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Vol. XIII No. 22 ~ EINet News Briefs ~ Oct 29, 2010


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

1. Influenza News
- 2010 Cumulative number of human cases of avian influenza A/H5N1
- Global: Pandemic H1N1 influenza activity remains low worldwide
- Global: Influenza H3N2 continues to be most common influenza strain
- Global: EU committee recommends FluMist approval for children
- Global: H1N1 pandemic influenza still a threat in some countries
- Indonesia: Health Ministry reports two H5N1 avian influenza deaths
- India (Hyderabad): Bharat Biotech launches cell-based influenza vaccine
- Japan: Influenza drug goes on sale
- Mexico (Mexico City): Sanofi opens influenza vaccine plant in Mexico
- United States: Influenza vaccines called generally safe for egg-allergic patients
- United States: CDC sees low influenza activity, with all three types in the mix
- United States: Groups promote election-day influenza clinics
- United States: Health group launches influenza resource for businesses
- United States (Michigan): Doctors raise concerns about slow seasonal influenza vaccine deliveries
- United States (Michigan): Detroit officials nix high-dose influenza vaccine for seniors
- Cameroon: Cameroon launches 2009 H1N1 pandemic influenza vaccine campaign

2. Infectious Disease News
- Australia (Queensland): Pertussis outbreak continues
- Australia (Victoria ): Investigations continue in hepatitis C cases
- Indonesia: More than 100 dead in wake of tsunami
- Russia (Tatarstan): Hemorrhagic fever with renal syndrome
- Canada (London): Norovirus outbreak suppressed
- United States (California): Pertussis outbreak continues, but is being reined in
- United States (New York): Tuberculosis case reported at a school

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

4. Articles
- Association Between Medicaid Reimbursement and Child Influenza Vaccination Rates
- Reflections on the influenza vaccination of healthcare workers
- Prevalence of seroprotection against the pandemic (H1N1) virus after the 2009 pandemic
- A New Pandemic Influenza A(H1N1) Genetic Variant Predominated in the Winter 2010 Influenza Season in Australia, New Zealand, and Singapore
- Estimates of the True Number of Cases of Pandemic (H1N1) 2009, Beijing, China
- The Infection Attack Rate and Severity of 2009 Pandemic H1N1 Influenza in Hong Kong
- Acute Encephalopathy and Pandemic (H1N1) 2009 [letter]
- Low Pathogenic Avian Influenza (H7N1) Transmission Between Wild Ducks and Domestic Ducks
- An Avian Outbreak Associated with Panzootic Equine Influenza in 1872: An Early Example of Highly Pathogenic Avian Influenza?
- Combining Spatial-Temporal and Phylogenetic Analysis Approaches for Improved Understanding on Global H5N1 Transmission

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 / 8 (7)
Viet Nam 7 (2)
Total / 39 (20)

***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: 507 (302)
(WHO 10/18/10 http://www.who.int/csr/disease/avian_influenza/country/cases_table_2010_10_18/en/index.html

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

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

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

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Global: Pandemic H1N1 influenza activity remains low worldwide
Global influenza activity has yet to heat up in the Northern Hemisphere and is tailing off in the Southern Hemisphere. Canada and Europe are reporting low flu levels, with only 2 of 161 respiratory samples (1.2%) testing positive in Europe. Chile, South Africa, and New Zealand are reporting sharp drops in flu activity, and Australia and Thailand are reporting declining activity. More than two-thirds of influenza in Australia is pandemic 2009 H1N1.
(CIDRAP 10/21/2010)

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Global: Influenza H3N2 continues to be most common influenza strain
Flu activity is continuing to decline in the Southern Hemisphere and remains low in the Northern Hemisphere, while influenza A/H3N2 remains the most common strain detected. Most tropical countries reported decreased activity, but some countries in Southeast Asia and Central and South America, including Jamaica, Colombia, Cambodia, and Thailand, reported an increase, mainly involving H3N2 cases. In North America, Canada had a slight increase in flu-like illness activity. Thirty-five countries reported a total of 2,415 specimens that tested positive for flu during the two-week period. Of these, 89.7% were influenza A and 10.3% were influenza B. Of the influenza A viruses that were subtyped, 84.5% were H3N2 and 15.5% were 2009 H1N1. In the United States, 24 states described flu activity as sporadic, while 26 states listed no flu activity for the week. Of 92 flu isolates that were reported, 24 were influenza B and 68 were influenza A. Of the influenza A isolates, 11 were 2009 H1N1, 18 were H3N2, and 39 were not subtyped.
(CIDRAP 10/21/2010)

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Global: EU committee recommends FluMist approval for children
AstraZeneca announced on 22 October 2010 that the advisory panel for Europe's drug regulatory agency has recommended approval of its inhaled flu vaccine, Fluenz—known as FluMist and marketed by MedImmune in the United States—for children ages 2 to 18. The committee forwarded its recommendation to the European Commission, which makes final approval decisions, usually within a few months. In making its recommendation, the Committee for Medicinal Products for Human Use (CHMP) reviewed data from 73 global clinical studies and postmarketing studies conducted in 38 countries.
(CIDRAP 10/22/2010)

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Global: H1N1 pandemic influenza still a threat in some countries
Although health officials are anticipating that influenza A (H3N2) may play a greater role in the Northern Hemisphere's flu season, the 2009 H1N1 virus is still dominant and active in some parts of the world. Australia said some surveillance reports show that flu activity is increasing, while other systems show that circulation is declining. Activity is highest in South Australia state, and hospitalizations have increased slightly. About 67% of the respiratory specimens that tested positive for flu were the 2009 H1N1 strain. The country has experienced a late-season surge in flu infections. Meanwhile, health officials in Zimbabwe reported fresh outbreaks of 2009 H1N1 in all of the country's provinces. A remote southern district has reported 300 cases in school children. An epidemiologist with Zimbabwe's health ministry stated that the country's flu season typically runs from May through September and that she suspected that the H3N2 seasonal flu virus is circulating in the country, as well. Elsewhere, India reported another decline in 2009 H1N1 flu cases and deaths. The country's health ministry said cases declined in the week ending 17 October 2010 for the fifth week in a row.
(CIDRAP 10/19/2010)

