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Vol. XIV No. 5 ~ EINet News Briefs ~ Mar 04, 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: Influenza levels declining in many European countries
- Global: WHO reports North America the global hot spot for influenza
- Global: H5N1 avian influenza strikes more poultry in Asia.
- Cambodia: Ministry of Health confirm 12th and 13th human cases of H5N1 avian influenza
- Indonesia: First fatal case of H5N1 avian influenza reported
- South Korea: Farm hit with H5N1 avian influenza
- USA: FDA picks current strains for 2011-2012 influenza season
- Egypt: H5N1 avian influenza surfaces during political upheaval

2. Infectious Disease News
- Australia: Measles outbreak hits Mt. Druitt area
- Chinese Taipei: Reports first case of indigenous measles in 2011
- Indonesia (Bali): Rabies death toll tops 124
- New Zealand (Auckland): Latest update on measles outbreak
- Philippines: Two die of rabies in Capiz
- Philippines (South Cotabato): Possible measles outbreak eyed in several towns
- South Korea: Winning foot and mouth disease battle
- Peru (Amazonas): Rabies transmitted by vampire bats
- USA: Measles outbreak, tens of thousands exposed?
- USA (Arizona): Measles case in Maricopa County
- USA (New Mexico): Department of Health investigating measles case

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

4. Articles
- Effects of vaccination and population structure on influenza epidemic spread in the presence of two circulating strains
- Protecting the Public from H1N1 through Points of Dispensing (PODs)
- Safety of influenza A (H1N1) vaccine in postmarketing surveillance in China
- Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate
- Evaluating Research and Impact: A Bibliometric Analysis of Research by the NIH/NIAID HIV/AIDS Clinical Trials Networks
- Racial disparities in exposure, susceptibility, and access to health care in the US H1N1 influenza pandemic
- Public perceptions of the transmission of pandemic influenza A/H1N1 2009 from pigs and pork products in Australia

5. Notifications
- APEC Senior Officials Meeting I and Related Meetings
- Global Health Metrics & Evaluation: Controversies, Innovation, Accountability
- Communicable Disease Control Conference


1. Influenza News

Global
2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Cambodia / 3 (3)
Egypt / 6 (1)
Indonesia / 1 (1)
Total / 10 (5)

***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: 526 (311) (WHO 3/2/2011)
http://www.who.int/csr/disease/avian_influenza/country/cases_table_2011_03_02/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: Influenza levels declining in many European countries
Flu activity is still widespread in many European countries, but 17 countries reported decreasing indicators, the European Centre for Disease Prevention and Control (ECDC) reported on 25 February 2011. The proportion of positive respiratory specimens dropped to 40% on 18 February 2011, down from 43% on 11 February 2011 and the peak of 57% seen at the end of 2010. Increasing flu activity was reported by only three countries: Austria, Iceland, and Romania. The number of severe flu infections has decreased across western Europe, except for Greece, but the severe illness picture is uncertain in central and eastern Europe, where hospital surveillance is limited. Most of the severe flu infections have been linked to the 2009 H1N1 virus. About 67% of flu viruses are influenza A, nearly all of them the 2009 H1N1 strain, in contrast to the mix of H1N1 and H3N2 viruses in North America.
(CIDRAP 2/25/2011)

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Global: WHO reports North America the global hot spot for influenza
Although influenza activity appears to have peaked in Western Europe and remains low or sporadic in most other parts of the world, it is increasing somewhat in parts of North America, according to the World Health Organization (WHO). Part of the North American increase involves proportionately more cases of pandemic 2009 H1N1, particularly in Canada, and type B, particularly in the United States. However, the dominant flu virus in North America remains type A(H3N2), unlike in Europe, where 2009 H1N1 has been most common. In Canada, the highest activity is in Quebec and the Atlantic provinces; the consultation rate for influenza-like illness (ILI) country-wide has increased to 35.7 per 1,000 patient visits. US flu activity is widespread in 36 states, and the proportion of consultations for ILI reached 4.5%, an increase from the last WHO report. Deaths from pneumonia or influenza in the United States, at 8.9% of all deaths, also increased. The majority of viruses circulating in Europe and North America, match closely with the current trivalent flu vaccine strains.
(CIDRAP 2/28/2011)

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Global: H5N1 avian influenza strikes more poultry in Asia.
On 25 February 2011, South Korea's agriculture ministry stated that the H5N1 virus has hit another poultry farm, about 62 miles outside of Seoul. The farm's 30,000 birds were culled to control the outbreak. The ministry said H5N1 outbreaks in South Korea now seem to be declining. A series of outbreaks that began in December has led to the culling of 5.5 million birds. In Vietnam, the virus has been detected again in five provinces, Thai Nguyen, Vinh Phuc, Lang Son, Nam Dinh, and Kon Tum. In other developments, Dr Subhash Morzaria, regional manager of the United Nations Emergency Center for Transboundary Animal Diseases, said high-density farming systems, high human population, and deforestation are making people more vulnerable to zoonotic diseases. Morzaria said Japan is emerging as a new hot spot for zoonotic disease risk—joining countries such as Indonesia, Vietnam, and Bangladesh—and that wild birds appear to be playing a role in spreading the disease to Japan's poultry flocks. Most transmission is still related to poultry farming and trading, which is where most disease-fighting resources should remain focused.
(CIDRAP 2/25/2011)

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Asia
Cambodia: Ministry of Health confirm 12th and 13th human cases of H5N1 avian influenza
The Ministry of Health (MoH) of the Kingdom of Cambodia wishes to advise members of the public that an 11-month-old male residing in Takong village, Ta Kong Commune, Malay district, Banteay Meanchey Province died on 17 February 2011 as a result of respiratory complications after contracting avian influenza virus H5N1. Additionally further tests done on blood sample from his mother indicate that she too was infected with the H5N1 influenza virus. The 19-year-old mother from the same village died of respiratory complications on 12 February 2011.

