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Vol. XII, No. 10 ~ EINet News Briefs ~ May 15, 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:
- ***This bulletin was supplemented with information provided by Veratect***

1. Influenza News
- Cumulative number of human cases of influenza A/(H1N1)
- Cumulative number of human cases of avian influenza A/(H5N1)
- Global: Influenza A/H1N1 more contagious than seasonal influenza, says WHO
- Global: WHO likely to counsel restraint on antivirals for influenza A/H1N1
- Global: WHO rejects idea that novel H1N1 virus is lab-derived
- Europe: European Union extends Tamiflu shelf life
- Bangladesh: Poultry farms tests positive for avian influenza H5N1
- China (Sichuan): Reports country’s first case of influenza A/H1N1
- Viet Nam: Avian influenza H5N1 confirmed on Mekong Delta duck farm
- Canada: PHA update on influenza A/H1N1
- Canada (Alberta): Pig farm quarantined due to influenza A/H1N1 virus culls 500 hogs
- Costa Rica: Reports first influenza A/H1N1 death south of Mexico
- Mexico: APEC update on outbreak of influenza A/H1N1 virus infection
- Mexico: International frictions continue due to influenza A/H1N1 outbreak
- USA: CDC update on influenza A (H1N1)
- USA (New York City): Three schools close as principal is hospitalized due to influenza A/H1N1
- USA (Tennessee): Avian influenza found at another poultry farm
- USA (Washington): 30-year-old man is country’s third influenza A/H1N1 death
- Egypt: Children are country’s 69th and 70th cases of avian influenza H5N1 infection

2. Infectious Disease News
- China (Shandong): Hand-foot-mouth disease death toll in province reaches 27
- Malaysia: 4 people with mysterious illness in Pendang, chikungunya virus suspected
- Malaysia: Meningitis outbreak at training unit ails 20
- Russia: Rise in tick-related diseases in 2009
- Russia (Ryazan Region): Chicken pox outbreak continues
- USA (Arizona): Fast-evolving rabies virus found and appears to be spreading
- USA (New Mexico): Woman is state’s first case of hantavirus infection in 2009
- USA (Virginia): Three people receive treatment for rabies after being bitten by infected cats

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- DENGUE

4. Articles
- Pandemic Potential of a Strain of Influenza A (H1N1): Early Findings
- Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women --- United States, April--May 2009

5. Notifications
- Interim CDC Guidance for Public Gatherings in Response to Human Infections with Novel Influenza A (H1N1)
- Supercourse—Influenza A/H1N1: A global outbreak
- Webinar -- H1N1: Where do we go from here? An exclusive question-and-answer session with pandemic influenza, legal, and HR experts
- Influenza H1N1 planning conferences in US
- Free courses on preparedness from Northwest Center for Public Health Practice
- Launching of the Mesoamerican Public Health Institute

***This bulletin was supplemented with information provided by Veratect***

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1. Influenza News

Global
Cumulative number of human cases of influenza A/(H1N1)
Twenty-four countries have officially reported 6497 cases of influenza A/H1N1 infection.

Economy / Cases (Deaths)
2009
Argentina/ 1 (0)
Australia/ 1 (0)
Austria/ 1 (0)
Brazil/ 8 (0)
Canada/ 389 (1)
China/ 4 (0)
Colombia/ 1 (0)
Costa Rica/ 8 (1)
Cuba/ 1 (0)
Denmark/ 1 (0)
El Salvador/ 4 (0)
Finland/ 2 (0)
France/ 14 (0)
Germany/ 12 (0)
Guatemala/ 3 (0)
Ireland/ 1 (0)
Israel/ 7 (0)
Italy/ 9 (0)
Japan/ 4 (0)
Mexico/ 2446 (60)
Netherlands/ 3 (0)
New Zealand/ 7 (0)
Norway/ 2 (0)
Panama/ 29 (0)
Poland/ 1 (0)
Portugal/ 1 (0)
Republic of Korea/ 3 (0)
Spain/ 100 (0)
Sweden/ 2 (0)
Switzerland/ 1 (0)
Thailand/ 2 (0)
United Kingdom/ 71 (0)
United States/ 3352 (3)
Total/ 6497 (65)

(WHO 5/14/09)

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

2009
China/ 7 (4)
Egypt/ 18 (3)
Viet Nam/ 4 (4)
Total/ 29 (11)

***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: 424 (261).
(WHO 5/15/09 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 5/10/09): 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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Global: Influenza A/H1N1 more contagious than seasonal influenza, says WHO
The World Health Organization (WHO) said 11 May 2009 that the novel H1N1 influenza virus seems to be more contagious than seasonal flu, but it generally causes "very mild illness" in otherwise healthy people.

"The secondary attack rate of seasonal influenza ranges from 5% to 15%. Current estimates of the secondary attack rate of H1N1 range from 22% to 33%." (The secondary attack rate is defined as the frequency of new cases of a disease among the contacts of known cases.)

The WHO noted that, because the virus is new, scientists expect that few people are likely to have any immunity to it. In that context, the statement that the new virus is more contagious than seasonal flu is not surprising, but it appears to be the first time the WHO has offered any specific figures comparing the contagiousness of the novel virus and seasonal flu.

The WHO further stated, "With the exception of the outbreak in Mexico, which is still not fully understood, the H1N1 virus tends to cause very mild illness in otherwise healthy people. Outside Mexico, nearly all cases of illness, and all deaths, have been detected in people with underlying chronic conditions." The statement also noted that the outbreaks in Mexico and the United States have affected younger people more than seasonal flu typically does: "Though cases have been confirmed in all age groups, from infants to the elderly, the youth of patients with severe or lethal infections is a striking feature of these early outbreaks."

