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Vol. XIII No. 20 ~ EINet News Briefs ~ Oct 01, 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: Pandemic H1N1 influenza situation update
- Global: Pandemic H1N1 influenza makes late-season statement in parts of Southern Hemisphere
- Global: India, Thailand report H1N1 pandemic influenza cases and deaths
- Global: WHO pandemic H1N1 influenza review group concludes third session
- Australia: Pandemic influenza H1N1 cases up 500 percent
- United States: CDC finalizes pandemic H1N1 influenza prevention guidance for health settings
- United States: Officials preview upcoming influenza season, stress vaccination
- United States: Sebelius envisions cell-based influenza vaccine in 2011
- United States: Experts cautiously optimistic on future impact of H1N1 pandemic influenza

2. Infectious Disease News
- Australia (Queensland): TB outbreak at Treasury Casino
- Australia: Inmate with measles sparks warning
- China (Tibet): Outbreak of plague
- China (Tibet): Outbreak of pneumonic plague under control
- China (Xiamen City): Conjunctivitis spread
- Russia (Krasnodar): Anthrax cases reported
- Russia (Moscow oblast): Hemorrhagic fever with renal syndrome
- Thailand: Hand, foot, and mouth disease
- Thailand: Suspected mumps outbreak
- Chile: Hantavirus cases forty percent higher than in 2009
- Mexico (Guerrero): Conjunctivitis cases
- Mexico (Tamaulipas): Conjunctivitis outbreak
- Peru: Five deaths caused by rabies infections
- United States (California): Outbreak of whooping cough mirrors challenges in developing world
- United States (Indiana): Pertussis infections reaching highest rate since 1986

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

4. Articles
- Optimal antiviral treatment strategies and the effects of resistance
- Optimal antiviral treatment strategies and the effects of resistance
- Attending Work While Sick: Implication of Flexible Sick Leave Policies
- Report of the international forum on pandemic influenza 2010: Qingdao, China, 24–25 July 2010
- Needle-free influenza vaccination
- Surfing the web during pandemic flu: availability of World Health Organization recommendations on prevention
- Factors in vaccination intention against the pandemic influenza A/H1N1
- Moderate pandemic, not many dead—learning the right lessons in Europe from the 2009 pandemic
- Time and motion study to compare electronic and hybrid data collection systems during the pandemic (H1N1) 2009 influenza vaccination campaign
- [Letter] Underlying Medical Conditions and Hospitalization for Pandemic (H1N1) 2009, Japan
- Pandemic (H1N1) 2009 Virus on Commercial Swine Farm, Thailand
- [Letter] Internet Search Limitations and Pandemic Influenza, Singapore
- Heightened neurologic complications in children with pandemic H1N1 influenza
- Effectiveness of Public Health Measures in Mitigating Pandemic Influenza Spread: A Prospective Sero‐Epidemiological Cohort Study

5. Notifications
- 4th Vaccine and ISV Annual Global Congress
- Sixty-first session of the WHO Regional Committee for the Western Pacific
- International TB Symposium (ITBS-2010): TB Diagnostics – Innovating to Make an Impact


1. Influenza News

Global
2010 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Cambodia / 1 (1)
China / 1 (1)
Egypt / 22 (9)
Indonesia / 6 (5)
Viet Nam 7 (2)
Total / 37 (18)

***For data on human cases of avian influenza prior to 2010, go to:
http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 505 (300)
(WHO 08/31/10)
http://www.who.int/csr/disease/avian_influenza/country/cases_table_2010_08_31/en/index.html

Avian influenza age distribution data from WHO/WPRO (last updated 2/8/10):
http://www.wpro.who.int/sites/csr/data/data_Graphs.htm

WHO's map showing world's areas affected by H5N1 avian influenza (status as of 2/12/10):
http://gamapserver.who.int/mapLibrary/Files/Maps/Global_H5N1Human_2010_FIMS_20100212.png.

WHO’s timeline of important H5N1-related events (last updated 1/4/10): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: Pandemic H1N1 influenza situation update
Influenza virus circulation remains most active in areas of the temperate Southern Hemisphere and in parts of Asia, particularly South and Southeast Asia.

As of early to mid-September 2010, Chile continued to report an increasing national trend of ILI activity associated with increased co-circulation of seasonal and H1N1 (2009) influenza viruses. The current influenza season in Chile has been notable for its unusually late arrival and locally intense epidemics in several regions which have observed levels of ILI matching or slightly surpassing levels seen during the 2009 winter pandemic wave. Since the beginning of the current epidemic period, which began during early August 2010, the proportion of emergency department consultations for influenza has increased markedly among children <15 years of age followed by persons 15-64 years of age; during the same period, the proportion of emergency department consultations for pneumonia increased most among persons >65 years of age. In neighboring Argentina, limited data suggest that low levels of predominantly influenza type B viruses circulated between June and late August 2010.

In New Zealand, the national consultation rate for ILI fell below the seasonal baseline during the third week of September 2010 after peaking approximately one month earlier. Compared to the 2009 winter pandemic wave, the influenza season to date in New Zealand has been characterized by a late winter arrival, lower overall levels of ILI nationally but significant regional variability including locally intense outbreaks in some areas, and continued predominance of circulating H1N1 (2009) viruses relative to seasonal influenza viruses. In Australia, a steady increase in the national rate of ILI consultations was observed between late August and mid-September 2010, but overall levels remain well below those seen during the past three winter influenza seasons; geographically widespread activity has been recently reported in Victoria, South Australia, and Western Australia. Influenza H1N1 (2009) and seasonal type B viruses continue to co-circulate in Australia.

In Asia, significant influenza virus circulation continues to be reported in India and Thailand and to a lesser extent in China. In India, there is widespread persistence of active influenza virus circulation. As of mid-September 2010, at least 17 states and territories reported new cases, with the highest numbers reported in the Delhi, Maharashtra, and Karnataka; in all but a few states, overall influenza activity appears to be stable or declining suggesting that the national epidemic has passed its peak. Influenza H1N1 (2009) virus continues to be the predominant circulating influenza virus in India. In southern China and in Hong Kong (SAR China) and to a lesser extent in northern China, there has been an increasing reemergence of circulating seasonal influenza H3N2 viruses since July 2010. In Hong Kong (SAR China) but not in mainland China, increased detections of seasonal influenza H3N2 viruses over this period have been associated with a steady increase in the levels of consultations for ILI at sentinel sites. In Thailand, there has been active circulation of influenza H1N1 (2009) viruses and to a lesser extent seasonal influenza type B and H3N2 viruses since mid-July 2010, coinciding with a period of usual transmission of influenza viruses.

In South Africa, peak wintertime influenza activity has passed but there continues to be active co-circulation of seasonal influenza (type B and H3N2) viruses and also, more recently, influenza H1N1 (2009) viruses. Influenza virus detections among ILI and SARI patients at sentinel sites have declined since mid-August 2010.
(WHO 09/24/2010)

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Global: Pandemic H1N1 influenza makes late-season statement in parts of Southern Hemisphere
Flu activity is showing a late-season flourish in some parts of the Southern Hemisphere, such as Chile, where levels in some areas exceed 2009's pandemic peak, and in parts of Australia, the World Health Organization (WHO) said in its most recent influenza update.

In a 24 September 2010 update, WHO said that flu activity in several of Chile's regions equals or is slightly higher than the country's 2009 winter pandemic wave, with the disease hitting children under age 15 the hardest, followed by those ages 15 to 64.

The 2009 H1N1 virus is cocirculating in Chile alongside seasonal flu viruses. However, limited data from neighboring Argentina suggests low levels of flu, mainly influenza B, between June and late August 2010.

Health officials in Australia have reported steady increases in flu activity since late August 2010, though at levels well below the past three influenza seasons, the WHO reported. Activity is widespread in Victoria in South Australia state and West Australia state, where the 2009 H1N1 and influenza B viruses are cocirculating.

New Zealand also had a late start to its flu season, but activity, most of it 2009 H1N1 flu, has dipped below seasonal baselines.

India and Thailand continue to report significant flu activity, the WHO said. Though activity in India has been geographically widespread, with 17 states and territories reporting new cases, activity is stable or declining in all but a few states, suggesting that national activity may have peaked. The 2009 H1N1 virus has been India's predominant circulating strain.

The country is still reporting many cases and deaths, according to the Indian health ministry's report for the week that ended yesterday. Between 20 September and 26 September 2010 the ministry received 616 reports of lab-confirmed cases, including 93 deaths. States with the highest number of new case for the week were Tamil Nadu (129), Maharashtra (124), and Karnataka (93).

Meanwhile, southern China, Hong Kong, and to a lesser extent northern China have reported increased circulation of the seasonal influenza A (H3N2) virus. Officials in Hong Kong have linked increased H3N2 detections with a steady rise in doctor's visits for flulike illness.

Thailand is reporting active transmission of mainly the 2009 H1N1 virus, along with some H3N2 and influenza B strains, according to the WHO. The rise in flu activity is occurring at a time when increasing flu activity isn't surprising, it added.

The country's health ministry said rising 2009 H1N1 activity was causing officials to consider the possibility of buying more vaccine. An official said 20% of people seeking medical care for flulike illnesses were being diagnosed with 2009 H1N1 infections, and he said the country's two million monovalent doses might not be enough to meet rising demand.
(CIDRAP 09/27/2010)

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Global: India, Thailand report H1N1 pandemic influenza cases and deaths
India's health ministry said on 20 September 2010 that it received 1,038 new 2009 H1N1 case reports the week of 13 September 2010, including as many as 111 deaths. States reporting the highest number of illnesses include Tamil Nadu, Maharashtra, Karnatka, and Rajasthan. States with the highest number of deaths were Maharashtra, Gujarat, and Madhya Pradesh. Meanwhile, Thailand's health ministry warned about an increase in 2001 H1N1 flu activity and said it confirmed 338 cases and three deaths from the virus. In its latest post-pandemic flu update on 10 September 2010 the World Health Organization said the most active areas of flu transmission are temperate areas of the Southern Hemisphere and southern Asia.
(CIDRAP 09/20/2010)

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Global: WHO pandemic H1N1 influenza review group concludes third session
The external committee tasked with reviewing the World Health Organization's (WHO's) response to the H1N1 pandemic wrapped up its third round of live meetings in Geneva, hearing from an array of country and organization health representatives, as well as WHO Director-General Margaret Chan, who strongly defended the organization's response.

Chan, who spoke to the group during a public plenary session on the second day of its meeting, also said the WHO learned some important lessons that will position it to, for example, ease the flow of pandemic vaccine to developing countries. The pandemic review committee is simultaneously reviewing how the International Health Regulations (IHRs) functioned during their first use in an international health emergency.

Dr Harvey Fineberg, the group's chairman, briefed reporters at the conclusion of the group's three-day meeting. He said the committee is still in an information-gathering mode and that the agenda consisted of public plenary sessions and deliberation meetings during which members met by themselves. He is president of the Institute of Medicine of the US National Academy of Sciences.

The review committee's last meeting in Geneva was in early July 2010, and Fineberg told reporters the committee will meet again in November 2010 for deliberation sessions. He projected that the group would have a draft of a report for its own members to review by early January 2011 in time for its final plenary meeting. The members will submit a final report that includes a response from Chan in advance of the World Health Assembly in May 2011.

Fineberg said the group heard testimony from a wide range of health and industry experts and confirmed, based on a journalist's question, that Michael T. Osterholm, PhD, MPH, addressed the group during the plenary sessions. Osterholm is director of the University of Minnesota's Center for Infectious Disease Research and Policy, publisher of CIDRAP News.

One of the largest blocks of testimony came from key people who led the WHO's response and were involved in administering the IHRs, including Chan, Fineberg said. At the committee's last meeting in July 2010 they heard from some of sharpest critics of the WHO's response, including a Council of Europe representative and the editor of the British Medical Journal.

He said that one of the things that was not surprising, but very revealing, was that the principals at the WHO secretariat were very eager to tell their story. He added that they are as eager to tell their story as the critics are to tell theirs.

Chan spoke candidly about the challenges and successes she observed during the WHO's pandemic response and said the group welcomes the review and is mindful of the praise and criticisms it has received. She said the WHO is grateful for the moderate impact the pandemic had, and she said in retrospect some response measure may look excessive.

