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Vol. XIV No. 7 ~ EINet News Briefs ~ Apr 01, 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: H5N1 avian influenza outbreaks reported in Indonesia, Japan, and Bangladesh
- Global: Indonesia, Vietnam get H5N1 influenza prevention boost
- Global: Vietnam, Bangladesh report H5N1 influenza outbreaks
- Indonesia: H5N1 influenza killed mother of latest case-patient
- Japan: Influenza complicates operations at Japan's evacuation centers
- Myanmar: H5N1 avian influenza hits farm
- Canada: Finalizes backup plan for pandemic, seasonal influenza vaccine
- USA: Awards contract for long-acting influenza antiviral
- USA: Delaware reports three Tamiflu-resistant H1N1 influenza cases
- USA: H7N3 found on Missouri turkey farm
- USA: 2009 H1N1 virus infected three animals at San Diego Zoo
- Venezuela: Reports rise in 2009 H1N1 influenza infections
- Egypt: Reports three H5N1 influenza infections, one fatal

2. Infectious Disease News
- Australia: Measles may have spread at shops
- Chinese Taipei: Hog farm confirms foot-and-mouth disease
- Philippines: DOH buoys measles advocacy with new confirmed cases
- Philippines: DOH confirms increase in measles cases
- Russia: An occurrence of foot and mouth disease in domestic livestock
- Chile: Imported case of measles
- Chile (Maule): Confirmed case of Hantavirus infection
- Chile (Valdivia): Confirmed death of Hantavirus infection in Los Rios
- USA (California): Measles exposure alert in San Diego County
- USA: Measles outbreak
- USA: Superbug found in California hospitals

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- VECTOR-BORNE DISEASE

4. Articles
- Should Remaining Stockpiles of Smallpox Virus (Variola) Be Destroyed?
- Highly Pathogenic Avian Influenza Virus Infection in Feral Raccoons, Japan
- Telephone survey assessment of household patterns of influenza vaccination, Twin Cities seven county metro area, 2008–2009
- Adaptive human behavior in epidemiological models
- Hepatitis E virus infection in developed countries
- The incubation period distribution of tuberculosis estimated with a molecular epidemiological approach
- A dynamic model for tuberculosis transmission and optimal treatment strategies in South Korea
- Biological and cultural coevolution and emerging infectious disease: Ross River virus in Australia

5. Notifications
- Communicable Disease Control Conference
- ISID-Neglected Tropical Diseases Meeting
- 5th Ditan International Conference on Infectious Diseases


1. Influenza News

Global
2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 1 (0)
Cambodia / 3 (3)
Egypt / 14 (5)
Indonesia / 4 (3)
Total / 22 (11)

***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: 538 (317) (WHO 3/29/2011)
http://www.who.int/csr/disease/avian_influenza/country/cases_table_2011_03_29/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: H5N1 avian influenza outbreaks reported in Indonesia, Japan, and Bangladesh
Indonesian officials have reported recent avian flu outbreaks affecting three districts on the resort island of Bali as well as in Bengkulu province on the island of Sumatra. On 23 March 2011 Bali's animal husbandry office confirmed that at least 85 chickens have died of avian flu in February and March in Badung, North Denpasar, and Tabanan districts, all tourism areas. The virus strain was not specified. And on 22 March 2011, it was reported that 1,881 chickens tested positive as of 8 March 2011 for H5N1 avian flu in Bengkulu province, with most cases—1,175 fatal ones—recorded in the province's Seluma district.

Meanwhile, Japanese officials have confirmed two outbreaks near Chiba city in Chiba prefecture that led to the culling of nearly 100,000 poultry after 96 chickens died from highly pathogenic H5N1, the World Organization for Animal Health (OIE) reported on 23 March 2011. The first outbreak began 13 March 2011 and affected two chickens, leading to the culling of 34,998 birds. The second outbreak began 16 March 2011 at a separate farm, killing 94 chickens and necessitating the culling of 61,918 poultry.

And in Bangladesh, about 30,000 chickens and 50,000 eggs were destroyed at a farm in Gazipur district after samples from dead birds tested positive for an unspecified avian flu strain. A regional livestock officer said poultry had started dying 19 March 2011, and the order to cull the rest of the flock came 23 March 2011 after confirmation of the disease from a laboratory in Dhaka.
(CIDRAP 3/23/2011)

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Global: Indonesia, Vietnam get H5N1 influenza prevention boost
New funds will bolster the fight against H5N1 avian influenza in Indonesia and Vietnam, two countries where the virus is endemic in poultry. In Indonesia, a $22 million, four-year disease control project is being funded by Australia, reported 28 March 2011. Dr. Andy Carroll, Australia's chief veterinary officer, said the goal is to increase the response capacity of Indonesia's veterinary services. He said Australian officials are also organizing a conference bringing medical and animal health experts together to discuss better ways to battle zoonotic diseases, including avian influenza.

