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Vol. XII, No. 24 ~ EINet News Briefs ~ Nov 27, 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
- 2009 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO situation update on pandemic influenza H1N1
- Global: Public health significance of pandemic H1N1 virus mutation detected in Norway
- Global: WHO Director-General statement following the sixth meeting of the Emergency Committee
- Egypt: Eighty-ninth case of human HPAI avian influenza [H5N1]
- Ukraine: Five million pandemic H1N1 vaccine doses to be donated by WHO
- European Union: Regulators OK single vaccine dose for most
- Saudi Arabia: Saudi officials say four pilgrims have died of pandemic flu influenza
- China: Expert warns of possible pandemic flu mutation
- China & Hong Kong: Pandemic H1N1 virus mutations reported
- Japan: Reports of influenza related brain swelling
- Canada: Officials still probing recalled vaccine lot
- Mexico: First pandemic H1N1 vaccines received
- USA (West Virginia): CDC confirms pediatrician had pandemic H1N1 infection twice
- USA: Novartis unveils US cell-based flu vaccine plant

2. Infectious Disease News
- Thailand: Rabies threat returns
- Indonesia (Bali): Current rabies outbreak of Indonesian origin
- Viet Nam (Ho Chi Minh City): Increased measles incidence
- Russia (Moscow): Two districts quarantined following rabies alert
- USA: CDC warns about rise in serious pneumococcal disease

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

4. Articles
- Community-associated Methicillin-Resistant Staphylococcus aureus in Outpatients, United States, 1999-2006
- Prevalence of Antibodies against Avian Influenza A (H5N1) Virus among Cullers and Poultry Workers in Ho Chi Minh City, 2005
- From where did the 2009 'swine-origin' influenza A virus (H1N1) emerge?
- Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1
- Risk factors and outcomes among children admitted to hospital with pandemic H1N1 influenza
- Mutations in H5N1 Influenza Virus Hemagglutinin that Confer Binding to Human Tracheal Airway Epithelium
- Dengue hemorrhagic fever in a peripheral blood stem cell transplant recipient: the first case report

5. Notifications
- Northwest Center for Public Health Practice Hot Topics Preparedness forum
- EPIDEMICS˛: Second International Conference on Infectious Diseases Dynamics
- 14th International Congress on Infectious Diseases (ICID)
- ISHEID Symposium on HIV and Emerging Infectious Diseases
- Updated influenza guidance and information from the US CDC


1. Influenza News

Global
2009 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
China/ 7 (4)
Egypt/ 38 (4)
Viet Nam/ 4 (4)
Total/ 49 (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: 444 (262)
(WHO 11/27/09 http://www.who.int/csr/disease/avian_influenza/country/cases_table_2009_11_27/en/index.html)

Avian influenza age distribution data from WHO/WPRO (last updated 9/10/09): http://www.wpro.who.int/sites/csr/data/data_Graphs.htm

WHO's map showing world's areas affected by H5N1 avian influenza (status as of 09/24/09): http://gamapserver.who.int/mapLibrary/Files/Maps/Global_H5N1Human_2009_FIMS_20090924.png.

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 15 November 2009, worldwide more than 206 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 6,770 deaths. As many countries have stopped counting individual cases, particularly of milder illness, the case count is likely to be significantly lower than the actual number of cases that have occurred.

In the United States, influenza transmission remains active and geographically widespread, although disease activity appears to have recently peaked in most areas except in the northeastern United States. In Canada, influenza transmission continues to intensify without a clear peak in activity; the ILI consultation rate, which has been highest among children aged 5-19, continues to significantly exceed mean rates observed over the past 12 influenza seasons.

In Europe, widespread and increasing transmission of pandemic influenza virus was observed across much of the continent but the most intense circulation of virus occurred in northern, eastern, and southeastern Europe. Transmission appears to have peaked in few countries of Western Europe including Iceland, Ireland, the UK (Northern Ireland), and Belgium after a period of sustained intense transmission. Further east, a number of countries reported sharp increases in the rates of ILI** (Serbia, Moldova, Norway, Lithuania, Georgia) or ARI (Belarus, Bulgaria, Romania, and Ukraine). A moderate or greater impact on the healthcare system was reported in parts of northern and southeastern Europe. Greater than 20% of all sentinel respiratory specimens tested positive for influenza in at least 20 countries, with ? 50% of samples testing positive for influenza in Spain, Portugal, Estonia, Slovenia, Slovakia, Moldova, Bosnia and Herzegovina, Greece, Norway, Finland, Denmark, Belgium, Iceland, and Ireland. Over 99% of subtyped influenza A viruses in the Europe were pandemic H1N1 2009.

In Central and Western Asia, increasing diseases activity and pandemic influenza virus isolations continues to be reported in several countries. A high intensity of respiratory diseases with increasing trend was reported in Kazakhstan. Recent increases in rates of ILI or ARI have been observed in Uzbekistan and in parts of Afghanistan. In Israel, sharp increases in rates of ILI and pandemic virus detections have been reported in recent weeks.

