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Vol. XII, No. 11 ~ EINet News Briefs ~ May 29, 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 is spreading wider than official data show
- Global: WHO to change criteria for declaring an influenza A/H1N1 pandemic
- Australia: Reports brisk rise in influenza A/H1N1 cases
- Japan: Update on outbreak of influenza A/H1N1
- Mongolia: Avian influenza A/H5N1 infection kills wild swans
- New Zealand: Two New Zealanders on cruise ship have influenza A/H1N1
- Viet Nam: Receives avian influenza A/H5N1 preparedness supplies from the US
- Thailand: Chikungunya virus named biggest health risk in Southern provinces
- Canada: PHA update on influenza A/H1N1
- Chile: Government says influenza A/H1N1 is entrenched as cases surge
- USA: CDC update on influenza A/H1N1
- USA: CDC releases viruses for novel influenza A/H1N1 vaccine development
- USA (Missouri): Reports first case of tick-borne disease of 2009
- Egypt: Children are country’s 75th and 76th human cases of avian influenza A/H5N1

2. Infectious Disease News
- Australia: Murray Valley encephalitis kills 2nd man in Darwin in 2009
- Malaysia: Outbreak of leptospirosis at detention camp hospitalizes 26, kills 1
- Russia (Bashkiria): Ufa reports increase in hepatitis A infection
- Russia (Irkutsk): Increases of tick-related illnesses throughout region
- Russia (Krasnoyarsk): Five adult measles cases are first in two years
- Russia (Yaroslavl): Region reports its first case of tick-borne encephalitis
- South Korea: Reports first fatality of hand, foot and mouth disease due to enterovirus 71
- Mexico (Jalisco): Man dies of rabies infection due to bat bite

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

4. Articles
- Progressive Vaccinia in a Military Smallpox Vaccinee--United States, 2009
- The Role of Swine in the Generation of Novel Influenza Viruses
- Cluster analysis of the origins of the new influenza A(H1N1) virus

5. Notifications
- Weekly Epidemiological Record Bulletin
- Characteristics of the emergent influenza A/H1N1 viruses and recommendations for vaccine development
- International Swine Flu Conference
- Influenza H1N1 planning conferences in US

***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)
Forty-eight countries have officially reported 13,398 cases of influenza A/H1N1 infection, including 95 deaths.

Economy / Cases (Deaths)
2009
Argentina/ 19 (0)
Australia/ 39 (0)
Austria/ 1 (0)
Bahrain/ 1 (0)
Belgium/ 7 (0)
Brazil/ 9 (0)
Canada/ 921 (1)
Chile/ 86 (0)
China/ 22 (0)
Colombia/ 16 (0)
Costa Rica/ 33 (1)
Cuba/ 4 (0)
Denmark/ 1 (0)
Ecuador/ 28 (0)
El Salvador/ 11 (0)
Finland/ 2 (0)
France/ 16 (0)
Germany/ 17 (0)
Greece/ 1 (0)
Guatemala/ 5 (0)
Honduras/ 1 (0)
Iceland/ 1 (0)
India/ 1 (0)
Ireland/ 1 (0)
Israel/ 9 (0)
Italy/ 23 (0)
Japan/ 360 (0)
Korea, Republic of/ 21 (0)
Kuwait/ 18 (0)
Malaysia/ 2 (0)
Mexico/ 4541 (83)
Netherlands/ 3 (0)
New Zealand/ 9 (0)
Norway/ 4 (0)
Panama/ 76 (0)
Peru/ 27 (0)
Philippines/ 2 (0)
Poland/ 3 (0)
Portugal/ 1 (0)
Russia/ 2 (0)
Singapore/ 1 (0)
Spain/ 138 (0)
Sweden/ 3 (0)
Switzerland/ 3 (0)
Thailand/ 2 (0)
Turkey/ 2 (0)
United Kingdom/ 137 (0)
United States/ 6764 (10)
Total/ 13,398 (95)

(WHO 5/27/09)

***additionally, Venezuela has confirmed its first H1N1 case and Paraguay has confirmed first five cases of H1N1***

APEC economy updates: The US death toll related to influenza A/H1N1 influenza reaches 12, while Canada reports four fatalities. Chile reports novel influenza H1N1 cases far outnumber seasonal flu cases in country. Singapore confirms first case of influenza A/H1N1. Individual had a history of travel to New York. Australia reports sharp increase as H1N1 case pass 100. Russia confirms first three cases; two report travel to Dominican Republic, one to US. China’s 12 cases all reported recent travel to North America; two were detected by airport thermal scanners. Chinese Taipei confirms its first locally transmitted case of A/H1N1.
(CIDRAP 5/28/09; ProMED 5/22/09, 5/25/09, 5/26/09, 5/27/09)

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Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)
2009
China/ 7 (4)
Egypt/ 25 (4)
Viet Nam/ 4 (4)
Total/ 36 (12)

