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Vol. XIII No. 23 ~ EINet News Briefs ~ Nov 12, 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: Influenza levels stay low or drop in most parts of the world
- Global: WHO says overall global influenza activity remains low
- Global: WHO Influenza Update
- India: Committee recommends peramivir for H1N1 pandemic influenza
- Japan: Influenza A H3N2 outbreak kills six at Takanosu hospital
- United States: CDC reports low levels of US influenza activity
- United States: Influenza card program aims to streamline employee vaccination
- United States: Pandemic report warns against 'flu fatigue,' complacency
- Namibia: Mild strain of H1N1 pandemic influenza outbreak
- Zimbabwe (Harare): A/H1N1 influenza detected

2. Infectious Disease News
- Australia: Whooping cough outbreak linked to parents’ refusal to vaccinate children
- Philippines: Measles and leptospirosis cases rising
- Thailand: Leptospirosis following flooding
- Canada: C. difficile outbreak
- Canada (Toronto): NDM-1 superbug cases in Canada
- USA: E. coli outbreak related to cheese
- USA (California): Whooping cough cases still prevalent
- USA (Colorado): Hantavirus death
- USA (Illinois): Norovirus outbreaks in Cook County
- USA (Mississippi): Cal-Maine Foods recalls more than a quarter-million eggs due to salmonella scare
- USA (Washington): Number of tuberculosis cases has risen in 2010

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

4. Articles
- Influenza vaccination and all-cause mortality in community-dwelling elderly in Ontario, Canada, a cohort study
- Exploring pregnant women's views on influenza vaccination and educational text messages
- Establishing the baseline burden of influenza in preparation for the evaluation of a countywide school-based influenza vaccination campaign
- Implementing a Community-Supported School-Based Influenza Immunization Program
- Influenza Vaccine Given to Pregnant Women Reduces Hospitalization Due to Influenza in Their Infants
- Willingness to accept H1N1 pandemic influenza vaccine: A cross-sectional study of Hong Kong community nurses
- Serologic survey of pandemic influenza A (H1N1 2009) in Beijing, China
- Facing the threat of Influenza Pandemic: Roles of and Implications to General Practitioners
- Mass Vaccination for the 2009 H1N1 Pandemic: Approaches, Challenges, and Recommendations
- Factors that reduce the conflicts of health professionals about working during a public crisis: A cross sectional study of Motivation and Hesitation of hospital workers in Japan during the pandemic (H1N1) 2009.
- Relationship between intention of novel influenza A (H1N1) vaccination and vaccination coverage rate
- Incidence of hospital admissions and severe outcomes during the first and second waves of pandemic (H1N1) 2009
- General hospital staff worries, perceived sufficiency of information and associated psychological distress during the A/H1N1 influenza pandemic
- Can an Office Practice Telephonic Response Meet the Needs of a Pandemic?

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
Worldwide, H1N1 2009 virus transmission remains most intense in parts of India and in parts of the temperate southern hemisphere, particularly New Zealand and more recently in Australia.

In India, the current national influenza H1N1 2009 epidemic, which first began during late May and June 2010 in the southern state of Kerala (co-incident with start of the monsoon rains), continues to remain regionally intense in several western and southern states as well as the in the capital. The western state of Maharashtra, which to date, has detected the highest numbers of cases (including fatal cases), continues to record the most intense influenza H1N1 2009 activity, however, the rate of increase in the numbers of new cases reported per week appears to have slowed during mid-August 2010, suggesting that current epidemic activity may be peaking. Increasing H1N1 2009 activity has also been reported in Delhi since early August 2010, and in the southern states of Karnataka and Andhra Pradesh since late July 2010. A number of other states, primarily in western and northern India, reported small numbers of new cases during the third week of August 2010, suggesting that low level circulation of H1N1 2009 may be more geographically extensive. Since late July 2010, the vast majority of influenza virus detections have been H1N1 2009.

In New Zealand, H1N1 2009 virus transmission remains active and locally intense, particularly in areas that were less affected during last winter's first pandemic wave. As of the third week of August 2010, the overall national weekly rate of consultations for ILI continued to increase above the seasonal baseline for the fourth consecutive week, however, the rate of increase in ILI consultations appears have slowed during the most recent reporting week, suggesting that peak epidemic activity may occur in the weeks ahead. Although the overall national rates of ILI consultations has not exceeded levels seen during the 2009 winter pandemic wave, several areas of New Zealand, most notably Hawke's Bay, Hutt Valley and Lakes, are all reporting local rates of ILI consultations that match or surpass rates seen at the national level at the peak of last winter's pandemic wave. The vast majority of influenza virus detections during the current epidemic period have been H1N1 2009.

In Australia, during the first two weeks of August 2010, data from several surveillance systems indicate that influenza activity is increasing, including a one week increase in the national rate of ILI consultations, regional spread of ILI activity in three southern and eastern states, and a sharp two week rise in the proportion of sentinel respiratory samples testing positive for influenza virus (an increase from 5 to 15%). However, overall national rates of ILI consultations remain well below levels observed during the 2009 winter pandemic wave. The majority of recent influenza virus isolations have been characterized as H1N1 2009, however, seasonal H3N2 viruses have also been detected at low levels. Of note, an online influenza surveillance system that tracks the rate of ILI in the community found that recent increases in the rate of ILI have been among persons who were unvaccinated against H1N1 2009 virus. Although significantly fewer severe and total cases of H1N1 2009 virus infection have been detected this year compared to last winter, the median age of H1N1 2009 virus infected cases appears to similar although slightly older (21 vs. 26 years old).
(WHO 08/27/2010)

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Global: Influenza levels stay low or drop in most parts of the world
Flu activity in the United States remained at low levels since 30 October 2010, with levels remaining below baselines, the Centers for Disease Control and Prevention (CDC) said on 5 November 2010. Only 1.4% of specimens tested by the CDC and collaborating labs were positive for influenza. The US Virgin Islands reported regional activity, with Guam and Hawaii reporting local activity. The rest of the country reported sporadic or no flu activity. One pediatric death was reported, in a child from Georgia whose death was related to an unsubtyped influenza A virus last flu season. On 4 November 2010 the CDC issued a global flu update that said flu activity is low in the Northern Hemisphere's temperate climates, with levels decreasing in northern and southern China. Flu levels in the Southern Hemisphere's temperate climates dropped, especially in Central American and Caribbean nations. Influenza B has become dominant in some areas where H3N2 recently dominated, such as Cuba, Jamaica, El Salvador, and Honduras.
(CIDRAP 11/05/2010)

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Global: WHO says overall global influenza activity remains low
Influenza activity has remained low in most regions of the world, though Southeast Asia, tropical areas of the Americas, and parts of southern Africa continue to report cases. Flu activity has returned to near or below baseline in temperate areas of the Southern Hemisphere, following late winter and springtime epidemics, the WHO said. Thailand is the most active area for flu in Southeast Asia, with influenza A/H3N2, 2009 H1N1, and influenza B viruses all circulating. In tropical areas of the Americas, flu has declined substantially after epidemics in late summer and early fall of 2010. A post-season increase in 2009 H1N1 cases has been seen recently in parts of southern Africa, the WHO said. In Zimbabwe, the health ministry said 15,241 H1N1 cases have been reported since mid October 2010. A government epidemiologist said about 80% of the cases have been in children under age five. Virologic testing shows that H3N2 viruses continue to be the predominant subtype globally.
(CIDRAP 11/08/2010)

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Global: WHO Influenza Update
Overall influenza activity remained low, except in parts of the tropics, most notably in South East Asia, and to a lesser extent in the tropical areas of the Americas. After late winter and springtime influenza epidemics in several countries of the temperate southern hemisphere, influenza activity has returned to near or below baseline in most places.

Notably, however, a recent post-season rise in cases has been noted across parts of southern Africa associated with localized outbreaks of influenza H1N1 (2009) virus. Seasonal influenza A (H3N2) viruses continued to be the predominant circulating type or subtype of influenza viruses worldwide, however, in addition, in many countries there has been co-circulation of seasonal influenza B viruses and to a lesser extent, influenza H1N1 (2009) viruses. The latter has been recently predominant in a limited number of countries, including in India.

In Chile, an unusually late winter and springtime influenza epidemic, characterized by predominance of circulating seasonal influenza A (H3N2) viruses, and to a lesser extent seasonal influenza B and H1N1 (2009) viruses, appears to have largely subsided. A similarly timed influenza epidemic was also observed in Paraguay and Uruguay. In Argentina, however, little winter and springtime influenza activity was observed during 2010, with influenza B viruses accounting for the majority of sporadic influenza virus detections.

In South Africa, the 2010 winter influenza season, characterized by a predominance of seasonal influenza B viruses, and to lesser seasonal A(H3N2) viruses, had largely concluded by the end of September 2010 but was followed by a mild resurgence of influenza activity (with a similar distribution of influenza viruses) during October 2010. In neighboring Namibia, there have been reports of school and community outbreaks of influenza H1N1 (2009) during October 2010.

As of early to mid-October 2010, influenza activity had declined substantially or had fallen below seasonal baselines in Australia and New Zealand, respectively. In both countries, the season was marked by a predominance of circulating influenza H1N1 (2009) viruses, however, in Australia there was also co-circulation of seasonal A (H3N2) and B viruses.

