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Vol. XIV No. 2 ~ EINet News Briefs ~ Jan 21, 2011


*****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
- 2011 Cumulative number of human cases of avian influenza A/H5N1
- Global: Northern Hemisphere countries show steady rise in flu
- Israel: H1N1 influenza update
- Egypt: Ten-year-old boy infected with H5N1 influenza virus
- Egypt: Discovery of new human case of H5N1 avian influenza

2. Infectious Disease News
- Australia: Fears over Queensland floods disease surge
- Australia: Legionnaires' disease alert to travellers from Bali
- Chinese Taipei: German measles cases confirmed
- Chinese Taipei: Mad cow disease may have caused death
- Indonesia (Bali): Rabies update
- New Zealand: In-flight exposure to measles
- New Zealand: Warning after Legionnaires’ disease spike
- Philippines (Iloilo): Rabies kills victim who denied having rabies

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

4. Articles
- Influenza vaccination status is not associated with influenza testing among children: Implications for observational studies of vaccine effectiveness
- Effectiveness of Seasonal Vaccine in Preventing Confirmed Influenza-Associated Hospitalizations in Community Dwelling Older Adults
- Determinants of A (H1N1) vaccination: Cross-sectional study in a population of pregnant women in Quebec
- Risk Factors for Severe Illness with 2009 Pandemic Influenza A (H1N1) Virus Infection in China
- Effectiveness of the 2009 Seasonal Influenza Vaccine Against Pandemic Influenza A(H1N1)2009 in Healthcare Workers in New Zealand, June-August 2009
- Convalescent Plasma Treatment Reduced Mortality in Patients With Severe Pandemic Influenza A (H1N1) 2009 Virus Infection
- Excess Healthcare Burden during 1918-1920 Influenza Pandemic in Taiwan: Implications for Post-pandemic Preparedness
- Secondary attack rate of pandemic influenza A(H1N1)2009 in Western Australian households, 29 May–7 August 2009
- Oseltamivir-resistant influenza viruses circulating during the first year of the influenza A(H1N1)2009 pandemic in the Asia-Pacific region, March 2009 to March 2010

5. Notifications
- International Meeting on Emerging Diseases and Surveillance (IMED 2011)
- 29th Annual UC Davis Infectious Diseases Conference
- APEC Senior Officials Meeting I and Related Meetings
- CDC toolkit offers flu lessons for kids


1. Influenza News

Global
2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Egypt / 2 (0)
Total / 2 (0)

***For data on human cases of avian influenza prior to 2011, go to: http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 518 (306) (WHO 1/20/2011)
http://www.who.int/csr/disease/avian_influenza/country/cases_table_2011_01_20/en/index.html

Avian influenza age distribution data from WHO/WPRO (last updated 11/19/10): 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 12/9/10): http://www.who.int/csr/disease/avian_influenza/2010_12_09_h5n1_avian_influenza_timeline_updates.pdf

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Global: Northern Hemisphere countries show steady rise in flu
Flu activity is increasing in many of the Northern Hemisphere's temperate-zone countries, with influenza B co-circulating with the 2009 pandemic H1N1 virus across Europe and teaming up with influenza A (H3N2) in the United States and Canada, the World Health Organization (WHO) said.

North African and Middle East countries are among the regions reporting increases in flu activity, with Morocco, Algeria, and Tunisia reporting mostly influenza B and Iran and Pakistan reporting that most viruses are the 2009 H1N1 strain, according to the WHO.

In recent weeks some countries in northern Asia have reported rises in respiratory disease levels, the WHO said. Flu activity, most of it H3N2, appears to have peaked in Mongolia and northern China in the third week of December 2010, but South Korea and Japan are reporting that the 2009 H1N1 virus has become the dominant strain.

Over the past several weeks UK countries have seen a steady rise in the number of hospitalizations and deaths from the 2009 H1N1 virus, but other European countries such as France, Portugal, the Netherlands, and Denmark are also reporting hospitalizations and deaths from it and influenza B.

The European Centre for Disease Prevention and Control (ECDC) also issued a flu surveillance report on 14 January 2011, which provided more details on influenza in that region. It said most countries are reporting regional or widespread activity, especially in western European countries. In Denmark doctors visits for flu-like illness were highest in children younger than 15, but Ireland, England, and Norway all reported that visits were highest in those ages 15 to 64. In Ireland, the level of doctor's visits for flu-like illnesses is now the same as in January 2010, which was during the pandemic. England's level is three times higher than in January 2010.

