Vol. XIII No. 16 ~ EINet News Briefs ~ Aug 06, 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: H1N1 pandemic influenza definition should exclude severity, according to expert
- Bhutan: Suspected outbreak of pandemic influenza H1N1
- India: 38 new pandemic influenza H1N1 deaths
- India (Bhatkal): Pandemic influenza H1N1 outbreak
- India (Sikkim): Football team members ill with pandemic influenza H1N1
- New Zealand: Rise in H1N1 pandemic influenza cases
- New Zealand: Impact of H1N1 pandemic influenza evident
- USA: Federal advisors hope to build on H1N1 vaccine safety-monitoring lessons
- Egypt: WHO confirms fatal Egyptian avian influenza H5N1 case
- Gambia: H1N1 pandemic influenza vaccination campaign beginning

2. Infectious Disease News
- India (Orissa): Anthrax cases
- India (Uttar Pradesh): Mysterious virus not Japanese encephalitis
- Russia (Tajikistan): Polio update
- Viet Nam (Ho Chi Minh City): Increase in hand-foot-mouth disease cases
- Peru (La Libertad): Pneumonic and bubonic plague
- USA (Michigan): Legionnaires’ cases reported at Michigan National Guard base
- USA (Missouri): Two cases of veterans infected with hepatitis B

3. Updates

4. Articles
- Mandatory Influenza Vaccination of Healthcare Workers: A 5-Year Study
- The Impact of the Pandemic Influenza A(H1N1) 2009 Virus on Seasonal Influenza A Viruses in the Southern Hemisphere, 2009
- Changes in the Viral Distribution Pattern after the Appearance of the Novel Influenza A H1N1 (pH1N1) Virus in Influenza-Like Illness Patients in Peru
- Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010
- Prevalence of high-risk indications for influenza vaccine varies by age, race, and income
- Emerging, Novel, and Known Influenza Virus Infections in Humans
- Adult Hospitalizations for Laboratory-Positive Influenza during the 2005-2006 through 2007-2008 Seasons in the United States
- Seasonal influenza vaccine supply and target vaccinated population in China, 2004-2009
- Comparison of Pandemic (H1N1) 2009 and Seasonal Influenza, Western Australia, 2009
- Correlation of Pandemic (H1N1) 2009 Viral Load with Disease Severity and Prolonged Viral Shedding in Children
- Severe, critical and fatal cases of 2009 H1N1 influenza in China
- Household transmission of pandemic 2008 influenza A (H1N1) virus in Osaka, Japan in May 2009
- Knowledge, attitudes and practices towards pandemic influenza among cases, close contacts, and healthcare workers in tropical Singapore: a cross-sectional survey
- Perceptions and behaviors related to hand hygiene for the prevention of H1N1 influenza transmission among Korean University students during the peak pandemic period
- Event-Based BioSurveillance of Respiratory Disease in Mexico, 2007-2009: Connection to the 2009 Influenza A(H1N1) Pandemic?
- Transmission of pandemic influenza A (H1N1) 2009 within households: Edmonton, Canada
- Immunity to Pre-1950 H1N1 Influenza Viruses Confers Cross-Protection against the Pandemic Swine-Origin 2009 A (H1N1) Influenza Virus
- Reponses to Pandemic (H1N1) 2009, Australia
- Pandemic (H1N1) 2009 Surveillance for Severe Illness and Response, new York, New York, USA, April-July 2009
- Pandemic (H1N1) 2009 Surveillance in Marginalized Populations, Tijuana Mexico
- Quarantine Methods and Prevention of Secondary Outbreak of Pandemic (H1N1) 2009
- Pandemic (H1N1) 2009 Vaccination and Class Suspensions after Outbreaks, Taipei City, Taiwan
- Pandemic (H1N1) 2009 Virus and Down Syndrome Patients
- Community Psychological and Behavioral Responses through the First Wave of the 2009 Influenza A (H1N1) Pandemic in Hong Kong
- Immunisation and multi-dose vials
- Developing guidelines for school closure interventions to be used during a future influenza pandemic
- Characterizing hospital workers’ willingness to report to duty in an influenza pandemic through threat-and efficacy-based assessment

5. Notifications
- Second International Swine Flu Conference
- Options for the Control of Influenza VII
- Influenza 2010: Zoonotic Influenza and Human Health
- 4th Vaccine and ISV Annual Global Congress
- International TB Symposium (ITBS-2010): TB Diagnostics – Innovating to Make an Impact

1. Influenza News

2010 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Cambodia / 1 (1)
China / 1 (1)
Egypt / 20 (8)
Indonesia / 6 (5)
Viet Nam 7 (2)
Total / 35 (17)

***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: 503 (299)
(WHO 08/03/10

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 25 July 2010, worldwide more than 214 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 18398 deaths.

WHO is actively monitoring the progress of the pandemic through frequent consultations with the WHO Regional Offices and member states and through monitoring of multiple sources of information.

Worldwide, overall pandemic and seasonal influenza activity remains low. In the southern hemisphere (where the winter season is in progress), current influenza activity remains variable: ranging from low and stable activity in Chile and Argentina, to low but increasing activity in Australia and New Zealand, to elevated and recently peaked activity in South Africa. Significant seasonal and pandemic influenza virus transmission continues to be detected at variable levels across parts of the tropics, particularly in several countries of the Americas and South and Southeast Asia.

In the southern hemisphere, overall influenza virus transmission remains low to sporadic, except in South Africa, where recent wintertime influenza activity appears to have peaked, and in Australia and New Zealand, where influenza activity remains low but continues to increase steadily, particularly in recent weeks. In South Africa, virologic data from outpatient sentinel surveillance suggest that the current period of influenza activity (primarily attributable to circulating seasonal influenza H3N2 and B viruses) began and rose sharply during early June 2010, with a likely peak and decline in activity occurring since the first week of July 2010. Data on the full extent of severe illness associated with recent influenza activity are not yet available, however, early reports suggest the current influenza season has been generally mild in terms of levels of clinical disease in the population. In Australia, overall rates of ILI remain low and have increased only slightly over the past four weeks (through the second week of July 2010); however, of note, the number of viral respiratory disease presentations to the emergency departments in Western Australia increased more dramatically during the same period. Overall, the proportion of respiratory specimens testing positive for influenza virus was 5% at sentinel laboratories across Australia, of which approximately two-thirds were pandemic influenza viruses and one-third were seasonal influenza H3N2 viruses; respiratory viruses other than influenza continue to predominant in several regions of Australia. In New Zealand, rates of ILI are below the seasonal baseline but have increased steadily over the past month; recent reports suggest that more significant, but geographically uneven increases may have occurred during the third week of July 2010. Although the number of influenza virus detections remains low, the majority of virus isolates in New Zealand have been pandemic influenza virus. The most recent available virologic surveillance data (mid-July 2010) from Chile and Argentina indicate that very low levels of influenza viruses are currently circulating in the southern temperate regions of the Americas; the predominant circulating influenza viruses in Chile and Argentina are pandemic and seasonal influenza type B viruses, respectively. Recently data from Chile also indicate that overall levels of ILI in the population remain very low, except in the Los Lagos region, which has seen recent late season increases in levels of ILI slightly above the epidemic threshold.

In Asia, the most active areas of pandemic influenza virus transmission currently are in parts of India, particularly in several western and southern states. The majority of new cases continue to be reported in the southern state of Kerala and in the western state of Maharashtra, the later of which reported a sharp increase in the number of cases, including small numbers of fatal cases, between the second and third week of July 2010. Smaller numbers of new cases have also been recently reported in other southern states and in the eastern state of West Bengal. In neighboring Bangladesh, low level co-circulation of pandemic and seasonal influenza type B viruses continued to be detected over the month of July 2010. In Southeast Asia, low levels of pandemic influenza virus circulation were detected in several countries during July 2010, including Cambodia, Singapore and Malaysia. Significant levels of seasonal influenza H3N2 viruses continued to circulate in Singapore.

In sub-Saharan Africa (excluding South Africa), limited data indicate that seasonal influenza H3N2 and B viruses continued to circulate in parts of eastern Africa (Kenya) and central Africa (Cameroon), respectively. Ghana, in West Africa, reported sustained transmission of pandemic influenza virus during June and early July 2010.

In the tropical regions of the Americas, active subregional co-circulation of seasonal and pandemic influenza viruses was detected during July 2010. Since early June 2010, predominantly seasonal influenza H3N2 viruses have circulated in Panama and Nicaragua; predominantly seasonal influenza B viruses in El Salvador and Bolivia; and predominantly pandemic influenza viruses in Costa Rica and Columbia.

In the temperate regions of the Northern hemisphere, pandemic and seasonal influenza viruses have been detected only sporadically or at very low levels during the past month.
(WHO 07/30/2010)


Global: H1N1 pandemic influenza definition should exclude severity, according to expert
Though many are calling for the WHO to incorporate severity into its pandemic alert phases, a renowned virologist is saying no. Malik Peiris of the University of Hong Kong said there was no doubt novel H1N1 was a pandemic, well before the WHO declaration. We really do not have good assessments of severity, he said, and added that it would completely paralyze international public health policy if severity is linked to the definition of a pandemic.
(CIDRAP 07/29/2010)


Bhutan: Suspected outbreak of pandemic influenza H1N1
The H1N1 virus is now suspected to have surfaced in the southern central part of the country, with two schools closed for a week in Tsirang and Dagana. With about 175 students suffering from headache, high fever, and throat pain in Daga HSS. Dagana dzongkhag [district] declared a break for a week for the 503 students since 22 July 2010. The vice principal of the school, Loden, said that, as a preventive measure against spreading the disease, the students from nearby areas are being sent home, while those from Drujeygang and Lhamoizingkha are kept in the hostel, separate from the affected students. Loden said that the sick students are being given porridge and Horlicks to supplement their diet.

It has note been confirmed whether it is H1N1 or not. Eleven students reported to the Dagana BHU [basic health unit] complaining of fever, headache, and throat pain on 18 July 2010. Since then the numbers kept rising.

But the dzongkhag [district authorities] could not communicate and send the blood samples to Thimphu to confirm if it was an H1N1 outbreak because of road blocks due to landslides, erratic power supply, and network connection problems. The Dagapela doctor and health officials were conducting routine blood test yesterday 24 July 2010 in Dagana, which is still cut off from the rest of the country.

According to the vice principal, a few students complained of flu like symptoms after they returned from their mid term break on 15 July 2010. Dagana dzongda Tashi Gyaltsen said that, since there was no equipment to test whether it is H1N1 or not, the affected students were given paracetamol and some antibiotics.

Meanwhile, in Tsirang, the district education office, on the advice of health officials, kept Damphu LSS [lower secondary school] on break for a week since 23 July 2010, after three of the 11 students tested positive for the influenza A on 22 July 2010.

About 26 students from Damphu HSS became sick since 22 July 2010, suffering from common cold.

According to the DMO, about five blood samples were sent to the public health laboratory in Thimphu.