Although both patients became sick in Banteay Meanchey province, they were exposed to eating and preparing sick poultry while visiting relatives in Prey Veng province. They developed high fever and cough on 5 February 2011 a few days after preparing and eating sick poultry in Rokar Chor village, Bantey Chakrey commune, Prash Sdach district, Prey Veng Province.

The mother was admitted to a private clinic in Banteay Meanchey province but died as result of complications of infection on 12 February 2011. The baby was admitted to the Intensive Care Unit of Jayavaraman VII Hospital in Siem Reap. Despite intensive medical care, the baby died on 17 February 2011, two days after admission from complications. Samples that were sent to Institut Pasteur du Cambodge tested positive for influenza H5N1.

In a statement, HE Mam Bun Heng, Minister of Health affirmed that compared to 2010, Cambodia has seen more cases of H5N1 Avian influenza in 2011. There seems to be a strong link between preparing and eating sick birds and becoming infected in all the three cases. He urges people to only cook and eat healthy birds which do not cause infection. Also, he urges that all our medical and nursing professionals ask their patients with respiratory disease if they have had any contact with sick poultry. If suspicious, medical professionals should report to the MoH.

As part of the Ministry of Health's routine outbreak response measures, government Rapid Response Teams (RRT) are now in the area conducting field investigations to identify close contacts and to initiate preventive treatment as required. A public health education campaign is being conducted to inform families on how to protect themselves from contracting avian influenza.

From 2003 to 23 February 2011, there have been 13 laboratory confirmed cases of H5N1 avian influenza virus in humans in Cambodia, 11 of whom died. Globally since 2003, there have been 522 laboratory confirmed cases of avian influenza with 309 related deaths.
(ProMed 2/23/2011)

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Indonesia: First fatal case of H5N1 avian influenza reported
A 26-year-old Indonesian woman has died of H5N1 avian influenza, becoming the country's official first H5N1 case of 2011, the World Health Organization (WHO) reported on 2 March 2011. The woman, from West Java province, became ill 31 January 2011, was hospitalized 3 February 2011, and died 8 February 2011 despite oseltamivir (Tamiflu) treatment. She had bought poultry meat as well as chickens at a live market that were slaughtered and prepared on site before she brought them home. Laboratory tests confirmed the diagnosis, according to Indonesia's Ministry of Health. Since 2005 Indonesia has reported 172 H5N1 cases, including 142 deaths, for a case-fatality rate of 83%. In both categories the nation leads the world, accounting for a third of the world's WHO-confirmed 526 H5N1 cases and almost half of its 311 deaths.
(CIDRAP 3/2/2011)

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South Korea: Farm hit with H5N1 avian influenza
About 1,000 farm ducks found dead on 20 February 2011 in South Jeolla province of South Korea were confirmed on 26 February 2011 to have highly pathogenic H5N1 avian influenza. The farm is located in the southern part of the country, about 215 miles south of Seoul. The outbreak is South Korea's 46th since the first one was confirmed December 2010, and officials are concerned about the rapid spread of the disease. Since January and February 2011, a record 5.5 million domestic birds have been culled to prevent disease spread.
(CIDRAP 2/28/2011)

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Americas
USA: FDA picks current strains for 2011-2012 influenza season
The US Food and Drug Administration's (FDA's) vaccine advisory group voted on 25 February 2011 to follow the World Health Organization's (WHO's) lead in keeping the current three strains for 2011-12 seasonal flu vaccine.

The Vaccines and Related Biological Products Advisory Committee helps guide pharmaceutical companies that will be making seasonal flu vaccine for the US market.

The WHO and FDA normally pick flu strains for the Northern Hemisphere in February, because it takes several months to develop vaccine viruses based on the circulating strains, grow large quantities in chicken eggs, and formulate them into vaccines.

Shelly Burgess, a spokeswoman for the FDA stated that the vote on retaining each of the three strains was unanimous, except for one abstention on the 2009 H1N1 strain decision.

The strains chosen by the FDA panel on 25 February 2011, according to Burgess, are:
For the H1N1 component, a strain similar to A/California/7/2009
For the H3N2 component, a strain similar to A/Perth/16/2009
For the B component, a strain similar to B/Brisbane/60/2008

The FDA and WHO recommendations also match the recommendations made by WHO's vaccine experts for the Southern Hemisphere's 2011 flu season, which starts around May.
(CIDRAP 2/25/2011)

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Africa
Egypt: H5N1 avian influenza surfaces during political upheaval
The World Health Organization (WHO) confirmed on 28 February 2011 that three more H5N1 avian influenza infections in Egypt, one of them fatal surfaced the country's recent political upheaval.

