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Vol. XII, No. 12 ~ EINet News Briefs ~ Jun 12, 2009


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

1. Influenza News
- Cumulative number of human cases of influenza A/(H1N1)
- Cumulative number of human cases of avian influenza A/(H5N1)
- Global: WHO declares global influenza pandemic
- UK (Scotland): Considering vaccinating all children
- Australia: Laboratory test to diagnose influenza A/H1N1 said to be 90 percent accurate
- China (Hong Kong): Influeanza A/H1N1 vaccination plan approved
- India: May ask countries to screen departing passengers for influenza A/H1N1
- Canada: PHA update on influenza A/H1N1
- Canada: Serious cases of influenza A/H1N1 among First Nations people raise concern
- USA: CDC update on influenza A/H1N1
- USA: CDC says pandemic declaration will not change its response
- Egypt: Influenza A/H1N1 outbreak at university results in quarantine
- Egypt: Reports 80th human avian influenza H5N1 case

2. Infectious Disease News
- China (Shaanxi): Reports 11 rabies deaths since March 2009
- Chinese Taipei: Reports imported case of valley fever, first in 4 years
- Russia (Khakassia): Tick bites and tick-borne infections up from 2008
- Russia (Sverdlovskaya): Increase in tick bites results in 2 deaths
- Thailand: Chikungunya infection continues to spread, kills newborn
- USA (California): Tick-borne relapsing fever case in San Luis Obispo County
- USA (Missouri): Elderly man dies of tick-borne disease ehrlichiosis
- USA (New Mexico): Boy dies and sister hospitalized due to bubonic plague infections
- USA (Tennessee): Typhoid cluster in Chattanooga, source unknown

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- DENGUE
- HAND, FOOT, and MOUTH DISEASE

4. Articles
- Origins and evolutionary genomics of the 2009 swine-origin H1N1 influenza A epidemic
- Origins of the new influenza A(H1N1) virus: time to take action
- Influenza A(H1N1) and Pandemic Preparedness Under the Rule of International Law
- Use of Revised International Health Regulations during Influenza A (H1N1) Epidemic, 2009
- Preliminary analysis of influenza A(H1N1) individual and aggregated case reports from EU and EFTA countries
- Environmental transmission of low pathogenicity avian influenza viruses and its implications for pathogen invasion

5. Notifications
- Weekly Epidemiological Record Bulletin
- International Swine Flu Conference
- Influenza H1N1 planning conferences in US


1. Influenza News

Global
Cumulative number of human cases of influenza A/(H1N1)
74 countries have officially reported 29,669 of influenza A/H1N1 infection, including 145 deaths.

Economy / Cases (Deaths)
2009
Argentina/ 343 (0)
Australia/ 1307 (0)
Austria/ 7 (0)
Bahamas/ 1 (0)
Bahrain/ 1 (0)
Barbados/ 3 (0)
Belgium/ 14 (0)
Bolivia/ 5 (0)
Brazil/ 52 (0)
Bulgaria/ 2 (0)
Canada/ 2978 (4)
Cayman Islandas/ 2 (0)
Chile/ 1694 (2)
China/ 188 (0)
Colombia/ 35 (1)
Costa Rica/ 104 (1)
Cuba/ 6 (0)
Cyprus/ 1 (0)
Czech Republic/ 4 (0)
Denmark/ 11 (0)
Dominica/ 1 (0)
Dominican Republic/ 91 (1)
Ecuador/ 67 (0)
Egypt/ 10 (0)
El Salvador/ 69 (0)
Estonia/ 4 (0)
Finland/ 4 (0)
France/ 73 (0)
Germany/ 95 (0)
Greece/ 7 (0)
Guatemala/ 74 (1)
Honduras/ 89 (0)
Hungary/ 4 (0)
Iceland/ 4 (0)
India/ 9 (0)
Ireland/ 12 (0)
Israel/ 68 (0)
Italy/ 56 (0)
Jamaica/ 11 (0)
Japan/ 549 (0)
Korea, Republic of/ 53 (0)
Kuwait/ 18 (0)
Lebanon/ 8 (0)
Luxembourg/ 1 (0)
Malaysia/ 5 (0)
Mexico/ 6241 (108)
Netherlands/ 35 (0)
New Zealand/ 27 (0)
Nicaragua/ 56 (0)
Norway/ 13 (0)
Panama/ 221 (0)
Paraguay/ 25 (0)
Peru/ 79 (0)
Philippines/ 77 (0)
Poland/ 7 (0)
Portugal/ 2 (0)
Romania/ 11 (0)
Russia/ 3 (0)
Saudi Arabia/ 1 (0)
Singapore/ 18 (0)
Slovakia/ 3 (0)
Spain/ 488 (0)
Sweden/ 19 (0)
Switzerland/ 20 (0)
Thailand/ 8 (0)
Trinidad and Tobago/ 4 (0)
Turkey/ 10 (0)
United Kingdom/ 822 (0)
United States/ 13,217 (27)
Uruguay/ 36 (0)
Venezuela/ 25 (0)
Viet Nam/ 23 (0)
Total/ 29,669 (145)

(WHO 6/12/09)

APEC updates: US and Canada report increased risk for pregnant women related to novel H1N1 with two deaths in the US and six Canadian women on respirators. Influenza A/H1N1 has spread to every Australian state and territory.
(ProMED 6/11/09, 6/8/09)

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

2009
China/ 7 (4)
Egypt/ 27 (4)
Viet Nam/ 4 (4)
Total/ 38 (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: 433 (262).
(WHO 6/2/09 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO:
http://www.wpro.who.int/sites/csr/data/data_Graphs.htm (WHO/WPRO 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: WHO declares global influenza pandemic
After delaying action for weeks as the novel H1N1 influenza virus took hold in far-flung parts of the globe, the World Health Organization (WHO) declared a full-fledged pandemic on 11 Jun 2009, formally recognizing that the virus is becoming a global contagion.