***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: 431 (262).
(WHO 5/28/09 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 5/6/09)

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 is spreading wider than official data show
Influenza A/H1N1 is spreading more widely than official figures indicate, with outbreaks in Europe and Asia showing it's gained a foothold in at least three regions. One in 20 cases is being officially reported in the US, meaning more than 100,000 people have probably been infected nationwide with the new H1N1 flu strain, according to the Centers for Disease Control and Prevention (CDC). In the UK, the virus may be 300 times more widespread than health authorities have said, the Independent on Sunday newspaper reported on 24 May 2009. Japan, which has reported the most cases in Asia, began reopening schools during 23-24 May 2009 after health officials said serious medical complications had not emerged in those infected. The virus is now spreading in the community in Australia, Jim Bishop, the nation's chief medical officer, said on 24 May 2009.

The new H1N1 strain is persisting outside the Northern Hemisphere winter. "While we are seeing activities decline in some areas, we should expect to see more cases, more hospitalizations and perhaps more deaths over the weeks ahead and possibly into the summer," Anne Schuchat, CDC's interim deputy director for science and public health program, said on 22 May 2009.
(CIDRAP 5/25/09)

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Global: WHO to change criteria for declaring an influenza A/H1N1 pandemic
WHO said on 22 May 2009 that it will change the rules for declaring an influenza A/H1N1 pandemic, a virus the agency's chief called "sneaky" because of its ability to spread quickly from person to person and potentially mutate into a deadlier form.

Under political pressure from many of its 193 members to consider factors other than just the spread of the disease before announcing a global epidemic, WHO's flu chief said "course corrections" were being made. "What we will be looking for is events which signify a really substantial increase in risk of harm to people," Keiji Fukuda said.

So far the virus has been mild, according to WHO, but experts worry it could evolve into a more deadly strain or overwhelm countries unprepared for a major flu outbreak. Many countries fear a pandemic declaration would trigger mass panic and be economically and politically damaging. For developed countries that have already activated their pandemic preparedness plans, a pandemic declaration would change little in their response strategies.

Earlier in the week of 18 May 2009, Britain and other countries urged WHO to reconsider its pandemic definition. WHO hastily responded to these concerns, as Fukuda said the agency would revise the conditions needed to move from the current phase 5 to the highest level, phase 6, which makes it a pandemic. "The countries are telling us now that moving from phase 5 to 6 is not so helpful," Fukuda said. He said the alert phases were developed before the outbreak hit, and now need to be adjusted to the reality of the situation. The virus' lethality could become one of the required criteria before a pandemic is declared, Fukuda said.

Fukuda's comments echoed those of WHO director-general Margaret Chan, who told governments she would heed their call to caution in declaring a pandemic. However, Chan warned against complacency. "This is a subtle, sneaky virus," she said. "It does not announce its presence or arrival in a new country with a sudden explosion of patients seeking medical care or requiring hospitalization. We expect it to continue to spread to new countries and continue to spread within countries already affected," Chan said.

Meanwhile, countries taking part in the WHO meeting agreed on 22 May 2009 to delay efforts to finalize a deal on sharing flu viruses, instead instructing Chan to find a solution by early 2010. Developing countries lobbied hard to ensure they would benefit from any drugs created using their virus samples. Against that, the United States and the European Union called for samples to be shared without restriction, arguing that this was in the best interest of science and global efforts to combat disease. Both sides agreed Chan should form a task force to investigate unresolved questions, including whether countries should have to share samples and resulting drugs could be patented. They also want the task force to consider whether doses of any new pandemic flu vaccine should be reserved for developing countries, and to report back to members in January 2010 with recommendations.
(ProMED 5/25/09)

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Asia
Australia: Reports brisk rise in influenza A/H1N1 cases
As of 28 May 2009, Australia's health ministry has confirmed 103 novel H1N1 cases, up from 61 cases the previous day, and expects a steady increase over the next day or two. Five of the nation's six states have reported cases, along with one of Australia's two territories. About half of the cases (33) are in the southeastern state of Victoria, where authorities say they will open clinics to provide antiviral drugs to anyone with influenza symptoms.

On 28 May 2009, health officials said they were ordering enough doses of H1N1 vaccine to cover 10 million people. Ian Barr, deputy director of a public health lab in Melbourne, said the novel virus is now the main flu strain being identified in Australia, but it is too early to say if it is "truly community-wide," according to Bloomberg News.
(CIDRAP 5/27/09; Bloomberg News 5/28/09)

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Japan: Update on outbreak of influenza A/H1N1
As of 23 May 2009, the Japanese Ministry of Health, Labour and Welfare reported the additional 27 laboratory confirmed cases of novel influenza A (H1N1) since the last reporting on 22 May 2009. The affected prefectures with number of the confirmed cases are: Hyogo (167), Kanagawa (1), Kyoto (1), Osaka (141), Saitama (2), Shiga (1), Tokyo (3) and Chiba (5). No fatal case has been reported.

