhua news agency reported.

Henan, a rural province crowded with poor farmers, is the center of China's latest outbreak of the disease, which killed 40 children nationwide in 2008. The deaths in Henan were among nearly 20.000 cases of the disease confirmed in the province, including 5965 in hospital, as of 6 Apr 2009, the Xinhua News Agency stated.

The report from Shandong said 11,500 children had been diagnosed with the disease and 7100 had already recovered. Earlier in 2009, a 17-month-old boy died of the disease in eastern Anhui province.

Meanwhile, East China's Zhejiang Province reported on 8 Apr 2009, its first death from HFMD in 2009. A child in Cixi, Ningbo city died 5 Apr 2009 hours after he was admitted to hospital, said Zhang Leming, head of the Ningbo Municipal Health Bureau. The child developed symptoms of fever and rashes on his hands and feet on 3 Apr 2008 and was sent to a community clinic on 5 Apr 2008.

Ningbo city had reported 367 cases of infections from the highly contagious disease as of 5 Apr 2009, said Zhang.

Cases have also been reported in Beijing. The city has reported more than 1000 cases in 2009, according to the Beijing Health Bureau on 8 Apr 2008.

"The number of infected children has been growing fast recently in the city," the statement said. It said that nearly 90 percent of the infected children are below the age of five years. In addition, "Kindergartens which reported more than 20 cases or two severe cases within one week should be shut down for a thorough inspection."
(ProMED 4/8/09, 4/10/09)

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Indonesia: 47 people hospitalized after eating meat from tainted cow carcass
At least 47 villagers in Timor in East Nusa Tenggara (Nusa Tenggara Timur) were hospitalized after consuming meat from a cow carcass believed to be tainted with anthrax. The residents of Tetaf village in West Amanuban district complained of diarrhea, vomiting and high fever.

Head of veterinary health at the provincial animal husbandry agency Benyamin Bili confirmed on 9 Apr 2009 the incident. Dozens of villagers had to be treated after consuming meat from the dead cow. "There are no fatalities in the incident," he said. "Such food poisoning cases after consuming beef often occur in the area."

Another food poisoning case occurred at Takari district in Kupang regency, where 28 residents had to be treated after consuming pork. "The residents ate the pork at a mourning house," said provincial health agency head Stefanus Bria Seran.
(ProMED 4/12/09)

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Russia: SARS suspected in woman’s death
A Chinese woman has died from what may be Severe Acute Respiratory Syndrome (SARS) while traveling on a train from the Far East Russian city of Blagoveshchensk to Moscow, a medical source said on 15 Mar 2009.

The train was stopped in the central Russian city of Kirov and around 60 train passengers were sent to a local hospital. It is reported that six of them are running fevers, the source said, although Kirov Region officials have said that none of them were suffering from SARS. The carriage in which the woman was travelling was disconnected from the rest of the train. The train then continued on its way to Moscow.

Russia's public health spokesman was unable to confirm that the woman had died from SARS. "Doctors are currently establishing a preliminary diagnosis," he said. Kirov Region administration officials said that the final results of the analysis would be ready in 24 hours.
(ProMED 4/16/09)

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Russia (Moscow): Public health official warns of attacks by rabid dogs
Olga Gavrilenko, the senior public health official in the Moscow Region, reports two instances of attacks by rabid dogs in the region in 2009. In one case, an unvaccinated domestic dog contracted rabies and bit 14 humans in the town and neighborhood of Kikino-Dulevo. In the town of Krasnoarmeysk, a dog bit 10 persons, including seven children. Gavrilenko urged citizens to seek post-exposure vaccination as soon as possible after sustaining a bite and to avoid handling wild animals.

Gavrilenko stated that four people died in the Moscow Region during 2008 as a result of rabies virus infection; three of them resided in the Moscow region and one in the city of Moscow. All cases resulted from bites from wild animals.

During the course of 2008, some 25,000 people, including 5,000 children, required medical treatment as a result of animal bites.
(ProMED 4/9/09)

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Russia (Tartarstan): Concerns of widespread West Nile Virus infection
West Nile fever may become a widespread infection in the Republic of Tatarstan, as antibodies have been detected in 12 percent of blood donors among 500 persons tested, according to Professor Vladimir Boyko, head of the department in the Institute of Ecology and Land Use.