WHO Director-General Dr. Margaret Chan announced the long-expected move to pandemic alert phase 6, meaning that the virus has caused sustained community outbreaks in more than one global region. The move comes amid growing signs of community transmission in Australia, Chile, and the United Kingdom—far from the epidemic's birthplace in Mexico and the United States.

"The scientific criteria for a pandemic have been met," Chan said. "I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6. The world is now at the start of the 2009 influenza pandemic."

The announcement came as the WHO's global H1N1 count rose to 28,774 confirmed cases in 74 countries. The United States, Mexico, and Canada account for the vast majority of those, but cases have been mounting in Australia (with 1,307), Chile (1,694), and the United Kingdom (822), among others. "Spread in several countries can no longer be traced to clearly defined chains of human-to-human transmission," Chan said. "Further spread is considered inevitable."

She said there was unanimous agreement among WHO member countries and the agency's emergency committee that "we have indisputable evidence that we are at the beginning of a pandemic caused by a new H1N1 virus."

In making the announcement to a world conditioned by the H5N1 avian influenza virus to think that a pandemic means the global spread of an often-lethal virus, Chan explained that the virus causes mild illness in the vast majority of patients. But she also noted that it differs from seasonal flu in significant ways. In areas with large outbreaks, most cases have occurred in people younger than 25, and in some of these areas, about 2% of cases have been severe, Chan said. She added that most of the severe and fatal infections have involved people between 30 and 50, and about a third to half of those people were previously healthy.

"Although the pandemic appears to have moderate severity in comparatively well-off countries, it is prudent to anticipate a bleaker picture as the virus spreads to areas with limited resources, poor health care, and a high prevalence of underlying medical problems," Chan stated.

Seven weeks since emergence
The pandemic declaration comes a little more than seven weeks after the novel virus first reached public attention with a report of US cases on Apr 21 and 44 days after the WHO moved from pandemic alert phase 4 to phase 5 on 29 Apr 2009. That signaled that the virus was spreading in more than one country in one WHO region.

The pandemic is the first since the worldwide spread of an H3N2 flu virus in 1968-69, when the tools for tracking and identifying influenza viruses were far less sophisticated than today. Yet the H1N1 virus surprised the world by emerging in North America instead of Asia and causing mild illness in most people, instead of the severe disease associated with the H5N1 virus. But experts warn that it could evolve into a more threatening form.

The WHO had hesitated to move to phase 6 out of concern that it would cause undue alarm and lead to unnecessary and harmful measures such as trade embargoes, travel restrictions, and a flood of worried but healthy people into hospitals. Last week the agency promised to couple its pandemic announcement with an assessment of the severity of the threat in an effort to prevent overreactions.

Chan repeated the WHO's recommendations against travel restrictions and border closures. In a question period, she seemed to downplay the concern that the pandemic declaration would lead to new travel and trade restrictions. Noting that some countries did impose various restrictions in the early weeks of the epidemic, she said they have been lifting them since then. "We must recognize that with a new disease . . . it's not unusual to have a degree of overreaction. I think this is understandable," she said.

The meaning of 'moderate'
In assessing the pandemic as "moderate" in severity, the WHO did not offer a formal definition of the term or present a severity scale, something that had been talked about earlier. When asked what "moderate" meant, Dr. Keiji Fukuda, the WHO's assistant director-general for health security and environment, repeated the general clinical profile of H1N1 cases: mild illness in most cases, younger people most affected, some severe cases and deaths. "Health systems have been stressed, but in general they are able to cope. . . . This makes it moderate," Fukuda said.

As for what the world should do now that the pandemic has officially arrived, the general answer from Chan and Fukuda was essentially, "Stay vigilant." "Countries should prepare to see cases, or the further spread of cases, in the near future," Chan said. "Countries where outbreaks appear to have peaked should prepare for a second wave of infection." She added that the WHO has sent guidance on specific measures to all health ministries.

Chan said the epidemic in Mexico "is coming to a steady state," with sporadic cases and outbreaks. "In the event that Mexico is coming out of the first wave, it doesn't mean that Mexico should let down its guard. Mexico should prepare to continue and keep up its vigilance because the virus can come back in a second wave."

Chan also reminded reporters that the H5N1 virus is still lurking. "We should never forget it as we're talking about H1N1, we still have H5N1 in [pandemic alert] phase 3, and this is the first time we have two new viruses coexisting at the same time in pandemic alert," she said.

Antivirals distributed Concerning antiviral drugs, the WHO has sent doses of oseltamivir (Tamiflu) to 121 countries, disbursing all 5 million doses initially donated by Roche. Chan said the agency has received a second donation of 5.6 million doses, some of which are the pediatric formulation, and those will be sent to other countries.

As for a vaccine, Dr. Marie-Paule Kieny of the WHO said all vaccine manufactures have received the vaccine virus. She said a few have already started making a vaccine, and others will begin in the next week or two. Kieny predicted that the first doses will become available sometime in September 2009, depending on how production goes and how long it takes to get regulatory approval. Chan said the WHO will urge regulatory agencies to "fast track" the vaccines. As for who will get the first doses, Kieny said, "When enough is available in the coming weeks, we'll make a policy recommendation on which groups, which populations should be prioritized for the first vaccine doses."