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Asia
Indonesia: Health Ministry reports two H5N1 avian influenza deaths
Indonesia's health ministry recently announced two new H5N1 avian influenza deaths, both in adults. The first is a 35-year-old man from West Jakarta who got sick in mid-August, was hospitalized 20 August, and died on 27 August 2010. Investigators found that sudden chicken deaths had occurred around the man's house a week before he became ill. The other victim is a 40-year-old woman from Kota Depok, West Java, who got sick 9 September, was hospitalized 12 September, and died on 17 September 2010. The initial probe into the source of her infection suggests she may have been exposed to the virus at a live bird market. Kota Depok is part of an urban area that surrounds Jakarta. Indonesia's H5N1 total now stands at 170 cases and 141 deaths, both of which are the highest in the world.
(CIDRAP 10/18/2010)

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India (Hyderabad): Bharat Biotech launches cell-based influenza vaccine
Bharat Biotech, based in Hyderabad, India, announced on 17 October 2010 the launch of the country's first cell-culture 2009 H1N1 vaccine. The company said the vaccine marks the first cell-based vaccine to be made in a developing country. Indian drug regulators cleared the vaccine for marketing in early October 2010. The single-dose vaccine is available through the private sector and government agencies. Dr Krishna Ella, Bharat's chairman and managing director, said that many people in India have not been vaccinated against the 2009 H1N1 virus yet. He added that the company expects demand for flu vaccines in India to rise, because consumers have become more aware of the disease.
(CIDRAP 10/18/2010)

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Japan: Influenza drug goes on sale
The Japanese pharmaceutical company Daiichi Sankyo launched its newly licensed, long-acting influenza drug, laninamivir (Inavir), in Japan on 19 October 2010. The company plans to produce enough of the drug to treat about four million people. The launch raises the number of flu drugs available in Japan to four, with the total supply expected to be enough for 23 million people. Japanese authorities approved laninamivir, a neuraminidase inhibitor, in September 2010. Studies have indicated that one inhaled dose of the drug is about as effective as five days of treatment with oseltamivir, the most widely used flu drug, according to previous reports. Japan approved another new neuraminidase inhibitor, peramivir, which is given intravenously, in January 2010. Peramivir is currently in phase three clinical trials in the United States and was used on an emergency basis during the 2009 H1N1 pandemic.
(CIDRAP 10/20/2010)

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Americas
Mexico (Mexico City): Sanofi opens influenza vaccine plant in Mexico
Sanofi Pasteur has opened a $140 million facility to make influenza vaccines in Mexico City. Mexican President Felipe Calderon said the plant will improve Mexico's preparedness for flu pandemics. Sanofi Pasteur said the facility will make 30 million doses of antigen annually and that a government-run manufacturer will finish the production steps and distribute the vaccines. The plant was built outside Mexico City and inaugurated 15 October 2010.
(CIDRAP 10/18/2010)

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United States: Influenza vaccines called generally safe for egg-allergic patients
Most people with an egg allergy can safely receive an influenza vaccine, and they don't need a skin test first, according to new recommendations from the American Academy of Allergy, Asthma and Immunology (AAAAI).

Medical authorities have long urged caution concerning flu shots for those with egg allergies because of the concern that residual egg protein in the vaccines, which are grown in eggs, might cause a reaction. But the AAAAI says several recent studies have shown that egg-allergic people can be safely vaccinated.

The guidelines advise that allergic patients can be vaccinated with either a two-step, graded approach or with a single dose, followed in either case by 30 minutes of observation for allergic symptoms. The guidelines were prepared by Matthew J. Greenhawt, MD, MBA, of the University of Michigan in Ann Arbor, and James T. Li, MD, PhD, of the Mayo Clinic in Rochester, Minn.

The AAAAI statements says that there has been tremendous growth over 2010 in demonstrating that TIV [trivalent influenza vaccine] (and H1N1 [vaccine]) are safe for egg allergic individuals to receive. Additionally, while a few concepts bear further study, such as the safety of these vaccines in individuals with severe allergy to egg, it appears that most egg allergic patients can safety receive influenza vaccination if desired.

The group recommends use of the vaccine containing the lowest amount of ovalbumin, even though there is no conclusive evidence that ovalbumin is what triggers adverse reactions to flu vaccine in egg-allergic people. Most manufacturers now list the ovalbumin content for each vaccine lot, and studies last year showed that the listed amounts were accurate, the statement says.

The AAAAI experts also say egg-allergic people no longer routinely need skin testing for sensitivity to the vaccine before they are immunized. They stated that although skin testing has been used successfully in the past, recent data have indicated that neither prick testing nor intradermal skin testing using the vaccine is predictive of one's ability to tolerate the vaccine, nor was testing necessary to receive a booster dose from a different lot than the original dose.

The statement recommends that patients who have a history of suspected egg allergy be evaluated by an allergist. But even if the egg allergy is confirmed, the patient can still be vaccinated using either the two-dose or single-dose protocol followed by observation.

The two-step approach involves first giving the patient 10% of the age-appropriate dose, waiting 30 minutes, and then, if no symptoms develop, following up with a 90% dose. The patient should be observed for another 30 minutes after the second dose. If a reaction occurs after any step, further steps should be withheld and the patient should be referred to a vaccine allergy expert, the AAAAI advises.

The current flu vaccine information statement from the Centers for Disease Control and Prevention (CDC) says people with severe egg allergy should not be vaccinated. The AAAAI says three recent studies have indicated that flu vaccines are safe even for such patients, but the study samples were small.

The AAAAI statement said that while these results are promising, they must be interpreted cautiously given the sample size. Also adding that a multi-center trial further examining this issue is under way in the United States.

The authors say present evidence suggests that administering the vaccine in more than two steps is probably unnecessary, but multiple-step protocols remain an option for providers who are concerned about particular patients, such as those with a history of anaphylactic reaction to flu shots.
(CIDRAP 10/15/2010)

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United States: CDC sees low influenza activity, with all three types in the mix
Flu is circulating at low levels in the United States, with the 2009 H1N1 virus appearing sporadically along with H3N2 and influenza B strains, the US Centers for Disease Control and Prevention (CDC) said in its first official surveillance report of the new season.

Flu activity is sporadic in 19 states, the District of Columbia, Guam, and Puerto Rico, with 31 states reporting no flu activity. The number of outpatient visits for flu is below the national baseline, and flu- and pneumonia-related deaths are below the epidemic threshold. No pediatric deaths were reported.

In its review of ILINet state flu activity data, which allows the CDC to compare outpatient visits for flulike illnesses in each state with averages for spring and fall periods with little or no flu activity, activity was at minimal levels in 48 states and New York City. There weren’t enough data to gauge activity levels in the District of Columbia, Kentucky, and Maryland.