Chan stated that had the virus turned more lethal, the WHO would be under scrutiny for having failed to protect large numbers of people. Vaccine supplies would have been too little, too late, with large parts of the developing world left almost entirely unprotected.

She said experts assumed that H5N1, with its more lethal severity, would cause the next pandemic, which guided preparations for a more severe pandemic than what emerged with the 2009 H1N1 virus. The phased pandemic alert approach was developed as cues to help countries increase their preparedness levels without causing public alarm. Chan said that in reality there was an opposite effect. It dramatized the steps leading to the declaration of the pandemic and increased the build up of anxiety.

Chan rejected charges that the WHO exaggerated the pandemic threat and said when she announced the move to alert phase 6 she reminded the world that the number of deaths were small, that she didn't expect to see them increase suddenly, and that most patients were recovering without medical care.

During a time when health officials had to make decisions in an environment of scientific uncertainty, most health officials erred on the side of caution; she said that in this regard, the phased approach to the declaration of a pandemic was rigid and confining. In communicating the level of alarm, authorities need to be able to move down as well as up. She added that limited vaccine capacity and long production times also hampered the flexibility of countries' pandemic responses.

She strongly rejected charges that commercial interests tainted the WHO's pandemic alert level decisions. Chan said in her statement that she never saw a a single shred of evidence that pharmaceutical interests, as opposed to public health concerns, influenced any decisions or advice provided to WHO by its scientific advisors.

On a positive note, Chan said some elements of the world's pandemic response worked well, including the IHRs, which she said provided a useful set of checks and balances, and the early distribution of oseltamivir stockpiles to developing countries.

She said the Emergency Committee, with both experts and affected states represented, functioned well as a balanced and inclusive advisory body. The emergency committee met at least nine times to advise Chan during pandemic phase and response discussions, and some critics charged that the process lacked transparency, because member names were confidential. The WHO has said the names were kept secret during the pandemic to protect members from undue influence. It revealed the member names on 10 August 2010 when the WHO declared that the pandemic was over.

In response to journalists' questions, Fineberg said several times that the role of the committee isn't to assign blame, but to identify ways that the WHO can improve its pandemic response.

He said the review committee is hearing a lot about the challenge of decision making under conditions of great uncertainty and that some response measures, such as the vaccine donation process, are very complex.

Fineberg said that everyone came at this from their own perspective, but few had a vision of the whole. Each told an important side of the story. He added that their job is making a coherent whole out of these perspectives.
(CIDRAP 09/29/2010)

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Asia
Australia: Pandemic influenza H1N1 cases up 500 percent
Swine flu diagnoses have increased by almost 528 percent during September 2010, with preschoolers among the hardest hit.

The week of 20 September 2010, 459 new cases were confirmed in SA, compared with 400 cases in the previous week and just 73 in the third week of last month. SA Health chief medical officer Professor Paddy Phillips said about a third of cases were in children under five, including 150 last week.

We know from all of the published data that it's going to be mostly young people, he said. Professor Phillips said children had poorer hygiene and were less likely than adults to have had a seasonal flu shot. It was also possible adults were partially protected by having had influenza in previous years. There's some evidence that, in older people in particular, there's a cross-immunity from other flu strains, he said.

In 2009 SA recorded about 8,100 swine flu cases and 17 deaths but the epidemic was over by September. So far in 2009, only 1400 cases have been recorded but 1000 of them were in the past four weeks. Professor Phillips said he was aware of some admissions to intensive care but had not heard of any deaths related to swine flu in SA in 2010.

Emergency departments also have begun to report a rise in flu presentations. Health authorities are encouraging people to pay particular attention to hygiene, including handwashing, wiping surfaces and covering coughs and sneezes.

The message is, if you don't do that, you'll be eating other people's respiratory secretions, Professor Phillips said. Australian Medical Association SA president Dr Andrew Lavender said it was still not too late to be vaccinated, although there was a steadily increasing chance of catching the disease before the vaccination took effect.

At the end of August 2010, Dr Lavender forecast an imminent surge in flu cases. We're likely to see that for a few more weeks yet, he said. It is still worth considering vaccination and there is a safe vaccine for children. People with asthma, diabetes, renal failure and cardiac disease were among those for whom protection could be lifesaving.

The World Health Organization in August 2010 declared the H1N1 (swine flu) pandemic over. More than 17,000 deaths worldwide have been attributed to the virus.
(The Advertiser 09/24/2010)

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Americas
United States: CDC finalizes pandemic H1N1 influenza prevention guidance for health settings
The US Centers for Disease Control and Prevention (CDC) recently issued new guidance for preventing flu in healthcare settings that reflects a year's worth of new information about the 2009 H1N1 virus and recommends surgical masks rather than N-95 respirators when providing routine care for flu patients.

In 2009 when the CDC issued a new set of recommendations for preventing the pandemic virus in healthcare settings, it said it would update the guidance as new information became available. In the middle of June the CDC previewed the change to its personal protective equipment (PPE) recommendation when it asked the public to comment on the proposed guidance. At that time, members of some healthcare groups, such as the Society for Healthcare Epidemiology of America (SHEA) said they were pleased by the new mask recommendation and its focus on the latest scientific data.

The CDC said the newest version of the 17-page guidelines for seasonal flu takes into account the wide availability of a trivalent seasonal flu vaccine that includes the 2009 H1N1 virus, which the CDC expects to see again during the upcoming flu season.

Other new information that triggered the update includes more certain estimates of hospitalizations and deaths from the 2009 H1N1 virus and new data that suggest face masks and hand hygiene practices can reduce the risk of flu in homes and healthcare settings.

Previous CDC pandemic flu prevention guidance for healthcare settings has recommended N-95 respirators for protecting workers who care for flu patients, but the advice has been controversial. Some professional groups have opposed their routine use because efficacy has been inconclusive and employees have said the N-95s are uncomfortable to wear for long periods.

In September 2009 an unpublished study by Australian researchers found that respirators may be better than masks at protecting healthcare workers, though the difference may not be significant. However, an October 2009 Canadian study of flu in nurses suggested that masks weren't inferior to N-95 respirators. A study in January 2010 showed that surgical masks and hand hygiene reduced flulike illnesses in the college setting, and while some experts said the findings seemed to support the view that masks are sufficient for routine healthcare tasks, they cautioned about generalizing the results to the community at large.

When pressed by some health groups last fall about the N-95 recommendation, federal health officials said they were swayed by the unique pandemic flu conditions, such as low levels of population immunity, late and scarce availability of a vaccine targeted to the virus, and increased exposure of healthcare workers to the new virus.

Dr John Jernigan, a medical epidemiologist with the CDC who was involved with developing the new guidance, told CIDRAP News that as the face of the 2009 H1N1 virus looks more and more like seasonal flu, changes in the new guidance emphasize droplet precautions in the context of a multifaceted flu prevention approach. Jernigan stated that PPE is likely to be one of the least effective methods, with vaccination being most important.

He said the new guidelines emphasize identifying flu patients early and applying engineering and environmental prevention strategies, as well as appropriately managing sick healthcare workers. Health facilities need robust programs to discourage healthcare workers from coming to work sick, Jernigan added.

Dr Jeff Hageman, an epidemiologist with the CDC who also helped develop the guidance, said a major change for seasonal flu prevention in health settings involves the recommendations for PPE and other devices during high-risk activities such as aerosol-generating procedures. Though not all facilities have negative-pressure rooms or devices, a topic covered in the new guidance, the recommendation to use N-95s and eye protection during the procedures should be feasible for all situations, he said.

Jernigan said the CDC received numerous and varied comments on the draft guidance while it was open for public comment this summer. However, he said there was a general level of support for the new changes. He added that new data on PPE protection that were published over the summer didn't suggest that one form was superior to another.

In addition, Hageman said that putting together the new guidelines showed a continuing need for more research, and that there is a lack of data to definitively say which modes are more important.

Though some medical groups such as SHEA, the Infectious Diseases Society of America, and the American Academy of Pediatrics have recently issued statements supporting mandatory flu immunization for healthcare workers, the CDC guidance stops short of recommending the measure.

Instead, it highlights the elements of programs that can successfully raise healthcare worker vaccination rates, such as providing incentives, offering free vaccine, having a systematic approach, and disseminating clear and timely communication on the topic.

Jernigan said the purpose of the guidelines is to emphasize the importance of vaccination and the practices that are likely to result in high coverage levels. The CDC's Advisory Committee on Immunization Practices (ACIP) is expected to address the topic next June, and he added that the new document probably isn't the right springboard for taking a step toward recommending mandatory vaccination.

Hageman added that one of the challenges in producing the flu prevention guidelines is making them relevant across a spectrum of healthcare settings and giving professionals enough leeway to, for example, decide what methods work best in each setting to boost vaccination rates. He said that if current approaches are successful, there is no need to change them.

The CDC again included the caveat that its guidance will change as it receives new information.

Updated guidance still includes detailed recommendations for periods of increased flu activity, such as segregating patients with suspected flu who present for care and minimizing visits from patients with mild flulike symptoms who aren't at increased risk of complications by, for example, offering a flu telephone consultation line.

In the section on workers who develop fever and respiratory symptoms, the updated guidance retains the recommendation that they should stay home until they have been fever-free without the use of fever-reducing medications for 24 hours.

The CDC recommends that healthcare workers who are still coughing and sneezing wear a facemask during patient care. More stringent measures are recommended when treating high-risk patients such as those undergoing stem-cell transplants.
(CIDRAP 09/20/2010)

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United States: Officials preview upcoming influenza season, stress vaccination
In a look ahead to the coming flu season in 2010, federal officials said experts have a good grasp on the strains expected to circulate and plenty of vaccine on hand.

At a US Health and Human Services (HHS) Web presentation, HHS secretary Kathleen Sebelius pointed out that last year public health officials were managing a new virus that arrived early in the flu season, well in advance of a steady supply of the pandemic vaccine.

Sebelius stated that for 2010, scientists know what is coming, and that HHS has plenty of vaccine. According to a 24 September 2010 estimate from the US Centers for Disease Control and Prevention (CDC), as of 17 September 2010, about 89 million doses of seasonal flu vaccine have been distributed, and manufacturers project they will produce 160 million to 165 million total doses for the upcoming season.

Public health officials have said they expect the 2009 H1N1 strain to reappear and will probably circulate alongside seasonal influenza A (H3N2) and influenza B strains, as it has over the past several months in other parts of the world, such as China and South Africa.

This season's flu vaccine for Northern Hemisphere countries includes the 2009 H1N1 virus along with a Perth-like H3N2 strain and an influenza B Brisbane strain, a member of the Victoria lineage.

In August 2010 the CDC alerted healthcare providers about small H3N2 outbreaks in Iowa and scattered H3N2 cases in other states.

Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, said that in the United States flu seems to be settling into more of a normal seasonal pattern. She said the flu is around here and there with a few clusters, but nothing major. Adding that the strains the CDC is seeing look very similar to what is included in 2010's vaccine.

Though the CDC monitors flu activity year-round, it will issue its first weekly flu surveillance report for the new season on 15 October 2010, which will cover activity for the week ending 9 October 2010.

Howard Koh, MD, MPH, assistant secretary for health at the HHS, said the major message for this year's flu season is the new universal immunization recommendation, which advises flu vaccination for almost everyone age six months and older. He said the year 2009 showed that everyone is vulnerable to flu, and that the flu shot is a great investment in prevention.

Sebelius said a new provision of the healthcare reform bill is designed to ease access to flu shots, other vaccines, and a range of prevention measures. She said new insurance plans written after 23 September 2010 must offer the prevention measures, including flu vaccination, without copays. She added that the same policy will take effect for seniors in the Medicare program in 2011.

During today's Web conference, Sebelius also announced that HHS would be teaming up with Google to offer a flu vaccine locator on the HHS' flu.gov Web site. She said she expects the locator to launch on 5 October 2010.

Schuchat said people often ask about the best timing for getting their flu shots, and some worry that early-season vaccination won't protect them throughout the whole flu season. She said the best time to get the flu shot is when it's available in the community, stating that we she got her shot on Friday, and expects it to protect her the whole season. Schuchat advises friends and family to do the same.
(CIDRAP 09/28/2010)

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United States: Sebelius envisions cell-based influenza vaccine in 2011
Speaking at a Senate committee hearing, US Health and Human Services (HHS) Secretary Kathleen Sebelius said a cell-based seasonal influenza vaccine from Novartis could be on the US market in time for the 2011-2012 flu season.