Egypt saw a dramatic spike in human H5N1 infections in 2009 and 2010, and in each of those years the country reported the most H5N1 illnesses globally, outpacing even traditional avian flu hotspots such as Indonesia and Vietnam. The cell phone and Internet blackouts that occurred during Egypt's leadership transition led to some anxiety in the infectious disease community about the status of the H5N1 threat in Egypt.

The country's latest H5N1 infections are from three different governorates and do not appear to be linked, though investigations into the illnesses suggest the patients all had been exposed to sick poultry.

The WHO said the first case-patient is a 26-year-old woman from Dakahlia governorate who got sick on 18 January 2011 and was hospitalized on 23 January 2011. She recovered and was released from the hospital on 7 February 2011. The second patient is a 45-year-old man from Menofia governorate who got sick on 20 January 2011, was hospitalized on 26 January 2011, and died on 5 February 2011. The third case is a four-year-old boy from Damieta governorate who started having symptoms on 14 February 2011 and was hospitalized on 16 February 2011, where he remains in stable condition.

Egypt's Central Public Health Laboratory, a member of the WHO's global influenza surveillance network, confirmed the three cases, which push the country's number of H5N1 cases to 125, including 41 deaths. Egypt has the world's second-highest number of confirmed cases, behind Indonesia. The global H5N1 count now stands at 525 cases, of which 310 have been fatal.

According to reports about poultry H5N1 outbreaks posted on Egypt's Strengthening Avian Influenza Detection and Response (SAIDR) website, detections were sporadic in early February during political unrest. However, animal health officials now appear to have resumed their active surveillance activities, along with outbreak response duties.

Since 13 February 2011 officials have reported 24 outbreaks from nine different governorates. Three occurred at farms, one took place at a checkpoint, and the rest involve household birds. The farm outbreaks led to the culling of 63,500 birds to control the spread of the disease.
(CIDRAP 2/28/2011)

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2. Infectious Disease News

Asia
Australia: Measles outbreak hits Mt. Druitt area
An outbreak of measles has families in the Mt. Druitt, St. Marys and Rooty Hill on high alert. New South Wales (NSW) Health issued a warning earlier the week of 28 February 2011 to be on the look out after eight confirmed cases in February 2011.

Communicable diseases manager for the local public health unit Dr. Vicky Sheppeard said there had been an increase in the eastern states in 2011 in reported cases of measles. Measles is one of the most easily spread diseases and just being in the same room as someone with measles can result in infection, she said. Around one in five people who catch measles require hospitalization.
(ProMED 3/1/2011)

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Chinese Taipei: Reports first case of indigenous measles in 2011
A 20-year-old college student was the first person to contract measles in Taiwan in 2011, the Center for Disease Control (CDC) said on 26 February 2011. The patient, who attends school in Taipei, came down with a rash on Friday 18 February 2011, the center said. Further investigation found that the student had received a vaccine against measles when she was one-year-old. However, there was no record of follow-up vaccination after she entered elementary school, CDC Deputy Director-General Shih Wen-yi said. Two days before the rash developed, the patient visited Pingsi Township for the sky lantern festival and the Shifenliao area in New Taipei City, she said.

So far, the CDC has tracked 15 people who had contact with the student, and two of them have reported feelings of discomfort, Shih said. To prevent the disease from spreading, the CDC called for passengers who took Taiwan Railway trains on 16 February 2011 to and from Taipei, Pingsi and Shifenliao to conduct self-health management.

Taiwan had 12 confirmed cases of indigenous and imported measles in 2010, CDC statistics show.
(ProMED 3/1/2011)

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Indonesia (Bali): Rabies death toll tops 124
The outbreak of rabies that has hit Indonesia's resort island of Bali since late 2008 has killed 124 people, officials said 24 February 2011.

A 62-year-old man who died on 23 February 2011 became the latest victim of the disease, said Ken Wirasandhi, a member of a team in charge of handling the disease at the main Sanglah hospital. The man was in critical condition when he was admitted, he said.

On 20 February 2011, two more people died of the disease.

The Bali government has embarked on a campaign to vaccinate nearly 400,000 dogs in an effort to eradicate rabies by 2012. Bali health chief Nyoman Sutedja said a lack of control in the dog trade could further fuel the spread of the disease. But he said despite the new deaths, cases of dog bites had fallen from about 200 a day to 130. The new cases won't threaten the goal of eradicating rabies by 2012, Sutedja said. The trend is cases are on the decline. Official data put the number of dogs in Bali at around 450,000, the actual figure could be a lot higher, officials have said. Balinese are known for their love of dogs.

Rabies has been reported on the Indonesian islands of Java and Flores, but Bali was free of the disease for decades until 2008.

[ProMED: The precise number of human victims of rabies virus infection on the Indonesian island of Bali is difficult to establish, but cases are still occurring and it is clear that the outbreak is far from contained.]
(ProMED 2/28/2011)

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New Zealand (Auckland): Latest update on measles outbreak
The Auckland Regional Public Health Service (ARPHS) reports two more people confirmed with measles the week of 21 February 2011 with another likely to be confirmed. In addition, five people are under investigation for measles. This brings the latest number of people with confirmed measles to 18.

