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Vol. XII, No. 14 ~ EINet News Briefs ~ Jul 10, 2009


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
- ***This bulletin was supplemented with information provided by Veratect***
- Note: According to the WHO, FAO, and OIE the official nomenclature for the currently circulating pandemic strain of influenza A (H1N1) is “pandemic (H1N1) 2009 virus.”

1. Influenza News
- Weekly update of pandemic influenza (H1N1) 2009
- Cumulative number of human cases of avian influenza A/(H5N1)
- Global: Pandemic influenza H1N1 updates: testing, resistance to antivirals, & geographical spread
- Denmark: First case of oseltamivir resistant pandemic H1N1 influenza virus reported
- Hong Kong: Antiviral resistance reported in patient not treated for pandemic H1N1 infection
- Canada: Reports new influenza strain in farm workers; announce risk to public health is low
- USA: Officials announce federally supported fall pandemic H1N1 vaccination drive

2. Infectious Disease News
- New Zealand: Measles outbreak in Christchurch school
- Russia (Moscow): Risk of rabies infection continues to increase in the region
- Viet Nam: Rabies outbreak kills four, vaccine prohibitively expensive for many at risk
- Canada (Ontario): Respiratory virus outbreak contained at neonatal ICU unit
- USA: E. coli outbreak results in national ground beef recall
- USA: Possible salmonella contamination prompts a variety of nationwide recalls
- USA (Arizona, New Mexico): Hantavirus infection kills one and hospitalizes a second
- USA (New York): State health department alerts New York City doctors to measles
- USA (North Carolina): Extremely rare bacterium from local lake infects teenager

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- CHIKUNGUNYA
- CHOLERA, DIARRHEA, & DYSENTARY
- DENGUE

4. Articles
- The emerging influenza pandemic: estimating the case fatality ratio
- Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey

5. Notifications
- Updated US Centers for Disease Control pandemic H1N1 influenza guidance
- Canadian system uses air traffic patterns to predict global infectious disease spread
- Weekly Epidemiological Record Bulletin
- International Swine Flu Conference

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

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Note: According to the WHO, FAO, and OIE the official nomenclature for the currently circulating pandemic strain of influenza A (H1N1) is “pandemic (H1N1) 2009 virus.”

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1. Influenza News

Global
Weekly update of pandemic influenza (H1N1) 2009
The WHO has confirmed 94,512 of pandemic influenza (H1N1) 2009 infection, including 429 deaths. Countries with the most confirmed cases of H1N1 are detailed below.

Economy/ Cases (Deaths)
2009
Australia/ 5298 (10)
Canada/ 7983 (25)
Chile/ 7376 (14)
Mexico/ 10,262 (119)
United Kingdom/ 7447 (3)
United States/ 33,902 (170)

Case totals for other APEC economies
Brunei Darussalam/ 124 (0)
China/ 2040 (0)
Indonesia/ 20 (0)
Japan/ 1790 (0)
Korea/ 202 (0)
Malaysia/ 112 (0)
New Zealand/ 1059 (3)
Papua New Guinea/ 1 (0)
Peru/ 916 (0)
Philippines/ 1709 (1)
Russia/ 3 (0)
Singapore/ 1055 (0)
Chinese Taipei/ 61 (0)
Thailand/ 2076 (7)

Map the spread of confirmed pandemic H1N1 influenza at http://www.who.int/csr/don/Map_20090701_1100.png.
(WHO 7/6/09)

Other APEC updates:
Peru and New Zealand report their first pandemic H1N1 related deaths. New Zealand officials report that flu activity has reached a 12-year high point and predicted the season hasn't peaked yet. A flu surveillance report for the week ending 5 Jul 2009 notes that novel H1N1 makes up 80% of circulating flu strains in New Zealand, an increase from the 48% reported in the previous week's report. Data from to first 44 pandemic H1N1 influenza patients at the Hospital for Tropical Diseases in Viet Nam suggests that patients treated with oseltamivir have a favorable clinical and virological response within five days of treatment. Reportedly, all of the patients suffered mild symptoms related to infection. Thailand institutes community mitigation efforts ordering more than 1000 schools to close for 15 days starting on 13 Jul 2009. Japanese official quarantined 20 American university students after two of their instructors contracted pandemic H1N1.
(ProMED 7/8/09; CIDRAP 7/5/09, 7/8/09, 7/9/09)

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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/ 41 (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: 436 (262).
(WHO 7/1/09 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 6/30/09)

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: Pandemic influenza H1N1 updates: testing, resistance to antivirals, & geographical spread
The World Health Organization (WHO) said on 7 Jul 2009, it will soon advise most countries to ease the volume of testing for pandemic H1N1 influenza and said testing related to recent oseltamivir-resistant cases has so far turned up no additional cases.

