Vol. XIV No. 16 ~ EINet News Briefs ~ Aug 05, 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
- Australia: Influenza cases continue to climb
- Cambodia: Confirmed case of H5N1 avian influenza death
- USA: NIH head says universal influenza vaccine may be ready within five years

2. Infectious Disease News
- Global: ECDC, CDC offer standard terminology for multidrug-resistant bacteria
- USA (Michigan): Three tetanus cases in renew call for vaccinations
- Australia: States commit further $6m to fund Hendra research as authorities blame rain for spike
- Australia (Queensland): Second meningococcal case after student's death
- Hong Kong: Scarlet fever cases continue to ebb
- Malaysia (Bakun): Speculations on mysterious disease ends, deaths caused by melioidosis and leptospirosis
- New Zealand (Waikato): Two more measles cases confirmed
- Viet Nam: Severe hand, foot, and mouth disease epidemic reported
- USA: Multistate outbreak of human Salmonella Heidelberg infections
- USA: Papaya Salmonella strain has links to earlier outbreak
- USA (New York): Pertussis outbreak in two Columbia County school districts
- USA (Pennsylvania): Warns of measles exposure
- Canada (Ontario): Clostridium difficile superbug tied to 35th Niagara death
- Mexico: First measles case reported since 2007, with more possible cases detected

3. Updates

4. Articles
- Notes from the Field: Fatal Fungal Soft-Tissue Infections After a Tornado --- Joplin, Missouri, 2011
- Emergence of a New Pathogenic Ehrlichia Species, Wisconsin and Minnesota, 2009
- International Spread of an Epidemic Population of Salmonella enterica Serotype Kentucky ST198 Resistant to Ciprofloxacin
- Epidemiology and characteristics of antimicrobial resistance in China
- Clostridium difficile laboratory testing in Australia and New Zealand: national survey results and Australasian Society for Infectious Diseases recommendations for best practice
- Imported measles and implications for its elimination in Taiwan
- Enterovirus 68 among children with severe acute respiratory infection, the Philippines
- Novel arenavirus infection in humans, United States
- Early warning system for West Nile virus risk areas, California, USA
- Reassortment Events Among Swine Influenza A Viruses in China: Implications for the Origin of the 2009 Influenza Pandemic
- Potential role of human challenge studies for investigation of influenza transmission
- Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among healthcare workers in three countries

5. Notifications
- Influenza 2011: Zoonotic Influenza and Human Health
- 5th Vaccine and ISV Annual Global Congress
- Sixth TEPHINET Southeast Asia and Western Pacific Bi-regional Conference

1. Influenza News

2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 2 (0)
Cambodia / 7 (7)
Egypt / 31 (12)
Indonesia / 7 (5)
Total / 47 (24)

***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: 563 (330) (WHO 8/2/2011)

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 5/2/11):


Australia: Influenza cases continue to climb
Levels of influenza-like illness continue to climb in Australia as the country moves deeper into its winter flu season, its Department of Health and Ageing (DHA) said on 3 August 2011. As of 22 July 2011, the country had seen 10,060 confirmed cases of influenza, compared with just 1,571 for the same period in 2010. The DHA noted that Australia's flu season began very early in 2011. Queensland accounts for 4,501 confirmed cases, followed by New South Wales, with 2,040, and South Australia, with 1,706. Of the 2,333 flu cases reported the week of 18 July 2011, 813 (35%) were untyped influenza A, 774 (33%) were pandemic 2009 H1N1, 728 (31%) were influenza B, and 15 (less than 1%) were A/H3N2. Compared to the beginning of 2011, there appears to be very little A/H3N2 circulating. Overall in 2011, 7% of cases have been H3N2. In South Australia, influenza B represents 72% of all flu cases.
(CIDRAP 8/3/2011)


Cambodia: Confirmed case of H5N1 avian influenza death
The Ministry of Health (MoH) of the Kingdom of Cambodia has announced a confirmed case of human infection with avian influenza A (H5N1) virus.

The case was a 4-year-old female from Chork Reaksmey Village, Rohath Teuk Comune, Mongkul Borei District, Banteay Meanchey Province. She developed symptoms on 11 July 2011, was initially treated by local private practitioners with no effect and was later admitted to Jayavarma VII Hospital on 18 July 2011. She died on 20 July 2011, two days after admission.

There have been reports of poultry die off in her village and the case is reported to have had exposure to dead poultry. The female is the seventeenth person in Cambodia to become infected with the H5N1 virus and the fifteenth to die from complications of the disease. All seven cases of H5N1 infections in humans in Cambodia in 2011 have been fatal.

The National and local Rapid Response Team (RRT) is conducting outbreak investigation and response following the national protocol.

