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Vol. XIII No. 7 ~ EINet News Briefs ~ Apr 02, 2010


*****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
- 2010 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO situation update on pandemic influenza H1N1
- Global: WHO sets up external panel to review pandemic influenza H1N1 response
- Bulgaria (Varna): Avian influenza H5N1 discovered in common buzzard
- Egypt (Damietta and Beba districts): Two new human cases of H5N1 avian influenza
- Romania (Tulcea): World Organization for Animal Health (OIE) confirmation of H5N1 avian influenza outbreak in poultry
- Bangladesh (Chittagong): Avian influenza panic
- Nepal (Seti and Lumbini): Two outbreaks of avian influenza H5N1 reported
- Viet Nam (Binh Duong Province): Confirmed human case of H5N1 avian influenza
- USA (South): Regional pandemic H1N1 influenza spread on Southern campuses
- USA (Southeast): CDC reports sustained pandemic H1N1 influenza activity
- USA (Georgia): Reports of unusually high levels of pandemic H1N1 influenza

2. Infectious Disease News
- China (Henan Province): Two hand-foot-mouth disease deaths
- Philippines (Central Visayas): Three rabies deaths in first quarter of 2010
- Singapore: 4,269 cases of hand-foot-mouth disease in first three months of 2010
- Vietnam (Ho Chi Minh City): Hand-foot-mouth disease incidence on rise
- Canada (British Columbia): Measles outbreak sparks health advisory
- Chile (Santiago): Hantavirus case

3. Updates
- INFLUENZA A/H1N1
- VECTOR-BORNE DISEASE
- CHOLERA, DIARRHEA, and DYSENTARY
- AVIAN INFLUENZA

4. Articles
- H1N1 Influenza: Initial Chest Radiographic Findings in Helping Predict Patient Outcome
- Letter: Dual Seasonal Patterns for Influenza, China
- Behavioral intentions in response to an influenza pandemic
- Age, influenza pandemics and disease dynamics
- Estimating the Disease Burden of Pandemic (H1N1) 2009 Virus Infection in Hunter New England, Northern New South Wales, Australia, 2009
- Analysis of the effectiveness of interventions used during the 2009 A/H1N1 influenza pandemic
- Entry screening to delay local transmission of 2009 pandemic influenza A (H1N1)
- Conference Summary: Findings, Gaps, and Future Direction for Research in Nonpharmaceutical Interventions for Pandemic Influenza
- Letter: Triple Reassortant Swine Influenza A (H3N2) Virus in Waterfowl
- Lymphocyte to monocyte ratio as a screening tool for influenza
- Which Health Care Workers Were Most Affected During the Spring 2009 H1N1 Pandemic?

5. Notifications
- 28th Annual Infectious Disease Seminar for Physicians, Pharmacists and Other Healthcare Professionals
- Thailand Conference on Emerging Infectious and Neglected Diseases
- CDC 7th International Conference on Emerging Infectious Diseases
- Options for the Control of Influenza VII
- Influenza 2010: Zoonotic Influenza and Human Health
- Updated influenza guidance and information from the US CDC

6. To Receive EINet Newsbriefs
- Subscribe to EINet


1. Influenza News

Global
2010 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Egypt / 18 (6)
Indonesia / 1 (1)
Viet Nam / 5 (2)
Total / 24 (9)
***For data on human cases of avian influenza prior to 2010, go to: http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 492 (291)
(WHO 3/30/10 http://www.who.int/csr/disease/avian_influenza/country/cases_table_2010_03_30/en/index.html

Avian influenza age distribution data from WHO/WPRO (last updated 2/8/10):
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 2/12/10):
http://gamapserver.who.int/mapLibrary/Files/Maps/Global_H5N1Human_2010_FIMS_20100212.png.

WHO's timeline of important H5N1-related events (last updated 1/4/10):
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 28 March 2010, worldwide more than 213 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 17,483 deaths.

The most active areas of pandemic influenza virus transmission currently are in parts of the tropical zones of Asia, the Americas, and Africa. Pandemic influenza activity remains low in much of the temperate areas of both the northern and southern hemispheres. Although pandemic influenza virus continues to be the predominant influenza virus circulating worldwide, seasonal influenza type B viruses are predominant in much of East Asia, and have been increasingly detected at low levels across southeast and western Asia, East Africa, and in parts of eastern and northern Europe. Seasonal influenza A (H3N2) is still being detected in very small numbers in parts of Asia and Australia.

In Southeast Asia, pandemic influenza virus transmission remains active but variable across the region. Thailand continues to report the most active circulation of pandemic virus in the region, however, disease activity may have recently peaked and begun to decline. Approximately half of all provinces in Thailand reported that >10% outpatient visits were due to influenza like illness (ILI). The proportion of outpatient sentinel respiratory samples testing positive for influenza dropped to 10% after peaking at approximately 30% during mid February 2010. In Malaysia, limited data suggest pandemic influenza virus transmission persists as new cases continue to be reported. In Indonesia, no recent pandemic influenza activity has been reported, however, low levels of seasonal influenza H3N2 and type B viruses continue to be detected. In Myanmar, limited data suggest that pandemic influenza has declined substantially since a period of active transmission during February 2010.