Countries in tropical zones and the Southern Hemisphere's temperate zones are reporting very little flu activity. H3N2 circulation in Paraguay and severe 2009 H1N1 infections in Sri Lanka that were reported earlier are declining. The WHO noted that one exception is Australia, where small numbers of H3N2 and influenza B viruses continue to circulate.
(CIDRAP 1/18/2011)

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Asia
Israel: H1N1 influenza update
As of 14 January 2011, 28 patients have been hospitalized in serious condition as a consequence of the outbreak of influenza A/(H1N1) 2009 virus infection and four have died. Beginning the week of 16 January 2011, doctors are expected to petition the High Court because of shortage of beds. Of the 28 hospitalized patients, 24 are on respirators and three are in serious condition. Four patients are reported to have died as a result of influenza A/(H1N1) 2009 virus infection.

Some 8,000 Israelis have reported symptoms of swine flu already the winter of 2010-2011, the Ministry said. About 15 percent of Israel's general population and a little more than half of those in the high-risk categories have been vaccinated.

[ProMED note: The information above suggests that the influenza outbreak in Israel is having more severe consequences than in most countries in the Northern Hemisphere. However, the vaccination uptake has been low.]
(ProMED 1/19/2011)

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Africa
Egypt: Ten-year-old boy infected with H5N1 influenza virus
The Ministry of Health of Egypt has announced a new case of human infection of H5N1 avian influenza. A ten-year-old male from Giza Governorate, developed symptoms on 5 January 2011 and was hospitalized on 8 January 2011. He is in a stable condition. Investigations into the source of infection indicated that the case had exposure to poultry. The case was confirmed by the Egyptian Central Public Health Laboratories, a National Influenza Center of the WHO Global Influenza Surveillance Network (GISN). Of the 120 cases confirmed as of 13 January 2011 in Egypt, 40 have been fatal.
(WHO 1/13/2011)

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Egypt: Discovery of new human case of H5N1 avian influenza
Dr. Abdel Rahman Shahin, spokesman for the Egyptian Ministry of Health, has stated on 19 January 2011 that a new human case of avian influenza A/(H5N1) virus infection has been discovered. The case is an 18-month-old child in the governorate of Alexandria. This case is the 121st since the onset of the disease in Egypt in March 2006. He stated that the child has been admitted to a hospital in Alexandria and is suffering from high fever, cough, runny, and febrile convulsion. The child had been exposed to domestic birds (chickens and ducks) that appeared to be infected with bird flu. The child was given Tamiflu and his health condition is now stable.
(ProMED 1/19/2011)

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2. Infectious Disease News

Asia
Australia: Fears over Queensland floods disease surge
Medical officials are bracing for rampant disease in swamped Queensland, with filthy floodwaters harboring sewage, dead animals and dangerous debris, as the town of Goondiwindi is evacuated. Dozens of towns have been inundated including large areas of Brisbane, Australia's third-largest city, in flooding across an area twice the size of Texas, or France and Germany combined.

More than 100,000 Brisbane homes were without power and fresh water supplies had been cut or compromised in some areas, while raw sewage spilled into waterways from submerged homes across the state of Queensland.

We anticipate the number of patients with infections to swell as food, water and sanitation continue to be compromised, the Australian Medical Association (AMA) warned. Infections may vary from ingestion varieties including gastroenteritis and parasitic infestations causing vomiting, diarrhea, and abdominal pains to systemic infections. Mosquito-borne diseases were also expected to surge as the insects multiply in the stagnant waters, and any cut exposed to the murky wet should be treated with antiseptic and closely monitored, AMA Queensland president Gino Pecoraro said. People should avoid wading in even shallow water as it may be contaminated. If you must enter shallow floodwaters wear solid boots for protection, Pecoraro said, urging people to seek medical advice and a tetanus shot for more serious injuries. Food spoiled due to the widespread power cuts was another crucial health risk, and Pecoraro said it was also vital to acknowledge the psychological trauma brought by the disaster and seek help.
(World News Australia 1/13/2011)

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Australia: Legionnaires' disease alert to travellers from Bali
Australia's chief medical officer, Professor Jim Bishop, has issued an alert to travellers in Bali or who have recently returned, who experience flu-like symptoms such as fever and cough to consult their GPs or hospital emergency departments. It is important that patients advise their doctor or hospital of their recent travel to Bali, Professor Bishop said. Over recent months, Australian health authorities have been made aware of 11 cases of Legionnaires’ disease detected in Victorian and Western Australian residents returning from holidays in the Kuta area of Bali between August 2010 and January 2011.

Professor Bishop said Indonesian health authorities and the World Health Organization are aware of the problem and are investigating. They have taken water samples from possible sources of outbreak for testing and have advised on appropriate disinfection and cleaning of water supply systems at the hotel and buildings in the vicinity. A number of those who contracted the disease stayed in the same hotel in Kuta (the Ramayana Resort and Spa) and most had visited the same local shopping centre.
(ProMED 1/19/2011)

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Chinese Taipei: German measles cases confirmed
In late December 2010, Taiwan Centers for Disease Control (CDC) received a report of a suspected rubella case from a clinic in Songshan District, Taipei City. The case is a 40 year old man with no recent travel history. On 18 December 2010, he developed symptoms such as fever, rash and headache. Taiwan CDC later confirmed German measles infection in the case.

