Vol. XIV No. 10 ~ EINet News Briefs ~ May 13, 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: WHO says influenza activity is pausing between seasons
- Global: Few influenza hot spots reported in the Americas
- Indonesia (West Jakarta): H5N1 avian influenza case confirmed
- USA: Influenza activity wanes further

2. Infectious Disease News
- Chinese Taipei: Serious case of encephalitis confirmed
- Chinese Taipei: Cases of rubella hit 12 year high
- Japan: Third person dies in food poisoning outbreak
- New Zealand (Auckland): Measles cases reported
- Russia: Yersinia pseudotuberculosis in Krasnoyarsk
- Canada (Quebec): Hit by measles outbreak
- Chile (Los Rios): New Hantavirus case detected
- Chile (Araucania): New victim of Hantavirus infection
- Chile (Santiago): First outbreak of measles in eight years prompts revaccination
- USA: On track for most measles cases in a decade
- USA (California): Health officials launch investigation into rabies case
- USA (Florida): Cholera oyster outbreak sickens eleven
- USA (Kansas): Two more measles cases in Johnson County
- USA (Montana): Woman dies of Hantavirus pulmonary syndrome
- USA (New Mexico): Man diagnosed with bubonic plague
- USA (Oregon): Three cases of whooping cough confirmed at school
- USA (Utah): Whooping cough outbreak in Cache County

3. Updates

4. Articles
- Clinical Study Concerning the Relationship between Community-Acquired Pneumonia and Viral Infection in Northern Thailand
- Emergency Department Visits for Antiviral Adverse Events during the 2009 H1N1 Influenza Pandemic
- Relationship between Clinical Signs and Transmission of an Infectious Disease and the Implications for Control
- West Nile Virus Neuroinvasive Disease
- Understanding and Harnessing the Health Effects of Rapid Urbanization in China
- Distribution of Mosquitoes and Mosquito-Borne Arboviruses in Yunnan Province near the China-Myanmar-Laos Border
- Reported Cases of Measles in International Air Travelers to the United States, August 2005-March 2008
- A Local, Regional, and National Assessment of Pediatric Malaria in the United States
- Health Care-Associated Measles Outbreak in the United States after an Importation: Challenges and Economic Impact
- Japanese Encephalitis, Tibet, China
- Acceptance of pandemic 2009 influenza A (H1N1) vaccine in a minority population: determinants and potential points of intervention
- Dynamic Epidemic Model for Influenza with Clinical Complications
- Changes in the Incidence of Candidaemia during 2000-2008 in a Tertiary Medical Centre in Northern Taiwan.

5. Notifications
- Keystone Symposia – Pathogenesis of Influenza: Virus-Host Interactions
- ISID-Neglected Tropical Diseases Meeting
- 5th Ditan International Conference on Infectious Diseases

1. Influenza News

2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 2 (0)
Cambodia / 5 (5)
Egypt / 24 (7)
Indonesia / 6 (5)
Total / 36 (16)

***For data on human cases of avian influenza prior to 2011, go to:

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 553 (323) (WHO 5/13/2011)

Avian influenza age distribution data from WHO/WPRO (last updated 2/7/2011):

WHO's map showing world's areas affected by H5N1 avian influenza (status as of 2/12/10):

WHO’s timeline of important H5N1-related events (last updated 4/4/11):


Global: WHO says influenza activity is pausing between seasons
Influenza activity is back to baseline or preseason levels across temperate parts of the Northern Hemisphere and has not yet started to increase in the temperate Southern Hemisphere, the World Health Organization (WHO) said. In northern countries, one exception to the downward trend in flu indicators occurred in Mexico, where the proportion of respiratory specimens testing positive for flu increased from 9% to 14%. The increase involved mainly 2009 H1N1 viruses, following a recent outbreak of that strain in Chihuahua State. In Europe, northern China, and Japan, most or all of the few respiratory specimens that tested positive were influenza B. Flu activity also was generally low in tropical regions, though Ghana and Kenya reported ongoing transmission of 2009 H1N1 and type B viruses.
(CIDRAP 5/9/2011)


Global: Few influenza hot spots reported in the Americas
Flu in the regions covered by the Pan American Health Organization (PAHO) is mainly declining or circulating at low levels, with other viruses such as respiratory syncytial virus (RSV) responsible for the bulk of flu-like illnesses in some locations, according to an update on 4 May 2011. The percentage of respiratory samples testing positive increased in Mexico, with most of it the 2009 H1N1 virus. Flu activity increased in some Caribbean countries, but the predominant strain has varied among locations. In Central America, the percentage of samples that yielded respiratory viruses remained low, though Costa Rica saw in increase, mainly from adenovirus and parainfluenza. The respiratory illness situation varied in South American countries. For example, respiratory virus levels were low in Colombia and Paraguay, with RSV the predominant virus. In the United States and Canada, flu levels continued to decline, with influenza B accounting for the greatest proportion of flu viruses in Canada.

In other flu developments, the US Centers for Disease Control and Prevention (CDC) issued on 4 May 2011 flu information for travelers, noting that though flu activity is low in the United States during the summer, the viruses can circulate at high levels in other parts of the world during those months. It urged travelers who have not been vaccinated during the US flu season to get immunized before departing, especially those at high risk for flu complications and those who will be traveling with large tourist groups, such as on cruise ships. The CDC warned travelers that flu vaccines made for the 2010-11 season expire in June and that the new version of the vaccine won't be available until the fall. The CDC also urged travelers to check flu activity ahead of time in regions they will be visiting and follow hand hygiene and other precautions during the trip.
(CIDRAP 5/5/2011)


Indonesia (West Jakarta): H5N1 avian influenza case confirmed
The Center of Health Research and Development Laboratory, Indonesia Ministry of Health, confirmed a bird flu H5N1 patient in April 2011. The victim was an 8-year-old female from West Jakarta (Jakarta Province).