Keiji Fukuda, MD, the WHO's assistant director-general for health security, said the pandemic situation is evolving rapidly across the globe, with changes occurring continuously even within individual countries. In the next few days the WHO will release its new surveillance recommendations, advising countries that have already confirmed cases to cut back on testing all suspected cases and move toward larger surveillance indicators such as influenza-like illnesses or pneumonia hospitalizations.

"This will also ease the burden on labs," he said, adding that countries will still be urged to continue testing when unusual situations surface, such as severe cases, clusters, and symptoms that haven't previously been reported. However, Fukuda said the WHO will still advise countries that haven't yet identified any novel H1N1 cases to continue testing people who have suspected infections.

In other developments, he said the WHO's Strategic Advisory Group of Experts (SAGE) on immunization met 7 Jul 2009 and is expected to forward its report to Dr. Margaret Chan, the WHO's director-general, over the next several days. The agenda reportedly includes updates on pandemic H1N1 vaccine production, safety, regulatory issues, and discussion on key topics such as how much vaccine will be needed and which groups should be immunized first.

Oseltamivir-resistant strains
Regarding the three recently identified oseltamivir (Tamiflu)-resistant pandemic H1N1 strains in Denmark, Japan, and Hong Kong, Fukuda said that so far there is no evidence of widespread movement of the resistant strains, that testing of the patients' close contacts has so far identified no other infections with the strains, and that experts see no evidence of reassortment with the seasonal H1N1 strain. Experts expect to see some spontaneous mutations in circulating novel H1N1 flu strains, he said.

Though the patient in Hong Kong had not taken the antiviral drug oseltamivir, raising concerns that she may have contracted the infection from someone else taking the medication, the virus that caused her illness had the same mutation as the resistant viruses identified in Denmark and Japan, he said. "An important point is to continually monitor to make sure we're not seeing widespread movement [of the antiviral-resistant strain]," Fukuda said. "And the single most important point is that we're not recommending any clinical changes."

Varied activity in southern hemisphere
Pandemic flu activity in the northern hemisphere is high right now, but it's hard to predict how the virus will spread over the rest of the summer, Fukuda said. In the southern hemisphere, influenza activity varies by country, with heavy activity reported in Australia and South America, but with the first cases detected in 12 African countries only over the past few weeks.

The dominance of the pandemic H1N1 also seems to vary by country, he said. For example, Chile is reporting that 99% of circulating strains are the pandemic virus, though Australia is seeing a mixed picture of both novel H1N1 and seasonal H3N2. In contrast, the seasonal H1N1 strain is more predominant in South Africa.
(CIDRAP 7/7/09)

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Europe/Near East
Denmark: First case of oseltamivir resistant pandemic H1N1 influenza virus reported
Experts have reported the first case of pandemic influenza H1N1 that is resistant to Tamiflu (oseltamivir), the main drug being used to fight the pandemic. Roche Holding AG confirmed a patient with H1N1 influenza in Denmark showed resistance to the antiviral drug. David Reddy, company executive, said it was not unexpected given that common seasonal flu could do the same.

Medical officials have been using Tamiflu in an attempt to stop pandemic H1N1 from spreading in communities. If taken early, it ensures that symptoms are mild and reduces the chance of a victim giving the illness to someone else.

Mr Reddy stressed that there were no signs of a Tamiflu-resistant strain of H1N1 circulating in the community. This is in contrast to seasonal H1N1 flu, where a Tamiflu resistant strain emerged earlier in 2009 and is now widely circulating. Experts fear if this were to happen, it could render Tamiflu ineffective in treating pandemic H1N1 virus infection.
(ProMED 6/30/09)

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Asia
Hong Kong: Antiviral resistance reported in patient not treated for pandemic H1N1 infection
Public health authorities in Hong Kong announced 3 Jul 2009 they have found a case of Tamiflu resistance in a woman who had not taken the drug. This development means she was infected with swine flu viruses that were already resistant to Tamiflu, the primary antiviral used in treating influenza.

The two previous cases, reported in Denmark and Japan, involved people who had been taking the medication. While always unwelcome, that type of resistance is known to occur with seasonal influenza virus strains and may be less of a threat to the long-term viability of this key flu drug. "It was not at all surprising to see resistance in patients on treatment, but seeing it in someone who was not treated, it certainly is more concerning," says Dr. Malik Peiris, a flu expert at the University of Hong Kong.

There is currently no evidence Tamiflu-resistant viruses are spreading widely. Still, some experts see the Hong Kong case as a warning that Tamiflu's role in this pandemic may not be as long-lived as pandemic planners would like. "I think it's too early to judge," says Dr. Frederick Hayden, an expert on influenza at the University of Virginia. "But I think that possibility has existed from the beginning, and it's something that needs to be certainly considered in making determinations about things like antiviral stockpiling, management of patients with more serious illness in hospital and how the available drugs will be used."