Pandemic phases versus severity
Much of the WHO statement, titled "Assessing the severity of an influenza pandemic," explained the numerous variables that affect the severity of a pandemic. It was released on 11 May 2009, the same day that Dr. Keiji Fukuda, took pains to explain that the WHO's pandemic alert phases do not describe the severity of an outbreak but refer only to how widely the disease has spread.

"In the past few weeks we've been asked, is this a mild event? The response is that we are not sure right now. The situation is evolving," said Fukuda, the WHO's assistant director-general for health security and environment.

Phase 5, which the WHO declared on 29 Apr 2009, means that sustained community transmission is occurring in more than one country in one global region. Phase 6 means a full-scale pandemic, with community transmission going on in more than one region. The WHO says that has not happened yet: While countries such as Spain and the United Kingdom have dozens of cases, they have been limited to school and institutional settings and have not escaped into the wider community.

"Now severity is a different characteristic," Fukuda said. The severity of an epidemic can refer to the incidence of mild, moderate, or severe illness, and it can also refer to the overall social and economic impact of an outbreak on a country, he said.

The WHO statement goes into more detail. It says the virulence of the virus largely determines the number of severe illnesses and deaths, but many other factors influence the overall severity, including the contagiousness of the virus, the age distribution of cases, the prevalence of chronic health problems and malnutrition in a population, viral mutations, the number of waves of illness, and the quality of health services.

Although WHO officials have been careful not to characterize the severity of the H1N1 situation, the agency is working on a system to help provide that kind of information, Fukuda said. He said that providing severity information has been "an active part of the pandemic preparedness thinking" in recent years. However, on 13 May 2009, WHO signaled that the agency is stepping back from plans to develop a way to grade pandemic severity, because its experts believe severity will vary from place to place, making the development of a severity index difficult and its use impractical.

The US Department of Health and Human Services (HHS) announced its Pandemic Severity Index in February 2007 as part of its guidance on community interventions for combating a pandemic. The index is based on case-fatality rates (CFRs), with a CFR of 2% or greater signaling the most severe pandemic: category 5. The pandemics of 1957 and 1968 qualify as category 2 events, with CFRs between 0.1% and 0.5%, HHS officials said.

Defining community spread
In other comments, Fukuda said the criterion for "community spread" of a disease is "when you begin to see people who are getting infected and you're just not clear where they're getting infected from." He added that many US cases can't be traced anywhere, unlike the cases in school and institutional outbreaks. But in response to questions, he said there is no specific number of cases that signals community spread. "What you're really looking for is something that's convincing. . . not something that's just a quirk or an oddity," he said. "We're very mindful that going from phase 5 to phase 6 is a very important step and it really would be interpreted that way. I can't tell you whether that's 10 people or 100 people or so on."
(CIDRAP 5/11/09; CIDRAP 5/13/09)

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Global: WHO likely to counsel restraint on antivirals for influenza A/H1N1
The World Health Organization (WHO) plans to release clinical guidance that will say most patients sick with the novel H1N1 influenza will not need antiviral treatment, but the drugs should be considered for high-risk groups, a WHO official said on 12 May 2009.

"Soon we will be publishing initial guidance for clinical management for this disease," said Dr. Nikki Shindo, leader of the WHO clinical team for response to the H1N1 epidemic. "We are highlighting the fact that most of the patients will not require hospitalization or antiviral therapy." Later she added, "We will recommend to consider the use of antivirals for high-risk groups or the group of people at increased risk, depending on availability."

On11 May 2009, the WHO said the new virus usually causes only a mild illness in otherwise healthy people. As described by Shindo, the WHO guidance on antivirals will probably align with what the US Centers for Disease Control and Prevention (CDC) is recommending. The CDC's interim clinical guidance says that patients who have an uncomplicated febrile illness typically do not need antiviral treatment unless they are at risk for complications. High-risk groups are the same as those for seasonal flu:
• Children under 5
• Adults 65 and older
• People with chronic medical conditions or immunosuppression
• Pregnant women
• Children and youth on long-time aspirin therapy
• Nursing home residents

The CDC and WHO say the new virus is sensitive to oseltamivir and zanamivir (the neuraminidase inhibitors), but resistant to amantadine and rimantadine (the adamantanes).

Shindo emphasized that the use of antiviral treatment in any given country will be strongly influenced by the availability of the drugs and the country's pandemic preparedness plan. Shindo also commented that antivirals are being used much more extensively for H1N1 in Europe than in North America.

"European countries, which are mainly importing their cases, have been using antivirals very aggressively," she said. "Countries like Mexico and the United States are trying to save their treatment for patients with underlying conditions and also the other groups at increased risk, such as pregnant women."

At a CDC news briefing on 12 May 2009, Dr. Anne Schuchat said that the focus in the United States is on using antivirals for treatment of sick people, whereas some other countries are using antivirals to try to prevent the virus from spreading from infected travelers to others. Since geographic containment of the virus is no longer possible in the United States, the emphasis is on reducing its impact, she noted. Shindo was asked if the aggressive use of antivirals in Europe might contribute to resistance to the drugs. She replied that the rise of osletamivir resistance in seasonal H1N1 viruses over the past two years seemed unrelated to use of the drug, as it arose in areas where oseltamivir was not often prescribed for seasonal flu.

Also, in some human H5N1 cases in Viet Nam, the rise of oseltamivir resistance was ascribed to "suboptimal treatment doses," she said, adding, "so public health officials may decide to use antivirals aggressively because that's what they've been preparing for and that's part of their pandemic preparedness plan."
(CIDRAP 5/12/09)

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Global: WHO rejects idea that novel H1N1 virus is lab-derived
An international group of experts has examined and rejected the idea proposed recently by an Australian scientist that the novel H1N1 influenza virus is the product of a laboratory accident, the World Health Organization (WHO) reported on 14 May 2009.

