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Vol. XII, No. 22 ~ EINet News Briefs ~ Oct 30, 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
- Weekly APEC update of pandemic influenza (H1N1) 2009
- 2009 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO situation update on pandemic influenza H1N1
- Global: Experts advise WHO on pandemic vaccine policies and strategies
- European Union: Up to 30 percent of population could contract pandemic influenza
- European Union: Regulators stick with 2-dose pandemic vaccine schedule
- China: Tough flu fight ahead
- China: Public's interest in H1N1 vaccine plunges
- Chinese Taipei: Second case of oseltamivir-resistant pandemic H1N1
- Japan: New antiviral drug in clinical trials
- Canada: Some doctors slow to join vaccination effort
- Canada: Canada buys unadjuvanted vaccine
- El Salvador: H1N1 and dengue co-infection
- USA: Experts show benefits of IV antivirals for severe H1N1
- USA: Statins may help patients with severe seasonal flu
- USA: Novartis vaccine order is on track
- USA: President Obama Signs Emergency Declaration for H1N1 Flu
- USA: MedImmune reports clinical findings on intranasal pandemic vaccine

2. Infectious Disease News
- Philippines: Leptospirosis deaths climb to 167
- Viet Nam (Quang Ngai, Can Tho): Conjunctivitis outbreak
- Viet Nam (Hanoi): Suspected chikungunya outbreak
- Russia (St. Petersburg): Outbreak of hand, foot and mouth disease
- Russia (Ryazansk Oblast): Outbreak of hepatitis A
- USA (New York): Mumps outbreak strikes 57 people

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

4. Articles
- Identification and characterization of a highly virulent triple reassortant H1N1 swine influenza virus in the United States.
- Acceptability of A/H1N1 vaccination during pandemic phase of influenza A/H1N1 in Hong Kong: population based cross sectional survey
- Vaccination with ALVAC and AIDSVAX to Prevent HIV-1 Infection in Thailand
- Pandemic influenza in a southern hemisphere setting: the experience in Peru from May to September, 2009

5. Notifications
- APEC EINet "Hot Topics" Video Conference: Lessons Learned from the First Wave
- World Response Conference on Global Outbreak 2009: H1N1 Flu + H5N1 Flu
- ISHEID Symposium on HIV and Emerging Infectious Diseases
- EPIDEMICS²: Second International Conference on Infectious Diseases Dynamics
- Updated influenza guidance and information from the US CDC
- HealthMap iPhone App


1. Influenza News

Global
Weekly APEC update of pandemic influenza (H1N1) 2009

China
The Chinese mainland reported 2,024 confirmed cases of the A/H1N1 influenza in the 48 hours ending at 3 p.m. 23 Oct 2009, bringing the total number to 33 064, the Ministry of Health said. So far, a total of 26,588 patients have recovered. Fourteen of 44 patients in serious condition have been cured, the ministry said. China is currently experiencing what experts called "a second round of A/H1N1 flu infection," as recent infections are more widespread and increasing rapidly.
(ProMED 10/25/2009)

Thailand
According to data compiled by the Bureau of Epidemiology, Department of Disease Control, three new deaths from novel strains of influenza type A (H1N1) infection were confirmed between 11-17 Oct 2009. A total of 96 cases were identified in 32 provinces between 3-17 Oct 2009. There have been reported cases from every sector in the provinces, with new cases reported in the north, northeast, and central regions. New cases of influenza-like illness are increasingly reported in Roi Et province.
(ProMED 10/25/2009)

USA
A report from the Centers for Disease Control and Prevention (CDC) estimates that the true number of H1N1 influenza cases in the first 4 months of the epidemic may have been as high as 5.7 million, or more than 100 times the official case count. CDC officials have said repeatedly that the actual number of cases is probably far more than the number of known, confirmed cases. Today's report in Emerging Infectious Diseases appears to be the agency's first methodical attempt to estimate the true numbers.

To estimate the real number of cases and hospitalizations, the authors used a probabilistic multiplier model similar to one that has been used to estimate the extent of foodborne disease in the United States. For each step, they identified a range of values derived from previous studies and from recent surveys and investigations of H1N1 outbreaks. They adjusted for the fact that confirmatory testing was done much more often in the first few weeks of the epidemic than it was later, after physicians were encouraged to reserve testing mainly for hospital patients. Using this method, the researchers estimated that each known H1N1 case represented a total of between 47 and 148 cases, with a median of 79 cases. This yielded an estimated total of between 1.8 million and 5.7 million cases, with a median estimate of 3.0 million, in a nation with a current estimated population, according to the Census Bureau, of about 307 million.
(CIDRAP 10/29/2009)