Meanwhile, all the 26 sick students were given H1N1 vaccination and even the teachers were vaccinated. But vaccinating all the students isn't possible, since there are limited numbers of vaccine, said a source.

Tsirang district education officer, Sonam Gyeltshen, said that the education officials, along with dzongda [chief executive of the district] and the DMO, visited schools and briefed the students on H1N1.

[ProMED note: Bhutan lies in the eastern part of the Himalayas. To the west and east, rugged mountain ranges stand between it and the hill districts of India and to the south it borders with the northern plains of West Bengal and Assam Provinces of India.

It has not been confirmed that the outbreaks of illness in these schools are due to influenza pandemic (H1N1) virus infection, or indeed any other specific respiratory virus. The outbreaks are sufficiently serious, however, to alarm the local authorities. Further information from the region would be welcomed.]
(ProMED 07/25/2010)


India: 38 new pandemic influenza H1N1 deaths
India reported 548 pandemic flu cases and 38 deaths for the week ending 25 July 2010, up significantly from 332 cases and 21 deaths the previous week, according to the country's Press Information Bureau (PIB). The southern states of Maharashtra, Kerala, and Andhra Pradesh reported the most deaths. All of the newly infected patients contracted the disease within the country.
(CIDRAP 07/27/2010)


India (Bhatkal): Pandemic influenza H1N1 outbreak
Several villages of Bhatkal taluk [local authority district], including Hadlur, Hallari, Ashikan, and Hakodlu, are in the grip of swine flu. As many as 22 people of Hadlur village of Konur Gram Panchayat were brought to the government hospital at Bhatkal with the help of 108-ambulance service on 23 July 2010. They have been reportedly suffering from swine flu symptoms, including fever, body pain, cold and cough.

On 21 Juy 2010 a three-and-a-half-year-old child of Hadlur village died of swine flu at the KMC Hospital in Manipal. The hospital authorities confirmed on 23 July 2010 that the child died of swine flu. District Health Officer Dr Shivanna Reddy also confirmed it. In fact, the entire family of the child, including her father, his pregnant wife and his other daughter, who have been suffering from fever, are being treated at the Manipal Hospital.

Meanwhile, Bhatkal MLA JD Naik visited the local government hospital. Taluk health officer Manjunath Shetty said that Tamiflu tablets are available in government hospitals for treating the swine flu patients.
(ProMED 07/25/2010)


India (Sikkim): Football team members ill with pandemic influenza H1N1
As many as six players of the Sikkim football team, including East Bengal midfielder Sanju Pradhan, who is the captain of the team as well, have been reported to have fallen ill after reaching Kolkata.

When medical check-ups were conducted, it was confirmed that three players from the squad tested positive for swine flu.

As swine flu is a contagious disease, the organizers, Indian Football Association (WB), were scheduled to hold a meeting 25 July 2010. It has also been heard that the tournament committee might be forced to ask Sikkim FA to withdraw their team from the tournament due to these medical conditions.

Skipper Sanju Pradhan, though not testing positive for swine flu, remains to be hospitalized. In this situation, the Sikkim team is left with only 13 fit players to continue in the tournament.
(ProMED 07/24/2010)


New Zealand: Rise in H1N1 pandemic influenza cases
Some New Zealand emergency departments struggled to keep up the week of 26 July 2010 as pandemic H1N1 flu cases increased. Almost 1,900 people sought medical care for flu-like symptoms, with Auckland's hospitals running near capacity. Officially, 59 hospitalized H1N1 cases were confirmed for the week. Australia is also reporting a rise in cases, with several requiring intensive care.
(CIDRAP 08/02/2010)


New Zealand: Impact of H1N1 pandemic influenza evident
The frequency of pandemic H1N1 flu is rising in New Zealand's Wairarapa region, with five schools reporting 20% to 50% of students affected. All told, more than 400 children are out sick. A Wellington health official said the outbreak is particularly severe and spreading rapidly. The country has had more than 380 confirmed H1N1 cases and 183 hospitalizations in the past two weeks.
(CIDRAP 08/04/2010)


USA: Federal advisors hope to build on H1N1 vaccine safety-monitoring lessons
During autumn 2010, the nation's healthcare providers will shift from giving the pandemic H1N1 vaccine to a seasonal flu vaccine that contains the new virus, which has federal officials grappling with how to transition from a massive vaccine monitoring effort to a likely more routine system for the seasonal version.

Members of the National Vaccine Advisory Committee (NVAC), which advises the Department of Health and Human Services on its immunization programs, discussed the transition 27 July 2010 during a public teleconference. In efforts to detect any problems with the new vaccine and assure the public of its safety, federal officials beefed up existing vaccine monitoring systems and added new components, such as collaborations with large managed care organizations, academic institutions, the Department of Defense.

Though the group was not in a position to take any action immediately, members said lessons learned during safety monitoring of the pandemic H1N1 vaccine will be useful as the nation advances toward a more universal flu vaccination recommendation. In February 2010, a Centers for Disease Control and Prevention (CDC) advisory group recommended seasonal flu immunizations for nearly everyone except babies younger than six months old.

Gus Birkhead, MD, MPH, chairman of the group and deputy commissioner of the New York Department of Health, said a lesson learned during pandemic vaccine safety monitoring was the usefulness of coordination among federal agencies on vaccine safety monitoring issues. However, he said NVAC would like to hear more from its members about any efficiency measures for gathering and analyzing vaccine safety data.

Marie McCormick, MD, ScD, a member of NVAC's H1N1 and seasonal flu vaccine safety working groups, said, for example, experts involved with pandemic H1N1 vaccine safety monitoring may have tips about which key pieces of information on medical records were most useful for detecting possible safety signals. In addition, they may be able to offer advice on how to collect the data more efficiently, which could prove useful for upcoming flu seasons, she said.

McCormick, a professor of maternal and child health at Harvard School of Public Health, added that efficiencies could reduce the cost of future flu vaccine monitoring.

Members of NVAC who spoke at the meeting said they envisioned some sort of standing federal flu vaccine monitoring group that meets less frequently than every other week as they did for the pandemic H1N1 vaccine but more often than at the end of a flu season to issue a safety wrap-up report.

McCormick said an important issue is making sure future flu vaccine safety monitoring systems examine key diverse subgroups, such as ethnic minorities and patients with certain medical conditions.

NVAC members also alluded to a federal survey of agencies that is under way to assess what plans they have to scale down their pandemic response efforts.

In other developments, members discussed a request from the assistant secretary of health for NVAC guidance on a host of other flu issues, including safety monitoring for seasonal flu vaccines, mandates for healthcare worker vaccination, and what impact the new universal flu vaccine recommendation will have had in its first year.

The next NVAC teleconference is scheduled for 25 August 2010, and the next full face-to-face meeting of the group is slated for 14 – 15 September 2010.
(CIDRAP 08/27/2010)


Egypt: WHO confirms fatal Egyptian avian influenza H5N1 case
The WHO confirmed the H5N1 avian influenza illness and death of a 20-year-old Egyptian woman whose infection was recently reported by the country's health ministry. The woman, from Qalyubia governorate, was hospitalized on 21 July 2010, where she received oseltamivir (Tamiflu) and was placed on a ventilator. She died 27 July 2010. The cases raises Egypt's number to 110, of which 35 have been fatal. In a statement made 29 July 2010, the WHO said an investigation into the source of the woman's illness found that she had been exposed to sick and dead poultry.
(CIDRAP 07/29/2010)


Gambia: H1N1 pandemic influenza vaccination campaign beginning
Gambia's Ministry of Health and Social Welfare announced 26 July 2010 that it has started its vaccination campaign against pandemic H1N1 flu in collaboration with the World Health Organization. The program lasted a week and aims to reach 170,000 people, with priority given to health workers, pregnant women, children, and those with underlying disease.
(CIDRAP 07/27/2010)


2. Infectious Disease News

India (Orissa): Anthrax cases
At least 25 people, including six women and a child, have fallen ill with suspected anthrax contracted from dead animals in Orissa's Sundergarh district, health official said 30 July 2010.

The people found with the infection are residents of Dukatola village and its nearby hamlets, some 500 km [310 mi] from state capital Bhubaneswar, chief district medical officer Bikrant Kindo told IANS. He said all of them are responding to treatment and recovering.

About two days ago two residents of the area came to the hospital with anthrax symptoms. Kindo said they sent health officials to the area and found more people having the similar symptoms. Health officials including doctors are camping in the area and treating the patients at their homes, he said.

Blood samples of at least five patients were sent 30 July 2010 to the Veer Surendra Sai (VSS) Medical college and Hospital at Burla in Sambalpur district, Kindo said.

Dukatola village and its nearby hamlets have a population of about 500 and most of them belong to Oraon tribe. Kindo said the villagers told them they had consumed the meat of dead animals recently.

Anthrax is a bacterial disease that mostly affects animals and spreads to humans through consumption of contaminated meat. Kindo said the district has a history of anthrax infections.
(ProMED 07/30/2010)


India (Uttar Pradesh): Mysterious virus not Japanese encephalitis
Despite claiming close to 100 lives up to 26 July 2010, and with another 550 admitted in the hospitals, scientists and doctors are still groping in the dark for the identity of a viral strain that has been active in India for the past three decades.

Director general Dr RR Bharti said they are sure about one thing, that it is not Japanese encephalitis virus. Only 11.71 per cent of the samples have tested positive for Japanese encephalitis virus, while the rest are still unknown.

When even the local unit of the National Institute of Virology (NIV) Pune, based in Gorakhpur, failed to arrive at any conclusion, Bharti requested the Union Health Ministry to intervene. A team of Union Health Ministry officials and scientists from the Indian Council of Medical Research (ICMR) -- along with Bharti and Dr SP Ram -- visited Gorakhpur on 24 July 2010. However, they also failed to diagnose the viral strain causing deaths of children in the region. Bharti said that at times, it shows symptoms of an enterovirus [meningitis?] but not uniformly, so no concrete conclusions can be arrived at.

Meanwhile, the official daily bulletin at the State Health Directorate reported 94 deaths due to the mystery virus, with another 543 admitted to hospital.

On the other hand, the State Human Rights Commission (SHRC) and nearly half a dozen public representatives have raised questions about the functioning of the Health Department. SHRC has sought explanation from the Health Department over the rising number of children's deaths in Gorakhpur region.

According to the figures at the Control Room in Lucknow, 543 children are suffering from AES as of 26 July 2010. Another 94 have died, while 10 have tested positive for Japanese encephalitis virus infection. One child has died due to Japanese encephalitis in Gorakhpur also.

Local health activist Dr RN Singh claimed that he actual number of deaths have surpassed 100 in Gorakhpur region.

State health officials have issued directives that the children be treated at the local health center level. In a letter by Bharti, district health officials in Purvanchal have been directed to refer only serious cases to Baba Raghav Das Medical College in Gorakhpur.