As a consequence of the construction of the Kuybyshevskoe water reservoir and a warming climate, the numbers of waterfowl – a reservoir of West Nile virus – have increased significantly. Infection is transmitted by a species of mosquito which feeds on the blood of nestlings. During recent years, conditions in the summer have been favorable for virus spread due to an increase in mosquito numbers.
(ProMED 4/12/09)

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Russia (Udmurtia): Rare parasitic disease reported for first time in 2009
Specialists of the Rospotrebnadzor administration report that a rare parasitic disease, dirofilariasis, has been registered in Udmurtia for the first time in 2009. Dirofilariasis is caused by Dirofilaria, which usually parasitize subcutaneously in different parts of the body, in mucous membranes, and in eye conjunctiva. The infection is caused by a 5-15 cm long roundworm.

The infection is transmitted by mosquitoes. The first sign of the disease is a painful nodule. Patients feel itching and burning in the bite area. A sensation of crawling within the consolidated skin is considered to be a specific sign. The standard treatment is surgical removal of the parasite from the nodule or eye.

Subcutaneous dirofilariasis is distributed in Kazakhstan, Uzbekistan, Georgia, Ukraine and in many oblasts of Russia, such as Astrakhan, Volgograd, Nijegorodskiy, Saratov, Rostov, Chelyabinsk, and many others. People usually become infected during agricultural work, hiking, hunting, and fishing in places where infected mosquitoes and infected animals are prevalent. Prophylactic methods include extermination of mosquitoes, timely treatment of dogs and cats, control of wandering animals, and repellent use.
(ProMED 4/5/09)

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Russia (Udmurtia): Increased incidence of HFRS reported since 2008
Since the beginning of 2009, 114 cases of hemorrhagic fever with renal syndrome (HFRS) have been reported in the Republic of Udmurtiya. This is six times the rate recorded during the same period in 2008. In total since the beginning of 2008 there have been 1330 cases of HFRS and two fatalities in the Republic of Udmurtiya. HFRS was recorded in all administrative regions of Udmurtiya, but the highest incidences were reported in the Sjumsinsky, Seltinsky, Kiznersky, Vavozhsky, Uvinsky, Few-Purginsky, Jakshur-Bodinsky, and Zavjalovsky regions of the Republic.

The woodland rodent population has survived the winter of 2008/2009 well and consequently the HFRS prognosis for 2009 remains unfavorable. In Udmurtiya, half of all patients contract infection during visits to forested areas for recreation and collection of fungi and berries. City dwellers often become infected in their gardens and during visits to their summer residences in the country. In 2008, every third patient was a town or city dweller.
(ProMED 4/14/09)

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Singapore: Food poisoning incident hospitalizes 48 and kills two
The mass food poisoning incident involving an Indian rojak stall at the Geylang Serai temporary market has claimed its second victim. A 59-year-old woman who was hospitalized in Alexandra Hospital died on 8 Apr 2009. The hospital said she was admitted with food poisoning on 4 Apr 2009. The incident has also killed another woman, a 57-year-old canteen assistant, and caused a 38-year-old expectant mother to miscarry.

So far, 146 people have been affected by the food contamination, 48 of whom were hospitalized. The Health Ministry says it appears that the transmission, caused by a cross-contamination of rojak and raw seafood ingredients harboring the Vibrio parahaemolyticus bacteria, has ceased. Laboratory investigation confirmed 12 cases tested positive for Vibrio parahaemolyticus, including the first death.

Meanwhile, the Geylang Serai temporary market, which houses about 300 stalls, was closed for routine cleaning on 8-9 Apr 2009. The last time cleaning took place there was in October 2008.

Indian rojak consists of various food items that are deep fried then chopped up and served with a sweet orange sauce. The most popular components are potato, dough-covered hard-boiled eggs, various dough balls (including a flattened dough ball with a large prawn embedded (shell and all)).
(ProMED 4/13/09, 4/15/09)

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Americas
USA (California): West Nile Virus found in bird, first case in Fresno County
A dead crow discovered in Fresno is the first bird to test positive for West Nile virus in Fresno County in 2009, the Fresno County Health Department said 3 Apr 2009. Fresno County joins Los Angeles, Orange, and San Diego counties as sites where the virus, which can be fatal to humans, has been discovered in birds in 2009.
(ProMED 4/6/09)

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USA (Illinois): Hundreds possibly exposed to TB unknowingly by infected doctor
A Northwestern University resident physician potentially exposed hundreds of patients including infants at three Chicago-area hospitals to tuberculosis (TB) in what is being called an unusual case of a medical-care provider putting patients' health at risk.