In East Asia, influenza transmission remains active. Intense influenza activity continues to be observed in Mongolia with a severe impact on the healthcare system; however, disease activity may have recently peaked in the past one to two weeks. In Japan, influenza activity remains elevated but stable nationally, and may be decreasing slightly in populated urban areas. A small number of seasonal H3N2 and H1N1 influenza viruses continue to be detected in China and South East Asia, though the proportion of seasonal viruses is declining in relation to the proportion of pandemic influenza H1N1.

In tropical zone of the Americas and Asia, the intensity of influenza transmission is variable. In the tropical areas of Central and South America, most countries continue to report declining influenza activity, with the exception of Peru and Colombia. In the Caribbean Epidemiology Centre (CAREC) countries, after a recent peak of disease activity, rates of ARI have declined over the past three to four weeks. With the exception of Sri Lanka, overall transmission continues to decline in most parts of tropical South and Southeast Asia. In Hong Kong SAR, rates of ILI have returned baseline after a recent wave of predominantly pandemic H1N1 influenza in September and October.

In the temperate region of the southern hemisphere, little pandemic influenza activity has been reported.
(WHO 11/20/2009)

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Global: Public health significance of pandemic H1N1 virus mutation detected in Norway
The Norwegian Institute of Public Health has informed WHO of a mutation detected in three H1N1 viruses. The viruses were isolated from the first two fatal cases of pandemic influenza in the country and one patient with severe illness. Norwegian scientists have analyzed samples from more than 70 patients with clinical illness and no further instances of this mutation have been detected. This finding suggests that the mutation is not widespread in the country.

The virus with this mutation remains sensitive to the antiviral drugs, oseltamivir and zanamivir, and studies show that currently available pandemic vaccines confer protection. Worldwide, laboratory monitoring of influenza viruses has detected a similar mutation in viruses from several other countries, with the earliest detection occurring in April. In addition to Norway, the mutation has been observed in Brazil, China, Japan, Mexico, Ukraine, and the US.

Although information on all these cases is incomplete, several viruses showing the same mutation were detected in fatal cases, and the mutation has also been detected in some mild cases. Worldwide, viruses from numerous fatal cases have not shown the mutation. The public health significance of this finding is thus unclear. Although further investigation is under way, no evidence currently suggests that these mutations are leading to an unusual increase in the number of H1N1 infections or a greater number of severe or fatal cases.
(WHO 11/20/2009)

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Global: WHO Director-General statement following the sixth meeting of the Emergency Committee
Having considered the views of the Emergency Committee, and the ongoing pandemic situation, the Director-General determined it was appropriate to continue all three temporary recommendations, namely:

  1. Countries should not close borders or restrict international traffic and trade
  2. Intensify surveillance of unusual flu-like illness & severe pneumonia
  3. If ill, it is prudent to delay travel.
(WHO 11/26/2009)

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Europe/Near East
Egypt: Eighty-ninth case of human HPAI avian influenza [H5N1]
The Ministry of Health of Egypt has reported a new confirmed human case of avian influenza A(H5N1). The case is a three year-old male from Minia Governorate. His symptoms started on 21 November 2009. He was admitted to hospital on 22 November and his condition is stable. Investigations into the source of infection indicated that the case had close contact with dead and/or sick poultry. The cases were confirmed by the Egyptian Central Public Health Laboratories.

Of the 89 cases confirmed to date in Egypt, 27 have been fatal.
(WHO 11/27/2009)

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Ukraine: Five million pandemic H1N1 vaccine doses to be donated by WHO
The WHO said it would provide five million H1N1 vaccine doses to the Ukraine. The news came during a meeting between WHO officials and the country's president, the president's press service reported. Authorities from the WHO have been in the Ukraine to investigate a dramatic increase in respiratory illnesses, including severe cases and deaths. However, initial reports found no significant pandemic virus changes.
(CIDRAP 11/24/2009)

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European Union: Regulators OK single vaccine dose for most
In a reversal of earlier advice, Europe's drug regulatory agency said that a single dose of the approved adjuvanted H1N1 vaccines may be sufficient in most adults and older children. In October the agency had affirmed an earlier two-dose recommendation. But today regulators said a single dose can be used in adults between ages 18 and 60, and also in children from age 9 (for Focetria) or 10 (for Pandemrix). They said a single dose of Pandemrix is also sufficient for elderly people.
(CIDRAP 11/20/2009)

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Saudi Arabia: Saudi officials say four pilgrims have died of pandemic flu influenza
Saudi Arabia's health ministry announced the first four pandemic H1N1 flu deaths in hajj pilgrims. Three of the patients were age 75, hailing from Morocco, Sudan, and India. The fourth was a 17-year-old girl from Nigeria. The health ministry said all four had underlying conditions, including cancer and respiratory illness. Sixteen other flu infections were detected in hajj pilgrims, four of whom are hospitalized in critical condition.
(CIDRAP 11/23/2009)

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Asia
China: Expert warns of possible pandemic flu mutation
China must be alert to any mutation or changes in the behavior of the H1N1 swine flu virus because the far deadlier H5N1 bird flu virus is endemic in the country, a leading Chinese disease expert said. Zhong Nanshan, director of the Guangzhou Institute of Respiratory Diseases in China's southern Guangdong province, said "China, as you know, is different from other countries. Inside China, H5N1 has been existing for some time, so if there is really a reassortment between H1N1 and H5N1, it will be a disaster."