In the tropics of Asia, the most active reported circulation of influenza viruses continued to be in Thailand. Since late July 2010, influenza H1N1 (2009) viruses have been the predominant circulating influenza viruses in Thailand, however, more recently beginning in early October 2010, seasonal influenza A(H3N2), B, and H1N1 (2009) viruses began to co-circulate at similar levels. In southern China and Hong Kong (SAR), recent periods of active circulation of seasonal influenza A(H3N2) viruses during late summer and autumn now appear to have largely subsided. In Hong Kong SAR (China) but not in southern China, circulation of seasonal influenza A(H3N2) viruses was associated with a significant increase in sentinel levels of ILI [influenza-like illness] activity. In India, the national epidemic of influenza H1N1 (2009), which began during June 2010 and lasted until late September 2010, has largely subsided but small numbers of new cases continued to be reported weekly. In neighboring Bangladesh, there has been persistent influenza virus transmission since the early part of 2010, however only in recent months has circulation of seasonal influenza.

In the tropics of the Americas, between late July and early October, many countries or parts of countries experienced periods of active circulation of influenza viruses, including but not limited to southern Mexico, Costa Rica, Nicaragua, El Salvador, Honduras, Jamaica, Cuba, Peru, Colombia, and Bolivia. In most of these countries, seasonal influenza A (H3N2) was the predominant circulating influenza virus. Notably, Nicaragua observed circulation of predominantly influenza B viruses, while Colombia and Bolivia experience circulation of predominantly influenza H1N1 (2009) viruses. In most countries of the region, overall influenza virus transmission has declined substantially or returned to very low levels.

Limited data from the tropical areas of sub-Saharan Africa suggest that overall influenza activity has remained low. Since late spring and late summer, there have been persistent low levels of circulation of seasonal influenza A (H3N2) viruses in Kenya and Madagascar, respectively. A similar, but brief period of late summer circulation of seasonal influenza A (H3N2) viruses was also observed in Tanzania. More recently, since late September 2010, Cameroon, in central Africa, has also begun to detect significant level of seasonal influenza A (H3N2) viruses. In contrast, little influenza activity has been reported in West Africa during recent months.

In Canada and the United States, rates of ILI have increased slightly, but remain at or below seasonal baselines; small numbers of seasonal influenza A (H3N2) and B viruses have been detected during October 2010.

Most countries in the European Region continued to report low overall levels of ILI activity, with sporadic detections of influenza A(H3N2), H1N1 (2009), and influenza B viruses.

Overall influenza activity remains sporadic in Northern China, Japan, and South Korea.
(PROMED 11/11/2010)

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Asia
India: Committee recommends peramivir for H1N1 pandemic influenza
An advisory committee in the Indian state of Maharashtra has recommended that the state import the intravenous antiviral drug peramivir to better combat pandemic 2009 H1N1 influenza. The state has confirmed 4,677 novel H1N1 cases, including 518 deaths, since 1 April 2010. An audit by the committee suggested that oseltamivir (Tamiflu) has failed to prevent death in high-risk patients and when treatment is delayed. It said that most deaths in the populous state, which includes Mumbai, have resulted from comorbidities and treatment delay. Committee member Dr Om Shrivastav stated that such patients have not responded to Tamiflu and have eventually succumbed. Shrivastav said peramivir may help reduce deaths in the state, which remain higher than in other parts of the country. The drug is not currently approved for use in India. It was approved for use in certain high-rish US patients during the H1N1 pandemic through an emergency use authorization.
(CIDRAP 11/01/2010)

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Japan: Influenza A H3N2 outbreak kills six at Takanosu hospital
An outbreak of influenza A (H3N2) has killed six older people and sickened about 80 others at a hospital in Japan's Akita prefecture. According to the prefecture government, the patients tested positive in "simple" flu tests before they died between 31 October and 5 November 2010. A local health center confirmed that one of the patients from Takanosu Hospital in Kitaakita had the H3N2 strain. Others infected at the hospital include patients and healthcare staff. Ages of the fatal cases ranged from 60 to 90. FluTrackers, a Web message board that focuses on flu and other infectious diseases, has been monitoring and translating Japanese-language media reports on the outbreak since 6 November 2010. Translations, which are sometimes unclear, suggest the facility is a psychiatric hospital and that the outbreak reportedly occurred in a vaccinated population.
(CIDRAP 11/08/2010)

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Americas
United States: CDC reports low levels of US influenza activity
The US Centers for Disease Control and Prevention (CDC) reported in its 29 October 2010 update that influenza activity remains at low levels in the country, with physician visits for influenza-like illness (ILI) down slightly from the week of 22 October 2010. For the week ending 23 October 2010, only three percent of respiratory specimens tested were positive for influenza, with the proportion of deaths for pneumonia and flu and the proportion of outpatient visits for ILI below baseline levels. Two states reported local flu activity, 22 states reported sporadic activity, and 26 states reported no activity, while Guam and the US Virgin Islands reported local flu activity.
(CIDRAP 10/27/2010)

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United States: Influenza card program aims to streamline employee vaccination
Citi, a financial services company based in New York City and San Antonio, on 9 November 2010 launched the Citi Flu Care Card, a new product designed to help employers reduce the cost of offering seasonal flu vaccine to workers. Citi said that the program reduces costs by shifting the administration of flu shots from doctor's offices to a network of 17,000 pharmacies. It said the card program can reduce the cost for a vaccination by 63% while providing a convenient, no-cost option for employees. The program helps businesses rein in costs by enabling them to pay for the vaccinations only when they're administered, eliminating the need for prepayment. Dan Miller, senior vice president of Rite Aid, one of the pharmacy chains participating in the Flu Care Card program, said that the program is a good way to keep employees healthy. He added that it is also a good way to get out the message that the CDC recommends a yearly flu vaccine as the first and most important step in protecting against flu viruses.
(CIDRAP 11/09/2010)

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United States: Pandemic report warns against 'flu fatigue,' complacency
A review of several after-action pandemic assessments released on 10 November 2010 shows that earlier investments in emergency preparedness were helpful, but serious gaps such as low flu vaccination rates in minority groups and continued erosion of public health infrastructure could undermine response to the next national health emergency.

The big-picture view of the nation's pandemic response was provided by the Trust for America's Health (TFAH), a nonprofit health advocacy group based in Washington, DC. Jeffrey Levi, PhD, executive director of TFAH, said on 10 November 2010 that reviewing the pandemic lessons raises important public policy issues. He said the nation is at a crossroads, and we can go back to complacency or build on the momentum of our pandemic efforts.

The report, titled "Fighting Flu Fatigue," comes as seasonal flu vaccination campaigns ramp up across the nation during the first year of the federal government's universal flu immunization recommendation. However, the TFAH report notes that the recommendation faces a stiff headwind: one public opinion poll showed that only 37% of respondents planned to get this season's flu vaccine.

During the 2009 seasonal and pandemic flu vaccine campaigns, public health officials saw immunization rates rise for children, especially in areas where school-based vaccination clinics were held. Years of flu vaccination messages targeted to seniors have pushed levels in that group to high levels, but rates have foundered in adults, minority groups, and even healthcare providers, the TFAH report points out.

To increase vaccination rates, TFAH said a major campaign is needed to educate people about the need for an annual flu shot and to increase access to the vaccine, even in those who are uninsured or don't receive regular medical care.

Litjen (L.J.) Tan, PhD, the American Medical Association's director of medicine and public health, told reporters that elevating seasonal flu vaccination for all groups will require a culture change and an underlying message that flu is unpredictable and can be serious. He said that flu vaccination needs to be a routine part of fall and winter activities, adding that getting a flu shot this time of year should be as common as other seasonal icons, such as turkey, Christmas presents, and New Year's parties.

One strategy to increase uptake is to target high-priority groups, especially minorities. TFAH, citing figures from the US Centers for Disease Control and Prevention (CDC), said 2009 H1N1 vaccination levels were lower for African-Americans and Hispanics and that pandemic flu hospitalization rates for those two groups, plus Native Americans, were nearly twice as high as rates for whites.

Flu vaccine campaigns aimed at minority groups need to address negative beliefs and misinformation and should be delivered through a variety of channels, including trusted religious and community leaders, the report says. Levi said long-term relationships between public health and minority groups that address health issues that the communities deem important on an ongoing basis, such as chronic health conditions, can help pave the way for better acceptance of flu vaccination messages.

TFAH said a major flu vaccination campaign would also include increased access to flu shots, with a focus on more affordability and convenience, and incentives for healthcare workers to be immunized.

When the new H1N1 virus emerged in the spring of 2009, the federal government quickly responded with emergency supplemental and contingency funding. However the report says the emergency funding could not backfill long-existing gaps in the nation's public health infrastructure.

The nation's response to the pandemic seemed to validate the importance of planning, but plans are effective only if the public health infrastructure, which includes surveillance, lab capacity, and the workforce, is strong enough to carry them out, TFAH points out. Other key response areas that are vulnerable to the pressures of limited resources include surge capacity and updated pharmaceuticals, vaccines, and medical equipment.
(CIDRAP 11/10/2010)

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Africa
Namibia: Mild strain of H1N1 pandemic influenza outbreak
Primary health care supervisor at the Keetmanshoop State Hospital, Sister Rauna Namukwambi, says the outbreak of H1N1 at the town is only a mild strain of the virus, and is thus not deadly. Namukwambi emphasized that there is no need for panic, and urged the public to take precautionary measures not to be exposed to the virus.

She said over the week of 7 November 2010, there were people who presented signs of flu. Samples were taken from six people, and four tested positive for the H1N1 virus. Since then, 1,500 people have reported to have flu-like symptoms, like coughing, fever, headache, running nose, with still more coming forward. Only three people with severe cases have been hospitalised, but Namukwambi said they are doing well.