The 26-year-old female pediatric resident was diagnosed with TB on 7 Apr 2009 with TB at Northwestern Memorial Hospital in Chicago after experiencing symptoms consistent with the infectious disease, hospitals and the Chicago Department of Public Health said. Symptoms of "active" TB include coughing, night sweats, fever, chills, and weight loss.

As 10 Apr 2009, no patients or workers related to this case had been diagnosed with TB. The three hospitals -- Northwestern, Children's Memorial and Evanston -- said they believe the risk to patients is "minimal" from the resident, whose identity was not released. However, hospitals are continuing to notify patients who may have been exposed to the resident over the past 10 months.

The pediatric resident most recently was at Children's Memorial Hospital in Chicago, where she came in contact with at least 150 children and infants and more than 300 workers, hospital officials said. Her work rotations also affected more than 100 patients, including 17 newborns, at Northwestern Memorial's Prentice Women's Hospital from 3-19 Nov 2008.

An additional 80 babies at Evanston Hospital's infant special care unit, including 20 who were still there on 10 Apr 2009, and a "small group of employees" were in close contact with the doctor between 12 Feb and 11 Mar 2009. All three hospitals are part of Northwestern University's residency training program.

Children's Memorial Hospital said no evidence suggests the resident has drug-resistant TB. There were 12,898 cases of TB reported in the USA in 2008, according to the U.S. Centers for Disease Control and Prevention (CDC), and just 214 cases diagnosed in Chicago, though worldwide TB kills about 2 million.

The resident's infection was "susceptible and sensitive" to treatment, Gerber said on 10 Apr 2009. The recommended length of drug therapy for most types of TB is from 6-9 months.

The resident was admitted to Northwestern Memorial on 3 Apr 2009 after being encouraged by fellow workers at Children's Memorial Hospital to seek medical attention, sources close to the investigation said. She was kept in isolation until her diagnosis was confirmed on 7 Apr 2009 and was discharged 8 Apr 2009. Northwestern Memorial called the health department 6 Apr 2009 after her first set of tests came back to confirm the diagnosis. The investigation involves the CDC and the Chicago, Cook County and Illinois departments of public health.

Medical professionals stressed the rarity of an infected health-care worker exposing patients to TB, adding that staffers are screened each year for the disease. But that doesn't preclude a person from contracting TB in between screenings. "It happens rarely to occasionally," said Dr. Stanford Shulman, chief of infectious diseases at Children's. "It's the reason why hospitals, including ours, annually test hospital employees on a routine basis." Shulman confirmed that the resident had been tested in the past.
(ProMED 4/12/09)

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USA (New York): Raccoon roundworm infection identified in NYC
Two cases of Baylisascaris procyonis (B. procyonis or raccoon roundworm) infection have been identified in children from Brooklyn, both with serious sequelae: 1) An infant with eosinophilic meningoencephalitis from neural larva migrans resulting in severe permanent brain damage, and 2) A teenager with ocular larva migrans resulting in loss of vision in one eye.

The New York City (NYC) Health Department asks providers to consider and test for baylisascariasis in patients presenting with encephalopathy with peripheral eosinophilia or a CSF eosinophilic pleocytosis, ocular larva migrans, diffuse unilateral subacute neuroretinitis (DUSN) or eosinophilic pseudotumor.
(ProMED 4/10/09)

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USA (North Carolina, Georgia): Man bit by rabid fox, suspected increase in wildlife rabies
A rabid fox ran inside a house and bit a man at least twice on 30 Mar 2009. The victim, who lives near Fields of the Wood, was asleep when he heard scratching at his front door. Thinking it was his cat, he opened the door. A fox immediately ran in and bit his big toe. He kicked the fox across the room and it went on a rampage, running all over the house before it came back and grabbed his other foot. He then kicked the fox again, then grabbed a mop handle and killed the fox.

The remains were sent for testing and confirmed rabid on 31 Mar 2009 and the victim began the rabies vaccine regimen. Full vaccination requires five injections over 28 days.

The fox was the sixth confirmed case of rabies in Cherokee County in 2009, all occurring since 16 Mar 2008, when a large dog fought and killed a raccoon in Peachtree. Rabies cases have been spread all over the county with the exception of the Andrews and Marble areas, said Philip Anderson who runs the Cherokee County Health Department's rabies prevention program. He has collected 36 animals for the U.S. Department of Agriculture (USDA) for a rabies surveillance program in an attempt to convince the USDA that an oral rabies vaccine drop to immunize wildlife is needed. Anderson said USDA has collected 30 of the animals, which are animals that haven't been proven to have bitten other animals or people and include animals found dead on the roads. "We haven't heard back from [USDA] on any of the animals," Anderson said. "We have been doing this [since August 2008]. I didn't expect this [long of a] delay."