"The group of scientists feels that this hypothesis does not really stand up to scrutiny, that the evidence suggests that this is a naturally derived virus, and not a laboratory-derived virus," said Dr. Keiji Fukuda, WHO assistant director-general for health security and environment.

Adrian Gibbs, age 75, a veteran flu researcher, said recently that he had concluded from his analysis of the virus's genetic sequence that it might have evolved in eggs used by scientists to grow viruses and by drug companies to make flu vaccines. Gibbs said he intended to publish a scientific paper describing his hypothesis, according to a news report on 13 May 2009.

Fukuda said Gibbs contacted the WHO on 9 May 2009 to communicate his idea, which he had arrived at by studying genetic data deposited in public databases, not from studying the virus directly. "Because of the nature of the hypothesis and the credible nature of the scientist, we took this seriously," Fukuda said. Gibbs was involved in research that led to the development of oseltamivir (Tamiflu).

After hearing Gibbs' idea, the WHO asked five of its collaborating centers to evaluate it, Fukuda said. A day later the agency asked the United Nations Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE) to do the same. WHO officials discussed the hypothesis with a large group of experts in both human and animal influenza two days ago, he said. They concluded that Gibb's proposition didn't fit the evidence.

Fukuda added that the WHO will need to review Gibbs's research article when it is published, but he indicated that it is unlikely to change the experts' conclusions.
(CIDRAP 5/14/09)

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Europe/Near East
Europe: European Union extends Tamiflu shelf life
The European Medicines Agency, the European Union's pharmaceutical regulatory agency, on 9 May 2009 extended the shelf life of oseltamivir (Tamiflu) by two years to address potential shortages spurred by novel H1N1 influenza outbreaks. The extension increases the drug's shelf life to 7 years.
(CIDRAP 5/11/09)

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Asia
Bangladesh: Poultry farms tests positive for avian influenza H5N1
More than 1,800 chickens have been culled in southeastern Bangladesh after avian flu H5N1 was detected on a farm, an official said on 12 May 2009. Veterinary surgeon Rupen Chakma, of the Cox's Bazar livestock office, said tests were conducted after a farmer reported sudden chicken deaths. “We took samples and tests confirmed the presence of the H5N1 strain of flu and so the chickens were all culled,” he said.

Bangladesh was hit by bird flu in February 2007 and more than one million birds were slaughtered. The last major outbreak was in November 2008 when 10,000 birds were culled in a two-month period, with smaller outbreaks detected earlier in 2009.

Bangladesh's poultry industry is one of the world's largest, producing 220 million chickens and 37 million ducks annually.

The country reported its first confirmed human case of bird flu in May 2008, but the government said the 16-month-old baby who contracted the virus recovered.
(AFP 5/12/09)

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China (Sichuan): Reports country’s first case of influenza A/H1N1
Authorities in China announced that a 30-year-old Chinese man who flew home after attending college in Missouri in the USA has the country's first novel H1N1 case, and they are locating and quarantining passengers who traveled on two flights with him. He reportedly had a fever and cough during a flight from Beijing to his home in Chengdu in Sichuan province. So far 130 passengers from 21 provinces have been quarantined at their local health facilities.
(CIDRAP 5/11/09)

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Viet Nam: Avian influenza H5N1 confirmed on Mekong Delta duck farm
The Southwestern province Dong Thap in Viet Nam confirmed of being hit by the bird flu, said a report of the Department of Animal Health under the Ministry of Agriculture and Rural Development on 14 March 2009.

The bird flu broke out in a local farm on 10 May 2009, killing 49 ducks out of a flock of 142, said the report. Local animal health authorities had been implementing measures to curb the spread of the virus to nearby areas.

Currently, Vietnam reports three provinces hit by avian flu including the two central provinces of Thanh Hoa and Quang Ngai and a newly-confirmed Mekong Delta province of Dong Thap, said the department.

Vietnam has reported five human cases of bird flu so far this year, four of them died.
(Xinhua 5/14/09)

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Americas
Canada: PHA update on influenza A/H1N1
The PHA has confirmed 449 human cases of influenza A/H1N1 in 10 provinces. The provinces most heavily burdened are Onterio (155), British Columbia (96), Alberta (67), and Nova Scotia (66). Provinces that have not reported cases are Newfoundland, Northwest Territories, and Nunavut.
(PHA 5/14/09)

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Canada (Alberta): Pig farm quarantined due to influenza A/H1N1 virus culls 500 hogs
Five hundred hogs have been culled on a pig farm in central Alberta where the herd was found to be infected with the influenza A/H1N1 virus. Authorities say the decision to cull the animals was the result of discussions between the producer and federal and Alberta officials. They say it was the best course of action for the welfare of the herd and that it eased overcrowding conditions on the farm.

The entire herd of 1700 pigs remains under quarantine. Health officials say because of the quarantine the producer was unable to ship hogs to market and as a result the farm had reached maximum capacity.
(ProMED 5/14/09)

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Costa Rica: Reports first influenza A/H1N1 death south of Mexico
Costa Rica reported that a 53-year-old man died of a novel H1N1 flu infection, marking the first death from the disease outside of Mexico, the United States, and Canada, the Associated Press (AP) reported. The fatality is one of eight influenza H1N1 cases in the country confirmed by the U.S. Centers for Disease Control and Prevention, Health Minister Maria Luisa Avila. The health ministry said the man had underlying health conditions, including diabetes and chronic lung disease. So far officials don't know how the man became infected, because he had not recently traveled out of the country.
(CIDRAP 5/11/09; AP 5/9/09)

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Mexico: APEC update on outbreak of influenza A/H1N1 virus infection
As of 13 May 2009, Mexico has reported 2446 confirmed cases of infection, including 60 deaths. Other APEC economies affected by this virus are: United States (3352 cases, including 3 deaths), Canada (358 cases, including 1 death), New Zealand (7 cases), Japan (4 cases), Korea (3 cases), China (3 case), Thailand (2 cases), and Australia (1 case).