In South Asia, overall pandemic influenza activity remains low, except in Bangladesh, which reported regional spread of pandemic influenza virus in association with an increase in new cases since late February 2010. In India, low level circulation of pandemic influenza virus persists in the western part of the country.

In East Asia, overall pandemic influenza activity remained low as circulation of seasonal influenza B viruses continued to increase across the region. In China, ILI activity has greatly decreased; however, approximately 20-30% of respiratory samples have tested positive for influenza in recent weeks. Of these, over 85% were seasonal influenza B viruses. In Mongolia, recent intense influenza activity due to seasonal influenza B viruses continues to decrease. Overall rates of ILI have returned to near baseline in both Japan and the Republic of Korea as pandemic influenza virus circulation continues to wane. Seasonal influenza B viruses are circulating at low level across other parts of East and Southeast Asia and Oceania (Hong Kong SAR (China), Japan, Republic of Korea, China, Chinese Taipei, Philippine, Thailand, Vietnam, Indonesia, Bangladesh and Australia). Also, small numbers of seasonal influenza H3N2 viruses have been detected in several countries of East and Southeast Asia as well as Oceania, particularly in Indonesia and in Australia.

In North Africa and Western Asia, limited data suggests that pandemic influenza virus continues to circulate at low levels, as overall disease activity remained low across much of the region. In Iran, no pandemic influenza viruses have been detected recently, however, low levels of seasonal influenza B viruses continue to be detected.

In Sub-Saharan Africa, limited data suggests that pandemic influenza virus transmission remains variable but most active in western Africa and in limited areas of eastern Africa. Localized areas of active pandemic influenza transmission persist in areas of Eastern Africa, particularly Rwanda and Tanzania. Pandemic influenza virus continues to be the predominant influenza virus circulating in West and East Africa, however, small numbers of seasonal influenza H3N2, H1N1, and seasonal influenza B viruses have also been identified.

In tropical zone of the Americas, limited data suggests that overall influenza activity remains low but variable with localized areas of active transmission in a number of countries. Guatemala, Nicaragua, El Salvador, Panama, Brazil, Peru, and Bolivia, all reported an increasing trend of respiratory diseases associated with circulation of pandemic influenza virus for at least one week during March 2010. Localized increases in pandemic influenza activity have been associated with school outbreaks in several countries; however, in some places disease activity may be partially accounted for by co-circulation of other respiratory viruses. The most active area of pandemic influenza virus circulation in the region appears to be in Brazil where disease activity in the northern region has been associated with pandemic influenza virus transmission. In Mexico, limited data suggests that localized active transmission of pandemic influenza virus continued to occur in several states throughout March 2010, although overall influenza activity did not increase to peak levels observed during fall influenza season.

In the northern and the southern temperate zones of the Americas, overall pandemic influenza transmission remained low as influenza virus continues to circulate at low levels. Although the national level of ILI activity remained below the seasonal baseline in the United States, three of ten sub-regions reported a resurgence of ILI activity above their respective baselines. The most active areas of pandemic influenza transmission currently appears to be in the southeastern United States, particularly in the states of Alabama, Georgia, and South Carolina, all of which reported regional spread of influenza activity. A corresponding increase in confirmed severe cases of pandemic H1N1 has also been noted in the southeastern United States in recent weeks. In Canada, overall ILI activity remained below the seasonal baseline. In temperate countries of the southern hemisphere, overall influenza activity remained low, with sporadic detections of pandemic and seasonal influenza viruses.

In Europe, low levels of pandemic influenza virus continue to circulate across the region, particularly across southern and eastern Europe. The proportion of sentinel respiratory samples testing positive for influenza remained low (4.6%). Three countries (Latvia, Lithuania and Bulgaria) reported an increasing trend of respiratory diseases activity, however, these trends have not been associated with increased detections of pandemic influenza virus. Increased circulation of seasonal influenza B virus has been observed in the Siberian and far eastern regions of the Russian Federation, and in Italy and Sweden, where it continues to be the predominant circulating virus (although at overall low levels).
(WHO 04/02/2010)

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Global: WHO sets up external panel to review pandemic influenza H1N1 response
WHO is in the final stages of putting together an independent committee to review its preparation for and response to the H1N1 pandemic, a group of about 29 experts that will meet for the first time in the middle of April.

The WHO is still putting together the pandemic review group, which will have a broad range of expertise, including scientists and public health experts both inside and outside the infectious disease arena. Dr. Keiji Fukuda, Special Adviser on Pandemic Influenza to the Director General, said that though the review group will operate independently from the WHO, members will be required, like the WHO's internal expert groups, to make declarations of interest and reveal potential conflicts of interest.

The group will hold its first meeting 12-14 Apr 2010. The committee will elect its own chair and co-chair, set its own agenda, and seek out its own expert assessments. It will produce a preliminary report on its actions for the WHO director-general to present to the World Health Assembly in May.