Namukwambi said because H1N1 is likely to develop into a severe situation, it has to be handled with extra caution. People are being treated according to the symptoms they show. To prevent contact with the virus, Namukwambi suggested that people avoid big crowds; that they cough into their elbow instead of their hands; that they practice basic hygiene such as regular hand washing; and that they get enough rest when they develop flu-like symptoms. Namukwambi stressed that this virus is in the air and people must take care.
(PROMED 11/09/2010)

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Zimbabwe (Harare): A/H1N1 influenza detected
Zimbabwe's capital Harare has recorded its first confirmed case of influenza A/ H1N1 and six suspected others since a fresh outbreak of the viral flu broke out in north western parts of the country in October 2010.

Of the six suspected cases in Harare, one has tested positive to the deadly influenza bringing to 16 the total number of confirmed cases from the outbreak.

So far 16 people have tested positive to H1N1 after undergoing rapid diagnostic testing stated the Health and Child Welfare Deputy Minister Douglas Mombeshora.

However, the minister urged the nation not to panic, saying the government has enough stocks of the drugs to cure the A/H1N1.

He also urged patients to seek treatment early when they suspect any case of the virus.

Five of the country's ten provinces, including Harare, have recorded 15, 453 suspected cases of the deadly influenza by Friday 5 November 2010.

So far Matabeleland North Province has the highest number of suspected cases at 14,182, of which eight have tested positive, followed by Matabeleland South which has recorded 1,160 and seven positive results.

In Masvingo, 105 suspected cases have been reported, but the results have not yet been released, while Harare has the lowest number with six suspected cases and one positive result.

The influenza outbreak is coming at a time when the government in August 2010 launched a nationwide vaccination campaign against the disease targeting school children, pregnant women and health workers.

A/H1N1 was first detected in Mexico in March of 2009 and was declared a pandemic after spreading rapidly across the world. The disease reached Zimbabwe in August 2009 and has infected about 416 people though no death has been recorded.
(Xinhua News Agency 11/09/2010)

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2. Infectious Disease News

Asia
Australia: Whooping cough outbreak linked to parents’ refusal to vaccinate children
Parents who refuse to vaccinate their children are contributing to the worst whooping cough outbreak on record in Queensland, with notifications likely to exceed 7000 in 2010.

Pockets of the expensive sea change and tree change areas of the Sunshine and Gold Coast hinterlands have the highest rate of children with no immunizations recorded. Between 8-18 per cent of children have no recorded vaccines administered in those areas.

Four to eight per cent of children on the Sunshine Coast are registered as so-called "conscientious objectors", meaning their parents refuse to immunize them.

Immunization is a victim of its own success, said Dr Christine Selvey, Queensland Health senior director of communicable diseases. People become complacent because they don't see children die any more.

Whooping cough is deadly to babies who are too young to be vaccinated. One in 200 babies who contract whooping cough will die.

There have been five deaths of babies since March 2009 across Australia. Queensland is still in the grip of a whooping cough epidemic that has been running now for two years.

As of 31 October 2010, we've had 6143 cases of whooping cough notifications, which is the highest on record, Dr Selvey said. She said that the biggest problem with whooping cough is that immunity wanes over time so many adults are not covered. That's why it's such a hard disease to control.

Dr Selvey said the program for booster shots for Year 10 students was designed to address this.

Other vaccine-preventable diseases such as measles are now very rare in Australia but an outbreak in 2009 at a Beerwah school on the Sunshine Coast highlighted low immunization levels.
(CourierMail.com.au 11/07/2010)

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Philippines: Measles and leptospirosis cases rising
The Department of Health (DOH) is alarmed over the rising number of measles and leptospirosis cases in the country.

Speaking on ANC's "Headstart," Dr. Eric Tayag, head of the DOH-National Epidemiology Center, said they have recorded 2,123 cases of measles in the country as of 30 October 2010 with six deaths.

He added the health department is stepping up its information and vaccination drive to prevent an outbreak.

We are going to advocate an extensive campaign with the private sector and the medical society so we can address the twin problem of measles and leptospirosis. We have to be prepared because this is the month when the measles virus begins to spread and will continue until first quarter of the year, he said. He said that officials want to prevent more outbreaks of measles now that they are eliminating it, and that they are going to start a supplementary activity in high-risk areas around the country in January 2011.

The DOH is also monitoring the number of leptospirosis cases across the country.

Tayag said they have recorded 690 cases of leptospirosis, most of them in Metro Manila. A total of 36 deaths have been recorded.

Leptospirosis is endemic in the country. It is not only associated with contaminated floodwater, it is also an occupational hazard, especially for farmers. You get leptospirosis from being exposed to bodies of water contaminated with urine from infected rats. People should watch out for symptoms of fever, yellowish skin, urine turning tea-colored, then you have to go to the hospital immediately, he said.

Tayag said they are now trying to verify a possible outbreak of leptospirosis in Pangasinan.

We are in touch with officials in Region One. They've reported 24 cases and two dead. It's alarming, and we have to verify it because they may have an outbreak there, he said.
(ABS-CBN News.com 11/11/2010)

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Thailand: Leptospirosis following flooding
Sa Kaeo Provincial Public Health Office warns people of the risk of leptospirosis when cleaning houses after flooding, especially in Aranyaprathet and Khok Sung, areas that have been heavily affected by flooding. Recently, seven cases were reported.

Dr Yutthapong Srimongkol, preventive medicine doctor of Sa Kaeo reported that there was flooding in nine districts in Sa Kaeo province. Severe flooding was reported in two border districts (Aranyaprathet and Khok Sung). The concern is post-flooding outbreaks, particularly leptospirosis. In the past, cases of leptospirosis were reported throughout the year especially during the rainy season and after flooding. Risk groups are those working in inundated fields and living in post-flooding areas.

Public health officers in the province encourage people to stay clean amidst flooding and avoid walking through flooded areas for a long time. In addition, people are advised to wear waterproof boots when working in inundated fields and clean their body immediately after that.

Between 1 January 2010 and 3 November 2010, there were seven cases of leptospirosis reported in the province. No death was reported. High numbers of cases were reported in Watthana Nakhon, Khlong Hat and Aranyaprathet districts. According to case reports of leptospirosis in the previous five years (2005-2009), there were approximately 25 leptospirosis cases per year, during June through November each year. The provincial Public Health Office instructed health officials and health volunteers in Arunyaprated and Koh Sung districts to keep vigilant of four main post-flooding diseases for eight weeks; leptospirosis, conjunctivitis, acute diarrhea, and dysentery.

Dr Yutthapong mentioned that the symptoms of leptospirosis are high fever, chills, headache, nausea, vomiting and muscle pain especially the calf muscles. Pain can be found in 40-100 percent of people. People experiencing these symptoms are advised to see a doctor immediately in order to prevent serious complications that may cause death, such as liver or kidney failure. The disease can be cured, however, it is possible to be re-infected.

[ProMED note: The newswire above is the first report of leptospirosis after heavy flooding in most parts of Thailand in October 2010. Before flooding, leptospirosis cases were also reported from several provinces in the northeastern region: Kalasin, Maha Sarakham, and Surin (see prior PRO/MBDS postings listed below).

According to the Thai Ministry of Public Health, Bureau of Epidemiology (BOE) report on leptospirosis, available in Thai at http://203.157.15.4/surdata/disease.php?dcontent=situation&ds=43, between 1 January 2010 and 30 October 2010, a total of 3745 cases and 32 fatalities were reported from 70 provinces. The attack rate was 5.9 per 100 000 population. Among these, seven cases and no deaths were reported from Sa Kaeo province in 2010; one case was reported in June, five cases in September and another case in October 2010.

The highest percentage of cases was reported in the 45-54 years old age group (21.82 percent), followed by the 35-44 years old age group (21.63 percent), and 25-34 years old age group (16.13 percent). The northeastern region has the highest attack rate (per 100 000 population) of leptospirosis (12.58), followed by the south (5.72), north (3.19) and central regions (0.76). High attack rates (per 100 000 population) were reported in these five provinces: Buriram (40.86), Ranong (31.36), Surin (30.12), Si Sa Ket (29.18) and Phang Nga (27.82).
(ProMED 11/08/2010)

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Americas
Canada: C. difficile outbreak
Four new C. difficile cases at St. Joseph’s hospital surfaced 30 October and 1 November 2010, bringing the total patients in the outbreak up to 22.

There are 21 in-hospital C. diff patients, St. Joseph’s hospital president Dr. David Higgins said 1 November 2010. Eighteen of those cases are associated with the Charlton Campus hospital and three have contracted the infection outside the facility, he added.

All the patients except one are in their 70s or older, Higgins said. They’re all elderly and have underlying medical conditions, he said. C. diff is brought on generally by the use of antibiotics that kill competing gut bacteria. The naturally occurring C. diff bacteria become too numerous and release toxins that can cause bloating and diarrhea with abdominal pain, which may become severe.

One patient has been discharged and was also elderly.

It’s spread out over the wards. There’s no specific, obvious cluster of patients, he said, adding the hospital will continue to track patients’ activity and review retrospectively to see if there are common units they have been in.

Hamilton public health is investigating the death of one patient who contracted C. diff while at St. Joe’s in October and died after being transferred to Oakville Trafalgar Memorial Hospital. A second death that occurred in September in which C. diff was a factor but not the direct cause is also being investigated.

St. Joe’s is continuing to enforce strict cleaning protocols for all surfaces in affected rooms and units outside of the rooms, review patients’ antibiotic use and increase the availability of equipment in patients’ rooms so they’re not being transferred from room to room, Higgins said.