One of the people confirmed with measles was on board the Malaysian Airlines Flight MH131 which flew from Kuala Lumpur to Auckland Airport on 18 February 2011
(ProMED 2/26/2011)

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Philippines: Two die of rabies in Capiz
Since the beginning of January 2011, Capiz province has recorded two fatalities due to rabid dog bites. Provincial Health Medical Specialist Dr. Evelyn Bolido stated that these occurred in Jamindan and Panitan. Bolido said also that the public must likewise be vigilant regarding dog bites, especially during summer season of 2011, when most cases of dog bite occur. She also urged the public to immediately seek medical attention after a dog bite even if there is only slight abrasion.

Bolido also reminded Capicenos to be responsible pet owners because neglected pets could endanger the lives of others. She said that responsible dog owners should have their pets immunized. This should be arranged through the veterinary or agriculture office responsible for canine anti-rabies vaccination in their area.

In Roxas City alone, about 10,000 dogs are being targeted for vaccination by the Office of the City Veterinarian.

[ProMED note: Although the incidence of rabies has declined somewhat in the Philippines in recent years, disease rates continue to be higher in the Philippines than in neighboring countries. In 2010, the Department of Health stated that rabies continued to be a public health problem in the Philippines, where dogs are responsible for 90% of human cases of rabies. In 2005, it was reported that the Philippines ranked fifth in Asia (after India, China, Pakistan, and Bangladesh).]
(ProMED 2/28/2011)

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Philippines (South Cotabato): Possible measles outbreak eyed in several towns
Health authorities in South Cotabato province are studying the possible declaration of a measles outbreak in several parts of the province following the confirmation of at least seven positive cases of the disease in the area.

Three cases of measles were confirmed in Tampakan town and two cases each in Polomolok town and in Koronadal City. Integrated Provincial Health Office's epidemiology and surveillance unit (PESU) chief Dr. Salvecio Dagang said they are currently intensifying their campaign on Garantisadong Pambata (GP) program, which focuses on the massive immunization of infants and children at the household level. The program is held every April and October.

Dagang said their records showed that Tampakan town registered the lowest GP turnout during the last several years. According to the DOH's guidelines, a person who had not been vaccinated should be given vaccine shot regardless of age to cut the vicious cycle of the measles virus.

Dagang said measles in South Cotabato had been silent for several years and the province was already preparing for the declaration of the areas as measles-free when an outbreak occurred during the last quarter of 2010.
(ProMED 2/26/2011)

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South Korea: Winning foot and mouth disease battle
The worst appears to be over for South Korean livestock producers as the latest foot-and-mouth disease (FMD) outbreak appears to have peaked on the wake of a second round of vaccines. The epidemic forced Korean officials to slaughter nearly a third of the country's hog and cattle herds. Damages caused by the outbreak are expected to hover around USD 2.6 billion.

The South Korean Ministry for Food, Agriculture, Forestry and Fisheries announced an improvement in slaughter totals for animals culled to stop the spread of FMD, indicting success in eradicating the disease from their herds. The decrease in daily cull numbers appears to be a result of the second wave of a vaccination campaign. Nearly 74% of hogs and 99% of cattle had been vaccinated by 21 February 2011.

We're cautiously predicting that FMD will abate early next month once vaccination is completed late this month, Yoo Jeong-bok, the country's farm minister, said. Yoo also said that damages are estimated at USD 2.6 billion. Damages are focused on the direct losses to livestock and compensation for quarantine efforts.

The FMD epidemic was first reported in Nov 2010. More than 3.3 million animals -- primarily hogs -- were culled to keep the disease from spreading. The country began their first round of vaccinations in late December 2010, but the initial vaccinations were deemed unsuccessful as more cases continued to be reported and confirmed.

Judging by the fact that the FMD spread rapidly in heavily controlled areas while they were quarantined, there is great possibility that the disease was boosted by this winter's cold snap and strong winds, transmitting pathogens via air, said the Icheon municipality.

South Korea announced in January 2011 that 60,000 tons of imported frozen pork would be temporarily duty-free. Following the continued spread of the FMD outbreak, officials nearly doubled the quota for duty-free pork imports. Officials increased the quota by 50,000 tons to 110,000 tons. According to Bloomberg, South Korean pork imports are expected to jump by as much as 20% in 2011. The country imported roughly 180,000 metric tons of pork in 2010.
(ProMED 2/26/2011)

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Americas
Peru (Amazonas): Rabies transmitted by vampire bats
In Bagua, six children died because of rabies. The disease is transmitted through the bite of infected vampire bats. Rabies claimed its sixth victim in San Ramon and Yupicusa native communities, which are located in Imaza district, Bagua province, Amazonas region in Peru.

On Tuesday 15 February 2011, it was reported that 25 children from Yupicusa native community developed symptoms such as fever, muscle pain, seizures, cough, vomiting, loss of consciousness, and difficulty speaking, being all these symptoms compatible with a diagnosis of rabies.

Health authorities presume that there may be additional cases that have not been reported yet. Meanwhile, a team including physicians and biologists was sent to the affected area, and they are vaccinating every person reporting being bitten by a vampire bat. Simultaneously, they are sensitizing the population about how to protect themselves in order to prevent bites from vampire bats.

