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Vol. ~ EINet News Briefs ~ Oct 15, 2010


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

1. Influenza News
- 2010 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO situation update on pandemic influenza H1N1
- Global: CDC sees US, global H3N2 influenza activity
- Global: H3N2 influenza a player in early Northern Hemisphere influenza season
- Global: Expert pair airs lessons learned from global H1N1 pandemic influenza response
- China (Hong Kong): Swine influenza outbreak in hospital
- United States: Top influenza officials make strong case for vaccination
- United States: CDC confirms record doses of influenza vaccine

2. Infectious Disease News
- United States (Connecticut): Polio case
- Chinese Taipei: Asymptomatic gastrointestinal carrier of carbapenem-resistant Enterobacteriaceae with NDM-1 identified
- India: Polio cases continue
- India: Undiagnosed fatal illness
- India: Japanese encephalitis continues to exact toll
- Indonesia (Bali): Rabies infections continue to affect country
- Malaysia (Sarikei): Leptospirosis scare results in temporary pond closure
- New Zealand: E. coli in Avon River
- Russia: Outbreak of hemorrhagic fever with renal syndrome
- Russia (Kazakhstan): Polio case discovered
- Canada (Nunavut): TB outbreak among Inuit
- United States (Oregon): Bubonic plague case

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

4. Articles
- Effects of Adverse Events on the Projected Population Benefits and Cost-effectiveness of Using Live Attenuated Influenza Vaccine in Children Aged 6 Months to 4 Years
- The Promise of Maternal Vaccination to Prevent Influenza in Young Infants
- Maternal Influenza Vaccination and Effect on Influenza Virus Infection in Young Infants
- Authors' reply: Benefit and risks of trivalent 2010 seasonal influenza vaccine in Australian children
- Impact of influenza vaccination of schoolchildren on medical outcomes among all residents of Maryland
- Influenza vaccination for healthcare workers who work with the elderly: Systematic review
- Household Transmission of the 2009 Pandemic A/H1N1 Influenza Virus: Elevated Laboratory‐Confirmed Secondary Attack Rates and Evidence of Asymptomatic Infections
- Seasonal Influenza Vaccine and Increased Risk of Pandemic A/H1N1‐Related Illness: First Detection of the Association in British Columbia, Canada
- Pandemic A(H1N1) 2009 influenza: review of the Southern Hemisphere experience
- Reflections on Pandemic (H1N1) 2009 and the International Response
- Seroprevalence of 2009 pandemic influenza A(H1N1) virus in Australian blood donors, October – December 2009
- Inside the Outbreak of the 2009 Influenza A (H1N1)v Virus in Mexico
- Healthcare workers as parents: attitudes toward vaccinating their children against pandemic influenza A/H1N1
- Healthcare workers as parents: attitudes toward vaccinating their children against pandemic influenza A/H1N1
- Health service resource needs for pandemic influenza in developing countries: a linked transmission dynamics, interventions and resource demand model

5. Notifications
- APEC Hot Topics Videoconference
- 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: WHO situation update on pandemic influenza H1N1
Influenza activity is decreasing in most parts of the temperate Southern Hemisphere and the season does not yet appear to have definitively started in the temperate areas of the Northern Hemisphere. Influenza A(H3N2) is now the predominant influenza virus world wide after several weeks of increasing detections in much of the world, but many areas still have active transmission of H1N1 (2009) influenza. Most of the influenza A(H3N2) viruses detected are A/Perth/16/2009-like, which is the strain included in the seasonal vaccine for the Northern and Southern Hemispheres.

The winter influenza transmission season of the temperate countries of the southern hemisphere is now waning in most areas. The most common virus types associated with the influenza season of 2010 in the temperate southern hemisphere have varied greatly depending on the location. In Australia, influenza-like illness (ILI) activity, hospital, and intensive care unit admissions related to influenza in Australian sentinel hospitals have all decreased in the past week. The H1N1 (2009) influenza virus is still the most frequently detected virus in Australia, with a lower number of influenza type B and A(H3N2) viruses. Rates of ILI activity in New Zealand are below the baseline level for the second week with a low rate of influenza virus detection. The most common influenza virus found this season in New Zealand is H1N1 (2009) with very few other subtypes detected.

In the southern cone of South America, overall respiratory disease activity is decreasing, with a mixed picture of influenza viruses. In Chile the seasonal outbreak arrived at a later time than normal and respiratory disease activity is still high but decreasing, indicating that the peak activity has passed. Reported cases of severe acute respiratory infections (SARI) caused by influenza have decreased the last weeks, and emergency consultations for pneumonia have also declined. Although some regions of the country have experienced higher ILI activity in 2010 than during last year's outbreak of H1N1 (2009), at a national level overall activity has been much lower. The most frequently detected virus in Chile this season has been A(H3N2) with co-circulation of smaller numbers of H1N1 (2009) and even fewer influenza type B viruses.

The influenza season in South Africa has peaked and is declining; influenza type B was the predominant virus of the season co-circulating with H1N1 (2009) and A(H3N2). The median age of influenza cases in South Africa was lower for those with H1N1 (2009) and influenza B infections than for those with influenza A(H3N2).

Influenza activity in tropical areas of the world have been varied and discordant in time. While most tropical areas have seen recent peaks in transmission that are now decreasing in intensity, Southeast Asia is currently experiencing increasing levels of influenza activity. The viruses indentified in tropical areas have varied even between neighboring countries and co-circulation of multiple types has commonly been observed.

Influenza activity is decreasing in Central American. The influenza viruses detected have been a mixture of influenza A (H3N2), influenza H1N1 (2009), and influenza type B. Overall, influenza A(H3N2) is the most commonly detected but this is not uniformly true in every country. Among characterized influenza viruses in Costa Rica and Honduras in September 2010, the large majority was A(H3N2), while Nicaragua has had predominantly influenza type B. Cuba had an outbreak of mainly H1N1 (2009) in April-May, but since August has detected much more influenza A(H3N2).

Mexico has detected an increase in ILI and acute respiratory disease (ARI) since August 2010, particularly in the southern part of the country. This activity has coincided with an increased proportion of samples testing positive for influenza, but during September 2010 this proportion has again decreased. The majority of positive influenza samples have been influenza A(H3N2) viruses and a subset that was further characterized was all the A/Perth/16/2009-like strain, which is included in both the 2010-2011 Northern Hemisphere and the 2010 Southern Hemisphere influenza vaccine.

In south Asia, data from India indicates that the country-wide outbreak of H1N1 (2009) has peaked and a declining number of laboratory-confirmed cases has been reported the last weeks though activity is still quite high in some areas of the country. Bangladesh also has decreasing influenza activity, though with influenza A(H3N2) virus more commonly detected than H1N1 (2009).

Southeast Asia, in contrast, is experiencing increases in activity in some areas. Cambodia has reported increasing detections of influenza viruses for the last two weeks, with A(H3N2) the most frequent virus detected but with a high number of H1N1 (2009) detections and a few influenza B viruses. Neighboring Thailand has reported on an increasing number of ILI cases and is experiencing local outbreaks of H1N1 (2009).

In Africa, Cameroon and Senegal continue to report a low number of circulating influenza B viruses, while the Eastern African countries Kenya, Tanzania and Madagascar have low circulation of predominantly A(H3N2).

In Asia, China is experiencing moderate circulation of influenza A(H3N2) virus with many fewer detections of influenza B. In Northern China, the proportion of outpatients with ILI in sentinel hospitals is increasing. In Hong Kong SAR, ILI activity in sentinel sites of general practitioners is decreasing but remains high and with a majority of influenza A(H3N2) viruses among the laboratory-confirmed cases.

In North America, both the United States and Canada are reporting low influenza activity with sporadic detections of A(H3N2) and influenza B in the US.

WHO Euro Region had low influenza activity last months; with Russia notably reporting increasing activity of ARI.
(WHO 10/08/2010)

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Global: CDC sees US, global H3N2 influenza activity
In its review of the 2010 summer flu activity in the United States and across the globe, the US Centers for Disease Control and Prevention (CDC) said that patterns, which included a few clusters and sporadic illness, were typical.

The CDC's report, however, which appears in the current issue of Morbidity and Mortality Weekly Report (MMWR), describes H3N2 influenza activity both globally and domestically, a strain often linked to more severe flu.

The report comes during the first official week of the US flu season.

Of respiratory samples from the United States that were analyzed over the summer, 326 (1.3%) were positive for influenza, of which 261 were influenza A and 65% were influenza B. Of the 185 influenza A viruses that were subtyped, most (70%) were H3N2, with rest the 2009 H1N1 subtype.

The number of positive samples grew slowly through the late 2010 summer, with the largest portion coming from the southeastern states. Two unrelated H3N2 clusters were reported in Iowa in early July 2010, and in August 2010 Maryland's health department reported an influenza B outbreak in children visiting the United States as part of an international exchange program. About 35 of the 400 children who were sick were treated at a local hospital, and influenza B was confirmed in eight cases.

Outpatient visits for flu-like illnesses stayed below the national baseline, and mortality stayed below epidemic thresholds over the summer except for three nonconsecutive weeks. No pediatric flu deaths were reported.

Globally, H3N2, influenza B, and 2009 H1N1 viruses circulated over the summer, with influenza B predominant during the first part of the summer, the 2009 H1N1 becoming more common after early July, and H3N2 becoming the most commonly identified subtype since late August.

CDC officials said they anticipated more H3N2 activity in 2010, which is often linked to more severe flu infections. They listed the likelihood of H3N2 circulation as another good reason for Americans to get their flu immunizations.

The CDC said in an editorial note that accompanied the flu report that the disease clusters it received, along with sporadic reports of 2009 H1N1 and influenza B infections, are typical for summer months.

The agency said that antigenic analysis suggests the circulating strains are similar to the ones in the vaccine strains, which suggests the vaccines will be a good match.

The WHO in a report on recommendations for the Southern Hemisphere's 2011 flu vaccine said the same thing and added that the vast majority of 2009 H1N1 viruses were sensitive to oseltamivir (Tamiflu), and the few resistant viruses detected were mostly linked to prophylaxis or treatment. Most 2009 H1N1 viruses and all H3N2 viruses that were tested were resistant to the adamantane antiviral drugs amantadine and rimantadine, the WHO said.

The WHO noted that a small number of seasonal H1N1 viruses it saw came from China and were closely related to the Brisbane seasonal H1N1 strain. In its analysis of influenza B strains, the WHO said the Victoria lineage, included in this season's vaccines for the Northern Hemisphere, continues to predominate, though the Yamagata lineage had recently become predominate in China at low levels.

In a separate report on 5 October 2010, international flu activity from 21 September 2010 to 5 October 2010, the CDC said the number of respiratory samples in southern China that have tested positive for influenza, which has risen about 8% in September, with H3N2 accounting for most of the activity.

In Chile, flu activity dipped in September 2010, with H3N2 accounting for about half of the samples.