The victim started to develop signs such as fever, cough, and chest pain on 1 April 2011. She was then admitted to a bird flu referral hospital in Jakarta on 8 April 2011. She received treatment according to the standard procedure and died on 8 April 2011 in the hospital.
(ProMED 5/12/2011)


USA: Influenza activity wanes further
Influenza activity in the United States decreased further during the week of 24 April 2011, according to the Centers for Disease Control and Prevention (CDC), with the proportion of deaths from pneumonia and flu below the epidemic threshold. Influenza-associated pediatric deaths numbered three, including one associated with pandemic H1N1, one with nonsubtyped influeza A, and one with influenza B, raising the season total to 100. Regional flu activity was reported in two states (New Hampshire and New York), local activity in seven states and the District of Columbia, and sporadic activity in 33 states and Puerto Rico, the US Virgin Islands, and Guam. Eight states reported no flu activity.
(CIDRAP 5/6/2011)


2. Infectious Disease News

Chinese Taipei: Serious case of encephalitis confirmed
The Centers for Disease Control (CDC) in Taiwan under the Department of Health confirmed on 26 April 2011 the first case of encephalitis caused by Acanthamoeba spp in Taiwan.

The patient is a 63-year-old male in central Taiwan. The previously healthy farmer fell into a ditch during farm work in a rice field in December 2008, said a CDC researcher on 26 April 2011. He later displayed symptoms such as a high fever, severe headaches and abdominal distention ten days after the accident. He was then sent to a hospital in central Taiwan's Changhwa County for treatment.

His cerebrospinal fluid test revealed a high number of white blood cells which could indicate a parasite infection. A further test showed that the farmer was infected by Acanthamoeba spp, which are free-living amoebae that inhabit a variety of air, soil, and water environments.

Ditch water specimens also found identical Acanthamoeba spp. The patient was later transferred to National Taiwan University Hospital in Taipei for further treatment after being diagnosed with the rare disease. It took him 78 days before his full recovery. However, the patient has developed some side effects since his recovery, such as speech problems.

The mortality rate associated with Acanthamoeba infection is very high, at around 80 to 90%. It is therefore rare that a local hospital was able to help the patient to recover, according to the CDC. The case has been published in international medical journals. CDC Deputy Director-General Chou Jih-haw reminded the public not to bathe in dirty water if one has a wound or cut in the skin, to avoid infection.
(ProMED 4/30/2011)


Chinese Taipei: Cases of rubella hit 12 year high
Health officials say Taiwan has recorded its 34th confirmed case of German measles in 2011, a new 12 year high. However, they note most of the cases were contracted abroad, not locally.

Officials with the Centers for Disease Control (CDC) here said that of the 34 cases, a total of 25 were contracted overseas. Of those, the majority were from Viet Nam, including six tourists. One CDC official said the weather in Viet Nam has not been normal in 2011 and that the German measles season has started early. He noted that Viet Nam already has in excess of 1,000 cases.

The official is urging people traveling throughout Southeast Asia to make sure they are vaccinated if they haven't previously caught the disease. He said the government is also going to strictly enforce regulations passed in 2009, mandating that foreign laborers and exchange students must show immunization certificates before coming to Taiwan.
(ProMED 5/4/2011)


Japan: Third person dies in food poisoning outbreak
A woman died 4 May 2011 of food poisoning linked to a raw meat dish at a restaurant chain in central Japan, bringing the total number of deaths since the week of 25 April 2011 to three.

The woman had eaten yukhoe, similar to tartare, at the same restaurant in Tonami, Toyama prefecture, where a 6-year-old boy had fallen ill and died on 29 April 2011 after eating the same dish. The restaurant is run by Foods Forus Co, based in nearby Kanazawa.

Another boy died the week of 25 April 2011 in Fukui prefecture after eating the same dish at another of the company's restaurants. Both boys were infected with E coli O-111 strain.

On 3 May 2011, 56 other people were confirmed to be suffering from food poisoning after eating the same dish at four of the company's restaurants.

The company said at a news conference that it had failed for the last two years to conduct hygiene inspections of raw meat supplied for the dish by a Tokyo-based wholesaler.
(ProMED 5/4/2011)


New Zealand (Auckland): Measles cases reported
Four cases of measles have been reported to Auckland Regional Public Health Service in a ten-day period, which says it's likely more cases will be diagnosed in the next few days.

Earlier in 2011, an outbreak occurred in which 24 cases surfaced. Medical Officer of Health Cathy Pikholz says the latest cases, reported in the ten days from 20 April 2011, occurred in various parts of the city.

She says immunization is the only effective way to prevent outbreaks, but people should be aware of symptoms, which include a red rash, sore eyes, a runny nose and a fever. She says there is a period of ten days during which someone with measles is infectious.
(ProMED 5/2/2011)


Russia: Yersinia pseudotuberculosis in Krasnoyarsk
According to Rospotrebnadzor (Federal Service on Customers' Rights Protection and Human Well-Being Surveillance), nine people in Krasnoyarsk krai have been infected by Yersinia pseudotuberculosis since the beginning of 2011.

The clinical picture was variable, and the local public health services consider the situation to be of no major concern. There have not been any outbreaks of pseudotuberculosis in Krasnoyarsk since 2007. Since the main source of local infections is rodent-contaminated vegetables, the specialists recommend against consuming vegetables kept in cellars over the winter.
(ProMED 5/2/2011)


Canada (Quebec): Hit by measles outbreak
Public health officials in the Quebec City region are dealing with a minor outbreak of the measles. Of the 36 cases reporting in the province, 19 are in the capital region, and officials are now warning people who have not been vaccinated for measles to make an appointment. The vaccination rate in Quebec is 95%, according to Dr. Horatio Arruda, the head of prevention for Quebec's public health department. Arruda said he didn't expect the current outbreak to spread, as it did in the 1989 measles epidemic when 10,000 Quebecers became sick and several died.