A final report on the WHO's pandemic response will likely be completed in time for the WHO director-general to present to the May 2011 World Health Assembly.
(CIDRAP 03/29/2010)

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Europe/Near East
Bulgaria (Varna): Avian influenza H5N1 discovered in common buzzard
The regional laboratory for influenza diagnosis among birds in the coastal city of Varna has established a positive result for H5N1 flu in a common buzzard, the National Veterinary Service announced.

Veterinary inspectors found the bird dead in Konstantin and Elena resort in the district of Varna while carrying out monitoring on influenza among domestic and wild birds in Bulgaria.

Samples have been sent to the National Diagnosis and Research Veterinary Institute in Sofia for confirmation. The results are expected at the beginning of next week.
(ProMED 03/29/2010)

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Egypt (Damietta and Beba districts): Two new human cases of H5N1 avian influenza
Two new H5N1 avian influenza cases were reported. The first case was announced on 28 March 2010 and is a 30 year-old female from Damietta district, Damietta Governorate. The case was admitted to hospital on 24 March 2010 where she received oseltamivir treatment. She is in a critical condition.

The second case was announced on 21 March 2010 and is a four year-old male from Beba district, Beni Suaif Governorate . The case was admitted to hospital on 18 March 2010 where he received oseltamivir treatment. He died on 24 March 2010.

Investigations into the source of infection indicated that both cases had exposure to sick and dead poultry.

Of the 108 laboratory confirmed cases of Avian influenza A(H5N1) reported in Egypt, 33 have been fatal.
(WHO 03/30/2010)

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Romania (Tulcea): World Organization for Animal Health (OIE) confirmation of H5N1 avian influenza outbreak in poultry
An outbreak of avian influenza that began on 27 March 2010 at Plaur in the region of Tulcea has been confirmed. This is the same region as the previous outbreak that was confirmed in Letea 15 March 2010. Of a population of 80 hens in a backyard, 28 were found dead and 52 sick at the veterinarian's visit.

Plaur is situated in the Danube Delta, 55km from Letea. The village has 31 backyards, of which 17 hold 699 poultry (626 hens, 18 ducks, 28 geese, 21 turkeys and six guinea hens).

The presence of the H5N1 sub-type of the virus has been confirmed.
(OIE 03/31/2010)

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Asia
Bangladesh (Chittagong): Avian influenza panic
Panic caused by avian influenza has gripped the Chittagong poultry farmers again after the outbreak of bird flu was reported in Sitakunda upazila (sub-district).

The panic has also led to an increase in the price of chicken this season, when farmers usually opt not to run poultry businesses, in order to avert loss due to bird flu.

Sources in the Chittagong District Livestock Office said the disease outbreak this season was reported at SM Golabaria Poultry Farm at village Golabaria in Sitakunda upazila on 14 March 2010.

[Editorial comment: We presume the outbreak is due to H5N1, and would appreciate further details.]
(The Daily Star, 04/01/2010)

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Nepal (Seti and Lumbini): Two outbreaks of avian influenza H5N1 reported
Avian influenza H1N5 outbreaks have been reported in two areas of Nepal. One of these was in a mixed village flock of 123 backyard chickens, ducks, and pigeons in Tikapur municipality in the region of Seti. 40 of the birds died and the remaining birds were destroyed.

The second outbreak occurred at Deurali VDC ward No 6 in the Lumbini region in a similar mixed flock of 4,767 birds; 216 died and the rest were destroyed.

The presence of the H5N1 sub-type of the virus has been confirmed.
(ProMED 03/30/2010)

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Viet Nam (Binh Duong Province): Confirmed human case of H5N1 avian influenza
The Ministry of Health has reported a new confirmed case of human infection with the H5N1 avian influenza virus; the case had been previously reported 19 March 2010. This case was confirmed at Pasteur Institute, Ho Chi Minh City.

The case was a 3 year old girl residing in Thuan An district, Binh Duong province. She developed symptoms on 5 March 2010 and presented to Thuan An District Hospital and a private health facility for investigation and treatment. On 10 March, she was presented to the Pediatrics Hospital No. 2 where she was suspected to have influenza A (H5N1). Despite treatment, the case died on 17 March 2010. Confirmatory test results for influenza A (H5N1) were also obtained on that day.

Of the 117 cases confirmed to date in Viet Nam, 59 have been fatal.
(WHO 03/29/2010)

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USA (South): Regional pandemic H1N1 influenza spread on Southern campuses
Flulike illness on college campuses stayed at low levels for the 16th consecutive week, though some regional activity continued in the Southeastern area, consistent with what federal officials are reporting, the American College Health Association (ACHA) said. Significant, short increases were seen in mid February to early March, especially in the Carolinas and Georgia. The attack rate was 1.4 cases/10,000 students, down slightly from the week ending 27 March 2010.
(CIDRAP 03/31/2010)

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Americas
USA (Southeast): CDC reports sustained pandemic H1N1 influenza activity
Flu indicators are showing signs of increased and sustained pandemic flu activity in some Southeastern states, though rates remain steady at the national level, the Center for Disease Control (CDC) reports.

