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Vol. XIV No. 13 ~ EINet News Briefs ~ Jun 24, 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: South Africa battling influenza, few other global hot spots
- Australia: FDA finds CSL probe into flu-vaccine side effects inadequate
- Egypt: Reports five H5N1 avian influenza infections, three fatal
- Egypt: Man dies of H5N1 avian influenza

2. Infectious Disease News
- Global: EHEC outbreak update
- Germany: EHEC outbreak update
- Germany: Unusual traits blended in E. coli strain
- Hong Kong: Alert over high level of scarlet fever cases
- Australia (New South Wales): Fatal respiratory syncytial virus in nursing home
- Australia (New South Wales): Murine typhus must be considered in meningoencephalitis
- China: Novel Bunyavirus disease
- Indonesia: Legionnaires' disease warning for Bali travelers
- New Zealand: Large measles outbreak hits city
- Philippines (Palo, Leyte): Schistosomiasis grips villages
- Philippines (Cotabato City): Suspected measles outbreak
- Viet Nam: Hand-foot-mouth disease widespread
- Canada (British Columbia): Mumps outbreak hits Metro Vancouver
- Canada (Quebec): MMR vaccine update
- Chile: Salmonella outbreak affects 47 people in the Biobio Region
- USA: Number of measles cases becoming a concern
- USA (Maine): Hantavirus update
- USA (Missouri): Deadly fungus strikes Joplin Tornado survivors and volunteers
- USA (Washington, Montana): Q fever, goat disease spreads to humans
- USA (Wisconsin): Camplyobacteriosis tied to raw milk consumption; 16 people sickened

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

4. Articles
- Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany — Preliminary Report
- An Assessment of Mumps Vaccine Effectiveness by Dose during an Outbreak in Canada
- Detection of Dengue Virus Type 4 in Easter Island, Chile
- Methicillin-Resistant Staphylococcus aureus Nasal Colonization among Adult Patients Visiting Emergency Department in a Medical Center in Taiwan
- Intussusception Risk and Health Benefits of Rotavirus Vaccination in Mexico and Brazil
- Nonlinear Effect of Climate on Plague during the Third Pandemic in China
- Ecological Factors Associated with Dengue Fever in a Central Highlands Province, Vietnam
- Estimation of Type- and Subtype-Specific Influenza Vaccine Effectiveness in Victoria, Australia Using a Test Negative Case Control Method, 2007-2008
- Transmission of Influenza-like Illness on International Flights, May 2009
- Oseltamivir and Risk of Lower Respiratory Tract Complications in Patients with Flu Symptoms: A Meta-analysis of Eleven Randomized Clinical Trials
- Phylogeography and Evolutionary History of Reassortant H9N2 Viruses with Potential Human Health Implications
- Place of Influenza Vaccination among Adults --- United States, 2010--11 Influenza Season
- Age-specific Differences in Influenza A Epidemic Curves: Do Children Drive the Spread of Influenza Epidemics?
- Spatial and Temporal Characteristics of the 2009 A/H1N1 Influenza Pandemic in Peru

5. Notifications
- Radio panel discussion on Europe E. coli outbreak
- ISID-Neglected Tropical Diseases Meeting
- 5th Ditan International Conference on Infectious Diseases
- Influenza 2011: Zoonotic Influenza and Human Health


1. Influenza News

Global
2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 2 (0)
Cambodia / 6 (6)
Egypt / 30 (11)
Indonesia / 7 (5)
Total / 45 (22)

***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: 561 (328) (WHO 6/16/2011)
http://www.who.int/csr/disease/avian_influenza/country/cases_table_2011_06_16/en/index.html

Avian influenza age distribution data from WHO/WPRO (last updated 2/7/2011):
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 5/2/11):
http://www.who.int/csr/disease/avian_influenza/H5N1_avian_influenza_update.pdf

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Global: South Africa battling influenza, few other global hot spots
With the Southern Hemisphere entering its flu season, the only country to see a dramatic activity spike so far is South Africa, where the 2009 H1N1 virus is dominating and has been linked to an increase in severe infections, the World Health Organization (WHO) said 17 June 2011.

The flu season is over in Northern Hemisphere countries and is circulating locally in some tropical locations, such as Ghana and Togo, the WHO reported.

Australia is reporting that the level of doctor's visits for flu-like illness is stable and is below levels seen in June of 2008 and 2010. Though that statistic is also below the seasonal threshold in New Zealand, one Northland district has exceeded its baseline. So far influenza B is the most common virus circulating in New Zealand, although numbers are small, the WHO said. Australia's health ministry said that, in spite of low overall flu levels, South Australia recently reported an increase in flu activity, most of it influenza B. Queensland state has recorded the country's highest number of flu infections so far in 2011. Most virus detections have been the 2009 H1N1 virus, though H3N2 and influenza B are cocirculating.

Some South American countries are reporting low flu activity, limited to localized transmission. For example, Brazil is reporting low levels of influenza B and H3N2 circulation, and Bolivia and Colombia are reporting a slight increase in flu activity—H3N2 in Bolivia and 2009 H1N1 in Colombia. Colombia has reported an increase in intensive care admissions for severe respiratory infections, but most of the patients are children under age five, and the respiratory syncytial virus has been in wide circulation in recent weeks, the WHO noted.

In African countries, flu viruses circulating locally show a mixed picture, with Ghana reporting mostly the 2009 H1N1 virus and Togo reporting mainly influenza B. Nigeria and Cameroon are also reporting modest numbers of influenza B viruses.

Tropical Asian countries are reporting low flu activity, with influenza B dominant in locations such as southern China, India, and Cambodia. However, the 2009 H1N1 virus is more common in Vietnam, where about 10% of patients with flu-like illnesses are testing positive for flu.

On 17 June 2011, The US Centers for Disease Control and Prevention (CDC) said that although the percentage of respiratory samples positive for influenza is extremely low at 0.32%, the percentage of deaths from flu and pneumonia crept slightly above the epidemic threshold of 7% to 7.2%. Two more pediatric flu deaths were reported, raising the total for the season to 108. Both of the deaths were linked to the 2009 H1N1 virus.
(CIDRAP 6/17/2011)

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Asia
Australia: FDA finds CSL probe into flu-vaccine side effects inadequate
The US Food and Drug Administration (FDA) called the investigation into flu-vaccine side effects in children by vaccine maker CSL Biotherapies of Australia “inadequate”. The agency cited “a number of significant objectionable conditions” that contravened good manufacturing practice (GMP) at CSL's plant in Parkville, Victoria. Australian officials pulled CSL's seasonal flu vaccine Fluvax from use in children younger than five years old after 23 children from Western Australia were hospitalized with post-vaccination convulsions and high fever, according to the Melbourne-based Herald Sun on 22 June 2011. The company's investigation found that adverse events were reported in one in ten children from one Fluvax batch, which is about ten times higher than expected. By the time the vaccine was taken off the market, 67 cases of convulsions, high fever, and vomiting were reported. The FDA letter cited a lack of documentation of the investigation, limited analysis of the manufacturing process, no assessment of the testing of raw material, and other problems. In a response to the letter on 21 June 2011, CSL Biotherapies Executive Vice President Dr. Jeff Davies said, our technical team is in the process of preparing more substantive detail about our corrective actions to meet the FDA's requirements. We will work diligently with the FDA to resolve these GMP issues as quickly as possible.
(CIDRAP 6/22/2011)

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Africa
Egypt: Reports five H5N1 avian influenza infections, three fatal
Egypt announced five new H5N1 avian influenza infections that occurred in May, three of them fatal, the World Health Organization (WHO) said on 16 June 2011.

