Vol. XIII No. 11 ~ EINet News Briefs ~ May 28, 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
- India: Three new H1N1 pandemic influenza variants detected
- Malaysia (Kuala Lumpur): 29 more cases of H1N1 pandemic influenza
- Brazil: Economy extends vaccine campaign
- USA: President’s advisory group looks to speed up flu vaccine
- USA: FDA Clears First 2009 H1N1 Influenza Virus Test Previously Available Under Emergency Use Authorization
- Ghana: Quarantining of students after pandemic influenza H1N1 reported

2. Infectious Disease News
- USA (California): Elevation in number of mumps cases, may be related to East Coast outbreak
- Indonesia (Balikpapan): Public health emergency declared due to diphtheria
- Philippines: Measles outbreak
- Canada (Alberta): Increase in measles cases

3. Updates
- Introduction of WWARN: WWARN Description

4. Articles
- Differences in the Epidemiological Characteristics and Clinical Outcomes of Pandemic (H1N1) 2009 Influenza, Compared with Seasonal Influenza
- Differing Symptom Patterns in Early Pandemic vs Seasonal Influenza Infections
- Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial
- Effect of influenza-like illness and other wintertime respiratory illnesses on worker productivity: The child and household influenza-illness and employee function (CHIEF) study
- Pandemic (H1N1) 2009, Shanghai, China
- Editorial: Journals, Academics, and Pandemics
- Prior immunity helps to explain wave-like behavior of pandemic influenza in 1918-9
- Clinical and Molecular Evidence for Transmission of Novel Influenza A(H1N1/2009) on a Commercial Airplane
- Transmission of pandemic A/H1N1 2009 influenza on passenger aircraft: retrospective cohort study
- Estimating the effective reproduction number for pandemic influenza from notification data made publicly available in real time: A multi-country analysis for influenza A/H1N1v 2009
- Pandemic Vaccines – The Legal Landscape

5. Notifications
- Second APEC Senior Officials’ Meeting (SOM II)
- Thailand Conference on Emerging Infectious and Neglected Diseases
- CDC 7th International Conference on Emerging Infectious Diseases
- 4th Ditan International Conference on Infectious Diseases
- Options for the Control of Influenza VII
- Influenza 2010: Zoonotic Influenza and Human Health
- 4th Vaccine and ISV Annual Global Congress

6. To Receive EINet Newsbriefs
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1. Influenza News

2010 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Cambodia / 1 (1)
Egypt / 19 (7)
Indonesia / 3 (2)
Viet Nam 7 (2)
Total / 30 (12)
***For data on human cases of avian influenza prior to 2010, go to:

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 498 (294)
(WHO 05/06/10 http://www.who.int/csr/disease/avian_influenza/country/cases_table_2010_04_09/)

Avian influenza age distribution data from WHO/WPRO (last updated 2/8/10):

WHO's map showing world's areas affected by H5N1 avian influenza (status as of 2/12/10):

WHO’s timeline of important H5N1-related events (last updated 1/4/10):


Global: WHO situation update on pandemic influenza H1N1
As of 23 May 2010, worldwide more than 214 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 18,114 deaths.

The most active areas of pandemic influenza virus transmission currently are in parts of the Caribbean and Southeast Asia, where low level circulation is occurring. Except for localized areas of pandemic influenza activity in parts of Chile, there is little evidence of pandemic influenza activity in the temperate zone of the southern hemisphere. Of note, Respiratory Syncitial Virus (RSV) is widely circulating in South America resulting in an increase in respiratory disease activity, complicating somewhat the interpretation of syndromic surveillance data from the area. RSV primarily affects children under the age of 5 years. Seasonal influenza A viruses continue to be detected at low to sporadic levels in all regions. Influenza B has been reported in increasing but low numbers in South America, where it only recently appeared, while it is decreasing in Asia.

In the Caribbean and Central America, Cuba and to a much lesser extent Costa Rica, continue to experience active circulation of pandemic influenza virus. In Cuba, current pandemic influenza activity, which began during late February 2010, remains unchanged since reaching a plateau during mid-April 2010; in addition, over the past month, there have been sporadic detections of seasonal influenza B viruses and also evidence of co-circulation of other respiratory viruses. In Costa Rica, sustained low levels of pandemic influenza virus have been co-circulating with other respiratory viruses since the beginning of 2010. Several other countries in the region continue to report sporadic detections of seasonal influenza B viruses and low level co-circulation of other respiratory viruses.

In the tropical zone of South America, pandemic and seasonal influenza viruses continued to circulate at low to sporadic levels. In Peru, recent regional increases in respiratory diseases activity (in children under age 5) has been largely associated with circulating respiratory syncitial virus (RSV). In Colombia and Brazil, low levels of pandemic and seasonal influenza H3N2 viruses have been detected over the past month. In Bolivia, a recent period of circulation of predominantly seasonal influenza type B viruses appears to have concluded.

In Asia, overall pandemic influenza activity remains low to sporadic, except in limited areas of south and southeast Asia, particularly Singapore, Malaysia, and Bangladesh. In Singapore, levels of ARI have been elevated since April 2010 and in recent weeks have remained near epidemic threshold; approximately 39% of respiratory specimens from ILI patients tested positive for pandemic influenza virus during mid May 2010. In neighboring Malaysia, limited data suggest that active pandemic influenza virus circulation persist after recent activity peaked during mid April 2010; small numbers of fatal cases have been reported since that time. In Bangladesh, co-dominant circulation of pandemic and seasonal influenza B viruses has been observed since mid April 2010, however, the overall intensity of respiratory diseases was reported to low during this period. Low levels of pandemic influenza virus continued to circulate in western India, while low and declining levels of seasonal influenza B viruses continued to be reported across East Asia.