Epidemiological investigations are ongoing to clarify the transmission route and epidemiological links between the cases. Public Health interventions that were implemented include school closure and advice for cancelling or postponing large public gatherings.
(ProMED 5/23/09)

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Mongolia: Avian influenza A/H5N1 infection kills wild swans
Mongolia's Emergency Situations Agency announced on 25 May 2009 that a number of swans had died of unknown causes on 22 May 2009 in Ogii Nuur Lake, in the Arkhangai Aimag. After analysis, the Mongolian National Livestock Infectious Disease Prevention and Control Center announced that the swans died due to H5N1 avian influenza infection. On 24 May 2009, the governor of Arkhangai Aimag ordered the closure of the outbreak area.
(ProMED 5/27/09)

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New Zealand: Two New Zealanders on cruise ship have influenza A/H1N1
Two New Zealanders holidaying in Australia have tested positive for swine flu. The two had arrived in Sydney on the Pacific Sun company's Pacific Dawn cruise ship and were asked to self-quarantine at a hotel by New South Wales Health. They checked into the Darling Harbour Holiday Inn but it was not until several days later that tests confirmed they had swine flu. Masked health personnel took them away from the hotel.

The hotel came under scrutiny after it was accused of evicting the guests, but hotel officials said the hotel took appropriate steps once it was notified of their status by NSW Health. "I think it's our view that a hotel is not an appropriate place for the quarantining of confirmed sufferers of the H1N1 virus," a hotel staff said.

Meanwhile, New Zealand port health officials are on "high alert" for any vessels reporting people with influenza symptoms. "All ships are required to notify any suspected cases of non-seasonal influenza A swine flu, which have occurred during the voyage," said deputy director of public health Dr Fran McGrath. The Pacific Dawn, with 2500 passengers, was refused permission to dock and ordered to change course off the coast of Australia because three crew members had the illness.

New Zealand health authorities usually check all cruise vessels the first time they visit each season to ensure they have appropriate protocols for recognising, treating, controlling and notifying illness on board. The masters are told to notify cases of illness and any disease outbreaks that occur while the vessel is in New Zealand territorial waters.
(NZHerald 5/30/09)

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Viet Nam: Receives avian influenza A/H5N1 preparedness supplies from the US
The US Embassy in Hanoi announced 27 May 2009 that it is donating avian influenza preparedness supplies to Viet Nam, which includes 4,000 sets of personal protective equipment and 100 boxes of biodegradable powder that can produce more than 20,000 liters of disinfectant to help public health workers respond to new outbreaks of avian or H1N1 influenza. Viet Nam's agriculture ministry requested the supplies, which will be distributed to veterinary departments in 10 provinces that are at high risk for avian flu. The supplies are worth more than $57,000.
(CIDRAP 5/27/09)

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Thailand: Chikungunya virus named biggest health risk in Southern provinces
The Public Health Ministry issued an alert about the return of chikungunya disease, which has spread to 23 provinces and affected more than 20,000 people since January 2009. The southern provinces are hardest hit with almost 8000 cases reported in Songkhla province alone.

The announcement, released on 23 May 2009, said health authorities will intensify their war on garden-striped mosquitoes, the vector of the virus. The number of people taken ill, which has increased by more than 5000 people in less than a month, has persuaded provincial public health officials to step up their mosquito eradication campaign, particularly in the south, where dark and humid rubber plantations make ideal mosquito breeding grounds.

Pattira Thangrattanasuwan, director of the Crown Prince Hospital in Pattani's Sai Buri district, said the vector-borne virus had become the most serious health threat to people in the deep South. The re-emergence of the disease in rural areas after a long period of absence in 1995 prompted health authorities to question whether chikungunya disease had developed into a more dangerous strain. Vichai Satimai, director of the vectorborne disease bureau, said the current chikungunya outbreak was related to the African strain of virus, which could spread rapidly. A specific study on changes in virus virulence had not yet been made. However, an expert in vectorborne diseases believed climate change might affect the life cycle of mosquitoes, enabling them to produce a minimum infective dose of the dengue or chikungunya viruses faster than before.

"Chikungunya fever is not life threatening. But patients may experience persistent joint and muscle pain up to a year or more, which obviously can affect their way of life," Satimai said. Symptoms of chikungunya fever occur among adults more than children, unlike dengue fever. Pain medication and long-term anti-inflammatory therapy might be required, he said.
(ProMED 5/27/09)

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Americas
Canada: PHA update on influenza A/H1N1
The PHA has confirmed 1118 human cases of influenza A/H1N1 in 10 provinces. Two fatalities have been reported. The provinces most heavily burdened are Ontario (495), Quebec (207), British Columbia (120), Alberta (109) and Saskatchewan (104). One death has been reported in both Alberta and Ontario. Provinces that have not reported cases are Newfoundland, Northwest Territories, and Nunavut.
(PHA 5/27/09)

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Chile: Government says influenza A/H1N1 is entrenched as cases surge
Chile’s government confirmed 46 new cases of swine flu, raising the total to 165, and said the virus is firmly entrenched in the country. Chile, which reported its first case on 17 May 2009, is now the fifth-most affected country in the world, the Health Ministry said on 27 May 2009.