Some say this early sign of resistance should prompt rethinking of how often and in which circumstances Tamiflu is used to battle the pandemic H1N1 virus. "It. . .probably highlights the importance of not using these antiviral drugs indiscriminately, given that the disease is relatively mild," says Peiris, whose hospital monitored the woman who was found to be carrying the resistant virus. "In people who don't have underlying risk factors, they probably should not be treated with Tamiflu, basically."

Others suggest countries should limit how often they use the drug to prevent infection, a regimen known as prophylaxis. In prophylaxis, people who have been exposed to the virus are given one pill a day for 10 days, compared to the treatment regime of two pills a day for five days. Some countries, including Canada, have been reserving prophylaxis for people at high risk for pandemic flu, such as pregnant women. But others have taken a different approach, using Tamiflu to try to curb spread of the virus. For instance, Britain has made the drug widely available to contacts of confirmed cases, though it recently announced it was changing that policy.

The World Health Organization (WHO) is drafting guidance for countries on the use of antivirals. While the WHO advises rather than instructs, it has been stressing that saving these drugs for treatment makes the most sense, says Dr. Keiji Fukuda, the agency's top flu expert. "In general we have been pushing the advice that using these drugs for treatment is definitely the priority use of them," says Fukuda, the acting assistant director general for health security and environment. "And I think this is not just from a theoretical resistance perspective but also from the fact that if you have limited amounts of antiviral drugs, then you need to make some choices about how you use them."
(ProMED 7/6/09)

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Americas
Canada: Reports new influenza strain in farm workers; announce risk to public health is low
Canada announced on 7 Jul 2009 that they have detected a new influenza strain—one that contains human seasonal flu and a swine flu virus—in two workers on a Saskatchewan hog farm. Canada said it has notified the World Health Organization (WHO) about the new virus, as required under international health regulations.

The workers had mild illness and have recovered, and authorities are investigating a third suspected case, the Public Health Agency of Canada said. Canada's health minister Leona Ablukkaq said federal officials are working with Saskatchewan to learn more about the new virus. "Preliminary results indicate the risk to public health is low and that Canadians who have been vaccinated against the regular, seasonal flu should have some immunity to this new flu strain," she said.

Dr Greg Douglas, Saskatchewan's chief veterinary officer, said on 8 Jul 2009 that the new virus contains genes from the seasonal human H1N1 flu strain and a triple reassortant H3N2 strain that is common in swine populations. Initial testing on the pigs indicates they were infected with swine influenza A, common in swine herds, but not the new human strain found in the workers, the Public Health Agency said. Further surveillance will be conducted on Saskatchewan's hog industry workers, and the Canadian Food Inspection Agency is providing the province with guidance on swine herd surveillance.

Saskatchewan's health agency said on 7 Jul 2009 that additional responses include reinforcing biosecurity measures at the affected farm and vaccinating the hog farm's workers. It added that in most cases, viruses such as the one found in the hog farm workers are not transmitted easily between humans. "To date, there is no evidence that this strain has transmitted between humans," the agency said. Douglas, the province's chief veterinary officer, said, "It is important to remember that only healthy hogs go to slaughter and that pork is safe to eat. Influenza is not transmitted by eating pork products."

Dr Carolyn Bridges, associate director of epidemiologic science in the US Center for Disease Control and Prevention's (CDC's) influenza division, said that the reassortment event in Canada isn't surprising. "We know that humans pass influenza viruses to pigs on a regular basis," she said, adding that the human seasonal H3N2 influenza virus first entered North American swine herds in 1998 and that multiple reassortment events have been detected since then. "This is just another demonstration of how dynamic these viruses are," Bridges said.

The virus detected in Canadian hog farm workers is not a pandemic flu threat because it contains external human virus proteins—the part the immune system recognizes, she said. "That's what matters most, and the flu vaccine provides good coverage. A large proportion of the population has some preexisting immunity." Sustained transmission of the new virus among humans is unlikely, she added. However, the events highlight the need for ongoing surveillance in pig populations to monitor for changes, she said.
(CIDRAP 7/8/09)

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USA: Officials announce federally supported fall pandemic H1N1 vaccination drive
If an effective vaccine for pandemic H1N1 influenza is available, the US federal government expects to mount an H1N1 vaccination campaign in fall 2009, initially targeting schoolchildren, adults with health problems, pregnant women, and healthcare and emergency workers, a top US official said on 9 Jul 2009.