In Sub-Saharan Africa, limited data from several countries continues to suggest that active transmission of pandemic influenza virus in West Africa has now largely subsided. In addition to the persistence of low level circulation of pandemic influenza virus in Ghana, sporadic detections of pandemic influenza virus have been reported during the past month in Cameroon, Angola, and Rwanda. In Cameroon, there has been persistent active circulation of seasonal influenza B viruses since mid-March 2010.

In the temperate regions of the northern and southern hemisphere, overall pandemic influenza activity remains low to sporadic. In southern hemisphere, Chile continues to report increased ILI in several regions of the country (notably Los Lagos), however, the increase in respiratory disease activity has been predominantly associated with circulating RSV and only to a much lesser extent pandemic influenza virus. In neighboring Argentina, Paraguay, and Uruguay, all recent respiratory diseases activity during the past month has been associated with viruses other than influenza. Similarly, there have been no recent detections of influenza virus in South Africa. In New Zealand and Australia, overall levels of ILI remain low; only sporadic detections of seasonal influenza H3N2 and pandemic influenza viruses have been recently reported in Australia.

As of 12 May 2010, 4 additional cases of oseltamivir resistant pandemic influenza A (H1N1) 2009 viruses have been reported. It brings the cumulative total to 289 so far. All but one of these have the H275Y substitution and are assumed to remain sensitive to zanamivir.
(WHO 05/28/2010)


India: Three new H1N1 pandemic influenza variants detected
The National Institute of Virology (NIV) has detected three new variants of the H1N1 virus. Fortunately, all three variants have shown susceptibility to Tamiflu, the drug used in the treatment of swine flu. However, with the virus actively acquiring new properties, NIV scientists are apprehensive that it might develop resistance to the medicines used in treating swine flu.

NIV assistant director Sarah Cherian said seven mutated variants of the virus have been found across the world so far. She said that the H1N1 virus is going through constant genetic variations which might lead to significant changes in its antiviral resistance.

The variants of the H1N1 virus, representing both recovered and fatal cases from major cities -- Pune, Mumbai, Delhi, Hyderabad and Bangalore -- were analyzed at the NIV, and the complete genomes of these variants were sequenced. The results of the genetic analysis have been published in the March 2010 issue of the journal, PLOS One.
(Times of India 05/25/2010)


Malaysia (Kuala Lumpur): 29 more cases of H1N1 pandemic influenza
Twenty-nine cases of Influenza A (H1N1) were reported nationwide by 24 May 2010, taking the cumulative number of cases so far to 14,692, Director-General of Health Tan Sri Mohd Ismail Merican said 26 May 2010.

He also said that three cluster incidents of Influenza-like Illness (ILI) were reported in Selangor.

He said five cases were in intensive care and at risk of H1N1 infection, but there were no deaths from the disease. The death toll stands at 86.
(Bernama 05/26/2010)


Brazil: Economy extends vaccine campaign
Brazil's Health Ministry last week announced plans to extend its H1N1 vaccination campaign by almost two weeks, to 2 June 2010. Since March 2010, the country has vaccinated more than 61 million people, about 70% of the campaign's goal. The ministry also decided to broaden vaccination to include children two to five years old, which will require almost 11 million additional doses.
(CIDRAP 05/24/2010)


USA: President’s advisory group looks to speed up flu vaccine
In the wake of a pandemic vaccine that came too little and too late to blunt the second wave of pandemic flu infections fall 2009, President Barack Obama's science advisory group presented a set of recommendations on 21 May 2010 on how to more quickly produce a vaccine in the face of another novel flu outbreak or other public health emergency.

In a report to the President's Council of Advisors on Science and Technology (PCAST), the group's co-chair, Dr. Harold Varmus, a virologist who is president and chief executive officer at Memorial Sloan-Kettering Cancer Center in New York, presented the findings of a working group that was tasked in February 2010 with studying how to speed influenza vaccine production. In November 2010, Dr John Holdren, Obama's science and technology advisor, and John Brennan, homeland security advisor, proposed that PCAST study the issue.

Varmus said the task force briefed Obama on its findings in March 2010, and after provisional approval on 21 May 2010 from the PCAST group, will submit the final report to the president soon.

In the early stages of the pandemic, the Obama Administration called on PCAST to assess the new virus's threat to the nation, and in late August 2010 the group weighed in on recommendations that the federal government accelerate pandemic H1N1 vaccine production and appoint a White House pandemic preparedness point person. Their report also made waves when its illness and death projections came in higher than what federal health officials had projected earlier.

Though the group's task was narrowly focused on influenza vaccines, the findings have broad implications that touch on basic science, public policy, regulatory systems, and manufacturing, Varmus said. He added that applicability to other biological threats could help build momentum for making the host of research and technology improvements needed to speed the production of flu vaccines.

He said in August 2010 when PCAST delivered its first pandemic-related report, it was already clear that the vaccine wouldn't be as timely and as plentiful as originally thought. The bulk of the vaccine didn't arrive until the end of the year, he said. No one group bears responsibility for the vaccine delays, much of which Varmus attributed to the "antiquated" egg-based production system. He said it was difficult to make changes in a large established industry that has commodity status.

When group members reviewed the pandemic vaccine production timeline, they found that some steps occurred on schedule, while others didn't.