The infections were reported from four different governorates, and four of the case-patients are adults. The WHO said investigations revealed all five of the patients had been exposed to poultry that had suspected avian influenza. Their infections push Egypt's H5N1 totals to 149 cases, including 51 deaths.

The first case is in a 40-year-old woman from Aswan governorate who got sick on 14 May 2011. She was hospitalized, where she was treated with oseltamivir (Tamiflu). She recovered and has been discharged from the hospital.

Two of the patients are from Menoufia governorate's Ashmoun district, a 21-year-old pregnant woman and a 16-year-old boy. The report didn't say if the two cases had any connections, besides the geographic location. They both started having symptoms on 21 May 2011. The woman died on 29 May 2011 after she was hospitalized and treated with oseltamivir. The boy was in critical condition, but is recovering in the hospital after antiviral treatment.

The fourth case-patient is a 31-year-old man from Qaliobia governorate who got sick on 21 May 2011 and died on 5 June 2011 after he was hospitalized and treated with oseltamivir.

The fifth H5N1 infection was detected in a 32-year-old man from Cairo governorate who became ill on 23 May 2011 and was hospitalized and received oseltamivir. He died on 2 June 2011. The United Nations Food and Agriculture Organization (FAO) reported a fatal H5N1 infection in an Egyptian patient from Cairo governorate on 8 June 2011, with few other details available other than a 23 May 2011 observation date. It's not clear if the WHO and FAO reports are referring to the same patient.

As of 16 June 2011, Egypt has reported 30 H5N1 infections in 2011, which exceeds the 29 cases it reported for all of 2010. However, the number of infections is still below 2009 levels, when the country saw its H5N1 case count hit 39, its highest yearly total. Egypt's latest H5N1 infections raise the global count to 561 cases, including 328 deaths.
(CIDRAP 6/16/2011)

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Egypt: Man dies of H5N1 avian influenza
Egypt's Ministry of Health has confirmed that a 27-year-old man has died of H5N1 avian flu, according to the World Health Organization (WHO) on 22 June 2011. The man, from the Deshna district of Qena governorate, first developed symptoms on 5 June 2011, was hospitalized and given oseltamivir (Tamiflu) on 13 June 2011, and died 14 June 2011. Officials said he had been exposed to poultry that were suspected to have avian flu. The case was confirmed by a lab in Cairo, a National Influenza Center of the WHO's Global Influenza Surveillance Network. His case brings Egypt's 2011 total to 31, including 12 deaths. Since 2006 the country has confirmed 150 H5N1 cases and 52 deaths. The global count for WHO-confirmed H5N1 cases now stands at 562, with 329 deaths, for a case-fatality rate of 58.5%.
(CIDRAP 6/22/2011)

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2. Infectious Disease News

Global
Global: EHEC outbreak update
In the EU/EEA, 853 HUS cases, including 28 deaths, and 2,833 non-HUS cases, including 12 deaths, have been reported. On 21 June 2011, Germany reported four new HUS cases and 89 new non-HUS STEC cases.

Total cases: 3,686 with 40/3,686 -- 1.08% case fatality rate.
(ECDC 6/21/2011)

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Europe/Near East
Germany: EHEC outbreak update
Since week 23 June 2011, the number of reported cases of haemolytic uraemic syndrome (HUS)/enterohaemorrhagic Escherichia coli (EHEC) has declined significantly. In Germany, the daily numbers of reported cases have steadily decreased since they peaked on May 22 2011. Nevertheless, the cumulative numbers of cases from Germany continue to rise, primarily owing to delays in notification.

Investigations by the German authorities indicate that the vehicle of the bacterium responsible for the outbreak, enteroaggregative verocytotoxin-producing E. coli (EAggEC VTEC) O104:H4, is bean and seed sprouts, and the Robert Koch Institute has warned people in Germany not to eat raw sprouts of any origin.

The latest date of onset of diarrhea for a HUS case is 12 June 2011 and for an EHEC case, 15 June 2011. All but five of the HUS and EHEC cases were in people who had travelled to or lived in Germany during the incubation period for infection, typically three to four days after exposure (range: two to ten days). The remaining five cases can also be linked to the outbreak in Germany.
(WHO 6/23/2011)

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Germany: Unusual traits blended in E. coli strain
The E. coli bacteria that killed dozens of people in Germany over the month of June 2011 have a highly unusual combination of two traits and that may be what made the outbreak among the deadliest in recent history, scientists there are reporting.

One trait was a toxin, called Shiga, that causes severe illness, including bloody diarrhea and, in some patients, kidney failure. The other is the ability of this strain to gather on the surface of an intestinal wall in a dense pattern that looks like a stack of bricks, possibly enhancing the bacteria’s ability to pump the toxin into the body.

The thought is that the bacteria started out being able to aggregate with the brick pattern and then were infected with a bacterial virus that gave them the Shiga toxin, said Dr. Matthew K. Waldor, an infectious-disease expert at Harvard Medical School who was not connected with the new research.

With the two traits combined in one strain of E. coli bacteria, now they are highly virulent, Dr. Waldor said. The new findings, by a team led by Dr. Helge Karch of the University of Münster, were published on 22 June 2011 in the journal Lancet Infectious Diseases. They result from two days of fevered work to characterize the bacteria causing the illness that raced through Germany in May 2011.

Experts in the United States praised the German scientists’ work. The work and the entire outbreak are a real game-changer, said Dr. Philip I. Tarr, a professor of pediatrics and an expert in gut infections at the Washington University School of Medicine in St. Louis. Dr. John Mekalanos of Harvard called the paper extremely important.

The full article may be accessed at http://www.nytimes.com/2011/06/23/health/research/23ecoli.html.
(The New York Times 6/22/2011)

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Asia
Hong Kong: Alert over high level of scarlet fever cases
On 20 June 2011 the Centre for Health Protection (CHP) of the Department of Health urged members of the public to maintain vigilance against scarlet fever as the number of reported cases remained at a high level.

A spokesman for the CHP said that the number of scarlet fever cases reported to the CHP up to 17 June 2011 reached 419, which exceeded the annual number of cases recorded in the past ten years. The number of reports surged since April 2011, with 75 cases recorded in April 2011, 100 cases in May 2011 and 142 cases up to 17 June 2011.

Among the 419 cases, the patients aged between one month and 37 years old. 93% of cases were children under ten years old. Most cases were mild and their characteristics were similar to cases reported in previous years.

So far, there have been six institutional outbreaks in 2011, comprising three kindergartens / child care centers, two primary schools and one residential special child care centre. A total of 22 persons were affected, with two to seven cases involved in each outbreak. Another 11 small clusters occurred in household settings, affecting two to three persons in each cluster.

The spokesman said the CHP is attentive to the high level of scarlet fever activity for 2011 and is closely monitoring the situation. A simultaneous increase of scarlet fever cases is also noted in the Mainland and Macao, suggesting a regional phenomenon at play. Letters have been issued to doctors, institutions and schools to remind them to take prevention and control measures.

