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Vol. XIII No. 25 ~ EINet News Briefs ~ Dec 10, 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
- Australia: H1N1 pandemic influenza pandemic phase status dialed down
- Hong Kong: H1N5 avian influenza alert level lowered
- Indonesia (Badung City): H5N1 avian influenza case reported
- Russia: Reports good influenza H1N1 vaccination coverage
- Canada (Manitoba): Fatal influenza cases reported on First Nations reservation
- Canada (Manitoba): First Nation H1N1 influenza outbreak under control
- USA (Iowa): Three separate influenza strains present in state
- USA: CDC announces first signs of influenza season
- USA (Southeast): H1N1 pandemic influenza cases increasing
- Egypt: WHO confirms H5N1 avian influenza death

2. Infectious Disease News
- Canada (Ottawa): Case of red measles under quarantine
- USA (Iowa) FDA clears Wright County Egg to resume retail sales
- USA (Kentucky): Pertussis vaccination urged after sharp rise in cases
- USA (Washington): Fourth APEC EINet “Hot Topics” Video Symposium Held

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

4. Articles
- Influenza surveillance in Shenzhen, the largest migratory metropolitan city of China, 2006–2009
- Lessons from pandemic influenza A(H1N1): The research-based vaccine industry's perspective
- Co-detection of Pandemic (H1N1) 2009 Virus and Other Respiratory Pathogens
- Oseltamivir-Resistant Pandemic (H1N1) 2009 Virus, South Korea
- Online Flutracking Survey of Influenza-like Illness during Pandemic (H1N1) 2009, Australia
- Pandemic (H1N1) 2009 Outbreak at Canadian Forces Cadet Camp
- Pandemic (H1N1) 2009 Infection in Patients with Hematologic Malignancy
- Pandemics in the Age of Twitter: Content Analysis of Tweets during the 2009 H1N1 Outbreak
- Adverse events associated with the 2009 H1N1 influenza vaccination and the vaccination coverage rate in health care workers
- Novel influenza A (H1N1): clinical features of pediatric hospitalizations in two successive waves
- Mortality Risk Factors for Pandemic Influenza on New Zealand Troop Ship, 1918

5. Notifications
- International TB Symposium (ITBS-2010): TB Diagnostics – Innovating to Make an Impact
- Keystone Symposia: Tuberculosis: Immunology, Cell Biology and Novel Vaccination Strategies


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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Asia
Australia: H1N1 pandemic influenza pandemic phase status dialed down
In the wake of an influenza season that was milder than 2009’s, Australian health officials 1 December 2010 announced a downgrade in the country's pandemic phase from "protect" to "alert." Australia had been in "protect" status since 17 June 2009. The "protect" phase focuses on identifying and protecting people at risk for serious illness, while the "alert" phase involves increased vigilance for a new flu virus or a change in a circulating virus, the Department of Health Ageing said. This is consistent with the WHO's recommendation to continue ongoing vigilance in the early post-pandemic period, the agency said. The WHO declared the world to be in the post-pandemic period on 10 August 2010, while cautioning that localized outbreaks were likely to continue. The Australian officials said they maintained the "protect" status at that time because their flu season was still under way and a late surge in 2009 H1N1 cases was still possible. The pandemic H1N1 vaccine will remain freely available until 31 December 2010, when all doses will reach expiration.
(CIDRAP 12/01/2010)

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Hong Kong: H1N5 avian influenza alert level lowered
The Hong Kong government 8 Wednesday 2010 lowered its bird flu alert level, three weeks after detecting the city's first human case of the virus in seven years.

The classification on the city's influenza pandemic response mechanism was lowered from "serious" to "alert" after no further signs of an outbreak were found, officials announced. Hong Kong's bird flu alert level was raised to serious on 17 November 2010 after a 59-year-old woman was diagnosed with the H5N1 bird flu virus after returning from a holiday in China.

Tests confirmed the patient contracted the virus in China and she remained in a stable condition at Hong Kong's Princess Margaret Hospital, a spokesman for the Department of Health said. City-wide tests on farms and wholesale markets conducted since the woman's diagnosis found no trace of the H5N1 virus anywhere else, the spokesman said.

Six people died and 12 others were infected in Hong Kong in the first modern case of bird flu to jump the species barrier in 1997, leading to a cull of millions of chickens and ducks. Hong Kong has since prevented any further significant local outbreaks. The last case in the city involved a father who died and whose son fell ill after a visit to China in 2003.
(Earth Times 12/08/2010)

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Indonesia (Badung City): H5N1 avian influenza case reported
Indonesia’s health ministry reported an H5N1 avian influenza infection in a 21-year-old woman from Bandung City in West Java province. She got sick on 14 November 2010 and has been hospitalized since 22 November 2010. Her illness raises the number of WHO-confirmed H5N1 cases in Indonesia to 171, of which 141 were fatal. An investigation into the source of her infection found that she lived near a business where live poultry were kept in unsanitary conditions. The WHO said more investigations into her illness are under way. The woman's infection raises the global number of H5N1 infections to 510, including 303 deaths.
(CIDRAP 12/09/2010)