There’s always a concern this time of the year with regard to the increased use of antibiotics, he said, adding there has been a rise in C. diff cases across the province.

They’ve also collected samples to test to see if it is the same type of bug infecting patients, or if there are different ones, Higgins said. If it’s the same bug, then it makes you concerned that it is the hospital. If there were different types, then it clearly wasn’t.

Higgins said test results should be available in a couple weeks.

In the spring of 2009, seven C. diff patients, who were all in their 80s, died during an outbreak at St. Joe’s. At the time, the hospital said C. diff contributed to four of the seven deaths but did not directly cause the fatalities.
(TheSpec.com 11/05/2010)

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Canada (Toronto): NDM-1 superbug cases in Canada
Eight Canadians have been sickened by NDM-1 bacterial infections, a jump of five confirmed cases of the highly drug-resistant superbugs in less than three months, the Public Health Agency says.

While officials said there is no need for the public to be alarmed, it's important that infectious disease experts and other doctors are aware of the increasing tally of cases, which includes one reported the week of 4 November 2010.

Four of the patients lived in British Columbia, one in Alberta, two in Ontario and one in Quebec, said Dr. Michael Mulvey, chief of Antimicrobial Resistance and Nosocomial Infections at the federal agency.

Two of the four, a 76-year-old B.C. woman and a Quebec patient, died — although not directly from the NDM-1 infections, Mulvey said. All of the other patients recovered.

NDM-1 is an enzyme that has found its way into several types of bacteria, including some strains of E. coli. NDM-1 — or New Delhi metallo-beta-lactamase — makes the disease organisms resistant to most and, in some cases, all antibiotics.

We're highlighting that it's in Canada, that many other countries now are reporting NDM-1 infections. Many of them are linked to India, Pakistan, Bangladesh. The U.S.A. has seen it and numerous countries in Europe, Japan, Hong Kong, Taiwan, Australia, he said.

I guess these are sort of initial cases. They haven't really spread a great deal in any of these countries. But they're starting to see them sporadically, said Mulvey. However, he noted that the superbug infections are on the rise in the U.K. and are becoming more pervasive in south Asian countries like India.

The 76-year-old B.C. woman, whose case is described in the journal Emerging Infectious Diseases, died from complications of sepsis. The Quebec patient, whose sex was not identified, succumbed to cancer.

At least five of the eight people had travelled to India or Pakistan, where NDM-1 superbug infections are becoming more widespread. Four of those patients spent time in hospital in those countries, and one person had contact with the health-care system.

The B.C. woman spent more than three months in northern India, where she developed persistent diarrhea. She was hospitalized and treated for high blood pressure, congestive heart failure, the diarrhea and a urinary tract infection.

Antibiotics failed to cure her infections and her condition continued to worsen. She was transferred home to Vancouver in February and admitted to hospital, but her health deteriorated and she died.

Tests showed the woman had contracted strains of E. coli and Klebsiella pneumoniae, both of which contained NDM-1.

She was a very ill person, said Mulvey, lead author of the report published Wednesday in the U.S. Centers for Disease Control journal.

Dr. Linda Hoang, medical microbiologist at the B.C. Centre for Disease Control laboratory, agreed Canadians shouldn't be worried about an outbreak of NDM-1 infections because there's no evidence of transmission within hospitals or the community.

It doesn't mean that these organisms can't be spread; it's just that through our general infection-control practices and through our hygiene practices, we have not seen the spread and may have been able to prevent it, Hoang said Wednesday from Vancouver.

There may be other cases "out there" that haven't been identified, she said. But having said that, she said, if it was extensive we would see it by now. We would see it in the hospital setting, we would see it in our out-patient setting — and we're not seeing it.

Mulvey said the spread of NDM-1 bacterial infections would be a major concern because they are difficult to treat and there are virtually no new antibiotics in development that might combat the superbugs.

We wouldn't want to see cases begin to spread in our hospitals. That's the first potential indication where we might begin to see a problem. But infection control in Canada is quite good and we've managed to keep other multidrug-resistant organisms (such as MRSA) fairly low compared to other countries, he said.

NDM-1 infections are not reportable in Canada, meaning doctors aren't required to inform provincial and federal health officials about cases. But a group of 50 sentinel hospitals across the country, which make up the Canadian Nosocomial Infection Surveillance program, has been keeping track of cases involving NDM-1-affected organisms since September 2009, Mulvey said.

Hoang advised Canadians who travel abroad, especially to countries known to have a high prevalence of superbug infections, to contact their doctors after returning home if they have lingering illnesses that began during their trip.

Those countries are expanding in number, the CDC journal suggests.

In a second report, Austrian doctors describe two patients with NDM-1 infections. The first, a 30-year-old Austrian man initially treated in Pakistan and India for injuries from a motorcycle accident while travelling, spent five months receiving various treatments before fully recovering.

The second was a 14-year-old boy, who was admitted in April to a hospital in Graz, Austria, for abdominal abscesses following appendix removal in his home country of Kosovo. The boy, who had not travelled to any of the NDM-1 hotspot countries, remains in hospital.

The teenager's travel history suggests the superbug may be spreading within hospitals or the community in countries outside the Indian subcontinent — and the report's authors warn the emergence of NDM-1 infections could lead to the enzyme transferring between different bacterial strains, creating a serious threat.

Immediate action is needed to control the spread of NDM-1 and avoid a worldwide public health problem, they write.
(Canadian Press 11/11/2010)

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USA: E. coli outbreak related to cheese
Bravo Farms Dutch Style Gouda cheese, (Costco item 40654) offered for sale and in cheese sampling events at Costco Wholesale Corporation (Costco) locations is preliminarily linked with an outbreak of E. coli O157:H7 infections. The cheese was available for sale, and free samples were offered for in-store tasting at Costco stores in Arizona, California, Colorado, New Mexico, and Nevada.

Consumers who have any of this cheese should not eat it. They should return the cheese to the place of purchase or dispose of it in a closed plastic bag and place in a sealed trash can to prevent people or animals, including wild animals, from eating it.

As of 4 November 2010, 25 persons infected with the outbreak strain of E. coli O157:H7 have been reported from five states since mid-October 2010. The number of ill persons identified in each state with this strain is as follows: AZ (11), CA (1), CO (8), NM (3), and NV (2). There have been nine reported hospitalizations, one possible case of hemolytic uremic syndrome (HUS), and no deaths.

[ProMED note: As can be seen in the list of previous postings below, a spate of infections can be spread through cheese vehicles. Overall, the common co-factor is the lack of proper pasteurization of milk used to produce the cheese. No details have been released regarding what and/or where the process was defective. - Mod.LL]
(ProMED 11/05/2010)

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USA (California): Whooping cough cases still prevalent
As of the week beginning 27 October 2010, there have been 6,431 cases of whooping cough or pertussis in California – the most cases the state has seen in 60 years, writes Vincent Iannelli, M.D., on his 5 November 2010 Pediatric Blog on About.Com.

Whooping cough – or pertussis – is a serious and very contagious respiratory disease that can cause long, violent coughing fits and the characteristic “whooping” sound that follows when a person gasps for air. It takes a toll on anyone, but for infants it can be deadly. State health officials report that 10 infants have died so far in 2010.

Because whooping cough usually starts with cold-like symptoms, it often goes undiagnosed and the coughing fits can continue for weeks or months. People may not even know they have whooping cough and unknowingly spread the disease to others, including babies.

Health officials say that immunization is the best protection and are urging parents to vaccinate their babies and small children. They also strongly recommend that adults, especially those who have contact with infants or small children, get vaccinated.

The Centers for Disease Control and Prevention (CDC) recommends that infants and children get the childhood vaccine that includes protection against whooping cough, diphtheria, and tetanus (DTaP) at two months, four months, six months, and 15 through 18 months of age. A booster of DTaP is given at four through six years of age.

While no one cause for the outbreak has been pinpointed, some health experts are looking to the rising number of parents who have opted to not immunize their children out of fear that the vaccines may be the cause for the increase in children with autism or other health problems.

Consider that in Marin County, which has the fifth highest per capita income in the United States, rates of exemptions for vaccines are reported to be as high as 33 to 54 percent in some school districts, and they have one of the highest rates of whooping cough infections in the state.

Iannelli disputes claims that undocumented immigrants may be to blame, noting that there have been no whooping cough outbreaks in Mexico or Central America, and that Hispanic children generally have high immunization rates in California.

Early detection is key, add health officials.
(EGP News 11/11/2010)

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USA (Colorado): Hantavirus death
A Montezuma County man who died suddenly 19 October 2010 had contracted a hantavirus infection from rodent feces and urine, a Colorado Department of Public Health and Environment veterinarian said 29 Oct 2010. Laboratory tests confirmed the cause of death, Elisabeth Lawaczeck said. She couldn't release personal information, but she said the victim, 35, worked at least part time in construction. The man, a resident of Mancos, had traveled in several places where he could have come in contact with rodent feces, Lawaczeck said. State health officials will try to pin down a source the week of 1 November 2010, she said.

The last hantavirus death of a Montezuma County resident killed a woman in 1993, Lawaczeck said. She contracted the disease in San Miguel County.

La Plata County has registered a number of human hantavirus cases, including three deaths, since 1985, Lawaczeck said. One of the deaths occurred in 1993, the others in 1998.
(ProMED 11/01/2010)

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USA (Illinois): Norovirus outbreaks in Cook County
Gastrointestinal illnesses apparently being spread through Cook County schools have sickened more than 125 people, public health officials said 9 November 2010.