Meanwhile, state health officials narrate their efforts in combating the Japanese encephalitis menace. A separate ward with 126 beds has been constructed at a cost of Rs 5.88 crore [USD 1.26 million]. Nearly 3.5 crore [35 million] children were vaccinated against Japanese encephalitis in 2009. An extensive awareness campaign has been launched in the region, with special emphasis on sanitation and cleanliness.

[ProMED note: Previously, in mid-April 2010, Mod.TY commented that the region of Gorakhpur, Uttar Pradesh reported over 500 encephalitis cases last year (2009), some due to Japanese encephalitis virus (JEV), and others were described as acute encephalitis of undefined etiology but not due to JEV infections. There is no information indicating how many of these current cases are due to JEV and how many to another etiological agent, perhaps enteroviruses or Nipah virus.

There appears to have been little progress in establishing the identity of the non-Japanese encephalitis virus presumed to be responsible for as many as 88 percent of cases of acute pediatric illness in Uttar Pradesh. The undiagnosed illness has been graced with the designation acute encephalitis syndrome, but it is unclear whether a single etiological agent is responsible for this condition. Further information would be welcomed.]
(ProMED 07/28/2010)


Russia (Tajikistan): Polio update
The Ministry of Health of the Republic of Tajikistan has since 1 January 2010 reported 430 cases of polio following the importation of a wild poliovirus type 1 into the country. Of those cases, 19 were fatal. A total of seven virologically related cases have been detected in the Russian Federation, the only other country in the WHO European Region to confirm cases. The poliovirus causing the outbreak originated in northern India. This is the first outbreak of polio since the Region was certified polio-free in 2002.

In response to the outbreak, four rounds of national immunization days (NIDs) with oral polio vaccine have been held in Tajikistan. Coverage was reported to be high and confirmed by independent monitors. The most recent round was conducted on 15-19 June 2010 (except in Dushanbe and six surrounding regions, where it started on 13 June 2010). Preliminary data report nationwide coverage of 99.3 percent. Coverage higher than 97 percent is reported from all regions and in the groups aged 0-6 and 7-15 years.

The most recent polio case had onset on 12 June 2010, and the number of new cases of acute flaccid paralysis (AFP) -- of which polio can be one of the causes -- being detected and reported to WHO has dropped sharply. However, there is not sufficient virological testing data from the recent AFP cases to revise WHO's assessment of the risk for further international spread, which remains 'high.'

A joint national/international surveillance review is under way, under the auspices of the Ministry of Health, to further inform the current risk assessment and guide additional surveillance and immunization activities. The need for additional rounds of mass oral polio vaccine (OPV) immunization will be based on an ongoing evaluation of epidemiological and laboratory data. International travelers to and from polio affected areas should continue to be adequately immunized against polio as recommended in Chapter Six of International Travel and Health guidance.

The European Regional Commission for the Certification of Poliomyelitis Eradication met in Copenhagen, Denmark, on 28-29 June 2010. Addressing the meeting, Ms Zsuzsanna Jakab, WHO Regional Director for Europe, noted that the outbreak in Tajikistan threatens both the polio-free status of the Region and the eradication of polio globally.

The Commission recognized that the European Region has reached a critical juncture and its polio-free status is in jeopardy. The gravity of the situation requires that all Member States reinforce their polio surveillance so that any spread will be detected rapidly and effective control measures instituted at the earliest possible moment.

Neighboring countries are responding to the outbreak by heightening surveillance while reviewing immunization status of children and conducting necessary supplementary immunization activities. Uzbekistan has held three national rounds of supplementary immunization with efforts to synchronize these rounds with Tajikistan in May and June. The first round of nationwide NIDs started in Turkmenistan on 12 July 2010, and Kyrgyzstan started its first round on 19 July 2010.

[ProMED note: According to the above WHO report, there are now 430 confirmed cases of polio in Tajikistan -- up from 425 cases as of 20 July 2010 -- and seven confirmed cases of polio in the Russian Federation. As a reminder, in the previous ProMED-mail posting on this outbreak there had been lay press reports mentioning the confirmation of cases of wild poliovirus (WPV) related polio in the Russian Federation, but until today, there was no official confirmation of these cases (see Poliomyelitis - worldwide (15): Russia, RFI 20100723.2467). The reports of vaccination coverages of greater than 90 percent following the supplemental immunization days will hopefully serve to interrupt the transmission of the WPV in Tajikistan as well as in those areas in the Russian Federation where cases have been confirmed to date.]
(ProMED 07/23/2010)


Viet Nam (Ho Chi Minh City): Increase in hand-foot-mouth disease cases
The number of cases of hand-foot-mouth disease (HFMD) has increased quickly in Ho Chi Minh (HCM) City. Hand-foot-mouth disease has spread to five districts. 340 cases were reported in June 2010 alone, up 23 percent against 2009, raising the number of cases in the first six months to 1640 cases, up 20 percent over the same period of 2009.

[ProMED note: The activity of HFMD in some parts of Asia in 2010 is higher compared to previous years in that the case numbers are significantly higher in several countries and the epidemic season appears to have started earlier this year for at least one country.

The epidemiological situation for HFMD in Asia is difficult to compare between countries as surveillance systems, laboratory confirmation practices, and reporting requirements differ widely between countries. According to a recent ECDC (European Centre for Disease Prevention and Control survey <http://www.ecdc.europa.eu/en/healthtopics/hand_foot_and_mouth_disease/Pages/index.aspx>), as of 11 May 2010 the Chinese Ministry of Health has reported a total of 497 447 cases of HFMD (6861 severe).

Between March and April 2010, 326 365 cases of HFMD were reported, with 215 fatal cases, compared to 267 148 cases and 96 fatalities during the same months in 2009 -- representing a 22 percent increase in cases and a 2-fold increase in deaths. In Shanghai there has been a 40 percent increase in cases compared to 2009 with 13 371 cases, 67 severe cases and two deaths reported cumulatively in 2010. The majority of cases in China are being reported from rural communities.

Consequently, currently available data indicate that there is an increased activity of HFMD in the region, with a higher incidence and an earlier start of the epidemic season. Also, surveillance data from Japan suggests that there is an increased proportion of HFMD cases caused by enterovirus 71 (EV71) infection compared to previous years.

The reasons for the current unusual epidemiological picture of HFMD (and specifically EV71 in Japan) are not well understood. The methods used in Asian countries for surveillance of HFMD, as well as the protocols for laboratory confirmation and testing do vary between countries. Furthermore it is not known to what extent different countries have recently adapted and/or strengthened their surveillance for HFMD which could mean that the current observed increase is simply due to a surveillance artifact. In order to fully understand the current epidemiological picture of HFMD in the Asian region it would be important to know the proportion of HFMD cases that are positive for EV71 as well as the type of EV71 virus that is the dominant circulating strain.

EV71 infections in Europe have been successively caused by viruses of sub-genogroups B0, B1 and B2. A genogroup shift occurred in 1987, after which viruses of subgenogroups C1 and C2 were detected exclusively. This is distinct from the situation in the Asian Pacific region, where EV71 subgenogroups B3-B5 and C4-C5 have caused large outbreaks since 1997 (see van der Sanden et al, J Gen Virol 2010 Aug; 91(Pt 8): 1949-58 <http://vir.sgmjournals.org/cgi/content/abstract/91/8/1949>).

There are existing gaps in the knowledge about HFMD that [if they could be filled] would contribute to a better understanding of the situation, including:

1. Seasonality: even though most Asian countries have annual epidemics of HFMD, it is not well understood what factors are triggering the epidemics to start earlier (as confirmed by Japan in the present year).

2. Cyclical nature of the disease: some countries have suggested a cyclical nature of the outbreaks every 2-3 years. The last large outbreaks of HFMD in SE Asia occurred in 2008, and therefore the outbreaks this year (2010) could confirm such a cyclical pattern.
(ProMED 08/01/2010)


Peru (La Libertad): Pneumonic and bubonic plague
Peru's health minister says an outbreak of plague has killed a 14-year-old boy and infected at least 31 people in a northern coastal province. Health Minister Oscar Ugarte says authorities are screening sugar and fish meal exports from Ascope province in the La Libertad region, located about 325 miles (520 km) northwest of Lima. Popular Chicama beach isn't far away.

Ugarte says the boy, who had Down syndrome, died of bubonic plague 26 July 2010. He said Monday, 2 August 2010, that most of the infections are bubonic plague, with four cases of pneumonic plague.

The first recorded plague outbreak in Peru was in 1903. The last, in 1994, killed 35 people.

[ProMED note: Ascope province is located in the region of La Libertad, in northwestern Peru. It shares a border with Trujillo province where the disease has also been recently reported. It is not clearly stated in the posting whether the pneumonic cases were directly acquired from person-to-person spread or were a complication of bubonic plague. Of note, there was an outbreak of bubonic plague reported in Chicama district of Ascope province in April 2010, suggestive that these current cases may be part of this previously reported outbreak.]
(ProMED 08/03/2010)


USA (Michigan): Legionnaires’ cases reported at Michigan National Guard base
Health officials at Selfridge Air National Guard Base, about 30 miles northeast of Detroit, are investigating a possible Legionnaires' disease outbreak that has sickened 31 people, with two confirmed cases of the disease. During the outbreak, which occurred 12-24 July 2010 , six people were hospitalized and later released. Two buildings on the base were closed for sanitizing, and results from air and water testing is expected in the next 10 days. Legionnaires' disease, caused by Legionella bacteria, is a type of pneumonia that infects about 8,000 to 18,000 people each year.
(CIDRAP 07/29/2010)


USA (Missouri): Two cases of veterans infected with hepatitis B
The Veteran's Administration (VA) 3 August 2010 released the latest results of tests taken by dental patients at the John Cochran VA Hospital in St. Louis, Missouri. As of 28 July 2010, the VA confirms two positive results for hepatitis B and two positive results for hepatitis C. The data were presented at a Congressional hearing the morning of 3 August 2010.

In July 2010, the VA reported 1812 patients may have been exposed to hepatitis B, hepatitis C and human immunodeficiency virus (HIV) infections due to improper sterilization methods at its Cochran Dental Clinic. An inspection revealed the procedure was in place for a little over a year at the facility.

The VA said it notified 1769 veterans about the issue, and is working with homeless coordinators to reach veterans with no known home address. The VA said 1598 responded to the disclosure by calling for an appointment for testing. Some veterans opted to have their blood drawn by a private lab of their choosing at the VA's expense. The VA reported 13 veterans declined testing or an appointment.

The infections may or may not be related to dental equipment issues at the Cochran clinic. The VA said it is performing more extensive testing to determine the time period and possible source of the infections. The VA said it will provide all related health care at no cost to the infected veterans.

[ProMED note: Nosocomial transmission of blood-borne infections, particularly those involving dental procedures, are rare in the United States. It is not clear from this report that the transmission of infection has been due to medial negligence, or to some other factor. Further information would be welcomed.]
(ProMED 08/03/2010)


3. Updates
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.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/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/

FDA News Release: FDA Approves Vaccines for the 2010-2011 Influenza Season:

CDC: Prevention and Control of Influenza with Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010:

CDC Central Vaccine Recovery Program Update:


- 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:
Read about the latest news on avian influenza H5N1 in wild birds and poultry.