There is no evidence of increased ILI activity in the local health centre or any increase in number of SARI cases from the affected village. Thirteen contacts were tested for A/H5N1 influenza, all of whom were negative. There is enhanced surveillance for ILI and SARI in the local health centre and hospital for a further two weeks. Health education messages are ongoing in the community.
(WHO 8/2/2011)


USA: NIH head says universal influenza vaccine may be ready within five years
Dr. Francis Collins, director of the National Institutes of Health (NIH), says that a universal flu vaccine providing protection against all strains may be created within five years. Collins said that he is guardedly optimistic about the prospect of a shot that would provide long-term protection, replacing the annual shots now required. He said a universal flu vaccine seemed completely out of reach a few years ago, but scientists now know there are part of the virus's coat that don't change, and a vaccine targeting the constant part of the virus could protect against all strains. Dr. Arnold Monto, a flu expert at the University of Michigan, said a universal flu vaccine is not a question of whether, but when. But he added, I think five years is a bit ambitious, given where we are now. Many research teams are currently working to create broadly protective flu vaccines. Collins talked about flu vaccines in a discussion of many advances stemming from NIH research, against the backdrop of a congressional budget debate that could lead to trimming the NIH's $31 billion budget.
(CIDRAP 7/27/2011)


2. Infectious Disease News

Global: ECDC, CDC offer standard terminology for multidrug-resistant bacteria
With the aim of improving surveillance for antimicrobial-resistant bacteria, a committee of experts from European Centre for Disease Prevention and Control (ECDC) and the CDC has released a set of standardized definitions and terms for bacteria that are resistant to multiple drugs, the ECDC announced 26 July 2011. The terms describe resistance profiles in several pathogens that commonly cause infections in hospitals and are prone to multidrug resistance: Staphylococcus aureus, Enterococcus species, Enterobacteriaceae (other than Salmonella and Shigella), Pseudomonas aeruginosa, and Acinetobacter species. The ECDC said harmonized definitions are needed so that epidemiologic and surveillance data can be reliably collected and compared across healthcare settings and countries. The definitions were published online 26 July 2011 by Clinical Microbiology and Infection. The article notes that many different definitions are currently used in the medical literature for multidrug-resistant, extensively drug-resistant, and pandrug-resistant.
(CIDRAP 7/27/2011)


USA (Michigan): Three tetanus cases in renew call for vaccinations
Three people in southeast Michigan have been diagnosed with tetanus, the Department of Community Health said 28 July 2011. There was one case each in Detroit, Oakland and Wayne counties.

Also known as "lock jaw," tetanus is caused by a bacteria commonly found in soil and can enter the body through wounds contaminated with dirt, feces, soil, or saliva. Those affected have difficulty swallowing and can end up with breathing problems, muscle spasms and seizures. Left untreated, it can be fatal.

DCH officials said teens and adults should get the Tdap vaccine, which also protects against diphtheria and pertussis (whooping cough), or a booster shot every 10 years. The best treatment for this disease is prevention through immunization, said Dr. Dean Sienko, DCH's Interim Chief Medical Executive.

The third person with tetanus also lives in southeast Michigan, but department spokeswoman Kelly Niebel wasn't sure which county. The three cases so far in 2011 match the number of cases reported in all of 2006. In 2010, only two cases were reported; none were reported in 2009, one in 2008, and none in 2007.
(ProMED 7/28/2011)


Australia: States commit further $6m to fund Hendra research as authorities blame rain for spike
Authorities believe widespread summer rains may have contributed to an unprecedented spike in Hendra virus, as a joint Queensland-NSW task force has announced $6 million in extra research funding to fight the disease.

An emergency meeting of medical and scientific leaders was convened in Brisbane 27 July 2011 to discuss the escalating situation, after 11 outbreaks from far north Queensland to northern NSW since June.

On 26 July 2011, it was revealed a dog on a southern Queensland property, 80km from Brisbane, had become infected with Hendra virus, an unprecedented jump between species. Previously Hendra has only been confirmed in flying foxes, the carrier host, before being passed on to horses and humans.

Queensland Premier Anna Bligh said research into the virus was advanced but the transmission to the dog gives rise to more questions that science is able to answer at the moment. She said the funding, to the Queensland Centre for Emerging Infectious Diseases and the Australian Animal Health Laboratory, would delve into the environmental and ecological factors around Hendra virus.

A horse vaccine should be ready by 2013.

Dr. Hume Field, from the Queensland Centre for Emerging Infectious Diseases, said it was likely the spike in outbreaks was linked to the summer rains. He said heavy rainfall had reduced the amount of flowering in trees and flying foxes had to range further in small groups to find food. That has the potential to impact their immune capacity to fight off infection and is likely the reason why this infection is higher in flying foxes in 2011 than previous years, he said. We suspect it's an aberration and it will be back to normal in 2011.

He said Hendra was evident each year but the likelihood of spillovers from flying foxes to horses and humans varied each year. Clearly in 2011 there is more virus in flying foxes and there seems to be evidence of environmental and ecological impacts that are making that virus persist longer, he said. Nutritional stress can impact the size of flying fox populations, the way they interact with each other, the way that viruses circulate.

Dr. Jeannette Young said 64 people in Queensland were being monitored for signs of the virus but people had heeded the advice to avoid sick horses.

Meanwhile, The Queensland opposition wants to use smoke bombs and choppers to evict urban bat colonies despite warnings it could lead to more Hendra cases. Liberal National Party leader Campbell Newman says that once bats have been moved on, the trees they roost in should be cut down. Scientists have frequently said that culling or moving on colonies increases stress levels in bats, which carry the disease. Stressed bats shed more of the Hendra virus, increasing the risk of it passing to horses, and subsequently possibly to humans.