The CDC also included links to other surveillance sources in its weekly update. The Distribute Project, a syndromic surveillance collaboration between the CDC and the International Society for Disease Surveillance, suggested that emergency department visits for flulike illnesses were up in the region that includes Colorado, Montana, the Dakotas, Utah, and Wyoming. Meanwhile, Google Flu Trends suggested that flu activity across the nation is low, with levels normally seen in October. Google Flu Trends measures flu-related Web searches.

About 3% of respiratory specimens tested were positive for influenza, the CDC said. Among the influenza A samples, about 13% were the 2009 H1N1 virus, 16% were H3N2, and 71% weren't subtyped. Influenza B accounted for about 33% of the positive samples.

Most of the viruses were closely related to components included in the 2010 season's Northern Hemisphere flu vaccine. About three quarters of the influenza B viruses that were subtyped belonged to the Victoria lineage, which is included in the vaccine.

In other flu-related developments, Minnesota health officials warned that a greater proportion of H3N2 viruses circulating in the nation in 2010 could make for a difficult flu season for the elderly.

Dr Ruth Lynfield, Minnesota's state epidemiologist, stated that in years when there has been primarily H3 influenza A circulating, we've seen higher rates of serious illness, particularly in the elderly. Lynfield urged people who live with or care for the elderly, especially healthcare workers, to receive the seasonal flu vaccine.

US and global health officials have been tracking a rising percentage of flu infections caused by the H3N2 virus. CDC officials have said they expect to see more of the virus in the United States in the 2010 season, which they say could portend a more difficult season and is another reason for the public to get vaccinated.

The CDC said in a 14 October 2010 vaccine supply update that 129 million flu vaccine doses have already been distributed. Vaccine companies expect to make about 160 to 165 million vaccine doses for the US market this season, a record number. 2010 is the first year of the federal government's universal flu vaccination recommendation; all people age six months and older are urged to receive the vaccine.
(CIDRAP 10/18/2010)

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United States: Groups promote election-day influenza clinics
Two national nonprofit groups have teamed up again to encourage flu vaccination at US polling locations on the 2 November 2010 election day. In a follow-up to its nationwide Vote & Vax Election Day initiative in 2008, the Robert Wood Johnson Foundation and the Sickness Prevention Achieved through Regional Collaboration (SPARC) are helping local health providers launch the election-day vaccination clinics at or near polling sites. Resources for setting up a successful clinic are available on the Vote & Vax Web site, along with background materials for election officials. In 2008 the program delivered 21,434 flu vaccinations at 331 polling places in 42 states and the District of Columbia.
(CIDRAP 10/19/2010)

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United States: Health group launches influenza resource for businesses
A nonprofit health group, Community Health Charities of America, launched a video podcast on 22 October 2010 on seasonal flu guidance for employers and workers. As part of the "Health Matters at Work" series, participants in the podcast include Dr Nicole Lurie, assistant secretary for preparedness and response at the US Department of Health and Human Services; Steven Miranda, chief human resources officer at the Society for Human Resource Management (SHRM); Dr Jonathan McCullers, an infectious disease specialist at St Jude Children's Research Hospital, and Dr Christopher Collins, a rheumatologist at Washington Hospital Center and an advisor to the Lupus Foundation. Though the episode was taped in October 2009 during a surge in 2009 H1N1 infections, it focuses specifically on preventing seasonal flu in the workplace, with an emphasis on vaccination. Miranda said encouraging employees to stay home when they have flu symptoms is one of the top workplace flu-prevention tactics. He said that this is not a time for the employee to play the part of a martyr. They might get the project done on time, but they could send ten workers home with the flu. He suggested that employers explore whether flextime policies allow employees to leave work to receive a flu shot and to make sure health benefits packages cover flu immunization. In the long run, this simple preventive measure up front can save tens or hundreds of thousands dollars in saved productivity, Miranda added. The experts noted that flu-prevention resources for employers are available online from the Centers for Disease Control and Prevention and SHRM.
(CIDRAP 10/20/2010)

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United States (Michigan): Doctors raise concerns about slow seasonal influenza vaccine deliveries
Physicians in Michigan, frustrated by delays in getting seasonal flu vaccine, plan to ask the American Medical Association to lobby for a federal requirement that would put doctors' offices first in line to get the vaccine, ahead of pharmacies and urgent care clinics. David Share, MD, chairman of the Michigan State Medical Society's Public Health Committee, said that despite plentiful supplies, physician's offices often get only small, periodic deliveries of vaccine, causing them to run short. Doctors have raised concerns about not being able to vaccinate their high-risk patients as soon as the vaccine is available and about some pharmacies not keeping detailed records about who was vaccinated. He said pharmacy chains are in a better position to receive the vaccine because they buy larger quantities. However, Donna Cary, a spokeswoman for vaccine maker Sanofi Pasteur, stated that delivery concerns are becoming less of an issue with plenty of vaccine available, and providers should be able to get as much vaccine as they want when they need it.
(CIDRAP 10/22/2010)

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United States (Michigan): Detroit officials nix high-dose influenza vaccine for seniors
Health officials in the Detroit metro area have decided not to buy high-dose flu vaccine designed for the elderly because of cost and potential confusion for consumers. Steve Gold, the director of the Macomb County Health Department stated that it's not a criticism of the vaccine. It's a matter of keeping it simple. The Sanofi vaccine, Fluzone High-Dose, has four times the antigen of regular flu vaccine to boost the response in seniors, whose immune response to the shot often lags that of younger people. Local costs for Fluzone High-Dose ran from double to triple that of regular seasonal flu vaccine.
(CIDRAP 10/26/2010)

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Africa
Cameroon: Cameroon launches 2009 H1N1 pandemic influenza vaccine campaign
Cameroon's health ministry has launched a 2009 H1N1 flu vaccine campaign aimed at priority groups, including healthcare workers, children between ages 5 and 15, pregnant women, and people with underlying medical conditions. The campaign will use 1.3 million doses that Cameroon received from the World Health Organization, and 3,000 healthcare workers will administer the doses during the five-day event. The health ministry has received 75 reports of 2009 H1N1 infections since the beginning of 2010.
(CIDRAP 10/27/2010)

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2. Infectious Disease News

Asia
Australia (Queensland): Pertussis outbreak continues
A whooping cough (pertussis) outbreak is continuing to sweep across the Gladstone region [Queensland]. There are ongoing reports of the highly contagious respiratory infection, which can be life threatening, running rampant in the Miriam Vale and Agnes Water communities and further afield.