The report tracks closely with media reports this week of a rise in flu hospitalizations in Georgia and rising flu-like illnesses in Louisiana and surrounding states. The report of increased activity in the Southeast is also consistent with regional flu activity at college campuses in the Southeast reported by the American College Health Association.

Three of the CDC's 10 regions reported increases in doctors' visits for flu-like illnesses, including the one encompassing Southeastern states; the region that includes Iowa, Kansas, Missouri, and Nebraska; and the area that covers Arizona, California, Hawaii, and Nevada. The increases were over regional, not national, baselines. On a national level, the doctor's visit flu barometer stayed below the national baseline.

No states are reporting widespread flu activity, and only three-Alabama, Georgia, and South Carolina-are reporting regional activity. Local activity was reported by Puerto Rico and eight states: Arkansas, Hawaii, Louisiana, Mississippi, New Mexico, North Carolina, Tennessee, and Virginia.

The nation's deaths from pneumonia and flu increased slightly during the previous week to above the seasonal baseline, but the level is still below the epidemic threshold.

The pandemic H1N1 virus is still the dominant flu strain, the CDC reported. Though several other countries are increasingly detecting influenza B cases, only two of the 3,050 respiratory specimens tested in the United States last week were that strain.

One more case of oseltamivir-resistant pandemic flu was reported to the CDC the week ending 27 March 2010. Most patients have been given oseltamivir (Tamiflu) for treatment or prophylaxis.
(CIDRAP 03/26/2010)

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USA (Georgia): Reports of unusually high levels of pandemic H1N1 influenza
Public health officials are so concerned by an uptick of serious cases of H1N1 flu in the southeastern United States that they called a short-notice press briefing today to urge Americans to be vaccinated against the pandemic strain.

Surgeon General Dr. Regina Benjamin and Dr. Anne Schuchat, director of the Centers for Disease Control and Prevention's (CDC's) National Center for Immunization and Respiratory Diseases, told reporters on a conference call that they are particularly concerned about the "worrisome trend" in Georgia, where "more than 40" people were hospitalized in the past week for lab-confirmed flu.

Schuchat said the new cases are occurring in adults with chronic medical conditions, a group that health officials have consistently urged to take the H1N1 shot. The new victims were not vaccinated, she said, adding that Georgia had one of the lowest rates of flu-vaccine acceptance last fall.

The CDC is sufficiently concerned about the Georgia cases that it has loaned a team of its disease detectives to the state Division of Public Health to investigate the cases and help crunch data. A full analysis is expected shortly, Schuchat said, but the CDC felt the Georgia signal was so concerning that they went ahead with a briefing in advance of the analysis's delivery.
(CIDRAP 03/29/2010)

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2. Infectious Disease News

Asia
China (Henan Province): Two hand-foot-mouth disease deaths
Two children have died of hand-foot-mouth disease (HFMD), and another 1,717 cases have been reported since January 2010 in Pingdingshan City in central China's Henan Province, local authorities said. The city reported a daily high of 120 cases on 11 Mar 2010, and there are currently 30 to 50 cases reported every day. Some kindergartens have been closed in Ruzhou City, which is under the administration of Pingdingshan. Schools and kindergartens have been ordered to conduct health checks twice a day.
(ProMED 03/29/2010)

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Philippines (Central Visayas): Three rabies deaths in first quarter of 2010
The Department of Health in Central Visayas reported at least three rabies-related deaths in the first quarter of 2010. The deaths were recorded in Carmen town and Toledo City in Cebu province and Mabinay town in Negros Oriental.

In 2009, the DOH-7 recorded a total of 16 rabies cases, 12 of whom died. 90 percent of the cases were caused by dog bites while the remaining 10 percent were due to cat bites. Half of the victims were school children, aged 15 and below.
(ProMED, 03/29/2010)

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Singapore: 4,269 cases of hand-foot-mouth disease in first three months of 2010
Singapore reported 4,269 hand-food-mouth disease (HFMD) cases in the first three months 2010, a 15 percent increase compared with 3,705 cases in the same period of 2009.

496 cases were recorded in the week ending 20 Mar 2010, just four short of the warning level of 500. The Singapore government said that currently no child care center has been closed due to HFMD.
(ProMED 03/29/2010)

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Vietnam (Ho Chi Minh City): Hand-foot-mouth disease incidence on rise
The number of children contracting hand-foot-mouth disease (HFMD) is on the rise even though the peak season is still one month away, Children Hospitals No.s 1 and 2 in Ho Chi Minh City have announced. At Children Hospital No. 1, nearly 20 children were hospitalized due to HFMD, which brings the total number of infected children to 39. 28 of the cases involve serious nerve complications that require special treatment.

Children Hospital No. 2 received 32 children with HFMD, an increase of 50 percent during the week ending 27 March 2010. An 18-month-old baby was reported to have been in critical condition and died 20 hours after being hospitalized. The peak season of the illness is between April and May. However, early hot weather has led to a sudden onset of illness among children.
(ProMED 03/29/2010)

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Americas
Canada (British Columbia): Measles outbreak sparks health advisory
Health officials are advising the public of a recent outbreak of measles in the Lower Mainland.