Mr. Newman said the Queensland government needed to get real about removing bat colonies from urban areas, but stopped short of advocating a cull. There needs to be a proper use of the tools available - smoke bombs, noise and helicopters and when the bats have been moved from the vegetation they've been roosting in these urban areas, basically that vegetation should appropriately come down, he said. If those things happen I don't think they need to be culled.
(The Australian 7/27/2011)


Australia (Queensland): Second meningococcal case after student's death
One university student is dead and a second is in hospital after an outbreak of meningococcal disease in Townsville in north Queensland, Australia. An 18-year-old medical student was found dead in his bedroom at James Cook University on 27 July 2011.

The dean of medicine and dentistry, Professor Richard Murray, says the student was from Western Australia and was planning a career in humanitarian medicine. He says a memorial service was held on 30 July 2011. This is a fine, very talented, and widely admired and liked young man, he said. Another medical student from the college has also tested positive for the infection. The university says he is responding well to treatment.

Professor Murray says people who have been in close contact with the men have been interviewed and given antibiotics. Certainly with the widened antibiotic clearance we wouldn't be expecting to see any further cases, however, vigilance of anybody really is important, he said. Students and staff have also been offered counselling.

Since 2007, there have been between two and four deaths in the state annually. Meningococcal is uncommon and has similar symptoms to the flu. As of 1 August 2011, there have been 38 cases in Queensland; but it is believed this is the first death.

Queensland Premier Anna Bligh says the cases are concerning. It is very worrying. It is tragic to see a young 18-year-old lose their life to this awful disease, she said. That's why Queensland Health is, as of right now, out tracing every contact that they can so that we can understand where this disease may be operating.
(ABC News 8/1/2011)


Hong Kong: Scarlet fever cases continue to ebb
The number of newly diagnosed scarlet fever infections in Hong Kong's outbreak continued to drop, with only eight new cases reported since 26 July 2011 and 50 cases reported since 11 July 2011. The region's Centre for Health Protection (CHP) said that no new outbreaks or deaths have been reported. The latest cases raise the outbreak total to 998 cases, and the number of fatalities stands at two.
(CIDRAP 7/27/2011)


Malaysia (Bakun): Speculations on mysterious disease ends, deaths caused by melioidosis and leptospirosis
State health director Dr. Zulkifli Jantan put an end to speculations on mysterious diseases and curses from angry spirits in the Bakun area by confirming that three deaths reported in the Bakun area were caused by melioidosis and leptospirosis, on 2 August 2011.

The people of Bakun believed that spirits of the jungle who are angry over the construction of the dam and the destruction of the surroundings caused the deaths. They believed that their dead ancestors are also very angry that their graves have been submerged by the dam water.

Dr. Zulkifli added that the claim by the news portal that ten people hired by the Sarawak Forestry Corporation (SFC) to save animals from being drowned following the impoundment of the Bakun Dam had died from the mysterious disease was wrong. He clarified that the ten fatalities were actually the total number of people in the state who died from melioidosis and leptospirosis from January 2011 to 23 July 2011.

The latest victim of the disease was a 28-year old SFC worker who worked on the project. The father of the deceased, was quoted to have said that his son fell gravely ill after returning from Bakun Dam and died two days later.

Besides the Bakun area, two fatal cases from melioidosis were reported in Kapit and one fatal case reported in Tatau. Apart from the deaths reported in Bakun area, one fatal case was reported in Kuching, Sri Aman, Betong and Limbang during the same period.

As of 3 August 2011, two clusters have been reported of melioidosis, namely one in Bakun Hydroelectric project (Belaga) and the second in Iron Wall Logging Camp in Kapit, said Dr. Zulkifli. There were 31 cases of positive melioidosis detected in Sarawak since the beginning of 2011 to 23 Jul 2011 compared to 343 reported cases in 2010. As for leptospirosis, there were 51 positive cases reported from the beginning of 2011 to 23 Jul 2011 compared to 49 total cases in 2010.

Dr. Zulkifli disclosed that under the Preventive and Control of Infectious Disease Act and Regulations 1988 he might close the contaminated areas or sources of the diseases. We will alert the public regarding the possible hazards from the contaminated area. Health hazard warning signage will be erected in specific areas that are confirmed to be sources of infection, he said. He added that the department was giving health education talks on the two diseases to the public.
(ProMED 8/3/2011)


New Zealand (Waikato): Two more measles cases confirmed
A three-month-long outbreak of measles in Auckland is thought to have spread to Waikato. It had 10 confirmed cases on 1 August 2011 and was analyzing a further five cases. A Waikato medical officer of health, Anita Bell, says there are now 12 confirmed and a further three suspected cases.

Dr. Bell says one of the confirmed cases is a secondary case and Waikato regional public health officials are expecting more such cases. A secondary case occurs when a person who has not been immunized, catches measles from an earlier case before that person knew they had the disease, she says.
(HealthMap 8/4/2011)


Viet Nam: Severe hand, foot, and mouth disease epidemic reported
Nguyen Van Binh, chief of the Preventive Medicine Department in Ho Chi Minh City warned of a severe epidemic as 17,000 cases of hand foot and mouth disease (HFMD) have been reported in the country, with South Viet Nam reporting 13,600 cases alone. Moreover, 90 patients of those afflicted patients have succumbed to the disease. Binh blamed the outbreak to a new etiological agent, human enterovirus 71 (EV71) of sub-genotype C4 which causes severe complications.