Meanwhile, Vietnam's government has approved a $25 million project to continue an H5N1 prevention project that has been in place since 2007, reported on 23 March 2011. The project will be funded by the government and a loan from the World Bank. Vietnam's agriculture ministry said the new investments will help contain poultry outbreaks, detect the disease in animals and humans, and prepare response activities.

In other H5N1 developments, South Korean agriculture officials reported on 28 March 2011 that the virus struck chickens at a commercial farm in Northern Gyeongsang province in the eastern part of the country, according to the World Organization for Animal Health (OIE). The outbreak began 22 March 2011, killing 520 birds. About 17,480 poultry at the facility and within a 500-meter radius of the farm were culled to control the outbreak.
(CIDRAP 3/28/2011)

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Global: Vietnam, Bangladesh report H5N1 influenza outbreaks
Vietnam's agriculture ministry described on 30 March 2011 eight H5N1 avian influenza outbreaks that occurred during the first part of March. Outbreaks occurred in six provinces, mainly in northern and central Vietnam. All but one of them were in villages. In total, the outbreaks killed 5,147 birds, and 6,140 more were culled to stop the virus from spreading. In Bangladesh, officials reported two more H5N1 outbreaks, which occurred at poultry farms in two different cities in Rangpur division's Dinajpur district in the northwestern part of the country, reported 30 March 2011. Outbreak response operations included the culling of 7,866 birds and destruction of 512 eggs.
(CIDRAP 3/30/2011)

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Asia
Indonesia: H5N1 influenza killed mother of latest case-patient
The World Health Organization (WHO) reported 25 March 2011 new details about an Indonesian toddler who is recovering from H5N1 avian flu, including that her mother died from the virus a day before the girl got sick.

On 25 March 2011, WHO said the two-year-old girl from Bekasi City in West Java province became ill on 2 March 2011, was admitted to a healthcare facility 3 March 2011, and was referred to a hospital on 9 March 2011. She has fully recovered from her H5N1 infection, according to the WHO. Confirmation of her illness raises Indonesia's H5N1 case total to 175, of which 144 were fatal.

The WHO said that the girl's mother is the case-patient described in its 14 March 2011 statement. The 31-year-old woman, from Bekasi City, West Java province, got sick on 23 February 2011 and died on 1 March 2011 after in-patient treatment at a private clinic and a hospital where she received oseltamivir (Tamiflu).

The girl accompanied her mother to a traditional market that sold live poultry, but investigators are still exploring the source of the two infections. The Indonesia's health ministry said earlier that ornamental birds were reared in the girl's neighborhood and that some had recently tested positive for the H5N1 virus.

So far in 2011 Indonesia has reported four H5N1 cases, of which three were fatal, according to WHO records. Indonesia is among a handful of countries where the virus is endemic, and local media have recently reported several H5N1 outbreaks in the country, including a recent one on the island of Bali.
(CIDRAP 3/25/2011)

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Japan: Influenza complicates operations at Japan's evacuation centers
Influenza is spreading in some of Japan's 383 local earthquake evacuation centers, reported on 26 March 2011. Healthcare teams sent to deliver flu medication are having a difficult time reaching some of the centers in Iwate prefecture because of transportation problems. Naoto Wakuishi, a prefecture spokesman, said that evacuees who are sick with flu are being separated from others in the centers to limit the spread of the virus. He added that the centers are also experiencing shortages of sanitary goods, clothes, and bathing facilities.
(CIDRAP 3/28/2011)

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Myanmar: H5N1 avian influenza hits farm
H5N1 avian flu struck a poultry farm in Myanmar, killing 350 chickens within four days, the World Organization for Animal Health (OIE) reported 23 March 2011. The outbreak occurred at a layer chicken operation in Sagaing state, located in central Myanmar. The farm's remaining 430 birds were culled to control the spread of the virus. The outbreak, which started 16 March 2011, is Myanmar's tenth since the virus surfaced in January after a ten-month lull.
(CIDRAP 3/24/2011)

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Americas
Canada: Finalizes backup plan for pandemic, seasonal influenza vaccine
Canada's government has forged agreements with two vaccine companies to provide it with backup supplies of pandemic and seasonal flu vaccine, reported 25 March 2011. The agreements are designed to supplement flu vaccine made by GlaxoSmithKline, which for the past several years has been Canada's sole flu vaccine supplier. Canada's contract with Glaxo was designed to provide the company with a reliable, domestic-based source of flu vaccine, but problems the company and others had producing the 2009 H1N1 vaccine delayed its rollout in Canada and led to shortages. The government's three-year contract with Sanofi Pasteur is for a backup supply of pandemic vaccine for vulnerable groups, and its contract with Novartis is for extra seasonal flu vaccine when needed.
(CIDRAP 3/25/2011)

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USA: Awards contract for long-acting influenza antiviral
The US government announced 31 March 2011 the award of a $231 million, five-year contract to an Australian company for advanced development of a single-dose, long-acting influenza drug in the neuraminidase inhibitor class. The contract was awarded to Biota Scientific Management Pty, Ltd., of Melbourne, according to the Biomedical Advanced Research and Development Authority (BARDA), part of the Department of Health and Human Services.