Viet Nam
Viet Nam confirmed 4 additional A/H1N1 influenza related deaths on 23 Oct 2009. The four victims were a 25-year old woman in her fourth month of pregnancy, a 24-year old woman in her seventh month of pregnancy, a 2-year-old girl with congenital heart disease and a 48-year old woman suffering from blood disease. The total fatalities from the virus now total 31. On the same day, Viet Nam confirmed 10,376 A/H1N1 infections scattered across 59 provinces and cities. However, 9,952 of those have recovered and have been discharged from hospital.
(ProMED 10/25/2009)

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2009 Cumulative number of human cases of avian influenza A/H5N1

Economy / Cases (Deaths)
China/ 7 (4)
Egypt/ 36 (4)
Viet Nam/ 4 (4)
Total/ 47 (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: 442 (262)
(WHO 9/24/09 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 (last updated 9/10/09)

WHO's map 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 7/27/09): >http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: WHO situation update on pandemic influenza H1N1

As of 17 October 2009, worldwide there have been more than 414,000 laboratory confirmed cases of pandemic influenza H1N1 2009 and nearly 5000 deaths reported to WHO. As many countries have stopped counting individual cases, particularly of milder illness, the case count is significantly lower than the actually number of cases that have occurred. WHO is actively monitoring the progress of the pandemic through frequent consultations with the WHO Regional Offices and member states and through monitoring of multiple sources of data.

Mongolia, Rwanda, and Sao Tome and Principe have reported pandemic influenza cases for the first time this week. Iceland, Sudan, and Trinidad and Tobago reported their first fatal cases.

In general, influenza activity in the northern hemisphere is much the same as in the last week, though respiratory disease activity continues to spread and increase in intensity. In North America, the USA is still reporting nationwide rates of Influenza-Like Illness (ILI) well above baseline rates with high rates of pandemic H1N1 2009 virus detections in clinical laboratory specimens (29% of all specimens tested are positive for influenza A and all of those subtyped are pandemic H1N1 2009 virus). Canada reports increases in ILI rates for the fourth straight week but the highest level of activity is in the western province of British Columbia. Mexico still reports active transmission in some areas of the country. Although influenza activity is low in most countries in Europe, in Belgium, Israel, the Netherlands, Norway, and parts of the United Kingdom consultation ILI/ARI rates are above baseline levels. Similarly the number of influenza virus detections relatively high, which may indicate the early start of an influenza season. Rates of respiratory illness in Eastern Europe and Northern Asia are increasing but are not yet at levels normally seen in an influenza season (baseline levels are not defined in many countries of the area). Of note, the proportion of cases in Asia that are related to seasonal influenza A(H3N2) continue to decline globally as the proportion related to pandemic H1N1 2009 virus increases. Currently, only East Asia is reporting any significant numbers of influenza A(H3N2) isolates.

In tropical areas of the world, rates of illness are generally declining, with a few exceptions. Cuba, Colombia, and El Salvador are reporting increases in the tropical region of the Americas. In tropical Asia, of the countries that are reporting this week, all report decreases in respiratory disease activity. The temperate region of the southern hemisphere has no significant pandemic related activity in the past week.
(WHO 10/23/2009)

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Global: Experts advise WHO on pandemic vaccine policies and strategies

The Strategic Advisory Group of Experts (SAGE) on Immunization, which advises WHO on policies and strategies for vaccines and immunization, devoted a session of its 27-29 October meeting to pandemic influenza vaccines. The experts reviewed the current epidemiological situation of the pandemic worldwide and considered issues and options from a public health perspective. Items on the agenda included the status of vaccine availability, results from clinical trials on vaccine immunogenicity, and early results from safety monitoring in countries where administration of the H1N1 pandemic vaccine is currently under way.

Current situation
Globally, teenagers and young adults continue to account for the majority of cases, with rates of hospitalization highest in very young children. Between 1% to 10% of patients with clinical illness require hospitalization. Of hospitalized patients, from 10% to 25% require admission to an intensive care unit, and from 2% to 9% have a fatal outcome. Overall, from 7% to 10% of all hospitalized patients are pregnant women in their second or third trimester of pregnancy. Pregnant women are ten times more likely to need care in an intensive care unit when compared with the general population.

Based on these and other current findings, the experts made a number of recommendations.

Single dose recommended
The experts noted that a variety of pandemic vaccines, including live attenuated and both adjuvanted and non-adjuvanted inactivated vaccines, have now been licensed for use by regulatory authorities. SAGE recommended the use of a single dose of vaccine in adults and adolescents, beginning at the age of 10 years, provided such use is consistent with indications from regulatory authorities.

Data on immunogenicity in children older than 6 months and younger than 10 years are limited and more studies are needed. Where national authorities have made children a priority for early vaccination, SAGE recommended that priority be given to the administration of one dose of vaccine to as many children as possible. SAGE further stressed the need for studies to determine dosage regimens effective in immunocompromised persons.