The working group's short-term recommendations for speeding up influenza vaccine production include quicker and better identification of pandemic viruses, a shift from egg-based to cell culture production, better seed strains, improved methods to speed sterility testing, modernized and more reliable potency test reagents, and larger and more modern fill-and-finish facilities.

Longer-term recommendations include:
* Studying obstacles and incentives that affect cell culture production facilities
* Exploring the wider use of live attenuated influenza virus (LAIV) vaccines
* Developing and testing at least three recombinant influenza vaccines
* Creating an investment strategy for improved methods and vaccines
* Supporting clinical trials of adjuvanted vaccines
* Aiming for a universal flu vaccine
* Implementing a new management in federal departments in overseeing long-term strategies to speed vaccine production

Another measure that could streamline vaccine production is guidance from the US Food and Drug Administration for the pharmaceutical industry on what it takes to have a new flu vaccine approved.

Varmus told the group that the world dodged a bullet, because the virus was less virulent than originally thought. He said it was important to get the vaccine right, and that producing a vaccine in three or four months rather than six or eight would have a dramatic effect.
(CIDRAP 05/21/2010)


USA: FDA Clears First 2009 H1N1 Influenza Virus Test Previously Available Under Emergency Use Authorization
The U.S. Food and Drug Administration announced it has cleared the Simplexa Influenza A H1N1 (2009), a test for the 2009 H1N1 Influenza Virus in patients with signs and symptoms of respiratory infection.

Until this clearance, tests for 2009 H1N1 Influenza were only available through an Emergency Use Authorization (EUA), which allows the FDA, based on the evaluation of available data, to authorize the use of unapproved or uncleared medical products or unapproved or uncleared uses of approved or cleared medical products, during the time a declaration of emergency is in effect.

On 26 April 2010 the U.S. Department of Health and Human Services declared a public health emergency due to the 2009 H1N1 Influenza Virus. EUAs for devices will cease to be effective when the public health emergency declaration expires.

Using specimens from nasal swabs or nasal aspirates, the Simplexa Influenza A H1N1 (2009) test simultaneously amplifies and detects two regions of the influenza virus genome and an internal control. A positive result indicates that the patient is infected with the 2009 H1N1 influenza virus, but the test does not indicate the stage of infection. A negative result does not preclude influenza virus infection.

The Simplexa Influenza A H1N1 (2009) test is manufactured by Focus Diagnostics Inc. in Cypress, California.
Press release available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm212997.htm
(FDA 05/24/2010)


Ghana: Quarantining of students after pandemic influenza H1N1 reported
About 170 students of St. Martin's Senior High School at Adoagyeri, near Nsawam in the Akuapem South District of the Eastern Region have been affected by the H1N1 influenza virus. Reports say the symptoms of the disease were first detected on 15 May 2010. A student of the school reported that they were quarantined after the detection in a bungalow to prevent the spread of disease.

The Head of the Language Department of the School, Gabriel Dzededzi, said samples taken to the Noguchi Laboratory tested positive. He said 48 students were affected with about 12 of them being treated at Koforidua Government Hospital as of 22 May 2010. Asked why the school authorities do not want parents of the students to know about the infections, Mr Dzededzi explained that, the decision was based on advice from the health team from Koforidua and Nsawam.

The Eastern Regional Director of the Ghana Health Service, Dr Erasmus Adongo, confirmed more than 170 cases and said even though the disease was spreading, health authorities are on top of it. Dr. Adongo also said closing the school would not solve the problem as the students would spread the disease in their various communities. Sporting activities have been suspended.

[ProMed note: The 21 May 2010 update from WHO indicated that up to 6 percent of respiratory samples were positive for pandemic H1N1 (see http://www.who.int/csr/don/2010_05_21/en/index.html). The current cluster occurred in a school where cases have been confirmed and isolated and the school closed off to the public. There is however need to improve communication with the parents and the public so that they understand why the current measures are being implemented at the school. As of 19 May 2010, Ghana had notified 720 cases to the WHO (see < http://www.afro.who.int/index.php?Itemid=2544 >).]
(ProMED 05/24/2010)


2. Infectious Disease News

USA (California): Elevation in number of mumps cases, may be related to East Coast outbreak
A mumps outbreak on the East Coast -- the largest in the United States in four years -- may be spreading to Los Angeles County. So far in 2010, nine cases of mumps have been reported, two more than were seen in all of 2009, according to county health officer Jonathan Fielding.

Four of the mumps cases may be related to an outbreak, largely among Orthodox Jews, that has persisted in New York and New Jersey for almost a year. According to the New York State Department of Health, there have been more than 2,800 confirmed and probable mumps cases in New York and 315 in New Jersey. The outbreak has also spread to Quebec, Canada, where 20 mumps cases have been linked to the New York outbreak, and to Israel, where more than 2,600 have been infected.

Dr. David Keene, a pediatrician in Beverly Hills, saw two mumps cases recently, involving a student who attends the private high school Yeshiva Ohr Elchonon Chabad in the Fairfax district of Los Angeles and a two-year-old whose uncle attends the school. He said a lot of students had been traveling lately, due to Passover.

Health officials said the Orthodox Jewish community as a whole has high vaccination rates, which is limiting the outbreak's size. The problem is that the vaccine is not completely effective. One dose is 73 percent to 91 percent effective; those who get a booster shot see 79 percent to 95 percent effectiveness.