The drug, CS-8958, is already licensed in Japan as Inavir, known generically as laninamivir. BARDA said the antiviral requires only one dose for full treatment, as compared with five days of twice-daily dosing for oseltamivir and zanamivir. Like zanamivir, it is delivered with a powder inhaler.

The ability to treat influenza by delivering a single dose of medicine would provide real advantages to doctors and patients during an emergency and would be an important addition to our pandemic influenza arsenal, BARDA Director Dr. Robin Robinson commented.

The contract calls for Biota to establish US manufacturing, optimize its manufacturing processes, and conduct clinical trials of the drug in adults and children, BARDA said. The trials would be in preparation for applying for US licensing of the drug. The contract is fully funded over an estimated five-year period and is contingent on the delivery of key milestones throughout the period, Biota Holdings Ltd., parent company of Biota Scientific, said.

In August 2009, Biota reported that laninamivir compared well with oseltamivir in a phase three trial in adults. The trial, conducted in Japan, Korea, Taiwan, and Hong Kong, showed that a single dose of the new antiviral was as effective as oseltamivir given twice a day for five days, the company said. The drug was approved in Japan in September 2010. It is marketed there by Daiichi Sankyo Co. Ltd.
(CIDRAP 3/31/2011)

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USA: Delaware reports three Tamiflu-resistant H1N1 influenza cases
Delaware health officials reported on 23 March 2011 three recent infections with 2009 H1N1 influenza viruses resistant to oseltamivir (Tamiflu). The cases were in an 1-month-old girl and a 33-year-old woman from Kent County and a 3-year-old boy from Sussex County, the Delaware Division of Public Health reported. All the patients recovered without hospitalization, and there were no connections between them, division officials said. The state had identified one other case earlier in the season, officials said. Noting that oseltamivir-resistant H1N1 cases are rare, officials said there is no need to change treatment approaches. Nationally, the Centers for Disease Control and Prevention (CDC) has found three oseltamivir-resistant H1N1 isolates among 533 tested this season, according to the agency's latest flu surveillance update, released 18 March 2011.
(CIDRAP 3/24/2011)

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USA: H7N3 found on Missouri turkey farm
Routine pre-slaughter testing has identified H7N3 avian influenza at a commercial turkey farm in Missouri, the World Organization for Animal Health (OIE) reported on 30 March 2011. Located in Polk County, the turkey operation had 14,000 19-week-old turkeys in one barn and 16,000 five-week-old birds in another. Testing was conducted as part of the National Poultry Improvement Plan's Avian Influenza Clean Program. The birds did now show any signs of disease. An investigation has not found the source of the virus. The findings prompted Missouri to implement its H5/H7 response and containment plan, including a quarantine of the farm, but the report did not mention culling. Polk County is in south-central Missouri, not far from Springfield. The United States' last low-pathogenic avian influenza outbreak occurred in August 2009, when the H7N9 virus turned up on a turkey farm in Meeker County, Minnesota.
(CIDRAP 3/30/2011)

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USA: 2009 H1N1 virus infected three animals at San Diego Zoo
The 2009 H1N1 influenza virus was detected in three animals of diverse species at the San Diego Zoo in the fall of 2009, further broadening the virus's range of animal hosts. The virus was found in a 12-year-old American badger, a 19-year-old Bornean binturong, and a 7-year-old black-footed ferret. The badger and binturong got severely sick with pneumonia and had to be euthanized, but the ferret had a mild illness and recovered with antibiotic and fluid treatment. The source of the infections was not determined but was probably a human. Ferrets are known to be susceptible to influenza A viruses, but such cases have not been previously reported in badgers or binturongs. Other species that have been naturally infected with flu viruses include swine, a dog, cats, turkeys, skunks, cheetahs, and giant anteaters, and experimental infections have been reported in mice and cynomolgous macaques. The ubiquity of pandemic (H1N1) 2009 and its ability to infect a diverse range of hosts is worrisome for the health of wildlife and for the possibility of creating additional reservoirs that could alter the evolution of subtype H1N1 viruses by applying varied selection pressures and establishing new ways of generating unique reassortant strains.
(CIDRAP 3/22/2011)