There have been 65 notifications of whooping cough recorded in Gladstone in 2010. This is an alarming increase on the 11 notifications recorded for the same period in 2009. This dramatic rise in reported cases has prompted a plea by local medical officials for residents to get [re-]immunized against this infection, which is capable of causing serious health complications in babies under six months of age.

A local medical practitioner said his practice alone had recorded 14 cases in the past four months and a total of 18 for 2010. The medical practitioner said it was an alarming number, particularly considering a number of babies had become ill. It's a bit of an epidemic which has been going on for some time now, the medical practitioner said.

Caused by the bacterium Bordetella pertussis, whooping cough can affect babies, infants, adolescents, and adults. For adolescents and adults the infection may cause an irritating, persistent cough, which can last up to eight weeks. However, for babies and young children the infection can be life threatening, particularly for those not fully protected by vaccination.

[ProMED note: Cases of pertussis in previously vaccinated older children and adults are generally attributed to waning immunity without considering potential differences in Bordetella pertussis strains. As pointed out in 2009 by Dr Frits Mooi (ProMED-mail Pertussis - Australia (02): (SA) 20091108.3876): There are now many studies which show that outbreaks of pertussis are often associated with changes in the B. pertussis population. Most recently, we have shown that more virulent (P3) strains have appeared which we believe to be (partly) responsible for the outbreak in the Netherlands. The P3 strains have emerged worldwide. Any discussion on the causes of sudden upsurges in infectious diseases should include changes in the pathogen population. This is even true for pertussis.]
(ProMED 10/20/2010)

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Australia (Victoria ): Investigations continue in hepatitis C cases
Victoria’s chief health officer 23 October 2010 confirmed that screening of patients treated by a doctor suspected of infecting dozens of women with hepatitis C would be widened to include another 1100 people seen at three more clinics.

The development followed early morning raids by police on five Melbourne addresses including the Hawthorn home of anesthetist James Latham Peters and two buildings at the Croydon abortion clinic, where 41 of his former patients are suspected of having contracted the strain of the virus he carries.

Police also searched homes in Toorak and Croydon Hills, belonging to two persons associated with the management of the surgery. There is reason to believe that the homes belong to Mark Schulberg, the Croydon clinic's former owner, and a member of the nursing staff.

Police said they were not considered suspects at this stage.

It is unclear what triggered the raids - which came more than six months after chief health officer John Carnie first alerted the public to the Croydon cases.

Dr Carnie has consistently maintained that patients from other facilities where Dr Peters practiced were not at risk, as no hepatitis C clusters had been detected through the Health Department's infectious diseases surveillance.

However, just hours after the raids, Dr Carnie announced the department would expand hepatitis C testing to 1066 male and female patients who had been treated at three of Dr Peters's previous workplaces.

Dr Carnie stressed that there remained no evidence of transmission at the other clinics.

The only reason I have decided to extend this process is so that in a few months' time I can stand here and say to the public I have done absolutely everything I can to confirm the fact that this problem has been confined to Croydon, he said.

But opposition health spokesman David Davis said the backflip was an embarrassment for the Health Department and Health Minister Daniel Andrews, who has remained in the background.

Their failure to act on these matters earlier needs immediate explanation. It's clear that this has been mishandled and Victorians are entitled to assurance that no one has been put at risk, he said.

The department is trying to trace 900 patients who attended Fertility Control in East Melbourne between January 2008 and November 2009, 150 from St Albans Endoscopy who were treated between February and September 2008, and 16 who attended the Western Day Surgery in Sunshine in March 2008.

The department has tested more than 3000 patients treated between 2006 and 2009 at the Croydon Day Surgery - now called Marie Stopes Maroondah - but has been unable to trace a further 300 women, who have been urged to make contact.

Police swooped on the properties around 7am. About 20 officers went to the Croydon surgery, which was cordoned off. The search was expected to go well into the night and a temporary shelter was set up on site. A source said police spent several hours turning the house upside down, with several computers in each of the houses removed.

Detective Senior Sergeant Paul Robotham, from Taskforce Clays which is leading the investigation, would not say if charges were imminent.

Dr Peters, who has a history of pethidine addiction, was suspended by the Medical Practitioners Board of Victoria in February but it is believed police have yet to interview him.

Paula Shelton, medical negligence lawyer with Slater and Gordon, said 37 women who were treated at Croydon and had tested positive for Dr Peters's strain of hepatitis C had joined a class action lawsuit against the Medical Board and the clinic.

She said the Health Department should have started testing patients from other clinics earlier. I thought it was very odd, she said, that they were saying because they hadn't had a cluster of cases of hepatitis C that patients weren't at risk. The vast majority of people don't get sick, they're asymptomatic, and so I didn't think it was reliable to say that just because there hasn't been any diagnoses there haven't been any infections. So I suspected that they knew something else about Croydon or the other clinics.

A government spokeswoman said the opposition's criticisms were unfounded and the issue was too important to be used for cheap political point-scoring.

The chief health officer and the Department of Health are working diligently and in the best interests of all affected patient, she said.
(The Age.com 10/24/2010)

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Indonesia: More than 100 dead in wake of tsunami
Indonesia's most volatile volcano began erupting and a powerful earthquake triggered a tsunami that pounded villages on remote islands off the western coast, killing more than 100 people and leaving as many as 500 others missing, officials said 26 October 2010.

The 7.7-magnitude quake struck late 25 October 2010 along the same fault line that caused the massive 9.1-magnitude earthquake in 2004 and generated the deadliest tsunami on record, killing about 230,000 people in a dozen countries.

Vulcanologists said Mount Merapi rumbled and groaned for hours and then started to erupt just before dusk, spewing hot ash. Scientists warned that pressure building beneath its lava dome could trigger one of the most powerful blasts in years. Thousands of residents on the slopes have been evacuated. But most who fled were the elderly and children, while adults stayed to tend to homes and farms on the mountain's fertile slopes.

The energy is building up. ... We hope it will release slowly, government volcanologist Surono told reporters. Otherwise, we're looking at a potentially huge eruption, bigger than anything we've seen in years.

The alert level for the 9,737-foot mountain has been raised to its highest level.

The temblor hit 13 miles beneath the ocean floor near the sparsely populated Mentawai islands off the coast of Sumatra. A 10-foot-high wave surged ashore on Pagai Island, damaging most of the buildings there and sweeping away numerous residents.