In recent interviews in anticipation of the pandemic declaration, public health experts said they would welcome the move and downplayed the risk of panic and overreactions. "It'll potentially raise awareness again in the country," said Dr. Paul Jarris, executive director of the (US) Association of State and Territorial Health Officials (ASTHO). "There seems to be a sentiment among some policymakers that this thing is gone and the response was an overreaction. It's still in the US, it's still spreading, it's not just another seasonal flu. Seasonal flu doesn’t put 23-year-olds in intensive care. . . . It's still here, and we need to plan for a resurgence in the fall."

Jarris said he doesn't expect panic in the wake of the announcement. "If we let them know that it means that a new virus has traveled around the world, people will understand it," Jarris added. "We need to reinforce the hygiene and hand washing, but also reinforce that this is the time for planning."

At the same time, Jarris voiced concern about science's capability to accurately assess the threat posed by the new virus. "Right now I think we still are unable to accurately portray the transmissibility or severity of this virus," he said. "We don't really know how many have been ill, how many have been exposed. We don't have the lab capacity to test everyone."
(CIDRAP 6/11/09)

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Europe/Near East
UK (Scotland): Considering vaccinating all children
As the number of confirmed novel H1N1 cases in Scotland soared to 232 as of 9 Jun 2009, officials discussed the idea of vaccinating all of the country's children. Though no final decisions on vaccine prioritization have been made, a government spokesperson said children and healthcare workers will likely be in the top tier and that the goal is to vaccinate all Scottish citizens by the middle of 2010.
(CIDRAP 6/9/09)

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Asia
Australia: Laboratory test to diagnose influenza A/H1N1 said to be 90 percent accurate
Some Australians may have been falsely diagnosed with influenza A/H1N1 while others with the disease may have been sent home with a negative result because the laboratory test used to identify the virus is only about 90 percent accurate.

As of 10 June 2009, more than 1200 Australians have tested positive to H1N1. New South Wales (NSW) Health is among those departments using polymerase chain reaction testing (PCR) to identify the H1N1 strain of influenza. The latest information from the World Health Organization (WHO), supported by the US Food and Drug Administration (FDA), suggests the newly developed rRT-PCR "rapid" testing method gives only a "presumptive positive" rather than a "definitive positive" result for H1N1 influenza. According to reports from both organizations, the test can also provide a "false negative" result in cases where the patient actually has the virus.

In April 2009, the FDA issued an emergency use authorization to allow a "rapid" form of the method to be rushed to laboratories across the US to combat a potential swine flu epidemic, even though the method had not been fully developed or obtained approval. A document released by the FDA on 28 Apr 2009 states only that rRT-PCR novel H1N1 testing "may be effective" in testing for influenza A/H1N1. The FDA report states that "a positive result indicates that the patient is presumptively infected with [influenza A/H1N1 virus, but not the stage of infection", and that "a negative result does not, by itself, exclude the possibility of [influenza A/H1N1] virus infection."

The WHO has issued its protocols for using the new test method to laboratories around the world. That document states tests can provide only a "presumptive positive" result for H1N1. The WHO document also said "a false negative result may occur if inadequate numbers of organisms are present in the specimen due to improper collection, transport, or handling".

The rRT-PCR testing method was developed by the global pharmaceutical Roche -- the company that also owns the rights to Tamiflu, one of just two anti-viral drugs used to treat the virus. George Koumantakis, the Scientific and Regulatory Affairs manager for Roche Diagnostics Australia, said the PCR testing method was "about 90 percent accurate." During the week of 1 Jun 2009, Roche reported that stocks of Tamiflu had sold out in Australia due to unprecedented demand. The health minister, Nicola Roxon, said the virus was mild in Australia, and only about 10 people had been hospitalized.
(ProMED 6/10/09)

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China (Hong Kong): Influeanza A/H1N1 vaccination plan approved
On 9 Jun 2009, Hong Kong's government endorsed a plan to immunize 2.5 million people with a novel flu vaccine that it expects to be available no earlier than October 2009. According to the plan, four groups will receive free vaccination: healthcare workers, children between 6 months and 6 years old, those older than age 65, and people who have chronic medical conditions. The government will stockpile enough doses for an additional 500,000 people.
(CIDRAP 6/10/09)

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India: May ask countries to screen departing passengers for influenza A/H1N1
India may ask countries reporting large numbers of novel H1N1 cases to screen passengers on departing flights, Indo Asian News Service (IANS) reported on 8 Jun 2009. The health ministry is repeating its request that the nation's external affairs ministry ask affected countries to conduct screening for possible flu. A health official said India's confirmed novel flu cases have been flagged during airport screening and that travelers with symptoms should be encouraged to postpone their trips.
(CIDRAP 6/10/09)

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Americas
Canada: PHA update on influenza A/H1N1
The PHA has confirmed 2878 human cases of influenza A/H1N1 in 12 provinces/territories. Four fatalities have been reported. The provinces most heavily burdened are Ontario (1562) and Quebec (611). Two deaths have been reported in Ontario and one death in both Alberta and Quebec. Only Newfoundland has not reported any cases.
(PHA 6/10/09)

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Canada: Serious cases of influenza A/H1N1 among First Nations people raise concern
Update from 6/10/09: Some of the Canadian indigenous groups that have been hit by serious cases of H1N1 influenza are not Inuit, but rather are among the groups known in Canada as First Nations or aboriginals. In particular, a Canwest News Service report referred to hundreds of cases and 20 hospitalizations at St. Theresa Point, a First Nation in northern Manitoba.