Zhong told the Chinese media last week that China may have had more H1N1 flu deaths than it has reported, with some local governments possibly concealing suspect cases. While some regions simply lack the technology to test for H1N1, other areas may have been treating deaths as cases of ordinary pneumonia. "Some local healthcare authorities are reluctant, unwilling to test patients with severe pneumonia because there's some latent rule which says the more H1N1 deaths, the less effective the control and prevention work in your area," Zhong said. According to Zhong, China's health minister Chen Zhu recently contacted him and agreed with his views. A notice then appeared on the ministry's website threatening severe punishment for officials caught concealing deaths from H1N1 swine flu.
(Reuters 11/25/2009)

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China & Hong Kong: Pandemic H1N1 virus mutations reported
A Chinese official said on 25 November 2009 that China detected the pandemic H1N1 virus mutation seen in Norway and other countries during the summer of 2009. Feng Zijian, with the Chinese Centers for Disease Prevention and Control, said the mutated virus didn't seem to be more virulent and wasn't linked to any deaths. On Nov 23 Hong Kong officials said they detected the mutation in July in a toddler who has recovered.
(CIDRAP 11/25/2009)

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Japan: Reports of influenza related brain swelling
Japan has identified 132 influenza patients who have developed encephalopathy, or brain swelling caused by an immune overreaction. This is triple the expected annual number. Patients ranged in age from one to 67, but most were under 15, with seven-year-olds most commonly affected. Three patients died. A senior health official said that flu patients who have slow responses or say "strange things" should see a doctor immediately.
(CIDRAP 11/24/2009)

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Americas
Canada: Officials still probing recalled vaccine lot
In the investigation of a batch of GlaxoSmithKline H1N1 vaccine in Canada that has been linked to more allergic reactions than expected, a company spokeswoman said no clues have yet emerged. Six cases of anaphylaxis may be linked to a lot containing 172,000 doses shipped to five provinces. Japan, which expects Glaxo vaccine in December, said it will send experts to assess a possible link.
(CIDRAP 11/25/2009)

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Mexico: First pandemic H1N1 vaccines received
Mexico's health ministry announced 23 November 2009 that it had received its first 865,000 doses of pandemic H1N1 vaccine. The country's health secretary, Jose Angel Cordova, said officials will review the vaccine and administer the first doses this week to pregnant women and health workers. He said Mexico expects 30 million doses from Sanofi and GlaxoSmithKline by February 2010. Doses will go to states based on population.
(CIDRAP 11/24/2009)

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USA (West Virginia): CDC confirms pediatrician had pandemic H1N1 infection twice
The US CDC has confirmed that a West Virginia physician has contacted pandemic H1N1 2009 virus twice. Dr. Debra Parsons, a pediatrician, was met with reactions of doubt from local health officials in October 2009 when she said two flu tests had come back positive for pandemic H1N1. The first positive test was in August 2009 and the second was in October 2009. Both samples were retested by the CDC, with the final positive results given on 20 November 2009.
(ProMED 11/24/2009)

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USA: Novartis unveils US cell-based flu vaccine plant
The era of cell-based influenza vaccine production in the United States seemed to move closer as Novartis unveiled its new, nearly billion-dollar manufacturing plant in Holly Springs, N.C., but onshore production and marketing of cell-based vaccines remains a few years away. As the Swiss-based company held a ribbon-cutting ceremony at the plant, it said the facility will be ready to start making the firm's vaccine adjuvant, MF59, as soon as next month, but the earliest it could start churning out flu vaccine is 2011, with full commercial production expected in 2013.

Novartis is one of five companies that were awarded large HHS contracts in 2006 to develop cell-culture technology for making flu vaccines. The four other companies are: Solvay Pharmaceuticals, MedImmune, GlaxoSmithKline, and a partnership of DynPort Vaccine Co. and Baxter. The contracts totaled well over $1 billion. In addition, Sanofi Pasteur received a $97 million HHS contract for similar work in 2005. Some of the companies are continuing work under those contracts, while others have suspended the work or dropped it.

Cell culture technology-growing vaccine viruses in mammalian cells, such as canine kidney cells-is said to be more flexible and somewhat faster than the decades-old method of growing flu vaccines in chicken eggs. Cell-culture technology is used to make certain other vaccines, such as polio and rabies.