Dr. Orlando Caceres, Head of the Bagua-Amazonas health region, declares that this rabies outbreak has occurred because of lack of surveillance for epidemics in the area. No reports were made regarding children being bitten by vampire bats, which led to lack of health control for these young people, who were brought to the health centers when vaccines were not able to control the disease. There was also lack of training for health care personnel with respect to diseases endemic for the affected area, and there was lack of a good relationship with the Aguaruna people, the native community, so people bitten by bats did not go to health centers seeking care.

Mr. Roberto Guevara, local ombudsman for Amazonas, declared that in health centers located in the areas where native communities live there is no availability of rabies vaccines. Dr Cesar Velasquez, Regional Director of the Amazonas health region, justified this, stating that 75% of the budget assigned to his office is for paying salaries, and the 25% remaining is for purchasing medicines.
(ProMED 2/21/2011)

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USA: Measles outbreak, tens of thousands exposed?
Federal health officials are scrambling to prevent a massive measles outbreak after a young woman traveled through three airports the week of 21 February 2011 with an active case of the highly contagious measles virus. The 27-year-old woman, who tested positive for measles, departed the U.K. before traveling through airports in Washington, DC, Denver, and Albuquerque on 22 February 2011 exposing possibly tens of thousands of passengers to the disease.

Because measles is transmitted through the air, health experts say passengers who traveled on the same planes as the woman, or passed through the same airports could have been exposed. Measles is the most communicable virus that we know and it can be transmitted not just person to person, but over considerable distances because it wafts in the air and then people can inhale it when they are some distance away, Schaffner said. While the Centers for Disease Control and Prevention (CDC) is trying to tracking down the passengers, airport officials are doing the same with employees.

In the U.S., only about 60 cases of measles are reported to the CDC each year. Health officials say children who never received an immunization or adults who declined to be immunized are at greatest risk. It's a potentially devastating illness, Schaffner said. It still kills many children worldwide, so this is not a disease which we wish to reintroduce into the United States.

Measles can take 18 days to develop, so it may be a while before the scope of the exposure is fully recognizable. The CDC says the woman who tested positive had not been immunized because of her religious beliefs.
(ProMED 3/1/2011)

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USA (Arizona): Measles case in Maricopa County
If you're behind on your kid's vaccinations, health officials say now is a good time to get caught up. There is a confirmed case of measles in Maricopa County, and several cases in Pima County.

A man living in Maricopa County who recently traveled abroad has a confirmed case of the measles. Symptoms of measles include head-to-toe red spots on the body, red eyes, and coughing or a cold. It's a very contagious virus. Health officials say the man spent time in public places around town before finding out, and they're worried others may be exposed.
(ProMED 2/26/2011)

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USA (New Mexico): Department of Health investigating measles case
The New Mexico Department of Health announced on 25 February 2011 that it is investigating a case of measles in Santa Fe County. The Department's Scientific Laboratory Division confirmed the case in a 27-year-old woman who was not immunized against the disease and had recently returned from a trip overseas. The person is currently hospitalized. This is the first confirmed measles case in New Mexico since 2008.

The Department of Health has identified the following airline flight the person was on while contagious: Southwest Airlines flight 2605 scheduled departure from Denver at 9:55pm and arriving at Albuquerque Sunport at approximately 11:10pm on 22 February 2011. Passengers are considered protected from measles infection if they were born before 1957, had measles in the past, or have received two doses of measles vaccine.
(ProMED 2/26/2011)

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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
The number of cases of Ross River virus has increased in Australia. The highest number of cases of this mosquito-borne virus disease has been reported from the South West, the Peel region. More than 150 cases of the virus have been confirmed from Perth metropolitan area.

The health department says that high tides have resulted in an increase in the number of salt marsh mosquitoes which carry Ross River virus. It has warned the residents and holidaymakers to protect themselves against the disease by avoiding mosquito bites.

From every region of the country, an increase in the number of cases has been seen. The number of cases has almost doubled in Western Australia as compared to the cases reported in 2010. Nearly 408 cases have been reported from this state since August 2010. More than 160 cases were confirmed from the South West, which shows that the figure has increased by 82 as compared to 2010.
(ProMED 3/2/2011)


Australia (Victoria)
Health authorities have warmed Geelong residents to avoid mosquito bites after a dramatic increase in cases of Ross River fever virus infections. There have been 15 cases of Ross River fever reported to the health department in the Barwon south western region so far in 2011, the same number as was reported for the whole of 2010.

Barwon Health department of infectious diseases associate professor Eugene Athan on 14 February 2011 warned that Geelong residents could expect more mosquito-borne viruses such as Ross River fever and dengue fever. We actually don't see much Ross River virus in Victoria. It's fairly common in northern New South Wales and Queensland. So this is a genuine phenomenon and it's related to heavy rains and an increased mosquito population.
(ProMED 2/21/2011)


Australia (Victoria)
Health authorities are urging Victorians to protect themselves against mosquito bites because of fears the insects are carrying a life-threatening virus that has not been diagnosed in a Victorian for 37 years. Victoria's chief health officer Dr, John Carnie said on 22 February 2011 that sentinel chickens in the state's north, which are designed to alert health authorities to emerging mosquito-borne diseases, had tested positive for Murray Valley encephalitis (MVE) virus.