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Russia: Reports good influenza H1N1 vaccination coverage
Russia's top public health official 1 December 2010 said 31.5 million people, just over 22% of the population, have received flu immunization so far. Gennady Onishchenko, chief sanitary doctor, said the vaccine campaign started in early October 2010 and has already been completed in 71 of Russia's 83 regions. The federal government has paid for vaccines for 27.8 million (16.6 million adults and 11.2 million children) of those immunized so far, while employers have paid for the rest.
(CIDRAP 12/01/2010)

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Americas
Canada (Manitoba): Fatal influenza cases reported on First Nations reservation
Public health officials in Manitoba are monitoring developments surrounding three severe flu cases, two of them fatal, that occurred recently on a native reserve in the northern part of the province. David Harper, grand chief of the Keewatinowi Okimakanak, Manitoba's northernmost First Nations group, said that the two who died were in their 30s and 40s and were healthy before they got sick with influenza. He said one more person is hospitalized and that other related illnesses are suspected. Dr Joel Kettner, Manitoba's chief public health officer, said rapid tests on one of the fatal cases revealed an influenza A virus, and more tests are underway on other cases. He added that certain factors put some First Nations members at risk for flu complications, including poor sanitation and underlying medical conditions.
(CIDRAP 12/03/2010)

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Canada (Manitoba): First Nation H1N1 influenza outbreak under control
Manitoba's chief public health officer says a flu outbreak in a northern First Nation is under control.

Doctor Joel Kettner says he spoke to a doctor in the Garden Hill First Nation who told him there is sufficient staffing to deal with the situation. Kettner was responding to comments from the leader of Manitoba's northern chiefs. Grand Chief David Harper said more doctors were needed to cope with the outbreak that's been blamed for two deaths.

He said one doctor for four thousand people was totally unacceptable. Kettner says additional medical help has been provided.

But he agrees with Harper that it would be good to see more physicians work in the north on a regular basis.

Kettner says officials have ruled out the possibility of a pandemic, saying it's a flu strain that's been circulating.
(CTVNews 12/09/2010)

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USA (Iowa): Three separate influenza strains present in state
State health officials say three separate flu strains have been identified in Iowa as flu season gets under way.

The Iowa Department of Public Health says the findings are unusual, but point out that 2010's vaccine protects against all three.

State medical director Dr. Patricia Quinlisk says it's rare to see three strains so early in the season, which means it's possible for someone to get the flu three times. She advises Iowans to get a flu shot.

Iowa saw a jump in flu cases the week of 29 November 2010, which officials say is a clear indication that flu season has started.

The flu shot protects against influenza A, influenza B and the swine flu, or HINI virus, that so caused so much illness in the 2009 season.
(Chicago Tribune 12/06/2010)

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USA: CDC announces first signs of influenza season
The first signs that the flu season is upon us have arrived, reports the CDC. In some states, for example Georgia, reported cases of flu have suddenly risen so rapidly that state authorities are referring to a "regional outbreak". It seems that the virus strains identified so far closely match those used in 2010's vaccinations.

The CDC has announced 5-11 December 2010 as National Influenza Vaccination Week. The aim is to stress the importance of vaccinations and to get as many people as possible immunized.

The three flu strains that will be circulating during the current/coming flu season, according to the CDCs' Advisory Committee on Immunization Practices, are:
An A/H3N2 strain
A B strain
The H1N1 (2009) pandemic strain, which for a while was informally termed "swine flu."
The current vaccine protects against these three strains. The CDC says 160 vaccines have been distributed throughout the USA.

Dr. Anne Schuchat, Assistant Surgeon General of the U.S. Public Health Service and CDC's Director of the National Center for Immunization and Respiratory Diseases, said that the new vaccination recommendation shows the importance of preventing the flu in everyone. People who do not get vaccinated are taking two risks: first, they are placing themselves at risk for the flu, including a potentially long and serious illness, and second, if they get sick, they are also placing their close contacts at risk for influenza.

Howard K. Koh, M.D., M.P.H.,Assistant Secretary for Health, said the bottom line is, anyone - even healthy people - can get sick from the flu.