The New York outbreak began in June 2009 when an unvaccinated 11-year-old boy visited Britain, where mumps outbreaks remain a problem. He then attended a summer camp in New York's Sullivan County for Jewish boys. The disease, transmitted by coughing and sneezing, spread when the campers returned home.

The outbreak fits the profile of the last major US mumps outbreak in 2006, spreading in places where people have prolonged, close contact. Outbreaks have been notable at boys-only Orthodox Jewish schools, where students sit for long periods facing a study partner. Another reason could be the larger size of many Orthodox families, the CDC said.

Health officials have been concerned about a drop in childhood vaccinations based on allegations, since discredited, that vaccines cause autism. The Los Angeles Times in 2009 reported that a rising number of California parents were choosing to send their children to kindergarten without routine vaccinations, putting hundreds of elementary schools in the state at risk for outbreaks of childhood diseases eradicated in the US years ago.
(ProMED 05/17/2010)


Indonesia (Balikpapan): Public health emergency declared due to diphtheria
Balikpapan’s health agency has declared a public health emergency (KLB) after eight children and teenagers in the municipality were infected with diphtheria.

Health agency head Diyah Muryani said the state of emergency will remain valid until the disease is eradicated from the area.
(The Jakarta Press 05/24/2010)


Philippines: Measles outbreak
Two months after some parts of the country experienced a measles outbreak, the number of measles cases has almost reached the 2,000 mark based on statistics from the Department of Health's National Epidemiology Center (NEC).

An NEC Disease Surveillance Report dated 10 Apr 2010 said a total of 1794 measles cases have been confirmed since 1 Jan 2010, an increase in the number of confirmed cases of 387.5 percent.

Most of the confirmed cases in 2010 have been found in the National Capital Region (967 cases), Calabarzon (268 cases), Central Luzon (105 cases), and Bicol (101 cases).

The number of deaths also grew from only three in 2009 to eight during the first 3.5 months of 2010.

In March of 2010, at least 18 communities recorded a measles outbreak, with the total number of confirmed cases breaching the 368 cases set in 2009. Health officials had said then that they were looking at the possibility that the outbreak was caused by a new strain from overseas.

Aside from the confirmed cases, 1,228 other cases have pending laboratory results to confirm if they are measles.
(ProMED 05/24/2010)


Canada (Alberta): Increase in measles cases
Alberta Health Services (AHS) reports four more cases of measles have been reported in the Calgary area and that number could grow.

The week of 3 May 2010, AHS announced a case in a young child under the age of five, and now it reports more cases of the highly contagious virus. Of the new cases, three are connected to a case reported 7 May 2010. They are either family members or friends of the family, and the virus matches the virus involved in an outbreak in British Columbia.

No emergency rooms that treated the patients were shut down, but AHS says some staff were sent home as a precaution. AHS is investigating eight more suspected cases of the measles.
(ProMED 05/14/2010)


3. Updates
Introduction of WWARN: WWARN Description
The WorldWide Antimalarial Resistance Network (WWARN) is working to provide geographically relevant and timely, quality-assured intelligence to track antimalarial drug resistance. We are currently developing an online interactive data analysis tool, the WWARN Explorer, which allows users to visualize standardized datasets, including treatment outcomes and measures from clinical trials of drug efficacy; pharmacological profiles of antimalarial drugs across key target populations; in vitro assessment of drug susceptibility of parasite isolates; and molecular markers of parasite resistance. Active in Southeast Asia, we recently established the WWARN Asia Regional Centre in Bangkok which will be working across the region to bridge the gap between the generation of research results and their use by Ministries of Health, National Malaria Control Programmes (NMCPs), funders and implementers. For more information on WWARN, please visit www.wwarn.org or contact us at info@wwarn.org.
(WWARN 05/20/2010)


Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions:
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
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.phpoption=com_content&task=blogcategory&id=805&Itemid=569
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Europe: http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/influenza/pandemic-influenza
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:
ProMED: http://www.promedmail.org/

CIDRAP Novel H1N1 Influenza Update
21 May 2010:


- 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:
- 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.


Chinese Taipei
The Department of Health (DOH) has asked the public to take precautions against dengue fever, as the disease's second wind seems to be gaining strength.

Lin Ting, deputy director general of the DOH's Centers for Disease Control, said that the dengue fever outbreak during 2010 has come in two waves. Thirty-eight cases were recorded in the first round, which started last year and extended into the spring of 2010.

After the outbreak eased off for more than one month, a second wave has struck, and the number of dengue fever cases has risen to seven, mainly in Kaohsiung City.
(Taiwan Headlines 05/25/2010)

A total of three cases of chikungunya were reported during the week since 9 May 2010, a drop of two cases compared to the five reported in the week of 2 May 2010. Of the three cases reported, two were in Selangor while the other was in Negeri Sembilan.

The number of accumulated chikungunya cases in 2010 was 549 compared with 1,945 cases, a drop of 1,396 cases or 72 percent from the corresponding period of 2009.

The director-general of Health, Dr. Tan Sri Dr Mohd Ismail Merican, in a statement 19 May 2010 said the rate of Aedes breeding was high, which was between 2-3.6 percent (household index.)

This is a mixed dengue-chikungunya virus outbreak, transmitted by the same Aedes mosquito vectors. Fortunately, there are significantly fewer cases than in 2009, but the Aedes household index remains high with the risk of ongoing chikungunya virus transmission.
(ProMED 05/19/2010)

A total of 766 dengue cases with two deaths were reported for a period of seven days from 9 May 2010, an increase of six cases or one percent compared with the 760 cases reported in the previous week. Six states showed a rise in the number of cases reported, namely Selangor (36 cases), Negeri Sembilan (9 cases), Melaka (5), Terengganu (4), Pahang (2), and Penang (1).