Health officials have identified 25 separate clusters across suburban Cook County where students, school staffers or family members have fallen ill with viral infections that cause vomiting, diarrhea, stomach cramps and fevers.

People who fall ill — particularly children — should stay home until they recover to avoid spreading the illness, officials said.

One cluster of illness is being caused by a norovirus, tests show. The other clusters found so far are causing symptoms consistent with the norovirus, officials said.

The clusters have been found in grade schools, high schools and a college, officials said, declining to identify any of the schools where the viruses have caused illness.

The noroviruses are “very highly contagious” and are capable of surviving on tables or utensil surfaces for up to 12 days, said Amy Poore, a spokeswoman for the health department.

Anyone sickened should remain home for at least 24 hours after becoming symptom-free, Poore said.
(Fox Chicago News 11/10/2010)

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USA (Mississippi): Cal-Maine Foods recalls more than a quarter-million eggs due to salmonella scare
Close on the heels of the giant egg recall after thousands were sickened in summer 2010 comes another recall, bringing to light the need for additional food safety measures.

Mississippi-based Cal-Maine Foods, the nation's largest egg producer, initially recalled 288,000 eggs on 5 November 2010 and then added another 120 dozen batches to the already-recalled lot on 9 November 2010, amid concerns of a salmonella contamination.

The two batches of contaminated eggs were purchased from Ohio Fresh Eggs in Croton, the farm behind the massive recall earlier in 2010.

The recall was initiated after the Food and Drug Administration (FDA) notified Cal-Maine of salmonella detection in a routine environmental sample test at the Ohio facility from where the eggs originated.

Cal-Maine had purchased 24,000 dozen unprocessed eggs from Ohio Fresh Eggs that were processed and repackaged under the brands Sunny Meadow, Springfield Grocer, Sun Valley, and James Farm in its Green Forest, Ark., plant from 9 to 12 October 2010.

Though Cal-Maine also raises their own chickens for eggs, only those bought from Ohio Fresh Eggs are subject to the recall.

The tainted eggs have been shipped and distributed to both retail grocery stores and wholesalers in eight states including Arkansas, California, Illinois, Iowa, Kansas, Missouri, Oklahoma, and Texas.

The contaminated eggs come under the Pippin Loose Medium brand, with a 1457 plant number, and a Julian Date of 282, 284 and 285. The sell-by expiration date is 7 November 2010.

Unlike the summer 2010 outbreak, no confirmed illnesses have been tied to the current recall.

But as a precautionary measure, Cal-Maine Foods Inc. is urging consumers not to eat the recalled eggs and immediately get in touch with the store they purchased them from for a refund.
(The Money Times 11/10/2010)

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USA (Washington): Number of tuberculosis cases has risen in 2010
While cases of tuberculosis decreased between 2008 and 2009 nationwide, the number of TB cases rose in King County and the rate of infection is nearly twice as high as the national average, according to King County Public Health.

Public Health found that the number of TB cases rose to 130 in 2009 from 121 in 2008, increasing the county rate to 6.8 cases per 100,000 people. The national rate is 3.8 cases per 100,000.

They said more than 80 percent of those with TB living in the county were born outside the United States.

The news comes during an economic downturn that has forced Public Health to cut critical services, including the TB control program.
(The Seattle Times 11/10/2010)

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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

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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
Asia
WHO has warned that 2.5 billion people are at risk from one of the world's fastest-emerging infections, which has grown dramatically in recent decades. Officials at the WHO say Asia, home to 70 percent of the at-risk population, has seen a rise in dengue mainly because of higher temperatures due to climate change, rising populations, and greater international travel. The organization says that a rapid rise in urban mosquito populations is also bringing ever greater numbers of people into contact with the virus.

The highest number of reported cases in Asia up to August, 2010 are in Indonesia (80,065) followed by Thailand (57,948) and Sri Lanka (27,142). The disease has spread fast. Dengue is appearing in new areas, said Yogesh Choudhri, an expert at the WHO on the Asia region, who said the disease had crossed new international borders and spread within countries. It was found in the Himalayan countries of Bhutan and Nepal for the first time in 2004, and is endemic in most of Southeast and South Asia as well as Indonesia and East Timor.
(ProMED 11/01/2010)


Australia (Northern Queensland)
Queensland Health confirmed two new cases of type 2 dengue, which brings the number of victims in the latest outbreak to 19.

The cases were confirmed after adults from Westcourt presented with symptoms of the disease last week, but neither victim needed to be hospitalized.

Queensland Health identified an infected area between Mulgrave Rd and Gatton, Boland and Buchan streets. The Dengue Action Response Team has been inspecting yards in the grid since the suspected cases were reported. So far, they have visited 470 houses in the area.

The latest cases have been linked to the same strain of the disease that broke out in Parramatta Park in late August 2010.

Queensland Health medical director Jeffrey Hanna said the low cost of international travel and the large number of overseas visitors carrying the disease were responsible for the number of imported cases of dengue in North Queensland this year. We have had 35 known imported cases of dengue fever so far this year, which is a record, he said. He added that officials have seen more and more travelers bringing dengue back with them, particularly from Bali.

Of course we welcome international travelers, but if they are infected with dengue fever while they’re here, there is a chance that they will pass it to our mosquitoes, he said.

He has urged residents of Westcourt to clear their yards of containers capable of holding water.
(Cairns Post 11/04/2010)


Chinese Taipei
More than 1,000 Taiwan residents have been infected with dengue fever since August 2010. Kaohsiung City in southern Taiwan was the worst hit with 589 dengue virus infections. The week of 27 October 2010 the island reported 128 new cases of dengue fever, mostly in the southern cities of Kaohsiung and Tainan.
(ProMED 11/10/2010)


Indonesia
Dengue fever has killed 29 residents of the Indonesian resort island of Bali from January to November 2010, the province’s health authority said.

They were among 10,230 residents who suffered from the dengue fever virus between January and October 2010, Head of Bali Province`s Health Office dr.I Nyoman Suteja said.

A total of 10,201 patients can recover from the fever after having intensive medical treatments, he said.

Bali`s population was 3.9 million people; and 0.28 percent was vulnerable to the dengue fever attacks, he said.

Denpasar city`s neighborhood areas were the most vulnerable because there were 3,716 cases with the death toll of 20 this year, he said.

Besides Denpasar city, the dengue fever cases were also found in the districts of Badung, Buleleng,Gianyar, and Klungkung, he said.

The dengue fever remains a serious threat to Indonesians. In Palu, Central Sulawesi, the dengue fever had killed ten Palu residents from January to August 2010.

In Lebak district, Banten Province, the sub-district, which were reportedly vulnerable to the dengue fever cases were Warunggunung, Rangkasbitung, Cibadak, Kalanganyar, Sajira, Cimarga, Binuangeun, Cikulur, Maja and Leuwidamar.

Most of the patients lived in densely-populated areas, a local health worker said.

In curbing the virus, people were urged to practice a healthy life style and avoid creating stagnant water ponds, which could be used by the Aedes mosquitoes as a breeding ground.

The World Health Organization (WHO) has warned that the bite of infected female Aedes mosquitoes transmit the virus to human beings.

WHO estimated that some 2.5 billion people were at risk from dengue in which 50 million dengue infections were found worldwide every year.

In Indonesia, the dengue fever cases can be found in Java and other islands.
(Antara News 11/10/2010)


Malaysia
A total of 119 people died from dengue fever in the first 10 months of 2010, with the latest reported death on 23 October 2010.

Health director-general Tan Sri Dr Mohd Ismail Merican said this was an increase of 45 deaths (or 61%) of the reported deaths within the same period in 2009. He said the latest death involved a housewife from Ampang Jaya, who first showed signs of fever on 17 October 2010.

She went to a private clinic 19 October 2010 and, at about 3pm on the same day, was warded at a private hospital when she complained of fever and body aches.

After four days she was diagnosed with dengue fever. The 69-year-old patient died 23 October 2010, with the cause of death attributed to dengue shock syndrome.

The medical officer who treated her was penalized with a compound under the Destruction of Disease Bearing Insects Act 1975 for making a late report on the case to the district health department.

Dr Ismail said in its efforts to reduce dengue cases, the Health Ministry is being more strict with enforcement. Medical practitioners who fail to report dengue fever cases and errant landowners found to be breeding Aedes at their premises could find themselves facing a compound of up to RM500 for the offence.

Dr Ismail said 40,959 cases of dengue fever cases were reported between January and October 2010, an increase of 19% of cases in the corresponding period in 2009.

However, he said, there were 807 cases of dengue fever the week of 27 October 2010, down 9% from the 888 cases in the previous week.

Selangor reported the most number of new cases, with 19. This was followed by Perak (four) and the Federal Territories of Kuala Lumpur and Putrajaya (two each). Dr Ismail said only three of 26 hot spotsť carried out gotong-royong (community clean-up) to get rid of the menace.

Meanwhile, the number of Chikungunya cases had dropped significantly, down 80%, with 787 cases from January to October 2010 against 3,988 cases reported in the corresponding period in 2009.
(The Star Online 11/04/2010)


Mexico (Tamaulipas)
The Ministry of Health in Tamaulipas has issued an alert to the public about the presence of a new dengue virus which, as well as being immune to certain drugs, re-infects a person who has already had the disease (caused by a different dengue virus serotype). This was announced by Fernando Garza Frausto who explained that the municipalities of Reynosa and Rio Bravo have detected cases of this type of dengue since patients present the same symptoms when they reach the hospitals. [Pro-MED note: Anti-viral drugs are not effective against dengue viruses, calling into question the statement above. - Mod.TY]

The director of Prevention and Health Protection added that there are three cases in Reynosa, one in Rio Bravo, which are already controlled, but that they are on the alert for more cases in the jurisdiction, where a total of 98 cases have been recorded.