The CDC says that the National Influenza Vaccination Week must engage at-risk audiences - people who have not yet been immunized, individuals who are hesitant or unsure whether having the jab is good for them.
(Medical News Today 12/04/2010)

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USA (Southeast): H1N1 pandemic influenza cases increasing
US flu activity remained low but showed an increase in the Southeast. CDC data showed that, for the week ending 20 November 2010, Georgia became the first state this flu season to report regional flu activity, while Alabama, Hawaii, Mississippi, Oklahoma, Pennsylvania, Puerto Rico, South Carolina, and Texas reported local activity. Thirty-four states or territories reported sporadic activity, and 11 states reported no activity. Two flu-related deaths were reported nationwide, but the proportion of deaths attributed to pneumonia and influenza remained below the epidemic threshold. Likewise, the proportion of outpatient visits for flu-like illness was 1.4%, below the national baseline of 2.5%. Of 2,896 respiratory samples tested, 284 (9.8%) were positive for influenza. Of those, 169 (59.5%) were influenza B and 115 (40.5%) were influenza A. Of the 30 influenza A samples that were subtyped, nine were determined to be 2009 pandemic H1N1, and 21 to be an H3 subtype, presumably H3N2. Circulating strains appear to be well-matched to the vaccine strains.
(CIDRAP 11/30/2010)

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Africa
Egypt: WHO confirms H5N1 avian influenza death
On 8 December 2010 the WHO confirmed Egypt's most recent H5N1 avian influenza fatality, that of a 30-year-old woman. The woman, who was from Gharbia governorate, is listed by the WHO as Egypt's 113th case and 37th death. She got sick on 28 November and was hospitalized on 1 December 2010, where she was treated with oseltamivir (Tamiflu). She died the next day. An investigation into the source of the woman's infection found that she had been exposed to sick and dead poultry. Her case raises the global H5N1 case count to 509, which includes 303 fatalities.
(CIDRAP 12/09/2010)

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2. Infectious Disease News

Americas
Canada (Ottawa): Case of red measles under quarantine
Ottawa doctors are on high alert because an Ottawa woman has contracted red measles — a highly contagious and untreatable infection — the city’s first case since 2002, according to Ottawa’s medical officer of health.

Dr. Isra Levy faxed a letter to all Ottawa physicians informing them the woman, who is between 18 and 40 years old, picked up the infection while in the Philippines.

Ottawa Public Health has told her co-workers about the woman’s condition and warned them to see a doctor if they have any of the symptoms, including a rash, fever, cough and runny nose.

The woman is now in quarantine.

Measles is very transmittable and once it’s in the community people can easily pick it up, said Levy, who added local health care officials needs to be extra cautious to “snuff out” the measles.

He said he wouldn’t be surprised to see secondary cases but that they are attacking this aggressively like all unusual infections.

In Canada, there are about 10 measles cases a year and Ottawa has only had five cases since 1995.

Levy said most of the population is considered immune but those who haven’t been vaccinated and those children whose parents refused the vaccine should be the most careful.

All school-aged children have the chance to get the MMR vaccine, which protects against measles, mumps and rubella (also called German measles).

Public health asks residents to seek health care immediately if they think they have measles or have been exposed to the infection.
(Ottawa Sun 12/03/2010)

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USA (Iowa) FDA clears Wright County Egg to resume retail sales
The US Food and Drug Administration (FDA) 30 November 2010 cleared Wright County Egg to resume shipping eggs directly to consumers, now that the company has corrected conditions in two of its egg-laying houses and addressed possible sources of Salmonella contamination.

Since August 2010, when the Galt, Iowa, company's eggs were linked to a multistate Salmonella Enteritidis (SE) outbreak, it has been allowed to send its eggs to "breaker operations," companies that use the broken and heated eggs in other food products.

Dr Margaret Hamburg, FDA commissioner, said that during the outbreak the FDA said it wouldn't agree to allow Wright County Egg to resume selling eggs to consumers until the agency was confident that the eggs could be safely shipped and consumed. After four months of intensive work by the company and oversight, testing, and inspections by FDA, I am satisfied that time has come, she said.

The FDA's clearance hinged on corrections that addressed four contamination pathways. In contaminated egg-laying areas, birds present during the outbreak were removed, and the barns were cleaned, sanitized, and tested to make sure SE was no longer present. Infected pullets were removed and replaced with birds free of and vaccinated against SE.

Rodent problems have also been corrected, and the company has put in place control and weekly monitoring systems, the FDA said.

During the outbreak investigation, federal officials found SE contamination in feed produced at the farm's feed mill. The FDA said today that the company has cleaned and disinfected the mill, repaired structural defects, and eliminated egg shells, meat, and bone meal from the feed. It is also testing its feed ingredients for SE.

The FDA said it confirmed Wright County Egg's corrective actions during inspections in October and November 2010. Since October 2010 the inspections have involved 13 investigators working 900 personnel hours to analyze 40 feed samples, 236 environmental samples, and 13,900 shell eggs, the FDA said.

During the course of the investigation, eggs from the two laying houses tested positive for SE twice in FDA tests and once in Wright County Egg's tests. The FDA said the firm will conduct monthly tests for SE and that it would continue to do environmental sampling and inspections to ensure that the corrective measures are effective.

Corrective measures are still being implemented in other laying houses at six Wright County Egg farms, and the FDA said it would continue working with the company to ensure that corrections are made before the agency allows eggs to be shipped from the other houses and farms.

On 19 October 2010, the FDA cleared the other company involved in the SE outbreak, Hillandale Farms, to resume sale of eggs to the retail market. At that time it warned Wright County Egg that it would take further enforcement action unless it corrected problems that inspectors found in August 2010.