The CHP has commissioned the Department of Microbiology of the University of Hong Kong (HKU) to perform genetic study on the bacterium (Group A Streptococcus) causing scarlet fever. On testing an isolate from the six-year-old boy who developed septicaemia, as reported on 13 June 2011, the HKU found that one unique gene fragment was inserted into the genome of the bacteria, which might contribute to increased transmissibility of this strain.

CHP will collaborate with the Department of Microbiology of HKU to perform genetic study on other recent scarlet fever cases. The Public Health Laboratory Centre under CHP is also closely monitoring the genetic sequences among local cases stated the spokesman. The CHP will inform the Mainland and Macao health authorities of this finding.

The CHP will further strengthen public education on scarlet fever prevention. The spokesman explained that scarlet fever is caused by Group A Streptococcus bacteria and can be cured by appropriate antibiotics. This disease usually affects children under ten years of age and presents as fever, sore throat and rash. The rash appears over the trunk and neck and spreads to the limbs especially the armpits, elbows and groin. The illness is usually clinically mild but can be complicated by shock, heart and kidney diseases.
(Dept. of Health, the Government of the Hong Kong Special Administrative Region 6/20/2011)

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Australia (New South Wales): Fatal respiratory syncytial virus in nursing home
A highly infectious respiratory virus is being blamed for the deaths of five elderly people at a nursing home in Westmead, Sydney. According to reports, 50 people contracted respiratory syncytial virus infection (RSC) akin to a severe chest infection, at the Mayflower Nursing Home. Contagious like a common cold, the illness spread rapidly and Mayflower reportedly put infection control procedures in place. They were compelled to close the facility to the public.

NSW (New South Wales State) Health inspected the nursing home when the outbreak was reported and found no obvious breach of protocols or hygiene. A number of those people became quite ill and unfortunately some of those people did die, says Dr. Vicky Sheppeard from NSW Health addressing the unusual loss of five people within the same facility in a month. It's been extraordinarily difficult, it's been very sad and the staff have at all times worked to the standards we really expect of them, she continued.

It is believed that the infection was brought into the nursing home by a visitor. Currently there is no vaccine to protect against respiratory syncytial virus.
(ProMED 6/15/2011)

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Australia (New South Wales): Murine typhus must be considered in meningoencephalitis
The first case of murine typhus occurring in New South Wales (NSW), Australia since the 1940s has been reported in a 20-year-old rural man who became ill after contact with a pet rat. The case is the first in Australia of murine typhus causing isolated meningoencephalitis with raised intracranial pressure, neurologists said.

The man, from the mid-north coast of NSW, recovered after antibiotic treatment and 17 days in hospital. The case illustrates that murine typhus should be considered in the differential diagnosis of a patient presenting with 'aseptic' meningitis or meningoencephalitis with or without raised intracranial pressure, stated the specialist.
(ProMED 6/20/2011)

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China: Novel Bunyavirus disease
As of 16 June 2011, more than 280 cases of tick-borne disease have been reported in central and east China's provinces of Henan, Hubei, Shandong, Anhui and Jiangsu, according to the Chinese Center for Disease Control and Prevention (CDC). A dozen people have died from the disease. 90% of the cases occurred in people over 40 years of age, and farmers accounted for 90% of these cases.

The tick-borne disease, named by the center as fever-thrombocytopenia syndrome, is a new infectious disease caused by Bunyavirus found in central China regions. The CDC said that most of the victims have suffered from nausea, fatigue and a lack of appetite.

In October of 2010, the Ministry of Health issued a guideline on the control and prevention of tick-borne diseases, asking local governments to report on possible cases through a nationwide disease control network.
(ProMED 6/16/2011)

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Indonesia: Legionnaires' disease warning for Bali travelers
The Department of Health issued the warning on 10 June 2011 after a WA (Australian state of Western Australia) woman was found to have developed the disease. The department's communicable disease control director, Paul Armstrong, says the latest diagnosis brings the state's total to ten since August 2010. Five other people from around the nation are also found to have contracted Legionnaires' disease after travel in Bali.

Dr. Armstrong said the source of the disease remained unknown, but all infected Western Australians had stayed in the central Kuta area. The early symptoms of Legionnaires' disease are similar to a severe flu-like illness, he said. People most susceptible to Legionnaires' disease include middle-aged and elderly people, particularly those who smoke or have a lung disease, diabetes, kidney disease, or a weakened immune system. People with these risk factors who visit Bali should avoid the central area of Kuta in the vicinity of the intersection of Jalan Signosari and Jalan Kartika Plasa, he said.

In February 2011, the health department narrowed down the cause of a Legionnaires' outbreak to a Kuta hotel, linked to the infection of at least two Western Australians.
(ProMED 6/10/2011)

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New Zealand: Large measles outbreak hits city
17 people have been confirmed as having measles in Auckland, the second largest outbreak in the city for 2011. Auckland Regional Public Health Service (ARPHS) medical officer of health Richard Hoskins said all cases were linked to Oratia Primary School in west Auckland, with three people requiring hospitalization. Almost all of those struck by the illness were not immunized.

Dr. Hoskins said ARPHS was trying to trace people who may have been exposed to the infection. More than 200 individuals, as well as large groups such as schools, had been traced so far, with some instructed to isolate themselves. Measles must be taken very seriously, especially as we are seeing an increase in the number of cases presenting. It is a disease that can have severe complications, especially in vulnerable groups in the community, including children too young to be immunized, pregnant women, and those with suppressed immunity.

Dr. Hoskins urged those who had been isolated to remain at home and avoid contact with other people. And as always, we urge people to be vigilant if they suspect they could have measles, or have been exposed to someone who could have measles. Getting measles can be avoided by immunization with the MMR (measles, mumps, rubella) vaccine, which is typically given in two doses, at 15 months and four years of age. Immunization not only protects your child from serious illness, but also protects more vulnerable children and members of the community who could suffer more serious illness or death.
(ProMED 6/15/2011)

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Philippines (Palo, Leyte): Schistosomiasis grips villages
A total of 99 persons from Palo, Leyte, have fallen ill due to schistosomiasis, a parasitic disease that is spread by contact with contaminated water. Lilia Navarra, laboratory technician of the Schistosomiasis Research and Training Center based in Palo, said authorities examined the stool and blood samples of 148 persons, and found that 99 of them had schistosomiasis.

The patients were from the 33 barangays (the smallest administrative division in the Philippines) of Palo, about 12 km (7.5 mi) from the capital city of Tacloban, which was one of the areas in Leyte that were hit by floods on 16 and 17 March 2011. The floods that hit Palo in March 2011 were confirmed as the cause of the spread of infection.

The number of patients may rise since several people from different barangays in Palo had visited the center to have their blood and stool samples examined for possible infection, said Navarra.

On 8 June 2011, 23 persons went to the center for tests. One of them was a 21-year-old woman, who asked not to be identified. She said she had been suffering from fever and body malaise in the past few days. She decided to go to the center after several of her neighbors tested positive of schistosomiasis. I just hope that my test results will be negative, she said.

According to Navarra, the patients may have waded in flood waters which were populated with snails, the intermediate host of cercaria, and the parasitic larvae that cause the disease.
(ProMED 6/10/2011)

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Philippines (Cotabato City): Suspected measles outbreak
Health officers in Cotabato City fear a possible measles outbreak at evacuation centers amid two suspected cases of the disease. Some 8,000 families were forced to leave their homes and transfer to evacuation centers as floods submerged Cotabato City, affecting over 25,000 families in 33 out of the city's 37 barangays (suburbs).