US Health and Human Services (HHS) Secretary Kathleen Sebelius at the Obama administration's H1N1 Influenza Preparedness Summit, a one-day meeting designed to stimulate preparedness nationwide. The session drew about 500 state, tribal, and territorial health and education officials to Bethesda, Maryland, and was streamed over the Web.

She advised leaders to plan for the worst-case scenario of the virus reappearing with renewed strength in the 2009 fall. "What we need to assume is that it will come back in a much more severe form," she said. Sebelius added that extensive planning to combat the spread of the virus always could be scaled back later but that officials could not delay starting work on those preparations. "We can step back from our planning. What we can't do is wait until October," she said.

"While we have made no final decisions about its scope, and have 'off ramps' built into our decision making process if the circumstances change, at this point, we expect to initiate a voluntary fall vaccination program against the 2009 H1N1 flu virus," Sebelius said. She said the risk of increased antiviral resistance in the virus is a "serious consideration," underlining the importance of vaccination.

Sebelius said the current estimate is that some vaccine will be ready for distribution in mid-October 2009. HHS is working with its advisory committees to decide which groups will be offered vaccine and in what order, but added, "We know that young people have been disproportionately impacted by this virus, and we anticipate that school-aged children, non-elderly adults with underlying health conditions, pregnant women, and healthcare and emergency workers who are likely to come in contact with the virus will be priority groups to whom vaccine will be offered."

The National Institute of Allergy and Infectious Diseases (NIAID) hopes to evaluate the first candidate H1N1 vaccine in early August 2009, said NIAID Director Dr. Anthony Fauci.

$350 million to states
While urging states and other jurisdictions to help prepare for the potential vaccination drive, Sebelus promised that some money will be available to support those preparations. On 10 July 2009, HHS will formally announce the availability of $350 million for preparedness grants to states, money that Congress included in the recently passed 2009 supplemental appropriation bill. The sum includes $260 million to go to state health departments "to support your ongoing work and to prepare for the vaccination campaign, while $90 million will help hospitals prepare for the surge of patients they will treat if an outbreak impacts their community," Sebelius said.

Vaccination planning starts now
She urged state and local health officials to begin planning now for the likely vaccination campaign. "It may not be possible, at least in the early stages, to use the standard channels to distribute the vaccine," she said. "We will need your assistance to identify vaccination sites."

The federal government will pay for the vaccine, Sebelius promised: "The vaccine will be purchased by the federal government and made available for distribution by state and tribal governments, and we will provide financial and technical assistance all along the way." She said Congress has already approved about $1 billion to buy the bulk vaccine ingredients and that another $7.5 billion will be available for the program. "This will be a federally funded program that may have an opportunity to recover some funding back from folks with private insurance. But don't expect this will be done through private sources as seasonal flu vaccination is; this will really be a public effort funded by the federal government."
(CIDRAP 7/9/09; CNN 7/9/09)

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2. Infectious Disease News

Asia
New Zealand: Measles outbreak in Christchurch school
Four Christchurch Boys High School pupils have been confirmed as having measles during the week of 29 Jun-3 Jul 2009 and another is suspected of having the disease. Canterbury District Health Board's Community and Public Health Division has been working with the school, pupils, and parents to prevent the disease spreading further. Measles, sometimes known in New Zealand as English measles, is a viral infection that can lead to ear infections, pneumonia, and/or diarrhea. Sometimes it can cause serious problems such as inflammation of the brain.

Canterbury medical officer of health Dr Ramon Pink said, "the boys who are unwell are being isolated at home and their close contacts are being advised to stay at home for several days unless they have had two MMR [measles, mumps, and rubella] immunizations which would give them immunity from the disease. All pupils and parents at the school are being informed of the measles cases and have been asked to contact their general practitioner if they see any signs of the disease which include fever, red eyes, runny nose, spots on the inside of the mouth, or a rash that appears in days 3 to 7 of the illness.
(ProMED 7/5/09)

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Russia (Moscow): Risk of rabies infection continues to increase in the region
According to the Federal Agency for Veterinary and Phytosanitary Supervision, the numbers of stray dogs and cats that are the vectors of rabies infection, have continued to increase throughout the Moscow region. The number of rabies cases among animals during 2008 was 2.5 times their number during 2007. Eighty percent of the cases involved wildlife, in which population growth is uncontrolled. The other 20 percent were in pets. During the first five months of 2009, 11,000 persons applied for post-exposure rabies treatment. This is an 11 percent increase over the same period in 2008.
(ProMED 7/5/09)

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Viet Nam: Rabies outbreak kills four, vaccine prohibitively expensive for many at risk
Northern Lai Chau Province announced a rabies epidemic after four people died of the disease and at least 500 people were bit by rabid dogs in the last two months. "The 500 cases only account for the number of patients who got a rabies [vaccination] at the province's Preventive Healthcare Centre after being bitten," said Do Van Giang, deputy director of Lai Chau Province's Health Department, adding that the actual number of infected people could be much higher.