An official from the World Health Organization (WHO) said 9 Jun 2009, that health experts are closely monitoring novel H1N1 influenza infections in Canada's Inuit populations, following reports that the communities are seeing more than their share of severe cases.

The WHO’s Keiji Fukuda stated, "We can say now that we know a larger number than expected of young Inuit people developed serious illnesses and had to get hospitalized." He added that the WHO doesn't know if the trend is linked to socioeconomic factors, genetic factors, or chronic underlying diseases, and commented that Inuit groups were hit hard in some earlier pandemics. Fukuda is assistant director-general for health security and the environment. On 8 Jun 2009, Joel Kettner, Manitoba's chief medical officer, said that 26 people were being treated in intensive care units for suspected novel influenza infections, which is unusual for an influenza outbreak. He said more than half of the patients are of aboriginal descent, with an average age of 35.

Further, Manitoba's health department said that 15 extra ventilators have arrived at the province's ICUs and that the Winnipeg Regional Health Authority is helping the departments prioritize patients and was considering deferring non-urgent surgical procedures that would normally require use of the units.

As of 8 Jun 2009, Manitoba said it had confirmed 40 novel flu cases in six of its 11 health regions. Meanwhile, health officials in Canada's Nunavut territory said on 9 Jun 2009 that the number of confirmed novel flu cases has jumped from 25 to 53, with six patients in the hospital. Nunavut's population is primarily Inuit.

Donald R. Olson, research director for the International Society for Disease Surveillance, said that the severe cases in Canada's Inuit populations are puzzling. However, he added that among remote populations, the 1918 pandemic influenza was more severe and didn't follow the age patterns seen in the rest of the world. "Inuit groups didn't show the same apparent sparing of the elderly, so possibly the older proportion of the population had not been exposed" to previous viruses related to the pandemic strain, he said. The medical literature tells of "flu orphans" from remote Alaskan villages who survived the 1918-19 pandemic, though their parents and grandparents died, presumably because they had not been exposed to earlier H1-like viruses.

In 2006 at a state summit in Alaska, former US Health and Human Services Secretary Mike Leavitt described the impact of the 1918 pandemic virus on Alaska's native populations. "The Alaska native population in Nome was decimated—176 of the 300 Alaska Natives in the region died," he said in comments posted on the HHS pandemic flu Web site. "The pandemic swept through communities, killing whole villages." Preexisting health conditions may also have contributed to the severity of the 1918 pandemic in Inuit populations, which also had high tuberculosis rates in the early 20th century.

Officials don't know if higher rates of chronic illnesses in today's Inuit populations are playing a role in the high number of severe cases. However, Health Canada reports that when compared to the rest of the nation, First Nations and Inuit people have 1.5 times the rate of heart disease, 3 to 5 times the rate of type 2 diabetes, and 8 to 10 times the rate of tuberculosis infection.

On 8 Jun 2009, an Australian health expert from Darwin warned that the country's indigenous populations might be at greater risk for novel H1N1 infections. Besides citing lack of exposure to similar virus and underlying conditions as possible risk factors, experts have also theorized that remote populations might have a genetic predisposition that makes them more susceptible to the virus, Olson said. But he expressed doubt that the factor is playing a role in Canada's current outbreak. The signals coming out of Canada are worrying, he said. "The less developed world may have a terrible experience with this, though there is a lot of coughing and sneezing in the rest of the world," Olson said.

Danuta Skowronski, a physician and epidemiologist at the University of British Columbia, said that over the past few years, circulation of seasonal H1N1 viruses in North America has been patchy, and people in remote communities are likely to have had less exposure to the viruses than have people living in urban settings. There's still much that researchers don't know about possible cross-protection against the novel H1N1 virus from exposure to previous H1N1 strains, she said. Though researchers have identified antibody markers and determined that seasonal vaccination offers little protection, they still haven't gauged the cell-mediated response—which can offer protection during severe infections—afforded by exposure to previous H1N1 strains, Skowronski added.

Public health officials will also be looking for environmental factors that might be contributing to the infections in the First Nations and Inuit groups, she said. For example, large numbers of people living in one household may have greater exposure to the virus. "This all needs to be assessed, because we're picking up possible signals of concern," Skowronski said.
(CIDRAP 6/9/09)

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USA: CDC update on influenza A/H1N1
The CDC has confirmed 17,855 cases of influenza A (H1N1) in all 50 states, as well as Washington, DC and Puerto Rico. Forty-five deaths have been attributed to the disease with New York reporting 13 fatalities. States most heavily burdened are Wisconsin (3008), Texas (2049), and Illinois (1983).
(CDC 6/12/09)

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USA: CDC says pandemic declaration will not change its response
The World Health Organization's (WHO's) pandemic declaration on 11 Jun 2009 was not a surprise and will not affect the United States' response to the spread of the novel flu virus, which is already aggressive, officials from the US Centers for Disease Control and Prevention (CDC) said.

Thomas Frieden, who as the CDC's new director spoke on 11 Jun 2009 at his first press conference on the novel H1N1 virus, said US officials expected the declaration. He added that the decision fits with the scientific data supporting continued human-to-human transmission in more than one WHO region. "For all intents and purposes, the US government has been in phase 6 of the pandemic for some time now," he said. "This, however, is important, because it does send the strong message that the virus is here, and, in all likelihood, it's going to stay." He emphasized the pandemic level change doesn't signify a change in the severity level or behavior of the new virus. Moving forward, the CDC's goals are to identify where the virus is spreading and blunt its impact, particularly on vulnerable populations, such as those with chronic health conditions and infants, he said.

