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Vol. XII, No. 13 ~ EINet News Briefs ~ Jun 26, 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: Risk factors for severe novel H1N1 influenza infection encompass many people
- Global: Agricultural experts speculate on origin of novel influenza H1N1 virus
- Global: World Bank expects influenza pandemic to impede economic output
- Australia: Expert recommends broad use of antivirals among aboriginal populations
- Indonesia: Child dies of avian influenza H5N1 infection
- Viet Nam: H5N1 avian influenza outbreak in poultry
- Canada: PHA update on influenza A/H1N1
- Canada: Novel H1N1 influenza vaccine policy to target young people and aboriginal populations
- Canada (Manitoba): Aboriginal groups seek emergency declaration due to novel H1N1 influenza
- USA: CDC update on influenza A/H1N1
- USA: Firm wins federal funding to develop new influenza vaccine technology
- USA: State Department warns travelers of risk of quarantine in China

2. Infectious Disease News
- Russia (Stavropol): Crimean-Congo hemorrhagic fever rates stable in 2009
- Viet Nam: Measles and scarlet fever on the rise in 2009
- Viet Nam: Bad tuna sickens hundreds of workers
- USA: E coli outbreak linked to prepackaged cookie dough sickens 70 people
- USA: Federal advisory panel determines only 4 rabies shots needed for prophylaxis
- USA (North Carolina): Man treated for rabies after bite from rabid raccoon

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

4. Articles
- Brucella suis Infection Associated with Feral Swine Hunting--Three States, 2007--2008
- What Is the Optimal Therapy for Patients with H5N1 Influenza?
- Do State Written Pandemic Plans Include Federal Recommendations? A National Study

5. Notifications
- Sonafi-Aventis donates 100 million doses of novel H1N1 influenza vaccine to WHO
- Providing a Safer Environment for Health Care Personnel and Patients through Influenza Vaccination: Strategies from Research and Practice
- 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)
The WHO has confirmed 55,867 of influenza A/H1N1 infection, including 238 deaths.

Economy / Cases (Deaths)
2009
Algeria/ 2 (0)
Antigua and Barbuda/ 2 (0)
Argentina/ 1213 (7)
Australia/ 2857 (2)
Austria/ 12 (0)
Bahamas/ 4 (0)
Bahrain/ 15 (0)
Bangladesh/ 1 (0)
Barbados/ 5 (0)
Belgium/ 30 (0)
Bermuda/ 1 (0)
Bolivia/ 44 (0)
Brazil/ 334 (0)
British Virgin Islands/ 1 (0)
Brunei/ 4 (0)
Bulgaria/ 5 (0)
Cambodia/ 1 (0)
Canada/ 6457 (15)
Cap Verde/ 3 (0)
Cayman Islands/ 7 (0)
Chile/ 4315 (4)
China/ 906 (0)
Colombia/ 71 (2)
Costa Rica/ 189 (1)
Cote d’Ivoire/ 2 (0)
Cuba/ 15 (0)
Cyprus/ 5 (0)
Czech Republic/ 7 (0)
Denmark/ 34 (0)
Dominica/ 1 (0)
Dominican Republic/ 108 (2)
Ecuador/ 115 (0)
Egypt/ 40 (0)
El Salvador/ 160 (0)
Estonia/ 5 (0)
Ethiopia/ 2 (0)
Fiji/ 2 (0)
Finland/ 26 (0)
France/ 171 (0)
France, French Polynesia/ 1 (0)
France, Martinique/ 2 (0)
Germany/ 301 (0)
Greece/ 58 (0)
Guatemala/ 235 (1)
Honduras/ 118 (0)
Hungary/ 7 (0)
Iceland/ 4 (0)
India/ 64 (0)
Ireland/ 23 (0)
Israel/ 375 (0)
Italy/ 96 (0)
Jamaica/ 19 (0)
Japan/ 893 (0)
Jordan/ 15 (0)
Korea, Republic of/ 115 (0)
Kuwait/ 26 (0)
Laos/ 3 (0)
Latvia/ 1 (0)
Lebanon/ 25 (0)
Luxembourg/ 3 (0)
Malaysia/ 68 (0)
Mexico/ 7847 (115)
Montenegro/ 1 (0)
Morocco/ 9 (0)
Netherlands/ 110 (0)
Netherlands Antilles, Curacao/ 3 (0)
Netherlands Antilles, Sint Maarten/ 1 (0)
New Zealand/ 386 (0)
Nicaragua/ 220 (0)
Norway/ 22 (0)
Oman/ 3 (0)
Panama/ 330 (0)
Papua New Guinea/ 1 (0)
Paraguay/ 58 (0)
Peru/ 217 (0)
Philippines/ 445 (1)
Poland/ 13 (0)
Portugal/ 6 (0)
Qatar/ 10 (0)
Romania/ 19 (0)
Russia/ 3 (0)
Samoa/ 1 (0)
Saudi Arabia/ 45 (0)
Singapore/ 194 (0)
Slovakia/ 4 (0)
Slovenia/ 1 (0)
South Africa/ 1 (0)
Spain/ 539 (0)
Sri Lanka/ 5 (0)
Suriname/ 11 (0)
Sweden/ 55 (0)
Switzerland/ 33 (0)
Thailand/ 774 (0)
Trinidad and Tobago/ 25 (0)
Tunisia/ 2 (0)
Turkey/ 26 (0)
Ukraine/ 1 (0)
United Arab Emirates/ 2 (0)
United Kingdom/ 2905 (1)
United Kingdom, Isle of Man/ 1 (0)
United Kingdom, Jersey/ 3 (0)
United States/ 21,449 (87)
Uruguay/ 195 (0)
Vanuatu/ 1 (0)
Venezuela/ 135 (0)
Viet Nam/ 56 (0)
West Bank and Gaza Strip/ 8 (0)
Yemen/ 6 (0)
Total/ 55,867 (238)