With the help of a $487 million HHS contract, Novartis Vaccines and Diagnostics recently built a facility in Holly Springs, N.C., to make cell-based flu vaccines and vaccine adjuvants. No cell-based flu vaccine has yet been licensed in the United States, though such vaccines have been approved in Europe.

Sebelius said that the Novartis facility is scheduled to apply online for licensing early in 2011 for cell-based seasonal vaccine, and a licensed vaccine is expected to be marketed for the 2011-2012 flu season.

But in response to a query after the hearing, Novartis officials took a more cautious stance.

Novartis stated that it opened its Holly Springs, North Carolina facility in November 2009 in collaboration with the US Department of Health and Human Services (HHS). Novartis plans to file for cell-based vaccine technology in the US in the first half of 2011, but approval is contingent upon FDA [Food and Drug Administration] review, so the company cannot confirm when cell-based vaccines would be on the market in the US.

When the North Carolina plant was unveiled in 2009, Novartis officials said the earliest it could start making flu vaccine was 2011, with full commercial production expected in 2013.

Sebelius made her comments at a hearing of the Senate Appropriations Committee's Labor-HHS Subcommittee on "Defending against public health threats." The session focused on HHS efforts to develop medical countermeasures against biological weapons.

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

Commenting on Sebelius's prediction, Andrew Pavia, MD, of the Infectious Diseases Society of America (IDSA), who also spoke at the hearing said the news seems optimistic and good if it’s true. Pavia, a pediatric infectious disease specialist at the University of Utah, chairs the IDSA's Pandemic Influenza Task Force.

Pavia commented further that as far as he knows, the FDA has already given Novartis a reasonably clear signal of what it's going to take to get the vaccine licensed, and it's reasonably similar to regular flu vaccine. Novartis was going to be using fairly similar potency assays and demonstrating efficacy in clinical trials.

Sebelius also told the subcommittee that a recombinant flu vaccine from Connecticut-based Protein Sciences Corp. may also be licensed in time for the 2011-2012 flu season. The company's application for approval of the vaccine is currently being reviewed by the FDA, according to the firm's Web site. The vaccine is made by using a baculovirus to grow the antigen in insect cells.

Sebelius talked about the Novartis and Protein Sciences vaccines in response to questions from Sen. Tom Harkin, D-Iowa, chair of the subcommittee. He said the subcommittee has provided $15 billion for pandemic flu preparedness since 2006. That includes the money for the Novartis facility, and that it may not operate until 2013.

Harkin said that there is no cell-based vaccine in the US, but one is currently licensed in Europe. He questioned the problem of getting the vaccine licensed in the US if they're already licensed in Europe.

In response, Sebelius noted that HHS has stockpiled a vaccine for H5N1 avian influenza, before discussing the Novartis and Protein Sciences vaccines.

In her prepared statement to the panel, Sebelius discussed five initiatives that were described in a major HHS review, released in August 2010, of civilian biodefense efforts. The review was prompted by the delays in production of the 2009 H1N1 flu vaccine and by the general perception that countermeasures development has been slow.

The HHS initiatives include, among others, improving the FDA's science capabilities, establishing advanced development and manufacturing centers for medical countermeasures, and speeding flu vaccine production by providing seed strains that grow better and improving sterility testing methods.

Sebelius said HHS released a draft solicitation this month for the proposed centers for advanced development and manufacturing and plans to issue the final request for proposals by the end of the year. The intention is that each center could produce more than one type of countermeasure, she reported.

Eric Rose, MD, co-chair of the Alliance for Biosecurity and head of a biotechnology company, defended the record of HHS's Biomedical Advanced Research and Development Authority (BARDA), the agency charged with developing biodefense tools.

Rose, who is CEO of Siga Technologies (which is developing an antiviral for smallpox) said the BARDA advanced development program is bearing fruit. He stated that while many have criticized the slow pace, their experience is that the program is leading to important novel countermeasures less than seven years, and that there is a trickle, but the pipeline is beginning to flow.

Pavia said the IDSA wants to see the countermeasures program get a consistent stream of funding. He said that we support at least $1.7 billion for BARDA for new countermeasures in 2011. He stated that this amount is well above what the Obama administration is proposing.

Considerable discussion at the hearing focused on the FDA's heavy workload and its ability to evaluate new countermeasures.

Harkin predicted that a food safety reform bill will soon pass, which will increase the demands on the FDA. He said that asking the FDA to do more, without sufficient funds or personnel will hinder the focus it needs. He suggested that the FDA may need some restructuring.

Rose had a specific recommendation to propose that FDA create a Center for Biodefense, like CDER [the Center for Drug Evaluation and Research] and CBER [the Center for Biologics Evaluation and Research]. He stated that having a full-blown center where there is a leader responsible for signing off would be valuable.
(CIDRAP 09/29/2010)

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United States: Experts cautiously optimistic on future impact of H1N1 pandemic influenza
With most Americans already possessing some degree of immunity to the 2009 H1N1 virus, the history of pandemics suggests that it's not very likely to make a big comeback anytime soon, according to three experts at the US National Institute of Allergy and Infectious Diseases (NIAID).

Writing in the online journal mBio, the experts—David M. Morens, Jeffrey K. Taubenberger, and NIAID Director Anthony S. Fauci—estimate that about 59% of Americans already have immunity to the virus, which reduces the risk of an "explosive" resurgence. While cautioning that flu remains unpredictable and poorly understood, they say the virus could even disappear.

On 28 September 2010, they stated in a perspective article that the history and current understanding suggests cautious optimism that pH1N1 will eventually adapt to stable circulation via genetic changes resulting in continuing moderate or low mortality rates or possibly even disappear entirely.

In addition, they say that the population segment that is still vulnerable to the virus is mostly people younger than 50. Those older than 50 should remain "substantially protected" if they get their annual flu shot, which this year includes the former pandemic virus.

Serologic data from the United States and elsewhere suggest that about 19% of the US population, mostly people over 55, had some protection against the novel H1N1 virus even before it was detected last year, the article says. With the addition of about 62 million people without previous immunity who were vaccinated and another 61 million who were infected during the pandemic, roughly 59% of the US population is now protected, the authors estimate.

Certain other factors, such as possible protection provided by the 1976 "swine flu" vaccine, may push that percentage even higher, they commented that a large percentage of the U.S. population must already be immune to pH1N1, reducing opportunities for explosive pandemic spread in the future.

Given this high level of population immunity, the authors look to history to assess what mutations or mechanisms might enable the virus to continue circulating. They write that the previous four pandemics—those of 1889, 1918, 1957, and 1968—suggest several possibilities.

The record of the 1889 and 1918 pandemics shows that new waves of cases are possible in completely naïve or partially immune populations after the initial wave of a pandemic. But current population immunity to pH1N1 probably already exceeds the levels achieved in the first year of past pandemics, and records from the past six pandemics indicate that there was only one "explosive recurrence," if any, the article says.

Other possible survival mechanisms explored by the authors include antigenic shift (a major change in the virus's hemagglutinin protein); viral evolution by "intrasubtypic reassortment" (ISR), leading to a minor shift in the hemagglutinin; and antigenic drift, or gradual evolution that enables the virus to avoid extinction.

History leaves many uncertainties about the potential impacts of all of these, but there are reasons to think that an ISR or even an antigenic shift to an H2 or H3 type of hemagglutinin would not have a severe impact, the authors write.

They say that the possibility of successful antigenic drift remains especially unpredictable. For example, no one knows how and why seasonal H1N1 viruses, which had disappeared with the H2N2 pandemic in 1957, reemerged in a partly immune population 1977 and have continued to circulate since then.

The articles summarizes that history suggests that pH1N1 likely faces extinction unless it mutates, either by mechanisms (such as antigenic shift or ISR) that have never been documented to occur in early pandemic years or by successful antigenic drift, whether slow (as with seasonal H1N1) or aggressive (as with H3N2). It adds that aside from population immunity, the factors driving pH1N1 evolution are poorly understood.

While finding reasons for cautious optimism, the authors advise that other postpandemic viruses have continued to cause various rates of excess mortality among younger persons for years after pandemic appearance. Therefore, everyone from the age of six months up to about 50 years will be "aggressively targeted" for vaccination this fall. (The Centers for Disease Control and Prevention now recommends flu vaccination for essentially everyone older than six months.)
(CIDRAP 09/28/2010)

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2. Infectious Disease News

Asia
Australia (Queensland): TB outbreak at Treasury Casino
Queensland Health’s Tuberculosis (TB) Control Centre is providing advice to Treasury Casino after confirmation a staff member had been diagnosed with the rare illness.

Chief Health Officer Dr Jeannette Young has reassured casino visitors it was highly unlikely they might develop tuberculosis as a result of an infected staffer.

The situation poses a relatively low risk of transmission, since TB is not a highly contagious disease, Dr Young said. She said that despite the low risk, Queensland Health’s TB Control staff are working with the casino to ensure employees are fully informed of the situation,” she said. Screening and assessment clinics will be available for those casino staff identified as workplace contacts. Clinicians will screen them to determine their level of exposure to TB, and offer initial skin tests. This is the standard management protocol whenever someone is diagnosed with TB in Queensland, Dr Young said.

Dr Young said the public health screening was being done to ensure anyone who had inadvertently been exposed to TB, could have treatment to prevent them from becoming ill and exposing others.

Tuberculosis is a fully treatable disease that does affect Queenslanders, but it is extremely well managed, she said.
(The Redland Times 09/23/2010)

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Australia: Inmate with measles sparks warning
The North Coast Public Health Unit has issued a health alert after an inmate transferred from the Grafton jail to the Kempsey jail was found to have measles.

The Department of Corrective Services, Justice Health, the public health unit and New South Wales Health are working to minimize further spread of the illness. Staff and inmates who may have been exposed have been advised about symptoms of measles and some have been offered post-exposure treatment or vaccination.

Anyone who visited the jail on 27 August 2010 (Fathers Day), or the weekend of 11-12 September 2010, is advised they may have been exposed to measles.
(ProMED 09/20/2010)

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China (Tibet): Outbreak of plague
China issued a health alert in its southwestern region of Tibet after five people were diagnosed with the plague, an often fatal infectious disease.

One of the five has already died from a severe lung infection attributed to the pneumonic plague, while one other patient was in a critical condition, the Tibet health department said in a statement 23 September 2010.

The outbreak was first detected on 23 September 2010 in Latok village in Tibet's Nyingchi Prefecture, the department said.

The four patients, all of whom had contact with the deceased, have been quarantined. Disease control experts have been dispatched to the area in an effort to control the further spread of the disease, it said.

The department also issued a warning to anyone who has visited the region near the outbreak to seek immediate medical attention should they develop fever, cough or other flu-like symptoms common to the plague.

Pneumonic plague is spread by rodents like marmots, which are numerous in Tibet.

An outbreak of the disease in 2009 killed three people in Ziketan, a town in a Tibetan area in neighboring Qinghai province.

[ProMED note: Of note, in June 2005 there was an outbreak of plague in the Tibetan Autonomous Region involving five individuals. An association with handling marmots for consumption was attributed as the vehicle for transmission. At that time the reports did not specify the form of plague (bubonic vs pneumonic) but with the implementation of quarantine measures, it was hypothesized that there were pneumonic manifestations.

More information on this outbreak from knowledgeable sources in the region would be greatly appreciated.]
(ProMED 09/26/2010)

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China (Tibet): Outbreak of pneumonic plague under control
An outbreak of pneumonic plague in southwest China's Tibet Autonomous Region is under control, Tibet's Center for Disease Control said.

The outbreak was detected 23 September 2010, and the victim died from severe lung infections. Four other people in Latok Township, in China's Nyingchi Prefecture, also contracted the disease, but were in stable condition.

Latok Township was quarantined, and people leaving the area were being examined for the disease at road checkpoints. An unnamed official at the CDC said authorities are looking for more cases in Latok.

The plague's source has not been determined, and health officials were educating residents about the disease. Pneumonic plague is a lung infection, and is a rare, but deadly form of plague.