At a congressional hearing earlier this month, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said cell culture technology will be an improvement but will not be the final answer to flu vaccine production problems. He said the "end game" is to get away from vaccines that involve growing the virus and instead to produce particular viral proteins.
(CIDRAP 11/24/2009)

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2. Infectious Disease News

Asia
Thailand: Rabies threat returns
Rabies has re-emerged as a threat after the number of deaths in Thailand rose to 23 in 2009, from nine in 2008. Health authorities said seven people had died in Bangkok alone, compared with only one in 2008. Dr Teerawat Hemajuta, a member of Chulalongkorn University's Faculty of Medical Science and a leader of the rabid dog study team, said the rise in rabies deaths -- which numbered in the hundreds 20 years ago before a concerted campaign to eradicate the deadly disease -- was a warning to the public that the disease still existed and people needed to be more careful. "Half of the deaths are from household dogs. It is very important for people to be aware of vaccinating their dogs, especially puppies," he said.

Dr Teerawat said dog birth control should be given a higher priority. Unless more efficient action is taken, the dog population, both household and stray, in Thailand would rise from some two million today to about 17 million in the next 20 years. The rabid dog study team has successfully introduced a new method for birth control in male dogs by injecting zinc gluconate into the genitalia instead of performing a vasectomy. The new treatment is regarded as quick, permanent, and safe. The research team had also claimed success in lab trials to halt the protein growth associated with the rabies virus. It was a significant development in preventing the virus from spreading to the human brain.
(ProMED 11/26/2009)

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Indonesia (Bali): Current rabies outbreak of Indonesian origin
The Molecular Biology Laboratory at the University of Udayana's School of Medicine [located in Bali] has confirmed the rabies outbreak in Bail originated in Indonesia. Ni Nyoman Sri Budayanti, head of the laboratory, denied reports the virus was related to international bioterrorism as previously speculated by a government official. "After conducting research and studies, we have concluded the rabies virus has similar characteristics to those identified in Sulawesi and East Nusa Tenggara," Budayanti said.

A number of virologists including Budayanti, Ngurah Mahardika, Raka Sudewi and Susilawati conducted a close examination of the rabies virus taken from victims in Bali. The four virologists used sequence data from all types of rabies found in Indonesia [obtained] from GenBank. "We assume the virus entered Bali through inter-island animal trafficking. Our study found the virus came from Flores in East Nusa Tenggara and Sulawesi," she said. Budayanti went on to say that many fishermen from East Nusa Tenggara and Sulawesi had taken their rabies-affected dogs while they were fishing in Bali waters. The increasing demand for dog meat among Balinese people may have also exacerbated the spread of the virus on the island. "Many people are now consuming dog meat daily," she added.

The rabies outbreak hit Bali in November 2008 and has, so far, claimed 17 lives. Bali has a dog population of 500,000. The Bali administration has carried out anti-rabies schemes including dog vaccination, the mass culling of stray dogs, public education and advocacy. The outbreak has hit seven out of nine regencies in Bali.
(ProMED 11/22/2009)

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Viet Nam (Ho Chi Minh City): Increased measles incidence
Children's hospitals in Ho Chi Minh City report the incidence of measles among children is rising. Children's Hospital II has admitted 158 toddlers with the disease since the beginning of November 2009, with one of them, a 10-month-old baby, dying. So far in 2009 it has treated 881 patients. In addition, the city's Tropical Diseases hospital received more than 50 children with measles on 19 Nov 2009.
(ProMED 11/21/2009)

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Russia (Moscow): Two districts quarantined following rabies alert
A total of three people have been hospitalized in Moscow on suspicion of rabies virus infection after being bitten by a suspected rabid dog. Moscow Oblast veterinarians state that 230 cases of animal rabies had been reported so far in 2009, which is more than for the whole of last year.

The death of a 6-month-old pup alarmed city veterinarians because this rabid animal had roamed freely around north Moscow for two months. As a result a quarantine was imposed immediately in two districts of Moscow. All pets were called in for immunization. All cats and dogs in neighborhoods in these two districts are considered to be at risk and must be immunized and kept in isolation for 60 days. All owners of pets are recommended to avoid travelling between quarantine zones and all animal trade and exhibitions are prohibited.
(ProMED 11/20/2009)

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Americas
USA: CDC warns about rise in serious pneumococcal disease
In a worrisome but not unexpected pandemic-related development, the US CDC said 25 November 2009 that it is seeing a spike in serious pneumococcal disease, particularly in younger patients. Health officials expect to see more pneumococcal disease when seasonal flu circulates, but the infections typically strike people who are older than 65. In past pandemics secondary bacterial pneumonia infections, particularly those involving Streptococcus pneumoniae, frequently contributed to illnesses and deaths.

Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, told reporters that the CDC is seeing an increasing number of invasive pneumococcal disease cases around the country, but the numbers were particularly high in Denver at a time when pandemic H1N1 activity was peaking in the area. Over the past five years [2004-2008] the Denver area averaged 20 pneumococcal disease cases in October, but in 2009 the area recorded 58, and most were in adults between the ages of 20 and 59, many of whom had underlying medical conditions.
(CIDRAP 11/25/2009)

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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/h1n1flu/update.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 (Hanoi)
Dengue fever has killed two additional patients in Hanoi according to the Hanoi Department of Health on 19 November 2009. The victims are a 53-year-old woman in Ha Dong district and a 15-year-old boy in Dong Anh district. In late September [2009], the capital also had two fatal cases.

According to the Health Ministry, Viet Nam had over 77,000 dengue fever patients in 33 out of 63 provinces and cities between January-October 2009. The number of patients rose by 7.3 percent year-on-year while the number of deaths fell by over 11 percent. Notably, the number of dengue fever patients in the southern region was reduced in both the number of cases and deaths while there were increases in other regions in the country, especially the north, where figures were 4-fold.
(ProMED 11/23/2009)

Chinese Taipei
Chinese Taipei recorded over 70 new cases of dengue fever virus infection in the past week, bringing to 387 the number of people infected with the mosquito-borne disease since the summer, the Chinese Taipei CDC reported 17 Nov 2009. All are indigenous cases, CDC deputy director Chou Jih-haw said. All the outbreaks in 2009 have been reported from seven cities and counties, mostly in southern Chinese Taipei.

Chou urged those who feel they might have been infected with the disease to report to their local health authorities, adding that those who report and test positive are entitled to a cash reward of TWD 2500 (USD 77.85) for reporting the case.
(ProMED 11/23/2009)

USA (Florida)
Survey results are back from the US CDC's dengue research center in Puerto Rico. Out of 240 Old Town Key West residents who gave blood for testing, 99 tested positive for dengue fever or the associated antibodies. More specifically:

  1. 91 people tested positive for dengue antibodies, meaning that at some point in their lives, they had been exposed to the virus
  2. Six tested positive for having had the virus in the past three months.
  3. Two tested "acute positive," meaning they actually had dengue fever when their blood was drawn a month ago.
Dengue fever was first reported in Key West in July 2009. It represented the first documented presence of dengue in Florida in more than 40 years.
(ProMED 11/15/3009)

Australia (Queensland)
Dengue fever has returned to north Queensland, just three months after health officials declared an end to the worst outbreak in 50 years. The early onset of the mosquito-borne virus this season has authorities desperate to stop the insects from breeding and spreading the potentially deadly disease.

During the last epidemic, over 1,000 people in Queensland's north contracted dengue fever, and for the first time, all four strains of the virus were present, although type 3 was responsible for 90 percent of cases. Dr Brian Montgomery, a senior medical entomologist with Queensland Health, says there is already an assortment of strains circulating this season. Dr Montgomery is concerned about those people who had dengue last season catching it again. "If you had dengue 3 earlier this year [2009], you definitely do not want to catch dengue [type] 2 or 1 or 4 this year, because that's when we see these more severe complications of dengue," he said.

So far, dengue fever has only struck in Queensland's north, but infectious diseases experts say the virus is likely to be common in all Australian capital cities by 2050. They say the spread of urban water tanks and increasing warmer weather may see dengue spread south.
(ProMED 11/15/3009)

Indonesia (North Sumatra)
A dengue fever epidemic reportedly occurred in Medan throughout October and November 2009. Pirngadi Hospital spokesman Susyanto was cited as stating that dengue patient numbers rose significantly in one month. In October 2009 there were 43 dengue patients treated at the hospital compared to only 10 in September 2009.
(ProMED 11/15/3009)

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CHOLERA, DIARRHEA, and DYSENTARY
Thailand (Pattani)
According to the most recent information available from the Pattani health care team and the Surveillance Rapid Response Team (SRRT), from mid-October 2009 through 13 Nov 2009, there have been 93 people identified to have Vibrio cholerae O1 El Tor Ogawa infection. Most of the infected people were fishermen and their family members, who live in fishing communities on the Pattani riverbanks. Among these 93 people, 33 patients sought treatment at local hospitals (28 in Pattani, four in Kok Poh hospital, and one in Sai Buri hospital).