Though flu activity dropped sharply in New Zealand, Australian officials reported a late-season rise in 2009 H1N1 activity. Elsewhere, two Thai provinces reported a rise in flu activity in September, with 2009 H1N1 as the primary subtype.
(CIDRAP 10/05/2010)

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Global: H3N2 influenza a player in early Northern Hemisphere influenza season
More signals suggest the Southern Hemisphere's flu season is winding down, while activity is low at the start of the Northern Hemisphere's flu season, except in China, which is seeing moderate H3N2 circulation.

Some parts of the world are still reporting some 2009 H1N1 transmission, according to the most recent World Health Organization (WHO) update. Many, though, are also finding influenza A (H3N2), with most of it the Perth-like strain included in 2010’s seasonal flu vaccines.

US officials have said they expect to see more H3N2 circulation in 2010 and have noted that flu seasons can be worse when H3N2 is the dominant strain.

Australia, which recently experienced a late-season surge of 2009 H1N1 influenza, is reporting decreasing activity according to several markers, including hospital and intensive care unit admissions, the WHO said in an 8 October 2010 report. Virus type varied by country, with the 2009 H1N1 virus detected most often in Australia and New Zealand and influenza B predominating in South Africa.

Chile, like Australia, also reported a late-season rise in flu activity, which is now declining, the WHO said. In some regions of Chile, flu activity exceeded 2009 pandemic levels, though the national level in 2010 was lower overall. H2N2 was the strain detected most frequently, with low levels of 2009 H1N1 and influenza B.

The WHO said flu activity in tropical countries has varied widely, and although flu is decreasing in most countries, it is increasing in Southeast Asian countries such as Cambodia and Thailand.

The type of flu circulating in the tropical countries has also shown a lot of variation, even among neighboring countries, with cocirculation common in many locations. For example, in Cambodia, H3N2 is the most frequently detected virus, but in neighboring Thailand, most outbreaks involve 2009 H1N1. In Costa Rica and Honduras, H3N2 has been the most common virus detected, but influenza B has been dominant in Nicaragua.

China is reporting moderate H3N2 circulation, with tests showing much lower levels of influenza B activity, the WHO said. Northern China is experiencing an increase in the number of outpatient visits for flu-like illness, and Hong Kong officials said flu activity is decreasing some but still remains high, with most of it the H3N2 virus.

Flu activity is starting to decline in India, where the 2009 H1N1 virus was dominant, and in Bangladesh, where H3N2 was more common. India's health ministry, in an 11 October 2010 update for the week ending 10 October 2010 showed that cases declined for the fourth week in a row.

Saudi Arabia recently reported three deaths from the 2009 H1N1 virus, and a health ministry spokesman said the overall level of flu, including the H1N1 strain, is normal for the season. Pilgrims from Muslim countries are arriving in Saudi Arabia in advance of early November 2010 hajj observances in Mecca and Medina. Many countries have advised hajj travelers to receive the seasonal flu vaccine in advance of their pilgrimages.

Mexico reported a spike in flu-like illnesses in August 2010, especially the southern part of the country, though reports leveled off in September 2010. Most flu detections in the country have been H3N2, with a subset characterized as the Perth-like strain, which is included in flu vaccines for the Southern and Northern Hemisphere flu vaccines.

Elsewhere in North America, Canada and the United States reported low levels of flu activity, with US officials noting sporadic detections of H3N2 and influenza B.
(CIDRAP 10/13/2010)

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Global: Expert pair airs lessons learned from global H1N1 pandemic influenza response
On 5 October 2010, two internationally known health officials gave their assessment of the global response to the 2009 H1N1 pandemic, saying good decisions were made based on what was known early in the outbreak but adding that the experience yielded several important lessons, such as the need for more flexible pandemic plans and the need to communicate more clearly about risks.

The experts are Dr Gabriel Leung, of Hong Kong's Food and Health Bureau, and Dr Angus Nicoll, of the European Center for Disease Prevention and Control in Stockholm. Their review covers the first 12 months of the pandemic response.

Their reflections on the world's pandemic response comes in the midst of an independent review of the World Health Organization's (WHO's) response and how the International Health Regulations (IHRs) functioned in their first major test during a public health crisis.

Though the 2009 H1N1 virus seemed to cause mild-to-moderate infections in most people, experts are still sorting out the mortality impact, Leung and Nicoll wrote. Young people were among the hardest-hit groups, and their deaths amount to more years of life lost than the deaths involving older people and those with chronic medical conditions.

Some countries turned quickly to containment strategies when the new virus emerged, using nonpharmaceutical interventions such as isolation and quarantine of people with suspected and confirmed disease, which in some ways was understandable for countries that had already grappled with the H5N1 avian influenza virus and the 2003 SARS epidemic, the authors wrote.

Though some of the measures may have delayed community transmission, it's unclear if the benefits were worth the costs.

Until the pandemic virus emerged, hardly any countries except Japan had used antiviral medications widely. Some struggled with whether to use the drugs for the treatment of sick patients or to prescribe them for prophylaxis. A few countries, such as England, developed innovative distribution methods.

Early evidence suggests that neuraminidase inhibitors reduced severe disease without causing adverse events. However, they added that delayed antiviral treatment was linked to more severe complications worldwide, which points to gaps in indentifying and treating patients early.

The authors gave mixed reviews to the pandemic vaccine. Though they said it was a scientific success, it arrived too late with not enough supply to blunt the Northern Hemisphere's second pandemic wave. They noted that public health officials struggled with a difficult message when urging people to get the vaccine—that although the virus usually caused mild disease, it could sometimes be lethal, even in young and previously healthy people.

Though some critics have questioned their countries' expenditures for what may have later appeared to be excessive amounts of vaccine, the authors noted that when health officials placed their orders they didn't expect the later finding that a single dose rather than multiple doses was immunogenic in all but the youngest children.

Leung and Nicoll stated that hindsight always gives perfect vision and using post-hoc information to evaluate prior decisions at best confuses and often produces unfair conclusions.

In addressing critics' charges that vaccine makers may have improperly influenced the expert advice WHO relied on in determining their recommendations and response actions, Leung and Nicoll emphasized that receiving advice is different than making decisions. Advisors' declarations of interest should be fully transparent and comprehensive and follow strict rules that can hold up to intense scrutiny, they said the decision makers should also be prepared to justify their actions.

They predicted that communication about risk will remain a challenge in the months ahead because the 2009 H1N1 virus could undergo antigenic drift, given the greater number of people who are now immune through infection or vaccination.

As the lessons emerge about the pandemic response, countries will likely be retooling their pandemic plans, the authors wrote, urging the WHO to take a leadership role to coordinate the efforts. They stated that a strong argument exists for making future plans more flexible and having extra descriptions including the many aspects of severity when a pandemic is emerging that then determine the consequential public health actions.

Their other recommendations include: Establishing a clinical research infrastructure to help speed the collection and sharing of clinical data during the next flu pandemic or other disease outbreak, improving surveillance systems to help gauge the true burden of flu, and developing new tools for treating severe flu infections. Easing developing countries' access to antiviral medications and vaccines still represents a big gap, the authors wrote "It is an indefensible fact that these vaccines started to flow to the poorer countries well after they began going to the countries with advance purchase agreements."

However, they noted that the long-term solution isn't simple and includes improving surveillance, monitoring disease burden, expanding flu prevention and control efforts, and establishing seasonal flu vaccine production and use in all parts of the world.
(CIDRAP 10/06/2010)

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Asia
China (Hong Kong): Swine influenza outbreak in hospital
Nine female patients (aged 23 to 87) and two staff members of an infirmary ward in TWGHs Wong Tai Sin Hospital (WTSH) have presented with fever, sore throat or cough symptoms since 8 October 2010. Appropriate viral tests have been arranged for the patients. The results of seven patients are positive to human swine influenza virus. The patients are now on Tamiflu treatment and under isolation. The condition of seven patients are stable while two are serious. The staff members concerned have attended private doctors and were given sick leave.

Deep cleansing and disinfection have been conducted in the concerned ward and infection control measures have already been enhanced. Admission to and discharge from the ward are suspended for the time being. Restricted visiting policy is also enforced. All patients and staff in the ward are under close surveillance.

The cases have been reported to the Hospital Authority Head Office and the Center for Health Protection for necessary follow-up.
(TWGHs Wong Tai Sin Hospital 10/14/2010)

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Americas
United States: Top influenza officials make strong case for vaccination
As the nation enters its first flu season under a new universal flu immunization recommendation, federal health officials and representatives from several professional groups gathered in Washington, DC, to rally support for seasonal flu vaccination, armed with new information about vaccine patterns in physicians, consumers, and mothers.

Tom Frieden, MD, MPH, director of the US Centers for Disease Control and Prevention (CDC) said the new universal flu immunization recommendation—that all people over age six months should get the vaccine—will greatly simplify the flu vaccine message. He said that people and their doctors do not need to wonder anymore, and that there is plenty of vaccine available in 2010, well before flu circulates.

A universal flu vaccination policy is also useful because the disease can be serious and disabling, even in healthy people, Frieden said. He added that when individuals are vaccinated they reduce time missed from school and work and help protect vulnerable people around them.

Though he said it's difficult to make predictions about what strains will circulate throughout the season, early indications from US and international labs suggest that the current circulating strains are a good match with the strains in this year's trivalent seasonal flu vaccine, including the 2009 H1N1 virus.

Dan Jernigan, MD, MPH, deputy director of the CDC's influenza division in the National Center for Immunization and Respiratory Diseases, said the influenza A H3N2 virus has been circulating in different parts of the globe over the summer and into fall. He said US officials expect the virus may circulate in greater numbers in the fall.

He said that, compared with other strains, H3N2 viruses often cause more severe illnesses, so the expectation that the strain will circulate in the United States this season is another reason to get vaccinated.

As of 24 September 2010 about 119 million doses of seasonal flu vaccine have been distributed, 30 million more than this time in 2009, Jernigan said.

Stephan Foster, PharmD, a representative from the American Pharmacists Association and liaison to the CDC's flu vaccine advisory group, said on 7 October 2010 that pharmacies administered 14 million doses of seasonal and H1N1 vaccine in the 2009 flu season, accounting for 10% of all doses given. He said pharmacies are on track to exceed that in 2010. Foster is professor and vice chair for community practice at the University of Tennessee College of Pharmacy.

He said community pharmacies are the most accessible vaccine provider and are especially useful for targeting people ages 19 to 49, who often don't have a primary care provider. However they do walk into pharmacies, he said.

William Schaffner, MD, NFID president, unveiled the results of NFID surveys on flu vaccine behaviors in physicians, consumers, and mothers. He said public attitudes about flu vaccination can sometimes be as unpredictable as the virus itself; some years uptake is lukewarm, with people rushing to get it in other years. Schaffner is chairman of preventive medicine at Vanderbilt University School of Medicine and a professor of medicine in the school's infectious disease division.

The NFID's survey of 400 primary care physicians revealed that 94% received at least one flu vaccine in 2009, with 80% receiving both the seasonal and 2009 H1N1 vaccine. About 100 of those surveyed are pediatricians.

For the 2010 season, 5% of primary care physicians have already been immunized, and an additional 90% say they intend to be immunized. More than 75% reported that all of their immediate family members were vaccinated or intended to be vaccinated in 2010.