The Centers for Disease Control and Prevention (CDC) said in a 19 October 2010 update that about 1,813 SE infections were probably linked to the contaminated eggs.
(CIDRAP 11/30/2010)

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USA (Kentucky): Pertussis vaccination urged after sharp rise in cases
The Kentucky Department of Public Health is urging the state's residents to ensure that children receive their recommended pertussis vaccines and that people ages 11 to 64, especially those who have contact with children younger than one, get a pertussis booster. The plea for pertussis vaccination comes amid a steep rise in 2010 in pertussis cases. So far in 2010 it has received reports of 250 cases, up from 47 in 2007.
(CIDRAP 12/09/2010)

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USA (Washington): Fourth APEC EINet “Hot Topics” Video Symposium Held
On 2 December 2010, the Seattle campus of the University of Washington, in Washington state, hosted the fourth APEC EINet “Hot Topics” video symposium. The symposium convened nine APEC economies in order to share economies’ experiences emerging infectious diseases after natural disasters. Case studies presented covered leptospirosis after Hurricane Ketsana, various diseases after Hurricane Katrina, and disease after the Sichuan earthquake. Economy feedback reported that the video symposium was very helpful.
(APEC EINet 12/02/2010)

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

- WHO regional offices
Africa: http://www.afro.who.int/
Americas:
http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=805&Itemid=569
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Europe: http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/influenza/pandemic-influenza
South-East: http://www.searo.who.int/EN/Section10/Section2562.htm
Western Pacific: http://www.wpro.who.int/health_topics/h1n1/

- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: http://www.flu.gov
MOH México: http://portal.salud.gob.mx/index_eng.html
PHA of Canada: http://fightflu.ca

- Other useful sources
CIDRAP: Influenza A/H1N1 page:
http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promedmail.org/

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

CDC Teleconference results: Healthcare groups need to share emergency plans:
http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/sep0210standards.html

American Academy of Pediatrics Policy Statement: Recommendations for Prevention and Control of Influenza in Children, 2010-2011:
http://pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2216v1

Big 10+2 Universities H1N1 Lessons Learned Webinar:
https://umconnect.umn.edu/p27358212/?launcher=false&fcsContent=true&pbMode=normal

CDC Open Letter to Americas urging influenza vaccination:
http://www.cdc.gov/flu/pdf/nivw/2010-2011open_letter_color.pdf

Results of CDC November 2010 Rapid Flu Survey:
http://www.cdc.gov/flu/pdf/vaccination/rapidflusurvey.pdf

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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
Global
A tropical disease expert predicted today that treating dengue fever will become more difficult in the future as more people become overweight and obese, according to a Reuters report. The story said dengue patients suffer from blood leakage from capillaries, leading to breathing problems and complications in major organs such as the brain and liver. Jeremy Farrar, a professor of tropical medicine and director of the Oxford University Clinical Research Unit in Vietnam, said obesity itself makes capillary leakage more likely, and dengue infection makes the condition worse. Farrar made the comments in an interview after speaking at a conference in Singapore. The story noted that the World Health Organization estimates there are 50 million cases of dengue each year, including 500,000 severe cases.
(CIDRAP 12/03/2010)


Mexico (Tamaulipas)
The head of the fourth Sanitary District, Mario Salinas Alfonso Saenz said that with the increase in the number of cases of dengue they are seeking to control the epidemic that emerged in the wake of flooding and waterlogging problems reported after the overflowing of the Rio Bravo. He mentioned that in the municipalities under this jurisdiction 194 cases of dengue have been recorded. In the municipality of Rio Bravo, 145 positive cases were registered, of which 102 are classical dengue fever and 43 were DHF.
[ProMED note: This is a high ratio of DHF cases to dengue fever cases, suggesting that there is significant underreporting of classical dengue virus infections.]
(ProMED 12/03/2010)


Mexico (Sonora)
State officials have discussed the possibility of seeking to declare a dengue emergency in the state. According to recent official reports, in Sonora, there have been more than 2,700 cases of dengue, of which close to 400 have been DHF, with at least three deaths in 2010.
(ProMED 12/03/2010)


United States
Arizona experienced the nation's worst outbreak of West Nile virus during this year's season, accounting for nearly one in five severe cases in the nation, a new report shows.

A total of 159 confirmed cases were reported in Arizona in 2010 through November, according to the Centers for Disease Control in Atlanta. At least a dozen Arizonans died. State officials updated the count on 2 December 2010, reporting 163 cases.

Arizona had nearly 20 percent of the nation's neuroinvasive-disease cases. The disease attacks the nervous system and can lead to life-threatening West Nile encephalitis and West Nile meningitis.

New York, with a total of 127 cases, was the only other state to have more than 100 reported West Nile cases so far in 2010.