The novel H1N1 flu virus now accounts for 90 percent of all flu cases in the country and may be replacing the seasonal flu, the ministry said. Health Minister Alvaro Erazo said authorities will change their strategy for dealing with the virus from one of containment to one of mitigation.

Beginning next month only at-risk patients, such as pregnant women or those with severe symptoms, will be given antiviral drugs, Erazo said. Checks on passengers arriving in Chile’s airports will be ended, he said. The extent of transmission of the virus in Chile “doesn’t justify having so many control barriers, because the virus is now here, it’s installed,” he said.
(CIDRAP 5/28/09; Bloomberg News 5/27/09)

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USA: CDC update on influenza A/H1N1
The CDC has confirmed 7927 cases of influenza A (H1N1) in 48 states, including Washington, DC. Eleven deaths, including three in both Arizona and Texas, two in New York, and one each in Missouri, Utah, and Washington, have been attributed to the virus. States most heavily burdened are Texas (1358), Wisconsin (1130), Illinois (927), Washington (575), California (553), Arizona (532), and New York (456). The states that have not reported cases are Alaska, West Virginia, and Wyoming.
(CDC 5/27/09)

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USA: CDC releases viruses for novel influenza A/H1N1 vaccine development
Sanofi Pasteur announced on 27 May 2009 that it has received a novel H1N1 influenza vaccine virus from the Centers for Disease Control and Prevention (CDC), moving the company a step closer to starting production of a vaccine. CDC spokesman Tom Skinner said that the agency is also sending the vaccine virus to other manufacturers, located overseas, who should receive the samples within a few days.

WHO officials have said that production of H1N1 vaccines is most likely to begin in July 2009. The preparation of a vaccine strain involves combining a clinical sample of the target virus with another influenza virus that grows in eggs. This process creates a new virus that has some of the properties of the target virus and the ability to grow in eggs, the US Department of Health and Human Services noted in a fact sheet. Most flu vaccines are still produced by growing them in eggs.

Wayne Pisano, president of Sanofi Pasteur, said, "As a company committed to protecting human health, Sanofi Pasteur looks forward to quickly understanding how this virus performs in a vaccine manufacturing environment and developing a working seed that will enable large-scale production." Sanofi will now begin "passaging" the virus, referring to "the process for acclimating virus to grow in a production environment at optimum yield," the company said. The process will take about two weeks. "Following quality controls, Sanofi Pasteur will be prepared to begin industrial production as soon as directed by public health agencies," he added.

Health officials have estimated it would take manufacturers four to six months from when they receive the vaccine strain to start producing a vaccine in quantity. But a Sanofi spokeswoman said that the company may be able to start producing its first doses in 3 to 4 months.

In related news, the WHO has recommended that vaccines for the novel H1N1 influenza virus be based on an isolate from California, saying most H1N1 viruses isolated so far are very similar to it. A majority of the novel H1N1 viruses isolated so far are antigenically and genetically related to the isolate known as A/Calfornia/7/2009 (H1N1), the WHO said. The WHO said that its collaborating laboratories, certain regulatory agency laboratories, and other partners are developing reassortant viruses antigenically similar to the California strain for use in vaccines.
(CIDRAP 5/27/09)

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USA (Missouri): Reports first case of tick-borne disease of 2009
Missouri's tick season officially got under way late in April 2009 with the year's first confirmed case of a potentially life-threatening tick-borne disease. The first illness involved a woman in her 80s from south of St. Louis. She was hospitalized, but has been discharged and is now recovering. The woman contracted the disease known as ehrlichiosis (also called human monocytotropic ehrlichiosis), which can cause renal failure if left untreated.

Ehrlichiosis is transmitted by the lone star tick and symptoms begin with a sudden onset of fever and headache. Patients often report fatigue and muscle aches as well as other flu-like symptoms. Without prompt treatment, ehrlichiosis can be fatal. Tick bites caused a record number of tick-borne diseases in 2008, when the first case also was confirmed in late April. Missouri health officials are urging people to check their bodies for ticks if they have been outdoors.