Schaffner said the findings are promising, given that physicians have the greatest impact at setting a good example for their patients. However, he said the high uptake in physicians contrasts with much lower rates in healthcare workers in general, which hovers at about 40%.

He said that we have to consider the role of everyone in the healthcare facility, adding that everyone in health settings—from parking valets to janitors—should be vaccinated to help build a protective cocoon around patients and to protect themselves and their families from flu.

The most common reasons physicians gave for getting immunized were not wanting to miss work and family time, concerns about patient health, protecting themselves, and protecting their families, according to a background sheet on the study. About 9 in 10 physicians said they personally discuss flu vaccination with their patients.

The NFID's survey on consumer attitudes about the flu vaccine revealed that 60% intend to get the flu vaccine in 2010, but that the public has some misconceptions about it. The telephone survey of 1,010 adults was conducted 27 August 2010 through 30 August 2010. Seniors expressed the highest intent to be vaccinated, at 73%, while the lowest level, 49%, was seen in adults age 45 to 54.

More than two-thirds said they were aware of the new universal flu vaccine recommendation. Healthcare practitioners, especially doctors, played a key role in motivating patients to be vaccinated.

Consumers' top three misconceptions about the flu vaccine were that there are other effective ways besides vaccination to prevent flu, that flu isn't a threat to healthy people, and that the vaccine can cause the flu or side effects.

More than a third believed that hand washing works as well as or better than the vaccine for preventing flu. Schaffner is glad that hand washing is embedded, however he believes that it is the vaccine that is fundamental and much more important for preventing flu. He added that while we're moving the needle toward more fluency, we need to correct misperceptions.

The NFID's poll of mothers found that, despite last year's pandemic flu activity, 80% had not changed their feeling about getting their children vaccinated: 65% said they intend to have them immunized, while 33% said they would be unlikely. Two percent were undecided.

The telephone survey included 505 mothers of children age six months through 18 years and was conducted from 12 August through 15 August 2010. Additional interviews were conducted among 104 African-American mothers and 100 Hispanic mothers.

Of the 18% who said they had changed their minds about vaccination, most said they shifted their opinion in favor of vaccination.

The top reasons women gave for having their children vaccinated included protecting their children and easing their own worries about their children contracting a serious disease. The intent to vaccinate was highest in moms of children younger than six years and lowest in those with children ages 12 to 17.

Findings also revealed that mothers favored pediatricians and other primary care providers as sources of flu vaccine information, and 73% said a strong recommendation from a pediatrician would make them more interested in getting their kids vaccinated.
(CIDRAP 10/07/2010)

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United States: CDC confirms record doses of influenza vaccine
On 7 October 2010, the US Centers for Disease Control and Prevention (CDC) issued final estimates for the 2009 season's flu vaccine and the 2009 H1N1 monovalent vaccine, confirming a record number of flu vaccine doses distributed.

The CDC's report on the vaccines, published on 7 October 2010 on its Web site, is a follow-up to preliminary and state-by-state coverage estimates that it issued in April 2010.

The agency had anticipated that uptake of seasonal flu vaccine in the fall and winter of 2009 would be influenced by heightened interest in flu due to pandemic flu activity, which came with public health recommendations to get the seasonal vaccine early. Manufacturers rushed to roll out the seasonal flu vaccine to make way for the pandemic vaccine, which came more slowly and with fewer early doses than first projected.

The 2009-10 flu season was also the first full year that seasonal flu vaccines were formally recommended for all school-aged children.

Health officials are eager to see how a new universal flu vaccination recommendation for everyone age six months and older that takes effect this season will influence uptake levels for the coming flu season.

The CDC based its estimates for the two vaccines on two surveys, the Behavioral Risk Factor Surveillance System, an ongoing state-based phone survey of about 400,000 adults, and the National 2009 H1N1 Flu Survey (NHFS), which began October 2009 and ended in June 2010. It based its final estimates for the vaccines on vaccinations reported through May 2010 and interviews conducted through June 2010.

Estimates are a little higher than previous projections for both vaccines because the data includes a broader vaccination period that extended through May 2010.

For the seasonal vaccine, the CDC estimates that national coverage for all people ages six months and older was 41.2%, slightly higher than its earlier projection of 39.7% for the population as a whole. It said about 123 million people received the seasonal flu vaccine through May 2010, an increase from the previous estimate of 118.8 million.

Rates were highest for seniors at 69.6%, followed by adults between the ages of 50 and 64 (45%), children ages six months through 17 years (43.7%), younger adults with underlying conditions (38.2%), and healthy younger adults (28.4%).

The CDC cautioned that the seasonal flu vaccine coverage is an overestimate, because the reported coverage level of 123 million exceeds the 114 million doses of seasonal vaccine that were distributed. In its early estimate the CDC had said that respondent confusion over the two types of flu vaccines might have contributed to some overreporting.

Compared with the 2008-2009 flu season, coverage rates rose for all groups except for adults ages 50 through 64.

For the pandemic vaccine, the CDC estimates that national coverage for all groups was 27%, which is slightly higher than the April 2009 estimate of 24%. About 80.8 million people received the 2009 H1N1 vaccine, according to the latest estimate, compared with the earlier estimate of 72 million.

Coverage was highest in children ages six months through age 17 at 40.5% followed by seniors (28.9%), people ages 25 through 64 in high-risk groups (28.6%), and healthy people ages 25 through 64 (18.7%). Pandemic vaccine coverage was 34.2% in the CDC's initial target group: children, younger adults, people with underlying medical conditions, pregnant women, and healthcare workers.

The CDC said high uptake of the pandemic vaccine in children probably reflects the focus many states had on childhood vaccinations, the use of school-based vaccination clinics, and a recognition that children were at risk for severe disease.
(CIDRAP 10/07/2010)

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2. Infectious Disease News

Asia
United States (Connecticut): Polio case
A student at a Hartford elementary school has been diagnosed with tuberculosis.

The school department said health officials have also begun notifying people who may have had primary exposure to the disease. Those individuals will be tested for TB beginning next 19 October 2010 in the auditorium of the Dr. James H. Naylor Elementary School.

Principal Robert Travaglini said the student, who was not identified, is undergoing treatment with antibiotics and is no longer contagious.

Officials said testing would be provided in November 2010 for any other members of the Naylor community who request it.

Informational sessions for parents will also be held in the coming days.
(NECN 10/14/2010)

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Chinese Taipei: Asymptomatic gastrointestinal carrier of carbapenem-resistant Enterobacteriaceae with NDM-1 identified
Taiwan has detected an asymptomatic gastrointestinal carrier of carbapenem-resistant Enterobacteriaceae with NDM-1 [New Delhi metallo-beta-lactamase-1] in a Taiwanese cameraman who was shot in India in September 2010. The patient, a 38-year-old male, sustained an abdominal wound in New Delhi, India, on 19 September 2010 and was admitted to Lok Nayak Jaiprakash Narayan Hospital. He received a right hemicolectomy, and was left with two drains inserted. The patient was treated with a third-generation cephalosporin. On 27 September 2010, patient was discharged without any signs or symptoms of infection and was flown back to Taipei.

After his arrival in Taipei, he was admitted to an isolation room at the Taipei Veterans General Hospital for evaluation. Bacterial culture of patient's two drainage wounds, urine, and rectal swab were performed on 27 September 2010. Carbapenem-resistant Klebsiella pneumoniae (CRKP) with NDM-1 confirmed by PCR and sequencing was detected in his rectal swab on 1 October 2010. A repeat rectal swab was collected on 1 October 2010, which was also positive for CRKP with NDM-1.

[ProMED note: The New Delhi metallo-beta-lactamase-1 (NDM-1) is a an enzyme produced by some Gram-negative bacteria that confers resistance to all beta-lactam antibiotics, exceptaztreonam (a monobactam). Nevertheless, these isolates are commonly resistant to aztreonam, presumably by a different mechanism. NDM-1 also can co-exist with resistance to other classes of antibiotics, including the fluoroquinolones and aminoglycosides. Colistin and tigecycline may retain activity against NDM-1 producing bacteria, but these antibiotics either have significant side effects, are potentially inferior to more conventional therapies, and can be costly.

NDM-1 has been linked to receipt of medical care in India and Pakistan. The US CDC asks that carbapenem-resistant isolates from patients who have received medical care within six months in India or Pakistan be forwarded through state public health laboratories to CDC for further characterization.]
(ProMEd 10/05/2010)

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India: Polio cases continue
With one more polio case reported from Beed district, the number of polio cases in Maharashtra has gone up to five in the last 10 months, health officials said 6 October 2010.

An 11-month-old child from a ''banjara (migrant)'' family in Beed was reported to be suffering from polio, state Health Directorate additional director CM Kulkarni said.

The child had received three doses of oral polio in June, July, and September 2010. However, he developed paralysis on 16 September 2010 and was admitted to a hospital at Umargaon in Osmanabad, he said.

Although Uttar Pradesh and Bihar were reported for the last few years as the breeding ground for poliovirus, in 2010, out of the total 16 cases of P-1 type (more harmful and spreads faster) polio [also known as wild poliovirus type 1 or WPV1], five are from Maharashtra, seven from Mushirabad in West Bengal, one from Jammu and Kashmir, and three from Bihar, director of the Enterovirus Research Institute of ICMR [India Council of Medical Research] JM Deshpande said.

From January to September 2010 a total of 38 polio cases were reported from across the country, Deshpande said.
(ProMED 10/06/2010)

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India: Undiagnosed fatal illness
The total toll from "mysterious" fever has continued to escalate with 13 more deaths reported from Ramabai Nagar district (formerly Kanpur Dehat) on 10 October 2010. More and more people infected with the unidentified virus have flocked the district hospital in Akbarpur. So far, 256 people have already died. A team of district officials visited the affected villages on 10 October 2010 to ascertain the facts and figures of human casualties. It has been learnt during the visit that as many as 400 people, most of whom are minors, are down with fever.

The disease started from Ahrauli Sheikh village in Amraudha block and within a month spread to 48 villages, housing 3000 families. It was also learned that the infants who fell victim to the disease were suffering from acute malnutrition. The infants were suffering from malnutrition and that made some of them vulnerable to the killer virus, said district nodal officer Arvind Sachan.

[ProMED note: This report provides no additional information about the nature of the disease (other than fever), nor its likely etiological agent (other than "killer virus") beyond similar statements in the first report of 4 October 2010. There has been a significant increase in the number of fatal cases, from 180 in the 4 October 2010 report to 256 indicated above. In the absence of additional information, it is impossible to speculate rationally about what is going on in this outbreak. Sadly, the complete article goes on at some length about complaints by local people charging inadequate availability of medical facilities and attention in this area. If samples have been collected and sent to a reference laboratory, ProMED-mail would be interested in receiving information about the results as they become available.]
(ProMED 10/10/10)

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India: Japanese encephalitis continues to exact toll
Acute encephalitis syndrome (AES) has taken a heavy toll in the state of Uttar Pradesh, with 125 deaths reportedly caused by the disease in October 2010 alone. In 2009, by October, the total cases of AES in the state were reported to be 2300 with 357 deaths. However, in 2010, the cases have already risen to 2,538, with 369 deaths. In the last month, more than 950 patients of AES have tested positive across 14 districts of the state [ProMED note: tested positive for what?]