The Americas were declared "measles-free" in 2002, and in Quebec, there are usually only one or two cases of measles a year, according to the health Ministry's website. Officials said the disease was brought to Canada by people who travelled to France, where 4,937 cases of measles were reported between January and March 2011. France has a vaccination rate of 60%.
(ProMED 5/2/2011)


Chile (Los Rios): New Hantavirus case detected
A new case of a Hantavirus infection was detected this Thursday 5 May 2011 in a 37-year-old man who is admitted in good condition to the Valdivia Hospital Base in the Los Rios region. The man contracted the virus while collecting mushrooms in the Los Lagos community. It is worth noting that this is the sixth Hantavirus infection in the region during 2011, with the other cases in Corral port, resulting in the deaths of two people.
(ProMED 5/9/2011)


Chile (Araucania): New victim of Hantavirus infection
A new Hantavirus victim has been discovered after the SEREMI (Secretaria Regional Ministerial de Salud; Regional Ministerial Secretariat of Health) confirmed the death of a woman from the Pucon community, who was rapid test positive in the Temuco Regional Hospital. The woman, 35 years of age, died the morning of 6 May 2011 in the Hernan Henriquez Hospital in Temuco where she was admitted in a serious condition, having been transported from the Pucon community. Gloria Rodriguez, the SEREMI, confirmed the death of the woman from a rural zone in the lake area, as a possible Hantavirus infection after carrying out a rapid test that was positive.

This signals the fourth Hantavirus death in the Araucania region in 2011, the other three cases in the Cunco community.
(ProMED 5/9/2011)


Chile (Santiago): First outbreak of measles in eight years prompts revaccination
The alert was given because of the appearance of three cases of measles in March 2011: a father, 35, a mother, 34, and her daughter 10 months. They were joined by a woman from eastern Santiago and the doctor who attended her. What was significant was the age range of infections, men and women between 30 and 37, in addition to the infant. All had one thing in common: they had left the country or come into contact with a traveler.

After eight years with no transmission of measles in the country, this was of concern for specialists at the Ministry of Health, who found the answer in historical studies of immunization. Records revealed that the age group described had not been covered by the vaccination campaigns of the last decades or had had a lower dose of vaccine, so that their immunity has expired or was deficient. For a period a single dose was used, because medical knowledge said that a single dose was sufficient. This is now known to be insufficient, because medical knowledge has changed in 30 years, said Jorge Diaz, undersecretary of public health. Diaz added that other reasons for the low immunization coverage group were economic crises and supply difficulties.

According to the Health Ministry, the vulnerable group comprises nearly 1.5 million people. It is not as straight forward as vaccination of children, where infants and young children are vaccinated at clinics and healthcare centers, because adults are not regularly monitored, said Carlos Perez, a member of the Advisory Committee on Vaccines and Immunization Strategies (Cavei).

In addition, the group to be immunized will incur costs of about CLP 2,500 million (about USD 5.4 million), making it difficult to achieve complete coverage in a single campaign. Consequently the campaign will be organized in phases, starting with specific groups at higher risk of infection.

The plan is to immunize in the second half of 2011 50,000 people who are at greatest risk of importing measles, such as frequent travelers, people who work in border areas and international terminals, and health care personnel in the vulnerable age group. This is in accordance with a recommendation by the World Health Organization, which indicates the desirability of vaccinating travelers.

The mode of implementation of vaccination, meanwhile, is another matter that must be resolved. One possibility is to implement a recommendation for those who leave the country. Another is to have immunization be obligatory. That is something that will have to be reviewed by experts because it may involve legal issues, said Diaz.

Infants under one year of age are another group that could be immunized. This is because vaccination now covers only children older than one year, on the premise that the immunity obtained from the mother protects the child from getting this virus until about 18 months. Another factor is that the age range of risk of contracting measles fluctuates between 30 and 37 years, which coincides with childbearing families. Infants have immunity that is transmitted during pregnancy by transplacental transfer and also through breast milk. These antibodies can last up to a year and a half, but infants born to unimmunized parents are at risk, said Carlos Perez.

Up to April 2011, 33 European countries had reported outbreaks of measles, with more than 6,000 cases. Other outbreaks have occurred in the United States, Canada, Brazil, and Argentina, now joined by Chile, to a lesser extent.
(ProMED 5/9/2011)


USA: On track for most measles cases in a decade
The United States seems to be on track to have more measles cases than any year in more than a decade, with virtually all cases linked to other countries, including Europe where there's a big outbreak. Already there have been 89 cases reported so far. The US normally sees only about 50 cases of measles in a year thanks to vaccinations. Health officials are reluctant to make predictions, but acknowledge the pace of reports is unusually hot.

It's hard to say, but we're certainly getting a lot, said Dr. Greg Wallace, who leads the measles, mumps, rubella, and polio team at the US Centers for Disease Control and Prevention. Europe, especially France, has been hit hard by measles, with more than 6,500 cases reported in 33 nations. International health officials are blaming it on the failure to vaccinate all children. Just about all US outbreaks were sparked by people bringing it here from other countries. This week, international health officials posted an alert urging travelers everywhere to get the recommended two doses of vaccine before flying overseas.