The oral vaccination drop consists of plastic packets containing the Raboral V-RG rabies vaccine which are dropped into selected areas by airplane. The packets are sprinkled with fishmeal coating or encased in fishmeal so they are eaten by wildlife. Animals that swallow an adequate dose of the vaccine develop immunity to rabies. As the proportion of vaccinated animals in the population increases, they act as a buffer to stop spread of the disease to other wildlife, domestic animals and people.

Anderson said rabies cases in Cherokee County seem to be escalating. At this time in 2008, there were only two confirmed cases of wildlife rabies in the county. He got an e-mail from an USDA representative who said the incidence of rabies in Polk and Monroe counties in Tennessee have decreased. A bait drop was done in those counties in September or October 2008.
(ProMED 4/9/09)

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USA (Vermont): Five cows contract rabies, little risk to humans
Vermont agriculture officials are urging farmers to vaccinate their cows for rabies after five have tested positive for the disease. The cows were likely infected by a rabid raccoon. Sources say it is unclear why rabies cases in cows are increasing. But one veterinarian suspects farmers may have dropped the vaccine as a cost-cutting measure. The rabid cows pose a minimal risk to humans. No one has ever contracted rabies from drinking milk but the Centers for Disease Control says people who drink raw milk from a rabid cow are at risk for the disease. Farm workers also are at risk.
(ProMED 4/10/09)

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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 reported a local scientist has been diagnosed with dengue virus infection. The researcher was infected while working with the virus in a laboratory as part of the dengue fever eradication program. Chief health officer Dr Jeannette Young says they're not sure yet how he caught the virus, so safety precautions in the lab have been increased.

The scientist was sick enough to be admitted to hospital, but has been released. Dr Young says he's recovering well. "Because we don't know how he got it, we've increased the use of personal protective equipment in that laboratory," she said. "That means they'll wear the gear all the time -- masks, double gloves, gowns, all those sorts of things. . . no one outside that lab is at any risk," she said.
(ProMED 4/6/09)

Australia (North Queensland)
Almost 1000 people have been infected with dengue fever in north Queensland, officially making it the worst outbreak in almost 20 years. But there is some good news, with experts saying the rate of infection is slowing.

The count on 9 Apr 2009 was 935 cases, mostly in Cairns. That tops the previous worst outbreak of 1992-93 when about 900 people were infected with the mosquito-borne virus in Townsville and Charters Towers.

The latest outbreak started on 1 Dec 2008, and Queensland Health officials say it's been particularly virulent, leaving people "sicker than we have previously seen" and claiming one life. A frail 82-year-old Manoora woman died on 1 Mar 2009 at Cairns Base Hospital. Although she had other health problems, she tested positive to dengue and the disease probably contributed to her death.

Public Health Medical Officer Margaret Young said the latest epidemic was also "fast." A less severe outbreak in 2003 and 2004 took more than a year to get to 536 cases. This outbreak took just 14 weeks to reach the same figure.

"The epidemic has also left people sicker than we have previously seen, with approximately one in four dengue cases requiring some form of hospital care," Dr Young said.

Authorities fear that if the virus continues to spread in low numbers during the winter, it could spark a fresh wave of infections when the weather warms up again. "The last time a dengue outbreak continued through the winter in Cairns was in 1998," Dr Young said. "There is a long term risk that dengue could become endemic in North Queensland, so it's important that local residents continue to clear their yards of breeding sites throughout the winter."

Dengue is not currently endemic in Australia. Outbreaks begin when a traveler picks up the virus overseas and returns home while infected. While the current outbreak is the worst in recent decades, Dr Young said there were reports of dengue outbreaks in the early to middle of last century that "affected many thousands of people, including in Brisbane."
(ProMED 4/13/09)

Indonesia
Dengue fever season is underway and patients are thronging Jakarta hospitals. In Central Jakarta, the city-owned Tarakan Hospital has a 300 bed capacity and worked at full stretch to treat 68 dengue patients over the weekend of 28-29 Mar 2009. "We're running out of nurses, and all of our economy-class beds are occupied. Some patients have to use portable beds," head nurse Zuraidah stated.

The hospital has recorded 654 dengue cases between January and March 2009, seven of them fatal. The city-owned Pasar Rebo Hospital in East Jakarta recorded 551 dengue cases in the same period. Tarakan Hospital receives 15-20 new dengue patients daily, Zuraidah said, adding it had prepared 70 portable beds, 16 of them now in use. The hospital's 260 nurses are barely enough, she said, since they do not work at the same time. Zuraidah said the hospital had been overwhelmed since January 2009.