Due to the high demand for dog meat, many local people transported dogs from Phu Tho and Vinh Phuc provinces. These dogs then infected the local dogs, leading to the rabies outbreak, said Nguyen Cong Huan, director of the province's Health Department.

"More people will die of rabies because they do not get the vaccine," he said. The cost for the vaccine is high -- nearly VND one million (USD 56) for a course of five injections -- and 40 per cent of people in the province have an average monthly income of VND 200,000 (USD 11), according to Giang.

"My pregnant daughter was killed by a rabid dog because she couldn't get the vaccine in time," said a 64-year-old in Lai Chau Town, who recovered from rabies after several days of treatment in the province's hospital. "Authorities should support patients like us and get us free treatment. If not, we will not be able to afford the vaccine," said Thanh.

The province recently decreed that the poor would get free rabies vaccines and others would get 50 percent of the vaccine cost subsidized, said Huan. Some local ethnic minorities lack information about the disease and choose to treat it with herbal remedies instead of getting the vaccine. "Many people rush around looking for herbal medicine after being bitten by dogs. However, this is useless and causes more harm because there is no scientific basis for this treatment," said Bui Tien Thanh, a doctor at the province's General Hospital.

Local health officers have handed out leaflets about rabies and treatment to educate people about the disease and have asked anyone who has been bitten by dogs to go to the Preventive Healthcare Centre for treatment, according to Nguyen Van Ngoc, deputy director of the Preventive Healthcare Centre. "In addition, relevant authorities have increased the management of dog transports from other provinces and are more closely monitoring the province's current canines," said Huan.
(ProMED 7/3/09)

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Americas
Canada (Ontario): Respiratory virus outbreak contained at neonatal ICU unit
Officials have declared an outbreak at McMaster hospital's neonatal intensive care unit after three newborns became ill with a respiratory virus. The premature babies were confirmed to have parainfluenza type 3 virus infection. It is a seasonal virus associated with respiratory symptoms such as a cough and fever. There have been no new cases since then. The neonatal intensive care unit, which has 44 babies, remains open to visitors and patient admissions and the three affected babies are in isolation and being monitored closely. All are recovering, said hospital spokesperson Lillian Badzioch.

The virus is not a flu virus and not associated with the pandemic H1N1 influenza virus that is spreading in the community, according to Dr Chris Mackie, Hamilton associate medical officer of health. Mackie said although parainfluenza type 3 virus doesn't carry the same risks as regular seasonal influenzas, it does pose a risk for babies born prematurely. Most cases do not require treatment and the virus is commonly seen in infants during spring and summer months. It can mimic the symptoms of the flu, Mackie said.

Badzioch said, "It is very common in children under two." But, she added, because it is in an intensive care unit and because the babies were all prematurely born, the hospital declared the outbreak and erred on the side of caution to prevent further spread. "We're already dealing with a fragile population and we wanted to take all the precautions."
(ProMED 7/5/09)

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USA: E. coli outbreak results in national ground beef recall
At least 12 people, two of them suffering kidney failure, have been hospitalized in connection with a possible Escherichia coli (E. coli) outbreak in beef suspected of having sickened people in nine states, federal health officials said on 1 Jul 2009. The victims may have become ill after eating beef produced by JBS Swift Beef Company of Greeley, Colorado, the US Centers for Disease Control and Prevention (CDC) reported. The number of people reported ill so far is 23.

The company recalled about 380,000 pounds (about 172 tons) of beef on 28 Jun 2009 after some illnesses were reported and a government investigation showed a possible connection to the company's product. That recall expanded a 24 Jun 2009 recall of just over 41,000 pounds (about 19 tons).

CDC said health officials in several states investigating the strain of E. coli found that most ill persons had consumed ground beef, and many reported that it was undercooked. Ground beef with the strain of E. coli was obtained from the home of one person infected. "At least some of the illnesses appear to be associated with products subject to these recalls," CDC stated.

The first reported illness began on 2 Apr 2009, according to CDC, and the last on 13 Jun 2009. Wisconsin and Michigan appear to be the hardest hit by the outbreak so far, with six ill people in each state identified by CDC. Other cases were reported in California, Maine, Minnesota, New Hampshire, New Jersey, New Mexico, and New York. CDC did not specify the states in which people were hospitalized. The agency said that two of those who fell ill suffered from hemolytic uremic syndrome, a type of kidney failure. Kidney failure is found in the most severe cases of E. coli. In less serious cases, the potentially deadly bacterium can cause bloody diarrhea and dehydration.
(ProMED 7/2/09)

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USA: Possible salmonella contamination prompts a variety of nationwide recalls
What began as a small investigation into tainted milkshake powder has become a nationwide recall of related products. No illnesses have been linked to the contamination of ingredients sold by a Minnesota milk cooperative, says the Food and Drug Administration's (FDA) Stephanie Kwisnek. But the recalls, which are cascading through the food system and are expected to expand, illustrate the interconnectedness of the system, in which just one tainted ingredient can affect dozens of companies. Recalled products range from Malt-O-Meal's Maple & Brown Sugar Instant Oatmeal packets to Meijer hot chocolate mix to some Kroger popcorn toppings.