In the US, the worst year for measles in the last decade was 2008, when 140 cases were reported. There have been no measles deaths in 2011, but health officials warn the disease can be dangerous. Since 2003, there have been no measles-related deaths reported in the United States, where children have been getting vaccinated against the virus for almost 50 years. Before the vaccine, nearly all children got measles by their 15th birthday and epidemics cycled through the nation every two to three years -- generally peaking in the late winter or spring. In those days, about 450 to 500 Americans died from measles each year, on average. Vaccination campaigns reduced the toll dramatically, and today, roughly 90% of US kids are protected from measles, according to studies of teenagers.
(ProMED 5/9/2011)


USA (California): Health officials launch investigation into rabies case
Humboldt County public health officials launched a full-scale investigation Monday 9 May 2011 into what may be the first ever confirmed case of human rabies in Humboldt County.

Department of Health and Human Services (DHHS) public health branch director Susan Buckley said that the victim in the case, a resident of Willow Creek whose name was not released, remained at the UC Davis Medical Center on 9 May 2011 in serious condition. The Centers for Disease Control and Prevention confirmed that the case was a rabies infection on 6 May 2011, Buckley said, and the strand of the virus was then tested a second time on 7 May 2011 with the same results. Health officials remain in contact with the family of the victim, whose condition stayed the same over the weekend.

There are currently no known cases of human-to-human transfer of rabies. It remains unclear what type of animal transferred rabies to the victim, Buckley said, adding that the success of the vaccination against infection depends on the timing of when it is given. While the vaccine is almost 100% effective in preventing rabies, there is only one known survivor who did not receive the vaccine before symptoms were reported.

Leslie Lollich, the public education and outreach officer for DHHS, confirmed there is only one victim in the case and said that figuring out when and how the victim contracted the virus was difficult because of the myriad ways in which it can be transferred. Lollich said that a person may be exposed to rabies yet not show symptoms for up to seven years, something that makes identifying it a challenge for doctors.

While the investigation into the incident continues, Buckley stressed that there was no risk of rabies exposure for Willow Creek residents and that she is hopeful that the victim would survive.

While rabies cases are rare in the United States, an estimated 55,000 people die from the infection outside the country each year, according to the CDC.
(ProMED 5/11/2011)


USA (Florida): Cholera oyster outbreak sickens eleven
As many as 11 people have reported getting sick from eating raw oysters contaminated with cholera bacteria in northern Florida, officials said on Tuesday, 10 May 2011.

The oysters came from Apalachicola Bay, near Panama City in northern Florida, about 300 miles (482 kilometers) from New Orleans along the Gulf of Mexico coast, and the FDA issued a warning not to eat them. There are ongoing, collaborative discussions among all state and federal partners as we look at this new pathogen to analyze the first ever outbreak of this unique strain of Vibrio cholera, Florida's Department of Agriculture said.

State officials said 11 cases of illness were reported, while the FDA said eight of those have so far been confirmed as caused by toxigenic Vibrio cholera O75. No one was hospitalized or died.

The high number of cases is unusual, given that the Centers for Disease Control typically log one to two cases per year, an FDA spokesman said. From 2000-2010, a total of 17 persons with toxigenic V. cholera O75 infection were reported to CDC, the numbers are greatest when the water is warm, spokesman Douglas Karas said.

The FDA said the affected oysters were harvested from Area 1642 in Apalachicola Bay between 21 March 2011 and 6 April 2011. The Florida Department of Agriculture said it closed the area to oyster harvesting on 29 April 2011 and was investigating the cause of the outbreak. As of 10 May 2011, we have learned of two events that may be the cause of the cholera related illnesses. First, there was a dredging operation near the 1642 harvesting area that may have stirred up organisms on the floor of the ocean. We have also learned there was a sewer break in East Point and we are investigating whether it had any impact on oysters in 1642. The harvesting area will remain closed until our investigation is complete.

Area 1642 is home to about 10% of the state's oyster harvest, and oysters taken from there are mainly consumed in Florida, Georgia, and Alabama.
(ProMED 5/11/2011)


USA (Kansas): Two more measles cases in Johnson County
The Johnson County Health Department on Monday 2 May 2011 confirmed two more measles cases among school-age children. The children, who developed symptoms between 30 April 2011 and 1 May 2011, had come in contact with another Johnson County child who became ill in mid-April, said Nancy Tausz of the department. That case was the county's first in nearly six years.

The first child to become ill had not been vaccinated against measles. In the new cases, the children had received the vaccine, but not soon enough to prevent symptoms.

Tausz said the Health Department was getting in touch with people who had come in contact with the new cases. Any unvaccinated children among the contacts will have to be vaccinated to remain in school, she said.
(ProMED 5/9/2011)


USA (Montana): Woman dies of Hantavirus pulmonary syndrome
Park County health officials say a 46-year-old Livingston-area woman has died of Hantavirus pulmonary syndrome. Coroner Al Jenkins says that the woman died on 8 April 2011 while she was being transported to a Billings hospital. The woman had visited Park Clinic on 7 April 2011 with symptoms including a high fever, muscle fatigue and an extreme headache. She checked into the emergency room on 8 April 2011 also suffering from shortness of breath and extreme congestion.

Hantavirus can be contracted through inhaling the droppings or urine of deer mice Peromyscus maniculatus or touching the droppings or urine and then touching one's eyes, nose or mouth.
(ProMED 4/30/2011)


USA (New Mexico): Man diagnosed with bubonic plague
A 58-year-old man in New Mexico was recently treated for bubonic plague, the first case of the disease to surface in 2011.

Health officials in Santa Fe said the unidentified man spent a week in the hospital after suffering high fever, intense pain in his stomach and groin, and swollen lymph nodes. He was treated and released, but officials would not say when. The results of blood tests released 5 May 2011, confirmed the man had bubonic plague, officials said.

Doctors said the man was most likely bitten by a flea carrying the plague bacteria, the most common method of transmission to humans. Rat-borne fleas can carry the bacterium, and humans can also catch the disease from contact with infected rodents or animals.