Pattani Health Care teams, SRRTs as well as a Field Epidemiology Training Program team conducted outreach activities aimed at further case detection in the communities. The outreach teams did house to house surveys and interviews. Approximately 500 people who were at risk of infection were reached and 393 rectal swabs were collected. Subsequently, 60 positive cultures Vibrio cholerae O1 El Tor Ogawa were detected. Of these, 46 culture positive individuals never had any diarrhea, and 14 had a mild watery diarrhea.
(ProMED 11/25/2009)

Malaysia (Terengganu)
The outbreak of cholera in Terengganu which was first reported on 11 Nov 2009, has now recorded 174 cases with one death. Health minister Datuk Seri Liow Tiong Lai said 116 cholera cases detected from 451 patients being treated for diarrhea in hospitals while 56 cases were contact cases involving 1,074 people.
(ProMED 11/25/2009)

Malaysia (Saba)
Sabah, a state in East Malaysia, is confirmed to be the second state in the country to have recorded a cholera outbreak, a Malaysian official said on Mon 23 Nov 2009. There were 18 cases reported in the state, said Malaysian deputy health minister Rosnah Abdul Rashid Shirlin after launching the Second International Conference on Rural Medicine 2009 at KotaKinabalu, Sabah's state capital.

While two states in Malaysia had reported cholera cases, Rosnahsaid the ones in Terengganu, an eastern state in Malaysian peninsula, were caused by different bacterial strains, requiring different antimicrobial agents for treatment.
(ProMED 11/25/2009)

Papua New Guinea (East Sepik)
The East Sepik provincial administration and health authorities confirmed a cholera outbreak in Angoram district. In a statement released on 19 Nov 2009, provincial administrator Samson Torovi said more than 90 people had been confirmed with cholera with five people having died from it. The update superseded the figures released by Wewak General Hospital chief executive officer Dr Louis Samiak in the morning, which stood at 70 confirmed cases and three deaths.

Cholera was first reported in Morobe province in August 2009, where an outbreak was declared. Some deaths in Eastern Highlands and Gulf provinces were linked to the disease, but not confirmed. It later spread to Madang, where an outbreak was declared in October 2009.
(ProMED 11/25/2009)

Papua New Guinea (Madang)
The Madang health department in Papua New Guinea is still waiting for national funding to help fight a cholera outbreak which it says is now affecting over 400 people. The Madang provincial health director says about 20 people a day are coming through the Modilon hospital to seek treatment. Mark Kachau says they have so far only received help from the provincial government, the World Health Organization and other aid agencies.
(ProMED 11/25/2009)

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4. Articles
Community-associated Methicillin-Resistant Staphylococcus aureus in Outpatients, United States, 1999-2006
Klein E, Smith DL, Laxminaraya Ramanan. Emerg Infect Dis. 12 December 2009; 15(12). doi:10.3201/eid1512.081341.
Available at http://www.cdc.gov/EID/content/15/12/1925.htm.

Abstract. Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has become a major problem in US hospitals already dealing with high levels of hospital-associated MRSA (HA-MRSA). Using antimicrobial drug susceptibility data for 1999-2006 from The Surveillance Network, we characterized the relationship between outpatient and inpatient levels of CA-MRSA nationally. In outpatients, the frequency of CA-MRSA isolates has increased >7× during 1999-2006, which suggests that outpatients have become a major reservoir for CA-MRSA. However, contrary to results in other reports, although CA-MRSA increases are associated with decreases in the frequency of HA-MRSA in hospitals, the decreases are only modest. This finding suggests that instead of replacing HA-MRSA in the hospital, CA-MRSA is adding to the overall presence of MRSA already found within the hospital population.

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Prevalence of Antibodies against Avian Influenza A (H5N1) Virus among Cullers and Poultry Workers in Ho Chi Minh City, 2005
Schultsz C, Van Dung N, Hai LT, et al. PLoS ONE. 23 November 2009; 4(11): e7948. doi:10.1371/journal.pone.0007948
Available at http://www.plosone.org/article/fetchObjectAttachment.action?uri=info%3Adoi%2F10.1371%2Fjournal.pone.0007948&representation=PDF.

Background. Between 2003 and 2005, highly pathogenic avian influenza A (H5N1) viruses caused large scale outbreaks in poultry in the Ho Chi Minh City area in Vietnam. We studied the prevalence of antibodies against H5N1 in poultry workers and cullers who were active in the program in Ho Chi Minh City in 2004 and 2005.

Methodology/Principal Findings. Single sera from 500 poultry workers and poultry cullers exposed to infected birds were tested for antibodies to avian influenza H5N1, using microneutralization assays and hemagglutination inhibition assay with horse blood. All sera tested negative using microneutralization tests. Three samples showed a 1:80 titer in the hemagglutination inhibition assay.

Conclusions/Significance. This study provides additional support for the low transmissibility of clade 1 H5N1 to humans, but limited transmission to highly exposed persons cannot be excluded given the presence of low antibody titers in some individuals.

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From where did the 2009 'swine-origin' influenza A virus (H1N1) emerge?
Gibbs AJ, Armstrong JS, Downie Jean C. Virology Journal. 24 November 2009; 6:207. doi:10.1186/1743-422X-6-207
Available at http://www.virologyj.com/content/6/1/207.