Frausto Garza explained that a few months ago Tamaulipas had registered only classical dengue fever and DHF, but said that in recent weeks the presence of this new virus had been detected which can affect the same person a second time.

Dengue virus serotype one has already occurred in Tamaulipas and affected persons are immune. However, with the new virus, people are susceptible and may become ill with dengue, he said.

The health official mentioned that the risk now is that the new type has not affected the people from the state, which means that those who have already suffered from dengue may be reinfected, so he urged people to strengthen precautionary measures.

[ProMED note: Because dengue virus type three circulates in southern Mexico, health authorities in the north eastern state of Tamaulipas are concerned about its arrival there, affecting a population with no immunity to that virus serotype. That population has only had recent experience with dengue virus type one.]
(ProMED 11/01/2010)


Singapore
The number of dengue fever cases in Singapore is expected to remain high for the rest of 2010.

An average of about 105 cases have been recorded every week in 2010 and this is expected to continue, said the National Environment Agency (NEA).

There is good news though, as the number of cases has dropped in recent weeks, from a high of 182 seen during one week of October 2010.

A sweeping check by the authorities of more than 300 construction sites over a two-week period last month identified 52 as mosquito-breeding sites.

The recent spike in cases can also be attributed to the larger number of breeding spots discovered in homes and hot spots like construction sites, NEA said.

Some 19,000 such spots had been found in the year until September, compared to 16,878 in the first nine months of 2009.

So far, a total of 4,364 cases of the vector-borne diseases have been reported in Singapore in 2010, up from 3,775 in the same period in 2009.

(XinhuaNet.com 11/04/2010)


Singapore.
An average of about 105 cases have been recorded every week of 2010, and this is expected to continue. So far, a total of 4,364 cases of the vectorborne diseases have been reported in Singapore this year, up from 3775 in the same period last year (2009).
(ProMED 11/10/02010)


USA
The season for West Nile virus is peaking late in 2010.

County health officials reported 3 November 2010 that three men have been stricken with the virus. That brings the county’s total for the year to four.

The victims ranged in age from 57 to 71. They resided in Colton, Fontana and Redlands. All are recovering.

Cooler weather usually keeps mosquitoes in check. But, that has not happened as mosquitoes continue to breed in stagnant water.
(Inland News Today 11/09/2010)

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CHOLERA, DIARRHEA, and DYSENTERY
Papua New Guinea
The cholera outbreak appears to have spread. Thirteen children have died on a remote island near the maritime border with Australia in the Torres Strait.

Infection rates have slowed after the outbreak began on PNG's north coast in August 2009 and spread throughout the mainland. Now the disease appears to have surfaced on remote Daru Island, 50 km [31 mi] from Saibai Island on the Australian side of the Torres Strait.

Thirteen children have died from cholera-like symptoms and 64 other people are being treated in the local hospital.

Australia's aid agency AusAID is monitoring the situation and working to confirm the details.
(ProMED 11/09/2010)


Philippines
Health officials said that heavy rains and massive flooding in northern Luzon could trigger an outbreak of diarrhea, particularly in Isabela and Cagayan.

Dr. Carlos Cortina, deputy chief of Cagayan provincial health department told GMANews.TV that their agency is on heightened alert because a diarrhea outbreak is possible after the recent flooding.

The possibility is always there but personnel from our Rural HealthUnits (RHU) are well trained to do surveillance activities to prevent an outbreak. We are currently doing information campaign so that the community will be protected, he said.

Cortina added that they have already augmented provisions to chlorinate water in some villages.

However, he advised areas they cannot reach to boil drinking water and to avoid eating spoiled and leftover food. He added that it is very important too to practice washing of hands before eating.

Anti-diarrhea medicines and potable water supply have been distributed by the Provincial Disaster Risk Reduction Management Council (PDRRMC) to evacuation centers.

PDRRMC personnel said the massive flooding across the northern part of Cagayan Valley, caused by days of heavy downpour, has contaminated water supply.

Reports indicated that eleven persons from Solana town in Cagayan have already been hospitalized due to symptoms associated with diarrhea after drinking contaminated water.
(GMA NewsTV 11/08/2010)

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4. Articles
Influenza vaccination and all-cause mortality in community-dwelling elderly in Ontario, Canada, a cohort study
Campitellis MA, Rosella LC, Stukel TA, et al. Vaccine. 31 October 2010.
doi:10.1016/j.vaccine.2010.10.049.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-51C4VTM-2&_user=10&_coverDate=10%2F31%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=f4f1baee2af2ded08e11c9a78b8a41e6&searchtype=a

Abstract. The objective of this study was to evaluate the effectiveness of influenza vaccines in reducing all-cause mortality among community-dwelling elderly. We included 25,922 Ontario residents over age 65 who responded to population health surveys. After full adjustment, influenza vaccination was associated with a statistically significant reduction in all-cause mortality during influenza seasons (hazard ratio (HR) = 0.61; 95% CI 0.47–0.79). Contrary to expectations, statistically significant associations between influenza vaccination and mortality were also observed during periods preceding (HR = 0.55; 95% CI 0.40–0.75) and following (HR = 0.74; 95% CI 0.59–0.94) influenza seasons, indicating the presence of residual confounding. Adjustment for functional status indicators, excluding individuals with high one-year predicted mortality at baseline, and moving the start date of follow-up failed to eliminate the refractory confounding. Since observational studies are prone to bias, future efforts to estimate vaccine effectiveness in the elderly should strive to minimize bias through improved data quality, novel data sources, and/or new analytical techniques.

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Exploring pregnant women's views on influenza vaccination and educational text messages
Kharbanda EO, Vargas CY, Castano PM, et al. Preventive Medicine. 1 November 2010.
doi:10.1016/j.ypmed.2010.10.009.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WPG-51C9JYJ-3&_user=10&_coverDate=11%2F01%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=3ae5b1348bab8b0cd030e34813771ca0&searchtype=a

Background. The influenza vaccine has the potential to reduce morbidity among pregnant women and newborns but immunization coverage remains low. Effective interventions are needed to promote vaccine uptake in this population.

Purpose. The goal of this study was to explore attitudes toward influenza vaccination and interest in targeted educational text messages among urban pregnant women.

Methods. English and Spanish language focus groups were conducted with pregnant women in New York City in April 2010. Transcripts were independently coded using content analysis.

Results. The 40 participants ranged in age from 19–35 years (mean = 26, SD = 5). Their gestational age ranged from 8–40 weeks (mean = 27, SD = 8). Most were Latina (85%), had other children (70%), and were publicly insured (78%). Nearly half had received the seasonal or H1N1 influenza vaccine in the 2009–2010 season. Barriers to vaccination included concerns regarding vaccine safety and efficacy, misperceptions regarding risks for influenza, and lack of provider recommendation. Pregnant women expressed interest in receiving educational text messages regarding influenza. Even women who had refused the influenza vaccine thought the text messages would encourage vaccine-related discussions during prenatal visits.

Conclusion. Among urban pregnant women, educational text messages regarding influenza would be well received and may effectively address current barriers to vaccination.

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Establishing the baseline burden of influenza in preparation for the evaluation of a countywide school-based influenza vaccination campaign
Grijalva CG, Zhu Y, Simonsen L, et al. Vaccine. 2 November 2010.
doi:10.1016/j.vaccine.2010.08.072.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-51CJ1B0-1&_user=10&_coverDate=11%2F02%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=1e2f740e39849628311e6e026a31c583&searchtype=a

Background. School-based influenza vaccination campaigns could mitigate the effects of influenza epidemics. A large countywide school-based vaccination campaign was launched in Knox County, Tennessee, in 2005. Assessment of campaign effects requires identification of appropriate control populations. We hypothesized that contiguous counties would share similar pre-campaign patterns of influenza activity.

Methods. We compared the burden of influenza emergency department (ED) visits and hospitalizations between Knox County (Knox) and eight counties surrounding Knox (Knox-surrounding) during five consecutive pre-campaign influenza seasons (2000–01 through 2004–05). Laboratory-defined influenza seasons were used to measure the weekly incidence of medically attended acute respiratory illnesses (MAARI) attributable to influenza in school-aged children 5–17 years old (campaign target) as well as in other age groups. Seasonal rates of MAARI attributable to influenza for Knox and Knox-surrounding counties were compared using rate ratios.

Results. During five consecutive influenza seasons, MAARI attributable to influenza showed synchronous temporal patterns in school-aged children from Knox and Knox-surrounding counties. The average seasonal rates of ED visits attributable to influenza were 12.37 (95% CI: 10.32–14.42) and 13.14 (95% CI: 11.23–15.05) per 1000, respectively. The respective average seasonal influenza hospitalization rates for Knox and Knox-surrounding were 0.38 (95% CI: 0–0.79) and 0.46 (95% CI: 0.07–0.85) per 1000 children. Rate ratio analyses indicated no significant differences in the incidence of MAARI attributable to influenza between school-aged children from Knox and Knox-surrounding counties. Estimates for other age groups showed similar patterns.

Conclusion. Before the Knox school-based influenza vaccination campaign, influenza resulted in an average of about 12 ED visits and 0.4 hospitalizations per 1000 school-aged children annually in Knox County. Since similar morbidity was observed in surrounding counties, they could serve as a control population for the assessment of the campaign effects.