State health department statistics show that the number of tick-borne illnesses in Missouri grew to 668 last year [2008], up nearly 100 compared with 2007. That gave Missouri a rate of 11 tick-borne illnesses for every 100,000 Missourians. The most commonly reported tick-borne diseases in Missouri are Rocky Mountain spotted fever, ehrlichiosis, and tularemia.
(ProMED 5/20/09)

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Africa
Egypt: Children are country’s 75th and 76th human cases of avian influenza A/H5N1
Two 4-year-old Egyptian children have contracted the highly pathogenic H5N1 avian flu virus, raising the number of cases reported in Egypt to 76, the state news agency MENA reported on 26 May 2009. Egypt has been hit harder by bird flu than any other country outside Asia and has seen a surge of cases in recent weeks. The children, one boy and one girl, were from different areas of Sharkiya province in the Nile Delta region. Both fell ill after coming into contact with birds with the virus.

The avian A(H5N1) influenza virus rarely infects people, but experts say they fear it could mutate into a form that humans could easily pass to one another, sparking a pandemic. Most of those infected have previously been in contact with infected domestic birds in a country where 5 million households raise poultry as a significant source of food and income.
(ProMED 5/27/09)

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2. Infectious Disease News

Asia
Australia: Murray Valley encephalitis kills 2nd man in Darwin in 2009
A man from the Gold Coast died in Darwin from a mosquito-borne virus infection. The 83-year-old man is the second person to die in Darwin 2009 after contracting the Murray Valley encephalitis (MVE) virus.

MVE is transmitted by the common banded mosquito, which bites after sundown in the first two hours of the night. About one person in 1000 bitten by infected mosquitoes contracts the disease. One in four of these people die from the infection.

A mango farmer died in March 2009 from brain failure after contracting MVE at his home in Batchelor, 100 km south of Darwin. The 58-year-old farmer went into a coma two weeks before his death, but the NT health department was widely criticized for only issuing a warning about the virus on the day his wife decided to turn off his life support. The farmer's death was the first from MVE in the Darwin region for almost a decade.
(ProMED 5/28/09)

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Malaysia: Outbreak of leptospirosis at detention camp hospitalizes 26, kills 1
A Myanmar immigrant from the Juru detention centre in Bukit Mertajam, Penang died of leptospirosis at Bukit Mertajam Hospital on 12 May 2009. As of 15 May 2009, 26 cases were reported; all affected were detainees at the centre.

The 21-year-old Myanmar national died after being treated at the hospital's intensive care unit for suspected leptospirosis. He showed symptoms of pedal oedema (fluid accumulation in the leg), fever, decreased urine output, constipation, and lethargy. Three cases with similar symptoms were also reported on 12 May 2009 and upon further investigation by the state health department and Seberang Perai Tengah district health office, more cases were identified and referred to Bukit Mertajam Hospital.

The department said samples from the camp's water supply had been taken for checks on contamination, and that its health teams were visiting the camp daily to monitor the inmates for similar symptoms. Disinfection had also been carried out at the detention camp's blocks, toilets, and bathrooms. It is believed that the outbreak of the disease was caused by rat urine. Sources said initial investigations revealed that bacteria similar to that found in rat urine were found in the fresh water sample taken from the camp.

Leptospirosis, which is also known as Weil's disease or syndrome, canicola fever, or Fort Bragg fever, is a rare and severe contagious bacterial infection that affects humans and a wide range of animals. The infection is commonly transmitted to humans by allowing animal urine-contaminated water to come in contact with unhealed breaks in the skin, eyes, or the mucous membranes.
(ProMED 5/18/09)

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Russia (Bashkiria): Ufa reports increase in hepatitis A infection
Increased incidence of hepatitis A virus infection has been observed in the city of Ufa since mid-April 2009. During the week from 11 to 17 May 2009, 27 cases of hepatitis A have been diagnosed. According to the Bashkiria Branch of Rospotrebnadzor (Federal Service for Consumer Affairs and Human Welfare), approximately 200 people have been admitted to hospital suffering from hepatitis A since the beginning of May 2009. All of them were infected in mid-April. In late April 2009, 17 employees of the "Farmlend" network were hospitalized with the same diagnosis, presumed to have been acquired during a gathering on 6 Mar 2009.

The last large increase in incidence of hepatitis A virus infection in Bashkiria occurred in 2004, when there were 353 cases of the disease (32.7 per 100,000 population). In all of 2008, 41 people in Ufa contracted hepatitis A. In the first quarter of 2009, 12 people were affected in the capital of Bashkiria according to the Rospotrebnadzor Office.
(ProMED 5/20/09)

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Russia (Irkutsk): Increases of tick-related illnesses throughout region
Altogether 918 people, including 217 children, have sought treatment for tick bites in the Irkutsk Oblast. During the same period of 2008, a total of 699 people sought treatment for tick bites. Most of the bites occurred in Irkutsk city, Irkutsk district, Angarsk, and Usolye-Sibisrk.