Chinese Taipei has reported 61 confirmed case of influenza A (H1N1) with 0 deaths. Cases from Chinese Taipei are included in the cumulative total above.
(WHO 6/24/09)

APEC updates: Chile confirms its fourth, Australia its first three, and Philippines its first deaths due to novel influenza H1N1. Indonesia confirms its first two cases of H1N1; both reported recent travel to Australia. In Malaysia, the first H1N1 case is confirmed on Borneo.
(ProMED 6/19/09, 6/22/09, 6/25/09)

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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: Risk factors for severe novel H1N1 influenza infection encompass many people
Whether speaking of a 58-year-old man or a 38-year-old woman, or a little boy of 9, officials announcing influenza H1N1 deaths almost always quickly note that "underlying health conditions" may have contributed to the fatal outcome. Asthma, heart disease, diabetes, and maybe even obesity are among the conditions used to help explain why novel H1N1 infection is hospitalizing and killing younger people, people who would be expected to make a full recovery from seasonal flu.

It could create the impression that only the sickly are dying from the new H1N1 flu virus -- a claim no one is making. To the contrary, many, including the World Health Organization, say between one-third and one-half of H1N1 flu deaths have occurred in people who were previously healthy. But how healthy is previously healthy? The answer depends on who you ask.

Dr Anand Kumar is a critical care specialist who has been treating H1N1 flu cases in embattled intensive care units (ICU) in several Winnipeg hospitals. He says a small portion of the ICU patients look like flu's typical victims -- people with health conditions known to be badly exacerbated by a bout of influenza. But more are younger and -- until they got sick -- healthier than flu patients hospitals typically see during a regular influenza season. "For the most part, these young, relatively healthy people aren't marathon runners or anything like that," he admits. "They're normal people. . .If you asked them 'Are you healthy?' they'd say 'Yeah, pretty healthy."'

Dr Michael Gardam, head of infectious disease prevention and control for Ontario's public health agency, believes the constant refrain of "underlying conditions" bespeaks a sort of wishful thinking, an attempt to explain away the unusual age range of the people the new virus is sending to hospital or to the morgue. "That's the story that I think people haven't really registered," says Gardam. "We're clinging to these 'Oh, they had underlying illness, therefore it's OK. But. . .I would argue that the 30-year-old with mild asthma -- how big of an underlying illness is that compared to the 80-year-old person with bad lung disease from smoking, who's got heart disease? That's the usual group that unfortunately gets really sick with flu, not this healthy adult group." You'll find little argument that this virus, at this time, is causing more severe disease in people far younger than those normally hospitalized and killed by flu or its complications in a typical flu season.

"This is not a disease of older adults. There's no question," says Dr Allison McGeer, an influenza expert with Toronto's Mount Sinai Hospital. "For people under 50, this is a significantly more severe disease than seasonal flu. For people over 50, it's much better," she notes. But are the people under 50 who are being badly hit by the virus specimens of perfect health or are many of them already shaded by the broad umbrella known as "pre-existing health conditions?" How you view a condition like asthma -- seen in 41 per cent of the hospitalized cases in New York City -- may influence how you answer that question. "A lot of that is about labeling people," McGeer admits. "Half of me doesn't want you to think you're diseased if you have asthma, and the other half of me wants you to get your flu vaccine because you're at increased risk." "How do you walk that line?"

Year in and year out, public health authorities get plenty of evidence many people who have some health issues plunk themselves firmly on the "healthy" side of the divide. Scans of people with asthma, diabetes and other conditions, and women who are pregnant forego the flu shots public health officials urge them to get, suggests Dr Scott Harper, an influenza expert with New York City's Department of Health. New York City has had one of the biggest swine flu outbreaks to date.