Seven were reportedly killed in North Cotabato, while another person is missing in Cotabato City due to the floods. An estimated 140,000 people have been affected by the floods, more than half of the city's population. Floodwaters have also entered the town proper. A state of emergency was declared in Pikit, North Cotabato, Cotabato City and in Maguindanao on 11 June 2011 following incessant rains.
(ABC News 6/18/2011)

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Viet Nam: Hand-foot-mouth disease widespread
The Preventive Medicine Department reported on 11 June 2011 that since the beginning of this 2011, the country has recorded over 7,300 cases of hand-foot-mouth disease with 26 deaths. The department added that the number was 40% higher than during the same period in 2010 and most of the patients were young children.

There have been over 1,200 cases of hand-foot-mouth disease in 28 provinces and cities around the country within the week of 12 June 2011 alone.

All the southern provinces and cities are presently facing an epidemic of the disease, which has already resulted in 24 deaths. The northern region has recorded 14 cases of hand-foot-mouth disease without any fatalities.
(ProMED 6/12/2011)

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Americas
Canada (British Columbia): Mumps outbreak hits Metro Vancouver
The British Columbia Centre for Disease Control (BCCDC) has issued a health alert for mumps virus infection for the Lower Mainland, following an outbreak in Whistler earlier this spring 2011. A total of 77 people have contracted the disease according to the BCCDC. About 50 of those cases were from an earlier outbreak in Whistler and Squamish and the rest have been in the Lower Mainland. About 70% of the cases were between 18 and 35 years of age, but cases have ranged from one to 54 years of age.

We do have cases in the Vancouver area now, whereas the earlier part of the outbreak was really in Whistler and Squamish, said Dr. Monica Naus. It's the first sizeable mumps outbreak in the province since 2008 and it is largely affecting young adults. But the centre did not say how many cases have been discovered or specify where it has been detected around Metro Vancouver or the Fraser Valley. In 2008 nearly 200 people in the Fraser Valley and Metro Vancouver were infected with the normally rare virus. The outbreak was been traced back to a Fraser Valley religious group that opposes the mumps vaccination.

The center is asking parents to immunize their children with the MMR vaccine and for adults to make sure their own immunizations are up to date. In BC, children receive two doses of mumps vaccine at 12 and 18 months. The vaccine is given as the combined measles, mumps and rubella (MMR) vaccine, and provides protection against all three diseases. For best protection against mumps, those born in 1970 and later should also receive two doses.

Since 1995, children in BC have received a mumps vaccine at 12 months of age and 18 months, Dr Perry Kendall, the provincial health officer said in 2008. But older children may have only gotten one dose of the vaccine, meaning they are at an 80% level of protection, versus 95% protection for those with a second dose.
(ProMED 6/21/2011)

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Canada (Quebec): MMR vaccine update
Almost a decade ago, measles was declared eradicated in the Americas, thanks to widespread vaccination efforts. But outbreaks in Quebec and several of the United States show that Western Hemisphere countries are still not immune to the virus, which can be imported by travelers and quickly infect pools of the unprotected. And the number of those vulnerable to measles may, in fact, be growing, as some parents choose not to vaccinate their children for various reasons, among them fear of possible side effects or a belief that measles and other infectious diseases are merely a benign rite of passage in childhood.

Quebec's outbreak, which began in early 2011 and in the week of 11 June 2011 jumped to 330 confirmed and suspected cases, has been traced to a traveler from France, where uptake of the measles, mumps and rubella (MMR) vaccine hovers around 60% of the population, far below the 90% plus rate in Canada. Information provided by Quebec health authorities shows most of those infected were unvaccinated or inadequately vaccinated, making them easy targets for the highly infectious virus, said Dr. John Spika of Canada's Public Health Agency.
(ProMED 6/11/2011)

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Chile: Salmonella outbreak affects 47 people in the Biobio Region
The Emergency Unit of the Regional Hospital treated 25 people for foodborne illness: two children, a pregnant woman and two adults, one elderly person and a diabetic. Five people remain hospitalized at the Guillermo Grant Benavente de Concepcion Hospital related to a salmonellosis outbreak that affected 47 individuals who ingested homemade mayonnaise.

They consumed homemade mayonnaise at a baptism in the Concepcion municipality. There are 18 cultures from patient specimens that confirmed the illness as salmonellosis and six food samples have been taken, but results of these are still pending, said Andrea Silva, from the Epidemiology Unit the Health SEREMI Regional Offices of the Health Ministry in Biobio.
(ProMED 6/17/2011)

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USA: Number of measles cases becoming a concern
Health officials say that 118 cases of measles have been reported already for 2011; that's the highest number of measles cases to be reported this early in the year since 1996.

On 14 June 2011, The Centers for Disease Control and Prevention released the count for 1 January to 20 May 2011. Cases were seen in 23 states. None of the patients died, but about 40% were hospitalized. The US normally sees about 50 cases of measles in a year, thanks to vaccinations. About 90% of the cases in 2011 were unvaccinated. Measles is highly contagious and up to 90% of people exposed to an infected person get sick. The virus spreads easily through the air and in closed rooms; infective droplets can linger for up to two hours.
(ProMED 6/15/2011)

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USA (Maine): Hantavirus update
On 25 April 2011, the Maine Center for Disease Control and Prevention was notified of a suspected case of hantavirus pulmonary syndrome (HPS) in a 70-year-old man with no recent out-of-state travel. The Maine resident went to a community hospital in early April 2011 with a five-day history of fatigue, decreased appetite, weakness, chills, myalgias, and progressive shortness of breath. On examination, he was hypoxic and tachypneic. The patient was admitted with laboratory evidence of acute renal insufficiency, leukocytosis and thrombocytopenia, and appearance of diffuse bilateral infiltrates on chest radiograph. Two days later, he was transferred to a tertiary-care facility for management of respiratory failure with hypoxemia and worsening renal insufficiency. The next day, he was intubated and mechanically ventilated. Serum specimens demonstrated high titers of hantavirus reactive immunoglobulin M (1:6400) and immunoglobulin G (1:1600) antibodies. Hantavirus RNA was detected in the patient's blood. The patient was discharged to a skilled nursing facility one month after admission and is recovering with extensive rehabilitation.

HPS is caused by hantavirus infections. The viruses are transmitted to humans by exposure to excreta or direct contact with infected rodents. An investigation revealed that the patient had potential exposure to rodent excreta on his farm. A grain storage shed was not rodent-proof and had grain on the floor. The patient reportedly had climbed a ladder to place rodenticide in the upper level of the shed, where insulation was contaminated with rodent droppings.

HPS is a life-threatening illness first identified in 1993 following an outbreak of unexplained, severe pulmonary illness in the southwestern United States. As of 15 December 2010, a total of 560 HPS cases from 32 states had been reported to CDC, including 529 since 1993; until this case, none of the cases had been diagnosed or contracted in Maine.

However, potential reservoirs for pathogenic hantaviruses exist across the entire continental United States. This case highlights the importance of clinician and public awareness of HPS and avoidance of risk factors for hantavirus infection (i.e., exposure to rodent droppings in the home, vacation home, workplace, or campsite), even in regions of the United States that have not had documented cases previously. Early recognition of HPS can reduce mortality.
(ProMED 6/19/2011)

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USA (Missouri): Deadly fungus strikes Joplin Tornado survivors and volunteers
The Greene County (Missouri) Health Department has issued a memo to health care workers who are treating injured victims of the 22 May 2011 deadly Joplin, Missouri tornado, warning them that a powerful fungus has infected patients' wounds.