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Venezuela: Reports rise in 2009 H1N1 influenza infections
Venezuelan health officials noted a spike in 2009 H1N1 infections, which is centered in the western state of Merida and is affecting seven other of the country's 23 states, reported on 23 March 2011. The government has closed Merida schools and limited large indoor gatherings in the state to slow the spread of the virus. Though schools are closed in Merida City, a study-abroad program in the city—where 27 students from US colleges are studying, including 16 from the University of Minnesota—remains open. The school's dean said he kept the school open because the students have a return flight on 3 May 2011 and need to complete their program. Venezuela's president Hugo Chavez said the country has two million doses of seasonal flu vaccine and that supplies have been sent to Merida, which began vaccinating people on 18 March 2011.
(CIDRAP 3/23/2011)

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Africa
Egypt: Reports three H5N1 influenza infections, one fatal
Egypt's health ministry has announced three more H5N1 avian influenza infections, including a 32-year-old man who died, the World Health Organization (WHO) reported on 29 March 2011. The three new illnesses and death push Egypt's H5N1 burden so far this year to 14 cases, which include five deaths. The WHO said investigations into all three illnesses suggest that the patients had been exposed to sick and dead poultry.

The man, from Suez governorate, got sick on 8 March 2011, was hospitalized on 12 Mar 2011 where he died on 13 March 2011, the WHO said. The other cases include a 28-year-old woman from Giza governorate who started having symptoms on 8 March 2011 and was hospitalized on 10 March 2011, where she is stable condition. The third patient is a 4-year-old boy from Beheira governorate who became ill on 5 March 2011 5 and was hospitalized on 7 March 2011. He was discharged on 12 March 2011 and has recovered.

Egypt's newly reported cases push the country's total number of H5N1 infections to 133, including 45 deaths. Though the country is still second to Indonesia in the total number of H5N1 cases, since 2009 it has led the world in WHO-confirmed H5N1 cases and since 2010 has led in H5N1 deaths.
(CIDRAP 3/29/2011)

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2. Infectious Disease News

Asia
Australia: Measles may have spread at shops
A second measles case has been confirmed on the Gold Coast, following the first outbreak at the end of February 2011. Queensland Health is urging anyone who was at the Westfield Helensvale shopping Centre from 10 to 18 March 2011 to be alert for symptoms after the confirmation of measles in a person working at the centre during this period. Gold Coast Public Health medical officer, Dr. Don Staines, said the person had no history of overseas or interstate travel, and no obvious link to the first case reported on the Gold Coast.
(ProMED 3/28/2011)

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Chinese Taipei: Hog farm confirms foot-and-mouth disease
Foot-and-mouth disease has broken out on a Taiwan hog farm, 14 years after an epidemic hit the island and shattered its pork exports, the Council of Agriculture said on 23 March 2011. Health workers on the Penghu Islands in the middle of the Taiwan Strait noticed the outbreak 22 March 2011 after 30 hogs on a pig farm developed blisters around their months, the council said. The council slaughtered 999 hogs on the farm overnight, disinfected surrounding areas and barred the movement of cloven-hoofed animals. The council also ordered Penghu's meat markets temporarily closed.

Hsu Tien-lai, director of the council's animal and plant health inspection and quarantine bureau, said foot-and-mouth disease could be caused by hogs shipped to Penghu from Taiwan proper. He said that he believed the outbreak would have no effect on Taiwan's pork exports because its shipments of fresh pork are small.

Taiwan has been on guard against foot-and-mouth disease after outbreaks occurred in recent months in Japan, North Korea and South Korea.

Foot-and-mouth disease broke out on Taiwan hog farms in March 1997, prompting Taiwan to cull 3.8 million swine. Taiwan's current production is 6.4 million head a year, mostly for domestic consumption.
(USAgNet 3/25/2011)

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Philippines: DOH buoys measles advocacy with new confirmed cases
The Department of Health 7 (DOH-7) has strengthened its campaign against measles, a communicable disease, as two new cases were confirmed in Central Visayas. The new cases brought to seven the number of measles cases in the region since January 2011. DOH-7 measles-rubella campaign point person Dr. Nayda Bautista said the two new cases came from two highly-urbanized cities in Cebu. Outbreaks have already been declared in the National Capital Region and in Regions four, nine, and eleven, Bautista revealed.

Bautista however, said the incidence of measles in the region has declined compared to 2010’s figure from January to mid-March where there were ten confirmed cases.

Due to the rising incidence of measles in some parts of the country, the DOH is undertaking a one-month-long measles house-to-house vaccination campaign for children less than eight years old. Bautista said they are targeting 1.4 million children to be vaccinated in the region. The total target nationwide is 14 million children. Measles vaccines for Cebu and Negros Oriental will arrive the week of 20 March 2011. A total of 140,000 vials have been allocated to Central Visayas. Although one to four year old children are the most vulnerable to develop measles, Bautista said measles does not spare adults.
(ProMED 3/22/2011)