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Implementing a Community-Supported School-Based Influenza Immunization Program
Tran CH, McElrath J, Hughes P, et al. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 5 November 2010. doi:10.1089/bsp.2010.0029.
Available at http://www.liebertonline.com/doi/abs/10.1089/bsp.2010.0029

Abstract. School-based influenza immunization programs are increasingly recognized as a key component of community-based efforts to control annual influenza epidemics. Computer modeling suggests that immunizing 70% of schoolchildren could protect an entire community from the flu. Most of the school-based influenza immunization programs described in the literature have had support from industry or federal grants. This article describes a program that used only community resources to administer live, attenuated influenza vaccine supplied by the state health department. Beginning in 2006, the Alachua County Health Department and school system, working in collaboration with the University of Florida, began exploration of a nonmandatory community-wide school-based influenza immunization program, with the goal of achieving high levels of immunization of the 22,000 public and private pre-K through grade 8 students in the county. In 2009-10 the program was repeated. This report describes the procedures developed to achieve the goal, the barriers that were encountered, and solutions to problems that occurred during the implementation of the program. Preliminary data suggest that the crude immunization rate in the schools was approximately 55% and that at least 10% more students were immunized by their health providers. At an operational level, it is possible to achieve high immunization rates if the stakeholders share a common vision and there is extensive community involvement.

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Influenza Vaccine Given to Pregnant Women Reduces Hospitalization Due to Influenza in Their Infants
Benowitz I, Esposito DB, Gracey KD, et al. Clin Infect Dis. 8 November 2010. doi: 10.1086/657309.
Available at http://www.journals.uchicago.edu/doi/abs/10.1086/657309

Background. Infants aged <12 months are at high risk of hospitalization for influenza. Influenza vaccine is recommended for pregnant women and for most children; however, no vaccine is approved for infants aged <6 months. Effective approaches are needed to protect this vulnerable population. Vaccination of women during pregnancy may protect the infant through transfer of antibodies from the mother. Few studies have examined the effectiveness of this strategy, and those studies produced mixed results.

Methods. In a matched case‐control study, case patients were infants aged <12 months admitted to a large urban hospital in the northeastern United States because of laboratory‐confirmed influenza from 2000 to 2009. For each case, we enrolled 1 or 2 control subjects who were infants who tested negative for influenza and matched cases by date of birth and date of hospitalization (within 4 weeks). Vaccine effectiveness was calculated on the basis of matched odds ratios and was adjusted for confounding.

Results. The mothers of 2 (2.2%) of 91 case subjects and 31 (19.9%) of 156 control subjects aged <6 months, and 1 (4.6%) of 22 case subjects and 2 (5.6%) of 36 control subjects aged 6 months, had received influenza vaccine during pregnancy. The effectiveness of influenza vaccine given to mothers during pregnancy in preventing hospitalization among their infants, adjusted for potential confounders, was 91.5% (95% confidence interval [CI], 61.7%–98.1%; ) for infants aged <6 months. The unadjusted effectiveness was 90.7% (95% CI, 59.9%–97.8%; ).

Conclusions. Influenza vaccine given to pregnant women is 91.5% effective in preventing hospitalization of their infants for influenza in the first 6 months of life.

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Willingness to accept H1N1 pandemic influenza vaccine: A cross-sectional study of Hong Kong community nurses
Wong SYS, Wong ELY, Chor J, et al. BMC Infect Dis. 29 October 2010;10:316.doi:10.1186/1471-2334-10-316.
Available at http://www.biomedcentral.com/1471-2334/10/316

Background. The 2009 pandemic of influenza A (H1N1) infection has alerted many governments to make preparedness plan to control the spread of influenza A (H1N1) infection. Vaccination for influenza is one of the most important primary preventative measures to reduce the disease burden. Our study aims to assess the willingness of nurses who work for the community nursing service (CNS) in Hong Kong on their acceptance of influenza A (H1N1) influenza vaccination.

Methods. 401 questionnaires were posted from June 24, 2009 to June 30, 2009 to community nurses with 67% response rate. Results of the 267 respondents on their willingness to accept influenza A (H1N1) vaccine were analyzed.

Results. Twenty-seven percent of respondents were willing to accept influenza vaccination if vaccines were available. Having been vaccinated for seasonable influenza in the previous 12 months were significantly independently associated with their willingness to accept influenza A (H1N1) vaccination (OR=4.03; 95% CI: 2.03-7.98).

Conclusions. Similar to previous findings conducted in hospital healthcare workers and nurses, we confirmed that the willingness of community nurses to accept influenza A (H1N1) vaccination is low. Future studies that evaluate interventions to address nurses' specific concerns or interventions that aim to raise the awareness among nurses on the importance of influenza A (H1N1) vaccination to protect vulnerable patient populations is needed.

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Serologic survey of pandemic influenza A (H1N1 2009) in Beijing, China
Tian L-L, Shi, W-X, Deng, Y, et al. Preventive Medicine. 1 November 2010. doi:10.1016/j.ypmed.2010.10.006.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WPG-51C9JYJ-1&_user=10&_coverDate=11%2F01%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=653097a3b0b35431f87f89ec35e0efb1&searchtype=a

Objective. To examine the frequency and distribution of antibodies against pandemic influenza A (H1N1 2009) [H1N1] in populations in Beijing and elucidate influencing factors.

Methods. In January 2010, a randomized serologic survey of pandemic H1N1 was carried out. Six districts that were randomly selected with a total of 4601 participants involved in the survey have their antibody level tested by hemagglutination inhibition assay.

Results. Among the 4601 participants, the overall seropositive rate for pandemic H1N1 antibodies was 31.7%. The seropositivity prevalence in participants who received the pandemic H1N1 vaccination was 60.9%. Only 53.1% of the pandemic H1N1 seropositive individuals who had not received the vaccination experienced respiratory tract infection symptoms. Multivariate logistic regression revealed that factors such as age, occupation, dwelling type, whether the participant's family included students in school, and the vaccination history with pandemic H1N1 were associated with antibody titers (p < 0.05).

Conclusions. Our data indicated that almost 30.0% of the residents had appropriate antibody titers against pandemic H1N1 in Beijing, and these titers may provide an immune barrier.

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Facing the threat of Influenza Pandemic: Roles of and Implications to General Practitioners
Lee A, Chuh AAT. BMC Public Health. 2 November 2010;10:661. doi:10.1186/1471-2458-10-661.
Available at http://www.biomedcentral.com/1471-2458/10/661

Abstract. The 2009 pandemic of H1N1 influenza, compounded with seasonal influenza, posed a global challenge. Despite the announcement of post-pandemic period on 10 August 2010 by theWHO , H1N1 (2009) virus would continue to circulate as a seasonal virus for some years and national health authorities should remain vigilant due to unpredictable behaviour of the virus. Majority of the world population is living in countries with inadequate resources to purchase vaccines and stockpile antiviral drugs. Basic hygienic measures such as wearing facemasks and the hygienic practice of hand washing could reduce the spread of the respiratory viruses. However, the imminent issue is translating these measures into day-to-day practice. The experience from Severe Acute Respiratory Syndrome (SARS) in Hong Kong has shown that general practitioners (GPs) were willing to discharge their duties despite risks of getting infected themselves. SARS event has highlighted the inadequate interface between primary and secondary care and valuable health care resources were thus inappropriately matched to community needs. There are various ways for GPs to contribute in combating the influenza pandemic. They are prompt in detecting and monitoring epidemics and mini-epidemics of viral illnesses in the community. They can empower and raise the health literacy of the community such as advocating personal hygiene and other precautious measures. GPs could also assist in the development of protocols for primary care management of patients with flu-like illnesses and conduct clinical audits on the standards of preventive and treatment measures. GPs with adequate liaison with public health agencies would facilitate early diagnosis of patients with influenza. In this article, we summarise the primary care actions for phases 4-6 of the pandemic. We shall discuss the novel roles of GPs as alternative source of health care for patients who would otherwise be cared for in the secondary care level. The health care system would thus remain sustainable during the public health crisis.

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Mass Vaccination for the 2009 H1N1 Pandemic: Approaches, Challenges, and Recommendations
Rambhia KJ, Watson M, Kirk Sell T, et al. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 2 November 2010. doi:10.1089/bsp.2010.0043.
Available at http://www.liebertonline.com/doi/abs/10.1089/bsp.2010.0043

Abtract. The 2009 H1N1 pandemic stimulated a nationwide response that included a mass vaccination effort coordinated at the federal, state, and local levels. This article examines a sampling of state and local efforts during the pandemic in order to better prepare for future public health emergencies involving mass distribution, dispensing, and administration of medical countermeasures. In this analysis, the authors interviewed national, state, and local leaders to gain a better understanding of the accomplishments and challenges of H1N1 vaccination programs during the 2009-10 influenza season. State and local health departments distributed and administered H1N1 vaccine using a combination of public and private efforts. Challenges encountered during the vaccination campaign included the supply of and demand for vaccine, prioritization strategies, and local logistics. To improve the response capabilities to deal with infectious disease emergencies, the authors recommend investing in technologies that will assure a more timely availability of the needed quantities of vaccine, developing local public health capacity and relationships with healthcare providers, and enhancing federal support of state and local activities. The authors support in principle the CDC recommendation to vaccinate annually all Americans over 6 months of age against seasonal influenza to establish a standard of practice on which to expand the ability to vaccinate during a pandemic. However, expanding seasonal influenza vaccination efforts will be an expensive and long-term investment that will need to be weighed against anticipated benefits and other public health needs. Such investments in public health infrastructure could be important for building capacity and practice for distributing, dispensing, and administering countermeasures in response to a future pandemic or biological weapons attack.