During the investigation into the source of his infection, personnel from Taiwan CDC discovered that a 44 year old woman who resides in the same district had developed similar symptoms in mid-November 2010. When she sought medical attention, she was diagnosed with an upper respiratory tract infection. Taiwan CDC also later confirmed rubella infection in her. Although she travelled to Japan during early November 2010, the CDC was not able to determine where she became infected with rubella as she was travelling back and forth between Taiwan and Japan when she developed her infection.

Due to the difference in their disease onset times, they are not directly related even though both cases reside in the same district. The local health bureau has already compiled a list of close contacts and is closely monitoring the close contacts. As of now, no suspected case has been reported.

[ProMED note: An astute piece of diagnosis revealing that measles and mumps infections are not the only detrimental consequences of deficits in MMR vaccine coverage. The detection of rubella virus infection in unrelated adults in Taiwan signals the continued transmission of rubella virus in the community and reinforces the need to achieve universal MMR vaccination, there and elsewhere.]
(ProMED 1/13/2011)

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Chinese Taipei: Mad cow disease may have caused death
A 36-year-old Taiwanese male is very likely to have died from Creutzfeldt-Jakob disease (CJD), the Cabinet-level Department of Health (DOH) said on 8 December 2010. The patient, who died May 2010, resided in the United Kingdom between 1989 and 1997, when bovine spongiform encephalopathy (BSE) in cattle was at its peak in the UK. It is unlikely that the patient contracted his disease in Taiwan, the DOH said.

Scientists believe that many years after eating cattle infected with BSE, patients can develop symptoms of CJD. In the case of the 36-year-old patient, he began to show CJD symptoms, including memory loss and hypersomnia, in the second half of 2008. Doctors reported to health authorities in March 2009 that they suspected he had CJD.

After the patient died in 2010, his family refused to give doctors permission to perform an autopsy, the only way the doctors could determine the cause of death with certainty. His body has since been cremated. Though tests were not conducted, the man is an extremely likely case of CJD, based on his symptoms, travel history, and the results of magnetic resonance imaging and electroencephalograms, the Centers for Disease Control under the DOH said. The DOH further specified that the patient probably died from variant CJD (vCJD). The World Health Organization has listed the man as a vCJD case as his brain waves and cerebrospinal fluid showed symptoms of CJD and vCJD simultaneously, said Chen Shun-seng, convener of DOH's CJD advisory committee and a neurologist at Kaohsiung Chang Gung Memorial Hospital.

As of October 2010, there have been 243 possible or extremely possible cases of CJD reported in Taiwan, resulting in 102 deaths. Of the deaths, five have been confirmed as resulting from CJD, the DOH said.
(ProMED 1/10/2011)

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Indonesia (Bali): Rabies update
According to Dr. Ken Wirasandhi, the secretary of the Rabies Control Team at the Sanglah Hospital, the number of dog bite cases who have came to Sanglah Hospital in 2011 is lower than in the previous months. Previously, in a day more than 40 people requested anti-rabies vaccination (VAR), whereas in January 2011, VAR demands are around 20-30 people.

Decreasing VAR demand is expected to continue. Meanwhile, based on Bali Health Department's data, the stock of VAR is about 70,000 vials in Bali which will provide cover up to April 2011. The sufficiency of stocks of VAR in all regencies can be one reason for the decrease in number of dog bite cases at Sanglah Hospital.

However, rabies is still a threat. In the first two weeks of January 2011, four people died as a result of rabies virus infection. The most recent rabies fatality, a Nusa Penida resident, occurred on 7 January 2011. This death raises the total number of rabies deaths in Bali to 118.
(ProMED 1/10/2011)

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New Zealand: In-flight exposure to measles
The Ministry of Health is warning passengers on an Emirates flight from Dubai to Auckland the week of 3 January 2011 to watch for symptoms of measles after one passenger was found to have measles. Emirates flight EK406 departed Dubai on 3 January 2011 flying via Melbourne to Auckland on 4 January 2011. A passenger who disembarked in Melbourne has been confirmed as a case of measles.

Many other passengers on the flight continued on to Auckland. People sitting in a row close to the affected passenger are potentially at risk as measles is easily spread through the air, the Ministry said on 11 January 2011. The Ministry has sent information about the Emirates flight to public health units around the country.