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Philippines: DOH confirms increase in measles cases
The Department of Health (DOH-CAR) confirmed on 16 March 2011, that there is an increasing number of measles cases recorded not only in the Cordillera Administrative Region (CAR) but also in other parts of the country. According to DOH-CAR Regional Epidemiology and Surveillance Unit head, Dr. Nicolas Gordo, there were 476 recorded measles cases in the region in 2010, 81 of which were laboratory confirmed. Subsequent to this, 95 cases have also been recorded, where 15 were laboratory confirmed during the first eight weeks of 2011. Gordo said this may still increase as they are still awaiting the results of other tests they submitted for confirmation at the Research Institute for Tropical Medicine in Manila.
(ProMED 3/22/2011)

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Russia: An occurrence of foot and mouth disease in domestic livestock
On 21 March 2011, in the Trans-Baikal region, the State Veterinary Service received confirmation of an occurrence of foot and mouth disease in domestic livestock in the village of Ust-Imalk, which borders Mongolia and China. The village is currently being quarantined and additional restrictive measures are being prepared.

Ust-Imalke has approximately 1,500 cattle, 2,900 sheep and 75 pigs. Of these, less than 10% of the cattle, and 1 pig have been infected as of 23 March 2011. A re-vaccination campaign is currently underway in an effort to halt the outbreak. The preliminary suspected cause of the occurrence appears to be wild antelope migrating between Russia and Mongolia.
(HealthMap 3/23/2011)

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Americas
Chile: Imported case of measles
On 16 March 2011 the Institute of Public Health confirmed an imported case of measles in a ten-month-old infant. The Secretariat of Public Health has launched an immediate investigation to prevent spread of infection through the child's contacts. It has been established that the origin of the disease was through the mother, who previously had travelled to a country where the disease is present.

The last case of measles in Chile, also imported, was reported in 2009. It should be noted that since 1992 there has been no indigenous transmission in Chile.
(ProMED 3/22/2011)

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Chile (Maule): Confirmed case of Hantavirus infection
The Health SEREMI (Regional Ministerial Secretariat) issued information of the first case of a Hantavirus infection in Maule. The case is a 37-year-old agricultural worker from the Casa Blanca de Molina area. The man is in stable condition in the Curico Assistance Center and is progressing satisfactorily. This case of this young man was mild, as he did not present with a cardiopulmonary syndrome, so his recuperation has been rapid, explained the head of the Public Health Department of the Health SEREMI, Alex Silva.

Silva mentioned that the epidemiological situation for Hantavirus infections is, as of 19 March 2011, 12 reported confirmed cases in Chile, figures within the expected range for the spring-summer period. A campaign for Hantavirus infection prevention is being carried out since December 2010.
(ProMED 3/23/2011)

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Chile (Valdivia): Confirmed death of Hantavirus infection in Los Rios
On 26 March 2011, health authorities in the Los Rios Region confirmed the death of a second person caused by a Hantavirus infection. The victim was a 73-year-old man, an accomplished sportsman and Corral community municipal official who since 19 March 2011 was hospitalized in the intensive care unit of the Clinico Regional Hospital for a serious pulmonary condition. The death of the second affected individual was confirmed by the Director of Health Services of Valdivia, Marienela Caro, based on the samples sent to the Public Health Services and to the Hospital of the Universidad Catolica.

Thus, there are now a total of two fatal victims due to a Hantavirus infection, while another two people remain in stable condition with their serious situation, but progressing favorably despite their Hantavirus infection diagnosis.
(ProMED 3/27/2011)

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USA (California): Measles exposure alert in San Diego County
A 27-year-old Poway man became ill after traveling overseas. As a consequence people in Rancho Bernardo, Carmel Mountain Ranch, and Poway may have been exposed to measles recently, San Diego County's Health and Human Services agency announced 18 March 2011. According to the agency, a 27-year-old Poway man became ill after traveling to the Philippines and Thailand, and visited several local places, including the Radisson Suites Hotel Rancho Bernardo.

Measles is highly contagious and is spread easily by coughing, sneezing, or even coming in close contact with an infected person, county deputy public health officer Eric McDonald said. The individual visited several places during the time he was infectious. Anyone who was at those locations during the same time, and who develops a rash and fever should contact their medical provider by telephone and be evaluated for measles.
(ProMED 3/22/2011)

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USA: Measles outbreak
The Minnesota measles outbreak that began with an unvaccinated child who had traveled to Kenya has now grown to 11 confirmed cases. According to the Minnesota Department of Health, among the cases were four children who were too young to be vaccinated. Most of the others were unvaccinated too, although they were old enough to have gotten the MMR vaccine. Fear of a link between MMR and autism among many of the Somali immigrants who are affected by this measles outbreak in Minnesota is thought to account for low vaccine rates.