Rescuers were having a hard time reaching the islands because of strong winds and rough seas, but reports of damage and injuries were steadily climbing.

Mujiharto, who heads the Health Ministry's crisis center, said 113 bodies have been recovered so far. The number of missing was between 150 and 500.

The earthquake jolted Sumatra's western coast, including the city of Padang — which last year was hit by a deadly magnitude 7.6 tremor that killed more than 700. Loudspeakers at mosques blared out tsunami warnings, and roads leading to high ground were quickly clogged with the vehicles of fleeing residents.

Indonesia, the world's largest archipelago, is prone to earthquakes and volcanic activity because of its location on the so-called Pacific Ring of Fire.

Getting to the Mentawais, a popular surfing spot 175 miles from the Sumatra coast, takes 12 hours, and the islands are reachable only by boat.

Ade Edward, a disaster management agency official, said 23 bodies were found in coastal villages — mostly on the hardest hit island of Pagai — and another 167 people were missing.

Water in some places reached rooftops, and in Muntei Baru, a village on Silabu, 80 percent of the houses were damaged.

Some 3,000 people were seeking shelter Tuesday in emergency camps, Edward said, and the crews from several ships were still unaccounted for in the Indian Ocean.

Everyone was running out of their houses, said Sofyan Alawi, adding that the roads in Padang leading to surrounding hills were quickly jammed.

We kept looking back to see if a wave was coming, said 28-year-old resident Ade Syahputra.

[EINet note: It will be important to see if any infectious diseases become more prevalent in the wake of this tsunami.]
(NPR 10/26/2010)

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Russia (Tatarstan): Hemorrhagic fever with renal syndrome
During the week of 18-24 October 2010, 17 cases of hemorrhagic fever with renal syndrome (HFRS) were recorded in the Republic of Tatarstan according to the regional office of Rospotrebnadzor [Federal Agency for Consumer Protection and Welfare]. Most of the cases were registered in Kazan [the capital of Tatarstan]. Some cases were recorded also in the city of Naberezhni Chelni, and the remainder in the districts [rayons] of Nizhnekamsk, Almetevski, Leninogorsk, and Sarmanovski.

[ProMED note: Although not specifically stated, it is likely that Pummala virus is the specific hantavirus responsible for this outbreak of HFRS in Tatarstan, and the rodent reservoir is the bank vole (Myodes glareolus). In some places the original text is ambiguous and some of the cases may have been diagnosed as Lyme disease, another tick-transmitted infection. Cases of HFRS earlier in 2010 were attributed to an increase in the rodent population throughout Tatarstan.]
(ProMED 10/25/2010)

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Americas
Canada (London): Norovirus outbreak suppressed
Londoners were kept in the dark about a viral outbreak at the London Hunt and Economy Club and now experts are questioning whether health officials did enough to investigate.

At least 25 people were stricken with suspected norovirus after a Thanksgiving buffet 11 October 2010 at the Hunt Club and at least four more became ill after attending an event for medical residents on 13 October 2010, the Middlesex-London Health Unit acknowledged 28 October 2010.

We were notified 14 October 2010 by an attendee who was ill, said Cathie Walker, who manages the Unit’s infectious disease control team.

Laboratory tests were to show the outbreak was caused by norovirus, the leading cause of what those stricken would call a stomach flu.

Public health officials didn’t reported the outbreaks to the general public and instead relied on the Hunt Club, which had e-mailed a newsletter to its members about the incident, and the organizer of the event for medical residents.

Walker defends the lack of public notification, saying people who didn’t attend the events weren’t at risk and that the private club had taken over the task of notifying those who attended.

We would trust Hunt Club officials based on their co-operation, Walker said.

But experts in food-borne illness are questioning that stance and say all Londoners should have been told.

Health Units are loathe to report it because it creates more work but there’s value to reporting and the public has a right to know, said Doug Powell, an associate professor of food safety at Kansas State University, who taught at the University of Guelph.

In outbreaks such as these the cause is most often a food handler who is already sick, Powell said.

That’s even more likely because people became sick after attending two functions served by the same kitchen crew, said Barbara Kowalcyk, director of food safety for the U.S.-based Center for Foodborne Illness Research & Prevention.

A worker would be the logical place to look, she said.

While kitchen staff worked at both events and some later reported be stricken with illness, it’s not clear if any of the diners attending both events — health investigators never asked to compare the lists, the Hunt Club says.

The health unit instead interviewed 29 ill people, some who responded to the Hunt Club email and others mentioned by the initial people interviewed. But health investigators didn’t speak to the roughly 370 other people who attended, Walker said.

That’s a significant oversight, said Kowalcyk, who is a statistician completing a doctorate in Environmental Health with a focus in Epidemiology.

If they don’t even talk to people who weren’t sick, I don’t know how they can say they did an investigation, she said.

If a sick worker was the source it’s possible he or she doesn’t know it and may be still infecting people, she said.

The public may want to know that, Kowalcyk said. I’d think public health official would want that worker not to handle food.

Hunt Club General Manager Jeff Scott defended the club’s response, saying workers were told to stay home if they had any signs of illness and that there have since been no reports of illness among diners.

We went above and beyond, he said.
(London Free Press 10/28/2010)

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United States (California): Pertussis outbreak continues, but is being reined in
Marin County, which has one of the highest rates of whooping cough in California, has seen its caseload ease during what state health officials called the largest statewide epidemic since 1950.

More than 6,200 cases of whooping cough have been confirmed statewide since 1 January 2010 state health officials announced the week of 25 October 2010.

In Marin, three cases of whooping cough were confirmed while the state reported an increase of 279 cases in the same period, since 25 October 2010.

Dr. Anju Goel, deputy public health officer for Marin County, said the number of Marin whooping cough cases peaked in May and June 2010 at 33 per week.

We've seen a fairly steady decline since then, with a little bit of a bump in September, Goel said.

She said that since the onset of the epidemic there have been 320 cases of whooping cough, also known as pertussis, reported in Marin. That translates into a rate of about 126 cases of pertussis for every 100,000 people in Marin, according to the California Department of Public Health. The only county with a higher rate is San Luis Obispo with a rate of 137. The average rate for the state is 16.

Goel said one possible explanation for the high incidence rate in Marin is that health care providers in Marin are doing a better job diagnosing and reporting pertussis cases than other counties.