The B.C. Center for Disease Control said 10 confirmed and four suspected cases of measles have been identified in the past two weeks. More than half of the cases have been linked to a single family with unvaccinated members. One other recent case was spotted in a visitor returning from India to the B.C. Interior.

The Lower Mainland measles cases have been linked to at least two out-of-country visitors in February or early March, said the center, as two separate strains have been identified.
(The Province, 03/30/2010)

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Chile (Santiago): Hantavirus case
A man of 28 years remains in an extremely critical state, in the first confirmed hantavirus case detected in the capital. The patient was infected in the southern areas of the country while working to help victims of the earthquake.

The Chief of the Critical Care Unit, Clinical Hospital, University of Chile, Dr Rodrigo Cornejo, stated that the condition of the patient is extremely serious.
(ProMED 04/02/2010)

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3. Updates
INFLUENZA A/H1N1

- 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 México: 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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VECTOR-BORNE DISEASE

Japan
Six travelers who visited Bali, Indonesia were diagnosed with dengue fever in February and March 2010. All six of these cases were viremic upon returning to Japan and dengue virus genome was detected.

Current co-circulation of at least 3 DENV serotypes in a popular tourist destination such as Bali increases the risk of DENV re-infection in both locals and tourists. As such, one of the six imported cases, a 90-year-old male, was serologically confirmed to be secondary DENV infection. Viremic international travelers also increase the risk of dissemination of DENV in non-endemic areas, such as Japan, where one of the competent vectors, Aedes albopictus, is present.
(ProMED 03/29/2010)

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CHOLERA, DIARRHEA, and DYSENTARY

Viet Nam
A 28-year-old woman in Tay Ho district was hospitalized at the Central Hospital for Tropical Diseases on 12 Mar 2010 in serious condition, but has been released. The patient was first treated at a private hospital, but failed to recover. She was moved to Central Hospital for Tropical Diseases with dehydration and exhaustion, reported Nguyen Hong Ha, the deputy director of Central Hospital for Tropical Diseases on 17 Mar 2010.

After five days, the woman completely recovered and left the hospital on 17 Mar 2010. This is the first cholera case in Hanoi in 2010. The Central Epidemiology Institute has been investigating the possible source of the cholera.
(ProMED 03/24/2010)

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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. 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 H5N1.
- 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 health officials prepare for an influenza pandemic.
- The US government's website for pandemic/avian flu: http://www.flu.gov/. "Flu Essentials" are available in multiple languages.
- CIDRAP: Avian Influenza page: http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/.
- 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 avian influenza H5N1 in wild birds and poultry.

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4. Articles
H1N1 Influenza: Initial Chest Radiographic Findings in Helping Predict Patient Outcome
Aviram G, Bar-Shai A, Sosna J, et al. Radiology. April 2010;255:252-259: doi: 10.1148/radiol.10092240
Available at http://radiology.rsna.org/content/255/1/252.abstract

Purpose. To retrospectively evaluate whether findings on initial chest radiographs of influenza A (H1N1) patients can help predict clinical outcome.

Materials and Methods. Institutional review board approval was obtained; informed consent was waived. All adult patients admitted to the emergency department (May to September 2009) with a confirmed diagnosis of H1N1 influenza who underwent frontal chest radiography within 24 hours were included. Radiologic findings were characterized by type and pattern of opacities and zonal distribution. Major adverse outcome measures were mechanical ventilation and death.

Results. Of 179 H1N1 influenza patients, 97 (54%) underwent chest radiography at admission; 39 (40%) of these had abnormal radiologic findings likely related to influenza infection and five (13%) of these 39 had adverse outcomes. Fifty-eight (60%) of 97 patients had normal radiographs; two (3%) of these had adverse outcomes (P = .113). Characteristic imaging findings included the following: ground-glass (69%), consolidation (59%), frequently patchy (41%), and nodular (28%) opacities. Bilateral opacities were common (62%), with involvement of multiple lung zones (72%). Findings in four or more zones and bilateral peripheral distribution occurred with significantly higher frequency in patients with adverse outcomes compared with patients with good outcomes (multizonal opacities: 60% vs 6%, P = .01; bilateral peripheral opacities: 60% vs 15%, P = .049).

Conclusion. Extensive involvement of both lungs, evidenced by the presence of multizonal and bilateral peripheral opacities, is associated with adverse prognosis. Initial chest radiography may have significance in helping predict clinical outcome but normal initial radiographs cannot exclude adverse outcome.