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Factors that reduce the conflicts of health professionals about working during a public crisis: A cross sectional study of Motivation and Hesitation of hospital workers in Japan during the pandemic (H1N1) 2009.
Imai H, Matsuishi K, Ito A, et al. BMC Public Health. 4 November 2010;10:672. doi:10.1186/1471-2458-10-672.
Available at http://www.biomedcentral.com/1471-2458/10/672

Background. The professionalism of hospital workers in Japan was challenged by the pandemic (H1N1) 2009. To maintain hospital function under critical situations such as a pandemic, it is important to understand the factors that increase and decrease the willingness to work. Previous hospital-based studies have examined this question using hypothetical events, but so far it has not been examined in an actual pandemic. Here, we surveyed the factors that influenced the motivation and hesitation of hospital workers to work in Japan soon after the pandemic (H1N1) 2009.

Methods. Self-administered anonymous questionnaires about demographic character and stress factors were distributed to all 3635 employees at three core hospitals in Kobe city, Japan and were collected from June to July, 2009, about one month after the pandemic (H1N1) in Japan.

Results. Of a total of 3635 questionnaires distributed, 1693 (46.7%) valid questionnaires were received. 28.4% (N=481) of workers had strong motivation and 14.7% (N=249) had strong hesitation to work. Demographic characters and stress-related questions were categorised into four types according to the odds ratios (OR) of motivation and hesitation to work: some factors increased motivation and lowered hesitation; others increased motivation only; others increased hesitation only and others increased both motivation and hesitation. The strong feeling of being supported by the national and local governments (Multivariate OR: motivation; 3.5; CI 2.2-5.4, hesitation; 0.2; CI 0.1-0.6) and being protected by hospital (Multivariate OR: motivation; 2.8; CI 2.2-3.7, hesitation; 0.5; CI 0.3-0.7) were related to higher motivation and lower hesitation. Here, protection included taking precautions to prevent illness among workers and their families, providing for the care of those who do become ill, reducing malpractice threats, and financial support for families of workers who die on duty. But 94.1 % of the respondents answered protection by the national and local government was weak and 79.7% answered protection by the hospital was weak.

Conclusions. Some factors have conflicting effects because they increase both motivation and hesitation. Giving workers the feeling that they are being protected by the national and local government and hospital is especially valuable because it increases their motivation and lowers their hesitation to work.

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Relationship between intention of novel influenza A (H1N1) vaccination and vaccination coverage rate
Kwon Y-H, Cho H-Y, Lee Y-K, et al. Vaccine. 4 November 2010. doi:10.1016/j.vaccine.2010.10.063.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-51CYBMX-8&_user=10&_coverDate=11%2F04%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c34024cd8db649bf93e733bcb1c160d7&searchtype=a

Abstract. We carried out this study to describe the difference between intention to receive vaccine against influenza A (H1N1) before the vaccination campaign and actual vaccine coverage rate after vaccination campaign; and to find out the factors affecting the acceptability. We analyze data on intention to receive vaccine against influenza A (H1N1) and actual vaccination coverage rate from IR (immunization registry). In a survey of pre-vaccination, the sample size was 1042 and the survey results were weighted with gender and age distribution for sample distribution to be similar to population distribution. Although the intention to receive vaccine against influenza A (H1N1) was high, the actual vaccination coverage was lower than their intention. The factors affecting their intention were the degree of fear for novel influenza A (H1N1), the possibility to be infected with the virus, priority for production of novel influenza vaccine between timing and safety, and belief for effectiveness of novel influenza vaccine. Besides 2009 influenza A (H1N1) vaccination experience developing to resolve the effecting factors on intentions to receive vaccine, which would be the effective way to prepare for anther pandemic in the future.

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Incidence of hospital admissions and severe outcomes during the first and second waves of pandemic (H1N1) 2009
Helferty M, Vachon J, Tarasuk J, et al. CMAJ. 8 November 2010. doi:10.1503/cmaj.100746.
Available at http://www.cmaj.ca/cgi/content/abstract/cmaj.100746

Background. Canada experienced two distinct waves of pandemic (H1N1) influenza during the 2009 pandemic, one in the spring and the second in early fall 2009. We compared the incidence of hospital admissions and severe outcomes (admission to intensive care unit [ICU] and death) during the two waves.

Methods. We reviewed data on all laboratory-confirmed cases of pandemic (H1N1) influenza that resulted in hospital admission, ICU admission or death reported to the Public Health Agency of Canada by all provinces and territories from Apr. 18, 2009, to Apr. 3, 2010.

Results. A total of 8678 hospital admissions (including 1473 ICU admissions) and 428 deaths related to pandemic (H1N1) influenza were report ed during the pandemic and post-peak period. There were 4.8 times more hospital admissions, 4.0 times more ICU admissions and 4.6 times more deaths in the second pandemic wave than in the first wave. ICU admissions and deaths as a proportion of hospital admissions declined in the second wave; there was a 16% proportional decline in ICU admissions and a 6% proportional decline in deaths compared with the first wave. Compared with patients admitted to hospital in the first wave, those admitted in the second wave were older (median age 30 v. 23 years) and more had underlying conditions (59.7% v. 47.5%). Pregnant women and Aboriginal people accounted for proportionally fewer patients who were admitted to hospital or who died in the second wave than in the first.

Interpretation. The epidemiologic features of the first and second waves of the 2009 pandemic differed. The second wave was substantially larger and, although the patients admitted to hospital were older and more of them had underlying conditions, a smaller proportion had a severe outcome.

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General hospital staff worries, perceived sufficiency of information and associated psychological distress during the A/H1N1 influenza pandemic
Goulia P, Mantas C, Dimitroula D, et al. BMC Infect. Dis. 9 November 2010;10:322. doi:10.1186/1471-2334-10-322.
Available at http://www.biomedcentral.com/1471-2334/10/322

Background. Health care workers (HCWs) presented frequent concerns regarding their health and their families' health and high levels of psychological distress during previous disease outbreaks, such as the SARS outbreak, which was associated with social isolation and intentional absenteeism. We aimed to assess HCWs concerns and anxiety, perceived sufficiency of information, and intended behavior during the recent A/H1N1 influenza pandemic and their associations with psychological distress.

Method. Between September 1st and 30th, 2009, 469 health-care workers (HCWs) of a tertiary teaching hospital completed a 20-item questionnaire regarding concerns and worries about the new A/H1N1 influenza pandemic, along with Cassileth's Information Styles Questionnaire (part-I) and the GHQ-28.

Results. More than half of the present study's HCWs (56.7%) reported they were worried about the A/H1N1 influenza pandemic, their degree of anxiety being moderately high (median 6/9). The most frequent concern was infection of family and friends and the health consequences of the disease (54.9%). The perceived risk of being infected was considered moderately high (median 6/9). Few HCWs (6.6%) had restricted their social contacts and fewer (3.8%) felt isolated by their family members and friends because of their hospital work, while a low percentage (4.3%) indented to take a leave to avoid infection. However, worry and degree of worry were significantly associated with intended absenteeism (p<0.0005), restriction of social contacts (p<0.0005), and psychological distress (p=0.036). Perceived sufficiency of information about several aspects of the A/H1N1 influenza was moderately high, and the overall information about the A/H1N1 influenza was considered clear (median 7.4/9). Also, perceived sufficiency of information for the prognosis of the infection was significantly independently associated with the degree of worry about the pandemic (p=0.008).

Conclusions. A significant proportion of HCWs experienced moderately high anxiety about the pandemic, and their degree of worry was an independent correlate of psychological distress. Since perceived sufficiency of information about the A/H1N1 influenza prognosis was associated with reduced degree of worry, hospital managers and consultation-liaison psychiatry services should try to provide for HCWs' need for information, in order to offer favourable working conditions in times of extreme distress, such as the current and future pandemics.

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Can an Office Practice Telephonic Response Meet the Needs of a Pandemic?
North F, Varkey P, Bartel GA, et al. Telemedicine and e-Health. 8 November 2010. doi:10.1089/tmj.2010.0102.
Available at http://www.liebertonline.com/doi/abs/10.1089/tmj.2010.0102

Introduction. The H1N1 (subtype hemagglutinin 1 neuraminidase 1) influenza pandemic of 2009 was associated with a large increase in demand for primary care office visits. However, many patients with H1N1 symptoms or exposure could be assessed and treated with telephone protocols. Methods: Specific H1N1 influenza telephone protocols were developed by Mayo Clinic physicians using Centers for Disease Control recommendations. Using symptom calls to a primary care practice in the United States, we captured nurse telephone triage recommendations, telephone antiviral prescriptions, and what callers would have done without telephone advice. We retrospectively analyzed all symptom calls from July 2009 through January 2010. Results: Call volume was 5,596 calls monthly during the peak influenza months, which was 56% above the monthly average of 3,595 calls for the nonpeak months (p<0.001). The calls during October 2009 were 111% over the nonpeak months (p<0.001). In October 2009, telephone triage nurses gave 412 prescriptions for antivirals accounting for 5.4% of calls and 39% of all telephonic prescriptions for that month. In the peak H1N1 month of October, there were 1,522 callers who intended to stay home for their care. For the same month, triage nurses suggested 3,250 of the callers stay home. For an October 2009 appointment capacity of 35,126 visit slots, a potential 5% capacity was preserved. Conclusions: A telephone triage solution for the acute demands of influenza H1N1 demonstrated how patients had needs met telephonically while preserving medical access for others.

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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