The national capital reported the first dengue death of the season with a child succumbing to the disease at the AIIMS [All India Institute of Medical Sciences] , even as civic authorities expressed concern over detection of mosquito breeding in various offices and Commonwealth Games venues. An eight-year-old dengue patient died 22 July 2010 at AIIMS. He resides in Okhla area of Delhi but had contracted the virus from Bihar, where he had gone on a vacation with his family, Municipal Health Officer N K Yadav said.

The city has reported 26 cases of the disease, he said. The Municipal Corporation of Delhi [MCD] has expressed concern over detection of mosquito breeding in different offices and sports venues including Games Village, MTNL Exchange [Mahanagar Telephone Nigam Ltd.] in Hauz Khas, G B Pant Hospital, DMRC Project [Delhi Metro Rail Corporation Ltd.] in Saket, IG Stadium and R K Khanna Stadium.

Since dengue is a viral illness with cyclical trend of increase in cases after every three to four years, which coincides with Commonwealth Games in 2010, there is an urgent need to take adequate precautions against dengue, Municipal Commissioner K S Mehra has said.

According to official data, a total of 11 dengue cases have been reported from MCD areas, six from NDMC areas, and another six had been from outside the state. The address of the remaining three is yet to be ascertained, Yadav said.

The MCD has engaged a total of 3,500 domestic breeding checkers from April in 2010.
(ProMED 07/23/2010)

A total of 27,400 cases and 91 deaths due to dengue have been reported between January and 25 July 2010, according to Health Minister Datuk Seri Liow Tiong Lai. He said the death toll reported so far in 2010, which involved mostly adults, was higher than the number recorded in 2009, which was 88.

In the week of 18July 2010, seven deaths due to dengue were reported from 1,071 cases, the highest weekly cases recorded so far, he said.

He said prevention programs and enforcement operations, especially in 34 identified hot spots, would be intensified as 80 percent of premises inspected so far in the these places were found to have Aedes mosquito breeding grounds.

Selangor still has the highest number of dengue hot spots with 17, followed by Johor (6), Kuala Lumpur (6) and Sarawak (5).
(ProMED 08/04/2010)

Mexico is facing a sort of perfect storm of floods that breed mosquitoes, prompting a big increase in the number of hemorrhagic dengue cases, the country's top epidemiological official said 21 July 2010.

The disease’s type 2 strain, which makes people who have already had the type 1 variant more vulnerable to developing the hemorrhagic form, is now in the Gulf coast state of Veracruz and moving north toward the region on the U.S. border.

Dengue virus type 1 is already present in border states like Tamaulipas, which suffered extensive flooding in the weeks after Hurricane Alex made landfall on 30 June 2010. Miguel Angel Lezana, director of the National Epidemiological Center said it is possible, if not in 2010, then in 2011, for type 2 virus to reach Tamaulipas. Veracruz borders Tamaulipas to the south.

Cases of the milder, classic form of dengue fever in Mexico have declined slightly since 2009. But the more serious hemorrhagic form has spiked to about 1900 cases in 2010, compared with about 1430 in the same period of 2009. Only 16 people have died in 2010 from the hemorrhagic form, but the seriousness of the disease makes it a concern.

Lezana said the recent flooding in border areas created ideal conditions for the Aedes aegypti mosquitoes that spread dengue fever. State and federal government workers are fighting the mosquitoes with control programs.
(ProMED 07/21/2010)

The Ministry of Public Health of Sonora reported in 2010 that there are a total of 44 people who have been infected by rickettsiae, five of whom died. The director of the Epidemiology Department of the state agency, Sergio Olvera Alba, said that the southern region of the state [Sonora] is where most cases of the disease have occurred, spread by the bite of lice, ticks, fleas and mites.

He said that to date, the disease has been detected in the municipalities of Guaymas, Ciudad Obregon, Hermosillo, Navojoa, Nogales, Quiriego, Huatabampo, Puerto Penasco and Etchojoa. Of the deaths attributable to this disease, two were reported in the municipality of Miguel Aleman and the other three in Nogales, north of the town, he said.

The bacteria are transmitted to humans through the bite of ticks, he said, which are carried by household pets such as dogs. The doctor said that keeping dogs and cats clean reduces the possibility of them having parasites which may be agents of disease. He added that children are the age group most at risk, as they have more direct contact with dogs and play on the floor.

According to information from the state SSP [health secretariat], it is maintaining a campaign to inform communities about the importance of measures to prevent rickettsiosis.

[ProMED note: The species of rickettsia here is not specifically mentioned, but the attention to dogs and ticks suggests that the illness is due to Rickettsia rickettsii.

R. rickettsii infections have been identified in southern Canada, the USA, northern Mexico, Costa Rica, Panama, Brazil, and Argentina. Some synonyms for Rocky Mountain spotted fever in other countries include tick typhus, Tobia fever (Colombia), Sao Paulo fever and fiebre maculosa (Brazil), and fiebre manchada (Mexico).]
(ProMED 07/25/2010)

Philippines (Cagayan)
The Department of Health here has cautioned villagers to be vigilant against dengue fever amid a reported six deaths during the first months of 2010. The reported dengue deaths from January to June of 2010 is higher than the five recorded during the same period in 2009. The dengue deaths in 2010 were reported in Lasam, Santa Ana and Claveria, all in Cagayan; in Ilagan in Isabela; Diadi in Nueva Vizcaya and Maddela in Quirino with one death each. But the reported 336 dengue fever cases for the first six months of 2010 is lower than the 442 of 2009.

Not wanting to be complacent, health workers have been deployed to villages to conduct massive information campaigns on preventing dengue fever, a flu-like illness spread by Aedes aegypti-infected mosquitoes, said Floro Orata, regional health information officer.

He asked villagers to wear long-sleeved clothing and long trousers when outdoors during the day and evening, spray permethrin or DEET repellents on clothing, use mosquito netting over the bed and do constant cleaning of the environment.
(ProMED 07/20/2010)

Philippines (Camarines Norte)
The Department of Health [DOH] in Bicol region has declared a malaria epidemic in Camarines Norte province after recording 182 cases there.

DOH officials said that while most of the cases were in Jose Panganiban town, the epidemic was declared province-wide to prepare local health officials against the spread of the disease.

The DOH Bicol is closely monitoring malaria cases in areas near the border of Camarines Norte and Camarines Sur, specifically in the towns of Sipocot and Lupi, to prevent further spread of the disease.

Incidentally, the DOH and the WHO have already declared as malaria-free some of the region's provinces -- these are: Albay, Sorsogon, Catanduanes, and Masbate.

Further assessment and validation is being done in Camarines Sur for it to be declared malaria-free.

DOH Bicol Malaria Prevention and Control Program coordinator Camilo Aquino said the DOH team dispatched to Jose Panganiban found out that most victims were children and elderly. At least 20 percent were members of a tribal community.

Health officials lamented more victims barely recovered or not treated totally, as health workers had difficulty in administering treatment. In many cases, patients would refuse to follow procedures, like the schedule of taking medicines.

Aquino said malaria is a disease caused by the parasite Plasmodium, transmitted by infected mosquitoes. The parasites multiply in the liver and infect red blood cells. Symptoms include fever, headache, and vomiting -- they usually appear 10 to 15 days after infection.

[ProMED note: Camarines Norte is located on Southeasten Luzon, and is usually considered a low risk area. Both Plasmodium vivax and P. falciparum are found in the Philippines and the report above does not state which species is responsible.]
(ProMED 07/24/2010)

Despite an increase in 2010 in cases of mosquito-borne dengue fever in the United States and Latin America, the CDC faces elimination of funding for its vectorborne diseases program, according to the American Society of Tropical Medicine and Hygiene (ASTMH). President Obama's 2011 fiscal budget contains no funding for the program. In addition to dengue, the CDC program focuses on detecting and controlling plague, Lyme disease, and viral encephalitis, among other diseases. In a release made 26 July 2010, ASTMH President Edward T. Ryan, MD, said the organization is concerned that the currently proposed 2011 budget would not provide sufficient funding for this important government function. He said that one in fifty people in the world dies of an illness acquired from an insect bite, and tens of thousands of Americans already fall ill each year from infections transmitted by mosquitoes and ticks.
(CIDRAP 07/27/2010)

USA (Florida)
A Brandon-area (Florida) infant has died from a rare and devastating disease transmitted by mosquitoes that causes inflammation of the brain, health officials said 29 July 2010. It was the second death in Hillsborough County in July 2010 from eastern equine encephalitis [EEE] -- see ProMED ref. below, prompting officials to issue a public health alert and step up mosquito spraying around the Tampa Bay area.

Since no more than 5-10 cases of EEE are typically reported nationwide each year, and Florida's last reported death was in 2008, these back-to-back fatalities are highly unusual. The state recorded a third EEE fatality in July 2010, in the Panhandle's Wakulla County.

There is no vaccine for the disease, which kills about 1/3 of those infected and disables others, so officials are urging people to protect themselves from mosquito bites. The summer of 2010 could be the worst in years for the spread of mosquito-borne illnesses. There aren't more mosquitoes here than usual, officials say, but more of them are carrying diseases, posing greater health risks to the people they bite. Due to factors such as water levels and animal breeding patterns, mosquito-borne illnesses tend to rise and fall over time. After several quiet years, health experts are concerned that people have forgotten that these insects are not just a backyard nuisance. While mosquito-borne disease is generally rare in the United States, mosquitoes are the world's most dangerous animal, responsible for millions of cases of [arthropod-borne pathogens] worldwide.

In response to the increased threats, Hillsborough's health department on Thursday placed the county under a "mosquito-borne illness alert." Warren McDougle, manager of the Hillsborough Health Department's epidemiology program said that every effort is being taken by mosquito control and all of the public health entities to do the surveillance on the disease, but individuals have to protect themselves against mosquitoes.

The week of 26 July 2010, officials reported that a woman who lived in northern Hillsborough died on 1 July 2010 from an EEE [virus] infection. She likely was infected while sitting outside her apartment building, officials say. The Brandon-area infant's cause of death was reported to the health department 28 July 2010; officials declined to share more information about the victims.

The week of 26 July 2010, Hillsborough County sprayed extensively by air in the suburbs. Carlos Fernandes, director of mosquito control in Hillsborough, urged people to stay inside at dusk and dawn when mosquitoes are most active. Trucks are also planned to be dispatched to fog along the Hillsborough and Pasco county lines. Nancy Iannotti, operations manager for Pinellas mosquito control, said the mosquito-borne diseases are rare, but sensible precautions still should be taken.