The Ministry of Health of Mexico has encouraged to fully resume activities as of 13 May 2009, while maintaining preventive measures against virus A/H1N1.

President of Mexico, Felipe Calderón stressed that the Mexican government has acted quickly and decisively from the very first moment it became aware of the new virus, and that it would continue to do so as long as new cases appear in Mexico.

The Ministry of Economy estimates that the impact to the Mexican economy has been considerable. To illustrate: aviation services decreased (down 34.9% 30 April and down 55% 6 May 2009 in relation to the same days in 2008); department stores’ sales have fallen significantly (99% May 2nd, 35% May 5th,) in relation to the previous year. Tourism has also been highly affected.

On the other hand, the Ministry of Economy has eliminated import tariffs on antiviral, antihistamines, analgesics, vitamins, and medical equipment necessary to combat the Influenza A/H1N1 virus.

Mexico appreciates the decision by Ecuador, Honduras, United Arab Emirates and Kazakhstan to eliminate restrictions imposed to the trade of Mexican swine products.

The Ministry of Finance announced on 5 May 2009 that economic incentives measures to contribute to the recovery of the economy, specifically fiscal and financial measures to support SMEs and tourism, would total 11 billion pesos, supported by fiscal resources to contract guarantees for 2.2 billion pesos. These resources are for assisting small- and medium-sized businesses in the amount of 5 billion pesos, two billion pesos for the tourism, restaurant and entertainment industries, three billion pesos for the aviation industry, and one billion pesos for the pork industry.

Additionally, the Ministry of Foreign Affairs has engaged in an intense diplomatic process, aiming to eliminate flight and movement of people restrictions that certain countries have unjustifiably and discriminatorily imposed against Mexicans. Such measures do not comply with recommendations from the World Health Organization, United Nations, International Civil Aviation Organization, and World Tourism Organization.

Since scientific investigation has proven to be an important tool to address this contingency, Mexico created a scientific advisory committee consisting of 12 expert researchers. Funds totaling 83 million pesos to analyze the virus, contribute to the development of vaccines, and improve the attention to patients to the maximum extent possible.

For further information visit:
www.prevencioninfluenza.gob.mx/
www.sre.gob.mx
www.economia.gob.mx

(Mexico MOE 5/13/09)

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Mexico: International frictions continue due to influenza A/H1N1 outbreak
Mexico said on 10 May 2009 it would not participate in a Shanghai trade fair in a dispute due to influenza A/H1N1 measures adopted by the country. Thirty Mexican companies had planned to participate. Mexico had been planning to showcase its pork products at the Shanghai fair, but China's withdrawal of its guest of honor status fed a growing sense of grievance at anti-flu measures aimed at the Latin American nation, especially flight bans, quarantines and trade bans against its pork products. Many Mexicans wondered why — with the total of U.S. cases at 2,532 and Mexico at 1,626 — countries like Argentina that were quick to prohibit flights from Mexico were not doing the same with U.S. flights. Mexico's Foreign Relations Department said that it had pressed Argentina, Cuba, Ecuador and Peru to drop restrictions.
(AP 5/11/09)

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USA: CDC update on influenza A (H1N1)
The CDC has confirmed 4298 cases of influenza A (H1N1) in 47 states, including Washington, DC. Three deaths, including two in Texas and one in Washington, have been attributed to the virus. States most heavily burdened are Illinois (620), Wisconsin (510), California (473), Texas (439), Arizona (431), New York (224), and Washington (195). The states that have not reported cases are Alaska, Mississippi, West Virginia, and Wyoming.
(CDC 5/14/09)

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USA (New York City): Three schools close as principal is hospitalized due to influenza A/H1N1
Three public schools in Queens were being disinfected on 15 May 2009 after the city closed them because of outbreaks of influenza A/H1N1. An assistant principal was in critical condition with the city’s most serious case of swine flu since the outbreak began in late April 2009. The Department of Health and Mental Hygeine indicated that the schools would closed for at least five days.

“These schools have experienced unusually high levels of influenza-like illness in recent days,” the department stated. “We are also seeing an increase in flu activity in Queens more generally. We hope that these temporary closures will prevent new infections and avoid unnecessary illness.”

Mayor Bloomberg said on 14 May 2009 that Mr. Wiener appeared to have had some health problems that could have made him more susceptible to the virus, and colleagues and friends of the educator said he had diabetes and sometimes walked with a cane. But on Friday morning, the man’s son said that his father’s only pre-existing condition was “gout, which is unrelated to complications he’s experienced now."
(Veratect 5/14/09; NY Times 5/15/09)

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USA (Tennessee): Avian influenza found at another poultry farm
Avian flu has been found at another poultry farm in Tennessee. It is a low-pathogenic form, and the flu virus is the same as that found during the week of 27 Apr 2009 at another farm in the state. Tennessee and federal authorities are investigating a Lincoln County poultry farm after tests found a strain of avian influenza virus.

The Tennessee Agriculture Department said in a statement on 4 May 2009 that the strain poses minimal risk to human health and is not the strain associated with human and poultry outbreaks in other countries. Officials said the strain can cause slight illness in poultry.