Co-administration of vaccines
Clinical trials investigating the co-administration of seasonal and pandemic vaccines are ongoing, but SAGE acknowledged the recommendation, from the US Centers for Disease Control and Prevention, that live attenuated seasonal and live attenuated pandemic vaccines should not be co-administered. The experts recommended that seasonal and pandemic vaccines can be administered simultaneously, provided both vaccines are inactivated, or one is inactivated and the other is live attenuated. The experts found no evidence that co-administration of vaccines, as recommended, would increase the risk of adverse events.

Vaccine safety
The experts reviewed early results from the monitoring of people who have received pandemic vaccines and found no indication of unusual adverse reactions. Some adverse events following vaccination have been notified, but these are well within the range of those seen with seasonal vaccines, which have an excellent safety profile. Although early results are reassuring, monitoring for adverse events should continue.

Vaccines for pregnant women
Concerning vaccines for pregnant women, SAGE noted that studies in experimental animals using live attenuated vaccines and non-adjuvanted or adjuvanted inactivated vaccines found no evidence of direct or indirect harmful effects on fertility, pregnancy, development of the embryo or fetus, birthing, or post-natal development. Based on these data and the substantially elevated risk for a severe outcome in pregnant women infected with the pandemic virus, SAGE recommended that any licensed vaccine can be used in pregnant women, provided no specific contraindication has been identified by the regulatory authority.

Vaccines for the southern hemisphere in 2010
SAGE also considered vaccines for use in the southern hemisphere during the 2010 winter season. Two options were assessed: a trivalent vaccine, effective against the H1N1 pandemic virus, the seasonal H3N2 virus, and influenza B viruses, and a bivalent seasonal vaccine, effective against H3N2 and influenza B viruses, which might need to be supplemented with a separate monovalent H1N1 pandemic vaccine. The experts concluded that both options should remain available for vaccine formulations in the southern hemisphere, subject to national needs.
(WHO 10/30/2009)

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Europe/Near East
European Union: Up to 30 percent of population could contract pandemic influenza

In the coming months one in three EU citizens could contract the H1N1 flu virus, according to a European health commissioner. "From the information we have, up to 30 percent of the population could catch swine flu. In this event we must unfortunately expect a significant number of deaths," said Androulla Vassiliou. "The virus may evolve and become significantly more aggressive in the coming months," she warned, calling for Europeans to "be vigilant" and "not neglect" the socio-economic effects swine flu could have. "The economic recovery in the EU could be weakened," the commissioner said, citing tourism and the leisure industry as possible sectors to be hit.
(Agence France-Presse 10/26/2009)

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European Union: Regulators stick with 2-dose pandemic vaccine schedule

Europe's drug regulatory agency today announced that it would stick to its initial recommendation that the three pandemic H1N1 vaccines it approved be given in two doses, despite data from two companies that suggests one-dose efficacy. The agency said the data on the GlaxoSmithKline and Novartis vaccines, both adjuvanted, were too limited to warrant recommending a single-dose schedule, but added that one dose may be sufficient in adults. The third vaccine is a cell-based product made by Baxter.
(CIDRAP 10/23/2009)

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Asia
China: Tough flu fight ahead

Chinese government sources said flu activity is spiking in many parts of the country and clusters of illnesses are occurring in schools. China's state council said the country's challenge is grim. The assessment was prompted by the death of a student at a university in Beijing where other students were ill. The fatality is China's fourth from the pandemic H1N1 virus.
(CIDRAP 10/29/2009)

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China: Public's interest in H1N1 vaccine plunges

A poll finds that only 30% of Chinese would like to get the H1N1 flu vaccine, far below the 76% who said they wanted it in a poll 2 months ago, according to a report in the British newspaper The Independent. Citing safety concerns, 54% said they did not plan to be vaccinated, according to the poll by China Daily and the Web site sohu.com. The government plans to inoculate 5% of the population, about 65 million people, the story said. So far 300,000 people have been vaccinated.
(CIDRAP 10/26/2009)

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Chinese Taipei: Second case of oseltamivir-resistant pandemic H1N1

On 27 Oct 2009, the Pandemic (H1N1) Central Epidemic Command Center of Taipei announced the detection of another isolate of pandemic (H1N1) 2009 virus which was resistant to oseltamivir. The virus, isolated from a patient with documented exposure to oseltamivir treatment, is the second case of oseltamivir-resistant strain among 339 isolates tested in Taipei since 1 Jun 2009. Investigations have not found the resistant virus in close contacts of patients harboring oseltamivir-resistant virus. Therefore, the patient represents a sporadic case of oseltamivir resistance.
(ProMED 10/27/2009)

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Japan: New antiviral drug in clinical trials

Today Fujifilm Holdings Corp, the parent company of Toyama Chemical, announced the launch of phase 3 clinical trials of T-705, a viral RNA polymerase inhibitor. The company said that phase 2 studies showed promising results as a treatment for seasonal flu and that animal studies have shown efficacy against the pandemic H1N1 virus. The company says because the drug's mechanism of action is different than existing antivirals, it might provide an alternative treatment, especially given concerns about viruses developing resistance to neuraminidase inhibitors like oseltamivir, zanamivir, and peramivir.
(CIDRAP 10/29/2009)