Although they aren't getting as much attention as the Minnesota outbreak, there are also other reports of measles cases in the USA:
- Two new measles cases in New York City that were diagnosed in residents that had traveled to Romania and India.
- Two new measles cases in Tennessee
- One measles case in California which involved a 27-year-old who got measles while traveling to the Philippines and Thailand

In addition to highlighting the importance of the MMR vaccine for children, these measles cases are a good reminder for everyone to make sure their immunizations are up-to-date before traveling out of the country. Fortunately, there have been no new measles cases in the measles outbreak in Boston and Clark County, Washington.
(ProMED 3/28/2011)

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USA: Superbug found in California hospitals
A deadly superbug, thought to be rare on the West Coast, is appearing in large numbers in Southern California. In seven months last year, there were 356 cases of carbapenem-resistant Klebsiella pneumonia (CRKP), according to the Los Angeles County Department of Health. The cases were in health care facilities such as hospitals and nursing homes. People outside such facilities were not affected.

CRKP has been officially reported in 36 states, but health officials expect it’s in the 14 other states as well, where reporting is not required.

Only one antibiotic, called Colistin, is effective against CRKP, and it doesn’t always work and can cause kidney damage, according Dr. Arjun Srinivasan, associate director for health care associated infection prevention programs at the Centers for Disease Control and Prevention.

It’s not known how many people died in L.A. County from the bacteria, but previous outbreaks have shown a 35% death rate. This is the first time CRKP has been studied in L.A. County and the infection rate was unexpectedly high, according to the Society for Healthcare Epidemiology of America. We do not know if the presence of CRKP in these long-term acute care settings is the result of improper care, or has more to do with the population they serve, says Dr. Dawn Terashita, a medical epidemiologist with L.A. County Department of Public Health. Patients with CRKP tend to be elderly, have multiple health problems, and have a catheter or are on a respirator– foreign objects that can become breeding grounds for bacteria.

Large outbreaks of CRKP have been documented in the United States, Greece, and Israel.

CRKP, and other infections in the same family, are a huge threat, precisely because of how resistant and how lethal it is, and how readily it can spread within health care facilities, says Dr. Mitchell Schwaber, director of Israel’s National Center for Infection Control.

Some hospitals have seen infection rates decline when they enforce staff hand washing rules, remove ventilators and catheters as quickly as possible, and take other precautions. Patients and their families can help decrease the risk of infection by asking staff to wash their hands and by following other Empowered Patient tips for staying safe in the hospital.
(CNN Health 3/28/2011)

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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)
Residents in South Australia (SA) areas populated by water birds and mosquitoes are at risk from a deadly tropical disease. Areas along the River Murray and Riverland region are understood to be the areas most at risk of Murray Valley encephalitis (MVE) virus infection, a disease virus passed to humans from mosquitoes.

A 47-year-old man from regional SA has been admitted to hospital with MVE virus infection -- the state's first case in more than 35 years. Authorities have also been notified of a 27-year-old man in a more serious condition suspected of having the virus. Both men are understood to be from the Riverland region.

SA Health believes the virus was passed on after mosquitoes bit water birds, such as pelicans, carrying the virus to the state from tropical areas. South Australia Health chief medical officer Professor Paddy Phillips said Adelaide and suburban areas were potentially at risk of infection, but said authorities were most concerned about regional areas along the Murray and the Riverland where large numbers of water birds and mosquitoes were located.

[ProMED note: The occurrence of this confirmed human MVE virus infection case occurred at the same time that the virus was detected in birds in this area of South Australia. The recent unusually heavy rains and flooding in the state have created breeding sites for mosquito vectors.]
(ProMED 3/31/2011)


Australia (Queensland)
Queensland Health has confirmed two cases of the mosquito-borne dengue disease in Mooroobool and Manunda, with test results pending for a further three people.
(ProMED 3/28/2011)


Australia (Cairns, Queensland)
Queensland Health has declared a dengue fever outbreak in Cairns, following confirmation of the mosquito borne disease in two suburbs. Queensland Health medical officer Steven Donohue said it was too early to say whether the cases were linked to two outbreaks in Innisfail, where 47 dengue virus type-2 cases and eight dengue virus type-4 cases have been diagnosed in 2011.
(ProMED 3/25/2011)


USA (Hawaii)
State health officials aren't calling it an outbreak but with at least four cases of dengue fever in the Pearl City area (Oahu) it's a warning for all to safeguard your home. These cases are a big concern for the health department and the state is taking precautions.

The four cases have been isolated to one Pearl City neighborhood. They involve three family members and a neighbor. All four became sick at the end of February 2011 and have since recovered. About 70 other people that live around them have been notified and some have taken blood tests to see if they too have the disease.

The reason we're concerned typically we get cases any time of year when someone comes back from Polynesia or Central America and they get exposed to dengue virus and they come home and get sick. In the case we have here these are people that have not traveled so it means someone that did travel brought the disease home and the exposure was here locally, by local mosquitoes, said Gary Gill, Hawaii Health Department deputy director.