As of 16 Jun 2009, more than 700 New Yorkers had been hospitalized with novel H1N1 flu and 23 people in the city have died from infections. With those kinds of numbers, one might expect to see patterns emerge. But Dr Scott Harper, an influenza expert with the New York City Department of Health, says in fact the department believes that many of the health conditions known for years to increase the risk posed by flu are being seen in the people suffering serious disease with H1N1. "The majority of deaths that are being seen have well recognized underlying health risks," he insists. "Those that don't may have and we just haven't seen them yet. And then we may also find new risk factors, but they have not yet been adequately described analytically to be able to say it's a legitimate risk factor."

One such potential new risk factor is obesity. An early study from the US Centers for Disease Control suggested it may be contributing to poor outcomes in people who contract the new H1N1. The WHO is concerned about that possibility. "Obesity is now a huge global problem," says Dr Nikki Shindo, an expert with the WHO's global influenza program. "And if obesity is a risk factor, then I would be very much worried about some of the populations that are living with obese conditions." Four of the people who died in New York City were obese. Still, Harper says it's too soon to say whether that's a risk factor in and of itself, or if some of the things that go hand-in-hand with obesity -- like early heart disease, like diabetes -- are the real risk factors. Teasing out that answer will be tough but necessary, he says, noting that knowing who is truly at the most risk will dictate who stands where in the queue for flu vaccine once it becomes available and who should get priority access to antiviral drugs.
(ProMED 6/19/09)

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Global: Agricultural experts speculate on origin of novel influenza H1N1 virus
Contrary to the popular assumption that the new H1N1 influenza pandemic originated on factory farms in Mexico, some US federal agriculture officials now believe that it most likely emerged in pigs in Asia, but then traveled to North America in a human. But they emphasized that there was no way to prove their theory and only weak data underpinning it. There is no evidence that this new virus, which combines Eurasian and North American genes, has ever circulated in North American pigs, while there is tantalizing evidence that a closely related "sister virus" has circulated in Asia.

American breeding pigs, possibly carrying North American swine flu, are frequently exported to Asia, where the flu could have combined with Asian strains. But because of disease quarantines that make it hard to import Asian pigs, experts said, it is unlikely that a pig brought the new strain back West. "The most likely scenario is that it came over in the mammalian species that moves most freely around the world," said Dr. Amy L. Vincent, a swine flu specialist at the Agriculture Department's laboratory in Iowa, referring, of course, to people.

The first person to carry the flu to North America from Asia, assuming that is what happened, has never been found and never will be, because people stop carrying the virus when they become well. Moreover, the officials said, the chances of proving their theory are diminishing as the virus infects more people globally. Since some of those people will inevitably spread it to pigs, its history will become impossible to trace. "To tell whether a pig is newly infected by a human or had the virus before the human epidemic began really can't be done," said Dr. Kelly M. Lager, another Agriculture Department swine disease expert.

The highly unusual virus -- which includes genetic bits of North American human, avian and swine flus and Eurasian swine flu -- has not been detected in any pigs except those in a single herd in Canada that was found infected in late April 2009. A carpenter who worked on the farm after visiting Mexico had been thought to have infected the herd. But in mid-June 2009, Canadian health agencies said he was not to blame. The whole herd was culled, and the virus has not been found elsewhere in Canada, as it would have been if it were endemic, since American and Canadian laboratories test thousands of flu samples to help the pork industry develop vaccines.

But a sample taken from a pig in Hong Kong in 2004 was recently found to have a virus nearly matching the new flu. That flu, which had seven of the new flu's eight genome sequences, was noted in an article in Nature magazine on 11 Jun 2009, which called it a "sister virus."

Scientists tracking the virus's lineage have complained that there is far too little global surveillance of flu in swine. Public databases have 10 times as many human and avian flu sequences as they do porcine ones, said Dr. Michael W. Shaw, a scientist in the flu division of the US Centers for Disease Control and Prevention, and there are far fewer pig flu sequences from Asia than from North America and Europe, and virtually none from South America or Africa. "Something could have been going on there for a long time, and we wouldn't know," Dr. Shaw said. But national veterinary officials said they knew of no close relatives of the new virus in the large private North American databases either. That makes it most likely, they said, that it has been circulating in Asia.

The new virus was first isolated in late April 2009 by American and Canadian laboratories from samples taken from people with flu in Mexico, Southern California and Texas. Soon, the earliest known human case was traced to a 5-year-old boy in La Gloria, Mexico, a rural town in Veracruz. Because that area is home to hog-fattening operations with thousands of pigs in crowded barns near lagoons of manure, opponents of factory farming were quick to blame the industry. In May 2009, the Mexican government said it had tested pigs on the Veracruz farms and found them free of the virus. Smithfield Foods, an owner of the farms, and the National Pork Producers Council, the industry's lobbying arm, were quick to publicize that announcement. But outside veterinary experts still disagree on whether those tests proved anything.