Two people died in a previous pneumonic plague outbreak in Nangxian County in September 2008.
(UPI.com 09/27/2010)

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China (Xiamen City): Conjunctivitis spread
Many people in Xiamen are suffering from viral conjunctivitis, commonly known as "pink eye," and half of the infected persons are students [i.e., school children]. Many hospitals in Xiamen admitted more than 50 infected persons every day.

Schools in Jimei District and Haicang District have canceled doing eye exercises temporarily. According to the experts, doing eye exercises may cause cross-infection among students and the peak season of "pink eye" incidence is autumn. But the epidemic can be contained if people are vigilant about personal hygiene.

A public warning has been issued by China's hygiene and disease control department about the outbreak.
(ProMED 09/21/2010)

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Russia (Krasnodar): Anthrax cases reported
Cases of anthrax both in animals and humans have been reported in Russia's southern Krasnodar territory, a spokesman for the Southern regional emergencies center told Itar-Tass on 24 September 2010.

According to the spokesman, anthrax infections have been confirmed at a dairy farm in the village of Uspenskoye. As many as 20 infected cows have already been slaughtered, and their carcasses have been burnt. Measures are being taken to prevent the spread of the disease.

Moreover, two people have been hospitalized with suspected anthrax. The health condition of 30 more farm's staff members is being monitored.

[ProMED note: Unfortunately it seems that the Krasnodar authorities slaughtered the cows if sick. Treatment with oxytetracycline can save them, maybe not all, but it would aid herd reconstruction. Neither OIE nor ProMED-mail has carried reports from Krasnodar in the last ten years.]
(ProMED 09/24/2010)

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Russia (Moscow oblast): Hemorrhagic fever with renal syndrome
During the first half of 2010, ten cases of hemorrhagic fever with renal syndrome (HFRS) were recorded in the Moscow Oblast. This is three times more than during the same period in the preceding year. In seven of these ten cases, rodents were confirmed as the source of the infection. Concern has been expressed by some medical authorities about the possibility of an epidemic in the oblast.

[ProMED note: HFRS is caused by the hantavirus species Puumala virus, carried by the bank vole (Myodes glareolus). This virus is widespread across most of Europe, except for the UK, the Mediterranean coastal regions and the northernmost areas. Other hantaviruses occur in Europe, but have lesser public health importance.
(ProMED 09/26/2010)

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Thailand: Hand, foot, and mouth disease
The Ministry of Public Health has ordered the provincial public health offices to monitor the spread of hand-foot-mouth disease (HFMD) after over 10,000 patients have been infected in 2010.

According to Deputy Public Health Minister Dr Phansiri Kullanartsiri, a change from the rainy season to the winter has provided a climate suitable for HFMD spread. Ninety percent of the patients are infants aged less than five due to their low immunity. Besides, no vaccine is currently available to immunize them.

According to the recent statistics provided by the Epidemiology Bureau, there have been 10,684 patients suffering from HFMD since January 2010, with no fatalities reported. This figure is one-fold more [2-fold?] than during the same period in 2009.

HFMD usually spreads in places where groups of children play or study together; therefore, one infected child can spread the disease to others very easily. The disease can be transmitted via mucus, saliva, wounds, and feces of infected patients. Key spots to monitor are kindergartens, infant care centers, nurseries, swimming pools, as well as indoor and air-conditioned playgrounds in department stores. Entrepreneurs are hence requested to sanitize their premises on a daily basis to help protect infants from the disease.

[ProMED note: Previously hand-foot-mouth disease was reported in Phuket province of Thailand. According to the Thai Ministry of Public Health, Bureau of Epidemiology's (BOE) report on cases and deaths of diseases under surveillance by province, Thailand as of week 37 (12-18 Sep 2010), the cumulative number of HFMD cases in Thailand was 11,298 cases with one death in 2010, which was higher than the number of cases during the same period in 2009 (6172 cases). The median of cumulative number of cases between 2005 and 2009 was 4150 cases. However, the number of HFMD cases during week 37,2010 (64 cases) was less than that reported in the same period of 2009 (183 cases). The median of cases during week 37 between 2005 and 2009 was 143 cases.

According to the report, infection seems to be mild; only one fatality was reported among 11,298 cases of HFMD. It is likely, therefore, that the infections were not caused by enterovirus 71, which in previous outbreaks elsewhere has been associated with serious disease.]
(ProMED 09/28/2010)

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Thailand: Suspected mumps outbreak
On 24 September 2010 officials from disease control unit of Si Sa Ket's public health office and Khukhan hospital went to investigate students in Si-sa-ard wittayakhom school in Khukhan district after 25 students sought medical treatment with symptoms of fever, cheek pain, runny nose and sore throat at Ban Ta Kien Bang He Health Center.

Officials found that around 100 cases are suspected mumps. Cases are suffering from high fever, runny nose and sore throat. Among cases, 55 cases are students, two cases are teachers, one case is caretaker and 14 cases are parents. In the meantime, blood tests are randomly collected in 10 students, three parents and three teachers for the laboratory test.

Mr. Sunthorn Kumarijit, director of Si-sa-ard wittayakhom school, said that there are total 373 students, 26 teachers and two caretakers in this school. The service area of school covers four villages. The number of suspected mumps cases has increasing since the week of 20 September 2010.

[ProMED note: In Thailand, mumps vaccine (Urabe strain) has been introduced into national immunization program via MMR vaccine since 1997. One dose of MMR vaccine is routinely given to children at their first year of elementary school. A recent study showed effectiveness of MMR vaccine is 73 percent.

According to the Thai Ministry of Public Health, Bureau of Epidemiology (BOE)'s report of the situation of mumps infection in Thailand, between 1 January 2010 and 18 September 2010, a total of 12,253 cases were reported nationwide. No death was reported. The attack rate was 19.29 per 100,000 population. The highest percentage of cases was reported in the 10-14 years old age group (15.32 percent), followed by the 7-9 years old age group (10.94 percent) and 15-24 years old age group (10.90 percent).

The five provinces with the highest attack rates of mumps (per 100,000 population) were Buriram (70.99), Mukdahan (70.40), Tak (62.54), Mae Hong Son (62.44) and Chiang Rai (51.97). Highest attack rates were reported in northern region (26.81), followed by northeastern region (24.66), southern region (16.44) and central region (10.95).

PRO/MBDS would highly appreciate further information from knowledgeable sources about the investigation and results of laboratory test of etiologic agent that responsible for this outbreak.]
(ProMED 09/26/2010)

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Americas
Chile: Hantavirus cases forty percent higher than in 2009
After four years during which it seemed that hanta infections were controlled, based on the low number of cases, the situation has again become relevant to public health. As of 26 September 2010, there are 49 people infected with the virus, a figure greater than what is expected for this period, according to the Ministry of Health (MINSAL) epidemiological report. Of these, 17 died.

Given this, the authorities issued an alert to the assistance network. During the fall and winter of 2010 an expected seasonal increase will begin for hantavirus.

The chief of Epidemiological Surveillance of MINSAL, Maritza Garcia, explained that although the numbers are still lower than those registered in an epidemic year (in 2001 there were 81 cases), mortality is high and represents 35 percent of infections. This increase in case numbers is due to an increase in the rodent population that transmits the virus (the long-tailed pygmy rice rat Oligoryzomys longicaudatus). If 2010 is a year of more rain, if the quila plants [a perennial bamboo that grows in the humid temperate forests of Chile and Argentina] are flowering more or if there is greater availability of grain, on which the rodents feed, the disease spreads more.

She also added that when the disease incidence decreases, people tend to relax their preventive measures, which also affects the risk of infection.

The regions where the most cases have occurred are Biobio (14 cases) and Maule (9). The Biobio health SEREMI [Regional Ministerial Secretariat] epidemiologist, Cecilia Soto, said that 93 percent of the infected individuals are males. The environmental conditions are by far an important factor, such as firewood collection, Osvaldo Palma, of the Maule health SEREMI, said. On the other hand, the earthquake, after which many families decided to remain living in their destroyed houses, in 2010 there was not a substantial increase in cases."

[ProMED note: Cases of infection by a hantavirus continue and are increasing in this region of central Chile. Although not stated, the hantavirus involved in this and previous cases doubtless is Andes virus.]
(ProMED 09/26/2010)

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Mexico (Guerrero): Conjunctivitis cases
So far in 2010, Guerrero has reported 9,000 cases of conjunctivitis due to changes in temperature and rainfall, said the director of the State Institute of Ophthalmology, Pablo Vargas Mendez. He said the Costa Grande region is highest in cases of conjunctivitis, as there have been 450 cases per month of patients with this disease. He said that 50 percent of cases are found in Acapulco, with the rest in the region of the Costa Grande, Chica and the center of the state.

He explained that although it is a disease that does not have serious implications, nevertheless people should take measures to prevent transmission to others. He also recommended avoiding touching the eye area with unwashed hands, and, if infected with the disease, avoiding shaking hands. He asked people who suffer from the disease to not self-medicate or use home remedies, because they can generate a stronger infection.

[ProMED note: The three most common types of conjunctivitis are 1) viral, 2) bacterial, and 3) allergic. It is presumed that the outbreaks of conjunctivitis in the coastal states of Colima and Guerrero are consequences of viral infection, but this is not clearly stated in either report.]
(ProMED 09/19/2010)

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Mexico (Tamaulipas): Conjunctivitis outbreak
The state health secretary, Juan Guillermo Mansur Arzola, confirmed an outbreak of hemorrhagic conjunctivitis, with 7000 cases localized in the central region of the Mexican state of Tamaulipas.

We had an outbreak of conjunctivitis with 7,000 cases of the hemorrhagic type, which is now under control, said Mansur. The state secretary said they are alert, and that with the necessary measures, conjunctivitis has no consequences, because it is a rapidly self healing disease if lubricants are applied. There have been no consequences, he said.

[ProMED note: Another coastal state in Mexico, this time on the eastern coast, is being afflicted by an outbreak of conjunctivitis. Within the past few days, outbreaks of conjunctivitis have been reported in the states of Collima and Guerrero on the west coast of Mexico.]
(ProMED 09/22/2010)

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Peru: Five deaths caused by rabies infections
At present, five children from the indigenous communities Awajun and Wampis have died in Peru due to rabies spread by vampire bats, according to information issued by the Ministry of Health.

This case brings the total number of fatalities of this outbreak to 20.

Fernando Borjas, a local health official said that some 3,500 people had been bitten by these vampire bats, and warned that there are not enough vaccines in the affected areas since those are located in remote places.

To make matter worse, some indigenous people were reported to have refused treatment.

Vampire bats usually feed on animals, but sometimes, if possible preys become scarce, may attack humans, especially when their habitat has been destroyed.
(Living in Peru 09/23/2010)

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United States (California): Outbreak of whooping cough mirrors challenges in developing world
The outbreak of whooping cough in Texas, California, and other states in 2010 underscores the critical importance of widespread vaccination coverage, both locally as well as around the world, said a leading global health official attending conferences on world affairs and immunization in Fort Worth the week of 27 September 2010.

Alex Palacios, a special representative of the GAVI Alliance, a public-private partnership aimed at increasing immunization rates in poor countries, said that despite public health advances in the US and other wealthy countries over the last 60 years, regular diseases that have all but been eradicated can still threaten lives if immunization rates fall.

Whooping cough, diphtheria and diseases that some of us don't even recognize anymore are not gone forever. They are widespread in developing countries and do also arise here in the US, said Palacios. It is important that vaccine-preventable diseases are kept under control no matter where they crop up, whether it be in Texas or in Kenya. Diseases don't recognize borders.

Last year, 3,358 Texans had whooping cough, also known as pertussis, and three of them died. It was the highest number of cases in a half-century. So far this year, Texas has reported 1,783 cases. California has at least 4,017 cases of the highly infectious disease and is on track to break a 55-year-old record. Ohio has reported 1,019 cases. In contrast, in Kenya last year, there were an estimated 1,900 deaths due to pertussis; 7,500 deaths to rotavirus, a diarrheal disease; and 36,000 deaths due to pneumonia and influenza.

Anna Dragsbaek, President and CEO of The Immunization Partnership, said that Texans should be concerned about outbreaks of vaccine-preventable diseases anywhere in the world.