The number of accumulated cases reported for 2010 was 17,981 cases compared with 20,187 cases for the corresponding period of 2009, said the director-general of health, Tan Sri Dr Mohd Ismail Merican, in a statement 19 May 2010. There was a drop in cases by 11 percent, but the number of fatalities also increased by 11 percent, from 52 deaths in 2009 to 58 deaths in the corresponding period of 2010.
(ProMED 05/24/2010)

A team from the Epidemiologic Surveillance Unit (ESU) of Iloilo Provincial Health Office (IPHO) visited Brgy. Cadapdap of this town yesterday to check the status of 15 suspected dengue cases.

A total of four deaths were already recorded in Iloilo province from January 2010 up to the present. Casualties came from towns of Guimbal, Oton, Pototan and one component city of Passi. In 2009, from January to June 10, a total of 286 dengue cases were already recorded by the IPHO.

In Western Visayas region, the Department of Health 6 (DOH-6) has so far recorded a total of 1,311 cases – with seven deaths – from January to 8 May 2010. Negros Occidental has the highest number of recorded cases at 380 with two deaths, followed by Bacolod City with 266 cases. Iloilo Province has 231 cases with four deaths, while Iloilo City has 126 cases. There were 194 cases in Capiz, 79 in Aklan, with one death, 16 in Guimaras and 12 in Antique.

It is expected that the number of dengue cases will increase during rainy season, which begins in June.
(The News Today 05/25/2010)

Viet Nam (An Giang)
Health officials in An Giang have voiced concern over the rapid spread of dengue fever in the province during May 2010. More than 858 cases have been hospitalized, with three fatalities since the beginning of May 2010. Most of them were in Long Xuyen City, Cho Moi, and Chau Thanh districts.

Tu Quoc Tuan, head of the provincial Health Department, warned that the number of dengue cases would increase in coming months. The department asked relevant agencies to spray areas where mosquitoes breed and raise residents' awareness about prevention of dengue and eradication of breeding areas around houses.

As of 2 Apr 2010, Viet Nam's Ministry of Health reported 7,300 cases and three deaths of dengue fever and dengue hemorrhagic fever (DF/DHF) from January to March 2010, which was 10 times higher than that of same period in 2009.
(ProMED 05/24/2010)


Hong Kong
A 46-year-old HK woman was found to have contracted cholera during her trip to Singapore, the city's Center for Health Protection (CHP) said on 24 May 2010. She is now in an isolation unit at the Princess Margaret Hospital and is in stable condition. Her home contacts have no cholera symptoms.

The CHP's investigation revealed that the patient had traveled alone to Singapore between 10 and 17 May 2010. This is the second case of reported in 2010.
(ProMED 05/24/2010)

Papua New Guinea
Papua New Guinea's Minister of Health has declared a public health emergency in Central Province following criticism of the government's response to the latest cholera outbreak. The announcement follows a public health emergency declaration in Port Moresby in the latest flare-up of an outbreak first detected in remote provinces in August 2009.

Three people in the capital have died from the disease, which has infected 132 people there, and there have been two deaths in Central Province, where there are another 117 cases of infection.

The Papua New Guinea Secretary for Education, Dr. Joseph Pagelio, says awareness is being carried out on preventative hygiene measures to stop the spread of cholera in Port Moresby's schools.
(ProMED 05/24/2010)

Peru (Mariscal Caceras)
A possible epidemic that causes fever, vomiting and diarrhea in young children has been reported in a village in the province of Mariscal Caceres, in the region of San Martin.

Over 100 similar cases have occurred among the population of the Bagazan area in the Sapuena district capital, which has concerned health authorities.

The Provincial Health Directorate has initiated research to determine which organism is causing the symptoms.
(ProMED 05/24/2010)

According to the latest report from the Regional Epidemiology Office, 99.2% of the districts of Cajamarca reported a case of watery diarrhea or dysentery, except the town of Eduardo Villanueva in San Marcos province.

The epidemic curve for total Acute Diarrhoeal Diseases (watery and dysenteric) has been declining, but is still of concern.
(HealthMap 05/22/2010)

USA (Kentucky)
Kentucky health officials in three counties are attempting to battle an outbreak of shigellosis that has continued for several weeks, but despite their efforts, the disease continues to spread.

The outbreak, first reported at the beginning of May 2010, has more than doubled in size every week, according to weekly updates from local news media. There are now a reported 30 cases in Daviess County; additional cases have been confirmed in Meade and Hardin counties.

Most of those sickened by the outbreak are children under 13. Shigellosis is a highly contagious disease caused by a bacterial infection and is spread mainly through food and drink contamination.
(ProMED 05/24/2010)

Viet Nam (North)
More cholera patients have been discovered in some northern provinces, said Dr. Tran Nhu Duong, Central Institute for Epidemiology Vice-Director, on 12 May 2010. The latest case was reported on 8 May 2010, when a 65-year-old woman from Hanoi's Dong Da District was hospitalized at the Central Hospital for Tropical Diseases for cholera.

Since early March 2010, a total of 106 cholera patients have been recorded in five northern provinces, including Hanoi, Ha Nam, Hai Duong, Hai Phong and Bac Ninh. The southern provinces of An Giang, Tay Ninh and HCM City have also detected cholera patients in the last two months.