As many as nine cases have been reported in tornado victims across the area in various hospitals. Once the aggressive fungus (of the class, Zygomycetes) enters the body, they cause the death of infected cells. Three or four patients, who otherwise would have survived their wounds, have died from the fungal infection.

If the fungus stays in a limb, like an arm or leg, some treatments have necessitated amputation to save the patient. Others with wounds near the head weren't so lucky, as soon as brain tissue started dying; it was too late to save the patient.

The National Institutes of Health says this rapid form of infection most often occurs in patients with suppressed immune systems. One study in 2009 noted a diabetes patient who died of the fungal infection at age 48. Despite being treated early, the man's health rapidly declined as the fungus spread through his lungs.

Infections spread through the blood and affects blood circulation. It is unknown how many people may be suffering from infections, but the problem doesn't stop with those injured by the tornado.

KYTV in Springfield reports those helping with cleanup efforts may become scratched by nails or splinters and any fungus residue on those objects may infect someone.

Anyone with diabetes should be extremely careful. The National Institutes of Health lists severe symptoms of the infection: fever, headache, sinus pain, and swelling. Complications that can arise from these fungal infections include nerve damage, blindness, blood clots to the brain and lungs, or even death in extreme cases.

Cases of the deadly fungal infection have shown up in massive disasters before such as the 2004 tsunami off the coast of Indonesia. Health officials in Greene County stated in their memo that this particular infection is invasive and that aggressive treatment may be needed within 24 hours of recurring symptoms. Any patients suspected of having this infection have been told to seek the guidance of a trauma surgeon or the infectious disease doctor on call.
(ProMED 6/12/2011)

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USA (Washington, Montana): Q fever, goat disease spreads to humans
Health officials are working to contain a rare bacterial infection called Q fever that has spread from goats to humans and sickened at least 11 people in Washington and Montana. The illness since May 2011 has stricken five people in the Moses Lake, Washington area with flulike symptoms. Officials also have traced infected goats to Cascade and Teton counties in Montana, where six people have become ill, officials said on 23 June 2011.

The goats from the Moses Lake area have also been traced to nine other counties in Washington, said Donn Moyer of the Washington state Health Department. No illnesses have been confirmed in other counties, Moyer said. This is a case of following the goats to see if the disease goes with them. The disease can take several weeks to appear after a human is exposed, he said. Moyer said human cases of Q fever are rare, with no more than three confirmed cases per year in the state.

It does raise your eyebrows a little bit, he said of the five cases in Grant County. The information we have is that no one had a particularly serious illness. The illness is treated with antibiotics, Moyer said. Many people can be infected with the bacteria and not know it, Moyer said. Most at risk of getting sick are pregnant women, people with suppressed immune systems and people with heart valve problems, he said.

The outbreak began at a Grant County farm that breeds and sells goats, Moyer said. Some of the goats had trouble giving birth in April 2011 and were found to be infected with the Q fever bacteria, he said. Goats from that farm were subsequently traced to Spokane, Adams, Pend Oreille, Walla Walla, Franklin, Clark, Thurston, Kittitas and Chelan counties of Washington. The cases are being investigated by local, state and federal experts, he said.

People can become ill with the bacteria if they inhale barnyard dust particles contaminated by infected animals. They suffer flulike symptoms and can develop pneumonia or hepatitis, Moyer said. High fever, headaches, malaise, abdominal pain, chills, muscle pain, chest pain, nausea, vomiting and diarrhea can be caused by the bacteria. Left untreated, serious cases of Q fever can lead to chronic illness that may affect a person's heart, liver, brain and lungs and may be fatal. The infected goats were used in shows and possibly for meat.
(The Seattle Times 6/23/2011)

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USA (Wisconsin): Camplyobacteriosis tied to raw milk consumption; 16 people sickened
Laboratory test results show that the Campylobactor jejuni bacterium that caused diarrheal illness among 16 individuals who drank unpasteurized (raw) milk at a school event early June 2011 in Raymond was the same bacterial strain found in unpasteurized milk produced at a local farm, according to officials from the Department of Health Services (DHS) and Western Racine County Health Department (WRCHD). A parent had supplied unpasteurized milk from the farm for the school event.

Stool samples submitted to the WRCHD by ill students and adults were sent to the State Laboratory of Hygiene where they tested positive for the bacterium. Department of Agriculture, Trade and Consumer Protection (DATCP) food inspectors collected milk samples from the bulk tank at the farm, which tested positive for Campylobacter jejuni. Further testing by the State Hygiene lab showed the bacterial strains from the stool samples and the milk samples matched.

Additionally, interviews with event attendees revealed that consuming the unpasteurized milk was statistically associated with illness. Health officials said that this combination of laboratory and epidemiological evidence indicates that the illnesses were caused by the unpasteurized milk consumed at the school event.

The farm did not sell the unpasteurized milk and there was no legal violation associated with the milk being brought to the school event. The farm is licensed and in good standing with the Department of Agriculture, Trade and Consumer Protection.
(ProMED 6/19/2011)

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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 (Queensland)
Queensland Health has declared dengue fever outbreaks in Innisfail, Cairns, and Townsville to be officially over. During the outbreaks, 69 people were diagnosed with the mosquito borne disease. The worst was in Innisfail where 47 people were reported as being infected with the potentially life-threatening illness. About half of those required admission to hospital. Tropical Regional Services public health medical officer Steven Donohue said three months had elapsed since the last new dengue fever case was recorded on 14 March 2011, allowing authorities to declare the outbreaks over.
(ProMED 6/14/2011)


Peru (Loreto)
On 13 June 2011, a patient with DHF was evacuated to Iquitos. There are now three patients hospitalized with dengue. In the week of 13 June 2011 the Aedes aegypti house index was 11%. An alarm is given when the house index reaches 5%.
(ProMED 6/14/2011)

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4. Articles
Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany — Preliminary Report
Frank C, Werber D, Cramer JP, et al. N Engl J Med. 22 June 2011; doi: 10.1056/NEJMoa1106483.
Available at http://www.nejm.org/doi/full/10.1056/NEJMoa1106483?query=TOC

Background. In this report, we provide a preliminary description of an ongoing large outbreak of gastroenteritis and the hemolytic–uremic syndrome caused by Shiga-toxin–producing Escherichia coli in Germany in May and June 2011.

Methods. We analyzed data from reports in Germany of Shiga-toxin–producing E. coli gastroenteritis and the hemolytic–uremic syndrome and clinical information on patients presenting to Hamburg University Medical Center. An outbreak case was defined as a reported case of the hemolytic–uremic syndrome or of gastroenteritis in a patient infected by Shiga-toxin–producing E. coli, serogroup O104 or serogroup unknown, with an onset of disease on or after May 1, 2011, in Germany.

Results. As of June 18, 2011, a total of 3222 outbreak cases (including 39 deaths) have been reported in Germany, 810 of which (25%) involved the hemolytic–uremic syndrome. The outbreak is centered in northern Germany and peaked around May 21 to 23. Most of the patients in whom the hemolytic–uremic syndrome has developed are adults (89%; median age, 43 years), and women are overrepresented (68%). The estimated median incubation period is 8 days, with a median of 5 days from the onset of diarrhea to the development of the hemolytic–uremic syndrome. Among 59 patients infected with the outbreak strain who were prospectively followed at Hamburg University Medical Center, the hemolytic–uremic syndrome developed in 12 (20%), with no significant difference between patients in whom the syndrome developed and those in whom it did not with respect to sex or reported initial symptoms and signs. The outbreak strain was typed as an enteroaggregative Shiga-toxin–producing E. coli O104:H4, producing extended-spectrum beta-lactamase.