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Americas
Canada: Some doctors slow to join vaccination effort

Family physicians in parts of Canada have been slow to sign up to give H1N1 vaccinations, citing various obstacles. In Ontario, some doctors have been deterred by a requirement that they order vaccine in 500-dose lots, while others objected to a demand that they provide a weekly record of every dose delivered. Some provinces are not asking family doctors to help launch the vaccination drive and instead are focusing on mass immunization clinics.
(CIDRAP 10/29/2009)

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Canada: Canada buys unadjuvanted vaccine

To provide pregnant women earlier access to pandemic H1N1 vaccine, Canada's health minister announced yesterday the purchase of 200,000 doses of an unadjuvanted product from CSL Ltd in Australia, the Canadian Press reported. Officials are particularly concerned about women in remote communities. The bulk of Canada's H1N1 vaccine is adjuvanted, and its unadjuvanted version awaits approval. Pregnant women are among those at greatest risk for flu complications.
(CIDRAP 10/27/2009)

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El Salvador: H1N1 and dengue co-infection

In the eastern zone of the country, there have been reports of patients with co-infection of influenza A (H1N1) and classical dengue fever, confirmed by the Vice Minister of Health, Eduardo Espinoza. In total, there have been 4 such cases of co-infection nationwide. Up to the present, El Salvador has reported 6 deaths from dengue hemorrhagic fever and 22 from H1N1 infection.
(ProMED 10/25/2009)

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USA: Experts show benefits of IV antivirals for severe H1N1

Though only available for emergency use, intravenous (IV) antivirals peramivir and zanamivir have been lifesaving for some pandemic H1N1 patients, including two dramatic cases that doctors presented yesterday during a US Centers for Disease Control and Prevention (CDC) conference call for clinicians. The first case described a severely ill 17-year-old boy who was given 600 mg doses of IV peramivir for 5 days after an apparent failure to uptake oseltamivir suspension through his nasogastric tube. The second case was of a 10-year-old immunocompromised girl with prolonged shedding of oseltamivir-resistant H1N1. She was treated with IV zanamivir, 600 mg every 12 hours. Both patients recovered after receiving IV antiviral treatment.

On Oct 23 federal officials issued an emergency use authorization for IV peramivir, to make it easier for physicians to obtain for their severely ill. Though IV zanamivir has not been studied as long as IV peramivir, physicians can request it through the emergency use provision and have used it during the H1N1 pandemic, especially when managing the few oseltamivir-resistant cases that have surfaced.
(CIDRAP 10/29/2009)

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USA: Statins may help patients with severe seasonal flu

Research presented recently examined the effect of the cholesterol-lowering drugs called statins on the clinical course of people who were already taking the drugs and then were hospitalized with lab-confirmed flu infections in the 2007-08 flu season. Those who were already on statins were half as likely to die, Meredith Vandermeer of the Oregon Public Health Division said. The patients were identified via surveillance in 10 states conducted by the CDC's Emerging Infections Programs; data on their lab results, prescriptions and outcome were drawn from reviews of their medical records. There were 2,800 lab-confirmed cases of flu in the surveillance results, Vandermeer said; 801 of those patients were recorded as taking statins during their hospital stay, presumably because they had been prescribed them before admission. Among the 2,800, 17 people who were on statins died, versus 64 were not on statins. Proportionally, that is 2.1% of those on statins and 3.2% of those not taking the drugs-a risk reduction of approximately half, Vandermeer said.

The connection between statins and flu survival, which has been reported in other research, may be due to the drugs' ability to damp down the body's inflammatory response to influenza. Because the study was purely observational, it should not be taken as a recommendation to administer statins during severe flu infection, Vandermeer cautioned: "We encourage further research and randomized controlled trials."
(CIDRAP 10/29/2009)

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USA: Novartis vaccine order is on track

Novartis said today it is on track to produce 90 million units of bulk pandemic vaccine antigen to the US market, enough for 60 million doses. It expects multidose and prefilled vial deliveries to reach 25 to 30 million by the end of November. The company has shipped 7.5 million doses. Novartis said early vaccine yield was low, but a new seed strain it began using in mid September is getting a 63% yield. The CDC said that total US H1N1 vaccine received is now at 24.8 million doses.
(CIDRAP 10/29/2009)

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USA: President Obama Signs Emergency Declaration for H1N1 Flu