Only about 10 to 15 people in the USA catch the illness each year, typically in western states. It is particularly prevalent in New Mexico because the state has a high population of both rodents and fleas.

It can be treated with antibiotics, but one in seven cases is fatal. The last reported outbreaks of plague in New Mexico were in 2009, when three people, including an 8-year-old in Santa Fe, died.
(NY Daily News 5/8/2011)


USA (Oregon): Three cases of whooping cough confirmed at school
Three cases of pertussis, also known as whooping cough, have been confirmed at a Portland elementary school. Parents of students at Butler Creek Elementary School in southeast Portland received a letter about the cases, which were all in a fifth-grade classroom. Most people are vaccinated, but immunity decreases over time. The illness usually begins within seven to ten days after being exposed and symptoms include an irritating cough that’s often accompanied by a whooping sound. Pertussis can be deadly for some children under the age of one.
(HealthMap 5/12/2011)


USA (Utah): Whooping cough outbreak in Cache County
Health Officials are warning parents about an outbreak of whooping cough in Utah. Four cases of the pertussis disease have been discovered in three schools in Cache County. The affected schools include Thomas Edison South, Spring Creek Middle School and Heritage Elementary. Parents of children at any of the schools who have not been immunized were asked to keep their kids at home.

The whooping cough is highly contagious. A few months ago, health officials say a baby in Utah County contracted the disease from someone who likely didn't even know they had it.

Bear River Heath officials claim they're trying to stop this disease from spreading, but residents can help reduce the risk of getting it by keeping families up to date on vaccinations, and by keeping kids away from people with cough illnesses.
(HealthMap 5/6/2011)


3. Updates
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions:
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
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:
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:
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


- 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.


USA (Hawaii)
The first cases of locally contracted dengue fever in ten years appear to be limited to five Pearl City residents and did not become a major outbreak. The state Department of Health has ended its investigation of a possible dengue fever outbreak after 65 of the 83 reports of suspected dengue cases received from physicians since 24 March 2011 were ruled out or found to be negative, Environmental Health deputy director Gary Gill said on 4 May 2011. The department did not have results of the remaining 18 cases. The Health Department had known of four probable cases of dengue fever since March 2011 and recently found a fifth case believed to be the person who first brought the mosquito-borne disease to Pearl City. That fifth person, a Pearl City resident, had traveled to Asia, became infected there, then returned home, where the disease spread by mosquitoes to the other four Pearl City residents, the department said.
(ProMED 5/10/2011)

Viet Nam (Hanoi)
We are entering a weather pattern of high temperatures and humidity, which provides better conditions for mosquitoes which spread dengue fever, said Deputy Director of Ha Noi's Preventive Medicine Centre Nguyen Nhat Cam. During the first four months of 2011, the number of cases diagnosed with dengue fever was 220, an increase of 15 to 20% compared to the same period in 2010.
(ProMED 5/2/2011)


Mexico (Sinaloa)
The Ministry of Health issued a national epidemiological alert after detecting a case of cholera in the state of Sinaloa.

In an interview, Undersecretary of Prevention and Promotion of Health, Mauricio Hernandez Avila, said the new case of cholera was detected in a 10-year-old. He said the case was treated quickly and the patient has recovered.

The federal official called on state governments to maximize the monitoring of their water systems, because locally where you found a new case of cholera the chlorination systems not working properly. The goal, he added, is to detect a possible infection rapidly.

He said they were working with the Federal Commission for Protection Health Risks (Cofepris) and the National Water Commission (Conagua) to strengthen the chlorination systems throughout the country. He rejected that could be risks of an epidemic as had occurred in Haiti, as he said, the Epidemiological surveillance systems are active and running.
(ProMED 4/30/2011)


4. Articles
Clinical Study Concerning the Relationship between Community-Acquired Pneumonia and Viral Infection in Northern Thailand
Hara K, Yahara K, Gotoh K, et al. Internal Medicine. 1 May 2011; 50(9):991-998. doi:10.2169/internalmedicine.50.4738.
Available at http://www.jstage.jst.go.jp/article/internalmedicine/50/9/50_991/_article

Objective. The etiological agents associated with community-acquired pneumonia (CAP) in Thailand have been studied extensively in bacterial pathogens, but not in viral pathogens. To clarify the association of viral pathogens with CAP, we conducted a comprehensive study of viral and bacterial pathogens in patients with CAP.

Methods. We enrolled 119 hospitalized patients with CAP in Nakornping Hospital, Chiang Mai, Thailand between 2006 and 2008. The severity of pneumonia was classified and the risk factors for death were estimated. Bacterial and fungal pathogens were determined from specimens taken from blood and sputum, and viral pathogens were identified from nasopharyngeal specimens by RT-PCR using primers specific for 7 respiratory viruses.

Results. Overall, 29 patients were HIV-infected and 90 patients were non-HIV-infected. The microbial pathogens most commonly isolated among HIV-infected patients were: 4 Klebsiella pneumonia, 4 Mycobacterium tuberculosis and 3 Haemophilus influenza. Among non-HIV infected patients, predominant microbial pathogens were: 6 Pseudomonas aeruginosa, 5 Haemophilus influenza and 4 Klebsiella pneumonia. As for viral pathogens for CAP, influenza virus was identified from 2 HIV-infected patients and 5 non-HIV infected patients. In addition, human rhinovirus (HRV) and respiratory syncytial virus (RSV) were identified from 2 patients each among non-HIV-infected patients.

Conclusion. Our study demonstrates that the most common viral agent was influenza virus (5%), followed by HRV (2%) and RSV (2%) among CAP patients in northern Thailand. The underlying chronic obstructive pulmonary disease (COPD) seems to be correlated with the severity of illness.