Abstract. The swine-origin influenza A (H1N1) virus that appeared in 2009 and was first found in human beings in Mexico, is a reassortant with at least three parents. Six of the genes are closest in sequence to those of H1N2 'triple-reassortant' influenza viruses isolated from pigs in North America around 1999-2000. Its other two genes are from different Eurasian 'avian-like' viruses of pigs; the NA gene is closest to H1N1 viruses isolated in Europe in 1991-1993, and the MP gene is closest to H3N2 viruses isolated in Asia in 1999-2000. The sequences of these genes do not directly reveal the immediate source of the virus as the closest were from isolates collected more than a decade before the human pandemic started. The three parents of the virus may have been assembled in one place by natural means, such as by migrating birds, however, the consistent link with pig viruses suggests that human activity was involved. We discuss a published suggestion that unsampled pig herds, the intercontinental live pig trade, together with porous quarantine barriers, generated the reassortant. We contrast that suggestion with the possibility that laboratory errors involving the sharing of virus isolates and cultured cells, or perhaps vaccine production, may have been involved. Gene sequences from isolates that bridge the time and phylogenetic gap between the new virus and its parents will distinguish between these possibilities, and we suggest where they should be sought. It is important that the source of the new virus be found if we wish to avoid future pandemics rather than just trying to minimize the consequences after they have emerged. Influenza virus is a very significant zoonotic pathogen. Public confidence in influenza research, and the agribusinesses that are based on influenza's many hosts, has been eroded by several recent events involving the virus. Measures that might restore confidence include establishing a unified international administrative framework coordinating surveillance, research and commercial work with this virus, and maintaining a registry of all influenza isolates.

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Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1
Memish ZA, McNabb SJN, Mahoney F, et al. The Lancet. 21 November 2009; 374(9703): 1786-1791. doi:10.1016/S0140-6736(09)61927-9
Available at http://www.thelancet.com/journals/lancet/article/PIIS0140673609619279/.

Summary. Mass gatherings of people challenge public health capacities at host locations and the visitors' places of origin. Hajj-the yearly pilgrimage by Muslims to Saudi Arabia-is one of the largest, most culturally and geographically diverse mass gatherings in the world. With the 2009 pandemic influenza A H1N1 and upcoming Hajj, the Saudi Arabian Ministry of Health (MoH) convened a preparedness consultation in June, 2009. Consultants from global public health agencies met in their official capacities with their Saudi Arabian counterparts. The MoH aimed to pool and share public health knowledge about mass gatherings, and review the country's preparedness plans, focusing on the prevention and control of pandemic influenza. This process resulted in several practical recommendations, many to be put into practice before the start of Hajj and the rest during Hajj. These preparedness plans should ensure the optimum provision of health services for pilgrims to Saudi Arabia, and minimum disease transmission on their return home. Review of the implementation of these recommendations and their effect will not only inform future mass gatherings in Saudi Arabia, but will also strengthen preparedness efforts in other settings.

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Risk factors and outcomes among children admitted to hospital with pandemic H1N1 influenza
O'Riordan S, Barton M, Yau Y, et al. CMAJ. 19 November 2009. doi:10.1503/cmaj.091724
Available at http://www.cmaj.ca/cgi/rapidpdf/cmaj.091724.

Abstract. Background: Limited data are available on disease characteristics and outcomes of children with 2009 pandemic influenza A(H1N1) virus infection (pandemic H1N1 influenza) who have required hospital admission.

Methods: We reviewed the charts of 58 children with pandemic H1N1 influenza admitted to a large pediatric hospital in Ontario, Canada, between May 8 and July 22, 2009. We compared risk factors, severity indicators and outcomes of these children with those of 200 children admitted with seasonal influenza A during the previous five years (2004/05 to 2008/09).

Results: Children with pandemic H1N1 influenza were significantly older than those with seasonal influenza (median age 6.4 years v. 3.3 years). Forty-six (79%) of the children with pandemic H1N1 influenza had underlying medical conditions; of the other 12 who were previously healthy, 42% were under two years of age. Children admitted with pandemic H1N1 influenza were significantly more likely to have asthma than those with seasonal influenza (22% v. 6%). Two children had poorly controlled asthma, and six used inhaled medications only intermittently. The median length of stay in hospital was four days in both groups of children. Similar proportions of children required admission to the intensive care unit (21% of those with pandemic H1N1 influenza and 14% of those with seasonal influenza) and mechanical ventilation (12% and 10% respectively). None of the children admitted with pandemic H1N1 influenza died, as compared with one (0.4%) of those admitted with seasonal influenza.

Interpretation: Pandemic H1N1 influenza did not appear to cause more severe disease than seasonal influenza A. Asthma appears to be a significant risk factor for severe disease, with no clear relation to severity of asthma. This finding should influence strategies for vaccination and pre-emptive anti viral therapy.

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Mutations in H5N1 Influenza Virus Hemagglutinin that Confer Binding to Human Tracheal Airway Epithelium
Ayora-Talavera G, Shelton H, Scull MA, et al. PLoS ONE. 18 November 2009; 4(11): e7836. doi:10.1371/journal.pone.0007836
Available at http://www.plosone.org/article/info:doi/10.1371/journal.pone.0007836.