In an effort to proactively address the ongoing pandemic, the President signed a National Emergency Declaration on H1N1 that allows healthcare systems to quickly implement disaster plans should they become overwhelmed. This declaration gives authority for the Department of Health and Human Services (HHS) to waive certain regulatory requirements for healthcare facilities in response the ongoing pandemic. Specifically, healthcare facilities will be able to submit waivers to establish alternate care sites, and modified patient triage protocols, patient transfer procedures and other actions that occur when they fully implement disaster operations plans.
(The White House Blog 10/25/2009)

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USA: MedImmune reports clinical findings on intranasal pandemic vaccine

MedImmune yesterday reported long-awaited clinical trial findings on the immunogenicity of its nasal-mist pandemic H1N1 flu vaccine. US officials approved the live attenuated vaccine on Sep 15 2009 without the immunogenicity results. In a press release the company said trials in children and adults showed that the safety and immunogenicity profiles of the pandemic vaccine are similar to those of its seasonal vaccine. The firm said further data are being collected after a second dose of the vaccine.
(CIDRAP 10/23/2009)

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2. Infectious Disease News

Asia
Philippines: Leptospirosis deaths climb to 167

Almost a month after storm Ondoy flooded Manila and Rizal, about 167 Filipinos have died from leptospirosis, a health official said on 26 Oct 2009. The country's total number of leptospirosis cases related to the Ondoy floods alone hit 2,158 -- a 3-fold increase from 2008's total of 769 cases, said Dr Lyndon Lee Suy, program manager for emerging and re-emerging infectious diseases division of the Department of Health (DoH). Lee Suy said the number of cases will continue to rise over the next few weeks but not to the same degree as seen in recent weeks.
(ProMED 10/26/2009)

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Viet Nam (Quang Ngai, Can Tho): Conjunctivitis outbreak

Quang Ngai Province General Hospital on the central coast has treated more than 1200 people with conjunctivitis in the past week. Most of them have been children under 6 years old, a hospital spokesman said. Private clinics are also overloaded, with each treating between 100 and 120 cases of conjunctivitis in the last week. In the provincial capital, also called Quang Ngai, many kindergarten classes are two thirds empty as infected children are forced to stay home until their eyes heal.

Conjunctivitis is also afflicting the city of Can Tho in the Mekong Delta, as it does to a lesser degree every year. Chief ophthalmologist Hoang Quang Binh of the Can Tho Eye and Odonto-Stomatology Hospital said 2009's outbreak of conjunctivitis had come later and was more widespread than usual, especially in the city's schools. Binh's hospital is handling over 100 fresh cases of conjunctivitis daily, while Can Tho General Hospital reports a tripling in the number of patients with the condition.
(ProMED 10/26/2009)

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Viet Nam (Hanoi): Suspected chikungunya outbreak

Viet Nam is verifying an outbreak in Hanoi of a mosquito-borne virus that closely resembles the dengue fever virus, a health ministry official said on 19 Oct 2009. Thus far, 60 percent of patients with classic dengue symptoms have tested negative for dengue, according to Vu Sinh Nam, deputy director general of the Preventive Health and Environment Department. At this stage it seems they have contracted the look-a-like chikungunya virus, which is carried by the Aedes albopictus mosquito. In response, the World Health Organization has provided 50 testing kits for the chikungunya virus for testing patients who present with dengue-like symptoms at local cities and large towns.

Since the beginning of 2009, 6,750 people in Hanoi have been admitted to hospitals with dengue symptoms, 14 times more than in the same period in 2008, according to the Ministry of Health.
(ProMED 10/22/2009)

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Russia (St. Petersburg): Outbreak of hand, foot and mouth disease

Since August of this year cases of hand, foot and mouth disease (HFMD) have been recorded in several kindergartens and schools in St. Petersburg. The disease has been present among young children for several months. A quarantine is not usually announced or enforced, hence information on the extent and progress of the outbreak is sparse. HFMD is associated with enterovirus infection. Enterovirus 71-associated infection is considered to be the most medically significant, since this virus has neuropathogenic potential.
(ProMED 10/23/2009)

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Russia (Ryazansk Oblast): Outbreak of hepatitis A

About 20 children in the village of Kostin in the Ribnovskii Region have contracted hepatitis A virus. Most of the infected children are pupils of a local residential school. Among the possible causes of the outbreak is the poor quality drinking water available in the village of Kostin. Local physicians have also reported a general rise in the incidence of hepatitis A in the Region. According to the Ryazansk Oblast Public Health Service, there have been more than 250 cases of hepatitis A virus infection recorded since the beginning of the year. However, the current outbreak in Kostin is the most severe.
(ProMED 10/20/2009)

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Americas
USA (New York): Mumps outbreak strikes 57 people

The New York Department of Health has confirmed an outbreak of mumps in the Borough Park section of Brooklyn where at least 57 confirmed or probable cases have been reported since 21 Aug 2009. Officials say the outbreak was traced back to a child who went to Britain, then attended summer camp in upper New York State and infected fellow campers there who brought the disease back with them to Brooklyn where it has continued to spread. Most of the victims have been between the ages of 10 to 15, but the youngest patient so far was a 1-year-old, while the oldest victim was 42. Health officials are puzzled over why it is spreading since at least 75 percent of the Brooklyn victims had received the normal 2 doses of mumps vaccine.
(ProMED 10/23/2009)

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3. Updates
INFLUENZA A/H1N1

The following websites provide the most current information, surveillance, and guidance.