At Budhi Asih Hospital in East Jakarta, one of 17 city-owned hospitals, the number of dengue patients has risen to 340 in March 2009, up from 320 in February 2009, while in January 2009 it was 228. "We have the highest daily number of patients this week [30 Mar 2009], with 95 people being treated," said medical service head Hamonangan Sirait. The hospital treated 89 dengue patients on 27 Mar 2009, while the daily intake of new patients is 20 people.

Cengkareng Hospital in West Jakarta treated 32 patients on 27 Mar 2009. "There's no lack of health workers or medicine. As a city-owned hospital, we can just ask for extra workers or medicine," he said, adding the hospital had some 60 doctors, 48 of them dealing with dengue fever. He called the past few months an "extraordinary situation."

But Jakarta Health Agency head Dien Emawati said the city's dengue profile was still considered normal. "We don't need to declare an emergency status yet," she said. The agency recorded 8086 dengue fever cases between January-March 2009, 16 of them fatal. Agency spokeswoman Tini Suryani said that 30 percent of the cases occurred in East Jakarta.
(ProMED 4/6/09)

Viet Nam
The number of dengue fever cases in Ho Chi Minh (HCM) City in the first quarter of 2009 has increased by 8 percent compared with the same period in 2008, according to the municipal Department of Health. To date, the department has recorded 2250 people hospitalized with dengue fever, one of whom died.

Many hospitals in the city have reported increasing numbers of dengue fever cases since the beginning of 2009. Dr Tran Van Ngoc, head of the HCM City Tropical Disease Hospital's Pediatrics A Ward, says the ward has been receiving an average of 10 dengue fever patients per day. Dr Vu Quang Vinh, deputy head of Pediatrics Hospital No 2's general accounting department, says that the hospital has received 124 cases so far in March 2009.

The situation is rather serious, says Dr Nguyen Dac Tho, deputy director of the city's Preventative Health Centre. He says a survey conducted by the center in districts 12, 6, and Binh Thanh found disease-carrying mosquitoes in more than 90 percent of the houses.

To discuss ways to prevent new outbreaks in the upcoming rainy season in southern provinces, the Ministry of Health's Preventive Medicine Department held a meeting on 27 Mar 2009 with representatives of provincial health departments on implementing the National Dengue Fever Prevention Programme.

A representative from the Preventive Medicine Department said that in 2009, the ministry would run the National Dengue Fever Prevention Programme in all provinces and cities nationwide at a cost of more than VND 91 billion (USD 5.2 million). The program aims to reduce, by the end of 2009, both the number of people infected and those dying from dengue fever by 10 percent over the average number during the 2003-07 period.

Meanwhile, since the beginning of 2009, Can Tho City Children's Hospital has treated over 310 cases of dengue fever, with 96 at the serious levels III and IV. Most patients are from Can Tho City, Hau Giang, Soc Trang, Vinh Long, and Dong Thap provinces.

The epidemic has come in the dry season instead of the rainy season as is typical, Le Hoang Son, director of the hospital said. The weather has been changeable in 2009. The increase of unseasonable rains has created advantageous conditions for mosquitoes, director of the Can Tho City Preventive Health Center Nguyen Trung Nghia said.

Can Tho City authorities have deployed solutions to prevent the dengue epidemic. They have organized training courses on dengue prevention for teachers so that they can teach their students. The city has also provided schools with equipment to help families breed fish in places with mosquito larvae. In April 2009, Can Tho's Health Department will conduct a campaign to destroy mosquito larvae in 11 wards where dengue fever may break out.
(ProMED 4/6/09, 4/13/09)

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4. Articles
Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Food--10 States, 2008
US Centers for Disease Control and Prevention. MMWR. 10 Apr 2009; 58(13): 333-337. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5813a2.htm?s_cid=mm5813a2_x.