Conclusions. In this large outbreak of the hemolytic–uremic syndrome, caused by an unusual strain of Shiga-toxin–producing E. coli, cases have occurred predominantly in adults, with a preponderance of cases occurring in women. The hemolytic–uremic syndrome has developed in a quarter of the symptomatic outbreak cases that have been ascertained thus far.

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An Assessment of Mumps Vaccine Effectiveness by Dose during an Outbreak in Canada
Deeks SL, Lim GH, Simpson MA, et al. CMAJ. 14 June 2011; 183(9):1014-20.
Available at http://www.cmaj.ca/cgi/content/full/183/9/1014

Background. This investigation was done to assess vaccine effectiveness of one and two doses of the measles, mumps and rubella (MMR) vaccine during an outbreak of mumps in Ontario. The level of coverage required to reach herd immunity and interrupt community transmission of mumps was also estimated.

Methods. Information on confirmed cases of mumps was retrieved from Ontario's integrated Public Health Information System. Cases that occurred between Sept. 1, 2009, and June 10, 2010, were included. Selected health units supplied coverage data from the Ontario Immunization Record Information System. Vaccine effectiveness by dose was calculated using the screening method. The basic reproductive number (R(0)) represents the average number of new infections per case in a fully susceptile population, and R(0) values of between 4 and 10 were considered for varying levels of vaccine effectiveness.

Results. A total of 134 confirmed cases of mumps were identified. Information on receipt of MMR vaccine was available for 114 (85.1%) cases, of whom 63 (55.3%) reported having received only one dose of vaccine; 32 (28.1%) reported having received two doses. Vaccine effectiveness of one dose of the MMR vaccine ranged from 49.2% to 81.6%, whereas vaccine effectiveness of two doses ranged from 66.3% to 88.0%. If we assume vaccine effectiveness of 85% for two doses of the vaccine, vaccine coverage of 88.2% and 98.0% would be needed to interrupt community transmission of mumps if the corresponding reproductive values were four and six.

Interpretation. Our estimates of vaccine effectiveness of one and two doses of mumps-containing vaccine were consistent with the estimates that have been reported in other outbreaks. Outbreaks occurring in Ontario and elsewhere serve as a warning against complacency over vaccination programs.

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Detection of Dengue Virus Type 4 in Easter Island, Chile
Fernández J, Vera L, Tognarelli J, et al. Arch Virol. 21 June 2011; doi:10.1007/s00705-011-1049-1 [Epub ahead of print].
Available at http://www.springerlink.com/content/4898152158725476/

Abstract. We report the detection of dengue virus type 4 (DENV-4) for the first time in Easter Island, Chile. The virus was detected in serum samples of two patients treated at the Hospital in Easter Island. The two samples were IgM positive, and the infection was confirmed by RT-PCR and genetic sequencing; viral isolation was possible with one of them. The Easter Island isolates were most closely related to genotype II of dengue type 4.

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Methicillin-Resistant Staphylococcus aureus Nasal Colonization among Adult Patients Visiting Emergency Department in a Medical Center in Taiwan
Lu SY, Chang FY, Cheng CC, et al. PLoS ONE. 13 June 2011; 6(6): e18620; doi:10.1371/journal.pone.0018620.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0018620

Background. Within the past 10 years, methicillin-resistant Staphylococcus aureus (MRSA) has not only been a hospital pathogen but also a community pathogen. To understand the carriage rate of methicillin-resistant Staphylococcus aureus (MRSA) among the adult patients visiting emergency department (ED), we conducted this study.

Methodology/Principal Findings. From May 21 to August 12, 2009, a total of 502 adult patients visiting emergency department (ED) of a tertiary care hospital in northern Taiwan were recruited in this study and surveyed for nasal carriage of MRSA. A questionnaire regarding the risk factors for MRSA acquisition was also obtained. The overall prevalence of MRSA nasal carriage among the patients was 3.8%. The carriage rate was significantly higher in patients with risk factors for MRSA acquisition (5.94%) than those without risk factors (2.12%). Patients with urinary complaints, diabetes mellitus, chronic kidney disease and current percutaneous tube usage were significantly associated with MRSA colonization. By multiple logistic regression analysis, only current usage of catheters or tubes was the independent predictor for MRSA nasal colonization. Of the 19 MRSA, most isolates belonged to one of two linages, characterized as sequence type (ST) 239 (32%) and ST 59 (58%). The latter linage, accounting for 83% of 6 isolates from patients without risk factors, is a community-associated (CA) clone in Taiwan, while the former linage is among healthcare-associated clones.

Conclusion/Significance. A substantial proportion of patients visiting ED, particularly with current usage of percutaneous catheter or tubes, in northern Taiwan carried MRSA, mostly community strains, in nares.

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Intussusception Risk and Health Benefits of Rotavirus Vaccination in Mexico and Brazil
Patel MM, López-Collada VR, Bulhões MM, et al. N Engl J Med. 16 June 2011; 364(24):2283-92.
Available at http://www.nejm.org/doi/full/10.1056/NEJMoa1012952

Background. Because postlicensure surveillance determined that a previous rotavirus vaccine, RotaShield, caused intussusception in 1 of every 10,000 recipients, we assessed the association of the new monovalent rotavirus vaccine (RV1) with intussusception after routine immunization of infants in Mexico and Brazil.

Methods. We used case-series and case-control methods to assess the association between RV1 and intussusception. Infants with intussusception were identified through active surveillance at 69 hospitals (16 in Mexico and 53 in Brazil), and age-matched infants from the same neighborhood were enrolled as controls. Vaccination dates were verified by a review of vaccination cards or clinic records.

Results. We enrolled 615 case patients (285 in Mexico and 330 in Brazil) and 2050 controls. An increased risk of intussusception 1 to 7 days after the first dose of RV1 was identified among infants in Mexico with the use of both the case-series method (incidence ratio, 5.3; 95% confidence interval [CI], 3.0 to 9.3) and the case-control method (odds ratio, 5.8; 95% CI, 2.6 to 13.0). No significant risk was found after the first dose among infants in Brazil, but an increased risk, albeit smaller than that seen after the first dose in Mexico--an increase by a factor of 1.9 to 2.6 - was seen 1 to 7 days after the second dose. A combined annual excess of 96 cases of intussusception in Mexico (approximately 1 per 51,000 infants) and in Brazil (approximately 1 per 68,000 infants) and of 5 deaths due to intussusception was attributable to RV1. However, RV1 prevented approximately 80,000 hospitalizations and 1300 deaths from diarrhea each year in these two countries.

Conclusions. RV1 was associated with a short-term risk of intussusception in approximately 1 of every 51,000 to 68,000 vaccinated infants. The absolute number of deaths and hospitalizations averted because of vaccination far exceeded the number of intussusception cases that may have been associated with vaccination. (Funded in part by the GAVI Alliance and the U.S. Department of Health and Human Services.).