A preliminary test on 1 May 2009 indicated the possibility of avian flu on the farm. Additional testing was completed by the US Department of Agriculture. The farm provides breeding stock for poultry farms and none of the poultry have entered the food supply. State officials stated this is the same strain found on a poultry farm in Giles County during the week of 27 Apr 2009, but there is no apparent connection.
(ProMED 5/12/09)

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USA (Washington): 30-year-old man is country’s third influenza A/H1N1 death
Officials from the Washington State Department of Health (WSDH) announced on 9 May 2009 that a man in his 30s from Snohomish County died of complications from the novel H1N1 flu infection, raising the US death toll from the disease to three. The man had pneumonia and an underlying cardiac condition.
(CIDRAP 5/11/09)

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Africa
Egypt: Children are country’s 69th and 70th cases of avian influenza H5N1 infection
A 5-year-old Egyptian girl has contracted the highly pathogenic bird flu virus after coming into contact with infected birds, the state news agency MENA reported on 10 May 2009. This is the 69th case of confirmed H5N1 avian influenza virus in humans in Egypt. MENA said the girl from Sohag province was admitted to hospital on 9 May 2009 where she was being treated with the antiviral drug Tamiflu (oseltamivir) and in a stable condition.

The 70th case is a 4-year-old boy from the Nile Delta province of Sharkiya, according to MENA. He had entered hospital suffering from a high fever and showing flu symptoms. He was being treated with the anti-viral drug Tamiflu [oseltamivir] and was in a stable condition. It appears that he contracted the virus from sick household birds.

Some 26 Egyptians have died after contracting the virus and 10 new human infections have been reported since 1 Apr 2009, which is more than was reported in all of 2008.
(ProMED 5/11/09; ProMED 5/14/09)

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2. Infectious Disease News

Asia
China (Shandong): Hand-foot-mouth disease death toll in province reaches 27
The Ministry of Health of Shandong Province has published hand-foot-mouth disease statistics for the first 18 weeks of the current epidemic. As of 3 May 2009, hand-foot-mouth disease in Shandong province in 2009 has been responsible for 27 deaths, 18 of which occurred in the city of Heze.

During the period 1 Jan to 3 May 2009, a total of 34,585 cases of hand-foot-mouth disease were reported. Of these, 987 patients were severely ill and there were 27 deaths. In Heze City, of 8341 cases, 559 patients were severely ill and there were 18 deaths.

Between 27 Apr and 3 May 2009 there were 5497 cases of hand-foot-mouth disease across the whole province, 125 of whom were severely affected cases. In Heze City during the same period there were in 611 cases, 43 of whom were severely ill and one fatality was reported.
(ProMED 5/5/09)

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Malaysia: 4 people with mysterious illness in Pendang, chikungunya virus suspected
Four people suffering from a mysterious illness in Pendang district are suspected of having contracted chikungunya virus infection. Kedah Health Department director Datuk Dr Hasnah Ismail said the victims were from Kampung Bendang Raja, Kampung Perupuk, Kampung Banggol, and Kampung Charok Tok Min in the Pendang district. She said the viral disease was suspected of also infecting several residents in the Padang Terap and Kota Setar districts.

Chikungunya was first detected in Pokok Sena, Kedah in March 2009 when more than 200 people were affected by symptoms.

Dr Hasnah urged the public to cooperate in stamping the disease by ensuring cleanliness of their surroundings and destroying all mosquito breeding grounds, while the health department would carry out fogging. She advised those having fever, joint aches, and rashes to immediately seek medical treatment.
(ProMED 5/11/09)

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Malaysia: Meningitis outbreak at training unit ails 20
The Health Ministry has identified the diplococci bacteria (presumably Neisseria meningitides) as the cause of the meningitis afflicting trainees of the Road Transport Department (JPJ) Academy in Tiang Dua, Malacca, resulting in one death during the week of 4 May 2009.

Health minister Datuk Seri Liow Tiong Lai said that until 10 May 2009, 20 trainees were warded at Malacca Hospital, two in the intensive care unit and 18 at the isolation ward. He said six new patients were warded at the same hospital on 9 May 2009. "However, we believe the bacterial infection can be controlled with the preventive and rehabilitative measures taken by Malacca Hospital," he said after visiting the patients at the hospital.

"We are also investigating the source of the bacteria by obtaining samples from where the trainees had their practical training, namely in Pedas (Negeri Sembilan), Muar (Johor), and Bukit Katil (Malacca)." He said all trainees and staff of the JPJ Academy in Tiang Dua were given antibiotics to control the spread of the meningitis bacterial infection.
(ProMED 5/14/09)

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Russia: Rise in tick-related diseases in 2009
According to the press center of the Territorial Management of Rospotrebnadzor, 52 cases of suspected Siberian tick typhus, including 19 cases in children, have been recorded in the Altai region in 2009. For the same period in 2008, 129 cases, including 37 in children, were recorded. In addition, four cases of suspected tick-borne encephalitis were recorded in 2009 with two cases recorded in 2008.

Since the tick season began in 2009, 1561 people, including 554 children, with tick bites presented for medical aid at out-patient departments in the Altai region (versus 1329 people with 506 children in 2008). Peak tick activity usually occurs during the first three weeks of May.

In addition, as of 4 May 2009 the Novosibirsk region (Oblast) reported 1135 people sought medical attention after being bitten by ticks in 2009. By contrast, in 2008 only 591 cases were recorded. In total in 2009, 367 (32 percent) of those cases were children. Ten people have been hospitalized with suspected tick-borne encephalitis virus infection.

The largest numbers of tick bites were reported in the Iskitimsky, Toguchinsky, and Novosibirsk districts, and from the city of Berdsk.