- 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/disease/swineflu/frequently_asked_questions/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.

- WHO regional offices
Africa: http://www.afro.who.int/
Americas: http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=805&Itemid=569
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Europe: http://www.euro.who.int/influenza/ah1n1
South-East: http://www.searo.who.int/EN/Section10/Section2562.htm
Western Pacific: http://www.wpro.who.int/health_topics/h1n1/

- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: http://www.flu.gov
MOH Mexico: http://portal.salud.gob.mx/index_eng.html
PHA of Canada: http://fightflu.ca

- Other useful sources
CIDRAP: Influenza A/H1N1 page: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promedmail.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/.
- 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.flu.gov/. View archived Webcasts on influenza pandemic planning.
- CIDRAP: http://www.cidrap.umn.edu/
- 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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DENGUE

Viet Nam The Ministry of Health said on 24 Oct 2009 that within the last month, 55 out of 63 provinces in Viet Nam recorded 17,140 cases of dengue fever with 14 deaths. Since the beginning of the 2009, Viet Nam has seen over 74,242 dengue cases, an increase of 16.8 percent over the same period in 2008. Of the total, 58 have died, 6 less compared to 2008. Hanoi has seen the highest increase of people infected in the country, with 8000 patients so far in 2009, 15 times higher than in 2008. It is also the capital city's worst dengue outbreak in the past 10 years.
(ProMED 10/26/2009)

Philippines (Cebu)
The dengue virus claimed yet another life, this time that of a 3-year-old boy, bringing the fatalities for this year to 31. This latest fatality was brought to the Cebu City Medical Center after few days of experiencing fever, a move that was discouraged by medical experts who insist that children should be rushed to the hospital upon showing signs of fever. The boy died the next day. Although there were already 31 dengue-related deaths recorded in Cebu City alone from January 2009, this figure is still comparatively low compared to the 43 deaths for the same period last year. While there are fewer deaths during the first 9 months this year, there are more dengue cases compared to the same period in 2008. Statistics place dengue infection at 2 persons for every 1000 people in Cebu City.
(ProMED 10/20/2009)

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CHOLERA, DIARRHEA, and DYSENTARY

Papua New Guinea (Morobe)
Lae city in Papua New Guinea's Morobe Province has again been put on red alert after 6 people were admitted to the cholera treatment center in a single day late last week. The National newspaper reports that on 15 Oct 2009, 6 people were reported to have gone to the centre with symptoms of cholera. Another person was admitted on 16 Oct 2009. Dr Likei Theo, chairman of the Morobe cholera outbreak task force, says the emergence of a large number of cases in one day showed that the people were returning to their old ways and were not as fastidious over hygiene as they had been.
(ProMED 10/23/2009)

Russia (Novosibirsk)
Workers in a Novosibirsk factory making chemical concentrates begun seeking medical care for gastrointestinal (GI) symptoms over the past week. Valentina Varlamova, who is the head of 25th regional section of Federal Medical-Biological Agency, reported that the number of cases increased to 24 from 8 Oct to 14 Oct 2009. 15 people are in the hospital and 9 people are being treated at home. Tests confirmed shigellosis caused by S. sonnei. An outbreak investigation found the suspected source to be sour cream from the factory canteen. Contamination is thought to have taken place in the canteen itself because the sour cream is sold in open glasses allowing for external contamination.
(ProMED 10/23/2009)

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4. Articles
Identification and characterization of a highly virulent triple reassortant H1N1 swine influenza virus in the United States.

Ma W, Vincent AL, Lager KM, et al. Virus Genes. 28 October 2009; (doi: 10.1007/s11262-009-0413-7). Available at http://www.springerlink.com/content/g0648u86m07370j4/fulltext.pdf.

Abstract. A highly virulent H1N1 influenza A virus, A/Swine/Kansas/77778/2007 (KS07), which caused approximately 10% mortality in finishing pigs, was isolated from herds in the Midwestern United States. Molecular and phylogenic analysis revealed this swine isolate was a triple reassortant virus, similar to an H1N1 virus that infected humans and pigs at an Ohio county fair in August 2007. A pig challenge model was developed to evaluate the pathogenicity and transmission capacity of the KS07 virus. The results confirmed that the KS07 virus is highly virulent in pigs and easily transmitted to sentinel animals. The KS07 virus failed to cross-react with a panel of H1-specific swine sera. Interestingly, the KS07 virus shed for a prolonged period up to 7 days in infected pigs, indicating that this virus can spread efficiently between animals. The highly virulent H1N1 swine influenza virus is further evidence of reassortment among avian, human and swine influenza viruses and justifies the need for continued surveillance of influenza viruses in swine.