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Nonlinear Effect of Climate on Plague during the Third Pandemic in China
Xu L, Liu Q, Stige LC, et al. Proc Natl Acad Sci USA. 21 June 2011; 108(25):10214-9.
Available at http://www.pnas.org/content/108/25/10214.long

Abstract. Over the years, plague has caused a large number of deaths worldwide and subsequently changed history, not the least during the period of the Black Death. Of the three plague pandemics, the third is believed to have originated in China. Using the spatial and temporal human plague records in China from 1850 to 1964, we investigated the association of human plague intensity (plague cases per year) with proxy data on climate condition (specifically an index for dryness/wetness). Our modeling analysis demonstrates that the responses of plague intensity to dry/wet conditions were different in northern and southern China. In northern China, plague intensity generally increased when wetness increased, for both the current and the previous year, except for low intensity during extremely wet conditions in the current year (reflecting a dome-shaped response to current-year dryness/wetness). In southern China, plague intensity generally decreased when wetness increased, except for high intensity during extremely wet conditions of the current year. These opposite effects are likely related to the different climates and rodent communities in the two parts of China: In northern China (arid climate), rodents are expected to respond positively to high precipitation, whereas in southern China (humid climate), high precipitation is likely to have a negative effect. Our results suggest that associations between human plague intensity and precipitation are nonlinear: positive in dry conditions, but negative in wet conditions.

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Ecological Factors Associated with Dengue Fever in a Central Highlands Province, Vietnam
Pham HV, Doan HT, Phan TT, et al. BMC Infect Dis. 16 June 2011; 11(1): 172 [Epub ahead of print].
Available at http://www.biomedcentral.com/1471-2334/11/172

Background. Dengue is a leading cause of severe illness and hospitalization in Vietnam. This study sought to elucidate the linkage between climate factors, mosquito indices and dengue incidence.

Methods. Monthly data on dengue cases and mosquito larval indices were ascertained between 2004 and 2008 in the Dak Lak province (Vietnam). Temperature, sunshine, rainfall and humidity were also recorded as monthly averages. The association between these ecological factors and dengue was assessed by the Poisson regression model with adjustment for seasonality.

Results. During the study period, 3,502 cases of dengue fever were reported. Approximately 72% of cases were reported from July to October. After adjusting for seasonality, the incidence of dengue fever was significantly associated with the following factors: higher household index (risk ratio [RR]: 1.66; 95% confidence interval [CI]: 1.62-1.70 per 5% increase), higher container index (RR: 1.78; 95% CI: 1.73-1.83 per 5% increase), and higher Breteau index (RR: 1.57; 95% CI: 1.53-1.60 per 5 unit increase). The risk of dengue was also associated with elevated temperature (RR: 1.39; 95% CI: 1.25-1.55 per 20C increase), higher humidity (RR: 1.59; 95% CI: 1.51-1.67 per 5% increase), and higher rainfall (RR: 1.13; 95% CI: 1.21-1.74 per 50 mm increase). The risk of dengue was inversely associated with duration of sunshine, the number of dengue cases being lower as the sunshine increases (RR: 0.76; 95% CI: 0.73-0.79 per 50 hours increase).

Conclusions. These data suggest that indices of mosquito and climate factors are main determinants of dengue fever in Vietnam. This finding suggests that the global climate change will likely increase the burden of dengue fever infection in Vietnam, and that intensified surveillance and control of mosquito during high temperature and rainfall seasons may be an important strategy for containing the burden of dengue fever.

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Estimation of Type- and Subtype-Specific Influenza Vaccine Effectiveness in Victoria, Australia Using a Test Negative Case Control Method, 2007-2008
Fielding JE, Grant KA, Papadakis G, et al. BMC Infectious Diseases. 14 June 2011; 11:170; doi:10.1186/1471-2334-11-170.
Available at http://www.biomedcentral.com/1471-2334/11/170

Background. Antigenic variation of influenza virus necessitates annual reformulation of seasonal influenza vaccines, which contain two type A strains (H1N1 and H3N2) and one type B strain. We used a test negative case control design to estimate influenza vaccine effectiveness (VE) against influenza by type and subtype over two consecutive seasons in Victoria, Australia.

Methods. Patients presenting with influenza-like illness to general practitioners (GPs) in a sentinel surveillance network during 2007 and 2008 were tested for influenza. Cases tested positive for influenza by polymerase chain reaction and controls tested negative for influenza. Vaccination status was recorded by sentinel GPs. Vaccine effectiveness was calculated as [(1 - adjusted odds ratio) x 100%].

Results. There were 386 eligible study participants in 2007 of whom 50% were influenza positive and 19% were vaccinated. In 2008 there were 330 eligible study participants of whom 32% were influenza positive and 17% were vaccinated. Adjusted VE against A/H3N2 influenza in 2007 was 68% (95% CI, 32 to 85%) but VE against A/H1N1 (27%; 95% CI, -92 to 72%) and B (84%; 95% CI, -2 to 98%) were not statistically significant. In 2008, the adjusted VE estimate was positive against type B influenza (49%) but negative for A/H1N1 (-88%) and A/H3N2 (-66%); none was statistically significant.

Conclusions. Type- and subtype-specific assessment of influenza VE is needed to identify variations that cannot be differentiated from a measure of VE against all influenza. Type- and subtype-specific influenza VE estimates in Victoria in 2007 and 2008 were generally consistent with strain circulation data.

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Transmission of Influenza-like Illness on International Flights, May 2009
Foxwell AR, Roberts L, Lokuge K, et al. Emerg Infect. July 2011; doi: 10.3201/eid1707.101135 [Epub ahead of print].
Available at http://www.cdc.gov/eid/content/17/7/pdfs/10-1135.pdf

Abstract. Understanding the dynamics of influenza transmission on international flights is necessary for prioritizing public health response to pandemic incursions. A retrospective cohort study to ascertain in-flight transmission of pandemic (H1N1) 2009 and influenza-like illness (ILI) was undertaken for 2 long-haul flights entering Australia during May 2009. Combined results, including survey responses from 319 (43%) of 738 passengers, showed that 13 (2%) had an ILI in flight and an ILI developed in 32 (5%) passengers during the first week post arrival. Passengers were at 3.6% increased risk of contracting pandemic (H1N1) 2009 if they sat in the same row as or within 2 rows of persons who were symptomatic preflight. A closer exposed zone (2 seats in front, 2 seats behind, and 2 seats either side) increased the risk for postflight disease to 7.7%. Efficiency of contact tracing without compromising the effectiveness of the public health intervention might be improved by limiting the exposed zone.

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Oseltamivir and Risk of Lower Respiratory Tract Complications in Patients with Flu Symptoms: A Meta-analysis of Eleven Randomized Clinical Trials
Hernán MA and Lipsitch M. Clin Infect Dis. 15 June 2011; doi: 10.1093/cid/cir400.
Available at http://cid.oxfordjournals.org/content/early/2011/06/14/cid.cir400.short?rss=1

Abstract. An independent reanalysis of 11 randomized clinical trials shows that oseltamivir treatment reduces the risk of lower respiratory tract complications requiring antibiotic treatment by 28% overall (95% confidence interval [CI], 11%–42%) and by 37% among patients with confirmed influenza infections (95% CI, 18%–52%).