Area water sources transmitted cholera in An Giang province, but the reasons for cholera in other locations have not been identified.
(ProMED 05/24/2010)

Viet Nam (South)
Three more patients with cholera have been recorded in Ben Tre, increasing the number of patients with the disease in the Mekong Delta province to 25 in 2010.

The provincial Preventive Health Center is cooperating with health clinics at districts where the patients live in order to test water samples and instruct local people about preventive measures.

Ben Tre is one of eight provinces and cities to be hit by cholera so far. Hanoi and Ho Chi Minh City are among the affected localities. Seven cases have been recorded in the southern metro, while the capital has reported one patient so far.
(ProMED 05/24/2010)


4. Articles
Differences in the Epidemiological Characteristics and Clinical Outcomes of Pandemic (H1N1) 2009 Influenza, Compared with Seasonal Influenza
Shiley KT, Nadolski G, Mickus T, et al. Infect Control Hosp Epidemiol. 2010;31:000-00. DOI: 10.1086/653204
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/653204

Background. There are limited data comparing the clinical presentations, comorbidities, and outcomes of patients with infections due to seasonal influenza with patients with infections due to pandemic (H1N1) 2009 influenza.

Objective. To compare the epidemiological characteristics and outcomes of pandemic (H1N1) 2009 influenza with those of seasonal influenza.

Methods. A cross-sectional study was conducted among patients who received diagnoses during emergency department and inpatient encounters at 2 affiliated academic medical centers in Philadelphia, Pennsylvania. Cases of seasonal influenza during the period November 1, 2005, through June 1, 2008, and cases of pandemic influenza during the period from May 1, 2009, through August 7, 2009, were identified retrospectively.

Results. Forty-nine cases of pandemic influenza and 503 cases of seasonal influenza were identified. Patients with pandemic H1N1 were younger (median age, 29 years) than patients with seasonal influenza (median age, 59 years) ( ). More patients with pandemic H1N1 (35 [71%] of 49) were African American, compared with patients with seasonal influenza (267 [53%] of 503; ). Several symptoms were more common among patients with pandemic influenza infections than among patients with seasonal influenza infections: cough (98% vs 83%; ), myalgias (71% vs 46%; ), and pleuritic chest pain (45% vs 15%; ). Pregnancy was the only comorbidity that occurred significantly more often in the pandemic influenza group than in the seasonal influenza group (16% vs 1%; ). There were no significant differences in frequencies of deaths of hospitalized patients, intensive care unit admission, or length of hospitalization between groups.

Conclusion. Other than pregnancy, there were few clinically important differences between infections due to seasonal influenza and those due to pandemic influenza. The greater rate of lower respiratory tract symptoms in pandemic cases might serve to differentiate pandemic influenza from seasonal influenza.


Differing Symptom Patterns in Early Pandemic vs Seasonal Influenza Infections
Tang JW-T, Tambyah PA, Lai, FLL, et al. Arch Intern Med. 2010;170(10):861-867.
Available at http://archinte.ama-assn.org/cgi/content/short/170/10/861?rss

Background. Singapore is a tropical country with a temperature range of 23°C to 35°C and relative humidity of 48% to 100% throughout the year. Influenza incidence peaks in June through July and November through January, though influenza cases can be detected throughout the year.

Methods. Between May 1 and July 28, 2009, a novel dual-gene diagnostic polymerase chain reaction assay targeting the hemagglutinin (HA) and nucleoprotein (NP) genes of the new influenza A(H1N1/2009) virus was specifically designed for enhanced influenza surveillance using nasopharyngeal swabs collected from symptomatic patients (including their close contacts) and returning travelers returning from influenza A(H1N1/2009)–affected areas, presenting to affiliated primary care clinics as well as the main hospital emergency department.

Results. From the week of June 16 to June 23, 2009, this pandemic influenza A(H1N1/2009) displaced and then replaced the seasonal influenzas (H3N2, H1N1, and B). Of 2683 samples tested during this 12-week surveillance period, 742 (27.6%) were positive for any influenza virus using this assay, with 547 cases of A(H1N1/2009) (20.4%), 167 cases of A(H3N2) (6.2%), 14 cases of A(H1N1) (0.5%), and 12 cases of influenza B (0.4%). Results of multivariate analysis showed that age (P < .001), fever (P < .001), cough (P < .001), sore throat (P = .002), rhinorrhea (P = .001), and dyspnea (P < .001) were significantly different among these groups.

Conclusions. From this large prospective study, there was a lower incidence of fever and dyspnea in patients with pandemic influenza A(H1N1/2009) infection. Similar to reports from elsewhere, it was also found that this pandemic virus tends to infect younger people, though with fewer symptoms, on average, than seasonal influenza. Early pandemic influenza A(H1N1/2009) infections appeared to be slightly milder than seasonal influenza as indicated by different symptom patterns in the presentation of more than 500 cases of influenza A(H1N1/2009) during April through July to a large teaching hospital in Singapore.


Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial
Looijmans-van den Akker I, van Delden JJM, Verheij TJM, et al. Vaccine.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-504SVYG-1&_user=10&_coverDate=05%2F23%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=a28c2ff33477a8837fb86ef1e5becea7

Abstract. Despite the recommendation of the Dutch association of nursing home physicians (NVVA) to be immunized against influenza, vaccine uptake among HCWs in nursing homes remains unacceptably low. Therefore we conducted a cluster randomised controlled trial among 33 Dutch nursing homes to assess the effects of a systematically developed multi-faceted intervention program on influenza vaccine uptake among HCWs. The intervention program resulted in a significantly higher, though moderate, influenza vaccine uptake among HCWs in nursing homes. To take full advantage of this measure, either the program should be adjusted and implemented over a longer time period or mandatory influenza vaccination should be considered.