Emergency Department Visits for Antiviral Adverse Events during the 2009 H1N1 Influenza Pandemic
Lovegrove MC, Shehab N, Hales CM. Public Health Rep. May-June 2011; 126(3):312-317.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21553658

Abstract. The 2009 pandemic influenza A (H1N1) outbreak was associated with an increased use of antiviral agents and highlighted the role of population-based monitoring for related adverse drug events (ADEs). An ongoing, nationally representative emergency department-based surveillance system was used to identify and characterize ADEs during the pandemic. Active surveillance for ADEs successfully provided timely, population-based data during the pandemic. Increases in antiviral ADEs paralleled increases in prescribing. Type and severity of ADEs were similar across all seasons.


Relationship between Clinical Signs and Transmission of an Infectious Disease and the Implications for Control
Charleston B, Bankowski BM, Gubbins S. Science. 6 May 2011; 332(6030):726-729.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21551063

Abstract. Control of many infectious diseases relies on the detection of clinical cases and the isolation, removal, or treatment of cases and their contacts. The success of such "reactive" strategies is influenced by the fraction of transmission occurring before signs appear. We performed experimental studies of foot-and-mouth disease transmission in cattle and estimated this fraction at less than half the value expected from detecting virus in body fluids, the standard proxy measure of infectiousness. This is because the infectious period is shorter (mean 1.7 days) than currently realized, and animals are not infectious until, on average, 0.5 days after clinical signs appear. These results imply that controversial preemptive control measures may be unnecessary; instead, efforts should be directed at early detection of infection and rapid intervention.


West Nile Virus Neuroinvasive Disease
Debiasi RL. Curr Infect Dis Rep. 5 May 2011 [Epub ahead of print]. doi: 10.1007/s11908-011-0193-9.
Available at http://www.springerlink.com/content/033823u217761313/

Abstract. West Nile virus (WNV), first recognized in North America in 1999, was responsible for the largest arboviral epidemic of human encephalitis in history and continues to be the most frequent cause of epidemic meningoencephalitis in North America. WNV neuroinvasive disease (WNND) occurs in fewer than 1% of infected individuals, with presentations including aseptic meningitis, encephalitis, and poliomyelitis. Between 1999 and 2009, over 12,000 cases of WNND were reported in the United States, with the peak annual incidence occurring in epidemics of 2002 and 2003. In this review, we first summarize the epidemiology of WNV over the past decade and the salient clinical features of WNND, including a discussion of laboratory and radiographic findings, risk factors, morbidity, and mortality. In addition, we review recent progress in our understanding of virus and host determinants of the pathogenesis of WNND, as well as the prospects for the development of specific therapeutic targets.


Understanding and Harnessing the Health Effects of Rapid Urbanization in China
Zhu YG, Ioannidis JP, Li H. Environ Sci Technol. 4 May 2011 [Epub ahead of print]. doi: 10.1021/es2004254.
Available at http://pubs.acs.org/doi/full/10.1021/es2004254

Abstract. China is undergoing a rapid transition from a rural to an urban society. This societal change is a consequence of a national drive toward economic prosperity. Rapid urbanization impacts on infrastructure, environmental health and human wellbeing. Unlike many cases of urban expansion, Chinese urbanization has led to containment, rather than to increase, in the spread of infectious diseases. Conversely, the incidence of chronic conditions such as cardiovascular and metabolic diseases has risen, with higher rates occurring in urban regions. This rural–urban gradient in disease incidence seems not to be a reflection simply of more aggressive diagnosis or healthcare access. Other diseases exhibit little rural versus urban differences (e.g., liver cancer or respiratory disease), or even occur at a higher rate in the rural population (e.g., esophageal cancer). This article examines the impact of this changing demographic on environmental health and human wellbeing in China. Lessons learned from epidemiological studies mostly carried out in Europe and the U.S. may not be directly transferable to China. We advocate that there is now a need to establish robust systems of accurate data collection, a Chinese biobank network to facilitate the profiling of human health effects, and relevant randomized controlled trials to identify effective interventions in the Chinese urbanized setting. Such studies could allow for the future implementation of disease-preventive strategies.


Distribution of Mosquitoes and Mosquito-Borne Arboviruses in Yunnan Province near the China-Myanmar-Laos Border
Wang J, Zhang H, Sun X. Am J Trop Med Hyg. May 2011; 84(5):738-746.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21540383

Abstract. Economic development and increased tourism in the southern region of Yunnan Province in China, adjacent to several countries in Southeast Asia, has increased the likelihood of import and export of vectors and vector-borne diseases. We report the results of surveillance of mosquitoes and mosquito-borne arboviruses along the border of China-Myanmar-Laos in 2005 and 2006, and information associating several arboviruses with infections and possibly disease in local human populations. Seventeen mosquito species representing four genera were obtained, and 14 strains of mosquito-borne viruses representing six viruses in five genera were isolated from Culex tritaeniorhynchus. In addition, IgM against Japanese encephalitis virus, Sindbis virus, Yunnan orbivirus and novel Banna virus was detected in acute-phase serum samples obtained from hospitalized patients with fever and encephalitis near the areas where the viruses were isolated. This investigation suggests that Japanese encephalitis virus, Sindbis virus, and lesser-known arboviruses circulate and may be infecting humans in the China-Myanmar-Laos border region.


Reported Cases of Measles in International Air Travelers to the United States, August 2005-March 2008
Edelson PJ, Anderson JA. J Travel Med. May 2011 [Epub April 2011]; 18(3):178-182. doi: 10.1111/j.1708-8305.2011.00502.x.
Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1708-8305.2011.00502.x/abstract?systemMessage=Wiley+Online+Library+will+be+disrupted+14+May+from+10-12+BST+for+monthly+maintenance

Background. In countries with high rates of measles immunization, imported cases of measles represent an important continuing source of measles infection.