The spike in Arizona was so severe that CDC officials visited in September to study the outbreak. It was primarily concentrated in the southeast Valley municipalities of Gilbert, Chandler and Tempe, as well as in Pinal County.

The CDC studies took blood samples from birds, which carry the virus, and mosquitoes, which transmit it to humans through bites, and studied human cases. The CDC is still analyzing the data.

The goal is to try to have some conclusions made and lessons learned before the 2011 (West Nile) season, said Craig Levy, a manager for the Arizona Department of Health Services' vector-borne disease program.

Scientists were surprised to see Arizona's urban desert region lead the nation in cases, considering West Nile was thought to be more prevalent in mosquito-rich environments, he said.

Levy hoped that studying the outbreak would lead to a better understanding of the disease, which was first found in Arizona in 2004. That year, there were 391 reported cases and 16 deaths.

West Nile first appeared in North America in 1999, and spread to the U.S., spiking in humans in 2002 and 2003.

Since then, the federal government and each state have adopted prevention programs. Those programs include public-awareness campaigns about the importance of using insect repellent and removing stagnant water where mosquitoes breed, as well as fogging larger regions.

Marc Fischer, an epidemiologist with the CDC's division of vector-borne diseases, said that the fight against West Nile since it spiked globally has frustrated scientists.

We've learned how to identify it and can intervene, make physicians aware, but still don't know how to prevent it, he said. We use the real-time data to find out in the longer term how we can better identify and predict the places where these outbreaks are going to happen so we can intervene before an outbreak.
(Arizona Republic 12/09/2010)

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CHOLERA, DIARRHEA, and DYSENTERY
Chinese Taipei
Although there were 106 reported cases of dengue fever the week of 14 November 2010), the increased rate over the past four weeks indicated that the situation is under control, said Taiwan CDC officials. Of the 1216 reported cases of indigenous dengue fever since the beginning of August 2010, 1,196 were in the southern part of the island, including Kaohsiung and Tainan cities and counties and Pintung County.
(ProMED 11/29/2010)


Indonesia (West Nusa Tenggara)
West Nusatenggara had a total of 1,781 dengue fever cases in the January-October 2010 period, up from 625 in the same period in 2009, a local public health official said. Of all the cases, eight sufferers died.
(ProMED 11/29/2010)


Mexico (Tampico)
Due to the continued spread of cholera cases in Haiti, the appearance of some patients in the USA, and the risk that a case could enter and pass through Tamaulipas Mexico, officials of Sanitary District Number Two in Tampico, in conjunction with the State Commission for Protection Against Health Risks (Coepris), are monitoring this epidemiological situation closely.

The head of Sanitary District Number Two, Sergio Camargo Uriegas, said samples have been taken of the more serious cases of diarrhea, so far 1,500 samples and they are constantly analyzing clean water and sewer water through Moore swabs every 15 days to verify if cholera is present.

Camargo Uriegas said 670 cases of diarrhea are recorded weekly but there is concern for problems related to cholera, so they ask the public that if anyone is evacuating up to five times daily for more than five days, to consult the Health Center because it could be cholera.
(ProMED 11/30/2010)


Papua New Guinea
The cholera outbreak in Papua New Guinea has now affected more than 27 hundred people. 300 people have lost their lives to the disease.

The original point of the outbreak was Daru, a tiny island off the coast of PNG's Western Province. The situation stabilized there but it's now on the move, emerging in villages on the mainland. Restrictions are still in place for travel between Australia's Torres Strait Islands and PNG.
(RadioAustralia 12/08/2010)


Philippines (Negros Oriental)
Provincial Health Officer Ernell Tumimbang reported yesterday that dengue cases have dropped by 50 percent in Negros Occidental, as of the week of 22 November 2010. Tumimbang said dengue cases dropped from 108 in week 42 to 56 in week 44. Official records showed that the number of dengue cases peaked at 665 in week 33, which was in August 2010, and dropped to 56 in week 44.
(CIDRAP 11/29/2010)


Philippines (Cebu)
Health authorities declared a typhoid fever outbreak in Alegria town, Cebu, after the number of cases rose to 221 as of 8 December 2010.

Regional Director Dr. Susana Madarieta of the Department of Health in Central Visayas (DOH-7) said she ordered health personnel to inform town officials of the declaration.

Medical supplies were delivered to the district hospital of nearby town Malabuyoc and Alegria health center.

Dr. Cristina Giango, chief of the Integrated Provincial Health Office (IPHO), said only 36 were confined in Malabuyoc while 185 were outpatients who sought treatment at the Alegria rural health center.

The affected patients came from barangays Sta. Felomina and Poblacion, said Alegria Mayor Emelita Guisadio.

She said water samples were taken to verify if the fever originated from contaminated water supply. The town sources its water from a spring, which supplies all nine barangays. A single chlorinator is installed in the water system. Municipal planning coordinator Engr. Jesus Cavalida said an engineering team was sent to inspect the reservoirs and pipelines for leakages.

He said the problem was precipitated by last Friday's downpour.