The largest number of deaths -- 105 -- have occurred in Gorakhpur district, while the toll in Kushinagar is 96. Deoriya has reported 57 deaths and Maharajganj around 40. Of the 2,538 cases, more than 2,400 patients were admitted in BRD Medical College, Gorakhpur alone. These are not exact figures as we don't track patients going to private practitioners, said Dr KP Kushwaha of BRD Medical College, Gorakhpur.

[ProMED note: The numbers of cases continue to increase, and the reports of this outbreak continue to be confusing. The last report (28 Sep 2010, ProMED-mail archive no. 20101001.3568) attributed the cases to Japanese encephalitis virus (JEV) infections. However, reports before that indicated that less than half the "acute encephalitis syndrome" cases were shown to be caused by JEV infection. One earlier report associated the cases with water, suggesting enterovirus infections. The report above simply classifies them as "acute encephalitis syndrome" with no indication of what etiological agent(s) might be involved, nor if samples have been sent to a reference laboratory for testing, although the report states that they "tested positive".]
(ProMED 10/12/2010)

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Indonesia (Bali): Rabies infections continue to affect country
The human death toll from the Bali rabies outbreak has almost certainly now exceeded 100, and may now be higher than 130, but tracking the deaths has become much more difficult, since the Bali newspapers appear to have suspended reporting deaths throughout the month of September 2010.

The outbreak started on the southern tip of the Ungasan peninsula in mid-2008, apparently originating with a single infected dog, which arrived with his master from Flores. The master was apparently the first person bitten and the fourth to die.

Through 6 August 2010, the Bali and Indonesian governments recognized 76 human rabies deaths. A list of 64 victims has been identified by name and date of death. Bali sources indicated that there had been at least 20 unreported deaths in poor and remote villages.

The next officially stated toll was 98, after the 8 October 2010 death of a 32-year-old male resident of Jalan Kartini, Wangaya, Denpasar.

According to Sanglah Hospital, the official rabies treatment center, 112 patients had been treated for rabies. This leaves 14 unaccounted for.

The unknown question is whether the count of 98 incorporates the previously unreported deaths, or whether there were in fact 22 new reported deaths from rabies between 6 August and 8 October 2010. 130-plus may be the actual toll.

On 21 September 2010, the Bali government signed a memorandum of understanding with the Bali Animal Welfare Association (BAWA) and a separate memorandum of understanding with the World Society for the Protection of Animals (WSPA), which will facilitate and fund vaccinating the entire remaining unvaccinated dog population of Bali within the next six months, if all goes without further delay.

However, while the vaccination campaign should finally bring this outbreak to an end, two years after it could and should have been isolated and eradicated before ever leaving the Ungasan peninsula, human rabies deaths resulting from bites suffered earlier are likely to continue to occur at least through the end of 2010, and probably into 2011.

The public and political response to each bite will continue to present a challenge to BAWA, WSPA, and local health officials, who must reassure the public and politicians that the continuing deaths do not mean the failure of the vaccination program -- only that it was begun two years too late, after a failed attempt to quell the outbreak through selective vaccination and culling.

[ProMED note: It is to be hoped that, as the dog vaccination initiative sponsored by the WSPA and the BAWA is extended throughout all nine regencies of Bali, the number of new human cases of rabies will begin to decline and the final human death toll will not greatly exceed the current estimate of 130.]
(ProMED 10/11/2010)

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Malaysia (Sarikei): Leptospirosis scare results in temporary pond closure
Members of the public are prohibited from getting into contact with the water in Lake Garden located at Km 1, Jalan Repok.

This prohibition by the Sarikei District Council (SDC) was posted 5 October 2010.

The notice of warning has been put up because the ponds are suspected to be contaminated with leptospirosis-causing bacteria, leptospira.

SDC chairman, Chan Kam Wuai, said the action taken was a precautionary measure following a suspicious find in the water that was sampled by the council’s Public Health Section.

According to him, the public health team had in the past few days collected samples of the water for a routine test. After something suspicious was detected, the council was prompted to take a precautionary measure by restricting the public from getting close to the pond, he explained.

I hope the public would not panic as it is just a precautionary measure. Furthermore, there is no case of leptospirosis reported in the district so far, he said.

He also called on the people to give full co-operation by abiding by the order, he stressed, adding that they should also advise their children not to get in contact with the water for the time being.

The people can still visit the Lake Garden as areas outside the restricted boundary including the canteen and recreational ground are considered safe.

Just stay away from the pond water till we are satisfied that it is free from contamination, he said.
(The Borneo Times 10/05/2010)

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New Zealand: E. coli in Avon River
Christchurch's Avon river has been labeled a health hazard, as authorities record dangerously high levels of E. Coli.

E. Coli readings should be under 270, but in some areas along the river, results show a count of 4500 - 17 times higher than normal.

Health authorities are warning that the public should steer clear of the river.

For recreational users it is not a good time to be on the water at the moment. We have occasionally had cases of people getting very sick, being in contact with the water now is the best time to stay away, medical health officer Dr Alistair Humphrey said.

The high reading is being blamed on human sewage entering the river from a pump station that was damaged in last month's devastating earthquake.

We know that it is human sewerage and that is the difference, we know that it is coming from humans, and therefore there could be viruses attached to it, Environment Canterbury's Tim Davie said.
(New Zealand Herald 10/11/2010)

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Russia: Outbreak of hemorrhagic fever with renal syndrome
Annually the incidence of hemorrhagic fever with renal syndrome (HFRS) in the Republic of Udmurtia is up to 10 times higher than the average figure for the whole of Russia, according to Rospotrebnadzor (Federal Service for Consumer Protection and Human Welfare). Annually about 2,000 people contract HFRS in the Republic. Human fatalities can also result from this infection. The main vector of the infection is the bank vole (Myodes glareolus), which migrates into human habitats with the onset of colder weather. Rospotrebnadzor recommends rodent extermination and enhanced hygiene as the only protective measures against this infection.
(ProMED 10/06/2010)

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Russia (Kazakhstan): Polio case discovered
A seven-year-old child in Southern Kazakhstan Oblast (SKO) has contracted polio, as reported 11 October 2010.

The ministry plans to immunize all children ages six to 15 in SKO districts bordering Uzbekistan. Tajikistan and Russia have registered 458 and 12 polio cases, respectively in 2010.
(Gazeta 10/12/2010)

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Americas
Canada (Nunavut): TB outbreak among Inuit
The Nunavut territory is seeing its worst tuberculosis outbreak in more than a decade, with 87 cases diagnosed so far in 2010. From 1 January to 30 September 2010, 87 TB cases were diagnosed in Nunavut, with 92 per cent of them [80 cases] in the Baffin region, said Elaine Randell, communicable disease consultant with Nunavut's Department of Health and Social Services. She added 40 of those cases were in Iqaluit, 27 in Cape Dorset, and the rest in other communities. Randell also said 15 to 24-year-olds were hit the hardest.

The outbreak peaked in May 2010. Only three TB cases were diagnosed in the territory in September. There seems to be a downward trend, although with TB, it's probably too early to tell but we're hoping that this is the beginning of a downward trend, Randell said. It would appear that Iqaluit and Cape Dorset both have their own strains. The outbreaks don't seem to be related.

2010’s surge in cases already surpasses the previous record set in 2008, when 58 people were diagnosed with TB. Nunavut has all the elements for a perfect storm when it comes to TB, Randell said. A high rate of infection among the Inuit, which places all the communities at risk for outbreaks. There are also social determinants for health -- the poverty, lack of access to healthy foods, and crowded housing conditions. Those factors make the territory ripe for this type of outbreak, she said.

She added they have traced anyone who might have been in contact with an infected person, sought other cases, and added staff to the busiest areas. Randell said they are also revising the TB manual for health care workers and developing a communications strategy. She said they have even offered taxi vouchers as incentives for people to come for treatment. For the most part, most of the clients have been very co-operative in helping us, she said. In Cape Dorset, mayor Cary Merritt, as the general manager of the local co-op, has provided food vouchers to the co-op's restaurant as an incentive for people to follow their treatment. It's helping making sure people come in to get their treatments on time, he said.

He said they are not so worried because they have a really good nurse in place right now. He said that she has been very proactive with making sure people come in and get their treatment: I believe she is really doing a good job bringing down the cases now and with the level of treatment, she's ensuring it's happening. I think we will see a drastic reduction now.

[ProMED note: Nunavut, the largest federal territory of Canada, is the size of Western Europe; it comprises a major portion of Northern Canada, and has an estimated population in 2010 of about 33,000, mostly Inuit. The territorial capital Iqaluit, which had a population in 2006 of 6,184, is on Baffin Island, which had a population of 11,000 in 2007. Cape Dorset is a town located on Dorset Island at the southern tip of Baffin Island with a population in 2006 of 1,236.

The TB incidence rate for the first nine months of 2010 is thus 727 per 100,000 in the Baffin region with 80 cases, 647 per 100,000 in Iqaluit with 40 cases, and 2,184 per 100,000 in Cape Dorset with 27 cases, whereas the annual incidence rate for Canada as a whole has been reported to be less than 5 per 100,000.

Aboriginal peoples in Canada comprise the Inuit, First Nations, and Metis (indigenous First People of Canada who trace their descent to mixed European and First Nations parentage) The 2006 census counted a total Canadian Aboriginal population of 1,172,790 (3.75 percent of the population), which includes 698,025 First Nations (2.23 percent), 389,785 Metis (1.25 percent), and 50,480 Inuit (0.16 percent).

Since the first contact with Europeans, the Canadian Aboriginals have had a disproportionately high burden of TB disease. For example, high incidence rates for TB have been reported among Aboriginals, mainly First Nations, in Northern Manitoba: specifically 48.4 per 100,000 overall, with rates as high as 496.3 per 100,000 in select communities.

In 2002, the Public Health Agency of Canada reported that from 1991-1999, of 17,590 new active and relapsed TB cases, 3013 (17 percent) occurred among Canadian-born Aboriginals (which constitute only 3.75 percent of the population). Of the remaining cases, 4,201 (24 percent) occurred in Canadian-born non-Aboriginals and 10,281 (58 percent) occurred in foreign-born individuals. Aboriginals with TB were younger (median 27 years) than foreign-born (median 39 years) and non-Aboriginals (median 59 years). In this report, drug resistant strains of TB had not yet emerged as a significant problem in this population. Less than two percent of reported cases were resistant to one or more drugs. The extent of HIV co-infection could not be estimated using data from this surveillance system. (HIV status was known for only two percent of reported Aboriginal cases.) In the 1990's, Aboriginal people were said to have an overall TB rate almost four times higher than the Canada-wide rate.

More recently, the situation has apparently worsened. In a news release in March 2010, the Inuit were reported to be the most at risk of tuberculosis infection with a rate that is 186 times higher than the non-aboriginal average. This is double what it was just four years ago. The high rates for TB in the Canadian Aboriginal population have been attributed to limited access to healthcare in remote regions, substandard housing, with whole families living in a single room, widespread poverty, and malnutrition.