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Acceptability of A/H1N1 vaccination during pandemic phase of influenza A/H1N1 in Hong Kong: population based cross sectional survey

Lau JT, Yeung NC, Choi KC, et al. BMJ. 27 October 2009; 339:b4164. Available at http://www.bmj.com/cgi/content/abstract/339/oct27_1/b4164.

Objective. To investigate the intention of the Hong Kong general population to take up vaccination against influenza A/H1N1.

Setting. Cross sectional population based anonymous survey.

Participants. Random sample of 301 adults interviewed by telephone (response rate 80%).

Main outcome measure. Intention to take up vaccination against influenza A/H1N1 under five hypothetical scenarios: vaccination is free; vaccination per dosage costs less than $HK100 (£8; {euro}9; $13), $HK101-200, or more than $HK200; and no data are available on the efficacy and safety of the vaccine.

Results. 45% (n=135) of the participants reported that they would be highly likely take up vaccination if it was free. When vaccination incurred a cost, however, the prevalence of uptake decreased: 36% (n=108) would take up vaccination if it cost less than $HK100, 24% (n=72) if it cost $HK101-200, and 15% (n=45) if it cost more than $HK200; and in absence of proved efficacy and safety decreased to 5% (n=14). Moreover, 32% (n=95) considered universal A/H1N1 vaccination unnecessary. Overall, 39% (n=117) of participants believed that A/H1N1 vaccination would prevent the virus being contracted; 63% (n=189) erroneously believed that efficacy of the vaccine had been confirmed by clinical trials, and 16% (n=49) believed that it is necessary for everyone in Hong Kong to take up vaccination against influenza A/H1N1.

Conclusions. The uptake of vaccination against influenza A/H1N1 by the general population of Hong Kong is unlikely to be high and would be sensitive to personal cost. Evidence about safety and efficacy is critical in determining the prevalence of uptake of vaccination.

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Vaccination with ALVAC and AIDSVAX to Prevent HIV-1 Infection in Thailand

Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S, et al. NEJM. 20 October 2009; (doi: 10.1056/NEJMoa0908492). Available at http://content.nejm.org/cgi/content/full/NEJMoa0908492?query=TOC.

Background. The development of a safe and effective vaccine against the human immunodeficiency virus type 1 (HIV-1) is critical to pandemic control.

Methods. In a community-based, randomized, multicenter, double-blind, placebo-controlled efficacy trial, we evaluated four priming injections of a recombinant canarypox vector vaccine (ALVAC-HIV [vCP1521]) plus two booster injections of a recombinant glycoprotein 120 subunit vaccine (AIDSVAX B/E). The vaccine and placebo injections were administered to 16,402 healthy men and women between the ages of 18 and 30 years in Rayong and Chon Buri provinces in Thailand. The volunteers, primarily at heterosexual risk for HIV infection, were monitored for the coprimary end points: HIV-1 infection and early HIV-1 viremia, at the end of the 6-month vaccination series and every 6 months thereafter for 3 years.

Results. In the intention-to-treat analysis involving 16,402 subjects, there was a trend toward the prevention of HIV-1 infection among the vaccine recipients, with a vaccine efficacy of 26.4% (95% confidence interval [CI], -4.0 to 47.9; P=0.08). In the per-protocol analysis involving 12,452 subjects, the vaccine efficacy was 26.2% (95% CI, -13.3 to 51.9; P=0.16). In the modified intention-to-treat analysis involving 16,395 subjects (with the exclusion of 7 subjects who were found to have had HIV-1 infection at baseline), the vaccine efficacy was 31.2% (95% CI, 1.1 to 51.2; P=0.04). Vaccination did not affect the degree of viremia or the CD4+ T-cell count in subjects in whom HIV-1 infection was subsequently diagnosed.

Conclusions. This ALVAC-HIV and AIDSVAX B/E vaccine regimen may reduce the risk of HIV infection in a community-based population with largely heterosexual risk. Vaccination did not affect the viral load or CD4+ count in subjects with HIV infection. Although the results show only a modest benefit, they offer insight for future research. (ClinicalTrials.gov number, NCT00223080.)

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Pandemic influenza in a southern hemisphere setting: the experience in Peru from May to September, 2009

Gómez J, Munayco CV, Arrasco JC, et al. Euro Surveill. 22 October 2009; 14(42):pii=19371. Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19371.