Meanwhile, the Pasteur Institute in Ho Chi Minh City claimed that 50 out of 15,000 patients infected with HFMD in South Vietnam have died in 2011, tripling the death toll from the same period in 2010. Localities with the largest number of patients are Ho Chi Minh City, and the southern provinces of Dong Nai, Binh Duong, Long An and Tien Giang.

The Ministry of Health and epidemiologists are on alert for new, developments of the virus and the disease. Any new developments will be reported immediately. Binh warned that more children may contract the disease as its peak infection time falls between the months of August till November.
(ProMED 7/22/2011)


USA: Multistate outbreak of human Salmonella Heidelberg infections
CDC is collaborating with public health officials in many states and the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS) to investigate a multistate outbreak of Salmonella Heidelberg infections that is likely caused by eating ground turkey. Public health investigators are using DNA fingerprints of Salmonella bacteria obtained through diagnostic testing with pulsed-field gel electrophoresis, or PFGE, to identify cases of illness that may be part of this outbreak. They are using data from PulseNet, the national subtyping network made up of state and local public health laboratories and federal food regulatory laboratories that performs molecular surveillance of foodborne infections. The outbreak strain of Salmonella Heidelberg is resistant to many commonly prescribed antibiotics; this antibiotic resistance can increase the risk of hospitalization or possible treatment failure in infected individuals.

A total of 77 persons infected with the outbreak strain of Salmonella Heidelberg have been reported from 26 states between 1 March and 1 August 2011. The number of ill persons identified in each state is as follows: AL (1), AZ (2), CA (6), GA (1), IA (1), IL (7), IN (1), KY (2), LA (1), MA (1), MI (10), MN (1), MO (2), MS (1), NC (1), NE (2), NV (1), NY (2), OH (10), OK (1), OR (1), PA (5), SD (3), TN (2), TX (9), and WI (3).

Among persons for whom information is available, illnesses began on or after 9 March 2011. Ill persons range in age from less than one year to 88 years old, with a median age of 23 years old. 48% are female. Among the 58 ill persons with available information, 22 (38%) have been hospitalized. One death has been reported.
(US CDC 8/1/2011)


USA: Papaya Salmonella strain has links to earlier outbreak
The US Centers for Disease Control and Prevention (CDC) said 26 July 2011 that two more patients have been sickened in a multistate Salmonella Agona outbreak linked to papayas imported from Mexico. The new reports push the total to 99 cases, and the number of affected states stayed the same at 23. The distributor, Agromod Produce based in McAllen, Tex., recalled the papayas it sells under four different brand names after tests found the outbreak strain in produce samples from its facility and from papayas at a US border station that were bound for the company. The CDC also said the outbreak strain is made up of four closely related pulse-field gel electrophoresis (PFGE) patterns that have rarely been seen in its PulseNet, an electronic network for sharing molecular fingerprinting. Three of the patterns were first identified starting in 2010 and were seen in 119 patients from 14 states between 28 May 2011 and 10 September 2011; however, an investigation that summer by the CDC and its partners did not find an outbreak source, though the probe focused on fresh fruit, including papaya. The CDC said the profile of the 2010 outbreak resembles the 2011 outbreak.
(CIDRAP 7/26/2011)


USA (New York): Pertussis outbreak in two Columbia County school districts
In other developments, two school districts in Columbia County, New York, have alerted parents about pertussis outbreaks. The districts are in east central New York. County health officials asked Chatham Central School District and the Ichabod Crane School District in Valatie to post notices on their websites, and the Chatham district notified parents through its automated phone alert system. No details were available on the number of students affected by the outbreak.
(CIDRAP 7/26/2011)


USA (Pennsylvania): Warns of measles exposure
Pennsylvania health officials 25 July 2011 issued an alert that people in four counties may have been recently exposed to measles at certain locations on 21 and 22 July 2011. The locations, which include a grocery store, two restaurants, a coffee shop, a bank, and a liquor store, are in Berks, Delaware, Lehigh, and Bucks counties. The Pennsylvania Department of Health stated that the exposure is related to an earlier alert they issued when a patient diagnosed with measles visited a Rite Aid drug store in Berks County on 11 July 2011. Health departments in Berks, Delaware, and Lehigh counties are offering free immunoglobulin immunization.
(CIDRAP 7/27/2011)


Canada (Ontario): Clostridium difficile superbug tied to 35th Niagara death
Another patient has died in relation to the Clostridium difficile outbreak, the morning of 29 July 2011 at St Catharine's General Hospital. This brings the total of C. difficile-related deaths in Niagara to 35, including six community-acquired cases, since the first outbreak was declared by Niagara Health System (NHS) on 28 May 2011.

Sue Matthews, NHS interim president and CEO, assured the community the health system is not taking its eye off the ball and is on track to end the outbreak. We're working to do better for our community. We will do better, she said.

Cleaning of the in-patient areas at Welland, St Catharine's and Niagara Falls hospitals has been completed and crews are now working to clean the out-patient and public areas including lobbies and washrooms, Matthews said. All three hospitals are expected to be finished by 4 August 2011. Cleaning procedures have also begun at the NHS's smaller sites and are expected to be completed in the next two to three weeks, Matthews said.

Staff in hospital emergency departments, she said, have been vigilant in assessing and isolating patients who come in with signs and symptoms of C. difficile-associated disease (CDAD). Tools have also been put in place to help staff assess whether they themselves are experiencing any symptoms of the disease.