As long as there is polio and other vaccine-preventable diseases in the world, outbreaks are only a plane flight away, she said. It may seem like it's safe to be complacent. But in actuality, diseases such as whooping cough and measles arise only because we have been complacent. We are still all at risk because not enough people are immunized worldwide. The health of people in developing countries matters to Texas.'

Vaccination of children and adults can prevent pertussis. The pertussis vaccine is given along with diphtheria and tetanus vaccines in the same shot (called DTaP) for children. DTaP cannot be given to babies less than six weeks old or to anyone seven years of age or older. After that, children and adults are given a booster shot.

Experts say that the lack of vaccine coverage among adults in the US is the main reason for the upsurge in the last two years of whooping cough. Infants, who are too young to be fully immunized against the illness, are at particular risk. Health officials recommend that parents and caretakers receive booster shots to extend their immunity to the disease and lower the risk to babies.

Palacios and Dragsbaek will speak on the global state of immunizations at the Texas Immunization Summit 2010 in Fort Worth on 30 September 2010, hosted by The Immunization Partnership and sponsored by St. David's Foundation. Palacios will give a keynote address over lunch on "The Global Health Equity Challenge: New Vaccines Against Pneumonia and Rotavirus" on 1 October 2010. He will also be speaking at a World Affairs Council of Dallas/Fort Worth event on "Saving the Future: Global Efforts to Reduce Child Mortality" on September 30th.

The week of 20 September 2010 at the United Nations Summit on the Millennium Development Goals in New York City, global political leaders endorsed immunization of the world's children as one of the priorities to saving lives and improving health.

Palacios, who attended the UN Summit, said people everywhere, including in the United States, will be affected by the outcome of discussions about stopping vaccine-preventable diseases around the world.

There is the potential to save four million lives over the next five years if we can immunize a significant number of the world's poor children against the two biggest childhood killers: pneumonia and diarrhea, he said.

He noted that the GAVI Alliance requires $4.3 billion in order to introduce the vaccines.

In its first 10 years, with funding from the Bill & Melinda Gates Foundation and the United States and other nations, GAVI has helped to deliver vaccines to more then 250 million children, an investment that is expected to save 5.4 million lives in the poorest nations.

In the last decade, despite the progress of developing countries in using more childhood vaccines, an estimated eight million children died from pneumococcal disease, a leading cause of pneumonia and meningitis, and five million children died from rotavirus, the major cause of severe diarrhea among young children that is most deadly in poor nations. Experts predict that the introduction of the two vaccines can eventually save the lives of one million children per year.

Vaccines are great value for money, and their impact is measured in the number of children whose lives we can save, said Palacios.
(The Medical News 09/29/2010)

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United States (Indiana): Pertussis infections reaching highest rate since 1986
State health officials say Indiana is on track for the highest number of pertussis infections since 1986, mirroring a national trend in the escalation of the highly contagious respiratory disease better known as whooping cough.

Health experts say the rise in reported cases may be due in part to better diagnostic testing. But they also point to the number of children who may not have been vaccinated against the disease as well as the number of teenagers and adults who’ve failed to get the booster shots designed to keep their immunity from waning.

Infants are the most vulnerable and they can die from the disease, said Dr. John Christenson, director of Pediatric Infectious Disease at Riley Hospital for Children in Indianapolis. But teenagers and adults serve as the vectors for the disease, transmitting it to infants who have no immunity.

As of mid-September, the number of whooping cough cases reported to the Indiana State Department of Health for 2010 had surpassed 390, close to the total number for 2009.

Epidemiologist Angie Cierzniewski of the Indiana State Department of Health said health experts are fighting the misconception that whooping cough had been nearly eradicated.

People think it went away with polio and measles, Cierzniewski said.

It came close, according to the Centers for Disease Control and Prevention. Before the first pertussis vaccine was introduced in the 1940s, whooping cough infected more than 160,000 Americans a year and killed about 5,000.

By 1976, the number of cases nationwide had dropped to 1,010 a year, due to what experts say was the widespread use of the vaccine. But the numbers have increased tenfold since. In California alone, there have been more than 4,000 cases reported this year; including nine infants who’ve died — most of them after being misdiagnosed initially.

California public health officials cite concerns similar to those voiced by Indiana public health officials, including difficulty in tracking who has been immunized.

Immunizations may be one factor why officials at the Clark County Health Department say they have not seen a major spike in cases reported.

We really haven’t noticed a large number of people with whooping cough said Bridget McCurdy, Clark County public health nurse.

McCurdy said she knows of three cases of whooping cough reported in 2009 and of only one reported so far in 2010. Because the disease is vaccine-preventable she said the state tracks the numbers and there could be additional cases of the disease reported in the county of which she is not aware.

I guess we’ve been lucky more than anything, she said. I don’t think we’ve done anything far beyond anyone else.

The Clark County Health Department has, and does, offer vaccinations for pertussis at its clinic for a requested donation of $2. The vaccine is also available through most family physicians.

A separate vaccine offered through the health department may be helping to prevent the instances of the disease from showing up locally.

An immunization program that started in 2009, which requires tetanus shots for sixth through 12th grade students, also contains a component that protects against whooping cough.

McCurdy said the pertussis vaccine is recommended for those who may have or care for an infant or if they have not been immunized in five years.

Indiana has a state law that requires students starting school to provide proof that they are up-to-date on their immunizations for whooping cough as well as polio, diphtheria, tetanus, measles, mumps, rubella, hepatitis B and chickenpox — or show evidence they’ve had chickenpox.

A new state law also requires vaccinations against meningitis, a second chicken pox shot and an updated shot inoculating children against whooping cough, diphtheria and tetanus. Exemptions are granted only for religious or medical reasons.

But during the 2009-10 school year, there were some counties in Indiana where more than 20 percent of kindergarten students had no records of their immunizations, according to the state health department.

It’s a state law, but it’s really up to the school districts to enforce it, Cierzniewski said. There are some schools that have so many students without immunization records that if they enforced the law, they wouldn’t be able to have school — there wouldn’t be enough students to attend.

That’s a scenario for trouble, warned Christenson. A lot of epidemics start when someone with the disease comes into a community with an under-immunized population.
(News and Tribune 09/26/2010)

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3. Updates
INFLUENZA A/H1N1
- WHO
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions: http://www.who.int/csr/disease/swineflu/frequently_asked_questions/en/index.html
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
http://www.who.int/csr/disease/influenza/pipguidance2009/en/index.html
International Health Regulations (IHR) at http://www.who.int/ihr/en/index.html

- WHO regional offices
Africa: http://www.afro.who.int/
Americas: http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=805&Itemid=569
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Europe: http://www.euro.who.int/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: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promedmail.org/

Pandemic (H1N1) 2009 press briefing:
http://www.who.int/mediacentre/multimedia/swineflupressbriefings/en/index.html

WHO H1N1 pandemic influenza update 115:
http://www.who.int/csr/don/2010_08_27/en/index.html

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AVIAN INFLUENZA
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza H5N1.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help health officials prepare for an influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.flu.gov/. “Flu Essentials” are available in multiple languages.
- CIDRAP: Avian Influenza page: http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- Link to the Avian Influenza Portal at:
http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on avian influenza H5N1 in wild birds and poultry.

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VECTOR-BORNE DISEASE
WHO Statement
Warning regarding surge in dengue cases in Asia: http://www.wpro.who.int/media_centre/press_releases/pr_20100916.htm
(WHO 09/16/2010)


Dengue fever prediction market invitation
The Iowa Electronic Health Markets (IEhM) at the University of Iowa invites you to participate in a project designed to forecast dengue related events. Perspectives from health experts like you will contribute to prediction of future disease trends.

The project is funded by the Robert Wood Johnson Foundation's Pioneer Portfolio. Additional information can be found at the project website at http://iehm.uiowa.edu.


Australia
An outbreak of dengue fever in Cairns has doctors concerned it could foreshadow a bad season for the mosquito-borne disease. Four people from the suburb of Parramatta Park have tested positive to dengue, and another eight are awaiting test results, Queensland Health medical director Dr Jeffrey Hanna said. More confirmed cases of dengue type 2 are expected, he said. And there are concerns the disease will be spread by travelers setting out from the far north.
(ProMED 09/27/2010)


China
A case of locally-acquired dengue fever, involving a 46-year-old man, was confirmed in Hong Kong, which was the first locally acquired case in seven years, the Center for Health Protection under the city's Department of Health said 22 September 2010. A spokesman with the Center for Health Protection said the Department of Health was highly concerned about this case of locally-acquired dengue fever infection since the last local dengue fever outbreak in Hong Kong occurred in 2002. We are working with the Food and Environmental Hygiene Department closely to make an all-out effort to assess if there is any spread of the infection, contain the infection, and prevent the spread, he said.

A total of 61 cases of dengue fever [60 imported] has been reported to the Center for Health Protection in Hong Kong so far in 2010. There were 43 cases in 2009, and all of them were classified as imported.
(ProMED 09/27/2010)


Chinese Taipei
Concern grows over the worsening dengue situation in Kaohsiung City. That was the word from Health Minister Yaung Chih-liang on 26 September 2010. Dengue fever is raging in Kaohsiung, with 227 cases reported so far in 2010. Yaung is visiting the southern city to review the epidemic prevention work there. Yaung said that in addition to the indigenous cases in the city, there has been an increase in the number of imported cases of dengue.

He said those were mainly from Southeast Asian countries. Yaung also said the department is considering rewarding those clinics that cooperate on the matter and punishing those that fail to follow the reporting policy.

Yaung also said people should use well-made mosquito nets and that they should empty containers of standing water.
(ProMED, Radio Taiwan International 09/26/2010, 09/27/2010)


India (Delhi)
Dengue continues to surge in the national capital, with 95 more cases being reported 26 September 2010, taking the total number of people infected with the mosquito-borne disease to 2,916, an official said. This year, five people have succumbed to dengue in the capital, including one from outside Delhi, a Municipal Corporation of Delhi (MCD) official said.

[ProMED note: Since patients coming to private clinics and hospitals may not be reported officially, this number is probably a significant under-estimate of the actual number of cases.]
(ProMED 09/27/2010)


India (Bihar)
In the Munger district of Bihar, six people have died so far due to the outbreak of dengue, while 518 others have tested positive, official sources said 22 September 2010. Unofficial sources have, however, claimed that the number of casualties due to suspected mosquito-bred fever stands at 27. As many as 518 out of 1,361 people diagnosed for symptoms of the dengue fever have tested positive, officials said.
(ProMED 09/27/2010)


India
Now adding to its woes, chikungunya has made a comeback in the national capital. The city reported six new cases of the viral disease on 22 September 2010, taking the total number of cases in Delhi to eight. As per the report released by the Municipal Corporation of Delhi (MCD), the figure in 2009 was zero. According to health department officials, the vector which carries dengue is also responsible for spreading chikungunya.

The cases were reported from the Palam area in outer Delhi. They were initially reported to Public Health Centre Palam. A medical team from Lady Hardinge Medical College (LHMC) took the samples and found them to be positive.

MCD has deployed a number of specialists to find the source of the disease. We have deputed a team of entomologists and epidemiologists to find the source of infection. They will take appropriate action to check breeding of mosquitoes and elimination of adult mosquitoes in the area. Chikungunya virus also spread by the vector Aedes. But the virus is different from dengue, said Dr V K Monga, chairman MCD.

[ProMED note: The transmission of chikungunya virus in Delhi, along with dengue virus, is not surprising. India is endemic for both viruses, and apparently Delhi has an abundance of Aedes mosquito vectors, which are transmitting both viruses. Since there is no commercially available vaccine for either of the viruses, the only feasible control measure is vector control, with emphasis on eliminating breeding sites in and around buildings. The appearance of chikungunya virus infections is not good news for the upcoming Commonwealth Games, which is suffering infrastructure problems as well.

With just five days left for the Commonwealth Games in Delhi, the city continued to grapple with a dengue outbreak as cases of the vector-borne disease reached 3013 after 97 more patients tested positive. The capital has reported five dengue deaths this season. South Delhi continued to be worst-affected this season recording 437 cases, followed by MCD Civil Lines Zone (392), Rohini (354) and Central Zone (337). The civic bodies are attributing the rapid increase in dengue cases this season to prolonged monsoon and stagnation of water at Commonwealth Games construction sites.