[ProMED note: Unfortunately, this fatal human case comes just 10 days after the previous one in Hillsborough county, Florida. This state is endemic for EEE virus. There have been a number of equine cases of EEE virus infection in 2010. This is the second human case in 2010 in Hillsborough County and the third in 2010 in Florida. There is no vaccine available for human use, although EEE vaccinations are available and recommended for equine animals.]
(ProMED 08/31/2010)

USA (Mississippi)
A case of the mosquito-borne illness LaCrosse encephalitis has been reported in Montgomery County. The Mississippi State Department of Health says the illness is similar to West Nile virus infection.
(ProMED 08/02/2010)

USA (Minnesota)
A six-year-old Caledonia, Minn., boy has become the year's first confirmed case of La Crosse encephalitis in the region. The onset of the mosquito-borne virus was reported 11 July 2010, and the boy was hospitalized in Rochester, Minnesota., until last week, said Dave Geske, La Crosse County Health Department mosquito control officer.

Aedes or Ochlerotatus triseriatus, the mosquito that carries La Crosse encephalitis (LACV) was found in water on a tarp and in open bins close to the boy's home, Geske said. The boy's home also is near a woodland area within 50 yards of traps set up by Geske's staff to catch mosquitoes, he said. Houston and Winona counties are hotbeds for Ae triseriatus in Minnesota, Geske said.

The risk for La Crosse encephalitis has increased this year, he said. As La Crosse endures its third-wettest summer on record, the potential is great for a bad encephalitis year, Geske said.

The La Crosse area averages four-six encephalitis cases every summer, with the peak months in August and September. La Crosse encephalitis affects the nervous system and causes acute inflammation of the brain, with a five to 20 percent death rate among children. [ProMED note: CDC reports that fatal cases are rare, less than one percent. Neurological sequelae in encephalitis survivors have been reported in some cases.]

While it's a bit early to have a first encephalitis case, Geske said he has seen June cases in past years. The first 2009 case came in mid-August.
(ProMED 08/05/2010)

USA (Tennessee)
Among new tick-related infectious disease findings presented at the International Conference on Emerging Infectious Disease (ICEID), which ended 14 July 2010 in Atlanta, were a report on the first zoonotic babesiosis case documented in Tennessee and a report on ehrlichiosis infections in Minnesota and Wisconsin involving a species that had not previously been identified in North America [<http://www.iceid.org/images/stories/newsroom/wednesday_abstracts.pdf>].

In the first report, a group from the Tennessee Department of Health, Vanderbilt University, and the CDC diagnosed babesiosis in an immunosuppressed patient who began to have fever, fatigue, and headache. He had not traveled outside Tennessee in several years and had been exposed to ticks during hunting trips.

Babesia parasites were noted on the man's blood smear and molecular analysis revealed that it was a novel species, but attempts to isolate it were unsuccessful. The man's symptoms resolved after 10 days of treatment.

The researchers said efforts to identify the animal host and tick vectors are ongoing and that the case serves as a reminder that patients can have babesiosis without exposure to known endemic areas and without testing positive to previously known species.

In the second report, local health officials and CDC and Mayo Clinic experts described the identification of Ehrlichia DNA from Mayo Clinic blood samples of patients from the two states involving a species similar to E. muris that had not been previously identified in North America.

The organism was found in 2009 in the blood of four patients, three from Wisconsin, and one from Minnesota. All had reported fever and headache, and all had lymphopenia. All recovered with doxycycline treatment. Serological studies also suggested 40 more probable cases among Wisconsin residents. A survey of the patients found dog contact in 91 percent and possible tick exposure in 85 percent. The group concluded that more studies are needed to identify the epidemiologic and clinical features of infections with the E. muris-like organism and that better testing in the region could help identify the infections.
(ProMED 07/24/2010)


Chinese Taipei
Taipei County Health Department said that five people complained of headache and diarrhea upon their return from India. Of these, two are confirmed to have paratyphoid.

The two cases went to India for a spiritual growth course. One began to have symptoms on 22 June 2010, while still in India. The person had headache, watery diarrhea, anorexia, malaise, and fever. She sought medical attention while in India, but her symptoms did not improve. Upon returning to Taiwan, she was hospitalized on 12 July 2010. The patient has since been discharged. The other patient had similar symptoms, and is still hospitalized.

Investigation revealed that there were 87 people who went to the same spiritual course. So far, five people have reported symptoms and sought medical attention.
(ProMED 07/31/2010)


4. Articles
Mandatory Influenza Vaccination of Healthcare Workers: A 5-Year Study
Rakita RM, Hagar BA, Crome P, et al. Infect Control Hosp Epidemiol. 1 Sept 2010; 31:9, 889-892.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/656210

Background. The rate of influenza vaccination among healthcare workers (HCWs) is low, despite a good rationale and strong recommendations for vaccination from many health organizations.

Objective. To increase influenza vaccination rates by instituting the first mandatory influenza vaccination program for HCWs.

Design and setting. A 5]year study (from 2005 to 2010) at Virginia Mason Medical Center, a tertiary care, multispecialty medical center in Seattle, Washington, with approximately 5,000 employees.

Methods. All HCWs of the medical center were required to receive influenza vaccination. HCWs who were granted an accommodation for medical or religious reasons were required to wear a mask at work during influenza season. The main outcome measure was rate of influenza vaccination among HCWs.

Results. In the first year of the program, there were a total of 4,703 HCWs, of whom 4,588 (97.6%) were vaccinated, and influenza vaccination rates of more than 98% were sustained over the subsequent 4 years of our study. Less than 0.7% of HCWs were granted an accommodation for medical or religious reasons and were required to wear a mask at work during influenza season, and less than 0.2% of HCWs refused vaccination and left Virginia Mason Medical Center.

Conclusion. A mandatory influenza vaccination program for HCWs is feasible, results in extremely high vaccination rates, and can be sustained over the course of several years


The Impact of the Pandemic Influenza A(H1N1) 2009 Virus on Seasonal Influenza A Viruses in the Southern Hemisphere, 2009
Blyth CC, Kelso A, McPhie KA, et al. Eurosurveill. 2010; 15(31):pii=19631.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19631

Introduction. Historically influenza pandemics have been associated with replacement of the previously circulating influenza A subtype, as was observed in 1957 when influenza A(H2N2) replaced A(H1N1), and in 1968 when influenza A(H3N2) subsequently replaced A(H2N2). As global viral surveillance was limited during the pandemics of 1957 and 1968, the proportion of disease attributable to seasonal influenza viruses during the early pandemic periods and the rate of subtype replacement are uncertain. It is postulated that cross-protective immunity following infection with a pandemic influenza virus results in protection against circulating seasonal influenza subtypes. This protection results in displacement and replacement of seasonal influenza subtypes by pandemic viruses. Co-existence of different subtypes is possible when the introduction of a virus does not generate a pandemic. The reintroduction of an influenza virus in a context of considerable residual herd immunity, as was observed with influenza A(H1N1) in 1977, can result in co-circulation of more than one influenza subtype. We cannot be certain whether emerging pandemic influenza strains will replace or co-exist with the previously circulating subtypes or strains, and if replacement is observed, how quickly this will occur. As this outcome has implications on the selection of viruses to be included in influenza vaccines, improved surveillance and rapid influenza A subtyping methods have important roles to play in monitoring the circulation dynamics of influenza strains during modern epidemics and pandemics.

The pandemic influenza A(H1N1) 2009 virus was first identified in April 2009. As its detection in the northern hemisphere coincided with declining seasonal influenza activity, the impact on the circulation of seasonal influenza viruses could not be fully assessed. In contrast, the first wave of the pandemic influenza virus in the southern hemisphere coincided with the onset of the winter influenza and respiratory virus season. Thus, data obtained from the 2009 southern hemisphere winter provide an opportunity to examine the circulation dynamics of pandemic and seasonal viruses during the early pandemic period.

This report presents data obtained by five World Health Organization (WHO) National Influenza Centres in the southern hemisphere for the winter of 2009. The pattern of circulating pandemic and seasonal influenza A strains in the southern hemisphere provides important information that can contribute to decision making regarding vaccine strain selection, and preventative and therapeutic strategies.


Changes in the Viral Distribution Pattern after the Appearance of the Novel Influenza A H1N1 (pH1N1) Virus in Influenza-Like Illness Patients in Peru
Laguna-Torres VA, Gomez J, Aguilar PV, et al. PLos ONE. 5(7): e11719.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0011719

Background. We describe the temporal variation in viral agents detected in influenza like illness (ILI) patients before and after the appearance of the ongoing pandemic influenza A (H1N1) (pH1N1) in Peru between 4-January and 13-July 2009.

Methods. At the health centers, one oropharyngeal swab was obtained for viral isolation. From epidemiological week (EW) 1 to 18, at the US Naval Medical Research Center Detachment (NMRCD) in Lima, the specimens were inoculated into four cell lines for virus isolation. In addition, from EW 19 to 28, the specimens were also analyzed by real time-polymerase-chain-reaction (rRT-PCR).

Results. We enrolled 2,872 patients: 1,422 cases before the appearance of the pH1N1 virus, and 1,450 during the pandemic. Non-pH1N1 influenza A virus was the predominant viral strain circulating in Peru through (EW) 18, representing 57.8% of the confirmed cases; however, this predominance shifted to pH1N1 (51.5%) from EW 19–28. During this study period, most of pH1N1 cases were diagnosed in the capital city (Lima) followed by other cities including Cusco and Trujillo. In contrast, novel influenza cases were essentially absent in the tropical rain forest (jungle) cities during our study period. The city of Iquitos (Jungle) had the highest number of influenza B cases and only one pH1N1 case.

Conclusions. The viral distribution in Peru changed upon the introduction of the pH1N1 virus compared to previous months. Although influenza A viruses continue to be the predominant viral pathogen, the pH1N1 virus predominated over the other influenza A viruses.


Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010
Fiore AE, Uyeki TM, Broder K, et al. MMWR. 29 Jul 2010. 59; 1-62.
Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm

Summary. This report updates the 2009 recommendations by CDC's Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine for the prevention and control of influenza (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2009;58[No. RR-8] and CDC. Use of influenza A (H1N1) 2009 monovalent vaccine---recommendations of the Advisory Committee on Immunization Practices [ACIP], 2009. MMWR 2009;58:[No. RR-10]). The 2010 influenza recommendations include new and updated information. Highlights of the 2010 recommendations include 1) a recommendation that annual vaccination be administered to all persons aged ¡Ý6 months for the 2010--11 influenza season; 2) a recommendation that children aged 6 months--8 years whose vaccination status is unknown or who have never received seasonal influenza vaccine before (or who received seasonal vaccine for the first time in 2009--10 but received only 1 dose in their first year of vaccination) as well as children who did not receive at least 1 dose of an influenza A (H1N1) 2009 monovalent vaccine regardless of previous influenza vaccine history should receive 2 doses of a 2010--11 seasonal influenza vaccine (minimum interval: 4 weeks) during the 2010--11 season; 3) a recommendation that vaccines containing the 2010--11 trivalent vaccine virus strains A/California/7/2009 (H1N1)-like (the same strain as was used for 2009 H1N1 monovalent vaccines), A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like antigens be used; 4) information about Fluzone High-Dose, a newly approved vaccine for persons aged ¡Ý65 years; and 5) information about other standard-dose newly approved influenza vaccines and previously approved vaccines with expanded age indications. Vaccination efforts should begin as soon as the 2010--11 seasonal influenza vaccine is available and continue through the influenza season. These recommendations also include a summary of safety data for U.S.-licensed influenza vaccines. These recommendations and other information are available at CDC's influenza website (http://www.cdc.gov/flu); any updates or supplements that might be required during the 2010--11 influenza season also will be available at this website. Recommendations for influenza diagnosis and antiviral use will be published before the start of the 2010--11 influenza season. Vaccination and health-care providers should be alert to announcements of recommendation updates and should check the CDC influenza website periodically for additional information.