However there are still around 20 people who sat in the rows nearest the infected passenger whose current locations in New Zealand were not known. Dr John Holmes of the Ministry of Health said the symptoms those passengers need to watch out for are fever, runny nose, and sore eyes followed about two days later by a red blotchy rash. Some people develop further complications such as diarrhea or a middle ear infection. But Holmes said they should not go directly to a doctor's office or to an emergency department, because they might infect other people. Holmes said measles is now rare in New Zealand, thanks to vaccination. New Zealand had three outbreaks in 2009-2010, each started by people who were infected overseas.
(ProMED 1/11/2011)

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New Zealand: Warning after Legionnaires’ disease spike
A record spike in the number of people with Legionnaires’ disease has prompted the Canterbury District Health Board to issue a warning about the dangers associated with potting mix and compost. Canterbury had a record 62 cases of Legionnaires’ disease in 2010, 22 of which were in December alone -- the highest ever in a single month. Medical officer of health Dr. Alistair Humphrey says two thirds of the cases were a type of Legionella associated with gardening soils. December's 22 cases compare with eight in November 2010. Three patients required intensive care and one died. Altogether four people died of Legionnaires’ disease in Canterbury in 2010, and one person remains quite unwell in intensive care.
(ProMED 1/16/2011)

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Philippines (Iloilo): Rabies kills victim who denied having rabies
A 38 year old mother of three in Brgy. Botong, Badiangan town died on 8 January 2011, the first recorded person to die of rabies here in 2011. The woman, together with her sister, was bitten by a puppy, about three months old, on 22 June 2010. Her sister had shots of an anti-rabies vaccine, but the victim did not. According to Estifania Gigare, provincial rabies coordinator for Iloilo, the victim hesitated to seek medication right after she was bitten. Even before she died, she denied having rabies, said Gigare.

The victim was already having aerophobia and hydrophobia when she was brought to the Federico Roman Tirador Sr. Memorial District Hospital in Janiuay town on 8 January 2011, Gigare said. The victim complained of body pains on 1 January 2011 and had paresthesia on 4 January 2011. On 6 January 2011, the patient suffered from severe pain on her right leg and on 7 January 2011, she had difficulty swallowing, Gigare added. Symptoms of rabies infection, according to Gigare, are fever, headache, general weakness and discomfort. If these symptoms manifest in the patient, he or she may die, she said.

Meanwhile, passive and active vaccines were already injected to the members of the victim's family who were believed also to have been exposed to the virus. Among these family members were the woman's 69 year old father, 30 year old husband, and her two year old daughter. Previously, her two other older children and her mother had been subjected to pre-exposure treatment.

A total of about one million peso (about 22,500 USD) has been allocated by the provincial government for the purchase of anti-rabies vaccine for all Animal Bite Centers in this province. Half of the budget has already been released; the remaining amount will be released sometime this month, according to Gov. Arthur Defensor Sr.
(ProMED 1/15/2011)

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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

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

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VECTOR-BORNE DISEASE
Australia (South Australia)
Mosquito-borne viruses are on the rise in South Australia. Health authorities in South Australia say a rise in mosquito-borne diseases has prompted a warning to residents and holidaymakers in the state's Riverland area to protect themselves from being bitten. Seventy people have been infected with the Ross River and Barmah Forest viruses in December 2010, well up on the 28 cases reported in 2009. SA Health says it'll be carrying out mosquito control measures in public areas.

[ProMED note: Although there is no current flood warning for the Riverland area along the Murray River in eastern South Australia State, the rains in the area are predicted to continue on 13 January 2011, which are likely to create additional breeding sites for mosquitoes that are vectors of Ross River and Barmah Forest viruses. Occurrence of additional cases of infection by these viruses would not be surprising.]
(ProMED 1/13/2011)


Peru (Loreto)
For the first time in 20 years after the reintroduction of dengue in the Peruvian Amazon, there is an outbreak of dengue-2, with an unusual number of severe cases. Health services are receiving an overload of cases with warning signs and have already reported the first death from dengue.

In Iquitos (Loreto region) all serotypes of dengue have already circulated, however only mild and sporadic cases of dengue hemorrhagic fever (DHF) I-II were reported. However, in this outbreak an unusual number of cases are being observed with warning signs (basically vomiting and abdominal pain with ultrasonographic signs of extravasation of plasma-ascites), mostly in children. It is thought to be due to the introduction of dengue-2 genotype III Asian/American virus in Brazil and was associated with a large number of severe cases with increased mortality.