Matthews said there are still people who refuse to wash their hands when entering the hospitals. Some have even gone so far as to cross their arms, telling staff to make them when asked to clean their hands before entering, she said. The NHS cannot say enough, cannot remind people enough about the importance of proper hand washing to help stop the spread of CDAD, she said. Whether it's in the hospital or out in the community, hand washing will help to keep the disease under control, she added.
(ProMED 8/1/2011)


Mexico: First measles case reported since 2007, with more possible cases detected
Health authorities in the northeastern Mexican state of Tamaulipas established a sanitation barrier around border neighborhoods in the city of Nuevo Laredo after detecting two possible cases of measles, officials said.

The head of Health District No. 5, Jaime Emiliano Gutierrez, said that the two cases were detected in children ages one and five, which prompted the state's Health Secretariat to carry out the corresponding studies to confirm or disprove the existence of the disease. These are suspicious cases, he said.

While results were being obtained, sanitation barriers were established on 22 July 2011 around 40 blocks in each of the two neighborhoods where the children live. Gutierrez said that vaccination has been stepped up for people who never had the disease, along with other preventive measures. It's an illness you can only have once in a lifetime, so if you had it as a child, you no longer run the risk of contagion, he said.

Federal authorities had already detected one case that of a little French girl who arrived in the Mexican capital from Paris, the first case of the disease detected in the country since early 2007. Because of it, the Mexican government announced it will purchase 3.6 million doses of measles vaccine to prevent the disease from spreading. We must act very quickly because of the speed with which it spreads, Health Secretary Jose Angel Cordova said. Vaccination stations will be set up at hospitals and clinics as well as at Mexico City's international airport. The vaccine will be offered to all Europe-bound flyers over the next 20 days, while airport employees are required to get shots. Mexico's last indigenous case of measles was in 1997.

He emphasized that around 95% of Mexican children receive vaccinations. Around 1,500 Mexico City airport workers have already received shots, and authorities are trying to track down the other passengers who arrived on the same flight as the French girl.
(ProMED 7/24/2011)


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.


As of 25 Jul 2011 there are three dengue clusters with more than 10 cases; two are in residential areas- the Serangoon Central/Lor Lew Lian cluster has 14 cases while the Seletar Hills Drive/Jalan Ketumbit/Jalan Antoi/Jalan Keruing cluster has 11 cases. The third cluster of 22 cases is a dormitory in the Woodlands industrial area - the first time a cluster has been formed in a dormitory in 2011. A large cluster at the Upper Paya Lebar area closed on 22 Jul 2011 when 51 cases were reported there. The last transmission date was on 6 July 2011 but National Environment Agency (NEA) is monitoring the cluster as a precautionary measure. NEA found 6,011 breeding sites in the first seven months of 2011, compared to 2,741 during the same period in 2005, the year of the last major dengue outbreak.
(ProMED 7/27/2011)

Philippines (Kalinga province)
Based on the report of the Provincial Epidemics and Surveillance Unit, dengue suspect cases in Kalinga (Cordillera Administrative Region) shot up to 90 in July 2011 with one death, a case that was registered in a hospital in Tuguegarao City, Cagayan. Based on the monitoring report, the morbidity week or the time the cases started to rise was 26 thru 30 June 2011 with 26 suspect cases recorded.
(ProMED 7/30/2011)

USA (New Mexico)
State health officials say a 23-year-old man from McKinley County has died from hantavirus pulmonary syndrome. The New Mexico Health Department said 25 July 2011 that this is the fourth hantavirus case reported in the state for 2011.

Hantavirus is contracted by breathing particles of rodent droppings, urine or saliva. There’s no specific treatment for hantavirus, but officials say the chances for recovery are better with early medical attention.

The earlier cases for 2011 consist of a 39-year-old McKinley County man who recovered from the illness and a 51-year-old McKinley County woman and a 35-year-old Torrance County man who both died from hantavirus.
(ProMED 7/25/2011)

USA (North Carolina)
A Macon County child is North Carolina's first confirmed case of La Crosse viral encephalitis for 2011. State health officials say the child contracted the illness from a mosquito bite. Symptoms of the ailment can include fever, headache and nausea. Victims of a severe case can experience convulsions or they may even fall into a coma. Officials didn't identify the child who caught the virus, but say he or she is recovering.

La Crosse encephalitis is largely found in western North Carolina, and is the state's most common mosquito-borne disease. In 2010, North Carolina recorded 21 cases. Although it's rarely fatal, a Swain County child died from the illness in 2009.
(ProMED 7/23/2011)

USA (Washington)
The Yakima Health District (YHD) has received confirmation from the Washington State Department of Health (DOH) and the Centers for Disease Control and Prevention (CDC) that the death earlier this July 2011 of a Yakima County man in his 50s was caused by a hantavirus. This is the first hantavirus death in Washington State since 2009 and the first case reported in the state for 2011. Because some hantavirus infections are fatal in about one of every three cases, YHD is encouraging residents to take simple precautions to prevent exposure to this rare but life-threatening infection.
(ProMED 7/21/2011)


4. Articles
Notes from the Field: Fatal Fungal Soft-Tissue Infections After a Tornado --- Joplin, Missouri, 2011
Center for Disease Control and Prevention. MMWR. 29 July 2011. 60(29);992.
Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6029a5.htm

Abstract. On May 22, 2011, at 5:34 p.m. a tornado with winds >200 mph struck Joplin, Missouri, injuring approximately 1,000 persons and causing 159 deaths. On June 3, a local physician notified the Springfield-Greene County Health Department and the Missouri Department of Health and Senior Services (MODHSS) of two patients hospitalized with tornado injuries who had suspected necrotizing fungal soft-tissue infections. MODHSS initiated active surveillance for such infections at hospitals and laboratories serving patients injured in the tornado, and CDC began assisting MODHSS with identification of fungal isolates. By June 10, eight patients with necrotizing fungal soft-tissue wound infections caused by Mucormycetes (formerly Zygomycetes) were identified. On June 14, a CDC field team arrived in Missouri to assist with the onsite investigation.