Laboratory investigations showed tick-borne encephalitis virus in 42 ticks of 346 tested (12 percent). As of 4 May 2009 in the Novosibirsk Oblast, 115,731 persons, including 43,000 children up to the age of 18 years, have been vaccinated against tick-borne encephalitis virus infection.

Elsewhere, the first case of Crimean-Congo hemorrhagic fever in 2009 has been recorded in the Neftecumskiy region of Stavrapolskiy Krai. In all, 21 people have been admitted to hospital for assessment. According to the Rospotrebnadzor (Health Protection) administration, the number of people experiencing bites by ticks increased 1.5-fold during the week of 26 Apr 2009 in the Stavropolskiy Krai. In total, 745 people, including 266 children, have sought medical care as a result of tick bites in 2009.

A warm winter and an early spring have resulted in early awakening and activation of the tick vectors of Crimean-Congo hemorrhagic fever. Tick infestation of humans and animals continues to increase on account of the higher temperatures.

In 2008, Crimean-Congo hemorrhagic fever was registered in most territories of South Federal Okrug, particularly in the Rostov, Volgogradskiy and Astrakhan Oblasts and in the Stavropolskiy and Krasnoyarsk Krais, and in Dagestan, Ingushetia and Chechnya. More than 250 people were seriously ill, and 20 have died during the past 10 years.
(ProMED 5/6/09; ProMED 5/8/09; ProMED 5/9/09)

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Russia (Ryazan Region): Chicken pox outbreak continues
A serious outbreak of chickenpox has broken out in the Ryazan region in 2009 and is increasing in severity. In total, 2304 cases have been registered since Feb 2009. The incidence rate is 202.9 per 100,000 inhabitants. This rate exceeds the incidence rate in the same period of the previous year by 47.2 percent with an average long-term index of morbidity of 30.5 percent. Eighty-nine percent of patients are children under 14-years-old.

A vaccine against chickenpox—Varilrix—is now available in the Russian Federation for vaccination of children after 12 months of age and other vulnerable groups.
(ProMED 5/8/09)

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Americas
USA (Arizona): Fast-evolving rabies virus found and appears to be spreading
A northern-Arizona rabies strain has mutated to become contagious among skunks and now foxes and is evolving faster than any other new rabies virus on record, experts believe. The strain looks to be spreading fast, commanding attention from disease researchers across the United States. It is not unusual for rabid animals to attack people on hiking trails and in driveways, or even in a bar as happened 27 Mar 2009, when an addled bobcat chased pool players around the billiards table at the Chaparral in Cottonwood. Nor is it odd that rabid skunks and foxes are testing positive for a contagious rabies strain commonly associated with big brown bats.

What is unusual is that the strain appears to have mutated so that foxes and skunks are now able to pass the virus on to their kin not just through biting and scratching but through simple socializing, as humans might spread a flu. Usually the secondary species in this case, a skunk or fox bitten by a bat, is a dead-end host. The infected animal may become disoriented and even die but is usually unable to spread the virus, except through violent attacks.

So far in 2009, county officials have documented 33 rabid foxes in the Flagstaff area. Laboratory studies at the US Centers for Disease Control and Prevention (CDC) in Atlanta appear to confirm that the fox and skunk rabies viruses are mutated forms of the bat strain. "We can see degrees of relatedness and patterns in their genetic codes," said Charles Rupprecht, chief of the rabies program for the CDC. This sort of rapid evolution is exactly what worries public health officials when it comes to all manner of viruses. Virologists haven't seen such fast adaptation to a new species in rabies before. That's why Flagstaff is such an interesting story worldwide," said David Bergman, the US Department of Agriculture's (USDA) state director for Arizona. "We're watching evolution in action on the ground."

Could rabies become contagious in humans? The Arizona rabies situation is risky, because the infected species live so close to people. Flagstaff's sprawl in recent decades has created a perfect opportunity for rabies to mutate into species-hopping forms, the CDC's Rupprecht said. New-home construction, often in wooded areas, has actually increased habitat and food sources for bats, skunks, and foxes. As more rabies-susceptible animals congregate in the region, more infections can take place. And each infection is an opportunity for the virus to mutate into a more virulent form literally upping the odds of a new strain developing. "That's a pattern that we see all over the United States," Rupprecht said. Similar suburban development in the eastern US in the late 1970s, he noted, led to the spread of raccoon rabies from the Canadian border to the Deep South.

Rabies cases among animals are expected to increase as the spring and summer mating seasons bring potential pairs and rivals together. Already, Flagstaff has declared a 90 day pet quarantine meaning all dogs on leashes and all cats indoors which began in April 2009. A wildlife vaccination plan could stem the virus's spread. Local and state officials enacted vaccination programs in northern Arizona in 2001 and 2005 but discontinued each effort after two years without rabies, reports the World Health Organization's standard for declaring an area rabies-free. Now state vaccination funds have been reallocated, the USDA's Bergman said, and emergency funds are increasingly rare due to the recession. Adding to the worries, Lawaczeck, the Arizona veterinary official, said she and other public heath officials were "very unsettled" when the first rabid fox reports came in from Flagstaff this year and not just because of the evolutionary implications for rabies. "This means a much wider spread of rabies," she said, "because [foxes] travel so much farther."
(ProMED 5/12/09)

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USA (New Mexico): Woman is state’s first case of hantavirus infection in 2009
A Santa Fe County woman was in critical condition on 8 May 2009 at an Albuquerque hospital with the first case of hantavirus pulmonary syndrome of 2009, the New Mexico Department of Health announced. State health officials are conducting an environmental investigation to look for places where the woman may have been exposed to the virus. The 25-year-old woman was being treated at University of New Mexico Hospital.