The TB control plan described in the news release above seems inadequate for the situation. For example, the treatment plan in Nunavut relies on the patients self-administering medication. Because of the frequency of non-adherence to TB treatment regimens in all populations, directly observed therapy (DOTS) is the internationally recommended strategy for TB case management. DOTS requires an independent observer watching patients swallow each dose of their anti-TB therapy. The independent observer is not necessarily a healthcare worker; the person could be, for example, a tribal elder or similar senior person within that community. Because drug resistance and HIV co-infection may require modification of the TB treatment regimens, HIV status and drug resistance should be determined in each case, if not done already, in the current outbreak in Nunavut.

A program to prevent latent from becoming active disease should accompany early detection of cases of active tuberculosis and its prompt and complete treatment. Most cases of progression from latent TB to active tuberculosis occur within two to 12 months of initial infection. Children and adolescents are especially at high risk for progression to tuberculosis disease (with potential for disseminated disease). Most children with latent TB have been recently infected (especially those younger than age five years), usually from exposure to a person with active TB in their immediate environment, usually the household. Children exposed to active TB must be evaluated and treated for latent TB. TB control requires government commitment of funds and personnel more than a single nurse in the field for such a large and remote region, even though she may be "a really good nurse".]
(ProMED 10/04/2010)

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United States (Oregon): Bubonic plague case
State health officials say a woman in Lake County has been diagnosed with bubonic plague. It is the first diagnosis of plague in Oregon in 15 years. The disease terrorized Europe's population more than 600 years ago, but the plague is treatable when caught early.

Dr. Emilio DeBess is the public health veterinarian and an epidemiologist with the Oregon Department of Human Services. He says the disease, once known as the Black Death, got somewhat of a bad rap after killing off 1/3rd of Europe's population in the 1300s.

But he says that thanks to scientific advances, it's a very treatable condition with antibiotics, and so that's usually not a concern; back then, they didn't have antibiotics. We do have very good antibiotics that treat the infection.

DeBess says authorities are now trying to determine the source of the infection.

[ProMED note: Most cases of Y. pestis infections in the USA occur in the area of the "Four Corner" states: Colorado, Arizona, New Mexico and Utah, although California and to a lesser extent Oregon also may have cases.]
(ProMED 10/04/2010)

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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/

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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
Australia
Health authorities say 13 people have been diagnosed with dengue fever in Cairns in far north Queensland.

Twelve people from the inner city suburb of Parramatta Park have now been diagnosed with the mosquito-borne illness. Another case has been confirmed at nearby Cairns North. Teams of Queensland Health and council workers have inspected and sprayed hundreds of properties in the inner city area.

Medical entomologist Joe Davis says the Paramatta Park residents are all suffering from type 2 dengue fever, but the north Cairns resident has a different strain, type 1. The good news is that we don't have any more suspect or pending cases and no new onset of illness since the treatment has been in effect, which is good news, he said.

[ProMED note: Scott O'Neill of the University of Queensland in Brisbane, Australia and colleagues have found a fruit-fly bacterium called Wolbachia that infects Aedes mosquitoes and makes them less able to carry the dengue virus. It also halves their life span, which is crucial, as only older insects transmit virus. Wolbachia is passed on through the eggs of infected females, so only descendants of the released mosquitoes will carry it, O'Neill says. But dengue-free descendants should rapidly dominate, as Wolbachia-infected females have a competitive advantage: they can reproduce with infected or wild males, and wild females cannot. Infected mosquitoes will be released in Australia and Viet Nam.

Success of this approach will rest on the Wolbachia-infected mosquitoes being able to compete with or even out-compete uninfected individuals in nature. The results of the field trials is awaited with considerable interest.
(ProMED 10/12/2010)


China
When Xue-jie Yu came to China in 2009 to probe a lethal fever outbreak, everyone -- Yu included -- assumed he would provide damning testimony against a known suspect. Every summer for three years, hundreds of people in central China came down with an illness characterized by high fever and gastrointestinal (GI) distress. Many victims bled profusely, and an alarming number of the sick -- rough estimates are as high as 30 percent in some areas -- died. By early 2007, scientists at the Chinese Center for Disease Control and Prevention (CDC) here fingered the killer as human granulocytic anaplasmosis (HGA), an emerging bacterial infection from tick bites. But to Yu, an expert on tick-borne diseases at the University of Texas Medical Branch in Galveston, things didn't add up.

The fatality rate was too high, Yu says, and in his experience it was "rare" for HGA patients to have GI symptoms. Working at the Chinese CDC's National Institute of Communicable Disease Control and Prevention (NICDC) here, Yu tested blood samples for Anaplasma phagocytophilum, the HGA bacterium and came up empty. In December of 2009, his team identified a new kind of bunyavirus. The finding, in a paper submitted to The New England Journal of Medicine (NEJM), unmasks a dangerous new emerging virus.

Behind the scenes, however, a fierce argument has broken out over who discovered the virus. This summer, a Chinese CDC team led by hantavirus expert Li Dexin, director of the agency's Institute of Virology, also uncovered a bunyavirus. They have submitted a deeper analysis of the pathogen, including complete RNA sequences of 11 strains, to The Lancet. Yu charges Li's group with trying to rob him of the discovery.

Several key questions are disputed or unanswered. For starters, researchers do not know how lethal the virus is. The mortality rate may be high in China in part because clinics often prescribe the steroid dexamethasone to bring down high fevers; steroids suppress the immune system, which usually worsens infections. And although the infection shows a seasonal pattern associated with tick-borne diseases; cases begin in early spring and peak in midsummer before tapering off by autumn. The putative vector is still a mystery.

One indisputable fact is that the emerging disease has claimed scores of lives -- mostly of farmers -- in China's heartland. The first documented outbreak was in 2006, in Anhui Province. At that time, a HGA was suspected. Curiously, however, none of the patients recalled having been bitten by ticks. And when outbreaks recurred in 2007 and 2008, the disease did not respond to antibiotics.

That summer of 2009, the pathogen surfaced in Henan and Hubei provinces. In June, Yu went to Hubei's capital, Wuhan, to collect blood samples from patients. Yu spotted virus particles that December in cell culture using electron microscopy. Then in February 2010, he says, a member of his Texas lab, Yan Liu, cracked the code of the viral genome. Two days after he informed scientists at the Chinese CDC about his findings. Chinese CDC Director Wang Yu was intrigued by Xue-jie Yu's findings and invited him to share them at a 15 April 2010 meeting at CDC headquarters to plot strategy for studying the disease. Among the attendees were Li and CDC virologist Liang Mifang; they found Yu's presentation unconvincing. He said he isolated a bunyavirus, but he had gotten just fragments, says Liang. Yu confirms that the virologists were dismissive.

Yu and his colleagues have named the virus Dabie Mountain virus after the range that straddles the borders of Hubei, Anhui, and Henan provinces where they collected samples. But Yu was not invited back to China the summer of 2010 to continue his research. I am the first scientist to discover the viral pathogen for an emerging infectious disease who has no access to study the virus and the disease anymore, he says.

In May 2010, the Chinese CDC set up surveillance for the pathogen in Henan and Hubei provinces. The disease flared up in four other provinces as well, and Li's team collected blood and serum from all six affected provinces. They amplified viral RNA sequences and from more than 500 clones linked 14 to bunyavirus. They also isolated bunyavirus in cell culture and sequenced 11 strains. They have named it severe febrile and thrombocytopenic syndrome (SFTS) virus and have classified it in the Phlebovirus genus of bunyaviruses. Li's group also detected the virus in 35 patients from three provinces. They clearly show that a new virus is causing disease, says a U.S. scientist who has seen the data and asked to remain anonymous.

The squabbling has put Wang, the Chinese CDC's director, in an awkward position. There is no doubt, he says, that Xue-jie Yu discovered the novel bunyavirus. While noting that Yu's results are not as "rich" as Li's team's, Wang says everyone knows what a scientific breakthrough is, and what is accumulating work. After the NEJM paper is published, he hopes, other papers can go smoothly. But it may take Wang's best diplomatic skills to get any collaboration on the emerging virus to go smoothly.

[ProMED note: It is clear from these events that a novel bunyavirus belonging to the genus Phlebovirus is prevalent during the summer months in several central provinces of China that may be associated with an undiagnosed lethal disease distinct from the tick-transmitted bacterial human granulocytic anaplasmosis (HGA). The virus does not appear to be transmitted by ticks but the vector has not been identified, nor has the association of this virus with a 'severe febrile and thrombocytopenic syndrome' been unequivocally established. Once the dispute between the two groups (which has been simplified in this abbreviated account) investigating this virus has been resolved, some clarity may emerge. Interested readers are referred to the full account in 'Science'.

The different members of the genus Phlebovirus of the family Bunyaviridae are transmitted by phlebotomine flies, culicoides mosquitoes or ticks. The vector of the provisionally named Dabie Mountain phlebovirus has yet to be established.]
(ProMED 10/05/2010)


China
From 1-5 October 2010, 15 new confirmed cases of chikungunya fever, an insect borne virus, appeared in Dongguan City. The Department of Health of Guangdong Province reported on the evening of 6 October 2010that as of 4:00 p.m. on 5 October 2010, 204 total cases of the virus had been reported, 38 of which had been confirmed by a laboratory and 166 suspected, awaiting verification.

At present, all cases were mild. The patients are in stable condition and there have been no severe cases or deaths.

[ProMED note: This outbreak is continuing, with numbers of reported cases increasing from 10 on 4 October 2010 to the 38 confirmed and a total of 204 confirmed and suspected cases in the report above. ProMED-mail would be interested in receiving information about measures being taken to control the Aedes mosquito vectors. Since Aedes mosquitoes can transmit both chikungunya and dengue viruses, this area is at risk of dengue virus transmission as well.]
(ProMED 10/12/2010)


China
At least 38 people in Dongguan, an industrial city in south China's Guangdong Province, have been infected by the mosquito-borne chikungunya virus, the local health department has confirmed. Meanwhile, another 166 people were suspected of being infected and were still waiting for test results, the Guangdong Provincial Health Department announced 6 October 2010. Most of the infected suffered fevers, joint pains and rashes, it said. All the patients are in stable condition. There are no severe cases or deaths, it said.

Local health authorities have set up a task force of medical experts to oversee the treatment of the disease, it added.
(ProMED 10/08/2010)


India
With more than 600 cases being reported from Bhatu Kalan, Ratia and Tohana areas of the district, a malaria epidemic is under way. Stagnant water at several places, mostly in the rural areas after heavy rains and floods, is being blamed for the outbreak. The actual number of cases may be higher, however, as many patients are being treated in private hospitals and clinics.

The health department has started measures to create awareness among the people. The most number of cases have been reported from Bhattu Kalan. We have managed to contain the spread of malaria in other parts of the state, said Dr Narbir Singh, director general, Health Services (DGHS), Haryana.

Besides malaria, as many as 237 cases of dengue, 348 cases of Japanese encephalitis and 127 cases of swine flu have been reported from various parts of the state, mostly from Gurgaon and Faridabad districts.
(ProMED 10/11/2010)


India (Delhi)
As of 6 October 2010, Delhi reported 79 new cases of dengue, for a total of dengue cases to 3,782 for 2010, an official said.