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Letter: Dual Seasonal Patterns for Influenza, China
Shu YL, Fang LQ, de Vlas SJ, et al. Emerg Infect Dis. April 2010; doi: 10.3201/eid1604.091578
Available at http://www.cdc.gov/eid/content/16/4/725.htm#cit

Letter. To the Editor: Since 2000, the People's Republic of China has had a nationwide surveillance network for influenza, which as of 2005 has been reported on the Chinese Center for Disease Control and Prevention website (www.cnic.org.cn/ch). This surveillance has shown a remarkable dual pattern of seasonal influenza on mainland China. Whereas a regular winter pattern is noted for northern China (similar to that in most parts of the Northern Hemisphere), the pattern in southern China differs. In southern China, influenza is prevalent throughout the year; it has a clear peak in the summer and a less pronounced peak in the winter. Because this dual seasonal pattern of influenza has not been reported outside China and is relevant to pandemic (H1N1) 2009, we describe surveillance data for rates of consultation for influenza-like illness (ILI) and influenza subtypes in patients with ILI. We emphasize the spread of influenza from southern to northern China.
[Please refer to the article link for more information]

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Behavioral intentions in response to an influenza pandemic
Kok G, Jonkers R, Gelissen R, et al. BMC Public Health. 30 March 2010;10:174. doi:10.1186/1471-2458-10-174
Available at http://www.biomedcentral.com/1471-2458/10/174/abstract

Background. Little is known about which behavioral responses may be expected in case of an influenza pandemic.

Methods. Survey among the Dutch population with questions based on risk perception theories, especially Protection-Motivation-Theory.

Results. Fear for an influenza pandemic is high, but participants do not feel well informed. Family doctors and local health services are the most trusted sources, and the most urgent information needed are the protective measures to take. Participants intend to comply with protective advises but response-efficacy and self-efficacy are low. Maladaptive behaviors are to be expected. Increasing numbers of sick people and closure of schools will lead to a decrease of the work force. Participants want anti-viral drugs even when not enough are available.

Conclusions. Health protective messages from local health authorities need to find a balance in preventing both underestimation and avoidance or denial. When protective advises of health professionals are in conflict with company policy, it is unclear what workers will do.

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Age, influenza pandemics and disease dynamics
Greer Al, Tuite A, Fisman DN. Epidemiology and Infection. 22 March 2010; doi:10.1017/S0950268810000579
Available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=7409060#

Abstract. The world is currently confronting the first influenza pandemic of the 21st century [caused by a novel pandemic influenza A (H1N1) virus]. Earlier pandemics have been characterized by age distributions that are distinct from those observed with seasonal influenza epidemics, with higher attack rates (and correspondingly increased proportionate or relative mortality) in younger individuals. While the genesis of protection against infection in older individuals during a pandemic is uncertain, differential vulnerability to infection by age has important implications for disease dynamics and control, and for choice of optimal vaccination strategies. Age-related vulnerability to infection may explain differences between school- and community-derived estimates of the reproductive number (R) for a newly emerged pandemic strain, and may also help explain the failure of a newly emerged influenza A (H1N1) virus strain to cause a pandemic in 1977. Age-related factors may also help explain variability in attack rates, and the size and impact of influenza epidemics across jurisdictions and between populations. In Canada, such effects have been observed in the apparently increased severity of outbreaks on Indigenous peoples' reserves. The implications of these patterns for vaccine allocation necessitate targeted research to understand age-related vulnerabilities early in an influenza pandemic.

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Estimating the Disease Burden of Pandemic (H1N1) 2009 Virus Infection in Hunter New England, Northern New South Wales, Australia, 2009
Dawood FS, Hope KG, Durrheim DN, et al. PLoS ONE. 25 March 2010;5(3): e9880. doi:10.1371/journal.pone.0009880
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0009880

Introduction. On May 26, 2009, the first confirmed case of Pandemic (H1N1) 2009 virus (pH1N1) infection in Hunter New England (HNE), New South Wales (NSW), Australia (population 866,000) was identified. We used local surveillance data to estimate pH1N1-associated disease burden during the first wave of pH1N1 circulation in HNE.

Methods. Surveillance was established during June 1-August 30, 2009, for: 1) laboratory detection of pH1N1 at HNE and NSW laboratories, 2) pH1N1 community influenza-like illness (ILI) using an internet survey of HNE residents, and 3) pH1N1-associated hospitalizations and deaths using respiratory illness International Classification of Diseases 10 codes at 35 HNE hospitals and mandatory reporting of confirmed pH1N1-associated hospitalizations and deaths to the public health service. The proportion of pH1N1 positive specimens was applied to estimates of ILI, hospitalizations, and deaths to estimate disease burden.

Results. Of 34,177 specimens tested at NSW laboratories, 4,094 (12%) were pH1N1 positive. Of 1,881 specimens from patients evaluated in emergency departments and/or hospitalized, 524 (26%) were pH1N1 positive. The estimated number of persons with pH1N1-associated ILI in the HNE region was 53,383 (range 37,828-70,597) suggesting a 6.2% attack rate (range 4.4-8.2%). An estimated 509 pH1N1-associated hospitalizations (range 388-630) occurred (reported: 184), and up to 10 pH1N1-associated deaths (range 8-13) occurred (reported: 5). The estimated case hospitalization ratio was 1% and case fatality ratio was 0.02%.

Discussion. The first wave of pH1N1 activity in HNE resulted in symptomatic infection in a small proportion of the population, and the number of HNE pH1N1-associated hospitalizations and deaths is likely higher than officially reported.