A total of nine people, including three children, have been hospitalized with a preliminary diagnosis of tick-borne encephalitis. Another four people were hospitalized with a preliminary diagnosis of boreliosis and four more with a diagnosis of tick-borne ricketsiosis. One case of boreliosis and two cases of ricketsiosis have been confirmed.
(ProMED 5/19/09)

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Russia (Krasnoyarsk): Five adult measles cases are first in two years
Russian Sanitary Surveillance (public health) registered five cases of measles among adults in Krasnoyarsk for the first time in the last two years. All five cases had no contact with each other and came from different neighborhoods. Consequently, the cases have been designated an outbreak and all five patients were admitted to an infectious diseases hospital.
(ProMED 5/20/09)

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Russia (Yaroslavl): Region reports its first case of tick-borne encephalitis
The first case of tick-borne encephalitis (TBE) virus infection has been recorded in Yaroslavl in a 7-year-old child. The child's parents stated that an attached tick had been found in the child's ear five days after potential exposure. After the tick had been removed, it was confirmed to be TBE virus infected.

Immunoglobulin was administered. Due to the delay in administration of immunoglobulin until 12 days after the tick bite, the child's condition began to deteriorate two weeks after exposure and became severe, with a temperature of 40 degrees Celcius. The child suffered headache and vomiting. Two days later, the child's condition improved, and the child is now out of danger according Vyacheslav Shadrin, the head of the Neurological Department in the Regional Children's Hospital.

The situation in the region continues to worsen. Recently, the Yaroslavl laboratory has examined 3500 ticks, and 84 were found to be carriers of the TBE virus.
(ProMED 5/24/09)

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South Korea: Reports first fatality of hand, foot and mouth disease due to enterovirus 71
The nation's first fatal case of hand, foot and mouth disease (HFMD) was reported on 13 May 2009. A one year-old girl died of brain inflammation on 5 May 2009 after being infected with enterovirus 71 (EV-71), a virulent intestinal virus, said Jun Byung-yul, a senior official of the Korea Centers for Disease Control and Prevention.

Caused by intestinal viruses coxsackie A virus and enterovirus 71, the human syndrome HFMD is a common childhood disease that mainly affects children under the age of five during the summer and early autumn months. Early symptoms of the disease are similar to those of ordinary flu such as fever and a sore throat. Even though there is no specific vaccine for the disease, most patients recover in a week without medical treatment. However, in severe cases, patients can suffer from neurological complications such as brain inflammation and meningitis, sometimes leading to death.

There have been some cases where children infected with the coxsackie A virus have had complications in Korea. But it is the first time for the enterovirus 71, which has killed more than 80 children in China since April 2009, to be found in the country.

"Because the girl had never been to China and other South East Asian countries where the virus has thrived in recent years, we think the virus has already been localized in this country after being transferred from China," Jun said. It is possible the virus is responsible for some deaths of children who died of brain inflammation or meningitis in South Korea in recent years, Jun said.

Despite the worsening situation in and out of the country, health authorities said they do not know the exact number of children infected with EV-71 because the disease is not a legally designated infectious disease monitored by the government. According to recent government figures, which were offered by 186 sample pediatrics in the latest 19 weeks, the number of patients seems to be increasing. However, the outbreak is not large enough to be considered an epidemic, health officials said.

"Some fatal cases in China are considered because children in some regions were malnourished and couldn't be supported by the better medical system," Jun said. "We will launch a monitoring system on the outbreak situation of the disease in cooperation with related medical organization, especially in Suwon, Gyeonggi Province, where the nation's 1st fatal case was found," he added.
(ProMED 5/15/09)

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Americas
Mexico (Jalisco): Man dies of rabies infection due to bat bite
A 63-year-old man residing in a small community in the Hostotipaquillo municipality became the second fatal wildlife rabies victim in the state so far in 2009. After interviews with family members, the Jalisco Secretariat of Health (SSJ) presumed that he was bitten by a bat that transmitted the virus.

On 20 May 2009, the director general of Public Health of the SSJ (Jalisco Health Secretariat), Elizabeth Ulloa Robles, said the man indicated to his family that something bit him on the elbow. On 10 May 2009, three days before going to the Magdalena Regional Hospital, he began to show general weakness, paralysis of the hands, and alterations in gait, among other symptoms. Evaluation indicated an infectious disease neurological process. He underwent tests, including tomography, but he died on 17 May 2009. After discarding diseases such as tuberculosis and influenza A H1N1, a sample of brain tissue was sent to the state Public Health Laboratory, where they determined that he suffered from rabies virus infection.

Ulloa Robles indicated that epidemiological barriers were established in La Venta de Mochitiltic, where the man resided, as well as in eight other localities in Hostotipaquillo municipality, where they are seeking other possibly affected individuals.