Preparing for a second wave
Heath and Humans Services (HHS) Secretary Kathleen Sebelius and Department of Homeland Security (DHS) Secretary Janet Napolitano said on 11 Jun 2009 that the next challenge is to prepare for a possible return of the virus in the fall. CDC officials said that it has deployed its scientists to several southern hemisphere countries to directly monitor developments.

Napolitano said, "We are reaching out to our partners in state and local government, in school districts and the private sector to urge them to modify and update their pandemic plans." She added that the government is working with scientists to test and prepare a possible vaccine and comparing notes on the virus with experts in other countries.

Virus acting much like seasonal H1N1
Anne Schuchat, interim deputy director CDC's science and public health program, stated that though the CDC has reduced its focus on case numbers, the agency has received reports of more than 13,000 cases, more than 1,000 hospitalizations, and at least 27 deaths. The highest illness rates are in children younger than age 5, followed by the 5- to 24-year-old age-group, she said.

The novel H1N1 virus is behaving like its seasonal H1N1 counterpart, which typically has a bigger impact on younger people, Schuchat said. Of people who were hospitalized with novel flu infections, 71% had underlying conditions such as asthma, chronic obstructive pulmonary disease, immune deficiency, or pregnancy, she said.

CDC officials said people should contact a healthcare provider right away if they or a loved one has a measured fever of 100.4°F or higher with a cough or a sore throat, along with an underlying health condition such as asthma or pregnancy. Though the CDC sees ongoing transmission in all states, two regions are above the influenza-like illness baseline for this time of year—New England and the New York and New Jersey area.

Vaccine development
The CDC has ordered novel H1N1 vaccine components from five companies, $650 million worth of antigen and $287 million worth of adjuvant. Schuchat said, however, that the CDC does not have a projection for the number of doses, because researchers haven't yet pinpointed how much antigen and doses will be needed. "Even if the decision to use the vaccine is not made, these orders permit the chemicals to be stored in bulk where they could be later formulated," she said.

So far, there's no evidence to suggest that circulating novel H1N1 strains won't be a good match for the seed strains used in the vaccines, Schuchat said. Testing of isolates from different countries and states so far shows no changes. "But with influenza, we need to keep looking," she added.
(CIDRAP 6/11/09)

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Africa
Egypt: Influenza A/H1N1 outbreak at university results in quarantine
The influenza A/H1N1 virus was detected in seven foreign students of the American University of Cairo (AUC) while another 140 students have been placed in quarantine, according to the medical services and the establishment. The dormitory's 110 students from 10 nationalities, as well as 124 workers and lecturers who use the building, were tested following the outbreak and the university announced it would suspend classes until 14 Jun 2009.

All of the new cases are Americans. The first two AUC cases were a woman who arrived from New Jersey via New York and London, and a man from Florida who came via New York. The five more recent cases had been in contact with the original two infections, Nasser Al Sayyed, assistant minister for preventive medicine, stated.

"The dormitory will remain under quarantine for a week until no more cases are detected. We will provide all facilities they need including food and communication around the clock," Sayyed said. A ministry official has taken up residence in the dorm to monitor possible infections around the clock.

The first Egyptian case of influenza A was detected on 2 Jun 2009. It is a 12-year-old American girl who arrived on holiday in Cairo. It was also the first case detected in Africa.
(ProMED 6/9/09, 6/11/09)

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Egypt: Reports 80th human avian influenza H5N1 case
The ministry of health has announced that a 4-year-old girl has been infected by the H5N1 influenza virus. She is number 80 in Egypt’s H5N1 infection toll. She is from a village in Dakahlia Governorate Delta. She began to suffer the symptoms on 5 Jun [2009] and was admitted to the Mansoura hospital on 6 Jun 2009. She was treated with Tamiflu and her condition is stable. She will be transferred to Manshiat El-Bakery hospital.
(ProMED 6/9/09)

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2. Infectious Disease News

Asia
China (Shaanxi): Reports 11 rabies deaths since March 2009
In Hanzhong city of northwest China's Shaanxi Province, two more people have died of rabies bringing the rabies death toll in the city since March 2009 to 11. The two fatalities were both women, one aged 58 and the other 56, said a local government official. The first death was reported on 21 Mar 2009 and the number of people injured by dog bites in the city has since reached 6256. So far, approximately 335,900 pet dogs have been vaccinated in the city. The city, with more than 370,000 registered dogs, reported 35 total deaths from rabies from 1985 to 1992.

Human deaths indicate the rabies virus is very active and poses a great public health threat, Shi Ruihua, local agricultural bureau chief, said early June 2009. The city carried out a rabies prevention campaign from 23 May-1 Jun 2009, implementing door-to-door compulsory vaccinations of dogs and urging dog owners to put their pets on a leash or keep them off the streets.
(ProMED 6/9/09)

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Chinese Taipei: Reports imported case of valley fever, first in 4 years
The Centers for Disease Control (CDC) in Tapei reported on 6 June 2009, Taipei’s first imported case of valley fever, or coccidioidomycosis, for 2009, which involved a local citizen returning recently from the United States, where the disease is endemic.