It is the second time the virus has been detected in the chickens, which were strategically placed across the state after an outbreak of the rare disease hit Victoria in 1974. No human cases have been noted in Victoria since the 1974 epidemic. Dr. Carnie said chickens were diagnosed with the virus the week of 21 February 2011 in Mildura, Robinvale, Kerang, Barmah, and Tooleybuc across the border in New South Wales near Swan Hill.

He said although the virus had not been detected in a human, Victorians living along the Murray River should avoid being bitten by mosquitoes. He said when outdoors people should wear long,loose-fitting clothes, and use insect repellent containing picaridin or DEET and ensure door and window screens were in good repair.

Dr. Carnie said people with symptoms of the virus, which include severe headache, high fever, drowsiness, tremor, and seizures, should seek urgent medical attention. While some people with MVE experience no or few symptoms, a small proportion will develop a severe viral brain infection that can kill them or result in permanent brain damage.

[ProMED note: Recent heavy rains and flooding in Victoria, especially along the Murray River have doubtless created a significant increase in mosquito breeding habitats. MVE virus is transmitted by the common banded mosquito Culex annulirostris, which bites after sundown in the first two hours of the night. It is found throughout Australia. Avoidance of mosquito bites it the only practical measure for prevention of MVE virus infection. There is no commercially available vaccine.]
(ProMED 2/23/2011)


Australia (North Queensland)
A total of 31 people have been diagnosed with type-2 dengue virus infections at East Innisfail, south of Cairns, and another eight have type-4 dengue virus infections. Queensland Health says the outbreak has so far managed to stay contained to East Innisfail.
(ProMED 2/28/2011)


Indonesia (Jakarta)
Intensified activities of the mosquito-nest eradication program (PSN) run by Jakarta capital city government together with the community have been proved effective to reduce the number of dengue fever cases to only 877 cases in January 2011 compared to the same period of 2010, reaching 1,486 cases. Meanwhile, as of 16 February 2011, 75 cases were recorded, far lower than 1,815 cases in February in 2010.
(ProMED 2/22/2011)


Peru (Piura)
Up to 18 February 2011, there are 16 confirmed dengue cases, that is to say that the disease advances, but we are certain that it will not become epidemic, stated the Director of Epidemiology, Ciro Garcia, on 17 February 2011.
(ProMED 2/22/2011)

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CHOLERA, DIARRHEA, and DYSENTERY
Papua New Guinea
Papua New Guinea's top health official says nearly 500 people have died from the country's prolonged cholera outbreak. The health secretary, Dr. Clement Malau said that 483 people have died while more than 10,000 have been diagnosed with cholera since the first outbreak in August 2009 in Morobe Province.

So far, seven regions, including the capital Port Moresby, have been affected by cholera with Dr. Malau saying Western Province was the worst hit with 300 deaths.
(ProMED 2/22/2011)


Papua New Guinea
In Papua New Guinea, cholera has raised its ugly head once more in Morobe Province, with 19 cases reported to the health authorities in the province since 23 January 2011. A lone case was reported from Mandok Island in Siassi district while 18 cases were reported in Lae city.

Morobe Province's health adviser and chairman of the cholera task force, Dr. Likei Theo said 12 patients with signs of cholera were admitted to the cholera treatment centre at Angau Memorial Hospital with no deaths. Dr. Theo said the cases are not confined to one specific location but all over the city and most of these areas are settlements.

He said that Morobe Province was in dry season now and the lack of access to clean drinking water in the settlement areas and the return of cooked food being sold in open-air markets and roadsides posed a very high risk. He said poor personal and environmental hygiene was also contributing to cholera re-emerging. He warned all city residents and people in Morobe Province that cholera has never left the province. He said it was now one of the illnesses we had to contend with in our daily lives from now on.

[ProMED note: Although cholera outbreaks are often linked to rainy seasons with flooding, it is also clear, as this posting states, that drought also can be linked to cholera as less potable water is ingested.]
(ProMED 2/22/2011)

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4. Articles
Effects of vaccination and population structure on influenza epidemic spread in the presence of two circulating strains
Alexander ME, Kobes R. BMC Public Health. 25 February 2011; 11(Suppl 1):S8 doi:10.1186/1471-2458-11-S1-S8.
Available at http://www.biomedcentral.com/1471-2458/11/S1/S8

Background. Human influenza is characterized by seasonal epidemics, caused by rapid viral adaptation to population immunity. Vaccination against influenza must be updated annually, following surveillance of newly appearing viral strains. During an influenza season, several strains may be co-circulating, which will influence their individual evolution; furthermore, selective forces acting on the strains will be mediated by the transmission dynamics in the population. Clearly, viral evolution and public health policy are strongly interconnected. Understanding population-level dynamics of coexisting viral influenza infections, would be of great benefit in designing vaccination strategies.

Methods. We use a Markov network to extend a previous homogeneous model of two co-circulating influenza viral strains by including vaccination (either prior to or during an outbreak), age structure, and heterogeneity of the contact network. We explore the effects of changes in vaccination rate, cross-immunity, and delay in appearance of the second strain, on the size and timing of infection peaks, attack rates, and disease-induced mortality rate; and compare the outcomes of the network and corresponding homogeneous models.