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Analysis of the effectiveness of interventions used during the 2009 A/H1N1 influenza pandemic
Halder N, Kelso JK, Milne GJ. BMC Public Health. 29 March 2010;10:168: doi:10.1186/1471-2458-10-168
Available at http://www.biomedcentral.com/1471-2458/10/168/abstract

Background. Following the emergence of the 2009 A/H1N1 influenza pandemic, public health interventions were activated to lessen its potential impact. Computer modelling and simulation can be used to determine the potential effectiveness of the social distancing and antiviral drug therapy interventions that were used at the early stages of the pandemic, providing guidance to public health policy makers as to intervention strategies in future pandemics involving a highly pathogenic influenza strain.

Methods. An individual-based model of a real community with a population of approximately 30,000 was used to determine the impact of alternative interventions strategies, including those used in the initial stages of the 2009 pandemic. Different interventions, namely school closure and antiviral strategies, were simulated in isolation and in combination to form different plausible scenarios. We simulated epidemics with reproduction numbers R0 of 1.5, which aligns with estimates in the range 1.4-1.6 determined from the initial outbreak in Mexico.

Results. School closure of 1 week was determined to have minimal effect on reducing overall illness attack rate. Antiviral drug treatment of 50% of symptomatic cases reduced the attack rate by 6.5%, from an unmitigated rate of 32.5% to 26%. Treatment of diagnosed individuals combined with additional household prophylaxis reduced the final attack rate to 19%. Further extension of prophylaxis to close contacts (in schools and workplaces) further reduced the overall attack rate to 13% and reduced the peak daily illness rate from 120 to 22 per 10,000 individuals. We determined the size of antiviral stockpile required; the ratio of the required number of antiviral courses to population was 13% for the treatment-only strategy, 25% for treatment and household prophylaxis and 40% for treatment, household and extended prophylaxis. Additional simulations suggest that coupling school closure with the antiviral strategies further reduces epidemic impact.

Conclusions. These results suggest that the aggressive use of antiviral drugs together with extended school closure may substantially slow the rate of influenza epidemic development. These strategies are more rigorous than those actually used during the early stages of the relatively mild 2009 pandemic, and are appropriate for future pandemics which have high morbidity and mortality rates.

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Entry screening to delay local transmission of 2009 pandemic influenza A (H1N1)
Cowing BJ, Lau LLH, Wu P, et al. BMC Infectious Diseases. 30 March 2010; doi:10.1186/1471-2334-10-82.
Available at http://www.biomedcentral.com/1471-2334/10/82/

Background. After the WHO issued the global alert for 2009 pandemic influenza A (H1N1), many national health agencies began to screen travelers on entry in airports, ports and border crossings to try to delay local transmission.

Methods. We reviewed entry screening policies adopted by different nations and ascertained dates of official report of the first laboratory-confirmed imported H1N1 case and the first laboratory-confirmed untraceable or 'local' H1N1 case.

Results. Implementation of entry screening policies was associated with on average additional 7-12 day delays in local transmission compared to nations that did not implement entry screening, with lower bounds of 95% confidence intervals consistent with no additional delays and upper bounds extending to 20-30 day additional delays.

Conclusions. Entry screening may lead to short-term delays in local transmission of a novel strain of influenza virus. The resources required for implementation should be balanced against the expected benefits of entry screening.

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Conference Summary: Findings, Gaps, and Future Direction for Research in Nonpharmaceutical Interventions for Pandemic Influenza
Vukotich Jr CH, Coulborn RM, Aragon TJ, et al. Emerg Infect Dis. April 2010; 4
Available at http://www.cdc.gov/eid/content/16/4/e2.htm?rss#cit

Abstract. In June 2006, the Centers for Disease Control and Prevention (CDC) released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs) to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010) (1). Eleven studies (Table 1) were funded to identify optimal, discrete, or combined NPIs for implementation during an influenza pandemic. During March 4-6, 2009, the principal investigators met to share results, identify research gaps, and define future research needs in 9 areas as described here. A total of 16 research gaps were identified.
[Please refer to the summary link for more information]

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Letter: Triple Reassortant Swine Influenza A (H3N2) Virus in Waterfowl
Ramakrishnan MA, Wang P, Abin M, et al. Emerg Infect Dis. April 2010; 16:4
Available at http://www.cdc.gov/eid/content/16/4/728.htm

Letter. In 1998, a new lineage of triple reassortant influenza A (H3N2) virus (TR-H3N2) with genes from humans (hemmaglutinin [HA], neuraminidase [NA], and polymerase basic 1 [PB1]), swine (matrix [M], nonstructural [NS], and nucleoprotein [NP]), and birds (polymerase acidic [PA] and PB2) emerged in the U.S. swine population. Subsequently, similar viruses were isolated from turkeys (1,2), minks, and humans in the United States and Canada (3,4). In 2007, our national influenza surveillance resulted in isolation of 4 swine-like TR-H3N2 viruses from migratory waterfowl (3 from mallards [Anas platyrrhynchos] and 1 from a northern pintail [Anas acuta] of 266 birds sampled) in north-central South Dakota. We report on the characterization of these TR-H3N2 viruses and hypothesize about their potential for interspecies transmission.
[Please refer to the article link for more information]