This was the third valley fever case ever recorded in Taipei. The previous two cases, also imported, were recorded in 2005 and 1991, respectively, according to the CDC. The latest case was a 30-year-old woman who was in the US between 1 Jul 2008 and 1 May 2009. The infection was diagnosed on 3 Jun 2009 through blood tests, the CDC said.

Valley fever is caused by Coccidioides immitis, a fungus commonly found in the soil of desert regions in the United States, Mexico, and Central and South America, the CDC said. People can be infected after inhaling the fungus spores in the air. The disease is not spread person to person. While many infected persons display no symptoms, some may develop fever, cough, chills, night sweats, headache, joint aches, chest pain, and a red spotty rash. Rarely, the infection can lead to pneumonia, meningitis, and even death.
(ProMED 6/10/09)

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Russia (Khakassia): Tick bites and tick-borne infections up from 2008
During the week of 1 Jun 2009, 334 persons sought medical aid for tick bites. Since the beginning of the epidemiological season, 2056 persons including 610 children have suffered from tick bites. It is 1.4 fold more than the corresponding period of 2008.

The highest rate of tick attacks have been observed in nearby Sayanogorsk. Epidemiologists indicated that among tick bite victims who came for medical assistance not more than 20 percent are vaccinated against tick-borne encephalitis virus. As result the majority of tick bite victims are at risk of infection. Tick-borne encephalitis has been confirmed in 17 inhabitants of the republic. Also, 18 persons, including two children, contracted Lyme disease; in 2008 it was just 10 persons.
(ProMED 6/9/09)

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Russia (Sverdlovskaya): Increase in tick bites results in 2 deaths
Since the beginning of the 2009 season, 10,733 cases of tick bites have been registered in Sverdlovskaya oblast and in 119 cases tick-borne encephalitis have been confirmed. A 71-year-old died from the disease in Rege in May 2009. The day prior, a 72-year-old man died in Tavde. Neither case had been vaccinated.

The vice head of Sverdlovski oblast Rospotrebnadzor administration Andrey Yurovskickh said elderly people and small children are not getting vaccines properly. The plan for vaccination has been completed by 21 percent. Acaricidal (anti-tick) treatments in parks have been completed by 60 percent. Specialists forecast that ticks will be more abundant in 2009, compared with 2008.
(ProMED 6/6/09)

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Thailand: Chikungunya infection continues to spread, kills newborn
In the past five months, 22,276 people have been found to be infected with the chikungunya virus, according to the Public Health Ministry. Public health minister Witthaya Kaewparadai, who opened a campaign to combat the virus in the southern province of Phatthalung, said the rapid spread of the virus from the lower south to the upper south between January and May 2009 was alarming. Infected people had been found in 28 provinces, he said. Songkhla has the most infections, with 9078 people being treated, followed by Narathiwat, with 7011 and Pattani, with 2942.

On 30 May 2009, Trang Hospital chief Somneuk Cheuthong announced that the mosquito-borne chikungunya disease is believed to have killed for the first time in Thailand, claiming a 6-day-old baby boy. Trang doctors performed emergency surgery on a 28-year-old pregnant chikungunya patient on 23 May 2009 to save her baby. However, the baby had died from respiratory complications. The infant had contracted the virus from his mother's blood and that it had penetrated 40 percent of his body. The hospital has put 10 other pregnant women with chikungunya virus infection under close observation.
(ProMED 5/31/09, 6/1/09)

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Americas
USA (California): Tick-borne relapsing fever case in San Luis Obispo County
A case of tick-borne relapsing fever (TBRF) has been diagnosed in a San Luis Obispo County resident. TBRF is a relatively rare disease, with approximately 25 cases diagnosed in the USA each year from states where TBRF is a reportable disease. The case was diagnosed in a North County resident, which is consistent with the epidemiology of TBRF, with cases found between 1500-8000 feet of elevation.

Cases of TBRF are characterized by fever, generalized body aches, headaches, chills, and sweats. Relapsing fever gets its name from the fact that the patient experiences a fever, which resolves and then returns. Most cases of TBRF are self-resolving, although some cases can have long-term symptoms. The tick associated with TBRF is a night feeding tick that is generally found in rodent nests and burrows. The rodents most generally associated with the ticks are ground or tree squirrels and chipmunks.
(ProMED 6/5/09)

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USA (Missouri): Elderly man dies of tick-borne disease ehrlichiosis
A 74-year-old man from the St Louis area died of the tick-borne disease ehrlichiosis, officials announced on 6 Jun 2009. The case was one of nine reported cases of diseases transmitted by ticks in the state during the 2009 season. Ehrlichiosis is similar to Rocky Mountain spotted fever and causes flu-like symptoms that can in rare cases lead to kidney failure and breathing complications. The man had discovered a tick on his body after a fishing trip in northeast Missouri. He had underlying health problems that may have been a factor in his death, according to health officials.

In 2008, there were a record number of tick-borne diseases at 668 in the state. Health officials are urging people to wear insect repellent and check their skin for ticks after being outdoors.
(ProMED 6/8/09)

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USA (New Mexico): Boy dies and sister hospitalized due to bubonic plague infections
An 8-year-old New Mexico boy has died and his 10-year-old sister was hospitalized after both contracted bubonic plague, the first recorded human plague cases in the USA so far in 2009. New Mexico health officials did not say how the brother and sister contracted the infectious disease, but they are conducting an investigation at the family's residence to determine if there is any risk to other people. third case of plague was confirmed on 10 Jun 2009 in a 56 year-old man. He was hospitalized, treated and has been released and is recovering.