Health authorities are implementing contingency measures in hospitalization and emergency services; a greater influx of cases is expected since the reporting of the outbreak began in December 2010.
(ProMED 1/11/2011)


Peru (Loreto)
At least five people died of dengue since the beginning of 2011 in the province of Loreto in the northeast Amazon, almost as many as throughout Peru in 2010, and more than 1,110 cases were reported in this province, according to the regional health authority. 1,130 dengue cases were diagnosed, including 26 serious cases. The most affected areas are in indigenous communities that are difficult to access.
(ProMED 1/17/2011)

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CHOLERA, DIARRHEA, and DYSENTARY
Papua New Guinea (East Sepik)
The cholera outbreak in East Sepik has spread to Ambunti district's Iniok village and neighboring villages from the Tunap sub-district. At least ten people have been confirmed dead since 31 December 2011, with unconfirmed reports of more casualties. Since cholera is waterborne, contaminated waste in the river will prove fatal, because there are many villages along the banks of the Sepik River, and it could spread to villages downstream.
(ProMED 1/9/2011)


Papua New Guinea (Port Moresby)
There has been a sharp rise in the number of cholera infections in Papua New Guinea's capital Port Moresby. Health authorities say there were 295 serious cases of cholera in Port Moresby in December 2010. So far in January 2011 there have been 138 with one death. The city's cholera task force leader, Dr Timothy Pyakalyia, says wet weather and large gatherings of people over the holidays are to blame for the surge in infections. Altogether there have been six deaths and nearly 4,000 infections since the contagious disease arrived in the city in April 2010.
(ProMED 1/18/2011)

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4. Articles
Influenza vaccination status is not associated with influenza testing among children: Implications for observational studies of vaccine effectiveness
Ferdinands JM, Belongia EA, Nwasike C, et al. Vaccine. 8 January 2011. doi:10.1016/j.vaccine.2010.12.098.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-51WW4Y8-5&_user=10&_coverDate=01%2F08%2F2011&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=32b7cb789fbde7e4df4a3872e32c09e1&searchtype=a

Abstract. Estimates of influenza vaccine effectiveness from observational studies that rely on physician-ordered influenza tests may be biased if physician testing behavior is influenced by patient vaccination status. To assess the potential for differential diagnostic testing of children by vaccine status, we examined the association between receipt of a commercial influenza diagnostic test and influenza vaccination among children aged 6–59 months who sought care at the Marshfield Clinic for acute respiratory or febrile illnesses during the 2004–05 through 2007–08 influenza seasons. There was no significant association between prior influenza vaccination and receipt of a diagnostic test for influenza. These findings suggest that estimates of vaccine effectiveness derived from observational studies among children are unlikely to be biased due to differential diagnostic testing.

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Effectiveness of Seasonal Vaccine in Preventing Confirmed Influenza-Associated Hospitalizations in Community Dwelling Older Adults
Talbot HK, Griffin MR, Chen Q. et al. J Infect Dis. 10 January 2011. doi: 10.1093/infdis/jiq076.
Available at http://jid.oxfordjournals.org/content/early/2011/01/10/infdis.jiq076.full

Background. Current evidence supporting the effectiveness of influenza vaccine in preventing hospitalizations in older adults is insufficient.

Methods. During 3 influenza seasons, 2006–2009, community-dwelling adults aged ≥50 y hospitalized with respiratory symptoms were prospectively enrolled in this study. We tested nose and throat samples for influenza virus by reverse transcriptase–polymerase chain reaction. We estimated vaccine effectiveness by comparing vaccination status between influenza-positive cases and influenza-negative controls using logistic regression models with propensity score adjustment.

Results. Overall, 450 (59%) of 763 eligible patients were enrolled; 417 (93%) of enrolled patients had adequate respiratory samples, had known influenza vaccination status, and were community-dwelling. The proportions of influenza-positive patients were 8%, 20%, and 6% in the 3 successive seasons. Of 39 influenza-positive participants, 14 (36%) were vaccinated compared with 250 (66%) of 378 influenza-negative controls. Propensity score–adjusted vaccine effectiveness for the 3 seasons combined was 61.2% (95% confidence interval, 17.5%–81.8%).

Conclusion. Overall, in this moderately well-vaccinated population of older adults, laboratory-confirmed influenza virus accounted for 9.3% (95% confidence interval, 6.6%–12.1%) of all respiratory hospitalizations during 3 influenza seasons, and influenza vaccination prevented 61.2% of such hospitalizations.


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Determinants of A (H1N1) vaccination: Cross-sectional study in a population of pregnant women in Quebec
Fabry P, Gagneur A, Pasquier J-C. Vaccine. 8 January 2011. doi:10.1016/j.vaccine.2010.12.109.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-51WW4Y8-9&_user=10&_coverDate=01%2F08%2F2011&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=a2f02f240f7155a30e02e3f1a0113ee2&searchtype=a

Background. Because of the risk of complication, pregnant women were a priority target for vaccination during the A (H1N1) pandemic influenza. In Quebec, 63% of pregnant women were vaccinated, which is a higher rate than vaccination against seasonal influenza. However, the behaviour of pregnant women relative to the vaccination during the H1N1 pandemic is unknown. The present study was aimed at identifying factors influencing the decision-making of pregnant women regarding H1N1 vaccination.