Emergence of a New Pathogenic Ehrlichia Species, Wisconsin and Minnesota, 2009
Pritt BS, Sloan LM, Hoang DK, et al. N Engl J Med. 4 August 2011. 365:422-429.
Available at http://www.nejm.org/doi/full/10.1056/NEJMoa1010493

Background. Ehrlichiosis is a clinically important, emerging zoonosis. Only Ehrlichia chaffeensis and E. ewingii have been thought to cause ehrlichiosis in humans in the United States. Patients with suspected ehrlichiosis routinely undergo testing to ensure proper diagnosis and to ascertain the cause.

Methods. We used molecular methods, culturing, and serologic testing to diagnose and ascertain the cause of cases of ehrlichiosis.

Results. On testing, four cases of ehrlichiosis in Minnesota or Wisconsin were found not to be from E. chaffeensis or E. ewingii and instead to be caused by a newly discovered ehrlichia species. All patients had fever, malaise, headache, and lymphopenia; three had thrombocytopenia; and two had elevated liver-enzyme levels. All recovered after receiving doxycycline treatment. At least 17 of 697 Ixodes scapularis ticks collected in Minnesota or Wisconsin were positive for the same ehrlichia species on polymerase-chain-reaction testing. Genetic analyses revealed that this new ehrlichia species is closely related to E. muris.

Conclusions. We report a new ehrlichia species in Minnesota and Wisconsin and provide supportive clinical, epidemiologic, culture, DNA-sequence, and vector data. Physicians need to be aware of this newly discovered close relative of E. muris to ensure appropriate testing, treatment, and regional surveillance.


International Spread of an Epidemic Population of Salmonella enterica Serotype Kentucky ST198 Resistant to Ciprofloxacin
Hello SL, Hendriksen RS, Doublet B, et al. J Infect Dis. 2 August 2011. doi: 10.1093/infdis/jir409 (Epub ahead of print).
Available at http://jid.oxfordjournals.org/content/early/2011/07/28/infdis.jir409.abstract

Abstract. National Salmonella surveillance systems from France, England and Wales, Denmark, and the United States identified the recent emergence of multidrug-resistant isolates of Salmonella enterica serotype Kentucky displaying high-level resistance to ciprofloxacin. A total of 489 human cases were identified during the period from 2002 (3 cases) to 2008 (174 cases). These isolates belonged to a single clone defined by the multilocus sequence type ST198, the XbaI-pulsed-field gel electrophoresis cluster X1, and the presence of the Salmonella genomic island 1 variant SGI1-K. This clone was probably selected in 3 steps in Egypt during the 1990s and the early 2000s and has now spread to several countries in Africa and, more recently, in the Middle East. Poultry has been identified as a potential major vehicle for infection by this clone. Continued surveillance and appropriate control measures should be implemented by national and international authorities to limit the spread of this strain.


Epidemiology and characteristics of antimicrobial resistance in China
Xiao YH, Giske CG, Wei ZQ, et al. Drug Resist Updat. 30 July 2011. doi:10.1016/j.drup.2011.07.001 (Epub ahead of print).
Available at http://www.sciencedirect.com/science/article/pii/S1368764611000513

Abstract. A comprehensive surveillance system for bacterial resistance in tertiary hospitals has been established in China that involves tertiary hospitals in distinct regions nationwide, enabling the collection of a large amount of antimicrobial surveillance data. Antimicrobial resistance in China has become a serious healthcare problem, with high resistance rates of most common bacteria to clinically important antimicrobial agents. Methicillin-resistant S. aureus, ESBL-producing Enterobacteriaceae and carbapenem-resistant Acinetobacter baumannii represent more than 50% of microbial isolates. Additionally, bacterial resistance to fluoroquinolones, macrolides and third-generation cephalosporins is of serious concern. The molecular epidemiology and resistance mechanisms of the antimicrobial strains in China exhibited regional specificity, as well as the influence of dissemination of international clonal complexes. The molecular characteristics of MRSA, ESBL- and carbapenemase-producing Enterobacteriaceae, and macrolide-resistant gram-positive Streptococci in China were significantly different from those in other countries and regions, while S. pneumonia serotypes appear to have been affected by the global spread of prevalent clones in other parts of the world. Moreover, important antimicrobial resistant bacteria such as community-acquired-MRSA, multidrug-resistant P. aeruginosa and extensive-resistant A. baumannii, and the antimicrobial resistance in primary healthcare and outpatient setting should be intensely monitored and investigated in the future.