Plague is generally transmitted to humans through the bites of infected fleas, but also can be transmitted by direct contact with infected animals. Fleas collected from the area are being sent to the CDC for testing. Health workers also canvassed the neighborhood to tell other residents that plague had been confirmed in the area.

The CDC says an average of 10 to 15 persons contract the plague each year in the USA. Modern antibiotics are an effective treatment.
(ProMED 6/5/09, 6/11/09)

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USA (Tennessee): Typhoid cluster in Chattanooga, source unknown
Local health officials have identified two confirmed cases and one probable case of typhoid fever, a potentially deadly disease. Cases of typhoid fever in Chattanooga are not unheard of, but those sickened usually have contracted the disease while traveling internationally, said Margaret Zylstra, epidemiologist with the Chattanooga-Hamilton County Health Department. None of the children sickened locally had been outside Tennessee recently, Ms Zylstra said. "That is a little bit more unusual, but across the country that does happen," she said. "We're still currently working on an investigation" into the source of the infections. All three children have recovered, she said. The disease is often seen in developing countries with unsanitary conditions in which food and water sources can become contaminated with raw sewage, according to the health department.
(ProMED 6/8/09)

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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
Philippines
Health Secretary Francisco T. Duque III launched a nationwide anti-dengue campaign, reiterating that dengue is more dangerous than influenza A (H1N1) on 3 June 2009. The campaign, dubbed "Ako, Ikaw, Tayong Lahat Laban sa Dengue," was meant to increase the public's awareness on the 4S strategy of the health department to avoid dengue-carrying mosquitoes. The 4S stands for search and destroy, self-protection, seek early treatment, and say no to indiscriminate fogging.

The health department disease surveillance report showed that from January to 9 May 2009, there were a total of 6537 cases of dengue with 62 deaths as compared to 15,334 cases and 163 deaths over the same period in 2008. The figures reveal a 57.4 percent decrease in the number of dengue cases compared to 2008. Clustering of dengue cases was seen in three or more barangays during the past four weeks in the following areas: Metro Manila; Calabarzon; Negros Occidental; Cebu and Davao City, among others.
(ProMED 6/8/09)

Viet Nam
Although it is not yet the peak season for dengue fever, the number of people infected has increased in the southern and central regions, said a senior official of the Ministry of Health. Nguyen Huy Nga, head of the ministry's Preventive Medicine and Environment Department, said the rainy season has come early in 2009 with increased rainfall, contributing to the rise in dengue fever cases. In the cyclical rise and fall pattern that the disease follows, 2009 is a year of increase, which is another factor, Nga said.

The Ho Chi Minh City (HCMC) Pediatrics Hospital No. 1 received between 66 and 84 patients a day during the week of 26 May 2009, double that of the last week of April 2009. HCMC has led the country in dengue fever cases so far in 2009, with 3600 cases and four fatalities reported. Dengue fever cases are also surging in the Cuu Long (Mekong) Delta provinces of Kien Giang and Soc Trang and the central province of Khanh Hoa.

The number of dengue fever cases nationwide has risen to 16,600 since the beginning of 2009, up 20 percent from the same period in 2008. Seventeen people have died in 2009 compared with 11 people during the same period of 2008.
(ProMED 6/1/09)

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HAND, FOOT, and MOUTH DISEASE
Since March 2009, a growing number of cases of hand, foot, and mouth disease (HFMD) have been reported in parts of Asia, including China, Hong Kong, Singapore, and Chinese Taipei. HFMD is common among infants and children, and most of the recently reported cases have occurred in children.

China
On 10 Apr 2009, China's Ministry of Health Information Office reported that 54,713 cases of HFMD had been detected through the end of March 2009. Most of these cases were in rural areas. The provinces and regions most affected by this outbreak are the central provinces of Henan, Jiangsu, Guangxi, Anhui, Guangdong, Hebei, Hunan, Zhejiang, Hubei, and the eastern province of Shandong. As of 30 Mar 2009, the Chinese Center for Disease Control and Prevention confirmed that at least 19 children have died from HFMD in 2009. The Chinese government has enhanced its surveillance, prevention, and control activities, along with training of local medical staff to identify and report cases promptly.

Hong Kong
As of 27 Mar 2009, the Center for Health Protection of Hong Kong had confirmed one case of HFMD. Nine other children who were exposed at the nursery where the ill child attended also developed HFMD symptoms. This is the seventh case reported to the Center for Health Protection of Hong Kong in 2009.

Singapore
As of 11 Apr 2009, Singapore's Ministry of Health has reported 5471 cases of HFMD infections in 2009. Typically, Singapore experiences annual peaks of HFMD from March to May.

Chinese Taipei
As of 31 Mar 2009, the Taipei Center for Disease Control and Prevention has reported nine cases of HFMD with severe complications, all in children under 5 years of age. Two cases each were located in the northern and central area of Taipei, and five additional cases were located in the southern area.
(ProMED 6/3/09)

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4. Articles
Origins and evolutionary genomics of the 2009 swine-origin H1N1 influenza A epidemic
Smith GJD et al. Nature. 4 June 2009. Available at http://www.nature.com/nature/journal/vnfv/ncurrent/abs/nature08182.html.