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Lymphocyte to monocyte ratio as a screening tool for influenza
Merekoulias G, Alexopoulos EC; Belezos, T, et al. PLoS Currents: Influenza. 29 Mar 2010; PMC2847387.
Available at http://knol.google.com/k/george-merekoulias/lymphocyte-to-monocyte-ratio-as-a/wwim31ohhvdl/1?collectionId=28qm4w0q65e4w.1&position=1#

Abstract. In fall 2009 the emergency department of a clinic in Greece with increased patient visits due to influenza-like illness observed a particular pattern in the complete blood count (CBC) of these patients. In 90% of all patients with probable influenza, lymphopenia and/or monocytosis were present. Relative lymphopenia with or without monocytosis appears to be a laboratory marker for H1N1 virus infection, a finding that could play a major role in early identifying and treating patients with new influenza A. A ratio of lymphocytes to monocytes below 2 is proposed as a screening tool for influenza infection instead of rapid tests.

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Which Health Care Workers Were Most Affected During the Spring 2009 H1N1 Pandemic?
Santos CD, Bristow RB, Vorenkamp JV. Disaster Medicine and Public Health Preparedness. March 2010. 1938-744X
Available at http://www.dmphp.org/cgi/content/short/4/1/47

Objectives: To identify health care workers most at risk for H1N1 infection before vaccination and compare health outcomes after vaccination.

Methods: The indices used to gauge employee health were laboratory-confirmed H1N1 data, laboratory-confirmed influenza A data, and employee sick hours records. In phase 1 of this 2-phase study, absenteeism records for 6,093 hospital employees before vaccine administration were analyzed according to department and employee position during the spring 2009 H1N1 pandemic.

Results: Records of 123 confirmed reports of laboratory-confirmed influenza A or novel H1N1 infections in hospital employees were also analyzed. Two thirds of the H1N1 cases occurred during June (infection rates in parentheses): 34 in physicians and medical personnel (6.7%), 36 in nurses and clinical technicians (2.2%), 39 in Administrative & Support Personnel (infection rate = 1.2%), 3 in Social Workers & Counselors (infection rate = 1.0%), 8 in Housekeeping & Food Services (infection rate = 2.7%), and 3 in Security & Transportation (infection rate=3.9%). When analyzed according to department, the adult emergency department (infection rate = 28.8%) and the pediatric emergency department (infection rate = 25.0%) had the highest infection rates per department.

Conclusions: Of the reported cases of H1N1 in health care workers, 49% occurred in a population that constitutes less than 20% of the total population studied. Physicians and medical personnel had a higher infection rate than other employee positions, whereas ED personnel had the highest infection rate.

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5. Notifications
28th Annual Infectious Disease Seminar for Physicians, Pharmacists and Other Healthcare Professionals
Hilton Head, SC, USA, 7-9 April 2010
This seminar is designed to provide practical, cutting-edge information to practicing physicians and other health care providers concerning evaluation and management of common infectious diseases as well as those making headlines.
Additional information available at: http://www.neoucom.edu/ce.

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Thailand Conference on Emerging Infectious and Neglected Diseases
Pattaya, Thailand, 3-4 June 2010
Outbreaks of various diseases, including SARS, avian influenza, influenza H1N1 pandemics, and the most recently chikungunya fever, continue to challenge our abilities to prepare for the emerging infectious disease threats. This conference, therefore, will facilitate national and international updating and sharing of knowledge, experiences, and scientific expertise which is crucial for handling these global threats.
Additional information and registration available at http://nstda.or.th/eid2010/.

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CDC 7th International Conference on Emerging Infectious Diseases
Atlanta, Georgia, USA, 11-14 Jul 2010
The 2010 International Conference on Emerging Infectious Diseases (ICEID) is the principal meeting for emerging infectious diseases organized by CDC. This conference includes plenary and panel sessions, as well as oral and poster presentations, and covers a broad spectrum of infectious diseases of public health relevance. ICEID 2010 will also focus on the impact of various intervention and preventive strategies that have been implemented to address emerging infectious disease threats.
Additional information is available at http://www.iceid.org/.

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Options for the Control of Influenza VII
Hong Kong, 3-7 Sep 2010
Options for the Control of Influenza VII is the largest forum devoted to all aspects of the prevention, control, and treatment of influenza. As it has for over 20 years, Options VII will highlight the most recent advances in the science of influenza. The scientific program committee invites authors to submit original research in all areas related to influenza for abstract presentation. Accepted abstracts will be assigned for oral or poster presentation.
Additional information is available at http://www.controlinfluenza.com.

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Influenza 2010: Zoonotic Influenza and Human Health
Oxford, United Kingdom, 22 Sep 2010
The Oxford influenza conference, Influenza 2010, will address most aspects of basic and applied research on zoonotic influenza viruses (including avian and swine) and their medical and socio-economic impact.
Additional information available at http://www.libpubmedia.co.uk/Conferences/Influenza2010/Home.htm.

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Updated influenza guidance and information from the US CDC
CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April 2009 - January 16, 2010 Released 29 March 2010
Available at http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm.

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