The dengue outbreak has also raised concern among several countries which are sending teams to participate in the Games to be held October 2010. India has issued a health advisory for participants and visitors coming for the event asking them to take precautions like carrying full-sleeve clothes and bringing mosquito repellent creams, oils, mats or coils. The government yesterday sought to play down concerns over dengue during the Games saying the prevalent variant of the mosquito-borne disease was not very dangerous. Dengue count in the country is still low. The type of vector-borne disease is subtype 3, which is not very dangerous, Union health minister Ghulam Nabi Azad had said.

The current outbreak was first reported in mid-July 2010 and has been steadily increasing ever since. Declaring that dengue virus 3 is "not very dangerous" is not supported by the facts. The hospitalized cases and the families of the five fatal cases in Delhi would certainly not agree with that statement. The dengue virus 3 Asian subtype has been especially virulent in South and Central America, although its genetic relationship to the dengue virus 3 currently circulating is Delhi is not known.]
(ProMED 09/29/2010)


Indonesia
It seems that dengue fever is still a serious threat for Central Jakarta residents, especially with the recent transition weather happening. Evidently, the number of dengue cases in Central Jakarta area from January-September 2010 reached 1,565 cases, and from 1-20 Sep 2010, 260 dengue cases have been recorded.
(ProMED 09/27/2010)


Malaysia
Malaysia said 20 September 2010 its dengue fever death rate spiraled 53 percent in 2010, but backed away from a controversial trial of releasing genetically modified mosquitoes to wipe out the disease.

There was a major rise in deaths due to dengue fever, with 107 deaths so far in 2010, compared to 70 deaths for the same period in 2009, said deputy premier Muhyiddin Yassin.

Muhyiddin said the majority of the deaths could have been avoided, and urged the public to take action to eradicate the Aedes aegypti mosquitoes from their homes and workplaces. We have identified 19 hotspots throughout the country where the disease is prevalent, and action is being taken to tackle the situation in these areas, he said.

However, Muhyiddin was cool on a plan to release genetically modified male mosquitoes designed to combat dengue fever, in a proposed landmark field trial that has come in for criticism from environmentalists. In the first experiment of its kind in Asia, 2,000-3,000 male Aedes aegypti mosquitoes were to be released in two Malaysian states in October or November 2010 if the plan had won government support. The insects in the study have been engineered so that their offspring quickly die, curbing the growth of the population in a technique researchers hope could eventually eradicate the dengue mosquito altogether. Muhyiddin said the project would not be implemented "at the moment." The field trial for the GM anti-dengue mosquitoes was developed by a British-based insect bio-tech company, Oxitec, and was to be undertaken by Malaysia's Institute for Medical Research, an agency under the health ministry.

[ProMED note: It appears that Oxitech is applying the sex-specific alternative splicing in insects to engineer female-specific autocidal genetic systems developed in the Mediterranean fruit fly, Ceratitis capitata to Aedes aegypti. It will be interesting to see what the results are of this approach to dengue vector control if and when field trials are carried out. Success would likely depend on the released, genetically modified male mosquitoes being able to survive in nature and compete with wild males for mating with wild females.]
(ProMED 09/27/2010)


Mexico
The dengue outbreak remains at 1,668 cases, of which 30 percent are hemorrhagic, although for now a reoccurrence of the outbreak cannot be considered to exist, nor have cases doubled, so that one hopes to continue in a more or less stable trend even with the contingency of increased rains.

[ProMED note: The occurrence of 30 percent of DHF of the total dengue cases is unusually high. Either the classification of DHF cases is in error, or there is serious underreporting of non-DHF dengue cases.]
(ProMED 09/27/2010)


Philippines
The Department of Health on 28 September 2010 said it has recorded a total of 90,771 dengue cases since January 2010 even as it noted that dengue incidence has started decreasing.

The DOH said reported dengue cases have dropped from an average of 7,285 cases per week in August 2010 to only 2,740 cases per week in September 2010.

It noted that the disease only has a 1% mortality rate.

The health department said dengue incidence has decreased in Central Visayas, Eastern Mindanao and Ilocos region except La Union.

Dengue cases are still rising in Caloocan, Manila and Quezon City, the DOH added.

Militant groups, meanwhile, chided the national government for its slow response to the dengue outbreak.

They said the government should increase the health budget to P90 billion to facilitate the purchase of more medicine and medical equipment to combat dengue.

Dengue fever is an acute illness caused by a bite of a striped Aedes aegypti mosquito. In the Philippines, dengue usually occurs during the rainy season, or from June to September.

The DOH earlier devised a strategy to educate the public on home treatment of mild dengue cases in an effort to decongest hospitals.
(ABS-CBN News 09/29/2010)


Philippines
Dengue cases in Iloilo province have now reached 4825 with 27 deaths as reported by the Iloilo Provincial Health Office from 1 January - 18 September 2010. Of the total dengue cases, the number of patients confined in the 12 provincial and district hospitals in Iloilo for the month of September 2010 alone starting 19 August 2010 is 32.
(ProMED 09/27/2010)


Philippines
Swimming pools in the Philippines' richest neighborhoods could be partially to blame after tens of thousands of people were struck down in a dengue fever outbreak, health authorities said 24 September 2010.

Caused by a mosquito-borne virus that inflicts an influenza-like illness, dengue is an annual scourge during the country's wet season, with residents of Manila's slums usually comprising many of those affected.

However health authorities at the Manila suburb of Muntinlupa suspect that the carrier mosquitoes could be breeding at swimming pools in Ayala Alabang, home to some of the wealthiest Filipinos, said surveillance chief Romeo Javier.

These mosquitoes don't make a distinction between rich or poor, Javier said, adding that dengue cases have also been reported even in the affluent enclave.

Local health authorities have formally notified the city mayor about the issue, the city health official added.

The leafy, gated community of Ayala Alabang sprawls over nearly 700 hectares (1,729 acres) of southern Manila. The area's housing association could not be reached for comment. An official said they are checking the untended pools of houses of deceased owners or properties that have been foreclosed by banks.

June Corpuz, a staff member at the health ministry's National Epidemiology Center, said it was plausible that the mosquito species that spreads the virus could be breeding in swimming pools found in the homes of the rich. She said they can lay eggs in any type of clear water.

She said the ministry had monitored 84,023 cases of dengue up to 11 September 2010, already double the cases for 2009.

The disease can lead to a potentially deadly complication called dengue haemorrhagic fever.

The health ministry said 2010’s death toll has topped 500, compared to 369 for the whole of 2009.

The World Health Organization said dengue incidence has risen dramatically around the world in recent decades, with two-fifths of the global population at risk.

Southeast Asia and the Western Pacific are considered the most seriously affected.
(Agence France-Presse 09/24/2010)


Russia
This year about 16,000 people in the Chelyabinsk oblast reported being bitten by ticks in its forests and 74 of them were diagnosed with tick-borne encephalitis (TBE). Although the numbers are 8.6 percent lower than during 2009, the risk of TBE virus infection is considerable.

Scientists have reported that ticks of the Dermacentor genus have become more active recently. They advise that the autumn is the optimal time for immunization against TBE virus infection, since the high risk season is from Spring to Summer and protective immunity takes some time to develop. It is planned this autumn to immunize more than 30,000 1st-grade pupils in the Chelyabinsk oblast.

[ProMED note: Tick-borne encephalitis is caused by a virus (genus Flavivirus, family Flaviviridae) which includes subtypes. TBE has become a growing public health challenge in Europe and other parts of the world. The number of human cases of TBE in all endemic regions of Europe has increased by almost 400 percent in the last 30 years; the risk areas have spread and new foci have been discovered.

The Chelyabinsk Oblast (Region) is located at the boundary between Europe and Asia in the southern Ural mountains. It is situated in the watershed of the Volga, Ural and Tobol rivers. Chelyabinsk Region has nearly 3,170 lakes and a variety of therapeutic springs and mud baths. In fact the Chelyabinsk Oblast is highly industrialized and ranks 5th in Russia in terms of industrial output.]
(ProMED 09/25/2010)


Russia
A woman in Chelyabinsk has contracted West Nile [WN] virus infection without any travel history out of the province. She was hospitalized several days ago with headache and fever. At first, doctors suspected meningitis; however, the diagnosis was rejected later on. Samples were taken for testing for any neurotoxic infection, and the results for West Nile virus infection were positive. This case was the first in the region in all history.

Currently, the specialists are trying to estimate the probability of more cases, and the government is discussing the need for screening of humans, birds and mosquitoes.

There were 448 registered West Nile virus infection cases in Russia between 7 July-15 September 2010, six of which were fatal. The most of cases happened in Volgograd, Rostov and Voronezh oblasts, with only few cases in Krasnodar krai, Kalmikia republic, Astrakhan and Chelyabinsk oblasts. The most affected age group are the elderly, and the peak of morbidity came during the last two-thirds of August 2010.

[ProMED note: These WN virus infections in people are scattered around southwestern Russia. If the decision is made to screen birds and mosquitoes, the results would be of interest.]
(ProMED 09/21/2010)


Thailand
Public Health Minister Jurin Laksanawisit stated that from January - 11 September 2010, the numbers of patients infected by dengue fever were at 75,852 with 87 deaths. Most patients were found in Northeastern provinces, followed by the Central, Southern and Northern regions.

However, the Minister said the number of dengue fever patients in the South was already reduced, but the North and Northeast still needed to be closely monitored. The Ministry has also instructed all related agencies to report the progress of problem-solving continuously.

Relevant agencies nationwide are ordered to educate the people on preventive measures against dengue fever to control disease outbreaks in each area.

[ProMED note: According to the Thai Ministry of Public Health, Bureau of Epidemiology's (BOE) report of the situation of dengue infection in Thailand, between 1 January 2010 and 10 September 2010, available in Thai, a total of 75 852 cases and 87 deaths were reported nationwide. The attack rate was 119.53 per 100 000 population. The case fatality rate was 0.11 percent. The highest percentage of cases was reported in the 15-24 years old age group (27.5 percent), followed by the 10-14 years old age group (25.1 percent), 5-9 years old age group (16.7 percent) and 25-34 years old age group (11.8 percent).

In the last four weeks, the ten provinces with the highest attack rates of dengue infection (per 100 000 population) were Phayao (65.9), Chiang Mai (51.0), Songkhla (31.6), Narathiwat (31.5), Phatthalung (31.3), Petchabun (27.6), Rayong (27.1), Tak (26.9), Lopburi (25.3) and Surin (24.8).]
(ProMED 09/27/2010)


United States (Florida)
We would like to provide a correction to the PAHO dengue alert recently published in ProMED-mail that erroneously reported both dengue 1 and dengue 3 virus circulation in Monroe County, Florida. This is not the case; dengue 1virus has been the only dengue serovar detected in multiple samples collected in Monroe both in the fall of 2009 and since re-emergence or re-introduction in March of 2010.

Dengue 3 serovar was identified by the Florida Department of Health Bureau of Laboratories in a single patient from Broward County, Florida several weeks ago (patient onset date was 1 August 2010). Since that time no further locally acquired cases have been identified in Broward even following initiation of active surveillance conducted by the Broward County Health Department. Broward County does not directly border Monroe County.

We thank PAHO for quickly correcting their report and webpage once we alerted them to the error. The Florida Department of Health Bureau of Environmental Public Health Medicine weekly arbovirus surveillance reports include all confirmed human and veterinary arbovirus cases as well as positive results from sentinel chickens and may be viewed at http://myfloridaeh.com/medicine/arboviral/Weekly-Summary.html

[ProMED note: ProMED-mail thanks Dr Stanek for bringing this correction to our attention. The failure to detect ongoing dengue virus transmission of dengue virus 3 in Broward County is good news, indeed.]
(ProMED 09/15/2010)


United States (New Mexico)
Two more cases of West Nile virus have been confirmed in Doña Ana County, according to the New Mexico Department of Health. That brings to five the total number of county residents who have been afflicted with the virus, carried by mosquitoes.

Altogether, 13 cases of West Nile have been reported across the state. Doña Ana County has the most confirmed cases, with San Juan County following with four. Chaves, Curry, McKinley and Eddy counties have reported one case each.

Ten of the patients had the more serious West Nile neurological disease, including meningitis and encephalitis, and were hospitalized. Three of the cases had the less severe West Nile fever. All cases have survived and are recovering.