The U.S. Department of Agriculture (USDA) first detected salmonella in a milkshake powder in June 2009. The USDA and the FDA traced the contamination back to the Plainview Milk Products Cooperative in Minnesota. FDA investigators found salmonella in the plant, and the cooperative issued a voluntarily recall of instant non-fat dried milk, whey protein, fruit stabilizers and thickening agents produced over the past two years. The cooperative sells only to food manufacturers and distributors.
(USA Today 7/6/09)

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USA (Arizona, New Mexico): Hantavirus infection kills one and hospitalizes a second
A Minnesota woman who died from a hantavirus infection may have contracted the rodent-linked virus during a trip through the Grand Canyon, authorities said. The woman, whose name and hometown were not released, died 12 Jun 2009 at a hospital outside Arizona, said Trish Lees, a spokeswoman for the Coconino County Arizona Health Department. The woman, in her early 50s, may have contracted the disease during a family boating trip on the Colorado River in mid- to late-May 2009, Lees stated.

It is the first hantavirus infection case linked to Arizona in 2009. In 2008, one case was reported in the state, Lees said. Hantavirus infections are contracted by inhaling infected particles from mouse droppings and urine. The woman told health officials she was not aware of any recent contact with mice.

Meanwhile, the New Mexico state health department reports that a 65-year-old San Miguel County man has also contracted hantavirus infection. The man has been hospitalized at the University of New Mexico Hospital. The state health department is conducting an environmental investigation to try to determine where the man contracted the virus and whether people may be at risk.
(ProMED 7/8/09)

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USA (New York): State health department alerts New York City doctors to measles
The health department has identified 11 cases of measles in Brooklyn since May 2009, and is urging doctors to be vigilant and promptly report suspected cases to the agency. Nearly all the known cases have occurred in children who went unvaccinated, leaving them unprotected against the disease. Measles is not common in New York City, but it is highly contagious. "Children should be vaccinated against measles at one year of age," said Dr Jane R Zucker, the Health Department's assistant commissioner for immunization. "Vaccinating eligible children will protect them and help protect infants who are too young to be vaccinated, by reducing their risk of exposure. Delaying a child's vaccination increases the risk of contracting measles and infecting others."
(ProMED 7/5/09)

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USA (North Carolina): Extremely rare bacterium from local lake infects teenager
A 14-year old-boy from North Carolina is in hospital with a rare infection that cost him part of his nose and five teeth after swimming in a local lake. The Fayetteville Observer reports that doctors at University of North Carolina Hospitals in Chapel Hill are treating the boy for an infection caused by a bacterium called Chromobacterium violaceum, which was found in Hope Mills Lake.

The Centers for Disease Control and Prevention says that fewer than 150 cases have been reported worldwide since 1927. The patient's father said his son is in serious condition but that antibiotics are beginning to clear the infection. Doctors had to remove the left side of his nose and palate, and his father said he lost five teeth. Doctors won't consider reconstructive surgery until the infection is gone.
(ProMED 6/29/09)

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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

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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

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CHIKUNGUNYA
Malaysia
Health director-general Tan Sri Dr Mohd Ismail Marican said the chikungunya epidemic registered a drop during the week of 27 Jun 2009, with 61 cases compared with 88 cases the previous week. However, cases had risen in five states: Penang (5 cases), Johor (2), and one in each of Selangor, Kuala Lumpur, Putrajaya, and Negeri Sembilan. The total number of chikungunya cases so far in 2009 was 2836 cases compared with 4271 in 2008.
(ProMED 7/5/09)

Thailand
While much attention has been placed on the fight against the spread of pandemic H1N1 influenza in Phuket, the island is still suffering from a chikungunya outbreak and has the highest per capita infection rate of any province in Thailand.

According to recently released figures from the Phuket Public Health Office (PPHO), there have been 2155 confirmed cases of the disease in the province in the first half of 2009 with no deaths. Phuket had an overall incidence of 669 reported cases per 100,000 people for the first half of 2009. The province thus ranks first in the country although the number of cases remains much higher in the lower south, where the outbreak originated. Dr Pongsawas also noted the high incidence rate for Phuket is skewed by Phuket's huge unregistered population of migrant workers.