Prevalence of high-risk indications for influenza vaccine varies by age, race, and income
Zimmerman RK, Lauderdale DS, Tan SM, et al. Vaccine. 30 Jul 2010.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-50NB9PS-3&_user=10&_coverDate=07%2F30%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7117852ce9fb0c552b2cff8d07e9eaa0

Abstract. Estimates of the proportions of the population who are at high risk of influenza complications because of prior health status or who are likely to have decreased vaccination response because of immunocompromising conditions would enhance public health planning and model-based projections. We estimate these proportions and how they vary by population subgroups using national data systems for 2006–2008. The proportion of individuals at increased risk of influenza complications because of health conditions varied 10-fold by age (4.2% of children <2 years to 47% of individuals >64 years). Age-specific prevalence differed substantially by gender, by racial/ethnic groups (with African Americans highest in all age groups) and by income. Individuals living in families with less than 200% of federal poverty level (FPL) were significantly more likely to have at least one of these health conditions, compared to individuals with 400% FPL or more (3-fold greater among <2 and 30% greater among >64 years). Among children, there were significantly elevated proportions in all regions compared to the West. The estimated prevalence of immunocompromising conditions ranged from 0.02% in young children to 6.14% older adults. However, national data on race/ethnicity and income are not available for most immunocompromising conditions, nor is it possible to fully identify the degree of overlap between persons with high-risk health conditions and with immunocompromising conditions. Modifications to current national data collection systems would enhance the value of these data for public health programs and influenza modeling.


Emerging, Novel, and Known Influenza Virus Infections in Humans
Tan JW, Shetty N, Lam TTY, et al. Infect Dis Clin North Am. Sept 2010. 24(3): 603-617.
Available at http://www.id.theclinics.com/article/S0891-5520(10)00028-0/abstract

Abstract. Influenza viruses continue to cause yearly epidemics and occasional pandemics in humans. In recent years, the threat of a possible influenza pandemic arising from the avian influenza A(H5N1) virus has prompted the development of comprehensive pandemic preparedness programs in many countries. The recent emergence of the pandemic influenza A(H1N1) 2009 virus from the Americas in early 2009, although surprising in its geographic and zoonotic origins, has tested these preparedness programs and revealed areas in which further work is necessary. Nevertheless, the plethora of epidemiologic, diagnostic, mathematical and phylogenetic modeling, and investigative methodologies developed since the severe acute respiratory syndrome outbreak of 2003 and the subsequent sporadic human cases of avian influenza have been applied effectively and rapidly to the emergence of this novel pandemic virus. This article summarizes some of the findings from such investigations, including recommendations for the management of patients infected with this newly emerged pathogen.


Adult Hospitalizations for Laboratory-Positive Influenza during the 2005-2006 through 2007-2008 Seasons in the United States
Dao CH, Kanimoto L, Nowell M, et al. J Infect Dis. 2 Aug. 2010. doi:10.1086/655904.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/655904

Background. Rates of influenza©\associated hospitalizations in the United States have been estimated using modeling techniques with data from pneumonia and influenza hospitalization discharge diagnoses, but they have not been directly estimated from laboratory©\positive cases.

Methods. We calculated overall, age©\specific, and site©\specific rates of laboratory©\positive, influenza©\associated hospitalization among adults and compared demographic and clinical characteristics and outcomes of hospitalized cases by season with use of data collected by the Emerging Infections Program Network during the 2005¨C2006 through 2007¨C2008 influenza seasons.

Results. Overall rates of adult influenza©\associated hospitalization per 100,000 persons were 9.9 during the 2005¨C2006 season, 4.8 during the 2006¨C2007 season, and 18.7 during the 2007¨C2008 season. Rates of hospitalization varied by Emerging Infections Program site and increased with increasing age. Higher overall and age©\specific rates of hospitalization were observed during influenza A (H3) predominant seasons and during periods of increased circulation of influenza B. More than 80% of hospitalized persons each season had 1 underlying medical condition, including chronic cardiovascular and metabolic diseases.

Conclusions. Rates varied by season, age, geographic location, and type/subtype of circulating influenza viruses. Influenza©\associated hospitalization surveillance is essential for assessing the relative severity of influenza seasons over time and the burden of influenza©\associated complications.


Seasonal influenza vaccine supply and target vaccinated population in China, 2004-2009
Feng L, Mounts AW, Feng Y, et al. Vaccine. 3 Aug 2010. doi:10.1016/j.vaccine.2010.07.064.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-50P4V8K-3&_user=10&_coverDate=08%2F03%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=83804ea9e59400394dd9cbc7f55fb9f3

Abstract. To better understand the gap between limited influenza vaccine supply and the target population for vaccination in China, we conducted a retrospective survey to quantify the production capacity, supply and sale of seasonal trivalent inactive vaccine (TIV) from the 2004–2005 through the 2008–2009 season, and estimated the target population who should receive annual influenza vaccine. The maximum domestic capacity to produce TIV was 126 million doses in 2009. A total of 32.5 million doses of TIV were supplied in 2008–2009, with an average annual increase rate of 18% from 16.9 million in 2004–2005. This represents an amount sufficient to vaccinate 1.9% of Chinese population. The average number of doses of TIV for sale by province ranged from <5 to 108 per 1000 people. The differences are explained in part by level of economic development but also influenced by local reimbursement policies in some provinces. Based on national recommendations, we estimated a target population of 570.6 million or 43% of the total population. Supply and domestic production capacity for influenza vaccine is currently insufficient to vaccinate the estimated target population in China. The Government of China should consider measures to improve domestic production capacity of influenza vaccine, expand successful promotional campaigns, and add cost subsidies in high risk groups to further encourage influenza vaccine usage.


Comparison of Pandemic (H1N1) 2009 and Seasonal Influenza, Western Australia, 2009
Carcione D, Giele C, Dowse GK, et al. Emerg Infect Dis. 2010 Sept;[Epub ahead of print] doi: 10.3201/eid1609.100076.
Available at http://www.cdc.gov/eid/content/16/9/PDFs/10-0076.pdf

Abstract. We compared confirmed pandemic (H1N1) 2009 influenza and seasonal influenza diagnosed in Western Australia during the 2009 influenza season. From 3,178 eligible reports, 984 pandemic and 356 seasonal influenza patients were selected; 871 (88.5%) and 288 (80.9%) were interviewed, respectively. Patients in both groups reported a median of 6 of 11 symptoms; the difference between groups in the proportion reporting any given symptom was <10%. Fewer than half the patients in both groups had >1 underlying condition, and only diabetes was associated with pandemic (H1N1) 2009 influenza (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1–3.5). Of the patients, 129 (14.8%) persons with pandemic (H1N1) 2009 and 36 (12.5%) persons with seasonal influenza were hospitalized (p = 0.22). After controlling for age, we found that patient hospitalization was associated with pandemic (H1N1) 2009 influenza (OR 1.5; 95% CI 1.1–2.1). Contemporaneous pandemic and seasonal influenza infections were substantially similar in terms of patients’ symptoms, risk factors, and proportion hospitalized.


Correlation of Pandemic (H1N1) 2009 Viral Load with Disease Severity and Prolonged Viral Shedding in Children
Li, C-C, Wang L, Eng H-L, et al. Emerg Infect Dis. Aug 2010. doi: 10.3201/eid1608.091918.
Available at http://www.cdc.gov/eid/content/16/8/1265.htm

Abstract. Pandemic (H1N1) 2009 virus causes severe illness, including pneumonia, which leads to hospitalization and even death. To characterize the kinetic changes in viral load and identify factors of influence, we analyzed variables that could potentially influence the viral shedding time in a hospital-based cohort of 1,052 patients. Viral load was inversely correlated with number of days after the onset of fever and was maintained at a high level over the first 3 days. Patients with pneumonia had higher viral loads than those with bronchitis or upper respiratory tract infection. Median viral shedding time after the onset of symptoms was 9 days. Patients <13 years of age had a longer median viral shedding time than those >13 years of age (11 days vs. 7 days). These results suggest that younger children may require a longer isolation period and that patients with pneumonia may require treatment that is more aggressive than standard therapy for pandemic (H1N1) 2009 virus.


Severe, critical and fatal cases of 2009 H1N1 influenza in China
Yang P, Deng Y, Pang X, et al. J Infect. 27 Jul 2010. doi:10.1016/j.jinf.2010.07.010.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJT-50MN7CR-3&_user=10&_coverDate=07%2F27%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=654c909355a5153c14e9e6e90357555a

Objective. For severe, critical and fatal cases of 2009 H1N1 influenza in the winter in the Northern Hemisphere, the detailed features are not fully known. The aim of this study was to examine these features through describing these cases in Beijing, China in 2009.

Methods. Data on severe, critical and fatal cases were collected via the Notifiable Disease Surveillance System and a designated surveillance system for managing 2009 H1N1 influenza cases in Beijing. The characteristics and risk factors of these cases were elucidated.

Results. A total of 475 severe cases, 73 critical ones and 69 deaths were identified in 2009. The proportion of obesity was low, as well as pregnancy. About half of them had no underlying disease. Most of deaths had multi-organ failure, with a median interval from illness onset to death of ten days. Delay in visiting hospital, cardiovascular disease and allergy predicted a higher risk of severe disease, and cases aged 6-17 years were at lower risk. Cases not promptly receiving neuraminidase inhibitors were at increased risk of death.

Conclusions. Age and underlying disease are significantly associated with severity of outcomes of 2009 H1N1 influenza; prompt presentation to hospital and use of neuraminidase inhibitor were protective.


Household transmission of pandemic 2008 influenza A (H1N1) virus in Osaka, Japan in May 2009
Komia N, Gu Y, Kamiya H, et al. J Infect Dis. 27 July 2010. doi:10.1016/j.jinf.2010.06.019.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJT-50MN7CR-1&_user=10&_coverDate=07%2F27%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=b67776eeedb9f24d01b02386462efc6d

Objective. To assess household transmission of pandemic influenza A (H1N1) and effectiveness of postexposure prophylaxis (PEP) of antiviral drugs among household contacts of patients during the first pandemic influenza A (H1N1) outbreak in Osaka, Japan in May 2009.