Results. Pre-vaccination is more effective than vaccination during an outbreak, resulting in lower attack rates for the first strain but higher attack rates for the second strain, until a “threshold” vaccination level of ~30-40% is reached, after which attack rates due to both strains sharply dropped. A small increase in mortality was found for increasing pre-vaccination coverage below about 40%, due to increasing numbers of strain 2 infections. The amount of cross-immunity present determines whether a second wave of infection will occur. Some significant differences were found between the homogeneous and network models, including timing and height of peak infection(s).

Conclusions. Contact and age structure significantly influence the propagation of disease in the population. The present model explores only qualitative behaviour, based on parameters derived for homogeneous influenza models, but may be used for realistic populations through statistical estimates of inter-age contact patterns. This could have significant implications for vaccination strategies in realistic models of populations in which more than one strain is circulating.

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Protecting the Public from H1N1 through Points of Dispensing (PODs)
Rinchiuso-Hasselmann A, McKay RL, Williams CA, et al. Biosecurity and Biotenrrorism: Biodefense Strategy, Practice, and Science. 1 March 2011. doi:10.1089/bsp.2010.0049.
Available at http://www.liebertonline.com/doi/abs/10.1089/bsp.2010.0049

Background. In fall 2009, the New York City Department of Health and Mental Hygiene (DOHMH) operated 58 points of dispensing (PODs) over 5 weekends to provide influenza A (H1N1) 2009 monovalent vaccination to New Yorkers. Up to 7 sites were opened each day across the 5 boroughs, with almost 50,000 New Yorkers being vaccinated. The policies and protocols used were based on those developed for New York City's POD Plan, the cornerstone of the city's mass prophylaxis planning. Before the H1N1 experience, NYC had not opened more than 5 PODs simultaneously and had only experienced the higher patient volume seen with the H1N1 PODs on 1 prior occasion. Therefore, DOHMH identified factors that contributed to the success of POD operations, as well as areas for improvement to inform future mass prophylaxis planning and response. Though this was a relatively small-scale, preplanned operation, during which a maximum of 7 PODs were operated on a given day, the findings have implications for larger-scale mass prophylaxis planning for emergencies.

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Safety of influenza A (H1N1) vaccine in postmarketing surveillance in China
Liang XF, Li L, Liu DW, et al. N Engl J Med. 17 February 2011;364(7):638-47.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21288090

Background. On September 21, 2009, China began administering vaccines, obtained from 10 different manufacturers, against 2009 pandemic influenza A (H1N1) virus infection in priority populations. We aimed to assess the safety of this vaccination program.

Methods. We designed a plan for passive surveillance for adverse events after immunization with the influenza A (H1N1) vaccine. Physicians or vaccination providers were required to report the numbers of vaccinees and all adverse events to their local Center for Disease Control and Prevention (CDC), which then reported the data to the Chinese CDC through the online National Immunization Information System's National Adverse Event Following Immunization Surveillance System. Data were collected through March 21, 2010, and were verified and analyzed by the Chinese CDC.

Results. A total of 89.6 million doses of vaccine were administered from September 21, 2009, through March 21, 2010, and 8067 vaccinees reported having an adverse event, for a rate of 90.0 per 1 million doses. The age-specific rates of adverse events ranged from 31.4 per 1 million doses among persons 60 years of age or older to 130.6 per 1 million doses among persons 9 years of age or younger, and the manufacturer-specific rates ranged from 4.6 to 185.4 per 1 million doses. A total of 6552 of the 8067 adverse events (81.2%; rate, 73.1 per 1 million doses) were verified as vaccine reactions; 1083 of the 8067 (13.4%; rate, 12.1 per 1 million doses) were rare and more serious (vs. common, minor events), most of which (1050) were allergic reactions. Eleven cases of the Guillain-Barré syndrome were reported, for a rate of 0.1 per 1 million doses, which is lower than the background rate in China.

Conclusion. No pattern of adverse events that would be of concern was observed after the administration of influenza A (H1N1) vaccine, nor was there evidence of an increased risk of the Guillain-Barré syndrome.

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Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate
Ottenberg AL, Wu JY, Poland GA, et al. Am J Public Health. 2011 February; 101(2):212-6.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21228284

Abstract. Despite improvements in clinician education, symptom awareness, and respiratory precautions, influenza vaccination rates for health care workers have remained unacceptably low for more than three decades, adversely affecting patient safety. When public health is jeopardized, and a safe, low-cost, and effective method to achieve patient safety exists, health care organizations and public health authorities have a responsibility to take action and change the status quo. Mandatory influenza vaccination for health care workers is supported not only by scientific data but also by ethical principles and legal precedent. The recent influenza pandemic provides an opportunity for policymakers to reconsider the benefits of mandating influenza vaccination for health care workers, including building public trust, enhancing patient safety, and strengthening the health care workforce.