Clostridium difficile laboratory testing in Australia and New Zealand: national survey results and Australasian Society for Infectious Diseases recommendations for best practice
Ferguson JK, Cheng AC, Gilbert GL, et al. Pathology. August 2011. 43(5):482-487.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21716158

Aims. In order to improve the future reliability of surveillance for Clostridium difficile infection (CDI), an Australia/New Zealand-wide survey was conducted to examine methods of laboratory diagnosis in use, identify deficiencies in practice and burden of CDI.

Methods. An online survey of 48 Australian and New Zealand microbiology laboratories (private and public) was conducted in late 2009 and 2010 to collect information about methods of detection in use and collective testing experience from July 2008 to June 2009.

Results. The overall prevalence (proportion positive of all faecal specimens tested) of C. difficile in 123 574 tested samples was 5.3%. The incidence rate across jurisdictions varied between 18.0 per 100 000 population in Victoria to 35.8 per 100 000 population in Tasmania, with a mean for Australia of 25.6 per 100 000 population. The incidence rate in New Zealand was 21.5 per 100 000 population. Most laboratories (60%) screened stools with an enzyme immunoassay (EIA) or equivalent that detected both toxins A and B.

Conclusions. The low overall rates reported here may reflect the lack of sensitivity of diagnostic testing procedures currently used in Australia and New Zealand to detect C. difficile. Recommendations for best practice in diagnosis of C. difficile were developed by the Australasian Society for Infectious Diseases (ASID) C. difficile working party and later endorsed by ASID.


Imported measles and implications for its elimination in Taiwan
Cheng WY, Yang CF, Hou YT, et al. Emerg Infect Dis. August 2011. 17(8):1523-6.
Available at http://www.cdc.gov/eid/content/17/8/100800.htm

Abstract. During November 2008–May 2009, an outbreak of 53 measles cases occurred in Taiwan. Of these, 3 cases were sporadic, and the other 50 cases could be grouped into 8 clusters by genetic analysis. We determined 7 H1 genotypes linked to importation and 1 G3 genotype linked to an untraceable source.


Enterovirus 68 among children with severe acute respiratory infection, the Philippines
Imamura T, Fuji N, Suzuki A, et al. Emerg Infect Dis. August 2011. doi:10.3201/eid1708.101328.
Available at http://www.cdc.gov/EID/content/17/8/101328.htm

Abstract. Enterovirus 68 (EV68) is a rare enterovirus associated with respiratory illness that, unlike other enteroviruses, has been identified only from respiratory specimens. We identified EV68 from respiratory specimens of children hospitalized with a diagnosis of severe pneumonia in Leyte, Republic of the Philippines. Twenty-one samples showed high similarity with EV68 by sequencing of 5’ nontranslated region; 17 of these samples were confirmed as EV68 by sequencing of viral protein 1 capsid coding region. Most previously reported EV68 cases had been identified as sporadic cases. All 21 patients we identified had severe illness, and 2 died, possibly the first reported fatal cases associated with EV68 infection. Our study suggests that EV68 may be a possible causative agent of severe respiratory illnesses.


Novel arenavirus infection in humans, United States
Milazzo ML, Campbell GL, Fulhorst CF. Emerg Infect Dis. August 2011. doi:10.3201/eid1708.110285.
Available at http://www.cdc.gov/EID/content/17/8/110285.htm

Abstract. Immunoglobulin G against Whitewater Arroyo virus or lymphocytic choriomeningitis virus was found in 41 (3.5%) of 1,185 persons in the United States who had acute central nervous system disease or undifferentiated febrile illnesses. The results of analyses of antibody titers in paired serum samples suggest that a North American Tacaribe serocomplex virus was the causative agent of the illnesses in 2 persons and that lymphocytic choriomeningitis virus was the causative agent of the illnesses in 3 other antibody-positive persons in this study. The results of this study suggest that Tacaribe serocomplex viruses native to North America, as well as lymphocytic choriomeningitis virus, are causative agents of human disease in the United States.


Early warning system for West Nile virus risk areas, California, USA
Carney RM, Ahearn SC, McConchie A, et al. Emerg Infect Dis. August 2011. doi:10.3201/eid1708.100411.
Available at http://www.cdc.gov/EID/content/17/8/100411.htm

Abstract. The Dynamic Continuous-Area Space-Time (DYCAST) system is a biologically based spatiotemporal model that uses public reports of dead birds to identify areas at high risk for West Nile virus (WNV) transmission to humans. In 2005, during a statewide epidemic of WNV (880 cases), the California Department of Public Health prospectively implemented DYCAST over 32,517 km2 in California. Daily risk maps were made available online and used by local agencies to target public education campaigns, surveillance, and mosquito control. DYCAST had 80.8% sensitivity and 90.6% specificity for predicting human cases, and k analysis indicated moderate strength of chance-adjusted agreement for >4 weeks. High-risk grid cells (populations) were identified an average of 37.2 days before onset of human illness; relative risk for disease was >39× higher than for low-risk cells. Although prediction rates declined in subsequent years, results indicate DYCAST was a timely and effective early warning system during the severe 2005 epidemic.