[ProMED note: The actual number of cases is probably underreported.]
(ProMED 10/12/2010)


India (Uttar Pradesh)
Of the 35 blood samples collected from 25 September 2010 during the outbreak of undiagnosed fatal illness, 17 have been confirmed dengue positive by Ganesh Shankar Vidyarthi Memorial (GSVM) on 4 October 2010.
(ProMED 10/12/2010)


India (Uttar Pradesh, Lucknow)
As of Sun 10 October 2010, over 24 dengue patients have been admitted to different hospitals in the city, with three deaths.
(ProMED 10/12/2010)


Malaysia
Malaysia 13 October 2010 criticized the WHO for failing to tackle the spread of dengue in the region, which saw 242,000 cases of the mosquito-borne disease in 2009 and 831 deaths so far in 2010.

Health Minister Liow Tiong Lai, who is chairing a World Health Organization regional conference the week of 4 October 2010, said the UN body needed to push countries to adopt a more comprehensive strategy to deal with the threat.

We want them to do a lot more. We want the WHO to do more on dengue, we think they are not doing enough, he said at the meeting of the organization’s Asia Pacific member states.

Malaysia itself is reeling from a 53 per cent increase in dengue with about 38,000 cases and 117 deaths so far in 2010.

We want the WHO to implement more comprehensive measures to eradicate this communicable disease effectively. We urge the WHO to pay more attention to dengue, Mr Liow said.

He said that it is multi-pronged, it cannot just be handled by the health ministry, the WHO must come in forcefully and enable more governments to take the whole government approach. In some other countries they only leave dengue prevention to the health ministry. The WHO must enable a multi-agency, inter-ministry approach as well as a community approach to come in. It is not just one agency that can prevent dengue.' Mr Liow said the WHO was closely following Malaysia's proposed field trials later this year of genetically modified anti-dengue mosquitoes.
(The Straits Times 10/13/2010)


Philippines
Dengue cases continue to climb and have now reached 98,934 cases or 135 per cent higher than the same period in 2009 covering the months of January to 25 September 2010, the National Epidemiology Center (NEC) of the Department of Health (DoH) reported on 11 October 2010.

In 2009, there were only 42,075 nationwide. But health officials are still optimistic that cases will decline in the coming weeks. A total of 644 deaths were also registered within the same period in 2010.
(ProMED 10/11/2010)


Philippines
In light of the spike of dengue cases in Central Visayas, the Region Seven office of the Department of Health (DoH) has declared a dengue outbreak covering six barangays [smallest administrative division] in the region. The week of 27 September 2010 has been the peak season of the dengue cases and we already anticipated this given the average trend in the last five years, she said.

Meanwhile, DoH-7 regional epidemiology surveillance unit (RESU) nurse Rennan Cimafranca bared that dengue cases in the region remains high with 8,708 cases covering the months of January to 25 September 2010. It is 75.5 percent higher as compared to 2009 on the same period. However, fatalities are fewer this year, with only 63 deaths while last year RESU recorded 67. Cebu city tops the list with the most number of cases posting 27.4 percent out of the total cases followed by Tagbilaran City and Dumaguete City.

Meanwhile, the number of dengue cases recorded by the National Epidemiology Center (NEC) from January to 18 September 2010 reached 90,771, which is 124.37 percent higher compared to the same period in 2009. There were also 611 deaths registered by NEC. With this development, health officials asked residents of areas affected by water interruption to take caution on where they store water so as not to make breeding grounds of dengue-carrying mosquitoes. Our concern is for the parts of Quezon City that have no water for the next few days. The public should be very careful not only in the water that they will drink but the water that they will collect. They should be made aware that dengue mosquitoes breed in clean and stagnant water, health secretary Enrique T Ona said.

The DoH chief said there is now a downward dengue case trend in Western Visayas, Eastern Mindanao, and Central Visayas. This is also the same in Region 1 although in La Union, cases were reported to be increasing. Outbreaks of dengue were reported in La Union and Capiz, particularly in Roxas City.
(ProMED 10/04/2010)


Viet Nam
Despite a 6.3 per cent drop in the number of people infected with dengue fever over the same period in 2009, the disease has been growing more complex in different areas since the beginning of 2010. According to the Department for Preventive Health and the Environment, by early October 2010, Viet Nam has had around 80,000 cases of dengue fever, and 59 people have died of the disease, nine per cent higher than 2009’s death toll.

As in previous years, dengue fever is often seen in southern provinces, but the central and central highland regions have now become "hot spots" for the disease. The number of infected people in some central and central highland provinces is more than 21,600, up 168 per cent compared with the same period of 2009.

It is worth noting that the number of patients with more serious problems has increased sharply due to the widening circle of the disease; a dengue fever epidemic broke out in the northern region in 2009.

[ProMED note: The situation of the dengue epidemic in Viet Nam continues to be complicated. The reported number in nine months in 2010 for the country as a whole has decreased. However, it has increased in the central and the highland central regions. Both the number of deaths due to dengue and the number of serious problem in 2010 have increased compared with the same period in 2009.

These trends and differences might be due to the changes in the dengue surveillance system -- that is, a better system might be detecting more cases of dengue in highland central and central Viet Nam; severe cases or deaths are easier to report than less severe cases. PRO/MBDS would appreciate comments from a knowledgeable source on this moderator's assumption.

According to the WHO Regional Office for the Western Pacific report, a total of 12,868 cases and 12 deaths were reported in Viet Nam during 2010, as of 15 June 2010. During 2009, a total of 105 370 cases and 87 deaths from DF/DHF were reported in Viet Nam.
(ProMED 10/10/2010)

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CHOLERA, DIARRHEA, and DYSENTERY
Papua New Guinea
A fresh outbreak of cholera has been reported in East Sepik’s Yangoru-Saussia district with two confirmed cases the week of 4 October 2010.

Yangoru-Saussia program manager for health Francis Ipangu said that the first case was reported at Soli village where an adult male was diagnosed with the disease on 30 September 2010. He was admitted to the Wewak General Hospital where he was treated and later released after his condition improved.

The second case was discovered about a kilometer away at Yehimbole village where another adult male developed similar symptoms 7 October 2010.

He was also rushed to Wewak 8 October 2010 where he was on treatment at the hospital at Boram. Ipangu said clinical tests had confirmed both cases and people in the district should be careful with the basic hygiene practice.

He appealed to people to strictly observe basic hygiene rules, minimize unnecessary movement from villages and refrain from buying cooked food at the roadside or village markets in order to prevent the disease from spreading.

Meanwhile, a cholera task force had been set up in the district with local MP Peter Wararu committing K58,000 from his DSIP funds to stop the spread. District administrator Theo Kileyawi is the chairman of the task force and will be assisted by Ipangu. Ipangu said the task force team was in place and they were looking forward to setting up a care center when resources were made available the week of 11 October 2010 so that they would keep the patients in the districts instead of transporting them to Wewak.
(The National 10/11/2010)

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4. Articles
Effects of Adverse Events on the Projected Population Benefits and Cost-effectiveness of Using Live Attenuated Influenza Vaccine in Children Aged 6 Months to 4 Years
Prosser LA, Meltzer MI, Fiore A, et al. Arch Pediatr Adolesc Med. 4 October 2010.
doi:10.1001/archpediatrics.2010.182.
Available at http://archpedi.ama-assn.org/cgi/content/short/archpediatrics.2010.182

Objective. To evaluate the effect of adverse events associated with live attenuated influenza vaccine (LAIV) in children younger than 5 years on the cost-effectiveness of influenza vaccination.

Design. A decision analytic model was developed to predict costs and health effects of no vaccination, vaccination with LAIV, and vaccination with inactivated influenza vaccine (IIV). Probabilities, costs, and quality adjustments for uncomplicated influenza, outpatient visits, hospitalizations, deaths, vaccination, and vaccine adverse events were based on primary and published data. The analysis included the possible increased incidence of adverse events following vaccination with LAIV for children younger than 5 years, including fever, wheezing, and hospitalization. A societal perspective was used. Sensitivity analyses, including probabilistic sensitivity analysis, were conducted.

Setting. Vaccination in the physician office setting in the United States.

Participants. Hypothetical cohorts of healthy children aged 6 months to 4 years.

Intervention. Vaccination with LAIV or IIV.

Main Outcome Measure. Incremental cost-effectiveness ratio in dollars per quality-adjusted life-year (QALY).

Results. Cost-effectiveness ratios ranged from $20 000/QALY (age 6-23 months) to $33 000/QALY (age 3-4 years) for LAIV and from $21 000/QALY to $37 000/QALY for IIV for healthy children aged 6 months to 4 years. Inclusion of possible new adverse events for LAIV had varying effects on cost-effectiveness results. Results were not sensitive to the inclusion of wheezing as an adverse event but were sensitive to a possible increase in the probability of hospitalization.

Conclusion. Live attenuated influenza vaccine had comparable cost-effectiveness compared with IIV for children younger than 5 years under a wide range of assumptions about the incidence of adverse events.

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The Promise of Maternal Vaccination to Prevent Influenza in Young Infants
Ortiz JR, Neuzil KM. Arch Pediatr Adolesc Med. 4 October 2010.
doi:10.1001/archpediatrics.2010.193
Available at http://archpedi.ama-assn.org/cgi/content/short/archpediatrics.2010.193

Summary. Public health surveillance and scientific research in varied settings worldwide have consistently demonstrated the high burden of influenza-associated illness among infants. In the United States, children younger than 6 months have higher influenza-associated hospitalization rates than any other pediatric age group.1-5 In Gambia, 16% of children younger than 3 months hospitalized with respiratory symptoms had influenza virus infection,6 and in Thailand, children younger than 1 year were found to have more than 6 times the risk of hospitalization for influenza pneumonia compared with the general population.7 During the recent 2009 influenza A (H1N1) pandemic, high rates of influenza-associated hospitalizations in infants were also evident.

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Maternal Influenza Vaccination and Effect on Influenza Virus Infection in Young Infants
Eick AA, Uyeki TM, Klimov A, et al. Arch Pediatr Adolesc Med. 4 October 2010.
doi:10.1001/archpediatrics.2010.192.
Available at http://archpedi.ama-assn.org/cgi/content/short/archpediatrics.2010.192

Objective. To assess the effect of seasonal influenza vaccination during pregnancy on laboratory-confirmed influenza in infants to 6 months of age.

Design. Nonrandomized, prospective, observational cohort study.

Setting. Navajo and White Mountain Apache Indian reservations, including 6 hospitals on the Navajo reservation and 1 on the White Mountain Apache reservation.

Participants. A total of 1169 mother-infant pairs with mothers who delivered an infant during 1 of 3 influenza seasons.

Main Exposure. Maternal seasonal influenza vaccination.

Main Outcome Measures. In infants, laboratory-confirmed influenza, influenzalike illness (ILI), ILI hospitalization, and influenza hemagglutinin inhibition antibody titers.