According to Smithfield, Mexican government veterinarians tested snout swabs taken on 30 Apr 2009 and blood samples stored since January 2009. But since the human outbreak in Veracruz is believed to have started in February 2009, many veterinary experts said testing pig snouts for live virus in April 2009 proved nothing. Any pig sick in February 2009 would have long since recovered and, since hogs are usually slaughtered at 6 months old, many of those alive in early February 2009 would be bacon by April 2009. But Dr. Greg Stevenson, an expert in swine diagnostics at Iowa State University, said that since flu could persist in a large herd for months, "if it had been there in February 2009, it would probably still be there at the end of April 2009."

The blood tests -- in which scientists look for antibodies formed in response to a previous infection -- present a different set of problems. Antibodies are much harder to tell apart from one another than viruses are. A pig that had the new H1N1 flu would come up positive on an antibody test. But so would a pig that had the regular H1N1 swine flu that has circulated since 1930, or even a pig that had been vaccinated against the earlier H1N1 flu, and all the Smithfield pigs routinely get flu shots. The company said vaccinated pigs could be distinguished from previously ill pigs because illness produced more antibodies. But outside experts were skeptical. An antibody test specific enough to identify only the new flu strain "would take months to develop, at a minimum, and would require considerable R & D expertise and technology," said Dr. Christopher W. Olsen, a swine flu expert at the University of Wisconsin's veterinary medical school.

The governor of Veracruz has asked the National Autonomous University Mexico to do its own investigation of industrial hog farming in his state; the work is expected to take months. Carlos Arias, the biochemist leading the team, said he hoped to test all the swab and tissue samples stored by the farms and the national veterinary laboratory.
(ProMED 6/24/09)

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Global: World Bank expects influenza pandemic to impede economic output
In a report released on 22 Jun 2009 on effects of the economic downturn, the World Bank said the severity and impact of the current pandemic seem to resemble the Hong Kong influenza pandemic of 1968-69, which could mean a drop in gross domestic product of 0.7%. The World Bank said developing countries are most vulnerable to pandemic effects because of high population density, weak healthcare systems, and high prevalence of chronic diseases. The pandemic will likely erode Mexico's output by 5.8% in 2009.

Access the full World Bank report at
http://web.worldbank.org/WBSITE/EXTERNAL/EXTDEC/EXTDECPROSPECTS/EXTGDF/EXTGDF2009/0,,menuPK:5924239~pagePK:64168427~piPK:64168435~theSitePK:5924232,00.html.
(CIDRAP 6/23/09)

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Asia
Australia: Expert recommends broad use of antivirals among aboriginal populations
A disease-control specialist in Australia's Northern Territory said on 23 Jun 2009 that the government's recent decision to restrict oseltamivir (Tamiflu) use to "critical case criteria" should be relaxed for aboriginal patients who have suspected pandemic flu symptoms, the Australian Broadcasting Corporation reported. The expert said that 50% of people in the communities have chronic health conditions and that broader antiviral use could reduce the risk of disease transmission to vulnerable people.
(CIDRAP 6/23/09)

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Indonesia: Child dies of avian influenza H5N1 infection
The bird flu virus killed another victim in South Jakarta. A 5-year-old child died on 19 Jun 2009. Since 2005, avian influenza H5N1 has killed 11 of 13 total cases in South Jakarta.

Head of Livestock and Marine Subservice of South Jakarta, Chaidir Taufik, said the child was reported to have returned from his relatives in Sukabumi, West Java where a number of chickens suddenly died during his stay. After return from Pejaten Barat, the victim, the younger of two siblings, experienced high fever the following day on 8 Jun 2009. He received an antipyretic drug from a health worker. "The victim had improved [immediately], but the fever came back on Saturday [13 Jun 2009]. The child was then admitted to Triadapa hospital,” said Chaidir.

Tegal Parang chieftain Abdul Khalit added that after examination at Triadapa hospital, the victim was allowed to return home. Three days later, the child's condition worsened and was accompanied by breathing difficulty. The child was then rushed to Triadapa hospital again. Chest X-ray revealed liquid accumulation in the lungs, which suggested the illness was caused by bird flu infection. "After two days of treatment, Triadapa hospital referred the child to Persahabatan hospital on Thursday [18 Jun 2009]. But the child passed away four hours after admission," said vice chieftain of Tegal Parang, Gita Puspitasari.
(ProMED 6/21/09)