The incidence is calculated as the number of reported cases divided by the registered population, which is less than half of the actual number of people on the island according to most estimates. However, chikungunya cases often go unreported as many sufferers do not seek medical attention from hospitals, but from private clinics or simply by treating themselves with non-prescription drugs.
(ProMED 7/3/09)

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CHOLERA, DIARRHEA, & DYSENTARY
Indonesia
Diarrhea has spread rapidly in Polewali Mandar (Polman) regency, killing at least nine people in the past two weeks. The Polman Health Agency recorded 1200 cases of diarrhea in the regency, forcing it to declare an emergency situation in Luyo district, which had 396 cases with five fatalities. "Most victims were sent too late to the hospital for medical treatment," agency head Ayub Ali said on12 Jun 2009. He said besides Luyo, diarrhea was also prevalent in other districts.

From October to December 2008, the agency recorded 2800 cases of diarrhea in the districts, with 28 deaths attributed to the disease. Ayub said his agency had conducted several activities to prevent the disease from spreading, such as opening medical posts, providing medical treatment, chlorinating residents' wells and advising people on healthy living. "The problem is residents are still consuming contaminated river water. It's difficult to chlorinate the river."

Meanwhile, Alor regency administration in East Nusa Tenggara declared an emergency situation on 9 Jun 2009 after five residents died of diarrhea in West Kalondama village in the past four days. Alor Health Agency head Yulius Plaikol said his agency had sent a team to the village to prevent the disease from spreading to neighboring villages.
(ProMED 7/9/09)

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DENGUE
Chinese Taipei
On 2 Jul 2009, the Taiwan Centers for Disease Control (CDC) advised travelers to Southeast Asia to take proper precautions against dengue fever, as a large number of imported cases have been confirmed in Taipei so far in 2009.

The 90 imported cases of dengue fever recorded in Taipei in 2009 represent a steep rise compared to the same period in 2008 when 64 cases were confirmed. According to the data, 46 of the cases were contracted in Indonesia, 22 were imported from Viet Nam, 6 from Thailand, 5 from Cambodia, 4 from the Philippines, and 2 each from Myanmar and Singapore.
(ProMED 7/6/09)

Malaysia
The level of involvement of communities in 'gotong-royong' (self-help) activities for combating and controlling dengue fever is still low, as only 28 activities were held throughout the country compared to the 69 called for in the first 25 weeks of 2009.

During the period of 21-27 Jun 2009, there were 749 dengue fever cases with one death each in Kuala Lumpur and Kelantan compared to 738 cases the week before, Health Director-General Tan Sri Dr Mohd Ismail Marican said on 3 Jul 2009. "The five states that showed sharp rises in dengue cases were Perlis (57 percent), Melaka (36 percent), Kuala Lumpur and Putrajaya (34 percent), Penang (30 percent) and Kedah (15 percent)," he said.

According to him, the total number of dengue cases in 2009 is 24,534 cases with 62 deaths compared to 20,721 cases with 45 deaths in the same period of 2008.
(ProMED 7/6/09)

Philippines
A dengue outbreak was declared in Isabela's Santiago City amid rising cases of people afflicted with the disease since January 2009, including three recent deaths. Classes have been suspended in a private elementary school for three days in Ramon town, also in Isabela, following fears of possible spread of dengue among schoolchildren.

Santiago City's dengue outbreak declaration came after 181 cases of dengue had been reported there from January to June 2009 with at least two deaths, recently. Of these, 67 cases were reported in June 2009 alone while at least 30 cases were monitored in May 2009, with health officials expressing alarm that cases may increase with the onset of the rainy season.

In addition, dengue has claimed its 11th victim in Cebu City this year with the death of a 3-year-old child on 1 Jul 2009, a day after she was brought to the Cebu City Medical Center (CCMC). The child was the third victim to die of dengue fever in Barangay Labangon in 2009. Her death came 12 days after a 4-year-old boy from Barangay Talamban succumbed to dengue. A 10-year-old girl from Sikatuna St. died of dengue on 9 May 2009.

Macasocol said that City Hall offers free complete blood counts and platelet counts to possible cases of dengue, so there should have been no reason for residents not to bring the sick to the CCMC or to the barangay health centers for consultation.

City Health Department records showed that 381 persons have contracted dengue fever in Cebu City from 1 Jan - 20 Jun 2009. That figure is 42 percent lower than the 653 dengue cases recorded during the same period in 2008. While 11 lives have been lost in 2009, the number is 62 percent lower compared to the 29 deaths due to dengue in 2008.
(ProMED 6/29/09, 7/6/09)

Viet Nam
Viet Nam's Ministry of Health confirmed 26 deaths out of the country's 27,000 cases of dengue fever in the first half of 2009, according to reports on 2 Jul 2009. The number of infected cases represents a 32 percent increase from the same period of 2008, said the ministry.