Effect of influenza-like illness and other wintertime respiratory illnesses on worker productivity: The child and household influenza-illness and employee function (CHIEF) study
Palmer LA, Rousculp MD, Johnston SS, et al. Vaccine. 2010.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-5044P89-1&_user=10&_coverDate=05%2F20%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=e39654f342703800a115642ef70b523d

Abstract. Acute respiratory illnesses (ARI), comprising influenza-like illness (ILI) and other wintertime respiratory illnesses (ORI), impose substantial health and economic burdens on the United States. Little is known about the impact of ILI among household members (HHM), particularly children, on employees’ productivity. To quantify the impact of employee and HHM-ILI and ARI on employee productivity, a prospective, observational cohort study was conducted among employees from three large US companies. Employees who had at least one child living at home (N = 2013) completed a monthly survey during the 2007–2008 influenza season, reporting the number of days missed from work and hours of presenteeism due to: (1) personal ILI, (2) HHM-ILI, and (3) personal and HHM-ARI. Employee ILI ranged from 4.8% (April) to 13.5% (February). Employees reporting ILI reported more absences than employees not reporting ILI (72% vs 30%, respectively; P < 0.001). Overall, 61.2% of employees surveyed had at least one child with an ILI; these employees missed more days of work due to HHM illness than employees without an ARI-ill child (0.9 days vs 0.3 days, respectively; P < 0.001). Employees with ILI were less productive, on average, for 4.8 h each day that they worked while sick, 2.5 h of which was due to ILI. HHM illnesses accounted for 17.7% (1389/7868 days) of employee absenteeism, over half of which was due to HHM-ARI. ILI causes a significant amount of employee absence. Household members, particularly children, comprise a sizable proportion of general illness and injury-related employee absences.


Pandemic (H1N1) 2009, Shanghai, China
Shen Y, Lu H. Emerging infectious Diseases. June 2010;16(6)
DOI: 10.3201/eid1606.090991
Available at http://www.cdc.gov/eid/content/16/6/1011.htm

Abstract. To understand the clinical and epidemiologic characteristics of pandemic (H1N1) 2009 virus infection, we retrospectively reviewed medical records of 237 patients with laboratory-confirmed cases reported in Shanghai, China, during May–July 2009. Surveillance activities effectively contained the outbreak and provided useful epidemiologic data for future strategies.


Editorial: Journals, Academics, and Pandemics
PLoS Medical Editors. PLoS Med. 25 May 2010;7(5): e1000282.
Available at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000282

Excerpt. Two articles published recently in PLoS Medicine highlight the problem of how to effectively share information in the wake of a rapidly spreading disease, and prompted us to ask the question “How well are journals doing?” with regard to this important goal. The answer, sadly, seems to be “not well enough.” Although the potential of the Internet for improving the dissemination of information is now taken for granted, it would seem that the attitudes of those involved in sharing this information have not kept pace with the technology. Accordingly, it is fair to ask whether the flow of information in the face of a crisis is truly enabled by publication in medical journals (even online journals) or whether we need new avenues for rapid data sharing.
[For the rest of the editorial, please refer to the link above.]


Prior immunity helps to explain wave-like behavior of pandemic influenza in 1918-9
Mathews JD, McBryde ES, McVernon J., et al. BMC Infectious Diseases. 25 May 2010;10(128)
Available at http://www.biomedcentral.com/1471-2334/10/128

Background. The ecology of influenza may be more complex than is usually assumed. For example, despite multiple waves in the influenza pandemic of 1918-19, many people in urban locations were apparently unaffected. Were they unexposed, or protected by pre-existing cross-immunity in the first wave, by acquired immunity in later waves, or were their infections asymptomatic?

Methods. We modelled all these possibilities to estimate parameters to best explain patterns of repeat attacks in 24,706 individuals potentially exposed to summer, autumn and winter waves in 12 English populations during the 1918-9 pandemic.

Results. Before the summer wave, we estimated that only 52% of persons (95% credibility estimates 41-66%) were susceptible, with the remainder protected by prior immunity. Most people were exposed, as virus transmissibility was high with R0 credibility estimates of 3.10-6.74. Because of prior immunity, estimates of effective R at the start of the summer wave were lower at 1.57-3.96. Only 25-66% of exposed and susceptible persons reported symptoms. After each wave, 33-65% of protected persons became susceptible again before the next wave through waning immunity or antigenic drift. Estimated rates of prior immunity were less in younger populations (19-59%) than in adult populations (38-66%), and tended to lapse more frequently in the young (49-92%) than in adults (34-76%).

Conclusions. Our model for pandemic influenza in 1918-9 suggests that pre-existing immune protection, presumably induced by prior exposure to seasonal influenza, may have limited the pandemic attack-rate in urban populations, while the waning of that protection likely contributed to recurrence of pandemic waves in exposed cities. In contrast, in isolated populations, pandemic attack rates in 1918-9 were much higher than in cities, presumably because prior immunity was less in populations with infrequent prior exposure to seasonal influenza. Although these conclusions cannot be verified by direct measurements of historical immune mechanisms, our modelling inferences from 1918-9 suggest that the spread of the influenza A (H1N1) 2009 pandemic has also been limited by immunity from prior exposure to seasonal influenza. Components of that immunity, which are measurable, may be short-lived, and not necessarily correlated with levels of HI antibody.