Another explanation, Goel said, is that Marin has a high rate of students entering kindergarten who avoid immunization because their parents claim a personal belief exemption. In 2009, 7.1 percent of Marin kindergartners used the exemption to avoid immunizations. Statewide, only 2 percent of kindergartners used the exemption to avoid vaccination in 2009.

What we're seeing now is many fewer cases than we saw at the peak of our outbreak, Goel said. I would still very much encourage people to get vaccinated. It will protect them from several years going forward and it will protect people around them who can't get immunized.

Reacting to the California epidemic, a federal advisory panel on 27 October 2010 recommended that people 65 and older who are around infants get vaccinated against whooping cough.

The Advisory Committee on Immunization Practices noted that nine of the 10 California infants who have died due whooping cough were too young to be fully vaccinated against the disease.
(Marin Independent Journal 10/27/2010)

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United States (New York): Tuberculosis case reported at a school
Parents in the Glen Cove School District are waiting to hear if their children were exposed to tuberculosis after a student was treated for the illness, the district superintendent and the Nassau County Department of Health said.

Superintendent Joseph A. Laria told parents in a letter on 26 October 2010 that health department officials informed him that “an individual in this district is presently receiving treatment for tuberculosis.” The district posted a copy of the letter on the Web site.

It was not immediately clear what grade the patient attended or what school or schools may have been affected.

Laria said the individual is no longer at school; therefore, there is no further risk of transmission.

Nassau County Health Department spokesperson Mary Ellen Lorrain said that the department is making every effort to offer services for those who may have been infected.
(CBS New York 10/28/2010)

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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 (Queensland)
Another three cases of dengue fever have been recorded at Townsville in north Queensland, bringing the city's tally to 13 since the start of 2010.
(ProMED 10/18/2010)


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 that as of 4:00 p.m. on 5 Oct 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 Oct 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 Aedesmosquito 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)


Chinese Taipei
As two epidemic-command centers were established 21 October 2010, to combat dengue fever in southern Taiwan, the Center for Disease Control (CDC) also drew attention to a new case in Taipei County and put the North on alert against the disease.

A 72-year-old male from Wugu Township became the third confirmed case of indigenous dengue fever in Taipei in 2010. Acknowledging that this number was yet small, CDC Deputy Director-General Ting Lin said that many more as-yet unidentified cases might come to light.

The elderly patient had not visited the South nor been abroad, but he had lived close to two patients found to be infected with dengue fever after returning from a trip to Cambodia in late August.

We have reasons to believe that this is the result of a cluster infection, and suspect that the elderly patient is not the only indigenous dengue patient living in Wugu, said Lin, explaining that other people might experience only minor symptoms and not seek treatment.

Department of Health (DOH) officials immediately disinfected the patient's surroundings, mobilized volunteers to clean up possible mosquito-breeding sites, and set up a dengue-screening station locally to provide free blood tests.

Lin said that dengue cases hit a record high the week of 25 October 2010 with 156 cases nationwide, 139 of them in the southern cities of Kaohsiung and Tainan. Nevertheless, he warned residents in the North not to lower their guard toward possible infection.
(The China Post 10/27/2010)


Chinese Taipei
A total of 111 new dengue fever cases originating in Taiwan were reported during the week of 3 October 2010, setting a new single week record, with most of the cases concentrated in southern Taiwan, CDC Deputy Director-General Shih Wen-yi said. Shih also said all four serotypes of dengue virus have emerged.
(ProMED 10/18/2010)


Chinese Taipei
With three new cases, including a DHF case in a four-year-old child, the number of recorded indigenous cases is 658 since August 2010, with 256 imported cases since the beginning of 2010.
(ProMED 10/26/2010)


Malaysia
According to the Malaysian Health Ministry, a total of 37,419 dengue cases were reported in the country from January 2010 to 2 October 2010, an increase of 17 percent or 5,411 cases compared with 32,008 cases recorded in the same period in 2009. During the period, 117 dengue deaths were reported, a surge of 65 percent or an increase of 46 cases compared with the same period in 2009. The Malaysian government is researching on the possibility of using genetically modified mosquitoes to control dengue .
(ProMED 10/18/2010)


Mexico
There have been 365 dengue cases in Tamaulipas, 800 in Nuevo Leon, and 500 in Veracruz states.
(ProMED 10/18/2010)


Mexico (Sonora)
According to official figures from the director of Health Services, from 1 January -15 October 2010, 647 confirmed dengue cases have been recorded, representing an increase of more than 1000 percent over the same period in 2009.
(ProMED 10/26/2010)


Philippines
Eight persons died of dengue fever in the Caraga region (Davao Oriental region) while a total of 2,369 cases were admitted in different hospitals in the region from 1 January 2010 - 8 October 2010, health officials reported on14 October 2010. The number of cases was 174 percent higher compared to 2009 when only 853 cases were recorded.
(ProMED 10/18/2010)


Viet Nam
More than 250 dengue fever cases had been diagnosed in the city's [Da Nang] hospitals since mid-October 2010, raising the total cases to about 3,000 since early 2010, a six-fold increase over the same period in 2009. A report from Da Nang General Hospital shows that the facility receives between 20 and 30 patients per day, which has forced people to share the limited number of beds available at the facility. About 80 percent of the patients have been young adults and children, and 150 patients are in serious condition, the Municipal Preventive Health Centre said.
(ProMED 10/26/2010)

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CHOLERA, DIARRHEA, and DYSENTERY
Papua New Guinea
Central's West Hiri district is beginning to record a high number of suspected cholera cases, according to Central health authorities. Hiri district health coordinator, Michael Masket said on 3 October 2010 when arriving back from the affected area that eight patients from Papa in severe conditions were admitted to the cholera treatment centre (CTC) at the Papa clinic while only three came from Lealea.

He said the situation was getting worse with people coming to the CTC in severe conditions. Masket added that it’s not over yet, and that when cholera comes, it spreads fast. Every day the CTC is seeing five to six severe cases.

Another problem that Masket pointed out was the capacity to house the patients.
(ProMED 10/25/2010)

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4. Articles
Association Between Medicaid Reimbursement and Child Influenza Vaccination Rates
Yoo B-K, Berry A, Kasajima M, et al. Pediatrics. 18 October 2010. doi:10.1542/peds.2009-3514.
Available at http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-3514v1

Objective. We examined associations between influenza vaccination rates and Medicaid reimbursement rates for vaccine administration among poor children who were eligible for Medicaid (<100% of the federal poverty level in all states)

. Methods. We analyzed 3 consecutive National Immunization Surveys (NISs) to assess influenza vaccination rates among nationally representative children 6 to 23 months of age during the 2005–2006 (unweighted N = 12 885), 2006–2007 (unweighted N = 9238), and 2007–2008 (unweighted N = 11 785) influenza seasons (weighted N = 3.3–4.0 million per season). We categorized children into 3 income levels (poor, near-poor, or nonpoor). We performed analyses with full influenza vaccination as the dependent variable and state Medicaid reimbursement rates (continuous covariate ranging from $2 to $17.86 per vaccination) and terms with income levels as key covariates.