Foodborne diseases remain an important public health problem in the United States. The Foodborne Diseases Active Surveillance Network (FoodNet) of CDC's Emerging Infections Program collects data from 10 U.S. states on diseases caused by enteric pathogens transmitted commonly through food. FoodNet is an active, population-based surveillance system for these laboratory-confirmed infections. This report describes preliminary surveillance data for 2008 and trends since 1996. In 2008, the estimated incidence of infections caused by Campylobacter, Cryptosporidium, Cyclospora, Listeria, Shiga toxin-producing Escherichia coli (STEC) O157, Salmonella, Shigella, Vibrio, and Yersinia did not change significantly when compared with the preceding 3 years. For most infections, incidence was highest among children aged <4 years, whereas the percentage of persons hospitalized and the case fatality rate were highest among persons aged >50 years. None of the Healthy People 2010 targets for reduction of foodborne pathogens (objective 10-1) were reached in 2008. The lack of recent progress points to gaps in the current food safety system and the need to continue to develop and evaluate food safety practices as food moves from the farm to the table. (Excerpt with references removed.)

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The Role of Environmental Transmission in Recurrent Avian Influenza Epidemics
Breban R et al. PLoS Comp Biol. 10 Apr 2009. Available at http://www.ploscompbiol.org/article/info:doi/10.1371/journal.pcbi.1000346.

Abstract
Avian influenza virus (AIV) persists in North American wild waterfowl, exhibiting major outbreaks every 2-4 years. Attempts to explain the patterns of periodicity and persistence using simple direct transmission models are unsuccessful. Motivated by empirical evidence, we examine the contribution of an overlooked AIV transmission mode: environmental transmission. It is known that infectious birds shed large concentrations of virions in the environment, where virions may persist for a long time. We thus propose that, in addition to direct fecal/oral transmission, birds may become infected by ingesting virions that have long persisted in the environment. We design a new host-pathogen model that combines within-season transmission dynamics, between-season migration and reproduction, and environmental variation. Analysis of the model yields 3 major results. First, environmental transmission provides a persistence mechanism within small communities where epidemics cannot be sustained by direct transmission only (i.e., communities smaller than the critical community size). Second, environmental transmission offers a parsimonious explanation of the 2-4 year periodicity of avian influenza epidemics. 3rd, very low levels of environmental transmission (i.e., few cases per year) are sufficient for avian influenza to persist in populations where it would otherwise vanish.

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Register data suggest lower intelligence in men born the year after flu pandemic
Eriksen W et al. Ann Neurol. 18 Mar 2009. Available at http://www3.interscience.wiley.com/journal/122263905/abstract?CRETRY=1&SRETRY=0.

Abstract
Objective:
To test the hypothesis that prenatal exposure to the Hong Kong flu, an influenza pandemic that haunted Europe during winter 1969 to 1970, was associated with reduced intelligence in adulthood.

Methods:
Data from the Medical Birth Register of Norway were linked with register data from the National Conscript Service. The sample comprised all registered boys born alive in single birth after 37 to 43 weeks' gestation during 1967 to 1973 (n = 205,634). Intelligence test scores, recorded at military conscription, were available for 182,913 individuals.

Results:
The mean intelligence score increased from one birth year to another, except for a downturn in 1970. The birth year 1970 was inversely associated with intelligence score (-0.03 standard deviation [SD]; p < 0.001) after adjustments for birth characteristics, parental characteristics, and the trend of increasing scores over the 7 birth years. Analyses with the sample stratified by birth month showed that the inverse association between the birth year 1970 and intelligence score was significant only among men born in July (-0.04 SD; p = 0.049), August (-0.05 SD; p = 0.013), September (-0.09 SD; p < 0.001), and October (-0.06 SD; p = 0.008). Thus the intelligence scores of the men born 6 to 9 months after the epidemic were lower than the mean values for the men born in the same months a few years before or after.

Interpretation:
Early prenatal exposure to the Hong Kong flu may have interfered with fetal cerebral development and caused reduced intelligence in adulthood. Ann Neurol 2009

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Epidemiology of antituberculosis drug resistance 2002—07: an updated analysis of the Global Project on Anti-Tuberculosis Drug Resistance Surveillance
Wright A et al. Lancet. 16 April 2009. Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60331-7/fulltext.

Background:
The Global Project on Anti-Tuberculosis Drug Resistance has been gathering data since 1994. This study provides the latest data on the extent of drug resistance worldwide.

Methods:
Data for drug susceptibility were gathered from 90 726 patients in 83 countries and territories between 2002 and 2007. Standardised collection of results enabled comparison both between and within countries. Where possible, data for HIV status and resistance to second-line drugs were also obtained. Laboratory data were quality assured by the Supranational Tuberculosis Reference Laboratory Network.