The disease mostly occurs in the country's southern provinces such as Ho Chi Minh City, Kien Giang, Soc Trang, Ben Tre and Dong Nai. The ministry has dispatched working groups to 15 provinces and municipalities to inspect the prevention and control work on dengue fever.
(ProMED 7/6/09)

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4. Articles
The emerging influenza pandemic: estimating the case fatality ratio
Wilson N, Baker MG. Eurosurveillance. 2 Jul 2009; 14(26). Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19255.

To determine appropriate influenza pandemic containment and mitigation measures, health authorities need to know the approximate case fatality ratio (CFR) for this new infection. We present four different methods for very provisionally estimating the plausible range of the CFR for symptomatic infection by this pandemic strain in developed countries. All of the methods produce substantially lower values (range 0.06% to 0.0004%) than a previously published estimate for Mexico (0.4%). As these results have many limitations, improved surveillance and serological surveys are needed in both developed and developing countries to produce more accurate estimates.

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Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey
Ruben GJ et al. BMJ. 2 July 2009; 339. Available at http://www.bmj.com/cgi/content/abstract/339/jul02_3/b2651.

Abstract
Objective To assess whether perceptions of the swine flu outbreak predicted changes in behaviour among members of the public in England, Scotland, and Wales.

Design Cross sectional telephone survey using random digit dialling. Setting Interviews by telephone between 8 and 12 May. Participants 997 adults aged 18 or more who had heard of swine flu and spoke English.

Main outcome measures Recommended change in behaviour (increases in handwashing and surface cleaning or plans made with a "flu friend") and avoidance behaviours (engaged in one or more of six behaviours such as avoiding large crowds or public transport).

Results 37.8% of participants (n=377) reported performing any recommended behaviour change "over the past four days . . . because of swine flu." 4.9% (n=49) had carried out any avoidance behaviour. Controlling for personal details and anxiety, recommended changes were associated with perceptions that swine flu is severe, that the risk of catching it is high risk, that the outbreak will continue for a long time, that the authorities can be trusted, that good information has been provided, that people can control their risk of catching swine flu, and that specific behaviours are effective in reducing the risk. Being uncertain about the outbreak and believing that the outbreak had been exaggerated were associated with a lower likelihood of change. The strongest predictor of behaviour change was ethnicity, with participants from ethnic minority groups being more likely to make recommended changes (odds ratio 3.2, 95% confidence interval 2.0 to 5.3) and carry out avoidance behaviours (4.1, 2.0 to 8.4).

Conclusions The results support efforts to inform the public about specific actions that can reduce the risks from swine flu and to communicate about the government’s plans and resources. Tackling the perception that the outbreak has been "over-hyped" may be difficult but worthwhile. Additional research is required into differing reactions to the outbreak among ethnic groups.

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5. Notifications
Updated US Centers for Disease Control pandemic H1N1 influenza guidance
Guidance for obstetric settings: http://www.cdc.gov/h1n1flu/guidance/obstetric.htm.
Home care guidance: http://www.cdc.gov/h1n1flu/guidance_homecare.htm/?breaknews.
Guidance on state and local planning for vaccination program: http://www.cdc.gov/h1n1flu/vaccination/statelocal/planning.htm/?breaknews.

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Canadian system uses air traffic patterns to predict global infectious disease spread
The Canadian BIO.DIASPORA system, developed by an infectious disease physician and colleagues, uses air traffic patterns to predict global infectious disease spread. The system is based on air travel patterns to predict how infectious diseases will spread around the world, offering a means of halting transmission by taking preventive measures as soon as an outbreak occurs. BIO.DIASPORA accurately predicted how the H1N1 flu virus would circulate worldwide after arising in Mexico earlier this year.

Using the system, the team analyzed the flight itineraries of more than 2.3 million passengers who departed Mexico on commercial flights during March and April 2008 to predict the spread of H1N1 a year later. The findings show the international destinations of air travelers leaving Mexico were strongly associated with confirmed importations of the virus around the world.

Additional information available at http://www.biodiaspora.org/.

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Weekly Epidemiological Record Bulletin
WHO. 2 July 2009; 84(27): 261-280. Available at http://www.who.int/wer.

Contents include:
- Human infection with new influenza A (H1N1) virus: WHO Consultation on suspension of classes and restriction of mass gatherings to mitigate the impact of epidemics caused by influenza A (H1N1), May 2009
- Progress towards the 2012 measles elimination goal in WHO's Western Pacific Region, 1990-2008

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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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 apecein@u.washington.edu