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Evaluating Research and Impact: A Bibliometric Analysis of Research by the NIH/NIAID HIV/AIDS Clinical Trials Networks
Rosas SR, Kagan JM, Schouten JT, et al. PLoS ONE. 4 March 2011;6(3):e17428.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21394198

Abstract. Abstract. Evaluative bibliometrics uses advanced techniques to assess the impact of scholarly work in the context of other scientific work and usually compares the relative scientific contributions of research groups or institutions. Using publications from the National Institute of Allergy and Infectious Diseases (NIAID) HIV/AIDS extramural clinical trials networks, we assessed the presence, performance, and impact of papers published in 2006-2008. Through this approach, we sought to expand traditional bibliometric analyses beyond citation counts to include normative comparisons across journals and fields, visualization of co-authorship across the networks, and assess the inclusion of publications in reviews and syntheses. Specifically, we examined the research output of the networks in terms of the a) presence of papers in the scientific journal hierarchy ranked on the basis of journal influence measures, b) performance of publications on traditional bibliometric measures, and c) impact of publications in comparisons with similar publications worldwide, adjusted for journals and fields. We also examined collaboration and interdisciplinarity across the initiative, through network analysis and modeling of co-authorship patterns. Finally, we explored the uptake of network produced publications in research reviews and syntheses. Overall, the results suggest the networks are producing highly recognized work, engaging in extensive interdisciplinary collaborations, and having an impact across several areas of HIV-related science. The strengths and limitations of the approach for evaluation and monitoring research initiatives are discussed.

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Racial disparities in exposure, susceptibility, and access to health care in the US H1N1 influenza pandemic
Quinn SC, Kumar S, Freimuth VS, et al. Am J Public Health. February 2011; 101(2):285-93. Epub 16 December 2010.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21164098

Objectives. We conducted the first empirical examination of disparities in H1N1 exposure, susceptibility to H1N1 complications, and access to health care during the H1N1 influenza pandemic.

Methods. We conducted a nationally representative survey among a sample drawn from more than 60,000 US households. We analyzed responses from 1479 adults, including significant numbers of Blacks and Hispanics. The survey asked respondents about their ability to impose social distance in response to public health recommendations, their chronic health conditions, and their access to health care.

Results. Risk of exposure to H1N1 was significantly related to race and ethnicity. Spanish-speaking Hispanics were at greatest risk of exposure but were less susceptible to complications from H1N1. Disparities in access to health care remained significant for Spanish-speaking Hispanics after controlling for other demographic factors. We used measures based on prevalence of chronic conditions to determine that Blacks were the most susceptible to complications from H1N1.

Conclusion. We found significant race/ethnicity-related disparities in potential risk from H1N1 flu. Disparities in the risks of exposure, susceptibility (particularly to severe disease), and access to health care may interact to exacerbate existing health inequalities and contribute to increased morbidity and mortality in these populations.

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Public perceptions of the transmission of pandemic influenza A/H1N1 2009 from pigs and pork products in Australia
Dhand NK, Hernandez-Jover M, Taylor M, et al. Prev Vet Med. 1 February 2011; 98(2-3):165-75. Epub 13 December 2010.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21146879

Abstract. A cross-sectional study was conducted at the height of the pandemic influenza H1N1/09 outbreak in Australia in 2009. The objectives of the study were to evaluate public perceptions about transmission and prevention of the disease, to understand their concerns and preparedness to cope with the disease, and to investigate drivers influencing their behaviour. A questionnaire was designed and administered to 510 customers visiting 15 butcher shops in the Greater Sydney region between 26th June and 2nd August 2009. Data were analysed to estimate the proportion of people with certain perceptions and to evaluate the influence of these perceptions on two binary outcome variables: (1) whether or not people believed that avoiding pork would protect them from contracting H1N1/09, and (2) whether or not they actually made some changes to pork consumption after the outbreak. A majority of the respondents had perceptions based on fact about transmission and prevention of H1N1/09. As many as 96.8% of the respondents believed that washing their hands frequently was likely to protect them from contracting H1N1/09. Similarly, most believed that they could contract H1N1/09 by travelling on public transport with a sick person present (94.1%), by shaking hands with a sick person (89.2%), or by attending a community gathering (73.7%). Women were more likely than men to have factual perceptions about protective behaviours. Misconceptions regarding transmission of the disease were evident, with 21.7% believing that avoiding eating pork could protect them against H1N1/09, 11.1% believing that they could contract H1N1/09 by drinking tap water, 22.8% by handling uncooked pork meat and 15.6% by eating cooked pork. Approximately one third of respondents believed that working in a pig farm or an abattoir increased their likelihood of contracting H1N1/09 (36.9% and 32.3%, respectively). Younger people (<35 years old) were more likely to have these misconceptions than older people. Reduction in consumption of pork, ham or bacon was significantly associated with misconceptions regarding the risk of contracting H1N1/09 from eating pig meat products. It is recommended that in the event of a future disease emergency, communication activities providing factual information and targeting younger people should be used.

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5. Notifications
APEC Senior Officials Meeting I and Related Meetings
Washington DC, USA, 27 February to 12 March 2011
The Health Working Group Meetings will be held on 6-7 March, 2011.

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Global Health Metrics & Evaluation: Controversies, Innovation, Accountability
Seattle, Washington, USA, 14-16 March 2011
GHME aims to gather different disciplines involved in health measurement and evaluation to share innovative tools and methods to get a better understanding of what the possibilities are in approaching population health measurement.
Additional information at http://ghme.org

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Communicable Disease Control Conference
Canberra, ACT, Australia, 4-6 April 2011
The Communicable Disease Control Conference aims to promote evidence-based discussions on the theme: Science and Public Health meeting the challenges of a new decade.
Additional information at http://www.phaa.net.au/2011CommunicableDiseaseConference.php

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 apecein@u.washington.edu