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Viet Nam: H5N1 avian influenza outbreak in poultry
Avian influenza H5N1 has resurfaced in the country on the northeastern border of Quang Ninh Province's Yen Hung District and infected more than 500 poultry. An additional 1300 birds have been killed and disposed of to prevent the spread of the disease in accordance with the regulations on epidemic disease prevention, said Hoang Van Nam, head of the Veterinary Department. Deputy Minister of Agriculture and Rural Development Diep Kinh Tan said the reason for the problem was the lack of disease prevention measures taken by some localities.
(ProMED 6/25/09)

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Americas
Canada: PHA update on influenza A/H1N1
The PHA has confirmed 6732 human cases of influenza A/H1N1 in all provinces/territories with 19 fatalities. The provinces that appear most heavily burdened are Ontario (2665) and Quebec (1660). However, Quebec searches systematically for novel H1N1 among all patients with influenza-like illness. Nine deaths have been reported in Quebec, seven in Ontario, two in Manitoba, and one in Alberta.
(PHA 6/24/09)

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Canada: Novel H1N1 influenza vaccine policy to target young people and aboriginal populations
As the Public Health Agency of Canada works on its priority list for the novel H1N1 vaccine, people aged 5 to 40 and those living in aboriginal communities may be at the top of the list, Canwest News Service (CNS) reported on 22 Jun 2009. Officials said the pandemic strain, unlike seasonal flu, is striking mainly children and young adults. Though older people appear to have some immunity to the virus, immunizing their grandchildren may provide an extra measure of protection, an expert said.
(CIDRAP 6/22/09)

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Canada (Manitoba): Aboriginal groups seek emergency declaration due to novel H1N1 influenza
Aboriginal leaders in Manitoba have declared an emergency in their communities over the novel flu, and they want the Canadian federal and provincial governments to do the same, the Canadian Press reported. The emergency declaration permits aboriginal groups to divert money from other programs, and a similar declaration at higher levels would lead to increased efforts to provide emergency supplies and healthcare workers to hard-hit communities, said the leader of the Assembly of Manitoba Chiefs.
(ProMED 6/25/09)

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USA: CDC update on influenza A/H1N1
The CDC reports 27,717 confirmed and probable cases of influenza A (H1N1) in all 50 states, as well as Washington, DC and Puerto Rico including 127 deaths. States most heavily burdened are Wisconsin (4273), Texas (2981), Illinois (2875), and New York (2272). New York has reported 35 deaths, 16 in California, 12 in Illinois, and 10 in both Texas and Utah.
(CDC 6/25/09)

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USA: Firm wins federal funding to develop new influenza vaccine technology
The US government has granted Protein Sciences Corp. (PSC) of Meriden, Connecticut, a $35 million contract to develop its technique for making influenza vaccines by growing flu virus proteins in insect cells, an approach said to be faster than traditional methods.

"The technology has advanced in recent years to the point that we believe it could help meet a surge in demand for US-based vaccine for seasonal and pandemic flu," Health and Human Services (HHS) Secretary Kathleen Sebelius said on 23 Jun 2009.

PSC's approach involves extracting a gene from a flu virus and inserting it into a baculovirus, which infects insects but not people. The recombinant baculoviruses multiply quickly in insect cells, producing many copies of the flu gene, and the cells are purified and used to make a vaccine, HHS said. The method may make it possible to produce vaccine candidates, vaccine for clinical trials, and commercial-scale amounts of vaccine faster than with the traditional method of growing flu viruses in chicken eggs, the agency said. It said the insect cells can be frozen and stored indefinitely, contributing to faster large-scale production.

If the technology is licensed by the Food and Drug Administration, the company will be required to establish a domestic manufacturing capability. The contract calls for the company to be prepared to make a finished vaccine within 12 weeks after a pandemic onset and to make 50 million doses within six months after pandemic onset, according to HHS. The contract could be extended up to five years at a total cost of about $147 million, HHS officials said. PSC has said it is using its baculovirus and insect-cell technology to make a vaccine for the novel H1N1 flu virus. But the vaccine, like any other, will require extensive animal and human testing and regulatory approval before it can be marketed.
(CIDRAP 6/23/09)

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USA: State Department warns travelers of risk of quarantine in China
The US State Department warned on 19 Jun 2009 that travelers to China may be quarantined for seven days if they arrive with a fever or flu-like symptoms. Chinese authorities target travelers with even slightly elevated temperatures if they come from areas with novel H1N1 cases, plus people sitting near them, the statement said. It also said the US has received reports of children being separated from parents and travelers being held in unsuitable quarantine conditions with poor drinking water and food.
(CIDRAP 6/22/09)

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2. Infectious Disease News

Asia
Russia (Stavropol): Crimean-Congo hemorrhagic fever rates stable in 2009
A total of 23 cases of Crimean-Congo hemorrhagic fever (CCHF) have been recorded in the Stavropol Krai, including six cases in the Arzgirsky region, four in the Apanasenkovsky region, three in each of the Petrokumsky and the Ipatovsky regions, two in the each of the Turkmen and the Andropovsky regions and a single case in the each of the Budenovsky, Stepnovsky and Novoaleksandrovsky regions.