Methods. A cross-sectional survey was conducted in February 2010 in pregnant women or in early postpartum at the Sherbrooke University Hospital Centre using a self-administered questionnaire based on the Health Belief Model (HBM). Data items collected were: socio-demographic data, vaccination status, information sources consulted, knowledge on vaccination, and the HBM dimensions: effectiveness and risks of vaccination, severity and vulnerability towards the influenza. The associations between questionnaire variables and vaccination status were assessed by univariate and multivariate analysis.

Results. Of the 250 women interviewed, 95% knew that the vaccination was recommended, but only 76% received the vaccine. Variables positively associated with vaccination were late vaccination during pregnancy (OR = 7.3, 95% CI 2.1–25.3), belief in the efficacy of the vaccine (OR = 7, 95%CI 2–23.4), and consultation of the Pandémie-Québec website (OR = 4.5, 95% CI 1.5–13.4). However, the belief that the vaccine had not been adequately tested (OR = 0.08, 95% CI 0.02–0.35) and consultation of mainstream websites (OR = 0.22, 95%CI 0.06–0.81) were associated with lower vaccination rates.

Conclusions. The vast majority of pregnant women were aware of the recommendations relative to A (H1N1) vaccination. Internet media played an important role in their decision to get vaccinated. Better information on the safety of the vaccine must be prepared for future pandemics.

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Risk Factors for Severe Illness with 2009 Pandemic Influenza A (H1N1) Virus Infection in China
Yu H, Feng Z, Uyeki TM, et al. Clin Infect Dis. 10 January 2011. doi: 10.1093/cid/ciq144.
Available at http://cid.oxfordjournals.org/content/early/2011/01/10/cid.ciq144.full

Background. Data on risk factors for severe outcomes from 2009 pandemic influenza A (H1N1) virus infection are limited outside of developed countries.

Methods. We reviewed medical charts to collect data from patients hospitalized with laboratory-confirmed 2009 H1N1 infection who were identified across China during the period from September 2009 through February 2010, and we analyzed potential risk factors associated with severe illness (defined as illness requiring intensive care unit admission or resulting in death).

Results. Among 9966 case patients, the prevalence of chronic medical conditions (33% vs 14%), pregnancy (15% vs 7%), or obesity (19% vs 14%) was significantly higher in those patients with severe illness than it was in those with less severe disease. In multivariable analyses, among nonpregnant case patients aged ≥2 years, having a chronic medical condition significantly increased the risk of severe outcome among all age groups, and obesity was a risk factor among those <60 years of age. The risk of severe illness among pregnant case patients was significantly higher for those in the second and third trimesters. The risk of severe illness was increased when oseltamivir treatment was initiated ≥5 days after illness onset (odds ratio, 1.42; 95% confidence interval, 1.20–1.67). For persons <60 years of age, the prevalence of obesity among case patients with severe illness was significantly greater than it was among those without severe illness or among the general population.

Conclusions. Risk factors for severe 2009 H1N1 illness in China were similar to those observed in developed countries, but there was a lower prevalence of chronic medical conditions and a lower prevalence of obesity. Obesity was a risk factor among case patients <60 years of age. Early initiation of oseltamivir treatment was most beneficial, and there was an increased risk of severe disease when treatment was started ≥5 days after illness onset.

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Effectiveness of the 2009 Seasonal Influenza Vaccine Against Pandemic Influenza A(H1N1)2009 in Healthcare Workers in New Zealand, June-August 2009
Jefferies S, Earl D, Berry N, et al. Eurosurveillance. 13 January 2011;16(2):pii=19761.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19761

Abstract. There is uncertainty whether the 2009 seasonal influenza vaccination influences the risk of infection with the 2009 pandemic influenza A(H1N1) virus. This issue was investigated in 548 healthcare workers from Capital and Coast District Health Board, Wellington, New Zealand, presenting with influenza-like illness during the influenza pandemic between June and August 2009. All workers completed an assessment sheet and had a nasopharyngeal swab tested by real-time RT-PCR. The risk of pandemic influenza A(H1N1) infection associated with the 2009 seasonal inactivated trivalent influenza vaccine was determined by logistic regression, with adjustment for potential confounding variables. In 96 workers pandemic influenza A(H1N1) RNA was detected and 452 tested negative. The multivariate analysis did not show any effect of vaccination on PCR-confirmed influenza A(H1N1)2009 infection (odds ratio 1.2, 95% confidence interval 0.7–1.9, p=0.48). We conclude that 2009 seasonal influenza vaccination had no protective effect against influenza A(H1N1)2009 infection amongst healthcare workers. To protect against further waves of the current pandemic influenza or future pandemics in which the influenza virus is antigenically distinct from contemporary seasonal influenza viruses, it would be necessary to vaccinate with a specific pandemic influenza vaccine, or a seasonal influenza vaccine that includes the pandemic influenza serotype.