Findings:
The median prevalence of resistance to any drug in new cases of tuberculosis was 11.1% (IQR 7.0—22.3). The prevalence of multidrug resistance in new tuberculosis cases ranged from 0% in eight countries to 7% in two provinces in China, 11.1% in Northern Mariana Islands (although reporting only two cases), and between 6.8% and 22.3% in nine countries of the former Soviet Union, including 19.4% in Moldova and 22.3% in Baku, Azerbaijan (median for countries surveyed 1.6%, IQR 0.6—3.9). Trend analysis showed that between 1994 and 2007, the prevalence of multidrug-resistant (MDR) tuberculosis in new cases increased substantially in South Korea and in Tomsk Oblast and Orel Oblast, Russia, but was stable in Estonia and Latvia. The prevalence of MDR tuberculosis in all tuberculosis cases decreased in Hong Kong and the USA. 37 countries and territories reported representative data on extensively drug-resistant (XDR) tuberculosis. Five countries, all from the former Soviet Union, reported 25 cases or more of XDR tuberculosis each, with prevalence among MDR-tuberculosis cases ranging between 6.6% and 23.7%.

Interpretation:
MDR tuberculosis remains a threat to tuberculosis control in provinces in China and countries of the former Soviet Union. Data on drug resistance are unavailable in many countries, especially in Africa, emphasizing the need to develop easier methods for surveillance of resistance in tuberculosis.

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Update: Influenza Activity--United States, September 28, 2008--April 4, 2009, and Composition of the 2009--10 Influenza Vaccine
US Centers for Disease Control and Prevention. MMWR. 17 April 2009; 58(14): 369-374. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5814a4.htm?s_cid=mm5814a4_x.

This report summarizes U.S. influenza activity from September 28, 2008, the start of the 2008--09 influenza season, through April 4, 2009, and reports on the 2009--10 influenza vaccine strain selection. Low levels of influenza activity were reported from October through early January. Activity increased from mid-January and peaked in mid-February. Influenza A (H1N1) viruses have predominated overall this season, but influenza B viruses have been isolated more frequently than influenza A viruses since mid-March. Widespread oseltamivir resistance was detected among circulating influenza A (H1N1) viruses and a high level of adamantane resistance was identified among influenza A (H3N2) viruses. (Excerpt with references removed.)

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Influenza and vaccine development: a continued battle
Nicholson KG. Expert Rev Vaccine. April 2009; 8(4): 373-374. Available at http://www.expert-reviews.com/toc/erv/8/4?cookieSet=1/.

The discovery of influenza A virus in 1933 followed an intensive search for the pathogen responsible for the 1918–1919 pandemic. This breakthrough led to the development and production of egg-grown, whole-virus, formalin-inactivated influenza vaccines that were shown to be effective in military recruits. They were never formally tested in the elderly, in whom influenza is most severe, or in young, immunologically naive children, in whom attack rates are highest. Whole-virus vaccines were replaced in the late 1970s by split and subunit vaccines that were far less reactogenic, particularly in young children. However, with the remergence of H1N1 virus during the 1970s, it soon became clear that split and subunit vaccines were less immunogenic than whole-virus vaccines in immunologically naive people. This finding was again observed in man during recent trials of H5 and H9 subtypes of avian influenza, but it evidently mattered little during the 1980s and 1990s as the principal targets of immunization were the elderly and those with comorbidities, who were already primed by H1N1 and H3N2 strains of influenza A and B. Trials of live-attenuated influenza vaccines began during the 1970s, but the path to vaccine licensure has been slow, and live influenza vaccines currently have a limited role. (Excerpt.)

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Current status and progress of prepandemic and pandemic influenza vaccine development
Leroux-Roels I and Leroux-Roels G. Expert Rev Vaccine. April 2009; 8(4): 401-423. Available at http://www.expert-reviews.com/doi/abs/10.1586/erv.09.15.

H5N1 viruses are widely considered to be a probable cause of the next influenza pandemic. Influenza vaccines are considered to form the main prophylactic measure against pandemic influenza. The world’s population is expected to have no pre-existing immunity against the pandemic virus strain and will need two vaccine doses to acquire protective immunity. A pandemic outbreak will spread much faster than it will take for pandemic vaccines to be produced and distributed. Therefore, increasing efforts are being made to develop prepandemic vaccines that can induce broad cross-protective responses and that can be administered as soon as a pandemic is declared or even before, in order to successfully prime the immune system and allow for a rapid and protective antibody response with one dose of the pandemic vaccine. Several vaccine manufacturers have developed candidate pandemic and prepandemic vaccines, predominantly based on reverse-genetics reference strains and have improved the immunogenicity by formulating these vaccines with different adjuvants. Clinical studies with inactivated split-virion or whole-virion vaccines based on H5N1 indicate that two immunizations appear necessary to elicit the level of immunity required to meet licensure criteria. A detailed overview is given of the most successful candidate vaccines developed by seven vaccine manufacturers. (Excerpt.)