A total of 6175 persons have sought medical attention for tick bites in 2009, of whom 2393 were children. In the same period in 2008, there were 36 cases of CCH including two fatalities, and a total of 5750 persons, including 1956 children, sought medical treatment for tick bites.

A survey of cases CCHF found that tick bites had been incurred during care of cattle (9), as a consequence of removal of ticks with unprotected hands (8), during shearing of sheep and goats (5), and associated with cattle herding, agricultural labor and recreational activities.
(ProMED 6/20/09)

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Viet Nam: Measles and scarlet fever on the rise in 2009
The Ministry of Health is urging local governments to boost preventive measures against scarlet fever and measles due to a 40 percent increase in the number of cases of scarlet fever compared to last year 2009, according to Deputy Minister of Health Trinh Quan Huan. There have been 23,000 cases reported so far in 2009, with the number of cases in some southern provinces, including Dong Nai and Kien Giang, as well as in the city of Can Tho, as much as 100-300 percent higher than 2008. "Pediatrics Hospital No. 1 receives 30 new cases of scarlet fever per day," said Dr Truong Huu Khanh.

Dr. Luong My Binh of Central Pediatrics Hospital warned that August or September 2009 could bring an epidemic of scarlet fever, and urged people to actively protect themselves by sleeping with mosquito nets and clearing their surrounding environment. Those with high fever for more than two days should be taken to the hospital for treatment, the doctor said. The number of measles patients is also increasing, with 25 cases admitted to the hospital per day. The hot weather further weakens many patients, said Khanh.

The Ministry of Health has asked local authorities to draw up plans for spraying chemicals against mosquitoes and disinfecting disease-prone areas, directing them to allocate 30 percent of their local public health budgets to preventive measures against measles and scarlet fever. Those local authorities which failed to take these measures would be penalized, said Huan.
(ProMED 6/20/09)

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Viet Nam: Bad tuna sickens hundreds of workers
Rotten tuna caused food poisoning that struck down hundreds of workers between 11 and 13 Jun 2009, Ho Chi Minh City's Health Department said on 20 Jun 2009. The department collected food samples from the companies to test immediately after workers got food poisoning.

According to the department, during the recent hot weather quality of tuna worsened and histamine in the tuna was created, causing severe physical reactions in people. A large amount of histamine can be poisonous, the department said. Although the department warned people that tuna caused food poisoning, city shoppers continued to buy cheap local tuna.

On 20 Jun 2009, after eating lunch, more than 80 workers at Ha Yen Co Ltd in My Tho City, Tien Giang Province, were hospitalized with skin rashes, stomach pains and dizziness. The workers said they had eaten tuna with bamboo.

One week earlier, more than 350 footwear workers in Ho Chi Minh City's Thu Duc and Binh Chanh Districts were hospitalized with food poisoning after eating lunch provided by their companies. More than 170 workers at Minh Nghe Trading and Industrial in Thu Duc District also presented similar symptoms, with skin rashes, headache, and dizziness after eating stewed tuna and water morning glory soup and were rushed to Thu Duc Hospital.

Another 76 workers from Vi An Co. in Tan Phu District and My Hao Co. in Binh Tan District were hospitalized on 12 Jun 2009 for the same reason.
(ProMED 6/23/09)

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Americas
USA: E coli outbreak linked to prepackaged cookie dough sickens 70 people
The number of patients sickened in a multistate Escherichia coli O157:H7 outbreak linked to prepackaged Nestle cookie dough has grown to 70 from 30 states, the US Centers for Disease Control and Prevention (CDC) said 22 Jun 2009.

The update reflects an increase of four cases and two states since the CDC's first statement on the outbreak on 19 Jun 2009. The cases are distributed broadly among all 30 of the states, with Minnesota (6), Colorado (5), and Washington (5) reporting the most. The outbreak appears to be ongoing, with cases rising above the expected baseline in May 2009 and continuing into June 2009.

Meanwhile, the US Food and Drug Administration (FDA) said that it is working with Nestle to ensure that products that might be contaminated with E coli O157:H7 are removed from distribution and retails shelves. The FDA also said in an update that its investigators are at the plant where the dough is made in Danville, Virginia, inspecting the facility and examining records and procedures to determine how the suspected contamination could have occurred.

The E coli outbreak strain has not turned up in microbiological tests that federal officials are conducting on cookie dough samples. However, the CDC has said preliminary epidemiological studies indicate a strong association between the E coli sicknesses and eating raw prepackaged Nestle Toll House cookie dough. Nestle voluntarily recalled all varieties and sizes of its prepackaged cookie dough products on 19 Jun 2009 after it learned of the epidemiologic findings.