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Phylogeography and Evolutionary History of Reassortant H9N2 Viruses with Potential Human Health Implications
Fusaro A, Monne I, Salviato A, et al. J. Virol. 15 June 2011; doi:10.1128/JVI.00219-11 [Epub ahead of print].
Available at http://jvi.asm.org/cgi/content/short/JVI.00219-11v1?rss=1

Abstract. Avian influenza viruses of the H9N2 subtype have seriously affected the poultry industry of the Far and Middle East since the mid-1990's and are considered one of the most likely candidates to cause a new influenza pandemic in humans. To understand the genesis and the epidemiology of these viruses we investigated the spatial and evolutionary dynamics of complete genome sequences of H9N2 viruses circulating in nine Middle Eastern and Central Asian countries from 1998 to 2010. We identified four distinct and co-circulating groups (A, B, C and D), each of which has undergone widespread inter- and intra- subtype reassortment, leading to the generation of viruses with unknown biological properties. Our analysis also suggested that Eastern Asia served as the major source for H9N2 gene segments in the Middle East and Central Asia, and that in this geographic region within-country evolution played a more important role in shaping viral genetic diversity than between-country migration. The genetic variability identified among the H9N2 viruses was associated with specific amino acid substitutions that are believed to result in increased transmissibility in mammals as well as resistance to antiviral drugs. Our study highlights the need to constantly monitor the evolution of H9N2 viruses in poultry to better understand the potential risk for human health posed by these viruses.

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Place of Influenza Vaccination among Adults --- United States, 2010--11 Influenza Season
Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 17 June 2011; 60(23):781-5.
Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6023a3.htm

Abstract. The 2010--11 influenza season was the first season after the 2009 influenza A (H1N1) pandemic and the first season that the Advisory Committee on Immunization Practices (ACIP) recommended influenza vaccination for all persons aged ¡Ý6 months (1). During the pandemic, many new partnerships between public health agencies and medical and nonmedical vaccination providers were formed, increasing the number of vaccination providers (2). To provide a baseline for places where adults received influenza vaccination since the new ACIP recommendation and to help vaccination providers plan for the 2011--12 influenza season, CDC analyzed information from 46 states and the District of Columbia (DC) on influenza vaccination of adults aged ¡Ý18 years for the 2010--11 season, collected during January--March 2011 by the Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which found that, for adults overall, a doctor's office was the most common place (39.8%) for receipt of the 2010--11 influenza vaccine, with stores (e.g., supermarkets or drug stores) (18.4%) and workplaces (17.4%) the next most common. For those aged 18--49 years and 50--64 years, a workplace was the second most common place of vaccination (25.7% and 21.1%, respectively). Persons aged ¡Ý65 years who were not vaccinated at a doctor's office were most likely (24.3%) to have been vaccinated at a store. The results indicate that both medical and nonmedical settings are common places for adults to receive influenza vaccinations, that a doctor's office is the most important medical setting, and that workplaces and stores are important nonmedical settings.

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Age-specific Differences in Influenza A Epidemic Curves: Do Children Drive the Spread of Influenza Epidemics?
Schanzer D, Vachon J, Pelletier L. Am J Epidemiol. 1 July 2011; doi: 10.1093/aje/kwr037 [Epub 30 May 2011].
Available at http://aje.oxfordjournals.org/content/early/2011/05/20/aje.kwr037.abstract

Abstract. There is accumulating evidence suggesting that children may drive the spread of influenza epidemics. The objective of this study was to quantify the lead time by age using laboratory-confirmed cases of influenza A for the 1995/1996–2005/2006 seasons from Canadian communities and laboratory-confirmed hospital admissions for the H1N1/2009 pandemic strain. With alignment of the epidemic curves locally before aggregation of cases, slight age-specific differences in the timing of infection became apparent. For seasonal influenza, both the 10–19- and 20–29-year age groups peaked 1 week earlier than other age groups, while during the fall wave of the 2009 pandemic, infections peaked earlier among only the 10–19-year age group. In the H3N2 seasons, infections occurred an average of 3.9 (95% confidence interval: 1.7, 6.1) days earlier in the 20–29-year age group than for youth aged 10–19 years, while during the fall pandemic wave, the 10–19-year age group had a statistically significant lead of 3 days compared with both younger children aged 4–9 years and adults aged 20–29 years (P < 0.0001). This analysis casts doubt on the hypothesis that younger school-age children actually lead influenza epidemic waves.

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Spatial and Temporal Characteristics of the 2009 A/H1N1 Influenza Pandemic in Peru
Chowell G, Viboud C, Munayco CV, et al. PLoS ONE. 21 Jun 2011; 6(6): e21287; doi:10.1371/journal.pone.0021287
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0021287

Background. Highly refined surveillance data on the 2009 A/H1N1 influenza pandemic are crucial to quantify the spatial and temporal characteristics of the pandemic. There is little information about the spatial-temporal dynamics of pandemic influenza in South America. Here we provide a quantitative description of the age-specific morbidity pandemic patterns across administrative areas of Peru.

Methods. We used daily cases of influenza-like-illness, tests for A/H1N1 influenza virus infections, and laboratory-confirmed A/H1N1 influenza cases reported to the epidemiological surveillance system of Peru's Ministry of Health from May 1 to December 31, 2009. We analyzed the geographic spread of the pandemic waves and their association with the winter school vacation period, demographic factors, and absolute humidity. We also estimated the reproduction number and quantified the association between the winter school vacation period and the age distribution of cases.

Results. The national pandemic curve revealed a bimodal winter pandemic wave, with the first peak limited to school age children in the Lima metropolitan area, and the second peak more geographically widespread. The reproduction number was estimated at 1.6–2.2 for the Lima metropolitan area and 1.3–1.5 in the rest of Peru. We found a significant association between the timing of the school vacation period and changes in the age distribution of cases, while earlier pandemic onset was correlated with large population size. By contrast there was no association between pandemic dynamics and absolute humidity.

Conclusions. Our results indicate substantial spatial variation in pandemic patterns across Peru, with two pandemic waves of varying timing and impact by age and region. Moreover, the Peru data suggest a hierarchical transmission pattern of pandemic influenza A/H1N1 driven by large population centers. The higher reproduction number of the first pandemic wave could be explained by high contact rates among school-age children, the age group most affected during this early wave.

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5. Notifications
Radio panel discussion on Europe E. coli outbreak
The Today show on CRI held a radio panel discussion on 13 June 2011 about the recent outbreak of E. coli cases throughout Europe and discussed the health/ medical impacts of E. coli in humans. Methods for future prevention of E. coli in the EU and other countries were also discussed. Audio files now available online at http://media.iphone.cri.cn/magazine/today/2011/06/110614today1.mp3 and http://media.iphone.cri.cn/magazine/today/2011/06/110614today2.mp3.
Additional information available at http://english.cri.cn/8706/more/8908/more8908.htm

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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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Influenza 2011: Zoonotic Influenza and Human Health
Oxford, England, United Kingdom, 7-9 September 2011
The 4th Oxford influenza conference, Influenza 2011, will address most aspects of basic and applied research on zoonotic influenza viruses and their medical and socio-economic impact, and invites proposals for podium and poster sessions in the following general areas: epidemiology and evolution; molecular virology and immunology; host-pathogen interaction - virulence and pathogenecity; mathematical models; national and international surveillance and contingency strategies; antiviral drug development and treatment strategies, including vaccination; and advances in viral detection and identification technologies.
Additional information at http://www.libpubmedia.co.uk/Conferences/Influenza2011/Influenza2011%20Home.htm

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 apecein@u.washington.edu