Results. A total of 1160 mother-infant pairs had serum collected and were included in the analysis. Among infants, 193 (17%) had an ILI hospitalization, 412 (36%) had only an ILI outpatient visit, and 555 (48%) had no ILI episodes. The ILI incidence rate was 7.2 and 6.7 per 1000 person-days for infants born to unvaccinated and vaccinated women, respectively. There was a 41% reduction in the risk of laboratory-confirmed influenza virus infection (relative risk, 0.59; 95% confidence interval, 0.37-0.93) and a 39% reduction in the risk of ILI hospitalization (relative risk, 0.61; 95% confidence interval, 0.45-0.84) for infants born to influenza-vaccinated women compared with infants born to unvaccinated mothers. Infants born to influenza-vaccinated women had significantly higher hemagglutinin inhibition antibody titers at birth and at 2 to 3 months of age than infants of unvaccinated mothers for all 8 influenza virus strains investigated.

Conclusions. Maternal influenza vaccination was significantly associated with reduced risk of influenza virus infection and hospitalization for an ILI up to 6 months of age and increased influenza antibody titers in infants through 2 to 3 months of age.

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Authors' reply: Benefit and risks of trivalent 2010 seasonal influenza vaccine in Australian children
Kelly H, Carcione D, Dowse G, et al. Eurosurveillance. 7 October 2010; 15(40):pii=19681.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19681

To the editor. Dr Lopert from Australia’s regulatory body for therapeutic goods, the Therapeutics Goods Administration (TGA), raises a number of issues about our quantification of the risk-benefit ratio for seasonal trivalent influenza vaccines administered to children aged six months to four years in Australia in 2010 [1]. While we continue to believe the current data support vaccination of healthy children, it is important to conduct robust post-marketing surveillance, support an open scientific discussion of the observations, and ensure a rapid, comprehensive response to any potential adverse events following immunisation (AEFI).

The authors of the Cochrane review of influenza vaccine effectiveness in children have commented on the relative paucity in the public domain of good quality safety data on influenza vaccines for children aged less than five years [2]. Risk-benefit estimations, such as the approach we have explored, are also uncommon. However, one should not dismiss febrile convulsions as an adverse event. Febrile convulsions would be expected only rarely as demonstrated in a recent large population-based safety study which reported no significantly elevated risk for adverse events (including seizures in children) following administration of more than one million doses of trivalent influenza vaccine to children under the age of 18 years between 2005 and 2008 in the United States [3].

Our rapid communication to Eurosurveillance aimed to explore a method to quantify both risk and benefit [4] and was prompted by the TGA status report of 1 July 2010 that describes the investigation of an observed increase in febrile convulsions in young children following receipt of seasonal influenza vaccine in Australia [5] and contains a detailed analysis of risk by the vaccine manufacturer CSL Biotherapies. We did this after governments in New Zealand and Australia had recommended against using the CSL vaccines in children aged less than five years [4] and after the CSL vaccines had been licensed for use in the United States only for children nine years or older [6]. Our results support this decision. Moreover we indicated that our estimate of an unfavourable risk-benefit ratio applied only to one vaccine manufacturer in one year. Generalisation to wider vaccine programmes would have been inappropriate.

We chose to examine hospital admission for a febrile convulsion within 24 hours of receipt of seasonal influenza vaccine because hospital admission (or prolongation of hospital admission) is one of the four serious AEFI identified by the World Health Organization. The other three are death, permanent disability and any event that is life-threatening [7]. We acknowledge that hospital admission for febrile convulsion may be of shorter duration than hospital admission for influenza and that associated morbidity may be different, but suggest it is important not to underestimate the impact of either cause of hospital admission. It is also important to compare outcomes in the current context.

Since 2008, for reasons we outlined in our rapid communication, Western Australia has conducted a population-wide vaccination programme aimed at assessing the public health benefits of providing greater access to influenza vaccines for children under five years of age [8,9]. This is not a clinical trial, but a programme using influenza vaccines licensed for use pre-school aged children, evaluated by observational studies. It is consistent with recommendations in the Australian Immunisation Handbook which states: 'Annual influenza vaccination is recommended for any person > 6 months of age who wishes to reduce the likelihood of becoming ill with influenza' [10]. Universal vaccination of healthy children in this age cohort has been recommended by the Advisory Committee on Immunization Practices in the United States since 2006 [11]. Moreover a study from South Australia supports the need to evaluate a policy of providing influenza vaccine to healthy children, as well as those with known underlying conditions. The study demonstrated that 81% of children aged less than five years admitted to hospital with influenza between 1996 and 2006 had no documented risk factor that increased their risk of a serious outcome following infection [12]. We believe assessing risk and benefit will ultimately improve confidence in vaccine programmes.

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Impact of influenza vaccination of schoolchildren on medical outcomes among all residents of Maryland
King Jr JC, Lichenstein R, Cummings GE, et al. Vaccine. 8 October 2010.
doi:10.1016/j.vaccine.2010.09.064.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-5166DV1-1&_user=10&_coverDate=10%2F08%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=12da992d18f023a0dbc4f3d3bbbb3782&searchtype=a

Abstract. Special influenza vaccination programs of elementary school-aged children (ESAC) in some or all of Maryland Counties were conducted during the falls of 2005–2007. Rates of emergency department (E.D.) visits and hospitalizations for medically attended acute respiratory illnesses (MAARI) as well as deaths due to pneumonia and influenza for county residents were determined. The degree to which these rates were modulated during intense influenza outbreak periods (IIOP) in counties who vaccinated a greater percentage of ESAC was estimated using Poisson regression. Notably, for every 20% increase in vaccination rates, MAARI related E.D. visits during IIOP decreased by 8% (95% C.I., 5–12%) in children aged 5–11 years and by 6% (95% C.I., 3–8%) in adults aged 19–49 years (p < 0.001), which suggests both a direct and indirect benefit of the vaccination programs. In contrast, MAARI related hospitalizations increased during IIOP by 4% (95% C.I., 3–9%) in adults aged >50 years for every 20% increase in vaccination rates (p < 0.023) for which we have no plausible biologic explanation. No significant changes in deaths were noted.

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Influenza vaccination for healthcare workers who work with the elderly: Systematic review
Thomas RE, Jefferson T, Lasserson TJ. Vaccine. 10 October 2010.
doi:10.1016/j.vaccine.2010.09.085.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-516MBVJ-7&_user=10&_coverDate=10%2F10%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=67da1853d7d96d73b0e6d55adec43dd4&searchtype=a

Aim. To identify studies of influenza vaccination of HCWs and influenza in elderly residents in long-term care facilities.

Scope. We searched seven electronic databases for randomised controlled trials (RCTs) and non-RCTs. Two reviewers independently extracted data and assessed trial quality.

Conclusions. The key outcomes are serologically proven influenza, pneumonia, and deaths from pneumonia, and pooled data from three C-RCTs showed no effect. Pooled data from three C-RCTs showed lower resident all-cause mortality, but as influenza constituted less than 10% of all deaths even in epidemic years we question the appropriateness of this outcome measure. Pooled data from three C-RCTs showed vaccination of HCWs reduced ILI and data from one C-RCT that HCW vaccination reduced GP consultations for ILI, but as influenza constitutes less than 25% of ILI and we did not show that HCW influenza vaccination reduced serologically proven influenza we question whether this effect is due to confounding.

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Household Transmission of the 2009 Pandemic A/H1N1 Influenza Virus: Elevated Laboratory‐Confirmed Secondary Attack Rates and Evidence of Asymptomatic Infections
Papenburg J, Baz Mariana, Hamelin M-E, et al. Clin Infect Dis. 1 October 2010. 51:1033–1041.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/656582

Background. Characterizing household transmission of the 2009 pandemic A/H1N1 influenza virus (pH1N1) is critical for the design of effective public health measures to mitigate spread. Our objectives were to estimate the secondary attack rates (SARs), the proportion of asymptomatic infections, and risk factors for pH1N1 transmission within households on the basis of active clinical follow‐up and laboratory‐confirmed outcomes.

Methods. We conducted a prospective observational study during the period May–July 2009 (ie, during the first wave of the pH1N1 pandemic) in Quebec City, Canada. We assessed pH1N1 transmission in 42 households (including 43 primary case patients and 119 contacts). Clinical data were prospectively collected during serial household visits. Secondary case patients were identified by clinical criteria and laboratory diagnostic tests, including serological and molecular methods.

Results. We identified 53 laboratory‐confirmed secondary case patients with pH1N1 virus infection, for an SAR of 45% (95% confidence interval [CI], 35.6%–53.5%). Thirty‐four (81%) of the households had 1 confirmed secondary case patient. The mean serial interval between onset of primary and confirmed secondary cases was 3.9 days (median interval, 3 days). Influenza‐like illness (fever and cough or sore throat) developed in 29% (95% CI, 20.5%–36.7%) of household contacts. Five (9.4%) of secondary case patients were asymptomatic. Young children (<7 years of age) were at highest risk of developing laboratory‐confirmed influenza‐like illness. Primary case patients with both diarrhea and vomiting were the most likely to transmit pH1N1.

Conclusion. Household transmission of pH1N1 may be substantially greater than previously estimated, especially in association with clinical presentations that include gastrointestinal complaints. Approximately 10% of pH1N1 infections acquired in the household may be asymptomatic.

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Seasonal Influenza Vaccine and Increased Risk of Pandemic A/H1N1‐Related Illness: First Detection of the Association in British Columbia, Canada
Janjua NZ, Skowronski DM, Hottes TS, et al. Clin Infect Dis. 1 October 2010. 51:1017–1027.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/656586

Background. In April 2009, an elementary school outbreak of pandemic H1N1 (pH1N1) influenza was reported in a community in northern British Columbia, Canada—an area that includes both non‐Aboriginal and Aboriginal residents living on or off a reserve. During the outbreak investigation, we explored the relationship between prior receipt of trivalent inactivated influenza vaccine (TIV) and pH1N1‐related illness.

Methods. A telephone survey was conducted from 15 May through 5 June 2009 among households of children attending any school in the affected community. Members of participating households where influenza‐like illness (ILI) was described were then invited to submit blood samples for confirmation of pH1N1 infection by hemagglutination inhibition and microneutralization assays. Circulation of pH1N1 was concentrated among households of the elementary school and elsewhere on‐reserve to which analyses of TIV effect were thus restricted. Odds ratios (ORs) for the TIV effect on ILI were computed through logistic regression, with adjustment for age, comorbidity, household density, and Aboriginal status. The influence of within‐household clustering was assessed through generalized‐linear‐mixed models.

Results. Of 408 participants, 92 (23%) met ILI criteria: 29 (32%) of 92 persons with ILI, compared with 61 (19%) 316 persons without ILI, had received the 2008–2009 formulation of TIV. Fully adjusted ORs for 2008–2009 TIV effect on ILI were 2.45 (95% confidence interval, 1.34–4.48) by logistic regression and 2.68 [95% confidence interval, 1.37–5.25) by generalized‐linear‐mixed model.

Conclusions. An outbreak investigation in British Columbia during the late spring of 2009 provided the first indication of an unexpected association between receipt of TIV and pH1N1 illness. This led to 5 additional studies through the summer 2009 in Canada, each of which corroborated these initial findings.