The ages of the patients range from 2 to 65 years, though 66% are younger than 19. Seventy-five percent are female. Of 30 patients who were hospitalized, seven developed hemolytic uremic syndrome (HUS), a potentially fatal kidney condition. No deaths have been reported.
(CIDRAP 6/23/09)

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USA: Federal advisory panel determines only 4 rabies shots needed for prophylaxis
People exposed to rabies need only four vaccinations for post-exposure prophylaxis, not the five currently recommended, a vaccine advisory committee said on 24 Jun 2009. In the past, rabies shots were dreaded almost as much as the disease itself. Until the 1970s, an encounter with a rabid animal led to at least 14 shots in the abdomen. But vaccines have improved, and five shots in the arm or thigh have been the US standard for more than 20 years. The Advisory Committee on Immunization Practices voted unanimously that four shots -- all given within the first 14 days after exposure to rabies -- are sufficient. The panel advises the US Centers for Disease Control and Prevention, which issues official guidance to doctors.

Committee members made the decision after hearing that out of 20,000 to 40,000 Americans exposed to rabies each year, an estimated 1000 get only three or four shots and none of them have developed rabies. The shots cost between USD 100 and USD 200 apiece from the two companies make rabies vaccine for the US market, Novartis and Sanofi Pasteur.

The committee's recommendations usually harmonize with drug companies' package insert information about how their product should be used, but not in this case. A Novartis official, Clement Lewin, said he disagreed with the panel setting a precedent by making an off-label recommendation. He said it might confuse doctors who read company information about the vaccine that calls for five doses over 28 days, but see government guidance that says four shots are enough.
(ProMED 6/25/09)

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USA (North Carolina): Man treated for rabies after bite from rabid raccoon
A Hertford man is receiving anti-rabies treatments after being bitten by a rabid raccoon earlier this month. Perquimans Sheriff Eric Tilley said. The 29-year-old man was bitten on the right leg while working on a porch at a private residence on Harvey Point Road, on 6 Jun 2009. The victim, Tilley said, was busy working and never saw the animal approaching until the raccoon lunged at him and bit his leg. The man fought off the raccoon and killed it, Tilley said. The raccoon's head was sent to a state public health laboratory for testing, he said.

According to Jill C. Jordan, health education director and public information officer for Albemarle Regional Health Services (ARHS), the testing confirmed the raccoon had rabies. Jordan indicated that the state public health laboratory has confirmed 8 cases of rabies in the Albemarle since January 2008.
(ProMED 6/23/09)

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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
Thailand
A dengue fever outbreak is causing worries in the region of Mae Hong Son, as it is expected to be more serious than in 2008. There have been around 155 cases of dengue fever reported to date in 2009, which when compared to last year, is already a two-fold increase in cases.

Meanwhile, the Public Heath Ministry has set a target to achieve 100 percent control of dengue fever and prevent it spreading in the 29 high-risk provinces by 2011, deputy public health minister Manit Nop-armonbodi said. Mr Manit said control target for 2009 is 80 percent.

The 29 provinces most affected by dengue fever are Nonthaburi, Pathum Thani, Chachoengsao, Chanthaburi, Rayong, Samut Prakan, Nakhon Nayok, Ratchaburi, Nakhon Pathom, Prachuap Khiri Khan, Samut Sakhon, Buri Ram, Surin, Khon Kaen, Roi-et, Ubon Ratchathani, Si Sa Ket, Sakon Nakhon, Nakhon Sawan, Phichit, Lamphun, Surat Thani, Chumphon, Ranong, Phangnga, Krabi, Songkhla, Narathiwat, and Bangkok.
(ProMED 6/14/09)

Viet Nam
More than 21,000 people in Viet Nam have contracted dengue fever so far in 2009 and 20 have died, according to reports from the National Institute of Epidemiology and Pasteur institutes across the country. The figures show a 46.7 percent increase year-on-year, and the number of people dying of the mosquito-borne illness is four more than the same period in 2008. According to the Hanoi Healthcare Preventative Center, the capital city is facing a potential outbreak of the disease with 80 cases reported so far in 2009. Meanwhile, the Ministry of Health said the epidemic will continue in the south, as rain combined with hot, humid weather creates conditions for mosquitoes to flourish.
(ProMED 6/22/09)

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4. Articles
Brucella suis Infection Associated with Feral Swine Hunting--Three States, 2007--2008
US Centers for Disease Control and Prevention. MMWR. 12 June 2009; 58(22): 618-621. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5822a3.htm.