State public health veterinarian Dr Paul Ettestad said most people are exposed to hantaviruses in or around their homes, especially when cleaning out enclosed areas that have mouse droppings. "The best defense against a hantavirus infection is to avoid disturbing areas of rodent infestation, including nests and droppings" he said. "As warmer weather occurs, people need to air out their cabins and sheds before entering them for the first time."

Hantaviruses, often a cause of a deadly disease, are transmitted through the urine, droppings, or saliva of infected rodents. People contract the virus by breathing in dried particles containing the virus. Early symptoms include fever and muscle aches, possibly with chills, headache, nausea, vomiting, diarrhea, abdominal pain, and cough. Symptoms develop within 1-6 weeks after exposure. There is no specific treatment for a hantavirus infection, but health officials say the chances for recovery are better with early medical attention.

In 2008, New Mexico had two cases of hantavirus infection, both fatal.
(ProMED 5/11/09)

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USA (Virginia): Three people receive treatment for rabies after being bitten by infected cats
Three people face treatment for rabies after being bitten by two cats in Spotsylvania County that tested positive for the deadly disease in April 2009. The county health department is handling the cases. County animal control officers already have gone door to door to hand out information on the disease.

Lisa Hill, environmental health supervisor, said that on 30 Apr 2009, two men were exposed to rabies when they attended to a cat they thought was dead. She said one of the men was 85 years old, but she did not know the age of the other person. On 23 Apr 2009, she said a 26-year-old woman was trying to help a cat hit by a car when she was bitten in the western part of the county.

Rabies is caused by a virus that attacks the nervous system and is fatal to mammals and humans who are not treated "They are all currently being treated," Hill said of the three people. "Both of these cats come from an area where there have been cat colonies. Spotsylvania Animal Control is trying to handle it through education." Hill warned people not to touch or feed stray cats in either of these areas. She said she is unaware of any other reported cases.
(ProMED 5/10/09)

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3. Updates
INFLUENZA A/H1N1
The following websites provide the most current information and advice.

- WHO
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions: http://www.who.int/csr/swine_flu/swine_flu_faq_26april.pdf
Phase of pandemic alert: http://www.who.int/csr/disease/avian_influenza/phase/en/index.html
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
http://www.who.int/csr/disease/influenza/pipguidance2009/en/index.html
International Health Regulations (IHR) at http://www.who.int/ihr/en/index.html.

- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: www.pandemicflu.gov
MOH Mexico: http://portal.salud.gob.mx/index_eng.html
PHAC: http://www.phac-aspc.gc.ca/media/nr-rp/index-eng.php
PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm

- Other useful sources
CIDRAP: Influenza A/H1N1 page: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promed.org
(WHO; US CDC; MOH Mexico; PHAC; PAHO; CIDRAP; ProMED)

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AVIAN 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/ Access their Swine Influenza website at http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/index.html.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on H5N1 in wild birds and poultry.
(UN; WHO; FAO, OIE; CDC; CIDRAP; PAHO; USGS)

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DENGUE
Australia (North Queensland)
Queensland Health says the dengue fever outbreak in the state's north has become the largest outbreak in at least 50 years. Already 901 cases of type-3 dengue virus infections have been confirmed across the region. During an outbreak in 1992/93, 900 cases were recorded in Townsville and Charters Towers.

Queensland Health's Brian Montgomery says the total number of dengue cases in the north is expected to pass 1000 during the week of 5 May 2009. "We won't be stepping down our resources until the outbreak is officially declared over, which is three months after any active confirmed transmission," he said. "Our commitment is to make sure this outbreak ends, now whether that's going to be during winter, or a little bit later, is yet to be determined."
(ProMED 5/12/09)

Viet Nam
More than 13,000 people in southern Viet Nam have contracted dengue fever already in 2009, and 11 of them had died as of 3 May 2009, the director of the Pasteur Institute in Ho Chi Minh City said on 8 May 2009.

The south accounts for 84.4 percent of the current number of dengue fever cases nationwide, Dr Tran Ngoc Huu stated. Dengue is no longer restricted to the rainy season and could strike at any time of the year, he said. It is among the top five infectious diseases with the highest numbers of cases and deaths in Viet Nam. The poor drainage in slum areas, a result of the country's urbanization and industrialization, along with the warm climate create the ideal conditions for dengue fever to break out.

There is no commercial vaccine to protect against dengue, but several vaccines are at the experimental stage, Huu said. The Pasteur Institute is working with Sanofi-Pasteur, the vaccines division of Sanofi-Aventis Group, to carry out clinical studies of Sanofi's tetravalent dengue vaccine. The vaccine is also being trialed in Thailand, the Philippines, and Singapore.

If the trials yield good results, a novel vaccine against dengue will be available in 2015 or 2016, said Wartel Nguyen NT Anh, Sanofi-Pasteur's regional medical director of clinical development.
(ProMED 5/12/09)

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4. Articles
Pandemic Potential of a Strain of Influenza A (H1N1): Early Findings
Fraser C et al. Science. 11 May 2009. Available at http://www.sciencemag.org/cgi/content/abstract/1176062.

A novel influenza A (H1N1) virus has spread rapidly across the globe. Judging its pandemic potential is difficult with limited data, but nevertheless essential to inform appropriate health responses. By analyzing the outbreak in Mexico, early data on international spread, and viral genetic diversity, we make an early assessment of transmissibility and severity. Our estimates suggest that 23,000 (range 6,000-32,000) individuals had been infected in Mexico by late April, giving an estimated case fatality ratio (CFR) of 0.4% (range 0.3% to 1.5%) based on confirmed and suspect deaths reported to that time. In a community outbreak in the small community of La Gloria, Veracruz no deaths were attributed to infection, giving an upper 95% bound on CFR of 0.6%. Thus while substantial uncertainty remains, clinical severity appears less than that seen in 1918 but comparable with that seen in 1957. Clinical attack rates in children in La Gloria were twice that in adults (<15 years-of-age: 61%, 15: 29%). Three different epidemiological analyses gave R0 estimates in the range 1.4-1.6, while a genetic analysis gave a central estimate of 1.2. This range of values is, consistent with 14 to 73 generations of human-to-human transmission having occurred in Mexico to late April. Transmissibility is therefore substantially higher than seasonal flu, and comparable with lower estimates of R0 obtained from previous influenza pandemics.