The state is not expecting a widespread outbreak. The type of mosquito that carries the disease in Hawaii only travels about 100 yards and it has to bite an infected person then bite you in order to spread the disease. The state's vector control branch was hit by budget cuts. The department went from dozens of workers to just five. They stopped taking measures to prevent mosquitoes. The state won't say for sure if that caused these cases. The state is not sure how the disease was introduced in Oahu for these cases.
(ProMED 3/28/2011)

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4. Articles
Should Remaining Stockpiles of Smallpox Virus (Variola) Be Destroyed?
Weinstein, RS. Emerg Infect Dis. 18 March 2011; 17(4).doi: 10.3201/eid1704.101865.
Available at http://www.cdc.gov/eid/content/17/4/681.htm

Abstract. In 2011, the World Health Organization will recommend the fate of existing smallpox stockpiles, but circumstances have changed since the complete destruction of these cultures was first proposed. Recent studies suggest that variola and its experimental surrogate, vaccinia, have a remarkable ability to modify the human immune response through complex mechanisms that scientists are only just beginning to unravel. Further study that might require intact virus is essential. Moreover, modern science now has the capability to recreate smallpox or a smallpox-like organism in the laboratory in addition to the risk of nature re-creating it as it did once before. These factors strongly suggest that relegating smallpox to the autoclave of extinction would be ill advised.

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Highly Pathogenic Avian Influenza Virus Infection in Feral Raccoons, Japan
Maeda HT, Murakami S, Kiso M. Emerg Infect Dis. 25 March 2011;17(4). doi:10.3201/eid1704.101604.
Available at http://www.cdc.gov/eid/content/17/4/714.htm#cit

Abstract. Although raccoons (Procyon lotor) are susceptible to influenza viruses, highly pathogenic avian influenza virus (H5N1) infection in these animals has not been reported. We performed a serosurvey of apparently healthy feral raccoons in Japan and found specific antibodies to subtype H5N1 viruses. Feral raccoons may pose a risk to farms and public health.

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Telephone survey assessment of household patterns of influenza vaccination, Twin Cities seven county metro area, 2008–2009
Roblen MA, Lifson AR, Duval S. Vaccine. 29 March 2011. doi:10.1016/j.vaccine.2011.03.045.
Available at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-52GXY8C1&_user=10&_coverDate=03%2F29%2F2011&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=9ecb0ccfafb7021099f8d14391ce51f0&searchtype=a

Abstract. Major national surveys do not collect the influenza vaccination status of all household members, thus limiting current understanding of household influenza vaccination patterns. In an early 2009 telephone survey of 800 households in the metropolitan Minneapolis-St Paul area, household respondents reported the age, gender, and 2008–2009 seasonal influenza vaccination status of all household members. After poststratification to adjust for nonresponse, the full household influenza vaccination rate for multiperson households is 35.2%, partial household influenza vaccination rate is 39.9% and the rate of complete household nonvaccination is 24.9%. Full household influenza vaccination is more common in households with an elderly resident, intermediate in households with a child under 5 years of age, and less common in the remaining households. No household members are vaccinated in approximately 10% of multiperson households with either an elderly adult or young child; the corresponding rate in other households is 32.8%. An estimated 51.4% of households with children over 1 year of age have all children vaccinated against influenza; 43.5% of households with children had no children vaccinated against influenza. Households with younger children are more likely to have all children vaccinated and less likely to have no children vaccinated. We believe this is the first study to describe the prevalence of household influenza vaccination patterns. Continued efforts to monitor and increase household vaccination may be a valuable strategy to protect individuals and communities from influenza.

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Adaptive human behavior in epidemiological models
Fenichel EP, Castillo-Chavez C, Ceddia MG, Proc Natl Acad Sci USA. 2011 March 28. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21444809

Abstract. The science and management of infectious disease are entering a new stage. Increasingly public policy to manage epidemics focuses on motivating people, through social distancing policies, to alter their behavior to reduce contacts and reduce public disease risk. Person-to-person contacts drive human disease dynamics. People value such contacts and are willing to accept some disease risk to gain contact-related benefits. The cost-benefit trade-offs that shape contact behavior, and hence the course of epidemics, are often only implicitly incorporated in epidemiological models. This approach creates difficulty in parsing out the effects of adaptive behavior. We use an epidemiological-economic model of disease dynamics to explicitly model the trade-offs that drive person-to-person contact decisions. Results indicate that including adaptive human behavior significantly changes the predicted course of epidemics and that this inclusion has implications for parameter estimation and interpretation and for the development of social distancing policies. Acknowledging adaptive behavior requires a shift in thinking about epidemiological processes and parameters.