Methods. Airlines and state health departments report cases of suspected measles in international travelers to the Centers for Disease Control and Prevention Quarantine Stations. We reviewed these reports, maintained in an electronic database, to determine the demographic and epidemiologic characteristics of international air travelers infected with measles.

Results. We reviewed 35 confirmed cases of measles in air travelers and analyzed their demographic and epidemiologic characteristics. The median age of case travelers was 17 (range: 4 months-50 years). These travelers arrived from all regions of the world, including 10 countries with immunization rates of measles-containing vaccine below 90% and five others experiencing local outbreaks. Of 17 travelers for whom immunization status was known, 2 had been adequately immunized with at least two doses of a measles-virus containing vaccine, 9 were inadequately immunized, and an additional 6 infants had not been immunized because of age.

Conclusions. Measles importations continue in the United States. Travelers should be aware of the importance of assuring up-to-date immunizations, especially when visiting countries experiencing a local measles outbreak. In addition, parents traveling with infants, and their physicians, should be aware of recommendations regarding the early administration of a dose of measles-containing vaccine for infants at least 6 months old traveling internationally.


A Local, Regional, and National Assessment of Pediatric Malaria in the United States
Hickey PW, Cape KE, Masuoka P. J Travel Med. May 2011[Epub April 2011]; 18(3):153-160. doi: 10.1111/j.1708-8305.2011.00514.x.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21539653

Background. Imported malaria remains a public health concern in the United States, but the health impact on children and the financial costs to society have not been well defined.

Methods. Inpatient and outpatient malaria cases diagnosed at Children's National Medical Center (CNMC) in Washington, DC over an 8-year period are retrospectively reviewed. Cases are mapped against Census Bureau population data. These observations are compared with the national burden of pediatric malaria, including both disease severity and cost, by reviewing inpatient malaria cases in the Pediatric Health Information System (PHIS), January 2003 to June 2008.

Results. At CNMC, malaria most commonly affects children who traveled to West Africa to visit friends and relatives. Poor adherence to prophylaxis and self-treatment with antimalarial medications were commonly identified. Mapping demonstrates case clustering in communities with large sub-Saharan African populations. The cumulative incidence (CI) of malaria at CNMC of 9.0 per 10,000 admissions is 7.6 times the national average. The CI of malaria at PHIS hospitals is 1.2 per 10,000 admissions with an average cost of $17,519.

Conclusions. Malaria is a preventable disease for which the risk to life and costs of treatment are significant. Patterns of risk can be used by health planners to target prevention strategies at the community level. In regions with a high density of immigrants, particularly from sub-Saharan Africa, physicians must be aware of the risk, understand recommended prophylaxis and treatment regimens, and advocate for their appropriate use in the community.


Health Care-Associated Measles Outbreak in the United States after an Importation: Challenges and Economic Impact
Chen SY, Anderson S, Kutty PK. J Infect Dis. April 28 2011 [Epub ahead of print]. doi: 10.1093/infdis/jir115
Available at http://www.ncbi.nlm.nih.gov/pubmed/21531693

Background. (See the editorial commentary by Ostroff, on pages 1507-9.) On 12 February 2008, an infected Swiss traveler visited hospital A in Tucson, Arizona, and initiated a predominantly health care-associated measles outbreak involving 14 cases. We investigated risk factors that might have contributed to health care-associated transmission and assessed outbreak-associated hospital costs.

Methods. Epidemiologic data were obtained by case interviews and review of medical records. Health care personnel (HCP) immunization records were reviewed to identify non-measles-immune HCP. Outbreak-associated costs were estimated from 2 hospitals.

Results. Of 14 patients with confirmed cases, 7 (50%) were aged ≥18 years, 4 (29%) were hospitalized, 7 (50%) acquired measles in health care settings, and all (100%) were unvaccinated or had unknown vaccination status. Of the 11 patients (79%) who had accessed health care services while infectious, 1 (9%) was masked and isolated promptly after rash onset. HCP measles immunity data from 2 hospitals confirmed that 1776 (25%) of 7195 HCP lacked evidence of measles immunity. Among these HCPs, 139 (9%) of 1583 tested seronegative for measles immunoglobulin G, including 1 person who acquired measles. The 2 hospitals spent US$799,136 responding to and containing 7 cases in these facilities.

Conclusions. Suspecting measles as a diagnosis, instituting immediate airborne isolation, and ensuring rapidly retrievable measles immunity records for HCPs are paramount in preventing health care-associated spread and in minimizing hospital outbreak-response costs.


Japanese Encephalitis, Tibet, China
Li YX, Li MH, Fu SH. Emerg Infect Dis. May 2011; 17(5):934-936.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21529419

To the Editor. Tibet is located in the Qinghai-Tibet Plateau of western People's Republic of China and has been internationally recognized as a Japanese encephalitis (JE)-nonendemic area because the average altitude is thought to be too high to facilitate the cycle of Japanese encephalitis virus (JEV) between mosquitoes and vertebrates (1,2). In addition, JE is a reportable infectious disease in China, and no clinically confirmed case has been reported in Tibet since establishment of a national case reporting system in 1951 (3,4). Neither the mosquito vector of JEV nor JEV isolates have been described in Tibet. In this study, JEV was isolated from Culex tritaeniorhynchus mosquitoes, the main vectors of JEV, collected in Tibet. Serologic assays detected anti-JEV antibodies in a large number of human and porcine serum samples collected in this region. These data demonstrate that JEV is currently circulating in Tibet.