Clinical and Molecular Evidence for Transmission of Novel Influenza A(H1N1/2009) on a Commercial Airplane
Ooi PL, Lai FYL, Low CL., et al. Arch Intern Med. 24 May 2010;170(10):913-915
Available at http://archinte.ama-assn.org/cgi/content/extract/170/10/913

Abstract. Influenza A(H1N1/2009) has spread rapidly throughout the world by international air travel.1 However, in-flight transmission of the virus has not been well documented. We report 6 cases of influenza A(H1N1/2009) associated with a single flight from the United States to Asia via Europe ("Flight A") linked by molecular epidemiological data.


Transmission of pandemic A/H1N1 2009 influenza on passenger aircraft: retrospective cohort study
Baker MG, Thornley CN, Mills C., et al. BMJ. 21 May 2010;340:c2424
Available at http://www.bmj.com/cgi/content/abstract/340/may21_1/c2424

Objectives. To assess the risk of transmission of pandemic A/H1N1 2009 influenza (pandemic A/H1N1) from an infected high school group to other passengers on an airline flight and the effectiveness of screening and follow-up of exposed passengers.

Design. Retrospective cohort investigation using a questionnaire administered to passengers and laboratory investigation of those with symptoms.

Setting. Auckland, New Zealand, with national and international follow-up of passengers.

Participants. Passengers seated in the rear section of a Boeing 747-400 long haul flight that arrived on 25 April 2009, including a group of 24 students and teachers and 97 (out of 102) other passengers in the same section of the plane who agreed to be interviewed.

Main outcome measures. Laboratory confirmed pandemic A/H1N1 infection in susceptible passengers within 3.2 days of arrival; sensitivity and specificity of influenza symptoms for confirmed infection; and completeness and timeliness of contact tracing.

Results. Nine members of the school group were laboratory confirmed cases of pandemic A/H1N1 infection and had symptoms during the flight. Two other passengers developed confirmed pandemic A/H1N1 infection, 12 and 48 hours after the flight. They reported no other potential sources of infection. Their seating was within two rows of infected passengers, implying a risk of infection of about 3.5% for the 57 passengers in those rows. All but one of the confirmed pandemic A/H1N1 infected travellers reported cough, but more complex definitions of influenza cases had relatively low sensitivity. Rigorous follow-up by public health workers located 93% of passengers, but only 52% were contacted within 72 hours of arrival.

Conclusions. A low but measurable risk of transmission of pandemic A/H1N1 exists during modern commercial air travel. This risk is concentrated close to infected passengers with symptoms. Follow-up and screening of exposed passengers is slow and difficult once they have left the airport.


Estimating the effective reproduction number for pandemic influenza from notification data made publicly available in real time: A multi-country analysis for influenza A/H1N1v 2009
Hens N., Van Ranst M, Aerts M., et al. Vaccine. 22 May 2010; doi:10.1016/j.vaccine.2010.05.010
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-504JYMT-1&_user=10&_coverDate=05%2F22%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=542e7a0434340b4507ab87ccdcaca8b0

Abstract. In the early phase of an emerging pandemic such as A/H1N1v 2009, it is essential to have a good understanding of its transmissibility, which is often summarized by the reproductive number. Before a country is affected, its government may want to make their own assessment of what is going on in areas of the world that have previously been affected by the disease. However, having access to detailed data is problematic. The only publicly available international dataset with information for a large number of countries was the WHO cumulated case counts per country. In this paper, we show how and in which situations the recorded history of cumulated case counts provides valuable information to estimate the effective reproductive number in an early phase and for a large number of countries.


Pandemic Vaccines – The Legal Landscape
Parmet W. New Engl J Med. 27 May 2010;362(21):1949-1952 Available at http://content.nejm.org/cgi/content/full/362/21/1949 >Abstract. Vaccines and vaccination law feature prominently in pandemic preparedness plans. The recent H1N1 influenza vaccine program provides an important opportunity to assess the complex and perhaps paradoxical effects of vaccine laws during a pandemic.
[For remainder of article, please refer to the link above.]


5. Notifications
Second APEC Senior Officials’ Meeting (SOM II)
Sapporo, Japan 26 May 2010 – 4 June 2010.
APEC Senior Officials will discuss progress on the main tasks for the year. Topics will include: developing APEC's New Growth Strategy of balanced, inclusive, sustainable and knowledge-based growth; addressing the Bogor Goals Assessment; supporting the multilateral trading system; and accelerating regional economic integration. The Senior Officials will also develop recommendations for APEC Ministers and APEC Economic Leaders.
Additional Information available at http://www.apec.org/apec/enewsletter/apr_issue22/upcomingevents.html#


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/.


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/.


4th Ditan International Conference on Infectious Diseases
Beijing, China 15-18 July 2010
Ditan International Conference on Infectious Diseases is the annual conference held in Beijing to provide a platform for scientific exchange between Chinese and international experts.
Additional information is available at http://www.bjditan.org/


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.


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.


4th Vaccine and ISV Annual Global Congress
Vienna, Austria 3-5 October 2010
Now in its fourth year, the annual Vaccine Congress has become the forum for the exchange of ideas to accelerate the rate at which vaccines can come to benefit the populations that need them.
Organized by: Vaccine – the pre-eminent journal for those interested in vaccines and vaccination – in collaboration with the International Society for Vaccines
Deadline for abstracts/proposals: 18 June 2010
Additional information available at http://www.vaccinecongress.com


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