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Hepatitis E virus infection in developed countries
Miyamura T. Virus Res. 2011 March 25. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21443914

Abstract. Hepatitis E was considered to be endemic infectious disease in developing countries in tropical- or subtropical regions with poor sanitary conditions. Large, previously reported outbreaks were mainly due to contaminated water or heavy flooding. Prototype hepatitis E viruses of genotypes I and II were obtained from such endemic cases. In developed countries, in contrast, hepatitis E was rare and diagnosed only in travelers or imported cases. However, the development of accurate diagnostic tests, mainly PCR detection elucidated that autochthonous hepatitis E in developed countries is far more common than previously thought. Although the main route of transmission is food-borne, other routes including blood-borne have been suggested. Recent developments of gene-based diagnostic assays and molecular epidemiology have disclosed the significance of hepatitis E virus infection in developed countries.

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The incubation period distribution of tuberculosis estimated with a molecular epidemiological approach
Borgdorff MW, Sebek M, Geskus RB. Int J Epidmiol. 2011 March 26. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21441552

Background. There is limited information on the distribution of incubation periods of tuberculosis (TB).

Methods. In The Netherlands, patients whose Mycobacterium tuberculosis isolates have identical DNA fingerprints in the period 1993-2007 were interviewed to identify epidemiological links between cases. We determined the incubation period distribution in secondary cases. Survival analysis techniques were used to include secondary cases not yet symptomatic at diagnosis with weighting to adjust for lower capture probabilities of couples with longer time intervals between their diagnoses. In order to deal with missing data, we used multiple imputations.

Results. We identified 1095 epidemiologically linked secondary cases, attributed to 688 source cases with pulmonary TB. Of those developing disease within 15 years, the Kaplan-Meier probability to fall ill within 1 year was 45%, within 2 years 62% and within 5 years 83%. The incubation time was shorter in secondary cases who were men, young, those with extra-pulmonary TB and those not reporting previous TB or previous preventive therapy.

Conclusions. Molecular epidemiological analysis has allowed a more precise description of the incubation period of TB than was possible in previous studies, including the identification of risk factors for shorter incubation periods.

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A dynamic model for tuberculosis transmission and optimal treatment strategies in South Korea
Whang S, Choi S, Jung E. J Theor Biol. 2011 Mar 23. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21439972

Abstract. We have developed a dynamic model for tuberculosis (TB) transmission in South Korea using a SEIR model with the time-dependent parameters. South Korea ranked the highest TB incidence among members of the Organization for Economic Cooperation and Development (OECD) in 2005 yr. The observed data from the Korea Center for Disease Control and Prevention (KCDC) shows a certain rise of active-TB incidence individuals after 2001 yr. Because of this sudden jump, we have considered two different periods for best fitting the model: prior to 2001 yr and posterior to 2001 yr. The least-squares fitting has been used for estimating model parameters to the observed data of active-TB incidence. Our model agrees well with the observed data. In this work, we also propose optimal treatment strategies of TB model in South Korea for the future. We have considered three control mechanisms representing distancing, case finding and case holding efforts. Optimal control programs have been proposed in various scenarios, in order to minimize the number of exposed and infectious individuals and the cost of implementing the control treatment.

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Biological and cultural coevolution and emerging infectious disease: Ross River virus in Australia
Weinstein P, Judge D, Carver S. Med Hypotheses. 2011 Mar 22. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21435794

Abstract. Enhanced virulence of pathogens infecting host populations, with no previous exposure thereto, is characteristic of many diseases labelled "emerging" or "resurging". One cause of emergence characteristics can be interpreted as absence of co-evolutionary optimization of interactions between hosts and pathogens. We explore the historical and evolutionary development between Ross River virus (RRV) and its human host in Australia; a mosquito vectored pathogen causing polyarthritic symptoms. Epidemics of RRV have increased in frequency, size and range throughout European settlement. We hypothesise that human cultural evolution contributed to the emergence of RRV in humans, and argue that epidemics of RRV were unlikely to occur in Aboriginal hunter-gatherer societies in Australia's early human history, but only occur in more recent agrarian and industrial societies. A perspective of cultural evolution, in addition to biological evolution, may help with understanding the determinants of disease emergence and resurgence, and inform ongoing development of effective public health interventions.

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5. Notifications
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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ISID-Neglected Tropical Diseases Meeting
Boston, Massachusetts, USA, 8-10 July 2011
The ISID-NTD meeting will be a rare opportunity to meet and interact with colleagues from around the world who are working to end debilitating diseases that afflict the world's poorest people. Learn from world leaders in the fields of global health, tropical medicine, public policy and social research about what is happening, and what still needs to happen, to eliminate these neglected diseases.
Additional information at http://ntd.isid.org/

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5th Ditan International Conference on Infectious Diseases
Beijing, China, 14-17 July 2011
Ditan International Conference on Infectious Diseases is the annual conference holding in Beijing to provide platform for scientific exchange between Chinese and international experts. It is co-organized by Beijing Ditan Hospital, European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Global Chinese Association of Clinical Microbiology and Infectious Diseases (GCACMID).
Additional information at http://www.bjditan.org/

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 apecein@u.washington.edu