Abstract. This paper presents a description of Peru's experience with pandemic H1N1 influenza 2009. It is based on data from four main surveillance systems: a) ongoing sentinel surveillance of influenza-like illness cases with virological surveillance of influenza and other respiratory viruses; b) sentinel surveillance of severe acute respiratory infections and associated deaths; c) surveillance of acute respiratory infections in children under the age of five years and pneumonia in all age groups; and d) case and cluster surveillance. On 9 May 2009, the first confirmed case of pandemic H1N1 influenza in Peru was diagnosed in a Peruvian citizen returning from New York with a respiratory illness. By July, community transmission of influenza had been identified and until 27 September 2009, a total of 8,381 cases were confirmed. The incidence rate per 10,000 persons was 4.4 (in the 0-9 year-olds) and 4.1 (in the 10-19 year-olds). During epidemiological weeks (EW) 26 to 37, a total of 143 fatal cases were notified (a case fatality of 1.71%, based on confirmed cases). The maximum peak in the number of cases was reached in EW 30 with 37 deaths. Currently, the impact of the pandemic in the Peruvian population has not been too severe, and fortunately, healthcare centres have not been overwhelmed. However, the future of this pandemic is uncertain and despite the fact that our country has not been seriously affected, we should be prepared for upcoming pandemic waves.

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5. Notifications
APEC EINet "Hot Topics" Video Conference: Lessons Learned from the First Wave

APEC EINet is currently actively organizing a videoconference on pandemic influenza: "Pandemic H1N1 preparedness: lessons learned & preparing for the second wave". The videoconference is set for 4 Nov 2009 Americas time and 5 Nov 2009 Asia time. The session will feature case studies to discuss how preparedness plans affected the response to pandemic influenza, what worked, did not work, and what could be changed for a more effective response in the future. Participating economies are: Australia, Canada, Mexico, Philippines, Singapore, Chinese Taipei, and the USA.

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World Response Conference on Global Outbreak 2009: H1N1 Flu + H5N1 Flu
Las Vegas, Nevada, 12-13 Nov 2009

The purpose is to create an Ad Hoc multi-sector Crisis Management Consortium during the event, to be studied as a model by communities worldwide. It is the first world event to invite leaders representing every sector of society to model a community process to help prepare, respond, and recover from a localized outbreak, as well as broader pandemic.
Additional information and registration available at http://wrcgo.eve-ex.com/.

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ISHEID Symposium on HIV and Emerging Infectious Diseases

The 16th ISHEID Symposium on HIV & Emerging Infectious Diseases will take place in Marseille, France, from 24 to 26 March, 2010. Tackling each topic from basic science to clinical applications, this meeting will deal with issues of HIV/AIDS, Viral Hepatitis, Emerging Infectious Diseases, and welcome many Key Opinion Leaders.

Submit an abstract before 9 Nov 2009: http://ems6.net/r/?F=t52gxqgrsuxuaj8rzw4tzbgnse3bjbkvlppph78fc3wvvx2943s5v72-1224022

Preliminary program: http://ems6.net/r/?F=t52gxqgrsuxuaj8rzw4tzbgnstb7z348677srxae9269mghaltvxj72-1224022

Registration and hotel booking are open on-line, we recommend you secure your participation.

The ISHEID 2010 congress organizing office...
E-mail: isheid@clq-group.com; Ph. : +33 1 44 64 15 15 - Fax : +33 1 44 64 15 16

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EPIDEMICS²: Second International Conference on Infectious Diseases Dynamics
Athens, Greece, 2-4 Dec 2009

Following the highly successful inaugural Epidemics Conference in Asilomar, USA in 2008, the organizers are pleased to announce a second conference in the series to be held in Athens, Greece in December 2009.
H1N1 pdm abstract deadline: 13 November 2009
Additional information and registration available at http://www.epidemics.elsevier.com/.

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Updated influenza guidance and information from the US CDC

Peramivir IV Questions and Answers for Health Care Providers
Released 29 October 2009
Available at http://www.cdc.gov/h1n1flu/EUA/pdf/peramivir_qa.pdf.

2009 H1N1 Flu: Free Resources
Released 27 October 2009
Available at http://www.cdc.gov/h1n1flu/freeresources.htm.

H1N1 Influenza A (H1N1) 2009 Monovalent Vaccine Dosage Chart
Released 26 October 2009
Available at http://www.cdc.gov/h1n1flu/pdf/monovalent_vaccine_dosage_chart.pdf.

Prevention Of Pneumococcal Infections Secondary To Seasonal And 2009 H1N1 Influenza Viruses Infection
Released 23 October 2009
Available at http://www.cdc.gov/h1n1flu/vaccination/provider/provider_pneumococcal.htm.

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HealthMap iPhone App

A new iPhone application, named "Outbreaks Near Me", is now available free of charge. It utilizes GPS technology to show health alerts and ongoing outbreak news in the vicinity of the user. The application also allows users to submit disease reports, and to search for outbreaks in specific locations worldwide. These reports are screened and will be used to alert ProMED moderators about new disease events.
For more information and screenshots see: http://www.healthmap.org/iphone/.

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 apecein@u.washington.edu