The municipal council declared three barangays, including nearby Legazpi, on calamity status.

Both Giango and Madarieta said they are still verifying whether the fever was caused by water or food contamination.

Municipal health officer Dr. Samson dela Peña he is still skeptical on whether the fever was caused by water contamination. He said they conduct monthly inspections of their water pipes to ensure they function properly and monitor the chlorine level in the water.

The Alegria Water District is managed by the municipal government. We are confident on our water system, Dela Peña said.

Resident doctor Dennis Padaya said most of the patients are in the pediatric ward and are in stable condition.

The patients are residents from barangays Poblacion, Sta. Filomena, San Roque and Malubog.

Three patients who have been continually vomiting since 6 December 2010 were referred to the Vicente Sotto Memorial Medical Center (VSMMC).

Staff nurse Maricel Zamora said they have only 10 beds for 15 patients. She said they have to put up extra beds on the hallway and on the adjacent function room to accommodate the patients. I've never seen our hospital this full before, said Zamora, who had been working in the hospital for three years.

Still Dela Peña said that the situation in their municipality is still manageable.

He said they were teaching their barangay health workers to make household chlorine solution for the drinking water of the residents.
(Inquirer.net 12/09/2010)


Thailand (Phuket)
Phuket Town Mayor Somjai Suwansupapana said that there have been 693 confirmed cases of dengue in the city so far in 2010. The number of new cases being reported is on the rise. To combat the spread of dengue, four temples have been designated as model areas with strict mosquito control measures in force at all times. Health workers will collect mosquito specimens in each area for analysis to determine if they are resistant to pesticides.
(CIDRAP 11/29/2010)


USA (Florida)
A woman who moved from Haiti to the Orlando, FL., area within the past month was diagnosed as having cholera and has recovered, raising the state's number of cholera cases to two. Health officials from Orange County Health Department said the case was identified through Florida's disease surveillance system and that the US Centers for Disease Control and Prevention (CDC) analyzed samples from the patient and confirmed the infection. Florida is also investigating a possible third cholera case, reportedly in a doctor who got sick on a flight from the Dominican Republic. Health authorities have said they expect to see cases related to Haiti's cholera outbreak turn up in the United States. The risk of spread in the United States is low because of good sanitation conditions. Cholera typically spreads through contaminated water or food. Florida is home to a large Haitian population.
(CIDRAP 11/29/2010)

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4. Articles
Influenza surveillance in Shenzhen, the largest migratory metropolitan city of China, 2006–2009
Wang X, Cheng XW, Ma HW, et al. Epidemiology and Infection. 7 December 2010. doi: 10.1017/S0950268810002694.
Available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=7934908
Summary. Shenzhen is one of the largest migratory metropolitan cities in China. A standardized influenza surveillance system has been operating in Shenzhen for several years. The objectives of the present study were to describe the epidemiology of influenza in Shenzhen and to assess the impact of pandemic H1N1 on influenza activity. An average rate of 71 cases of influenza-like illness (ILI)/1000 consultations was reported, which was greater than the rate in the preceding 3 years. Laboratory surveillance showed that the annual proportion of specimens positive for influenza was 25·4% in 2009, representing a significant increase over the proportions of 5·4%, 11·6% and 12·2% in 2006, 2007 and 2008, respectively. A total of 414 ILI outbreaks were reported in 2009, which was a marked increase compared to the previous 3 years. Influenza activity reached a record high in Shenzhen in 2009. Seasonal A/H3N2 was the dominant strain during the summer and was gradually replaced by pandemic H1N1. A semi-annual cycle for influenza circulation began to appear due to the emergence of pandemic H1N1.

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Lessons from pandemic influenza A(H1N1): The research-based vaccine industry's perspective
Abelin A, Colegate T, Gardner S, et al. Vaccine. 27 November 2010. doi:10.1016/j.vaccine.2010.11.042.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-51JXJG4-B&_user=10&_coverDate=11%2F27%2F2010&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=4b42b112a25d932ce9f5af5f26a99cc2&searchtype=a

Abstract. As A(H1N1) influenza moves towards the post-pandemic phase, health authorities around the world are initiating reviews of the pandemic response. To ensure this process enhances future preparedness, it is essential that perspectives are included from all relevant stakeholders, including vaccine manufacturers.

This paper outlines the contribution of R&D-based influenza vaccine manufacturers to the pandemic response, and explores lessons that can be learned to improve future preparedness. The emergence of 2009 A(H1N1) influenza led to unprecedented collaboration between global health authorities, scientists and manufacturers, resulting in the most comprehensive pandemic response ever undertaken. This response was only possible because of the extensive preparations undertaken during the last decade.

Manufacturers greatly increased influenza vaccine production capacity, and estimates suggest a further doubling of capacity by 2014. Producers also introduced cell-culture technology as well as adjuvant- and whole virion technologies that significantly reduced pandemic vaccine antigen content. These measures substantially increased pandemic vaccine production capacity, which in July 2009 WHO estimated reached 4.9 billion doses per annum. Manufacturers worked with health authorities to establish risk management plans for robust vaccine surveillance during the pandemic.