Abstract. The emergence in 2009 of a swine-origin H1N1 influenza virus as the first pandemic of the 21st Century is a timely reminder of the international public health impact of influenza viruses, even those associated with mild disease. The widespread distribution of highly pathogenic H5N1 influenza virus in the avian population has spawned concern that it may give rise to a human influenza pandemic. The mortality rate associated with occasional human infection by H5N1 virus approximates 60%, suggesting that an H5N1 pandemic would be devastating to global health and economy. To date, the H5N1 virus has not acquired the propensity to transmit efficiently between humans. The reasons behind this are unclear, especially given the high mutation rate associated with influenza virus replication. Here we used a panel of recombinant H5 hemagglutinin (HA) variants to demonstrate the potential for H5 HA to bind human airway epithelium, the predominant target tissue for influenza virus infection and spread. While parental H5 HA exhibited limited binding to human tracheal epithelium, introduction of selected mutations converted the binding profile to that of a current human influenza strain HA. Strikingly, these amino-acid changes required multiple simultaneous mutations in the genomes of naturally occurring H5 isolates. Moreover, H5 HAs bearing intermediate sequences failed to bind airway tissues and likely represent mutations that are an evolutionary "dead end." We conclude that, although genetic changes that adapt H5 to human airways can be demonstrated, they may not readily arise during natural virus replication. This genetic barrier limits the likelihood that current H5 viruses will originate a human pandemic.

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Dengue hemorrhagic fever in a peripheral blood stem cell transplant recipient: the first case report
Visuthranukul J, Bunworasate U, Lawasut P, SuankratayC. IDR. 2009; 1(1).
Available at http://www.pagepress.org/journals/index.php/idr/article/view/idr.2009.e3/1585.

Abstract. Dengue infection, a mosquito-borne infectious disease in tropical and subtropical areas, has recently become an emerging global disease. Clinical course of dengue infection may be unfavorable in immunocompromised patients. In this report, we present a 16-year-old female patient with acute myeloid leukemia and receiving allogeneic peripheral blood stem cell transplant who was hospitalized at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, due to fever, headache, and myalgia for one day. During hospitalization, she developed capillary leakage syndrome and progressive thrombocytopenia. A diagnosis of dengue hemorrhagic fever was made and confirmed by positive dengue serology and polymerase chain reaction testing. She made a full recovery 14 days after hospitalization. In conclusion, this is the first reported case of dengue hemorrhagic fever in a peripheral blood stem cell transplant recipient. In addition, we review all previous reports of dengue infection in organ transplant recipients.

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5. Notifications
Northwest Center for Public Health Practice Hot Topics Preparedness forum
Noon-1:00 pm (PST), Dec 15, 2009

A live web seminar entitled "Pandemic Influenza H1N1 - How Prepared Were We?" will be given by Jeffrey Duchin, MD, FACP, FIDSA, Chief, Communicable Disease Epidemiology & Immunization Section, Public Health - Seattle & King County. Computer connections to the event are limited, so we encourage you to login as a group in a meeting room.
Registration information available at www.nwcphp.org/htip.

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EPIDEMICS˛: 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.
Additional information and registration available at http://www.epidemics.elsevier.com/.

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14th International Congress on Infectious Diseases (ICID)
Miami, Florida, Mar 9-12, 2010

The deadline for abstract submissions to the 14th ICID has been extended to November 30th. Take advantage of reduced registration fees by registering on or before January 15, 2010.
Additional information and registration available at http://www.isid.org/14th_icid/.

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ISHEID Symposium on HIV and Emerging Infectious Diseases
Marseille, France, 24-26 Mar 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.

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

Registration and hotel booking are open on-line, we recommend you to 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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Updated influenza guidance and information from the US CDC
2009 H1N1 Influenza: Resources for Pharmacists
Released 25 November 2009
Available at http://www.cdc.gov/h1n1flu/pharmacist/

CDC Guidance for Emergency Shelters for the 2009-2010 Flu Season
Released 24 November 2009
Available at http://www.cdc.gov/h1n1flu/guidance/emergencyshelters.htm

2009 H1N1 Monovalent Influenza Vaccine Dosage, Administration, and Storage
Released 24 November 2009
Available at http://www.cdc.gov/h1n1flu/vaccination/dosage.htm

2009 H1N1 Influenza Vaccine - Dose Spacing for Children 6 Months through 9 Years of Age
Released 23 November 2009
Available at http://www.cdc.gov/H1N1flu/vaccination/dosespacing.html

2009 H1N1 Influenza Vaccine Dose Spacing and Administration with Seasonal Influenza and Other Vaccines
Released 20 November 2009
Available at http://www.cdc.gov/h1n1flu/vaccination/vaccine_admin.html

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 apecein@u.washington.edu