Results. In total, 21.0%, 21.3%, and 28.9% of all US children and 11.7%, 11.6%, and 18.8% of poor children were fully vaccinated in the 2006, 2007, and 2008 NISs, respectively. Multivariate analyses of all 3 seasons found positive significant (all P < .05) associations between state-level Medicaid reimbursement and influenza vaccination rates among poor children. A $10 increase, from $8 per influenza vaccination (the US average) to $18 (the highest state reimbursement), in the Medicaid reimbursement rate was associated with 6.0-, 9.2-, and 6.4-percentage point increases in full vaccination rates among poor children in the 2006, 2007, and 2008 NIS analyses, respectively.

Conclusion. Medicaid reimbursement rates are strongly associated with influenza vaccination rates.

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Reflections on the influenza vaccination of healthcare workers
McLennan S, Wicker S. Vaccine. 22 October 2010. doi:10.1016/j.vaccine.2010.10.019.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-519668Y-5&_user=10&_coverDate=10%2F22%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=3d19d4cf1c9733ae005248f4fe10992d&searchtype=a

Abstract. Despite all that is known about the dangers of nosocomial transmission of influenza to the vulnerable patient populations in our healthcare facilities, and the benefits of the influenza vaccination, the low rates of influenza vaccination among healthcare workers (HCWs) internationally shows no sign of significant improvement. With the current voluntary ‘opt-in’ programmes clearly failing to adequately address this issue, the time has undoubtedly come for a new approach to vaccination to be implemented. Two different approaches to vaccination delivery have been suggested to rectify this situation, mandatory vaccination and ‘opt-out’ declination forms. It is suggested, however, that these two approaches are inadequate when used by themselves. In order to protect the most vulnerable patients in our healthcare facilities as best we can from serious harm or death caused by nosocomial transmission of influenza, while at the same time respecting HCWs autonomy, and in many jurisdictions, the related legal right to refuse medical treatment, it is recommended that ‘op-out’ declination forms should be used in conjunction with restricted mandatory vaccination. This ‘combined’ approach would allow any HCW to refuse the influenza vaccination, but would make the influenza vaccination a mandatory requirement for working in areas where the most vulnerable patients are cared for. Those HCWs not willing to be vaccinated should be required to work in other areas of healthcare.

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Prevalence of seroprotection against the pandemic (H1N1) virus after the 2009 pandemic
Skowronski DN, Hottes TS, Janjua NZ, et al. CMAJ. 18 October 2010. 10.1503/cmaj.100910.
Available at http://www.cmaj.ca/cgi/content/abstract/cmaj.100910v1

Background. Before pandemic (H1N1) 2009, less than 10% of serum samples collected from all age groups in the Lower Mainland of British Columbia, Canada, showed seroprotection against the pandemic (H1N1) 2009 virus, except those from very elderly people. We reassessed this profile of seroprotection by age in the same region six months after the fall 2009 pandemic and vaccination campaign.

Methods. We evaluated 100 anonymized serum samples per 10-year age group based on convenience sampling. We measured levels of antibody against the pandemic virus by hemagglutination inhibition and microneutralization assays. We assessed geometric mean titres and the proportion of people with seroprotective antibody levels (hemagglutination inhibition titre ≥ 40). We performed sensitivity analyses to evaluate titre thresholds of 80, 20 and 10.

Results. Serum samples from 1127 people aged 9 months to 101 years were obtained. The overall age-standardized proportion of people with seroprotective antibody levels was 46%. A U-shaped age distribution was identified regardless of assay or titre threshold applied. Among those less than 20 years old and those 80 years and older, the prevalence of seroprotection was comparably high at about 70%. Seroprotection was 44% among those aged 20-49 and 30% among those 50-79 years. It was lowest among people aged 70-79 years (21%) and highest among those 90 years and older (88%).

Interpretation. We measured much higher levels of seroprotection after the 2009 pandemic compared than before the pandemic, with a U-shaped age distribution now evident. These findings, particularly the low levels of seroprotection among people aged 50-79 years, should be confirmed in other settings and closer to the influenza season

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A New Pandemic Influenza A(H1N1) Genetic Variant Predominated in the Winter 2010 Influenza Season in Australia, New Zealand, and Singapore
Barr IB, Cui L, Komadina N, et al. Eurosuveillance. 2010 October 21; 15(42):pii=19692.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19692

Background. Pandemic H1N1 influenza virus is of global health concern and is currently the predominant influenza virus subtype circulating in the southern hemisphere 2010 winter. The virus has changed little since it emerged in 2009, however, in this report we describe several genetically distinct changes in the pandemic H1N1 influenza virus. These variants were first detected in Singapore in early 2010 and have subsequently spread through Australia and New Zealand. At this stage, these signature changes in the haemagglutinin and neuraminidase proteins have not resulted in significant antigenic changes which might make the current vaccine less effective, but such adaptive mutations should be carefully monitored as the northern hemisphere approaches its winter influenza season.

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Estimates of the True Number of Cases of Pandemic (H1N1) 2009, Beijing, China
Wang X, Yang P, Seale H, et al. Emerg Infect Dis. 21 October 2010. doi: 10.3201/eid1611.100323.
Available at http://www.cdc.gov/eid/content/16/11/1786.htm

Abstract. During 2009, a total of 10,844 laboratory-confirmed cases of pandemic (H1N1) 2009 were reported in Beijing, People's Republic of China. However, because most cases were not confirmed through laboratory testing, the true number is unknown. Using a multiplier model, we estimated that ≈1.46–2.30 million pandemic (H1N1) 2009 infections occurred.

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The Infection Attack Rate and Severity of 2009 Pandemic H1N1 Influenza in Hong Kong
Wu JT, Ma ESK, Lee CK, et al. Clin Infect Dis. 15 November 2010. doi: 10.1086/656740.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/656740

Background. Serial cross‐sectional data on antibody levels to the 2009 pandemic H1N1 influenza A virus from a population can be used to estimate the infection attack rates and immunity against future infection in the community.