A number of improvements would strengthen future preparedness. Technical improvements to rapidly select optimal vaccine viruses, and processes to speed. up vaccine standardization, would accelerate and extend vaccine availability. Establishing vaccine supply agreements beforehand would avoid the need for complex discussions during a period of intense time pressure.

Enhancing international regulatory co-operation, mutual recognition of approvals and bureaucracy reduction could accelerate vaccine supply, while maintaining safety standards. Strengthening communications with the public and healthcare workers using new approaches and new channels should help improve vaccine uptake. Increasing seasonal vaccine coverage could extend and sustain pandemic vaccine production capacity.

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Co-detection of Pandemic (H1N1) 2009 Virus and Other Respiratory Pathogens
Koon K, Sanders CM, Green J, et al. Emerg Infect Dis. 29 November 2010. doi: 10.3201/eid1612.091697.
Available at http://www.cdc.gov/eid/content/16/12/1976.htm#cit

Abstract. For previous and current influenza A pandemics, postmortem studies have established a strong link between secondary bacterial infections and increased deaths (1,2). Numerous respiratory pathogens can be detected from a single sample by using a multiplex molecular method called target-enriched multiplex PCR (3–6). During the 2006 influenza season, this method was used at Vancouver Children and Women's Hospital to study 1,742 patients with acute respiratory infections; >2 pathogens were detected for ≈27% of patients studied (7). We used this method to learn more about infections occurring concurrently with pandemic (H1N1) 2009.

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Oseltamivir-Resistant Pandemic (H1N1) 2009 Virus, South Korea
Yi H, Lee JY, Hong E-H, et al. Emerg Infect Dis. 29 November 2010. doi: 10.3201/eid1612.100600.
Available at http://www.cdc.gov/eid/content/16/12/1938.htm#cit

Abstract. Since April 2009, pandemic (H1N1) 2009 has spread worldwide and caused the first influenza pandemic of the 21st century. Pandemic (H1N1) 2009 virus initially showed resistance to amantadine but susceptibility to oseltamivir (1). Thereafter, 285 cases of oseltamivir-resistant pandemic viral infection were reported worldwide on April 14, 2010 (2). However, information is limited about oseltamivir-resistant pandemic influenza in South Korea. Monitoring of community circulation of oseltamivir-resistant viruses has not yet detected any evidence of oseltamivir resistance in South Korea. To identify these viruses, we conducted specific surveillance of antiviral drug–resistant infection in patients whose illness did not resolve after antiviral treatment.

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Online Flutracking Survey of Influenza-like Illness during Pandemic (H1N1) 2009, Australia
Carlson SJ, Dalton CB, Durrheim DN, et al. Emerg Infect Dis. 29 November 2010. doi: 10.3201/eid1612.100935.
Available at http://www.cdc.gov/eid/content/16/12/1960.htm#cit

Abstract. We compared the accuracy of online data obtained from the Flutracking surveillance system during pandemic (H1N1) 2009 in Australia with data from other influenza surveillance systems. Flutracking accurately identified peak influenza activity timing and community influenza-like illness activity and was significantly less biased by treatment-seeking behavior and laboratory testing protocols than other systems.

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Pandemic (H1N1) 2009 Outbreak at Canadian Forces Cadet Camp
Kropp RY, Bogaert LE, Barber R, et al. Emerg Infect Dis. 29 November 2010. doi: 10.3201/eid1612.100451.
Available at http://www.cdc.gov/eid/content/16/12/1986.htm#cit

Abstract. We conducted a case–control study to describe the clinical and epidemiologic characteristics of an outbreak of pandemic (H1N1) 2009 at a Canadian military cadet training center. We found that asthma and obesity confer greater risk for infection. Viral shedding was detected by PCR up to 18 days after symptom onset.

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Pandemic (H1N1) 2009 Infection in Patients with Hematologic Malignancy
Liu C, Schwartz BS, Vallabhaneni S, et al. Emerg Infect Dis. 29 November 2010. doi: 10.3201/eid1612.100772.
Available at http://www.cdc.gov/eid/content/16/12/1910.htm#cit

Abstract. To assess outcomes of patients with hematologic malignancy and pandemic (H1N1) 2009 infection, we reviewed cases during June–December 2009 at the University of California San Francisco Medical Center. Seventeen (63%) and 10 (37%) patients had upper respiratory tract infection (URTI) and lower respiratory tract infection (LRTI), respectively. Cough (85%) and fever (70%) were the most common signs; 19% of patients had nausea, vomiting, or diarrhea. Sixty-five percent of URTI patients were outpatients; 35% recovered without antiviral therapy. All LRTI patients were hospitalized; half required intensive care unit admission. Complications included acute respiratory distress syndrome, pneumomediastinum, myocarditis, and development of oseltamivir-resistant virus; 3 patients died. Of the 3 patients with nosocomial pandemic (H1N1) 2009, 2 died. Pandemic (H1N1) 2009 may cause serious illness in patients with hematologic malignancy, primarily those with LRTI. Rigorous infection control, improved techniques for diagnosing respiratory disease, and early antiviral therapy can prevent nosocomial transmission and optimize patient care.