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Pandemic A(H1N1) 2009 influenza: review of the Southern Hemisphere experience
Falagas ME, Koletsi PK, Baskouta E, et al. Epidemiology and Infection. 5 October 2010.doi: 10.1017/S0950268810002037.
Available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=7910105

Summary. We sought to systematically review the published literature describing the epidemiological aspects of the first wave of pandemic A(H1N1) 2009 influenza in the Southern Hemisphere. Fifteen studies were included in this review, originating from South America, Australia or New Zealand, and Africa. Across the different studies, 16·8–45·3% of the laboratory-confirmed cases were admitted to hospital, and 7·5–26·0% of these cases were admitted to intensive care units (ICUs). The fatality rate was 0·5–1·5% for laboratory-confirmed cases in 6/8 studies reporting specific relevant data, and 14·3–22·2% for cases admitted to ICUs in 5/7 studies, respectively. In 4/5 studies the majority of laboratory-confirmed cases were observed in young and middle-aged adults, the percentage of older adults increased the higher the level of healthcare the cases received (e.g. laboratory confirmation, hospitalization or ICU admission) or for fatal cases. Many of the cases had no prior comorbidity, including conditions identified as risk factors for seasonal influenza. Pregnant women represented 7·4–9·1% and 7·1–9·1% of unselected laboratory-confirmed cases and of those admitted to ICUs, respectively. Obesity and morbid obesity were more commonly reported as the level of healthcare increased.

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Reflections on Pandemic (H1N1) 2009 and the International Response
Leung GM, Nicoll A. PLoS. Med. 5 October 2010.7(10): e1000346.
doi:10.1371/journal.pmed.1000346.
Available at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000346

Summary Points. Many of the initial responses to the 2009 H1N1 pandemic went well but there are many lessons to learn for future pandemic planning. Clear communication of public health messages is crucial, and should not confuse what could happen (and should be prepared for) with what is most likely to happen. Decisions regarding pandemic response during the exigencies of a public health emergency must be judged according to the best evidence available at the time. Revising pandemic plans—to be more flexible and more detailed—should wait for WHO leadership if national plans are not to diverge. Surveillance beyond influenza should be stepped up, and contingencies drawn up for the emergence or re-emergence of other novel and known pathogens.

Data collection and sharing are paramount, and include epidemiological and immunological data. Clinical management of severe influenza disease should not be limited to the current antiviral regimen, and include the development of other therapeutics (e.g., novel antivirals and immunotherapy).

Greater and more timely access to antivirals and influenza vaccines worldwide remains an ongoing challenge.

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Seroprevalence of 2009 pandemic influenza A(H1N1) virus in Australian blood donors, October – December 2009
McVernon J, Laurie K, Nolan T, et al. Eurosurveillance. 7 October 2010. 15(40):pii=19678.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19678

Summary. Assessment of the severity of disease due to the 2009 pandemic influenza A(H1N1) in Australian states and territories has been hampered by the absence of denominator data on population exposure. We compared antibody reactivity to the pandemic virus using haemagglutination inhibition assays performed on plasma specimens taken from healthy adult blood donors (older than 16 years) before and after the influenza pandemic that occurred during the southern hemisphere winter. Pre-influenza season samples (April – May 2009, n=496) were taken from donation collection centres in North Queensland (in Cairns and Townsville); post-outbreak specimens (October – November 2009, n=779) were from donors at seven centres in five states. Using a threshold antibody titre of 40 as a marker of recent infection, we observed an increase in the influenza-seropositive proportion of donors from 12% to 22%, not dissimilar to recent reports of influenza A(H1N1)-specific immunity in adults from the United Kingdom. No significant differences in seroprevalence were observed between Australian states, although the ability to detect minor variations was limited by the sample size. On the basis of these figures and national reporting data, we estimate that approximately 0.23% of all individuals in Australia exposed to the pandemic virus required hospitalisation and 0.01% died. The low seroprevalence reported here suggests that some degree of prior immunity to the virus, perhaps mediated by broadly reactive T-cell responses to conserved influenza viral antigens, limited transmission among adults and thus constrained the pandemic in Australia

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Inside the Outbreak of the 2009 Influenza A (H1N1)v Virus in Mexico
Zepeda-Lopez HM, Perea-Araujo L, Miliar-Garcia A, et al. PloS Med. 8 October 2010. 5(10): e13256.
doi:10.1371/journal.pone.0013256.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0013256

Background. Influenza viruses pose a threat to human health because of their potential to cause global disease. Between mid March and mid April a pandemic influenza A virus emerged in Mexico. This report details 202 cases of infection of humans with the 2009 influenza A virus (H1N1)v which occurred in Mexico City as well as the spread of the virus throughout the entire country.

Methodology and Findings. From May 1st to May 5th nasopharyngeal swabs, derived from 751 patients, were collected at 220 outpatient clinics and 28 hospitals distributed throughout Mexico City. Analysis of samples using real time RT-PCR revealed that 202 patients out of the 751 subjects (26.9%) were confirmed to be infected with the new virus. All confirmed cases of human infection with the strain influenza (H1N1)v suffered respiratory symptoms. The greatest number of confirmed cases during the outbreak of the 2009 influenza A (H1N1)v were seen in neighbourhoods on the northeast side of Mexico City including Iztapalapa, Gustavo A. Madero, Iztacalco, and Tlahuac which are the most populated areas in Mexico City. Using these data, together with data reported by the Mexican Secretariat of Health (MSH) to date, we plot the course of influenza (H1N1)v activity throughout Mexico.

Conclusions. Our data, which is backed up by MSH data, show that the greatest numbers of the 2009 influenza A (H1N1) cases were seen in the most populated areas. We speculate on conditions in Mexico which may have sparked this flu pandemic, the first in 41 years. We accept the hypothesis that high population density and a mass gathering which took in Iztapalapa contributed to the rapid spread of the disease which developed in three peaks of activity throughout the Economy.

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Healthcare workers as parents: attitudes toward vaccinating their children against pandemic influenza A/H1N1
Torun SD, Torun F, Catak B. BMC Public Health. 10 October 2010.
doi:10.1186/1471-2458-10-596.
Available at http://www.biomedcentral.com/1471-2458/10/596

Background. Both the health care workers (HCWs) and children are target groups for pandemic influenza vaccination. The coverage of the target populations is an important determinant for impact of mass vaccination. The objective of this study is to determine the attitudes of HCWs as parents, toward vaccinating their children with pandemic influenza A/H1N1 vaccine.

Methods. A cross-sectional questionnaire survey was conducted with health care workers (HCWs) in a public hospital during December 2009 in Istanbul. All persons employed in the hospital with or without a health-care occupation are accepted as HCW. The HCWs who are parents of children 6 months to 18 years of age were included in the study. Pearson's chi-square test and logistic regression analysis was applied for the statistical analyses.

Results. A total of 389 HCWs who were parents of children aged 6 months-18 years participated study. Among all participants 27.0 % (n=105) reported that themselves had been vaccinated against pandemic influenza A/ H1N1. Two third (66.1%) of the parents answered that they will not vaccinate their children, 21.1 % already vaccinated and 12.9% were still undecided. Concern about side effect was most reported reason among who had been not vaccinated their children and among undecided parents. The second reason for refusing the pandemic vaccine was concerns efficacy of the vaccine. Media was the only source of information about pandemic influenza in nearly one third of HCWs. Agreement with vaccine safety, self receipt of pandemic influenza A/H1N1 vaccine, and trust in Ministry of Health were found to be associated with the positive attitude toward vaccinating their children against pandemic influenza A/H1N1.

Conclusions. Persuading parents to accept a new vaccine seems not be easy even if they are HCWs. In order to overcome the barriers among HCWs related to pandemic vaccines, determination of their misinformation, attitudes and behaviors regarding the pandemic influenza vaccination is necessary. Efforts for orienting the HCWs to use evidence based scientific sources, rather than the media for information should be considered by the authorities.

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Healthcare workers as parents: attitudes toward vaccinating their children against pandemic influenza A/H1N1
Torun SD, Torun F, Catak B. BMC Public Health. 10 October 2010.
doi:10.1186/1471-2458-10-596.
Available at http://www.biomedcentral.com/1471-2458/10/596

Background. Both the health care workers (HCWs) and children are target groups for pandemic influenza vaccination. The coverage of the target populations is an important determinant for impact of mass vaccination. The objective of this study is to determine the attitudes of HCWs as parents, toward vaccinating their children with pandemic influenza A/H1N1 vaccine.

Methods. A cross-sectional questionnaire survey was conducted with health care workers (HCWs) in a public hospital during December 2009 in Istanbul. All persons employed in the hospital with or without a health-care occupation are accepted as HCW. The HCWs who are parents of children 6 months to 18 years of age were included in the study. Pearson's chi-square test and logistic regression analysis was applied for the statistical analyses.

Results. A total of 389 HCWs who were parents of children aged 6 months-18 years participated study. Among all participants 27.0 % (n=105) reported that themselves had been vaccinated against pandemic influenza A/ H1N1. Two third (66.1%) of the parents answered that they will not vaccinate their children, 21.1 % already vaccinated and 12.9% were still undecided. Concern about side effect was most reported reason among who had been not vaccinated their children and among undecided parents. The second reason for refusing the pandemic vaccine was concerns efficacy of the vaccine. Media was the only source of information about pandemic influenza in nearly one third of HCWs. Agreement with vaccine safety, self receipt of pandemic influenza A/H1N1 vaccine, and trust in Ministry of Health were found to be associated with the positive attitude toward vaccinating their children against pandemic influenza A/H1N1.

Conclusions. Persuading parents to accept a new vaccine seems not be easy even if they are HCWs. In order to overcome the barriers among HCWs related to pandemic vaccines, determination of their misinformation, attitudes and behaviors regarding the pandemic influenza vaccination is necessary. Efforts for orienting the HCWs to use evidence based scientific sources, rather than the media for information should be considered by the authorities.

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Health service resource needs for pandemic influenza in developing countries: a linked transmission dynamics, interventions and resource demand model
Krumkamp R, Kretzschmar M, Rudge JW, et al. Epidemiology and Infection. 5 October 2010.doi: 10.1017/S0950268810002220.
Available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=7911466

Summary. We used a mathematical model to describe a regional outbreak and extrapolate the underlying health-service resource needs. This model was designed to (i) estimate resource gaps and quantities of resources needed, (ii) show the effect of resource gaps, and (iii) highlight which particular resources should be improved. We ran the model, parameterized with data from the 2009 H1N1v pandemic, for two provinces in Thailand. The predicted number of preventable deaths due to resource shortcomings and the actual resource needs are presented for two provinces and for Thailand as a whole. The model highlights the potentially huge impact of health-system resource availability and of resource gaps on health outcomes during a pandemic and provides a means to indicate where efforts should be concentrated to effectively improve pandemic response programmes.

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5. Notifications
APEC Hot Topics Videoconference
Videoconference, 2 December 2010 (3 December 2010 in Asian countries)
The next APEC Hot Topics Videoconference will convene APEC countries in discussing emerging infectious diseases as a result of climate change and natural disasters. Case studies and accounts of country experiences are being sought from APEC countries.
Additional information available by emailing apecein@u.washington.edu

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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