Reassortment Events Among Swine Influenza A Viruses in China: Implications for the Origin of the 2009 Influenza Pandemic
Lam TT, Zhu H, Wang J, et al. J. Virol. 27 July 2011. doi:10.1128/JVI.05262-11 (Epub ahead of print).
Available at http://jvi.asm.org/cgi/content/short/JVI.05262-11v1?rss=1

Abstract. That pigs may play a pivotal role in the emergence of pandemic influenza was indicated by the recent H1N1/2009 human pandemic, likely being caused by a reassortant between viruses of the American triple-reassortant (TR) and Eurasian avian-like (EA) swine influenza lineages. As China has the largest human and pig populations in the world and is the only place where both TR and EA viruses have been reported to co-circulate, China is potentially the source of the H1N1/2009 pandemic virus. To examine this, genome sequences of 405 swine influenza viruses from China were analysed. Thirty-six TR and EA reassortant viruses were identified before and after the occurrence of the pandemic. Several of these TR-EA reassortant viruses had genotypes with most segments having the same lineage origin as the segments of the H1N1/2009 pandemic virus. However, these viruses were generated from independent reassortment events throughout our survey period, and were not associated with the current pandemic. One TR-EA reassortant, which is least similar to the pandemic virus, has persisted since 2007, while all other variants appear to be transient. Despite frequent reassortment events between TR and EA lineage viruses in China, evidence for the genesis of the 2009 pandemic virus in pigs in this region is still absent.


Potential role of human challenge studies for investigation of influenza transmission
Killingley B, Enstone J, Booy R, et al. Lancet Infect Dis. 26 July 2011. doi:10.1016/S1473-3099(11)70142-6 (Epub ahead of print).
Available at http://www.sciencedirect.com/science/article/pii/S1473309911701426

Abstract. The importance of different routes of influenza transmission (including the role of bioaerosols) and the ability of masks and hand hygiene to prevent transmission remain poorly understood. Interest in transmission of influenza has grown as the effectiveness of prevention measures implemented during the 2009 H1N1 pandemic are questioned and as plans to better prepare for the next pandemic are debated. Recent studies of naturally infected patients have encountered difficulties and have fallen short of providing definitive answers. Human challenge studies with influenza virus date back to the 1918 pandemic. In more recent decades they have been undertaken to investigate the efficacy of antiviral agents and vaccines. Could experimental challenge studies, in which volunteers are deliberately infected with influenza virus, provide an alternative approach to the study of transmission? Here, we review the latest intervention studies and discuss the potential of challenge studies to address the remaining gaps in our knowledge.


Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among healthcare workers in three countries
Chor JS, Pada SK, Stephenson I, et al. Vaccine. 30 July 2011. doi:10.1016/j.vaccine.2011.07.079 (Epub ahead of print).
Available at http://www.sciencedirect.com/science/article/pii/S0264410X11011297

Abstract. The aim of this study was to identify the common barriers and facilitators for acceptance of pandemic influenza vaccination across different countries. This study utilized a standardized, anonymous, self-completed questionnaire-based survey recording the demographics and professional practice, previous experience and perceived risk and severity of influenza, infection control practices, information of H1N1 vaccination, acceptance of the H1N1 vaccination and reasons of their choices and opinions on mandatory vaccinations. Hospital-based doctors, nurses and allied healthcare workers in Hong Kong (HK), Singapore (SG) and Leicester, United Kingdom (UK) were recruited. A total of 6318 (HK: 5743, SG: 300, UK: 275) questionnaires were distributed, with response rates of 27.1% (HK), 94.7% (SG) and 94.5% (UK). The uptake rates for monovalent 2009 pandemic H1N1 vaccine were 13.5% (HK), 36.2% (SG) and 41.3% (UK). The single common factor associated with vaccine acceptance across all sites was having seasonal influenza vaccination in 2009. In UK and HK, overestimation of side effect reduced vaccination acceptance; and fear of side effect was a significant barrier in all sites. In HK, healthcare workers with more patient contact were more reluctant to accept vaccination. Drivers for vaccination in UK and HK were concern about catching the infection and following advice from health authority. Only a small proportion of respondents agreed with mandatory pandemic influenza vaccination (HK: 25% and UK: 42%), except in Singapore where 75.3% were in agreement. Few respondents (<5%) chose scientific publications as their primary source of information, but this group was more likely to receive vaccination.

The acceptance of pandemic vaccine among healthcare workers was poor (13–41% of respondents). Breaking barriers to accept seasonal influenza vaccination should be part of the influenza pandemic preparedness plan. Mandatory vaccination even during pandemic is likely to arouse substantial discontent.


5. Notifications
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


5th Vaccine and ISV Annual Global Congress
Seattle, Washington, United States, 2-4 October 2011
The annual Vaccine Congress is the leading global forum for the exchange of new ideas on the development of vaccines for infectious and non-infectious diseases. Now in its fifth year, the annual Vaccine Congress has become the forum for the exchange of ideas to accelerate the rate at which vaccines can come to benefit the populations that need them.
Additional information at http://www.vaccinecongress.com


Sixth TEPHINET Southeast Asia and Western Pacific Bi-regional Conference
Bali, Indonesia, 8-11 November 2011
The conference has the theme “Global Surveillance Networking for Global Health” and is organized by the Training Programs in Field Epidemiology and Public Health Intervention Network (TEPHINET). The conference is crucial given the transnational population mobility thanks to modern means of transportation and speedy transnational transmission of communicable diseases. At least 700 participants from more than 40 countries are expected to attend the conference.
Additional information at http://tephinet.fetpindonesia.org/