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Pandemics in the Age of Twitter: Content Analysis of Tweets during the 2009 H1N1 Outbreak
Chew C, Eysenbach G. PLoS One. 29 November 2010; 5(11): e14118. doi:10.1371/journal.pone.0014118.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0014118

Background. Surveys are popular methods to measure public perceptions in emergencies but can be costly and time consuming. We suggest and evaluate a complementary “infoveillance” approach using Twitter during the 2009 H1N1 pandemic. Our study aimed to: 1) monitor the use of the terms “H1N1” versus “swine flu” over time; 2) conduct a content analysis of “tweets”; and 3) validate Twitter as a real-time content, sentiment, and public attention trend-tracking tool.

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Adverse events associated with the 2009 H1N1 influenza vaccination and the vaccination coverage rate in health care workers
Park S-W, Lee J-H, Kim E-S, et al. American J of Infect Control. 2 December 2010. doi:10.1016/j.ajic.2010.08.007.
Available at http://www.ajicjournal.org/article/S0196-6553(10)00816-3/abstract

Introduction. We prospectively examined the 2009 H1N1 influenza vaccination coverage rate and the adverse events related to the monovalent vaccine in Korean health care workers. The H1N1 vaccination coverage rate was 91.7%. There were no significant adverse events discouraging the vaccination.

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Novel influenza A (H1N1): clinical features of pediatric hospitalizations in two successive waves
Launay E, Ovetchkine P, Saint-Jean M, et al. International J Infect Dis. 9 December 2010. doi:10.1016/j.ijid.2010.08.006.
Available at http://www.ijidonline.com/article/S1201-9712(10)02522-1/abstract

Objective. To describe and compare the characteristics of children hospitalized with novel influenza A (H1N1) during two successive waves.

Methods. This was a medical chart review of all children hospitalized in a French Canadian pediatric hospital in Montreal in the spring and fall of 2009 with a positive real-time polymerase chain reaction for novel influenza A (H1N1) and flu-like symptoms.

Results. We included 202 children with a median age of 4.9 (range 0.1–18) years. Demographic and clinical features of the children in the two waves were similar. One or more underlying medical conditions were found in 59% of the children. Clinical findings at admission were: fever (98%), cough (88%), congestion/rhinorrhea (58%), gastrointestinal symptoms (47%), oxygen saturation below 95% (33%), sore throat (20%), and neurological symptoms (9%). Admission to the intensive care unit was required for 22 (11%) children, and 14 patients needed respiratory support. During the second wave, the median duration of stay was shorter (3 vs. 4 days, p=0.003) and oseltamivir was used more often (84% vs. 40%, p<0.001).
v Conclusions. Children hospitalized during the two successive waves of H1N1 were mainly school-aged and suffered from moderate disease. Although clinical features and severity of disease were similar, oseltamivir was prescribed more frequently and the length of hospital stay was shorter in the second wave.

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Mortality Risk Factors for Pandemic Influenza on New Zealand Troop Ship, 1918
Summers JA, Wilson N, Baker MG, et al. Emerg Infect Dis. 29 November 2010. doi: 10.3201/eid1612.100429.
Available at http://www.cdc.gov/eid/content/16/12/1931.htm#cit

Abstract. We describe the epidemiology and risk factors for death in an outbreak of pandemic influenza on a troop ship. Mortality and descriptive data for military personnel on His Majesty's New Zealand Transport troop ship Tahiti in July 1918 were analyzed, along with archival information. Mortality risk was increased among persons 25–34 years of age. Accommodations in cabins rather than sleeping in hammocks in other areas were also associated with increased mortality risk (rate ratio 4.28, 95% confidence interval 2.69–6.81). Assignment to a particular military unit, the field artillery (probably housed in cabins), also made a significant difference (adjusted odds ratio in logistic regression 3.04, 95% confidence interval 1.59–5.82). There were no significant differences by assigned rurality (rural residence) or socioeconomic status. Results suggest that the virulent nature of the 1918 influenza strain, a crowded environment, and inadequate isolation measures contributed to the high influenza mortality rate onboard this ship.

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5. Notifications
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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Keystone Symposia: Tuberculosis: Immunology, Cell Biology and Novel Vaccination Strategies
British Columbia, Canada 15-20 January 2011

This Keystone Symposium on TB will focus on these relationships covering basic and clinical research. Topics include the molecular genetics and biochemistry of the pathogen with emphasis on unique lineage and growth state-specific features.

 Additional information at http://www.keystonesymposia.org/11J3

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 apecein@u.washington.edu