Acceptance of pandemic 2009 influenza A (H1N1) vaccine in a minority population: determinants and potential points of intervention
Frew PM, Hixson B, del Rio C. Pediatrics. May 2011; 127 Suppl 1:S113-9. [Epub 18 April 2011]. doi: 10.1542/peds.2010-1722Q
Available at http://www.ncbi.nlm.nih.gov/pubmed/21502254

Objective. We sought to understand pandemic 2009 influenza A (H1N1) vaccine acceptance in a minority community including correlates of vaccine hesitancy and refusal. We identified intervention points to increase H1N1 vaccine coverage.

Patients and Methods. Minority parents and caregivers of children ≤ 18 years participated in a cross-sectional survey. Statistical analyses included bivariate correlations, exploratory factor analyses, internal-consistency assessment, and logistic regressions.

Results. The sample (N = 223) included mostly lower-income (71% [n = 159]) and black (66% [n = 147]) participants. Potential and actual receipt of pediatric H1N1 vaccination was low (36% [n = 80]). Pediatric H1N1 vaccine acceptance was associated with lack of insurance (odds ratio [OR]: 3.04 [95% confidence interval (CI): 1.26-7.37]), perceived H1NI pediatric susceptibility (OR: 1.66 [95% Cl: 1.41-1.95]), child vaccination prioritization in family (OR: 3.34 [95% CI: 1.33-8.38]), believing that H1N1 is a greater community concern than other diseases (OR: 1.77 [95% CI: 1.01-3.09]), believing that other methods of containment (eg, hand-washing, masks) are not as effective as the H1N1 vaccine (OR: 1.73 [95% CI: 1.06-2.83]), and a desire to promote influenza vaccination in the community (OR: 2.35 [95% CI: 1.53-3.61]).

Conclusions. We found low acceptance of the H1N1 vaccine in our study population. Perceived influenza susceptibility, concern about H1N1 disease, and confidence in vaccinations as preventive methods were associated with vaccine acceptance. Physician support for HIN1 vaccination will aid in increasing immunization coverage for this population, and health departments are perceived as ideal community locations for vaccine administration.


Dynamic Epidemic Model for Influenza with Clinical Complications
Wang ST, Chen LS, Lee LT. Infect Control Hosp Epidemiol. May 2011; 32(5):456-64.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21515976

Objective. To incorporate clinical complications in the susceptible-infectious-recovered model to estimate parameters needed in dynamic changes of infectious diseases and to further evaluate the impact of disease-controlling methods.

Methods. We developed a new extended epidemic model that incorporates of disease-related complications. This model was applied to empirical data on influenza during the epidemic season of 2001-2002 in Taipei County, Taiwan, to estimate the transmission parameters that were converted to the basic reproductive rate (R(0)). The proposed model, in conjunction with estimated parameters, was applied in quantifying the efficacy of different preventive strategies.

Results. During the study period there were 5 outbreaks of influenza. The estimated transmission probability for outbreak 1 was 0.135, with corresponding estimate of R(0), 2.7; for outbreak 2, 0.165, with estimated R(0), 3.3; for outbreak 3, 0.15, with R(0), 4.5; for outbreak 4, 0.165, with R(0), 5; and for outbreak 5, 0.165, with R(0), 5. The efficacy of antiviral prophylaxis to reduce the total episodes was 18% (95% CI, 15%-21%) under the coverage rate of 30%, 31% (95% CI, 26%-36%) under the coverage rate of 50%, and 73% (95% CI, 59%-90%) under the coverage rate of 80%. The corresponding figures for the efficacy of vaccination were 17% (95% CI, 15%-20%), 41% (95% CI, 35%-48%), and 76% (95% CI, 61%-95%). Combination of both methods would yield efficacy of 32% (95% CI, 28%-38%), 59% (95% CI, 49%-71%), and 88% (95% CI, 66%-118%), respectively.

Conclusions. We demonstrate how to apply a novel extended model to empirical surveillance data of an influenza study for estimating parameters pertaining to dynamic changes in the infection process. These parameters were further used to evaluate the impact of antiviral prophylaxis alone, vaccination alone, or the use of both methods.


Changes in the Incidence of Candidaemia during 2000-2008 in a Tertiary Medical Centre in Northern Taiwan.
Chen LY, Liao SY, Kuo SC. J Hosp Infect. May 2011 [Epub 12 Feb 2011]; 78(1):50-3.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21316800

Abstract. Candidaemia is associated with high mortality and high healthcare costs. The incidence of candidaemia in Taiwan rose markedly during the period 1980-2000. We conducted this hospital-based surveillance study in order to explore the secular trend in incidence of candidaemia during the period 2000 to 2008. In our study, Candida spp. were the fourth most common cause of bloodstream infections, with a 30-day crude mortality rate of 36.7%. Candida albicans was the most common species identified, although mortality rate did not differ significantly among species. The incidence of candidaemia began to decrease in 2004. Risk factors related to higher mortality included longer hospital stay before onset of candidaemia, liver cirrhosis, malignancy, end-stage renal disease requiring renal dialysis, dependence on mechanical ventilation and urinary catheterisation.


5. Notifications
Keystone Symposia – Pathogenesis of Influenza: Virus-Host Interactions
Kowloon, Hong Kong, 23-28 May 2011
The mechanisms underlying the pathogenesis of influenza remain controversial. The current symposium brings together researchers working on the virus, viral receptors and tissue tropism, innate and adaptive immunity, systems biology and clinical aspects of lung injury and host defense, to address questions on the pathogenesis of influenza. The aim will be to integrate data from animal and ex vivo / in vitro human experimental models as well as human disease to understand pathogenesis of influenza and how this may lead to effective interventions. As this symposium will take place in the aftermath of the first pandemic in 40 years, there will be a wealth of new knowledge as well as intense scientific interest in the subject.
Additional information at http://www.keystonesymposia.org/meetings/viewMeetings.cfm?MeetingID=1127


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/


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/