Methods. Active surveillance of patients and their families was conducted. PublicHealth Center staff visited each home with an infected patient and advised every household member with regard to precautionary measures, and PEP was provided to household contacts to prevent secondary infection. We analyzed the effectiveness of PEP and characteristics of secondary infection.

Results. The secondary attack rate (SAR) among household contacts was 3.7%. The SAR among household contacts without PEP was 26.1%. However, the SAR among those with PEP was 0.6%. Only two of 331 household contacts with PEP became infected. One of the two was infected with an oseltamivir-resistant strain. Analysis of SAR by age group showed that those under 20 years of age were at higher risk than those over 20 (relative risk [RR] = 7.9; 95% confidence interval [CI] = 2.24–27.8). Significant differences with respect to sex, number of household contacts, and use of antiviral medications in the index cases were not observed.

Conclusions. Our present results indicate that PEP is effective for preventing secondary H1N1 infection among household contacts.


Knowledge, attitudes and practices towards pandemic influenza among cases, close contacts, and healthcare workers in tropical Singapore: a cross-sectional survey
Yap J, Lee VJ, Yau TY, et al. BMC Public Health. 28 Jul 2010, doi:10.1186/1471-2458-10-442.
Available at http://www.biomedcentral.com/1471-2458/10/442

Background. Effective influenza pandemic management requires understanding of the factors influencing behavioral changes. We aim to determine the differences in knowledge, attitudes and practices in various different cohorts and explore the pertinent factors that influenced behavior in tropical Singapore.

Methods. We performed a cross-sectional knowledge, attitudes and practices survey in the Singapore military from mid-August to early-October 2009, among 3054 personnel in four exposure groups - laboratory-confirmed H1N1-2009 cases, close contacts of cases, healthcare workers, and general personnel.

Results. 1063 (34.8%) participants responded. The mean age was 21.4 (SE 0.2) years old. Close contacts had the highest knowledge score (71.7%, p = 0.004) while cases had the highest practice scores (58.8%, p < 0.001). There was a strong correlation between knowledge and practice scores (r = 0.27, p < 0.01) and knowledge and attitudes scores (r = 0.21, p < 0.01). The significant predictors of higher practice scores were higher knowledge scores (p < 0.001), Malay ethnicity (p < 0.001), exposure group (p < 0.05) and lower education level (p < 0.05). The significant predictors for higher attitudes scores were Malay ethnicity (p = 0.014) and higher knowledge scores (p < 0.001). The significant predictor for higher knowledge score was being a contact (p = 0.007).

Conclusion. Knowledge is a significant influence on attitudes and practices in a pandemic, and personal experience influences practice behaviors. Efforts should be targeted at educating the general population to improve practices in the current pandemic, as well as for future epidemics.


Perceptions and behaviors related to hand hygiene for the prevention of H1N1 influenza transmission among Korean University students during the peak pandemic period
Park JH, Cheong HK, Son DY, et al. BMC Infec Dis. 28 July 28 2010. 10:222 doi:10.1186/1471-2334-10-222.
Available at http://www.biomedcentral.com/1471-2334/10/222

Background. This study was performed to better assess the perceptions, motivating factors, and behaviors associated with the use of hand washing to prevent H1N1 influenza transmission during the peak pandemic period in Korea.

Methods. A cross-sectional survey questionnaire was completed by 942 students at a university campus in Suwon, Korea, between December 1 and 8, 2009. The survey included questions regarding individual perceptions, motivating factors, and behaviors associated with hand washing for the prevention of H1N1 influenza transmission.

Results. Compared to one year prior, 30.3% of participants reported increasing their hand washing frequency. Female students were more likely to practice more frequent hand washing. Women also perceived the effectiveness of hand washing to be lower, and illness severity and personal susceptibility to H1N1 infection to be higher. Study participants who were female (OR: 1.79-3.90) who perceived of hand washing to be effective (OR: 1.34-12.15) and illness severity to be greater (OR: 1.00-3.12) washed their hands more frequently.

Conclusions. Korean students increased their frequency of hand hygiene practices during the pandemic, with significant gender differences existing in the attitudes and behaviors related to the use of hand hygiene as a means of disease prevention. Here, the factors that affected hand washing behavior were similar to those identified at the beginning of the H1N1 or SARS pandemics, suggesting that public education campaigns regarding hand hygiene are effective in altering individual hand hygiene habits during the peak periods of influenza transmission.


Event-Based BioSurveillance of Respiratory Disease in Mexico, 2007-2009: Connection to the 2009 Influenza A(H1N1) Pandemic?
Nelson NP, Brownstein JS, Hartley DM, et al. Eurosurveillance. 29 Jul 2010; 15(30):pii=19626.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19626

Abstract. The emergence of the 2009 pandemic influenza A(H1N1) virus in North America and its subsequent global spread highlights the public health need for early warning of infectious disease outbreaks. Event-based biosurveillance, based on local- and regional-level Internet media reports, is one approach to early warning as well as to situational awareness. This study analyses media reports in Mexico collected by the Argus biosurveillance system between 1 October 2007 and 31 May 2009. Results from Mexico are compared with the United States and Canadian media reports obtained from the HealthMap system. A significant increase in reporting frequency of respiratory disease in Mexico during the 2008–9 influenza season relative to that of 2007–8 was observed (p<0.0001). The timing of events, based on media reports, suggests that respiratory disease was prevalent in parts of Mexico, and was reported as unusual, much earlier than the microbiological identification of the pandemic virus. Such observations suggest that abnormal respiratory disease frequency and severity was occurring in Mexico throughout the winter of 2008–2009, though its connection to the emergence of the 2009 pandemic influenza A(H1N1) virus remains unclear.


Transmission of pandemic influenza A (H1N1) 2009 within households: Edmonton, Canada
Sikora C, Fan S, Golonka R, et al. J of Clin Vir. 29 Jul 2010. doi:10.1016/j.jcv.2010.06.015.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VJV-50N2BN4-1&_user=10&_coverDate=07%2F29%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=2bbbe02f6f9bcd0f54e058d39e322003

Background. In April 2009, a novel influenza A, subtype H1N1, now referred to as the Pandemic (H1N1) 2009 virus (pH1N1), began circulating in countries around the world. Describing the transmission characteristics of this novel influenza A virus is important to predict current, and future, disease spread. The Public Health response to the first wave of pH1N1 in Alberta focused on the identification and management of secondary cases within households.

Objectives. The purpose of this study was to describe transmission characteristics of pH1N1 in households in Edmonton, the capital city of Alberta, during the first wave, and to identify the serial interval and secondary attack rate (SAR) in this setting.

Study Design. This is a prospective analysis of pH1N1 household transmission within 87 urban Canadian households between April 30 and June 9, 2009; with each household having at least one laboratory-confirmed case. The secondary attack rate was calculated in the 262 household contacts using a weighted average by number of susceptible individuals in each household. The serial interval, or time to illness in secondary cases, was analyzed using survival analysis with a Weibull model.

Results. Within the 87 households, 42 (48.3%) had no secondary cases develop; 25 (28.7%) had one secondary case develop; and 20 (22.9%) had more than one secondary case develop. The secondary attack rate did not decrease with increasing household size and households with two members exhibited the lowest secondary attack rate at 14.1%. Children under the age of 19, and individuals with an underlying medical condition, were at increased risk (p < 0.05) of becoming a secondary case. The overall secondary attack rate among the 262 susceptible household contacts was 30.2% (95% CI: 12.6–52.2). The median serial interval for pH1N1 transmission was 3.4 days (95% CI: 2.9–3.9).

Conclusions. The identified transmission characteristics of pH1N1 among Canadian households differ slightly from other previously reported North American estimates, but are in keeping with historical transmission rates of pandemic influenza viruses.


Immunity to Pre-1950 H1N1 Influenza Viruses Confers Cross-Protection against the Pandemic Swine-Origin 2009 A (H1N1) Influenza Virus
Skountzou I, Koutsonanos DG, Kim JH, et al. J Immun. 28 Jul 2010. 185,1642-1649. doi:10.4049/jimmunol.1000091.
Available at http://www.jimmunol.org/cgi/content/abstract/185/3/1642

Abstract. The 2009 H1N1 influenza virus outbreak is the first pandemic of the twenty-first century. Epidemiological data reveal that of all the people afflicted with H1N1 virus, <5% are over 51 y of age. Interestingly, in the uninfected population, 33% of those >60 y old have pre-existing neutralizing Abs against the 2009 H1N1 virus. This finding suggests that influenza strains that circulated 50–60 y ago might provide cross-protection against the swine-origin 2009 H1N1 influenza virus. To test this, we determined the ability of representative H1N1 influenza viruses that circulated in the human population from 1930 to 2000, to induce cross-reactivity to and cross-protection against the pandemic swine-origin H1N1 virus, A/California/04/09. We show that exposure of mice to the 1947 virus, A/FM/1/47, or the 1934 virus, A/PR/8/34, induced robust cross-protective immune responses and these mice were protected against a lethal challenge with mouse-adapted A/California/04/09 H1N1 virus. Conversely, we observed that mice exposed to the 2009 H1N1 virus were protected against a lethal challenge with mouse-adapted 1947 or 1934 H1N1 viruses. In addition, exposure to the 2009 H1N1 virus induced broad cross-reactivity against H1N1 as well as H3N2 influenza viruses. Finally, we show that vaccination with the older H1N1 viruses, particularly A/FM/1/47, confers protective immunity against the 2009 pandemic H1N1 virus. Taken together, our data provide an explanation for the decreased susceptibility of the elderly to the 2009 H1N1 outbreak and demonstrate that vaccination with the pre-1950 influenza strains can cross-protect against the pandemic swine-origin 2009 H1N1 influenza virus


Reponses to Pandemic (H1N1) 2009, Australia
Eastwood, Durrhein DN, Butler M, et al. Emerg Infect Dis. 30 Jul 2010. doi:10.3201/eid1608.100132.
Available at http://www.cdc.gov/eid/content/16/8/1211.htm

Abstract. In 2007, adults in Australia were interviewed about their willingness to comply with potential health interventions during a hypothetical influenza outbreak. After the first wave of pandemic (H1N1) 2009 in Australia, many of the same respondents were interviewed about behavior and protection measures they actually adopted. Of the original 1,155 respondents, follow-up interviews were conducted for 830 (71.9%). Overall, 20.4% of respondents in 2009 had recently experienced influenza-like illness, 77.7% perceived pandemic (H1N1) 2009 to be mild, and 77.8% reported low anxiety. Only 14.5% could correctly answer 4 questions about influenza virus transmission, symptoms, and infection control. Some reported increasing handwashing (46.6%) and covering coughs and sneezes (27.8%) to reduce transmission. Compared with intentions reported in 2007, stated compliance with quarantine or isolation measures in 2009 remained high. However, only respondents who perceived pandemic (H1N1) 2009 as serious or who had attained higher educational levels expressed intention to comply with social distancing measures.