This is the second case of sylvatic rabies death in Jalisco in 2009. On 2 Jan 2009, a 4-year-old girl died after being bitten by a bat. There have been no human rabies cases transmitted from a dog or a cat in Jalisco since 1995. Given this case of wildlife rabies, the SSJ requested that SAGARPA (Ministry of Agriculture, Livestock, Rural Development, Fisheries, and Foods) analyze the bat population that inhabits caves in the area for circulation of rabies virus, and if found, proceed with their destruction.
(ProMED 5/21/09)

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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/avianflu/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 (Queensland)
The dengue fever outbreak in Townsville is officially over. Queensland Health (QH) says the outbreak, which began on 4 Jan 2009, resulted in 73 people confirmed with the mosquito-borne virus. Public health physician Dr Steven Donohue from QH says no new cases have been diagnosed since late February 2009, but has warned locals to remain "dengue aware" as outbreaks are still active in Cairns and Innisfail.

"Our policy is to allow a three month period to elapse after the last new dengue case has been notified before making an all-clear declaration," said Dr Donohue. "This is just in case low level dengue transmission might still be occurring. Now this period has elapsed, we can officially call the outbreak over. However, with the people movement between Townsville and Cairns, there is a chance of another dengue outbreak starting in Townsville, so I urge all residents to stay dengue alert."

The Townsville outbreak came during a record dengue epidemic in Cairns, with more than 900 people infected by the dengue virus type three, which has also seeded dengue outbreaks in Yarrabah, Port Douglas, Injinoo, and Mareeba.
(ProMED 5/25/09)

Malaysia
In the week ending 9 May 2009, five deaths due to dengue fever were recorded, bringing to 48 the number of people who have died of the disease so far in 2009. Director General of Health Tan Sri, Dr Mohd Ismail Merican said there was also a rise in the number of dengue fever cases in the country during that week, to 874 from 870 in the previous week, ending 2 May 2009. "The number of cumulative cases so far this year is 19,275 compared to 13,891 with 33 deaths in the same period last year," he said on 14 May 2009.

He said seven states recorded an increase in the number of cases so far in 2009, with Kedah registering nine, Kelantan eight, Johor 23, Penang 22, Kuala Lumpur and Putrajaya 20, Melaka three and Perak 13.

Up to 9 May [2009], 63 hotspots were reported, with 57 of the localities in Selangor, four in Kuala Lumpur and Putrajaya, and the rest in Johor, he said.

Dr Mohd Ismail said 579 compound fines totaling RM 68,850 (USD 19 451) were imposed and 201 clean-up notices were issued nationwide in the week ending 9 May 2009 to owners of premises found to harbor Aedes mosquito breeding places and potential breeding places. He said 71 percent of the houses and shops inspected were found to harbor Aedes breeding places.
(ProMED 5/18/09)

Mexico
Together with the state of Oaxaca, Jalisco is now in tenth place regarding the number of dengue cases in Mexico. The Secretariat of Health confirmed on 19 May 2009 two new patients from Puerto Vallarta and Tonala, which raises the number to 126. Of these, 10 have dengue hemorrhagic fever. This number is greater than that of the same period in 2008, when 83 dengue cases were recorded, stated Fermina Espinosa Alcantar, an official of the Department of Vectors and Zoonoses. Puerto Vallarta with 40 cases and Casimiro Castillo with 37 are the municipalities most affected.

A possible explanation for the increase in recorded cases is that the states that border Jalisco, such as Colima and Michoacan, are have the highest numbers of dengue cases in the country. Nationally, Colima is most heavily burdened with 1014 dengue cases, while Michoacan has 624 cases, Guerrero 548, Veracruz 538, Sinaloa 283, Morelos 199, and Nayarit 170.
(ProMED 5/25/09)

Viet Nam
A dengue fever room at Children's Hospital No. 1 in Ho Chi Minh City (HCMC) has seven sickbeds. They were holding 28 children on 21 May 2009. The number sometimes reached 30. Early onset of the monsoon has seen an unusual spurt in the disease, which caught people unprepared. Doctors have warned that mosquito-borne dengue fever cases in the city would be more severe this year [2009].

Children's Hospital No. 1 has had between 66 and 84 child inpatients every day since early May 2009, more than twice the normal count. Among the 15-20 children admitted to the hospital each day with dengue fever, half come from nearby provinces.

Children's Hospital No. 2 and the Hospital for Tropical Diseases in the city have also started to receive more dengue fever patients than normal. Every day, more than 30 children are being treated for dengue fever at Children's Hospital No. 2, while the Hospital for Tropical Diseases is admitting 10-17 adults.

HCMC has topped the list nationwide with more than 3600 dengue fever cases so far in 2009, said Nguyen Huy Nga, head of the Preventive Health and Environment Department under the Health Ministry. The country's total has reached more than 16,600, up 20 percent from 2008.