Historically, brucellosis from Brucella suis infection occurred among workers in swine slaughterhouses. In 1972, the U.S. Department of Agriculture National Brucellosis Eradication Program was expanded to cover swine herds. Subsequent elimination of brucellosis in commercial swine resulted in a decrease in B. suis-associated illness in humans. Currently, swine-associated brucellosis in humans in the United States is predominantly associated with exposure to infected feral swine (i.e., wild boar or wild hogs). In May and July 2008, CDC was contacted by the state health departments in South Carolina and Pennsylvania regarding two cases of brucellosis possibly linked to feral swine hunts. Both state health departments contacted the state health department in Florida, where the hunts took place. The subsequent investigation, conducted jointly by the three state health departments and CDC, determined that the two patients had confirmed brucellosis from B. suis infection and the brother of one patient had probable brucellosis. All three exposures were associated with feral swine hunting, and at least two patients did not have symptoms until 4--6 months after exposure. The findings from this investigation suggest that clinicians treating patients with unexplained febrile illness should consider brucellosis in the differential diagnosis and obtain a thorough history of travel (e.g., to enzootic areas), food consumption, occupation, and recreational activities, including feral swine hunting. Cross-agency collaboration by state health departments and agriculture agencies is needed on brucellosis investigations to reduce the risk for illness through contact with infected animals.

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What Is the Optimal Therapy for Patients with H5N1 Influenza?
White NJ et al. PLoS Med. 23 June 2009; 6(6). Available at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000091.

Commentary
In a 2007 article in PLoS Medicine, Holger J. Schünemann and colleagues described a new process used by the World Health Organization for rapidly developing clinical management guidelines in emergency situations. These situations include outbreaks of emerging infectious diseases. The authors discussed how they developed such a “rapid advice” guideline for the pharmacological management of avian influenza A (H5N1) virus infection. The guideline recommends giving the antiviral drug oseltamivir at a dose of 75 mg twice daily for five days. In this Debate, Nicholas White argues that such dosing is inadequate, Robert Webster and Elena Govorkova say that combination antiviral therapy should be used, and Tim Uyeki reminds us that clinical care of patients with H5N1 entails much more than antiviral treatment. These issues may also apply to therapy of patients hospitalized with severe disease due to novel swine-origin influenza A (H1N1) virus infection. (References removed.)

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Do State Written Pandemic Plans Include Federal Recommendations? A National Study
Klaiman TA et al. J Homeland Secure Emerg Manage. 2009; 6(1) Article 44. Available at http://www.bepress.com/jhsem/vol6/iss1/44/.

Abstract
The U.S. government has worked to empower states to respond to a pandemic, but there is minimal evaluation to determine the success of such efforts. The purpose of this study was to examine states' preparedness for a pandemic as documented by states' written pandemic plans. The study was a cross-sectional comparative analysis of 50 states' pandemic influenza plans as of March 2008. The CDC's State and Local Pandemic Influenza Planning Checklist was turned into a matrix with each of 85 recommendations making up 10 overarching domains coded as “no mention" = 1, “brief mention but no description or action item" = 2, or “description or action of the item" = 3. Domain scores were constructed by summing each state's factor scores and dividing the sums by the total possible score for that domain. Federal recommendations surrounding leadership, networking and surveillance have been well-integrated, but greater efforts are needed to develop partnerships with health care agencies and focus on antiviral preparedness and infection controls. The use of a clearly defined measurement tool can help states determine their level of preparedness and look to more prepared states for guidance as well as lobby their legislatures for additional resources.

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5. Notifications
Sonafi-Aventis donates 100 million doses of novel H1N1 influenza vaccine to WHO
At the Pacific Health Summit over 16-17 Jun 2009 in Seattle, USA, Sonafi Aventis announced the donation of 100 million doses of vaccine for pandemic H1N1 influenza to the World Health Organization.

The overarching theme of the Pacific Health Summit is to connect science, industry, and policy for a healthier world through effective utilization of scientific advances combined with appropriate policy. The 2009 Summit theme was “MDR-TB: Overcoming Global Resistance.” The Summit brought together top leaders to tackle how science, industry, and policy can accelerate the uptake of innovation to address this emerging global health threat. Participants explored ways to strengthen existing approaches to basic TB control and MDR-TB management and break through existing bottlenecks around technology development and treatment implementation in both developed and developing country health systems.

Additional information on the Pacific Health Summit at
http://www.pacifichealthsummit.org/about/news/default.aspx.

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Providing a Safer Environment for Health Care Personnel and Patients through Influenza Vaccination: Strategies from Research and Practice
Joint Commission report available at http://www.jointcommission.org/PatientSafety/InfectionControl/flu_monograph.htm.

The Joint Commission is releasing this free monograph, to help health care organizations of all types improve seasonal influenza vaccination rates in health care personnel.

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Weekly Epidemiological Record Bulletin
WHO. 19 June 2009; 84(25): 249-260. Available at http://www.who.int/wer.

Contents include:
New influenza A (H1N1) virus: global epidemiological situation, June 2009

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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