Methods. From April through December 2009, we obtained 12,217 serum specimens from blood donors (aged 16–59 years), 2520 specimens from hospital outpatients (aged 5–59 years), and 917 specimens from subjects involved in a community pediatric cohort study (aged 5–14 years). We estimated infection attack rates by comparing the proportions of specimens with antibody titers 1:40 by viral microneutralization before and after the first wave of the pandemic. Estimates were validated using paired serum samples from 324 individuals that spanned the first wave. Combining these estimates with epidemiologic surveillance data, we calculated the proportion of infections that led to hospitalization, admission to the intensive care unit (ICU), and death.

Results. We found that 3.3% and 14% of persons aged 5–59 years had antibody titers 1:40 before and after the first wave, respectively. The overall attack rate was 10.7%, with age stratification as follows: 43.4% in persons aged 5–14 years, 15.8% in persons aged 15–19 years, 11.8% in persons aged 20–29 years, and 4%–4.6% in persons aged 30–59 years. Case‐hospitalization rates were 0.47%–0.87% among persons aged 5–59 years. Case‐ICU rates were 7.9 cases per 100,000 infections in persons aged 5–14 years and 75 cases per 100,000 infections in persons aged 50–59 years, respectively. Case‐fatality rates were 0.4 cases per 100,000 infections in persons aged 5–14 years and 26.5 cases per 100,000 infections in persons aged 50–59 years, respectively.

Conclusions. Almost half of all school‐aged children in Hong Kong were infected during the first wave. Compared with school children aged 5–14 years, older adults aged 50–59 years had 9.5 and 66 times higher risks of ICU admission and death if infected, respectively.

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Acute Encephalopathy and Pandemic (H1N1) 2009 [letter]
Moon S-M, Kim S-H, Jeong M-H, et al. Emerg Infect Dis. 15 November 2010. doi: 10.3201/eid1611.100682.
Available at http://www.cdc.gov/eid/content/16/11/1811.htm

To the Editor. Since the World Health Organization declared a global pandemic of influenza A pandemic (H1N1) 2009 in June 2009, the number of cases of this strain of influenza has steadily risen. Although most cases have been mild, with complete and uneventful recovery, multiple cases of severe infection with complications, including death, have been reported. Yet the neurologic complications of this virus have been rarely described. We read with interest the article by Kitcharoen et al. (1) concerning a patient with encephalopathy associated with pandemic (H1N1) 2009, which progressed to produce quadriplegia with diffuse sensory loss. In that study, however, pandemic (H1N1) 2009 virus was not isolated from the patient's cerebrospinal fluid (CSF) or brain tissue or detected by reverse transcription–PCR (RT-PCR). We report a case in an adolescent patient with encephalopathy-associated pandemic (H1N1) 2009 that was confirmed by real-time RT-PCR of CSF.

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Low Pathogenic Avian Influenza (H7N1) Transmission Between Wild Ducks and Domestic Ducks
Therkildsen OR, Jensen TH, Handberg KJ, et al. Zoonoses and Public Health. 18 October 2010. doi: 10.1111/j.1863-2378.2010.01375.x.
Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1863-2378.2010.01375.x/abstract.

Summary. This article describes a virological investigation in a mixed flock of ducks and geese following detection of avian influenza virus antibodies in domestic geese. Low pathogenic H7N1 was found in both domestic and wild birds, indicating that transmission of virus was likely to have taken place between these. The importance of implementing and maintaining appropriate biosecurity measures is re-emphasized.

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An Avian Outbreak Associated with Panzootic Equine Influenza in 1872: An Early Example of Highly Pathogenic Avian Influenza?
Morens DM, Taubenberger JK. Influenza and Other Respir Vir. 19 October 2010; 4(6):373-377. doi: 10.1111/j.1750-2659.2010.00181.x.
Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1750-2659.2010.00181.x/full

Background. An explosive fatal epizootic in poultry, prairie chickens, turkeys, ducks and geese, occurred over much of the populated United States between 15 November and 15 December 1872. To our knowledge the scientific literature contains no mention of the nationwide 1872 poultry outbreak.

Objective. To understand avian influenza in a historical context.

Results. The epizootic progressed in temporal-geographic association with a well-reported panzootic of equine influenza that had begun in Canada during the last few days of September 1872. The 1872 avian epizootic was universally attributed at the time to equine influenza, a disease then of unknown etiology but widely believed to be caused by the same transmissible respiratory agent that caused human influenza.

Conclusions. Another microbial agent could have caused the avian outbreak; however, its strong temporal and geographic association with the equine panzootic, and its clinical and epidemiologic features, are most consistent with highly pathogenic avian influenza. The avian epizootic could thus have been an early instance of highly pathogenic avian influenza.

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Combining Spatial-Temporal and Phylogenetic Analysis Approaches for Improved Understanding on Global H5N1 Transmission
Liang L, Xu B, Chen Y, et al. PLoS ONE. 22 October 2010;5(10): e13575. doi:10.1371/journal.pone.0013575.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0013575

Background. Since late 2003, the highly pathogenic influenza A H5N1 had initiated several outbreak waves that swept across the Eurasia and Africa continents. Getting prepared for reassortment or mutation of H5N1 viruses has become a global priority. Although the spreading mechanism of H5N1 has been studied from different perspectives, its main transmission agents and spread route problems remain unsolved.

Methodology/Principal Findings. Based on a compilation of the time and location of global H5N1 outbreaks from November 2003 to December 2006, we report an interdisciplinary effort that combines the geospatial informatics approach with a bioinformatics approach to form an improved understanding on the transmission mechanisms of H5N1 virus. Through a spherical coordinate based analysis, which is not conventionally done in geographical analyses, we reveal obvious spatial and temporal clusters of global H5N1 cases on different scales, which we consider to be associated with two different transmission modes of H5N1 viruses. Then through an interdisciplinary study of both geographic and phylogenetic analysis, we obtain a H5N1 spreading route map. Our results provide insight on competing hypotheses as to which avian hosts are responsible for the spread of H5N1.

Conclusions/Significance. We found that although South China and Southeast Asia may be the virus pool of avian flu, East Siberia may be the source of the H5N1 epidemic. The concentration of migratory birds from different places increases the possibility of gene mutation. Special attention should be paid to East Siberia, Middle Siberia and South China for improved surveillance of H5N1 viruses and monitoring of migratory birds.

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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. APEC countries are invited to participate.
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