Also, state Health Department officials said three blood donors with no symptoms tested positive for the virus, indicating they had been infected with the virus but have recovered. The blood donors were in Doña Ana, Chaves, and Lea counties.

Mosquitoes collected from local mosquito control programs have also tested positive for West Nile Virus from Bernalillo, Cibola, and Doña Ana counties.
(Las Cruces Sun-News 09/29/2010)


United States (Pennsylvania)
A record number of mosquitoes tested positive for West Nile virus in Pennsylvania in 2010 because of the early onset of high temperatures in the spring, coupled with a more vigilant monitoring program.

The Pennsylvania Department of Environmental Protection said 990 mosquito samples have tested positive for the virus in 2010, which is higher than the previous record of 954 positive mosquito samples discovered in 2003.

West Nile virus is a mosquito-borne disease that can cause encephalitis, a brain inflammation. The virus is spread to birds, animals and humans through the bite of a mosquito.

The higher numbers are the result of a combination of factors, said DEP spokesman John Repetz.

We had a very warm spell back early in the spring. That allowed the mosquitoes to emerge a little bit earlier than usual, Repetz said. Combine that with the fact that there was an early emergence of the virus; it was detected earlier. If you have more mosquitoes acting at an earlier date and there is a presence of the virus at the earlier point, you are going to have an increased number as the year goes along.

In addition, the DEP and West Nile surveillance staff in each county have learned over the past ten years how to better detect the virus.

We aren't just placing traps out there at random. We have nine or ten years of data to go on, Repetz said. We are targeting those areas specifically. We're actually placing traps in areas where we suspect there is a greater chance of that happening. It kind of adds up to the increased numbers for this year.

While West Nile has been detected in 36 of Pennsylvania's 67 counties this year, Repetz said that statistic is misleading.

Back in 2003, when funding was available for monitoring staff in each county, the virus was detected in every county. This year, only 28 counties had staff available to conduct full-time, routine surveillance, roughly two to three nights per week, Repetz said.

In the other counties, DEP has been conducting the monitoring about once or twice a week.

If all counties were monitored at the 2003 levels, we would expect the number of positive mosquito samples to be higher, Repetz said.

Last year, 279 mosquito samples tested positive for the virus.

There is good news, however. In 2003, 237 human cases of West Nile were reported. In 2010, 13 cases have been reported. Of those, two have been confirmed by laboratory tests so far, according to the Pennsylvania Department of Health. There were no confirmed West Nile cases in 2009.

Most humans who contract West Nile suffer flu-like symptoms that typically last only a few days and do not cause any long-term health effects. But some people experience the more severe form of the disease, which impacts the brain, and can cause stupor, coma and even paralysis.

All of the human cases in 2010 have been reported in central and eastern Pennsylvania counties.

In this region, West Nile has been detected in mosquitoes or the birds they infect in Westmoreland, Indiana, Allegheny and Lawrence counties.

Westmoreland's positive avian West Nile test, revealed in a dead blue jay found in Youngwood, marks the first positive in the county since 2006.

Westmoreland West Nile virus coordinator Lisa Stipp said she continues to trap mosquitoes in areas known for positive West Nile tests. When standing water is found, Stipp uses a larvicide to kill mosquito larvae before they can grow.

She said homeowners seem to have become more cognizant of removing pools of standing water since monitoring began in 2000.

It seems like a lot of people are aware now to not leave their gutters clogged to provide standing water," she said. It has been helpful in that sense.

More West Nile positives are expected, because the mosquito season isn't over. Mosquitoes typically remain alive until the first hard frost, Repetz said.

If the weather stays hot during the fall, there is a chance the season could go a little bit longer," Repetz said.
(Pittsburgh Tribune-Review 09/27/2010)


Viet Nam
Prime Minister Nguyen Tan Dung has instructed health officials to take firm measures to combat dengue fever, which has claimed 42 lives so far in 2010 out of 55,400 cases reported nationwide. He urged the Ministry of Education and Training to mobilize pupils nationwide to join campaigns to kill mosquitoes in their houses and public places.

Ha Noi reported that the disease had hit 27 out of the city's 29 districts. In August 2010 alone, the whole country recorded 19,577 patients and 11 deaths in 54 cities and provinces, according to reports from the Preventive Medicine Department.

The number of patients hospitalized in HCM City in the first two weeks of September 2010 increased 30 percent, in comparison with the same period in previous months. Children's Hospital No 2 reported that it had received 555 dengue fever patients since the start of this month, and on average was receiving between 15-30 patients a day.

The preventive medicine department said it was working with relevant agencies to take preventive measures in key localities since early2010 focusing on cleaning the environment and killing mosquitoes.
(ProMED 09/27/2010)

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CHOLERA, DIARRHEA, and DYSENTERY
Philippines
An official said 28 September 2010 that the Department of Health (DOH) is checking a report that two residents of Caloocan City have died due to complications from cholera.

Dr. Eric Tayag, chief of the DOH’s National Epidemiology Center, said that the Research Institute for Tropical Medicine (RITM) was expecting to receive water samples from Pangarap Village, where the reports of cholera cases are coming from.

Tayag said that aside from the two reported cholera deaths, the DOH received information over the weekend that at least 11 people have been afflicted by the cholera infection.

He said the DOH would be able to confirm the presence of vibrio cholerae bacteria, which causes cholera, in the water supply of Pangarap Village in two to three days.

The vibrio cholerae bacteria are present in water contaminated with human waste.

Tayag said that while the DOH is making the confirmation, residents of Pangarap Village who are experiencing acute watery diarrhea may use the 1-8-1 formula, which stands of 1 litter of water, 8 teaspoons of sugar and 1 teaspoon of salt. He said the formula helps prevent dehydration.
(abs-cbnNEWS.com 09/28/2010)


Philippines
Aside from dengue fever, the Department of Health (DOH 7) 7 warned of the rise in the number of cases of diarrhea in Central Visayas.

DOH 7 Director Susanna Madarieta said that diarrhea is among the top three leading causes of death in the region. The other two are pneumonia and respiratory diseases like cough and colds.

These are sporadic cases for Central Visayas, Madarieta said.

Bad water systems and dirty hands usually cause diarrhea, Madarieta said.

From January to August 2010, the Cebu City Health Department recorded 1,443 diarrhea cases, with four deaths.

Most of the patients are children between six months to 15 years old.

According to Madarieta, Cebu health centers have enough Oresol for fluid replacement and chlorine to clean water systems to manage diarrhea cases in the region.
(Cebu Daily News 09/26/2010)

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4. Articles
Optimal antiviral treatment strategies and the effects of resistance
Hansen E, Day T. Proc R Soc B. 29 September 2010. doi: 10.1098/rspb.2010.1469.
Available at http://rspb.royalsocietypublishing.org/content/early/2010/09/22/rspb.2010.1469

Abstract. Recent pandemic planning has highlighted the importance of understanding the effect that widespread antiviral use will have on the emergence and spread of resistance. A number of recent studies have determined that if resistance to antiviral medication can evolve, then deploying treatment at a less than maximum rate often minimizes the outbreak size. This finding, however, involves the assumption that treatment levels remain constant during the entire outbreak. Using optimal control theory, we address the question of optimal antiviral use by considering a large class of time-varying treatment strategies. We prove that, contrary to previous results, it is always optimal to treat at the maximum rate provided that this treatment occurs at the right time. In general the optimal strategy is to wait some fixed amount of time and then to deploy treatment at the maximum rate for the remainder of the outbreak. We derive analytical conditions that characterize this optimal amount of delay. Our results show that it is optimal to start treatment immediately when one of the following conditions holds: (i) immediate treatment can prevent an outbreak, (ii) the initial pool of susceptibles is small, or (iii) when the maximum possible rate of treatment is low, such that there is little de novo emergence of resistant strains. Finally, we use numerical simulations to verify that the results also hold under more general conditions.

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Optimal antiviral treatment strategies and the effects of resistance
J of Occ and Environm Med. 25 September 2010. doi: 10.1097/JOM.0b013e3181f43872.
Available at http://journals.lww.com/joem/Abstract/publishahead/Factors_Associated_With_the_Ability_and.99744.aspx

Objective. To determine essential workers' ability and willingness to report to duty during a serious pandemic outbreak and to identify modifiable risk factors.

Methods. Workers (N = 1103) from six essential workgroups completed an anonymous, cross-sectional survey.

Results. Although a substantial proportion of participants reported that they would be able (80%), fewer would be willing (65%) to report to duty. Only 49% of participants would be both able and willing. Factors significantly associated with ability/willingness included individual-level (eg, intentions to adhere to respiratory protection and pandemic vaccination recommendations) and organizational-level factors (eg, preparedness planning for respiratory protection and worker vaccination programs).

Conclusions. During a serious pandemic event, non-illness-related shortfalls among essential workers could be substantial. Organizational preparedness efforts should focus on worker protection programs and the development of policies that would facilitate the attendance of healthy workers.

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Attending Work While Sick: Implication of Flexible Sick Leave Policies
J of Occ and Environ Med. 25 September 2010. doi: 10.1097/JOM.0b013e3181f43844
Available at http://journals.lww.com/joem/Abstract/publishahead/Attending_Work_While_Sick__Implication_of_Flexible.99742.aspx

Objective. To examine the impact of various flexible sick leave policies (FSLPs) on workplace attendance of employees with self-reported |P'severe" influenza-like-illness (ILI) symptoms.

Methods. This is a prospective study of employees from three US employers, which involved collection of information on employees' access to FSLPs and monthly experience with ILI and workplace attendance from November 2007 to April 2008. Multivariate analyses were used to estimate the impact of FSLPs on employees' workplace attendance while they were experiencing severe ILI symptoms.

Results. Among 793 employees with ILI, the average duration of severe ILI symptoms was 3.0 days. Most employees (71.9%) attended work with severe ILI symptoms, for an average of 1.3 days. Employees who could telework had a 29.7% lower rate of attending work with severe ILI symptoms (P = 0.026).

Conclusions. Employers that implement teleworking policies may be able to reduce employee-to-employee transmission of respiratory illness, including seasonal and pandemic influenza.

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Report of the international forum on pandemic influenza 2010: Qingdao, China, 24–25 July 2010
Varella Andre. Vaccine. 29 September 2010. doi:10.1016/j.vaccine.2010.09.067
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-51495V0-7&_user=10&_coverDate=09%2F29%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=b4bfc9db61df69fcb9110f3e8ef4a7ff&searchtype=a

Summary. The 2009 H1N1 influenza pandemic is the first pandemic to hit the world in the 21st century. According to World Health Organization (WHO) reports, as of 18 July 2010, more than 214 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, and over 18,336 people have died as a result of the disease [1]. In an effort to facilitate the exchange of strategic and operational experience in the fight against the pandemic, the Chinese Center for Disease Control and Prevention (China CDC), supported by the China Ministry of Health, in collaboration with WHO, the World Bank, the U.S. CDC, and co-organised with the Elsevier Publishing Group, hosted the International Forum on Pandemic Influenza 2010 in July. The two-day meeting, attended by over 600 international delegates, saw human health and animal health professionals discuss the current situation of the pandemic, the global response and vaccination strategies, pandemic surveillance and preparedness, and the animal–human interface in influenza and other emerging infectious diseases. A summary of the discussions is presented here.

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Needle-free influenza vaccination
Amorij JP, Hinrich WLJ, Frijlink HW, et al. Lancet Infect Dis. October 2010; 10(10) 699-711 doi:10.1016/S1473-3099(10)70157-2.
Available at http://www.thelancet.com/journals/laninf/article/PIIS1473309910701572/fulltext

Summary. Vaccination is the cornerstone of influenza control in epidemic and pandemic situations. Influenza vaccines are typically given by intramuscular injection. However, needle-free vaccinations could offer several distinct advantages over intramuscular injections: they are pain-free, easier to distribute, and easier to give to patients, and their use could reduce vaccination costs. Moreover, vaccine delivery via the respiratory tract, alimentary tract, or skin might elicit mucosal immune responses at the site of virus entry and better cellular immunity, thus improving effectiveness. Although various needle-free vaccination methods for influenza have shown preclinical promise, few have progressed to clinical trials—only live attenuated intranasal vaccines have received approval, and only in some countries. Further clinical investigation is needed to help realise the potential of needle-free vaccination for influenza.