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Convalescent Plasma Treatment Reduced Mortality in Patients With Severe Pandemic Influenza A (H1N1) 2009 Virus Infection
Hung IFN, To KKW, Lee C-K, et al. Clin Infect Dis. 19 January 2011. doi: 10.1093/cid/ciq106.
Available at http://cid.oxfordjournals.org/content/early/2011/01/19/cid.ciq106.abstract

Background. Experience from treating patients with Spanish influenza and influenza A(H5N1) suggested that convalescent plasma therapy might be beneficial. However, its efficacy in patients with severe pandemic influenza A(H1N1) 2009 virus (H1N1 2009) infection remained unknown.

Methods. During the period from 1 September 2009 through 30 June 2010, we conducted a prospective cohort study by recruiting patients aged ≥18 years with severe H1N1 2009 infection requiring intensive care. Patients were offered treatment with convalescent plasma with a neutralizing antibody titer of ≥1:160, harvested by apheresis from patients recovering from H1N1 2009 infection. Clinical outcome was compared with that of patients who declined plasma treatment as the untreated controls.

Results. Ninety-three patients with severe H1N1 2009 infection requiring intensive care were recruited. Twenty patients (21.5%) received plasma treatment. The treatment and control groups were matched by age, sex, and disease severity scores. Mortality in the treatment group was significantly lower than in the nontreatment group (20.0% vs 54.8%; P = .01). Multivariate analysis showed that plasma treatment reduced mortality (odds ratio [OR], .20; 95% confidence interval [CI], .06-.69; P = .011), whereas complication of acute renal failure was independently associated with death (OR, 3.79; 95% CI, 1.15-12.4; P = .028). Subgroup analysis of 44 patients with serial respiratory tract viral load and cytokine level demonstrated that plasma treatment was associated with significantly lower day 3, 5, and 7 viral load, compared with the control group (P < .05). The corresponding temporal levels of interleukin 6, interleukin 10, and tumor necrosis factor α (P < .05) were also lower in the treatment group.

Conclusions. Treatment of severe H1N1 2009 infection with convalescent plasma reduced respiratory tract viral load, serum cytokine response, and mortality.

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Excess Healthcare Burden during 1918-1920 Influenza Pandemic in Taiwan: Implications for Post-pandemic Preparedness
Hsieh Y-H, Chan C-H. BMC Public Health. 17 January 2011;11(41) doi:10.1186/1471-2458-11-41.
Available at http://www.biomedcentral.com/1471-2458/11/41

Background. It is speculated that the 2009 pandemic H1N1 influenza virus might fall into a seasonal pattern during the current post-pandemic period with more severe clinical presentation for high-risk groups identified during the 2009 pandemic. Hence the extent of likely excess healthcare needs during this period must be fully considered. We will make use of the historical healthcare record in Taiwan during and after the 1918 influenza pandemic to ascertain the scope of potential excess healthcare burden during the post-pandemic period.

Methods. To establish the healthcare needs after the initial wave in 1918, the yearly healthcare records (hospitalizations, outpatients, etc.) in Taiwan during 1918-1920 are compared with the corresponding data from the adjacent "baseline" years of 1916, 1917, 1921, and 1922 to estimate the excess healthcare burden during the initial outbreak in 1918 and in the years immediately after.

Results. In 1918 the number of public hospital outpatients exceeded the yearly average of the baseline years by 20.11% (95% CI: 16.43, 25.90), and the number of hospitalizations exceeded the corresponding yearly average of the baseline years by 12.20% (10.59, 14.38), while the excess number of patients treated by the public medics was statistically significant at 32.21% (28.48, 39.82) more than the yearly average of the baseline years. For 1920, only the excess number of hospitalizations was statistically significant at 19.83% (95% CI: 17.21, 23.38) more than the yearly average of the baseline years.

Conclusions. Considerable extra burden with significant loss of lives was reported in 1918 by both the public medics system and the public hospitals. In comparison, only a substantial number of excess hospitalizations in the public hospitals was reported in 1920, indicating that the population was relatively unprepared for the first wave in 1918 and did not fully utilize the public hospitals. Moreover, comparatively low mortality was reported by the public hospitals and the public medics during the second wave in 1920 even though significantly more patients were hospitalized, suggesting that there had been substantially less fatal illnesses among the hospitalized patients during the second wave. Our results provide viable parameters for assessing healthcare needs for post-pandemic preparedness.