Letter
In March and early April 2009, a new swine-origin influenza A (H1N1) virus (S-OIV) emerged in Mexico and the United States. During the first few weeks of surveillance, the virus spread worldwide to 30 countries (as of May 11) by human-to-human transmission, causing the World Heath Organisation to raise its pandemic alert to level 5 of 6. This virus has the potential to develop into the first influenza pandemic of the twenty-first century. Here we use evolutionary analysis to estimate the timescale of the origins and the early development of the S-OIV epidemic. We show that it was derived from several viruses circulating in swine, and that the initial transmission to humans occurred several months before recognition of the outbreak. A phylogenetic estimate of the gaps in genetic surveillance indicates a long period of unsampled ancestry before the S-OIV outbreak, suggesting that the reassortment of swine lineages may have occurred years before human emergence, and that the multiple genetic ancestry of S-OIV is not indicative of an artificial origin. Furthermore, the unsampled history of the epidemic means that the nature and location of the genetically closest swine viruses reveal little about the immediate origin of the epidemic, despite the fact that we included a panel of closely related and previously unpublished swine influenza isolates. Our results highlight the need for systematic surveillance of influenza in swine, and provide evidence that the mixing of new genetic elements in swine can result in the emergence of viruses with pandemic potential in humans. (Excerpt with references removed.)

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Origins of the new influenza A(H1N1) virus: time to take action
Nava GM et al. Eurosurveillance. 4 June 2009; 14(22). Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19228.

To gain insight into the possible origins of the 2009 outbreak of new influenza A(H1N1), we performed two independent analyses of genetic evolution of the new influenza A(H1N1) virus. Firstly, protein homology analyses of more than 400 sequences revealed that this virus most likely evolved from recent swine viruses. Secondly, phylogenetic analyses of 5,214 protein sequences of influenza A(H1N1) viruses (avian, swine and human) circulating in North America for the last two decades (from 1989 to 2009) indicated that the new influenza A(H1N1) virus possesses a distinctive evolutionary trait (genetic distinctness). This appears to be a particular characteristic in pig-human interspecies transmission of influenza A. Thus these analyses contribute to the evidence of the role of pig populations as “mixing vessels” for influenza A(H1N1) viruses.

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Influenza A(H1N1) and Pandemic Preparedness Under the Rule of International Law
Gostin LO. JAMA. 10 June 2009; 301(22): 2376-2378. Available at http://jama.ama-assn.org/cgi/content/short/301/22/2376.

Commentary
A novel strain of influenza A(H1N1) spread rapidly through Mexico in April 2009 and now spans the globe. By the time the World Health Organization (WHO) was notified and had responded, geographical containment was not feasible, leading the agency to call for mitigation. Early indications are that the first wave may not be as widespread or pathogenic as originally feared, but this influenza strain could evolve to become more dangerous in subsequent waves, as did the 1918 Spanish influenza that killed some 50 million individuals.

The international outbreak of severe acute respiratory syndrome (SARS) in 2003 and the more recent influenza A(H5N1) among birds with limited transmission to humans helped prepare the world for the current pandemic threat. SARS galvanized WHO to revise the antiquated International Health Regulations in 2005, which took effect June 15, 2007. Governments instituted preparedness plans in response to avian influenza. (Excerpt with references removed.)

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Use of Revised International Health Regulations during Influenza A (H1N1) Epidemic, 2009
Katz R. Emerg Infect Dis. August 2009. Available at http://www.cdc.gov/eid/content/15/8/pdfs/09-0665.pdf.

Strong international health agreements and good planning created a structure and common procedure for nations involved in detection and evaluation of the emergence of influenza A (H1N1). This report describes a timeline of events that led to the determination of the epidemic as a public health emergency of international concern, following the agreed upon procedures of the International Health Regulations. These events illustrate the need for sound international health agreements and should be a call to action for all nations to implement these agreements to the best of their abilities.

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Preliminary analysis of influenza A(H1N1) individual and aggregated case reports from EU and EFTA countries
ECDC working group on influenza A(H1N1). Eurosurveillance. 11 June 2009; 14(23). Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19238.

Since the first importation of influenza A(H1N1)v virus to Europe in late April of this year, surveillance data have been collected in the Member States of the European Union and European Free Trade Association. This is the first preliminary analysis of aggregated and individual data available as of 8 June 2009 at European level.

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Environmental transmission of low pathogenicity avian influenza viruses and its implications for pathogen invasion
Rohani P et al. PNAS. 3 June 2009. Available at http://www.pnas.org/content/early/2009/06/03/0809026106.full.pdf+html.

Understanding the transmission dynamics and persistence of avian influenza viruses (AIVs) in the wild is an important scientific and public health challenge because this system represents both a reservoir for recombination and a source of novel, potentially human pathogenic strains. The current paradigm locates all important transmission events on the nearly direct fecal/oral bird-to-bird pathway. In this article, on the basis of overlooked evidence, we propose that an environmental virus reservoir gives rise to indirect transmission. This transmission mode could play an important epidemiological role. Using a stochastic model, we demonstrate how neglecting environmentally generated transmission chains could underestimate the explosiveness and duration of AIV epidemics. We show the important pathogen invasion implications of this phenomenon: the non-negligible probability of outbreak even when direct transmission is absent, the long-term infectivity of locations of prior outbreaks, and the role of environmental heterogeneity in risk.

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5. Notifications
Weekly Epidemiological Record Bulletin
WHO. 12 June 2009; 84(24): 227-248. Available at http://www.who.int/wer.

Contents
- Human infection with new influenza A (H1N1) virus: clinical observations from a school-associated outbreak in Kobe, Japan, May 2009
- Strategic Advisory Group of Experts: recommendations on the use of licensed human H5N1 influenza vaccines in the interpandemic period

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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