The disease is growing faster in Kien Giang and Soc Trang provinces of the Mekong Delta, with more than 1100 patients in each province. Climate change, according to Nga, has caused the early onset of the rainy season and also increased the amount of rainfall, resulting in an increase in the number of dengue fever cases and the severity of the disease in Singapore and Indonesia as well.
(ProMED 5/25/09)

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4. Articles
Progressive Vaccinia in a Military Smallpox Vaccinee--United States, 2009
US Centers for Disease Control and Prevention. MMWR. 19 May 2009; 58(Early release): 1-4. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58e0519a1.htm?s_cid=rr58e0519a1_e.

Progressive vaccinia (PV), previously known as vaccinia necrosum, vaccinia gangrenosum, or disseminated vaccinia, is a rare, often fatal adverse event after vaccination with smallpox vaccine, which is made from live vaccinia virus. During recent vaccination programs potential cases of PV were investigated, but none met standard case definitions. PV has not been confirmed to have occurred in the United States since 1987. On March 2, 2009, a U.S. Navy Hospital contacted the Poxvirus Program at CDC to report a possible case of PV in a male military smallpox vaccinee. The service member had been newly diagnosed with acute mylegenous leukemia M0 (AML M0). During evaluation for a chemotherapy-induced neutropenic fever, he was found to have an expanding and nonhealing painless vaccination site 6.5 weeks after receipt of smallpox vaccine. Clinical and laboratory investigation confirmed that the vaccinee met the Brighton Collaboration and CDC adverse event surveillance guideline case definition for PV. This report summarizes the patient's protracted clinical course and the military and civilian interagency governmental, academic, and industry public health contributions to his complex medical management. The quantities of investigational and licensed therapeutics and diagnostics used were greater than anticipated based on existing smallpox preparedness plans. To support future public health needs adequately, the estimated national supply of therapeutics and diagnostic resources required to care for smallpox vaccine adverse events should be reevaluated. (Excerpt with references removed.)

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The Role of Swine in the Generation of Novel Influenza Viruses
Ma W et al. Zoonoses Public Health. 27 May 2009. Available at http://www3.interscience.wiley.com/journal/122408424/abstract?CRETRY=1&SRETRY=0.

ABSTRACT
The ecology of influenza A viruses is very complicated involving multiple host species and viral genes. Avian species have variable susceptibility to influenza A viruses with wild aquatic birds being the reservoir for this group of pathogens. Occasionally, influenza A viruses are transmitted to mammals from avian species, which can lead to the development of human pandemic strains by direct or indirect transmission to man. Because swine are also susceptible to infection with avian and human influenza viruses, genetic reassortment between these viruses and/or swine influenza viruses can occur. The potential to generate novel influenza viruses has resulted in swine being labelled 'mixing vessels'. The mixing vessel theory is one mechanism by which unique viruses can be transmitted from an avian reservoir to man. Although swine can generate novel influenza viruses capable of infecting man, at present, it is difficult to predict which viruses, if any, will cause a human pandemic. Clearly, the ecology of influenza A viruses is dynamic and can impact human health, companion animals, as well as the health of livestock and poultry for production of valuable protein commodities. For these reasons, influenza is, and will continue to be, a serious threat to the wellbeing of mankind.

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Cluster analysis of the origins of the new influenza A(H1N1) virus
Solovyov A et al. Eurosurveillance. 28 May 2009; 14 (21). Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19224.

In March and April 2009, a new strain of influenza A(H1N1) virus has been isolated in Mexico and the United States. Since the initial reports more than 10,000 cases have been reported to the World Health Organization, all around the world. Several hundred isolates have already been sequenced and deposited in public databases. We have studied the genetics of the new strain and identified its closest relatives through a cluster analysis approach. We show that the new virus combines genetic information related to different swine influenza viruses. Segments PB2, PB1, PA, HA, NP and NS are related to swine H1N2 and H3N2 influenza viruses isolated in North America. Segments NA and M are related to swine influenza viruses isolated in Eurasia.

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5. Notifications
Weekly Epidemiological Record Bulletin
WHO. 29 May 2009; 84(22): 197-212. Available at http://www.who.int/wer.
Includes the article, “Considerations for assessing the severity of an influenza pandemic”

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Characteristics of the emergent influenza A/H1N1 viruses and recommendations for vaccine development
WHO guidance release on 26 May 2009

Available at
http://www.who.int/csr/resources/publications/swineflu/H1N1Vaccinevirusrecommendation26May2009.pdf.

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International Swine Flu Conference
Dates: 19-20 August 2009
Location: Washington, DC

Learning objectives for the conference:
- Maintaining cash flow and work flow--keeping the business process alive.
- How to plan--making everyone a stakeholder and spelling out roles and responsibilities.
- Protecting your community--knowing your resources and testing them against your toughest scenarios.

Additional information available at http://new-fields.us/em/link.php?M=9950864&N=90&L=187&F=T.

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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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 apecein@u.washington.edu