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Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women --- United States, April--May 2009
US Centers For Disease Control and Prevention (CDC). MMWR. 58(Dispatch); 1-3. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0512a1.htm.

CDC first identified cases of respiratory infection with a novel influenza A (H1N1) virus in the United States on April 15 and 17, 2009. During seasonal influenza epidemics and previous pandemics, pregnant women have been at increased risk for complications related to influenza infection. In addition, maternal influenza virus infection and accompanying hyperthermia place fetuses at risk for complications such as birth defects and preterm birth. As part of surveillance for infection with the novel influenza A (H1N1) virus, CDC initiated surveillance for pregnant women who were infected with the novel virus. As of May 10, a total of 20 cases of novel influenza A (H1N1) virus infection had been reported among pregnant women in the United States, including 15 confirmed cases and five probable cases. Among the 13 women from seven states for whom data are available, the median age was 26 years (range: 15--39 years); three women were hospitalized, one of whom died. This report provides preliminary details of three cases of novel influenza A (H1N1) virus infection in pregnant women. Pregnant women with confirmed, probable, or suspected novel influenza A (H1N1) virus infection should receive antiviral treatment for 5 days. Oseltamivir is the preferred treatment for pregnant women, and the drug regimen should be initiated within 48 hours of symptom onset, if possible. Pregnant women who are in close contact with a person with confirmed, probable, or suspected novel influenza A (H1N1) infection should receive a 10-day course of chemoprophylaxis with zanamivir or oseltamivir. (Excerpt with references removed.)

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5. Notifications
Interim CDC Guidance for Public Gatherings in Response to Human Infections with Novel Influenza A (H1N1)
This document provides interim guidance for state, local, territorial, and tribal officials to use in developing recommendations for large public gatherings in their communities.

Available at http://www.cdc.gov/h1n1flu/guidance/public_gatherings.htm

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Supercourse—Influenza A/H1N1: A global outbreak
Supercourse is a repository of lectures on global health and prevention designed to improve the teaching of prevention. Supercourse has a network of over 64000 scientists in 174 countries who are sharing for free a library of 3623 lectures in 30 languages.

Influenza A/H1N1: A global outbreak available at: http://www.pitt.edu/~super1/lecture/lec34601/index.htm.
Supercourse main page at: http://www.pitt.edu/~super1/.

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Webinar -- H1N1: Where do we go from here? An exclusive question-and-answer session with pandemic influenza, legal, and HR experts
Date: 18 May 2009
In this live Webinar, Dr. Michael Osterholm, Director of CIDRAP, will provide a brief issue update, and then open the floor for an extended question-and-answer session with an expert panel. This is an opportunity to directly pose critical questions to credible experts.

Details and registration information available at http://online.krm.com/iebms/coe/coe_p2_details.aspx?oc=10&cc=00279763&eventid=15787.

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Influenza H1N1 planning conferences in US
You are invited to participate in an exciting day-long event that is designed to help you better meet the threat of a pandemic influenza in your community, as well as meet your planning requirements -on time, under budget, and with a minimum of disruption to your operations. In addition, special workshops will integrate all sectors of society, business, infrastructure, community-based organizations and public health, more directly in preparedness activities related to the threat of pandemic influenza H1N1.

Dates and locations as follows:
*Los Angeles, CA--June 9, 2009 * New York, NY--June 12, 2009 *Houston, TX--June 16, 2009 * *Chicago, IL--June 19, 2009 * Jacksonville, FL--June 23, 2009 * Columbus, OH--June 26, 2009* * Philadelphia, PA--June 30, 2009 * Detroit, MI--July 7, 2009 * Charlotte, NC--July 10, 2009 * *Boston, MA-- July 14, 2009 * Indianapolis, IN--July 17, 2009*

For more information, please visit:
www.new-fields.com/california_swine_flu_conference/agenda.pdf
To register, please visit:
www.new-fields.com/california_swine_flu_conference/registration.pdf

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Free courses on preparedness from Northwest Center for Public Health Practice
The Northwest Center for Public Health Practice (NWCPHP) offers free risk communication modules that are useful for preparedness practitioners. Practitioners can benefit by taking the time to brush up or improve their current skills.

Emergency Risk Communication for Public Health Professionals:
http://nwcphp.org/training/courses-exercises/courses/risk-communication

Emergency Distribution of Pharmaceuticals:
http://nwcphp.org/training/courses-exercises/courses/emergency-distribution-pharmaceuticals

Workforce Resiliency:
http://nwcphp.org/training/courses-exercises/courses/workforce-resiliency

Introduction to Outbreak Investigation:
http://nwcphp.org/training/courses-exercises/courses/outbreak-investigation

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Launching of the Mesoamerican Public Health Institute
The Mesoamerican Public Health Institute (MPHI), was launched as a virtual network of academic and research institutes in the Mesoamerican region. MPHI is an initiative lead and fostered by the Mexican government and the National Institute of Public Health of Mexico, with its Governing Board comprising of eight prominent institutions from six Mesoamerican countries thus far.

Access the website at: http://www.imesoamericano.org/

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 apecein@u.washington.edu