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Characterization of a highly pathogenic avian influenza H5N1 virus sublineage in poultry seized at ports of entry into Vietnam
Nguyen T et al. Virology. 2 April 2009.

Abstract
Highly pathogenic avian influenza H5N1 virus was detected in poultry seized at two ports of entry located in Lang Son Province, Vietnam. Sequence analysis of the hemagglutinin (HA) genes from five H5N1 virus isolates and ten PCR amplicons from chicken cloacal samples revealed their close phylogenetic relationship to clade 7 H5N1 HA genes. However, these HA genes exhibited extensive genetic divergence at both the nucleotide and amino acid levels in comparison to previously described clade 7 viruses; e.g., A/chicken/Shanxi/2/2006. In addition, hemagglutination inhibition tests revealed antigenic differences between these and previously isolated H5N1 viruses from Vietnam. These results indicate that viruses with clade 7 HA are evolving rapidly in poultry in Southeast Asia.

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A Novel Small-Molecule Inhibitor of the Avian Influenza H5N1 Virus Determined through Computational Screening against the Neuraminidase
An J et al. J Med Chem. 15 April 2009. Available at http://pubs.acs.org/doi/abs/10.1021/jm800455g.

Abstract
Computational molecular docking provides an efficient and innovative approach to examine small molecule and protein interactions. We have utilized this method to identify potential inhibitors of the H5N1 neuraminidase protein. Of the 20 compounds tested, 4-(4-((3-(2-amino-4-hydroxy-6-methyl-5-pyrimidinyl)propyl)amino)phenyl)-1-chloro-3-buten-2-one (1) (NSC89853) demonstrated the ability to inhibit viral replication at a level comparable to the known neuraminidase inhibitor oseltamivir. Compound 1 demonstrated efficacy across a number of cell-lines assays and in both the H1N1 and H5N1 viruses. The predicted binding of 1 to the known H5N1 neuraminidase structure indicates a binding interface largely nonoverlapping with that of oseltamivir or another neuraminidase inhibitor zanamivir. These results indicate that 1 or similar molecules would remain effective in the presence of virus mutations conferring resistance to either oseltamivir or zanamivir and also vice versa.

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5. Notifications
WHO Global Outbreak Alert & Response Network meets in Geneva
The WHO Global Outbreak Alert & Response Network convened in Geneva on 16-17 Apr 2009. The Global Outbreak Alert and Response Network (GOARN) is a technical collaboration of existing institutions and networks who pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance. The Network provides an operational framework to link this expertise and skill to keep the international community constantly alert to the threat of outbreaks and ready to respond.

The conference included discussion on the role of the GOARN in outbreak control and surveillance.

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London's revised pandemic flu plan envisions up to 94,000 deaths
The latest edition of the city of London's pandemic influenza surveillance plan, released recently, says health agencies should prepare for disease attack rates ranging anywhere from 25% to 50% and for case-fatality rates ranging from 0.4% to 2.5%. At the high end of those scales, London could have up to 94,000 deaths, the report says. Titled "The London Regional Resilience Flu Pandemic Response Plan," the report is the fourth version of a document that was first published in May 2006. The 126-page plan is intended to provide the agencies that compose the London Resilience Partnership with a strategic framework to support their preparedness and response efforts.

Report available at http://www.londonprepared.gov.uk/downloads/londonsplans/london-flu-planV4.pdf.

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Conference: BIT's 2nd Annual Congress and Expo of Molecular Diagnostics (CEMD-2009)
New Leadership of Personalized Medicine
Dates: November 19-21, 2009
Place: Beijing, China

Registration and program information available at http://www.bit-cemd.com/cemd2009.

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APEC Conference for the Surveillance, Treatment, Laboratory Diagnosis and Vaccine Development of Enteroviruses
Location: Chinese Taipei
Date: May 14-15, 2009

Chinese Taipei would like to invite all APEC members to participant in this conference which will be held in Taipei on May 14-15, 2009. The deadline for the registration is 10 April 2009. For the further information, please contact with Conference Secretariat Ms Ying- Chen Cheng (Amelia) by e-mail at amelia@mpat.org.tw or by telephone at 886-2-2321-2362 ext 20.

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CDC Symposium on Drug-resistant and Vaccine-escape HBV Mutants
Location: Atlanta, Georgia, USA
Venue: CDC Royal 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