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Secondary attack rate of pandemic influenza A(H1N1)2009 in Western Australian households, 29 May–7 August 2009
Carcione D, Giele CM, Goggin LS, et al. Eurosurveillance. 20 January2011;16(3):pii=19765.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19765

Abstract. Understanding household transmission of the pandemic influenza A(H1N1)2009 virus, including risk factors for transmission, is important for refining public health strategies to reduce the burden of the disease. During the influenza season of 2009 we investigated transmission of the emerging virus in 595 households in which the index case was the first symptomatic case of influenza A(H1N1)2009. Secondary cases were defined as household contacts with influenza-like illness (ILI) or laboratory-confirmed influenza A(H1N1)2009, occurring at least one day after but within seven days following symptom onset in the index case. ILI developed in 231 of the 1,589 household contacts, a secondary attack rate of 14.5% (95% confidence interval (CI): 12.9–16.4). At least one secondary case occurred in 166 of the 595 households (a household transmission rate of 27.9%; 95% CI: 24.5–31.6). Of these, 127 (76.5%) households reported one secondary case and 39 (23.5%) households reported two or more secondary cases. Secondary attack rates were highest in children younger than five years (p=0.001), and young children were also more efficient transmitters (p=0.01). Individual risk was not associated with household size. Prophylactic antiviral therapy was associated with reduced transmission (p=0.03). The secondary attack rate of ILI in households with a confirmed pandemic influenza A(H1N1)2009 index case was comparable to that described previously for seasonal influenza.

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Oseltamivir-resistant influenza viruses circulating during the first year of the influenza A(H1N1)2009 pandemic in the Asia-Pacific region, March 2009 to March 2010
Hurt AC, Deng YM, Ernest J, et al. Eurosurveillance. 20 January 2011;16(3):pii=19770.
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19770

Abstract. During the first year of the influenza A(H1N1)2009 pandemic, unprecedented amounts of the neuraminidase inhibitors, predominantly oseltamivir, were used in economically developed countries for the treatment and prophylaxis of patients prior to the availability of a pandemic vaccine. Due to concerns about the development of resistance, over 1,400 influenza A(H1N1)2009 viruses isolated from the Asia-Pacific region during the first year of the pandemic (March 2009 to March 2010) were analysed by phenotypic and genotypic assays to determine their susceptibility to the neuraminidase inhibitors. Amongst viruses submitted to the World Health Organization Collaborating Centre for Reference and Research in Melbourne, Australia, oseltamivir resistance was detected in 1.3% of influenza A(H1N1)2009 strains from Australia and 3.1% of strains from Singapore, but none was detected in specimens received from other countries in Oceania or south-east Asia, or in east Asia. The overall frequency of oseltamivir resistance in the Asia-Pacific region was 16 of 1,488 (1.1%). No zanamivir-resistant viruses were detected. Of the 16 oseltamivir-resistant isolates detected, nine were from immunocompromised individuals undergoing oseltamivir treatment and three were from immunocompetent individuals undergoing oseltamivir treatment. Importantly, four oseltamivir-resistant strains were from immunocompetent individuals who had not been treated with oseltamivir, demonstrating limited low-level community transmission of oseltamivir-resistant strains. Even with increased use of oseltamivir during the pandemic, the frequency of resistance has been low, with little evidence of community-wide spread of the resistant strains. Nevertheless, prudent use of the neuraminidase inhibitors remains necessary, as does continued monitoring for drug-resistant influenza viruses.

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5. Notifications
International Meeting on Emerging Diseases and Surveillance (IMED 2011)
Vienna, Austria, 4-7 February 2011
The Program for Monitoring Emerging Diseases (ProMED), is pleased to invite you to the IMED 2011, following highly successful meetings in 2007 and 2009. Along with our co-sponsors, the Wildlife Conservation Society, the European Centre for Disease Prevention and Control, the World Organisation for Animal Health (OIE), the European Commission, and the European Society of Clinical Microbiology and Infectious Diseases, we are developing a conference that will bring together the public health community, scientists, health care workers and other leaders in the field of emerging infectious diseases. The meeting will embrace the “One Health” concept recognizing that, just as diseases reach across national boundaries, so do they transcend species barriers. We therefore welcome the full participation of both the human and animal health communities.
Additional information at http://imed.isid.org/

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29th Annual UC Davis Infectious Diseases Conference
Sacramento, CA, USA, 11-12 February 2011,
Infectious disease is an area of medicine that is constantly changing. New pathogens are identified and newer therapeutic strategies are defined. This is an important opportunity to review and update participants on practical information.
Additional information at http://www.ucdmc.ucdavis.edu/cme/conferences/

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APEC Senior Officials Meeting I and Related Meetings
Washington DC, USA, 27 February to 12 March 2011

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CDC toolkit offers flu lessons for kids
The US Centers for Disease Control and Prevention (CDC) on 7 January 2011 released a toolkit for teaching children about flu prevention. The resources, primarily targeted to childcare providers, include lesson plans, suggested activities, songs, and coloring and puzzle pages. The materials also include posters for child-care centers and handouts that target flu prevention messages to parents. Lessons for children ages three to seven cover hand washing and covering coughs and sneezes. A lesson plan for children ages eight to ten focuses on how germs spread.
Additional information at http://www.cdc.gov/flu/pdf/business/TeachingChildernFlu.pdf
(CIDRAP 1/10/2011)

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 apecein@u.washington.edu