Pandemic (H1N1) 2009 Surveillance for Severe Illness and Response, new York, New York, USA, April-July 2009
Balter S, Gupta LS, Lim SW, et al. Emerg Infect Dis. doi: 10.3201/eid1608.091847.
Available at http://www.cdc.gov/eid/content/16/8/1259.htm

Abstract. On April 23, 2009, the New York City Department of Health and Mental Hygiene (DOHMH) was notified of a school outbreak of respiratory illness; 2 days later the infection was identified as pandemic (H1N1) 2009. This was the first major outbreak of the illness in the United States. To guide decisions on the public health response, the DOHMH used active hospital-based surveillance and then enhanced passive reporting to collect data on demographics, risk conditions, and clinical severity. This surveillance identified 996 hospitalized patients with confirmed or probable pandemic (H1N1) 2009 virus infection from April 24 to July 7; fifty percent lived in high-poverty neighborhoods. Nearly half were <18 years of age. Surveillance data were critical in guiding the DOHMH response. The DOHMH experience during this outbreak illustrates the need for the capacity to rapidly expand and modify surveillance to adapt to changing conditions.


Pandemic (H1N1) 2009 Surveillance in Marginalized Populations, Tijuana Mexico
Rodwell TC, Robertson AM, Aguirre N, et al. Emerg Infect Dis. 30 Jul 2010. doi: 10.3201/eid1608.100196.
Available at http://www.cdc.gov/eid/content/16/8/1292.htm

Abstract. To detect early cases of pandemic (H1N1) 2009 infection, in 2009 we surveyed 303 persons from marginalized populations of drug users, sex workers, and homeless persons in Tijuana, Mexico. Six confirmed cases of pandemic (H1N1) 2009 were detected, and the use of rapid, mobile influenza testing was demonstrated.


Quarantine Methods and Prevention of Secondary Outbreak of Pandemic (H1N1) 2009
Chu C-Y, Li CY, Zhang H, et al. Emerg Infect Dis. 30 Jul 2010. doi: 10.3201/eid1608.091787.
Available at http://www.cdc.gov/eid/content/16/8/1300.htm

Abstract. During the 2009 influenza (H1N1) pandemic, some countries used quarantine for containment or mitigation. Of 152 quarantined university students we studied, risk for illness was higher for students quarantined in a room with a person with a confirmed case; we found no difference between students quarantined in double or single rooms.


Pandemic (H1N1) 2009 Vaccination and Class Suspensions after Outbreaks, Taipei City, Taiwan
Hsueh P-R, Lee PI, Chiu AW-H, et al. Emerg Infect Dis. 30 Jul 2010. doi:10.3201/eid1608.100310.
Available at http://www.cdc.gov/eid/content/16/8/1300.htm

Abstract. In Taipei City, class suspensions were implemented beginning September 1, 2009 when transmission of pandemic (H1N1) 2009 infection was suspected. The uptake rate of pandemic (H1N1) 2009 vaccination (starting on November 16, 2009) among students 7–18 years of age was 74.7%. Outbreaks were mitigated after late November 2009.


Pandemic (H1N1) 2009 Virus and Down Syndrome Patients
Perez-Padilla Ro, Fernandez R, Garcia-Sancho C, et al. Emerg Infect Dis. 30 Jul 2010. doi:10.3201/eid1608.091931.
Available at http://www.cdc.gov/eid/content/16/8/1300.htm

Abstract. We compared prevalence of hospitalization, endotracheal intubation, and death among case-patients with and without Down syndrome during pandemic (H1N1) 2009 in Mexico. Likelihoods of hospitalization, intubation, and death were 16-fold, 8-fold, and 335-fold greater, respectively, for patients with Down syndrome. Vaccination and early antiviral drug treatment are recommended during such epidemics.


Community Psychological and Behavioral Responses through the First Wave of the 2009 Influenza A (H1N1) Pandemic in Hong Kong
Cowling BJ, Ng DMW, IpDKM, et al. J Infect Dis. 2 Aug 2010. doi:10.1086/655811.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/655811

Background. Little is known about the community psychological and behavioral responses to influenza pandemics.

Methods. Using random digit dialing, we sampled 12,965 Hong Kong residents in 13 cross]sectional telephone surveys between April and November 2009, covering the entire first wave of the 2009 influenza A(H1N1) pandemic. We examined trends in anxiety, risk perception, knowledge on modes of transmission, and preventive behaviors.

Results. Respondents reported low anxiety levels throughout the epidemic. Perceived susceptibility to infection and perceived severity of H1N1 were initially high but declined early in the epidemic and remained stable thereafter. As the epidemic grew, knowledge on modes of transmission did not improve, the adoption of hygiene measures and use of face masks did not change, and social distancing declined. Greater anxiety was associated with lower reported use of hygiene measures but greater social distancing. Knowledge that H1N1 could be spread by indirect contact was associated with greater use of hygiene measures and social distancing.

Conclusions. The lack of substantial change in preventive measures or knowledge about the modes of H1N1 transmission in the general population suggests that community mitigation measures played little role in mitigating the impact of the first wave of 2009 influenza A(H1N1) pandemic in Hong Kong.


Immunisation and multi-dose vials
Gosbell IB, Gottlieb T, Kesson AM, et al. Vaccine. 2 Aug 2010. doi:10.1016/j.vaccine.2010.07.052.
Available at http:/ http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-50P0DKT-2&_user=10&_coverDate=08%2F02%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=a204ca1441326fef93f78576200ed672

Abstract. The current novel H1N1 09 influenza virus pandemic has resulted in 37,722 diagnoses, 4992 hospitalisations, and 191 deaths in Australia as of 11 June 2010. A mass immunisation campaign has commenced using a multi-dose vial formulation to assist rapid deployment. However, in the past multi-dose vials have been associated with transmission of infective agents. Having the vaccine in single-dose vials with a lesser risk of transmission of infection but increased delay in implementation and increased cost needs to be weighed against the imperative to vaccinate the population against pandemic H1N1 09 influenza virus. This article reviews the infectious risks associated with multi-dose vials.


Developing guidelines for school closure interventions to be used during a future influenza pandemic
Halder N, Kelso JK, Milne GJ, et al. BMC Infect Dis. 27 Jul 2010. 10:221doi:10.1186/1471-2334-10-221.
Available at http://www.biomedcentral.com/1471-2334/10/221

Background. The A/H1N1 2009 influenza pandemic revealed that operational issues of school closure interventions, such as when school closure should be initiated (activation trigger), how long schools should be closed (duration) and what type of school closure should be adopted, varied greatly between and within countries. Computer simulation can be used to examine school closure intervention strategies in order to inform public health authorities as they refine school closure guidelines in light of experience with the A/H1N1 2009 pandemic.

Methods. An individual-based simulation model was used to investigate the effectiveness of school closure interventions for influenza pandemics with R0 of 1.5, 2.0 and 2.5. The effectiveness of individual school closure and simultaneous school closure were analyzed for 2, 4 and 8 weeks closure duration, with a daily diagnosed case based intervention activation trigger scheme. The effectiveness of combining antiviral drug treatment and household prophyaxis with school closure was also investigated.

Results. Illness attack rate was reduced from 33% to 19% (14% reduction in overall attack rate) by 8 weeks school closure activating at 30 daily diagnosed cases in the community for an influenza pandemic with R0 = 1.5; when combined with antivirals a 19% (from 33% to 14%) reduction in attack rate was obtained. For R0 >= 2.0, school closure would be less effective. An 8 weeks school closure strategy gives 9% (from 50% to 41%) and 4% (from 59% to 55%) reduction in attack rate for R0 = 2.0 and 2.5 respectively; however, school closure plus antivirals would give a significant reduction (~15%) in over all attack rate. The results also suggest that an individual school closure strategy would be more effective than simultaneous school closure.

Conclusions. Our results indicate that the particular school closure strategy to be adopted depends both on the disease severity, which will determine the duration of school closure deemed acceptable, and its transmissibility. For epidemics with a low transmissibility (R0 < 2.0) and/or mild severity, individual school closures should begin once a daily community case count is exceeded. For a severe, highly transmissible epidemic (R0 >= 2.0), long duration school closure should begin as soon as possible and be combined with other interventions.


Characterizing hospital workers’ willingness to report to duty in an influenza pandemic through threat-and efficacy-based assessment
Balicer RD, Barnett DJ, Thompson CB, et al. BMC Public Health. 26 Jul 2010. 10:436 doi:10.1186/1471-2458-10-436.
Available at http://www.biomedcentral.com/1471-2458/10/436

Background. Hospital-based providers' willingness to report to work during an influenza pandemic is a critical yet under-studied phenomenon. Witte's Extended Parallel Process Model (EPPM) has been shown to be useful for understanding adaptive behavior of public health workers to an unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among hospital staff.

Methods. We administered an anonymous online EPPM-based survey about attitudes/beliefs toward emergency response, to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. Responses were received from 3426 employees (18.4%), approximately one third of whom were health professionals.

Results. Demographic and professional distribution of respondents was similar to all hospital staff. Overall, more than one-in-four (28%) hospital workers indicated they were not willing to respond to an influenza pandemic scenario if asked but not required to do so. Only an additional 10% were willing if required. One-third (32%) of participants reported they would be unwilling to respond in the event of a more severe pandemic influenza scenario. These response rates were consistent across different departments, and were one-third lower among nurses as compared with physicians. Respondents who were hesitant to agree to work additional hours when required were 17 times more likely to be unwilling to respond during a pandemic if asked. Sixty percent of the workers perceived their peers as likely to report to work in such an emergency, and were ten times more likely than others to do so themselves. Hospital employees with a perception of high efficacy had 5.8 times higher declared rates of willingness to respond to an influenza pandemic.

Conclusions. Significant gaps exist in hospital workers' willingness to respond, and the EPPM is a useful framework to assess these gaps. Several attitudinal indicators can help to identify hospital employees unlikely to respond. The findings point to certain hospital-based communication and training strategies to boost employees' response willingness, including promoting pre-event plans for home-based dependents; ensuring adequate supplies of personal protective equipment, vaccines and antiviral drugs for all hospital employees; and establishing a subjective norm of awareness and preparedness.


5. Notifications
Second International Swine Flu Conference
Washington DC 18-19 Aug 2010
The 2nd ISFC builds on the success of the 1st ISFC held in August 2009 and attended by over 500 distinguished scientists, public health officials, law enforcers, first responders, and key decision-makers of major health companies from the United States, Europe, Asia, and the Middle East. Additional information is available at http://www.new-fields.com/2ndISFC/


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


International TB Symposium (ITBS-2010): TB Diagnostics – Innovating to Make an Impact
New Delhi, India 16-17 December 2010
The Symposium will take stock of current status of TB diagnostics and unravel future directions for translating research results into reliable and efficient point-of-care methods of TB diagnosis.
Additional information available at http://www.icgeb.org/meetings-2010.html