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Surfing the web during pandemic flu: availability of World Health Organization recommendations on prevention
Gesualdo F, Romano M, Pandolfi E, et al. BMC Public Health. 20 September 2010; 10:561doi:10.1186/1471-2458-10-561.
Available at http://www.biomedcentral.com/1471-2458/10/561

Background. People often search for information on influenza A(H1N1)v prevention on the web. The extent to which information found on the Internet is consistent with recommendations issued by the World Health Organization is unknown.

Methods. We conducted a search for "swine flu" accessing 3 of the most popular search engines through different proxy servers located in 4 English-speaking countries (Australia, Canada, UK, USA). We explored each site resulting from the searches, up to 4 clicks starting from the search engine page, analyzing availability of World Health Organization recommendations for swine flu prevention.

Results. Information on hand cleaning was reported on 79% of the 147 websites analyzed; staying home when sick was reported on 77.5% of the websites; disposing tissues after sneezing on 75.5% of the websites. Availability of other recommendations was lower. The probability of finding preventative recommendations consistent with World Health Organization varied by country, type of website, and search engine.

Conclusions. Despite media coverage on H1N1 influenza, relevant information for prevention is not easily found on the web. Strategies to improve information delivery to the general public through this channel should be improved.

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Factors in vaccination intention against the pandemic influenza A/H1N1
Setbon M, Raude J. Eur J Public Health. October 2010; 20(5):490-494. doi: 10.1093/eurpub/ckq054.
Available at http://eurpub.oxfordjournals.org/content/20/5/490.short

Background. Vaccination against pandemic influenza A/H1N1 is an effective strategy to mitigate the spread of the disease. While the vaccine is now available, social acceptance remains relatively uncertain in many societies. The purpose of this study was to examine the beliefs, attitudes and practices associated with the intention to get vaccinated against the A/H1N1 virus among the general population in France.

Methods. A representative sample of 1001 individuals (stratified random recruitment procedure, ages 16–90 years) was interviewed by telephone. The questionnaire included a variety of items associated with socio-demographic characteristics, risk perceptions, illness perceptions, political attitudes and worldviews as well as intention to get vaccinated.

Results. More than 6 out of 10 of the respondents indicated that they planned to get vaccinated when the vaccine becomes available. The same proportion of parents also reported the intention to vaccinate their children against the disease. In multiple regression analyses, socio-cognitive factors consistently predicting influenza A/H1N1 vaccination were: level of worry, risk perception and previous experience of vaccine against seasonal flu.

Conclusions. The factors found to predict vaccination intention and their distribution are assumed to be a consequence of the fact that people perceive the risk of swine flu to be similar to that of seasonal flu. As a result, in the absence of an increase of the risk perception of pandemic influenza A/H1N1, a very low level of actual vaccination is forecasted. Behavioural change would require that the risks and consequences of pandemic influenza A/H1N1 be perceived as highly different from seasonal flu.

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Moderate pandemic, not many dead—learning the right lessons in Europe from the 2009 pandemic
Nicoll A, McKee M. Eur J Public Health. October 2010; 20(5): 486-488. doi: 10.1093/eurpub/ckq114.
Available at http://eurpub.oxfordjournals.org/content/20/5/486.short

Background. It could have been very different (Table 1). Although it was clear, from an early stage, that the 2009 influenza pandemic was likely to be less severe than the 1918 ‘Spanish Flu’, which killed an estimated 50 million people,1 there was still much uncertainty among European authorities on how it might develop. Three factors played a role in mitigating its impact. First, many of those in their mid-50s and above possessed cross-immunity from a similar virus that circulated before the 1957 pandemic.2 Hence, older people who account for over 90% of deaths from seasonal influenza were relatively spared. Those who died were mainly children and younger adults; among deaths reported to ECDC, about 80% were >65 years old. Second, along with Japan and China, Europe was the last industrialized region to be affected, enabling it to draw on the experience of North America, temperate countries in the Southern Hemisphere, and the one European country, the UK, that experienced a significant Spring/Winter wave. Therefore, the UK authorities were well placed to advise the rest of Europe what to expect, and what not to do. Its experience endorsed the guidance from the WHO and ECDC not to try to contain the uncontainable. Third, many European countries had worked intensively to strengthen their previously variable degree of pandemic preparedness. As a consequence, there were no disproportionate government reactions such as those in Mexico, Argentina and the Ukraine.

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Time and motion study to compare electronic and hybrid data collection systems during the pandemic (H1N1) 2009 influenza vaccination campaign
Finkelstein M, Guay M, Buckeridge DL, et al. Vaccine. 21 September 2010. doi:10.1016/j.vaccine.2010.09.016. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-512K4P7-1&_user=10&_coverDate=09%2F21%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=80fbd3adbaa98bb95fe52881e0ffced5&searchtype=a

Abstract. During the pandemic (H1N1) 2009 influenza campaign, vaccine providers collected immunization data using hybrid (paper-based and electronic methods) and electronic data systems. We measured staff time spent on data collection tasks to compare system efficiencies. The sample consisted of 38 organizations across nine Canadian provinces/territories. The total mean data collection times per client were 104 s (electronic system), 143 s (hybrid system with electronic registration) and 172 s (hybrid system with paper registration). Electronic registration and record keeping were faster than paper-based methods; these findings should be used to improve data collection for future influenza seasons.

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[Letter] Underlying Medical Conditions and Hospitalization for Pandemic (H1N1) 2009, Japan
Tomizuka T, Takayama Y, Shobayashi T, et al. Emerg Infect Dis. 22 September 2010; 16(10) doi: 10.3201/eid1610.091755.
Available at http://www.cdc.gov/eid/content/16/10/1646.htm

To the Editor. Early epidemiologic reports suggested that infection with pandemic (H1N1) 2009 virus most commonly occurred in teenagers and young adults (1). Although this infection appears to have a mild clinical course and the mortality rate has been relatively low in Japan (1.6 deaths/1 million population) (2), the reported number of patients with severe (requiring incubation or admission to an intensive care unit) cases of this disease has been increasing (2). The difference in severity of pandemic (H1N1) 2009 infection may be attributed to differences in underlying medical conditions or to age-related differences in susceptibility. To explore these differences, we investigated the incidence of laboratory-confirmed cases of pandemic (H1N1) 2009 virus infections resulting in hospitalization in Japan and the patients’ age-specific risks for hospitalization associated with underlying medical conditions. [Refer to link above for remainder of letter.]

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Pandemic (H1N1) 2009 Virus on Commercial Swine Farm, Thailand
Sreta D, Tantawet S, Na Ayudhya SN, et al. Emerg Infect Dis. 22 September 2010; 16(10) doi: 10.3201/eid1610.100665.
Available at http://www.cdc.gov/eid/content/16/10/1587.htm

Abstract. A swine influenza outbreak occurred on a commercial pig farm in Thailand. Outbreak investigation indicated that pigs were co-infected with pandemic (H1N1) 2009 virus and seasonal influenza (H1N1) viruses. No evidence of gene reassortment or pig-to-human transmission of pandemic (H1N1) 2009 virus was found during the outbreak.

In April 2009, a novel swine origin influenza A (H1N1) virus, now referred to as pandemic (H1N1) 2009 virus, emerged in humans in Mexico and the United States and spread worldwide (1). In May 2009, pandemic (H1N1) 2009 was confirmed in 2 patients in Thailand who had a history of travel to Mexico. Shortly after the emergence of this virus, reports of transmission from humans to pigs on pig farms were documented (2,3). Human-to-pig transmission of this virus was reported in Thailand on December 17, 2009 (www.dld.go.th/dcontrol/Alert/Ah1n1/H1N1%20update22_12_2009.pdf). Pigs showed mild respiratory signs; only 1 pandemic (H1N1) 2009 virus was isolated from 80 nasal swab specimens. Swine influenza virus (SIV) was reported in Thailand in 1981 (4). All 3 subtypes (H1N1, H3N2, and H1N2) of this virus are circulating in Thailand (5). A recent pathogenesis study demonstrated that subtype H1N1 induces typical SIV-like illness and slightly more severe gross lesions than illness induced by subtype H3N2 (6). Genetic data indicate that SIV (H1N1) in Thailand differs from pandemic (H1N1) 2009 virus. SIV (H1N1) in Thailand contains surface proteins of influenza viruses from North America and Eurasia, which are also found in pandemic (H1N1) 2009 virus; SIV (H1N1) in Thailand contains internal proteins of viruses from Eurasia; and pandemic (H1N1) 2009 viruses contain swine, human, and avian virus gene segments (5,7).

We report an outbreak of infection with pandemic (H1N1) 2009 virus during November 2009–March 2010 on a commercial pig farm in Thailand. The outbreak presumably resulted from human-to-pig transmission because 1 of the workers on this farm had influenza-like clinical signs at the beginning of the outbreak. Infection in this worker was not confirmed because he quit his job on the farm after the start of the outbreak and could not be located.

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[Letter] Internet Search Limitations and Pandemic Influenza, Singapore
Cook AR, Chen MIC, Lin RTP. Emerg Infect Dis. 22 September 2010; 16(10) doi:10.3201/eid1610.100840.
Available at http://www.cdc.gov/eid/content/16/10/1647.htm

To the Editor. In the past few years, several publications have reported that Internet search queries may usefully supplement other, traditional surveillance programs for infectious diseases (1–3). The philanthropic arm of Google offers Flu Trends, a site that provides up-to-date estimates of influenza activity in 20 countries of the Pacific Rim and Europe (4) by using data mining techniques to find good predictors of historic influenza indicators (1). [Refer to link above for remainder of letter.]

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Heightened neurologic complications in children with pandemic H1N1 influenza
Ekstrand JJ, Herbener A, Rawlings J, et al. Ann Neurol. 23 September 2010. doi: 10.1002/ana.22184.
Abstract. http://onlinelibrary.wiley.com/doi/10.1002/ana.22184/abstract

Abstract. The 2009 pandemic influenza A (H1N1) has been recognized to cause neurological complications including seizures and encephalopathy. We identified 18 children with 2009 H1N1 influenza and neurological complications from first and second wave activity, and compared characteristics to seasonal influenza. Seizures, encephalopathy, and status epilepticus were common presentations. Focal neurological symptoms persisted in 22% of patients at discharge. Compared to seasonal influenza, patients with pandemic 2009 influenza were more likely to have encephalopathy, focal neurological findings, aphasia, and abnormal electroencephalographic findings. In addition, we noted a trend toward heightened neurological complications following second wave influenza activity.

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Effectiveness of Public Health Measures in Mitigating Pandemic Influenza Spread: A Prospective Sero‐Epidemiological Cohort Study
Lee VJ, Yap J, Cook AR, et al. J Infect Dis. 23 September 2010. doi: 10.1086/656480.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/656480

Background. Few studies have validated the effectiveness of public health interventions in reducing influenza spread in real‐life settings. We aim to validate these measures used during the 2009 pandemic.

Methods. From 22 June to 9 October 2009, we performed a prospective observational cohort study using paired serum samples and symptom review among 3 groups of Singapore military personnel. “Normal” units were subjected to prevailing pandemic response policies. “Essential” units and health care workers had additional public health interventions (eg, enhanced surveillance with isolation, segregation, personal protective equipment). Samples were tested by hemagglutination inhibition; the principal outcome was seroconversion to 2009 influenza A(H1N1).

Results. In total, 1015 individuals in 14 units completed the study, with 29% overall seroconversion. Seroconversion among essential units (17%) and health care workers (11%) was significantly lower than that in normal units (44%) ( ). Symptomatic illness attributable to influenza was also lower in essential units (5%) and health care workers (2%) than in normal units (12%) ( ). Adjusted for confounders, unit type was the only significant variable influencing overall seroconversion ( ). From multivariate analysis within each unit, age ( ) and baseline antibody titer ( ) were inversely related to seroconversion risk.

Conclusions. Public health measures are effective in limiting influenza transmission in closed environments.

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

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Sixty-first session of the WHO Regional Committee for the Western Pacific
Putrajaya, Malaysia: 11-15 October 2010
Additional information available at http://www.wpro.who.int/rcm/en/rc61/

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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

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 apecein@u.washington.edu